What makes telehealth feel like real therapy?

The part of therapy that is easy to miss

Therapy is more than someone explaining a technique or giving you something to practise between sessions. It also depends on whether the two of you can work out what you are trying to change, whether the work makes sense, and whether you can say when it is not helping. That is true in CBT and ACT, just as it is in EMDR, schema therapy or psychodynamic work.

Psychologists often use the term therapeutic alliance for this working relationship. It does not mean that the client and psychologist have to like each other, or that every session should feel comfortable. It is closer to a shared understanding of the job. What are we doing here? Why this approach? What are we going to do when the plan is not fitting?

Those questions can be answered in a consulting room without either person saying much about them. A pause, a change in posture or the feeling that the conversation has gone flat can prompt a psychologist to check in. Online, some of that information is harder to read. It can also be easier for a client to say everything is fine when they are actually distracted, uncomfortable or unsure how to raise a concern.

The evidence is reassuring, with some catches

A systematic review published in August 2026 brought together nine studies comparing the therapeutic alliance in face-to-face, online and blended psychotherapy. The studies involved adults receiving treatment mainly for depression or anxiety. Three were randomised trials and six were secondary analyses of existing trials.

The broad finding was that people rated the alliance similarly across the different formats. That is useful, particularly because telehealth is sometimes discussed as though a video call must be a thinner version of therapy. The result does not support that assumption.

There was a catch. In one study, people using an asynchronous online programme rated the relationship lower during the second week than people receiving face-to-face care. By the eighth week, the difference had gone. It is possible that people need time to understand how contact will work, what the psychologist expects from them and whether the exercises are worth doing. A slow start should not be treated as proof that online therapy is a poor fit, but neither should it be waved away.

The review found that the link between alliance ratings and treatment outcomes was less consistent in online and blended care than in face-to-face treatment. The authors suggested that digital therapy might put more weight on the practical business of working towards goals and a little less on the felt experience of sitting in the same room. That is an interesting possibility, not a settled conclusion.

The room still makes a difference

A video appointment can be personal and oddly impersonal at the same time. A client might be speaking from a bedroom, a parked car or an office where someone could walk in. There can be a slight delay before a response, a camera angle that makes eye contact feel unnatural, or a moment when both people are trying to work out whether the silence is thoughtful or technical.

None of this means that a psychologist needs to recreate a consulting room on a laptop. It does mean that the setting becomes part of the clinical picture. Privacy, concentration and the ability to stay emotionally present are not minor housekeeping details when someone is talking about trauma, shame, grief or a relationship that already feels unsafe.

For some people, the distance makes therapy possible. Someone living outside Perth may not be able to travel regularly. A busy professional may find it easier to protect an hour without losing half a day to transport. A person managing pain, fatigue, caring responsibilities or an unpredictable work roster may attend more consistently from home. Other people feel the separation keenly and find that difficult material is easier to approach in a shared physical space.

The same format can therefore be useful for one person and unhelpful for another. It can even change for the same person as treatment moves from assessment into exposure work, trauma processing or conversations about risk.

It is worth asking how the format is landing

In practice, I would rather ask about this directly than assume a calm-looking video call tells me much. Are you getting what you need from meeting this way? Is it easier to talk from home, or harder? Are we spending too much time working around the technology? Does the work feel connected to what you wanted help with?

These questions are not a sign that the psychologist lacks confidence in telehealth. They are a way of finding out whether the treatment is being delivered in a form the client can actually use. A person who keeps looking away from the screen may be thinking carefully, feeling watched by someone else in the house, or trying not to become overwhelmed. The psychologist cannot know which one without asking.

The client has a role here as well. It is reasonable to ask for a slower pace, a clearer explanation of an exercise, a different balance between talking and practising, or a change to the way the session is structured. Some people will benefit from using a shared document or bringing a particular situation into the session. Others might decide that certain appointments would be better in person.

That is not a complaint about the psychologist. It is useful information about the treatment.

Telehealth is a setting, not a guarantee

The research so far is encouraging, but it is not broad enough to settle every question. The 2026 review included only nine studies, mostly involving adults with depression or anxiety. The online treatments were not all the same, and the studies used different ways of measuring the alliance. A similar average score across groups cannot tell us how a particular person will experience a particular session.

A 2024 systematic review and meta-analysis of 31 studies involving 4,862 adults found a small association between the quality of the alliance and treatment outcomes in teletherapy. The association was stronger when the alliance was measured later in treatment and when the outcome was reported by the client. That fits ordinary clinical experience, but it does not show that alliance on its own caused the improvement. Engagement, expectations, symptom change and the person’s opportunity to use the treatment may all be involved.

For me, the conclusion is simpler. Online therapy will not suit everyone, and moving onto a screen does not automatically take something important away. The medium deserves to be discussed. If the client can speak privately, stay present and work actively with the psychologist, telehealth may be a very workable form of care. If those conditions are not there, the answer may be to change the session, change the setting or reconsider the treatment plan.

A good therapy relationship is not created by a room, a camera or a particular brand of software. It is built through attention, candour and a shared willingness to notice when the work needs to change.