Accepted for/Published in: JMIR Formative Research
Date Submitted: Feb 10, 2021
Date Accepted: Apr 4, 2021
Evidence of human-level bond established with a digital conversational agent: An observational study
ABSTRACT
Background:
There are more patients in mental distress than healthcare professional hours to support them. While digital tools may help, critics suggest that technology without human empathy prohibits a bond or therapeutic alliance from being formed, limiting their applicability.
Objective:
To investigate whether users of a cognitive behavioral therapy (CBT) based conversational agent report a similar level of therapeutic “bond” to literature from other CBT modalities.
Methods:
Cross sectional, retrospective analysis of de-identified aggregate data from a fully automated conversational agent delivering CBT (“Woebot”) available to smartphone users as “your self-care expert” via app stores in English-speaking countries between November 2019 and August 2020. Working alliance was measured by the Working Alliance Inventory-Short Revised (WAI-SR), and the 2-item Patient Health Questionnaire (PHQ-2) for depression symptom status, with WAI-SR data compared to data abstracted from recent reviews of the scientific literature.
Results:
The study analyzed aggregate, de-identified data from 36,070 adult users self-referred to a self-directed cognitive behavior therapy app for symptoms of anxiety and depression, guided by a fully automated conversational agent. Participants ranged in age from 18 to 78 years and 57% reported female gender. Mean PHQ-2 score was 3.03 (SD 1.79) with 55% scoring over the cutoff score of 3 for depression screening. Within 5 days of initial app use, mean WAI-SR score was 3.36 (SD 0.8) with a mean Bond subscale score of 3.8 (SD 1.0) comparing favorably with recent studies from the literature of traditional outpatient individual CBT and group CBT (mean Bond subscale 4 and 3.8, respectively). Bond did not differ meaningfully among Woebot users by age or gender.
Conclusions:
Woebot users spontaneously report that sharing their feelings and engaging in cognitive restructuring techniques feels easier with a non-human informant, with less potential to feel stigma or shame. Future research might consider further development of these “relational agents” and investigate the role of bond as a mediator of clinical outcomes. Clinical Trial: Not applicable
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