A Qualitative Description Study of the Patient's Experience With Community-Based Virtual Crisis Care in Canada: Illustrating the Potential Positives and Negatives of Remote Support on Recovery

Abstract

The study's objective is to describe how individuals accessing a virtual crisis stabilization program following discharge from an emergency mental health visit perceived the service as either facilitating or hindering recovery. Interested service users were identified through feedback surveys and contacted for an interview. Demographic and service utilization variables were obtained from the survey data. Interview data were analyzed thematically using an inductive approach focused on exploring perspectives related to recovery. Twenty-one participants were interviewed; one with a support person. Four recovery thematic categories were identified: (1) connection to others is possible or lacking; (2) access to care providers/therapeutic relationship; (3) ability to remain at home; and (4) virtual service provision. Each category generated subthemes that demonstrated both positive and negative impacts of the virtual service. Lived experience highlights typical aspects of crisis intervention, as well as unique themes related to the home environment and virtual care option. It is important to identify these contextual factors when determining if virtual care is right for an individual. Some areas for service improvement were also highlighted.

Introduction

The United States's National Alliance on Mental Illness defines a mental health crisis as “any situation in which a person's behavior puts them at risk of hurting themselves or others and/or prevents them from being able to care for themselves or function effectively in the community.” ¹ Often this represents a phase in the cyclical nature of mental illness; the crisis occurs, the individual deteriorates from baseline, followed by crisis intervention and recovery, and return to baseline. ² Common precipitants include trauma, stressful life events, and social withdrawal or exclusion. ³ The crisis intervention phase is critical to prevent loss of functioning and support recovery back to baseline. ² Individuals in crisis often present at emergency departments (EDs) with self-harm, suicidal ideation or attempt, depression, and psychosis.^4,5 Furthermore, this crisis presentation is frequently the first point of contact with mental health services. ⁶

Hospital admission has historically been the first-line management strategy for individuals experiencing acute psychiatric deterioration.^2,7 Hospital care has the benefit of close monitoring, psychiatric evaluation, medication access, and mitigation of risk behaviours, ⁴ with potential harms such as violence or harassment from co-patients, privacy breaches, stigmatization, social isolation, and boredom.^4,8,9 Furthermore, the experience of compulsory institutionalization can be traumatic for service users and represents a frequently cited fear and care-seeking barrier.^10,11 While inpatient services continue to be vital, ⁴ it is not ideal for every patient, and is not always necessary for successful crisis management in certain cases. ⁹

Alternatives to inpatient admission include crisis resolution teams (CRTs), partial hospitalization programs, low-acuity community residential alternatives, and various community services.^4,9,12,13 In recent years, virtual crisis management, where a team offers remote support via virtual communication tools, has increasingly become an option.^14,15 Some identified challenges include privacy and security factors, concerns over the therapeutic relationship, and technological barriers. ¹⁶ However, the virtual modality offers many benefits that make it a desirable option, including convenience and comfort,^16,17 as well as reducing possible stigmatization that is associated with inpatient services. ¹⁸

Crisis stabilization is a complex and dynamic process that is different for every individual.^19,20 The different types of crisis management services each have the potential to facilitate or impede recovery, ⁴ and thus an understanding of how and when each type of crisis service impacts recovery is essential. As they are newer, there has been little research investigating how virtual crisis services impact this process. This study aimed to describe how patients who received care at a virtual crisis stabilization unit (CSU) and their support persons perceived the impact of the virtual program on recovery, and specific characteristics of the service that impeded or facilitated the journey. The study findings can inform how this modality of support fits within the spectrum of crisis management services.

Methods

Study Design and Setting

We carried out a qualitative description study of patients’ experience with a virtual form of the CSU in a large urban center in central Canada. Qualitative descriptive methodology ²¹ is common in healthcare research and is especially appropriate for describing participants’ experiences and perceptions.^22,23 While qualitative description does not subscribe to a particular theoretical orientation, it is guided by certain basic assumptions, most notably that reality is subjective, data are analyzed inductively, and an emic stance is adopted by researchers. ²⁴ Research ethics for this study was obtained from the Health Research Ethics Board (HS25298(H2021:435)).

