Can we kind a digital therapeutic alliance with a psychological well being app?


Apps developed to advertise psychological well being can help people to handle their very own wellbeing, alongside being a complementary device for extra conventional therapies. These apps typically encompass options corresponding to video games, duties, info, and symptom trackers. Whereas there was a surge within the growth of such apps in recent times, the proof base remains to be restricted (Lecomte et al., 2020), indicating a necessity for additional exploration.

Within the psychological well being subject, the therapeutic alliance is often understood to be a mutual working relationship, constructed on three dimensions (Bordin, 1979):

  • Bond (emotional connection)
  • Duties (small steps to work on collectively)
  • Objectives (general targets of remedy)

Analysis means that the therapeutic alliance is prime to optimistic in-person and remotely delivered therapeutic outcomes (e.g., Ardito et al., 2011; Baier et al., 2020; Kaiser et al., 2021; Martin et al., 2000). However what a couple of digital therapeutic alliance, the place an individual varieties this therapeutic relationship with an app that has no human help? I’ve solely ever thought in regards to the therapeutic alliance as being a relationship between two or extra people (e.g., a consumer and a practitioner), developed by feeling listened to, understood, and ‘seen’, so this idea is fascinating to me.

General, analysis exploring individuals’s capability to develop bonds with apps has seen blended outcomes (Tong et al 2022). So, what does it imply to construct a digital therapeutic alliance with an app? Tong and colleagues (2023) aimed to discover the size of the digital therapeutic alliance with totally automated apps by a qualitative lens.

The therapeutic alliance is commonly understood to be a mutual working relationship, built on bond, tasks, and goals. But what of the therapeutic alliance with a digital mental health app?

The therapeutic alliance is often understood to be a mutual working relationship, constructed on bond, duties, and targets. So is a therapeutic alliance potential with a digital psychological well being app that has no human help?


Tong and colleagues (2023) performed on-line semi-structured interviews with 19 adults who recognized as at present or beforehand utilizing a totally automated (i.e., with out human help) psychological well being smartphone app (53% feminine, 58% 18-24 years outdated, 79% college students).

Members had been requested about their use, expertise of and relationship with psychological well being apps. To assist perceive this last aspect, members had been requested to consider a relationship they could have beforehand had with practitioner. Ten members had by no means skilled in-person remedy, so had been as an alternative requested to think about having a therapeutic alliance with a practitioner.

Interviews lasted between 26 to 61 minutes, and knowledge was analysed utilizing thematic evaluation.


Throughout the 19 members, 20 totally different apps had been recognized, together with Headspace, Calm, and Happify.

The authors generated 5 themes:

  • Valuing flexibility
  • The position of accountability
  • The significance of emotional experiences for connections
  • Enhanced openness
  • Lack of settlement upon targets

In abstract, they discovered that members favored the pliability provided by apps – they may choose them up and put them down as wanted, and will get speedy entry at any time, which helped to construct a way of security. Nevertheless, members additionally felt that there was loads of self-motivation and accountability required, which means that if somebody was experiencing excessive ranges of difficulties, discovering motivation to have interaction with the app could possibly be a battle. Regardless of this, members nonetheless felt they may construct an emotional reference to the app, and that this could be preferable to a human connection as a result of they wouldn’t really feel like a burden to others. This connection, nevertheless, could possibly be jeopardised by a perceived lack of genuineness from the app, corresponding to extreme promotion of paid options.

Members expressed that they skilled these apps as “caring, understanding, listening, pleasant, heat, comforting, considerate, compassionate, thoughtful and affected person”. Members had been blended of their sense of the ‘openness’ of the apps, in that some felt the apps had been non-judgmental, whereas others skilled a degree of mistrust within the apps and had been cautious of sharing an excessive amount of. These issues had been largely pushed by experiences with different apps, and had been associated to worries about knowledge privateness and safety, together with monitoring info, linking accounts, and accessing info with out permission. Some members additionally mentioned that they wanted to have two-way communication, corresponding to speedy responses or steady conversations; the dearth of such a interactivity meant that they weren’t capable of kind emotional connections with the app.

