Franzen, Guido

Herbst, Nirmal

Hertenstein, Elisabeth

Knaevelsrud, Christine

Külz, Anne Katrin

Nissen, Christoph

Thiel, Nicola

Voderholzer, Ulrich

English

Nirmal Herbst

Guido Franzen

Ulrich Voderholzer

Nicola Thiel

Christine Knaevelsrud

Elisabeth Hertenstein

Christoph Nissen

Anne Katrin Külz

Crossref

Psychotherapy and Psychosomatics

Working Alliance in Internet-Based Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder

Institutional Repository of the Freie Universität Berlin

E-Mail karger@karger.com Letter to the Editor pointed towards this factor and the communication modality to be of influence on the patient-therapist relation. The present data analysis was part of a randomized controlled trial on the efficacy of a text-based iCBT with therapist guidance and ERP for treating patients with OCD. In this trial, we observed a high level of acceptance and strong and stable effect sizes of the intervention  [10] . The present analysis focused on the patient-therapist relation. Thirty participants with a primary OCD diag-nosis according to ICD-10 criteria completed the iCBT interven-tion (14 sessions) and the posttreatment outcome measures. The WAI-SR was used to assess the patient-therapist relation. Obses-sive-compulsive symptoms were assessed using the Yale-Brown Obsessive Compulsive Scale Self-Report (Y-BOCS SR) and the  Obsessive-Compulsive Inventory – Revised (OCI-R). For data analysis, mean composite scores, change scores, Spearman’s rank correlations and a multiple regression model were calculated. With an arithmetical mean of 4.08 (SD = 0.78), the posttreat-ment WAI-SR composite score represents 77% of the maximum scale value, which indicates a high working alliance. The mean scores for the subscales are as follows: task = 3.82 (SD = 0.86),goal = 4.11 (SD = 0.94), bond = 4.32 (SD = 0.78). The patient-therapist relation was significantly correlated with the Y-BOCS SR change score (r = 0.33, p = 0.04; Y-BOCS SR: before = 19.87,SD = 5.92; after = 14.63, SD = 6.28). A marginal significant corre-lation was found between the OCI-R change score and the WAI-SR (r = 0.29, p = 0.06; OCI-R: before = 24.77, SD = 9.97; after = 16.57, SD = 9.69). Relevant parameters for all included variables of the linear multiple regression model (n = 29) are listed in  table 1 . Together, the results provide evidence that a solely text-based iCBT for OCD does not hinder a high working alliance. On the contrary, a strong and stable patient-therapist relation could be established, which was comparable to prior results for traditional face-to-face treatment (see above). Without any verbal or visual interaction between patients and therapists, the three dimensions of the working alliance, goal, task and bond, were implemented. With regard to the management of potential adverse events, in-cluding suicidal ideation, the therapeutic bond seems especially important when having no direct personal contact as in iCBT, since a high level of trust may promote patients confiding in their therapist about delicate issues, thereby allowing for a prompt re-sponse. The observed correlation with the reduction of OCD symp-toms suggests that fostering the working alliance is important in iCBT just as it is in face-to-face treatment. However, as always with correlations, the causality is not clear. Since the working alliance  The patient-therapist relation has consistently been found to be of importance for the outcome of psychotherapy with an overall effect size of r = 0.275  [1] . The same relevance of the patient-ther-apist relation holds true for the treatment of obsessive-compulsive disorder (OCD)  [2] . Cognitive-behavioral psychotherapy (CBT) with exposure and response prevention (ERP) constitutes an effec-tive treatment for OCD and is recommended as the first-line treat-ment  [3] . Yet, only a minority of patients receives it  [4] . The devel-oping field of Internet-based CBT (iCBT)  [5] is a promising op-portunity for further dissemination. Due to the anxiety-provoking nature of ERP, the treatment is associated with high levels of dis-comfort and is often perceived as demanding. Consequently, it seems of particular importance to establish a stable patient-thera-pist relation. While the findings on the patient-therapist relation mentioned above apply to face-to-face psychotherapy, less is known about its relevance and potential differences regarding the characteristics of iCBT (e.g. in many cases text-based and asynchronous communi-cation, lack of nonverbal cues). A systematic review found no dif-ferences in the patient-therapist relation between iCBT and face-to-face therapy  [6] . The short form of the Working Alliance Inven-tory (WAI-SR)  [7] scored in two samples at 72 and 84% of the maximum scale value, respectively  [7] . So far, only one study of iCBT for OCD reported on the patient-therapist relation  [8] . Even though the authors found a high working alliance, the result may not be generalizable to other – especially text-based – iCBT ap-proaches for OCD due to some major limitations (only 6 partici-pants, phone- or videoconference-based treatment). Furthermore, it is important to identify factors predicting the development of the patient-therapist relation. Results on the face-to-face treatment of OCD showed a negative correlation between pretreatment symptom severity and the development of the pa-tient-therapist relation  [9] . For iCBT, the review by Sucala et al.  [6]  Received: March 25, 2015  Accepted after revision: September 22, 2015  Published online: January 26, 2016  © 2016 S. Karger AG, Basel0033–3190/16/0852–0117$39.50/0  www.karger.com/pps  Psychother Psychosom 2016;85:117–118  DOI: 10.1159/000441282  Working Alliance in Internet-Based Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder  Nirmal Herbst a , Guido Franzen a , Ulrich Voderholzer a, b , Nicola Thiel a , Christine Knaevelsrud c , Elisabeth Hertenstein a , Christoph Nissen a , Anne Katrin Külz a ,  a   Department of Psychiatry and Psychotherapy, University Medical Center Freiburg,  Freiburg ,  b   Schoen Clinic Roseneck,  Prien , and  c   Department of Clinical Psychology andPsychotherapy, Free University Berlin,  Berlin , Germany  Dr. Nirmal Herbst, Dipl.-Psych.  Department of Psychiatry and Psychotherapy  University Medical Center Freiburg  Hauptstrasse 5, DE–79104 Freiburg (Germany)  E-Mail Nirmal.Herbst   @   arcor.de  Data presented in this article were taken from the unpublished mas-ter’s thesis of Guido Franzen at the University of Freiburg. Downloaded by: Freie Universität Berlin                               130.133.152.53 - 11/23/2017 2:21:31 PM Herbst/Franzen/Voderholzer/Thiel/Knaevelsrud/Hertenstein/Nissen/Külz Psychother Psychosom 2016;85:117–118DOI: 10.1159/000441282118was only assessed after treatment, it cannot be ruled out that pa-tients with a greater symptom reduction gave their working alli-ance a better rating in hindsight. In contrast to our expectations, the severity of initial OCD symptoms had no significant predictive value for the development of the working alliance. This indicates that an iCBT approach works not only for patients with mild OCD symptoms, but also for those with a higher symptom severity, as they too can develop a high working alliance and subsequently have the opportunity to profit from the treatment. Regarding subtypes of OCD, further studies with larger samples are needed to draw reliable conclu-sions. However, the significant and marginally significant results ( table 1 ) may indicate that younger patients with a specific neutral-izing compulsion – like washing or checking – are more likely to develop a stable and good working alliance than patients suffering from an ordering subtype of OCD. Some limitations restrict the generalizability of the present findings. The sample size was relatively small and the WAI-SR was only assessed once after treatment and only for patients, not for therapists. Based on our findings, future investigations with a larg-er sample could realize detailed subgroup analyses to determine which patient characteristics are linked to developing a higher working alliance. Overall, the development of a strong and stable working alliance in text-based iCBT for OCD is an important find-ing to open the path for further implementation of this method allowing for a broader dissemination of CBT as the first-line treat-ment for OCD. However, it should be noted that this access to treatment cannot be seen as a substitute for face-to-face treatment in general but offers an alternative with its own strengths and weaknesses. Disclosure Statement  Funding for this study was provided by the German Research Foundation (DFG), grant KU 2754/1-1. The DFG had no role in the study design, collection, analysis or interpretation of the data, preparation, review or approval of the manuscript, or the decision to submit the paper for publication. The authors are not aware of any affiliations, memberships, funding, or financial holdings that might be perceived as affecting the objectivity of this work.  Statement of Ethics  The study was approved by the local ethics committee of the University Medical Center in Freiburg/Germany and is registered in the German Clinical Trials Register (Main ID: DRKS00004612).  Table 1.  Summary of the multiple regression analysis to predict the posttreatment patient-therapist relation of the WAI-SR using pre-treatment symptom measures (n = 29)Model B SE B β t pConstant 2.803 1.437 1.950 0.069Age 0.049 0.023 0.606 2.081 0.054*Gender 0.633 0.470 0.399 1.348 0.196Living situation 0.046 0.242 0.049 0.191 0.851Duration of OCD –0.036 0.023 –0.463 –1.549 0.141OCI-R subscaleWashing 0.028 0.061 0.147 0.459 0.652Obsessing –0.072 0.089 –0.278 –0.812 0.429Hoarding –0.035 0.062 –0.144 –0.556 0.586Ordering –0.115 0.053 –0.539 –2.179 0.045**Checking 0.033 0.064 0.154 0.519 0.611Neutralizing 0.171 0.088 0.688 1.933 0.071*Y-BOCS SR subscaleObsessions –0.090 0.082 –0.439 –1.103 0.286Compulsions –0.018 0.071 –0.078 –0.253 0.804 R2 = 0.710, adjusted R2 = 0.133, p = 0.279, list-wise deletion of missing values. ** α < 0.05: significant contribution to the model; * α < 0.10: marginal significant contribution to the model. 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Psychother Psychosom 2014; 83: 165–175.  Downloaded by: Freie Universität Berlin                               130.133.152.53 - 11/23/2017 2:21:31 PM

Working Alliance in Internet-Based Cognitive-Behavioral Therapy for Obsessive-
Compulsive Disorder

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Working Alliance in Internet-Based Cognitive-Behavioral Therapy for Obsessive- Compulsive Disorder

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