Quick summary: Current evidence shows that therapy delivered by video or text can build a therapeutic alliance comparable to in person treatment, which matters because the strength of that relationship is closely linked to how well people recover. For clients, this means that distance, limited mobility or anxiety about attending a clinic need not stand in the way of effective care, although privacy at home, reliable internet and confidence with technology still shape who benefits. For healthcare services and policymakers, the practical step is to offer a range of formats, train therapists to build rapport through a screen, and match each person to the format that suits them instead of treating all digital therapy as one thing.
Imagine entering a therapy session without leaving the room you are sitting in. There is no waiting room or consulting room, only a screen connecting two people. Digital therapy has made support easier to reach for many people, yet it raises a question that psychologists take seriously: can meaningful therapeutic connection survive when therapist and client are separated by a screen? At the centre of this question is the therapeutic alliance, the collaborative relationship between therapist and client. Its importance is well established. A meta-analysis of 295 studies involving more than 30,000 patients found a significant positive association between alliance quality and treatment outcomes, and a comparable association appeared in internet-based psychotherapy.
What the therapeutic alliance involves
The alliance is more than whether a client likes their therapist. Bordin’s model describes it through three components: agreement on goals, agreement on the tasks needed to reach them, and a bond between therapist and client. Because the alliance is collaborative, physical proximity may matter less than it first appears. Goals, tasks and trust can all be built through a digital platform, although the way this happens may change. Measurement adds a complication. A systematic review of alliance research identified 48 instruments used in adult psychotherapy, yet only two were designed for online work. Applying a face-to-face measure to messaging or video may not capture the same thing, so asking whether online therapy has “the same” alliance as in-person therapy may be too simple a question.
The case against the screen
There are sensible reasons for concern. Face-to-face therapy offers speech, facial expression, posture and eye contact within a shared room. On video, framing, camera position and screen size alter what a therapist can see, and in text-based therapy most non-verbal information disappears. Poor connections, audio delays and frozen screens can interrupt conversational rhythm and emotional continuity. Therapy at home also brings privacy and boundary issues, since a client may worry about being overheard or be interrupted by family, pets or other responsibilities. A screen may reduce interpersonal intensity too, which could ease disclosure for some people and create emotional distance for others. Earlier research reflects this mixed picture. A 2018 research found good working alliance in videoconferencing psychotherapy, but their meta-analysis did not establish non-inferiority compared with face-to-face treatment. A possible difference therefore cannot be dismissed, although it also falls short of showing that digital therapy produces a poorer relationship.
What recent evidence shows
More recent work is more reassuring. A meta-analysis of 18 publications compared alliance in videoconferencing and in-person psychotherapy and found no statistically significant difference in ratings from either patients or therapists. Standardised mean differences were –0.09 for patient ratings and 0.04 for therapist ratings. This challenges the assumption that sharing a room is a prerequisite for a strong alliance. It does not prove the two experiences are identical, and it covers videoconferencing only. Text-based therapy offers further evidence. A scoping review of 23 studies, mostly involving email or integrated messaging, found generally high alliance scores and mostly positive links between alliance and outcomes, even without facial expression, vocal tone or physical presence. Writing also gives clients time to shape their thoughts before responding, which some find less intimidating. Separately, a review of teletherapy found a significant association between alliance and treatment outcomes. Technology therefore closes some relational possibilities and opens others.
Digital therapy is many things
Three encounters show why the term is slippery: a live video call, an exchange of asynchronous written messages, and a self-guided cognitive behavioural therapy programme with minimal therapist contact. All are digital, yet the relationships involved differ greatly, so findings from one cannot automatically be applied to another. Who benefits also varies. Remote sessions can remove geographical, physical and practical barriers, and a familiar setting may lower anxiety. A crowded household, unreliable internet or limited confidence with technology can work against the same client. Therapists matter too, since reading pauses and tone on video differs from the skills that asynchronous messaging demands.
What this means for practice
Digitalisation has changed the conditions in which therapeutic relationships develop, with real challenges around non-verbal communication, privacy and technical disruption. Current evidence does not suggest these changes necessarily compromise the alliance, and its strength appears to depend on the modality, the people involved and the context. A shared physical space may therefore be unnecessary for the alliance to remain meaningful. Future research could usefully examine how connection can be maintained and adapted as psychological practice becomes increasingly digital.
Nya Miller Davies is currently studying BSc education, psychology and special educational needs at Cardiff Metropolitan University.
