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Since the COVID-19 pandemic, the number of online mental health treatments have grown exponentially. Additionally, it seems inevitable that this technical resource is here to stay at health centers. However, there is still very little scholarly literature published on this topic, and therefore, the impact of the changes that have had to be dealt with in this regard has not been studied.
This study aims to evaluate the differences in the establishment of the therapeutic alliance (TA) based on the intervention modality (online or face-to-face), the type of attachment, and diagnosis.
A total of 291 subjects participated in the study, 149 (51.2%) of whom were men and 142 were (48.8%) women between the ages of 18 and 30 years. The instruments used were sociodemographic data, SOFTA-o (System for Observing Family Therapeutic Alliances—observational), and Relationship Questionnaire.
The results show that the treatments conducted face-to-face obtain significantly better scores in the creation of the TA than those conducted online (
We believe that professionals are not yet prepared to conduct remote treatment with a degree of efficacy similar to that of face-to-face. It is essential for professionals to receive training in this new technical resource and to understand and incorporate the variants it entails into their daily practice.
It seems inevitable that online psychological treatments are here to stay in mental health centers and services. The pandemic caused by COVID-19 has accelerated their advent and normalization among mental health professionals, forcing most of their psychotherapeutic activity to shift to the online methodology. Therefore, in a brief period of time, therapists and patients have had to adapt to conditions that forced them to change certain variables, especially the setting, without prior planning or awareness of what other changes they would have to grapple with besides technological ones [
Some authors [
Different authors [
In some countries such as Brazil, online psychological treatment may only be carried out if the purpose is to research its efficacy [
Rollman et al [
The TA is one of the most investigated variables related to success in psychological interventions, regardless of the theoretical orientation.
Many authors affirm that the TA is the main predictor variable of results in mental health treatments [
Bordin [
In this sense, there is still no certainty as to whether the establishment of the TA in online interventions is as powerful as in face-to-face interventions. However, a study by Anderson et al [
Attachment theory provides a model for understanding development within the context of the child’s primary and formative relationships, on the one hand, and an adult’s orientation toward lifelong intimate connections and social relationships, on the other. Researchers in psychotherapy have linked measures of patient attachment to the therapeutic alliance, therapeutic process, and therapeutic outcomes. The attachment organization and the therapist’s ability to mentalize play an important role in establishing a good therapeutic alliance and, therefore, in therapeutic success [
Smith et al [
Daniel [
This is the context within which we set out to conduct this study, whose main objective is to evaluate the differences in the establishment of the TA in online compared to face-to-face treatments.
Likewise, we shall also evaluate the subjects’ type of attachment and what effects this has on the establishment of the TA.
A total of 291 subjects participated in this study anonymously and voluntarily, 149 (51.2%) of whom were men and 142 (48.8%) women. The subjects were between the ages of 18 and 30 years, with a mean age of 23.1 (SD 2.82;
The participants came to the psychological guidance and consulting service voluntarily and free of charge and were invited to participate in the study. The main objective of this service is to psychologically assess or explore the users from 2 universities in Barcelona, and if needed, to refer them to the corresponding services in the public health care network. Participants who were involved in fewer than 3 sessions were excluded.
The participants responded to the following questionnaires: (1) sociodemographic data—sociodemographic data such as sex, age, whether the treatment was online or face-to-face, and the diagnostic was collected ad hoc; (2) therapeutic alliance—SOFTA-o (System for Observing Family Therapeutic Alliances—observational) for patients [
All the subjects filled out the SOFTA-o and the Relationship Questionnaire before the exploration began and filled out only the SOFTA-o after it. It is understood that the TA with the therapist will change if the exploration was a positive experience, but the type of attachment will not, as this construct is stable over time.
The explorations lasted between 3 and 5 sessions. The subjects themselves chose whether they wanted to be treated face-to-face or online. The online interventions were carried out through videoconference.
The subjects filled out the questionnaires individually and independently, and they were only assisted by the researcher if they requested help.
