ABSTRACT
Background: Digital mental health services leverage technology to increase access to care, yet less is known about how quality therapeutic relationships form in a virtual setting. This study examined therapeutic alliance (a mechanism underlying successful treatment) and its association with well-being among registrants of a digital mental health platform. Method: Adults (n=3,087, M age=36±9 years, 54% female) engaged in videoconference sessions with a licensed therapist (18%), certified coach (65%), or both (17%) between 9/29/20-10/12/21. Members completed 2 adapted items of the Working Alliance Inventory (goal and bond) after each session and we averaged ratings across visits (?=.72). We used the WHO-5 to measure changes in well-being. We performed Mann-Whitney U tests, Kruskal-Wallis tests, paired samples t-tests, and linear regressions to examine: (1) average alliance ratings;(2) differences in alliance by member demographics and provider type;and (3) if alliance was related to changes in well-being over time. Results: Members completed a median of 3 digital sessions over a median of 28 days. Median therapeutic alliance was 4.8 (range=1-5) and did not differ by age, country, or baseline well-being (ps>.07). Females reported higher alliance than males (4.88 vs. 4.67, p=.01). Members in coaching reported higher alliance than those in therapy or both modalities (4.83 v. 4.75, p=.004), though effect sizes were negligible. Members reported an average WHO-5 increase of 4.14 points (95% CI [3.44, 4.83], p<.001), a 10% improvement in well-being (d=0.22). Therapeutic alliance predicted greater well-being at follow-up (b=2.17, 95% CI [1.07, 3.28]) after controlling for age, sex, and baseline WHO-5 (R2=.22, p<.001). This association did not differ by provider type (p=.78). Conclusion: Members of a global digital mental health benefit formed a high therapeutic alliance with their providers, both coaches and therapists. Higher alliance was associated with greater well-being improvements, providing evidence that it is a key mechanism in virtual care outcomes as it is in face-to-face care. Continued focus on the quality of therapeutic relationships will ensure digital mental health services are patient-tailored as these platforms expand equitable access to evidence-based care.
ABSTRACT
During the coronavirus pandemic, communities have faced shortages of important healthcare resources such as COVID-19 vaccines, medical staff, ICU beds and ventilators. Public health officials in the U.S. have had to make decisions about two major issues: which infected patients should be treated first (triage), and which people who are at risk of infection should be inoculated first (vaccine distribution). Following Beauchamp and Childress’s principlism, adopted guidelines have tended to value both whole lives (survival to discharge) and life-years (survival for years past discharge). This process of collective moral reasoning has revealed our common commitment to both Kantian and utilitarian principles. For Kant, respecting people’s rights entails that we ought to value whole lives equally. Therefore we ought to allocate resources so as to maximise the number of patients who survive to discharge. By contrast, the principle of utility has us maximise life-years so that people can satisfy more of their considered preferences. Although people are treated impartially in the utilitarian calculus, it does not recognise their equal worth. Subjecting Kantian ethics and utilitarianism to the process of reflective equilibrium lends support to the idea that we need a pluralistic approach that would accommodate our moral intuitions regarding both the equal value of whole lives and the additive value of life-years. © Altman M. C., 2022.