Online Therapy for PTSD: Is a Stepped Approach Enough?
15 Oct 2026
In a new Australian trial, an online stepped-care programme for PTSD gave large improvements and was as good as standard therapy on the clinician-rated measure, but more people dropped out (43% against 26%) [1]. Trauma-focused therapies such as exposure therapy and EMDR have the strongest evidence, and no single one has been shown to be clearly better than the others [2,3].
Online Therapy for PTSD at a glance
- Trial: 84 adults with PTSD or subthreshold PTSD, comparing online stepped care with cognitive processing therapy (CPT) by telehealth [1].
- Stepped care used less clinician time (8 to 10% less) but 43% dropped out against 26% with CPT [1].
- Both groups improved a lot, and gains lasted to six months [1].
- Exposure therapy: large effects against waitlist or usual care, negligible difference against other trauma-focused therapies [3].
- EMDR: no significant difference against other psychological therapies in a pooled analysis of 8 trials [2].
What did the new PTSD trial test?
Researchers in Adelaide, Australia, tested "stepped care". Step one is a self-guided online course called This Way Up. If you do not improve enough by pre-agreed checkpoints, you move up to step two, cognitive processing therapy with a therapist by video. The idea is to save specialist time for those who need it [1].
They randomised 84 adults, most of them women, to either stepped care or CPT by telehealth from the start [1].
What did they find?
Both groups improved substantially on PTSD symptoms, depression and quality of life, and the gains were maintained at three and six months. Stepped care was non-inferior to CPT on the clinician-rated PTSD scale at the end of treatment, and for depression at every time point [1].
There were two caveats. On the PTSD self-report checklist (PCL-5) and on quality of life, non-inferiority could not be shown, and results favoured CPT. And dropout was higher with stepped care, 43% against 26% [1]. Stepped care did use 8 to 10% less clinician time [1].
For you, that means online-first care can work for many people, but it is not an automatic replacement for direct therapy, especially if your symptoms are severe or you struggle to stay engaged on your own.
Which therapies have the best evidence for PTSD?
Trauma-focused psychotherapies. A meta-analysis of 65 trials with 4,929 patients found that exposure therapy had large effects against waitlist and usual care, a small effect against therapies that do not focus on the trauma, and a negligible difference against other trauma-focused treatments or medicine. The different exposure-based therapies were similarly effective [3].
A pooled analysis of individual patient data from 8 randomised trials (346 patients) found EMDR did not differ significantly from other psychological treatments in reducing PTSD symptoms, response, remission or dropout [2]. That sounds like a negative result, but it really means EMDR performs about as well as other proven therapies. Note that the comparators included relaxation therapy and trauma-focused CBT, and the analysis was small [2].
| Approach | What the evidence shows | Main limit |
|---|---|---|
| Online stepped care [1] | Large improvements; as good as CPT on clinician rating | More dropouts (43% vs 26%) |
| Exposure therapy [3] | Large effect vs waitlist; similar to other trauma-focused therapy | Fewer benefits where substance use is common |
| EMDR [2] | No significant difference vs other psychological therapies | Only 8 trials with patient-level data |
Evidence for common PTSD therapies [1,2,3].
How do you choose between them?
The trials do not point to one winner, so the choice comes down to your situation. Think about:
- Your symptoms: nightmares, flashbacks, avoidance, constant alertness, or numbness.
- How much support you have at home and whether you can complete online work on your own.
- Whether you prefer to talk through the event in detail, or to process it with a more structured technique.
- Other problems such as depression, alcohol use or poor sleep, which should be treated at the same time.
Is it safe to start trauma therapy?
Trauma-focused therapy is done at your pace, with the therapist checking that you feel safe. It can be uncomfortable to face memories, which is why a trained clinician matters. If you are in crisis or thinking of harming yourself, do not wait for an appointment. Call Tele-MANAS on 14416 (free, 24 hours a day) or 112.
Getting help in Delhi
At Brain Bridge Clinic in Safdarjung Enclave, New Delhi, PTSD and trauma care starts with a careful assessment of your symptoms, sleep, mood and substance use, paced so you are not pushed to retell your story before you are ready. Depending on what you need, the plan can include trauma-focused approaches such as EMDR, exposure-based therapy or CBT, along with psychiatric care where it is indicated. Family members can join part of the process if that helps. If you would like an assessment, you can book through the website or by phone.
Related pages: PTSD Trauma, EMDR, Exposure Therapy, CBT.
Frequently asked questions
Can PTSD be treated online?
Yes, to a degree. In the new trial an online-first approach gave large improvements, but had more dropouts than direct therapy [1]. Discuss with a clinician whether it suits you.
Is EMDR better than CBT for PTSD?
A pooled analysis found no significant difference between EMDR and other psychological treatments, including trauma-focused CBT [2].
How long does PTSD therapy take?
It varies. The trial above followed people for six months after treatment [1], and your clinician will discuss the likely length for you.
Do I need medicine for PTSD?
Not always. The exposure therapy meta-analysis found a negligible difference against medication at the end of treatment, and a medium effect favouring exposure at follow-up [3]. A psychiatrist can advise on your situation.
Is talking about trauma necessary?
Trauma-focused therapies work with the traumatic memory in a structured way. Your therapist can adjust how, and how fast, this is done.
References
- Roberts LN, Nixon RDV. Online stepped care for the treatment of posttraumatic stress disorder: A randomized controlled noninferiority trial. Behaviour research and therapy. 2026;206:105166. doi:10.1016/j.brat.2026.105166. PMID 42832930.
- Wright SL, Karyotaki E, Cuijpers P, et al. EMDR v. other psychological therapies for PTSD: a systematic review and individual participant data meta-analysis. Psychological medicine. 2024;54(8):1580-1588. doi:10.1017/S0033291723003446. PMID 38173121.
- McLean CP, Levy HC, Miller ML, et al. Exposure therapy for PTSD: A meta-analysis. Clinical psychology review. 2022;91:102115. doi:10.1016/j.cpr.2021.102115. PMID 34954460.