Couple teletherapy in the era of COVID‐19: Experiences and recommendations

Abstract

The unprecedented times of the novel Coronavirus quarantine and subsequent stay‐at‐home orders have changed the way many couple therapists provide clinical services. Understanding couple therapists’ experiences with teletherapy is important for optimizing future telehealth delivery with couples. Thus, the purpose of this mixed methods survey study was to explore couple therapists’ experiences of transitioning from in‐person/traditional therapy to online/telehealth delivery. A total of 58 couple therapists completed an online survey for this study. Reported are both quantitative and qualitative findings. Overall, this study found that couple therapists experienced a positive shift from traditional/in‐person therapy to online/telehealth therapy, with a majority of couple therapists (74%) reporting they would continue providing teletherapy after the novel Coronavirus pandemic and social distancing regulations had ended. Thematic analysis was used to identify themes from couple therapists’ experiences related to advantages, challenges, and recommendations for practice. Implications for clinical training and future research are discussed.

INTRODUCTION

In the era of the novel Coronavirus, couples are likely experiencing external stressors at higher levels amid the world‐wide upheaval caused by COVID‐19 (Bader, 2020; Lebow, 2020; Liu, 2020; Pietromonaco & Overall, 2020). Since its official declaration as a pandemic on March 11th, 2020 by the World Health Organization, this significant human tragedy has continued to affect people, their relationships, world economies, and social structures in unforeseeable ways. There is significant concern that the impact is likely affecting the well‐being and health of couples in intimate relationships and leading to uncertainty about the future (Lebow, 2020; Stanley & Markman, 2020). Couple therapist Ellyn Bader (2020) uses the term “cabin fever” to describe the tension and challenges couples are experiencing while sheltering in place. These and other Coronavirus‐related challenges (e.g., financial and job losses, COVID‐19 infection) could lead to withdrawal, increased conflict, less responsive support, and ultimately declines in mental health and relationship satisfaction (Pietromonaco & Overall, 2020). Further consequences may include risk for infidelity (Gordon & Mitchell, 2020) and even divorce (Liu, 2020).

Paradoxically, the slowed pace that many couples are experiencing as a result of the pandemic can be an ideal time for working on one's relationship (Perel, 2020). Stanley and Markman (2020, pp. 937‐938) suggest couple therapists are needed during this time to help couples (a) be intentional about working together as a united front during transitional times, particularly as co‐parents (“decide, don't slide”), (b) increase safety and protection within and around their relationship (“make it safe to connect”), and (c) recognize and address patterns of blame, withdrawal, and negative escalating cycles in the relationship (“do your part”).

Not only are couple therapists uniquely suited to work with these challenges and promote these goals, they are needed particularly during the coronavirus pandemic; however, couple therapists are often unable to treat couples in the same way (e.g., traditional, in‐person therapy). Thus, the importance and necessity for remote relational therapy (i.e., couple teletherapy) cannot be overstated. Telehealth, however, has its own unique set of challenges and there may be doubt, uncertainty, reticence, unwillingness, or lack of experience and training on the part of couple therapists that make providing services in this way difficult to embrace. Although teletherapy services have existed for nearly two decades, the fields of mental health and family therapy have been slow to adopt these practices prior to the COVID‐19 pandemic and now many therapists who have never or sparingly used teletherapy face challenges to maintaining continuity of care with their clients. Thus, providing teletherapy has become more imperative than ever before. Understanding the perspectives of couple therapists who are now conducting teletherapy is critical to illuminate advantages, challenges, and recommendations for practice in addition to furthering the argument for insurance reimbursement of couple teletherapy; thus, helping to optimize the current and future delivery of telehealth services for couples.

In recent years, there has been increased attention in the literature to telehealth therapy and issues related to teletherapy training and education, accessibility, convenience, and competence in the delivery of relationally focused telehealth therapy (Benson et al. 2018; Bischoff, 2004; Cravens Pickens et al., 2019; Wrape & McGinn, 2018). Telehealth delivery also referred to as teletherapy, telemental health services, online video therapy, or telebehavioral health, is the use of telecommunications to provide and access mental health services across distance (Cravens Pickens et al., 2019; Nickelson, 1998). Teletherapy may be particularly useful to couples, as it addresses some of the barriers that may be more prominent, such as child‐care and scheduling (Wrape & McGinn, 2018) as well as connecting couples who are physically separated from one another or in long‐distance relationships (McCoy et al., 2013). Two prominent issues related to the delivery of relationally focused teletherapy have emerged: (a) demonstrated feasibility and satisfaction and (b) demonstrated equivalence between traditional/in‐person therapy and telehealth services (Turvey & Myers, 2013). Overall, research has demonstrated that telehealth has been endorsed at high levels of satisfaction among clients, their families, and clinicians (García‐Lizana & Muñoz‐Mayorga, 2010; Grady et al., 2011; Hilty et al., 2013).

Of course, the COVID‐19 pandemic and subsequent stay‐at‐home orders have now impacted the way almost all couple therapists provide clinical services. As telehealth delivery for marriage and family therapists (MFTs) was considered a specialized delivery service until only recently (Blumer et al., 2015), it is now nearly requisite of MFTs who want to continue seeing their clients (Burgoyne & Cohn, 2020). According to findings from Blumer et al. (2015), a majority of their sample consisting of family therapists from across the United States reported feeling unprepared to utilize online technology with couples and families. A growing body of empirical evidence supports synchronous video‐based teletherapy as an effective way to offer therapeutic services and improve client functioning (Godleski et al., 2012; Hilty et al., 2013; King et al., 2014; Rees & Maclaine, 2015; Spence et al., 2011). Although it has consistently shown favorable outcomes in areas of client satisfaction and therapeutic alliance (Duncan et al., 2003), less is known regarding the experiences of couple therapists who may be transitioning to telehealth delivery with their couples for the first time. Furthermore, literature on the experiences of MFTs transitioning their entire practices to telehealth delivery and specifically, providing relationship‐focused telehealth is rare, but emerging (see Burgoyne & Cohn, 2020). Given the potential impacts of the COVID‐19 pandemic and sheltering‐in‐place orders (Bader, 2020; Greenfield, 2020; Lebow, 2020; Liu, 2020; Pietromonaco & Overall, 2020), there are significant concerns about how these events will impact couple relationships now and in the future. Thus, there is an overwhelming need to serve couples via telehealth. As MFTs have shifted the way they practice, it seems important to gain insight and understand the unique barriers, advantages, and overall effects of couple therapists transitioning to telehealth delivery amid the widespread pandemic.

