Evidence of Human-Level Bonds Established With a Digital Conversational Agent: Cross-sectional, Retrospective Observational Study

Background: There are far more patients in mental distress than there is time available for mental health professionals to support them. Although digital tools may help mitigate this issue, critics have suggested that technological solutions that lack human empathy will prevent a bond or therapeutic alliance from being formed, thereby narrowing these solutions’ efficacy. Objective: We aimed to investigate whether users of a cognitive behavioral therapy (CBT)–based conversational agent would report therapeutic bond levels that are similar to those in literature about other CBT modalities, including face-to-face therapy, group CBT, and other digital interventions that do not use a conversational agent. Methods: A cross-sectional, retrospective study design was used to analyze aggregate, deidentified data from adult users who self-referred to a CBT-based, fully automated conversational agent (Woebot) between November 2019 and August 2020. Working alliance was measured with the Working Alliance Inventory-Short Revised (WAI-SR), and depression symptom status was assessed by using the 2-item Patient Health Questionnaire (PHQ-2). All measures were administered by the conversational agent in the mobile app.

Introduction. Significant barriers to mental health care are persistent [1]. The increased burden of depression and anxiety, which arose during the COVID-19 pandemic, has exacerbated this issue [2], as the

Discussion / Conclusion. This is the first study of working alliance among users of a CA for mental health. Most users were female (20,734/36,070, 57.48%) and had PHQ-2 scores that were indicative of depression (19,719/36,070, 54.67%). Working alliance scores were comparable to those in previously published studies on traditional, human-delivered services across different treatment modalities. Working alliance scores were highest for the bond subscale, suggesting that this subscale is a viable construct for CAs and should be included in hypothesized frameworks of digital working alliance.