ArticlePDF Available

The Digital Therapeutic Alliance: Prospects and Considerations



The growing prevalence of digital approaches to mental health care raises a range of questions and considerations. A notion that has recently emerged is that of the digital therapeutic alliance, prompting consideration of whether and how the concept of therapeutic alliance, which has proven to be a central ingredient of successful traditional psychotherapy, could translate to mental health care via digital technologies. This special issue editorial article outlines the topic of digital therapeutic alliance and introduces the five articles that comprise the special issue.
The Digital Therapeutic Alliance: Prospects and Considerations
Reeva Lederman*, PhD; Simon D'Alfonso*, PhD
School of Computing and Information Systems, The University of Melbourne, Carlton, Australia
*all authors contributed equally
Corresponding Author:
Simon D'Alfonso, PhD
School of Computing and Information Systems
The University of Melbourne
Melbourne Connect
700 Swanston Street
Carlton, 3053
Phone: 61 390355511
The growing prevalence of digital approaches to mental health care raises a range of questions and considerations. A notion that
has recently emerged is that of the digital therapeutic alliance, prompting consideration of whether and how the concept of
therapeutic alliance, which has proven to be a central ingredient of successful traditional psychotherapy, could translate to mental
health care via digital technologies. This special issue editorial article outlines the topic of digital therapeutic alliance and introduces
the five articles that comprise the special issue.
(JMIR Ment Health 2021;8(7):e31385) doi: 10.2196/31385
therapeutic alliance; digital therapeutic alliance; digital mental health; mental health apps; teletherapy; chatbots
The therapeutic alliance [1], a measure of the relationship quality
between a therapist and their client or patient, is associated with
the effectiveness of psychological interventions and successful
therapeutic outcomes. Recently, many are turning to online and
digital options as a less expensive and more accessible means
of therapy than traditional face-to-face care [2]. A growing
incidence of mental illness has led to the development of online
services by both evidence-based providers operating within
health systems and more opportunistic commercial software
developers. The need to access help online brought about by
COVID-19 can only increase both the demand for online
interventions and the desire by developers to meet that demand,
which in turn makes the need for online services to prove their
efficacy more significant. The increasing prevalence of digital
mental health research and interventions has given rise to the
term “digital therapeutic alliance” (DTA), which aims to
conceptually capture and measure the therapeutic quality of
online psychological therapy or digital mental health
The term DTA is a broad one that can apply to a range of types
of digital mental health care. The most straightforward of these
systems where the term DTA arises is the alliance between
client and therapist in the case of therapy sessions conducted
via email, online chat, or videoconferencing. These systems
require active input from the therapist despite the intermediary
presence of technology to facilitate the interaction. Research
suggests that the therapeutic alliance can also be achieved in
online modes, such as described above, in the same way that it
is in face-to-face therapy and that such digital interventions can
have a similar effect as face-to-face therapy [3]. These
interactions involve what is known as computer-mediated
communication, which is a field of study concerning computing
technology use that is relevant to online teletherapy [4].
At the other end of the spectrum of forms of digital mental
health care is engagement between a human client and an
artificial intelligence (AI)–driven therapy agent. This could
range from an online chatbot for mental health [5,6] to robotic
or virtual human therapists [7,8]. Such AI-driven therapy agents,
from the relatively simple to the more complex, raise a plethora
of interesting questions around the nature of the relationship
between the human client and the AI therapist. In terms of input
from a computing/technology field, human-robot interaction is
pertinent [9,10], including questions concerning the psychology
of an interaction between a human and an AI agent, particularly
its anthropomorphic aspects.
However, most of the work being carried out under the banner
of digital mental health concerns web and mobile apps for
JMIR Ment Health 2021 | vol. 8 | iss. 7 | e31385 | p. 1 (page number not for citation purposes)
Lederman & D'AlfonsoJMIR MENTAL HEALTH
mental health. Given their prevalence, it is important to
determine a conceptualization of therapeutic alliance that users
might form with an app and whether this is associated with app
Previous work examining the ability of mental health apps to
support therapeutic relationships has stressed the importance
of establishing whether the factors that make regular face-to-face
therapy effective are the same for digital therapy [11]. If this is
the case, how can we incorporate these factors into digital
therapies, and if not, what features of an app make it likely to
support DTA? Should app developers be trying to recreate
face-to-face therapy online, or should the online model have
completely different characteristics to traditional therapeutic
models? Previous starting points for constructing a
conceptualization and measure of DTA include work by Berry
et al [12], which adapted the Agnew Relationship Measure
(ARM) of therapeutic alliance and developed it into a measure
called the mobile Agnew Relationship Measure (mARM).
Similarly, Henson et al [13] devised a short DTA measure by
selecting 6 items from the Working Alliance Inventory measure
of therapeutic alliance and rewording “therapist” to “app.
However, given that such measures are more or less based on
existing measures of the traditional therapeutic alliance and
simply replace “therapist” with “app,” with possibly a few other
minor modifications, ultimately such an approach seems
unsatisfactory or incomplete, as it does not account for the
possibility of certain nuances, particularities, and complexities
that could arise in the context of digital interventions.
