Therapeutic alliance in videoconferencing psychotherapy: a review

Special Issue – Psychology in the BushOriginal Research

Therapeutic alliance in videoconferencing psychotherapy:A reviewSusan G. Simpson, DClinPsych,1 and Corinne L. Reid, PhD2

1Psychology Clinic, University of South Australia, Adelaide, South Australia and 2School of Psychologyand Exercise Science, Murdoch University, Perth, Western Australia, Australia

AbstractPsychotherapy services are limited in remote andrural areas in Australia and across the globe.Videoconferencing has become well established as a fea-sible and acceptable mode of psychological treatmentdelivery. Therapeutic alliance (TA) is an essential factorunderlying successful therapy across therapeuticmodels. In order to determine the state of knowledgeregarding TA in psychotherapy via videoconferencing, aliterature review was conducted on research studies thatformally measured TA as primary, secondary or tertiaryoutcome measures over the past 23 years. The databasessearched were Medline, PsycArticles, PsycINFO,PsycEXTRA and EMBASE. Searching identified 9915articles that measured satisfaction, acceptability ortherapeutic rapport, of which 23 met criteria for thereview. Three studies were carried out in Australia, 11 inUSA, 4 in Canada, 3 in Scotland and 2 in England.Studies overwhelmingly supported the notion that TAcan be developed in psychotherapy by videoconference,with clients rating bond and presence at least equally asstrongly as in-person settings across a range of diagnos-tic groups. Therapists also rated high levels of TA, butoften not quite as high as that of their clients early intreatment. The evidence was examined in the context ofimportant aspects of TA, including bond, presence,therapist attitudes and abilities, and client attitudes andbeliefs. Barriers and facilitators of alliance were identi-fied. Future studies should include observational mea-sures of bond and presence to supplement self-report.

KEY WORDS: rural mental health, telepsychology,videoconferencing, video therapy.

IntroductionThere are a number of barriers to the equitable provi-sion of evidence-based psychological treatments. Ageneral shortage of psychologists and other qualifiedproviders contribute to this problem, with the majoritybased in major cities. Rural and remote residents haveminimal local access to psychological expertise and areoften required to travel long distances to access appro-priate care. Other hindrances that are common to thoseliving both in rural and urban settings include physicalor psychological disability, incarceration, caring respon-sibilities, financial difficulties, work responsibilities andanxieties associated with the stigma of attending mentalhealth appointments, but these issues might becomeexacerbated in rural areas due to the requirement totravel long distances to access psychological care.1–3

Remote videoconferencing therapy services have startedto address some of the barriers experienced by ruralclients; however, it appears that the in-person model hasbeen assumed to be the gold standard for psycho-therapy, with technology-supported services in someway inferior and only suitable as an adjunct to in-personcommunication or when in-person options areunavailable.4 Despite this, alongside other forms ofremote communication technologies, videoconferencingis gaining credibility as a convenient and practical modeof psychological and psychiatric treatment delivery.The provision of psychotherapy via videoconferencingcarries several advantages, including promotion of equi-table service delivery, reduction in travel costs, as well astime and disruption to work commitments, reducedstigma (which may be heightened when attendinglocally provided mental health services in small commu-nities) and increased availability of support and profes-sional supervision for psychologists located in remoteareas.5 In short, videoconferencing has the potentialto make best use of scarce psychology and psycho-therapy resources over vast distances. The evidencebase supporting the effectiveness of psychotherapy viavideoconferencing is increasing with the publication of

Correspondence: Dr Susan G. Simpson, Psychology Clinic,University of South Australia, Magill Campus, GPO Box2471, Adelaide, South Australia, 5001, Australia. Email:[email protected]

Accepted for publication 17 September 2014.

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Aust. J. Rural Health (2014) 22, 280–299

© 2014 National Rural Health Alliance Inc. doi: 10.1111/ajr.12149

larger randomised research trials in recent years.6,7

Numerous studies to date have shown high levels ofsatisfaction and acceptability of psychotherapy viavideoconference (VC).8–17 In fact, some clients claim tofeel that there is something special about participating ina therapeutic service provided via videolink, and thatthey view themselves as pioneers in the area.18 In spiteof this, videoconferencing continues to appear to beunderutilised among clinical psychologists for the pur-poses of conducting face-to-face psychotherapy.19

There may be several factors inhibiting the growth oftelepsychology, not least of which is a lack of health carereimbursement for services carried out through remotetechnology.20 Perhaps even more pertinent is the widelyheld belief among psychologists that video therapy isinferior by comparison with in-person treatment.21–23

This is largely based on the assumption that the presenceof technology will interfere with the development of ahealthy therapeutic alliance (TA).22 This paper reviewsthe telepsychology research literature, which compel-lingly challenges this assumption.

Most research over the past 20 years has measured thetherapeutic relationship specifically in terms of workingalliance.24–31 TA has been operationalised by Bachelorand Horvath in 1999 as a collaborative effort by thera-pist and client to facilitate healing.24 Although TA hasbeen described in different ways according to a range oftheoretical orientations, most definitions concur on threemain conditions: the affective bond or attachmentbetween therapist and client, the collaborative quality ofthe relationship, and the ability of the therapist and clientto agree on mutually acceptable therapeutic tasks andgoals.31–34 It is well established that a positive TA, alongwith therapist effects, is one of the strongest factorsrequired for effective psychotherapy.35 A recent meta-analysis of 201 studies indicated that TA accounts forapproximately 8% of total variance in therapeutic out-comes across treatment models.29 In fact, TA as measured

early in therapy is a reliable predictor both for outcomeand attrition.28 Findings from several studies indicatethat it is the strongest influencing factor31,36–38 and thatthe correlation between TA and outcome increases astreatment progresses.28

Bordin described three factors that contribute to TA:agreement between therapist and client on goals fortherapy, agreement between therapist and client on spe-cific tasks of therapy, and the therapist–client bond.39

The bond signifies the attachment between therapist andclient, and is the basis for the development of trust andthe client’s ability to face personal fears and anxieties.Although it might be expected that goals and ther-apeutic tasks are unlikely to be adversely affected byvideoconferencing, one could contemplate that thetherapeutic bond may be affected by the presence oftechnology.40 Previous papers in this area have largelyincluded a brief summary of the current data on TA assecondary to other factors, such as outcome,41,42 or haveintegrated their review of TA studies with other processfactors, such as client satisfaction, therapeutic environ-ment, treatment expectations and clinical context.5,15,43

Typically, most systematic reviews do not include alltypes of evidence, often omitting feasibility studies,evaluation reports and different types of comparisonreports. The current review did not exclude these studiesas they were considered of value in increasing our under-standing of the way in which different aspects of TAfunction in the context of videoconferencing psycho-therapy. Both quantitative and qualitative studies, andpublished papers as well as unpublished dissertationsand case studies, were included, with the aim of

What is already known on this subject• Clinical and counselling psychology services

are inequitably distributed, with shortages inremote and rural areas of most countries.

• Numerous naturalistic studies have reportedthat psychotherapy provided via video-conferencing is associated with high levels ofclient satisfaction and acceptability.

• In spite of this, the use of videoconferencingfor psychotherapy has not yet become stan-dard practice for the majority of psycholo-gists, with some studies suggesting a negativebias.

What this study adds• This review synthesises a wide range of quan-

titative (both controlled and uncontrolled)and qualitative studies that have measuredtherapeutic alliance either as a primary orsecondary measure in the context of psy-chological therapy, providing a rich sourceof naturalistic data with high ecologicalvalidity.

• Evidence to date indicates that client-ratedtherapeutic alliance is high across diagnosticgroups and interventions, and therapist-ratedalliance is moderate to high in psychotherapyvia videoconferencing.

• Evidence suggests that in spite of hesitancyamong psychologists, even those with littleexperience in video therapy adapt their com-munication style and adjust to the technologyin a relatively short period of time.

ALLIANCE IN VIDEOCONFERENCING PSYCHOTHERAPY 281

© 2014 National Rural Health Alliance Inc.

providing a richer and more detailed investigation of thespecific aspects of TA, with a specific focus on ‘bond’and ‘presence’. By including findings from samples ofdiverse populations from naturalistic and multiple casestudy settings, this review provides greater contextualgeneralisability. The reader can determine to whatdegree the findings are generalisable in terms of whetherthe research settings described resemble those of thecontext of the reader.44 The inclusion of a range ofstudies that used mixed methods to analyse the datafacilitated the integration of both the subjective andobjective perspectives.45 Through combining quantita-tive and qualitative data, the researchers were able toaccess ‘multiple sources of evidence [which] essentiallyprovided multiple measures of the same phenomenon’(p. 92).46 Indeed, the range of settings and populationsstudied and the inclusion of mixed methods for dataanalysis may in fact enhance the authenticity ofthe conclusions that have been reached and theirgeneralisability to real clinical settings.47,48 The objectiveof this literature review was to explore research that hasformally investigated TA in the context of psycho-therapy via videoconferencing and to identify prelimi-nary factors in the literature to date that may beinfluential in either enhancing or inhibiting the develop-ment of rapport, with particular reference to the thera-peutic bond and experience of presence. This review wasguided by Bouchard et al.’s proposal that three centralfactors are likely to facilitate the development of a thera-peutic bond in VC: (i) the capacity of the client and thetherapist as individuals to develop a TA, (ii) the beliefsthat clients and therapists hold towards psychotherapyvia VC, and (iii) the experience of presence.49

We followed a systematic review protocol with thegoal of identifying the strengths and gaps in the litera-ture, clarifying the conclusions that can be drawn fromthe studies currently available in this area, and propos-ing suggestions for future research. The general purposeof this paper was to investigate four main questions: (1)‘What are the types of articles that have been publishedon TA in telepsychology and what is the relative fre-quency of each type of article?’ (2) ‘Is it possible todevelop an adequate TA via videoconferencing?’ (3) ‘Istherapeutic alliance equivalent when psychotherapy isdelivered via teleconferencing compared with inperson?’ and (4) ‘What are the components of TA thathave been measured in relation to psychotherapy viavideoconferencing?’

