Online behavioral therapy is still in its infancy

Posted3/7/2016 5:45 AM

Q: I've been looking into cognitive behavioral therapy to help with my anxiety. It would be convenient to do this therapy from home and, surprisingly, there seem to be many online CBT options. But would the therapy be less effective if I didn't have a personal connection with an actual therapist?

A: Cognitive behavioral therapy (CBT) attempts to correct ingrained patterns of negative thoughts and behaviors. It's an effective treatment for depression, anxiety and other behavioral health problems. It also is widely used to help people with chronic diseases cope with that burden.


Face-to-face visits with a therapist can be inconvenient and may be expensive (depending on your insurance). And there are online CBT options. But the question is: Are they effective?

I spoke to my colleague Dr. James Cartreine, a licensed clinical psychologist and a researcher at Harvard-affiliated Brigham and Women's Hospital. He pointed out that because these online programs are relatively new, there are only a few evaluations of how effective they are. He noted that a team of researchers recently reviewed five well-designed studies comparing online CBT to face-to-face visits with clinicians providing CBT. The patients were all working-age adults being treated for social anxiety or panic disorder.

All of the online therapies delivered treatment through written content. Some programs added text-messaging and discussion forums. Most also involved some communication with a mental health clinician, usually a psychologist, over email or private messaging systems. This could be quite limited, however. In one study, psychologists were limited to spending only 10 minutes per week on each patient. Finally, most included homework assignments that participants did between sessions.

All treatment groups, both face-to-face and online CBT, had significantly improved symptoms. One study found better outcomes for the online treatment. The others found equal results between the two types.

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While these results are encouraging for people who are interested in online CBT, I'd emphasize that they are not conclusive.

First of all, five small studies do not provide a lot of evidence. Furthermore, researchers tend to submit studies with a positive result for publication. They don't always seek to publish, and journal editors often don't want to publish, studies showing that treatment was ineffective.

More important, CBT is not one thing. What I mean is that a pill is a pill, whichever doctor has prescribed it. But CBT is a treatment that is practiced differently by different therapists, and those therapists are not all equally skilled. So it's hard to know from published studies whether the particular online CBT program that you are interested in will be effective.

I'm not knocking online CBT; I'm just saying that it is in its infancy. I hope that most online CBT programs prove to be effective. They not only are more convenient for the people that use them; they also require less time on the part of the therapists. That would allow therapists to offer treatment to more people.

• Dr. Komaroff is a physician and professor at Harvard Medical School. To send questions, go to

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