Journal of American College Health

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A comparison of online and in-person counseling

outcomes using solution-focused brief therapy for
college students with anxiety

Jocelyn K. Novella, Kok-Mun Ng & Jessica Samuolis

To cite this article: Jocelyn K. Novella, Kok-Mun Ng & Jessica Samuolis (2022) A comparison
of online and in-person counseling outcomes using solution-focused brief therapy for
college students with anxiety, Journal of American College Health, 70:4, 1161-1168, DOI:
10.1080/07448481.2020.1786101

To link to this article: https://doi.org/10.1080/07448481.2020.1786101

Published online: 23 Jul 2020.

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JOURNAL OF AMERICAN COLLEGE HEALTH
2022, VOL. 70, NO. 4, 1161–1168
https://doi.org/10.1080/07448481.2020.1786101

MAJOR ARTICLE

A comparison of online and in-person counseling outcomes using

solution-focused brief therapy for college students with anxiety
Jocelyn K. Novella, PhDa
, Kok-Mun Ngb, and Jessica Samuolisc
a
Counselor Education, Fairfield University, Fairfield, CT, USA; bCounseling, Oregon State University, Corvallis, OR, USA; cPsychology, Sacred
Heart University, Fairfield, CT, USA

ABSTRACT ARTICLE HISTORY

Objective: This study compared online, synchronous video counseling to in-person counseling Received 26 January 2020
using solution-focused brief therapy for college students with mild to moderate anxiety. Revised 21 May 2020
Participants: Participants were 49 undergraduate students who were seeking counseling for mild Accepted 12 June 2020
to moderate anxiety. The study was conducted from November, 2017 to December 2018.
KEYWORDS
Methods: In a randomized, non-inferiority design, undergraduate participants were randomly Anxiety; college counseling;
assigned to online, synchronous video counseling or in-person treatment for anxiety using solu- emerging adults; online
tion-focused brief therapy (SFBT). Participants completed the Beck’s Anxiety Inventory (BAI) and counseling; solution-focused
College Counseling Assessment of Psychological Symptoms (CCAPS) to assess outcomes. Results: brief therapy;
The results showed significant changes in scores on the BAI and the CCAPS Generalized Anxiety telemental health
and Social Anxiety subscales for participants in both study conditions, and no significant differen-
ces in effectiveness of the two delivery methods. Conclusions: The findings provide support for
the treatment of college students with anxiety with SFBT through online, synchronous video coun-
seling. Limitations related to sample size and diversity are discussed.

Emerging adulthood is a crucial time for the assessment and
treatment of mental health issues, including anxiety disor-
ders. Data from the 2019 National College Health Assessment
conducted by the American College Health Association
(ACHA) indicate that 72.3% of college women and 50.9% of
college men had felt overwhelming anxiety in the previous
twelve months.1 In fact, anxiety is the highest diagnosed
mental health disorder in the college population, with 12.6%
of men and 27.9% of women diagnosed or treated with an
anxiety disorder.1 These disorders develop gradually and can
begin at any point in the life cycle, although the years of
highest risk are in young adulthood.2 As such, addressing
anxiety disorders effectively in the college population has
far-reaching implications for societal wellness.
However, data further show that many of these distressed
students may never enter a college counseling center for in-
person treatment.3 The Healthy Minds Study 2018–2019
reported that only 43% of college students with a positive
depression or anxiety screen in the past year had received
any kind of support from a health professional, including a
primary care doctor.4 With more young adults attending
college and university,5 higher education institutions are
struggling to reach those who are distressed.6 How do col-
leges reach at-risk, anxious students who may not seek help
in the traditional way?
Online counseling
Web-based counseling represents an innovative delivery
mode with the potential to reach college students who may
not seek help in-person.7 Various terms have been used to
refer to Web-based services, for example, online counseling,
distance counseling, and telemental health. Recent data show
that 36.9% of U.S. college counseling centers offer some
kind of telemental health intervention.8 For purposes of
clarity, we will use “online counseling” in our narrative to
refer to synchronous delivery of mental health services via
Web-based videoconferencing.
Recent findings indicate notable student preferences for
online counseling. For example, Ryan et al.’s 9 study on
Australian university students found that “57.7% of students
in the high distress category were likely to use an online stu-
dent [mental health] program, as opposed to 36.1% in the low
distress.”9 However, Web-based mental health interventions
vary greatly. For example, there are psychoeducational mod-
ules available at the user’s convenience with no interaction
with a professional mental health provider. Synchronous con-
nection with a professional is another resource, either through
audio communication, text, or video. There also are hybrid
approaches that provide therapist-assisted support in conjunc-
tion with asynchronous Web-based interventions. Emerging
data indicate that telemental practices that involve two-way,
synchronous videoconferencing seem to be the most effective

