Acuity, Diagnosis, and Community Factors in Virtual and In-Person Treatment: Qualitative Study

The COVID-19 pandemic accelerated the adoption of virtual psychotherapy, making videoconferencing a vital tool for maintaining continuity of care. While virtual sessions offer flexibility and accessibility, concern has also been raised about the impact of virtual care on therapeutic relationships, a sense of community, and the ability to support clients with higher levels of clinical need.

This study sought to examine how mediums of care (ie, virtual vs in-person) impact the therapeutic experience for clients and providers in critical domains such as community, clinical presentation, and clinicians' use of clinical skills. The following themes were evaluated: (1) How therapeutic relationships and community dynamics differ across virtual and in-person mediums of mental health care? (2) How acuity and diagnosis influence the perception of effectiveness and safety of these mediums?

This study is a grounded theory design. Participants were intensive outpatient mental health clients and clinicians. Participants were interviewed in focus groups of either 6-8 clinicians or clients, assessing for important themes (ie, attendance, engagement, and therapeutic alliance) across the 2 modes of care (ie, virtual vs in-person). A total of 6 structured focus groups were conducted. Thematic analysis was conducted to analyze the transcripts until theoretical saturation was achieved.

Results highlighted the nuanced differences in client and clinician perceptions of relational dynamics and effectiveness of care in virtual versus in-person mental health care. This study revealed, the perspectives of the client and clinician, that in-person treatment fosters more engagement and interpersonal connection (ie, therapeutic alliance and peer-to-peer) than virtual settings. Additionally, in-person care better supports the ability to exercise important clinical skills, especially for highly acuity clients with complex diagnoses.

The results of this study outline how the medium of care (ie, virtual vs in-person) impacts therapeutic experience from the perspective of both client and clinician. It is understood that critical domains such as community, interpersonal relationships, and clinicians' use of clinical skills are affected by the medium of care, and key factors such as clinical presentation (ie, acuity and diagnosis) must be accounted for when choosing a particular mode of care for a client.