Norwood, Carl
(2019)
An explanatory sequential investigation of the working alliance as a change process in videoconferencing psychotherapy.
DClinPsy thesis, University of Nottingham.
Abstract
Background – The remote delivery of psychotherapy via secure video link— videoconferencing psychotherapy (VCP)— has the potential to overcome many of the regularly cited barriers to accessing psychological treatment and is becoming more recognised as a means of increasing access to services. Despite this, relatively little empirical investigation has been conducted examining the working alliance as a change process through this medium, and debate exists as to the experiential nature of the working alliance when therapy is delivered through this medium.
Aims – This thesis had two primary aims: (1) to investigate the working alliance as a potential change process in VCP, and (2) to gain an experiential understanding of the working alliance in VCP from the clients’ perspective to investigate this phenomenon.
Method – A two-phase explanatory sequential design was used.
Phase I: sessional data pertaining to outcome and working alliance was analysed using multilevel modelling from participants (n = 46) who took part in up to 15 sessions of cognitive behavioural therapy (CBT) delivered via VCP.
Phase II: participants (n = 12) from phase I were recruited to undertake a semi-structured interview, with the transcripts being analysed using thematic framework analysis.
Results – Phase I: Three models were constructed in phase I designed to assess: (1) the concurrent relationship between outcome and working alliance, (2) the extent to which working alliance leads outcome, and (3) the extent to which outcome leads working alliance. They demonstrated: (1) a significant correlation between working alliance and outcome (F(1, 15.19) = 25.01, p<.001), with the degree of association varying significantly between individuals (Var(u1j) = 1.06, p<.001), (2) previous session working alliance significantly predicted outcome in the next session (F(1, 355.61) = 4.47, p<.05), with a significant interaction of previous session working alliance and therapist seen (F(3, 354.1) = 4.29, p<.01) such that one therapist demonstrated a higher positive association between previous session working alliance and next session outcome (b = 1.06, t(0.39) = 2.79, p<.01), and (3) previous session outcome significantly predicted next session working alliance (F(1, 55.3) = 15.19, p<.001) to a varying degree for individual participants (Var(u1j) = 0.01, p<.001).
Phase II: Three synthesised core themes were identified pertaining to engaging with the medium, connection with the therapist, and working through the medium. These themes suggest that most participants expressed high levels of comfort with the medium, unrelated to previous videoconferencing experience and as something separate from the therapeutic processes (engaging with the medium). Most participants also reported a positive connection with their therapist (connection with the therapist). However, when the two combine, and therapeutic processes are facilitated by the medium, very polarised views are expressed (working through the medium).
Discussion – Results appear to provide evidence for the working alliance sharing a reciprocal influence with outcome in VCP, with two core concepts (engagement with the medium and connection with the therapist) combining from a participants’ perspective to uniquely influence therapeutic processes in VCP (working through the medium). These results are discussed and directions for future research recommended.
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