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The Digital Therapeutic Alliance: Prospects and Considerations

July 2021
JMIR Mental Health 8(7):e31385

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University of Melbourne

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.

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Editorial

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

Australia

Phone: 61 390355511

Email: dalfonso@unimelb.edu.au

Abstract

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

KEYWORDS

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

interventions.

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

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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

effectiveness.

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

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(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.

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Abbreviations

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

URL: https://mental.jmir.org/2021/7/e31385

doi: 10.2196/31385

PMID: 34283035

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Full-text available

Dec 2020

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.

A perspective on Client-Psychologist Relationships in Videoconferencing Psychotherapy: A Literature Review (Preprint)

Article

Full-text available

Mar 2020

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.

The therapeutic alliance in digital mental health interventions for serious mental illnesses: Narrative review (Preprint)

Article

Full-text available

Nov 2019

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.

“Our Online Life is Integrated with Our Physical Life” : End Users’ Perspectives on the Design and Delivery of a Blended Model of Care in First-Episode Psychosis Treatment (Preprint)

Article

Full-text available

Mar 2020

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.

Use of Social Robots in Mental Health and Well-Being Research: Systematic Review

Article

Full-text available

Jul 2019
J MED INTERNET RES

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.

Recent Developments in Digital Mental Health Interventions for College and University Students

Article

Full-text available

Sep 2019

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.

Can Your Phone Be Your Therapist? Young People’s Ethical Perspectives on the Use of Fully Automated Conversational Agents (Chatbots) in Mental Health Support

Article

Full-text available

Mar 2019

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.

Considering the Therapeutic Alliance in Digital Mental Health Interventions

Article

Mar 2019
HARVARD REV PSYCHIAT

Support for Carers of Young People with Mental Illness: Design and Trial of a Technology-Mediated Therapy

Article

Feb 2019

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.

The Digital Therapeutic Alliance: Prospects and Considerations

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