Teletherapy is one of the few areas in this series where the field has had time, since the COVID-19 acceleration of 2020, to accumulate substantial peer-reviewed evidence. Several meta-analyses and systematic reviews are now available, and the picture they paint is more nuanced than either the early enthusiasts or early skeptics predicted.
That nuance is worth sitting with rather than flattening.
A 2024 systematic review and meta-analysis in Journal of Telemedicine and Telecare compared therapeutic alliance in videoconferencing psychotherapy to in-person psychotherapy and found no statistically significant difference between the two as rated by either patients or therapists. A 2023 noninferiority study in Psychotherapy Research reached a similar conclusion: clients receiving teletherapy showed noninferior alliance and clinical outcome compared to in-person care. Multiple other reviews report consistent findings across depression, anxiety, and other common presentations - remote psychological interventions are, on average, roughly as effective as in-person care.
So far, the picture is permissive: teletherapy is, on average, a viable substitute for in-person therapy in terms of both alliance and clinical outcome.
The story does not end with “teletherapy is fine.” A 2024 meta-analysis in Journal of Telemedicine and Telecare on the alliance-outcome association in teletherapy specifically found a smaller effect size for the relationship between alliance and outcome in teletherapy than the larger correlations historically reported in in-person therapy across the broader psychotherapy research literature. The interpretation is careful: teletherapy may not weaken the alliance per se, but the way alliance translates into outcome may be subtly different in a teletherapy context, and the patient’s perspective on alliance - measured later in treatment - may matter more than it does in in-person work.
This is not a reason to avoid teletherapy. It is a reason to be more deliberate about how the alliance is built and measured in a teletherapy context. Bruce Wampold’s 2023 World Psychiatry synthesis supports the centrality of the alliance across modalities; what may be different in teletherapy is the texture of the work that creates and sustains it.
Three operational implications follow directly from the research.
First: treat the alliance as a measurable variable, not an assumed one. Brief alliance measures - the Working Alliance Inventory and its short forms, the Session Rating Scale, others as appropriate - can be administered between sessions without disrupting the work. The broader measurement-based-care literature suggests that integrating these measures into clinical practice strengthens both clinical work and the practice’s quality posture.
Second: invest in the texture of teletherapy specifically. Camera positioning, lighting, audio quality, the absence of visible distractions, the attention to silences, the explicit naming of what is harder to read on a screen - these are not small variables. They are the texture of the alliance in a teletherapy context. We know from HCI research that the medium shapes the interaction; teletherapy is not exempt from that.
Third: use between-session engagement to deepen connection. Teletherapy sessions are bookended by stretches in which the client is on their own with the work. Structured patient-reported outcomes, mood check-ins, CBT homework adherence tracking, and clinician review of between-session data - particularly when reimbursed under Remote Therapeutic Monitoring (CPT 98975–98981) where coverage exists - are not just productivity infrastructure. They are alliance infrastructure. The patient is met between sessions, not only inside them.
A teletherapy session is, legally speaking, conducted in the state where the patient is physically located. A clinician licensed in State A who treats a patient temporarily in State B is, in most cases, practicing without a license in State B. This concern is well-founded and increasingly the subject of licensing board enforcement.
Two compact frameworks have meaningfully reduced this friction. PSYPACT (the Psychology Interjurisdictional Compact) supports licensed psychologists in cross-state practice across participating states. As of late 2025, PSYPACT had 43 participating jurisdictions, with Montana joining as an active member in October 2025. The Counseling Compact supports licensed professional counselors in cross-state practice; as of early 2026, Arizona, Minnesota, and Ohio had completed technical and regulatory requirements to issue privileges, with Nevada joining effective January 1, 2026. For non-psychologist licensees outside Counseling Compact states, state-by-state licensure remains the operational reality.
The peer-reviewed evidence on teletherapy is permissive but not undifferentiated. Teletherapy is, on average, an effective modality, and the alliance is, on average, comparable to in-person work. The texture of the alliance in teletherapy may be subtly different, and practices that take that seriously - through measurement-based care, structured between-session engagement, RTM-supported reimbursement, and attention to the technical and human conditions of the video encounter - produce better outcomes than practices that treat teletherapy as Zoom with billing codes.
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