The study was approved by Research Ethics Committee of the Vidal i Barraquer Mental Health University Institute.
The statistical analyses were conducted using SPSS statistical package (version 27.0, SPSS Inc). First, the descriptive results of the sociodemographic data, the TA, attachment, and the diagnosis were presented. Subsequently, the relations between the TA and the intervention modality, attachment, sex, age, and diagnostic were presented. Next, the mixed model analysis was conducted. To do so, an unstructured variance-covariance matrix was calculated via the restricted estimation of maximum likelihood. The TA before and after treatment, treatment modality, attachment scale, and their interactions were considered fixed effects. Finally, gender and age were also included as fixed factors. The random effect was the subjects’ intersection parameter. The degrees of freedom were calculated with the Satterthwaite approximation. The end model was chosen by recalculating the models with and without interaction via maximum likelihood in order to compare the significance of the change on the Akaike information criterion (AIC). The residuals of the prediction and of the random factor were inspected via a quartile-quartile plot to assess the suitability of the model.
As shown in
The most prevalent diagnosis was anxiety (n=91, 31.3%), followed by depression (n=45, 15.5%) and grief (n=29, 10%). We can also see that 63.6% (n=185) of the participants had a secure attachment, while 36.4% (n=106) had an insecure attachment. Finally, regarding the TA, we see that prior to the treatment, the mean SOFTA-o score of the subjects was 8.62 while after treatment, it was 36.78.
Comparison between age, sex, modality, diagnosis, and attachment in relation to the therapeutic alliance before and after treatment.
We conducted
Via the Pearson correlation coefficient,
If we examine the relationship between TA and age, we see that prior to the treatment, there is a correlation of
As we can also see in
Finally, regarding the diagnosis, we conducted an ANOVA to determine whether there were differences in the establishment of a better TA by diagnosis, and the results both before and after the treatment showed that there are no significant differences (
Descriptive results.
Characteristics | Values | |
Age (years), mean (SD; range) | 23.1 (2.82; 18-29) | |
Pre-TAa scores, mean (SD; range) | 8.6 (3.03; 3-18) | |
Post-TA scores, mean (SD; range) | 36.8 (13.88; 11-56) | |
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Male | 149 (51.2) |
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Female | 142 (48.8) |
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Web-based | 127 (43.6) |
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Face-to-face | 164 (65.4) |
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Secure | 185 (63.6) |
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Insecure | 106 (36.4) |
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Anxiety | 91 (31.3) |
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Depression | 45 (15.5) |
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Grief | 29 (10) |
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Mistreatment | 25 (8.6) |
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Family problems | 16 (5.5) |
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Couple problems | 16 (5.5) |
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Concentration problems | 15 (5.2) |
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Social relation problems | 28 (9.6) |
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Adaptation problems | 23 (7.9) |
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Others | 3 (1) |
aTA: therapeutic alliance.
Therapeutic alliance and age correlation before and after intervention.
Correlation | Value | ||
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Age, |
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TAa before treatment | 0.092 | <.001 | –0.102 (.08) |
TA after treatment | 0.092 | <.001 | 0.022 (.70) |
aTA: therapeutic alliance.
Therapeutic alliance comparison between the groups before and after intervention.
Tests | Values | |||
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Modality | 0.15 | 268.130 | .89 |
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Attachment | –0.853 | 203.183 | .40 |
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Gender | 1.403 | 284.221 | .16 |
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Modality | –42.045 | 222.357 | .001 |
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Attachment | 6.068 | 217.342 | .001 |
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Gender | 0.22 | 287.029 | .33 |
aTA: therapeutic alliance.
Therapeutic alliance comparison by diagnosis.
ANOVA | Diagnosis | ||
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Mean square |
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TAa before treatment | 10.084 | 1.097 | .37 |
TA after treatment | 792.356 | 4.566 | .44 |
aTA: therapeutic alliance.