Causes for app use various and included (i) avoiding emotions of loneliness and tedium, (ii) managing stress, anxiousness, sleep issues and continual ache, and (iii) as an alternative choice to getting assist from a healthcare skilled in the course of the COVID-19 pandemic. Some members solely used the apps on the advice of their mates or office. Not all members recognized clear targets whereas utilizing the apps, which the authors decided might not be an essential aspect of the digital therapeutic alliance.

The authors instructed relationships between the themes, with belief in know-how underpinning each the ‘emotional connections’ and ‘openness’ themes. I’d have discovered it fascinating to contemplate epistemic belief right here, which is inbuilt human relationships by mentalization (the method of understanding the self and others), which makes individuals really feel secure to consider themselves and their difficulties, and to be taught new details about how they perceive and navigate the world (Fonagy & Allison, 2014).

Key elements to developing a digital therapeutic alliance with mental health apps include flexibility, self-motivation, emotional connections, openness, and trust.

Key components to creating a digital therapeutic alliance with psychological well being apps embrace flexibility, self-motivation, emotional connections, openness, and belief.


Tong et al. (2023) concluded that this space is under-researched, and that their research affords the primary qualitative exploration of the size of the digital therapeutic alliance with totally automated psychological well being apps. The authors emphasised that the research aimed to conceptualise the digital therapeutic alliance, and that it could actually,

be constructed by customers’ accountability, openness to apps, emotional experiences and connections with apps, and versatile interactions with apps.

In this under-researched area, Tong et al. (2023) offer the first qualitative exploration of the dimensions of the digital therapeutic alliance with fully automated mental health apps.

On this under-researched space, Tong et al. (2023) provide the primary qualitative exploration of the size of the digital therapeutic alliance with totally automated psychological well being apps.

Strengths and limitations

A substantial power of the research is that it provides to the restricted proof base on this space and gives thought-provoking insights into how individuals have interaction with and expertise psychological well being apps. Future analysis might concentrate on bigger and extra numerous samples; for instance, it could have been fascinating if the authors had requested for the ethnicity of the pattern and mirrored extra on the demographics they did acquire. You will need to discover how ethnicity might need been related to the digital therapeutic alliance, not least to contemplate the unidimensional attributes of apps and the way these align with the dimension of cultural empathy inside the therapeutic alliance (Asnaani et al., 2012; Ullrich, 2019; Vasquez, 2007).

Lower than half of the members had expertise of a human therapeutic alliance with a practitioner, to make use of as a foundation of comparability. It could have been fascinating to discover these interview responses individually from those that did have prior experiences, notably on condition that the research was performed in the course of the COVID-19 pandemic when many individuals had been remoted and didn’t have entry to in-person remedy. There was a missed alternative to present these comparisons extra consideration.

The assumed direct switch of a therapeutic alliance to an app, in addition to utilizing subject information questions from a earlier qualitative research on person-to-person therapeutic alliance, is an space for additional consideration. What influence this might need had on the interviews and the evaluation of them is at present unknown. The overarching query for me is whether or not the connection between a consumer and their practitioner and an individual and an app is similar factor. I used to be shocked to learn the findings referring to members describing emotional connections with the apps they used, and as such, it could be fascinating to discover the variations between alliances (person-person and person-app) and related psychological well being outcomes.

The authors state that the members skilled gentle psychological well being difficulties. A lot of the analysis centered on the person-person therapeutic alliance (which underpins the ideas used on this analysis) considers purchasers accessing remedy with various ranges of want. As such, it is very important take into account this when making use of the ideas and evaluating the analysis to digital therapeutic alliance with apps.

Future research should focus on larger and more diverse samples, alongside considering how we approach measuring the digital therapeutic alliance. Is a person-app relationship comparable to a person-person relationship?

Future analysis ought to concentrate on bigger and extra numerous samples, alongside contemplating how we strategy measuring the digital therapeutic alliance. Is a person-app relationship akin to a person-person relationship?

Implications for observe

You will need to discover what it’s that makes individuals like utilizing psychological well being apps – what attracts them in, retains them engaged, and helps to help their psychological well being. Provided that there are over 10,000 psychological well being apps out there (Torous & Roberts, 2017), the exploration of what’s beneath (i.e., the frequent parts of what’s perceived as efficient and acceptable) is important to understanding how finest to offer digital psychological well being help. Tong and colleagues (2023) communicate to those questions nicely with their analysis, with their themes protecting ideas corresponding to accountability and openness. It could be fascinating to discover a few of these ideas quantitatively on a bigger scale, to know how widespread these views are.

