Therapist- and client-rated therapeutic alliance in virtual cognitive behavioral therapy for psychosis: Correlates of alliance and associations with treatment outcomes

OBJECTIVE: Therapeutic alliance (TA) is positively associated with treatment outcomes in psychological therapies for psychosis. Limited research has examined TA in virtual cognitive behavioral therapy for psychosis (vCBTp). This study investigated correlates of TA in vCBTp and associations with clinical, functional, and personal recovery outcomes. METHOD: Participants (N = 30) with schizophrenia-spectrum disorders received up to 26 sessions of individual vCBTp in a randomized controlled trial. Client- and therapist-rated TA was assessed at weeks 4 (Early Treatment) and 26 (Post-Treatment). Assessments were conducted at baseline, post-treatment, and six-month follow-up. RESULTS: Therapeutic alliance did not significantly differ across raters nor sessions, except for an increase in the therapist-rated Bond subscale. At Early Treatment, no baseline variables were correlated with client-rated alliance, and only therapist years of training and years of experience were correlated with therapist-rated alliance, although in opposite directions. Neither client- nor therapist-rated TA at either Early or Post-Treatment significantly predicted clinical, functional, or personal recovery outcomes at post- or follow-up assessments. CONCLUSION: Therapeutic alliance can be developed and maintained in vCBTp. However, these findings highlight the complexity of this relationship between clients and clinicians and the difficulty in identifying correlates of TA and mechanisms by which it influences treatment outcomes. ClinicalTrials.gov identifier: NCT04752449.