JOURNAL OF MEDICAL INTERNET RESEARCH Sucala et al

Review

The Therapeutic Relationship in E-Therapy for Mental Health: A

Systematic Review

Madalina Sucala1,2, PhD; Julie B Schnur1, PhD; Michael J Constantino3, PhD; Sarah J Miller1, PsyD; Emily H
Brackman1; Guy H Montgomery1, PhD
1
Department of Oncological Sciences, Mount Sinai School of Medicine, New York, NY, United States
2
Department of Clinical Psychology and Psychotherapy, Babes-Bolyai University, Cluj-Napoca, Romania
3
Department of Psychology, University of Massachusetts Amherst, Amherst, MA, United States

Corresponding Author:
Madalina Sucala, PhD
Department of Oncological Sciences
Mount Sinai School of Medicine
Box 1130
1425 Madison Avenue
New York, NY, 10029
United States
Phone: 1 212 659 5504 ext 85504
Fax: 1 212 659 5479
Email: [email protected]

Abstract
Background: E-therapy is defined as a licensed mental health care professional providing mental health services via e-mail,
video conferencing, virtual reality technology, chat technology, or any combination of these. The use of e-therapy has been rapidly
expanding in the last two decades, with growing evidence suggesting that the provision of mental health services over the Internet
is both clinically efficacious and cost effective. Yet there are still unanswered concerns about e-therapy, including whether it is
possible to develop a successful therapeutic relationship over the Internet in the absence of nonverbal cues.
Objective: Our objective in this study was to systematically review the therapeutic relationship in e-therapy.
Methods: We searched PubMed, PsycINFO, and CINAHL through August 2011. Information on study methods and results
was abstracted independently by the authors using a standardized form.
Results: From the 840 reviewed studies, only 11 (1.3%) investigated the therapeutic relationship. The majority of the reviewed
studies were focused on the therapeutic alliance—a central element of the therapeutic relationship. Although the results do not
allow firm conclusions, they indicate that e-therapy seems to be at least equivalent to face-to-face therapy in terms of therapeutic
alliance, and that there is a relationship between the therapeutic alliance and e-therapy outcome.
Conclusions: Overall, the current literature on the role of therapeutic relationship in e-therapy is scant, and much more research
is needed to understand the therapeutic relationship in online environments.

(J Med Internet Res 2012;14(4):e110) doi: 10.2196/jmir.2084

KEYWORDS
e-Therapy; therapeutic relationship; therapeutic alliance; common factors in psychotherapy

conferencing, virtual reality technology, chat technology, or

Introduction any combination of these” [3].
As of 2011, 78.3% of the US population had Internet access Although there is growing evidence that e-therapy is effective
[1]. The widespread use of the Internet has affected mental for a variety of conditions [2,4-6], researchers have expressed
health care delivery, with a rapid expansion of e-therapy [2]. concerns about e-therapy use [7,8]. One of the primary concerns
E-therapy is defined as “a licensed mental health care about e-therapy is related to the perceived difficulty of
professional providing mental health services via e-mail, video