Furthermore, while there is bound to be some overlap between
traditional and digital therapy, one would expect that not all
aspects of a traditional therapeutic alliance will necessarily
apply to a DTA, and that there may also be dimensions of
alliance in the digital context that are not accounted for in
traditional therapeutic alliance models.
It is in this context that we invited papers for this special edition
on DTA.
The 5 papers published showcase the range of different means
through which digital technologies can be used to manage the
psychotherapeutic process. They provide an analysis of the
current literature in this nascent area and examine the arguments
for and against the likelihood of a therapeutic alliance emerging
through digital means and how we should view this phenomenon
going forward. We need to ask whether the current view of a
therapeutic alliance translates well into the digital arena or
whether new models should be developed.
In the paper “The Therapeutic Alliance in Digital Mental Health
Interventions for Serious Mental Illnesses: Narrative Review”
[14], the authors indicate that digital mental health applications
offer advantages not found in traditional therapies. These include
increased accessibility and autonomy, which can enhance
adherence and engagement. They suggest that opportunities for
self-guided therapy can lead to unique characteristics for
therapeutic alliance in digital contexts. They show that currently
the greatest support exists for the effectiveness of digital
interventions for anxiety and depression, as opposed to other
mental health conditions. They also emphasize the complexity
of reaching conclusions in this very diverse field.
In the paper “A Perspective on Client-Psychologist Relationships
in Videoconferencing Psychotherapy: Literature Review” [15],
the authors emphasize the prescience of this topic during the
time of the COVID-19 pandemic. Suddenly, mental health
therapy through digital means has become an imperative for
many consumers, and so the quality of these therapies in
establishing effective treatment has become a more urgent
problem to solve. The paper examines DTA in the context of
videoconferencing, a close technological option to face-to-face
therapy. They suggest conflicting results across their two
participant groups, therapists and clients. Clients of
psychotherapy were generally satisfied that it was possible to
establish a therapeutic alliance through video conferencing.
Conversely, therapists expressed concern about the quality of
the alliance and the ability to establish a satisfying therapeutic
relationship through digital channels. The paper proposes a new
model of interaction to deal with these contrasting experiences.
In the paper “Blended Digital and Face-to-Face Care for
First-Episode Psychosis Treatment in Young People: Qualitative
Study” [16], the authors examined and found client support for
a blended care trial intervention, which combined a digital
mental health web platform with human moderator support. In
this study of young people aged 18-25 years, qualitative data
suggest that the blending of online physical and virtual lives in
the therapeutic setting was seen as a natural extension of how
the clients live the rest of their lives in the current era.
Participants in the study identified one of the benefits of blended
therapy as strengthening the relationship between the client and
the clinician, which is clearly important for DTA. It would be
interesting to see this study extended to cover the views of
therapists so that it could be compared to the findings of Cataldo
et al [15].
In the paper “Impact of Jointly Using an e–Mental Health
Resource (Self-Management And Recovery Technology) on
Interactions Between Service Users Experiencing Severe Mental
Illness and Community Mental Health Workers: Grounded
Theory Study” [17], the authors study a scenario where e–mental
health resources are available to mental health consumers and
workers to use together. In this study, the digital intervention
is intended to augment rather than entirely replace face-to-face
care, as in a blended system. However, in contrast to an
asynchronous system, in this study, mental health workers and
clients used the intervention simultaneously during their regular
scheduled consultations. The research found that using this form
of interaction, relationships were able to be built between mental
health workers and consumers. They leave us with a final
message, which summarizes the lessons learned from this special
edition well: “digital mental health tools should be reframed as
tools that can strengthen and augment therapeutic relationships,
provided there is a clear shared understanding about how and
when they will be used.
Finally, in the paper “The Digital Therapeutic Alliance and
Human-Computer Interaction” [18], the authors start by covering
recent nascent work on DTA measures and discussing its
limitations, before considering how areas from the field of
human-computer interaction (HCI) can play a role in alliance
formation and shaping or generating a more suitable,
purpose-built measure of DTA. The four areas examined are
JMIR Ment Health 2021 | vol. 8 | iss. 7 | e31385 | p. 2 (page number not for citation purposes)
Lederman & D'AlfonsoJMIR MENTAL HEALTH
(1) persuasive system design, (2) affective computing, (3)
positive computing, and (4) human-smartphone connection. By
exploring the mobile Agnew Relationship Measure of DTA
through these HCI lenses, the paper also discusses how HCI
methods and knowledge can be used to foster DTA in mental
health apps.
We trust that readers will find this special edition interesting,
and that it will stimulate future research into the nascent and
important topic of DTA.
Conflicts of Interest
None declared.
