Therapy online or in person: the advantages and the limits

It is 17.58. You close the work document, pour yourself a glass of water, switch on the camera — and at 18.00 your therapy begins. No drive across town, no hunting for a parking space, no rushing. It sounds convenient. But somewhere at the back there is a question I hear often: is this even “real” therapy? Can what happens in person also happen through a screen?

The question is a fair one and it deserves an answer that is neither enthusiastic advertising nor nostalgic dismissal. Remote therapy has been thoroughly researched over the past decade and a half — enough for the two of us to talk about it with facts. In this post we look at what the research shows about its effectiveness, where its genuine advantages lie and where its honest limits are, who is better served by meeting in person, and, quite practically: how to set up your space so that a remote session is truly therapy, not a video call squeezed between two obligations.

What the research says: equivalent for many difficulties

Let us start with the most important finding: video therapy is not a makeshift copy of therapy. A meta-analysis led by Ephrem Fernandez (2021) compared psychotherapy delivered by video with in-person therapy and found that outcomes were on average comparable — with no significant differences in effectiveness, nor in client satisfaction. An earlier systematic review by Autumn Backhaus and colleagues (2012) pointed the same way, as did more recent meta-analyses led by Ashley Batastini (2021): across a wide range of difficulties — anxiety, depression, post-traumatic stress disorder — video therapy achieves results comparable to the classic form.

The study by Birgit Wagner and colleagues (2014) on depression is particularly telling: participants were randomly assigned to cognitive behavioural treatment either over the internet or in person. Outcomes at the end of treatment were equivalent — and at the three-month follow-up the internet group was even doing slightly better. One study is of course not proof of superiority; but it is a good indication that distance in itself does not weaken therapy.

And what about the therapeutic relationship, that strongest factor in therapy? This too has been researched: reviews (among them Simpson and Reid, 2014, and the meta-analysis by Norwood and colleagues, 2018) show that the working alliance builds and holds surprisingly well over video — clients as a rule rate it just as highly as in person. The screen evidently lets the essentials through: attention, understanding, the sense that someone is genuinely there for you. I have written about why this relationship is the heart of therapy in a post on why the therapeutic relationship heals.

It is only fair, though, to add where this research stops: most of it studied individual therapy with adults experiencing moderate difficulties. There is far less data on video therapy in severe crises, in complex trauma, or with couples in high conflict — and it is precisely there that caution is also most clinically justified. “Equivalent for many difficulties” therefore does not mean “equivalent for everyone, always”. What that means in practice is what we unpack next.

What the screen makes possible

When people ask me who benefits most from video therapy, this is my list:

• Access. Therapy is no longer tied to a place: it is available from the countryside, from abroad, from towns with no therapist nearby. For you it also means choosing a therapist by fit, not by postcode.
• No journey. An hour of therapy no longer means two and a half hours once travel is counted. For parents of small children, people with full schedules or fragile health, this is often the difference between “I go” and “I cannot manage to go”.
• Continuity. A work trip, a move, an illness, a snowy day — the process is not interrupted. Repeated interruptions are one of the quiet reasons why therapies fade out.
• Home as a safe setting. Many people open up more easily and more quickly in their own space, with their own blanket and their own tea, than in an unfamiliar office. For people with marked social anxiety or agoraphobia, video therapy is often the very first door to help — the journey to the consulting room can be a bigger obstacle for them than therapy itself.
• A lower threshold for starting. A click is less frightening than a waiting room. If you are afraid of therapy, beginning remotely can be a gentler way in — and later the two of us can move to meeting in person.

Limits that deserve an honest word

But I would be dishonest if I listed only the advantages. Video therapy has limits and it is right that you know them:

• The body is less visible. In person a therapist takes in the whole: posture, breathing, restless legs, a small shift in the way you sit. A camera shows the face and shoulders — a significant part of body language stays outside the frame. For approaches that work directly with the body (I wrote about them in a post on body-oriented psychotherapy), this is a serious limitation, though not an insurmountable one.
• Technology. A frozen picture in the middle of tears, a dropped connection in the middle of a difficult sentence — technical glitches are not merely a nuisance, they can cut through a delicate moment. A good connection and a backup plan (the phone) are part of taking the arrangement seriously.
• Privacy at home. Therapy needs a space where you can speak out loud and cry without anyone hearing you. In a small flat with a partner, children or flatmates this cannot be taken for granted — and if you spend the whole hour whispering carefully, therapy cannot breathe. (There are solutions — see the practical section below.)
• Serious crises belong in person. With acute suicidal risk, psychotic states or severe destabilisation, the remote form is as a rule unsuitable: a therapist’s options for acting are limited at a distance. In such moments the right path is help in person and crisis services — I explained the difference between a crisis conversation and a therapeutic process in a separate post.