The CSU is a subacute voluntary in-person unit that supports individuals in crisis who do not require hospitalization. In 2020, the CSU launched a virtual alternative (vCSU) in response to the COVID-19 restrictions, which has since remained open and expanded. ¹⁴ Individuals are referred from all EDs and urgent care centers in the city, including a 24-hour walk-in mental health crisis center. At both the CSU and the vCSU, service users have access to a multidisciplinary team of mental health professionals, as well as group psychoeducation sessions, psychiatric consultation, medication support, and connection to community mental health and addiction resources. ¹⁴ The vCSU operates 7 days a week during daytime hours through a combination of virtual means including telephone, video-conferencing, and email or SMS communication. After-hours support is available through an affiliated crisis helpline.

Data Collection

All individuals who were admitted to the vCSU or CSU between March 2022 and May 2023 were invited following discharge to complete a web-based survey on their experience. The survey was accessible via an email sent by the clinical team or via a link/QR code posted on the in-person unit. The survey collected demographic data on prior crisis admissions (in-person or virtual), age, gender, and ethnicity and contained questions relating to satisfaction with the service they utilized.

The research team contacted willing survey respondents who had any contact with the virtual program to be interviewed. Those who agreed were contacted to obtain informed consent. Interviewees had the option of being interviewed with a support person of their choice who provided further insight into the patient's experience. Interviews were conducted virtually over Zoom or telephone, and utilized a semistructured interview guide consisting of questions which explored personal experiences of receiving crisis care virtually (see Figure 1). Interviewees received a $25 e-gift card for participating.

Figure 1.

Sequence of interview topics.

All interviews were audio recorded using Zoom or a hand-held, digital voice recorder. The audio files were transcribed verbatim from an outside transcription service. The verified and deidentified transcripts were uploaded to NVivo 12.

Data Analysis

Demographic data collected in the survey were analyzed descriptively. The researchers employed thematic analysis for the interview data to generate a qualitative account of the data that was nuanced and in-depth. ²⁵ To further qualify and understand the sample, indicators for additional interviewee characteristics were derived from the interview data including reason(s) for coming to care, employment status, relationship status, living situation, and parental status. The qualitative analysis process began with 2 researchers (A1 and A5) independently coding the first 5 transcripts and meeting to compare initial themes. After reaching agreement, a codebook was generated and shared to guide the coding of subsequent transcripts. The remainder of the transcripts were then split between the 2 coders who continued to meet periodically to discuss themes and definitions and the codebook was revised and updated as needed. After the analysis of 10 transcripts, theoretical sampling, the selection of participants based on certain characteristics, was employed in an effort to fully develop emergent themes. ²⁶ Recruitment of participants continued until it was determined that theoretical saturation was reached as no new themes were emerging from the data ²⁷ and the benchmark average of 12 to 13 interviews for achieving saturation was surpassed. ²⁸ Once the codebook was finalized, the research team reviewed to consolidate the codes into categories aligned with broader themes related to recovery in the context of virtual crisis intervention. Throughout, the researchers exercised reflexivity by engaging in memo writing in an effort to identify subjectivity in order to clarify researcher bias and its influence on data interpretation. ²⁹

Results

This study aimed to describe the ways in which the vCSU impacted patient recovery. Twenty-six survey respondents agreed to be contacted for an interview. From those, 21 agreed to participate in interviews. One of the 21 interviews included a support person. Interviews ranged from 23 to 89 min in duration.

Participants’ Characteristics

Demographic and service utilization variables of service users are summarized in Table 1. There were high rates of prior crisis service use, with a third or more having in-person CSU admissions or psychiatric hospital admissions. The average age was 38.2 years, and the majority of participants identified as a woman (76.2%) and of white ethnicity (85.7%). The most common reason for coming to care was worsening symptoms, followed by experiencing a stressful life event or trauma. Most commonly, participants were employed or enrolled in school, and living alone with no children.

Table 1.

Characteristics of Interview Participants, N = 21.