CONTACT Jocelyn Novella jnovella@fairfield.edu Counselor Education, Fairfield University, 1073 North Benson Rd., Fairfield, CT 06824-5195.

This article is based on the first author’s dissertation project (2019) at Oregon State University titled, “A Comparison of Online and In-Person Counseling Using
Solution-Focused Brief Therapy for College Students with Mild to Moderate Anxiety.”
ß 2020 Taylor & Francis Group, LLC
1162 J. K. NOVELLA ET AL.
among the various delivery styles.10 The benefit of having a
therapist involved in individualized treatment in order to
address client motivation seems evident.11 Certain therapeutic
issues have been found to be effectively treated with online
counseling. For example, Simpson and colleagues used
synchronous videoconferencing to reach eating disorder adult
clients in remote locations.12,13 Their results showed improve-
ment in bulimic behaviors, borderline characteristics, and
depression; however, their samples were small, and they did
not include follow-up data.
Anxiety and online counseling
Several randomized controlled trials using online interven-
tions for anxiety disorders show positive outcomes among
adults. Titov et al.14 created a transdiagnostic treatment for
a variety of anxiety disorders that was delivered via online
educational programs, homework, weekly phone or email
contact with a professional, an online discussion group, and
automatic e-mails. The control group was a waitlist control.
Results showed the treatment group had a significant reduc-
tion in anxiety symptoms immediately post-treatment and at
3-month follow-up.14 In a meta-analysis of 22 articles on cog-
nitive-behavioral therapy (CBT) delivered over the Internet to
adult clients for anxiety and depressive disorders, Andrews
et al.15 found a mean effect size superiority of 0.88 for major
depression, panic disorder, social phobia, and generalized
anxiety disorder. Five of these studies investigated the benefit
of online CBT in comparison with face-to-face CBT, and
both delivery systems appeared to be equally beneficial. The
majority of participants were satisfied with the treatment,
with a median of 86% satisfied or very satisfied, and treat-
ment adherence was 80%.15 In a later study looking at social
anxiety, the results demonstrated significant improvements in
levels of social anxiety as well as quality of life when using
evidence-based anxiety treatments through videoconferencing
delivery.16 In 2014, Goetter, Herbert, Forman, Yuen, and
Thomas used exposure and ritual prevention to treat obses-
sive-compulsive disorder, another type of anxiety disorder,
and found videoconferencing to be a feasible delivery method
showing preliminary efficacy.17 A recent study compared in-
person CBT to Internet-delivered CBT for health anxiety.
Participants were randomly assigned, and results on the
Health Anxiety Inventory were comparable for the two deliv-
ery methods.18 These studies showed the potential for suc-
cessful use of online treatment for adults.
Online interventions for anxiety in the adolescent and
emerging adult populations have also shown some promise.
Hintz et al.19 evaluated an asynchronous online intervention
for stress management with college students and showed
that the intervention groups experienced significantly greater
reduction in stress-related symptoms, anxiety, and depres-
sion than the control group. The limitation was that stu-
dents were recruited by offering extra credit in a psychology
class.19 A study conducted in Germany examined an
Internet-delivered intervention for test anxiety in university
students. These researchers included some therapist guid-
ance in addition to self-help interventions and saw a
significant reduction in test anxiety. However, they did not
randomize participants or include a control group.20 An
Australian study compared an online versus clinic-based
CBT intervention for anxiety through a randomized con-
trolled trial. They studied 115 adolescents, aged 12–18 and
conducted 6- and 1-month follow-ups. Results indicated the
usefulness of online delivery of CBT in this age group and
the similarity to in-person delivery, even at 12-month fol-
low-up. However, this study also focused on asynchronous
intervention with minimal therapist check-ins.21 Although
these studies show promise regarding the use of online
counseling with adolescents and young adults, there is a
clear need for studies with random assignment, control
group and synchronous delivery to establish similarity
between effectiveness of online versus in-person counseling
for anxiety in the college population.
Solution-focused brief therapy
Most research in anxiety treatment focuses on CBT, applied
relaxation, exposure and response prevention, cognitive
processing therapy, and stress inoculation training.22
However, researchers in college counseling center settings
have started evaluating other types of interventions in search
of brief, effective treatment methods.23 Although research
exists supporting the efficacy of SFBT, a gap exists in the lit-
erature on the efficacy of solution-focused brief therapy
(SFBT) for college students with anxiety as well as its appli-
cation in online settings.
Research evidence supports SFBT’s effectiveness in the
general population. In 2006, Stams, Dekovic, Buist, and De
Vries reviewed 21 studies and found that SFBT had a small
to medium effect on reported outcomes (similar to other
approaches, like CBT).24 Kim and Franklin (2009) con-
ducted a review of seven SFBT studies in the American
school system and found modest but positive effect sizes,
averaging .50.25 Gingerich and Peterson’s (2013) systematic
qualitative review of 43 SFBT studies found significant posi-
tive outcomes for 65% of dissertation studies and 81% of
non-dissertation studies.26 In terms of anxiety treatment,
research from Helsinki on 326 outpatients with mood or
anxiety disorders showed SFBT was efficacious in providing
a rapid reduction in anxiety symptoms and maintaining the
impact for a year after treatment.27
Given the brief and effective nature of SFBT, it could be
an ideal treatment modality for the college setting,28 where
the mean number of sessions nationally is 4.71, and the
mode is one.29 Research on SFBT supports the claim that
fewer sessions are sufficient for the improvement of symp-
toms.30 However, devoid of evidence based on randomized
controlled studies supporting the efficacy of SFBT specific-
ally in college counseling centers, use of this treatment
modality is unlikely.
Study purpose
In response to the aforementioned needs, we designed the
present non-inferiority study to examine the efficacy of

