Examining the Longitudinal Effects of Therapeutic Alliance Based on Session Rating Scale Scores on Suicidal Desire in Homebound Older Adults

INTRODUCTION: The Session Rating Scale (SRS) is widely used to assess therapeutic alliance in clinical settings, yet its application in paraprofessional-delivered interventions for older adults remains underexplored. This study examined whether therapeutic alliance predicted improvements in suicide desire among community-dwelling older adults participating in a warm-calling intervention. METHODS: Binomial generalized linear mixed-effects models were used with dichotomized high-score responses for thwarted belongingness (TB) and perceived burdensomeness (PB) to evaluate the role of therapeutic alliance (SRS) over time. Participants were assigned to one of two 8-week conditions: (1) BE, emphasizing empathy and connection through befriending and reminiscence; or (2) BE + ASIST, which incorporated an aging-adapted LivingWorks Applied Suicide Intervention Skills Training (ASIST). Trained paraprofessionals delivered all sessions. RESULTS: For PB, the odds of being classified as elevated decreased over time, and this decrease was statistically significant. For TB, a three-way interaction among condition, time, and SRS further showed that higher SRS scores predicted greater reductions in the odds of elevated TB within the BE + ASIST condition. CONCLUSION: Findings underscore the importance of therapeutic alliance in enhancing paraprofessional-led interventions for late-life suicide prevention.