Working alliance with an avatar: How far can we go with internet interventions?

OBJECTIVE: To examine the working alliance between users and an avatar and users' treatment expectations in an unguided Internet intervention for the treatment of insomnia. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.