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.