title: Therapeutic Alliance With a Fully Automated Mobile Phone and Web-Based Intervention: Secondary Analysis of a Randomized Controlled Trial.
abstract: BACKGROUND
  Studies of Internet-delivered psychotherapies suggest that clients report development of a therapeutic alliance in the Internet environment. Because a majority of the interventions studied to date have been therapist-assisted to some degree, it remains unclear whether a therapeutic alliance can develop within the context of an Internet-delivered self-guided intervention with no therapist support, and whether this has consequences for program outcomes.
  
  
  OBJECTIVE
  This study reports findings of a secondary analysis of data from 90 participants with mild-to-moderate depression, anxiety, and/or stress who used a fully automated mobile phone and Web-based cognitive behavior therapy (CBT) intervention called "myCompass" in a recent randomized controlled trial (RCT).
  
  
  METHODS
  Symptoms, functioning, and positive well-being were assessed at baseline and post-intervention using the Depression, Anxiety and Stress Scale (DASS), the Work and Social Adjustment Scale (WSAS), and the Mental Health Continuum-Short Form (MHC-SF). Therapeutic alliance was measured at post-intervention using the Agnew Relationship Measure (ARM), and this was supplemented with qualitative data obtained from 16 participant interviews. Extent of participant engagement with the program was also assessed.
  
  
  RESULTS
  Mean ratings on the ARM subscales were above the neutral midpoints, and the interviewees provided rich detail of a meaningful and collaborative therapeutic relationship with the myCompass program. Whereas scores on the ARM subscales did not correlate with treatment outcomes, participants' ratings of the quality of their emotional connection with the program correlated significantly and positively with program logins, frequency of self-monitoring, and number of treatment modules completed (r values between .32-.38, P≤.002). The alliance (ARM) subscales measuring perceived empowerment (r=.26, P=.02) and perceived freedom to self-disclose (r=.25, P=.04) also correlated significantly in a positive direction with self-monitoring frequency.
  
  
  CONCLUSIONS
  Quantitative and qualitative findings from this analysis showed that a positive therapeutic alliance can develop in the Internet environment in the absence of therapist support, and that components of the alliance may have implications for program usage. Further investigation of alliance features in the Internet environment and the consequences of these for treatment outcomes and user engagement is warranted.
  
  
  BACKGROUND
  Australian New Zealand Clinical Trials Registry Number (ACTRN): 12610000625077; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=335772&isReview=true (Archived by WebCite at http://www.webcitation.org/6efAc5xj4).
authors.affiliation: School of Psychiatry, UNSW Australia, Sydney, Australia. Janine.clarke@unsw.edu.au.
authors.forename: Janine
authors.identifier: http://orcid.org/0000-0002-2652-5273
authors.initials: J
authors.lastname: Clarke
authors.forename: Judith
authors.identifier: http://orcid.org/0000-0002-3872-9871
authors.initials: J
authors.lastname: Proudfoot
authors.forename: Alexis
authors.identifier: http://orcid.org/0000-0002-7944-2172
authors.initials: A
authors.lastname: Whitton
authors.forename: Mary-Rose
authors.identifier: http://orcid.org/0000-0001-5829-5831
authors.initials: MR
authors.lastname: Birch
authors.forename: Megan
authors.identifier: http://orcid.org/0000-0003-0150-094X
authors.initials: M
authors.lastname: Boyd
authors.forename: Gordon
authors.identifier: http://orcid.org/0000-0003-3424-5519
authors.initials: G
authors.lastname: Parker
authors.forename: Vijaya
authors.identifier: http://orcid.org/0000-0001-6483-7780
authors.initials: V
authors.lastname: Manicavasagar
authors.forename: Dusan
authors.identifier: http://orcid.org/0000-0002-2059-3865
authors.initials: D
authors.lastname: Hadzi-Pavlovic
authors.forename: Andrea
authors.identifier: http://orcid.org/0000-0002-2939-7027
authors.initials: A
authors.lastname: Fogarty
keywords: Internet interventions; computerized cognitive behavior therapy; depression; e-therapy; therapeutic alliance