At a glance
Whether online therapy works in general is a different question from whether it will work for you, in the life you actually have. The second question has your circumstances in it. This article looks at what you would be giving up, what you would be gaining, and how to tell which of those matters more.
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.
- The hesitation is about being met, not about method. Clients who are unsure about online rarely doubt that the work would be the same. They doubt whether they will be fully reached through a camera.
- The ones who travelled furthest value it most. Clients who were spending an hour each way describe getting that hour back as part of what made the work possible to keep up.
- What spoils it is the setting, not the screen. Where online sessions go badly, clients are usually taking them somewhere they can be overheard or interrupted.
Clinical notes: My observations are anonymised and compounded from my session notes since 2004.
What am I actually afraid of losing?
Usually it is not the talking. It is the part of being in a room that nobody names.
When clients tell me they would rather come in, and I ask what for, the answers are specific and physical. Arriving somewhere that is not home and not work. A door that closes. A chair that is kept for this. The walk afterwards, which turns out to have been part of the session. None of that is sentimental. It is the frame that tells your system it is allowed to stop managing for 50 minutes.
That frame is real and it is worth something. What I would question is the assumption that a screen can carry no version of it. A good deal of what the room provides can be arranged elsewhere, and some of it cannot. Working out which is which is the whole decision, and it gets you further than asking in the abstract whether online is as good.
Does the work itself hold up on a screen?
On the evidence available, the medium changes less than people expect.
A 2024 review pooled 30 studies covering 3,275 adults, and the 12 studies that compared the same therapy delivered by video call and in person found no meaningful difference in how much symptoms improved.1 Two things sit alongside that. The trials were of cognitive behavioural therapy, which is not how I work, so it tells you about the medium rather than about my method. And a large share of the studies looked at post-traumatic stress in military populations in the United States, which is not most people’s situation.
So I would not offer it as proof that the format makes no difference to you. What it does is take the weakest version of the worry off the table. If working by video were a watered-down form of therapy, 30 studies is where that would show, and it has not shown there.
When is online the right call rather than the fallback?
When the alternative is not a room, but nothing.
This is the part that gets lost. The comparison people run in their heads is online against in-person. The comparison their week actually offers is often online against another six months of intending to start.
- The journey would decide your attendance. If getting here takes two hours, the first difficult week is the week you cancel. Turning up every week does more for the work than the setting does.
- You are not in one place. Work that moves you, a life split between two countries, a plan to leave Copenhagen next year. Continuity through the change matters more than the room you start in.
- Home is where the difficulty lives. For some of what we work on, being in the setting beats describing it from a chair across town.
- Coming in would mean explaining yourself. Where privacy from a household or an employer is the obstacle, online removes a reason not to start at all.
In each of those, online is the arrangement that lets the work happen, and the work happening is what counts.
When is the room worth the trouble?
When the difficulty is one you could leave on a screen.
Some patterns are easier to keep hold of through a camera. If you tend to manage a conversation, present well and leave with nothing touched, a screen hands you more control than is useful. You can arrange your face. You can look away without it reading as looking away. The small frictions of being in a room with another person are part of what makes the work land, and if your habit is to stay smooth, removing those frictions removes the difficulty along with the inconvenience.
The same holds where being alone afterwards is the problem. Ending a hard session and closing a laptop in the room where you then have to make dinner is a sharper turn than walking out of a building. Some people need the walk.
There are also situations that need more care than an article can set out: where what has to be looked at feels overwhelming, where you have been unsafe, or where you do not trust yourself to stay in the session once it gets hard. Those are worth saying at the start, whichever format you choose, so the arrangement can be built around them.
What makes an online session work?
Most of it is the 10 minutes either side.
- A door, not a corner. A room you can close, where nobody arrives. If that does not exist at home, a parked car or a booked room beats a kitchen with someone in the next room.
- Nothing scheduled on either side. Finish a session and go straight into a call and the hour does not land. Keep 15 minutes clear at each end and treat them as part of it.
- Headphones, and the camera at eye level. Small things that change how much of you arrives. Looking down at a laptop flat on a table puts you at a distance that has nothing to do with the connection.
- Say when the room has gone wrong. If someone has come home, or you cannot speak freely, say so rather than carrying on at half volume. That is workable. A quiet hour of pretending is not.
If you are weighing this up for your own circumstances, the answer tends to arrive in the first conversation rather than before it. Individual psychotherapy runs in Copenhagen and online, and a free 30-minute call is usually enough to work out which of the two your week can actually support.
Questions people ask
Is online therapy as serious as coming in?
The seriousness comes from what you bring and what gets looked at, and the room does not supply it. What changes is the logistics, and the logistics decide whether you keep coming.
Can we start online and move into the room later?
Yes, and people do it in both directions. The format is a practical arrangement rather than a commitment, and it can change as your circumstances do.
What if the connection drops in the middle of something hard?
We agree beforehand what happens, so it is not a question you have to solve while upset. It becomes an interruption rather than an ending, and interruptions are manageable once they have been expected.
Does it work if English is not my first language?
It works, and the screen makes little difference to that. What helps more is saying early which language the difficult material lives in, because it is often not the one you are most fluent in.
Can you tell how I am if you cannot see all of me?
More than you would expect, and I say so when I cannot. Where a face on a screen is not enough, asking beats guessing, and the asking is part of the work in any case.
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Sources
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.
