Clinicians’ Attitudes Toward Therapeutic Alliance in ETherapy

Abstract

Although therapeutic alliance is a crucial factor in face-to-face therapies, no data exist on clinicians’ attitudes towards alliance in E-therapy. The study explored clinicians’ perceived importance of alliance in E-therapy, clinicians’ confidence in their skills to develop alliance in E-therapy, and whether attitudes towards alliance in E-therapy are associated with intended E-therapy practice. Clinicians (n=106) responded to an online survey. The majority of clinicians considered alliance to be extremely important in both face-to-face therapy and E-therapy. However, clinicians’ ratings of the importance of alliance in face-to-face therapies were significantly higher than their ratings of the importance of alliance in E-therapy. Clinicians reported less confidence in their skills to develop alliance in E-therapy than in face-to-face therapy. Intended E-therapy practice correlated with confidence in one’s ability to develop alliance in E-therapy and with previous E-therapy practice.

E-therapy has been defined as “a licensed mental health care professional providing mental health services via e-mail, video conferencing, virtual reality technology, chat technology, or any combination of these,” (Manhal-Baugus, 2001, p.552). As opposed to in person therapy, when the client and the therapist interact in real time, face-to-face, at the same location, when using E-therapy, the client and therapist can be in separate or remote locations, using the Internet to communicate with each other either in real time or asynchronously (Manhal-Baugus, 2001). Whereas in person therapy takes place in the therapist’s office, E-therapy takes place in the online environment. Thus, E-therapy is not defined as a form of therapy per se, but rather a form of therapy delivery (e.g., a form of therapy like Cognitive Behavioral Therapy can be delivered either in person or online). There is growing evidence that E-therapy is effective for a variety of psychosocial presenting problems (Barak, Hen, Boniel-Nissim, & Shapira, 2008; Rochlen, Zack, & Speyer, 2004). However, there remain concerns about the practice of E-therapy, with researchers in particular pointing to the potential difficulty of developing a therapeutic alliance in the online environment (Reynolds, Stiles, & Grohol, 2006), due to the lack of nonverbal cues and time delay (Rochlen, Zack, & Speyer, 2004).

The therapeutic alliance is defined as the nature of the working relationship between patient and therapist (Norcross, 2011). There is an extensive literature on face-to-face psychotherapy outcome indicating that the therapeutic alliance accounts for more of the variability in psychotherapy outcomes than specific therapy ingredients (Lambert & Barley, 2001; Norcross, 2002; Wampold, 2001). There is considerable evidence indicating that therapeutic alliance correlates positively with therapeutic change across a variety of treatment modalities and presenting problems (Bickmore, Gruber, & Picard, 2005; Castonguay, Constantino, & Holforth, 2006; Horvath, Del Re, Fluckiger, & Symonds, 2011; Lambert & Barley, 2001; Norcross, 2011). Research indicates a robust, consistent, correlation between therapeutic alliance and treatment outcomes. Based on several meta-analyses, the effect size for therapeutic alliance-outcome association ranges from .22 to .26 (Castonguay, Constantino, & Holtforth, 2006; Horvath & Bedi, 2002; Martin, Garske, & Davis, 2000). Although it might be argued that the size of this relationship is not large, it appears to be robust (Castonguay, Constantino, & Holforth, 2006).

Although there is extensive literature on the crucial role of the therapeutic alliance in face-to-face therapies, the alliance has only been rarely studied in E-therapy contexts (for a review, see Sucala, Schnur, Constantino, Miller, Brackman, & Montgomery, 2012), and no data exist on clinicians’ attitudes towards the therapeutic alliance in E-therapy.

Therefore, the goal of the present study was to explore: (a) clinicians’ perceived importance of the alliance in E-therapy (on its own and in comparison to face-to-face therapy), (b) how confident clinicians are in their ability to develop a strong alliance in E-therapy relative to face-to-face therapy, (c) clinicians’ perceptions of barriers to and facilitators of developing a strong alliance in E-therapy, and (d) associations among clinicians’ attitudes towards developing an alliance in E-therapy, past E-therapy practice and intended E-therapy practice.

Method

Participants

Participants were recruited from the listservs of the American Psychological Association (Divisions 29 and 38) and the Society for Psychotherapy Research. Eligibility criteria included: self-reported current psychotherapy practice, ability to read English, and Internet access. Participants (n = 106) completed the survey during August and September of 2011. All responses were completely anonymous. Sample characteristics are presented in Table 1.

Table 1.