Additional research has discussed the ethical and clinical considerations unique to the delivery of telehealth to couples (Wrape & McGinn, 2018). For instance, when involving members of a couple who are located out of state in a therapy session, therapists must be aware of state licensing laws and guidelines for telehealth (Caldwell et al., 2017) as noted on the AAMFT website. Additionally, as technology continues to evolve and integrate further into couple and family life, therapists may benefit from lessons learned in conducting therapy through telehealth, as well as understanding the impact of technology on relationships (Hertlein & Blumer, 2014).

The existing research has documented positive experiences of couples who participated in teletherapy (Kysely et al., 2020). For instance, couples reported being “fully immersed in the therapeutic process” and felt as though teletherapy provided an element of distance from the therapist and thus, allowed them to feel a greater sense of control and comfort (Kysely et al., 2020, p. 1). Since there is limited research on couple therapists’ experiences of conducting teletherapy (Kysely et al., 2020) this study explored: (a) the challenges associated with transitioning to telehealth delivery, (b) the advantages or rewards to providing these services, and (c) recommendations on practices couple therapists have learned in providing teletherapy.

METHOD

Participant recruitment and description

In mid‐April shortly after the COVID‐19 lockdown and stay‐at‐home orders were enacted across the United States, couple therapists were recruited for participation in this study. After receiving approval by a university Institutional Review Board, a recruitment email with a link to the online survey was sent to participants via listserv email, message board posting, or as a Facebook post of relevant organizations. A reminder post was sent up until the survey closed on May 15, 2020. Participants received an informed consent prior to starting the survey, which was then followed by a series of brief demographic questions, and a mixture of both open‐ and closed‐ended questions. Participants were not compensated for their time. All participants who indicated that they were in clinical practice and that couple therapy was part of their work were included in the study. Participants who indicated they were not currently seeing couples through teletherapy, however, were only given a few brief questions to explore why. The rest of the participants were eligible to answer the main body of questions. This allowed us to prevent those with no experience conducting teletherapy from providing responses about its specifics. Those who did not fill out any open‐ended questions, or who only completed a minor portion of the study were removed from the final analyses so as to ensure reliability in the data.

Sample characteristics

A total of 74 couple therapists completed the online survey. Sixteen participants, however, did not complete any of the open‐ended questions and were therefore not included in the final analysis. Participants in this study (N = 58) ranged in age from 27 to 76 years, with a median age of 50 years (M = 50.93, SD = 13.68). On average, these participants reported having worked in clinical practice 11–15 years, with a range of 1–5 to 41–60 years. The majority of participants identified as female (66.1%) and White (76.3%), and reported practicing from various regions of the United States. Four participants reported practicing outside the United States. Further, most participants identified as marriage and family therapists (63%), whereas the remaining portion of participants identified as professional/mental health counselors (12%), clinical/counseling psychologists (11%), clinical social workers (6%), or other professionals (8%; sex therapy, student counseling, veteran's adjustment, professional coaching). The majority of the sample were fully licensed practitioners (77%), with the remaining working toward licensure (19%). Four participants indicated student status or graduates not currently working toward licensure. Additionally, results indicated that 48.3% of participants work with couples in their practice at least 50% of the time or more, with a range of 10%–100% of the time and an average of 6.84 couples per week (SD = 5.41). Eight out of the 58 participants did not make the transition to teletherapy for various reasons including couples not wanting teletherapy, participants feeling it was a substantially inferior method with couples (including hearing this experience from colleagues), and having a retreat‐based practice where teletherapy was not feasible. Fifty participants reported doing at least some teletherapy with couples. Hence, all quantitative and qualitative results that follow refer to these 50 participants. Finally, a portion of these participants had already been conducting teletherapy with couples (30%), whereas the majority began the transition to telehealth delivery this year (70%).

Measures

A Qualtrics survey containing 22 closed‐ended questions and 12 open‐ended questions (aside from the demographics and basic practice characteristic questions discussed in the sample characteristics section) was used to explore couple therapists’ experiences (See online supplemental file for the Qualtrics Survey). Participants were asked to respond to questions in open text boxes and encouraged to share as much or as little as they found appropriate. Four open‐ended questions represented follow‐up questions to a quantitative measure or asked for responses that would provide a quantitative description, whereas the other eight open‐ended questions represented our primary qualitative analysis. The following represent our three overarching open‐ended questions that were used for qualitative analysis: (a) What advantages have been provided to you and your couples because of teletherapy? (b) If relevant to your practice, what challenges have you been facing in transitioning with couples to teletherapy? and (c) In your opinion, what would you consider to be “best practices” for setting up a teletherapy practice with couples? The 22 closed‐ended questions provided another picture of couple therapists’ experiences. These were single‐item measures created for the exploratory purpose and descriptive nature of this study. As each item was analyzed one‐by‐one, the quantitative results section and Table 1 provides the essential information about each question. For further detail, see the online supplemental file.

TABLE 1.