Method

Search strategy

The electronic search engines of Medline, PsycArticles,PsycINFO, PsycEXTRA and EMBASE were searched toidentify eligible articles. There were variances in thesearch strategies used because of how the databasesoperated (Table 1). We began by searching the terms‘telepsychology’ OR ‘telepsychiatry’ OR ‘tele-mentalhealth’ OR ‘videoconferencing’ OR ‘video therapy’OR ‘video conferencing’. Following this, we combinedeach of the terms ‘therapeutic alliance’, ‘bonding’ and‘rapport’ with each of the terms used in the first search.The searches were conducted on 2 May 2013. Wescreened all titles and abstracts, and we obtained com-plete reports for the articles that appeared eligible for

TABLE 1: Searches conducted and terms used

Database Terms

PSYCINFO + PSYCARTICLES+ PSYCEXTRAS

telepsychology OR telepsychiatry OR tele-mental health OR videoconferencing OR videotherapy OR video conferencing: 1619 articles

telepsychology OR telepsychiatry OR tele-mental health OR videoconferencing OR videotherapy OR video conferencing AND therapeutic alliance: 1420 articles

telepsychology OR telepsychiatry OR tele-mental health OR videoconferencing OR videotherapy OR video conferencing AND bonding: 1420 articles

telepsychology OR telepsychiatry OR tele-mental health OR videoconferencing OR videotherapy OR video conferencing AND rapport: 1419 articles

EMBASE and MEDLINE 1. telepsychology OR telepsychiatry OR tele-mental health OR videoconferencing ORvideo therapy OR video conferencing: 3997 articles

2. telepsychology OR telepsychiatry OR tele-mental health OR videoconferencing ORvideo therapy OR video conferencing AND therapeutic alliance: 18 articles

3. telepsychology OR telepsychiatry OR tele-mental health OR videoconferencing ORvideo therapy OR video conferencing AND bonding: 3 articles

4. telepsychology OR telepsychiatry OR tele-mental health OR videoconferencing ORvideo therapy OR video conferencing AND rapport: 19 articles

282 S. G. SIMPSON AND C. L. REID


inclusion. All relevant papers published between 1990and July 2013 were included. A further snowballingtechnique was used where reference lists of relevantarticles were reviewed for literature that met this crite-rion. Because of the amount of literature, articlesalready captured by other means (e.g. systematicreviews and literature reviews) were excluded.

Selection criteria

We established three inclusion criteria: (i) published inEnglish language; (ii) empirical studies focused on livetelepsychology defined as any mode of psychologyservice delivery involving face-to-face communicationwhereby clinician and client were able to hear and seeeach other in real time (including the use of IntegratedServices Digital Network (ISDN)- and IP-basedvideoconferencing, Skype, iChat and interactive televi-sion systems). As most research in this area is in theform of small-scale naturalistic studies, both controlledand uncontrolled research was included, and (iii) at leastone of the following outcomes were reported: therapeu-tic relationship, TA, bond and presence. We excluded (i)search engine results without an abstract (includingletters to the editor), (ii) articles that were focused onpsychiatric services that did not involve psychotherapy(e.g. consultations, medication reviews), (iii) interven-tions that did not use video (i.e. telephone-based psy-chotherapy, email therapy, online computer-basedtherapeutic programs), (iv) self-help programs, and (v)articles where TA was not formally measured (includingstudies that focused exclusively on satisfaction and fea-sibility). A consensus by both authors was required toestablish eligibility of articles. Only 23 of the 9915articles found were included in this paper (Fig. 1). Themajority of articles that were excluded fell into one ofthe above categories, with most of these having omittedformal measurement of TA. This reflects the relativerecency and infrequency of the attention being paid tothis topic in the telepsychology literature and supportssupporting the need for the current focal review.

Classification analysis of all articles

Analysis of all articles

In order to address the research questions, all 23 articleswere analysed. Question 1 was addressed by identifyingthe types of articles available for review using the strat-egy described above. Articles were classified as (i)uncontrolled studies (encompassing case studies, caseseries and cross-sectional surveys); (ii) controlled, non-randomised studies; or (iii) randomised controlled trials(RCTs). Articles were further classified by country, diag-nostic group, measures used to assess alliance, mode of

videoconferencing and format of intervention (i.e. indi-vidual, group, family, undefined) and type (CognitiveBehavioural Therapy (CBT), family therapy, eclectic orother specified therapeutic model), and are reported inTable 2. Prior to answering Question 3, articles wereexamined to determine whether different empiricalarticles were reporting on the same data set. Two studieswere identified as having overlapping samples withanother study. These were included in Questions 2–3,but were counted as part of the study with the largersample size in each case. Those articles that wereexcluded are noted with an asterisk (*) in Table 2.

To address Questions 2, 3 and 4, we scrutinisedeach of the 23 articles by hand to summarise the con-clusions drawn from each study, for the purposeof identifying the degree to which TA via video-conferencing has been demonstrated and how it com-pares with TA in an in-person setting. In particular, weexamined the different aspects of TA as it relates tovideoconferencing.

ResultsWe identified 17 unique articles from the initial elec-tronic searches, and the search of reference lists yieldedan additional six unique articles. All of these studiesincluded the formal measurement of TA via either self-report questionnaires or qualitative methods either as aprimary, secondary or tertiary outcome measure, withthe majority falling into the latter categories.

Articles found (n=9915)

Exclusion of articles through review of title and abstract and removal of duplicates (n=9881)

Potentially eligible articles after title and abstract screening (n=40)

Exclusion of articles through full text screening (n= 17)

Articles reviewed which formally measured therapeutic alliance in videoconferencing (n=23) + 2 additional articles with a sample which overlapped with that of another study.

Addition of articles found in search of reference lists (n = 6)

FIGURE 1: Research flow chart.



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Types and frequency of articles(Question 1)

There were seven RCTs, three non-RCTs, five uncon-trolled pilot trials, four single case series and four singlecase studies. Three articles were PhD dissertations. Onecase study and one case series were exclusively based onqualitative studies. The remaining 21 studies carried outquantitative analyses. Three studies were carried out inAustralia, eleven in the USA, four in Canada, three inScotland and two in England. A wide range of clientgroups were included, including panic disorder withagoraphobia,7,51 mixed client groups including person-ality disorder,54,75 transsexual adjustments,61 mixedanxiety and depression,68,77,81 teenagers with epilepsyand their families,62 adult inmates with mood orpsychotic disorder,70 obsessive–compulsive disorder(OCD),63,67 social anxiety disorder,80 posttraumaticstress disorder (PTSD),57,65,82 eating disorders,56,74,76 andfamilies of children with traumatic brain injury.79 Themajority of studies reported on individual work withadults (18 articles) or adolescents (1), with a minorityusing other types of contact, including couples work (1)and family therapy (3). The psychotherapy treatmentmodels studied included CBT (13 articles), marital andfamily therapy (1), acceptance and behaviour-basedtherapy (1), ‘eclectic’ therapy (1), general mental healthand coping management (1), issue-specific family coun-selling (1), family problem solving (1), group angermanagement (1), exposure and response prevention (1),and PTSD assessments (1). One of the articles differedin that it focused on psychologists who rated an iden-tical session conducted either in-person or viavideoconferencing.26 As such, the clinical presentationand psychotherapeutic model was not stated, as theintention of the study was to measure psychologist per-ceptions of alliance in each condition. The modality ofvideoconferencing varied from study to study, with themajority of studies using ISDN-based videoconferencing(or via T1 lines or satellite),16 with a minority usingother forms of technology (i.e. iChat (1); Skype (2);other web-based service (1); closed-circuit TV (1); notstated (2)).

A range of measures were used to assess TA, includingthe following:1. The full or modified version of the Working Alli-

ance Inventory (WAI) is a 36-item instrument onwhich participants rate different aspects of theirexperiences in psychotherapy. The WAI has threesubscales derived from Bordin’s (1979) transtheore-tical conception of the alliance:27 task, goals andbond. The task subscale contains items related tospecific therapeutic techniques used during thesession and related technical details. The goalssubscale contains items that assess the extent to

which the patient and therapist are in agreement onand working towards therapeutic goals. The bondsubscale contains items relating to trust, empathyand other factors that contribute to therapeuticbond. This questionnaire includes a range of items,including ‘What I am doing in therapy gives me newways of looking at my problem’, ‘I am confident in[my therapist’s] ability to help me’, ‘We agree onwhat is important for me to work on’, ‘What I amdoing in therapy gives me new ways of looking atmy problem’ and ‘We have established a goodunderstanding of the kind of changes that would begood for me’. Each item is rated on a 7-point Likertscale, with ‘never’ and ‘always’ at opposing poles.The Working Alliance Inventory-Short Revised is a12-item measure that assesses three key allianceaspects: (i) agreement on the tasks of therapy, (ii)agreement on the therapeutic goals and (iii) devel-opment of an affective bond25,26,64 (14 studies).

2. The Penn Helping Alliance Scale (Penn) comprisesten 10-point Likert-type items, six of which mea-sure the patient’s experience of receiving help or ahelpful attitude from the therapist (HA 1), and fourof which measure the patient’s experience of beinginvolved in a joint or team effort with the therapist(HA 2)72 (2 studies).

3. The Agnew Relationship Measure (ARM) has fivescales: bond, which concerns the friendliness, accep-tance, understanding and support in the relation-ship; partnership, which concerns working jointlyon therapeutic tasks and towards therapeutic goals;confidence, which concerns optimism and respectfor the therapist’s professional competence; open-ness, which concerns the degree to which clientsperceive they are free to disclose personal concernswithout fear or embarrassment; and client initiative,which concerns the degree to which clients are ableto take responsibility for the direction of thetherapy. Items and scales are parallel across clientand therapist forms.73 The ARM has a simpleformat and uses language that is compatible withmost therapeutic approaches73 (3 studies).