1. Horvath A, Gaston L, Luborsky L. The therapeutic alliance and its measures. In: Miller NE, Luborsky L, Barber JP, Docherty
JP, editors. Psychodynamic Treatment Research: A Handbook for Clinical Practice. New York, NY: Basic Books;
2. Becker T, Torous J. Recent Developments in Digital Mental Health Interventions for College and University Students. Curr
Treat Options Psych 2019 Jun 14;6(3):210-220. [doi: 10.1007/s40501-019-00178-8]
3. Richards D, Viganó N. Online counseling: a narrative and critical review of the literature. J Clin Psychol 2013
Sep;69(9):994-1011. [doi: 10.1002/jclp.21974] [Medline: 23630010]
4. Walther J. Computer-Mediated Communication. Communication Research 2016 Jun 29;23(1):3-43. [doi:
5. D'Alfonso S, Santesteban-Echarri O, Rice S, Wadley G, Lederman R, Miles C, et al. Artificial Intelligence-Assisted Online
Social Therapy for Youth Mental Health. Front Psychol 2017;8:796 [FREE Full text] [doi: 10.3389/fpsyg.2017.00796]
[Medline: 28626431]
6. Kretzschmar K, Tyroll H, Pavarini G, Manzini A, Singh I, NeurOx Young People’s Advisory Group. Can Your Phone Be
Your Therapist? Young People's Ethical Perspectives on the Use of Fully Automated Conversational Agents (Chatbots) in
Mental Health Support. Biomed Inform Insights 2019;11 [FREE Full text] [doi: 10.1177/1178222619829083] [Medline:
7. Lucas G, Rizzo A, Gratch J, Scherer S, Stratou G, Boberg J, et al. Reporting Mental Health Symptoms: Breaking Down
Barriers to Care with Virtual Human Interviewers. Front Robot AI 2017 Oct 12;4:4. [doi: 10.3389/frobt.2017.00051]
8. Scoglio E, Reilly ED, Gorman JA, Drebing CE. Use of Social Robots in Mental Health and Well-Being Research: Systematic
Review. J Med Internet Res 2019 Jul 24;21(7):e13322 [FREE Full text] [doi: 10.2196/13322] [Medline: 31342908]
9. Billard A, Grollard D. Human-Robot Interaction. In: Encyclopedia of the Sciences of Learning. Boston, MA: Springer;
10. Dautenhahn K. Human-Robot Interaction. In: The Encyclopedia of Human-Computer Interaction, 2nd Ed. Denmark:
Interaction Design Foundation; 2014.
11. Lederman R, Gleeson J, Wadley G, D’alfonso S, Rice S, Santesteban-Echarri O, et al. Support for Carers of Young People
with Mental Illness. ACM Trans Comput-Hum Interact 2019 Feb 23;26(1):1-33. [doi: 10.1145/3301421]
12. Berry K, Salter A, Morris R, James S, Bucci S. Assessing Therapeutic Alliance in the Context of mHealth Interventions
for Mental Health Problems: Development of the Mobile Agnew Relationship Measure (mARM) Questionnaire. J Med
Internet Res 2018 Apr 19;20(4):e90 [FREE Full text] [doi: 10.2196/jmir.8252] [Medline: 29674307]
13. Henson P, Peck P, Torous J. Considering the Therapeutic Alliance in Digital Mental Health Interventions. Harv Rev
Psychiatry 2019;27(4):268-273. [doi: 10.1097/HRP.0000000000000224] [Medline: 30907764]
14. Tremain H, McEnery C, Fletcher K, Murray G. The Therapeutic Alliance in Digital Mental Health Interventions for Serious
Mental Illnesses: Narrative Review. JMIR Ment Health 2020 Aug 07;7(8):e17204 [FREE Full text] [doi: 10.2196/17204]
[Medline: 32763881]
15. Cataldo F, Chang S, Mendoza A, Buchanan G. A Perspective on Client-Psychologist Relationships in Videoconferencing
Psychotherapy: Literature Review. JMIR Ment Health 2021 Feb 19;8(2):e19004 [FREE Full text] [doi: 10.2196/19004]
[Medline: 33605891]
16. Valentine L, McEnery C, Bell I, O'Sullivan S, Pryor I, Gleeson J, et al. Blended Digital and Face-to-Face Care for
First-Episode Psychosis Treatment in Young People: Qualitative Study. JMIR Ment Health 2020 Jul 28;7(7):e18990 [FREE
Full text] [doi: 10.2196/18990] [Medline: 32720904]
17. Williams E, Fossey E, Farhall J, Foley F, Thomas N. Impact of Jointly Using an e-Mental Health Resource (Self-Management
And Recovery Technology) on Interactions Between Service Users Experiencing Severe Mental Illness and Community
Mental Health Workers: Grounded Theory Study. JMIR Ment Health 2021 Jun 16;8(6):e25998 [FREE Full text] [doi:
10.2196/25998] [Medline: 34132647]
18. D'Alfonso S, Lederman R, Bucci S, Berry K. The Digital Therapeutic Alliance and Human-Computer Interaction. JMIR
Ment Health 2020 Dec 29;7(12):e21895 [FREE Full text] [doi: 10.2196/21895] [Medline: 33372897]
JMIR Ment Health 2021 | vol. 8 | iss. 7 | e31385 | p. 3 (page number not for citation purposes)
Lederman & D'AlfonsoJMIR MENTAL HEALTH
AI: artificial intelligence
ARM: Agnew Relationship Measure
DTA: digital therapeutic alliance
HCI: human-computer interaction
mARM: mobile Agnew Relationship Measure
Edited by J Torous; this is a non–peer-reviewed article. Submitted 19.06.21; accepted 19.06.21; published 20.07.21.