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developing an effective therapeutic relationship in the absence For PsycINFO, the major search terms were ([exp counseling
of nonverbal cues [6]. OR exp psychotherapy] AND exp Internet). The search was
limited by language (the paper had to be in English), by
Extensive literature on face-to-face psychotherapy indicates
methodology (the study had to be an empirical study,
that the therapeutic relationship accounts for more variability
experimental replication, follow-up study, longitudinal study,
in psychotherapy outcomes than do specific therapy ingredients
prospective study, retrospective study, quantitative study, or
[9-11]. Given the crucial role of the therapeutic relationship in
treatment outcome/randomized clinical trial), by publication
face-to-face interventions, it is important to assess the role of
type (the study had to be a journal article published in a
therapeutic relationship in e-therapy as well.
peer-reviewed journal), and by sample (the study had to be
Although e-therapy research began over 15 years ago, there has conducted on humans). This search, with these limits, and taking
been no attempt to review the findings pertaining to the status only the items with an abstract, yielded a total of 188 abstracts.
of the therapeutic relationship in online interventions. Heeding
For CINAHL, the major search terms were ([MH psychotherapy
the guidelines published by the American Psychological
OR MH counseling] AND MH Internet). The search was limited
Association (Division 29), which state that descriptions of
by language (the paper had to be in English) and by publication
effective psychotherapies that do not mention the therapeutic
type (the study had to be a peer-reviewed research article). This
relationship are “seriously incomplete and potentially misleading
search, with these limits, and taking only the items with an
on both clinical and empirical grounds” [12], it is imperative
abstract, yielded a total of 184 abstracts.
to investigate systematically the status of the therapeutic
relationship in e-therapy. This paper represents the first attempt Selection Strategy
to summarize and review the existing findings. More We carefully screened the abstracts of all articles identified by
specifically, the review examined (1) how the therapeutic the electronic searches (840 in total) to determine whether the
relationship is being assessed in e-therapy, (2) patients’ abstracts met the following inclusion criteria: (1) described an
satisfaction with the therapeutic relationship in e-therapy, (3) intervention study that empirically assessed the effects of
differences in the therapeutic relationship between e-therapy e-therapy on an outcome (excluding qualitative studies, survey
and face-to-face therapy, (4) factors that may influence the studies, reviews, meta-analyses, etc), and (2) reported data
therapeutic relationship in e-therapy, and (5) the relationship relevant to the therapeutic relationship. Specifically, abstract
between the therapeutic relationship and treatment outcome in text had to use the word relationship or alliance to be included
e-therapy. in the review. Interventions had to be consistent with the above
definition of e-therapy. This excluded interventions that were
Methods described as self-help, peer-led groups, online communities, or
volunteer-led online support. If a given study had multiple
Search Strategy
intervention groups, at least one intervention group had to meet
We searched 3 electronic databases (PubMed, PsycINFO, and the e-therapy definition. There were no inclusion or exclusion
CINAHL) from their respective inceptions through August 2, criteria regarding the focus of the treatment.
2011. For PubMed, the search terms were (counseling[MeSH]
OR psychotherapy[MeSH]) AND Internet[MAJR]). The search Based on these criteria, the number of eligible abstracts was
was limited by language (the paper had to be in English), by reduced from 840 abstracts to 56 abstracts. Figure 1 details
methodology (the study had to be a clinical trial; randomized reasons for exclusion [13]. The 56 manuscripts were obtained
controlled trial; clinical trial, phase 1; clinical trial, phase 2; and read in full, independently, by two of the authors (MS and
clinical trial, phase 3; clinical trial, phase 4; comparative study; SJM). They completed a standardized form assessing the
controlled clinical trial; or a technical report), and by sample above-listed criteria. Any lack of consensus was discussed with
(human subjects). This search, with these limits, and taking only JBS and GHM until consensus was reached.
the items with an abstract, yielded a total of 468 abstracts.

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Figure 1. PRISMA 2009 Flow Diagram.

date, (2) the study sample (eg, demographic characteristics),

Data Abstraction and Study Characteristics (3) the intervention and the interventionists, (4) study design
We included 11 of the 56 studies in the review (Table 1). Each elements, (5) the therapeutic relationship element studied and
of the 11 papers was abstracted independently by MS and SJM. how it was measured (eg, scale), and (6) the findings pertaining
The data abstraction form included (1) authors and publication to the therapeutic relationship. Any discrepancies were discussed

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among the authors (MS and SJM) with reference to the original Study and Participant Characteristics
manuscript until consensus was reached. Table 1 summarizes design characteristics and quality scores.
The quality of each study was evaluated independently by MS The quality scores for the studies ranged from 0 to 7 out of a
and SJM according to the following eight validity criteria, which maximum of 8 points. Because blinding of participants to the
were adapted from the Consolidated Standards of Reporting type of intervention is often practically impossible in
Trials (CONSORT) guidelines [14,15] and Delphi criteria list psychosocial interventions, as participants must actively engage
[16]: randomization; allocation concealment; blinding of in them, no study could receive a perfect score of 8. A total of
outcome assessments; comparability of groups at baseline; 6 studies were described as randomized; 2 studies used only
withdrawals; handling of dropouts in analyses; use of pre-post comparisons to analyze data pertaining to the
intention-to-treat analysis; and multiple follow-up assessments. therapeutic relationship. The other studies had a nonequivalent
Scores were given, with 1 point allocated for each criterion group design: 2 studies compared e-therapy data with data from
satisfied (range 0-8 points). The interrater reliability between previously published studies and 1 study used naturalistic
them was .84, indicating strong agreement [17]. Any independent samples of participants provided by a youth
discrepancies were discussed (with JBS and GHM) with counseling service. The main limitations for the studies were
reference to the original manuscript until consensus was reached. not comparing groups at baseline [4,20,22,23]; not reporting
the use of intention-to-treat analyses or handling of missing
Although some quantitative data were available, there were data [4,6,18,21]; and not using follow-up assessments
insufficient data for formal comprehensive meta-analyses. [4,6,18,20,22,24].
Therefore, we report effect sizes where possible and informative.
The main therapeutic approach used in the analyzed studies was
Results cognitive behavioral therapy (CBT) (k = 9). E-therapists were
psychologists and psychotherapists (k = 6), psychology students
Among the included studies, investigating the therapeutic (k = 4), and counselors (k = 1). Overall, the dose of e-therapy
relationship was a primary objective for 6 [4,6,18-21], whereas ranged from 1 session to 11 weeks, with a mean of 7.75 (SD
for the other 5 studies, the assessment of the therapeutic 2.37) weeks. Communication between therapist and patient was
relationship was a secondary outcome. conducted via asynchronous email and website postings (k =
8), synchronous website text exchange (k = 1), synchronous
chat (k = 1), or a combination of asynchronous email and
synchronous chat (k = 1).

