Online psychotherapy just as effective as in-person treatments: meta-analysis

April 24, 2021
Video visits with a mental health professional might be just as effective as in-person couch time. (AP Photo/Mark Lennihan)

Video visits with a mental health professional might be just as effective as in-person couch time. (AP Photo/Mark Lennihan)

A meta-analysis of 68 studies that collectively included thousands of participants found that video-based psychotherapy through Zoom, Skype and other online platforms may be as efficacious as traditional, in-person forms of therapy.

The paper, published April 7 in Clinical Psychology and Psychotherapy, showed that people who had either video or in-person psychotherapy experienced virtually identical outcomes. Additionally, video therapy participants saw dramatic improvements compared to control groups that had experienced no therapy, reinforcing the idea that video therapy can be an effective tool for addressing mental health issues when in-person meetings are not possible.

"I think there is something almost intangibly, indescribably different about being present with someone in the same space, in the same time as compared to [video-delivered psychotherapy]," Ephrem Fernandez, a clinical psychology professor at the University of Texas at San Antonio and the paper's lead author, told The Academic Times. "But so far, from the outcome measures we've obtained, there really isn't a whole lot of difference [in outcome]."

The potential differences between in-person and digital therapies became increasingly relevant over the past year as the coronavirus pandemic closed in-person clinics around the world, prompting many mental health care providers to develop online alternatives for patients. Even before the pandemic, however, online services had become increasingly popular options for patients — especially those who could not afford in-person services or who were unable to visit an office each week. There's some evidence that online therapy can also be helpful to clinicians, who spend 7.8 times the amount of time with in-person patients as compared to online ones, according to a 2018 meta-analysis.

But social workers and psychologists have worried that video therapy was not comparable in terms of efficacy, arguing that it lacked the possibility of social cohesion that can arise when a therapist and patient are seated in the same room. Fernandez said the team pursued those questions over the course of its years-long investigation. 

"Could there be a loss of rapport bonding, or what we technically refer to as 'therapeutic alliance?' Could that be diminished when you're simply interacting with someone through a screen as compared to when you're there in the person's room, [where] the ambiance is different?" Fernandez asked.

The team ultimately discovered that, although some patients may have strong subjective preferences for visiting an office to participate in a therapy session, those qualities of social presence do not translate to a quantifiable change in the therapy's effectiveness. 

The findings indicated that people who participated in cognitive-behavioral therapy (CBT), in particular, showed the greatest improvements in pre- and post-treatment evaluations, compared to other forms of psychotherapy like psychodynamic therapy and counseling, both of which focus on exploring the origins of one's thoughts and emotions through deep introspection. And while CBT often asks participants to actively alter their daily behavioral patterns through learned skills, counseling and psychodynamic models less frequently emphasize any particular course of action to alter one's future actions. Although he emphasized that further research needs to assess why these differences were present, Fernandez explained that the success of CBT could be caused by its relatively straightforward, formulaic process, which may be more easily translatable online, as compared to other approaches in which nuanced verbal cues may play a more significant role.

People being treated for anxiety, depression and post-traumatic stress disorder showed the greatest benefit from video services, compared to those treated for obsessive-compulsive disorder and eating disorders. But the finding that treatment for other disorders may have been slightly less effective when delivered over video may have suffered from a smaller sample size of studies, Fernandez explained. The team was careful to exclude case studies that featured only one participant as well as narrative reviews, book chapters, unpolished dissertations and conference proceedings. 

The efficacy of other in-person therapy alternatives, including chat-based and artificial intelligence-initiated therapy, may be the subjects of future research. Those formats first garnered interest in the 1960s, when a Massachusetts Institute of Technology computer developer created a program called ELIZA that parroted users' own inputs back to them, mimicking the sorts of therapeutic techniques popularized by American psychologist Carl Rogers.

Psychologists are also investigating the potential benefits and limitations of developing therapy approaches that implement virtual reality systems. Recent studies indicate that virtual reality platforms can effectively initiate "sublime" feelings under certain conditions and can also generate feelings of empathy and compassion when users are exposed to painful or emotional stories. 

Although the team began its research well before the COVID pandemic, its findings became all the more relevant in the midst of city- and nation-wide shutdowns. "Our whole experience collectively, across the world, suggested that if there was one way to get through to people to deliver services to them, that was remotely. It was online," Fernandez said. "So it definitely increased our enthusiasm for this work."

The study "Live psychotherapy by video versus in-person: A meta-analysis of efficacy and its relationship to types and targets of treatment" published April 7 in Clinical Psychology & Psychotherapy, was authored by Ephrem Fernandez, Tuan Pham and Bianca Gleich, University of Texas at San Antonio; Yilma Woldgabreal, Deakin University; Andrew Day, University of Melbourne; and Elias Aboujaoude, Stanford University.

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