Please cite as:
Lederman R, D'Alfonso S
The Digital Therapeutic Alliance: Prospects and Considerations
JMIR Ment Health 2021;8(7):e31385
doi: 10.2196/31385
PMID: 34283035
©Reeva Lederman, Simon D'Alfonso. Originally published in JMIR Mental Health (, 20.07.2021. This
is an open-access article distributed under the terms of the Creative Commons Attribution License
(, which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work, first published in JMIR Mental Health, is properly cited. The complete bibliographic information, a
link to the original publication on, as well as this copyright and license information must be included.
JMIR Ment Health 2021 | vol. 8 | iss. 7 | e31385 | p. 4 (page number not for citation purposes)
Lederman & D'AlfonsoJMIR MENTAL HEALTH
... In general, there is now an increasing body of research on the digital therapeutic alliance, and its overall influence on the efficacy of help provided by mental health chatbots (51,52,54,56,(102)(103)(104)(105)(106)(107)(108)(109)(110)(111)(112). These studies, including randomized controlled trials, reveal varying strengths of the effects: from small up to comparable or even outperforming these found in therapy delivered by humans (as measured on traditional scales designed for assessing the strength of working alliance formed between a client and a human therapist). ...
... … given that such measures are more or less based on existing measures of the traditional therapeutic alliance and simply replace "therapist" with "app, " with possibly a few other minor modifications, ultimately such an approach seems unsatisfactory or incomplete, as it does not account for the possibility of certain nuances, particularities, and complexities that could arise in the context of digital interventions. Furthermore, … one would expect that not all aspects of a traditional therapeutic alliance will necessarily apply to a DTA, and that there may also be dimensions of alliance in the digital context that are not accounted for in traditional therapeutic alliance models (103) ...
Full-text available
Growing demand for broadly accessible mental health care, together with the rapid development of new technologies, trigger discussions about the feasibility of psychotherapeutic interventions based on interactions with Conversational Artificial Intelligence (CAI). Many authors argue that while currently available CAI can be a useful supplement for human-delivered psychotherapy, it is not yet capable of delivering fully fledged psychotherapy on its own. The goal of this paper is to investigate what are the most important obstacles on our way to developing CAI systems capable of delivering psychotherapy in the future. To this end, we formulate and discuss three challenges central to this quest. Firstly, we might not be able to develop effective AI-based psychotherapy unless we deepen our understanding of what makes human-delivered psychotherapy effective. Secondly, assuming that it requires building a therapeutic relationship, it is not clear whether psychotherapy can be delivered by non-human agents. Thirdly, conducting psychotherapy might be a problem too complicated for narrow AI, i.e., AI proficient in dealing with only relatively simple and well-delineated tasks. If this is the case, we should not expect CAI to be capable of delivering fully-fledged psychotherapy until the so-called "general" or "human-like" AI is developed. While we believe that all these challenges can ultimately be overcome, we think that being mindful of them is crucial to ensure well-balanced and steady progress on our path to AI-based psychotherapy.
... Several researchers have highlighted the importance of elucidating the nature of the relationship formed with technology in the settings of EHIs, in comparison to the wellstudied relationship between client and therapist in face-toface psychotherapy (Bickmore & Picard, 2005;Goldberg et al., 2021;Lederman & D'Alfonso, 2021). One study systematically reviewed published eHealth criteria to create a reviewer-led EHI rating scales (Enlight), which included evaluating the user's experience of TA toward the program . ...
Full-text available
Most measures designed to assess eHealth therapeutic alliance (ETA) derive from conventional factors of therapeutic alliance. This study examined whether integrating subscales developed directly to capture therapeutic alliance facets that are unique to the digital space contribute above conventional factors to understanding ETA. The eHealth Therapeutic Alliance Inventory (ETAI) was developed based on a review of face-to-face TA measures combined with new items related to ETA uniquely. Following development, a panel of psychologists who are also eHealth experts, evaluated ETAI’s content validity prior to testing. A sample consisted of 273 adults in the USA, participating in 6-month mobile alcohol reduction intervention who completed ETAI at the end of the intervention. Factor structure was examined using exploratory factor analysis; internal reliability using Cronbach’s α; regressions were calculated assessing items’ contribution to explaining two clinical-related-outcomes: participant experience of positive change, and commitment to change towards the future. Two-factor solution was found with conventional items loading on the first factor and items representing application-induced accountability, on the second, resulting in a 10-item scale with adequate internal consistency for both factors (α = 0.93; α = 0.83, respectively). Both factors had a unique contribution to explaining “experiencing positive change” (factor 1: β = 0.27, p < 0.001; factor 2: β = 0.30, p < 0.001); only factor 2 had a unique contribution to explaining “commitment to change” (factor 2: β = 0.39, p < 0.001). Unique scales capturing ETA may contribute to our understanding of user engagement with digital tools and to explaining clinical-related outcomes.