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Table 1. Study design characteristicsa.

Sample E-therapy Study

Authors size communication modality Therapists Treatment length Study design qualityb
Cook and 15 Email and chat, both asyn- 1 PhD, 3 masters level, 1–5 sessions Nonequivalent groups design; 1
Doyle [6] chronous and synchronous and 1 masters student compared e-therapy versus
communicationc previous normative data from
face-to-face counseling
King et al [18] 186 Website postings, syn- “Trained counselors” 1 session, with a typi- Nonequivalent group design; 2
chronous communication cal session duration of e-therapy versus telephone
50–80 minutes counseling
9 registered psycholo-
Kiropoulos et Website and email, asyn- gists, 1 probationary 8 weeks, weekly as- RCTd design; e-CBTe versus
al [24] 86 chronous communication psychologist signments face-to-face CBT 6
Klein et al 16 Website and email, asyn- 6 registered psycholo- 10 weeks, weekly as- RCT design; pre- to posttreat- 3
[22] chronous communication gists, 1 probationary signments ment comparisons
registered psychologist
Klein et al 22 Website and email, asyn- 6 registered psycholo- 10 weeks, weekly as- RCT design; pre- to posttreat- 4
[23] chronous communication gists, 1 probationary signments ment comparisons
registered psychologist
Knaevelsrud 48 Email, asynchronous com- 2 psychologists 5 weeks, 2 weekly 45- RCT; e-CBT versus waiting 3
and Maercker munication minute writing assign- list
[20] ments
Knaevelsrud 96 Email, asynchronous e- 2 clinical psychologists 5 weeks, 2 weekly 45- RCT; e-CBT versus waiting 6
and Maercker communication at the doctoral level minute writing assign- list
[19] ments
Reynolds et al 17 Email, asynchronous com- 16 psychotherapists Not reported Nonequivalent group design; 0
[4] munication (62.5% qualified to e-therapy versus data from
work in the United prior face-to-face studies
States)
Ruwaard et al 239 Email, asynchronous com- 25 doctoral and 1 post- 7 weeks, 5 hours of RCT; e-CBT versus waiting 6
[25] munication graduate student in therapist time list
clinical psychology
Ruwaard et al 54 Website, asynchronous 18 graduate-level clini- 11 weeks, 22–44 RCT; e-CBT versus waiting 6
[26] communication cal psychologists and 6 hours of patient time list
therapists and 7–14 hours of
therapist time
Trautmann 18 Chat, synchronous commu- 3 clinical psychology 6 weeks, a weekly RCT; e-CBT versus e-psy- 4
and Kroner- nication graduate students chat with the therapist choeducation
Herwig [21]

a
The table presents the information about the studies’ characteristics; not all of the studies provided a detailed description of the methods.
b
Score for number of validity criteria satisfied (range 1–8).
c
Synchronous communication between therapist and patient takes places in real time, in a same-time/different-place mode (eg, chat); asynchronous
communication takes place over a period of time through a different-time/different-place mode (eg, email).
d
Randomized controlled trial.
e
Cognitive behavioral therapy.

Table 2 summarizes participants’ characteristics by study. The problems (eg, symptoms of depression, symptoms of anxiety,
participants were receiving e-therapy for a variety of problems, stress, relationship issues, or childhood abuse; k = 2).
including mental health diagnosis (eg, posttraumatic stress Participants were both adolescents (k = 2) and adults (k = 9). A
disorder, k = 4; depression, k = 1; and panic disorder and majority of the adult patients were women (at least 60% across
agoraphobia, k = 1), psychological distress related to medical the studies) with a high level of education (at least 44% across
problems (eg, headaches, k = 1), work-related distress (k = 1), the studies completed college).
general distress (k = 1), and other self-reported presenting

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Table 2. Participants’ characteristicsa.

