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Online versus In-Person Counseling: A Review of Existing Studies

Martha Ramsey

Saint Leo University

Thesis/Capstone Project I: PSY-690

Instructor Lara Ault

March 9, 2024

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Abstract

Online psychotherapy and in-person counseling differ with respect to their effectiveness. The

current study was guided by a set of research questions which were considered in its review

approach. A total of 15 peer-reviewed sources were selected for the review after consideration of

various criteria. The selected articles not only met the criteria, but also satisfied the requirements

for research subjects, method, variables, and research outcomes. The findings of the study

established that in-person counseling was favored for effectiveness while online psychotherapy

was favored for convenience and affordability.

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Background

With the advancement in internet and digital technology, access to critical services such

as healthcare and support services has become easier (Greenwood et al., 2022). The proliferation

of internet technology and online communication has enabled accessibility to several health

services. Mental health services remain among the healthcare services that can be accessed

through online interaction with experts (Khan et al., 2021). However, the question as to whether

online counseling is more effective compared to in-person counseling widely remained

answered. Whereas online counseling can equally impact patients in reducing psychological

distresses, its effectiveness in terms of creating personal connections with the therapists,

increasing level of satisfaction after use, being executed devoid of distractions remain areas of

concern (Békés et al., 2021). Online counseling therapy has always been associated with ease of

access and affordability thereby making it considered by patients who give preferences to these

factors (Ierardi et al., 2022). Renn et al. (2019) opine that barriers such as location of counseling

services, stigma, and time commitment make some patients prefer online or digital

psychotherapy to in-person counseling (Renn et al., 2019).

The current study focused on the effectiveness of internet therapy as compared to

traditional in-person counseling in the prevention and cure of mental disorders. The study took a

review approach that considered articles published in the year 2019 all the way to the year 2024.

The selected time frame did not factor in the issue of mental health problem during the

COVID19- pandemic but considered a manageable number of most recent articles which could

be extracted within the time frame. The researcher intended to use more than more than 5600

articles for this purpose. However, this was narrowed down to a manageable size by sticking to

the research questions, research problem, and research purpose. Several websites that included

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PubMed, PsycINFO, and Google Scholar were explored for the purpose of extracting the right

articles. There are parameters that guided the inclusion and exclusion criteria for the articles that

were used in the study. The use of English language in the writing and publication of an article

was a mandatory requirement during the evaluation. The study prioritized peer-reviewed journal

articles in the review. Conference abstract, non-peer reviewed articles, and grey literature were

not considered for the evaluation.

Problem Statement: The use of online counseling and therapy versus in-person counseling in

terms of effectiveness widely remains unexplored with respect to review of the existing studies.

Purpose of the Review: The current review provides an in-depth analysis of current literature on

the effectiveness of internet-based therapy compared to in-person counseling and therapy. The

review provides information that can help patients and mental healthcare professionals make

informed decisions when using these approaches to counseling and therapy.

Research Questions

1. How effective is counseling and therapy on the internet as compared to traditional in-

person therapy?

2. What are the pros and cons of online therapy?

3. How is online therapy is perceived by the young and old demographics?

Review of Literature

This section of the paper performs a review of the selected studies in accordance with the

study questions. The section has been broken into the below segments which directly conform

with the research questions. The review was narrowed down to a total of 15-peer reviewed

articles that met the selection and evaluation criteria.

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Online Therapy

Numerous studies have looked at the subject of online therapy. However, only those

studies that have compared online therapy to in-person counseling were considered for this study.

The studies considered in this research were those that could give the researcher information in

doing this comparison as well as answering other research questions. Online therapy was

mentioned by Greenwood et al. (2022) who in their study compared telehealth versus face-to-

face psychotherapy. Despite the fact that telehealth covers a wide range of health services that

can be offered through the internet, Greenwood et al. (2022) not only mentioned psychotherapy

as one of the telehealth services, but also focused their study on the comparison of psychotherapy

versus face-to-face counseling. The article was therefore found to be relevant and applicable to

the study. Greenwood conveys online psychotherapy as a new area that can help patients seek

mental health services. The researchers also attributed the increased use of this method of

psychotherapy to the COVID19 pandemic which made it difficult for both patients and

healthcare providers to interact face-to-face. Online therapy was also mentioned by Khan et al.