... These findings are aligned with research suggesting that rapport building is strongly related to greater self-disclosure, cooperation, and affiliation [33]. Considering that digital interventions and in-person therapy yield similar potentials for therapeutic alliance building, one of the most powerful predictors of psychotherapy efficacy, a stronger moderator-participant relationship on HoryzonsCa would likely lead to better participant outcomes [34][35][36]. ...
Full-text available
Unlabelled: Horyzons is a digital health intervention designed to support recovery in young people receiving specialized early intervention services for first-episode psychosis (FEP). Horyzons was developed in Australia and adapted for implementation in Canada based on input from clinicians and patients (Horyzons-Canada Phase 1) and subsequently pilot-tested with 20 young people with FEP (Horyzons-Canada Phase 2). Objective: To understand the experiences of young adults with FEP who participated in the pilot study based on focus group data. Methods: Among the twenty individuals that accessed the intervention, nine participated across four focus groups. Three team members were involved in data management and analysis, informed by a thematic analysis approach. A coding framework was created by adapting the Phase 1 framework to current study objectives, then revised iteratively by applying it to the current data. Once the coding framework was finalized, it was systematically applied to the entire dataset. Results: Four themes were identified: (1) Perceiving Horyzons-Canada as helpful for recovery; (2) Appreciating core intervention components (i.e., peer networking; therapeutic content; moderation) and ease of use; (3) Being unaware of its features; and (4) Expressing concerns, suggestions, and future directions. Conclusions: Horyzons-Canada was well received, with participants wanting it to grow in scale, accessibility, and functionality.
... A new subdivision of the digital health system has been introduced to manage, prevent and treat disease since 2015 (13). It was formally defined as delivering evidence-based therapeutic interventions to patients driven by software to prevent, manage, or treat a medical disorder or disease (14,15). ...
Full-text available
Unlabelled: It has been reported that some exercise could enhance the anti-viral antibody titers after vaccination including influenza and coronavirus disease 2019 vaccines. We developed SAT-008, a novel digital device, consists of physical activities and activities related to the autonomic nervous system. We assessed the feasibility of SAT-008 to boost host immunity after an influenza vaccination by a randomized, open-label, and controlled study on adults administered influenza vaccines in the previous year. Among 32 participants, the SAT-008 showed a significant increase in the anti-influenza antibody titers assessed by hemagglutination-inhibition test against antigen subtype B Yamagata lineage after 4 wk of vaccination and subtype B Victoria lineage after 12 wk (p<0.05). There was no difference in the antibody titers against subtype "A." The SAT-008 also showed significant increase in the plasma cytokine levels of IL-10, IL-1β, and IL-6 at weeks 4 and 12 after the vaccination (p<0.05). A new approach using the digital device may boost host immunity against virus via vaccine adjuvant-like effects. Trial registration: Identifier: NCT04916145.
... Nevertheless, there are several challenges in the implementation of these technologies, such as (1) the lack of research; (2) the lack of clear standards for the safety of their daily use; (3) unclear roles of technology and a shift in the responsibilities of all parties; (4) constraints of data confidentiality; and (5) the lack of a user-centered design that meets the particular needs of patients with schizophrenia (Chivilgina, Elger, & Jotterand, 2021). Also, the treatment of mental illness has a very important relational part and because of that, the concept of "digital therapeutic alliance" (therapeutic quality of online psychological therapy or digital mental health interventions) should be better studied (Lederman & D'Alfonso, 2021). ...
Digital technologies like mobile applications, chatbots, virtual reality, and other technological solutions are already revolutionizing mental health care, including schizophrenia care. Digital mental health interventions are not intended to replace mental health professionals, in fact, they are a contribution to enhance prevention, improve diagnosis, and democratize monitoring and treatment. These systems usually handle large-scale sensitive data and require modern solutions to safely process and store data. Cloud-based services can respond to this challenge, but it is important to be aware of the current technical boundaries as well of dangers of health data handling. This chapter provides a review on the subject, presenting several data-driven applications for schizophrenia care and addressing some concerns such as efficacy, privacy and confidentiality, data security, accountability, engagement, ethical implications, and education and training. Some recommendations on clinical integration are also presented.
