Abstract
Objective: The onset of the COVID-19 pandemic during spring 2020 necessitated a sudden transition from in-person to telehealth mental health services. Burgeoning literature has supported the use of telehealth services generally, although there is little research related to its use among graduate-level trainees. Method: The present study utilized data collected from a university counseling training center to compare client outcomes, namely ratings of depression and anxiety, between in-person (pre-pandemic; n = 86) and telehealth (pandemic; n = 102) groups. Specifically, we examined treatment format (in-person vs. telehealth) as a moderator of the association between client-reported working alliance and client-reported outcomes. Results: Results showed a significant effect of the working alliance on symptoms of depression and anxiety regardless of format of treatment, such that higher levels of the working alliance predicted lower levels of depression and anxiety. Thus, as working alliance scores increased, client outcomes improved for both in-person and telehealth groups. Conclusion: This study suggests that the working alliance is a meaningful predictor of counseling outcomes for both in-person and telehealth formats, adding further support for use of telehealth counseling, including in counselor training settings. These findings are particularly significant given the increase of telehealth services provided since the onset of the COVID-19 pandemic. Implications for research, practice, and training are discussed.
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References
American Psychological Association (2023, August 3). Guidelines for the practice of telepsychologyhttps://www.apa.org/practice/guidelines/telepsychology.
Andrews, G., Basu, A., Cuijpers, P., Craske, M. G., McEvoy, P., English, C. L., & Newby, J. M. (2018). Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: An updated meta-analysis. Journal of Anxiety Disorders, 55, 70–78. https://doi.org/10.1016/j.janxdis.2018.01.001.
Arnow, B. A., Steidtmann, D., Blasey, C., Manber, R., Constantino, M. J., Klein, D. N., Markowitz, J. C., Rothbaum, B. O., Thase, M. E., Fisher, A. J., & Kocsis, J. H. (2013). The relationship between the therapeutic alliance and treatment outcome in two distinct psychotherapies for chronic depression. Journal of Consulting and Clinical Psychology, 81(4), 627–638. https://doi.org/10.1037/a0031530.
Barak, A., Hen, L., Boniel-Nissim, M., & Shapira, N. (2007). A comprehensive review and a meta-analysis of the effectiveness of internet-based psychotherapeutic interventions. Journal of Technology in Human Services, 26(2/4), 109–160. https://doi.org/10.1080/15228830802094429.
Colbow, A. J. (2013). Looking to the future: Integrating telemental health therapy into psychologist training. Training and Education in Professional Psychology, 7(3), 155–165. https://doi.org/10.1037/a0033454.
Constantino, M. J., Castonguay, L. G., & Schut, A. J. (2002). The working alliance: A flagship for the scientist-practitioner model in psychotherapy. In G. S. Tyron (Ed.), Counseling based on process research: Applying what we know (pp. 81–131). Allyn & Bacon.
Constantino, M. J., Coyne, A. E., Boswell, J. F., Iles, B. R., & Vîslă, A. (2018). A meta-analysis of the association between patients’ early perception of treatment credibility and their posttreatment outcomes. Psychotherapy, 55(4), 486–495. https://doi.org/10.1037/pst0000168.
Cook, J. E., & Doyle, C. (2004). Working alliance in online therapy as compared to face-to-face therapy: Preliminary results. CyberPsychology and Behavior, 5(2), 95–105. https://doi.org/10.1089/109493102753770480.
D’Agostino, A., Demartini, B., Cavallotti, S., & Gambini, O. (2020). Mental health services in Italy during the COVID-19 outbreak. The Lancet Psychiatry, 7(5), 385–387. https://doi.org/10.1016/S2215-0366(20)30133-4.
Dopp, A. R., Mapes, A. R., Wolkowicz, N. R., McCord, C. E., & Feldner, M. T. (2021). Incorporating telehealth into health service psychology training: A mixed-method study of student perspectives. Digital Health, 7, 1–15. https://doi.org/10.1177/2055207620980222.
Fish, J. N., McInroy, L. B., Paceley, M. S., Williams, N. D., Henderson, S., Levine, D. S., & Edsall, R. N. (2020). I’m kinda stuck at home with unsupportive parents right now: LGBTQ youths’ experiences with COVID-19 and the importance of online support. Journal of Adolescent Health, 67(3), 450–452. https://doi.org/10.1016/j.jadohealth.2020.06.002.
Fluckiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55(4), 316–340. https://doi.org/10.1037/pst0000172.
Gerton, J. M., Aoyagi, K., León, G. A., Bludworth, J., Spille, S., & Holzapfel, J. (2022). Outcomes in clients transitioning from in-person counselling to telehealth counselling with trainees. Counselling and Psychotherapy Research, 1–10. https://doi.org/10.1002/capr.12541.
Goldschmidt, L., Langa, M., Masilela, B., Ndhlovu, L. S., Mncina, B., Maubane, B., & Bujela, K. (2021). Telespychology and the COVID-19 pandemic: The experiences of psychologists in South Africa. South African Journal of Psychology, 51(2), 314–324. https://doi.org/10.1177/0081246321993281.
Hadler, N. L., Blu, P., Winler, A., & Alexander, A. W. (2021). College student perspective of telemental health: A review of the recent literature. Current Psychiatry Reports, 23(6), 1–8. https://doi.org/10.1007/s11920-020-01215-7.
Hanson, W. E., Curry, K. T., & Bandalos, D. H. (2002). Reliability generalization of Working Alliance Inventory scale scores. Educational and Psychological Measurement, 62(4), 659–673. https://doi.org/10.1177/0013164402062004008.
Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36, 223–233. https://doi.org/10.1037/0022-0167.36.2.223.
Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counselling Psychology, 38, 139–149. https://doi.org/10.1037/0022-0167.38.2.139.
Horvath, A. O., Re, D., Flückiger, A. C., C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48(1), 9–16. https://doi.org/10.1037/a0022186.
Kiluk, B. D., Seragini, K., Frankforter, T., Nich, C., & Carroll, K. M. (2014). Only connect: The working alliance in computer-based cognitive behavioral therapy. Behaviour Research and Therapy, 63, 139–146. https://doi.org/10.1016/j.brat.2014.10.003.
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x.
Kroenke, K., Spitzer, R. L., Williams, J. B., & Löwe, B. (2010). The Patient Health Questionnaire somatic, anxiety, and depressive symptom scales: A systematic review. General Hospital Psychiatry, 31, 345–359. https://doi.org/10.1016/j.genhosppsych.2010.03.006.
Laird, N. M., & Ware, J. H. (1982). Random-effects models for longitudinal data. Biometrics, 4, 963–974. https://doi.org/10.2307/2529876.
Lingely-Pottie, P., & McGrath, P. (2006). A therapeutic alliance can exist without face-to-face contact. Journal of Telemedicine and Telecare, 12, 369–399. https://doi.org/10.1258%2F135763306779378690.
Liu, S., Yang, L., Zhang, C., Xiang, Y. T., Liu, Z., Hu, S., & Zhang, B. (2020). Online mental health services in China during the COVID-19 outbreak. Lancet Psychiatry, 7(4), e17–e18. https://doi.org/10.1016/S2215-0366(20)30077-8.
Lopez, A., & Schwenk, S. (2021). Technology-based mental health treatment and the impact on the therapeutic alliance update and commentary: How COVID-19 changed how we think about telemental health. Current Research in Psychiatry, 1(3), 34–36. https://doi.org/10.46439/Psychiatry.1.012.
Lopez, A., Schwenk, A., Schneck, C. D., Griffin, R. J., & Mishkind, M. C. (2019). Technology-based mental health treatment and the impact on the therapeutic alliance. Current Psychiatry Reports, 21(76). https://doi.org/10.1007/s11920-019-1055-7.
Löwe, B., Decker, O., Müller, S., Brähler, E., Schellber, D., Herzog, W., & Herzberg, P. Y. (2008). Validation and standardization of the General anxiety disorder screener (GAD-7) in the General Population). Medical Care, 46(3), 266–274. https://doi.org/10.1097/MLR.0b013e318160d093.
Magezi, D. (2015). Linear mixed-effects models for within-participant psychology experiments: An introductory tutorial and free, graphical user interface (LMMgui). Frontiers in Psychology, 6(2), 1–7. https://doi.org/10.3389/fpsyg.2015.00002.
Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68(3), 438–450. https://doi.org/10.1037/0022-006X.68.3.438.
Meteyard, L., & Davies, R. A. I. (2020). Best practice guidance for linear mixed-effects models in psychological science. Journal of Memory and Language, 112, 1–22. https://doi.org/10.1016/j.jml.2020.104092.
