Therapeutic alliance in guided iCBT for patients with non-cardiac chest pain

Therapeutic alliance is a robust predictor of outcomes across psychotherapies, yet it remains unclear how alliance is experienced and negotiated in guided internet-delivered cognitive behavioural therapy (iCBT), particularly for persistent physical symptoms such as non-cardiac chest pain (NCCP). This study explored how participants in an 8-week guided iCBT programme for NCCP experienced the therapeutic alliance and how these experiences relate to established alliance models. Semi-structured interviews were conducted with 22 adults who completed the programme, and data were analysed using reflexive thematic analysis with a predominantly theory-driven but inductively sensitive approach. Three themes described how alliance was formed and maintained: Agreement on goals and tasks shaped by perceived personal relevance and workability; Emotional bond supported by timely, attuned, and appropriately calibrated therapist feedback; and Acceptability of the medium for collaboration, encompassing the platform, delivery modality, and treatment content. Participants described ongoing negotiations around structure and flexibility, challenge and support, and autonomy and relatedness, with therapist responsiveness shaping both engagement and the repair of strain. In conclusion, alliance in iCBT for NCCP is best understood as a negotiated digital alliance that depends on attuned therapist guidance and an acceptable medium, refining traditional alliance models by highlighting digital- and symptom-specific processes.