Authors Presenting Age (years), Gender Education Race/
problem mean (SD) ethnicity
Cook and Doyle Relationship issues and 41.40 (15.99) 93%women All participants completed at least “Primarily white”
[6] depression high school
King et al [18] Distress 14.25 (no SD provid- 80.1% women Not reported Not reported
ed)
Kiropoulos et al Panic disorder and ago- 38.96 (11.13) 72.1% women Mean education level 12.53 (SD Not reported
[24] raphobia 6.14) years
Klein et al [22] Posttraumatic stress 48 (no SD provided) 81.2% women Mean education level 13 years (no Not reported
disorder SD provided)
Klein et al [23] Posttraumatic stress 45.8 (no SD provid- 77.2% women Mean education level 13.3 (SD 3.5) Not reported
disorder ed) years
Knaevelsrud and Posttraumatic stress 35 (no SD provided) 92% women 55% had a university degree Not reported
Maercker [20] disorder
Knaevelsrud and Posttraumatic stress 35 (no SD provided) 90% women 44% had a university degree Not reported
Maercker [19] disorder
Reynolds et al [4] Depression, stress, anx- Median 39 71% women 94.1% completed high school 82% Caucasian
iety, and childhood
abuse
Ruwaard et al [25] Work-related stress 44 (8) 60% women 84% had a university degree Not reported
Ruwaard et al [26] Depression 21 (10) 69% women 65% had a university degree Not reported
Trautmann and Headache 13.4 (2.6) Not reported Not reported Not reported
Kroner-Herwig
[21]

a
The table presents the information about the patients’ characteristics that the studies provided; not all the studies provided the full range of demographic
information.

Reynolds et al [4] used the Agnew Relationship Measure-Short

Assessment of the Therapeutic Relationship in Form [31]. The scale evaluates the overall therapeutic alliance
E-Therapy with 3 subcomponents: bond and partnership, confidence
Table 3 presents, by study, the characteristics of the measures (defined as the confident collaboration between patient and
used to assess the therapeutic relationship. therapist), and openness (defined as “the felt freedom to disclose
and reveal personal material without fear of censure or
A total of 3 of the studies [22-24] used the Therapist/Therapeutic
embarrassment”) [32].
Alliance Questionnaire, a modified version of the Helping
Alliance Questionnaire [29]. The scale requires the participants Trautmann and Kroner-Herwig [21] used an Internet-based
to estimate the degree to which the therapeutic alliance with patient-therapist alliance/assistance questionnaire [33], which
their therapist was helpful. was adapted for use with children and adolescents and to the
conditions of e-therapy (eg, “My therapist’s explanations helped
Cook and Doyle [6] used the Working Alliance Inventory [27].
and supported me;” “This week I learned something that can
The scale is based on Bordin’s concept of therapeutic alliance:
help me cope with my headache”). The questionnaire was
therapist-patient agreement on therapeutic goals;
developed for the purpose of this study, and no other details
therapist-patient agreement on therapeutic tasks, and the quality
were provided about this measure.
of the emotional bond between the therapist and the patient
[35,36]. Two other studies [19,20] used the short version of the The other 2 studies included in this review [25,26] investigated
Working Alliance Inventory [30]. patients’ satisfaction with the therapeutic relationship. Both
used a scale with 4 items, which assessed the extent to which
King et al [18] used the Therapeutic Alliance Scale [28]. The
the participants regarded their relationship with the therapist as
scale evaluates the overall therapeutic alliance with 3
being pleasant and personal, whether they perceived the
subcomponents: mutual liking between therapist and patient,
relationship as growing during the treatment, and whether they
collaboration between therapist and patient, and resistance (ie,
missed face-to-face contact. No other details were provided
resistance to the treatment program).
about this measure.

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Table 3. Therapeutic relationship measures and findings.