Background A strong cooperative bond between the patient and provider (“therapeutic alliance”) is robustly associated with better alcohol use disorder (AUD) treatment outcomes. Although digital treatments for AUD have significant potential, the function of the alliance during digital programs is unclear. We compared the validity of patient‐reported measures of the alliance with a digital treatment (“digital alliance”) for AUD and the alliance with their clinician (“clinician alliance”). Methods We used data from a randomized clinical trial of a computerized cognitive behavioral therapy program (CBT4CBT) during outpatient AUD treatment. Treatment conditions included CBT4CBT with minimal clinical monitoring (CBT4CBT + monitor) or with treatment as usual (CBT4CBT + TAU). The digital alliance and clinician alliance were measured with similar versions of the Working Alliance Inventory (WAI). The WAI ratings were completed at the 2 nd and 6 th treatment sessions. A timeline followback calendar assessed daily alcohol use. Bayesian multilevel models compared the strength of the alliances and tested their associations with future alcohol use. Results Data from 43 participants were included (age M = 44; 65% male; 51% Black, 40% White, 9% other; 14% Hispanic). The digital alliance ratings had similar internal reliability as the clinician alliance ratings ( ω 's > 0.90). Differences between digital alliance and clinician alliance ratings were negligible in both treatment conditions ( BF 01 = 9 and 31). During treatment, within‐person increases in the digital alliance and the clinician alliance predicted modest decreases in future drinking to a similar degree ( BF 01 = 15). Alliance ratings were not associated with future drinking when posttreatment follow‐up drinking data were included ( BF 10 < 3). Conclusions The digital alliance with CBT4CBT was comparable to the clinician alliance. The digital alliance and clinician alliance had similar, albeit very small, associations with abstinence during treatment. Future research can explore how the digital alliance develops to improve AUD treatment efficacy.
Full-text available
Purpose: Interpersonal processes, including therapeutic alliance, may modulate the impact of interventions on pain experience. However, the role of interpersonal context on the effects of technology-enhanced interventions remains underexplored. This study elicited therapists' perspectives on how a novel rehabilitative process, involving Phantom Motor Execution (PME), may impact phantom limb pain. The mediating role of therapeutic alliance, and the way PME influenced its formation, was investigated. Methods: A qualitative descriptive design, using a framework method, was used to explore therapists' (n=11) experiences of delivering PME treatment. Semi-structured online-based interviews were conducted. Results: A 3-way interaction between therapist, patient, and the PME device was an overarching construct tying four themes together. It formed the context for change in phantom limb experience. The perceived therapeutic effects (theme 1) extended beyond those initially hypothesised and highlighted the mediating role of the key actors and context (theme 2). The therapeutic relationship was perceived as a transformative journey (theme 3), creating an opportunity for communication, collaboration, and bonding. It was seen as a cause and a consequence of therapeutic effects. Future directions, including the role of expertise-informed adaptations and enabling aspects of customised solutions, were indicated (theme 4). Conclusion: This study pointed to intrapersonal, interpersonal, and contextual factors that should be considered in clinical implementation of novel rehabilitative tools. The results demonstrated that therapists have unique insights and a crucial role in facilitating PME treatment. The study highlighted the need to consider the biopsychosocial model of pain in designing, evaluating, and implementing technology-supported interventions.
Mental health has become an exceptionally important social and public health issue in Australia. The government has invested billions of dollars in new services, while ubiquitous ad campaigns call on ordinary people to tend to their psychological well-being. This national valorization of mental health is striking, given the well-documented psychiatric harm suffered by refugees under Australia's offshore detention regime. This article draws on ethnographic work with a group of volunteer therapists who provide crisis counseling to these detained refugees over WhatsApp, allowing them to intervene in scenarios where therapy is inaccessible but badly needed. Highlighting the predictable challenges and surprising affordances of delivering care in this restrictive and high-stakes context, I show how my informants forge a genuine therapeutic connection with their clients. While this intervention is meaningful, I argue that the volunteers are aware that it is no substitute for winning political freedom.
Full-text available
Infant and Early Childhood Mental Health Consultation (IECMHC) is an evidence-based service in which consultants build capacity for early childhood professionals and programs to promote the social-emotional development of infants and young children. This paper describes the current state of the evidence for IECMHC, mapping the evidence to a new theory of change from the Center of Excellence (CoE) for IECMHC. There is a substantial literature base regarding the effects of consultation on outcomes for infants and young children; yet the evidence for consultation's specific mechanisms of change, moderators of impact, and reductions in disparities have been understudied. The authors identify gaps in the scholarly literature, articulate next steps for research, and conclude with a call to action for IECMHC researchers to expand rigorous studies to the range of settings in which IECMHC is implemented and to center social justice in the research questions, methods, and dissemination.
Full-text available
Background e–Mental health resources are increasingly available for people who experience severe mental illness, including those who are users of community mental health services. However, the potential for service users (SUs) living with severe mental illness to use e–mental health resources together with their community mental health workers (MHWs) has received little attention. Objective This study aims to identify how jointly using an interactive website called Self-Management And Recovery Technology (SMART) in a community mental health context influenced therapeutic processes and interactions between SUs and MHWs from their perspective. Methods We conducted a qualitative study using a constructivist grounded theory methodology. Data were collected through individual semistructured interviews with 37 SUs and 15 MHWs who used the SMART website together for 2 to 6 months. Data analysis involved iterative phases of coding, constant comparison, memo writing, theoretical sampling, and consultation with stakeholders to support the study’s credibility. Results A substantive grounded theory, discovering ways to keep life on track, was developed, which portrays a shared discovery process arising from the SU-worker-SMART website interactions. The discovery process included choosing to use the website, revealing SUs’ experiences, exploring these experiences, and gaining new perspectives on how SUs did and could keep their lives on track. SUs and MHWs perceived that their three-way interactions were enjoyable, beneficial, and recovery focused when using the website together. They experienced the shared discovery process as relationship building—their interactions when using the website together were more engaging and equal. Conclusions Jointly using an e–mental health resource elicited recovery-oriented interactions and processes between SUs and MHWs that strengthened their therapeutic relationship in real-world community mental health services. Further work to develop and integrate this novel use of e–mental health in community mental health practice is warranted.
