Zoom Psychotherapy Is Good, In-Person Is Better

Personal Perspective: Measuring the pros and cons of each produces a clear winner.

Reviewed by Monica Vilhauer Ph.D.

Key points

• Online therapy is popular and has many benefits, but in person therapy is the gold standard.
• In person therapy requires greater investment of time, presence, and interpersonal risk.
• Direct eye contact is far more personal than looking at a person's image on a screen.

COVID-19 introduced Zoom online technology to the world of psychotherapy. At a time when we were all suddenly isolated in our individual space capsules, this technological wonder prevented the disruption of therapeutic relationships and enabled therapists to accept new patients stressed by the pandemic. Suddenly, therapists were able to serve more distant populations. Rural communities had access to urban-based therapists. The multiple benefits of Zoom were obvious to everyone.

The pandemic eventually faded and we discovered Zoom-based psychotherapy had become deeply rooted in many therapists’ practices. Patients enjoyed no longer needing to disrupt their day with travel to and from their therapists’ office and many therapists enjoyed working from home. No longer needing to maintain a separate office was like getting a raise. And being able to travel freely while still maintaining their practice was a welcome benefit.

I would like to submit an argument that in-person psychotherapy should still be seen as the gold standard whenever possible. I know online therapy sessions are more convenient for both therapists and patients. However, psychotherapy is not meant to be convenient. It requires three investments missing in Zoom sessions — time, presence, and a level of interpersonal risk that does not exist to the same degree on screens.

Time spent commuting to a therapist’s office provides a break in the day to anticipate the session, to recall the last session, and contemplate what is important to discuss. And time commuting back from a therapy session provides an opportunity to mull over what has just happened. Emotions that have been stirred up can be experienced and understood. Any insights can be reviewed and integrated. All this time is part of therapy and contrasts starkly with interrupting your schedule at home or work for a therapy session, and then hopping right back into whatever work was interrupted.

Presence is more multifaceted in person than online. I generally greet patients of both sexes with a handshake. Before the patient even sits down, we make brief but meaningful physical contact. I have a gauge on a range of feelings communicated in the eagerness, hesitance, warmth, moistness, or coolness of their touch. Making direct eye contact is qualitatively different than staring at a picture on a screen. Direct eye contact is even more intimate than a handshake and often difficult to bear. There is far less immediacy on screens compared to being alone together in the same room making eye-to-eye contact. Subtle nonverbal cues are also much easier to pick up in person.

Interpersonal risk is an important part of psychotherapy. The hope is that patients will risk levels of emotional intimacy with a trusted therapist that were shut off earlier in life due to perceived disappointment or betrayal. At any moment during intense emotions, a patient might suddenly leave the office, break a lamp, or even attack if they feel offended. In-person therapy involves a layer of concrete immediacy that is harder to achieve online. Fear of exploring sexual feelings toward a therapist feels much riskier for both the patient and therapist in person. Such feelings could not be acted upon through a screen. In-person psychotherapy provides the best opportunity to learn how to tolerate the anxiety of intensely emotional interpersonal reality.

I am certain many patients benefit greatly from online therapy, and some would have no access to treatment without it. I am merely expressing a personal opinion, one without references to authoritative data. Lived experience is the only source for my opinion. I am taking the time to express this opinion because I worry the trend toward online psychotherapy may leave many patients and some therapists without ever experiencing what appears to me to be the gold standard.

If people disagree with me, I hope my thoughts generate useful discussion.