Text-based online therapy interventions have been used for more than a decade, but no comprehensive review of the effects on the alliance have been conducted. The authors have collected all of the empirical articles published up to December 2008 (n = 12) that examine the alliance of text-based online therapy. These studies involved a total of 574 clients who were treated by 18 therapists through various psychological interventions for a variety of problems. When compared to the face-to-face relationships (7 studies), participants in text based forms of online therapy mostly reported similar (3 studies) or stronger (2 studies) alliance ratings. The findings of this review suggest that online text therapists are able to meaningfully connect with their clients. Limitations of the findings and future research are discussed.
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The high prevalence of diagnosable psychological problems and their contribution to ill health and disability has been regularly cited in the mental health literature (e.g., World Health Organization, 2001). Unfortunately, many individuals never seek assistance for their treatable mental disorders (Surgeon General's Report on Mental Health, 1999). Barriers to traditional face-to-face therapy, such as managed care’s insistence on medical necessity, social stigma, and geographic isolation have prompted some people to turn to the growing number of therapists conducting psychotherapy over the Internet.
At this writing, the most common mode of delivery for Internet psychotherapy is text-based e-mail although text-based chat services are becoming more popular (Heinlen, Welfel, Richmond, & Rak, 2003; Stofle, 2001). E-mail services are asynchronous, meaning participants respond to one another when they have time, rather than immediately. Online psychotherapists have developed a variety of pricing arrangements including flat fees for standard message lengths, by-the-minute charges for time spent replying, or package deals for a set number of e-mail or unlimited e-mails for a specific period of time (Rochlen, Zack, & Speyer, 2004). Chat services are synchronous or involve a dialogue between client and practitioner in real time using an Internet chatroom or Instant Messaging software (AIM, ICQ, etc.). Typically, these sessions require a pre-determined appointment time and clients are charged by the half-hour or hour, although some sites charge by the minute (Anthony, 2006; Tyler & Guth, 2004). Therapists have also begun to offer their services using more sensory rich online technologies such as videoconferencing or audio-to-audio (Rochlen, Zack, & Speyer, 2004). However, we do not discuss these developments but rather choose to focus on the currently most popular form: text based online therapy.
In an extensive meta-analysis of the outcome effectiveness of Internet based psychotherapeutic interventions, Barak, Hen, Boniel-Nissim, & Shapira (2008) reported a medium mean weighted effect size (0.53). They reviewed 92 studies involving 9,764 clients with only 7 studies examining email therapy (N = 383, ES = 0.51) and 9 studies examining synchronous chat therapy (N = 231, ES = 0.53). Although this study concluded that online psychological interventions are a legitimate therapeutic activity, it did not systematically address a crucial aspect of therapeutic process: the therapeutic relationship.