top of page

Child Psychiatrist /Adult Psychiatrist

Online Therapy vs In-Person Therapy: The Physician’s Perspective

As the prevalence of mental illness continues to increase, so does the need for access to effective treatments, including psychotherapy. Since the onset of the COVID-19 pandemic, the use of online therapy (also known as virtual counseling, telepsychiatry, telepsychology, and telemental health) has greatly increased, expanding the availability of mental health services for individuals for whom in-person therapy is not available, affordable, or convenient.1 This article describes the potential benefits and drawbacks of online therapy for clinicians and patients alike.

Online Therapy

Online Therapy in the Era of COVID-19

Virtual therapy started in the 1960s to provide care to patients in rural and isolated areas. The use of telemedicine expanded exponentially during the COVID-19 pandemic, but even in the years leading up to the pandemic, the use of virtual mental health services had been increasing. A survey of state mental health facilities found that the use of telepsychiatry increased from 15% of facilities in 2010 to 29% in 2017. With the social distancing and isolation brought on by the COVID-19 pandemic, virtual mental health care became even more widely available, and psychiatric clinicians were able to treat patients remotely at a time when it was greatly needed.

Psychotherapy with a licensed therapist is now commonly available via telephone or video conferencing technology. Online therapy can take place via videoconferencing on a computer, tablet, smartphone, or other device using software that is compatible with the standards of the Health Insurance Portability and Accountability Act (HIPAA). Audio-only therapy sessions over the phone may be an appropriate option for patients who do not have internet access.

Several organizations offer resources to help clinicians who want to provide mental health care virtually. The American Psychological Association has established Guidelines for the Practice of Telepsychology. The American Psychiatric Association offers a Telepsychiatry Toolkit that provide extensive guidance on the technical, practical, and financial aspects of providing psychiatric care virtually. The American Telemedicine Association has similar resources available for a wide range of telehealth services.

Benefits of Online Therapy

Compared to in-person therapy, online therapy offers several logistical and practical advantages. The availability of virtual appointments makes it easier to treat people who live in rural or remote areas and, in general, makes it easier and faster for patients to get an appointment, which allows for more timely evaluation and treatment. Online therapy can also reduce stigma related to mental illness for individuals who are hesitant to make in-person appointments. Virtual therapy also can be cost-effective because it does not require transportation, parking, or taking additional time away from home or work to travel to appointments.

For clinicians, the benefits of online therapy include increased flexibility, which might reduce burnout. Therapists can schedule to see patients in-person or virtually, and virtual appointments can be done from home.8 Increased telecommunication options have allowed mental health clinicians to expand their services, potentially increasing revenue. Virtual therapy options have also resulted in fewer “no-shows” and cancellations.

Another potential benefit is that at-home health monitoring measures can be completed electronically to help inform the therapist about the patient’s progress and treatment expectations, and can allow more frequent observation. For example, patients can complete health questionnaires (such as the Patient Health Questionnaire-9) electronically before a therapy session to allow the clinician to better understand the patient’s symptoms and goals before the session begins.

One concern regarding online therapy is its effectiveness vs in-person treatment. Overall, the evidence supports the efficacy of virtual mental health care. In a review of 70 studies of telemental health published from 2003 to 2013, Hilty et al found that virtual treatment was as effective as in-person care for multiple patient populations with barriers to mental health treatment.

In a study of 125 adults with various eating disorders, Stieger et al reported that compared with in-person treatment, virtual treatment resulted in similar improvements in eating symptoms, weight gain (when indicated), and satisfaction with treatment. Alavi et al found that compared with in-person cognitive behavioral therapy (CBT), 12 weeks of online, therapist-supported CBT yielded comparable significant improvements in depressive symptoms and quality of life in 108 adults diagnosed with major depressive disorder.

A 2022 systematic review of 12 randomized controlled trials that included 931 patients with mental health conditions (including addiction disorders, eating disorders, and childhood mental health problems) found no significant difference between virtual vs in-person psychotherapy in measures of overall improvement, function, and patient satisfaction. Some evidence suggests online therapy can be effective for patients with a wide variety psychiatric disorders, including attention-deficit/hyperactivity disorder, posttraumatic stress disorder, depression, and anxiety.

The use of virtual mental health services has been associated with fewer psychiatric hospitalizations, fewer days spent in the hospital (on average), improved adherence to treatment, and improved treatment outcomes. Multiple patient populations have reported being highly satisfied with online mental health services.

Drawbacks of Virtual Mental Health Care

Before the COVID-19 pandemic, multiple factors limited the widespread implementation of online therapy, including insufficient clinician knowledge of and experience with providing virtual therapy, concerns for patient safety, limited reimbursement from insurance companies, and privacy/legal concerns. Clinicians, researchers, and policymakers devised effective solutions to most of these problems during the pandemic. However, some patient barriers to receiving online therapy have persisted, including limited internet access, difficulties in arranging a private space to participate in virtual therapy, and difficulties using technology due to age or disability (visual, hearing, attention deficits).

In a study that conducted semi-structured interviews with 17 mental health professionals, some participants cited limited nonverbal communication and limited ability to use certain therapeutic tools, such as music or painting, as potential drawbacks of virtual therapy. Patients may have concerns for privacy, trust, and security regarding online therapy.

With the increased use of telehealth, informed consent often takes place online, which raises privacy concerns in verifying a patient’s identity. Patients may participate in a virtual therapy while in a less secure/confidential location, and the session might be subject to frequent interruptions. Technical issues are also a potential barrier; approximately 30% of US adults have occasional or frequent problems connecting to the internet, and others have financial constraints to home internet or computer use.

Online therapy is an emerging treatment modality, and as such, universally recognized standards for training for therapists do not yet exist. Due to the lack of standardized formal training, a therapist who works virtually might not be adequately prepared to provide a standard of care equal to that of in-person therapy. While online therapy may be equally effective as in-person therapy for many patients, certain patient populations — such as a patient who is actively suicidal, homicidal, or experiencing psychotic symptoms, or a victim of abuse who have the potential for the abuser to be present during therapy — may require in-person sessions.


The growing use of online therapy has greatly increased the availability of mental services, and offers potential benefits for patients as well as therapists, with some drawbacks and scenarios in which care should take place in person. The decision to provide psychotherapy virtually vs in-person generally can be made based on the patient’s preference. Clinicians must ensure their competence with providing online care, set appropriate boundaries, understand the confidentiality risks that come with online therapy, consider the possible distractions, and understand the laws and regulations for telehealth in varying jurisdictions. Resources from the American Psychiatric Association, American Psychological Association, and American Telemedicine Association outline best practices and guidelines for delivering virtual mental health services.

Note: This article originally appeared on Psychiatry Advisor

1 view0 comments


bottom of page