The therapy relationship in telehealth

The working relationship online

Therapy depends partly on agreement about what needs to change and whether the proposed work makes sense, as well as whether the client can say when it is not helping. Psychologists describe this as the therapeutic alliance, which is relevant across CBT, ACT, trauma-focused methods and relational therapies.

Alliance can include trust and a shared understanding of the tasks, without requiring every session to feel comfortable. A clinician needs to check whether agreement is real, especially when a person finds it difficult to raise concerns.

In a consulting room, posture, pauses or a change in the atmosphere may prompt that discussion, while video can make some cues harder to read. A calm-looking call may conceal distraction, discomfort or uncertainty about how to interrupt an explanation.

Comparisons across delivery formats

An August 2026 systematic review included nine studies comparing alliance in face-to-face, online and blended psychotherapy, mainly for adults with depression or anxiety. Three were randomised trials and six were secondary analyses of existing trials.

Participants generally rated alliance similarly across formats, although one asynchronous online program received lower ratings in week two than face-to-face care, with the difference no longer present by week eight. That finding raises questions about how expectations and familiarity develop, without establishing that a slow start will resolve for every person.

The relationship between alliance ratings and outcomes was less consistent in online and blended treatment than in face-to-face care. The authors suggested that practical collaboration towards goals might have a different relative role in digital treatment, which remains a possible interpretation requiring further study.

Privacy and the setting around the screen

A client may join from a bedroom, car or workplace where interruptions are possible, while a delay or camera angle can make silence and eye contact harder to interpret. Those conditions can affect concentration and emotional presence, particularly when the person is discussing trauma, grief or an unsafe relationship.

Telehealth may make regular attendance possible for someone outside Perth or living with pain, fatigue, caring responsibilities or an unpredictable roster. Others find that a shared physical space makes it easier to approach difficult material, and the preferred format may change as treatment progresses.

Assessment, exposure, trauma processing or conversations about risk may therefore prompt a review of the setting. The decision should consider what the person can do privately and how well they can engage, alongside the convenience of attending.

A video appointment can involve a pause whose meaning neither person is sure of, particularly when a small delay overlaps with an emotionally difficult moment. Someone may be deciding how much to say while the psychologist is wondering whether the connection has frozen, making a direct check more useful than an interpretation based on the screen alone.

For a professional working around appointments or a person whose pain limits travel, avoiding the journey can make regular treatment more realistic. Someone else may need the journey and the separate room to mark a clear boundary around therapy, especially when home is busy or lacks privacy.

Discussing how the format is working

I would ask directly whether meeting online helps the person speak and whether the work remains connected to what they sought help with. Looking away from the screen might reflect thoughtfulness, concern about someone nearby or an effort to manage overwhelm, and those possibilities call for different responses.

The client can ask for a slower pace, a clearer explanation or a different balance between talking and practising. A shared document or a particular situation brought into the session may help, while some appointments may be better held in person.

Reviewing these details gives the clinician information about whether treatment is being delivered in a usable form. Repeated difficulty with privacy or presence needs to affect the plan, even when the technology itself is functioning.

I would want to know if the session feels polite but remote, or if the person finds themselves agreeing because it is difficult to interrupt. We can discuss whether an exercise needs more explanation and whether there is enough time to work with a recent example, including when a particular appointment would be easier in person.

Limits of the evidence and ongoing review

The nine-study review covered a limited range of populations and online treatments, using different alliance measures. Similar average ratings across formats therefore cannot determine how a particular person will experience a particular appointment.

A 2024 systematic review and meta-analysis of 31 studies and 4,862 adults found a small association between alliance quality and teletherapy outcomes, stronger when alliance was measured later and outcomes were client-reported. The association cannot establish that alliance alone caused improvement, since engagement, expectations and symptom change may also contribute.

When a client can speak privately, remain present and work actively with the psychologist, telehealth may provide a workable setting for care. Where those conditions are missing, the next step is to discuss changes to the session or setting and review whether the treatment plan remains suitable.