Therapeutic Instrument description
relationship Moment of Measured Item description and psychometric
a
Authors measure assessment constructs and properties properties Patient ratings
Cook and Working Al- Third session Overall therapeutic 36 items scored on a 7-point Good construct validity Overall therapeutic al-
Doyle [6] liance Invento- alliance and 3 sub- Likert scale ranging from 1 and high internal consis- liance, mean 215.07;
ry [27] components: (1) (never) to 7 (always). Sub- tency on the composite agreement on task,
agreement on scales scores can range from score (.93) as well as mean 70.33; agreement
goals, (2) agree- 12 to 84, and total scores for the subscales (.85- on goals, mean 72.27;
ment on tasks, (3) can range from 36 to 252. .88) [27] bond, mean 72.47
bond Higher scores reflect more
positive ratings of therapeu-
tic alliance.
King et al Therapeutic Posttreatment Overall therapeutic 30 items, scored on a 3-point Good internal consisten- Overall alliance, mean
[18] Alliance Scale alliance and 3 sub- Likert scale (disagree, cy for the subscales 74.0 (SD 10.4); resis-
[28] components: (1) somewhat agree, agree), (.83-.90) [28] and for tance, mean 24.6 (SD
mutual liking, (2) with scores ranging from 30 entire measure (.92) 4.6); mutual liking,
resistance, (3) col- to 90, where higher scores [18] mean 26.2 (SD 3.6);
laboration indicate more positive per- collaboration, mean
ceptions of alliance. 23.1 (SD 4.8)
Kiropoulos Therapist Al- Posttreatment Overall therapeutic 17 items rated on a Likert No data were found Mean 83.13 (SD 11.20)
et al [24] liance Ques- alliance (ie, the de- scale ranging from 1 to 7 about the psychometric
tionnaire [29] gree to which pa- and summed to produce a properties
tients experience total score, which can range
their therapeutic from 17 to 102. Higher
relationship as be- scores reflect more positive
ing helpful) ratings of the therapeutic al-
liance.
Klein et al Therapeutic Posttreatment Overall therapeutic 17 items rated on a Likert No data were found Mean 86.25 (SD 16.23)
[22] Alliance alliance (ie, the de- scale ranging from 1 to 7 about the psychometric
Questionnaire gree to which pa- and summed to produce a properties
[29] tients experience total score, which can range
their therapeutic from 17 to 102. Higher
relationship as be- scores reflect more positive
ing helpful) ratings of the therapeutic al-
liance.
Klein et al Therapeutic Posttreatment Overall therapeutic 17 items rated on a Likert No data were found Mean 89.18 (SD 15.13)
[23] Alliance alliance (ie, the de- scale ranging from 1 to 7 about the psychometric
Questionnaire gree to which pa- and summed to produce a properties
[29] tients experience total score, which can range
their therapeutic from 17 to 102. Higher
relationship as be- scores reflect more positive
ing helpful) ratings of the therapeutic al-
liance.
Knaevelsrud Working Al- Overall therapeutic 12 items scored on a 7-point Good internal consisten- Overall alliance, mean
and Maerck- liance Invento- alliance and 3 sub- Likert scale with scores cy for the subscales 5.8 (SD 0.62); agree-
er [20] ry-short ver- components: (1) ranging from 1 to 7. Higher (.90-.92) and for the ment on goals, mean
sion [30] agreement on scores reflect more positive composite score (.98) 5.8 (SD 0.77); agree-
goals, (2) agree- ratings of therapeutic al- [30] ment on tasks, mean 5.7
ment on tasks, (3) liance. (SD 0.80); bond, mean
bond 6.2 (SD 0.75)
Knaevelsrud Working Al- Fourth session Overall therapeutic 12 items scored on a 7-point Good internal consisten- Overall alliance, mean
and Maerck- liance Invento- alliance and 3 sub- Likert scale with scores cy for the subscales 5.8 (SD 0.72); agree-
er [19] ry-short ver- components: (1) ranging from 1 to 7. Higher (.90-.92) and for the ment on goals, mean
sion [30] agreement on scores reflect more positive composite score (.98) 5.8 (SD 0.77); agree-
goals, (2) agree- ratings of therapeutic al- [30] ment on tasks, mean 5.7
ment on tasks, (3) liance. (SD 0.83); bond, mean
bond 6.2 (SD 0.69)

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Therapeutic Instrument description

relationship Moment of Measured Item description and psychometric
Authors measure assessmenta constructs and properties properties Patient ratings
Reynolds et Agnew Rela- Fourth session Overall therapeutic 12 items, each rated on a 7- Good construct validity Bond and partnership,
al [4] tionship Mea- alliance and 3 sub- point Likert scale, with and high internal consis- mean 5.97 (SD 1.26);
sure-Short components: (1) higher scores indicating tency, ranging from .83 confidence, mean 6.19
Form [31] bond and partner- more positive perceptions of to .89 [32] (SD 1.24); openness,
ship, (2) confi- alliance. mean 5.27 (SD 1.42)
dence, (4) open-
ness
Ruwaard et Treatment sat- Posttreatment Aspects of pa- 4 items The scale was devel- Participants rated the
al [25] isfaction items tients’ perceived oped for the purpose of relationship as pleasant
[25] relationship with the study; no data pro- (88%) and personal
their therapists vided about the psycho- (75%); they perceived
metric properties the relationship to grow
during the treatment
(57%); 68% said that
they did not miss face-
to-face contact
Ruwaard et Treatment sat- Posttreatment Aspects of pa- 4 items The scale was devel- Participants rated the
al [26] isfaction items tients’ perceived oped for the purpose of relationship as pleasant
[25] relationship with the study; no data pro- (88%) and personal
their therapists vided about the psycho- (75%); they perceived
metric properties the relationship to grow
during the treatment
(57%); 89% said that
they did not miss face-
to-face contact
Internet-based
questionnaire
on patient- The scale was devel-
trainer al- The scale ranges from 0 to oped for the purpose of E-CBTb, median 2.8,
Trautmann liance/assis- 3, with higher scores indicat- the study; no data pro- range 2–3; e-psychoed-
and Kroner- tance scale Patient–trainer al- ing more positive percep- vided about the psycho- ucation, median 2.7,
Herwig [21] [33] Posttreatment liance tions of alliance. metric properties range 2–3

a
If multiple assessment points were used, we present the data for the earliest point of assessment, since previous studies showed that the level of alliance,
regardless of the length of therapy, is established within the first sessions, recommending that alliance be assessed at the beginning of therapy [34].
b
Cognitive behavioral therapy.