4. Videoconferencing Tele-Presence Scale (VTS) isan eight-item questionnaire that participants rateaccording to the degree to which they feel they were‘being with’ the therapist during their most recentvideoconferencing session. For each item, partici-pants must rate the degree to which they agree witha statement by using a percentage scale (0–100%).The validation study identified three factors: physi-cal presence (e.g. ‘I had the feeling I was in the sameroom as the other person’), social presence (e.g. ‘Itseemed the person or party located at the othervideoconference site and I were together and thatfeeling disappeared when the videoconference



session ended’) and absorption (e.g. ‘When thevideoconference session ended, I felt like I wascoming back to the real word’), with a Cronbach’salpha of 0.8452,5353 (4 studies).

5. Vanderbilt Psychotherapy Process Scale (VPPS)comprises 44 5-point Likert-type items assessingseven dimensions of therapist and patient attitudesand behaviours: patient exploration (PEXP), thera-pist exploration (TEXP), patient participation(PPAR), patient hostility (PHOS), therapist warmthand friendliness (TWFR), negative therapist atti-tude, and therapist directiveness (TDIR)55 (1 study).

6. Distance Communication Comfort Scale (DCCS) isa self-report questionnaire that contains 27 state-ments relating to participant comfort level withthree different types of communication: face to face,VC and telephone60 (1 study).

7. Session Evaluation Questionnaire (SEQ) measuressession evaluation and two dimensions of partici-pants’ post-session mood: positivity and arousal.58,59

Psychotherapy sessions are evaluated as good orbad along two main dimensions: (i) as powerful andvaluable versus weak and worthless (depth), and (ii)as relaxed and comfortable versus tense and dis-tressing (smoothness). In addition, the SEQ mea-sures two dimensions of participants’ post-sessionmood, positivity and arousal, which are generallyconsidered as basic theoretical dimensions of moodand emotion.83,84 The SEQ, Form 5, includes 21items in a 7-point bipolar Likert scale. Participantsare instructed the following: ‘Please circle theappropriate number to show how you feel aboutthis session’. The items are divided into two sec-tions: session evaluation and post-session mood.The stem ‘This session was:’ precedes the first 11items (session evaluation), bad–good, difficult–easy,valuable–worthless, shallow–deep, relaxed–tense,unpleasant–pleasant, full–empty, weak–powerful,special–ordinary, rough–smooth, and comfortable–uncomfortable. The stem ‘Right now I feel:’ pre-cedes the second 10 items (post-session mood),happy–sad, angry–pleased, moving–still, uncertain–definite, calm–excited, confident–afraid, friendly–unfriendly, slow–fast, energetic–peaceful, andquiet–aroused. Each item is scored from 1 to 7, withhigher scores indicating greater depth, smoothness,positivity or arousal. Each dimension is scored asthe mean of the constituent item ratings, rather thanthe sum of the item ratings. Consequently, thedimension scores lie on the same 7-point scale asthe individual items, making interpretation easier.The midpoint of each SEQ scale is 4.00, and thepossible range (e.g. from maximum shallowness tomaximum depth) is 1.00–7.00. The SEQ has hadseveral iterations, and factor analyses confirm an

independent and internally consistent set ofitems.58,59

8. Group Therapy Alliance Scale (GTAS) is a 36-itemquestionnaire of group therapy alliance, based onthe systemic model of alliance.69 This scale wasdesigned to measure a modified version of Bordin’s(1979) alliance model across four interpersonaldimensions: (i) individual group member to thera-pist alliance, (ii) members-as-a-group to therapistalliance, (iii) others-within-the-group to therapistalliance and (iv) member to member alliance. Itemsare rated on a 7-point Likert scale (completely dis-agree (1) to completely agree (7) to rate theirworking alliance with the group as a whole, thegroup members and the therapist(s)) (2 studies).

9. Qualitative interviews or analyses of ses-sions18,50,66,76,78,79 (4 studies).

Most studies used more than one measure. These aresummarised in Table 2.

Feasibility and strength of TA viavideoconference (Questions 2 and 3)

Consistent with previous reviews, comparisons betweenstudies were difficult due to variations in type and reli-ability of technology with attendant discrepancies inaudio/video quality and bandwidth.5,15,41,42,85 The pres-ence of a number of (possibly confounding) factorsmakes it difficult to draw clear conclusions. Thesefactors include aspects of TA: ‘bond, presence, therapistattitudes and abilities, client attitudes and beliefs’; typeof telepsychology, client and therapist experience acrossthe above parameters; types and wide range of patient/client groups across studies and therapeutic modality.Some studies stated the type of technology but did notstate either the bandwidth or the model/size of video-conferencing unit or screen, making juxtapositionimpractical. Nevertheless, the inclusion of a wide rangeof studies that have used different technologies and mea-sured TA in different ways gave us the opportunity toexamine different aspects of TA and to explore whetherTA can be established across different diagnostic group-ings and therapeutic models. The variations have alsoprovided an opportunity to consider how the specificelements of TA manifest in a range of therapeutic con-ditions and contexts. In spite of the variations betweenmodalities, it was considered important to include awide range in order to realistically reflect past andcurrent trends in this growing field. Due to the possibil-ity that each therapeutic model may have its own uniqueissues and differential outcomes, the modality usedwithin each study was clearly identified in Table 2, andpotential confounding factors were considered in rela-tion to the aspects of alliance reported in this review.Nonetheless, the majority of studies used a therapeutic



model that included cognitive and/or behavioural com-ponents, and were both problem-focused and time-limited. In spite of the inconsistencies across diagnosticgroups, technologies and therapeutic models, TA ratings(as measured by self-report questionnaires or qualitativemethods) for VC sessions were surprisingly homog-enous across studies, and roughly equivalent to TAratings for in-person therapy in those studies with acomparison group.6,51,54,56,57,65,70,77 All 22 studies thatmeasured therapist and/or client alliance concludedthat both perceive moderate to strong TA viavideoconferencing. Some patients described enhance-ment of the therapeutic relationship via telepsychology,with a few indicating a preference for these overin-person sessions.74,75,86 The strength of TA as rated byvideo therapy clients was demonstrated in some studiesto increase between pre- and post-therapy,80,81 whereasothers described high alliance throughout the courseof therapy.18,51,53,54,56,57,62,63,65,67,68,74–76,79,80 Two studiesreported comparatively higher alliance in the in-personcondition. Both were group settings, with one familytherapy62 and the other a group anger managementstudy.65 In the family therapy study, TA was rated on themodified WAI across three modalities (in-person, byspeakerphone and by videoconferencing) by teens withepilepsy and their parents. The parents rated good levelsof TA across the three modalities, while the teensreported lower levels of TA in the videocon-ferencing condition. The authors hypothesised that theneuropsychological deficits that can accompany epilepsymay have interfered with their ability to encode andinterpret social interactions via the videoconferencingformat. In the anger management group, male veteransrated high levels of TA in both conditions (over 4 on a5-point scale), but there was more variance in thetelepsychology condition alongside significantly lowerratings than the in-person condition. While TA ratingswere found to predict clinical outcomes for individuals,mean ratings within conditions did not mediate out-comes between the conditions (in which in-person treat-ment was not superior to telepsychology). The authorsproposed that alliance may have been affected by theduration and intensity of this group-based treatment, aswell as other patient-specific determinants (includingcomfort or familiarity with technology or treatmenthistory). It may be that group treatments can be expe-rienced as particularly demanding for some patientsdue to the need to manage multiple distractionsand demands on their attention, including balancingvideoconferencing etiquette with group interpersonaldynamics. In particular, patients with PTSD may beparticularly challenged due to the characteristichypervigilance associated with this disorder. Anotherstudy71 that evaluated individual therapy with veteransalso found a preference for in-person therapy, but TA

was moderate with no difference between groups. Inspite of their indicated preference for in-person sessions,90% indicated some degree of satisfaction with VC,stating that they would rather use videoconferencingthan travel to appointments.73 Interestingly, both groupstudies used videoconferencing with high-quality band-width, suggesting that quality of technology and con-nection may not have been major factors influencingalliance. Another finding supporting this notion wasthat those forms of videoconferencing that are consid-ered less reliable (e.g. Skype, iChat) did not appear to beassociated with lower alliance, with high client ratingsof alliance, satisfaction and presence reported in thesestudies.44,48,62

In the study that measured psychologist perceptionsof video therapy compared with in-person therapy,26 asimulated fourth treatment session was acted out by atherapist/actor pair to be as identical as possible acrossboth settings. Sessions were recorded and checked forequivalence by an independent psychologist. The scriptwas repeated verbatim in the video therapy session, andgestures, clothing and accessories remained constantacross settings. A sample of psychologists was randomlyassigned to watch either the face-to-face or video-conferencing session. The TA in the videoconferencingsession was rated as significantly lower compared withthe in-person session, suggesting that psychologists per-ceive that the technology hinders the development of thetherapeutic relationship, and in particular the client’sexperience of their therapist as understanding, warmand empathic.

The articles included in this study focused on differentaspects of TA, and more detailed findings will thereforebe discussed under the categories proposed by Bouchardet al.49 and Bordin39: bond, presence, therapist and clientbeliefs about psychotherapy delivered via VC, and therelative capacities of therapist and client to form a TA.These factors are explored in the context of previousfindings in this area.

Components of therapeutic alliance inpsychotherapy via VC (Question 4)

Bond and presence

Therapeutic bond, or emotional attachment betweentherapist and client, is a central component of TA and ismeasured most commonly by the bond subscales of theWAI, ARM and GTAS inventories. Most of the studiesincluded in this review referred to global TA ratings.Although they mostly included bond as a subcategory,only a minority specifically separated out these ratingsin their analyses. Those studies that did refer to bondsuggested that high levels of bond can be generated viatelepsychology even from the earliest stages of



therapy.7,18,49,51 One such study found that an initialmean bond rating of 26 (of a maximum of 28) aftersession 1 rose to 27 after five sessions, and remained atthis level at post-treatment, with a group of clientsreceiving telepsychology for agoraphobia and panic dis-order.51 The authors speculate that the use of P in P(Picture in Picture – an image of oneself on the screen)may have contributed to TA as it gave therapistsongoing visual feedback on their work. Similarly, arecent case series of clients with either depression oranxiety81 found that client ratings of bond improved byover one standard deviation over 15 sessions. Whereasfriendliness and acceptance items were endorsed morefrequently at the beginning of therapy, support andunderstanding items were also endorsed at higherratings as therapy progressed. The author suggests thata therapeutic bond was initially developed through afriendly or warm interaction style, but the bond deep-ened and became more intricate as the relationshipdeveloped. Indications from the client perspective wereclearly in support of the notion that warmth can becommunicated within the context of video therapy.Overall, these ratings suggest that the medium oftelepsychology (via VC) can transmit warmth directly,and can also promote the development of deeper levelemotions and attachment. In contrast, therapist ratingsof bond were positive and largely constant throughoutthe therapeutic process. Similar findings were reportedin a recent study56 whereby client ratings of bond didnot differ between treatment conditions and increasedover the course of treatment. Therapists rated higherlevels of bond in the in-person than in the VC condition,but in both the level of bond was high and improvedsignificantly over the treatment period.

