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How Effective Is Online CBT, Really?

Person in a video call with their therapist.
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Key Takeaways

  • Internet cognitive-behavioral therapy (iCBT) services can be effective, but it is not always the best choice for the treatment of severe depression.
  • The availability of online therapy gives therapists a chance to reach out to more patients safely and effectively.
  • While some iCBT techniques were beneficial, cognitive restructuring and relaxation strategies may not be as effective.

Many services shifted online during the pandemic, including psychotherapy. According to a recently published study in The Lancet Psychiatry, internet cognitive behavioral therapy (iCBT) services can effectively treat mild to moderate depression.

Many people are dealing with burnout from the tolls of the pandemic, so it is crucial to ascertain the efficacy of online psychotherapy treatment. As COVID-19 variants threaten physical health in the U.S., it will help to make use of effective approaches for addressing mental health issues remotely.

Understanding the Research

This research provided a systematic review and meta-analysis of studies on the efficacy of iCBT treatment programs for addressing depression. Researchers found that iCBT delivery was generally effective to treat mild to moderate depression but not recommended for severe depression.

For the sake of this study, iCBT programs were conceptualized broadly to include any components of cognitive and behavioral skill development for use through a website or app, such as cognitive restructuring, behavioral activation, interpersonal skills, structured problem solving, etc. 

As can be a limitation with any systematic review or meta-analysis, fragmented, inherently different evidence may be compared without highlighting such variations. These differences can skew research findings.

Online CBT Can Improve Access

Ariel Landrum, MA, LMFT, licensed marriage and family therapist, and certified art therapist at Guidance Teletherapy, says, “The pandemic forced many industries to jump to remote work to keep employees and customers safe. The same happened to the medical and mental health fields.”

Especially if clinicians were not used to providing therapy via video conferencing software, Landrum highlights how many had to learn how to use the technology and make services compliant with ethical protocols.

Landrum says, "This research adds to the literature around web-based therapy, which seems to agree that mild and moderate forms of mental unwellness can receive quality care when provided virtually."

When asked about the benefits that virtual psychotherapy services offer, Landrum highlights safety, flexibility, distance, specialties, accommodations, and resourcing, as it may be the best way to provide safe socially distant care with the highly contagious Delta variant spreading.

Landrum says, “Even providers who are attempting to provide therapy in person are having trouble understanding their clients with a mask on, are missing nuance in facial expression needed for clinical consideration, and are struggling to allow for proper airflow and spacing in smaller offices.”

Online psychotherapy services allow for flexibility for both the provider and the client, regarding scheduling. “This is crucial for single-parent households, college students with changing schedules, and for rural areas in the U.S., where it can be difficult to receive regular quality care,” she says.

Ariel Landrum, MA, LMFT

For many 2SLGBTQIA+ clients, they need providers with lived experience who have an understanding of the struggles they face. With online therapy, these clients can search their entire state for a provider with this background, instead of just their city.

— Ariel Landrum, MA, LMFT

Landrum emphasizes how some clients seek providers with specific specialties and backgrounds. “For many 2SLGBTQIA+ [two-spirit and LGBTQIA+] clients, they need providers with lived experience who have an understanding of the struggles they face. With online therapy, these clients can search their entire state for a provider with this background, instead of just their city,” she says.

In terms of accessibility, Landrum highlights how online therapy may make use of accommodations easier, including live closed captioning, easier access to schedule a session with an interpreter, and use of the chat feature in HIPAA compliant and video conferencing software for sharing resources.

Landrum admits that technology has issues, as individuals in rural areas may not have as much access and there may be a learning curve for using video conferencing software. Since providers will not receive clinical insight on the body below what the camera shows or from the use of other senses, Landrum notes this could be an issue for substance use counselors.

As a therapist who has been providing online services since 2016, Landrum explains that the biggest benefit was that sessions could be provided in a space in which the client was already comfortable, which increased the therapeutic bond immensely.

“The other positive contributing factor I noticed was that the coping skills I was teaching my clients were being taught, for them, in the environment they would use it in the most. This made skill transfer and use easier, as they already experienced and could visualize what the coping skill would look like in their space,” she says.

Since some may not seek online therapy because they have reservations about a virtual clinic setting, Landrum advises that they equip themselves. “Have a tissue box ready, a journal to take notes during the session, and comfort objects to access, like a fidget toy or a blanket. To create some privacy, ensure access to headphones, a closed-door if possible, or seeing if the provider is comfortable with chat-based responses,” she says.

Telemedicine May Be More Convenient

Leela R. Magavi, MD, a Johns Hopkins-trained child, adolescent, and adult psychiatrist and regional medical director for Community Psychiatry and MindPath Care Centers, says, "This study reviews existing literature until 2019; it would be helpful to understand the benefits of teletherapy during the pandemic. This study focuses upon adults, but it would be helpful to understand how teletherapy can aid children and adolescents as well."

Magavi reinforces Landrum’s earlier therapeutic rapport point, as she says, “The patient’s relationship with his or her psychiatrist or clinician is of utmost importance; data suggest that this relationship carries more weight with regard to outcomes than the specific form of therapy provided.”

Since CBT allows individuals to identify their anxiety pattern and combat this by reframing thinking and partaking in healthy behaviors, Magavi advises individuals to write down statements, which emphasize that their biggest fear is unlikely to occur or record their own voice making these statements.

“Reading or listening to these statements repetitively could help strengthen individuals and increase resilience. Positive affirmations and gratitude letters to oneself could also bolster self-compassion, weaken cognitive distortions and improve mood,” she says.

Leela R. Magavi, MD

Telemedicine allows us to care for individuals who live in regions with limited psychiatrists and resources.

— Leela R. Magavi, MD

Magavi, who evaluates all her child, adolescent, and adult patients via telemedicine, emphasizes that telepsychiatry and teletherapy have helped save lives. Various technological platforms have facilitated the prescription of medications and provision of therapy to patients in a safe manner. “Telemedicine allows us to care for individuals who live in regions with limited psychiatrists and resources,” she says.

Especially as it can facilitate treatment to individuals who do not have the ability to travel to clinics in person, Magavi highlights how she evaluates essential workers who are unable to leave their jobs for a prolonged period of time, therefore online communication is convenient.

“Kids and adults alike enjoy showing me their rooms and pets at home; some individuals open up more as they feel comfortable and safe in their own home,” she says.

To navigate a virtual clinic setting, Magavi recommends that individuals remain in a private space so they can freely discuss concerns, and silence their phones, so they do not miss out on any pertinent recommendations. “I encourage individuals to discuss their fears about teletherapy during the initial appointment and as warranted thereafter,” she says.

What This Means For You

As this study demonstrates, online cognitive-behavioral therapy services can be effective to treat mild to moderate depression. It can also offer additional benefits in terms of accessibility, convenience, etc. Especially for marginalized groups, it may open up state-wide access to service providers with lived experience of their specific challenges.

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  1. Furukawa TA, Suganuma A, Ostinelli EG, et al. Dismantling, optimising, and personalising internet cognitive behavioural therapy for depression: a systematic review and component network meta-analysis using individual participant data. Lancet Psychiatry. 2021;8(6):500-511. doi:10.1016/s2215-0366(21)00077-8