Demographic and professional information

Variable	Value (n=106)
Age	47.37 years (SD = 14.80)
Gender	58.5% Women
Ethnicity	93.4% White
Profession
Psychologist	84.8%
Social worker	5.7%
Psychiatrist	5.7%
Counselor	3.8%
Work site
Private practice	28.4%
University-based psychology department	16.5%
Medical hospital	15.6%
Other (multiple work places)	39.5%
Theoretical orientation
Cognitive-behavioral	30.2%
Psychodynamic/Psychoanalytic	20.8%
Integrative/Eclectic	17.0%
Systems	10.4%
Other	21.6%
Years licensed	15.27 (SD = 13.50)
E-therapy practice	24.8% (mean number of cases = 8, SD = 11.29)

Survey

The survey asked about clinicians’: (1) demographic and professional information, including past E-therapy practice, (2) perceived importance of alliance in both face-to-face therapy and E-therapy, (3) confidence in the skills needed to develop a strong alliance in both face-to-face and E-therapy (4) perceived barriers to developing a strong alliance in E-therapy, as well as skills needed to overcome these barriers, and (5) intended E-therapy practice (see Table 2).

Table 2.

Survey items

Survey items	Response type
1. Demographic and professional information
Age	Years
Gender	M/F
Ethnicity	Multiple choice response
Profession	Multiple choice response
Work site	Multiple choice response
Theoretical orientation	Multiple choice response
Years licensed	Years
E-therapy cases	No of e-therapy cases
2.Perceived importance of alliance
When thinking about face-to-face psychotherapeutic   interventions, how important do you think working alliance is?	1 = “not important at all” to 5 = “extremely important”
When thinking about online psychotherapeutic   interventions, how important do you think working  alliance is?”	1 = “not important at all” to 5 = “extremely important”
3.Confidence in the skills needed to develop a strong alliance
When thinking about face-to-face psychotherapeutic   interventions, do you feel you currently have the   interpersonal skills to develop and/or maintain a   strong working alliance with your clients?	1 = “with none of my clients” to 5 = “with all of my clients”
When thinking about online psychotherapeutic   interventions, do you feel you currently have the   interpersonal skills to develop and/or maintain a   strong working alliance with your clients?	1 = “with none of my clients” to 5 = “with all of my clients”
4.Perceived barriers to developing a strong alliance in E-therapy, as well as skills needed to overcome these barriers
What skills or techniques would you say are needed   in order to overcome the barriers in   developing/maintaining a strong working alliance   with online clients versus face-to-face clients?	Open answer
What do you think are the barriers in   developing/maintaining a strong working alliance   with online clients versus face-to-face clients?	Open answer
5.Intended E-therapy practice
What is the likelihood that you will use online   psychotherapeutic interventions in the next 1-3   years?	1= “extremely unlikely” to 5=“extremely likely”

Procedure

A description of the study was posted to the listservs described above, along with a link to the web-based survey. The study description stated that the goal of the survey was to better understand factors such as clinicians’ attitudes towards the therapeutic alliance over the Internet, clinicians’ perceptions of the differences and similarities between alliance in E-therapy versus face-to-face therapy, and perceived training needs in this area. Respondents were also informed that completing the survey would take no longer than 10 minutes. The survey was created using Google Docs. No personal identification or health information was collected. Participant responses were stored in a password-protected online database, which was created for the present study, and then transferred to an institutional secure server.

Statistical analysis

Quantitative data were analysed with descriptive and inferential statistics (bivariate correlations, regressions and t-tests) using SPSS, version 19. Two of the authors (initials removed for masked review) used open coding (i.e., identification of concepts within the data) (Berg, 1989) for responses to the two open-ended questions. The identified codes were then subjected to a frequency count.

Results

Perceived importance of alliance

Over 71% of the clinicians considered alliance to be extremely important in face-to-face therapies. Clinicians’ ratings of the importance of alliance in face-to-face therapies were significantly higher than their ratings of the importance of alliance in E-therapy, χ² (12, n=106) = 96.77, p< .01 (see Table 3). Neither demographic nor professional variables were significantly correlated with perceived importance of alliance in either face-to-face therapy or E-therapy (all p’s > .05).

Table 3.

Descriptive statistics and comparisons for the perceived importance of therapeutic alliance and for the confidence in one’s skills to develop therapeutic alliance

Sample frequencies (n= 106)
Question	In face-to-face therapy		In E-therapy		Comparison
How important do you think working alliance is?	71.7%	Extremely important	58.5%	Extremely important	X2 (12, n=106) = 96.77, p< .01
	23.6%	Very important	23.6%	Very important
	3.8%	Important	15.1%	Important
	.9 %	Somewhat important	1.9 %	Somewhat important
	0%	Not at all important	.9%	Not at all important
Do you feel you currently have the interpersonal skills to develop and/or maintain a strong working alliance with your clients?	47.2%	With all my clients	13.2%	With all my clients	X2 (8, n=106) = 23.66, p< .05
	8.1%	With 75%	21.7%	With 75%
	4.7%	With 50%	32.1%	With 50%
	0%	With 25%	19.8%	With 25%
	0%	With none	13.2%	With none

Perceived confidence in having the skills needed to develop therapeutic alliance

Over 47% of the clinicians stated that they were confident that they could establish a strong working alliance with all of their patients in face-to-face therapies. Clinicians reported relatively less confidence in their ability to develop a strong alliance in E-therapy, χ² (8, n=106) = 23.66, p< .05 (see Table 3). Perceived confidence in the ability to develop a strong therapeutic alliance in face-to-face therapy was correlated with the respondents’ years of experience, r(104) = .22, p < .05. No other demographic or professional variables were significantly correlated with this variable (p > .05).