Characteristics	n (%)
Previous crisis admissions, n (%)
None	9 (42.9)
In-person CSU admission	7 (33.3)
Psychiatric hospital admission	8 (38.1)
Average age, mean (SD)	38.2 (10.1)
Gender, n (%)
Man	3 (14.3)
Woman	16 (76.2)
Other/Prefer not to say	2 (9.6)
Ethnicity, n (%) a
White	18 (85.7)
Other	5 (23.8)
Reason for coming to care, n (%) a
Worsening symptoms	17 (81.0)
Life event or trauma	15 (71.4)
Unable to cope	13 (61.9)
Suicide or self-harm	12 (57.1)
Seeking advice or support	4 (19.0)
Employment status, n (%)
Working/attending school	8 (38.1)
Unemployed/on leave	5 (23.8)
Unknown b	8 (38.1)
Living situation, n (%)
Alone	5 (23.8)
With family (inclusive of partner, parents, siblings, and possibly children)	8 (38.0)
Homeless	1 (4.8)
Unknown b	7 (33.3)
Parental status, n (%)
Has children in their custody	6 (28.6)
No children in their custody	8 (38.1)
Unknown b	7 (33.3)

Note. ^a Categories are not mutually exclusive.

^b

Not explicitly mentioned in the interview.

Four thematic categories related to the impact that the virtual program had on crisis resolution and recovery were created, each with subthemes. These were Connection to others is possible or lacking; Access to care and building therapeutic relationships; Ability to remain at home; and Virtual service provision (see Table 2).

Table 2.

Themes Relating to Crisis Resolution and Recovery, Separated Into Those Being a Facilitator and Those That Were a Potential Barrier.

