Análisis de datos y comparación de

Qualitative research can provide rich and detailed insights regarding health-related experiences (Hawker, Payne, Kerr, Hardey, & Powell, 2002). It was decided that the inclusion of qualitative research was likely to present in-depth data regarding users' experiences of the human-technology relationship when engaging with a TBI. Accordingly, both qualitative and quantitative designs were included in this review, forming a systematic mixed studies review (SMSR; Pluye et al., 2009).

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3.3.1 Search strategy

The following databases were searched: Academic Search Complete; PsycINFO; PubMed; Scopus; and Web of Science. They were chosen because they index

literature from a wide range of relevant health professions, and cover technology and health. The indexing of relevant journals was also checked to ensure they were covered by these databases.

Groups of search terms were devised to locate papers covering the following: psychological interventions; an “online” or “digital technology” focus; the therapeutic alliance or relationship; and mental health (see Appendix A for full search terms and strategies). Search strategies differed only in the available MeSH or thesaurus terms in each database to narrow the results down to mental health. Some search terms (“online” words and “intervention” words) were limited to the abstract, to ensure relevance of results and a minimisation of “noise”.

The “alliance” words were searched for in the “full text” or “all” field. This was to pick up papers that did not have therapeutic alliance as a core focus of the paper, but might still have investigated the construct.

As searching databases may only yield 50% of all relevant research (Whittemore & Knafl, 2005), backwards and forward tracking of included papers was also

undertaken. Google Scholar was used for forward tracking, as well as database functions (Web of Science in the first instance; PsycINFO if the paper is not indexed in Web of Science).

3.3.2 Inclusion and exclusion criteria 3.3.2.1 Study design

Peer reviewed papers using qualitative, quantitative, or mixed methods were included which presented the results of a published primary research study in English.

3.3.2.2 Participants

The participant groups were those that used a TBI to improve their mental health. Participants were not required to have a diagnosis of any particular condition, and there was no age limit. Participants that used a TBI only for something other than a

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mental health condition (for example a physical health issue, neurological disorders, or developmental disorders) were not eligible for inclusion. Studies which had any groups other than mental health service users (for example therapists/clinicians) as the only providers of relevant data were also excluded. This criterion was set because we wished to understand therapeutic alliance experiences directly from those using TBIs.

3.3.2.3 Interventions

To be included, participants must have used an intervention which is consistent with the definition of “technology-based interventions” (TBI). Firstly, the intervention had to be technology delivered: it may be accessed via computer program, CD- ROM, website or smartphone application (not necessarily an exhaustive list). It must be mainly accessed on a self-help/self-guided basis, although some human support to use the intervention was acceptable. Interventions that still have contact from a human therapist as the key delivery method for the therapy (for example,

videoconferencing or email therapy) were excluded. The intervention had to be used on an individual basis, as opposed to a family-focused intervention, for example. It must be primarily focused upon mental health change; interventions focusing solely on other issues, such as physical health, were excluded. Whilst CBT-based TBIs are the most common, any theoretical approach was acceptable.

3.3.2.4 Relevance to the human-technology relationship

Relevance to therapeutic alliance, therapeutic relationship, or human-computer interaction had to be demonstrated. The paper could demonstrate this by containing a measure of therapeutic alliance or relationship, which has been applied to a person’s relationship with the technology (i.e. excluded if the measure was applied to a human therapist). Alternatively, a paper was included if somewhere in the method, results, or discussion section, there was a stated relevance to the therapeutic alliance, therapeutic relationship or human-computer interaction (for example, in qualitative themes).

3.3.3 Screening

The records retrieved from database searching were first downloaded into Endnote Web. Duplicates were excluded, initially by using the Endnote Web function and

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after that, manually by LH. Screening of the results was also conducted using Endnote Web.

Records retrieved in the search strategy were screened at multiple levels (title, abstract, full text) by two researchers (LH and BM). At each stage, the researchers met to discuss their decisions for each record. Discrepancies were discussed and resolved with reference to the criteria outlined above. In the event that a discrepancy could not be resolved, senior members of the research team (FL and SJ) were

consulted. At each stage, a subset of papers were screened (for example, the first 10%) to check criteria and clarify any issues before proceeding with the rest of the screening. Figure 1 summarises the screening procedure, consistent with PRISMA guidance (Liberati et al., 2009).

3.3.4 Data extraction

Two data extraction forms were constructed (see Appendix B). The first form concerned the “key study details”, for example: the sample’s clinical issues; TBI format; and methodology details. The second form was used to extract data for the framework synthesis (see “Analysis Strategy”). Data was extracted here about the measurement of participants’ relationship with the TBI, or whether a paper had studied the association of other factors with therapeutic alliance strength.

Data extraction was performed primarily by LH, with BM checking a subset (23%) of the papers.

3.3.5 Quality assessment

Papers were quality appraised using the Mixed Methods Appraisal Tool (MMAT; Pluye et al., 2009) which provides a method for appraising mixed methods studies. Papers were not excluded on the basis of quality, as all relevant findings were viewed as potentially valuable for adding to our understanding. Furthermore,

previous examples of framework synthesis exist in which studies are not excluded on the basis of quality (for example, Carroll et al., 2011). A consideration of the

methodological issues present in the papers contributes instead towards the synthesis.

Quality assessment was performed primarily by LH, and SJ checked the appraisal of all papers. See Appendix J for the full scoring of each paper.

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3.3.6 Analysis strategy

“Best fit framework synthesis” (Carroll et al., 2011) was the selected analysis approach. Whilst an a priori framework is used to begin analysis, there is also room for new themes which are identified in the data outside the framework. This review paper aims to examine whether therapeutic alliance theories remain valid in TBIs, by applying a framework built from existing theories onto the data, whilst also

inspecting the data for additional, emergent alliance dimensions.

The framework structure was informed firstly by Bordin’s (1979) tripartite model of the therapeutic alliance and the additional dimensions of the Agnew Relationship Measure (ARM; Agnew‐Davies et al., 1998): a sense that the client and therapist are working together jointly (partnership); optimism about treatment (confidence); the degree to which the client can take control over the therapy’s direction (client initiative); and feeling able to disclose personal issues without fear of judgement (openness). Framework synthesis was used to explore the model of the therapeutic alliance in TBIs, the factors that influence this alliance, and whether this alliance was connected with outcomes of therapy.

Due to the heterogeneity of the included studies in this review, a meta-analysis of the quantitative data was not feasible.

3.4 Results