Acuity, Diagnosis, and Community Factors in Virtual and In-Person Treatment: A Qualitative Exploration (Preprint)

BACKGROUND The COVID-19 pandemic accelerated the adoption of virtual psychotherapy, making it a vital tool for maintaining continuity of care. While virtual sessions offer flexibility and accessibility, they also raise concerns about the quality of therapeutic relationships, the sense of community, and the ability to support clients with higher levels of clinical need. OBJECTIVE This study sought to examine how mediums of care (i.e., virtual versus 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, and 2) How acuity and diagnosis influence the perception of effectiveness and safety of these mediums. METHODS 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 (i.e., attendance, engagement, therapeutic alliance) across the two modes of care (i.e., virtual versus in-person). A total of six structured focus groups were conducted. Thematic analysis was conducted to analyze the transcripts, until theoretical saturation was achieved. RESULTS 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. The present study uncovered, from the perspective of client and clinician, that in-person treatment fosters significantly more engagement and interpersonal connection (i.e., therapeutic alliance, 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. CONCLUSIONS This results of this study outline how medium of care (i.e., virtual versus in-person) impact 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 significantly affected by medium of care, and key factors such as clinical presentation (i.e., acuity, diagnosis) must be accounted for when choosing a particular mode of care for a client.