Exploring digital metacognitive therapy for bipolar disorder: effectiveness, therapist characteristics, and the therapeutic alliance in remote care

Abstract

The global mental health crisis underscores the pressing need for innovative approaches to address gaps in care, particularly for individuals with Severe and Enduring Mental Illness (SEMI). This thesis explores the potential for digital mental health interventions (DMHIs) to enhance accessibility and effectiveness of psychological treatments in SEMI, with a focus on synchronous telepsychological interventions (STIs), including videoconferencing (VCF), as a promising modality. A central theme is the adaptation and application of Individualised Metacognitive Therapy (MCT+), tailored for bipolar disorder type I, delivered digitally. Further, the therapeutic alliance and therapist characteristics, such as mentalisation capacity and attachment style, are examined as mechanisms of interest that can affect outcomes in digitally delivered psychotherapy. The current research is situated within Chile's healthcare system, and the introduction takes into account its historical, socio-political, and structural context, and the challenges of delivering equitable mental health care in a mixed public-private system. Next, a systematic review and meta-analysis of STIs for SEMI provide a comprehensive overview of their effectiveness, highlighting benefits such as increased accessibility, reduced stigma, and enhanced engagement. The review identifies gaps in the current research literature, and informs, the empirical and qualitative studies in subsequent chapters. A mixed-methods approach, informed by pragmatism, integrates quantitative and qualitative analyses to explore the implementation of MCT+ via videoconferencing. Quantitative findings from the implementation of MCT+ highlight its potential benefits and limitations. Anxiety symptoms showed a statistically significant reduction (GAD-7 scores: 10.08 to 5.75, p = .032), reflecting the intervention’s impact on emotional regulation. Depression scores demonstrated a positive trend (PHQ-9: 11.00 to 8.14, p = .087), but without statistical significance; however, a clinically meaningful reduction of three points suggests potential benefits for individual patients. Metacognitive beliefs improved significantly (MCQ-30: 71.57 to 63.07, p = .049), indicating reductions in maladaptive beliefs, while subscale improvements varied. The impact on quality of life (QoL) was minimal, with no significant changes observed (WHOQOL-BREF: 15.17 to 15.50, p = .791). Reliable Change Index (RCI) analyses further highlighted variability in outcomes, with some participants experiencing significant deterioration in domains such as anxiety (n = 2; RCI = -2.176, -1.995) and psychological distress (n = 2; RCI = -2.29, -2.10). Only one participant demonstrated clinically significant improvement in QoL (RCI = +2.06). Therapist characteristics were explored as potential predictors of therapeutic outcomes. Mentalisation capacity (MASC, RFQ) demonstrated a complex relationship with the therapeutic alliance, with significant interactions between automatic and controlled mentalisation (b = -0.451, p = .008), suggesting that a balance between these capacities is crucial. Attachment style (ECR-12) showed weak, non-significant correlations with alliance quality (rho = -0.54 to 0.25, p > .05), while between-patient differences accounted for the majority of alliance variability (65.3%–77.7%), underscoring the importance of patient-specific factors. Qualitative findings provided further depth, capturing patient and therapist perspectives on the dynamics of the therapeutic process. Themes such as balancing structure and flexibility, the role of engagement, and the impact of perceived therapist availability aligned with the quantitative results, offering insights into the mechanisms that drive variability in outcomes. Both groups highlighted the value of personalised care and the challenges posed by the digital format, such as the absence of non-verbal cues and the need for adaptive mentalisation strategies. The findings emphasise the potential of STIs, particularly videoconferencing, in addressing treatment gaps for SEMI in resource-limited settings, with implications for global mental health care. The thesis concludes by discussing the broader impact of digital psychotherapy, its limitations, and future directions, advocating for sustainable and inclusive digital interventions to improve mental health outcomes. Overall the thesis provides a useful contributions to the evolving field of digital mental health, particularly relevant to Chile, and provides actionable insights for enhancing therapeutic practices in diverse and challenging contexts