Online Therapy as Good as Face to Face

A small study suggests that online therapy is as effective as face to face.


Online psychotherapy is just as efficient as conventional therapy. Three months after the end of the therapy, patients given online treatment even displayed fewer symptoms.

Six therapists treated 62 patients, the majority of whom were suffering from moderate depression. The patients were divided into two equal groups and randomly assigned to one of the therapeutic forms. The treatment consisted of eight sessions with different established techniques that stem from cognitive behavior therapy and could be carried out both orally and in writing. Patients treated online had to perform one predetermined written task per therapy unit – such as querying their own negative self-image. They were known to the therapist by name.

“In both groups, the depression values fell significantly,” says Professor Andreas Maercker, summing up the results of the study. At the end of the treatment, no more depression could be diagnosed in 53 percent of the patients who underwent online therapy – compared to 50 percent for face-to-face therapy. Three months after completing the treatment, the depression in patients treated online even decreased whereas those treated conventionally only displayed a minimal decline: no more depression could be detected in 57 percent of patients from online therapy compared to 42 percent with conventional therapy.

If therapy works well online imagine what else might work online?


Because the success of therapy is based on the human capital involved, not on a third party's perception of the quality or prestige of the therapist.

You might not want the government to know everything you tell your therapist. The only way to accomplish that is with a face to face visit. I'm sure there are plenty of people who would be blackmailable or at least embarrassed by recordings of their therapy meetings.

Or encryption.

It is unlikely that there is any commercially available encryption which can withstand the NSA. They are unwilling to comment over whether or not they have cracked RSA, as is the standard procedure with classified operations, but I would not be willing to risk it.

'If therapy works well online imagine what else might work online'


Obsessive behavior?

Dr. Fiona Wallice was on to this several years ago.

Alex's extrapolation to online education seems far fetched: This study was basically conventional one-on-one therapy with a remote video-audio link added. The therapist was devoting his entire attention to you. No saving of therapist time was achieved other than travel time etc.

Online education promoters are selling an entire model change which is often asynchronous, unsupervised and far more leveraged than a traditional lecture. The success of that does not follow from this.

"Alex’s extrapolation to online education seems far fetched: This study was basically conventional one-on-one therapy with a remote video-audio link added. The therapist was devoting his entire attention to you. No saving of therapist time was achieved other than travel time etc."

Agreed about the extrapolation. But note that the therapist is also saving the cost of the office, and now has more flexibility in their scheduling. I'd guess this could cut the price of therapy by 25%.

A skilled therapist could live in a low cost area and bill into NYC.

<iThe success of that does not follow from this.

That's certainly true, but on the other hand I would think the success of on-line education would seem more likely in light of this information. To put it in a different light: If the result of this study had indicated that on-line therapy didn't work and it's results were similar to not getting any therapy, would you feel that it indicated that on-line education would tend to fail also?

Alex has already presented much better studies showing online education works, e.g.

his note is just tweaking people like Siva Vaidhyanathan who think that online education can't work because the classroom is almost a "sacred place."

I'm in the skeptic's corner on this. I agree online education has a role but I see it as complimenting not supplanting traditional education.

I'll change my position when I start encountering successful professionals that have gotten their degrees entirely online. So far, I've met none.

"entirely online" is a pretty high bar for proof. I think 25% (the equivalent of freshman year) is already feasible, and that 50% (sophomore level) is coming into focus. Getting beyond that will depend on the field: computer science, math, economics? Eventually a whole bachelor's degree should be achievable. Fields that involve lab work (most kinds of engineering; physical sciences) may never be.

I'm entirely optimistic of conventional universities adding more and more online components.

What I'm skeptical about is that we'll produce (anytime soon) a high quality BS student credentialed by an Online-only Univ (e.g Coursera / Udacity / MRUniv / Phoenix etc.).

Forget the lab work, but even in a field like Econ. or Math.

Until we have some incredible level of Virtual Reality I can't imagine how a lot of physical and natural science courses could be taught. But one interesting data point is a that in my field a lot of smller schools lack the students and resources to make a field camp class work. This has led to widespread outsourcing of this very important class. I suspect a one year practicum could easily be offered by adjusting the curriculum, in geology it would clearly be better to have a series of short intense courses on subjects like mineral and fossil identification that could take a week or so at the beginning of a program followed by one or two intense month long field camps in consecutive summers at the end. I am certain this sort of thing could work in many fields.

The study by Bowen that Alex eagerly cited showed that hybrid classes worked. Not online classes. Hybrid classes.

Online educational resources are useful complements to classroom education, but poor substitutes. The invention of literacy and of books did not make classrooms obsolete despite the fact that in theory students can simply read a book instead of attending class. And nowadays they can in theory sit at a computer instead of attending class.

But it is a rare student who can learn say intro economics simply by reading Mankiw. Similarly, pure online classes work only for highly motivated students. The massive dropout rates of MOOCs bear this out.

"Patients treated online had to perform one predetermined written task per therapy unit"

If there was no such requirement for the live patients, I wonder if this was the cause for the differences. Several studies support task-based therapy over the conventional "How do you feel today?" variety.

If we had divided the panel in 3 groups : one with online therapist, one with physical therapist and one with no therapy, we would have found the same score for the 3 groups. 50% is the rate of cure of depression by themselves.

Similarly, years ago I read that whatever therapy method you use, approximately the same percentage get better.

If so, the cited study is consistent with this and generalizing to other in person v. online contexts may not be appropriate.