Descriptive Statistics of Likert Scale Items (N = 50)

Item	M	SD	Range
Helpfulness of couple teletherapy training	2.30	0.66	1–7 (very helpful – very unhelpful)
Helpfulness of general teletherapy training	2.19	0.86	1–7 (very helpful – very unhelpful)
Sense of comfort distributing couple teletherapy	2.57	1.68	1–7 (extremely uncomfortable – extremely comfortable)
Sense of competence distributing couple teletherapy	2.15	1.68	1–7 (extremely incompetent – extremely competent)
End results of teletherapy appear similar to traditional therapy	3.13	1.55	1–7 (strongly agree – strongly disagree)
Couples appeared to respond well to teletherapy	2.04	1.05	1–7 (strongly agree – strongly disagree)
Couples experienced teletherapy similarly to traditional therapy	3.15	1.67	1–7 (strongly agree – strongly disagree)
Intentionality keeping individual time private from other partner	3.67	1.68	1–7 (completely true – completely untrue)
Sense of working effectively with conflict in teletherapy	2.63	1.32	1–7 (strongly agree – strongly disagree)
Couples’ responsiveness to “conflict interruptions”	3.14	0.77	1–5 (much more responsive – much less responsive)
How well traditional method(s) work in couple teletherapy	2.29	0.94	1–5 (extremely well – not well at all)
Likelihood of providing couple teletherapy post‐COVID‐19	2.74	1.9	1–7 (extremely likely – extremely unlikely)
Likelihood of pursuing additional training post‐COVID‐19	2.74	2.01	1–7 (extremely likely – extremely unlikely)
Overall satisfaction with results of couple teletherapy	2.65	1.54	1–7 (extremely likely – extremely unlikely)

Not all quantitative items are described in this table—only Likert scale items.

This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

Data analysis

The quantitative data were analyzed using basic descriptive statistics and bivariate correlations through SPSS. The qualitative data were analyzed using inductive thematic analysis, “a method for identifying, analyzing, and reporting patterns within the data set in detail” (Braun & Clarke, 2006, p. 79). The first two authors of this study engaged in analysis. The authors are both assistant‐rank faculty and licensed therapists. The first author has extensive training in quantitative analysis and the second author has published using qualitative analyses. Both authors are of the opinion that providing teletherapy services during a pandemic is better than not providing services at all, and that it generally still provides therapeutic benefits for couples.

Since this was an exploratory study, no hypotheses were made a priori. In this study, thematic analysis was utilized to identify potential themes and sub‐themes that were representative of the participants’ responses. After data were collected, the second author began the data analysis by immersing herself in the data in an effort to develop a knowing of the data (Braun & Clarke, 2006). After a comprehensive review of all data, the second author then searched for meaningful patterns in an effort to identify features of the data that represented participants’ perceptions of the possible rewards, challenges, and their recommendations on conducting couples teletherapy. As the second author searched for meaningful patterns, she began to identify codes or salient ideas that represented meanings that existed throughout the data or that seemed particularly important or in order to understand an idea shared by a participant. Throughout this process, a conscious effort was made to remain aware of internalized bias and how this bias may impact the interpretation of the data and codes through the use of a reflexivity journal. After initially coding the data, we (the first two authors) met for peer debriefings to add more credibility to the coding process (Daly, 2007; Lincoln & Guba, 1985). We then re‐read the data and linked codes that consisted of related material in an effort to identify categories, and then themes and subthemes (see Braun & Clarke, 2006) that represented participants’ perceptions of the rewards, challenges, and recommendations for practice of couple teletherapy. Once we agreed on the themes and sub‐themes, we then selected verbatim quotes to illustrate each theme and sub‐theme.

RESULTS

Quantitative results

Quantitative results are reported through frequency and descriptive statistics, item‐by‐item. Meaningful bivariate correlation statistics between items are reported afterward. Table 1 provides the statistical means, standard deviations, and ranges for all Likert scale items.

Teletherapy training

Thirty‐eight percent of respondents indicated they had received teletherapy training specific to couple therapy, of which 95% found it to be slightly helpful (25%), helpful (65%), or very helpful (5%), whereas 5% indicated it was neither helpful nor unhelpful. Sixty‐four percent of respondents indicated receiving at least some training in providing general teletherapy services, of which 91% found this training to be slightly helpful (19%), helpful (53%), or very helpful (19%), whereas 9% indicated it was neither helpful nor unhelpful.

Feelings about couple teletherapy

In terms of general feelings about providing teletherapy services, respondents were, on average, slightly or moderately “comfortable” distributing services and felt moderately “competent” distributing services. Respondents somewhat agreed the end results appear to be the same; agreed that couples generally respond(ed) really well to teletherapy; and somewhat agreed that couples seem to view their experiences very similarly to that of traditional therapy.

Setting‐up couple and individual sessions

We asked respondents their preferences for conducting “couple sessions” over teletherapy with four specific options (they could only choose one response). Seventy‐four percent expressed a preference that the couple is on the same video together; 0% expressed a preference that each partner is on a separate video; but 26% expressed that it depends on the situation or case or other. Participants were asked to explain their preference. Reasons described for being in the same room together included being able to better see their interactions and dynamics (including nonverbals), wanting them to practice speaking to each other, helping them connect, co‐regulate, and soothe each other, encouraging physical closeness and touching, tech problems with splitting (e.g. lag), no other option, harder to blame each other, joint video is less exhausting, attention is less divided, and a closer simulation of in‐person therapy. Reasons for being on separate videos included taking what you can get right now, some couples needing it this way, it can provide a way to deescalate conflict, and some couples cannot be together in the same room at the same time. In terms of setting up individual sessions when working with couples, 62% set up separate individual meeting times, while 12% split the time of a session between partners; 26% of respondents, however, did not answer this question suggesting the possibility that perhaps these participants do not or have not conducted individual sessions with couples via teletherapy or did not understand the question. When asked whether respondents were very intentional about keeping individual sessions or time private from the other partner, 51% of respondents indicated this was somewhat true (18%), very true (26%) or completely true (7%), whereas 49% indicated this was somewhat untrue (14%), very untrue (12%), or completely untrue (23%), suggesting a split between how respondents approached this issue.