(2021) in their study that looked at the experiences of the counselors in online psychotherapy.

The study highlighted a number of factors that that affect counselors’ experience. Some of the

factors are therapeutic alliance, convenience, online counseling skills, ethical and legal concerns,

reaching out to diverse client base, client suitability for online psychotherapy, professional and

personal goals, and client satisfaction.

Whereas Khan et al. (2021) mentioned psychotherapy by focusing on counselor

experiences when providing this type of psychotherapy, Zeren et al. (2022) mentioned online

psychotherapy but focused on client experiences of online counselling. Zeren et al. (2022) took

cognizance of the fact that there are few studies that have investigated the experiences of the

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clients in this type of counseling. Their study focused on two key themes which were associated

with client experiences. The themes were therapeutic alliance and patient experiences. Flexibility

of online counseling, limitations of online counseling, and improvement in the symptoms were

associated with patient satisfaction. On the other hand, therapeutic alliance was associated with

themes such as the bond between the counselor and the client, tasks, and goals. Zeren et al.

(2022) relied on semi-structured interviews to extract information from 6 client-participants.

Online therapy was also mentioned by Westerhof et al. (2019) who in their study looked at how

online therapy could be used to overcome depressive symptoms when it was led by the counselor

versus when it was supported by the peers. The results of the study established that counselor-led

online psychotherapy was more effective than peer supported counseling in terms of reducing

depressive symptoms.

Effectiveness of Online Therapy

Studies on online psychotherapy established that it was effective in helping patients

overcome depressive symptoms. For instance, Ierardi et al. (2022) established that online

psychotherapy was effective in helping patients reduce distresses such as anxiety, depression,

and obsessive and compulsive disorders. The study took a comparative approach and showed

that there were some differences in when online psychotherapy was compared to in-person

counseling in terms of effectiveness. Whereas online psychotherapy showed effectiveness in

managing psychological distresses in some subscales, in-person counselling was effective in

managing psychological distresses in all the subscales that were considered for the study. Sander

et al. (2021) conducted a study that looked into the effectiveness of online psychotherapy. The

study established that online psychotherapy was effective in helping patients overcome mental

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health disorders. However, the method could not be adapted to special needs patients with severe

mental illnesses.

Békés et al. (2021) conducted a study that investigated the effectiveness of online

psychotherapy. Even through the study also took a comparative approach, it established that

overtime online psychotherapy lost its effectiveness. Their study also raised concerns about

connectedness between the counselor and the patient. Schuster et al. (2020) looked at the pros

and cons of online psychotherapy and those of a blended model. The findings of the study

showed that a blended model was more effective than online psychotherapy. In-person

counseling was more effective compared to online psychotherapy in terms of creating personal

interactions between the counselor and the client. Sockalingam et al. (2022) in their study that

looked at the use of telephone-based psychotherapy for people with mental health distresses

established that the method was effective in treating psychological disorders in patients with

eating disorders. Xie et al. (2023) in their study established that there was short-term

improvement associated with remote dignity therapy. Patients who underwent the treatment

experienced reduction in dignity loss, gained more hope and meaning of life, and experienced

reductions in depression and anxiety.

Accessibility and Reach

Convenience is a key factor when it comes to the use of online psychotherapy in the

treatment of online psychological disorders. Renn et al. (2019) in their study that investigated the

factors associated with client preferences for digital psychotherapy in the treatment of depression

and anxiety found out that privacy, time commitment, location of services, and stigma were

among the factors that made patients to prefer online psychotherapy. In terms of location,

accessibility was considered a key factor in determining the use of online psychotherapy. The

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study which also looked at how rural dwellers in America could benefit from online

psychotherapy found out that individuals in the rural areas with interconnection could benefit

from this model of psychological care due to accessibility. Ncheka et al. (2024) in their study that

looked at the implementation of cognitive-based psychotherapy in low mood showed that

internet-based psychotherapy was recommended for students from low-incoming settings due to

convenience and affordability. The study which relied on student population also revealed that

students or young people who were technologically savvy preferred online psychotherapy to in-

person counseling. Accessibility in terms of demographics was also confirmed in the studies

conducted by Ierardi et al. (2022) who showed that young individuals were more likely to

subscribe to the use of online psychotherapy in the treatment of depressive disorders as

compared to older adults.

