Relational Agents in Mental Health A thesis submitted to the University of Manchester for the degree of Doctor of Clinical Psychology in the Faculty of Biology, Medicine and Health 2019 Hannah Gaffney School of Health Sciences Table of Contents Word Counts .............................................................................................................................. 7 List of Tables .............................................................................................................................. 8 List of Figures ............................................................................................................................. 8 Thesis abstract ........................................................................................................................... 9 Relational Agents in Mental Health ............................................................................... 9 Declaration ............................................................................................................................... 10 Copyright Statement ................................................................................................................ 10 Acknowledgements .................................................................................................................. 11 Paper 1: Systematic Review ..................................................................................................... 12 Abstract .................................................................................................................................... 13 Introduction ............................................................................................................................. 14 Rationale ...................................................................................................................... 14 Objectives..................................................................................................................... 15 Method .................................................................................................................................... 16 Literature Search .......................................................................................................... 16 Eligibility criteria .......................................................................................................... 17 Screening ...................................................................................................................... 17 Data extraction ............................................................................................................ 18 Risk of bias assessment ................................................................................................ 18 Results ...................................................................................................................................... 19 Study selection ............................................................................................................. 19 Figure 1. Flow diagram of included studies. Search updates were conducted until January 2019, and 2 new papers were identified and included. ................................. 20 Risk of bias ................................................................................................................... 21 Table 1. Descriptive statistics of methodological quality ............................................ 22 2 Study characteristics .................................................................................................... 24 Table 2. Characteristics of included studies. ............................................................... 26 Participants .................................................................................................................. 39 Relational agent interventions..................................................................................... 39 Feasibility and engagement ......................................................................................... 41 Psychological outcomes ............................................................................................... 42 User experience outcomes .......................................................................................... 43 Discussion................................................................................................................................. 44 Principal results ............................................................................................................ 44 Limitations of included studies .................................................................................... 46 Strengths and limitations ............................................................................................. 46 Future directions .......................................................................................................... 47 Conclusions .................................................................................................................. 48 Conflicts of interest .................................................................................................................. 49 Abbreviations ........................................................................................................................... 49 References ............................................................................................................................... 51 Paper 2: Empirical paper .......................................................................................................... 55 Acknowledgements .................................................................................................................. 56 Conflicts of interest .................................................................................................................. 56 Abstract .................................................................................................................................... 56 Significant outcomes ................................................................................................................ 57 Limitations................................................................................................................................ 58 Introduction ............................................................................................................................. 59 Aims of the Study ......................................................................................................... 61 Material and Methods ............................................................................................................. 62 Design ........................................................................................................................... 62 3 Participants .................................................................................................................. 62 Ethics ............................................................................................................................ 63 Procedures ................................................................................................................... 63 Intervention (MYLO) .................................................................................................... 64 Figure 1. MYLO conversation screen example............................................................. 65 Measures ...................................................................................................................... 66 Intervention process measure ..................................................................................... 66 Intervention engagement ............................................................................................ 67 Symptom measures ..................................................................................................... 67 Qualitative interview ................................................................................................... 68 Piloting ......................................................................................................................... 68 Statistical analysis ........................................................................................................ 69 Primary quantitative analysis....................................................................................... 69 Figure 2. Illustration of the two-level hierarchical structure of data, split by questions identified as helpful and unhelpful .............................................................................. 70 Secondary quantitative analyses ................................................................................. 71 Qualitative analysis ...................................................................................................... 71 Results ...................................................................................................................................... 72 Participant Characteristics ........................................................................................... 72 Figure 3. Recruitment flow diagram ............................................................................ 73 Primary results – intervention process ........................................................................ 74 Identification of helpful and unhelpful questions ......................................................