In the model without interactions, the pre-post change in the TA was significant (
The model with interactions (AIC=3305.5, with 12 parameters) was significantly better (χ24=742.78,
The results of this study show that the interventions carried out in person, with a sample of subjects aged between 18 and 30 years, obtain significantly better scores in the creation of the TA compared with those carried out with the web-based methodology. The same occurs with attachment, where users with secure attachment establish a better TA compared with those with insecure attachment. In relation to the variables’ diagnosis, age and sex, there were no significant differences.
First, we should highlight that this is a sample of university students, so we can assume a high sociocultural level with a social network (at least in terms of their belonging to the educational community: teachers, classmates, etc) and a certain predisposition to establish relational bonds (at least with referents in education). Likewise, they belong to an age group with knowledge and skills of the new technologies and therefore have a low level of interference and inconvenience associated with the use of this variable.
In terms of the modality chosen, the members of the sample distributed themselves in a balanced fashion (43.6% web-based and 56.4% face-to-face), with a slight preference for face-to-face treatment. We may think that this may be a pattern that is tending to gain ground in this age group, in a socioeconomic milieu that enables them to have sufficient technological resources and in a metropolitan setting that minimizes the difficulties of access to face-to-face encounters (remote residences, precarious environments, etc). It is likely that based on the experience of the pandemic, these patients’ initiative, at least in initial contacts, includes both methodologies. The fact that there was a slight predominance of those who requested face-to-face treatment seems to reflect the caregiving logic, in which the vast majority of conflicts associated with mental health directly imply other people with whom one has interactions in face-to-face settings (family, friends, partner, etc). In fact, Cabré and Mercadal [
Knaevelsrud and Mearcker [
In terms of the diagnosis, it is difficult to establish patterns with such a general and unspecific set of symptoms. Nonetheless, it is likely that in symptoms in which clinically active depressive features predominate, the first choice will tend to be the contact that is the “easiest” and entails the least effort, which is apparently the online connection (even though these same clinical components may respond better to closer human contact). In grief (even though it also contains these components of sadness and anhedonia), we may believe that the need to have close contact with the other and receive affection from them, without filters, may push the demand for face-to-face over web-based treatment. Finally, in symptoms in which anxious contact predominates, especially regarding human or relational contact (eg, social phobias, separation anxieties, and persecutory anxieties), the first choice may be heavily conditioned by this experience, defensive strategies will probably predominate, and thus web-based methodologies may be preferred. In fact, 73.2% (n=23) of the subjects in our study with a diagnosis of depression chose the web-based modality, 67.8% (n=20) of those who were grieving chose the face-to-face modality, and 59.6% (n=54) of the subjects who had anxiety preferred the web-based option.
The results of our study show that participants with secure attachment developed better TA compared with those with insecure attachment. These results are in line with other research projects in which it is concluded that a secure attachment predicts a better TA [
When we compared at the moment before the intervention if there were differences between TA and modality (web-based or face-to-face), the results showed that there were no differences between these two groups. However, when comparing the modality and the TA at the time after the intervention, the results showed that the face-to-face modality presents significantly better results when establishing a good TA, compared to web-based interventions. These results dispute the conclusions reached by investigations such as that of Anderson et al [
Finally, we see how the interaction at the time of evaluation and the therapeutic modality were significant; indeed, we found that the score on the TA was 3 times higher in the face-to-face modality (39.6), compared with that in the web-based modality (13.5). Therefore, even though the outcomes may be quite positive in the web-based modality (since it is assumed that TA has improved throughout the intervention), these results are contrary to those reported by Sucala et al [
Furthermore, we believe that is it obvious, as Tullio et al [
For all these reasons, we believe that, as Mercadal and Cabré [
Akaike information criterion
System for Observing Family Therapeutic Alliances—observational
therapeutic alliance
The authors wish to acknowledge the contributions and support of Manel Salamero throughout his entire professional career and, specifically, in this article.
None declared.