Differences in the Therapeutic Relationship Between

Patients’ Satisfaction With the Therapeutic
E-Therapy and Face-to-Face Therapy
Relationship in E-Therapy
A total of 3 studies investigated differences in the therapeutic
Ruwaard and colleagues [25] investigated the impact of
alliance between e-therapy and face-to-face therapy [4, 6, 24].
e-therapy on work-related stress on a sample of 239 participants.
Results were mixed, with 2 studies showing no significant
Results indicated that participants rated the e-therapy
differences in therapeutic alliance (eg, overall alliance and
relationship as being pleasant (210/239, 88%) and personal
various subscales) between e-therapy and face-to-face therapy,
(179/239, 75%); 136 of 239 (57%) perceived the relationship
and 1 study showing higher scores for therapeutic alliance in
to grow during the treatment, and 163 of 239 (68%) said that
e-therapy than in face-to-face therapy.
they did not miss face-to-face contact.
Kiropoulos and colleagues [24] investigated whether the
A second study conducted by Ruwaard and colleagues [26]
therapeutic alliance in e-therapy is different from face-to-face
investigated the impact of e-therapy on depression on a sample
therapy in a study comparing e-CBT with face-to-face CBT for
of 54 participants. The study yielded similar results to those
panic disorder and agoraphobia. Results indicated that there
previously described, in that the majority of the participants
was no significant difference between groups for therapeutic
rated the e-therapy relationship as being pleasant (47/54, 87%)
alliance score (t47 = –1.02, P = .31, d = 0.29; according to Cohen
and personal (42/54, 78%), perceived the relationship to be
growing during the treatment (42/54, 78%), and reported that [37], an effect size of 0.2 to 0.3 represents a small effect, around
they did not miss face-to-face contact (48/54, 89%). The results 0.5 represents a medium effect, and 0.8 or greater represents a
of the studies indicated that patients offered high ratings for large effect).
therapeutic relationship in e-therapy (see Table 3). Reynolds et al [4] compared e-therapy data with data from
previously published face-to-face studies. Results indicated that
patients gave high ratings for therapeutic alliance in e-therapy,
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with the means for the subscales of bond and partnership Is the Quality of the Therapeutic Relationship Linked
between therapist and patient (mean 5.97, SD 1.26) and to Treatment Outcome in E-Therapy?
confident collaboration between therapist and patient (mean
A total of 3 studies investigated the impact of the therapeutic
6.19, SD 1.24) within the range of reported means for previous
alliance on treatment outcome [18-20]. Knaevelsrud and
face-to-face therapy studies. The mean for openness (mean 5.27,
Maercker [20] investigated the relationship between working
SD 1.42) in e-therapy was below the range of means from the
alliance and the outcome of e-therapy for patients with
prior face-to-face studies. However, it is important to note that
posttraumatic stress disorder. Results showed that the composite
no test for statistical significance was performed.
score for therapeutic alliance correlated positively with residual
Cook and Doyle [6] investigated whether the therapeutic alliance gain scores for anxiety (r = .33, P < .05, d = 0.69), which
in e-therapy is different from face-to-face therapy in a sample indicates that patients who rated the alliance as better had greater
of 15 participants. Results indicated that the overall working reduction of their anxiety scores at posttreatment.
alliance scores (t14 = 3.03, P < .001, d = 0.60) and the agreement
Knaevelsrud and Maercker [19], in a later study investigating
between therapist and patient on the therapy goals subscale the impact of e-therapy on posttraumatic stress disorder, found
scores (t14 = 2.30, P = .03, d = 0.79) were significantly higher that overall patient-rated working alliance at posttreatment
in e-therapy than in face-to-face interventions, with medium to predicted 15% of the variance in the scores for posttraumatic
large effect sizes. The agreement between therapist and patient stress symptoms (adjusted R2 = .148, F2,39 = 8.15, P < .001),
on tasks (t14 = 1.26, P = .22, d = 0.22) and the bond between
