Does online therapy work just like face-to-face therapy? What does the evidence say

The pandemic forced an entire profession to move to the screen in a matter of days, and several years later the map was mixed: hybrid clinical practices, patients in another province or in another country, agendas that combine face-to-face and video call according to the week.

What was left open is the fundamental question, which many colleagues continue to ask with guilt: is something lost? Is it the same? The answer no longer depends on the intuition of each one. There is enough research accumulated.

TL;DR

• The most cited meta-analysis (103 studies, more than 5.000 participants) found that video therapy produces big improvements (g ≈ 0,99 pre-post) and that the difference against face-to-face is insignificant.
• Video call therapeutic alliance does not differ from the face-to-face, either by patients (MDS = -0,09) or by therapists (MDS = 0,04), in a review of 18 studies.
• The effect is more marked with TCC and in anxiety, depression, and post-traumatic stress.
• Adjusting by publication bias, the low pre-post effect of g = 0,99 to g = 0,54 remains real, but the literature is somewhat inflated.
• Equivalence is well established in common tables; not is equally established in severe tables, crises or specific populations.

Why it Matters

In Argentina, online therapy stopped being a plan B. It enables patients in the interior, supports treatments when someone moves, allows working with Argentines abroad and makes a schedule viable without two hours of travel between sessions. But if at the same time it compromises the quality of the treatment, it would be an expensive comfort.

And there's a second, more practical reason: if you're going to offer online, you should be able to explain to the patient, with data, why it's not a devalued version of therapy. See also our online therapy guide in Argentina for the operational and legal side.

What the evidence says

Clinical results

The reference work is the meta-analysis of Fernandez et al. (2021), published in Clinical Psychology & Psychotherapy. It collected 56 studies from a single group (N = 1.681) and 47 comparative studies (N = 3.564).

The central findings:

• Video psychotherapy produced a big improvement between initiation and end of treatment: g = 0.99.
• Compared to waiting list, it was clearly superior (g = 0,77).
• Compared to face-to-face therapy, the difference was insignificant.
• By model: TCC yielded more (g = 1,34) than non-TCC interventions (g = 0,66).
• By picture: anxiety, depression, and post-traumatic stress showed effects close to 1,00.

The authors also corrected by publication bias, and there the pre-post effect low to g = 0.54. It is an important fact and is usually omitted when this study is cited: the effect still exists, but the published literature exaggerates its size.

The therapeutic alliance

The most frequent objection is not about symptoms, it is about the link: "the same is not built on the screen." Seoul et al. (2024) reviewed 18 studies comparing alliance in video call and face-to-face, and published the results in Journal of Telemedicine and Telecare.

No significant differences were found:

• Patient alliance: MDS = -0,09 (IC 95% [-0.26; 0.07]).
• Alliance according to therapist: SMD = 0,04 (IC 95% [-0.17; 0.25]).

Non-inferiority tests

Beyond the meta-analysis, there are randomized trials designed specifically to test non-inferiority. In generalised anxiety disorder, for example, videoconferencing CCT was not statistically inferior to in-person CCT in primary, secondary and tertiary measurements at all times of evaluation. It is a more demanding design than the simple "no differences".

What does it mean in your clinical practice

• You can offer online without feeling that you offer less, especially in anxiety, depression and trauma work in structured formats.
• The frame weighs more than the channel. On camera, private place on both ends, protected schedule, without driving or walking down the street. What degrades online therapy is not the screen, it is the informality that the screen enables.
• Explicit the agreement from the beginning: what happens if the connection is cut, what platform, whether it can be recorded or not (spoiler: record has concrete legal implications), and how to proceed to an emergency.
• I have a crisis protocol with local data. It is the weakest point in the format: if the patient is 800 km away, you need in advance his address, a reference contact and the emergency resources of his area.
• Take care of technical confidentiality. Encrypted video calling, without third parties listening, and clinical registration in a secure system, not in a chat. About this we write in detail in data security and clinical practice.

Killings and limitations

• Equivalence is proven where there are studies. Anxiety, depression, PTSD and TCC concentrate most of the evidence. Severe symptoms, active suicidal risk, psychosis or severe eating disorders have much less comparative research.
• The publication bias exists and is measurable in this literature, as shown by the correction of Fernandez et al.
• Average noninferiority is not individual equivalence. There are patients who clearly perform better in face to face, and detecting it is part of your clinical work.
• The evidence is mostly from high-income countries. Connectivity, devices and privacy in the home are not distributed the same here.
• Almost all studies evaluate video calls, not chat, audio or apps. It cannot be extrapolated from one format to the other.

In summary

The question "online therapy works?" is quite well answered: yes, and in the most studied tables the results are comparable to the face-to-face, with a therapeutic alliance that does not suffer. The question that remains alive, and that is still clinical, is for whom and at what time each format fits.

Whether online or face-to-face, the record of what happened in the session is the same work, and it is the one usually left for the end of the day. Brauni prepares the draft of the note for you to review and sign it, in either of the two formats.

References

• Fernandez, E., Woldgabreal, Y., Day, A., Pham, T., Gleich, B., & Aboujaoude, E. (2021). Live psychotherapy by video versus in-person: A meta-analysis of efficacy and its relationship to types and targets of treatment. Clinical Psychology & Psychotherapy, 28(6), 1535-1549. doi.org/10.1002/cpp.2594
• Seuling, P. D., Fendel, J. C., Spille, L., Göritz, A. S., & Schmidt, S. (2024). Therapeutic alliance in videoconferencing psychotherapy compared to psychotherapy in person: A systematic review and meta-analysis. Journal of Telemedicine and Telecare, 30(10), 1521-1531. doi.org/10.1177/1357633X231161774