Is Online Therapy as Effective as In-Person? What the Research Says

Online therapy has moved from a niche option to a mainstream one over the past few years, and with that shift has come a legitimate question: is it actually as good? Not just convenient, but clinically equivalent to sitting in a room with a therapist?

This post tries to answer that honestly, drawing on the research rather than on what's commercially convenient to claim. The short answer is broadly yes, with some genuine caveats that are worth understanding.

What the research shows for therapy in general

The most comprehensive evidence on this question comes from a 2021 meta-analysis in Clinical Psychology Review (Batastini et al., 2021), which examined 57 studies comparing videoconference therapy to in-person delivery across a range of presentations and modalities. The finding was that outcomes were equivalent across the studies reviewed.

For depression specifically, a 2022 meta-analysis of randomised controlled trials (Giovanetti et al., 2022) found that video-based therapy produced results that were not meaningfully different from in-person therapy, with comparable dropout rates too. This is important: if online therapy were harder to engage with, you'd expect higher dropout, and that didn't appear to be the case.

For CBT in particular, the evidence is especially well-established. Carlbring et al. (2018) conducted a systematic review and meta-analysis of 20 studies directly comparing internet-delivered and face-to-face CBT, and found equivalent overall effectiveness. This is consistent across anxiety, depression, and related presentations, and the research has been building steadily for well over a decade.

The therapeutic relationship, consistently one of the strongest predictors of good outcomes in therapy, regardless of modality, also appears to develop comparably in online work. Research on therapeutic alliance in teletherapy finds that alliance-outcome associations are similar to those in in-person work, provided the technology is reliable and the therapist is comfortable working online.

What the research shows for online EMDR

The evidence base for online EMDR is smaller than for CBT, but what exists points consistently in the same direction.

McGowan et al. (2021), published in BMC Psychiatry, examined EMDR delivered remotely during the pandemic across both adult and younger populations, and found statistically significant and clinically meaningful reductions across all outcome measures used — comparable to what would be expected from in-person delivery. A primary care study (Liou et al., 2022) compared outcomes across 288 patients receiving virtual versus in-person EMDR and found no significant differences between the two groups.

A service evaluation conducted within an NHS Traumatic Stress Service (Strelchuk et al., 2023), published in the European Journal of Psychotraumatology, directly compared online and in-person EMDR for PTSD. Outcomes, session numbers, and dropout rates were broadly equivalent, and both therapists and clients generally reported online EMDR as safe and effective; although the authors noted that the non-randomised design limits the strength of conclusions that can be drawn.

The honest caveat is that the research base for online EMDR is still developing. The studies that exist are encouraging, but the field is awaiting larger randomised controlled trials before definitive conclusions can be drawn. Researchers have been careful to note this. What we can say is that the available evidence is consistent, and clinical experience among EMDR practitioners has broadly matched what the early research suggests.

Where the evidence is more nuanced

The research doesn't show that online therapy is identical to in-person in every respect, only that outcomes are comparable. There are real differences in the process that are worth being honest about.

Some research has found that therapists report online sessions can feel less emotionally deep, and that creating emotional closeness requires more active effort via a screen. Therapists working online tend to become more directive and verbal to compensate for the reduced access to non-verbal information. This isn't necessarily a problem because it may be a necessary adaptation (we don't know), but it's a genuine feature of online work, not a myth.

The evidence also shows that online therapy doesn't work equally well for everyone. People with poor internet access, those who lack a genuinely private space, and those with more severe or complex presentations may not be as well served by online delivery. These aren't trivial limitations.

There's also a meaningful selection effect in much of the research: people who choose and remain in online therapy tend to be those who are comfortable with the format. This makes it harder to draw conclusions about how online therapy would perform for the full range of people who might need it.

What this means in practice

The evidence supports online therapy as a clinically sound option for most presentations, not a compromise or a second-best. For many people it's simply the better practical choice, removing barriers of travel and scheduling that can make it difficult to start therapy at all, or to sustain it once started.

Where it matters most is in the match between format and person. Online therapy works well when the person has a private space, is comfortable with the technology, and has a presentation that doesn't require a higher level of in-person support. Those factors are more predictive of success than the format itself.

For more complex presentations, acute crisis, or where there are significant safeguarding considerations, in-person therapy may be more appropriate. A thorough initial assessment, with ongoing reviews, should clarify which applies, and allow practioners to adapt to any changes.

A note on what research can and can't tell us

Randomised controlled trials are the gold standard for comparing treatments, but they measure average outcomes across groups. Individual experience varies. Someone might find that the familiarity of their own home genuinely helps them engage with difficult material, or that the screen creates a distance they can't get past. Neither would be unusual, and neither invalidates the research.

What the evidence tells us is that for most people, with most presentations, online therapy is a clinically serious option rather than a workaround. Not a lesser version, but a different delivery method for the same work. How well it fits any particular person is a question that's better settled in an initial conversation with the therapist than by abstract comparison.

I'm Christian Hughes, a BABCP-accredited cognitive behavioural psychotherapist. I offer therapy for individuals and couples online across the UK and in person in Stourbridge, West Midlands, using CBT, ACT, and EMDR. If you'd like to discuss whether online or in-person work would suit your situation, you're welcome to get in touch or to book a free 15-minute call.

[Book a free 15-minute chat] | [Contact me with a question] | [Read more about online therapy] | [Read more about Online EMDR therapy]

References

Batastini, A. B., Paprzycki, P., Jones, A. C. T., & MacLean, N. (2021). Are videoconferenced mental and behavioral health services just as good as in-person? A meta-analysis of a fast-growing practice. Clinical Psychology Review, 83, Article 101944. https://doi.org/10.1016/j.cpr.2020.101944

Carlbring, P., Andersson, G., Cuijpers, P., Riper, H., & Hedman-Lagerlöf, E. (2018). Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: An updated systematic review and meta-analysis. Cognitive Behaviour Therapy, 47(1), 1–18. https://doi.org/10.1080/16506073.2017.1401115

Giovanetti, A. K., Punt, S. E. W., Nelson, E.-L., & Ilardi, S. S. (2022). Teletherapy versus in-person psychotherapy for depression: A meta-analysis of randomized controlled trials. Telemedicine and e-Health, 28(8), 1077–1089. https://doi.org/10.1089/tmj.2021.0294

Liou, H., Lane, C., Huang, C., Mookadam, M., Joseph, M., & Hecker DuVal, J. (2022). Eye movement desensitization and reprocessing in a primary care setting: Assessing utility and comparing efficacy of virtual versus in-person methods. Telemedicine and e-Health. https://doi.org/10.1089/tmj.2021.0454

McGowan, I. W., Fisher, N., Havens, J., & Proudlock, S. (2021). An evaluation of eye movement desensitization and reprocessing therapy delivered remotely during the Covid-19 pandemic. BMC Psychiatry, 21, 560. https://doi.org/10.1186/s12888-021-03571-x

Strelchuk, D., Turner, K., Smith, S., Bisson, J., Wiles, N., & Zammit, S. (2023). Provision of online eye movement and desensitisation therapy (EMDR) for people with post-traumatic stress disorder (PTSD): a multi-method service evaluation. European Journal of Psychotraumatology, 14(2), Article 2281182. https://doi.org/10.1080/20008066.2023.2281182