Only connect: The working alliance in computer-based cognitive behavioral therapy

“…Carroll, DiClemente, Longabaugh, & Donovan, 1997; Connors, DiClemente, Derman, Kadden, & Carroll, 2000; Fenton, Cecero, Nich, Frankforter, & Carroll, 2001), and (3) reflects the broad conceptualization of the alliance that is consistent with Bordin’s pantheoretical definition (Bordin, 1979).”

“The Substance Use Calendar (Carroll et al., 2004) was used to assess substance use, which is a calendar-based assessment of self-reported substance use similar to the Timeline Follow Back (Fals-Stewart, O'Farrell, Freitas, McFarlin, & Rutigliano, 2000; Sobell & Sobell, 1992).”

“The Working Alliance Inventory (WAI; Horvath & Greenberg, 1989) was selected as the starting point for the development of an instrument evaluating the working alliance in technology-based interventions, as it (1) is a widely used measure with very strong psychometric properties (Horvath &…”

“In traditional clinician-delivered interventions, the working alliance (also referred to as the therapeutic alliance) is one of the most consistent predictors of positive treatment outcomes (Horvath, Del Re, Fluckiger, & Symonds, 2011; Martin, Garske, & Davis, 2000).”

“…alliance in technology-based interventions, as it (1) is a widely used measure with very strong psychometric properties (Horvath & Greenberg, 1986; Horvath & Symonds, 1991; Tichenor & Hill, 1989; Tracey & Kokotovic, 1989), (2) has been shown to predict outcome in a variety of populations,…”

“…dissemination of evidence-based therapies, such as cognitive behavioral therapy (CBT), have spurred development of numerous technology-based interventions (see reviews, Cuijpers et al., 2009; Kaltenthaler et al., 2006; Marks et al., 2009; Richardson, Stallard, & Velleman, 2010; Spek et al., 2007).”

“…it (1) is a widely used measure with very strong psychometric properties (Horvath & Greenberg, 1986; Horvath & Symonds, 1991; Tichenor & Hill, 1989; Tracey & Kokotovic, 1989), (2) has been shown to predict outcome in a variety of populations, including substance users (Cecero, Fenton, Nich,…”

“Third, this study did not obtain WAI ratings from the clinicians, limiting the ability to separate the variability in WAI scores according to therapist variability and client variability (Baldwin et al., 2007; Crits-Christoph et al., 2009).”

“…guiding/providing the technology-based intervention are in line with ratings found in face-to-face therapies (Andersson et al., 2012; Cook & Doyle, 2002; Kay-Lambkin, Baker, Lewin, & Carr, 2011; Knaevelsrud & Maercker, 2007; Preschl, Maercker, & Wagner, 2011; Sucala et al., 2012).”

“Those that have measured a working alliance with a specific technology-based intervention did not include an evaluation of the psychometric characteristics of the adapted measure (Bickmore, Gruber, & Picard, 2005; Ormrod et al., 2010).”

“…a positive working alliance early in treatment has been associated with greater engagement, retention, and early improvements in substance use (Gibbons et al., 2010; Ilgen, McKellar, Moos, & Finney, 2006; Meier, Barrowclough, & Donmall, 2005; Meier, Donmall, McElduff, Barrowclough, & Heller, 2006).”

“…magnitude of therapist effects, multilevel models applied to clinical trial data have shown that 5–10% of the total variability in outcomes is attributable to between-therapists differences (Crits-Christoph et al., 1991; Elkin, Falconnier, Martinovich, & Mahoney, 2006; Kim, Wampold, & Bolt, 2006).”

“…such as providing broader access to empirically supported treatments, consistency in treatment delivery (i.e., increased fidelity), decreasing the demands on clinician time and clinic resources, and cost effectiveness (Carroll & Rounsaville, 2010; Marks & Cavanagh, 2009; Marsch & Dallery, 2012).”

“The Substance Use Calendar (Carroll et al., 2004) was used to assess substance use, which is a calendar-based assessment of self-reported substance use similar to the Timeline Follow Back (Fals-Stewart, O'Farrell, Freitas, McFarlin, & Rutigliano, 2000; Sobell & Sobell, 1992).”

“…use disorders, many technology-based interventions have demonstrated positive treatment outcomes (e.g., Bickel, Marsch, Buchhalter, & Badger, 2008; Budney et al., 2011; Carroll et al., 2008; Gustafson et al., 2011; Hester, Delaney, & Campbell, 2011; Ondersma, Chase, Svikis, & Schuster, 2005).”