Handling conflict

Respondents were asked three questions about how they handle conflict with couples in teletherapy. Eighty‐three percent of respondents agreed, at least somewhat, that they were able to deal with conflict just as effectively over teletherapy, compared to traditional therapy (29% somewhat agreed, 37% agreed, and 17% strongly agreed); 12%, however, disagreed. When asked what they have noticed about working through conflict with couples several things were noted. Many indicated that it was overall more difficult: harder to read and redirect conflict and escalations, harder to hold the space and be assertive, needing to go slower, harder for partners to attune to pain behind the conflict, more avoidance and less talking to each other, and harder to ensure safety. On the other hand, some found handling conflict to be essentially the same as in‐person therapy; some found that couples were more considerate and more prone to positively co‐regulate; others found they could read conflict more clearly, they felt the conflict was more authentic due to their home environment, and noticed couples could see themselves arguing through the video. Some respondents found couples more responsive in teletherapy (14%), more respondents found them less responsive (26%), but the majority (48%) indicated that couples were neither more nor less responsive to conflict interruptions. Respondents were asked what strategies they have used to interrupt rising conflict in a teletherapy session. They were given three strategies to choose from and an “other strategies” option (they could select more than one option). Seventy‐eight percent of respondents indicated they have verbally interrupted the couple's conflict process and redirected the conversation, 20% have asked the couple to calm down in session, and 8% have asked the couple to briefly separate. Thirty‐four percent of respondents, however, provided other strategies they have used including the following: an audible sound for redirecting, muting mikes, providing ground rules, implementing structured conversations, practicing emotion‐regulation or mindfulness, validation and support, circular questions, summarizing and reflecting, slowing the interaction down, probing for primary emotions, redirecting intensity towards the therapist, and taking a soft but direct position.

Applying couple therapy methods to teletherapy

We asked participants what type of therapeutic methods they use in their therapy practice and provided a set of fixed choices of which they could select more than one. The following indicates the percentage of participants that selected each modality: emotional (68%), cognitive (40%), behavioral (38%), systemic (60%), family‐of‐origin (32%), psychodynamic (10%), neuroscience (24%), and other (26%). Other responses included Gottman, emotionally focused therapy, relational life therapy, developmental model, imago, communications theory, positive psychology, mindfulness, narrative, person‐centered, and integrative. Of those who responded (42/50), 93% indicated that using these methods over teletherapy worked moderately well (33%), very well (38%), or extremely well (21%), with two respondents indicating only slightly well, and only one respondent indicating “not well at all”.

Therapeutic issues that prevent doing teletherapy with couples

We asked participants to indicate issues they would not be willing to treat over teletherapy that they normally would treat in traditional couple therapy practice and provided a set of fixed choices of which they could select more than one. Here we list each issue with the percentages: situational couple violence (50%), severe psychopathology (46%), suicidal ideation (40%), substance abuse issues (22%), trauma history (18%), and other issues (6%). Respondents who selected “other” indicated that they would not normally work with any of these issues in traditional practice (with “high‐conflict” as one exception). One person indicated a “lack of motivation” as an issue that would prevent teletherapy.

Couple teletherapy beyond COVID‐19?

When asked whether respondents would continue providing online services after the COVID‐19 crisis 74% of respondents indicated that this was slightly likely (6.5%), moderately likely (30.5%), or extremely likely (37%), whereas 6.5% indicated it was neither likely nor unlikely, 13% moderately unlikely, and 6.5% very unlikely. Similarly, 69.5% of respondents indicated it was at least slightly likely (6.5%), moderately likely (30.5%), or extremely likely (32.5%) that they would pursue additional training in couple teletherapy after COVID‐19, whereas 11% indicated it was neither likely nor unlikely, 6.5% slightly unlikely, 6.5% moderately unlikely, and 6.5% very unlikely. Finally, 80% were at least slightly satisfied (17%), moderately satisfied (46%), and extremely satisfied (17%) with the end results of couple teletherapy, whereas 7% indicated they were neither satisfied nor dissatisfied, 2% slightly dissatisfied, 9% moderately dissatisfied, and 2% extremely dissatisfied. Be that as it may, 72% of respondents still preferred traditional face‐to‐face therapy and 10% preferred teletherapy; 18%, however, did not provide a preference one way or the other.

Bivariate correlations

We hypothesized that training in couple teletherapy would be significantly correlated with positive experiences of teletherapy as it could increase a sense of efficacy with teletherapy. It was significantly associated comfort (r(44) = .34, p =.022), being intentional about giving private individual time to partners (r(41) = .47, p = .001), handling conflict effectively, (r(46) = .29, p = .045), seeing couples as responsive to conflict interruption (r(42) = .34, p = .024), being interested in continuing to use teletherapy after COVID‐19 (r(44) = .33, p = .026), and wanting to pursue more training after COVID‐19 (r(44) = .35, p = .016). We further hypothesized that items indicating positive perceptions and feelings about conducting couple teletherapy would be significantly associated with each other, which we found to be the case—with very few exceptions. We hypothesized that starting teletherapy with couples in 2020 (as compared to before) would not be negatively associated with most positive experiences in teletherapy given previous research indicating a lot of similar outcomes with the traditional format. While this was generally the case, it was negatively associated with receiving training in couple teletherapy (r(47) = −.29, p = .044), being likely to continue teletherapy after the pandemic (r(44) = −.38, p = .01), satisfaction with the end results (r(44) = −.36, p = .014), and a preference for teletherapy over in‐person therapy (r(39) = −.34, p = .032). These findings, however, are intuitive given the reality that these therapists were likely forced into conducting teletherapy and therefore, wouldn't have had as much training, or be as interested or satisfied with the format.

Qualitative results

Our thematic analysis led to the identification of nine overall themes related to couple therapists’ experiences of the challenges, rewards, and recommendations for practice in providing couple teletherapy. Fourteen total pages of text, 495 lines of text, and 5,819 words were generated from the qualitative data. We will describe these themes as first prefaced by the main question(s) that guided respondent answers.

Rewards and unforeseen advantages

The first question reflects the following themes related to the advantages couple therapists have experienced in transitioning to teletherapy: flexibility and convenience, enhanced connection, and no advantages. There were two themes and three sub‐themes for this survey question. Participants responded to the open‐ended question that was used for part of this qualitative analysis, “What advantages have been provided to you and your couples because of teletherapy (please include any unforeseen advantages)?”.