Telepsychology is frequently criticised on the basisthat the artificiality of the technology-mediated imageand audio quality will interfere with the sense of pres-ence considered to be a necessary condition for TA to bedeveloped and maintained (e.g.22,49). Presence has beendefined by one researcher as the perception of being in aspace or environment, even when one is physicallylocated in a different place,7,53 and has been closelylinked to the concept of TA and bond.51,57 This may beinfluenced by factors such as individuals’ ability toimmerse themselves in the virtual or technology-basedenvironment, as well as external factors (e.g. ease ofcommunication, quality of picture and sound, lip–voicesynchronisation, presence of distractions).87 In thecontext of telepsychology, this would translate to thesense that one is in the presence of the person atthe remote site, rather than being in a geographicallydifferent location. Several studies have described clientand therapist experiences of actually forgetting that theother person was not with them in the room, and beingcompletely engrossed in the therapeutic process without

feeling distracted by the technology.51,63,67,71 In one study,the subjective experience of social presence (i.e. thefeeling that they are actually in the room with the thera-pist) was found to predict more than 20% of the bondbetween client and therapist.7 Social presence was ratedas even stronger than physical presence, suggesting thatclients have a strong sense of being present with thetherapist and ‘in’ the therapy, while retaining a clearsense of their actual physical location. Notably,Germain et al. (2010) report that TA rated by clients didnot appear to be impacted by a range of factors associ-ated with videoconferencing, including initial level ofcomfort with and perceptions of videoconferencing, dif-ficult therapeutic tasks (e.g. in vivo exposure to avoidedsituations) or experience with telepsychotherapy in theirstudy with clients with PTSD, suggesting that even thosewho initially hold negative expectations are able tobenefit from this type of treatment.57

A key determinant of the therapeutic bond as con-strued by most TA measures is the level of empathyconveyed by therapists.66,88 In a meta-analysis of over 57studies, Elliot et al. found that empathy predicted treat-ment outcome consistently across different therapeuticmodels, treatment formats (individual, group) and levelsof client problem severity. This effect was greatest forclient- and observer-rated empathy compared withtherapist perceptions of empathic accuracy measures.This involves a conscious effort by the therapist to bothunderstand and demonstrate understanding throughresponding in ways that meet clients’ emotional needs.This includes checking out that they understand theclients’ experience correctly and providing validationfor the clients’ viewpoint.89 It is likely that therapistshave to consciously work at conveying empathy in videotherapy sessions in order to compensate for factors suchas delays in sound, lack of eye contact and inability tophysically hand over a box of tissues.71 In addition,therapists may need to rely more heavily on verbal ges-tures to convey understanding and TA in telepsychologythan in in-person settings.90 A recent study looking atexposure and response prevention for OCD67 showedthat therapists were more likely to rely on verbal rein-forcement of clients’ efforts. In this study, clientsreported high levels of therapist empathy, high TA and astrong sense that they were in the room with the thera-pist. The authors speculate that clients may also havefelt less anxious about showing distress via VC. Asin-session exposure sessions required clients to performtasks independently, they also felt more confident abouttransferring these skills to between-session homeworkpractice. Other studies have noted similar effects,whereby videoconferencing may enhance communica-tion by slowing down interactions through turn-taking,and paying more attention to social cues and to signs ofemotionality.86,91



Several studies have noted that clients describe feelingless self-conscious in VC sessions as compared within-person treatment.20,67,68,76 In a case series of clientswith bulimic disorders, participants reported that videotherapy was less intimidating, less pressured and moreconvenient than in-person sessions.74 Clients described agreater sense of personal space and increased personalcontrol in video therapy. In some cases, telepsychologywas also shown to ensure a greater sense of confidenti-ality (such as for those living in a small, close-knitcommunity). Others experienced anxiety regarding pos-sible stigmatisation associated with attendingtelepsychology sessions at their local mental healthclinic, although one might expect similar difficultieseven if a local in-person clinic were provided. Given thehigh levels of shame associated with the experience ofeating disorders, it was suggested that video therapymay in fact facilitate the development of a therapeuticrapport by providing the ‘distance’ or space required tominimise shame experienced in therapy. However, theauthors also recommended that ‘shame’ be directlyaddressed in treatment at an appropriate point so that itcan be faced and worked through, rather than avoidedaltogether, potentially jeopardising therapy. It was sug-gested that video therapy may be a factor that enhancesTA with this client group as a result of equalising thepower balance. Whereas in-person therapy takes placewithin the therapist’s office, video therapy requires thatboth participants have their own space, and clients areaware that they can use the controls to turn the volumeup or down, zoom the therapist in or out (or off!), oreven terminate a session if they so choose. Participantsin this study reported that this increased their sense ofcontrol, and reduced feelings of being ‘intimidated’ and‘pressured’ that may be induced by simply attendingtherapy. It was also suggested that those clients who findintimacy and ‘connection’ with others uncomfortable,such as those with avoidant coping styles, may find theyare more able to participate in therapy conducted viaVC. Video therapy may provide sufficient distance fromthe therapist, to provide clients with a sense of safety tothink about and experience closeness without feelinginvaded and without their sense of identity being threat-ened. For many such clients, this may be their firstopportunity to experiment with developing an attach-ment to another person in a safe holding environment,while retaining some sense of personal control. In fact,those who experience low levels of internal control intheir day-to-day lives and relationships may prefer theextra control offered by videoconferencing. Similarly,those who feel ashamed or self-conscious in thecontext of discussing their difficulties may also preferthe distance and opportunity for control offered byvideoconferencing.92 One client in this study describedfeeling safe to discuss her difficulties via VC, as she was

less fearful of losing control over her emotions. This wasassociated with feeling less ‘scrutinised’ and ‘embar-rassed’ when communicating in this modality (com-pared with in-person therapy). A similar experience wasdescribed by a client who was seeking help for an eatingdisorder with obesity,76 reporting that video therapyallowed her to feel less embarrassed and shy than shewould have been in in-person therapy, and therefore lessinhibited about discussing her difficulties. Previousstudies have indicated that clients who experience highlevels of shame or self-consciousness, as well as thosewho use avoidant coping styles, and those who requirehigh levels of control, may find that videoconferencingprovides a fertile environment for the development of apositive TA.51,74,76,80,93 Krum-Heller Roe conceptualisesthis as the dialectic of ‘hiding/exposing’, characterisedby the ambivalence that clients experience when theypartly feel an urge to keep their true selves hidden, andpartly to open up and be known by others.18 In thisstudy, one client described feeling that video-conferencing provided a sense of safety and protection,which allowed her to express her feelings. Video-conferencing also seemed to protect her sense of separ-ateness, thus allowing her to feel able to expose herdifficulties from the safety of distance. A different clientdescribed the videoconferencing as a barrier to the dis-cussion of difficult issues at first and accepted the offerof an in-person session to help establish a rapport. Heacknowledged that following this in-person session, hewas able to make the decision to learn to open up viavideoconferencing. Clearly, individuals respond differ-ently to the presence of technology, with some feelingsafer to communicate openly, and others feeling moreguarded and suspicious. In many cases, the opportunityto have an initial in-person meeting with the therapistcan help establish comfort and trust, enabling partici-pants to overcome initial anxieties about the use ofpsychotherapy and videoconferencing.78,94

Therapist attitudes and abilities

If therapeutic bond and TA are associated with factorssuch as empathy and transmission of warmth, thentherapist attitudes and abilities will be important com-ponents that may either facilitate or detract from thedevelopment of a strong rapport in telepsychology.Studies in in-person settings show that therapist anxietycan interfere with the development of TA, especially if itleads to reactivity to the client, such as being critical ortense.57,95 It is therefore of key importance to identifyattitudes that therapists hold towards the use of videotherapy, and the way in which this influences theirbehaviour and the TA. Indeed, psychologists haveexpressed scepticism about the potential for developinga TA via VC. In one study (Rees and Stone), psycholo-



gists were randomly assigned to rate TA of a 20-minvideo of a therapy session conducted either in-person orvia VC.22 Although the session was identical in bothconditions, psychologists expressed concern that thetechnology would have a detrimental effect on TA, andexpressed concern that client’s perception of therapistempathy, sensitivity, warmth and understanding wouldbe compromised. Shore et al. described similar findingswhen psychiatrists rated client satisfaction of psychiatricassessments by American Indian veterans (StructuredClinical Interview for DSM Disorders (SCID)) as mark-edly lower than participants actually rated themselves.96

Similar findings were found in another study23 in whichpsychologists’ attitudes to videoconferencing werequalitatively explored. Psychologists believed thattherapy conducted via videoconferencing would be lesseffective than in-person therapy. They also suggestedthat clients in crisis or with complex presentationswould be unsuitable for VC therapy, including thoseexperiencing psychosis, suicidal ideation or with person-ality disorders. A significant number of psychologists inthis study also believed that VC therapy would only beappropriate for time-limited, structured therapy (includ-ing CBT, assessments, psycho-education, case manage-ment, reviewing homework). They indicated that longerterm, less structured therapy approaches, such as psy-chodynamic therapy or therapy with complex clients,would be less suitable to deliver via VC. The majority ofpsychologists who were interviewed indicated thatalthough they felt that a collaborative relationshipwould be possible via VC, they anticipated that thetechnology would compromise the development ofa TA due to difficulties conveying empathy, sensitivity,warmth and understanding. So are these expectationsheld by psychologists with little or no personal experi-ence in the use of VC for therapeutic purposes borne outby the current evidence?