“…dissemination of evidence-based therapies, such as cognitive behavioral therapy (CBT), have spurred development of numerous technology-based interventions (see reviews, Cuijpers et al., 2009; Kaltenthaler et al., 2006; Marks et al., 2009; Richardson, Stallard, & Velleman, 2010; Spek et al., 2007).”

“…guiding/providing the technology-based intervention are in line with ratings found in face-to-face therapies (Andersson et al., 2012; Cook & Doyle, 2002; Kay-Lambkin, Baker, Lewin, & Carr, 2011; Knaevelsrud & Maercker, 2007; Preschl, Maercker, & Wagner, 2011; Sucala et al., 2012).”

“…magnitude of therapist effects, multilevel models applied to clinical trial data have shown that 5–10% of the total variability in outcomes is attributable to between-therapists differences (Crits-Christoph et al., 1991; Elkin, Falconnier, Martinovich, & Mahoney, 2006; Kim, Wampold, & Bolt, 2006).”

“…interventions, as it (1) is a widely used measure with very strong psychometric properties (Horvath & Greenberg, 1986; Horvath & Symonds, 1991; Tichenor & Hill, 1989; Tracey & Kokotovic, 1989), (2) has been shown to predict outcome in a variety of populations, including substance users…”

“…dissemination of evidence-based therapies, such as cognitive behavioral therapy (CBT), have spurred development of numerous technology-based interventions (see reviews, Cuijpers et al., 2009; Kaltenthaler et al., 2006; Marks et al., 2009; Richardson, Stallard, & Velleman, 2010; Spek et al., 2007).”

“…(2) has been shown to predict outcome in a variety of populations, including substance users (Cecero, Fenton, Nich, Frankforter, & Carroll, 2001; Connors, Carroll, DiClemente, Longabaugh, & Donovan, 1997; Connors, DiClemente, Derman, Kadden, & Carroll, 2000; Fenton, Cecero, Nich, Frankforter, &…”

“…to explore the relationship between the WAI-Tech and several common substance use treatment outcomes (Carroll, Kiluk, Nich, DeVito, et al., 2014; Donovan et al., 2012), such as the days retained in treatment, the percentage of days of self-reported abstinence from cocaine, the percentage of…”

“For the treatment of substance use disorders, many technology-based interventions have demonstrated positive treatment outcomes (e.g., Bickel, Marsch, Buchhalter, & Badger, 2008; Budney et al., 2011; Carroll et al., 2008; Gustafson et al., 2011; Hester, Delaney, & Campbell, 2011; Ondersma, Chase,…”

“…ratings with a clinician/therapist guiding/providing the technology-based intervention are in line with ratings found in face-to-face therapies (Andersson et al., 2012; Cook & Doyle, 2002; Kay-Lambkin, Baker, Lewin, & Carr, 2011; Knaevelsrud & Maercker, 2007; Preschl, Maercker, & Wagner, 2011;…”

“…period, which is consistent with reports in other areas indicating no relationship between treatment outcomes and alliance within technology-based interventions (Andersson et al., 2012; Bickmore, Gruber, & Picard, 2005; Knaevelsrud & Maercker, 2006; Ormrod et al., 2010; Preschl et al., 2011).”

“…use disorders, many technology-based interventions have demonstrated positive treatment outcomes (e.g., Bickel, Marsch, Buchhalter, & Badger, 2008; Budney et al., 2011; Carroll et al., 2008; Gustafson et al., 2011; Hester, Delaney, & Campbell, 2011; Ondersma, Chase, Svikis, & Schuster, 2005).”

“…a widely-used and well validated measure of the working alliance (WAI; Horvath & Greenberg, 1989) and implemented it in the context of a randomized trial evaluating the effectiveness of Computer-Based Training for Cognitive Behavioral Therapy (CBT4CBT; Carroll, Kiluk, Nich, Gordon, et al., 2014).”

“…robustness of the alliance as a predictor of treatment outcomes has been somewhat mixed after accounting for prior symptom change (e.g., Barber, Connolly, Crits-Christoph, Gladis, & Siqueland, 2000; Falkenstrom, Granstrom, & Holmqvist, 2014; Strunk, Brotman, & DeRubeis, 2010; Webb et al., 2011).”

“Briefly, CBT4CBT (Carroll et al., 2008; Carroll et al., 2009) is a computer-based version of CBT for substance use disorders (Carroll, 1998) that uses videos, games, cartoons, and interactive exercises to teach CBT concepts and coping skills in an engaging manner.”

