ICERT Press

The integration of digital technologies into mental health care has reshaped the delivery of psychological services worldwide. E-therapy described as teletherapy or online counselling, has moved from a peripheral option to a mainstream mode of intervention, a shift accelerated by the COVID-19 pandemic. During and after this period, practitioners increasingly relied on virtual platforms to sustain care, prompting a surge in empirical research on the effectiveness of digital interventions. Recent meta-analyses and systematic reviews indicate that teletherapy yields outcomes comparable to face-to-face therapy across a range of mental health conditions, including improvements in symptom reduction, treatment adherence, and client satisfaction (Altieri et al., 2024; Flückiger et al., 2024). In the domain of relational interventions, emerging evidence suggests that digital approaches can produce moderate and statistically significant gains in relationship satisfaction, with effects often sustained over time (Kernová et al., 2025).

Despite these advances, important conceptual and empirical gaps persist, particularly in the context of couples’ therapy. Much of the existing literature has focused on individual-level outcomes, with relatively limited attention to the complex interpersonal processes that define intimate relationships. Couples therapy involves dynamic interactions shaped by communication patterns, emotional responsiveness, and shared meaning-making processes that may be altered in virtual environments. While studies indicate that a therapeutic alliance can be established through teletherapy, its strength and influence on relational outcomes remain less clearly understood compared to traditional in-person settings (Flückiger et al., 2024). Furthermore, comparative studies suggest that teletherapy is generally equivalent, rather than superior, to face-to-face therapy (A. Bradford & V. Bradford, 2024), raising critical questions about the conditions under which digital delivery may enhance or constrain relational change. These gaps are particularly pronounced in developing contexts such as Nigeria, where structural and socio-cultural factors shape access to and engagement with mental health services. Limited availability of trained professionals, uneven distribution of services, and persistent stigma surrounding help-seeking have historically constrained access to counselling. In response, digital mental health interventions have been identified as a promising strategy to bridge service gaps and extend care to underserved populations (Onyeka et al., 2024). Empirical studies within Nigeria further indicate increasing acceptance of online counselling, especially among younger populations, who value its flexibility and accessibility (Bahago et al., 2025). However, the implementation of e-therapy in this context is challenged by infrastructural limitations, including unstable internet connectivity, varying levels of digital literacy, and concerns about confidentiality (Cole & Abubakar, 2025).

Moreover, cultural norms surrounding marriage and conflict resolution may influence how couples engage with digital therapy. In many Nigerian settings, marital issues are often addressed through informal or community-based systems, such as family mediation or religious counselling. While recent local studies have demonstrated the effectiveness of online counselling for individual psychological concerns (Pujar, 2025), there remains a notable lack of empirical research examining its impact on couples experiencing marital distress. This gap is further underscored by calls for the adaptation of counselling practices to align with the demands of the digital age and the Fourth Industrial Revolution, which emphasize technological competence and innovation in service delivery (Popoola et al., 2025). To provide a stronger explanatory foundation, this study is anchored in Family Systems Theory and Emotionally Focused Therapy. Family Systems Theory conceptualizes relationships as interdependent systems in which changes in one partner’s behaviour influence the entire relational dynamic. From this perspective, the effectiveness of e-therapy depends on its ability to facilitate systemic interaction and restructuring of maladaptive patterns, even within a virtual environment. Complementing this, Emotionally Focused Therapy emphasizes emotional bonding and attachment processes as central to relationship repair. The digital context raises important questions about whether emotional engagement, empathy, and responsiveness can be effectively conveyed through mediated communication channels. Together, these frameworks provide a lens for understanding how relational change may occur or be constrained within e-therapy settings.

Research Gap

Despite the growing body of evidence supporting the effectiveness of e-therapy, several important gaps remain in the literature. Previous studies have largely concentrated on the effectiveness of online counselling for individual mental health conditions such as anxiety, depression, and stress, with relatively fewer investigations focusing specifically on couples experiencing marital distress. Existing systematic reviews and meta-analyses have demonstrated that e-therapy produces outcomes comparable to face-to-face interventions and improves relationship satisfaction among couples (Altieri et al., 2024; Flückiger et al., 2024; Kernová et al., 2025). However, much of this evidence has been generated in Western countries where digital infrastructure, cultural norms, and access to mental health services differ considerably from those in developing countries such as Nigeria.