obtaining a large effect size.
therapist and patient were rated higher as well (t14 = 1.62, P =
.12, d = 0.33), although the difference did not reach statistical King and colleagues [18] investigated the impact of online
significance and the effect sizes were small. versus telephone counseling for adolescents. Their results
revealed a modest trend toward a relationship between the
Factors That May Influence the Therapeutic collaboration subscale scores and posttreatment distress (beta
Relationship in E-Therapy = 0.25, t = 1.83, P = .07, d = 0.14) and a significant effect of
A total of 2 studies investigated factors that might influence the the resistance subscale on posttreatment distress (beta = 1.21,
therapeutic relationship in e-therapy [6, 20]. Knaevelsrud and t = 2.40, P < .05, d = 0.19).
Maercker [20] reported an inverse relationship between
pretreatment symptom severity and therapeutic alliance ratings, Discussion
such that patients who experienced more severe anxiety
symptoms at the beginning of treatment tended to give lower To our knowledge, this study is the first to summarize and
ratings for the bond between therapist and patient subscale (r review the findings on the role of the therapeutic relationship
= –.34, P < .05, d = 0.72). There was an overall tendency for in e-therapy. The most striking finding was the limited number
an inverse relationship between pretreatment anxiety and of studies investigating the therapeutic relationship. Of the 840
depression symptoms, and agreement on goals and task reviewed studies, only 11 (1.3%) addressed and investigated
subscales ratings, but the correlations did not reach statistical the issue of the therapeutic relationship, and of these, only 6
significance and the effect sizes were small to moderate (all P investigated the therapeutic relationship as a primary objective.
> .05, all d < 0.40). In other words, the results indicate that, although the therapeutic
relationship is considered to be an important common factor
Cook and Doyle [6] investigated the impact of communication operating across all psychotherapies [34,38], the study of the
modality on the therapeutic relationship. Their results did not therapeutic relationship appears to have been largely ignored
reach statistical significance. However, they reported that in the e-therapy literature.
participants who used chat as the primary mode of
communication (eg, as opposed to email) had consistently higher The reviewed studies have the merit of providing a first glimpse
means for the therapeutic alliance than did participants who into the role of the therapeutic relationship in e-therapy.
used email (overall alliance, t13 = 1.54, P = .10, d = 1.13; However, due to the small number of studies and to their
methodological limits, the findings must be interpreted with
agreement on task, t13 = 0.89, P = .37, d = 0.54; agreement on
caution.
goals, t13 = 1.54, P = .12, d = 1.09; bond, t13 = 1.92, P = .07, d
= 1.19), obtaining medium to large effect sizes. Participants Study and Participant Characteristics
who used more than one modality of communication (eg, email The methodological limits of the studies included the lack of
plus chat) had higher ratings for the therapeutic alliance than suitable control groups (nonrandom allocation or nonequivalent
did participants who used only one modality of communication group design), lack of pretest information, poor reporting and
(overall alliance, t13 = 1.87, P = .08, d = 1.02; agreement on handling of dropouts in the analyses, and more generally an
tasks, t13 = 1.67, P = .11, d = 0.91; agreement on goals, t13 = often incomplete presentation of results (eg, not reporting
1.40, P = .18, d = 0.76; bond, t13 = 1.67, P = .11, d = 0.91). standard deviations, not reporting effect sizes). As research
However, it should be noted that these results were based on moves forward, it is important for future studies to adhere to
comparisons made on very small samples of participants (eg, the standards of conducting and reporting psychosocial
participants who used chat as a primary communication mode, interventions [13]. Improved reporting will lead to the
n = 3, versus participants who used email as a primary enrichment of systematic reviews and allow for better-informed
communication mode, n = 12). treatment decision making among practitioners. Another issue

