Is online psychotherapy a good idea?

When Covid began and internet-based treatment became the only option, I was working with 30 patients. Of them, 29 wanted to continue online. After about a year, in-person therapy became possible again, and with one exception, all of them returned to the practice, even though some put up with much longer trips to get there. That surprised me at the time. Convenience actually favored online therapy: no commute, no lost time. Nevertheless, almost all of them preferred face-to-face contact.

But not everyone has that choice. Long waiting times, rural areas with no therapists within reach, stays abroad, limited mobility, etc. At the same time, my work and personal experience have shown me that there is a demand for online services.

The state of the science is now good in some areas of application and considerably thinner in others.

A systematic review in the journal JMIR Mental Health summarized twenty randomized studies with a total of around 2,800 patients; the conditions treated were post-traumatic stress disorder, depression, and anxiety disorders. It found no significant differences between online and in-person treatment in effectiveness, patient satisfaction, the therapeutic relationship, or the dropout rate.

The same applies to internet-based cognitive behavioral therapy. A meta-analysis in World Psychiatry compared it directly with traditional in-person treatment across 31 studies and sixteen disorders and found both formats equivalent. However, one word in this sentence carries half the weight: therapist-supported. The study tested internet-based treatment with a therapist behind it, not a program that runs on its own.

The ground varies in firmness from one disorder to the next. For the established trauma therapies delivered by video, there is reliable evidence. I describe how EMDR works online and when it makes sense in a separate article. Internet-based programs also work for chronic pain and sleep disorders, although for sleep disorders they are less effective than in-person treatment. And the effects last: an analysis of 154 studies with more than 45,000 participants found online therapy effective, even a year or more after the end of treatment.

There is also a finding that points in the opposite direction, and I’d rather mention it than leave it out. An overview of 29 studies found video and in-person treatment equivalent for post-traumatic stress disorder, but in-person treatment performed slightly better for depression. Something similar shows up in the therapeutic relationship: a meta-analysis of video treatment measured a slightly weaker working relationship on screen, with equal improvement in symptoms. This aligns better with what I observe in my own work than a blanket claim of equivalence. For me, whether psychotherapy makes sense is rarely decided by the format anyway.

I’ve been working exclusively online since early 2024. Since then, I’ve heard several times, especially from less stable clients, that they would like in-person treatment. If you’re feeling really bad right now, I would definitely try to arrange in-person treatment if I were you. But before you end up with no one for the longer term, or if you want to seek counseling first or get your bearings, you’ll probably find what you’re looking for sooner online.

I’ve experienced both formats, as a client and as a therapist. I’m also currently getting online support from a psychotherapist in Germany whom I had previously seen at her practice. Intuitively, I would always prefer in-person treatment. However, working via video never struck me as a second-best solution.

Psychotherapy over the phone can also offer advantages in certain situations. Some people feel less observed on the phone and are able to relax more easily. Since the visual aspect is missing, other aspects such as tone of voice and content come more into focus. About one-third of my patients preferred it, and I haven’t seen any difference in quality. Research points in the same direction, with a caveat that is part of the picture: in a randomized study in the journal JAMA, patients dropped out of treatment considerably less often over the phone than in the practice, 20.9 percent versus 32.7 percent, and fared just as well at the end of treatment. Six months later, however, the in-person group was doing better. In my experience, psychotherapeutic treatment worked as well over the phone as in person.

In my view, online therapy is not equivalent to in-person therapy in every situation, but neither is it a stopgap measure that inevitably leads to poorer outcomes.

I now offer psychological counseling myself, not psychotherapy or treatment. My way of working is shaped by psychodynamic psychotherapy and Gestalt therapy. In Gestalt counseling by video, the aim is to notice more precisely what you feel and what you want.

Self-help apps can certainly be useful for some patients, just like a good book. However, those patients are then not sitting across from a person who has spent decades learning how to support others with mental health issues.

Some digital programs are evidence-based and can be helpful. Digital assistance can serve as a stopgap, a supplement, or a low-threshold entry point. The extent of its benefits is shown by a meta-analysis of 176 randomized trials in World Psychiatry: real but small effects on depressive symptoms and on anxiety. About one in twelve users benefits who otherwise would not have.

Two figures set the record straight. Programs that include personal support perform better than those that don’t, and the greater the initial burden, the wider the gap becomes. And almost no one sticks with it: across 93 popular apps, after thirty days on average 3.3 percent of users still opened the app.

A major problem I see with these apps is that health insurance providers and clients can use them to shirk their responsibilities. For the insurers, it’s one more argument for being able to say, “Yes, we do offer our customers something,” instead of helping to ensure there are enough psychotherapists available. For clients who have a motivation problem, these apps provide an excuse to continue avoiding effective treatment. “Honey, I know I still give you a smack sometimes, and at night I lie down next to our kids. But now I have this app!”

You can read up on whether ChatGPT would be an alternative, or on what the difference between psychological counseling and psychotherapy is, in these articles.

The biggest advantage of online apps and online treatment is that they help overcome barriers to access. Rural areas often lack local specialists. People with limited mobility have a hard time finding accessible practices. And those with demanding jobs or who are caring for young children are often unable to make appointments during regular practice hours.

Yes. Online psychotherapy can be billed as a regular service under statutory health insurance (GKV) and is no longer an emergency solution from the pandemic. Since April 1, 2025, according to the National Association of Statutory Health Insurance Physicians (KBV), physicians and psychotherapists may care for up to 50 percent of their treatment cases per quarter exclusively by video. Previously, the cap was 30 percent.

The decisive word is exclusively. The cap counts only treatment cases in which a patient is cared for solely by video throughout the whole quarter. Anyone who also had personal contact in the practice once during the same period falls out of this count. A patient who was seen three times by video and once in the practice in the quarter, for example, is not counted.

For a practice with a statutory health insurance license, this means: video consultations are possible, but not unlimited. For at least half of its treatment cases, at least one appointment must take place in the practice during the quarter. Anyone who permanently and exclusively looks for digital services and information therefore eventually hits this limit at a practice with a statutory health insurance license.

Anyone who looks for help on the internet will find services of very different quality. Within the statutory health insurance system, at least, it is regulated not only who may bill for a video consultation but also which technology it has to run on. The video service provider must be certified and, for that, must have submitted a self-declaration to the KBV and to the umbrella association of statutory health insurance (GKV-Spitzenverband). In return, the practice receives a certificate confirming the certification under Annex 31b. The requirements behind this are set out in an agreement under Section 365(1) of Book V of the Social Code (SGB V).

That is a separate, formal procedure with its own review. A video service that many people know and use at work anyway has therefore not automatically gone through this review. Being well known and being certified are two different things.

For you, this mainly means: you are allowed to ask. For example, which video service a practice uses and whether it is certified. Anyone who offers digital services should provide this information without evasion. That, too, is part of good treatment of patients. This applies to psychotherapeutic care just as much as to any other treatment that concerns mental disorders and your health.