How a Fully Automated eHealth Program Simulates Three Therapeutic Processes: A Case Study

Marianne T S Holter, Ayna Johansen, Håvar Brendryen, Marianne T S Holter, Ayna Johansen, Håvar Brendryen

Abstract

Background: eHealth programs may be better understood by breaking down the components of one particular program and discussing its potential for interactivity and tailoring in regard to concepts from face-to-face counseling. In the search for the efficacious elements within eHealth programs, it is important to understand how a program using lapse management may simultaneously support working alliance, internalization of motivation, and behavior maintenance. These processes have been applied to fully automated eHealth programs individually. However, given their significance in face-to-face counseling, it may be important to simulate the processes simultaneously in interactive, tailored programs.

Objective: We propose a theoretical model for how fully automated behavior change eHealth programs may be more effective by simulating a therapist's support of a working alliance, internalization of motivation, and managing lapses.

Methods: We show how the model is derived from theory and its application to Endre, a fully automated smoking cessation program that engages the user in several "counseling sessions" about quitting. A descriptive case study based on tools from the intervention mapping protocol shows how each therapeutic process is simulated.

Results: The program supports the user's working alliance through alliance factors, the nonembodied relational agent Endre and computerized motivational interviewing. Computerized motivational interviewing also supports internalized motivation to quit, whereas a lapse management component responds to lapses. The description operationalizes working alliance, internalization of motivation, and managing lapses, in terms of eHealth support of smoking cessation.

Conclusions: A program may simulate working alliance, internalization of motivation, and lapse management through interactivity and individual tailoring, potentially making fully automated eHealth behavior change programs more effective.

Keywords: Internet; behavior therapy; cell phones; eHealth; intervention mapping; motivational interviewing; smoking cessation; telemedicine; text messaging; working alliance.

Conflict of interest statement

Conflicts of Interest: None declared.

Figures

Figure 1
Figure 1
Different therapeutic processes affect behavior change differently.
Figure 2
Figure 2
Choosing a topic (“negotiating” goals).
Figure 3
Figure 3
The 4 “quitters” demonstrate how to do the program exercises and model how to combine Endre’s advice with one’s own personal style.
Figure 4
Figure 4
Eliciting self-efficacy change talk through a confidence ruler.
Figure 5
Figure 5
Endre has asked the user to choose a “support person” for her quit attempt, and the user has answered that he or she wants to quit without any help.
Figure 6
Figure 6
Handling sustain talk and discord.
Figure 7
Figure 7
Visual analogy for lapsing and resuming the quit attempt.
Figure 8
Figure 8
Advance organizer of returning to the quit attempt after a lapse (from top left section): realize (“innse”), choose (“velge”), act (“handle”), and continue (“fortsett”).
Figure 9
Figure 9
From the lapse management session: the user is unsure of what to do and is asked what topic to begin with.
Figure 10
Figure 10
Hypothesized synergy effects of the 3 therapeutic processes.

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