using SFBT in online counseling for mild to moderate anx-
iety in comparison with in-person SFBT among undergradu-
ate students at a university in Northeast United States. The
following research questions guided the study:
1. Will SFBT reduce symptoms of mild to moderate anx-
iety in emerging adults at college, as measured by the
Beck Anxiety Inventory (BAI) at three time points (pre-
test, posttest, and 3-week follow-up)?
2. Will online counseling using SFBT reduce symptoms of
mild to moderate anxiety in emerging adults at college
as much as in-person counseling using SFBT, as meas-
ured by the BAI?
3. Will online counseling using SFBT reduce symptoms of
mild to moderate anxiety in emerging adults at college
as much as in-person counseling using SFBT, as meas-
ured by the anxiety subscales of the Counseling Center
Assessment of Psychological Symptoms (CCAPS-62)?
Methods
Participants
Fifty two undergraduate students at a private, Catholic uni-
versity in the northeast United States were recruited; 49
remained in the study due to self-attrition. Four participants
identified as male and 45 as female. Total participant ethni-
city is as follows: 5 identified as African American, 2 as
Asian American, 4 as Latinx, and 38 as White. Twenty-five
indicated having previously received some kind of counsel-
ing while 24 had not. There were 20 first-year students, 10
sophomores, 11 juniors, and 8 seniors with ages ranged
from 18 to 22 (M ¼ 19.29, SD ¼ 1.2).
Treatment
The treatment was provided by two counselors from the
counseling center and involved three sessions, after an initial
screening. We offered a 3-session treatment because (a) the
average number of sessions attended by student clients in
this counseling center is three and (b) SFBT is most effective
in the 3- to 5-session range.31 These two counselors imple-
mented the SFBT treatment protocol developed based on
the literature.32 One of them was the first author, a licensed
professional counselor; the other counselor was a licensed
clinical social worker. Both have over 20 years of experience
in college counseling and were considered similar in experi-
ence and training. In order to limit researcher bias with the
first author, all research participants were given an I.D.#
and completed all inventories using this number. The
administrative assistant in the counseling center retained the
record connecting all I.D.#’s with participant names, and
the first author was blind to this information throughout
the entire study.
The second author has more than 20 years of experience
training and using SFBT and provided a 2-day intensive
SFBT training for all the counselors in this center in fall
2016. He continued to provide Web-based supervision for
JOURNAL OF AMERICAN COLLEGE HEALTH 1163
the two treatment providers during spring 2017 and
throughout the period of the study in November 2017
through December 2018 to ensure the providers maintained
an SFBT orientation.
Procedure
Participant recruitment began upon institutional review
board approval of the study protocol. We distributed
recruitment flyers in residence halls, high-traffic areas on
campus, and through global e-mails to undergraduates and
faculty. The majority of participants (60%) were students
who came for an initial screening appointment with the
counseling center and were recruited by the intake screening
counselors at the center. The research team members were
not involved in the screening of participants, in order not to
influence this decision. No students who were currently
receiving regular, in-person counseling at this counseling
center were allowed to participate in the study. A power
analysis was conducted indicating that 20 participants per
condition would be necessary to detect a medium effect
with a significance level of .05.
Students filled out the intake forms through the Titanium
system that included the CCAPS-62. The screening counse-
lors reviewed the symptom checklists before meeting with
the students to determine initial qualification. The intake
screening involved conducting a brief clinical interview and
