The Moderating Role of Working Alliance in the Association Between Depression and Suicide Ideation in Messaging Therapy

Introduction: Suicide is one of the leading causes of death worldwide, and it can be prevented by psychotherapy. The objective of this study was to examine the risk factors predicting suicide ideation during messaging psychotherapy, and the moderating role of working alliance (WA) in the association between baseline depression and later suicide ideation.Materials and Methods: A large outpatient sample (n = 4,388) engaged in daily messaging with licensed clinicians from a telemedicine provider. Using a longitudinal design, depression and anxiety symptoms were assessed at baseline, using the Patient Health Questionnaire (PHQ-8) for depression and the Generalized Anxiety Disorder (GAD-7) for anxiety. The WA was measured with the short version of the Working Alliance Inventory after 3 weeks of therapy, and suicide ideation was assessed at baseline and after 6 weeks of therapy, by item 9 of the Patient Health Questionnaire (PHQ-9). Demographic measures were also assessed.Results: Results indicate that depression (beta = 0.09, p < 0.001), baseline suicide ideation (beta = 0.50, p < 0.001), and WA (beta = -0.08, p < 0.001), especially the task subscale (beta = -0.14, p < 0.001), significantly predicted suicide ideation after 6 weeks. WA (beta = -0.07, p < 0.001), especially the task (beta = -0.14, p < 0.001) and bond subscales (beta = 0.06, p = 0.002), moderated the association between depression at baseline and suicide ideation after 6 weeks, so that experiencing higher quality of WA decreased the association between depression and suicide ideation.Discussion and Conclusions: Suicide ideation may be reduced by experiencing the therapeutic relationship as beneficial, even among at-risk populations, which suffer from depressive symptoms. It is the first study to show this moderation effect in any platform of therapy.