JZUS - Journal of Zhejiang University SCIENCE

Journal of Zhejiang University SCIENCE

Accepted manuscript available online (unedited version)

Therapeutic alliance across delivery modalities: a systematic narrative review of comparative strength and outcome prediction in face-to-face, online and blended psychotherapy

Author(s): Xiaoyi ZHOU¹, Huimin HUANG², Ruoxu BI³, Lena VERDELI⁴, Hailong LYU¹
Affiliation(s): ¹Department of Psychiatry, The First Affiliated Hospital, Zhejiang University School of Medicine; more
Corresponding email(s): Hailong LYU, hailonglyu@zju.edu.cn
Key Words: Therapeutic alliance; Working alliance; Telepsychology; Digital mental health; Blended psychotherapy; Online psychotherapy; Systematic narrative review

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Xiaoyi ZHOU¹, Huimin HUANG², Ruoxu BI³, Lena VERDELI⁴, Hailong LYU¹. Therapeutic alliance across delivery modalities: a systematic narrative review of comparative strength and outcome prediction in face-to-face, online and blended psychotherapy[J]. Journal of Zhejiang University Science ,in press.Frontiers of Information Technology & Electronic Engineering,in press.https://doi.org/10.1631/jzus.25-00701

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author="Xiaoyi ZHOU¹, Huimin HUANG², Ruoxu BI³, Lena VERDELI⁴, Hailong LYU¹",
journal="Journal of Zhejiang University Science ",
year="in press",
publisher="Zhejiang University Press & Springer",
doi="https://doi.org/10.1631/jzus.25-00701"
}

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%T Therapeutic alliance across delivery modalities: a systematic narrative review of comparative strength and outcome prediction in face-to-face, online and blended psychotherapy
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%A Huimin HUANG²
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%A Lena VERDELI⁴
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doi="https://doi.org/10.1631/jzus.25-00701"

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doi="https://doi.org/10.1631/jzus.25-00701"

Abstract
Chinese Summary
Academic Network
Reviewer Comment

Abstract: The frequency of online psychotherapy, including pure online (PO: videoconference [PO-VC], telephone [PO-TEL], asynchronous therapist-guided [PO-Async]), or blended (BLD) modalities, has grown exponentially, yet how the therapeutic alliance (TA), a key outcome predictor, compares across these formats and face-to-face (FTF) treatment remains unclear. Objectives: To compare (1) the TA strength and (2) the TA-outcome association across FTF, PO and BLD modalities. Methods: A systematic narrative review (PRISMA/SWiM) was performed by searching PubMed, PsycArticles, and Web of Science. Studies were deemed eligible if they quantitatively compared TA across at least two modalities in adults with depressive or anxiety disorders. PO arms were classified as telepsychotherapy (PO-VC/TEL) or therapist-guided digital interventions (PO-Async). The findings were synthesized by direction and consistency. Results: Nine studies (three primary RCTs; six secondary analyses) were finally included. TA strength was broadly comparable across all three modalities. One study found significantly lower patient-rated WAI scores at week 2 in PO-Async versus FTF, resolving by week 8. The TA-outcome association was mixed, varying by modality, rater perspective, and timepoint. Conclusions: TA was broadly equivalent across FTF, online, and blended formats, though asynchronous PO might show a transient week-2 lag. The TA-outcome association was less consistent in PO/BLD than FTF. As a preliminary hypothesis, digital delivery may shift the functional emphasis of the alliance from affective bonding toward task/goal engagement.

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