Working alliance with an avatar: How far can we go with internet interventions?
Open accessAbstract
To examine the working alliance between users and an avatar and users' treatment expectations in an unguided Internet intervention for the treatment of insomnia. The sample included participants from the treatment condition (N = 29) of a randomised controlled trial. The task and goal subscales of the Working Alliance Inventory Short Revised (WAI-SR) were applied in week three. Five items of the Bern Post-Session Report and one question about the extent to which users had missed a human therapist were administered after each session. Treatment expectations were measured with the Credibility Expectancy Questionnaire (CEQ), and the Insomnia Severity Index (ISI) was used as the primary outcome measure. The mean scores for the WAI-SR task and goal subscales were relatively high (M = 3.24, SD = 0.79; M = 3.16, SD = 0.91, respectively). The mean score of the five Bern Post-Session Report items remained stable over time, but some users increasingly indicated that they missed a real therapist over the course of the intervention, with a strong linear effect (t(87) = 3.16, p < 0.01). ISI chance score was predicted by the mean score of the Bern Post-Session Report (b = −0.3.83, t(21.80) = −2.97, p < 0.01), missing a human therapist (b = −0.0.13, t(20.47) = −2.72, p = 0.01) and the CEQ (b = 0.18, t(19.03) = −2.69, p = 0.01), but not by WAI-SR task and goal subscales. Results indicate that users established a working alliance with the avatar. The affective bond remained stable over time, but towards the end of the intervention some users indicated that they missed having a human therapist. Affective bond and missing a real therapist predicted symptom change.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Alliance may be possible toward a virtual therapist.
“There are indications, however, that alliance may be possible toward a virtual therapist.”
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
Statistical power analyses using G∗Power 3.1: tests for correlation and regression analyses
Faul, F., Erdfelder, E., Buchner, A., & Lang, A.-G. (2009) · Behavior Research Methods · doi:10.3758/brm.41.4.1149 · Cited by 37,615 · see citing works
nlme : Linear and nonlinear mixed effects models
DebRoy, S. (2006) · Medical Entomology and Zoology · Cited by 10,009 · see citing works
Validation of the Insomnia Severity Index as an outcome measure for insomnia research
Bastien, C. (2001) · Sleep Medicine · doi:10.1016/s1389-9457(00)00065-4 · Cited by 8,067 · see citing works
Comparison of Beck Depression Inventories -IA and -II in psychiatric outpatients
Beck, A. T., Steer, R. A., Ball, R., & Ranieri, W. F. (1996) · Journal of Personality Assessment · doi:10.1207/s15327752jpa6703_13 · Cited by 5,965 · see citing works
The generalizability of the psychoanalytic concept of the working alliance.
Bordin, E. S. (1979) · Psychotherapy: Theory, Research & Practice · doi:10.1037/h0085885 · Cited by 5,238 · see citing works
Morin, C. M., Belleville, G., Bélanger, L., & Ivers, H. (2011) · Sleep · doi:10.1093/sleep/34.5.601 · Cited by 4,620 · see citing works
Development and validation of the working alliance inventory
Horvath, A. O., & Greenberg, L. S. (1989) · Journal of Counseling Psychology · doi:10.1037//0022-0167.36.2.223 · Cited by 3,520 · see citing works
Psychometric properties of the credibility/expectancy questionnaire
Devilly, G. J., & Borkovec, T. D. (2000) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/s0005-7916(00)00012-4 · Cited by 2,295 · cited 13× · see citing works
“The CEQ was administered two weeks after the start of the intervention and the internal consistency for the full scale was α=0.969.”
MethodInfluentialnlme : linear and nonlinear mixed effects models. R package version 3.1-98
Pinheiro, J. C. (2011) · Medical Entomology and Zoology · Cited by 1,971 · see citing works
The psychotherapeutic process: A research handbook.
Greenberg, L. S., & Pinsof, W. M. (1986) · Cited by 1,386 · see citing works
Andersson, G., Cuijpers, P., Carlbring, P., Riper, H., & Hedman, E. (2014) · World Psychiatry · doi:10.1002/wps.20151 · Cited by 1,077 · see citing works
Zachariae, R., Lyby, M. S., Ritterband, L. M., & O'Toole, M. S. (2016) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2015.10.004 · Cited by 704 · cited 2× · see citing works
“One meta- analysis (Zachariae et al., 2016) identified eleven published randomised controlled trials, all of which used cognitive behavioural therapy (CBT).”