“…a positive working alliance early in treatment has been associated with greater engagement, retention, and early improvements in substance use (Gibbons et al., 2010; Ilgen, McKellar, Moos, & Finney, 2006; Meier, Barrowclough, & Donmall, 2005; Meier, Donmall, McElduff, Barrowclough, & Heller, 2006).”

“…guiding/providing the technology-based intervention are in line with ratings found in face-to-face therapies (Andersson et al., 2012; Cook & Doyle, 2002; Kay-Lambkin, Baker, Lewin, & Carr, 2011; Knaevelsrud & Maercker, 2007; Preschl, Maercker, & Wagner, 2011; Sucala et al., 2012).”

“…including substance users (Cecero, Fenton, Nich, Frankforter, & Carroll, 2001; Connors, Carroll, DiClemente, Longabaugh, & Donovan, 1997; Connors, DiClemente, Derman, Kadden, & Carroll, 2000; Fenton, Cecero, Nich, Frankforter, & Carroll, 2001), and (3) reflects the broad…”

“…such as providing broader access to empirically supported treatments, consistency in treatment delivery (i.e., increased fidelity), decreasing the demands on clinician time and clinic resources, and cost effectiveness (Carroll & Rounsaville, 2010; Marks & Cavanagh, 2009; Marsch & Dallery, 2012).”

“…a positive working alliance early in treatment has been associated with greater engagement, retention, and early improvements in substance use (Gibbons et al., 2010; Ilgen, McKellar, Moos, & Finney, 2006; Meier, Barrowclough, & Donmall, 2005; Meier, Donmall, McElduff, Barrowclough, & Heller, 2006).”

“…magnitude of therapist effects, multilevel models applied to clinical trial data have shown that 5–10% of the total variability in outcomes is attributable to between-therapists differences (Crits-Christoph et al., 1991; Elkin, Falconnier, Martinovich, & Mahoney, 2006; Kim, Wampold, & Bolt, 2006).”

“…robustness of the alliance as a predictor of treatment outcomes has been somewhat mixed after accounting for prior symptom change (e.g., Barber, Connolly, Crits-Christoph, Gladis, & Siqueland, 2000; Falkenstrom, Granstrom, & Holmqvist, 2014; Strunk, Brotman, & DeRubeis, 2010; Webb et al., 2011).”

“…such as providing broader access to empirically supported treatments, consistency in treatment delivery (i.e., increased fidelity), decreasing the demands on clinician time and clinic resources, and cost effectiveness (Carroll & Rounsaville, 2010; Marks & Cavanagh, 2009; Marsch & Dallery, 2012).”

“…such as providing broader access to empirically supported treatments, consistency in treatment delivery (i.e., increased fidelity), decreasing the demands on clinician time and clinic resources, and cost effectiveness (Carroll & Rounsaville, 2010; Marks & Cavanagh, 2009; Marsch & Dallery, 2012).”

“Third, this study did not obtain WAI ratings from the clinicians, limiting the ability to separate the variability in WAI scores according to therapist variability and client variability (Baldwin et al., 2007; Crits-Christoph et al., 2009).”

“There have been reports that some clients do describe a form of relationship with computerized interventions (Bickmore, Gruber, & Picard, 2005; Bickmore, Caruso, Clough-Gorr, & Heeren, 2005; Kaplan, Farzanfar, & Friedman, 2003; Ormrod et al., 2010).”

“…use disorders, many technology-based interventions have demonstrated positive treatment outcomes (e.g., Bickel, Marsch, Buchhalter, & Badger, 2008; Budney et al., 2011; Carroll et al., 2008; Gustafson et al., 2011; Hester, Delaney, & Campbell, 2011; Ondersma, Chase, Svikis, & Schuster, 2005).”

“…Tichenor & Hill, 1989; Tracey & Kokotovic, 1989), (2) has been shown to predict outcome in a variety of populations, including substance users (Cecero, Fenton, Nich, Frankforter, & Carroll, 2001; Connors, Carroll, DiClemente, Longabaugh, & Donovan, 1997; Connors, DiClemente, Derman, Kadden, &…”

“Others have measured the alliance with a therapist/clinician who provided online counseling (Andersson et al., 2012; Holmes & Foster, 2012; Sucala et al., 2012), or provided brief check-ins in accordance with a computer-assisted treatment (e.g., Kay-Lambkin et al., 2011).”

“Those that have measured a working alliance with a specific technology-based intervention did not include an evaluation of the psychometric characteristics of the adapted measure (Bickmore, Gruber, & Picard, 2005; Ormrod et al., 2010).”

“Others have measured the alliance with a therapist/clinician who provided online counseling (Andersson et al., 2012; Holmes & Foster, 2012; Sucala et al., 2012), or provided brief check-ins in accordance with a computer-assisted treatment (e.g., Kay-Lambkin et al., 2011).”

