Teletherapy by synchronous videoconferencing or telephone seems to result in similar clinical outcomes as traditional in-person therapy. However, clinicians feel that teletherapy compared to in-person therapy is less satisfactory, effective, and emotionally deep, and it requires more cognitive effort. Despite that, most clinicians intend to continue using teletherapy for at least part of their practice. Research on teletherapy is in its infancy, and we know very little about therapeutic processes and how they impact patient outcomes. For example, we know relatively little about the role of the therapeutic alliance in teletherapy. The therapeutic alliance refers to the collaborative agreement between patient and therapist on the goals of therapy, the tasks of therapy, and their relational bond. The alliance may lead to symptom reduction by improving patients’ interpersonal functioning providing a positive relational experience, and creating a safe context in which patients may use therapy best. Research suggests a highly robust moderate correlation between therapeutic alliance and patient outcomes across all types of therapy (r = 0.28). Previous studies suggest that compared to in-person therapy the level of the therapeutic alliance is similar in teletherapy. But is the alliance in teletherapy as important? In this meta-analysis, Aafjes-van Doorn and colleagues assessed if the therapeutic alliance is correlated with patient outcomes in teletherapy. The authors accumulated 34 different samples in which teletherapy (synchronized videoconferencing and by telephone), mostly CBT, was provided to individual adults. The overall correlation between therapeutic alliance and outcome was r = 0.15 (p = .001, 95% CI [0.07, 0.24], k = 34), and the correlation was slightly higher when considering only videoconferencing, r = 0.19 (p = .002, 95% CI [0.07, 0.31]). In other words, the effect is small but statistically significant and appears may be smaller than typically seen in in-person therapy.
Practice Implications
Although potentially important, the association between the therapeutic alliance and patient outcomes in teletherapy may be relatively small. If this is the case, then something different may be happening in teletherapy that sets it apart from in-person therapy. Factors like patient engagement, patient motivation, therapeutic presence, therapist fatigue during online work, and level of emotional engagement may be contributing to lowering the effect of the alliance. There are, however, technical problems with this research that lower our confidence in these findings. Therapeutic alliance scales were developed for the in-person context, and we do not know if these scales are valid in the teletherapy context. And no teletherapy research has disentangled the alliance's average effect across all patients from the session-to-session fluctuation of the alliance within individual patients. So, we need to learn more about how important the therapeutic alliance is for teletherapy.
Aafjes-van Doorn, K., Sping, D.S., Horne, S.J., & Bekes, V. (2024). The association between quality of therapeutic alliance and treatment outcomes in teletherapy: A systematic review and meta-analysis. Clinical Psychology Review, 110, 102430. https://doi.org/10.1016/j.cpr.2024.102430.
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