The working alliance in blended versus face-to-face cognitive therapy for depression: A secondary analysis of a randomized controlled trial

Samuel Askjer, Kim Mathiasen*

*Corresponding author for this work

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Introduction: We explored the working alliance as measured by both clients and therapists. The working alliance has been known to predict the outcome of psychotherapy and is often considered an important common factor. This study raised the question of how to conceptualize the working alliance in the blended format. Methods: This was an exploratory study derived from a randomized controlled trial comparing bCBT and face-to-face cognitive behavioural therapy (ftf CBT) on depression. The change in depressive symptoms was measured with the Patient Health Questionnaire (PHQ-9) and the working alliance was measured using the Working Alliance Inventory. Analyses: Correlation coefficients were calculated for the working alliance as reported by clients and therapists, working alliance was then examined at item and dimension level (task, bond, goal). Linear regression models were applied to investigate the predictive value of the working alliance on treatment outcome. Interaction between the level of working alliance and treatment condition was also considered. Results: Client and therapist working alliance ratings correlated at r = 0.44 and clients rated the working alliance higher than therapists (x̄clients = 48.6, x̄therapists = 44.6). ftf CBT and bCBT had comparable joint working alliance ratings (x̄ftf = 46.4, x̄bCBT = 46.8). Items had little deviation apart from item 4 with high positive values. The level of working alliance from the total sample did not significantly predict outcome based on the client's perspective. Contrarily, seen from the therapist's perspective, it did (b = 0.00, p =.044). Using the mean from these predictors as a composite variable, was also significant (b = 0.00, p =.039, R2adj = 0.07). There was no significant interaction with treatment condition. Discussion: Clients and therapists may lay emphasis on different aspects of the working alliance. The finding that therapist-rated working alliance was better than client working alliance at predicting outcome went against common findings; this pattern may be specific to bCBT. Conclusion: Clients rated the working alliance slightly higher than therapists on average. Clients and therapists as well as treatment conditions had different profiles on dimension deviations. Therapist ratings of the working alliance appeared to better predict treatment outcome than client ratings. Joint working alliance predicted outcome using client and therapist composite means. The working alliance was equally strong in ftf CBT and bCBT. The absence of interaction with treatment condition indicated that the working alliance was equally predictive of outcome in ftf CBT as in bCBT.

Original languageEnglish
Article number100404
JournalInternet Interventions
Number of pages8
Publication statusPublished - Sept 2021

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  • Blended cognitive behavioural therapy
  • Depression
  • Working alliance


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