Category	Theme	Subtheme	Description	Quotes
Connection to others is possible or lacking
Facilitators to recovery
	Connection to others through group sessions		Virtual group sessions (when available) add support and connection with others	“Because you get the connection of like, oh, yeah, there are other people in this virtual program, right? There are other people who are at home in a bad place just like I am.” (P. 4)
	Involvement of natural supports		Encourages involvement of natural supports with real time professional guidance	“They reached out to my secondary contacts to make sure that I was OK and still wanted to engage, so pulling in that support system.” (P. 8)
	Access to regular care providers and prescribers		Access to regular community-based prescribers and other professional supports for continuity paired with access to program specialists if needed (for assessment/review) OR bridges absences of regular providers	“I had my own doctor who I was also in communication with him about my medication…” (P. 8)
Barriers to recovery
	Feeling disconnected from others in group sessions		Virtual group sessions were perceived negatively (ie, impersonal or potentially judgmental) by the patient	“I really didn't really connect with the virtual groups, it was, I didn’t really partake in them, I was just there, because it felt impersonal.” (P. 14)
Access to care and building therapeutic relationships
Facilitators to recovery
	Check-ins		Daily check-ins provide monitoring (eg, “eyes on me”), reassurance, and rapid access to clinicians	“I felt supported and so I felt like it gave me the strength to hang on for another 24 hours until that next call.” (P. 12)
	Relationship building with the clinician is present		The patient is able to build a connection with the clinician(s)	“I really started to notice like that connection starting to build. It was just picking up where we left off the following day. So I was almost able to treat it like an extended therapy session just over, you know, the course of five days as opposed to an hour or two on one day.” (P. 15)
	Approachability of staff		Staff qualities that are appreciated by patients (ie, approachable, attentive, and genuine)	“They were non-judgmental, they were actually very encouraging.” (P. 16)
	Talking about difficult topics		Access to professional for “difficult” topics (ie, self-harm/suicidal thoughts) so as not to worry others	“At the beginning it was really helpful just to have like that outside perspective where, you know, I can be like yeah I’m having these really bad thoughts that I don’t want to share with my family to worry them, like there's somebody there.” (P. 5)
	Starting point for recovery		Virtual stay provided the patient with a starting point for recovery including referrals and connections to new services	“It helped me take this one step at a time, because I don’t have to do this all at once, I can just do one step at a time.” (P. 14)
Barriers to recovery
	Relationship building with the clinician is absent		The patient is not able to build a connection with the clinician, in some cases due to feeling that the contacts were impersonal	“It didn’t feel like they actually were phoning me because they cared what was happening to me, or that I was OK.” (P. 4)
Ability to remain at home
Facilitators to recovery
	Access to personal comforts		The patient has access to personal and familiar comforts in their own environment (ie, pets, own bed, own shower, etc)	“I think just being able to have at least control over things that are familiar and access to things that are familiar, that was helpful.” (P. 6)
	Coping in a natural environment		Encourages use of coping in natural environment	“They were really helpful and like really did work with me on a daily basis on trying to build tools to help myself that are non-medicine related. And that was just so helpful.” (P. 21)
	Continuation of responsibilities and obligations		The patient is able to continue responsibilities and obligations while admitted (ie, working, caring for children, and caring for pets)	“…to be able to continue working like is super-helpful.” (P. 5)
	Managing co-occurring health needs		The vCSU accommodates the need to manage health issues that the in-person CSU may not be responsive to (ie, diet concerns or digestive issues, chronic pain)	“I was able to have food that worked for my body.” (P. 2)
	Avoidance of inpatient triggers		The patient avoids potential inpatient service triggers
		Avoidance of COVID-19 triggers	Avoidance of receiving or transmitting COVID-19 virus outside the home	“Well one thing that is nice about virtual is if you’re sick or you’ve got COVID you can still get the attention you need.” (P. 3)
		Avoidance of socioenvironmental triggers	Avoidance of potentially unpleasant social encounters, violence, and triggers related to the physical space of the inpatient unit	“So I wasn’t sure if like being with other people would cause me more trauma or not, so having that virtual option was amazing and it was really good for me.” (P. 20)
Barriers to recovery
	Less engaged or committed		The patient finds it easier to disengage from help; includes when people may struggle to ask for help virtually (barrier created by separation in space)	“it's easier not to go sometimes when it's virtual.” (P. 1)
	Limited structure or socialization		The patient describes limited daily structure and/or socialization when admitted from home	“Because with no sort of—no schedule, no anything, I was completely just, like, out of control.” (P. 4)
	Community triggers		The patient is exposed to triggers in the community (ie, negative influences like drugs/alcohol, unhealthy relationships, expectations, and reliance on natural supports (if not supportive))	“It was really hard to manage how much I was smoking cigarettes too. And I was still using cannabis as well.” (P. 1)
Virtual service provision
Facilitators to recovery
	Viable alternative to in-person services		The virtual unit is a feasible option for the patient's needs and level of care	“So I mean really the only difference was it was over the phone and not in person. Really that was the only difference.” (P. 3)
	Convenience		Patients report the vCSU is convenient and/or flexible and options for access	“A big part of it was just wanting the convenience of doing it over the phone, having it at a little bit more flexible time to meet my work schedule.” (P. 15)
	Decreased wait times		In some cases, participants noted getting rapidly connected to specialists through the program	“For the diagnostic purposes, it was very excellent, because I got to see a doctor on the third day.” (P. 2)
	Personalized resources		Personalized resources for skill building/services can be shared electronically and adopted during stay to make progress on recovery goals	"They sent me a lot of workbooks and stuff and different resources and stuff, I would say that was the most beneficial part to me.” (P. 8)
Barriers to recovery
	Unpredictability or uncertainty of the service		The patient does not know what to expect from the service which increase in anxiety (ie, contacts, expectations of service, duration, and will they be forced in person)	“There wasn't really much information given about it at all. I was just told that it would be oh yeah, like pretty much the same as the [CSU] and it was like, very different.” (P. 2)
	Technological barriers		Inability to connect with patient due to technological or information factors (ie, patients not answering blocked numbers, clinicians having incorrect contact details for email, etc)	“So, it was all very, but the only thing was they were all like unknown numbers or you know numbers that yeah, like I don't pick up numbers, I don't know.” (P. 18)
	Contact availability was insufficient		The contacts were too infrequent during program hours and unavailable after hours
		Requiring more regular contact or check-ins	the patient wanted more regular/frequent check ins	“What would have really helped was more contact because I needed a lot of contact back then.” (P. 10)
		After hours support was lacking (check-ins and crisis support)	Patient especially needs a check in during the evening to feel adequately supported/the vCSU's afterhours crisis support is not well integrated	“And then like I said the daily contacts were OK but not enough especially at night, that was when I really needed it when I finished work at 10 PM and I was falling apart, that was when I needed it.” (P. 10)
	Format of contact was not adequate		The type of contact (ie, phone call) or the structure of the contact was not perceived as adequately meeting the participant's needs.
		Lack of options for care contacts	The patient has difficulty opening up to the provider over the phone (ie, length of phone call; gender of clinician; and video call); suggestions for alternative modes of contact (eg, app/text-based communication); preference for scheduled vs unscheduled contacts	“Yeah. Like, if there was an, if there was an app that had the clinicians on it, that would be incredible. Because then it would be 24/7 and be able to see it in writing.” (P. 1)
		Contacts were too brief	Patient found the phone call check ins were too brief/unhelpful or insufficient l (ie, clinical going through the motions, not invested in helping patient)	“I do think the phone conversations should be longer, possibly more structured.” (P. 8)
		Lack of visual cues over the phone	Patient is unable to see the provider's body language which makes it more difficult for the patient to share; also provider lacks visual cues of patient's state	“It would have been nice to see them because it feels easier to have a conversation with someone when you can see each other's reaction.” (P. 7)

