Darcy Alison, Daniels Jade, Salinger David, Wicks Paul, Robinson Athena
Woebot Health, San Francisco, CA, United States.
JMIR Form Res. 2021 May 11;5(5):e27868. doi: 10.2196/27868.
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.
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.
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.
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.
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.
处于精神困扰中的患者数量远远超过心理健康专业人员能够提供支持的时间。尽管数字工具可能有助于缓解这一问题，但批评者认为，缺乏人文关怀的技术解决方案将阻碍建立联系或治疗联盟，从而限制这些解决方案的效果。
我们旨在调查基于认知行为疗法（CBT）的对话代理的用户所报告的治疗联盟水平是否与关于其他CBT模式的文献中所描述的相似，这些模式包括面对面治疗、团体CBT以及其他不使用对话代理的数字干预措施。
采用横断面回顾性研究设计，分析2019年11月至2020年8月期间自行求助于基于CBT的全自动对话代理（Woebot）的成年用户的汇总、去识别化数据。使用简短修订版工作联盟量表（WAI-SR）测量工作联盟，并使用2项患者健康问卷（PHQ-2）评估抑郁症状状态。所有测量均由移动应用程序中的对话代理进行。将WAI-SR分数与近期综述中提取的科学文献中的分数进行比较。
分析纳入了36070名Woebot用户的数据。参与者年龄在18岁至78岁之间，57.48%（20734/36070）的参与者报告为女性。PHQ-2的平均分数为3.03（标准差1.79），54.67%（19719/36070）的用户在抑郁筛查中的得分超过了临界值3。在首次使用应用程序的5天内，WAI-SR的平均分数为3.36（标准差0.8），平均联盟子量表分数为3.8（标准差1.0），这与传统门诊个体CBT和团体CBT的近期文献研究结果相当（平均联盟子量表分数分别为4和3.8）。基线时的PHQ-2分数与联盟分数弱相关（r=-0.04；P<.001）；然而，有抑郁症状的用户和无抑郁症状的用户的联盟分数均较高，为3.45。
尽管通常认为建立联系是人类治疗关系的专属领域，但我们的研究结果挑战了数字疗法无法与用户建立治疗联盟的观点。未来的研究可以调查联系作为临床结果中介的作用，因为提高数字疗法的参与度和效果可能会带来重大的公共卫生益处。
