Online or In-person CBT?

Online vs. Face to Face CBT: Which Path is Right for You?

If you're considering Cognitive Behavioural Therapy (CBT) or any evidence-based psychotherapy, you're already taking a powerful, step towards improving your mental health.

A question I get regularly asked is: should I do therapy online or in person?

Since COVID-19 and the dramatic rise of telehealth, online CBT has become a popular and effective option. But is it the right choice for you? Up until 2020 I hadn’t delivered much online CBT at all and, in all honesty I wasn’t sure how I would feel about it at first.  In this article I will help to break down the pros and cons of each format, guided by up-to-date scientific research, to help you decide.

The Big Question: Does Online CBT Actually Work?

Let's start with the most important point: Yes. A large body of high-quality research shows that for many common conditions like depression, anxiety disorders, and panic disorder, online CBT is just as effective as traditional face-to-face therapy.

Going back a decade, a landmark meta-analysis (this is a way of making sense of lots of gold standard scientist studies – called randomised controlled trials (RCTs)) published in World Psychiatry concluded that online CBT is "an effective and acceptable alternative to face-to-face therapy" (Andersson et al., 2014). More recent research has consistently supported this, with studies finding "non-inferiority," meaning the outcomes for online therapy are statistically equivalent to those for in-person therapy (Carlbring et al., 2018). More recent data continues to support these earlier findings (Lin et al, 2022). In addition, despite my initial hesitation, data from my own practice with clients suggest that they do just as well with me, whether online or face to face and this is true of both my private and NHS roles.

So, since both are effective, the choice comes down to your personal circumstances, preferences, and needs.

Online CBT: The Pros and Cons

The Pros (Why it might be great for you):

• Accessibility & Convenience: This is the biggest advantage. Online therapy removes geographical barriers, offering access to specialists you might not have locally. It eliminates travel time and costs, and scheduling is often more flexible, fitting around work, childcare, or other commitments.

• Cost-Effective: Online therapy can sometimes be more affordable than traditional in-person sessions.

• Comfort & Privacy: Many people feel more comfortable opening up from the safety and privacy of their own homes. For those with social anxiety or agoraphobia, starting therapy from home can be a crucial first step.

• Consistency: It's often easier to stick with therapy when you can attend sessions from anywhere with an internet connection, reducing missed appointments due to travel, illness, or bad weather.

The Cons (What to be aware of):

• The Therapeutic Relationship: Some people worry it's harder to build a strong connection—what therapists call the "therapeutic alliance"—with their therapist over a screen. While research shows a strong alliance can be formed online, it can feel different. Therapists can miss subtle body language and non-verbal cues that are present in a shared physical space, as such I always have a discrete discussion about these factors before we engage in treatment together and how we might overcome them as much as possible.

• Technology Hurdles: A stable internet connection is non-negotiable. Technical glitches can disrupt a session and cause frustration. You also need a basic level of comfort with using video conferencing platforms.

• Distractions at Home: Your home environment can be filled with distractions—pets, family members, unfinished chores—that can pull your focus away from the session.

• Crisis Management: For individuals with severe mental health conditions or those at risk of self-harm, remote therapy can pose challenges. A therapist who is physically present can respond more immediately and effectively in a crisis situation.

In-Person CBT: The Pros and Cons

The Pros (The case for the classic approach):

• Stronger Personal Connection: For many, nothing beats the power of being in the same room. Face-to-face interaction allows for a full range of non-verbal communication, which can deepen the therapeutic relationship and understanding.

• Dedicated Space: The act of going to a therapist’s office creates a neutral, confidential, and dedicated space for your mental health. This separation from your daily life can help you focus entirely on your therapy.

• Accountability: The routine of physically attending an appointment can reinforce your commitment to the therapeutic process.

• Suitability for Complex Issues: In-person therapy is often recommended for more complex or severe conditions, as the therapist can provide more direct support and intervention.

The Cons (Potential drawbacks):

• Logistical Challenges: In-person therapy requires travel time, which can be difficult to manage with a busy schedule. Costs for transport and parking can add up.

• Limited Access: Your choice of therapists is limited to your geographical area. This can be a significant barrier for those in rural communities or areas with few qualified CBT practitioners.

• Potential for Stigma: Although attitudes are changing, some people still feel a stigma or discomfort about being seen entering a therapist's office.

How to Choose: Questions to Ask Yourself

1. What is my lifestyle like? Do I have a busy, unpredictable schedule? Do I have reliable transportation?

2. How comfortable am I with technology? Would a poor connection or software glitch frustrate me and disrupt my progress?

3. What kind of connection do I want? Do I value the nuances of in-person communication, or am I comfortable building a relationship digitally? (In my clinical experience it is much easier than you think to build a strong collaborative therapeutic relationship online)

4. What is my home environment like? Can I find a private, quiet space for an hour without being interrupted?

5. What are my specific needs? Am I dealing with severe symptoms or safety concerns that might be better addressed in person?

6. Where is it easier to share from? Is it easier to share highly personal information from the comfort of your home or would somewhere more neutral be preferable?

The Bottom Line: 

The "best" type of therapy is the one you will consistently attend and actively participate in. Both online and in-person CBT are powerful tools for change. Consider the points above, and perhaps most importantly, discuss this with your therapist, and if you are thinking of coming to therapy with me click here and get in touch with me to discuss this further. Best of Both? Like many therapists, I regularly offer a hybrid model, combining both formats to give you the best of both when it suits you.

References:

• Andersson, G., Cuijpers, P., Carlbring, P., Riper, H., & Hedman, E. (2014). Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: an updated systematic review and meta-analysis. World Psychiatry, 13(3), 288-295.

• Carlbring, P., Andersson, G., Cuijpers, P., Riper, H., & Hedman-Lagerlöf, E. (2018). Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: an updated systematic review and meta-analysis. Cognitive Behaviour Therapy, 47(1), 1-18.

• Lin, T., Heckman, T. G., & Anderson, T. (2022). The efficacy of synchronous teletherapy versus in-person therapy: A meta-analysis of randomized clinical trials. Clinical Psychology: Science and Practice, 29(2), 167.