making final determination of eligibility to participate in the
study. The screeners did not begin the counseling process or
a therapeutic relationship at this point. The screeners
described the study and reviewed the written informed con-
sent with students who met the study criteria described
below. Participation was voluntary. Those who were not
interested or did not qualify for the study were scheduled
for follow-up counseling in accordance with the center’s
established procedures. These initial screening appointments
were similar for all participants.
Inclusion criteria were based on scores on the anxiety
subscales of the CCAPS-62.33 The range of scores for inclu-
sion was between 40 and 90 for generalized anxiety and 50
and 95 for social anxiety, based on cutoff scores for mild
anxiety on the low end and more extreme clinical anxiety
on the high end. Scores below the minimal cutoff indicate a
subclinical anxiety issue, while scores above the upper cutoff
indicate a possible need for more intensive services.
Exclusion criteria further included scores above 80 on the
substance use subscale, given the impact of substances on
anxiety symptoms and possible need for substance use treat-
ment. These students were then referred to the alcohol/drug
counselor for further evaluation. Students who responded to
the item “I have thoughts of ending my life” with very much
like me or extremely like me were also excluded. They were
immediately seen by other counselors at the center for risk
assessment and treatment. Students taking psychotropic
medications were included as long as their symptoms indi-
cated an appropriate level of anxiety per the protocol at pre-
test. No students initiated the use of anxiety medication
during the study period.
1164 J. K. NOVELLA ET AL.
The center’s administrative assistant scheduled future
appointments with participants and used a six-sided die to
randomly assign them to the online or in-person counseling.
She also assigned them to one of the participating counse-
lors based on scheduling and a general balance of sessions
between counselors. Both counselors ran in-person and
online sessions, and participants could not choose the coun-
selor or delivery method. Twenty-nine were randomly
assigned to the in-person group and 23 to the online group;
after attrition, this resulted in 25 females, 1 male in in-person
group, and 20 females, 3 males in online group. Each partici-
pant was given an identification (ID) number to facilitate
anonymous data collection. Only the administrative assistant
had access to the names and ID numbers of participants. She
maintained this information in confidence.
All participants receiving online counseling were given
instructions on (a) how to access the online platform,
Doxy.me; (b) use of audio and video components with the
device they were using; and (c) how to upload documents.
The administrative assistant provided these instructions on
an appointment card to participants when they were ran-
domly assigned to the online treatment group. Online partici-
pants were given a technology check appointment to allow
them and their counselors to test the audio and video before
they started their first session together. Further, counselors
emailed online participants an additional informed consent
document specific to online counseling to ensure participants
understood the components of the online system and were
informed of all issues specific to this delivery method before
beginning counseling, particularly in relation to online secur-
ity and ethical codes for distance counseling.34 This was
reviewed during the technology-check appointment.
Participants completed the BAI36 during the screening
(pretest), after the 3rd session (posttest), and at the 3-week
follow-up. The BAI was given through a website to partici-
pants in both treatment groups. The pretest BAI was taken
on an iPad after the screening appointment in which it was
determined if the student would be participating in the
study. At posttest, the in-person participants took the BAI
