Therapeutic alliance in psychotherapy across online and face-to-face settings: A quantitative analysis

Lockdown enacted by government in response to the Covid-19 pandemic in Austria forced psychotherapy practice into an online-only setting for several months in 2020. Although there is evidence supporting the effectiveness of psychotherapy in remote settings, research investigating therapeutic alliance in online psychotherapy is still limited, with a specific need for research in assessing possible effects of changes in therapeutic setting from face-to-face to online and vice versa. We measured therapeutic alliance in client-therapist dyads using the Helping Alliance Questionnaire (HAQ) at the Adult Outpatient Clinic of Sigmund Freud University, Vienna. Eighty-seven dyads completed HAQ twice, assessing three time-points: after switching from face-to-face to online therapy, providing a retrospective assessment of their alliance before the setting change as well as a concurrent account of their experience during online therapy, then another assessment after switching back to face-to-face setting after lockdown restrictions were lifted. Data were analysed by fitting a multilevel linear model, where the variables person (client/therapist) and time (before online therapy; online therapy; back to face-to-face) were nested within the client-therapist dyad. We found a statistically significant small improvement in the quality of therapeutic alliance over time, but no differences due to change in therapeutic setting. Separate analysis of HAQ sub-scales revealed that clients rated their relationship statistically significantly higher than their therapists with medium effect size, while there were no differences in success ratings over time and settings, nor between clients and therapists. The findings support the feasibility of online therapy in terms of therapeutic alliance in general, and alternating between face-to-face and online therapy settings in particular.