Furthermore, many previous studies have employed either quantitative or qualitative approaches independently, thereby providing only a partial understanding of the effectiveness of e-therapy. Quantitative studies have primarily measured treatment outcomes without adequately explaining participants’ experiences, while qualitative studies have examined users’ perceptions without establishing therapeutic effectiveness through rigorous experimental comparisons (Bradford et al., 2024; Kernová et al., 2025). Consequently, limited evidence exists that simultaneously evaluates objective therapeutic outcomes alongside the lived experiences of couples receiving online counselling. Another limitation in the existing literature is the scarcity of randomized controlled studies comparing e-therapy with conventional face-to-face therapy within African settings. In Nigeria, available studies have mainly examined online counselling among university students or individuals with psychological concerns, leaving a significant knowledge gap regarding the application of e-therapy to couples experiencing marital distress (Bahago et al., 2025; Pujar, 2025). In addition, contextual factors such as technological limitations, digital literacy, cultural expectations concerning marriage, and concerns about confidentiality have received insufficient empirical attention despite their potential influence on therapeutic outcomes (Cole & Abubakar, 2025; Onyeka et al., 2024).

The present study addresses these gaps by employing a sequential explanatory mixed-methods design that combines a randomized controlled trial with qualitative interviews to evaluate the efficacy of e-therapy for couples experiencing marital distress in Oyo State, Nigeria. By integrating quantitative measures of relationship satisfaction, communication, emotional intimacy, and therapeutic alliance with participants lived experiences, the study provides context-specific evidence from a developing country and offers a more comprehensive understanding of both the effectiveness and implementation of e-therapy for couples. In doing so, it extends existing knowledge by demonstrating not only whether e-therapy is effective but also how couples experience and engage with digital therapeutic interventions within the Nigerian socio-cultural context. In response to these identified gaps, this study investigates the efficacy of e-therapy for couples experiencing marital distress in Oyo State, Nigeria. Using a sequential explanatory mixed-methods design, the study compares e-therapy with conventional face-to-face therapy by examining relationship satisfaction, communication patterns, emotional intimacy, and therapeutic alliance, while also exploring participants lived experiences of the intervention. The findings are expected to provide empirical evidence to inform counselling practice, policy, and future research on digital couple therapy in Nigeria and similar developing contexts.

Research Questions

1. Does e-therapy significantly improve relationship satisfaction among couples in marital distress? 

2. Is there a significant difference in outcomes (communication skills) between couples receiving e-therapy and those receiving face-to-face therapy? 

3. Does e-therapy significantly improve emotional intimacy relationship satisfaction among couples in marital distress? 

Hypothesis

H01: There is no significant difference in therapeutic alliance between the e-therapy group and the face-to-face group of marital distress couples.

Literature Review: The growing integration of digital technologies into mental health care has generated extensive research on e-therapy, shifting scholarly attention from questions of feasibility to questions of effectiveness, process, and contextual applicability. Rather than merely establishing whether e-therapy works, recent literature increasingly examines how, for whom, and under what conditions digital interventions produce meaningful outcomes. This section synthesises the literature thematically, focusing on effectiveness, associated challenges, and outcomes in couples’ therapy, while grounding the discussion in relevant theoretical frameworks.

Effectiveness of E-Therapy

A substantial body of evidence now supports the effectiveness of e-therapy across a wide range of psychological conditions. Earlier reviews established that online therapy can achieve outcomes comparable to face-to-face interventions, but more recent studies deepen this understanding by identifying the mechanisms underlying these outcomes. For instance, a meta-analysis by Flückiger et al. (2024) demonstrates that the therapeutic alliance remains a robust predictor of treatment success in teletherapy, although its strength may vary depending on modality and context. This suggests that effectiveness is less about the medium itself and more about the quality of relational processes within that medium. Similarly, a meta-analysis by Altieri et al. (2024) shows that remotely delivered cognitive behavioural therapy produces significant improvements in psychological outcomes, reinforcing the argument that structured, evidence-based interventions can be successfully adapted to digital formats. These findings are not simply confirming equivalence; they indicate that e-therapy can sustain core therapeutic mechanisms, such as cognitive restructuring and behavioural change, even in the absence of physical co-presence.

More recent work extends this evidence to relational contexts. A systematic review and meta-analysis by Kernová et al. (2025) report moderate, statistically significant improvements in relationship satisfaction following digital interventions. Importantly, these effects were sustained over time, suggesting that e-therapy is not merely a short-term substitute but can support enduring relational change. Comparative research by Bradford et al. (2024) further indicates that teletherapy yields outcomes similar to face-to-face therapy for couples, reinforcing the notion of non-inferiority rather than superiority. Taken together, these studies suggest that the effectiveness of e-therapy lies not in replicating face-to-face therapy exactly, but in adapting core therapeutic processes to new delivery contexts. The implication is that digital platforms are viable channels for intervention, provided that therapeutic integrity is maintained.