“…use disorders, many technology-based interventions have demonstrated positive treatment outcomes (e.g., Bickel, Marsch, Buchhalter, & Badger, 2008; Budney et al., 2011; Carroll et al., 2008; Gustafson et al., 2011; Hester, Delaney, & Campbell, 2011; Ondersma, Chase, Svikis, & Schuster, 2005).”

“…a positive working alliance early in treatment has been associated with greater engagement, retention, and early improvements in substance use (Gibbons et al., 2010; Ilgen, McKellar, Moos, & Finney, 2006; Meier, Barrowclough, & Donmall, 2005; Meier, Donmall, McElduff, Barrowclough, & Heller,…”

“Multiple challenges to dissemination of evidence-based therapies, such as cognitive behavioral therapy (CBT), have spurred development of numerous technology-based interventions (see reviews, Cuijpers et al., 2009; Kaltenthaler et al., 2006; Marks et al., 2009; Richardson, Stallard, & Velleman, 2010; Spek et al., 2007…”

“To build up a social relationship [28] and working alliance [22] with participants, the linguistic style of SELMA was based on the assumption that interpersonal closeness is positively related to the attachment bond between the patient and chatbot [25,58,59].”

“As mentioned above, these are small studies, including an open trial [65] and secondary analyses [53,63], and the alliance was heterogeneously assessed, raising questions about reliability.”

“So-called ”serious games,“ (ie, games developed for treatment purposes), are also showing promise in symptom improvement in certain cases [51,67,68].”

“However, some studies have not reported meaningful correlations between ratings and clinical outcomes in the digital context (32, 36, 41–43).”

“The WAI-TECH has adequate reliability and validity (Kiluk et al., 2014).”

“The therapeutic alliance was evaluated at weeks 2 and 6 using the Working Alliance Inventory (WAI; Horvath and Greenberg, 1986) for all participants (completed by both clients and clinicians), and a version of the WAI for technologybased interventions (WAI-Tech; Kiluk et al., 2014) for those assigned to CBT4CBT.”

“Even the so-called Working Alliance Inventory for Technology-Based Interventions essentially takes this approach [11].”

“[29] did not find that the total scores on the long form of the WAI-Tech were associated with the change in therapeutic outcomes.”

“…Molly (sense.ly), Lark (lark.com), koko (itskoko.com) and various other messaging services, have recently gained interest in academia and industry with both inconclusive [20] and promising results related to user acceptance [5], working alliance [4] and treatment success [9, 14].”

“’s [68] work, who adapted the complete WAI to measure working alliance with a technology-based intervention (WAI-Tech).”

“To assess attachment bond, we adopt the bond subscale of the Working Alliance Inventory for Technology-Based Interventions [32].”

“full-length guided internet-based psychotherapy is often on par with that of face-to-face psychotherapy, but few direct comparisons have been conducted [52].”

“For example, Kiluk and colleagues [30] assessed working alliance in a sample of cocaine-dependent patients who were assigned to either treatment as usual (TAU: methadone maintenance plus regular sessions with a counselor) or TAU plus 7 sessions of a computerized cognitive behavioral intervention.”

“Only Kiluk et al [24] presented an exploratory analysis of the adapted version of the WAI (ie, WAI-Tech) with some evidence of internal consistency (Cronbach alpha) and external validity (ie, significant correlations with the original WAI and with patient treatment satisfaction).”

“In both the general psychotherapy (Horvath and Luborsky, 1993; Wampold, 2001) and addiction-specific treatment literature (Beutler et al., 1994; Kiluk et al., 2014; Moos, 2007; Urbanoski et al., 2012), the “therapeutic alliance” is viewed as an essential factor in treatment.”

“…have shown that clients can and do report strong working alliances with their therapist (Andersson et al ., 2012b; Hadjistavropoulos et al ., 2017; Kiluk et al ., 2014; Knaevelsrud and Maercker, 2007; Perera-Delcourt and Sharkey, 2019; Schneider et al ., 2016), and that these are in line with the…”

“Within the group assigned to CBT4CBT, TAS-20 scores were not significantly associated with completion of CBT4CBT modules, homework assignments or reported ‘alliance’ with CBT4CBT as measured by the adapted WAI-Tech (Kiluk et al., 2014).”

“Comprising of task, bonds and goals (34) shared between coach and coachee, it is a key predictor of health behavior and attitude change (35).”

