Online working alliance predicts treatment outcome for posttraumatic stress symptoms in Arab war-traumatized patients

University Clinic for Psychosomatic Medicine and Psychotherapy, University of Leipzig, Germany.
Depression and Anxiety (Impact Factor: 4.41). 07/2012; 29(7):646-51. DOI: 10.1002/da.21962
Source: PubMed


Previous studies have shown that Internet-based interventions for posttraumatic stress disorder are feasible. However, little is known about how therapeutic process factors impact online interventions in war and conflict regions.
This study aims to assess the quality of the working alliance at midtreatment and posttreatment and its relationship with therapy outcome in an Internet-based cognitive-behavioral intervention for Arabic-speaking traumatized patients.
A trial was conducted from January 2009 to August 2011 with patients recruited specifically in Iraq. Fifty-five participants with posttraumatic stress symptoms completed the Working Alliance Inventory (WAI) after at least session 4. Participants' mean age was 27.7 years (SD = 6.9); 78% of participants were females. Participants received two weekly 45-min Internet-based cognitive-behavioral interventions over a 5-week period. The main outcome measures were the Posttraumatic Diagnostic Scale (PDS) and the WAI.
High ratings of the therapeutic alliance were obtained early in treatment, and results remained stable from sessions 4 to 10, indicating that it was possible to establish a positive and stable online therapeutic relationship. The working alliance at both assessment points predicted treatment outcome for posttraumatic stress symptoms.
Despite the instability of the settings and patients' ongoing exposure to human right violations through war and dictatorships, it was possible to establish a stable online therapeutic relationship.

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    • "Research on the role of the therapeutic alliance as a predictor of treatment outcome in online treatments is scarce and the results have been rather contradictory. A significant association between an intensive therapeutic alliance and a better therapy outcome was found in two studies on ICBT for anxiety disorders (Bergman Nordgren et al., 2013; Anderson et al., 2012), and for an online intervention for PTSD (Knaevelsrud and Maercker, 2007; Wagner et al., 2012); but another study by Knaevelsrud and Maerker (Knaevelsrud and Maercker, 2006), which investigated the same online treatment for PTSD, did not report a significant relationship between alliance and outcome. Preschl et al. (2011) and Andersson et al. (2012) also did not find a significant relationship with the primary outcome measures in the context of highly structured ICBT for depression, generalized anxiety disorders, and social anxiety. "
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    ABSTRACT: Objective This study (ID: NCT01205906) compared the impact of the working alliance between the therapist and the client on treatment outcome in a group and an Internet-based cognitive behavior therapy (GCBT vs. ICBT) for chronic tinnitus. Methods The Working Alliance Inventory — Short Revised (WAI-SR, scale range: 1–5) was administered to 26 GCBT and 38 ICBT participants after treatment weeks 2, 5, and 9, and the Tinnitus Handicap Inventory (THI) before and after the treatment. Results High alliance ratings were found in both ICBT (WAI-SR total scores at week 9: M = 3.59, SD = 0.72) and GCBT (WAI-SR total scores at week 9: M = 4.20, SD = 0.49), but significantly higher ratings occurred in GCBT on most WAI-SR scales (ps < .01). Significant time × group interactions for most WAI-SR scales indicated differences in alliance growth patterns between the treatments (ps < .001). Residual gain scores for the therapy outcome measure ‘tinnitus distress’ were significantly correlated with the agreement on treatment tasks between therapist and client in ICBT (r = .40, p = .014) and with the affective therapeutic bond in GCBT (r = .40, p = .043) at mid-treatment (week 5). Conclusion More time was needed to build a strong alliance in ICBT although GCBT yielded generally higher alliance ratings. Moreover, different aspects of the therapeutic alliance might be important for treatment success in ICBT versus GCBT.
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    • "Preschl et al. 2011; Richards et al. 2012), but is not universal. For example, Wagner et al. (2012) found that both mid-treatment and post-treatment measures of alliance were associated with post-traumatic stress disorder symptom outcomes. Additionally, in a trial of personalized ICBT for anxiety (where modules were selected for participants on the basis of their particular symptom profile and emailed responses to homework assignments were sent by trained therapists who spent no more than 15 min per week per participant), Bergman Nordgren et al. (2013) found that working alliance with therapist at week 3 correlated significantly with improvements on the primary outcome measure. "
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    ABSTRACT: E-mental health technologies are rapidly expanding the reach of psychological interventions around the globe. There is a growing evidence base supporting the potential benefits of these new technologies for psychological and behavioural health. Most of this evidence to date has focused on evaluating the feasibility and outcomes from such interventions, whilst limited research has begun to explore the change processes associated with their impact. In traditional psychological therapies the quality of common factors, including the therapeutic relationship, are widely held to be important for engagement and outcomes. E-mental health interventions present a challenge to the importance of these factors, as therapeutic interactions are typically remote, limited, or even absent in the case of fully automated e-mental health programmes. This paper explores the role of the therapeutic relationship in e-mental health. Where measured, it appears that the relationship is fairly robust to distance and limited contact, but may be less intimately associated with therapy outcomes than in traditional therapies. Where the intervention comprises little or no therapeutic contact, we explore how some of the variance in engagement and outcomes may still be accounted for by common and relational factors offered through a supportive frame or embedded within the technologies themselves. Implications for theory, research and practice are presented.
    Journal of Contemporary Psychotherapy 07/2013; 43(4). DOI:10.1007/s10879-013-9242-z
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    ABSTRACT: There has been an increased use of modern information and communication technology in healthcare services in recent years; however, little is yet known about the nature of the therapeutic alliance in internet-based interventions. This review aims to give a systematic overview of controlled evaluation studies with a focus on the nature and impact of the therapeutic alliance in internet-based interventions available to date. The results of internet-based randomized controlled trials indicate that a positive therapeutic alliance can be established regardless of the medium of communication. The therapeutic alliance was rated equally satisfying as in conventional face-to-face therapy.
    Der Nervenarzt 11/2012; · 0.79 Impact Factor
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