Challenges: Ethical and Technological Considerations

While evidence supports the effectiveness of e-therapy, the literature also highlights significant challenges that shape its implementation and outcomes. These challenges are not peripheral; they directly influence engagement, trust, and therapeutic success. Technological limitations remain a critical concern, particularly in low-resource settings. A systematic review by Cole & Abubakar (2025) identifies unstable internet connectivity, limited access to devices, and varying levels of digital literacy as major barriers to effective teletherapy in Nigeria. These constraints can disrupt session continuity, reduce client engagement, and ultimately affect treatment outcomes. What this means is that effectiveness is partly contingent on infrastructural readiness, not just therapeutic design. Ethical concerns also play a central role. Issues such as confidentiality, data security, and boundary management are amplified in digital environments. Research shows that clients’ willingness to disclose sensitive information is closely linked to their confidence in the privacy of the platform being used. In contexts where privacy cannot be guaranteed, such as shared living spaces, clients may withhold information, thereby weakening the therapeutic process.

Beyond technical and ethical issues, cultural factors further complicate implementation. In Nigeria, for example, mental health help-seeking is often influenced by stigma and reliance on informal support systems. As noted by Onyeka et al. (2024), digital interventions have the potential to expand access, but their acceptance depends on cultural alignment and trust in professional services. This suggests that technology alone cannot resolve access issues without addressing socio-cultural dynamics.

Overall, the literature indicates that challenges in e-therapy are not merely obstacles but determinants of how and whether therapeutic processes can unfold effectively.

Outcomes in Couples Therapy

Research on e-therapy for couples has expanded significantly in recent years, although it remains less developed than the extensive literature on individual psychotherapy. Overall, findings suggest that digitally delivered couple-based interventions can produce meaningful improvements in relational functioning, particularly in communication, emotional intimacy, and relationship satisfaction. However, the literature increasingly emphasises that these outcomes are not uniform but depend on the therapeutic model, delivery format, and relational context in which intervention occurs.

A growing body of evidence supports the effectiveness of structured online couples’ interventions. For example, randomized and quasi-experimental studies on internet-delivered relationship programmes have shown significant improvements in communication and satisfaction, demonstrating that behavioural and psychoeducational components translate well into digital formats (Doss et al., 2016; Roddy et al., 2020). Similarly, videoconferencing-based adaptations of couple therapy models such as Integrative Behavioral Couple Therapy (IBCT) have produced outcomes comparable to in-person delivery, particularly in improving relationship satisfaction and conflict management (Bradford et al., 2024). These findings suggest that structured, skills-based interventions are highly compatible with digital delivery systems, where guided exercises and therapist feedback can be effectively maintained.

However, not all therapeutic processes translate equally into online formats. Emotional engagement, a central mechanism in many couple therapy approaches, appears more sensitive to the limitations of virtual communication. This is particularly evident in Emotionally Focused Therapy (EFT), which prioritises emotional accessibility, attachment bonding, and corrective emotional experiences. EFT research indicates that emotional attunement and non-verbal responsiveness are critical for change processes (Johnson, 2019). In digital environments, reduced non-verbal cues, potential distractions, and physical separation may weaken these emotional signals, potentially affecting the depth of bonding and emotional restructuring.

From a systemic perspective, Family Systems Theory provides a useful explanation of how relational change occurs in couples’ therapy. This theory conceptualises couples as interdependent emotional systems in which each partner’s behaviour influences the other through recursive interaction patterns (Bowen, 1978; Nichols & Davis, 2020). Within this framework, e-therapy is expected to influence not only individual cognition but also interactional cycles such as demand withdraw patterns, escalation of conflict, and communication breakdowns. However, the effectiveness of systemic restructuring in digital contexts depends heavily on the therapist’s ability to observe, interpret, and intervene in relational dynamics through mediated communication channels.

In addition, Cognitive Behavioral Therapy (CBT) offers a strong explanatory model for why many e-therapy interventions show consistent effectiveness. CBT-based couple interventions focus on modifying maladaptive thoughts, improving communication skills, and enhancing problem-solving behaviours (Epstein & Baucom, 2002). These structured and goal-oriented components align particularly well with digital platforms, where worksheets, exercises, and guided tasks can be easily delivered and monitored. This explains why studies frequently report improvements in communication quality and conflict resolution following online interventions (Roddy et al., 2020; Doss et al., 2020).