Connection to Others is Possible or Lacking

Connection was a category often reflected in the participants’ recovery journeys. Participant narratives discussed how the virtual service either aided or hindered the service user's ability to form and maintain connections that were helpful in their crisis resolution. There were 4 themes, 3 of which indicated a positive effect on connection: (1) connection to others through group sessions, (2) involvement of natural supports, and (3) access to regular care providers and prescribers. For example, one participant noted that being part of group sessions provided a feeling of connection: “Because you get the connection of like, oh, yeah, there are other people in this virtual program, right? There are other people who are at home in a bad place just like I am” (P.4). The one negative theme was (1) feeling disconnected from others in group sessions, illustrated by a participant's experience of the virtual group sessions being less personal: “Whereas you can’t really do that with the virtual, I found that a lot of people don’t really want to talk in the virtual one” (P.10).

Access to Care and Building Therapeutic Relationships

This category captures how the virtual service either impacted a patient's ability to access and form a helpful therapeutic relationship with mental health professionals and how that related to recovery. Five positive themes include (1) check-ins, (2) relationship building with the clinician is present, (3) staff qualities, (4) talking about difficult topics, and (5) starting point for recovery. The value of brief check-ins with a mental health professional was identified by many participants such as one who stated, “I think that it is a really good resource to have and some people all they need is someone just to check in on them and that's good enough to help you through a crisis sometimes” (P.5). The continuity of daily support with the same clinician was also seen as important: “I really started to notice like that connection starting to build. It was just picking up where we left off the following day…” (P.15). One negative theme was (1) relationship building with the clinician is absent, where staffing changes or a perception that interactions were superficial made the participant feel that connection was absent.

Ability to Remain at Home

Access to the home environment with virtual support was discussed by participants as it related to their ability to engage in recovery. Five positive themes in this category include (1) access to personal comforts, (2) coping in a natural environment, (3) continuation of responsibilities and obligations, (4) managing co-occurring health needs, and (5) avoidance of inpatient triggers, which divided into (5a) avoidance of socioenvironmental triggers, and (5b) avoidance of COVID-19 triggers as this study assessed service use during parts of the pandemic. Access to personal comforts was discussed by many participants, including their own bed, pets and other coping objects. Many participants talked about having a sense of control over their environment as comforting. Three negative themes include (1) less engaged or committed, (2) limited structure or socialization, and (3) community triggers. For some, being at home reinforced more avoidance: “it's easier not to go sometimes when it's virtual” (P.1), and continued exposure to potentially unhelpful triggers in community such as substances.