BackgroundEspie, C. A., Kyle, S. D., Williams, C., Ong, J. C., Douglas, N. J., Hames, P., & Brown, J. S. L. (2012) · Sleep · doi:10.5665/sleep.1872 · Cited by 550 · see citing works
Munder, T., Wilmers, F., Leonhart, R., Linster, H. W., & Barth, J. (2010) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.658 · Cited by 538 · see citing works
Internet-based psychological treatments for depression
Johansson, R., & Andersson, G. (2012) · Expert Review of Neurotherapeutics · doi:10.1586/ern.12.63 · Cited by 509 · see citing works
Lange, A., Rietdijk, D., Hudcovicova, M., van de Ven, J.-P., Schrieken, B., & Emmelkamp, P. M. G. (2003) · Journal of Consulting and Clinical Psychology · doi:10.1037/0022-006x.71.5.901 · Cited by 495 · see citing works
Efficacy of an Internet-based behavioral intervention for adults with insomnia
Ritterband, L. M., Thorndike, F. P., Gonder-Frederick, L. A., Magee, J. C., Bailey, E. T., Saylor, D. K., & Morin, C. M. (2009) · Archives of General Psychiatry · doi:10.1001/archgenpsychiatry.2009.66 · Cited by 482 · cited 2× · see citing works
“Most surprisingly, two of the most effective interventions were fullyautomated self-help programmes with no additional human support (Espie et al., 2012; Ritterband et al., 2009).”
BackgroundAre patient expectations still relevant for psychotherapy process and outcome
Greenberg, R. P., Constantino, M. J., & Bruce, N. (2006) · Clinical Psychology Review · doi:10.1016/j.cpr.2005.03.002 · Cited by 477 · see citing works
Knaevelsrud, C., & Maercker, A. (2007) · BMC Psychiatry · doi:10.1186/1471-244x-7-13 · Cited by 398 · see citing works
Self-citationBerger, T. (2017) · Psychotherapy Research · doi:10.1080/10503307.2015.1119908 · Cited by 364 · see citing works
Ritterband, L. M., Thorndike, F. P., Ingersoll, K. S., Lord, H. R., Gonder-Frederick, L., Frederick, C., Quigg, M. S., Cohn, W. F., & Morin, C. M. (2017) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2016.3249 · Cited by 325 · see citing works
The Penn Helping Alliance Scales.
Alexander, L. B., & Luborsky, L. B. (1986) · Cited by 275 · see citing works
Interapy. Treatment of posttraumatic stress through the Internet: a controlled trial
Lange, A., van de Ven, J.-P., Schrieken, B., & Emmelkamp, P. M. G. (2001) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/s0005-7916(01)00023-4 · Cited by 245 · see citing works
Andersson, G., Paxling, B., Wiwe, M., Vernmark, K., Felix, C. B., Lundborg, L., Furmark, T., Cuijpers, P., & Carlbring, P. (2012) · Behaviour Research and Therapy · doi:10.1016/j.brat.2012.05.003 · Cited by 202 · see citing works
Meyer, B., Bierbrodt, J., Schröder, J., Berger, T., Beevers, C. G., Weiss, M., Jacob, G., Späth, C., Andersson, G., Lutz, W., et al. (2015) · Internet Interventions · doi:10.1016/j.invent.2014.12.003 · Cited by 188 · see citing works
Validation of the insomnia severity index as a web-based measure
Thorndike, F. P., Ritterband, L. M., Saylor, D. K., Magee, J. C., Gonder-Frederick, L. A., & Morin, C. M. (2011) · Behavioral Sleep Medicine · doi:10.1080/15402002.2011.606766 · Cited by 186 · see citing works
Berger, T., Boettcher, J., & Caspar, F. (2014) · Psychotherapy · doi:10.1037/a0032527 · Cited by 158 · see citing works
Internet-delivered psychotherapy for depression in adults
Titov, N. (2011) · Current Opinion in Psychiatry · doi:10.1097/yco.0b013e32833ed18f · Cited by 158 · see citing works
Preschl, B., Maercker, A., & Wagner, B. (2011) · BMC Psychiatry · doi:10.1186/1471-244x-11-189 · Cited by 158 · see citing works
Self-citationFlückiger, C., Regli, D., Zwahlen, D., Hostettler, S., & Caspar, F. (2010) · Zeitschrift für Klinische Psychologie und Psychotherapie · doi:10.1026/1616-3443/a000015 · Cited by 138 · see citing works
Lorenz, N., Heim, E., Rötger, A., Birrer, E., & Maercker, A. R. A. (2018) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465818000486 · Cited by 90 · see citing works
Self-citationJasper, K., Weise, C., Conrad, I., Andersson, G., Hiller, W., & Kleinstäuber, M. (2014) · Internet Interventions · doi:10.1016/j.invent.2014.04.002 · Cited by 68 · see citing works