Flexibility and convenience

The first theme reflects therapists’ beliefs about increased flexibility and convenience related to conducting teletherapy with couples, as illustrated by the following quotations “Flexibility in scheduling and location;” “I have more time to prepare before sessions when working from home, no travel time for clients or clinicians..;” “No babysitter costs;” and “I have been able to work from home completely confidentially…it has saved my couples commute of 45 min to 2 h! They have loved that!”.

Within the theme of Flexibility and Convenience, there are two sub‐themes, which are labeled, Increased Comfort for Couples and Increased Comfort for Therapists. These sub‐themes encompass therapists’ responses that their home environments—both for themselves and the couples with whom they work—have had a positive effect on the comfort level and overall convenience factor. As an example, one participant stated this about their client:

I get to see them in their space, which of course gives me different information about them than I have when they come to my office. One couple sits on their couch with blankets and I think that makes them much more comfortable during the session.

Additionally, another participant shared about their client: “They are comfortable (physically, also well fed/watered, etc.) and have a familiar environment. Their pets bring positive energy plus very few clients are late for telehealth…” A final example of this sub‐theme includes the following quotation: “Being able to see a bit of their home environment and how they engage there…it fosters an attitude of flexibility and an opportunity to model positive ways to deal with frustrations—such as internet issues.”

An example of the sub‐theme, Increased Comfort for Therapists, is illustrated by the following quotations: “Nice to be working from home. I can be home for dinner instead of at the office” and “As someone who is still fairly new in this career, I seem more comfortable with clients in teletherapy. I have not felt uncomfortable with meeting with my clients at all; I notice that I seem more at ease.” The final quotation is slightly unique as the participant describes even more comfort and ease with teletherapy than traditional/in‐person modalities.

Enhanced connection

This second theme reflects participants’ responses that the familiarity of the home environment for couples have led to a stronger therapeutic rapport or connection with their therapist. The following quotations illustrate this theme: “Increased opportunity to build rapport and show unconditional positive regard since clients are letting me into their homes/private spaces” and “Familiar environment for couples sometimes deepens interactions.”

One sub‐theme, Continuity of Services, was identified within this theme. This sub‐theme is representative of therapists’ perceived advantages of simply being able to continue seeing clients during the pandemic and stay‐at‐home orders. The following quotations are examples of the responses coded in this sub‐theme: “Just being able to continue seeing them. Being able to serve people from a distance who would not be able to get me otherwise” and “Continuing our consistent ritual of meeting regularly has been very important in these stressful times when everyone's life has been disrupted by the pandemic…”.

Challenges related to conducting teletherapy with couples

Four themes—client discomfort, technology connection, clinician fatigue, and ethical dilemmas—were reflected in the responses to the second set of survey questions—“If relevant to your practice, what challenges have you been facing in transitioning with couples to teletherapy?” “What challenges have you been facing or do you currently face in sessions with couples over teletherapy?”, and “What ethical dilemmas and/or risks have you seen in providing teletherapy services to couples?” .

Client discomfort

The first theme reflects couple therapists’ experiences of their clients’ discomfort with engaging in therapy from home. This theme is illustrated by the following quotations, “Discomfort with the unfamiliar 2‐D instead of 3‐D connection;” and “Their discomfort doing therapy at home with their kids present.” Three sub‐themes were identified within this theme. The first sub‐theme was labeled No Privacy, which reflects therapists’ beliefs about their clients’ inability to secure a secluded, quiet space to engage in couple teletherapy. The following quotations are representative of this sub‐theme, “Clients have no privacy because they are quarantined with children and/or extended family;” and “…finding a space where they can speak without the risk of being overheard by other people in their home, which then limits how open a client is willing/able to be.”

The second sub‐theme, Increased Distractions, describes therapists’ beliefs about their clients’ heightened interruptions they are experiencing outside the traditional, in‐person and in‐office sessions, as illustrated by the following quotation, “…the increased distractions such as doing therapy in car and looking at people walking by…” and “Disruptions (children), failure to keep both clients on the screen.” This subset of our participants was in consensus about the physical location of their clients’ sessions having increased interference with their ability to focus in couple therapy.

The third sub‐theme, Opting out of Teletherapy, describes clients’ choosing not to continue telehealth delivery of couple therapy at this present time. This third and final sub‐theme is illustrated by the following quotations, “Most have paused until we can see each other in person;” “They are in good shape so they would rather wait to get back to normal. They are older and intimidated by technology;” and “The older the age of the partners within a couple system, the more resistance (is) expressed toward video conferencing. My couples over age 65 have relied upon telephonic services over video.” The latter quotations speak to therapists’ beliefs about the impact of older/elderly couples’ usage of telehealth (or lack thereof).

Technology connection

The second theme reflected couple therapists’ responses to the impact of technology‐based connectivity issues they experienced. The following quotations illustrated this theme: “Tech problems, difficulty hearing dialogue during didactic interactions” and “internet connection, inability to read facial cues because of delays.”

This theme contained one sub‐theme, Clinician Attunement to Clients. The sole sub‐theme reflected therapists’ ability to “read” or relate to clients’ nonverbal body language while in couple teletherapy. This sub‐theme included the following quotations, “difficulty in reading and interpreting body language at times” and “…it is difficult to talk couples through some of the re‐engaging touch and trust exercises that I normally do in session…”.

Clinician fatigue

The third theme encompassed couple therapists’ experience of lethargy, tiredness, and discomfort while conducting couple teletherapy and contained no sub‐themes. Examples of responses coded in this theme include: “Personal fatigue level…doing teletherapy requires a different type of focus that was tiring at first;” and “therapist fatigue—I find online therapy much more tiring than ‘live’ (sessions).”

Another participant commented on their dislike for seeing both themselves as well as the couple virtually: “I would like a telehealth model whereby I don't have to see myself on the screen.” This quotation highlights a unique perspective that perhaps for some therapists, seeing themselves on the screen is unfavorable or adverse and is deserving of more consideration.