Who is better served by meeting in person

The limits also answer the question of whom I advise towards the classic form — at least to begin with:

• In more serious crises and periods of instability: when there is a risk that the material will overwhelm you, the therapist’s physical presence is an important safeguard.
• In deep work with trauma and the body: regulating arousal in a room where the therapist sees you whole is simpler and safer.
• If there is no privacy at home: therapy in which you keep track of who can hear you is not therapy.
• If screens “cut off” contact for you: some people simply do not feel another human being over video — and that is an entirely legitimate reason for meeting in person.
• In couples therapy and family therapy with high tension: a couple in conflict in front of a single camera is a demanding set-up; when the atmosphere is hot, a shared room offers more support and more structure.

There is one more group I like to mention separately: those for whom the screen is too comfortable. If you notice that the remote form lets you stay at a safe distance — the camera “happens” to go off during difficult topics, you take sessions half in passing, you glance at another window in between — that is a sign that comfort is working against the process. You do not necessarily have to change format straight away; but it is certainly worth saying out loud in therapy, because it says something important about how close you are willing to let another person come.

It is equally important to say the reverse: none of this is an absolute rule. The decision is always individual and is best made in conversation with your therapist — who should say honestly what, in their judgement, they can offer at a distance and what they cannot.

How to set up your space for a remote session

Now for the practical side. The quality of video therapy depends to a great extent on how seriously you take your end of the connection. A few tried and tested pointers:

• Privacy above all. A room with a door that closes, and an agreement with the household: “This hour is mine, please do not disturb me.” If home does not work: a car in a quiet car park is a surprisingly good therapeutic space, as is an empty office after working hours. Headphones should be standard — they make sure that at least half of the conversation stays yours alone.
• Stable technology. Check the connection and the sound before the first session, prop up your computer or phone (do not hold it in your hand), and keep the camera at eye level. Agree on a backup channel if the connection drops — usually an ordinary phone call.
• No interruptions. Close your email and notifications; your phone, if it is not your camera, face down and silenced. Fifty minutes without interruption is part of the therapeutic frame — at home too.
• Create a transition. The biggest trap of video therapy is that it gets squeezed between a meeting and cooking dinner, with no seam. A small ritual helps: prepare the space five minutes beforehand, a glass of water, tissues, perhaps a short walk before the session and after it. The journey to the therapist in person quietly served this function of transition — remotely you have to create it yourself.
• Do not jump straight on after the session. Give yourself at least ten minutes before you return to your roles. What has opened up needs a moment to settle — I wrote about why in a post on what happens between sessions.

What a first remote session looks like

If uncertainty grips you before a first online session, let me dissolve it with a description: it goes almost exactly as it does in person. A few minutes before the hour you receive (or already have) a link to a secure video call; at the agreed time the two of us meet on the screen, check sound and picture and agree what we will do if the connection drops. And then the conversation is simply a conversation. Getting to know each other, your story, your questions, an agreement about what comes next; everything I described in the post on the first session with a therapist applies here too.

There is one difference, though, and it is worth naming: remotely a therapist cannot look after your space the way she can look after her own room. So the two of us will talk about your end of the connection — where you sit, who can hear you, how much quiet you have — right at the start. This is not prying into your home; it is care for the frame within which therapy can work at all. And if it turns out mid-session that there is no privacy (someone comes home, a child knocks), it is entirely fine to say so and adjust the session — that too is part of caring for the space together.

Hybrid: you need not choose once and for all

Perhaps the most useful realisation of recent years, though, is that the choice is not binary at all. More and more therapeutic processes run in hybrid form: in person as the basis, and remotely when life demands it — a work trip, illness, a holiday, a week when the journey is simply beyond you. Or the other way around: starting remotely because the threshold is lower, and moving to meeting in person as the work deepens.

From a research point of view this is a sensible path too: since the outcomes of both forms are comparable for most concerns, the choice can be decided by what research struggles to measure — your life, your space, and the phase the process is in.

The hybrid form joins the best of both: the depth and fullness of a living presence, and the continuity and accessibility of the screen. It asks for just one more agreement — that you and your therapist discuss when each form serves the process and when it would be merely a convenient shortcut. Because that is possible too: if remote sessions become a way of keeping therapy at a safe distance, that is a topic for conversation, not for a quiet habit.

How I work with this

In my own work I offer both forms — sessions in person and remotely — and a combination of the two as well, however it serves you and the process. When working remotely I keep to the same frame as in person: a secure connection, a space where nobody can hear me, and a full fifty minutes without interruption; I expect the same commitment on the other side of the screen, because therapy deserves it. As a therapist in training in marriage and family therapy under supervision, I also review my remote work regularly with my supervisor — the form changes, the standard does not.

If you are considering therapy and weighing up the two forms, you do not have to decide in advance: this can be the first topic of our introductory conversation. What I offer and how the work goes can be found on the Services page, and you can get in touch through the Contact page — by email or phone, whichever feels closer. That, after all, is a question of distance and closeness too. And as the research shows: what matters is not how many kilometres lie between us, but what happens between us.