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Insights · Online Therapy

Is online therapy as effective as in-person therapy?

Reviewed by Barnardt & Fleming 6 minute read

It is a fair question. For many years, the evidence was limited. We now have a much clearer picture: for many common psychological difficulties, online therapy can be as effective as therapy delivered in person.

What the research shows

Across randomised controlled trials and meta-analyses, video-based psychotherapy has been found to produce outcomes broadly comparable to in-person therapy for a range of common difficulties, including depression, anxiety and post-traumatic stress disorder.1, 2

Research also suggests that a strong therapeutic alliance, meaning the working relationship between client and psychologist, can be established and maintained through video-based psychotherapy. The quality of this relationship is one of the more reliable predictors of therapeutic outcome, regardless of whether therapy takes place online or in person.3

The finding has held up across a growing body of research. Where differences do appear between online and in-person delivery, they are generally small and inconsistent in direction, rather than showing a consistent advantage for either format. The important qualification is that effectiveness is not simply a property of the format. The psychologist, therapeutic approach, clinical presentation and circumstances of the person seeking therapy all matter.

Where online therapy has the advantage

Online therapy offers some practical advantages that can make accessing and sustaining psychological treatment considerably easier.

Access to the right psychologist. You can work with a psychologist who is a good clinical fit rather than being limited to those within travelling distance.
Less time and disruption. There is no travelling or parking, which can make regular attendance easier to sustain.
Continuity of care. Therapy can continue through local travel, relocation or changes in circumstances that might otherwise interrupt treatment.
A lower barrier to starting. For people who find leaving home difficult, including those experiencing significant anxiety, exhaustion or physical health limitations, online therapy can remove an important barrier to accessing care.
A familiar environment. Some people find that being in their own environment helps them feel more comfortable and able to engage openly in therapy.

In a country the size of South Africa, access is an important consideration. Clinical psychologists are concentrated in certain areas, while access in smaller towns and rural communities can be considerably more limited. Online therapy can meaningfully expand the range of psychologists available to someone, without requiring them to travel long distances.

Where it is less suitable

Online therapy is not appropriate for everyone or for every clinical situation. Suitability depends on the nature and severity of the difficulty, the level of support available, and the circumstances in which therapy would take place.

Online therapy may not be the right choice when:

There is significant, active risk of harm to yourself or others, where immediate in-person assessment, local support or a higher level of care may be required.
The difficulty requires a level of care that outpatient therapy cannot provide, such as acute psychosis, severe eating disorders with significant medical risk, or acute substance withdrawal.
You do not have a sufficiently private space in which to speak freely and cannot arrange one. Privacy is an important part of creating a safe therapeutic environment.
Your internet connection is too unstable to support a reliable video session. Repeated interruptions can make meaningful therapeutic work difficult.

Part of an initial assessment is establishing whether online therapy is clinically appropriate for your situation. If we believe that in-person work or another level of care would be safer or more appropriate, we will tell you and help you consider other options.

What about EMDR online?

EMDR is sometimes assumed to require a therapist to be physically present because the traditional protocol uses guided eye movements. In practice, EMDR can also be adapted for online therapy. Depending on the protocol and the individual, bilateral stimulation may involve guided eye movements, alternating sounds or therapist-guided tapping.

Research into online EMDR is developing, with early findings suggesting that it can be effective for appropriately assessed clients.4 Careful assessment remains important. Online EMDR is not suitable for everyone, and the decision to work online or in person should take into account clinical presentation, stability, safety and the individual’s circumstances. More about this can be found on our EMDR therapy online page and in our discussion of the evidence behind EMDR.

The evidence, briefly

For many adults seeking therapy, online sessions produce outcomes comparable to in-person work, and a strong therapeutic relationship can be established and maintained over video. The more useful question is not simply whether therapy is online or in-person. It is whether the psychologist, therapeutic approach and format are appropriate for you.

Getting the most out of a video session

A few practical things can make online therapy more comfortable and effective:

Protect your privacy. Where possible, use a private room, headphones and let others know you are unavailable during the session.
Use a laptop or tablet where possible. A larger, stable screen can make it easier to maintain visual contact and engage naturally in the conversation.
Have a back-up plan. Agree in advance what will happen if the connection drops, usually reconnecting when possible or rescheduling.
Leave some space around the session. Going directly from a meeting into therapy and immediately back into your day leaves little room to arrive, engage fully, or process the session afterwards.

We work with adults across South Africa through a secure, encrypted video connection. If you are wondering whether online therapy would suit you, that is exactly the kind of question to raise in an enquiry.

The bottom line

For many people and many psychological difficulties, online therapy can provide an effective and clinically meaningful way of working with a psychologist. At the same time, the format is not right for everyone. The question is less about whether online or in-person therapy is universally better, and more about which approach is appropriate for you, your circumstances and the work you need to do.

This article is general information, not a substitute for individual professional advice, assessment or treatment. If you are in crisis, please see our emergency resources.

Sources

  1. Fernandez, E., et al. (2021). Live psychotherapy by video versus in-person: A meta-analysis of efficacy and its relationship to types and targets of treatment. Clinical Psychology & Psychotherapy, 28(6), 1535–1549.
  2. Norwood, C., et al. (2018). Working alliance and outcome effectiveness in videoconferencing psychotherapy: A systematic review and non-inferiority meta-analysis. Clinical Psychology & Psychotherapy, 25(6), 797–808.
  3. Flückiger, C., et al. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55(4), 316–340.
  4. de Jongh, A., et al. (2024). State of the science: Eye Movement Desensitization and Reprocessing (EMDR) therapy. Journal of Traumatic Stress.

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