El Alaoui, S., Ljótsson, B., Hedman, E., Svanborg, C., Kaldo, V., & Lindefors, N. (2016) · PLOS ONE · doi:10.1371/journal.pone.0161191 · Cited by 51 · see citing works
Systematic literature review of Internet interventions across health behaviors
Hou, S., Charlery, S.-A. R., & Roberson, K. (2014) · Health Psychology and Behavioral Medicine · doi:10.1080/21642850.2014.895368 · Cited by 48 · see citing works
Patient Expectations in Internet-Based Self-Help for Social Anxiety
Boettcher, J., Renneberg, B., & Berger, T. (2013) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2012.759615 · Cited by 47 · see citing works
Self-Help Books for People with Depression: the Role of the Therapeutic Relationship
Richardson, R., Richards, D. A., & Barkham, M. (2009) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465809990452 · Cited by 46 · see citing works
Mellado, A., Suárez, N., Altimir, C., Martìnez, C., Pérez, J., Krause, M., & Horvath, A. O. (2016) · Psychotherapy Research · doi:10.1080/10503307.2016.1147657 · Cited by 22 · see citing works
Flagged first, then by citations
Cited by
Sorted by citations
Fiske, A., Henningsen, P., & Buyx, A. (2019) · Journal of Medical Internet Research · doi:10.2196/13216 · Cited by 857 · see citing works
Better, Virtually: the Past, Present, and Future of Virtual Reality Cognitive Behavior Therapy
Lindner, P. (2021) · International Journal of Cognitive Therapy · doi:10.1007/s41811-020-00090-7 · Cited by 120 · see citing works
The Working Alliance Inventory for guided Internet interventions (WAI‐I)
Gómez Penedo, J. M., Berger, T., grosse Holtforth, M., Krieger, T., Schröder, J., Hohagen, F., Meyer, B., Moritz, S., & Klein, J. P. (2020) · Journal of Clinical Psychology · doi:10.1002/jclp.22823 · Cited by 100 · see citing works
Herrero, R., Vara, M. D., Miragall, M., Botella, C., García-Palacios, A., Riper, H., Kleiboer, A., & Baños, R. M. (2020) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph17176169 · Cited by 81 · see citing works
Miloff, A., Carlbring, P., Hamilton, W., Andersson, G., Reuterskiöld, L., & Lindner, P. (2020) · Journal of Medical Internet Research · doi:10.2196/16660 · Cited by 60 · see citing works
Gómez Penedo, J. M., Babl, A. M., grosse Holtforth, M., Hohagen, F., Krieger, T., Lutz, W., Meyer, B., Moritz, S., Klein, J. P., & Berger, T. (2020) · Journal of Medical Internet Research · doi:10.2196/15824 · Cited by 33 · see citing works
Hennemann, S., Böhme, K., Kleinstäuber, M., Ruckes, C., Baumeister, H., Daniel Ebert, D., Küchler, A.-M., & Witthöft, M. (2022) · Behavior Therapy · doi:10.1016/j.beth.2022.06.006 · Cited by 11 · see citing works
- Authors
- Heim, E., Rötger, A., Lorenz, N., & Maercker, A.
- Affiliations
- University of Zurich (CH)
- Leipzig University (DE)
- Corresponding author
- Heim, Eva
- Venue
- Internet Interventions
- Publisher
- Elsevier BV
- Published
- 2018-03
- Volume
- 11
- Pages
- 41-46
- ISSN
- 2214-7829 (ISSN-L)
- PMC
- PMC6084819
- OpenAlex
- W2791599715
- Cited by
- 41
- References
- 37
- Citations by year
- 2026: 4 · 2025: 3 · 2024: 5 · 2023: 5 · 2022: 5 · 2021: 7 · 2020: 9 · 2019: 3
- FWCI
- 5.99
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Internet Interventions (publishedVersion, cc-by-nc-nd)
- Europe PMC (PubMed Central) (publishedVersion, cc-by-nc-nd)
- PubMed Central (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- Zurich Open Repository and Archive (University of Zurich) (acceptedVersion, cc-by-nc-nd)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- SERVAL (Université de Lausanne) (submittedVersion)
- Zurich Open Repository and Archive (University of Zurich) (submittedVersion, cc-by-nc-nd)
- Zurich Open Repository and Archive (University of Zurich)
- Funders
- National Science Foundation
- Schweizerischer Nationalfonds zur Förderung der Wissenschaftlichen Forschung (150698)
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Keywords
- therapeutic relationship, insomnia treatment, treatment expectations, affective bonds, Insomnia Severity Index
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