Ethical dilemmas

The fourth theme describes therapists’ beliefs about the importance of upholding standards for ethical practice and expectations for couple teletherapy and any ethical dilemmas they have experienced. This theme is illustrated by the following quotation, “Safety planning is a bit different…remembering to confirm the location of the clients at the start of each session.”

Three sub‐themes were identified within this theme. The first sub‐theme was labeled Confidentiality Concerns, which reflects therapists’ apprehension about the security and safety of couple teletherapy regarding unencrypted communication tools that can be easily hacked and potential breaches of confidentiality that may extend beyond the therapist's control. The following quotations are representative of this sub‐theme, “I can't always be sure of confidentiality and privacy. Using the internet makes me weary;” “Lack of privacy in couples’ home due to other family members being home at the same time and worry people can hear in closeby rooms;” “Privacy and confidentiality, both in regards to the session vs. the outside world (i.e., hacking, neighbors, etc.)…” and “Confidentiality, safety cannot be guaranteed.”

The second sub‐theme, Boundaries, highlighted therapists’ unease related to the client/clinician relationship as well as general family boundaries. This sub‐theme is represented by the following quotations: “Boundaries become blurred. I had one couple take me on a tour of their home!!” “when an older child may become part of the session inadvertently;” and “…a client abruptly ended a session after expressing intense dissatisfaction with the clinician's response (or lack thereof) when asked for an opinion.”

The third and final sub‐theme is Emergency Issues. This sub‐theme illustrates participants’ concern over their inability to ensure safety among couples via telehealth and the belief that this task is more difficult via online. The following quotations illustrate this sub‐theme: “Worry about interpersonal violence;” “Harder to ‘sniff out’ possible abuse or other such ‘secrets;’” “Conflicted couples are more aggressive, even to me. Easier for them to feel comfortable being aggressive because not in person;” “More difficult to assess risk;” and “Hasn't happened to me, but what if you have a suicidal client, or one who is becoming psychotic?”.

Recommendations from participants

The third and final set of questions reflects themes related to participants’ recommendations for practice in conducting teletherapy with couples: “In your opinion, what are some best practices for setting up a

teletherapy practice with couples” and “What do you consider are the best "in‐session" practices for conducting teletherapy with couples?” These questions reflected the following themes: clarification, infrastructure, and focus.

Clarification

The first theme reflects therapists’ beliefs in the importance of clarifying with couples their rights, risks, and benefits associated with receiving teletherapy services. This theme is illustrated by the following quotations: “Set up the initial stage as they do with clients seen in the office. Make sure the counselors have used everything taught by HIPAA to make sure you are doing the right things on confidentiality…” and “Having conversations and agreements about setting up for sessions amongst the couples and the therapist.” Two sub‐themes were identified with this theme, namely, Informed Consent and Compliance.

The first sub‐theme reflects therapists’ beliefs around informed consent for couples seeking or currently engaging in teletherapy. The following quotes are representative of this sub‐theme: “Setting expectations for how sessions would run, and the pros and cons of telehealth versus in‐person sessions, especially if telehealth sessions are a ‘backup’ and not standard for your practice with the couple,” and “Informed consent updates relevant to telehealth; clear assessment protocols with concerns of violence/abuse.” This final quotation is especially salient as rates of domestic abuse have risen worldwide since Coronavirus (Taub, 2020).

The second sub‐theme, Compliance, highlights the importance of maintaining awareness of and following current applicable laws and standards surrounding online provision of couple teletherapy. The following quotations illustrate this sub‐theme: “Have a signed comprehensive form to use telehealth, use a HIPAA compliant platform;” and “Making sure I am operating in a HIPAA compliant way.”

Infrastructure

The second theme under Recommendations from Participants reflected therapists’ beliefs about the importance of having the basic physical and organizational structures in place for teletherapy. The following quotations illustrated this theme: “Having a video system that integrates paperwork and clinical note taking. Using many different systems makes it difficult to coordinate” and “Ensuring they (clients) understand how to use the software…”.

This theme contained two sub‐themes, Internet Connection and Physical Space. The first sub‐theme reflected therapists’ general beliefs about the importance of having a secure, reliable network bandwidth to provide telehealth services to couples. The following quotations illustrate this sub‐theme: “Having a strong, solid internet connection” and “having at least some degree of basic technical knowledge for basic tech glitches and IT issues.”

The final sub‐theme under this larger theme is Physical Space. This subset of participants expressed their beliefs in the importance of having the physical space conducive to conduct couple teletherapy, both for the couple and the therapist. The following quotations are representative of this sub‐theme: “well‐lit, private space, charged computer, etc.” and “arranging a location in the house/space that is conducive to good lighting and spacing.”

Focus

This final theme under Recommendations from Participants reflected participants’ ideas regarding a different attention that is required for couple teletherapy compared to in‐office/traditional, in‐person couple therapy. The following quotations highlight this sub‐theme: “doing teletherapy requires a different type of focus that was tiring at first;” “remaining present and focusing on the interactions and non‐verbal communication of the couple the best you can;” and “being alert and focused as if in person.”

DISCUSSION

The main findings of this study raise several important points pertaining to the rewards, challenges, and recommendations for practice described by therapists’ transitioning to and using online telehealth with couples. While noteworthy, it is also important to remember that data from our study were collected primarily from therapists (70%) who recently transitioned to providing couple teletherapy and thus, primarily captures a particular subset of therapists using telehealth.

Advantages and rewarding experiences

Consistent with previous findings (García‐Lizana & Muñoz‐Mayorga, 2010), our investigation of the advantages of conducting couple teletherapy present an overwhelmingly positive picture. We were surprised to find the majority of therapists (74%) indicated they were at least slightly likely to continue providing teletherapy services after the pandemic, suggesting a movement toward teletherapy that may be with us indefinitely. Indeed, the quantitative items that asked about participants perceptions and feelings (competence, comfort, seeing couples as responsive to teletherapy, feeling couples viewed the experience similarly, effectively working with conflict, seeing couples respond to conflict just as well, feeling they could apply their traditional methods of therapy, being satisfied with the end results, feeling the experience was similar to traditional therapy, and wanting to continue teletherapy after COVID‐19) indicated more positive experiences and views which were also almost completely significantly associated with one another. Our qualitative findings further illuminate several other satisfying features of conducting couple teletherapy such as greater flexibility and convenience including increased comfort for therapists and couples alike, and enhanced connection by means of continuing care and connecting with clients within their home environment. Furthermore, some therapists found dealing with conflict similar to in‐person therapy; and in some cases, helped generate more consideration, more authenticity, and ways to self‐monitor.

