Therapeutic alliance, self-efficacy, and agency as mechanisms of change in blended care and routine psychotherapy.

OBJECTIVE

Blended Care (BC) has emerged as a promising approach to address the growing demand for mental health treatment, but little is known about its change mechanisms and how they compare to traditional psychotherapy (PT). This study investigates therapeutic alliance, general and mental health self-efficacy, and therapeutic agency function as mechanisms of change.

METHODS

We conducted a secondary analysis of a randomized controlled trial (N = 1,159 patients) comparing BC to PT in routine outpatient care. Mechanism and outcome variables (mental distress, satisfaction with life) were assessed at four time points over six months. We used random-intercept cross-lagged panel models (RI-CLPM) to differentiate between- from within-person effects.

RESULTS

All constructs were associated with better outcomes. Temporal effects showed that mental health self-efficacy predicted subsequent increases in satisfaction with life, and therapeutic alliance predicted lower mental distress at specific time points. General self-efficacy showed inconsistent effects, with counterintuitive findings in the BC group, where higher self-efficacy predicted increased mental distress. Agency was mainly related to satisfaction with life. Outcomes also predicted changes in mechanisms. Differences between BC and PT were only significant for general self-efficacy.

CONCLUSION

Our findings suggest that therapeutic change is dynamic and reciprocal. The unexpected associations in the BC group need replication.