Virtual therapy expanded enormously during the pandemic, and for good reason. It removed barriers that had kept many families from accessing care, including geography, transportation, and the difficulty of getting a resistant teenager into a car and through a waiting room door.
For many mental health presentations and in many contexts, it works. It is worth stating this clearly, because this article is not an argument against virtual care. Rather, it is an attempt to be honest about where the evidence is nuanced, where the clinical picture is more complex than the convenience argument suggests, and why the decision between in-person and virtual treatment matters more for some children than others.
If your child is currently in virtual therapy and it is working, this article is not for you. If you are trying to decide what level and format of care to pursue, this might help you ask better questions.
Where virtual therapy genuinely works well
The evidence for telehealth in adult mental health is reasonably strong, particularly for mild to moderate anxiety and depression where the primary treatment modality is cognitive behavioural therapy. Adults can engage with structured therapeutic tasks, build on homework between sessions, and maintain therapeutic alliance through a screen in ways that do not appear to significantly compromise outcomes.
For adolescents with mild presentations (and who may live in areas with limited access to in-person care), virtual therapy is a meaningful improvement over no therapy. For teenagers who are highly motivated, articulate about their experience, and already comfortable with screen-based communication, virtual individual therapy can be effective.
It is important to state that not every child who comes to us needs a program like ours. Part of our job is saying so when we encounter these cases. When a child’s symptoms are manageable with weekly therapy and medication management, we say that directly and help the family find the right outpatient fit. This can include virtual care when that removes a significant barrier.
Telehealth can work well for a teen who is stable and needs consistency more than intensity, or for a family whose distance from our offices would make daily attendance unreliable. Inconsistent attendance in an intensive program helps no one.
There are also presentations where we push in the other direction. When a child has stopped leaving the house, virtual care can quietly reinforce the avoidance. Getting out the door, into a car, and into a room with other kids can be a meaningful component of treatment itself, and is not always just a logistical detail in that work.
Where the evidence gets more complicated
The research on virtual therapy in children is thinner and more mixed than the adult literature. This is particularly acute in both younger children and those with more complex presentations.
Younger children and developmental stage
Children under twelve engage with therapeutic work differently from teenagers and adults. Play-based interventions, non-verbal communication, and physical presence in the therapeutic relationship are not incidental to treatment: for many younger children, they are the treatment. A screen mediates these elements in ways that affect their therapeutic value.
Young children do not communicate the way a screen asks them to. They tell us what is going on through play, movement, and what they do with their bodies in a room. A child who positions himself near the door, who cannot settle into a chair, who drifts toward one peer and away from another, is giving us information that a video window does not carry.
We also watch how a child arrives. Separating from a parent in the waiting room, walking into a group of other kids, finding a place to sit, all of it is clinical data, and it is data we only get in person.
The other piece is escalation. In a room, our staff can see a child building well before anything happens: the breathing changes, the shoulders come up, the eyes start scanning. That window is where the teaching happens. On a screen, we usually only see the moment it breaks.
Further, group work itself only works if children are actually together. Turn-taking, conflict, and repair after conflict all have to be practiced with real people in real time.
Therapeutic alliance in complex presentations
Therapeutic alliance is the quality of the relationship between the therapist and the patient, and it is one of the strongest predictors of treatment outcome across modalities.
For children with complex presentations, significant trauma histories, or marked difficulty trusting adults, the relational repair that happens in a shared physical space is harder to replicate through a screen.
Group therapy
Group therapy is a cornerstone of Partial Hospitalization Programs (PHP) and Intensive Outpatient Programs (IOP).
The evidence for group therapy conducted in person is strong. The evidence for virtual group therapy, particularly in adolescent populations with social anxiety (which is one of the most common presentations in these programmes) is considerably weaker, however.
A teenager with social anxiety who is in a virtual group is insulated from precisely the experience that would help them: learning that they can be present with peers, that they can be seen and not judged, that social connection is survivable.
Treating social anxiety through a screen is a little like treating a fear of water by watching swimming videos. The exposure is missing.
Crisis response
When a child or adolescent is in acute distress during a session, the clinical response available in person is categorically different from what is available through a screen. This includes when a panic attack occurs mid-session, there is a disclosure of self-harm, or a moment of serious deterioration takes place.
In-person treatment means a clinician can stay with a young person through a crisis in real time. It means the family can be called into the room when needed. It means the response is immediate and embodied rather than mediated.
For children at higher risk, or children who have recently stepped down from hospitalisation, this is not a theoretical concern.
PHP and IOP specifically: why in-person matters
In the context of intensive programs, the in-person versus virtual question is particularly significant. PHP and IOP are not simply individual therapy that is conducted with more frequency. They involve group work, peer relationships, physical co-regulation, and the experience of being in a consistent therapeutic community across the week. These elements are very difficult to replicate virtually.
In these cases, the in-person model is not a preference. It is how the program is built.
Children arrive dysregulated more often than not. A dysregulated child does not calm down by being talked to. He calms down through his body and through his surroundings: room to move, a predictable sequence of where he goes and when, a quieter space he can step into without it being a punishment, and an adult who can walk beside him until he comes back down.
Our space is designed around this. The rooms, the transitions between them, and the staffing ratios at our Center all exist so that regulation can happen before anything else is asked of a child.
Group therapy works in the same way. What a child practices in group is being near other kids and staying regulated while they are in proximity. Part of the practice is waiting a turn when someone else is upset, repairing something after it goes wrong, and reading a face across a table. These are the skills that determine whether a child can hold a friendship or sit through a school day, and they can only be built with other people in the room.
All the facets of mental health and behavior that are downstream depend on this. A child who is regulated can use therapy, while a child who is not, cannot.
The honest conclusion
Virtual therapy is not categorically inferior to in-person therapy. However, the claim that it is equivalent across all presentations, all ages, and all levels of care is not supported by the current evidence.
For children with mild presentations that are seeking individual therapy, virtual care can be appropriate and effective.
For children who need intensive care, including structured group work, crisis support, significant family involvement, and community within a program, in-person treatment is most often the better clinical choice
This decision is ultimately a clinical one, and it should be made on the basis of your child’s specific presentation, history, and needs. If you are trying to work out which is right for your child, the most useful thing is a proper clinical assessment.
If you would like to talk through whether in-person PHP, IOP, or other care options are appropriate for your child, we offer a 24-hour clinical assessment response. Contact us today.
