How do users of a mental health app conceptualise digital therapeutic alliance? A qualitative study using the framework approach
Abstract Background Self-guided mental health smartphone applications (apps) have the potential to increase access to evidence-based psychological interventions and reduce the burden on staff resources in strained mental health services. Within human-delivered therapy, the working relationship (ther...
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2025-07-01
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| Online Access: | https://doi.org/10.1186/s12889-025-23603-5 |
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| author | Theresa Taylor Simon D’Alfonso Maria João Tralhão Dolan Jenny Yiend Pamela Jacobsen |
| author_facet | Theresa Taylor Simon D’Alfonso Maria João Tralhão Dolan Jenny Yiend Pamela Jacobsen |
| author_sort | Theresa Taylor |
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| description | Abstract Background Self-guided mental health smartphone applications (apps) have the potential to increase access to evidence-based psychological interventions and reduce the burden on staff resources in strained mental health services. Within human-delivered therapy, the working relationship (therapeutic alliance) between the client and therapist is well studied and has been consistently linked to effective and engaging therapy. However, less is known about whether a digital therapeutic alliance exists, what its components may be, and how it can be fostered to improve engagement and adherence to smartphone applications. This study explored the experiences of users of a mental health app to better understand digital therapeutic alliance and how persuasive systems design may help us understand which features of app design influence this relationship. Methods We conducted a qualitative study using semi-structured interviews with 13 participants who had recent experiences of using the STOP app which targets paranoia. Data were analyzed using framework analysis with therapeutic alliance and persuasive systems design as deductive theoretical frameworks. Results We constructed five dimensions of digital therapeutic alliance: 1) Humanness of the app, 2) Personal meaningfulness, 3) Progression towards goals, 4) How is it to use the app, and 5) Flexibility enhances relationship. Themes 1–4 map onto the existing dimensions of therapeutic alliance, and Theme 5 (Flexibility enhances relationship) provides the context within which a digital therapeutic alliance forms. Persuasive systems design features were found to reinforce and enhance aspects of digital therapeutic alliance. Conclusions This study provides valuable insight into the existence of digital therapeutic relationships (alliance) and its dimensions. From our findings, there are indicators that digital therapeutic alliance is a digital analogue of therapeutic alliance and is enhanced by persuasive features of the app. Findings from this study could be used to inform the design of mental health apps to enhance their capacity to foster digital therapeutic alliance with users, with the supposition that as with the traditional therapeutic alliance, its digital counterpart is also conducive to better efficacy in mental health apps. |
| format | Article |
| id | doaj-art-1b3afd329e124c3984a8c0f6d7eb2af9 |
| institution | Kabale University |
| issn | 1471-2458 |
| language | English |
| publishDate | 2025-07-01 |
| publisher | BMC |
| record_format | Article |
| series | BMC Public Health |
| spelling | doaj-art-1b3afd329e124c3984a8c0f6d7eb2af92025-08-20T03:46:15ZengBMCBMC Public Health1471-24582025-07-0125111510.1186/s12889-025-23603-5How do users of a mental health app conceptualise digital therapeutic alliance? A qualitative study using the framework approachTheresa Taylor0Simon D’Alfonso1Maria João Tralhão Dolan2Jenny Yiend3Pamela Jacobsen4Department of Psychology, University of BathSchool of Computing and Information Systems, University of MelbourneDepartment of Psychology, University of BathInstitute of Psychiatry, Psychology and Neuroscience, King’s College LondonDepartment of Psychology, University of BathAbstract Background Self-guided mental health smartphone applications (apps) have the potential to increase access to evidence-based psychological interventions and reduce the burden on staff resources in strained mental health services. Within human-delivered therapy, the working relationship (therapeutic alliance) between the client and therapist is well studied and has been consistently linked to effective and engaging therapy. However, less is known about whether a digital therapeutic alliance exists, what its components may be, and how it can be fostered to improve engagement and adherence to smartphone applications. This study explored the experiences of users of a mental health app to better understand digital therapeutic alliance and how persuasive systems design may help us understand which features of app design influence this relationship. Methods We conducted a qualitative study using semi-structured interviews with 13 participants who had recent experiences of using the STOP app which targets paranoia. Data were analyzed using framework analysis with therapeutic alliance and persuasive systems design as deductive theoretical frameworks. Results We constructed five dimensions of digital therapeutic alliance: 1) Humanness of the app, 2) Personal meaningfulness, 3) Progression towards goals, 4) How is it to use the app, and 5) Flexibility enhances relationship. Themes 1–4 map onto the existing dimensions of therapeutic alliance, and Theme 5 (Flexibility enhances relationship) provides the context within which a digital therapeutic alliance forms. Persuasive systems design features were found to reinforce and enhance aspects of digital therapeutic alliance. Conclusions This study provides valuable insight into the existence of digital therapeutic relationships (alliance) and its dimensions. From our findings, there are indicators that digital therapeutic alliance is a digital analogue of therapeutic alliance and is enhanced by persuasive features of the app. Findings from this study could be used to inform the design of mental health apps to enhance their capacity to foster digital therapeutic alliance with users, with the supposition that as with the traditional therapeutic alliance, its digital counterpart is also conducive to better efficacy in mental health apps.https://doi.org/10.1186/s12889-025-23603-5Therapeutic allianceDigital therapeutic alliancePersuasive systems designSelf-guided mental health smartphone applicationUnguided digital interventionMobile phone |
| spellingShingle | Theresa Taylor Simon D’Alfonso Maria João Tralhão Dolan Jenny Yiend Pamela Jacobsen How do users of a mental health app conceptualise digital therapeutic alliance? A qualitative study using the framework approach BMC Public Health Therapeutic alliance Digital therapeutic alliance Persuasive systems design Self-guided mental health smartphone application Unguided digital intervention Mobile phone |
| title | How do users of a mental health app conceptualise digital therapeutic alliance? A qualitative study using the framework approach |
| title_full | How do users of a mental health app conceptualise digital therapeutic alliance? A qualitative study using the framework approach |
| title_fullStr | How do users of a mental health app conceptualise digital therapeutic alliance? A qualitative study using the framework approach |
| title_full_unstemmed | How do users of a mental health app conceptualise digital therapeutic alliance? A qualitative study using the framework approach |
| title_short | How do users of a mental health app conceptualise digital therapeutic alliance? A qualitative study using the framework approach |
| title_sort | how do users of a mental health app conceptualise digital therapeutic alliance a qualitative study using the framework approach |
| topic | Therapeutic alliance Digital therapeutic alliance Persuasive systems design Self-guided mental health smartphone application Unguided digital intervention Mobile phone |
| url | https://doi.org/10.1186/s12889-025-23603-5 |
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