Therapeutic alliance across delivery modalities: a systematic narrative review of alliance strength and outcome prediction in face-to-face, online, and blended psychotherapy.

Abstract

The frequency of online psychotherapy, including pure online (PO: videoconference [PO-VC], telephone [PO-TEL], asynchronous therapist-guided [PO-Async]), or blended (BLD) modalities, has grown exponentially, yet how the therapeutic alliance (TA), a key outcome predictor, compares across these formats and face-to-face (FTF) treatment remains unclear. To compare the TA strength and the TA‒outcome association across FTF, PO, and BLD modalities, a systematic narrative review (Preferred Reporting Items for Systematic Reviews and Meta-Analyses/Synthesis Without Meta-analysis [PRISMA/SWiM]) was performed by searching PubMed, PsycARTICLES, and Web of Science. Studies were deemed eligible if they quantitatively compared TA across at least two modalities in adults with depressive or anxiety disorders. PO arms were classified as telepsychotherapy (PO-VC/TEL) or therapist-guided digital interventions (PO-Async). The findings were synthesized by direction and consistency. Nine studies, including three primary randomized controlled trials (RCTs) and six secondary analyses, were finally included in this study. TA strength was broadly comparable across all three modalities. One study found significantly lower patient-rated working alliance inventory (WAI) scores at Week 2 in PO-Async versus FTF, resolving by Week 8. The TA‒outcome association was mixed, varying by modality, rater perspective, and timepoint. The results showed that TA was broadly equivalent across FTF, PO, and BLD formats, although asynchronous PO might show a transient week-2 lag. The TA‒outcome association was less consistent in PO/BLD than in FTF. As a preliminary hypothesis, digital delivery may shift the functional emphasis of the alliance from affective bonding toward task/goal engagement. 在线心理治疗的应用频率近年来呈指数式增长，包括纯在线和混合式形式，其中纯在线形式包括视频会议(PO-VC)、电话(PO-TEL)及治疗师指导的异步干预（PO-Async）。然而，作为心理治疗关键结局预测因素的治疗联盟在上述形式与传统面对面治疗之间是否存在差异，目前尚不清楚。本研究旨在比较不同心理治疗媒介下治疗联盟的强度，以及治疗联盟与治疗结局之间的关联。本研究采用系统叙述性综述的方法，遵循系统综述和Meta分析的首选报告条目（PRISMA）与无Meta分析的综合（SWiM）指南，对PubMed、PsycARTICLES和Web of Science 数据库进行检索。纳入标准为:在抑郁障碍和/或焦虑障碍成人患者中，定量比较至少两种治疗媒介下治疗联盟的研究。纯在线治疗进一步划分为远程心理治疗（PO-VC/PO-TEL）和治疗师指导的数字心理健康干预（PO-Async）。研究结果依据效应方向及一致性进行综合。本研究最终纳入9项研究（3项原始随机对照试验，6项二次分析研究）。总体而言，三种治疗媒介下的治疗联盟强度大体相当。其中一项研究发现，与面对面治疗相比，PO-Async组患者在治疗第2周的工作联盟量表（WAI）评分显著较低，但该差异在第8周时消失。治疗联盟与结局之间的关联结果则较为不一致，随治疗媒介、评分者视角及评估时间点而变化。总体来看，面对面、在线及混合式心理治疗中的治疗联盟水平大致相当，但异步纯在线治疗可能在治疗第2周出现短暂的联盟滞后。与面对面治疗相比，在线和混合式治疗中，治疗联盟与结局之间的关联一致性较弱。作为一项初步假设，数字化治疗媒介可能使治疗联盟的功能重心由情感联结转向任务/目标投入。.