Virtual Service Provision

This final category details the specific aspects of a virtual modality that either helped or hindered crisis resolution. Four themes were positive: (1) viable alternative to in-person services, (2) convenience, (3) decreased wait times, (4) and personalized resources. Many found that the service came close to providing what an in-person program would do: “it was about as close to in person therapy as I could have asked for” (P.15). The convenience meant that participants could balance other demands like work or school and still receive needed support. Additionally, 4 negative themes include (1) unpredictability or uncertainty of the service, (2) technological barriers, (3) contact availability was insufficient, and (4) form of contact was not adequate. Contact availability further divided into (3a) requiring more regular contact or check-ins, and (3b) after hours support was lacking. Form of contact generated 3 subthemes: (4a) lack of options for care contacts, (4b) contacts were too brief, and (4c) lack of visual cues over the phone. Many of these themes related to the majority of contact being done by phone and the limitations felt with that.

Discussion

This study explored how patient recovery was impacted by virtual crisis stabilization support from the perspective of patients and their support persons. The results illustrate how users of the vCSU felt the service contributed to their crisis resolution and the various positive and negative impacts of the program. In addition to the essential components of crisis resolution like support, therapeutic relationships, and connections to resources, additional positive and negative themes arose. This highlights that while virtual services may be helpful for certain people, individual characteristics and contextual factors make it less suitable for others. This is consistent with the notion that recovery is complex^19,20,30 and that different crisis services have varying efficacy for different individuals. ¹⁹ Findings from this study also highlight areas for optimization in the delivery of virtual crisis care.

Recovery-oriented services are those services that function to facilitate a patient-centered view of recovery, rather than solely focusing on symptom resolution.^19,31 Some aspects of the virtual service promote patient self-management and align with recovery-oriented principles such as promoting a “starting point for recovery,” “connection to others,” and “coping in one's natural environment.” These findings are in-line with previous research on CRTs, which have been widely implemented throughout Europe. ¹² Like the vCSU, CRTs generally consist of a multidisciplinary team of mental health professionals who aim to deliver intensive mental health care to individuals who would otherwise require inpatient hospitalization. ¹² CRTs, through in-person home-based support, were designed to reduce the harms and stigmatization associated with inpatient admission, and the notion that coping skills are more likely to be effectively applied if they are being used in the same context in which they are taught. ¹² Not surprisingly, the strengths outlined by the CRT model^32–34 are consistent with the vCSU model which strives to achieve the same benefits through entirely remote support. Similar to the findings in this study, CRTs have been shown to have lower satisfaction and efficacy rates when there are inconsistent or infrequent home visits, and when patients do not feel they have the intensity of support that they require.^32,33

This study also identifies potential hindrances to crisis resolution with the virtual model. For some individuals, this model may perpetuate underlying patterns of avoidance or maladaptive coping that is preventing them from achieving meaningful recovery. Previous research has similarly explored the potential for a diminished therapeutic relationship^4,35,36 and concerns with the limitations of virtual care.^4,16,36 Ultimately, these findings emphasize the important notion that crisis intervention needs to be individualized. ¹⁶

Strengths and Limitations

Although theoretical saturation was achieved and the sample was representative of the typical CSU users, ³⁷ the sample lacked representation of the older patient demographic. Additionally, there may have been selection bias in that interview participants only consisted of individuals who were agreeable to utilize virtual services in the first place. A large number of participants had experience with both virtual and in-person services, which allowed some comparisons. Interview participants utilized the vCSU when it was still fairly new; some aspects of the service that were identified as hindering or inadequate could be improved with service enhancements. Additionally, the effects of the COVID-19 pandemic (although improving at the time of this study) may have continued to have an impact on service users’ attitudes toward virtual care. The use of videoconferencing for interviews allowed researchers to conveniently engage with participants in real-time, ³⁸ and the ability to witness facial cues to help contextualize those responses. ³⁹ Any barrier to using Zoom was mitigated by offering telephone or in-person interview options.

Conclusion

Overall, this study illustrates, for both service users and providers, how virtual crisis care can fit within available services. This study also highlights the feasibility and acceptability of this model of crisis stabilization support, and identifies some of the unique ways in which receiving help at home can facilitate one's recovery. Service users and providers who have access to this type of support can consider when and for whom this is a good option and where needed, be aware of the ways in which it could enhance or inhibit crisis resolution. Additionally, decision makers can consider the role of virtual crisis support in the local system as it seems to be a viable alternative to inpatient care for a number of individuals and could lead to more person-centered options that are cost-saving for the health system.