on an iPad at the center before they left their 3rd session.
For the online participants, the counselors emailed the BAI
survey link to them at the end of their 3rd session. They were
told to complete it immediately following the session. For fol-
low-ups, all participants were e-mailed the BAI website link
three weeks after the 3rd session and asked to complete it as
soon as possible. The CCAPS-34, which served as the follow-
up measure of the CCAPS-62 to assess treatment response,
was sent to all participants at follow-up, three weeks post-
treatment. The results were collected with the Titanium
system that computes reliable change indices (RCIs) for deter-
mining clinically significant change in clients.
As part of the SFBT protocol, participants were given a
feedback sheet completed by their counselor at the end of
each session. In-person participants received their feedback
before leaving the session. For online participants, two varia-
tions on feedback were used. The client and counselor could
remain on Doxy.me but take a 5-minute break in order for
the counselor to fill out the feedback form. This form was
reviewed online and then emailed to the client. Otherwise,
the counselor and client would exit Doxy.me, and the feed-
back form would be emailed to the participants immediately
following the session. This variability was due to the option
of e-mailing feedback with online participants. Researchers
ensured all aspects of in-person sessions were in-person,
including feedback. Time spent in counseling was compar-
able in the two groups (45-55 minutes).
Treatment fidelity was assessed by the second author and
another counselor who participated in the initial SFBT train-
ing with the treatment team. These two fidelity assessors
reviewed audio recordings of all 1st sessions and 10 ran-
domly selected subsequent sessions. All initial sessions,
whether in-person or through Doxy.me, were recorded for
the purposes of evaluating treatment fidelity. Because
Doxy.me does not allow for recording to ensure HIPAA
security, we recorded the sessions externally through an
audio digital recorder. All recordings were deleted upon
completion of the fidelity check. We developed two
adherence checklists—1st session and follow-up—to facilitate
the process. They were developed based on guidelines
recommended by the Solution Focused Brief Therapy
Association (2013).
Measures
Counseling center assessment of psychological symptoms-
62 (CCAPS-62)
The CCAPS-6238 was first released in June 2009 and
updated in 2012. It has 62 items with eight distinct subscales
of psychological symptoms for college students. It also indi-
cates the distress level through an index. Through factor
analysis, eight subscales emerged: (a) Depression (13 items),
(b) Generalized Anxiety (9 items), (c) Social Anxiety (7
items), (d) Academic Distress (5 items), (e) Eating Concerns
(9 items), (f) Family Distress (6 items), (g) Hostility (7
items), and (h) Substance Use (6 items). The present study
used the generalized anxiety and social anxiety subscales to
screen participant eligibility and outcomes. “I feel tense” is
an item in Generalized Anxiety. “I am concerned that other
people do not like me” is an item in Social Anxiety. The
Likert scale of responses range from “not at all like me (0)”
to “extremely like me (4).” Clinicians find the range of items
under each subscale clinically useful during initial assess-
ment and at termination to assess treatment effects.33
Test–retest reliability for the Generalized Anxiety subscale
is .782 after one week and .842 for a 2-week period; the
CCAPS has reliability coefficients greater than .75 for the
various identity groups (gender, race/ethnicity, and country
of origin) and is reported to be valid for diverse groups.33
McAleavey et al. (2012) provided evidence to support the
measure’s convergent validity with other established meas-
ures of psychological symptoms in the clinical population.35
Beck anxiety inventory (BAI)
The BAI42 was used to assess levels of clinical anxiety at
pretest, posttest, and follow-up. It is a 21-question, multiple-