Although therapists using VC sometimes rated TA ata lower level than clients,56,68,81 in general their TAratings ranged from moderate to very high. The evi-dence also suggests that even psychologists with littleexperience in video therapy usually become accustomedto it in a relatively short period of time.14,97 Severalfactors have been identified as crucial in terms of thecapacity of the therapist to facilitate TA in the context ofin-person therapy. As the creator of person-centredtherapy, and one of the very first therapists to describeTA, Rogers highlights several important factors that areconducive to a strong therapeutic rapport, including theexpression of unconditional positive regard, spontane-ous praise, acceptance and a sense of caring for theclient.98 The importance of conveying genuine andauthentic congruence is an essential ingredient, as com-municated through active and engaged listening andrelating.99–101 The evidence to date suggests that in fact

therapists do make adjustments when conductingtherapy via VC in order to convey these importantfactors while facilitating the development of TA.Bischoff et al. found that both therapists and clientsmade three main accommodations to their usual com-munication styles in order to adapt to the technologyand to promote TA.50 These accommodations includethe following: 1/being more deliberate and overt in non-verbal responses, such as through purposefully exagger-ating voice inflections and changes in tone, as well asgestures and mannerisms; 2/asking more questions inorder to clarify the meaning attached to clients’ facialexpressions and body language; and 3/offering anin-person session within the rural community at thestart of therapy as a way of boosting rapport. In fact,two of the three clients declined due to privacy concerns.These authors observed that therapists and clientsadjusted quickly to the change in pace of conversationrequired over videoconferencing, with minimal disrup-tion to the flow of communication. They note that, inmany cases, therapists and clients appear more investedin the therapeutic relationship conducted by VC, andmore tolerant of plans not turning out as expected,perhaps due to the understanding that working at adistance may be more difficult to initiate and sustain.Similarly, Manchandra and McLaren report that thetherapist in their study used gestures of encouragementand support and that were noticeably more exaggeratedthan in an in-person setting.68 Tuerk et al. observedthat those therapists who were competent invideoconferencing had developed clinical flexibility,strong rapport building skills and creativity whencarrying out prolonged exposure therapy via video-conferencing in the treatment of adults with PTSD.11

Even at low bandwidth and low audio and visualquality, therapists and clients are able to adjust to thetransmission delay by making adaptations, such as usingshorter sentences (allowing more opportunities for theother to speak, thereby reducing interruption of eachother caused by both talking at the same time) andturn-taking (i.e. waiting for the other to finish speakingand pause before beginning).61 In fact, therapists may bemore likely to take the time needed to prepare forsessions conducted via videolink than in-person ses-sions, which has the potential to enhance clinicaloutcomes.75,81

Client attitudes and beliefs

Just as therapist attitudes and skills play a role in thedevelopment of rapport, the individual capacities andpotential of clients also are of crucial importance. Ingeneral, clients did not appear to have a modality pref-erence,56 although some studies have indicated thatwhen given a choice clients expressed a preference for



telepsychology over in-person psychotherapy.8,74,75,102

Just as therapists appear to make adjustments whenworking by VC, a number of studies have identifiedsimilar patterns with clients, with significantly moreclient participation in videoconferencing than inin-person settings. Clients were found to be more active,with higher levels of initiative, spontaneity, trust anddisinhibition. The authors suggest that clients may havea propensity to make more effort to communicate andto take greater responsibility for their role in the dia-logues than in a conventional in-person setting. It mayalso be that the distance gives an extra dimension ofsafety that allows more openness in communication.54

Germain et al. noted that even when clients had negativepreconceptions or were not initially entirely comfortableat the start of video therapy, this did not interfere withthe development of a positive rapport.57 These authorsalso found that factors that have been found to under-mine TA in-person settings (e.g. defensive attitude, lackof psychological preparedness) did not adversely affectalliance in video therapy. Even the stress of carrying outexposure work with previously avoided tasks, did notinterfere with TA.57

DiscussionThe aims of this systematic review were to identify,synthesise and interpret the findings on TA via VC usinga predefined search and selection protocol to addressfour general questions. We will discuss the issues thatpertain to each of the four questions.

Types of articles (Question 1)

Of the 23 articles included in the review, seven wereRCTs, three non-RCTs, five uncontrolled pilot trials,four single case series and four single case studies. Twostudies were exclusively based on qualitative data, andthe remaining 21 studies carried out quantitative analy-ses. A range of client groups were covered in thesestudies, including panic disorder with agoraphobia,mixed client groups including personality disorder,transsexual adjustments, mixed anxiety and depression,teenagers with epilepsy and their families, families ofchildren with traumatic brain injury, adult inmates withmood or psychotic disorder, OCD, social anxiety disor-der, PTSD, and eating disorders. The majority of studiesreported on individual work with adults (18 articles),with a minority using other types of contact, includingcouples work and family therapy. The majority ofstudies used CBT as the main treatment focus, or asimilar time-limited solution-focused treatment app-roach. A range of videoconferencing modalities werealso used, including ISDN-based videoconferencing, (or

via T1 lines or satellite), with a minority using otherforms of technology (i.e. iChat, Skype, other web-basedservice, closed-circuit TV).

A range of measures were used to assess TA, includingthe WAI, Penn, ARM, VTS, VPPS, DCCS, SEQ, GTASand qualitative interviews or analyses of sessions. Moststudies used more than one measure.

Feasibility and strength of TA viavideoconference (Questions 2 and 3)

Preliminary evidence from this review suggests that TAis equivalent across in-person and VC modalities, andthat in-person therapy may not be the gold standard foreveryone.6,41,51,54,56,57,65,70,74,75,77 In spite of inconsistenciesacross diagnostic groups, technologies and therapeuticmodels, TA ratings (as measured by self-report question-naires or qualitative methods) for VC sessions weresurprisingly homogenous across studies, with all 22studies that included therapist and/or client ratingsreporting moderate to strong TA. Indeed, somepatients indicated a preference for using web-basedtechnology over in-person sessions,74,75,86 which is con-sistent with previous findings.40,103 Many studiesdescribed high TA throughout the course oftherapy.18,51,53,54,56,57,62,63,65,67,68,74–76,79,80 Two studies thatreported on group therapy (i.e. family therapy for epi-lepsy and group anger management) reported compara-tively higher TA in the in-person condition. Grouptreatments may be particularly demanding for somepatients in a VC setting due to the need to managemultiple distractions and demands on their attention,including balancing videoconferencing etiquette withgroup interpersonal dynamics. One study investigatedpsychologist perceptions (as observers) of an identicalsimulated therapy session conducted via VC andin-person therapy; the TA in the videoconferencingsession was rated as significantly lower compared withthe in-person session. This finding suggests that psy-chologists may have had negative expectations aboutthe impact of technology on TA that influenced theirratings of TA in the VC condition.22

Components of therapeutic alliance inpsychotherapy via VC (Question 4)

Of the minority of studies that specifically examinedtherapeutic bond, all indicated that high levels of bondcan be generated via VC even from the earliest stages oftherapy.7,18,49,51 In general, ratings suggest that VC can infact facilitate the transmission of warmth and thedevelopment of deeper level emotions and attachment.A sense of ‘presence’ has also been considered a keyfactor affecting the development of TA via VC, withseveral studies noting that both clients and therapists



described being completely absorbed by the therapeuticprocess without feeling distracted by the technol-ogy.51,63,67,71 Some studies suggested that VC mayenhance communication by slowing down interactionsthrough turn-taking, paying more attention to socialcues and to signs of emotionality,76,86,91 and equalisingthe power balance.74 Indeed, in many cases, clientsreport reduced shame and self-consciousness, such thatthe distance and opportunity for increased control pro-vided by therapy via videoconferencing allows themthe safety to communicate openly about theirdifficulties.74–76 For others, videoconferencing may ini-tially represent a barrier to communication, and theymay require more help with adjusting to the technology.It appears that with experience, both therapists andclients make accommodations to their usual communi-cation styles in order to adapt to the technology andfacilitate TA.50

The studies included in this study were mostly smallpilot studies, with a few RCTs. The small scale andnaturalistic setting of these studies increase ecologicalvalidity and enable a rich description of therapeuticfactors that might not have been possible to elucidate inlarger trials.46,47 However, larger, adequately poweredstudies will also be required in the future to verify thesefindings. Studies on TA in in-person settings suggest thattherapist anxiety or reactivity may undermine the devel-opment of TA.95 It will be important for future studies tomeasure clinician attitudes and perceptions in relationto videoconferencing, and to explore to what extentthese impact on the strength and development of TA.Therapist characteristics along the dimensions ofwarmth/hostility and flexibility/rigidity have also beenfound to be correlated with strength of TA, and it will beimportant to measure these factors in the future in rela-tion to videoconferencing psychotherapy. Future studiesmay also improve the reliability of the measurement ofbond and presence through triangulation of both psy-chometrically valid quantitative measures and qualita-tive assessment of this construct.

