At a glance
Online and in-person therapy both help, and the one that helps you is the setting where you say the difficult thing out loud. Privacy at home decides more than preference does, and the ease of the screen has a cost worth knowing about. This article helps you choose, and change your mind later.
Clinical insights from 22 years in psychotherapy
I’m Mark Colclough, MA, psychotherapist in Copenhagen. Qualified at the Psychosynthesis Education Trust and the University of East London. 22 years of full-time, face-to-face clinical practice.
- Body language is harder to see. On a screen I lose some of the small involuntary movement, the foot that starts going or the hand dried off on a trouser leg.
- Glass walls change what gets said. Clients who join from a meeting room with glass walls hold back, and I watch the hour shrink to what feels safe to be seen saying.
- People choose the room even when the screen is easier. Something in most of us wants to be in the same air as the person who is listening.
Clinical notes: My observations are anonymised and compounded from my session notes since 2004.
Does online therapy work as well as therapy in the room?
For the difficulties that have been studied properly, yes, closely enough that the setting is not the thing deciding your outcome.
What decides it is whether you speak unguardedly where you are sitting. Some of the most unguarded work I have seen has happened on a screen from a spare bedroom, and I have also sat with clients who said very little until they were in the room with me. The useful question is not which setting is better in general. It is where your shoulders come down far enough for you to say the thing you have been carrying.
The trials bear this out. Video and in-person therapy come out level on symptom change and on how many people stay in the work1, and clients and therapists rate the working relationship between them the same in both2. One qualification matters, though: most of that research covers shorter, structured work for depression and anxiety. Couples therapy and long, open-ended therapy are barely represented in it, so those averages have little to say about the work you and I would do together.
So averages will not choose for you. One person talks more easily from their own kitchen. Another spends the hour aware of the washing, the next meeting and whoever is on the other side of the wall. Tell me what helps you concentrate and what makes you hold back, in the first session rather than in the fifth.
Why does the easier setting sometimes do less for you?
The screen lets you attend without being quite met, which is a relief on a hard day and a cost over a run of weeks.
You book online because the trip is 40 minutes you do not have. Then you notice that you are watching your own face in the corner of the screen rather than looking at me, and that you have arranged yourself slightly out of frame. The hour ends and you are back in your kitchen in 4 seconds, with nothing between the session and the evening. Some weeks that is exactly what makes the therapy possible at all. Other weeks it is what lets you leave before anything has landed.
The room asks more of you. You travel, you sit down opposite someone, and there is nowhere to put your eyes that is not either them or the floor. Your breathing shortens a little as you start. That is the thing you came for and the thing you are wary of, and the wariness is not a fault to be corrected.
When you go quiet I will ask about it, and you will find that question easier to answer in one setting than in the other. Which way round it falls differs from person to person, and it is worth discovering rather than deciding in advance. What matters most is that the setting stays something we are allowed to talk about, rather than a fixed condition of the work.
What does a video session ask of you?
It asks you to supply the private room, which is the part most people underestimate.
- A door that closes. You need to speak at your ordinary volume without being overheard or interrupted.
- Nobody able to look in. Glass, a shared desk or a doorway behind you changes what you will let yourself say.
- A device you set down. Holding a phone keeps you managing the picture instead of the conversation.
- Headphones, with one caveat. They help you hear me and they do nothing at all to stop other people hearing you.
- A plan for a dropped connection. When the line goes, I rebuild the session and send you a fresh invitation, so we pick it up as soon as both ends are back.
- Minutes either side. Keep the time before and after clear, and avoid a meeting that starts the moment the session ends.
If the person you need to talk about is your partner, their being on the other side of the door shapes every sentence you choose, so find somewhere else beforehand rather than working around it. Read more about couples therapy alone.
What does the room offer, and what does it cost you?
The room gives you a place and an hour that belong to nothing else, and it takes the travel out of your day.
Nothing in the room needs answering. No delivery at the door, no colleague waiting for you to rejoin a call, no notification sliding into the corner of the screen. The travelling counts as well, in both directions: going there gives you time to arrive, coming back gives you time to come down, and on a week that is already full it is simply time you do not have.
For couples the room gives all 3 of us more to work with. We register posture, the turn of a head, who moves first when something has landed badly. One partner glances across to check how the other took a sentence, and on a screen that glance is invisible to me, and to them as well. Which setting steadies a tense conversation is not the same for every couple, so it is worth asking rather than assuming. One of you may want the room and the other the screen, and both answers belong in the first session.
What the sessions are for matters too, because focused work on a single pattern runs differently from open-ended therapy. Read more about the masterclass in recurring conflict.
How do I choose, and how do I change my mind later?
Start from where you speak freely, then weigh privacy, travel and the time either side, and treat the choice as reversible.
- Check the room before you rely on it. Ask someone you trust to stand outside the closed door while you talk at your normal volume.
- Read what that tells you. If they make out the words, headphones will not fix it and you need a different space.
- Protect the time either side. Look at the hour before and the hour after, not only the session itself.
- Count the travel honestly. Living abroad or travelling for work makes online the thing that keeps therapy regular rather than occasional.
- Say where you will be joining from. Tell me the country in advance, because that has to be agreed rather than assumed.
- Keep it open. Agree that either of us can raise the setting again, so the first decision does not harden into a rule.
These steps run out when no room you have access to is private, when the 2 of you want different settings and neither wants to give way, or when the sessions have gone flat and you cannot tell whether the setting or the work is the reason. They are beside the point altogether when the real question is whether this therapist suits you, which is a different conversation and worth having on its own. In my clinical judgement the setting is worth naming out loud in the first session and looking at again once you have a few behind you. A session, or the free 30-minute call, is enough to decide where to start. Read more about expat therapy in Copenhagen.
Questions people ask
Can I start online and move into the room later?
Yes, when the switch is agreed with your therapist in advance. Ask whether you keep the same therapist and the same arrangements across both settings, because neither is automatic.
Is couples therapy workable on video?
Yes, when both of you speak freely from the same room without being overheard or interrupted. Agree the seating and the camera beforehand, because a partner who sits out of frame changes the session.
What do I need for an online therapy session?
A room with a door that closes, a steady connection, and a device you set down rather than hold. Headphones help you hear the therapist and do nothing to stop other people hearing you.
Should I tell my therapist that the setting is making it harder to talk?
Yes, and early rather than after a run of flat sessions. What you notice about the setting is useful material for the work rather than a complaint about the arrangements.
Does it matter which country I join the session from?
Yes, so tell your therapist where you will be and agree it before you travel. A free 30-minute call is enough to settle the practical side before you book anything.
Whether you come to the room or meet me on screen, I offer both individual psychotherapy and couples therapy in either form.
You may also find these helpful
Sources
- Teletherapy versus in-person psychotherapy for depression: a meta-analysis of randomized controlled trials, Telemedicine and e-Health, 2022
- Therapeutic alliance in videoconferencing psychotherapy compared to psychotherapy in person: a systematic review and meta-analysis, Journal of Telemedicine and Telecare, 2024
How this article was written: I choose the subject and the angle. An AI assistant researches and drafts. I read the draft, correct and improve it and stand behind every clinical statement. The professional and clinical judgement is mine.
