The Therapeutic Alliance in Online Therapy

Is online therapy less effective than face-to-face therapy? Although the general consensus is that it is, what does scientific research say about this therapeutic modality that's on the increase?

Written and verified by the psychologist Loreto Martín Moya.

Last update: 20 October, 2022

The pandemic not only caused an increase in online processes but also in psychological conditions. Therefore, it was expected that online therapy would continue to develop during 2020.

In 2021, the COP (Spain) reported that 60 percent of licensed psychologists recognized an increase in demand for anxiety and depressive disorders. Likewise, 96 percent of the psychological care they carried out was conducted electronically (COP, 2021). Other university studies indicated that 68.11 percent of patients attended online sessions (Calero-Elvira, 2022).

However, what happens to therapy when it’s conducted telematically? Is online therapy less effective than face-to-face therapy? With this modality now established as a real alternative, what type of therapy is better? We answer all of these questions in this article.

The need for online care

The rise of online therapy appeared when there was an impossibility of going to face-to-face therapy due to confinement. It may have been hoped that, once the pandemic was over, so would the online therapy format come to an end. However, this wasn’t the case. In fact, the appearance of the pandemic not only helped to normalize psychological therapy in itself but also the conducting of it online.

The fact that increasingly more psychologists and companies offered online therapy made it more accessible. Similarly, it allowed people who couldn’t attend face-to-face therapy to undertake therapy.

Online therapy can be a vital tool for people who can’t travel to a center due to their geographical or physical location, especially in rural areas (Egede et al., 2009). Not everyone lives in connected areas, has their own vehicle, or someone who can drive them to therapy every week. Not all treatment centers are adapted for people with reduced mobility. Furthermore, an individual’s physical condition may prevent them from engaging in certain activities that require mobility.

Similarly, sufferers of certain conditions, such as severe OCD, may have a great deal of trouble leaving the house. Imagine an agoraphobic or sufferer of OCD with extensive and exhausting rituals. The simple fact of leaving their homes exposes them to such intense discomfort that they might completely abandon therapy, or never even attend in the first place.

Online therapy for seniors

Contrary to what might be expected, since 2009,  it’s been observed that telepsychology or online therapy is effective in population groups such as prisoners, children and adolescents, the rural population, and the elderly (Egede et al).

Older people were the first victims of the pandemic and also of the new fear that was implanted in our society: the fear of going outside. Consequently, elderly people increased their isolation, something that’s already very marked in this population group, especially in women.

Thus, the online medium became an effective option for breaking social isolation, working on this new phobia, as well as combating mobility problems and the consequences of the phobia itself. Furthermore, most of the patients only needed help from their relatives in managing the technology in the first few sessions or at the beginning of them.

Goldberg (2002) found benefits in online care for the elderly population. There was an increase in punctuality, better communication between caregivers and patients, a reduction in the burden of patients’ travel, and a greater facilitation of health education.

Effectiveness of online therapy versus face-to-face therapy

It seems to be a widespread belief in society that face-to-face therapy is more effective than online therapy. The reasons given are rather diverse. For example, the therapist doesn’t lose out on non-verbal information, it’s a more intimate process, or seeing a person in the flesh facilitates the bond between patient and therapist. However, what does science say?

Turner (2021) claimed that the positive results of online medical and psychological care were already taking place during the 2000s. Nevertheless, he also admitted that, without an event such as the pandemic, there would never have been the necessary investment for its development.

The attention and rapid development that online therapy gained gave rise to numerous meta-analyses. It was concluded that online therapy isn’t better than face-to-face therapy. That said, it was also demonstrated that face-to-face isn’t better than online (Batistini, 2021). In other words, the effectiveness of both methods was the same.

Reese et al. (2016) focused on the therapeutic alliance. In fact, they claimed that there were no significant differences between the alliance established in an online therapy process and a face-to-face one.

The indicators of the effectiveness of online therapy resided in the patient’s value judgments about the therapy model itself, and the empathy of the psychologist, both of which are present in the two methods.

Does online therapy work with all diagnoses?

We might think that online therapy doesn’t work as well with certain more serious diagnoses. In this regard, Abrams (2020) conducted a meta-analysis. He clarified some of the diagnoses whose effectiveness in online therapy was the same as in face-to-face therapy.

They were post-traumatic stress disorder (PTSD), depressive disorders, anxiety disorders, addictions, eating disorders, and specific disorders in children and adolescents.

The advantage of telepsychology: adherence to treatment

The effectiveness of the treatment, once conducted, seems to be the same both in the face-to-face and the online environment. However, it seems that online therapy has an advantage over more traditional therapy in respect of adherence to treatment. This means that fewer patients who start a therapeutic process online abandon it before finishing it.

Indeed, it seems that people abandon the therapeutic process less if it’s carried out online. Some of the observed advantages were not having to miss sessions for work reasons, not having to travel, not compromising family conciliation, and the fact that the therapy is conducted in a place chosen by the patient, where they feel comfortable.

Rafael San Román (2020) claims that one of the great challenges of online therapy that’s key to its effectiveness is the ability to adapt. For instance, what happens if a patient doesn’t have enough privacy to carry out the session at home? What if they have dependents and their caring duties interrupt the session? Or, if they’re older, they may not know how to handle the technology well. These challenges seem like a perfect scenario to strengthen the therapeutic alliance and highlight the creativity, empathy, and expertise of both psychologist and patient.

What we can conclude is that, once the therapeutic process has started, whether it be from a desk, with the help of a caregiver, or with a baby in a cradle next to the desk, we can be sure that the process will be just as effective as the one conducted in a professional’s office.