A promising tool for bettering people’s health is eHealth (or “mHealth”) programs: fully automated, web-based health interventions. However, we know surprisingly little about eHealth’s working mechanisms. One possible working mechanism is that program users benefit from a collaborative “relationship”—a “working alliance”—with the program. Although evidence support the existence of a person-to-program alliance it is unclear if and how it influences change. Therefore, we conducted a grounded theory study of how relating to an eHealth program for quitting smoking influenced the participants’ change processes. The ensuing model focuses on how participants got change-space—feeling free from social forcing and able to work constructively on changing—and how the relational processes “making come-alive” and “keeping un-alive” were instrumental in this process. By presenting evidence that relating may influence change in automated therapy, this study supports the person-to-program alliance as a working mechanism in eHealth.


Working Alliance, Therapeutic Alliance, E-Alliance, eHealth, mHealth, Telehealth, Grounded Theory, Qualitative Research

Author Bio(s)

Marianne T. S. Holter, MA, is a research fellow at the Norwegian Centre for Addiction Research, University of Oslo. This article is part of her PhD-dissertation, also handed in at the Norwegian Centre for Addiction Research. Her PhD research has focused on the working alliance in automated eHealth therapy. She has a MA in psychology and is currently working on a qualitative health reform evaluation project. Correspondence regarding this article can be addressed directly to: marianne.holter@protonmail.com.

Ottar Ness, PhD, family therapist, works as professor of counseling at the Norwegian University of Science and Technology, and adjunct professor of mental health care at University College of South-Eastern Norway and Nord University (Norway). He has considerable experience of doing action research projects within the field of family therapy, recovery, mental health and substance abuse field. His research is in the field of relational welfare in order to co-construct and co-create dignifying lives and communities. He is also working with research recovery processes and recovery-oriented practices and services with people with mental health and substance abuse problems. Among his latest books are a Handbook of Couples Therapy, and Handbook of Family Therapy and Action Research. Correspondence regarding this article can also be addressed directly to: ottar.ness@ntnu.no.

Ayna B. Johansen, PhD, was a senior research fellow at the Norwegian Centre for Addiction Research, University of Oslo, but tragically past away from sudden illness in spring 2018. She had a degree in clinical psychology and a PhD from Wayne State University in Detroit, Michigan, and extensive experience with research within the fields of substance abuse, eHealth, helping relationships, and the working alliance.

Håvar Brendryen, PhD in psychology, works as senior researcher at the Norwegian Centre for Addiction Research, University of Oslo. His research is centered around eHealth interventions, and he has published extensively on the design of such interventions and their efficacy. During the last years his research focus has shifted more and more towards the working mechanisms of eHealth. Correspondence regarding this article can also be addressed directly to: brendryen@gmail.com.

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