Digital CBT for OCD: Perspectives on the therapeutic alliance from adolescents and therapists

Abstract

Adolescents with obsessive-compulsive disorder (OCD) face unique challenges in engaging with cognitive-behavioural therapy (CBT), particularly the distress associated with exposure and response prevention (ERP) tasks. As digital delivery of CBT becomes increasingly widespread, questions remain about how the therapeutic alliance - a key predictor of treatment outcomes - is developed and sustained in this format. This study explored how adolescents and therapists experience the process of building and maintaining the therapeutic alliance during digital CBT for OCD, with particular attention to barriers, facilitators, and adaptations. Semi-structured interviews were conducted with six therapists and four adolescents who had participated in digital CBT for OCD. Although recruitment targeted ‘adolescents’, the client participants predominantly represented the upper end of adolescence, with all aged 18 or over (i.e. aligning with many definitions of emerging adulthood). For continuity with the study framing and service context, the term ‘adolescent’ is retained to denote older adolescents/emerging adults and interpret the findings with this developmental positioning in mind. A reflexive thematic analysis was used to identify patterns in participants’ experiences, highlighting both shared and divergent perspectives across the two groups. The analysis identified seven themes, illustrating both the opportunities and obstacles when fostering the alliance in digital settings. Therapists described making deliberate adaptations to humanise the digital space and maintain emotional presence, while adolescents emphasised the importance of privacy and developmentally-attuned approaches to support engagement. Technical and home-based disruptions, and the emotional distance of digital therapy were reported as barriers to openness - particularly during ERP tasks that rely on trust and in-the-moment support. Collaboration and flexibility emerged as essential strategies for overcoming these challenges, with both groups emphasising the importance of tailoring therapy to adolescents’ individual needs and daily environments. The findings underscore the importance of therapist adaptability, collaborative planning, and intentional rapport-building in digital CBT for OCD. Collectively, the themes point to concrete strategies - such as normalising the digital format, co-designing ERP tasks, and protecting privacy - that therapists can integrate into sessions to foster adolescent engagement and relational depth. Embedding these competencies into therapist training and service protocols may enhance digital CBT delivery and thus warrants systematic evaluation in future research