Evidence of Human-Level Bonds Established With a Digital Conversational Agent: Cross-sectional, Retrospective Observational Study
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Abstract
Background: 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.
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Woebot was shown to have working alliance scores comparable to those in previously published studies comparing chatbots to human-delivered services across different treatment modalities.
“Woebot was shown to have working alliance scores comparable to those in previously published studies comparing chatbots to human-delivered services across different treatment modalities [64]”
From Patient Engagement with Conversational Agents in Health Applications 2016–2022: A Systematic Review and Meta-Analysis (2024) · cites this paper as [64]
The Discussion (page unavailable) says Woebot’s working-alliance scores were comparable to those in published studies of traditional, human-delivered services across treatment modalities. The Results describe a comparison with scores reported in those studies, particularly bond-subscale scores; they do not establish that the earlier studies themselves compared chatbots with human-delivered services. (LLM, conf=0.85)
Experimental — accuracy not yet measuredThe finding that only the Fitzpatrick RCT study showed significantly higher chatbot retention over the control arm is supported by an observational study funded by the application's owner (Woebot).
“Only the Fitzpatrick RCT study showed significantly higher chatbot retention over the control arm and our result is supported by an observational study funded by the application’s owner (Woebot) [64].”
From Patient Engagement with Conversational Agents in Health Applications 2016–2022: A Systematic Review and Meta-Analysis (2024) · cites this paper as [64]
The Abstract Methods describe an observational study of Woebot users, supporting the identification of the cited study. But the study measured working alliance and depression symptoms, not retention against a control arm; its Introduction mentions engagement only in connection with the earlier Fitzpatrick trial. The passages found also do not establish that Woebot’s owner funded this study. (LLM, conf=0.82)
Experimental — accuracy not yet measuredConsistent with previous research, participants using BalanceUP established a strong alliance with the CA, which improved significantly with time.
“Consistent with previous research [67,125], participants using BalanceUP established a strong alliance with the CA, which improved significantly with time.”
From Development and Evaluation of a Smartphone-Based Chatbot Coach to Facilitate a Balanced Lifestyle in Individuals With Headaches (BalanceUP App): Randomized Controlled Trial (2024) · cites this paper as [125]
The Results report high bond scores among Woebot users, supporting the comparison to a strong alliance with a conversational agent. The Methods and Discussion describe a cross-sectional study measured within the first five days and identify longitudinal bond development as future research; this source does not establish that alliance improved significantly over time. The BalanceUP finding is the citing authors’ own result, not a finding of this source. (LLM, conf=0.86)
Experimental — accuracy not yet measuredResearch on therapeutic chatbots documents genuine benefits in circumstances of social disconnection.
“Research on therapeutic chatbots documents genuine benefits in such circumstances [21,22].”
From Encountering Generative AI: Narrative Self-Formation and Technologies of the Self Among Young Adults (2026) · cites this paper as [22]
The Results (page unavailable) report that Woebot users formed perceived therapeutic bonds comparable to those reported in studies of traditional CBT, supporting a potential relational benefit. The study did not examine people experiencing social disconnection or establish clinical benefits in that circumstance; its Conclusions say the effect of bonds on clinical outcomes needs further research. (LLM, conf=0.84)
Experimental — accuracy not yet measuredTwo studies showed that users could potentially build a bond with chatbot apps.
“However, two studies showed that users could potentially build a bond with chatbot apps.”
From Digital Therapeutic Alliance With Fully Automated Mental Health Smartphone Apps: A Narrative Review (2022) · cites this paper as [51]
Another study with Woebot found that the bond subscale rating was high and comparable to face-to-face therapy.
“Similarly, another study with Woebot found that the bond subscale rating was high and comparable to face-to-face therapy (51).”
From Digital Therapeutic Alliance With Fully Automated Mental Health Smartphone Apps: A Narrative Review (2022) · cites this paper as [51]
Two popular chatbots, Woebot and Wysa, have been shown to improve users' depression symptoms, and build therapeutic alliances that appear comparable to those formed with human therapists.
“For example, two popular chatbots, Woebot and Wysa, have been shown to improve users’ depression symptoms15,16, and build therapeutic alliances that appear comparable to those formed with human therapists17,18.”
From “It happened to be the perfect thing”: experiences of generative AI chatbots for mental health (2024) · cites this paper as [18]
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Self-citation
- Authors
- Darcy, A., Daniels, J., Salinger, D., Wicks, P., & Robinson, A.
- Affiliations
- Woebot Health (United States) (US)
- Corresponding author
- Darcy, Alison
- Venue
- JMIR Formative Research
- Publisher
- JMIR Publications Inc.
- Published
- 2021-05-11
- Volume
- 5
- Issue
- 5
- Pages
- e27868
- ISSN
- 2561-326X (ISSN-L)
- PMC
- PMC8150389
- OpenAlex
- W3161732502
- Cited by
- 260
- References
- 23
- Citations by year
- 2026: 83 · 2025: 66 · 2024: 44 · 2023: 36 · 2022: 25 · 2021: 6
- FWCI
- 24.92
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- JMIR Formative Research (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- Wellcome Trust
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Social Psychology › Social Robot Interaction and HRI
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Keywords
- therapeutic relationship, therapeutic bond, chatbots, Woebot, cognitive behavioral therapy, digital mental health interventions, depression, PHQ-2, self-referral, mobile application, empathy, group cognitive behavioral therapy, face-to-face therapy, user engagement, user retention
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