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that might limit enthusiasm for the findings is that the majority Differences in the Therapeutic Relationship Between
of studies were affected by a selection bias. The recruitment E-Therapy and Face-to-Face Therapy
was performed through webpages or email announcements,
A surprising finding, given the previous concerns related to the
which already rely on a certain familiarity with the use of the
lack of nonverbal cues in e-therapy, is that e-therapy seems to
Internet. This is a particularly important methodological
be at least equivalent to face-to-face therapy in terms of the
limitation, since previous studies indicated that, the more
therapeutic relationship (more specifically therapeutic alliance).
familiar participants are with Internet-based contact, the more
Although very promising and clearly worthy of attention, this
positively they judge Internet-based contact to be [39]. Future
line of research is in its infancy, and further research is needed
studies should clarify the role of Internet familiarity in the
to draw firm conclusions.
therapeutic relationship in e-therapy.
Factors That May Influence the Therapeutic
As for the studies’ characteristics, it is interesting to note that
the main therapeutic approach was CBT, which easily lends Relationship in E-Therapy
itself to standardized instructions and short-term, manualized Although the results do not allow firm conclusions to be drawn,
approaches. Because almost all studies included in this review it seems that investigating factors such as communication
used a CBT approach, it is difficult to infer the status of modality and pretreatment symptom severity as moderators of
therapeutic relationship in online interventions that use the therapeutic relationship might be a fruitful direction of
therapeutic approaches that are less structured. research. In addition, all of the studies included in this review
used text-based communication methods; thus, it would be
The overwhelming majority of participants were women, important to investigate the status of the therapeutic relationship
consistent with previous research that has found that more when the communication modality includes video conferencing
women than men use the Internet for mental health information (eg, through Skype), where the verbal cues are not missing and
and services [40]. Participants tended to be highly educated. the communication is synchronous.
Not all the studies provided information about other important
demographics, such as race and ethnicity, but it is interesting Is the Quality of the Therapeutic Relationship Linked
to note that in the 2 studies that reported this information, the to Treatment Outcome in E-Therapy?
participants were primarily white. These results are consistent The 3 studies investigating the impact of the therapeutic alliance
with previous findings, indicating that health information on treatment outcome indicate that these two factors have a
seeking over the Internet is more prevalent among white, positive relationship. This avenue of research should be further
educated women, and that mental health information seeking pursued, as it offers a hint that the beneficial effects of this
in particular tends to have the same type of consumers [40]. To therapeutic relationship element are not restricted to face-to-face
determine the appropriateness of e-therapy and to investigate therapies.
the status of the therapeutic relationship in online environments
across ethnic groups, future research should include more Limitations, Conclusions, and Future Directions
diverse samples of patients. The present review has limitations. First, it was based on
Assessment of the Therapeutic Relationship in searches in three databases—PubMed, PsycINFO, and
CINAHL—and was limited to published papers in English. It
E-Therapy
is possible that additional relevant papers exist outside of the
The majority of the studies focused on a specific element of the present sample of papers. Second, the reviewed abstracts were
therapeutic relationship, namely the therapeutic alliance. The required to report the assessment of the therapeutic relationship.
studies used a variety of measures to assess the therapeutic It is possible that papers exist for studies in which investigating
alliance, defining the concept by the instrument used to measure the relationship was not a main goal, and thus their abstracts
it. In that sense, as Norcross [34] suggested, “instrumentation might not refer to it. Future work may include more languages,
defines the construct.” In addition, some of the studies used include unpublished manuscripts, and use a wider variety of
measures that had been created on an ad hoc basis. If progress search terms to confirm the generalizability of the present
is to be made in this field, future studies should reach toward a conclusions. Additionally, once the literature grows large
consensus by using validated measures based on supported enough, a formal meta-analysis should be conducted to estimate
conceptualizations of what therapeutic alliance is [34,41]. the overall effect size for both the impact of the relationship on
As for the timing of the assessment, the majority of the studies psychotherapy outcome and differences in the relationship
investigated the therapeutic alliance at the end of therapy. between face-to-face therapy and e-therapy. Future
Previous studies indicate that the level of alliance, regardless meta-analyses would also have the potential to explore
of the length of therapy, is established within the first sessions moderators of relationship effects and would be an important
[34]. Meta-analytic studies also revealed that early alliance is step forward for the field.
more predictive of outcome than is alliance assessed later in Overall, this review summarizes research to date on the
therapy [42]. Accordingly, it is recommended that future therapeutic relationship in e-therapy. If relationship is considered
e-therapy studies assess alliance at the beginning of the a common factor in successful psychotherapy, it should become
treatment. commonly studied in e-therapy as well. Looking to the future,
we hope that the present findings will spur investigation into
the role of the therapeutic relationship in e-therapy.

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Acknowledgments
Preparation of this paper was supported by the National Cancer Institute (CA131473, CA081137, CA129094, CA159530). The
content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer
Institute or the National Institutes of Health.

Conflicts of Interest
None declared.

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Abbreviations
CBT: cognitive behavioral therapy

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Edited by G Eysenbach; submitted 19.02.12; peer-reviewed by B Wampold; accepted 24.05.12; published 02.08.12
Please cite as:
Sucala M, Schnur JB, Constantino MJ, Miller SJ, Brackman EH, Montgomery GH
The Therapeutic Relationship in E-Therapy for Mental Health: A Systematic Review
J Med Internet Res 2012;14(4):e110
URL: http://www.jmir.org/2012/4/e110/
doi: 10.2196/jmir.2084
PMID: 22858538

©Madalina Sucala, Julie B Schnur, Michael J Constantino, Sarah J Miller, Emily H Brackman, Guy H Montgomery. Originally
published in the Journal of Medical Internet Research (http://www.jmir.org), 02.08.2012. This is an open-access article distributed
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Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on
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