Teletherapy, also known as online therapy or telehealth, has gained significant traction in recent years. The COVID-19 pandemic accelerated its adoption, but even before this, teletherapy was slowly gaining recognition as a viable alternative to traditional in-person therapy. Within the UK context, this may be part of the overarching changes in the way health services are delivered, and in a bid to increase efficiency and maximise output in the stretched NHS. I myself looked at bibliotherapy (i.e. the use of books in psychotherapy) as my doctoral thesis, supplementing one group with the use of telephone support. Self-help books (a form of bibliotherapy) have also been around for many years. So whilst this isn’t a new phenomenon per se, there has been a global shift in the amount of uptake of alternatives to 1:1 therapy.
As more people turn to online therapy for mental health support, there is growing evidence to support its effectiveness. Numerous studies, clinical trials, and meta-analyses have explored the outcomes of teletherapy, offering compelling data that it can be as effective as face-to-face therapy for a wide range of mental health conditions.
Below, we explore the evidence supporting the efficacy of teletherapy, including studies on its effectiveness, the types of therapy that work well in online settings, and the factors that contribute to positive outcomes.
1. Effectiveness for common mental health issues
A variety of studies have shown that teletherapy can be just as effective as in-person therapy for treating common mental health issues, including low mood. For example, a meta-analysis published in 2022 examined 37 studies on teletherapy for depression. This found it was comparable to face to face therapy, with similar levels of attrition across both online and face to face options (Giovanetti et al. 2022).
Similar results have shown equity in outcomes for those experiencing Post Traumatic Stress Disorder (PTSD; Turgoose 2018), as well as with anxiety including at 3, 6 and 12 month follow-ups (Krzyzaniak et al. 2024).
2. Effectiveness across various delivery formats
Teletherapy is not limited to just video calls. Online therapy can take several forms, including:
- Video-based therapy (e.g., Zoom, Skype, or dedicated teletherapy platforms)
- Phone therapy
- Text-based therapy (e.g., messaging or email)
- Internet-delivered therapy (e.g., pre-recorded sessions, apps, or self-paced online modules)
Evidence suggests that the type of teletherapy delivery format matters less than the therapeutic approach used as discussed above. It is worth considering what mode of delivery works best for you, and what might be the area of expertise for your therapist. For example, I do not offer text-based therapy, in part due to the low amount of good quality research supporting this modality, in part due to the complexity of clients a clinical psychologist might see and finally due to this not being an area I am experienced or skilled in. Phone therapy may be less preferred in some cases, but it remains a highly effective option, particularly for people with limited access to video-capable devices or high-speed internet. This is also an option for people who might want a hybrid of some bibliotherapy / self-help books in combination with teletherapy. This might also be preferential for people without access to technology.
3. Client satisfaction and engagement
One of the key factors contributing to the success of teletherapy is client satisfaction. Studies consistently show that clients are generally satisfied with teletherapy and find it convenient, comfortable, and effective.
A 2021 study following the pandemic showed that client satisfaction is equal across both face to face and teletherapy modalities (Mazziotti & Rutigliano 2021). Some satisfaction studies rate teletherapy more highly as it can increase access, particularly in rural populations, as well as considering accessibility and flexibility. This brings us nicely to our next point…
4. Cost-effectiveness and accessibility
Another key area where teletherapy has shown promise is in its cost-effectiveness. Several studies suggest that teletherapy can be a more affordable option than in-person therapy, which makes it more accessible to individuals in rural areas, those with limited financial resources, or people with busy schedules. More than ever, people are able to do therapy on their lunch break, or without adding in long and arduous commutes. This also allows therapists to pass savings onto their clients, without the need for costly room rentals.
5. Therapeutic alliance: online vs. face-to-face
Now finally, but arguably most importantly, a key component of therapy outcomes is the therapeutic alliance, or the bond between therapist and client. The success of therapy often hinges on the strength of this relationship with some studies showing that over 80% of change comes from the relationship, rather than the model of therapy itself.
Research suggests that online therapy does not significantly diminish the therapeutic alliance. In fact, studies show that video-based therapy can foster a strong therapeutic alliance similar to in-person therapy. A study published in The Journal of Clinical Psychology (2017) compared therapeutic alliance scores between video therapy and face-to-face therapy. The study found that there was no significant difference in the quality of the therapeutic alliance between the two formats, and that clients rated the alliance just as strong in online therapy.
Limitations of online therapy
While online therapy has many benefits, there are certain limitations compared to face-to-face therapy:
- Technical issues: Poor internet connections, video or audio malfunctions, and other technical glitches can disrupt online therapy. In contrast, face-to-face therapy offers a more stable environment for communication.
- Non-verbal communication: Although video therapy allows for visual communication, it may not always capture the full range of non-verbal cues (such as body language) that are present in face-to-face sessions. Most therapists have become highly skilled at working online, but it is worth considering that if you are someone prone to avoidance or even masking, you may find clever ways hide or mask your non-verbal communication in therapy.
- Severe mental health conditions: Online therapy may not be appropriate for individuals with severe mental health conditions (e.g., severe psychosis or active suicidal ideation), who may require more intensive, in-person care.
It is worthy of note that some people have concerns about specific modalities, e.g. the use of Eye Movement Desensitisation and Reprocessing (EMDR). EMDR is a type of therapy when each hemisphere of the brain is stimulated in an alternating fashion; this is a whole blog post in itself! However, there are clever ways we can do this online; including the use of speakers alternating between each ear, or eye movements across a screen. I have found excellent outcomes with online EMDR, but if this is a concern of yours, please book a free initial consult where I can talk you through that process.
Final thoughts
The evidence comparing online therapy to face-to-face therapy is robust and generally points to similar effectiveness between the two modalities for a range of mental health difficulties, including depression, anxiety, PTSD, and more. While face-to-face therapy may have advantages in terms of non-verbal communication and the ability to provide intensive, hands-on care, online therapy offers greater accessibility, cost-effectiveness, and flexibility for many clients.
While there are certain challenges to consider—such as technology barriers, the potential for reduced non-verbal communication, and privacy concerns—the evidence overwhelmingly supports the idea that teletherapy is effective for treating a wide range of mental health conditions, offering comparable results to face-to-face therapy.
Ultimately, the choice between online therapy and in-person therapy depends on individual preferences, needs, and circumstances. For those who prioritise convenience, have time or mobility constraints, or live in areas with limited access to mental health care, online therapy can be an excellent option. However, those who need more personalized attention or are experiencing more severe mental health issues may still find face-to-face therapy to be the best fit.
References
Giovanetti, A. K., Punt, S. E., 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.
Krzyzaniak, N., Greenwood, H., Scott, A. M., Peiris, R., Cardona, M., Clark, J., & Glasziou, P. (2024). The effectiveness of telehealth versus face-to face interventions for anxiety disorders: A systematic review and meta-analysis. Journal of Telemedicine and Telecare, 30(2), 250-261.
Turgoose, D., Ashwick, R., & Murphy, D. (2018). Systematic review of lessons learned from delivering tele-therapy to veterans with post-traumatic stress disorder. Journal of telemedicine and telecare, 24(9), 575-585.
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