Preschl, B., Maercker, A., Wagner, B. (2011). The working alliance in a randomized controlled trial comparing online with face-to-face cognitive-behavioral therapy for depression. BMC Psychiatry, 11(189), doi: 10.1186/1471-244X-11-189
A recent pilot study found that internet-based cognitive behavior therapy (CBT) may facilitate a working alliance that is comparable in quality to the alliance formed in face-to-face therapy settings. The working, or therapeutic, alliance is a key tenet of CBT, and research suggests that it is crucial to positive therapeutic outcomes. The current study compares the working alliance between client and therapist in an internet-based intervention and in face-to-face treatment for depression. Participants were randomized into two groups; one group (n= 25) received the internet-based treatment and the second group (n=28) received face-to-face treatment. Both groups received 8 weeks of manualized CBT treatment for depression, which was based on a standard, evidence-based CBT manual for depression. Treatment was delivered by therapists trained in CBT specifically for this study, and involved an introduction to CBT, behavioral analysis, activity scheduling, cognitive restructuring, promotion of social competence, psychoeducation, relapse prevention, and a life review module. Patients in the face-to-face condition attended weekly one-hour sessions and were given weekly homework assignments. In the online condition, the treatment manual was adapted for use as a highly structured internet based treatment manual, and included writing and homework assignments based on the CBT approach. Writing assignments lasted 45-minutes and were scheduled regularly, two times per week. Therapists then provided written feedback within one working day. Working alliance was assessed with the Working Alliance Inventory (WAI) at mid-point and post-treatment. Ratings of the working alliance between the internet condition and face-to-face condition did not differ significantly. At post-treatment, there were positive correlations between clients’ ratings of the working alliance and treatment outcome for the online group, and at both mid and post treatment for the face-to-face group. The results of this preliminary research suggest that internet-based CBT may promote a working alliance comparable to that which is found in face-to-face treatment and produce positive treatment outcomes.