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During the early months of the COVID-19 pandemic, patients in individual psychotherapy needed to suddenly transition to telepsychotherapy (TPT), and for many patients it was their first experience of remote treatment. Since TPT appears to be here to stay after the pandemic ends, it is crucial to understand which factors determine whether TPT is a good fit for patients. We aimed to examine patients’ relational predictors, both trait- (attachment avoidance and attachment anxiety) and state-like (working alliance, real relationship) of patients’ attitudes towards TPT, and the potential mediating role of state-like relational variables between trait-like variables and attitudes. We used a longitudinal design, where patients ( N  = 719) who were in individual TPT participated in an online survey at the beginning of the pandemic and at follow-up three months later. Patients completed measures of symptom severity, Covid-related distress, attachment anxiety and avoidance, perceived quality of the therapeutic relationship (working alliance and real relationship), and attitude towards TPT. Results suggested that higher levels of attachment avoidance predicted more negative attitudes towards TPT, and that patient-reported quality of the real relationship in their TPT sessions mediated this negative relationship between attachment avoidance and attitudes towards TPT. Patient’s attachment avoidance and the real relationship are important predictors of patients’ attitudes towards TPT, and could indicate suitability of the TPT format, as well as inform clinicians’ efforts in building a real and genuine connection with their patients online.

Patients’ attachment avoidance and their perceived quality of the real relationship predict patients’ attitudes towards telepsychotherapy