How do users of a mental health app conceptualise digital therapeutic alliance? A qualitative study using the framework approach.

Abstract

Background: Self-guided mental health smartphone applications (apps) have the potential to increase access to evidence-based psychological interventions and reduce the burden on staff resources in strained mental health services. Within human-delivered therapy, the working relationship (therapeutic alliance) between the client and therapist is well studied and has been consistently linked to effective and engaging therapy. However, less is known about whether a digital therapeutic alliance exists, what its components may be, and how it can be fostered to improve engagement and adherence to smartphone applications. This study explored the experiences of users of a mental health app to better understand digital therapeutic alliance and how persuasive systems design may help us understand which features of app design influence this relationship.

Methods: We conducted a qualitative study using semi-structured interviews with 13 participants who had recent experiences of using the STOP app which targets paranoia. Data were analyzed using framework analysis with therapeutic alliance and persuasive systems design as deductive theoretical frameworks.

Results: We constructed five dimensions of digital therapeutic alliance: 1) Humanness of the app, 2) Personal meaningfulness, 3) Progression towards goals, 4) How is it to use the app, and 5) Flexibility enhances relationship. Themes 1-4 map onto the existing dimensions of therapeutic alliance, and Theme 5 (Flexibility enhances relationship) provides the context within which a digital therapeutic alliance forms. Persuasive systems design features were found to reinforce and enhance aspects of digital therapeutic alliance.

Conclusions: This study provides valuable insight into the existence of digital therapeutic relationships (alliance) and its dimensions. From our findings, there are indicators that digital therapeutic alliance is a digital analogue of therapeutic alliance and is enhanced by persuasive features of the app. Findings from this study could be used to inform the design of mental health apps to enhance their capacity to foster digital therapeutic alliance with users, with the supposition that as with the traditional therapeutic alliance, its digital counterpart is also conducive to better efficacy in mental health apps.