From the AAMFT Conference: Can you do effective therapy online?

There was much discussion at last week’s AAMFT Conference about online therapy: what it is, what the ethical standards are, and whether it can ever replace a therapy model where everyone is in the same room.

Beginning at the first question, the term “online therapy” is being used to reference a wide variety of approaches to offering therapeutic methods, from email to text messaging to online chat to videoconferencing. The most sophisticated model, offered by among others, pairs licensed therapists with clients via secure videoconferencing. Clients can use a simple webcam.

The ethical standards, while a bit more complicated, do not vary from the standards that always govern the field. They’re just harder to define and enforce. Confidentiality, for example, takes on a whole new level of importance when session data is being streamed across the internet. Furthermore, the constant accessibility that electronic communication offers — I’m rarely sans Blackberry — may create a “slippery slope” of boundary erosion through out-of-session emails, text messages, and so forth (Gutheil & Simon, 2005).

The final question is certainly the hardest: Can online therapy replace the traditional model of having all therapy participants — including the therapist — in the same room? Here’s at least some of what we seem to know so far, starting from attitudes and ending at outcomes. (Sorry for the lack of links, these are primarily restricted-access journal articles.)

  • Online therapy may bring in clients who would not ordinarily attend therapy. It’s easiest to think about this in regard to clients in rural settings, where a licensed therapist may be an hour’s drive away or more. But even in densely-populated areas, clients who believe there is a stigma associated with therapy or with their specific problem may be more willing to see a therapist online than in person (Nyazema, 2005).
  • The kids don’t like online therapy as much as you might think. In spite of strong computer literacy and great comfort in gathering information online, college students overall actually report negative attitudes toward seeking help online, and prefer face-to-face therapy (Chang, Chang, & Kim, 2002).
  • Online therapy is less dependent on therapeutic alliance. In face-to-face therapy, the quality of the relationship between therapist and client is strongly predictive of therapeutic outcome. In online therapy, there is still a connection between the two, but it is far weaker (Knaevelsrud & Maercker, 2006).
  • Online interventions work, but are rarely compared directly against face-to-face therapy. Online therapy has been shown effective in treating panic disorder, eating disorder, posttraumatic stress, and grief, and has shown promise for a range of other conditions (Rocklen, Zack, & Speyer, 2004). However, few studies have directly compared online therapy with face-to-face therapy, and those that do are by nature questionable. A therapist interacting online with a client will, necessarily, behave differently than a therapist in a face-to-face setting. Where differences exist, are they due to the computers themselves, or those related behavior changes on both ends?

I find myself continually torn about whether, and how, to advocate for the use of online therapy. As an educational tool, online interactions work well. As a therapeutic process, I’m less convinced — but that’s a “jury’s still out” less convinced, not an “I just don’t believe it” less convinced. Your thoughts are most welcome.


Chang, T., Chang, R., & Kim, N. Y. (2002, August). College students’ on-line help-seeking attitudes and behaviors. Poster presented at the annual meeting of the American Psychological Association, Chicago.

Gutheil, T. G., & Simon, R. I. (2005). E-mails, Extra-therapeutic Contact, and Early Boundary Problems: The Internet as a ‘Slippery Slope’. Psychiatric Annals, 35(12), 952-960.

Knaevelsrud, C., & Maercker, A. (2006). Does the quality of the working alliance predict treatment outcome in online psychotherapy for traumatized patients? Journal of Medical Internet Research, 8(4), no pagination specified.

Nyazema, N. D. (2005). HIV/AIDS stigma and shame: On-line psychotherapy. In N. S. Madu & S. Govender (Eds.), Mental health and psychotherapy in Africa, pp. 441-449. Sovenga, South Africa: UL Press of the University of Limpopo – Turfloop Campus.

Rocklen, A. B., Zack, J. S., & Speyer, C. (2004). Online therapy: Review of relevant definitions, debates, and current empirical support. Journal of Clinical Psychology, 60(3), 269-283.