Therapeutic Alliance and User Experience

Therapeutic alliance and user experience is another area that should be considered when

determining the use and effectiveness of online psychotherapy. Khan et al. (2021) in their study

found that therapeutic alliance is a key factor in determining user experience in online

psychotherapy. Even though the study lauded online psychotherapy in helping clients deal with

symptoms of psychological disorders, the study revealed that a strong therapeutic alliance or

personal interaction between a counselor and a client was necessary in improving client

experience. Therapeutic alliance and user experience was also mentioned by Zeren et al. (2022)

in their study that investigated client’s experiences of online counseling. The study also

considered patient satisfaction. The results of the study showed that tasks, bond, and goals were

the themes associated with therapeutic alliance while improvement in symptoms and flexibility

were associated with client satisfaction (Zeren et al., 2022). According to Zeren et al. (2022),

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clients who used online psychotherapy, reported positive experiences in relation to online

counseling.

Method

The current study, being a review of the existing studies on the chosen topic did not rely

on a specific measure to determine its methodological approach. No measurement tools or

devices were used as a guideline in obtaining the information for the research. The search for

studies that were included in the review was guided by topic and the research questions. The

researcher considered several constraints that helped to narrow down the materials that were

selected for the review. English language criterion for journalism was considered a critical

component in the evaluation. English language use was a key consideration because studies and

papers published in non-English languages were not only challenging to comprehend and

synthesize but could also comprise the rigor of the review.

Eligibility Criteria

Peer-reviewed articles published between year 2019 to the year 2024 were prioritized to

maintain the rigor of the review. The search process was confined to search terms that included

online therapy mental health outcomes, telepsychiatry effectiveness, internet-based interventions

for mental health, and pros and cons of online counselling. A total of 3500 articles from Santa

Leo University library were found. The search yielded a total of 696 downloadable articles. 2

Random chapters of the searchable articles and materials were also found. 34 books were found

to have met the above listed search terms. The search also yielded 4200 nonfiction articles.

Additionally, 2800 peer reviewed articles were found. Online mental therapy was the initial

search term considered during the search. The publication was limited to the articles published

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between year 2019 to those published in the year 2024. Searches from PubMed, PsycINFO, and

Google Scholar using the search terms yielded more than 260 articles for both peer-reviewed

articles and other materials.

Quality Evaluation

Several rules of evaluation were considered by the researcher in selecting the appropriate

peer-reviewed articles that were used in the review. The researcher relied on a score box guide

provided in the attached excel to perform the evaluation. 15 peer-reviewed journal articles met

the box criteria based on several factors that accurately linked them to the research question and

topic under study. These considerations were subjects, independent variables, dependent

variables, and outcomes. For instance, in terms of outcomes all the 15 articles had results that

could guide the direction of the study. The outcome from the 15 articles pointed to the fact that

online counseling and therapy had some impacts on mental health. According to the box score,

the 15 articles had methods of study that had very little variations. The outcomes from the 15

articles were sub-categorized by perceptions, effects, and experiences of the subjects. According

to these categorizations, 3 of the 15 articles focused their outcomes on perceptions, 7 focused on

their outcomes on effectiveness, and 5 leaned towards effects. The methodology and data

collection approaches used in the studies were those that considered reliable and could lead to

extraction of accurate data for validity. For instance, Ierardi et at. (2022) assessed psychological

problems that were experienced by university students in a symptom checklist. A questionnaire

was used to record their experiences including life satisfaction after online counseling.