To reduce the impact of apparent unsupportedbiases regarding the efficacy of telepsychology, psycho-therapists should be encouraged to become aware ofthe current process and outcome evidence that sup-ports the use of this modality in psychotherapy. Thismay be achieved through the incorporation of trainingin videoconferencing psychotherapy to help cliniciansdevelop insight and self-reflexivity into the way inwhich their behaviour and therapeutic style influencethe quality of TA with different client groups.104,105

Training could focus on the development of moment-by-moment awareness, and the cultivation of thetherapist’s ability to self-reflect both on theirown responses and on the therapeutic process as ittakes place via videoconferencing. In addition, thera-

pists may benefit from training in ‘relational sensitiv-ity’106,107 through which they can better recogniseand resolve therapeutic ruptures, thereby capitalisingon critical opportunities for change and growth invideo therapy. It will be important for clinicians toroutinely measure both TA and clients’ experiencesof and responses to video therapy itself in orderto improve their capacity to recognise and repairtherapeutic ruptures, and to prevent unplannedtermination.108

It will also be important to consider whether theremay be certain client groups who are more or less likelyto benefit from VC therapy. It has been suggested thatthe presence of certain personality characteristics (e.g.paranoid and avoidant) or difficulty trusting others maydetract from the ability of some clients to engage in thisform of therapy, due to fears about being watched orrecorded.74,75 For some clients, difficulty trusting othersand a lack of social confidence may increase the anxietythey feel about the use of videoconferencing. Richard-son also described a poor client-treatment match withtwo clients who had a history of childhood abuse, rigidpersonality characteristics and signs of dissociation.81

She suggested that these clients may be less suited tostand-alone telepsychology due to their approach-avoidance interpersonal style and emotional dysregula-tion, and might benefit more from the stability andincreased support offered by a combination of in-personand videoconferencing sessions. In another study, teen-agers with epilepsy62 were found to rate lower levels ofTA in videoconferencing sessions than those conductedvia speakerphone or in-person, even though theirparents rated equal alliance across conditions. In thisstudy, the authors speculate that the epilepsy may haveinterfered with their ability to process information com-municated by videolink. On the other hand, it has alsobeen suggested that some clients may be better suited toVC than in-person therapy. This might include thosewho experience high levels of shame and body-relatedself-consciousness, as well as those with a high need forcontrol,74 although further studies are needed to test thishypothesis.

Although in some cases we may be able to find a wayof matching client characteristics, such as presentingproblems, personality type and level of comfort withtechnology, to different modes of treatment delivery,54

for many clients living in remote and rural areasvideoconferencing may represent their only feasiblemeans of accessing psychotherapy.76,109,110 Therefore,further research should also be conducted into thefactors that may strengthen TA for clients who initiallyfind video therapy uncomfortable, or whose difficultiesare more complex or require more intensive psycho-therapy. Further studies are also required to identify therelative advantages and disadvantages of the types of



technology available, with a view to pinpointing factorsthat enhance or detract from the development of thera-peutic rapport.

There are inherent difficulties associated with measur-ing a subjective concept such as TA, with researchersemploying a range of definitions and measures in anattempt to quantify it in concrete terms. It may also besubject to bias, depending on the mode of administrationand patients’ perceptions of whether or not their thera-pist will view their ratings. It is suggested that futureresearch in this area would benefit from comparingobserver ratings of TA across VC and in-person modali-ties to determine the association between self-report andobserved TA. This would also allow the researcher toobserve any factors that may be specific to VC thatfacilitate or detract from the development of TA.

ConclusionOnly 23 telepsychology studies of more than 9000 wereidentified in this review that measured TA as a primary,secondary and tertiary outcome measure. Preliminaryevidence on the basis of the studies demonstrated highlevels of TA as rated by clients and therapists, even atlow bandwidths and poor quality image/sound. Ingeneral, clients have rated the TA at least as high in theVC as in-person therapy. Therapist ratings are also gen-erally high, often increasing over the course of therapy.There is evidence that therapists often make adjustmentswhen using videoconferencing, which allow them toexpress empathy and warmth in an active fashion.Therapists tend to be more likely to check with clientsfor clarification and to ask for more information aboutfacial expressions and bodily gestures. It may also bethat the additional preparation that therapists makebefore VC therapy sessions may be a factor that poten-tially enhances clinical outcomes. Clients have com-mented that the enhanced control and personal spacethat they feel in video therapy can enhance the TA.There is also initial evidence that clients are more activein video therapy than in-person therapy. This may be asa result of a greater sense of ownership or responsibilityfor their part in the therapeutic relationship, and alsodue to feeling less intimidated and thereby safer toopenly discuss feelings and problems. It seems that astherapists learn to tailor their approach to individualclient characteristics, the TA is strengthened. Thesepromising findings support the need for further researchin this area to encourage practice and training intelepsychology, and to make therapy more accessible forgeographically disadvantaged clients.

Author contributions

SGS and CLR contributed equally.

References1 Hollon SD, Muñoz RF, Barlow DH et al. Psychosocial

intervention development for the prevention andtreatment of depression: promoting innovation andincreasing access. Biological Psychiatry 2002; 52:610–630. [Cited 30/10/2013]. Available from URL:http://www.sciencedirect.com/science/article/pii/S0006322302013847

2 Sirey JA, Bruce ML, Alexopoulos GS, Perlick DA,Friedman SJ, Meyers BS. Stigma as a barrier to recovery:perceived stigma and patient-rated severity of illness aspredictors of antidepressant drug adherence. PsychiatricServices 2001; 52: 1615–1620. [Cited 30/10/13]. Avail-able from URL: http://www.ps.psychiatryonline.org/article.aspx?articleID=86814

3 Nutting PA, Rost K, Dickinson M et al. Barriers to initi-ating depression treatment in primary care practice.Journal of General Internal Medicine 2002; 17: 103–111.[Cited 30/10/13]. Available from URL: http://www.onlinelibrary.wiley.com/doi/10.1046/j.1525-1497.2002.10128.x/full

4 Wray BT. Attitudes of clinical psychologists in WesternAustralia to videoconferencing: an explorative study.Unpublished master’s dissertation, Curtin University ofTechnology. 2003.

5 Simpson S. Psychotherapy via videoconferencing:a review. British Journal of Guidance & Counselling2009; 37: 271–286.

6 Morland LA, Greene CJ, Rosen CS, Foy D, Reilly P,Shore J, He Q, Frueh C. Telemedicine for Anger Manage-ment Therapy in a Rural Population of Combat Veteranswith Posttraumatic Stress Disorder: A RandomizedNoninferiority Trial. J Clin Psychiatry 2010; 71: 855–863.

7 Bouchard S, Robillard G, Marchand A, Renaud P, RivaG, eds. Presence and the bond between patients and theirpsychotherapists in the cognitive-behavior therapy ofpanic disorder with agoraphobia delivered invideoconference. Proceedings of 10th InternationalWorkshop on Presence, Barcelona, Spain, 2007.

8 Christopher Frueh B, Henderson S, Myrick H. Telehealthservice delivery for persons with alcoholism. Journal ofTelemedicine and Telecare 2005; 11: 372–375.

9 Myers K, Valentine J, Melzer S. Feasibility, acceptability,and sustainability of telepsychiatry for children and ado-lescents. Psychiatric Services 2007; 58: 1493–1496.[Cited 30/10/13]. Available from URL: http://www.journals.psychiatryonline.org/article.aspx?articleid=98756

10 Cluver JS, Schuyler D, Frueh BC, Brescia F, Arana GW.Remote psychotherapy for terminally ill cancer patients.Journal of Telemedicine and Telecare 2005; 11: 157–159.[Cited 30/10/13]. Available from URL: http://jtt.sagepub.com/content/11/3/157.short

11 Tuerk PW, Yoder M, Ruggiero KJ, Gros DF, Acierno R.A pilot study of prolonged exposure therapy forposttraumatic stress disorder delivered via telehealthtechnology. Journal of Traumatic Stress 2010; 23:



116–123. [Cited 30/10/13]. Available from URL: http://www.onlinelibrary.wiley.com/doi/10.1002/jts.20494/abstract

12 Bose U, McLaren P, Riley A, Mohammedali A. The use oftelepsychiatry in the brief counselling of non-psychoticpatients from an inner-London general practice. Journalof Telemedicine and Telecare 2001; 7 Suppl1: 8–10.[Cited 30/11/13]. Available from URL: http://www.europepmc.org/abstract/MED/11576473/reload=0;jsessionid=ZCkoakZhtcRYJDdHGzP4.20

13 Harvey-Berino J. Changing health behavior viatelecommunications technology: using interactivetelevision to treat obesity. Behavior Therapy 1998;29: 505–519. [Cited 30/10/13]. Available fromURL: http://www.sciencedirect.com/science/article/pii/S0005789498800464

14 Ruskin PE, Silver-Aylaian M, Kling MA et al. Treat-ment outcomes in depression: comparison of remotetreatment through telepsychiatry to in-person treat-ment. American Journal of Psychiatry 2004; 161: 1471–1476. [Cited 30/10/13]. Available from URL: http://ajp.psychiatryonline.org/doi/abs/10.176/appi.ajp.161.8.1471

15 Mair F, Whitten P. Systematic review of studies of patientsatisfaction with telemedicine. British Medical Journal(Clinical Research Ed.) 2000; 320: 1517–1520. [Cited30/10/13]. Available from URL: http://www.bmj.com/content/320/7248/1517

16 Griffiths L, Blignault I, Yellowlees P. Telemedicine as ameans of delivering cognitive-behavioural therapy torural and remote mental health clients. Journal ofTelemedicine and Telecare 2006; 12: 136–140. [Cited30/10/13]. Available from URL: jtt.sagepub.com/content/12/3/136.short

17 Frueh BC, Monnier J, Yim E, Grubaugh AL, HamnerMB, Knapp RG. A randomized trial of telepsychiatry forpost-traumatic stress disorder. Journal of Telemedicineand Telecare 2007; 13: 142–147. [Cited 30/10/13].

18 Krumm-Heller Roe I. Therapeutic alliance in psycho-therapy conducted through videoconferencing (PhD).Santa Barbara, California, USA: Fielding Graduate Uni-versity, 2006.

19 Millar H. Telemental health in Scotland. 2009. [Cited30/10/13]. Available from URL: http://www.forensicnetwork.scot.nhs.uk/wp-content/uploads/2012/11/Mental-Health-Review-PDF-File.pdf

20 Richardson L. ‘Can You See What I am Saying?’: AnAction-Research, Mixed Methods Evaluation ofTelepsychology in Rural Western Australia. Perth, Aus-tralia: Curtin University, 2011.

21 Rees CS, Haythornthwaite S. Telepsychology andvideoconferencing: issues, opportunities and guidelinesfor psychologists. Australian Psychologist 2004; 39: 212–219. [Cited 30/10/13]. Available from URL: onlinelibrary.wiley.com/doi/10/1080/00050060412331295108/abstract

22 Rees CS, Stone S. Therapeutic alliance in face-to-faceversus videoconferenced psychotherapy. ProfessionalPsychology, Research and Practice 2005; 36: 649. [Cited

30/10/13]. Available from URL: http://psycnet.apa.org/psycinfo/2005-15843-010

23 Wray BT, Rees CS. Is there a role for videoconferencing incognitive–behavioural therapy? 11th Australian Associa-tion for Cognitive and Behaviour Therapy State Confer-ence, Perth, Western Australia, Australia, 2003.