Nakagawa, S., & Schielzeth, H. (2012). A general and simple method for obtaining R2 from generalized linear mixed-effects models. Methods in Ecology and Evolution, 4, 133–142. https://doi.org/10.1111/j.2041-210x.2012.00261.x.
Pasyk, V. S., Glazer, M., West, A., Campbell, A., & Kassan, A. (2022). Growth during a global pandemic: A polyethnography among doctoral counselling psychology students. Training and Education in Professional Psychology, 16(1), 95–107. https://doi.org/10.1037/tep0000372.
Pierce, B. S., Perrin, P. B., Tyler, C. M., McKee, G. B., & Watson, J. D. (2021). The COVID-19 Telepsychology Revolution: A national study of pandemic-based changes in U.S. mental health care delivery. American Psychologist, 76(1), 14–25. https://doi.org/10.1037/amp0000722.
Preschl, B., Maerker, 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, 1–10. https://doi.org/10.1186/1471-244X-11-189.
Richardson, T., Wrightman, M., Yeebo, M., & Lisicka, A. (2017). Reliability and score ranges of the PHQ-9 and GAD-7 in a primary and secondary care mental health services. Journal of Psychosocial Rehabilitation and Mental Health, 4(2), 237–240. https://doi.org/10.1007/s40737-017-0090-0.
Rowen, J., Giedgowd, G., & Demos, A. (2022). Effectiveness of videoconferencing delivered by novice clinicians in a training clinic. Training and Education in Professional Psychology. Advance online publication. https://doi.org/10.1037/tep0000410.
Sagui-Henson, S., Chamberlain, W., Smith, C. E., Li, B. J., Sweet, E. J. C., C., & Altman, M. (2022). Understanding components of therapeutic alliance and well-being from use of a global digital mental health benefit during the COVID-19 pandemic: Longitudinal observational study. Journal of Technology in Behavioral Science, 1–12. https://doi.org/10.1007/s41347-022-00263-5.
Schneider, M. B., Greif, T. R., Galsky, A. P., Gomez, D., Anderson, C., Edwards, D. S., Cherry, A. S., & Mehari, K. (2021). Giving psychology trainees a voice during the COVID-19 pandemic: Trainee mental health, perceived safety, and support. Training and Education in Professional Psychology, 15(1), 76–85. https://doi.org/10.1037/tep0000343.
Situmorang, D. D. B. (2020). Online/cyber counseling services in the COVID-19 outbreak: Are they really new? Journal of Pastoral Care & Counseling, 74(3), 166–174. https://doi.org/10.1177/1542305020948170.
Spitzer, R. L., Kroenke, K., Williams, J. B., & Lowe, B. (2006). A brief measure for assessing generalized anxiety disorder (the GAD-7). Archives of Internal Medicine, 166, 1092–1097. https://doi.org/10.1001/archinte.166.10.1092.
Swenson, I., Gates, T. G., Dentato, M. P., & Kelly, B. L. (2022). Strengths-based behavioral telehealth with sexual and gender diverse clients at Center on Halsted. Social Work in Health Care, 60(1), 78–92. https://doi.org/10.1080/00981389.2021.1885561.
Tracey, T. J., & Kokotovic, A. M. (1989). Factor structure of the Working Alliance Inventory. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 1(3), 207–210. https://doi.org/10.1037/1040-3590.1.3.207.
Varker, T., Brand, R. M., Ward, J., Terhaag, S., & Phelps, A. (2019). Effects of synchronous telepsychology interventions for people with anxiety, depression, posttraumatic stress disorder, and adjustment disorder: A rapid evidence assessment. Psychological Services, 16(40), 621–635. https://doi.org/10.1037/ser0000239.
Winter, B. (2013). Linear models and linear mixed effects models in R with linguistic applications. https://doi.org/10.48550/arXiv.1308.5499.
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This article is based on Jessica M. Gerton’s master’s thesis under the direction of James Bludworth and Lisa Spanierman at Arizona State University. We thank Frank Dillon and Ben Prytherch for their thoughtful comments on the analysis.
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Gerton, J.M., Bludworth, J. & Spanierman, L.B. Working Alliance and Client Outcomes in a Counselor Training Center: Comparing Telehealth and In-Person Formats. J. technol. behav. sci. 9, 83–90 (2024). https://doi.org/10.1007/s41347-023-00375-6
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DOI: https://doi.org/10.1007/s41347-023-00375-6