More broadly, recent meta-analytic evidence confirms that digital couple interventions produce moderate but significant improvements in relationship satisfaction, although effect sizes vary depending on engagement levels and intervention type (Kernová et al., 2025). These findings suggest that e-therapy is not inherently superior or inferior to face-to-face therapy, but rather conditionally effective, depending on how well therapeutic processes are adapted to digital contexts.

Overall, the literature indicates that e-therapy for couples is effective, but its success is contingent upon three interacting factors: (i.) the therapeutic model used (CBT vs EFT vs systemic approaches), (ii.) the quality of emotional and communicative engagement, and (iii.) the digital environment and delivery structure. Thus, e-therapy should not be viewed as a uniform intervention but as a modality that reshapes how established therapeutic mechanisms operate in relational contexts.

Despite the growing body of evidence, several important gaps remain. First, much of the existing research has been conducted in Western contexts, limiting its applicability to settings such as Nigeria, where infrastructural, cultural, and socio-economic factors differ significantly. Second, while studies have established the general effectiveness of e-therapy, there is limited empirical work examining its impact on marital distress specifically, particularly using rigorous designs such as randomized controlled trials combined with qualitative insights.

Third, existing studies tend to focus either on outcomes or experiences, but rarely integrate both. This creates a fragmented understanding of e-therapy, where statistical effectiveness is not fully explained by participants lived experiences. Finally, there is insufficient attention to how couples transition into e-therapy and the barriers they encounter in real-world contexts.

This study addresses these gaps by providing a mixed-methods evaluation of the efficacy of e-therapy for couples experiencing marital distress in Nigeria, thereby contributing context-specific evidence and a more integrated understanding of both outcomes and processes.

Conceptual Framework on the Efficacy of E-Therapy for Couples in Marital Distress

This conceptual framework explains how e-therapy can influence relationship outcomes among couples experiencing distress and the conditions that shape its effectiveness. E-therapy is treated as the central intervention, delivered through online counselling sessions and other digital platforms that support interaction between partners and therapists (See Figure 1)

The effectiveness of this intervention is influenced by a set of interrelated factors. Central to these are therapeutic process variables, including the strength of the therapeutic alliance, the quality of communication between partners, and the counsellor’s competence in managing virtual sessions. These elements determine the level of engagement and the extent to which couples are able to apply therapeutic insights in their relationships.

Equally important are technology-related conditions, such as access to appropriate devices, stability of internet connectivity, and users’ familiarity with digital tools. These factors shape participation and continuity of therapy. Issues of privacy and confidentiality are also critical at this level, as they directly affect clients’ trust and willingness to communicate openly during sessions. The framework (Figure 1) further recognises couple-specific characteristics as moderating influences. Factors such as the nature and severity of marital distress, length of the relationship, cultural context, and previous help-seeking experiences can affect how couples respond to e-therapy and the degree of improvement achieved. Outcomes of the intervention are reflected in relationship and individual well-being indicators, including improved communication, better conflict management, increased emotional closeness, higher relationship satisfaction, and enhanced psychological well-being of both partners.

In addition, barriers and facilitators operate as intervening factors. Challenges such as limited privacy, digital fatigue, or reluctance to engage online may weaken the impact of e-therapy, while flexibility, convenience, and wider access to professional support can enhance its effectiveness. Relatedly, Valley’s (2026) study on counsellors’ experiences with ethical boundaries in telehealth during the COVID-19 period provides useful background for this framework. The study highlights how the rapid expansion of online counselling required practitioners to navigate confidentiality concerns, blurred personal-professional boundaries, and other ethical issues in largely unregulated digital spaces. Although the findings are based on self-reported experiences within a specific global context, they offer practical insights into the realities of remote counselling and its ethical demands. Drawing from these insights, the present study adopts an e-therapeutic approach to addressing marital distress, with particular attention to how couples transition into digital counselling and the barriers that may influence its effectiveness (see Figure 1).

Methodology

This study employed a sequential explanatory mixed-methods design. This two-phase approach began with a quantitative randomized controlled trial (RCT) to assess the effectiveness of e-therapy compared to traditional face-to-face therapy. The second phase consisted of qualitative semi-structured interviews with a subsample of participants. The purpose of the qualitative phase was to elaborate on and provide a deeper understanding of the quantitative results, particularly regarding the participants lived experiences of the two therapeutic modalities.