Table 1. Descriptive statistics for beck anxiety inventory at three time points.
Method of Delivery M SD
BAI pre In-person 17.14 10.47
Online 15.64 6.49
Total 16.54 9.01
BAI post In-person 8.52 6.48
Online 8.71 6.27
Total 8.6 6.31
BAI follow-up In-person 9.38 9.10
Online 7.28 7.21
Total 8.54 8.35
choice, self-report inventory that asks the participants to
rate symptoms of anxiety during the last week from 0 ¼ not
at all to 3 ¼ severely. Examples of items include somatic
symptoms, like “feeling hot,” and cognitive symptoms, like
“fear of losing control” or “fear of worst happening.”
Evidence of reliability for the BAI is indicated by an aggre-
gated internal consistency of .91 and test–retest reliability of
.65.36 Evidence of validity for the BAI is indicated by robust
external validity scores with 33 other discrete anxiety-related
inventories.36 Internal consistency of the BAI for the current
study was .867.
Apparatus
The Doxy.me software platform was used to provide syn-
chronous Web delivery of SFBT for participants in our
study. Doxy.me allows for synchronous video and audio
communication and the ability to share documents and con-
duct screenshares. It is HIPAA secure for the delivery of
health-related information online and free of charge.
Participants assigned to the online treatment group were
instructed to use a computer or any mobile device that was
compatible with the system but did not have to download
software to access the platform. When participants clicked
on a URL provided by researcher, they were placed in a
waiting room for the counselor to be “admitted” to the syn-
chronous platform or “room”. Once the counselor had
admitted a participant into the synchronous room, the par-
ticipant and counselor could view and hear each other in
real time.
Results
We used a repeated measures ANOVA to address Research
Question 1: Will SFBT reduce symptoms of mild to moder-
ate anxiety in emerging adults at college, as measured by the
Beck Anxiety Inventory (BAI) at three time points (pretest,
posttest, and 3-week follow-up)?; and 2: Will online counsel-
ing using SFBT reduce symptoms of mild to moderate anx-
iety in emerging adults at college as much as in-person
counseling using SFBT, as measured by the BAI?
Only those BAIs that were 90% or more complete were
used in the analysis (n ¼ 39). Missing data on the BAI were
replaced using the mean of the completed items. Frequency
distributions were examined prior to proceeding with analy-
ses. Scores on the BAI were plotted for each participant
group for each session and differences between groups were
JOURNAL OF AMERICAN COLLEGE HEALTH 1165
Table 2. Repeated-measures ANOVA: Difference scores on beck anxiety
N inventory for two delivery methods at three time points.
21 df SS MS F p gp2
14 Within Subjects 3, 99 1091.26 1091.26 13.556 .001
.001
35 Between subjects 1, 33 32.46 32.46 0.313 .580 .009
21
p < .01.
14
35
21 evaluated using p < .05. To determine whether there were
14
35 differences in the two clinicians providing therapy, a
repeated-measures, mixed ANOVA was run. For Research
Question 3, the CCAPS raw scores for the two qualifying
subscales (Generalized Anxiety and Social Anxiety) were
computed, and t tests were run to compare scores in online
delivery to those in in-person delivery. Finally, the Reliable
Change Indices (RCIs)37 on the same subscales of the
CCAPs were counted, and a chi square was used to deter-
mine how well the observed distribution of data fit with the
expected distribution if the variables were independent.
The means and standard deviations of the study variables
are presented in Table 1. Results of a repeated-measures
ANOVA showed that BAI scores in posttest and follow-up
were significantly lower than those in pretest, indicating that
SFBT was effective for the treatment of mild to moderate
anxiety in college students, F(1, 33) ¼ 13.556, p ¼ .001, gp1
¼ .001 (see Table 2). The goal of determining the effect of
SFBT over three measurement points for the two groups
(online and in-person) was realized by conducting a
repeated-measures ANOVA. This analysis was performed to
compare scores on the BAI at pretest, posttest, and 3-week
follow-up in the experimental group (online) compared to
the treatment-as-usual group (in-person). The results
showed a lack of statistical significance in the difference on
BAI scores between the two delivery systems, F(1, 33) ¼
.313, p ¼ .580, gp1 ¼ .009 (see Table 2 and Figure 1).
Mauchley’s test of sphericity was significant, so the
Greenhouse-Geiser was used, F(1, 33) ¼ .260, p ¼ .667. The
effect size for an ANOVA with this sample size was
medium, f ¼ .25.
Given that this is a non-inferiority study, the conven-
tional method in clinical trials of answering the question of
“equivalent” treatment was used. The null hypothesis that
treatment-as-usual (in-person) would be superior to the
experimental treatment (online) in terms of effectiveness
(BAI) would be rejected if, and only if, the upper limit of
