The therapeutic relationship in in‐person, video call, and telephone psychotherapy sessions

Objective: To examine whether and how patients' perceptions of working alliance, alliance ruptures, real relationship and affective reactions towards the therapist differ across in-person, videoconferencing and telephone psychotherapy sessions. Method: A total of 1175 adult patients undergoing various individual psychotherapies completed self-report measures following sessions conducted in-person (746 sessions), via video call (1037 sessions), or by telephone (149 sessions). Linear mixed models with marginal structural model (MSM) were employed. Interaction effects with age group, time-in-treatment and session frequency were also examined. Results: Patients reported similar levels of alliance, real relationship, positive and negative affective reactions and occurrences of alliance ruptures and repairs in both in-person and video call sessions. However, levels of alliance dimensions—agreement on therapy goals, therapy tasks and affective bond—were significantly lower in telephone sessions compared to in-person (β = −.21 to −.25) and video call (β = −.34 to −.37) sessions. Positive affective reactions were also lower in telephone sessions compared to video call sessions (β = −.22). Age, time in treatment and session frequency significantly moderated some associations. Conclusions: The therapeutic relationship is comparable between in-person and video call sessions. Telephone sessions, however, are associated with lower working alliance and in-session positive affective reactions.