The working alliance in automated therapy: Development of an alliance-supporting eHealth program and two grounded theory studies of relating and change

Electronic health (eHealth) programs are promising for a variety of health purposes, but there are few eHealth-specific theories describing how such programs work to support change. One possible working mechanism is a “working alliance”, considered an important element in psychotherapy. However, the alliance usually assumes an emotional bond, which seems controversial in the context of automated therapy requiring both empirical and theoretical work. In her PhD study, Marianne T. S. Holter and her associates developed a quitting smoking program specifically to support an alliance. She then conducted two qualitative, grounded theory studies on how the users related to the program and whether ways of relating influenced change. The analysis reached theoretical saturation and is based on interviews (N = 16) and triangulated with written answers within the program (theoretical samples; Study 1: N = 55, Study 2: N = 16). The analysis led to two grounded theory models. The first model suggests that people relate to eHealth program through keeping un-alive and making come-alive; thinking about the program as an inanimate object and thinking about it (through a play-like process) as a social presence. The combination of making come-alive and keeping un-alive leads to a semi-social interaction or -relationship. Most participants alternated between making come-alive and keeping un-alive. The second model suggests that these relational processes can facilitate change-space (feeling free and supported to work constructively on changing on one’s own terms). Making come-alive made participants feel understood and supported by a social presence, while keeping un-alive kept the interaction free from social forcing. The thesis launches models that can be used to generate hypotheses for further research into the working alliance as a possible eHealth working mechanism, and provides evidence supporting the alliance as a meaningful and potentially useful concept in automated therapy.