Perceived confidence in the ability to develop a strong therapeutic alliance in E-therapy was significantly correlated only with the clinicians’ confidence in their ability to develop a therapeutic alliance in face-to-face therapy, r(104) = .21, p < .05. Neither demographic nor professional variables were significantly correlated with perceived confidence in the ability to develop a strong therapeutic alliance in E-therapy (all p’s > .05).

Perceived barriers to and facilitators of developing alliance in E-therapy

When asked what perceived barriers would impede their ability to develop a strong therapeutic alliance with their E-therapy clients, clinicians reported barriers such as: having difficulty: reading patient cues and understanding patients, conveying warmth and empathy, monitoring patients’ involvement in therapy, and dealing with technical barriers (see Table 4 for frequencies and examples).

Table 4.

Perceived barriers to and facilitating skills for developing online therapeutic alliance in E-therapy

Item	Themes	Frequency count	Examples
Perceived barriers in developing a strong therapeutic alliance in E- therapy	Reading patient cues/ understand patient	61%	-“reading the clients' emotions;” -“more difficult to interpret/see non-verbal gestures;” -“more difficult to pick up emotional cues and body language with on line clients”
	Conveying warmth and empathy	23%	-“it could be more difficult to form an emotional bond with the client;” - “a sense of distance and separation between the therapist and the client”
	Monitoring patient’s involvement in therapy	7%	-“it could be challenging to hold the client's interest and focus;” -“less control over the environment that the patient may be in when undertaking therapy”
	Technical barriers	7%	-“equipment issues, connection challenges and delays in information transfer”
Facilitating skills to overcome these barriers	Communication skills	27%	-“strong language skills;” -“ability to describe experience in a precise manner;” -“training on the impact of tone in written communication”
	The ability to accurately understand the client	16%	-“being able to use clarification frequently to really tune into what the client is try to communicate;” -“the ability to take the written words of the patient and also elicit information to fill in what may merely be hinted at or expressed by the patient”
	The ability to convey warmth and empathy via online channels	12%	-“strategies for conveying empathy and warmth concisely yet thoroughly in words online;” -“ability to express empathy and a sense of commitment via email- internet channels”
	Technical skills	11%	-“technological expertise, flexibility;” -“knowing how to use the technology”

Note. Participants had the option to give multiple responses so percentages might not add up to 100%

When asked about the skills/techniques needed to overcome the above-mentioned barriers, clinicians reported: online communication skills, the ability to accurately understand the client, the ability to convey warmth and empathy via online channels, and increased computer/Internet skills (see Table 4 for frequencies and examples).

Relationship between attitudes towards alliance and previous E-therapy practice

Only 24.8% of clinicians reported having ever provided E-therapy. Within this 24.8% (n=24), the mean number of E-therapy cases was 8 (SD = 11.26). Previous E-therapy practice was not significantly related to any demographic or professional variables (all p’s > .05), nor to the perceived importance of alliance or confidence in having the skills to develop it (all p’s > .05).

Relationship between attitudes towards alliance and intended E-therapy practice

As for intended E-therapy practice, 17.9% of participants reported that it is extremely likely that they would use it in the future, 13.2% said that it was very likely, 7.5% said that it was likely, 28.3% said that it was somewhat likely, and 33% said that it was extremely unlikely. None of the demographic or professional variables were associated with intended E-therapy practice, with the exception of previous E-therapy practice, r(104) = .23, p<.05 and confidence in one’s ability to develop a strong alliance in E-therapy, r(104) = .23, p<.05. Regression analyses of these variables revealed that previous E-therapy practice [F(1, 104) = 6.19, R² = .05, p < .05)] and greater confidence in having the skills needed to develop a strong alliance in E-therapy [F(1, 104) = 6.25, R² = .05, p < .05] significantly predicted intended E-therapy practice. When these two variables (previous E-therapy practice, confidence in one own skill to develop alliance with E-therapy clients) were entered into a multiple regression equation, results revealed that together these variables significantly predicted intended E-therapy practice, F(2, 105) = 5.66, R² = .09, p < .05,

