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How to Create a Strong Therapeutic Alliance over Telehealth

A mid age female therapist looking at her digital tablet while on a telemedicine session with a patient

For many mental healthcare professionals, the therapeutic alliance is the most important part of the job. So what is it?

Put simply, the therapeutic alliance is a description of the interactions between a therapist and their client. It is considered an essential part of the therapeutic process that greatly affects treatment outcomes. The typical goal of a therapeutic alliance is to increase patient engagement by establishing the therapist as a facilitator for the client to reach their goals. A good alliance makes the two feel more like equals than like a patient and an authority figure.

The therapeutic alliance is also why many therapists have stayed away from teletherapy for so long. There’s a prevailing belief that telehealth inhibits the alliance, but how true is that claim?

The therapeutic alliance—the biggest perceived barrier to teletherapy

This topic, establishing a good relationship with a client over telehealth, has come up many times on the Telehealth Heroes Podcast. Many mental health care professionals expressed their initial doubts.

“The relationship, the interaction in the room is critically important. And that’s the reason why I was opposed to the very idea of teletherapy for many years.”

–Dr. Chapman

“…I was leery [of telehealth] because the in-person contact is so crucial. New research in 2021 is saying 95% of communication is non-verbals.”

–Dr. Campinha-Bacote

However, both of these speakers said they later achieved great success with teletherapy once they incorporated it into their practices. Furthermore, some research suggests that teletherapy is actually beneficial for the therapeutic alliance.

“Historically, the uptake of videotherapy has been hindered by psychotherapist expectations of inferior therapeutic alliance and outcomes, in spite of considerable research evidence to the contrary. Research suggests that videotherapy provides a powerful pathway for clients to experience enhanced opportunities for self‐expression, connection and intimacy.” (Simpson et al., 2020)

Still, you, a mental healthcare professional, know how to establish a therapeutic alliance, but now you need to figure out how to do it during a telehealth call. Let’s examine what techniques you can use during a telehealth call to facilitate the creation of a strong therapeutic alliance.

Creating a strong therapeutic alliance over telehealth

Many of the in-person techniques you use to create a therapeutic alliance are still largely available to you during a telehealth call. In addition, here is a list of unique-to-telehealth techniques to improve the therapeutic alliance.

  • Enhance communication through intentional expressions of empathy, like leaning in to the screen, facial expressions, and voice tone
  • Encourage clients to play around with the video settings, zooming in or out until they find a comfortable virtual distance
  • Use features like Picture-in-picture to imitate eye contact by moving the client’s image to be directly under your webcam (also check out this article on creative ways to use PiP)
  • Incorporate a feedback form into your online practice, allowing the client to provide helpful feedback in a non-confrontational format


The therapeutic alliance is not as big a barrier to teletherapy as psychotherapists once assumed it was, and telehealth has massive potential to improve patient outcomes in mental health practices. So try out these techniques in your teletherapy sessions if you haven’t already, and see if they work for you or your clients. And, of course, sign up for to use the free telemedicine platform loved by therapists worldwide.