Introduction
Virtual psychotherapy expanded rapidly during the COVID-19 pandemic and continues to offer flexibility, convenience, and access to care for many clients, including those balancing demanding schedules or facing barriers to in-person treatment. At the same time, questions remain about what may be lost when care moves online, particularly in higher-acuity settings where community connection, nonverbal communication, and close clinical monitoring are central to treatment. This qualitative study explored how young adult clients and clinicians experience virtual versus in-person care, with particular attention to therapeutic community, clinical presentation, and the use of clinical skills across treatment modalities.
Summary of Findings
Across six semi-structured focus groups with clients (n=14) and clinical staff (n=18), three major themes emerged.
Community: In-person treatment was consistently described as more effective for fostering connection, accountability, and therapeutic rapport. Clients and clinicians emphasized the value of shared physical space, spontaneous interactions before and after sessions, and access to body language and other nonverbal cues. While virtual care offered continuity and flexibility, it was more often associated with distraction, reduced engagement, and fewer opportunities for organic peer connection.
Clinical Presentation: Participants reported that in-person care allowed for a fuller understanding of how clients were functioning day to day. Clinicians described greater difficulty in virtual settings assessing acuity, noticing hygiene or behavioral changes, and identifying signs of avoidance, distress, or symptom escalation. In-person treatment was viewed as especially important for clients with higher-acuity presentations, including eating disorders, substance use, psychotic symptoms, and conditions where avoidance is a central feature.Use of Clinical Skills: Clinicians reported that virtual care made it harder to engage clients, build rapport, and respond in real time to subtle shifts in affect or behavior. Limited visibility into posture, fidgeting, and environmental context reduced their ability to fully read the room and apply clinical judgment. These limitations were described as particularly relevant for emotionally intensive modalities, such as EMDR, where in-person care was often seen as the preferred setting.
