WRITTEN BY
Justin La Rose, RP, M.Psy is a Registered Psychotherapist (RP, M.Psy) and Clinical Director of The OCD Clinic in Toronto. He has worked in mental health for more than 25 years and has spent over a decade in clinical practice, specializing in treating OCD with Exposure and Response Prevention (ERP).
Clinical examples in this article are composites. Any identifying client details have been changed and anonymized to protect confidentiality.
- 01Research shows online therapy is equivalent to in-person for most conditions - this is not a close call.
- 02For OCD specifically, online may be better - because your triggers are in your environment, not in a therapist's office.
- 03COVID taught us something useful - moving online didn't worsen outcomes, and for many clients improved them.
- 04The meaningful variable isn't format - it's whether the therapist knows what they're doing.
- 05Practical factors matter - commute, cost, scheduling. Don't let format ideology get in the way of actually going.
The short answer: for most presentations, they're equivalent. The research is consistent on this. The fuller answer: for certain conditions - OCD especially - online therapy may actually have an edge. And it has nothing to do with convenience.
What the Research Says
A 2018 meta-analysis published in Behaviour Research and Therapy examined 22 randomized controlled trials comprising 1,796 participants and found no statistically significant difference in outcomes between remotely-delivered CBT and in-person CBT. Effect sizes were essentially identical across presentations including OCD, anxiety disorders, and depression. This finding has been replicated independently across multiple subsequent reviews.
Before 2020, there was legitimate clinical skepticism about online delivery. Would the therapeutic relationship suffer? Would non-verbal cues be too compromised? Would clients engage as seriously with sessions in their own space? These were reasonable questions. Then COVID forced the issue, and practitioners worldwide spent two years watching what happened when an entire profession moved online almost overnight.
What happened was: outcomes didn't worsen. In many cases, therapists reported client engagement improved - people were more likely to attend consistently when the barrier of commuting was removed, and some clients found it easier to be open in their own environment. The evidence that online therapy is "less effective" simply doesn't exist. The pre-COVID skepticism is not supported by the data.
Why Online Works for OCD
When I moved my practice online during the pandemic, something became clear that I hadn't fully appreciated before: my office was one of the least relevant environments for OCD treatment.
OCD is triggered by specific stimuli. The kitchen stove. The front door lock. An unread work email that might contain bad news. An intrusive thought that arrives during the commute and demands immediate mental engagement. None of these triggers live in a therapist's office. The office is, in a very literal sense, an OCD-irrelevant space.
ERP - Exposure and Response Prevention - works by having clients confront the situations and stimuli that trigger their OCD, while resisting the urge to perform compulsions. The exposure needs to be real. The anxiety needs to be genuine, not imagined. When a client is in their kitchen during a session, I am virtually present in the environment where their OCD actually operates. I can see them. I can guide them through not checking the stove for the fifth time. I can be present with them as they sit with the uncertainty of having left the house without triple-checking the lock.
These are ecologically valid exposures - happening in the real context where the disorder operates. For OCD treatment specifically, this isn't a neutral difference between formats. Online may genuinely produce better ERP.
Where In-Person Has a Genuine Edge
The equivalence research is real, and so are its limits. There are presentations where in-person therapy has a meaningful structural advantage - not because online is inferior, but because the specific needs of that work don't translate as well to a screen.
The Variable That Actually Matters
Most of the time, the online-vs-in-person debate is a proxy for a different question: "Is the therapist I'm considering finding online as good as the one I might find if I went in person?"
This is the right question. Format is not the lever that determines outcomes. Therapist expertise, the quality of the therapeutic relationship, and the appropriateness of the treatment approach for the presenting concern - these are the variables that predict whether therapy works. An excellent therapist working online outperforms a mediocre therapist working in person, every time, for every condition studied.
The format question, in other words, is secondary to the therapist question. And the therapist question has a clear answer for OCD: you need someone who does ERP, who has specific training in OCD treatment, and who understands the disorder. That person working online is significantly better than a general therapist sitting across from you in an office. See the guide on choosing the right therapist if you're still in the selection phase.
Practical Considerations
Even setting aside the clinical equivalence, there are real practical advantages to online therapy that shouldn't be dismissed as mere convenience.
Key Takeaway
- →Is this therapist excellent at treating what I have? Format is secondary.
- →For OCD: online may be genuinely better - your triggers are at home, not in an office.
- →The equivalence research is solid - don't let format ideology get in the way of getting help.
- →Practical advantages of online are real: access, scheduling, no commute.