Evidence of Human-Level Bonds Established With a Digital Conversational Agent: Cross-sectional, Retrospective Observational Study
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. WAI-SR scores were compared to those in scientific literature abstracted from recent reviews.
Results
Data from 36,070 Woebot users were included in the analysis. Participants ranged in age from 18 to 78 years, and 57.48% (20,734/36,070) of participants reported that they were female. The mean PHQ-2 score was 3.03 (SD 1.79), and 54.67% (19,719/36,070) of users scored over the cutoff score of 3 for depression screening. Within 5 days of initial app use, the mean WAI-SR score was 3.36 (SD 0.8) and the mean bond subscale score was 3.8 (SD 1.0), which was comparable to those in recent studies from the literature on traditional, outpatient, individual CBT and group CBT (mean bond subscale scores of 4 and 3.8, respectively). PHQ-2 scores at baseline weakly correlated with bond scores (r=−0.04; P<.001); however, users with depression and those without depression had high bond scores of 3.45.
Conclusions
Although bonds are often presumed to be the exclusive domain of human therapeutic relationships, our findings challenge the notion that digital therapeutics are incapable of establishing a therapeutic bond with users. Future research might investigate the role of bonds as mediators of clinical outcomes, since boosting the engagement and efficacy of digital therapeutics could have major public health benefits.
No keywords indexed for this article. Browse by subject →
Thomas Fuchs · 2026
Yaakov Ophir · 2026
Jorge Tavares, Yanrong Yang · 2026
Freddy Jackson Brown, Isabelle Stewart Muscat · 2026
Yining Hua, Steve Siddals · 2025
Michael V. Heinz, Daniel M. Mackin · 2025
Paul Formosa, Sarah Bankins · 2025
Julian De Freitas, Zeliha Oğuz-Uğuralp · 2025
Eliane M. Boucher, Joseph S. Raiker · 2024
Ohad Ashur, Chen R. Saar · 2024
Lauren S Weiner, Ryann N Crowley · 2024
Hang Ding, Joshua Simmich · 2023
J. P. Grodniewicz, Mateusz Hohol · 2023
Zoha Khawaja, Jean-Christophe Bélisle-Pipon · 2023
I. Neumann, M. Andreatta · 2023
Luke Balcombe · 2023
Valerie Hoffman, Megan Flom · 2023
Li Yang, Xiaokun Zhu · 2022
Eliane M. Boucher, Nicole R. Harake · 2021
- Published
- May 11, 2021
- Vol/Issue
- 5(5)
- Pages
- e27868
You May Also Like
Ginger Nicol, Ruoyun Wang · 2022
104 citations
Michael Nissen, Syrine Slim · 2022
58 citations
Emre Sezgin, Syed-Amad Hussain · 2023
56 citations
Radwan Qasrawi, Stephanny Paola Vicuna Polo · 2022
56 citations
Rosa Hernandez-Ramos, Adrian Aguilera · 2021
44 citations