the confidence interval (because lower scores are better with
the BAI) divided by the mean of the treatment-as-usual
group were less than .2.38 For the mean on the BAI at post-
treatment (3rd session), this value was .03. For the mean at
follow-up (3 weeks following treatment), this value was .03.
Therefore, the null could be rejected, and there was statis-
tical evidence for non-inferiority for online counseling com-
pared to treatment-as-usual (in-person) in terms of results
on the BAI.
We ran a repeated-measures mixed ANOVA to examine
the three measurement points for the two independent vari-
able groups (online and in-person), which also considered
the impact of the two clinicians. There was no statistically
significant difference effect for the two clinicians or the two
delivery systems, F(2, 30) ¼ 1.387, p ¼ .265, and gp1 ¼ .32.
1166 J. K. NOVELLA ET AL.
Figure 1. Beck anxiety inventory means at pretest, posttest, and follow-up.
Mauchley’s test of sphericity was significant, so the
Greenhouse-Geiser was used, F(2, 30) ¼ 1.587, p ¼ .219.
The effect size for the ANOVA with this size sample was
medium, f ¼ .25.
The CCAPS was used as an additional indicator of effect-
iveness. It was given twice, at pretest (CCAPS-62) and at fol-
low-up (CCAPS-34). We ran t test comparisons of means
for scores from pretest to follow-up for the two groups
(online and in-person) to determine if SFBT was effective.
The change scores were evaluated for the Generalized
Anxiety subscale separately from the Social Anxiety subscale
because the CCAPS provides no overall anxiety score, and
participants could qualify for the study based on either or
both scores. The independent-samples Welch’s t test showed
there was no significant difference in change scores on the
Social Anxiety subscale for in-person (M ¼ 4.312,
SD ¼ 4.14) versus online delivery (M ¼ 2.666, SD ¼ 3.80),
t(27) ¼ 1.161, p ¼ .291. Another Welch’s t test showed
there also was no significant difference in change scores on
the Generalized Anxiety subscale for in-person (M ¼ 7.29,
SD ¼ 6.71) versus online delivery (M ¼ 6.38, SD ¼ 4.79),
t(39) ¼ .222, p ¼ .640.
Jacobson and Truax (1991) developed the concept of clin-
ically significant change to define effectiveness across treat-
ments.37 This led to the RCI, which is used in the CCAPS
to indicate to the counselor the clinical change in a client
over time. The RCI for the two qualifying subscales for this
study were computed and a chi-square goodness of fit test
was run to determine how well the distribution of RCIs in
the online counseling group fit with the distribution of RCIs
in the treatment-as-usual (in-person) group. Results showed
no significant deviation from the hypothesized values,
v2(1)¼.702, p¼.402.
Comment
This was a non-inferiority study that examined the effective-
ness of SFBT for mild to moderate anxiety in undergraduate
students and compared that effectiveness between two deliv-
ery methods (online and in-person) using the BAI and the
CCAPS anxiety subscale scores. The results support the
non-inferiority of the experimental online delivery system as
well as the overall success of using SFBT for mild to moder-
ate anxiety in the study sample. Findings in this study add
to extant research on SFBT effectiveness26 and efficacy of
online counseling for anxiety.14 The use of two measures to
evaluate anxiety symptomology added to the strength of
our results.
The BAI focuses largely on physical sensations related to
anxiety, while the CCAPS covers additional behavioral indi-
cators. Mean BAI scores declined by 50% between first and
third session. For online participants, scores on the BAI
continued to decline, showing fewer anxiety symptoms for
up to three weeks post-treatment. In-person participants had
a slight increase in anxiety symptoms, although the mean
still remained 46% below pretest scores. This slight increase
in follow-up scores for in-person participants may suggest
that discontinuing counseling has a different impact on cli-
ents who were in an office compared to those meeting
online. A randomized controlled study with a larger diverse
sample could clarify this effect, as well as qualitative studies
looking at clients’ reactions to the termination of therapy.
Examining termination differences for the two delivery
methods and comparing them for various client issues may
inform future treatment as well.
On the CCAPS-34, we looked at two aspects of the sub-
scale scores for Generalized Anxiety and Social Anxiety.
Resulting t tests showed no significance for the difference in
these scores between the two groups of participants. The
chi-square test of the RCIs looking at RCI differences
between the two groups further supported the equivalency
of both delivery methods.
Though the overall number of participants was small, the
random assignment to delivery method as well as the
repeated testing of measures added to the strength of this
study. Our findings indicate that, at least in the emerging
adult population, clients can benefit from brief online

