Therapeutic Alliance in Telehealth: Evidence and Ethics

One of the most common questions I hear from both colleagues and clients is: “Will I still feel connected if therapy happens online?” The short answer is yes. Research consistently shows that the therapeutic alliance and client satisfaction in telehealth are comparable to in-person care. In other words, the heart of therapy — safety, trust, and connection — can absolutely translate through a screen.

At the same time, competence in telehealth requires more than good rapport. When we ground our practice in ethics CEUs from an APA-Approved Sponsor and follow established telepsychology guidelines, we strengthen the clinical, ethical, and technical foundation needed to provide care online. This combination allows us to show up with confidence, knowing our work is both evidence-based and ethically sound. 

Client Satisfaction and Working Alliance in Telehealth

Meta-analyses and systematic reviews (Greenwood et al., 2022; Mazziotti et al., 2021) consistently demonstrate that client satisfaction and working alliance remain strong in telehealth. Both clients and therapists tend to rate therapeutic quality and the therapeutic relationship as comparable to traditional in-person sessions. This is reassuring, given how central alliance is to positive outcomes across modalities.

What’s even more encouraging is that telehealth doesn’t just “hold its own” — for some groups, it may actually offer unique advantages. For instance, individuals with substance use disorders have reported higher satisfaction with online therapy, citing increased convenience, reduced transportation barriers, and a greater sense of confidentiality. These findings highlight that the therapeutic frame can feel more accessible and less stigmatizing when clients are able to engage from the safety of their own environment.

This reminds us that modality choice is not neutral — it can either enhance or undermine engagement depending on how well it fits client needs. A client who feels unsafe leaving home, for example, may be more willing to seek treatment if telehealth is available. Similarly, rural clients or those with mobility challenges often find online therapy to be a more realistic and consistent option. When we consider client context, telehealth becomes not just a backup plan but sometimes the best plan.

Of course, these benefits do not erase the ethical and clinical responsibilities of practicing online. Therapists must ensure that technology supports privacy, that informed consent covers digital risks, and that emergency protocols are in place. When combined with ethics CEUs from an APA-Approved Sponsor and adherence to telepsychology guidelines, these practices allow us to offer telehealth with confidence — keeping care both effective and ethically sound.

Earn CEUs with an APA-Approved Sponsor: Telehealth – Efficacy, Laws & Ethics

Ethical Issues in Telehealth Practice

While the research on alliance outcomes in telehealth is encouraging, ethical practice requires more than a strong connection — it requires deliberate attention to the unique responsibilities of online care. Telehealth introduces considerations that extend beyond in-person practice, and each one has the potential to impact client safety, trust, and therapeutic effectiveness.

Privacy and confidentiality remain central. Therapists must ensure they are using HIPAA-compliant platforms, protecting data through secure storage, and engaging clients in transparent conversations about the risks and limits of digital communication. Even simple issues, like a client joining from a public space, can create ethical challenges if not addressed directly.

Boundaries and professionalism take on new dimensions online. Establishing expectations around session structure, managing potential disruptions from technology, and clarifying therapist availability are essential for maintaining the integrity of the therapeutic frame. Without these safeguards, the therapeutic relationship can easily blur or destabilize.

Informed consent must also be expanded for telehealth. This includes planning for emergencies across state lines, providing backup options in case of technical failures, and outlining the scope and limits of care in a virtual environment. These conversations empower clients while protecting both client and clinician.

Completing ethics CEUs from an APA-Approved Sponsor equips psychologists to meet these challenges with confidence. By grounding our practice in evidence-based standards and professional guidelines, we safeguard ethical integrity while reinforcing the therapeutic alliance — ensuring that telehealth remains both effective and ethically sound.

APA Telepsychology Guidelines and Competence

The APA telepsychology guidelines emphasize that competence is multidimensional — it spans not only clinical expertise but also technical fluency and cultural responsiveness. In other words, it’s not enough to know the interventions; we must also know how to deliver them effectively in a digital space.

This begins with the ability to troubleshoot technology alongside clients. A frozen screen, dropped call, or unfamiliar platform can create frustration or even rupture the therapeutic flow. Being able to calmly guide clients through these challenges helps preserve safety and keeps the session on track.

Competence also means knowing how to adapt care for diverse needs. Clients may vary widely in digital literacy, access to technology, or comfort with virtual communication. Others may have disabilities that require accommodations, or cultural values that shape how telehealth is experienced. Meeting clients where they are — and adjusting our approach accordingly — is essential to both equity and clinical effectiveness.

Finally, competence requires that we maintain professional presence and therapeutic alliance even without physical co-presence. Tone of voice, eye contact through the camera, and intentional structuring of sessions all play a role in signaling attunement and presence across a digital medium.

In practice, competence is what bridges the gap between evidence and client trust. Research shows telehealth can be effective, but it is our ongoing professional development that turns evidence into lived experience for clients. Pairing outcome research with ethics CEUs from an APA-Approved Sponsor strengthens our ability to deliver telehealth that is not only evidence-based, but also ethically sound and authentically connecting.

 Earn CEUs with an APA-Approved Sponsor: Telehealth – Efficacy, Laws & Ethics

Bringing it all together

The data is clear: therapeutic alliance in telehealth is not compromised by the screen. Meta-analyses consistently show that clients report high levels of satisfaction, trust, and connection in virtual care. In fact, many clients describe online therapy as more accessible and less intimidating, which can help deepen engagement.

Of course, satisfaction alone is not enough — those bonds must also be protected through ethical practice. Using secure platforms, setting clear expectations, and expanding informed consent are all part of safeguarding the therapeutic relationship. By addressing privacy, boundaries, and emergency planning, we make sure the connection clients feel is backed by professional integrity.

When we integrate ethics CEUs from an APA-Approved Sponsor with the latest clinical research, we create a strong foundation for telehealth practice. This allows us to confidently reassure clients: “Yes, therapy online can be just as connected and effective as therapy in the room.”

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Read next in the series: Telehealth Access and Equity: Laws and Ethics for Psychologists

References

1. American Psychological Association. (2024). Proposed revision of guidelines for the practice of telepsychology. APA Task Force on Telepsychology. https://www.apa.org/practice/guidelines/telepsychology-revisions.pdf

2. Greenwood, H., Krzyzaniak, N., Peiris, R., Clark, J., Scott, A. M., & Glasziou, P. (2022). Telehealth versus face-to-face psychotherapy for less common mental health conditions: Systematic review. Journal of Telemedicine and Telecare, 28(5), 301–311. https://doi.org/10.1177/1357633X211066799

3. Mazziotti, R., Rutigliano, G., Vai, B., Poletti, S., Colombo, C., & Benedetti, F. (2021). Tele-mental health for reaching out to patients in a time of pandemic: Provider survey and meta-analysis of patient satisfaction. JMIR Mental Health, 8(7), Article e26187. https://doi.org/10.2196/26187

4. White-Williams, C., Liu, X., Shang, D., & Santiago, J. (2023). Use of telehealth among racial and ethnic minority groups in the United States before and during the COVID-19 pandemic. Public Health Reports, 138(1), 149–156. https://doi.org/10.1177/00333549221123575