In animal remedy analysis, researchers discuss with bonds between the animals and other people as having parallels with therapeutic alliance (Yorke et al., 2015), quite than referring to this as a therapeutic alliance itself. In an analogous method, I’m wondering if it’s okay to carry the person-person therapeutic alliance and the person-app therapeutic alliance individually, which is one thing the authors highlighted in earlier analysis (Tong et al., 2020). Within the present research, Tong and colleagues (2023) discovered that targets didn’t appear to be part of the digital therapeutic alliance, whereas that is central to the person-person therapeutic alliance. I ponder whether totally different themes would have been derived from the interviews if a distinct stance had been taken, which moved away from pre-existing information concerning the person-person therapeutic alliance, and as an alternative centered on the digital therapeutic alliance as its personal distinctive idea. This could be one thing to discover sooner or later.

Lastly, there are essential sensible and moral implications for each policy-makers and practitioners to contemplate when exploring how people work together with and expertise psychological well being apps. This analysis provokes questions corresponding to how these apps would possibly complement or change the in-person therapeutic course of, and what tips could also be wanted to help the prescribing and use of those apps.

More research is needed in this area, particularly in relation to how mental health apps are used and what common components make them effective and acceptable to users.

Extra analysis is required on this space, notably in relation to how psychological well being apps are used and what frequent parts make them efficient and acceptable to customers.

Assertion of pursuits



Main paper

Tong, F., Lederman, R., D’Alfonso, S., Berry, Okay., & Bucci, S. (2023). Conceptualizing the digital therapeutic alliance within the context of totally automated psychological well being apps: A thematic evaluation. Scientific Psychology & Psychotherapy. 

Different references

Ardito, R. B., & Rabellino, D. (2011). Therapeutic alliance and consequence of psychotherapy: historic excursus, measurements, and prospects for analysis. Frontiers in Psychology, 2, 270.

Asnaani, A., & Hofmann, S. G. (2012). Collaboration in multicultural remedy: Establishing a powerful therapeutic alliance throughout cultural traces. Journal of Scientific Psychology, 68(2), 187-197.

Baier, A. L., Kline, A. C., & Feeny, N. C. (2020). Therapeutic alliance as a mediator of change: A scientific assessment and analysis of analysis. Scientific Psychology Overview, 82, 101921.

Fonagy, P., & Allison, E. (2014). The position of mentalizing and epistemic belief within the therapeutic relationship. Psychotherapy, 51(3), 372.

Kaiser, J., Hanschmidt, F., & Kersting, A. (2021). The affiliation between therapeutic alliance and consequence in internet-based psychological interventions: a meta-analysis. Computer systems in Human Habits, 114, 106512.

Lecomte, T., Potvin, S., Corbière, M., Guay, S., Samson, C., Cloutier, B., … & Khazaal, Y. (2020). Cell apps for psychological well being points: meta-review of meta-analyses. JMIR mHealth and uHealth, 8(5), e17458.

Martin, D. J., Garske, J. P., & Davis, M. Okay. (2000). Relation of the therapeutic alliance with consequence and different variables: a meta-analytic assessment. Journal of consulting and scientific psychology, 68(3), 438.

Tong, F., Lederman, R., D’Alfonso, S., Berry, Okay., & Bucci, S. (2022). Digital therapeutic alliance with totally automated psychological well being smartphone apps: A story assessment. Frontiers in Psychiatry, 13, 819623.

Torous, J., & Roberts, L. W. (2017). Wanted innovation in digital well being and smartphone functions for psychological well being: transparency and belief. JAMA Psychiatry, 74(5), 437-438.

Ullrich, H. E. (2019). Tradition, empathy, and the therapeutic alliance. Psychodynamic Psychiatry, 47(4), 425-440.

Vasquez, M. J. (2007). Cultural distinction and the therapeutic alliance: an evidence-based evaluation. American Psychologist, 62(8), 878.

Yorke, J., Adams, C., & Coady, N. (2008). Therapeutic worth of equine-human bonding in restoration from trauma. Anthrozoös, 21(1), 17-30.

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