24 Bachelor A, Horvath A. The therapeutic relationship. In:Hubble MA, Duncan BL, Miller SD, eds. The Heart andSoul of Change: What Works in Therapy. Washington,DC: American Psychological Association, 1999; 133–178.

25 Horvath A. An Exploratory Study of the Working Alli-ance: Its Measurement and Relationship to OutcomeUnpublished Doctoral Dissertation. Vancouver, Canada:University of British Columbia, 1981.

26 Horvath A. Working Alliance Inventory (Revised). In:University SF, ed. Instructional Psychology ResearchGroup. Simon Fraser University Burnaby, British Colum-bia: Canada, 1982; 82.

27 Horvath AG, Leslie S. The Working Alliance: Theory,Research, and Practice. New York: John Wiley & Sons,1994.

28 Horvath AO, Del Re AC, Flückiger C, Symonds D. Alli-ance in individual psychotherapy. In Norcross JC.Evidence-based therapy relationships. (pp 5–6). 2010.[Cited 30/10/13]. Available from URL: http://www.nrepp.samhsa.gov/Norcross.aspx

29 Horvath AO, Del Re A, Flückiger C, Symonds D. Alliancein individual psychotherapy. Psychotherapy (Chicago,Ill.) 2011; 48: 9–16. [Cited 29/10/13]. Available fromURL: http://psycnet.apa.org/psycinfo/2011-04924-003

30 Horvath AO, Luborsky L. The role of the therapeuticalliance in psychotherapy. Journal of Consulting andClinical Psychology 1993; 61: 561–573.

31 Horvath AO, Symonds BD. Relation between workingalliance and outcome in psychotherapy: a meta-analysis.Journal of Counseling Psychology 1991; 38: 139–149.[Cited 30/11/13]. Available from URL: http://psycnet.apa.org/psycinfo/1991-22095-001

32 Martin DJ, Garske JP, Davis M. Relation of the thera-peutic alliance with outcome and other variables: a meta-analytic review. Journal of Consulting and ClinicalPsychology 2000; 68: 438–450. [Cited 30/10/13]. Avail-able from URL: doi.apa.org/journals/cou/38/2/139.pdf

33 Bordin ES. The generalizability of the psychoanalyticconcept of the working alliance. Psychotherapy: Theory,Research & Practice 1979; 16: 252–260.

34 Gaston L. The concept of the alliance and its role inpsychotherapy: theoretical and empirical considerations.Psychotherapy: Theory, Research, Practice, Training1990; 27: 143–153.

35 Wampold BE. The Great Psychotherapy Debate: Models,Methods, and Findings. Mahwah, NJ: LawrenceErlbaum, 2001.

36 Tichenor V, Hill CE. A comparison of six measures ofworking alliance. Psychotherapy: Theory, Research, Prac-tice, Training 1989; 26: 195–199. [Cited 29/10/13].Available from URL: http://psycnet.apa.org/journals/pst/26/2/195/



37 Safran JD, Wallner LK. The relative predictive validity oftwo therapeutic alliance measures in cognitive therapy.Psychological Assessment: A Journal of Consulting andClinical Psychology 1991; 3: 188–195. [Cited 29/10/13].Available from URL: psycnet.apa.org/journals/pas/3/2/188/

38 Hatcher RL, Barends A, Hansell J, Gutfreund MJ.Patients’ and therapists’ shared and unique views of thetherapeutic alliance: an investigation using confirmatoryfactor analysis in a nested design. Journal of Consultingand Clinical Psychology 1995; 63: 636–643. [Cited30/10/13]. Available from URL: http://dx.doi.org/10.1037/0022-006X.63.4.636

39 Bordin ES. The generalizability of the psychoanalyticconcept of the working alliance. Psychotherapy: Theory,Research & Practice 1979; 16: 252–260. [Cited 30/10/13].

40 Schopp L, Johnstone B, Merrell D. Telehealth andneuropsychological assessment: new opportunities forpsychologists. Professional Psychology, Research andPractice 2000; 31: 179–183. [Cited 30/10/13].

41 Richardson LK, Frueh B, Grubaugh AL, Egede L, ElhaiJD. Current directions in videoconferencing tele-mentalhealth research. Clinical Psychology: Science and Prac-tice. 2009; 16: 323–338.

42 Backhaus A, Agha Z, Maglione ML et al.Videoconferencing psychotherapy: a systematic review.Psychological Services 2012; 9: 111–131.

43 Simpson SG. The use of alternative technology for con-ducting a therapeutic relationship on videoconferencing.In: Anthony K, Nagel DM, Goss S, eds. The Use ofTechnology in Mental Health: Applications, Ethics andPractice. Springfield, IL: Charles C. Thomas Publisher,Ltd, 2010; 94–103.

44 Lincoln YS, Guba EG. Naturalistic Enquiry. ThousandOaks, CA: Sage Publications, Inc., 1985.

45 Tashakkori A, Teddlie C. Mixed Methodology: Combin-ing Qualitative and Quantitative Approaches. ThousandOaks, CA, London: Sage Publications, 1998.

46 Yin RK. Case Study Research: Design and Methods, 2ndedn. Thousand Oaks, CA: Sage, 1994.

47 Guba EG. ERIC/ECTJ annual review paper: criteria forassessing the trustworthiness of naturalistic inquiries.Educational Communication and Technology 1981; 29:75–91.

48 Reid C. Developing a research framework to inform anevidence base for person-centered medicine: keeping theperson at the centre. European Journal for Person-Centered Healthcare 2013; 1: 336–342.

49 Bouchard S, Payeur R, Rivard V et al. Cognitive behaviortherapy for panic disorder with agoraphobia invideoconference: preliminary results. CyberPsychology &Behavior 2000; 3: 999–1007. [Cited 30/10/13]. Availablefrom URL: http://www.online.liebertpub.com/doi/abs/10.1089%2F109493100452264

50 Bischoff RJ, Hollist CS, Smith CW, Flack P. Addressingthe mental health needs of the rural underserved: findingsfrom a multiple case study of a behavioral telehealthproject. Contemporary Family Therapy 2004; 26: 179–198.

51 Bouchard S, Paquin B, Payeur R et al. Deliveringcognitive-behavior therapy for panic disorder with ago-raphobia in videoconference. Telemedicine Journal andE-Health 2004; 10: 13–25.

52 Bouchard S, Robillard G. Telepresence in videoconferencescale. (Unpublished Manuscript) Cyberpsychology Lab ofUQO. Cited 30/10/13. Available at: URL: http://w3.uqo.ca/cyberpsy/docs/qaires/telepres/telepresence_en.pdf,2000, 2006.

53 Bouchard S. How to create a therapeutic bond intelehealth: the contribution of telepresence and emotions.Oral presentation at the 7th annual meeting of the Cana-dian Society of Telehealth, Québec, 2004, October 3 – 5.

54 Day SX, Schneider PL. Psychotherapy using distancetechnology: a comparison of face-to-face, video, andaudio treatment. Journal of Counseling Psychology 2002;49: 499–503. [Cited 30/10/13]. Available from URL:http://www.psycnet.apa.org/journals/cou/49/4/499/

55 O’Malley SS, Suh CS, Strupp HH. The VanderbiltPsychotherapy Process Scale: a report on the scaledevelopment and a process-outcome study. Journal ofConsulting & Clinical Psychology. 1983; 51: 581–586.

56 Ertelt TW, Crosby RD, Marino JM, Mitchell JE,Lancaster K, Crow SJ. Therapeutic factors affectingthe cognitive behavioral treatment of bulimia nervosavia telemedicine versus face-to-face delivery. Interna-tional Journal of Eating Disorders 2011; 44: 687–691.

57 Germain V, Marchand A, Bouchard S, Guay S, DrouinMS. Assessment of the therapeutic alliance in face-to-faceor videoconference treatment for posttraumatic stress dis-order. Cyberpsychology, Behavior and Social Networking2010; 13: 29–35.

58 Stiles WB, Reynolds S, Hardy GE, Rees A, Barkham M,Shapiro DA. Evaluation and description of psycho-therapy sessions by clients using the Session EvaluationQuestionnaire and the Session Impacts Scale. Journal ofCounseling Psychology 1994; 41: 175–185.

59 Stiles WB, Snow JS. Dimensions of psychotherapy sessionimpact across sessions and across clients. British Journalof Clinical Psychology 1984; 23: 59–63.

60 Schneider PL. Mediators of distance communication tech-nologies psychotherapy: development of a measure.107th Annual Convention of the American PsychologicalAssociation, Boston, August, 1999.

61 Ghosh GJ, McLaren PM, Watson JP. Evaluating the alli-ance in videolink teletherapy. Journal of Telemedicine &Telecare 1997; 1: 33–35.

62 Glueckauf RL, Fritz SP, Ecklund-Johnson EP, Liss HJ,Dages P, Carney P. Videoconferencing-based familycounseling for rural teenagers with epilepsy: phase 1 find-ings. Rehabilitation Psychology 2002; 47: 49–72. [Cited30/10/13]. Available from URL: http://psycnet.apa.org/journals/rep/47/1/49/

63 Goetter EM, Herbert JD, Forman EM et al. Deliveringexposure and ritual prevention for obsessive–compulsivedisorder via videoconference: clinical considerations andrecommendations. Journal of Obsessive-Compulsive and



Related Disorders 2013; 2: 137–143. [Cited 30/10/13].Available from URL: http://www.dx.doi.org/10.1016/j.jocrd.2013.01.003

64 Tracey TJ, Kokotovic AM. Factor structure of theWorking Alliance Inventory. Psychological Assessment1989; 1: 207–210.

65 Greene CJ, Morland LA, MacDonald A, Frueh BC,Grubbs KM, Rosen CS. How does tele-mental healthaffect group therapy process? Secondary analysis of anoninferiority trial. Journal of Consulting and ClinicalPsychology 2010; 78: 746–750.