“The emergence of computer-delivered interventions offers tremendous promise with respect to making evidence-based treatments more broadly accessible to those who may benefit from them (Carroll & Rounsaville, 2010; Greist, 2008; Marsch, Carroll, & Kiluk, 2014).”

“1) [40]; Short Screening Scale for lifetime Diagnostic and Statistical Manual of Mental Disorders, fourth edition, Posttraumatic Stress Disorder [41]; client satisfaction questionnaire [42]; Working Alliance Inventory adapted for web-based interventions [43], and treatment adherence (finished modules, time spent on mo…”

“For participants who receive human coaching, satisfaction with the human health coach will be assessed at the beginning, during, and the end of the program with the Session Alliance Inventory (α=.94) [86] and an adaption of the Working Alliance Inventory [87,88].”

“We further measured relationship quality with the German adapted item [40] “How would you characterize your relationship with Robo?” (translation by the authors), with answers on a scale ranging from 1 (“complete stranger”) to 5 (“close friend”), and the German adapted item [41] “I think Robo liked me” (translation by…”

“, 2011), and that clients can form a good therapeutic alliance using internet-based technologies (Andersson et al., 2012; Kiluk et al., 2014; Bengtsson et al., 2015).”

“The task subscale reflected how responsive Lumen was to the participant’s focus or need; the goal subscale reflected the extent to which goals were important, mutual, and capable of being accomplished; and the bond subscale reflected the degree of mutual liking and attachment [24].”

“…55,10 Hedman et al., 2015 guided self-help (2) nein 12 früh spezifisch 41,55 Jasper et al., 2014 guided self-help (2) nein 10 früh spezifisch 51,92 Kiluk et al., 2014 TAU + cCBT (3) ja 8 früh spezifisch 43,40 Knaevelsrud und Maercker, 2006 guided self-help (2) nein 5 mittel spezifisch 35,00…”

“The perceived relationship between the user and the eCoach will be assessed at the end of the program using the Working Alliance Inventory [37] adapted for Web-based interventions (WAI-TECH).”

“Similarly, Kiluk and colleagues (Kiluk et al., 2014) used a version of the Working Alliance Inventory (Horvath & Greenberg, 1989) adapted for e-interventions (WAI-Tech) to examine working alliance with their computer-based CBT intervention for cocaine use disorder.”

“To assess the attachment bond of the participants with the digital coaches PIA and PETE and also the shared understanding between them and subjects with respect to the EMA goals and tasks, a short version of the working alliance inventory for technology is adopted from previous work [110-113].”

“By exploring how participants related to the program, we hoped to achieve a better understanding of a person-to-program alliance [26-28] as a potential eHealth working mechanism.”

“Intervention acceptability measures include two end-of-session surveys completed after PST sessions 1, 4, and 8 in either active intervention group: User Experience Questionnaire-Short version (UEQ-S) [50] and adapted Working Alliance Inventory (WAI-Tech) [51].”

“Specifically, the affective bond seems to be lacking in comparison to the therapist, while there was no difference between the patients’ alliances with the online program and the therapists regarding the agreement on tasks and goals of the therapy [25].”

“There is evidence suggesting the existence of a personto-program alliance (Bickmore, Gruber, & Picard, 2005; Kiluk et al., 2014; Meyer et al., 2015).”

“It is worth noting that working alliance with IBIs may be different from working alliance with only clinicians [41]; thus, additional research is needed to further elucidate the nature of patients’ ratings of working alliance with IBIs and their comparability to working alliance ratings for clinicians in face-to-face…”

“…empirical studies that examined the association between outcomes and existing measures purported to assess digital alliance within unguided mHealth interventions have been mixed; some have detected the expected association (e.g., Miloff et al., 2020), and others have not (e.g., Kiluk et al., 2014).”

“In this study, we used the WAI-Tech survey, which kept the same subscales (task, bond, and goal) as the original WAI, but was adapted for digital interventions by rewording the items and omitting human elements [16].”

“Furthermore, studies have even suggested that online interventions do not make it possible to express empathy and, therefore, make it impossible to maintain an excellent therapeutic alliance (Cook & Doyle, 2002; Kiluk et al., 2014; Shulman & Shruf, 2020).”

“There is also emerging evidence that positive therapeutic alliance can be experienced in a completely un-supported digital environment (Clarke et al. 2016; Kiluk et al. 2014; Ormrod et al. 2010).”

“Research suggests that clients and counselors can develop a working alliance through telehealth services (Cook & Doyle, 2004; Kiluk et al., 2014; Lingely-Pottie & McGrath, 2006; Preschl et al., 2011).”

“A paper by Kiluk et al .”