The study recruited 100 heterosexual couples (N=200 individuals) through a multi-pronged strategy that included online advertisements, social media outreach, and referrals from community therapists and mental health organizations. Inclusion criteria required couples to be in a committed relationship for at least one year, for both partners to be willing to participate, and to have access to a reliable internet connection and a device capable of video conferencing. Exclusion criteria included couples currently receiving any other form of therapy or the presence of severe, untreated mental health issues (e.g., active psychosis, severe depression) in either partner that would require more intensive treatment. After providing informed consent, eligible couples were randomly assigned to either the e-therapy group (n=50 couples) or the face-to-face therapy group (n=50 couples) using a computer-generated randomization sequence.

Both groups received 12 weekly, 60-minute sessions of Integrative Behavioral Couple Therapy (IBCT), a well-established, evidence-based modality for treating relationship distress. All therapy sessions were conducted by licensed therapists who had received extensive training in both IBCT and the delivery of therapy via both in-person and e-therapy formats.

Quantitative phase: In the quantitative phase, data were gathered at three different stages of the study: before the intervention began (baseline), immediately after the completion of the twelfth session (post-intervention), and six months later to assess the sustainability of outcomes. Standardised instruments were employed to ensure consistency and reliability in measurement. Relationship satisfaction was assessed using the Couples Satisfaction Index (CSI), which captures overall satisfaction within the relationship. Communication patterns between partners were measured with the Communication Patterns Questionnaire (CPQ), focusing on the quality of interaction and exchange. Emotional closeness was evaluated through the Emotional Intimacy Scale (EIS), providing insight into the depth of partners’ emotional connection. In addition, the quality of the therapeutic relationship was assessed after the intervention using the Working Alliance Inventory (WAI), which examines the strength of collaboration and bond between the therapist and the couple. Data were analyzed using SPSS version 28. Descriptive statistics were used to summarize participant demographics. A series of repeated measures ANOVAs were conducted to analyze changes in the primary outcome variables (CSI, CPQ, EIS) over the three time points and to test for significant differences between the two therapy groups. An independent samples t-test was used to compare WAI scores between the groups.

Qualitative Phase: Following the completion of the follow-up data collection, a purposive sub-sample of 20 couples (10 from each group) was invited to participate in semi-structured interviews. The interviews were designed to explore their experiences with the therapy process, their perceptions of its impact, and any challenges they encountered.  The audio-recorded interviews were transcribed verbatim and analyzed using thematic analysis. This process involved several stages: familiarization with the data, generation of initial codes, searching for themes, reviewing themes, defining, and naming themes, and producing the final report. NVivo software was used to facilitate the coding and organization of the qualitative data.

Results

The findings of the study are presented in two parts, corresponding to the mixed-methods design. The quantitative results provide a statistical comparison of the two groups, while the qualitative results offer a deeper exploration of the participants’ experiences.

Quantitative Findings: The quantitative analysis revealed significant improvements in both groups over time, with no statistically significant differences between the e-therapy and face-to-face therapy groups on any of the primary outcome measures. The results for each research question are summarized below.

Research Question 1: Does e-therapy significantly improve relationship satisfaction among couples in marital distress? 

Table 1: Comparison of relationship satisfaction among couples in marital distress (CSI Scores) at pre-test and post-test

no significant difference in the degree of improvement.

Research Question 2: Is there a significant difference in outcomes between couples receiving e-therapy and those receiving face-to-face therapy.

Table 2: Comparison of Outcomes (Communication Skills) (CPQ Scores) at Pre-test and Post-test

and face-to-face groups in the extent of this improvement.

Research Question 3: How do couples perceive their experiences of engagement and effectiveness in e-therapy? 

Table 3: Comparison of Emotional Intimacy (EIS Scores) at Pre-test and Post-test

Hypothesis Testing

H01: There is no significant difference in therapeutic alliance between the e-therapy group and the face-to-face group of marital distress couples.

Table 4: Independent t-test comparison of the strength of the two groups therapeutic alliance

(M=58.2, SD=4.8) and the face-to-face group (M=58.9, SD=4.5), t (98) = 0.89, p > .05. Hence, the hypothesis not rejected.

Qualitative Findings: Thematic analysis of the interview data revealed four major themes that provide context to the quantitative results: (1) The Double-Edged Sword of Convenience; (2) Navigating the Technology; (3) The Surprisingly Personal Nature of Digital Connection; and (4) The Integration of Therapy into Daily Life.