66 Elliot R. Client change interview protocol. QualitativeInterview Protocol ed. Network for Research on Experi-ential Psychotherapies website, 1999 Available at URL:http://experiential-researchers.org/instruments.html.

67 Himle JA, Fischer DJ, Muroff JR et al.Videoconferencing-based cognitive-behavioral therapyfor obsessive-compulsive disorder. Behaviour Researchand Therapy 2006; 44: 1821–1829.

68 Manchanda M, McLaren P. Cognitive behaviour therapyvia interactive video. Journal of Telemedicine andTelecare 1998; 4 (Suppl 1): 53–55.

69 Pinsof WM, Catherall DR. The integrative psychotherapyalliance: family, couple, and individual therapy scales.Journal of Marital and Family Therapy 1986; 12: 137–151.

70 Morgan RD, Patrick AR, Magaletta PR. Does the use oftelemental health alter the treatment experience? Inmates’perceptions of telemental health versus face-to-face treat-ment modalities. Journal of Consulting and Clinical Psy-chology 2008; 76: 158–162. [Cited 29/10/13]. Availablefrom URL: http://psycnet.apa.org/journals/ccp/76/1/158/

71 Porcari CE, Amdur RL, Koch EI et al. Assessmentof post-traumatic stress disorder in veterans byvideoconferencing and by face-to-face methods. Journalof Telemedicine and Telecare 2009; 15: 89–94.

72 Alexander LB, Luborsky L. The Penn Helping AllianceScales. In: Greenberg LS, Pinsof WM, eds. The Psycho-therapeutic Process: A Research Handbook. New York:Guilford Press, 1986; 325–366.

73 Agnew-Davies R, Stiles WB, Hardy GE, Barkham M,Shapiro DA. Alliance structure assessed by the AgnewRelationship Measure (ARM). British Journal of ClinicalPsychology 1998; 37: 155–172.

74 Simpson S, Bell L, Knox J, Mitchell D. Therapy viavideoconferencing: a route to client empowerment?Clinical Psychology and Psychotherapy 2005; 12: 156–165.

75 Simpson S, Deans G, Brebner E. The delivery of a tele-psychology service to Shetland. Clinical Psychology &Psychotherapy 2001; 8: 130–135. [Cited 30/10/13].Available from URL: http://www.onlinelibrary.wiley.com/doi/10.1002/cpp.279/abstract

76 Simpson SG, Slowey L. Video therapy for atypical eatingdisorder and obesity: a case study. Clinical Practice andEpidemiology in Mental Health 2011; 7: 38–43.

77 Stubbings DR. The effectiveness of videoconference-based cognitive-behavioural therapy (PhD). Perth, Aus-tralia: Curtin University, 2012.

78 Wade SL, Wolfe CR, Pestian JP. A web-based familyproblem-solving intervention for families of children withtraumatic brain injury. Behavior Research Methods,Instruments & Computers 2004; 36: 261–269.

79 Wade SL, Wolfe C, Brown TM, Pestian JP. Puttingthe pieces together: preliminary efficacy of a web-basedfamily intervention for children with traumatic braininjury. Journal of Pediatric Psychology 2005; 30:437–442. [Cited 30/10/13]. Available from URL:http://www.jpepsy.oxfordjournals.org/content/30/5/437.short

80 Yuen EK, Herbert JD, Forman EM et al. Acceptancebased behavior therapy for social anxiety disorderthrough videoconferencing. Journal of Anxiety Disorders2013; 27: 389–397. [Cited 30/10/13]. Available fromURL: http://www.sciencedirect.com/science/article/pii/S0887618513000388

81 Richardson L. ‘Can You See What I am Saying?’:An Action-Research, Mixed Methods Evaluation ofTelepsychology in Rural Western Australia. Perth, Aus-tralia: Murdoch University, 2011.

82 Foy D, Reilly P, Shore J, He Q, Frueh BC. Telemedicinefor anger management therapy in a rural population ofcombat veterans with posttraumatic stress disorder:a randomized noninferiority trial. Journal of Clinical Psy-chiatry 2010; 71: 855–863.

83 Larsen RJ, Diener E. Promises and problems with thecircumplex model of emotion. In: Clark MS, ed.Emotion. Thousand Oaks, CA: Sage Publications, Inc.,1992; 25–59.

84 Reisenzein R. Pleasure-arousal theory and the intensity ofemotions. Journal of Personality and Social Psychology1994; 67: 525–539.

85 Garcia-Lizana F, Munoz-Mayorga I. What abouttelepsychiatry? A systematic review. Primary Care Com-panion to the Journal of Clinical Psychiatry 2010; 12:e1–e5.

86 Dunstan DA, Tooth SM. Using technology to improvepatient assessment and outcome evaluation. Rural andRemote Health 2012; 12: 2048.

87 Sadowski W. Presence in virtual environments. In:Stanney KM, ed. Handbook of Virtual Environments:Design, Implementation and Applications. Mahwah, NJ:IEA, 2002; 791–806.

88 Greenberg LS, Watson JC, Elliot R, Bohart AC. Empathy.Psychotherapy: Theory, Research, Practice. Training2001; 38: 380–384.

89 Elliott R, Bohart AC, Watson JC, Greenberg LS.Empathy. Psychotherapy (Chicago, Ill.) 2011; 48: 43–49.

90 Cowain T. Cognitive-behavioural therapy viavideoconferencing to a rural area. Australasian Psychia-try 2001; 35: 62–64. [Cited 29/10/13]. Available fromURL: http://www.informahealthcare.com/doi/abs/10.1046/j.1440-1614.2001.00853.x?journalCode=anp

91 Jerome LW, Zaylor C. Cyberspace: creating a therapeuticenvironment for telehealth applications. Professional Psy-chology, Research and Practice 2000; 31: 478–483.

92 Simpson S, Knox J, Mitchell D, Ferguson J, Brebner J,Brebner E. A multidisciplinary approach to the treatment



of eating disorders via videoconferencing in north-eastScotland. Journal of Telemedicine and Telecare 2003; 9:37–38.

93 Simpson S. Videoconferencing and technologicaladvances in the treatment of eating disorders. In: Swain P,ed. Eating Disorders: New Research. New York: NovaBiomedical, 2005; 99–115.

94 Maheu MM. The online clinical practice managementmodel. Psychotherapy: Theory, Research, Practice, Train-ing 2003; 40: 20–32.

95 Ackerman SJ, Hilsenroth MJ. A review of therapist char-acteristics and techniques negatively impacting the thera-peutic alliance. Psychotherapy: Theory, Research,Practice, Training 2001; 38: 171–185. [Cited 30/10/13].Available from URL: http://psycnet.apa.org/journals/pst/38/2/171/

96 Shore J, Savin D, Orton H, Beals J, Manson S. Diagnosticreliability of telepsychiatry in American Indian veterans.American Journal of Psychiatry 2007; 164: 115–118. [Cited 30/10/13]. Available from URL: http://www.ajp.psychiatryonline.org/article.aspx?articleID=97709&RelatedWidgetArticles=true

97 Austen S, McGrath M. Attitudes to the use ofvideoconferencing in general and specialist psychiatricservices. Journal of Telemedicine and Telecare 2006; 12:146–150.

98 Rogers CR. Client-Centered Therapy: Its Current Prac-tice, Implications and Theory. Boston: Houghton Mifflin,1951.

99 Farber BA. Positive regard. In: Norcross JC, ed.Psychotherapy Relationships that Work: TherapistContributions and Responsiveness to Patients.New York, NY: Oxford University Press, 2002; 175–194.

100 Kolden GG, Klein MH, Wang C-C, Austin SB.Congruence/genuineness. Psychotherapy (Chicago, Ill.)2011; 48: 65–71.

101 Norcross JC. Psychotherapy Relationships that Work:Therapist Contributions and Responsiveness to Patients.New York: Oxford University Press, 2002.

102 Dunstan DA, Tooth SM. Treatment viavideoconferencing: a pilot study of delivery by clinicalpsychology trainees. The Australian Journal of RuralHealth 2012; 20: 88–94.

103 Mohr DC, Siddique J, Ho J, Duffecy J, Jin L, Fokuo J.Interest in behavioral and psychological treatments deliv-ered face-to-face, by telephone, and by Internet. Annals ofBehavioral Medicine 2010; 40: 89–98.

104 Ackerman SJ, Hilsenroth MJ. A review of therapistcharacteristics and techniques positively impactingthe therapeutic alliance. Clinical Psychology Review2003; 23: 1–33. [Cited 29/10/13]. Available fromURL: http://www.sciencedirect.com/science/article/pii/S0272735802001460

105 Constantino M, Castonguay L, Schut A. The workingalliance: a flagship for the ‘scientist-practitioner’ model inpsychotherapy. In GS Tryon (Ed). Counseling Based onProcess Research: Applying What We Know 2002; pp.81–131.

106 Barrett-Lennard GT. The empathy cycle: refinement of anuclear concept. Journal of Counseling Psychology 1981;28: 91. [Cited 30/10/13]. Available from URL: http://psycnet.apa.org/journals/cou/28/2/91/

107 Samstag LW, Muran JC, Safran JD. Defining and Identi-fying Alliance Ruptures. In: Charman DP, ed. Core pro-cesses in brief psychodynamic psychotherapy: Advancingeffective practice. Mahwah NJ: Lawrence Erlbaum, 187–214.

108 Norcross JC, Lambert MJ. Psychotherapy relationshipsthat work II. Psychotherapy (Chicago, Ill.) 2011; 48: 4.[Cited 30/10/13]. Available from URL: http://.psycnet.apa.org/journals/pst/48/1/4/

109 Simpson SG, Rochford S, Livingstone A, English S,Austin C. Tele-web psychology in Rural South Australia:the logistics of setting up a remote university clinic staffedby clinical psychologists in training. Australian Psycholo-gist 2014; 49: 193–199.

110 Simpson S, Bell L, Britton P et al. Does video therapywork? A single case series of bulimic disorders. EuropeanEating Disorders Review 2006; 14: 226–241.



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Therapeutic alliance in videoconferencing psychotherapy: a review