Therapeutic Alliance Is Calming and Curing—The Interplay Between Alliance and Emotion Regulation as Predictors of Outcome in Internet-Based Treatments for Adolescent Depression

Abstract

Objective: Therapeutic alliance is one of the most stable predictors of outcome in psychotherapy, regardless of theoretical orientation. The alliance–outcome relationship in internet-based treatments has been investigated with mixed results. There is preliminary evidence that emotion regulation can work as a mediator for the alliance–outcome relationship. The present study aimed to investigate whether alliance predicted outcome session by session in two internet-based treatments for adolescent depression, and whether this relationship was mediated by emotion regulation. Method: Two hundred and seventy-two participants aged 15–19 years and diagnosed with depression were randomized to 10 weeks of internetbased psychodynamic or cognitive behavioral treatment. Both therapists and patients rated the alliance weekly. Patients also rated depressive symptoms and emotion regulation weekly. Analyses were made using cross-lagged panel modeling. Results: Alliance, as rated by both therapist and patient, predicted depression scores the following week. Emotion regulation rated by the patient also predicted depression scores the following week. Furthermore, alliance scores predicted emotion regulation scores the following week, which in turn predicted depression scores the week after, supporting the hypothesis that alliance influences outcome partly through emotion regulation. There were no group differences in any of these relationships. Conclusion: Alliance seems to play an important role in internet-based treatments, partly through emotion regulation. Clinicians working with text-based treatments should pay attention to the working alliance.