We are not exactly sure what participants were considering when they suggested a likelihood to continue teletherapy post‐pandemic. It could be that the majority of participants will ease back into in‐person therapy over a period of time—indeed, the majority (72%) still expressed a preference for traditional in‐person therapy. However, since so many (70%) indicated they would pursue more training after the pandemic, it is likely participants are expecting to more fully embrace this way of practice. Similar to assessments novice therapists make about their basic therapy skills when beginning to see clients (Cornille et al., 2003), we are not sure if therapists’ competence levels are impacted by the level of training—such that levels could indicate an overconfidence in their teletherapy abilities. It is, therefore, important to consider the challenges with conducting therapy in this way, particularly during the pandemic as well as if teletherapy becomes more of a norm. Incidentally, these challenges may also reveal why traditional therapy likely remains the most preferred therapy.

Challenges and concerns

Our qualitative findings showed several important challenges including client discomfort, technology connection, clinician fatigue, and ethical dilemmas. Therapists indicated clients struggling to find privacy, dealing with increased distractions, or simply opting out of doing teletherapy. Technology issues were common, particularly connection issues and difficulty being able to attune to clients particularly with their nonverbal communication. Clinicians also reported fatigue with providing online services. Several ethical dilemmas were reported including dealing with privacy and confidentiality, blurring of boundaries, and emergency issues (e.g., violence). Many therapists also indicated several different challenges with handling couple conflict in a teletherapy setting (e.g., harder to read and redirect the conflict and escalations). Furthermore, they indicated several clinical issues that might prevent them from doing teletherapy with couples that they might otherwise treat including trauma history, substance abuse issues, severe psychopathology, situational couple violence, and suicidal ideation. Perhaps respondents felt these issues were either too risky or too difficult to treat in a teletherapy context. This is somewhat concerning as these very issues may be increasing among couples due to the current pandemic (e.g., violence; Bettinger‐Lopez & Bro, 2020). It is also important to note that the field of psychotherapy has seen success in treating mental health and trauma through teletherapy (Godleski et al., 2012; Hilty et al., 2013; King et al., 2014; Rees & Maclaine, 2015; Spence et al., 2011). It is therefore incumbent upon the profession to explore the best ways to handle this dilemma. For instance, balancing both couples work and teletherapy may make attending to these issues all the more complicated. Taken together, these issues demonstrate the complexity of transitioning to an online practice and the need to find creative ways of resolving these issues. The field must particularly grapple with clarifying sound ethical principles and decision making in a couple teletherapy context (e.g., intimate partner violence, managing privacy between partners and for the couple, simultaneously treating mental health and relationship functioning).

Recommendations from participants

Therapists provided several useful ways in which they have successfully conducted couple teletherapy. First, they indicated that it is important to be following current applicable laws and standards associated with teletherapy and to clarify for clients informed consent and expectations including rights, risks, protocols, challenges, and benefits, associated with teletherapy. Second, they described the importance of having a physical, technological, and organizational structure in place for teletherapy which is made clear to clients, including video and case notes. This included the importance of having a secure and conducive physical space and internet connection. Third, they indicated that because teletherapy requires a different kind of focus and energy, it demands therapists to be intentional about alertness and presence. While all of these could apply to any teletherapy practice, participants also provided other helpful suggestions including ways in which they interrupt conflict effectively and explained several reasons they prefer to keep couples on the same video and reasons they may at times allow them to be apart. Overall, these findings offer therapists several areas to focus on and to more creatively explore in the context of couple therapy.

Clinical implications

Based on the findings of this study, there are several implications for telehealth delivery with couples that are important to address. First, as this is likely a difficult time for some couples, or at least an opportune time to help couples focus on their relationships (Stanley & Markman, 2020), these findings should be encouraging to therapists about the benefits of teletherapy, even to those who are reticent. The welfare of clients is the ultimate aim, and during times when this may be the only way couples can receive services, it may be worth the challenges to set‐up an online delivery service to benefit those in need during the pandemic. Online therapy may also become more central to some couples’ preferences for how they receive services post‐pandemic. Will the field be prepared to serve clients in this way? Of course, some clinicians were divided about their experience such that some indicated no challenges while others could see no perceivable advantages. Therapists also reported variability in their client couples—some wanted to continue services online, while others preferred to wait until the pandemic is over. Ultimately, clinicians and couples are likely to decide for themselves what they are willing and comfortable to do. That being said, as the world changes, therapists may need to adapt. That adaptation may be exactly what is needed at a time in history where couple therapy has become enormously popular. There will likely always be a preference and need for traditional couple therapy, but the field may need to make more room for online services. This data shows that this type of practice can be rewarding to both therapists and clients alike.

As many therapists embrace this new way of working, they will need to be cognizant of the several challenges that have been identified and how they might best deal with them by considering various recommendations from couple therapists. Although technology can be precarious, couples deserve the best care the field can possibly provide. First, therapists are encouraged to use HIPAA‐compliant telehealth platforms, a list of which can be accessed here: https://bhcoe.org/2020/03/hipaa‐compliant‐telehealth‐softwares/. Second, ensuring one has a good internet connection and video software is clearly important as well as educating couples on how they can get the best connection possible for services. Having protocols in place when a proper connection cannot be established is also critical. For example, discussing with clients what they can expect should internet connectivity be interrupted or poor are good measures therapists can take to assure their clients. Walking them through how to reconnect, rejoin the virtual platform, or planning to follow‐up via telephone are additional measures therapists can take. Finally, discussing with clients practical measures, such as making sure they are using a compatible web browser, checking their internet connection using FAST.com and making accommodations if their speed and performance are not optimal (e.g., adjusting placement of router, connecting via Ethernet cable, limiting the number of devices connected to Wi‐Fi, and contacting their internet service provider), and closing unnecessary software are all ways therapists can help provide support to their clients should they run into connection and software issues.