Full-text available
The therapeutic alliance (TA), the relationship that develops between a therapist and a client/patient, is a critical factor in the outcome of psychological therapy. As mental health care is increasingly adopting digital technologies and offering therapeutic interventions that may not involve human therapists, the notion of a TA in digital mental health care requires exploration. To date, there has been some incipient work on developing measures to assess the conceptualization of a digital TA for mental health apps. However, the few measures that have been proposed have more or less been derivatives of measures from psychology used to assess the TA in traditional face-to-face therapy. This conceptual paper explores one such instrument that has been proposed in the literature, the Mobile Agnew Relationship Measure, and examines it through a human-computer interaction (HCI) lens. Through this process, we show how theories from HCI can play a role in shaping or generating a more suitable, purpose-built measure of the digital therapeutic alliance (DTA), and we contribute suggestions on how HCI methods and knowledge can be used to foster the DTA in mental health apps.
Full-text available
Background During the COVID-19 pandemic, people have been encouraged to maintain social distance. Technology helps people schedule meetings as remote videoconferencing sessions rather than face-to-face interactions. Psychologists are in high demand because of an increase in stress as a result of COVID-19, and videoconferencing provides an opportunity for mental health clinicians to treat current and new referrals. However, shifting treatment from face-to-face to videoconferencing is not simple: both psychologists and clients miss in-person information cues, including body language. Objective This review proposes a new theoretical framework to guide the design of future studies examining the impact of a computer as a mediator of psychologist-client relationships and the influence of videoconferencing on the relationship process. Methods We conducted a literature review including studies focused on communication and key concepts of the therapeutic relationship and therapeutic alliance. Results Studies have reported that clients are generally satisfied with videoconference therapy in terms of the relationship with their therapists and the establishment of the therapeutic alliance. Conversely, studies indicate that psychologists continue to highlight difficulties in establishing the same quality of therapeutic relationship and therapeutic alliance. The contrasting experiences might underlie the differences in the type of emotional and cognitive work required by both actors in any therapy session; furthermore, the computer seems to take part in their interaction not only as a vehicle to transmit messages but also as an active part of the communication. A new model of interaction and relationship is proposed, taking into account the presence of the computer, along with further hypotheses. Conclusions It is important to consider the computer as having an active role in the client-psychologist relationship; thus, it is a third party to the communication that either assists or interferes with the interaction between psychologists and clients.
Full-text available
Background: Digital mental health interventions offer unique advantages, and research indicates that these interventions are effective for a range of mental health concerns. Although these interventions are less established for individuals with serious mental illnesses, they demonstrate significant promise. A central consideration in traditional face-to-face therapies is the therapeutic alliance, whereas the nature of a digital therapeutic alliance and its relationship with outcomes requires further attention, particularly for individuals with serious mental illnesses. Objective: This narrative review aims to encourage further consideration and critical evaluation of the therapeutic alliance in digital mental health, specifically for individuals with serious mental illnesses. Methods: A narrative review was conducted by combining 3 main areas of the literature: the first examining the evidence for digital mental health interventions for serious mental illnesses, the second illuminating the nature and role of the therapeutic alliance in digital interventions, and the third surrounding practical considerations to enhance a digital therapeutic alliance. Results: Results indicated that a therapeutic alliance can be cultivated in digital interventions for those with serious mental illnesses, but that it may have unique, yet-to-be-confirmed characteristics in digital contexts. In addition, a therapeutic alliance appears to be less directly associated with outcomes in digital interventions than with those in face-to-face therapies. One possibility is that the digital therapeutic alliance is associated with increased engagement and adherence to digital interventions, through which it appears to influence outcomes. A number of design and implementation considerations may enhance the digital therapeutic alliance, including human support and technological features. Conclusions: More research is required to further understand the nature and specific role of a therapeutic alliance in digital interventions for serious mental illnesses, particularly in informing their design. This review revealed several key research priorities to advance the therapeutic alliance in digital interventions.
