Digital Therapeutic Alliance With Fully Automated Mental Health Smartphone Apps: A Narrative Review

Abstract

Fully automated mental health smartphone apps show strong promise in increasing access to psychological support. Therefore, it is crucial to understand how to make these apps effective. The therapeutic alliance (TA), or the relationship between healthcare professionals and clients, is considered fundamental to successful treatment outcomes in face-to-face therapy. Thus, understanding the TA in the context of fully automated apps would bring us insights into building effective smartphone apps which engage users. However, the concept of a digital therapeutic alliance (DTA) in the context of fully automated mental health smartphone apps is nascent and under-researched, and only a handful of studies have been published in this area. In particular, no published review paper examined the DTA in the context of fully automated apps. The objective of this review was to integrate the extant literature to identify research gaps and future directions in the investigation of DTA in relation to fully automated mental health smartphone apps. Our findings suggest that the DTA in relation to fully automated smartphone apps needs to be conceptualized differently to traditional face-to-face TA. First, the role of bond in the context of fully automated apps is unclear. Second, human components of face-to-face TA, such as empathy, are hard to achieve in the digital context. Third, some users may perceive apps as more non-judgmental and flexible, which may further influence DTA formation. Subdisciplines of computer science, such as affective computing and positive computing, and some human-computer interaction (HCI) theories, such as those of persuasive technology and human-app attachment, can potentially help to foster a sense of empathy, build tasks and goals and develop bond or an attachment between users and apps, which may further contribute to DTA formation in fully automated smartphone apps. Whilst the review produced a relatively limited quantity of literature, this reflects the novelty of the topic and the need for further research.

Artificial intelligence technologies and compassion in healthcare: A systematic scoping review

“…Automated VR exposure therapies can improve adherence and efficacy of self-guided treatments ( Miloff et al, 2020 ) and address challenges of asynchronous feedback in traditional care ( Brandt et al, 2018 ). Learning from persuasive/positive technology and human-app attachment can potentially help to foster a sense of empathy, build tasks and goals, and develop bonds and digital therapeutic alliance ( Tong et al, 2022 ). Medical AI carebots can overcome barriers to care and adherence to treatment for people who experience stigma (the concept of beneficent dehumanization of care) ( Palmer and Schwan, 2022 ).…”

“…For example, in one design study black men ( n = 25) designed a Black male virtual clinician (VC) that was named Agent Leveraging Empathy for eXams (ALEX) and referred to as “brother-doctor”; participants wanted to interact with ALEX over their regular doctor ( Wilson-Howard et al, 2021 ). While automated services could extend access to psychological support, research into digital therapeutic alliance is needed to ensure AI technologies work for diverse patient groups ( Scholten et al, 2017 ; Grekin et al, 2019 ; Tong et al, 2022 ). The first therapeutic alliance instrument developed for use with embodied virtual therapists is the Virtual Therapist Alliance Scale (VTAS): preliminary assessments suggest that alliance toward a virtual therapist is a significant predictor of treatment outcome ( Miloff et al, 2020 ).…”

“…← Digital therapeutic bond research in conversational agents (Darcy et al, 2021) ← Automated VR exposure therapies (VRETs) for patient adherence and efficacy of self-guided treatments (Brandt et al, 2018;Miloff et al, 2020) ← Digital therapeutic alliance research (Tong et al, 2022) ← Using apps to promote access and adherence to treatment for people who experience stigma (beneficent dehumanization of care) (Palmer and Schwan, 2022) (4) Making a judgement about the suffering (the need to act) --…”

EMPOWER in Daily Life: A Qualitative Investigation of End User Experience of a blended digital intervention for relapse prevention in schizophrenia in a cluster randomised controlled feasibility trial.

“…The high user engagement observed in the EMPOWER trial appeared best explained by the intervention offering a range of potential affordances that were personally meaningful to participants. For example, participants who were isolated were afforded human contact; in contrast, participants who did not want to speak to people were also afforded the opportunity to communicate how they were feeling via self-monitoring without talking to another humanakin to a digital therapeutic alliance (Tong et al, 2022). Due to the flexibility of EMPOWER, both distinct affordances could be satisfied, resulting in engagement.…”

Enhancing the conversational agent with an emotional support system for mental health digital therapeutics

“…While face-to-face psychological counseling is an effective approach to treating a variety of mental health issues, only a small percentage of individuals have access to it. According to Tong et al ( 4 ), the demand for professional mental health therapists is high, and nearly 60 percent of those with a mental disorder are unable to receive treatment.…”