Discussion

Results indicated that the vast majority of the clinicians considered the therapeutic alliance to be extremely important in both face-to-face therapy and E-therapy. This result is heartening, although not surprising given the extensive literature supporting the important role of therapeutic alliance in predicting psychotherapy outcomes (Bickmore, Gruber, & Picard, 2005; Castonguay, Constantino, & Holforth, 2006; Horvath, Del Re, Fluckiger, & Symonds, 2011; Lambert & Barley, 2001; Norcross, 2011). However, it is interesting to note that clinicians’ ratings of the importance of alliance in face-to-face therapy were higher than their ratings of the importance of alliance in E-therapy, a result which might indicate that clinicians are less aware of the potentially important role of the therapeutic alliance in E-therapy. This result seems to reflect the current state of E-therapy literature, in which the therapeutic relationship has been very rarely studied (Sucala, Schnur, Constantino et al., 2012). It is possible that clinicians’ perceptions of the importance of the alliance in E-therapy will change if the E-therapy literature catches up to and begins to mirror the general psychotherapy literature in terms of recognizing the role that therapeutic alliance plays in the therapeutic process.

Results also indicated that although most clinicians felt confident in their ability to develop a strong therapeutic alliance with most of their clients in face-to-face therapy, few felt confident in their ability to develop a strong therapeutic alliance in E-therapy. Confidence in the ability to develop a strong therapeutic alliance in face-to-face therapy was correlated with the clinicians’ years of experience as therapists, whereas confidence in the ability to develop a therapeutic alliance in E-therapy was not. This finding indicates that even clinicians who have more experience in E-therapy do not necessarily feel confident in their ability to develop a strong therapeutic alliance in this specific context. This result is not surprising considering that alliance-focused strategies have become a growing element of training in face-to-face psychotherapy (Crits-Christoph et al., 2006; Crits-Christoph, Connolly Gibbons, & Hearon, 2006; Muran & Barber, 2011; Smith-Hansen, Constantino, Piselli, & Remen, 2011), whereas training for building a therapeutic alliance with E-therapy clients is exceedingly rare (Maheu, 2011; Schiller, 2009).

As for barriers to developing a strong therapeutic alliance with their E-therapy clients, clinicians reported their perception that the therapeutic alliance could be negatively affected not only by difficulty in reading patients’ emotions and understanding the patients’ messages in a text-based environment, but also by the increased difficulty in conveying warmth and empathy in a text-based online environment. It is important to note here that we only asked about text-only environment (e.g., chat, email). These perceived barriers may vary by type of E-therapy technology and this should be explored in future research. Clinicians also noted that the therapeutic alliance might be affected by difficulty in monitoring patients’ involvement in therapy and by possible technical barriers, such as connection challenges and disruptions. These clinician responses can be used to guide the content of future E-therapy training programs. For example, to overcome concerns about communication and perceived empathy, clinicians can be trained to develop concrete online communication skills, such as how to use emoticons (i.e., pictorial representations of facial expressions), how to simulate nonverbal gestures in online environments, and how to communicate empathy in text by typing their emotional reactions (e.g., “I am feeling as though I...”) or their nonverbal reactions to the client (e.g., “I’m smiling right now”) (Mallen, Vogel, & Rochlen, 2005).

Results further suggest that E-therapy alliance training might not only enhance clinicians’ confidence levels, but may also increase their intention to use E-therapy, as the intention to use E-therapy in the future was correlated with clinicians’ confidence in their possession of the skills needed to develop a strong alliance with their E-therapy clients.

Like any study, ours had limitations. First, the study had a small, self-selected convenience sample of clinicians, so the generalizing the results should be done with caution. Second, the survey was administered and completed online. Thus, all respondents had at least a minimal level of Internet skill and computer ability. It is possible that a paper-and-pencil survey approach might have reached a broader sample of respondents, including those who are less comfortable with computer/Internet use. Future research should consider also incorporating in-person and paper-and-pencil approaches in order to determine whether results are similar across these methods. Third, the survey was designed to keep participant burden to a minimum by specifically focusing on professional attitudes and using a limited number of items. Of course, additional information could potentially improve our understanding of clinicians’ attitudes towards E-therapy. Future research could also take into account variables such as computer/Internet self-efficacy or computer/Internet literacy, and should explore predictors of attitudes more broadly. Forth, the definition of E-therapy in the present survey precluded any interventions that were entirely automated (i.e., with no clinician involvement). Future research could assess practitioner attitudes towards such entirely automated interventions. Fifth, due to the fact that there was no validated pre-existent measure for clinicians’ attitudes on working alliance in E-therapy, we developed and used a new, face-valid measure that has not yet been validated.

In sum, this study highlights the gap between clinicians’ confidence in their possession of the necessary skills to develop a strong alliance in E-therapy versus face-to-face therapy. Training in developing and maintaining strong alliance in E-therapy may be needed to both enhance clinicians’ confidence levels, and, in turn, perhaps encourage greater and more skilled E-therapy use.