Full-text available
Background A small number of studies have found that digital mental health interventions can be feasible and acceptable for young people experiencing first-episode psychosis; however, little research has examined how they might be blended with face-to-face approaches in order to enhance care. Blended treatment refers to the integration of digital and face-to-face mental health care. It has the potential to capitalize on the evidence-based features of both individual modalities, while also exceeding the sum of its parts. This integration could bridge the online–offline treatment divide and better reflect the interconnected, and often complementary, ways young people navigate their everyday digital and physical lives. Objective This study aimed to gain young people’s perspectives on the design and implementation of a blended model of care in first-episode psychosis treatment. Methods This qualitative study was underpinned by an end-user development framework and was based on semistructured interviews with 10 participants aged 19 to 28 (mean 23.4, SD 2.62). A thematic analysis was used to analyze the data. Results Three superordinate themes emerged relating to young people’s perspectives on the design and implementation of a blended model of care in first-episode psychosis treatment: (1) blended features, (2) cautions, and (3) therapeutic alliance. Conclusions We found that young people were very enthusiastic about the prospect of blended models of mental health care, in so far as it was used to enhance their experience of traditional face-to-face treatment but not to replace it overall. Aspects of blended treatment that could enhance clinical care were readily identified by young people as increasing accessibility, continuity, and consolidation; accessing posttherapy support; strengthening the relationship between young person and clinician; and tracking personal data that could be used to better inform clinical decision making. Future research is needed to investigate the efficacy of blended models of care by evaluating its impact on the therapeutic alliance, clinical and social outcomes, cost-effectiveness, and engagement.
Full-text available
Background: Technology-assisted clinical interventions are increasingly common in the health care field, often with the proposed aim to improve access to and cost-effectiveness of care. Current technology platforms delivering interventions are largely mobile apps and online websites, although efforts have been made to create more personalized and embodied technology experiences. To extend and improve on these platforms, the field of robotics has been increasingly included in conversations of how to deliver technology-assisted, interactive, and responsive mental health and psychological well-being interventions. Socially assistive robots (SARs) are robotic technology platforms with audio, visual, and movement capabilities that are being developed to interact with individuals socially while also assisting them with management of their physical and psychological well-being. However, little is known about the empirical evidence or utility of using SARs in mental health interventions. Objective: The review synthesizes and describes the nascent empirical literature of SARs in mental health research and identifies strengths, weaknesses, and opportunities for improvement in future research and practice. Methods: Searches in Medline, PsycINFO, PsycARTICLES, PubMed, and IEEE Xplore yielded 12 studies included in the final review after applying inclusion and exclusion criteria. Abstract and full-text reviews were conducted by two authors independently. Results: This systematic review of the literature found 5 distinct SARs used in research to investigate the potential for this technology to address mental health and psychological well-being outcomes. Research on mental health applications of SARs focuses largely on elderly dementia patients and relies on usability pilot data with methodological limitations. Conclusions: The current SARs research in mental health use is limited in generalizability, scope, and measurement of psychological outcomes. Opportunities for expansion of research in this area include diversifying populations studied, SARs used, clinical applications, measures used, and settings for those applications.
Full-text available
Purpose Mental health problems are prevalent among university students. Insufficient resources at student health centers and other barriers to treatment result in low rates of students receiving treatment, potentially impacting academic performance and long-term health. Digital mental health interventions have been proposed as a means of reducing the treatment gap, given their potential for flexibility, cost-effectiveness, and stigma reduction. Recent Findings Randomized controlled trials (RCTs) of short-term online interventions based on cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness have had promising short-term effects on measurements of anxiety, depression, and sleep when compared to waitlist controls in small to medium size non-clinical samples of predominantly women university students in high-income countries. Most interventions suffer from low adherence and completion rates, sometimes partially offset by personal support. The impact of these interventions on long-term mental health and academic outcomes remains uncertain. Summary Although studies of Internet-based interventions have shown promising results, the effectiveness of current interventions is limited by low adherence and questionable long-term efficacy in real-world settings.
Full-text available
Over the last decade, there has been an explosion of digital interventions that aim to either supplement or replace face-to-face mental health services. More recently, a number of automated conversational agents have also been made available, which respond to users in ways that mirror a real-life interaction. What are the social and ethical concerns that arise from these advances? In this article, we discuss, from a young person’s perspective, the strengths and limitations of using chatbots in mental health support. We also outline what we consider to be minimum ethical standards for these platforms, including issues surrounding privacy and confidentiality, efficacy, and safety, and review three existing platforms (Woebot, Joy, and Wysa) according to our proposed framework. It is our hope that this article will stimulate ethical debate among app developers, practitioners, young people, and other stakeholders, and inspire ethically responsible practice in digital mental health.
In this article, we show how a technology-mediated mental health therapy involving psycho-education, therapist moderators, and social networking can provide support for carers of young people with mental illness. This multi-faceted tool provides opportunities for users to adapt the system to their needs, leading us to refocus the goal of treatment adherence toward a relatively new phenomenon in HCI, concordance, which has not previously been examined in the HCI literature in relation to online mental-health tools. Concordance shares important links with the development of therapeutic alliance, which is centrally important to mental health therapy, and to Self-Determination Theory (SDT), which informed our approach to design. We present a three-month user study, which provides initial encouraging support for both the suitability of concordance as a lens for viewing user engagement and the idea that users can develop a therapeutic alliance with an online support system. This latter result is surprising as the phenomenon of therapeutic alliance generally describes a relationship between client and (human) clinician. Therapeutic alliance has previously been explored for face-to-face groups, and between individuals and online systems, but not for online groups. We show how even automated system behavior can encourage engagement from users and contribute to alliance formation, if the non-human parts of an online system are interactive. We argue that a design approach involving peer/moderator support as well as automated feedback, and which takes account of SDT, can provide support for therapeutic alliance.