counseling, even if they do not necessarily select that deliv-
ery method. Because many of the concerns about online
delivery arise from feelings of comfort in both the client and
the counselor,39 our findings support this approach among
college-aged students, particularly in regard to treatment for
mild to moderate anxiety. Findings also support the equiva-
lency of using in-person or online delivery methods
for SFBT.
Limitations
There are limitations to this study. Although there was ran-
dom assignment of participants, the overall sample size was
small (N ¼ 49). The low number of participants made the
determination of effect size using t tests difficult. Also, the
participants were all students at one private, Catholic uni-
versity in the Northeast of the country, and they were not
diverse in terms of race, ethnicity, and gender identity. This
lack of diversity makes it challenging to make larger general-
izations to students nationally (or internationally) and to
those from more diverse backgrounds. The small number of
male participants (n ¼ 4) in the study makes it difficult to
generalize the study findings to all students, and this was
not controlled for in the analysis due to the low numbers.
Researchers could replicate the present study at large univer-
sities in different parts of this country or others to further
investigate the non-inferiority aspect of online counseling
and examine gender differences. We also recommend that
researchers conduct qualitative studies to give voice to stu-
dent reactions to and experience with brief online counsel-
ing. More information on students’ and counselors’ attitudes
toward and experience with brief online counseling would
inform such practice.
The first author decided to participate in the study after
consultation with other researchers at the institution and the
Institutional Review Board (IRB). However, none of the
researchers, including the first author, participated in
screening possible participants in order to not unduly influ-
ence this decision. Although the steps outlined in the pro-
cedure section were taken to limit bias, this participation
constitutes a limitation of the study.
Although a 3-week follow-up was conducted, future stud-
ies should consider a longer follow-up timeframe to evaluate
long-term benefits of brief counseling both in-person and
online. Also, it may be useful to examine if there is differ-
ence in treatment effect on the number of sessions of SFBT,
such as three sessions compared to six.
Additionally, given that this was a “real world” counsel-
ing center setting rather than a laboratory, there are real-
world variations in counseling styles and other details
regarding protocol that were difficult to control. For
instance, with some online participants, the feedback sheet
was e-mailed to them after the session ended; with others, a
break was taken, with both client and counselor remaining
online and then reviewing the feedback together. In add-
ition, some sessions were shorter than others, depending on
the counselor and other contextual variables. This variability
in session length was not specific to online or in-person
JOURNAL OF AMERICAN COLLEGE HEALTH 1167
sessions. Issues like clients showing up for an appointment
late or needing to find a private space for a session caused
some variability. Given that it was not a factor of one deliv-
ery system alone, this was a minor limitation; however, a
laboratory setting result would help to control for some of
these factors. Finally, participants who came to the counsel-
ing center for an initial in-person screening were offered
participation in the study (60% of participants); therefore,
the question of students who do not come for in-person
counseling being willing to access support if offered online
needs further study.
Non-inferiority studies are challenging and are typically
undertaken with clinical medical trials to determine if one
treatment is “as good as” the standard treatment. Increasing
the number of participants and diversifying the population
of participants in future studies should improve the general-
izability of these non-inferiority results.
Conclusions
In sum, notwithstanding its limitations, we believe our study
has added to the growing body of knowledge on online
counseling practice using SFBT for the treatment of anxiety
in a college counseling center.
Acknowledgments
The authors acknowledge the invaluable contribution of Janice Kessler,
LCSW who was the second clinician to provide SFBT in this study.
She contributed hours of her time to be trained and supervised in this
mode of therapy and online counseling. We also acknowledge the work
of Will Miller, student at Oregon State University who provided a sig-
nificant portion of the fidelity assessment.
Conflict of interest disclosure
The authors have no conflicts of interest to report. The authors con-
firm that the research presented in this article met the ethical guide-
lines, including adherence to the legal requirements, of the United
States and received approval from the IRB of Sacred Heart University.
Funding
No funding was used to support this research and/or the preparation
of the manuscript.
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