The therapeutic alliance in online psychotherapy
The therapeutic alliance is the feeling of comfort that people experience when they feel welcomed when they are being treated. The creation of the alliance is linked, on the one hand, to the existence of a positive bond between both parties and, on the other, to the negotiation and acceptance of the tasks and objectives that will mark the course of the therapeutic process (Corbella & Botella, 2003). For years, it has been well known that building a good therapeutic alliance is an essential element for the person being treated to have greater adherence to psychotherapy and, as a consequence, more positive results (Baier et al., 2020).
Generally, to achieve a good therapeutic alliance, it is necessary for the person receiving treatment to perceive that therapy is a space of trust where they can share their experiences safely (Okamoto et al., 2019). But is it possible that this alliance can be created in the context of online therapy? To answer this question, we must first investigate this “new” modality a little.
Online psychotherapy: accessibility, proximity and flexibility
Online psychotherapy is a tool that is very present in the daily lives of mental health professionals today. And, although the quarantine caused by the Covid-19 pandemic increased the number of professionals working by video call (Probst et al., 2021), this type of psychotherapy had been on the rise for years (Muriel, 2012). This increase in the number of professionals who use it as another resource in our daily lives is due to the fact that it is a tool with which we professionals feel comfortable , but also the people treated, who feel that it gives them more accessibility and proximity to the professional , and more flexibility and adaptation of the sessions to their weekly schedule (Machluf, et al., 2022).
Building a good therapeutic alliance is an essential element for the person receiving treatment to have greater adherence to psychotherapy and, as a consequence, more positive results.
Professionals who are less accustomed to using online psychotherapy may wonder whether it is as effective as face-to-face psychotherapy. Our profession is a task that is closely linked to interpersonal relationships and it is normal for us to feel that there is nothing like the closeness of face-to-face interaction . However, it is known that the effectiveness of online therapy is the same as that which can be had in a traditional therapeutic process. In fact, this effectiveness is maintained in all theoretical orientations and for a wide variety of disorders (Ierardi et al., 2022; Karyotaki et al., 2021; Probst et al., 2021). But how is it possible to maintain effectiveness , despite not having all the traditional communication elements? Well, on the one hand, it is important that the therapist is able to manage the expectations of the person being treated (Poletti et al., 2020). And, on the other hand, the creation of a quality therapeutic alliance is essential for the improvement of the person being treated when we work in the virtual modality.
The importance of the therapeutic alliance in online therapy
Many studies suggest that in online psychotherapy it is possible to establish a therapeutic alliance with the same intensity as in traditional psychotherapy, provided that the person being treated is predisposed to working in this modality (Casari & Stefanini, 2020). Usually, people who are part of this therapeutic process already know that it will be virtual and will not have any inconvenience. However, we have a duty to inform those who do not know in order to be able to offer a better mental health service and facilitate correct adherence to psychotherapeutic treatment.
The creation of a therapeutic alliance bond in virtual psychotherapy has been shown to be a predictor of effective symptom improvement in treating disorders such as depression, anxiety, psychotic disorders and sleep disorders, among others (Tremain et al., 2020; Watts et al., 2020; Wehmann et al., 2020). In fact, there are some studies that suggest that the therapeutic bond that can be created in the virtual modality is more intense than that which can be created in person (Watts et al., 2020). However, this is very much conditioned by the characteristics and preferences of each person. People who experience a better therapeutic bond are because they feel that it is a space where there are improved opportunities for expression , connection and intimacy due to doing the therapy in a more neutral space (Simpson et al., 2021). This is a phenomenon similar to what happens in the process of creating online friendships in video games, where there are people who feel they have more freedom to create new friendships and discuss important topics with their online friends, as they feel they will not be judged (Vella et al., 2016)
In online psychotherapy it is possible to establish a therapeutic alliance with the same intensity as in traditional psychotherapy, provided that the person being treated has a predisposition to work in this modality.
With this, it is important that professionals train themselves in the best possible way to achieve the goal of a good therapeutic alliance and be able to carry out our professional work effectively and responsibly in this new medium that is increasingly present (Mercadal & Cabré, 2022). To improve this praxis, it is recommended to read the article by Geller (2021), in which he talks about how psychologists can work on therapeutic presence in the development of our work when we do it online. In it, he talks about the setting , the distance from the screen, the light, the clothing... As well as the demands that we can make to the person so that they have their space, such as having tissues on the table, sending written guides, ensuring that they are in a private space... All this series of questions will help us create a space focused on strengthening the bond between the therapist and the person being treated .
The recovery model, a paradigm shift in the approach to mental health
How do we know if we are establishing a good therapeutic alliance online?
An interesting fact is that, in online therapies, professionals are usually more concerned about creating the therapeutic alliance than the people they treat. Therefore, it is important that we professionals are the ones who constantly review this alliance in order to provide a better service to people (López et al., 2019). We can do this by assessing the alliance using psychometric instruments. There are questionnaires that assess the face-to-face therapeutic alliance, such as the Working Alliance Inventory Short (WAI-S) (Hatcher & Gillapsy, 2007), which have been adapted for online therapies, such as the Working Alliance Inventory for Online Interventions-Short Form (WAI-TECH-SF) (Herrero et al., 2020). The use of these instruments can help us measure whether we are taking steps in the right direction to create a meaningful bond that allows for a perceptible improvement in the people we treat.
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