Greenwood et al. (2022) relied on randomized controlled trials that compared telehealth

counseling to face-to-face counseling. Renn et al. (2019) used online surveys to document

patients’ choices on online versus in-person counseling. Sockalingam et al. (2022) used

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telephone-based cognitive therapy to extract data, while Last et al. (2024) used semi-structured

interviews to collect data. Ncheka et al. (2024) equally used semi-structured interviews to collect

data. The same method was used by Posselt et al. (2024). In terms of subjects, the 15 peer-

reviewed journal articles considered populations who were likely to be affected by mental health

or those that had suffered from mental health. The study considered effects of mental health

problems such as anxiety, depressive symptoms, and personal health as some of the dependent

variables. The outcomes for the study were almost similar for the 15 articles.

Key Findings

The review established that the experience of counselors was a key determinant in the

success of online counseling. This was evident in the studies conducted by Khan et al. (2021).

Their study also showed that therapeutic alliance and patient satisfaction were associated with a

reduction in depressive symptoms, thus improving experiences of the users. Similar findings

were found out by Zeren et al. (2022). The review also showed that even though online

counseling was likely to be preferred with respect to convenience, cost effectiveness, and

accessibility, in-person or face-to-face counseling was favored by majority of the subjects in the

selected articles. The review explored the planning practices for public counseling therapists

(Khan et al., 2021).

In terms of effectiveness, Ierardi et al. (2022) established that online psychotherapy was

effective in helping patients reduce the effects of depressive symptoms such depression and

anxiety. In its comparative approach, the study showed that in-person counseling had the ability

to help clients overcome all the subscales of depressive disorders. Békés et al. (2021) in their

study also highlighted that online psychotherapy was effective in helping patients deal with

depressive symptoms, however, the effectiveness of this model decreased overtime due to lack of

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personal interaction between clients and counselors.

Schuster et al. (2020) in their study that looked at the pros and cons of both online

psychotherapy and blended models assert that blended models were more effective than internet-

based psychotherapy. Renn et al. (2019) in their study showed that clients were more likely to

use online psychotherapy for reasons such as accessibility, commitment to time, privacy,

affordability, and location of services. The findings were supported by Ncheka et al. (2024) who

showed that affordability and convenience were the key factors that made students from low-

income settings use online psychotherapy. Both Ncheka et al. (2024) and Ierardi et al. (2022)

mentioned the subject of demographics. The two studies revealed why young individuals were

more likely to use online psychotherapy instead of in-person counseling. Unlike older adults,

young individuals are technologically savvy and prefer to use online-psychotherapy due to cost

considerations (Ierardi et al., 2022).

Limitations

The results of this review were limited to several conditions. Defining the boundaries of

the present understanding of e-therapy's effect on mental health through recognition and

acknowledgment of these limitations is critical to build a basis for a transparent interpretation of

the findings and the further expansion and refinement of the research. The study was limited in

scope and therefore could not be generalized to other settings. For instance, the subjects in the

reviewed articles included individuals who were experiencing mental health problems or had

experienced mental health problems. The review was limited to peer-reviewed articles published

in the year 2019 to 2014. The review was confined to the three research questions.

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Conclusion

The current review had the key aim of answering the research question as to whether

online or internet-based psychotherapy was more effective in handling mental health problems

compared to in-person counseling. The reviewed materials showed that most of the subjects in

the articles considered for review were likely to favor in-person counseling in terms of

effectiveness. However, online counseling was favored for reasons such as convenience and

affordability. The study had several limitations and therefore cannot not be generalized to all

settings. One of the limitations was that the articles used in the review were published between

year 2019 to the year 2024. The practical implications are that counseling experts should

consider the conditions that may make a patient choose one counseling method in favor of the

other. Areas for future research are provided by limitations. Future studies should focus on

diverse articles from different library settings. Future studies should investigate issues such as

security in online psychotherapy, and patient privacy protection. In as much as online

psychotherapy comes with the benefits of convenience and cost savings, future studies should

focus on ethical issues associated with online psychotherapy.

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