Theme 1: The Double-Edged Sword of Convenience. Participants in the e-therapy group universally praised the convenience of online sessions. One participant noted, “Not having to fight traffic after work or find a babysitter was a game-changer. It just removed so much stress from the process. However, this convenience sometimes led to a more casual approach. Another participant admitted, “It was almost too easy to just log on. A couple of times, I was definitely multi-tasking, and I don’t think I would have done that if we were in a therapist’s office.”

Theme 2: Navigating the Technology. While most couples had a smooth technological experience, occasional issues were a source of frustration. One interviewee described, “There was one session where our internet kept cutting out. It was hard to get back into the flow of a difficult conversation when you have to keep saying, ‘Can you hear me now? This highlights the critical importance of a stable technological platform for the successful delivery of e-therapy.

Theme 3: The Surprisingly Personal Nature of Digital Connection. A common sentiment among e-therapy participants was an initial skepticism about their ability to connect with a therapist through a screen, which was ultimately overcome. One participant explained, “I was worried it would feel cold and distant, but our therapist was so engaging. After a while, I honestly forgot we weren’t in the same room.” Several couples also mentioned that being in their own home made it easier to be vulnerable.

Theme 4: The Integration of Therapy into Daily Life. A unique theme that emerged from the e-therapy group was the seamless integration of therapeutic skills into their home environment. As one participant put it, “We were learning these new communication techniques in the very same room where we usually have our arguments. It made it feel more real and easier to apply the skills right away.”

Discussion

This study provides robust, mixed-methods evidence supporting the efficacy of e-therapy for couples in distress. The quantitative findings clearly demonstrate that e-therapy is as effective as traditional face-to-face therapy in improving relationship satisfaction, communication skills, and emotional intimacy. The lack of statistically significant differences between the two groups across all primary outcome measures suggests that e-therapy is a viable and powerful alternative to in-person treatment. The qualitative findings enrich this conclusion by illuminating the user experience. The convenience of e-therapy is a significant facilitator, reducing barriers to access and adherence. However, this must be balanced with strategies to ensure full engagement and to mitigate the potential for distraction. The technological aspect of e-therapy is critical; while a strong therapeutic alliance can be formed online, it is contingent upon a reliable and seamless technological experience. The theme of a surprisingly personal digital connection is particularly noteworthy, as it challenges the common assumption that physical presence is a prerequisite for a strong therapeutic bond. The ability of participants to feel safe and vulnerable in their own homes may, for some, even enhance the therapeutic process.

Furthermore, the integration of therapeutic skills into the home environment represents a unique advantage of e-therapy. This seamless transfer of learning from the therapeutic space to the living space may accelerate the adoption of new, healthier relational patterns. The study’s findings align with the broader literature on teletherapy, confirming that the core components of effective therapy including a strong therapeutic alliance and the delivery of evidence-based interventions can be successfully translated to a digital format.

Limitations and Future Directions: Despite the strengths of its mixed-methods design, this study has several limitations. The sample, while diverse in its recruitment, was not fully representative of the general population, and further research is needed to explore the efficacy of e-therapy across different cultural and socioeconomic groups. The study also focused on a single therapeutic modality (IBCT); future research should investigate the effectiveness of other therapeutic approaches delivered via e-therapy. While the six-month follow-up provides some indication of the long-term effects, longer-term follow-up studies are needed to assess the durability of the therapeutic gains. Future research should also focus on the specific mechanisms of change in e-therapy. For example, what are the key therapist behaviors that foster a strong therapeutic alliance in a digital setting? How can technology be leveraged to enhance, rather than simply replicate, the therapeutic process? Exploring these questions will be crucial for the continued refinement and optimization of e-therapy for couples.

Conclusion

This study makes a significant contribution to the literature by providing a comprehensive, mixed-methods evaluation of e-therapy for couples. The findings demonstrate that e-therapy is a highly effective and viable alternative to traditional face-to-face therapy, producing comparable improvements in relationship satisfaction, communication, and emotional intimacy. The qualitative data provide a nuanced understanding of the user experience, highlighting both the benefits and challenges of this modality. As the demand for accessible mental health services continues to grow, e-therapy stands out as a powerful tool for meeting the needs of couples in distress. With continued research and refinement, e-therapy has the potential to transform the landscape of couples counselling, making effective relationship support more accessible than ever before.