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Outline

1. Research Question

Is clinicians’ emotion regulation associated with clinicians’ perception of their therapeutic alliance with virtual patients at high-risk for suicidal behaviors?

2. Independent Variables

The independent variable is clinicians’ emotion regulation ability (measured by the Emotion Regulation Questionnaire (ERQ).

3. Dependent Variables

The dependent variable is clinicians' perception of their therapeutic alliance with virtual patients, which is measured by the alliance 3rs self-report

4. Study Justification

The main focus of this study is to explore the relations between the emotion regulation skills of clinicians and their perception of therapeutic alliance with virtual patients at high-risk for suicidal behaviors. Past literature have provided abundant evidence and insights for clinicians’ emotion regulation as well as their therapeutic alliance with patients at high-risk for suicidal behaviors in their respective field. However, there is a lack of establishment for the relation between those two aspects, especially with the involvement of virtual patients. For instance, Fartacek et al. (2023) explored how a strong therapeutic alliance reduces suicidal ideation in psychiatric inpatients at risk for suicide, and factors such as initial ideation level and borderline personality disorder moderated this effect. Barzilay et al. (2020) found that clinicians’ negative emotional reactions to suicidal patients negatively affected the therapeutic alliance, which in turn affected patients’ suicidal ideation, whether it occurred immediately after the initial contact or one month later. Rufino and Ellis (2018) explored how suicide-related cognitions, psychological flexibility, and therapeutic alliance jointly influenced suicidal ideation in inpatient psychiatric patients and identified key predictors during and after treatment. Ibrahim et al. (2022) investigated whether therapist adherence to two different manualized treatments (attachment-based family therapy and family-enhanced non-directive supportive therapy) was associated with treatment outcomes for adolescents at risk for suicide and explored the moderating role of the therapeutic alliance. However, these studies only investigated the ability of the therapeutic alliance to influence patient treatment and did not involve the clinicians’ emotion regulation.

When establishing the therapeutic alliance with virtual patients at high-risk for suicidal behaviors, past literature also presented insights on the essential function of the therapeutic alliance when dealing with patients’ therapy treatment. Nevertheless, past literature has not yet explored the specific relation that emotion regulation has with clinicians’ interactions with virtual patient at high risk for suicide behaviors. To give certain examples, according to Owens et al. (2013), the important role of therapeutic alliance in emotion regulation has been verified in patients with schizophrenia, but virtual patients and suicide risk assessment have not been involved. Shepard et al. (2022) pointed out in their study that the therapeutic alliance can indirectly affect doctors’ risk judgment through emotion regulation, which suggests that ER skills may have the same effect in a virtual environment. Ruiz-Aranda et al. (2020) emphasized how secure attachment style affects the emotion regulation process through the working alliance, which further supports the potential importance of therapeutic alliance in virtual interactions. Brausch et al. (2021) showed that emotional suppression is a key predictor of non-suicidal self-harm, suggesting that physicians need to pay attention to the risk of emotionally suppressed patients when assessing suicide risk. Similarly, Barzilay et al. (2022) emphasized that clinicians’ ability to regulate emotions plays a key role in their treatment recommendations and affects patients' levels of suicidal ideation. However, these studies also did not relate the therapeutic alliance with clinicians’ emotion regulation skills when dealing with patients at high risk for suicide behaviors.

This study intends to fill the gap in existing literature by establishing the research on the relations between emotion regulation ability (especially through cognitive reappraisal) and the therapeutic alliance with virtual patients at high-risk for suicidal behaviors. In the study by Shepard et al. (2022), the therapeutic alliance helped alleviate anxiety symptoms by improving emotion regulation ability. This study shows a possibility that a strong therapeutic alliance can bring benefits to clinicians when treating patients as it is presented to be influential in easing anxiety symptoms for patients. Specifically, this study is inclined to explore whether clinicians' emotion regulation skills is associated with the formation of therapeutic alliance when treating patients at high risk for suicide behaviors. If clinicians can effectively manage their emotional reactions, they are more likely to remain objective and thorough in their assessments. Ong & Thompson (2019) found that positive emotion regulation strategies such as cognitive reappraisal help reduce suicide risk, while avoidance coping strategies increase suicide risk. Therefore, it is of great academic values to determine whether emotion regulation in virtual patient contexts is related to clinicians’ therapeutic alliance with patients.

5. Reasoning Justification

This study has practical significance because it generates positive indications for medical practices to determine whether emotion regulation skills of clinicians is associated with their perception of therapeutic alliance with virtual patients at high-risk for suicidal behaviors. By studying emotion regulation skills and suicide risk assessment in virtual patient interactions, this study will help clinicians better master judgment skills in virtual environments.

References 

Barzilay S, Schuck A, Bloch-Elkouby S, et al. Associations between clinicians' emotional responses, therapeutic alliance, and patient suicidal ideation. Depress Anxiety. 2020; 37: 214–223. https://doi.org/10.1002/da.22973

Barzilay, S., Gagnon, A., Yaseen, Z. S., Chennapragada, L., Lloveras, L., Bloch-Elkouby, S., & Galynker, I. (2022). Associations between clinicians' emotion regulation, treatment recommendations, and patient suicidal ideation. Suicide and Life-Threatening Behavior, 52, 329–340. https://doi.org/10.1111/sltb.12824

Brausch, A. M., Clapham, R. B., & Littlefield, A. K. (2022/03//). Identifying specific emotion regulation deficits that associate with nonsuicidal self-injury and suicide ideation in adolescents. Journal of Youth and Adolescence, 51(3), 556-569. doi:https://doi.org/10.1007/s10964-021-01525-w

Ibrahim, M., Levy, S., Gallop, B., Krauthamer Ewing, S., Hogue, A., Chou, J. and Diamond, G. (2022), Therapist Adherence to Two Treatments for Adolescent Suicide Risk: Association to Outcomes and Role of Therapeutic Alliance. Fam. Proc., 61: 183-197. https://doi-org.ezproxy.cul.columbia.edu/10.1111/famp.12660

Ong, E., & Thompson, C. (2019). The Importance of Coping and Emotion Regulation in the Occurrence of Suicidal Behavior. Psychological Reports, 122(4), 1192-1210. https://doi.org/10.1177/0033294118781855

Owens, K.A., Haddock, G. and Berry, K. (2013), The Role of the Therapeutic Alliance in the Regulation of Emotion in Psychosis: An Attachment Perspective. Clin. Psychol. Psychother., 20: 523-530. https://doi.org/10.1002/cpp.1793

Rufino, K.A. and Ellis, T.E. (2018), Contributions of Cognitions, Psychological Flexibility, and Therapeutic Alliance to Suicidal Ideation in Psychiatric Inpatients. Suicide Life Threat Behav, 48: 271-280. https://doi.org/10.1111/sltb.12353

Ruiz-Aranda, D., Cardoso-Álvarez, S., & Fenollar-Cortés, J. (2021). Therapist Attachment and the Working Alliance: The Moderating Effect of Emotional Regulation. Frontiers in psychology, 12, 784010. https://doi.org/10.3389/fpsyg.2021.784010

Shepard, C. A., Rufino, K. A., Daza, P., Pearson, A., Cuenod, M., & Patriquin, M. A. (2022). Emotion Regulation Mediates the Relationship Between Therapeutic Alliance and Anxiety in Emerging Adults During Inpatient Psychiatric Treatment. Journal of Psychiatric Practice, 28(5), 383–390. https://doi.org/10.1097/PRA.0000000000000656