Therapists must also be sure they are dealing with their own technology burnout (Jinag, 2020) by executing proper self‐care protocols that allow for adequate breaks from screens, such as disconnecting from screens for scheduled periods of time when not in session or spacing out sessions adequately. Sometimes couples live with children, parents, or extended family; thus, it is imperative that they find creative possibilities for a distraction‐free private space to ensure confidentiality. There are also ways in which to make the teletherapy environment more inviting by addressing lighting and background. Sound and privacy can also be enhanced with headphones and white noise machines. If teletherapy is not possible or preferred at this time, it is important for therapists to establish a follow‐up protocol for clients who may need or prefer services later.

Therapists should consider why they may be reticent to treat certain couples in an online format with particular issues (IPV, substance abuse, trauma, etc.). Therapists’ leanings may well be based in clinical wisdom, but could also represent an inaccurate belief about what is possible to work with online. Clearly future research is needed, but it remains a therapist's duty to find the ethical balance of increasing beneficence and decreasing malfeasance in their practice at a time when couples with complex problems will be seeking services. If therapists are to work with more complex problems, they will clearly need to have safe protocols for dealing with these issues in addition to potential emergencies that can occur in any case (e.g., violence, suicidality). Knowing the physical location of clients at each session, is one way to be ready to respond.

Furthermore, having therapy occur in a couple's home does not allow for a disconnect between a therapy space and a home space that can affect clients and therapists (Burgoyne & Cohn, 2020). Indeed, therapists need to attend to various ethical issues including the possibility of blurred boundaries when meeting with couples in their home and couples possibly virtually seeing therapists in their own homes as well. While this has many advantages for creating connection and possible comfort for the clients, it also invites a therapist more fully into the life of a couple (and vice versa), thus, calling into question how therapists will maintain professional boundaries while leveraging new opportunities for alliance building and therapeutic intervention (The first author had a client complain about her husband's lack of household responsibility by pointing the camera toward their Christmas tree, still set up in June!).

Finally, all therapists setting up and continuing an online practice need to consider, not only the recommendations for online service delivery (compliance with applicable laws, clarifying informed consent, setting up the proper physical/technological space), but also recommendations from participants that are specific to couple teletherapy. Some specific findings from our study include how to handle conflict online, how to set up individual meeting times with one partner, how to manage having two (or more) people on one (or more) screens, how to manage secrets and confidential communication, how to attend to the interactive (verbal and nonverbal) space between partners, and determining what issues can be adequately treated in an online format with couples. While there is a plethora of training on telehealth in general, there is very little on couple‐specific teletherapy. Recently, AAMFT’s Couples and Intimate Relationships Interest Network (CIRTIN) hosted a free couple teletherapy training currently available online (https://youtu.be/tupu_IRVFn0), but more training on this topic is needed.

Limitations and future directions

While this study was the first of its kind to explore the experiences of online/couple teletherapy from a therapist perspective, there are some limitations that should be considered. Although we used both quantitative and qualitative methods, we used a modified mixed‐methods approach more exploratory in nature that did not include a‐priori theories or hypotheses that integrated the two methods; thus, our integrative analysis of the results should be interpreted carefully and with this limitation in mind. The data were collected from a mostly White, female, heterosexual sample (66.1% women, 76.3% White). It is possible that the perspectives of therapists from more diverse populations (e.g., age, sexual orientation, gender identity, race) are not represented in the study; thus, future research may consider these demographic factors to better understand how demographic characteristics of specific populations of therapists affect their experiences with conducting teletherapy. Additionally, we did not ask about therapists’ socioeconomic status and geographic location; thus, future studies could examine how class and urban/rural locations might impact therapists’ ability to virtually connect with their clients (e.g., internet connection, privacy, etc.). Another limitation of this study was that data were collected in a cross‐sectional design. It is possible that therapists’ responses may have changed the longer duration they continued conducting couple teletherapy. Future research could examine the longitudinal attitudes and impact of providing teletherapy with couples long‐term, factoring in the utilization of telehealth training. While the answers to some closed‐ended questions are interesting, they can be difficult to interpret. For example, we are not fully sure what was meant by therapists indicating they were likely to continue practicing couple teletherapy post‐pandemic. Furthermore, many responses are relevant to providing teletherapy in general, but sometimes lacked specificity to couple teletherapy. Future research should consider priming therapists to answer questions even more specifically about the unique nature of seeing couples online. Finally, it is important to remember that these findings represented many diverse viewpoints and cannot be interpreted as a one‐size fits all. Therapists should consider these findings, but ultimately determine what makes the most sense for them and their clients in their practice.

CONCLUSION

In a pandemic era of isolation and uncertainty, the need to provide continued services for couples is imperative. During lockdowns, quarantines, mask mandates, and social distancing, technological advances have made the delivery of telehealth services possible, allowing couples in relational distress to receive ongoing therapeutic services. This study provides invaluable insight into the lived experiences of couple therapists about the rewards, challenges, and recommendations for conducting teletherapy. Overall, our findings indicate satisfaction with conducting couple teletherapy and a majority of couple therapists (74%) reporting they would continue doing so after the novel Coronavirus pandemic and social distancing regulations have ended. Therapists reported several challenges including discomfort, technology, fatigue, and ethics, but these were met with several recommendations for practice that could help with these challenges such as following ethical and informed consent standards, getting technology, space, and structure in order, and being intentional about alertness and presence for sessions. These results pave the way for a new kind of couple therapy that aims to reach couples across spatial limitations in order to continue the transformational work of engendering relational change, healing, and growth among couples.

Supporting information

Data S1