Development of the Therapeutic Alliance in Alternative Settings to Psychiatric Hospitalization: An Open Comparative Study

The quality of the patient-therapist alliance is one of the most consistent predictors of outcomes across therapeutic settings. In recent years, new therapeutic settings have been developed to address societal needs, such as online hospitalization and residential treatment. The aim of this article was to describe how the alliance develops in these settings.

Patients (N=188) were recruited from Sheba Medical Center psychiatric wards (N=61), Sheba online/telepsychiatric hospitalization (N=39), and Soteria Houses (residential care) (N=88) in Israel. Patients and therapists completed the Session Alliance Inventory after the first therapy session and at discharge or treatment termination.

Strength of alliance increased significantly from pre- to posttreatment, beyond treatment setting. No significant differences were found in development of alliance over time across the three groups. Although no interaction effect was detected, exploratory simple effect analyses indicated that the Soteria group exhibited a significant increase in patient-rated (b=0.32, 95% CI=0.02, 0.63, p=0.038) and therapist-rated (b=0.31, 95% CI=0.09, 0.54, p=0.007) alliance, the hospital group showed only a significant patient-rated increase (b=0.39, 95% CI=0.06, 0.73, p=0.022), and the online group showed no increase in alliance.

Two psychiatric hospitalization alternatives allowed alliances to develop in a manner similar to that in traditional hospitalization; nonetheless, patterns of alliance formation and development varied. Future studies should explore whether these dynamics affect therapy outcomes across the three treatment settings.