In Robyn Dawes' "House of Cards" it's noted that amateurs get results just as good as professional therapists.

Let's see...62 patients randomly assigned to two groups. So 31 in each group. All began with moderate-to-severe depression. At the end, 47% of the on-line group and 50% of the face-to-face group apparently still had symptoms of depression...I can't make those numbers work, so let's suppose it's really 30 in the online group and 32 in the face-to-face group. Then, therapy reduces the number of patients displaying symptoms of depression from 30 to 14 in the on-line group (down by 16) and from 32 to 16 in the face-to-face group...down by 16. And note that the online patients were required to complete a writtn task that was (implicitly) not required of the others.

I can't think of any statistical process which would allow one to conclude that on-line therapy was better. Maybe as good as. And, controlling for the required written exercies, it may well be that online performed *worse.*

The study and Alex agree:

Alex: A small study suggests that online therapy is as effective as face to face.

FreudOnline: Online psychotherapy is just as efficient as conventional therapy

Nobody said better.

I could easily see online therapy being better for a large subset of the population. Despite my best efforts,l know I would be self conscious in front of a live person who is a member of my community. I don't think the same would be true with respect to an individual I talk to over video chat and lives a 1,000 miles away.

Doesn't just reading a self help book like Feeling Good: The New Mood Therapy work about as well as going to a CBT therapist? Is this surprising?

The flaw with the study is the premise: therapy is designed to alleviate symptoms if depression. Of course most believe this is the value of therapy, but the real work goes deeper. Symptom reduction after three months is a superficial and accessible goal with any willing client (I've had thousands). They want to "feel better" and they can by simply practicing a few techniques they could learn by watching a video. It's not hard. The deeper work of growth and transformation (reforming the negative tendency, the cause that drives the symptom) is a neuro-relational process that is more potent when delivered face-to-face. This is why don't raise our babies (well) with robots and computer screens.

In what way is it more potent face to face and why? Not that i disagree with you, but you are making a gratuitous assertion.

"The brain is a social organ built through experience" write one of my favorite neuroscientists. Psychotherapy is designed to change neurology through a specific relationship, this is "less potent" from when there is a more narrow range of social data exchange. So, when I write "less potent" I mean that human brains developed in an anthropological and biological context. We are "wired" to input and transmit neuro-physical data through social proximity. I'm not saying that electronic communication methods are bad, useless or dangerous (although watch out for the Borg), but you and I do not "know" each other as we would if we were in a coffee shop having a conversation. In that situation there is a cognitive exchange of thoughts and words (neocortex), there is a non-conscious physical exchange of body shapes (muscular holding patterns) and chemicals (limbic system), there is even a synchronization of heart rate and breathing patterns (brainstem). Our social receptors are less engaged (I'm not saying "not engaged") in electronic interaction. If you doubt any of this, ask yourself one question: Would you be willing to raise a child by interacting solely though a TV screen?

I generally agree with the argument outlined but feel that online therapy is personally beneficial. My question that I want to know is the benefit limited to video based solutions. Does the lack of physical contact reduce the benefit every time or can in person therapy be suplemented by a video session in some kind of hybrid form?

Ultimately the primary factor is the quality of the therapist and the extent that the patient participates. The two are highly inter-related as well as a reticent patient needs a more skilled therapist.

Forgive my ignorance, but on a somewhat related note - does anyone have any figures on % of people who say 'they would study more, if only it weren't for work/family/etc. commitments'? Or anything among the lines of.

I am trying to help sell this idea to a higher education institution (at pretty senior level) and it's one thing no one seems to have thought worth investigating. Maybe I'm looking in the wrong places.

Thanks in advance (if anyone can help).

There is a shortage of mental health professionals in rural areas, so online therapy should have a positive impact there.

I wrote a paper about this back in graduate school. Australia has pioneered online therapy. Can't get a therapist in the outback mate.

Online and telephone therapy is the only kind available in a couple of high plains states. It is certainly better than nothing. I personally know of one state that lacks a single psychiatrist and all the official state mental psychiatric service is overseen by a single psychiatric nurse with assistance by an out of state psychiatrist who grew up in that state. I know this psycjiatrist who is very good and I can tell you he doesn't think it works very well. My mother, also a psychiatrist, has phone sessions with regular patients when they are travelling, and though these sessions are often far more emotional than her regular sessions both her and her patients tend to believe they are far less effective than face to face sessions. They do seem to provide considerable short term catharsid though, but it is almost never lasting. Anunethical therapist could make a mint with this sort of practise.

I wonder how ELIZA would perform by comparison? I hear her hourly rates are quite a bit less, and she's on call all hours of the day.

They're still doing therapy for depression? I thought it was pretty much 100% SSRIs these days.

Online education is already huge maybe even bigger that schooling already. What you are talking about is online schooling/credentialing, it has a very long way to go.

In the subjects where it is widely known what a person needs to know to pass, where what you need to know to pass is not so dependent of the professor people already go to internet video to learn.

Also for finding out how to fix a car or house, how to garden etc. people already go to the internet. Schooling is not about education but about testing.

Huge industry, cottage and institutional, in home school online learning right now and I think that is the hole to fill. You can get your kids a hefty education using online resources with many, many different models, but it's common to find parents who feel they have a gap in testing. Not evaluation, so much as the kind of testing that gives numbers for assessment by strangers -- the kind of strangers that admit to schools or grant internships or job placement.

Testing isn't fun, though. . ... .learning is fun, teaching is fun, but testing is not fun and often takes time away from actual education.

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