Staff Perspective: Couples Counseling During COVID-19 - Telehealth Lessons Learned

Staff Perspective: Couples Counseling During COVID-19 - Telehealth Lessons Learned

Dr. Jenny Phillips

Not long after the COVID-19 pandemic significantly altered the provision of behavioral health care, April Thompson shared some very helpful tips for clinicians working online with couples. Her blog reviewed an article (Wrape & McGinn, 2019) discussing important clinical and ethical issues involved in telehealth couples therapy. Now, more than a year after COVID struck, we are beginning to see the publication of studies and reports on the outcomes of online behavioral health during the pandemic. In today’s blog, we will take a look at a few of these articles that are specifically relevant to telehealth for couples.

The Family Institute at Northwestern University began to move some of its couple and family services online in 2018, reporting that about 2% of their practice occurred as telehealth prior to the COVID-19 pandemic. Although this represented a small portion of their overall services, this history did help to facilitate the transition to 100% telehealth services that they initiated in March 2020 in response to social distancing restrictions. By the summer of 2020, the Family Institute had published an article entitled Lessons from the transition to Relational Teletherapy during COVID-19 (Burgoyne & Cohn, 2020), sharing extensive information about the experiences and lessons learned by their providers during the transition to telehealth services.

While the paper includes information collected from a variety of the Family Institute’s services, there is an entire section devoted to working with couples via telehealth. One highlighted area of concern is the difficulty of delivering virtual couples therapy when there are potential issues of intimate partner violence or retribution for information shared in the online therapeutic sessions. As described by one of the Family Institute’s providers, endangered partners have expressed concerns over being “unable to escape the chaos and pain of living in the rubble” caused by negative partner interactions and disclosures during virtual sessions. To address this, they suggest considering the inclusion of individual sessions with partners that remain in service of shared treatment goals. These separate sessions may offer a “pressure valve” opportunity for processing affect and increasing the effectiveness and safety of joint sessions.

The Family Institute also noted some benefits of the move to telehealth with couples. They cited the enforced formality and turn-taking required in virtual sessions, aspects that are sometimes more difficult to enforce in a live, in-person setting. Providers also observed that encouraging the couple to focus on the screen and therapist may be even better at reducing tension than similar instructions given in-person. The Family Institute’s providers have attempted to use telehealth across a variety of preferred models for providing couples therapy, also highlighting unanticipated benefits. Therapists who used emotion-focused couples therapy found themselves unable to directly read body language via the telehealth monitors. As a result, the therapists encouraged patients to self-report their sensation and actions, prompting them to pay closer attention to what is happening to themselves and in the interactions with their partner. This emphasized how an assumed limitation of online therapy may, in fact, be a benefit in allowing participants to more clearly assess and describe their own emotions and reactions.

Not surprisingly, the Family Institute is not the only organization or practice that has experienced lessons learned from the move to online couples therapy during COVID-19. In fact, a soon-to-be-published issue of the Journal of Marital and Family Therapy (JMFT; available for early preview online now) includes several articles about telehealth in the context of family and couples therapy during COVID-19. In an article entitled Couple teletherapy in the era of COVID-19: Experiences and recommendations (Hardy, Maier, & Gregson, 2021), researchers report the outcomes of a mixed-methods survey (qualitative and quantitative methods) of 58 couple therapists engaged in telehealth during the pandemic. The study found that the response to the move to online/telehealth therapy was generally positive, with 74% of respondents stating that they would continue to provide teletherapy even after the pandemic ended. Of particular note to those interested in how to improve the clinical provision of telehealth for couples, the article also shares recommendations collected from the participants. Examples include the importance of reviewing applicable laws and regulations for your state or jurisdiction, the need to clearly communicate issues of rights, risks, challenges, expectations, etc. to patients when starting teletherapy, and the need for therapists to be especially attentional and alert during online sessions. The authors end the article with several clinical implications drawn from the data collected during the study, ultimately concluding that “these findings should be encouraging to therapists about the benefits of teletherapy, even to those who are reticent.”

In the same edition of the JMFT, researchers present findings from a qualitative study of patients who engaged in online couples or family therapy in the article entitled “It’s splendid once you grow into itClient experiences of relational teletherapy in the era of COVID-19" (Maier, Riger, & Morgan-Sowada, 2021). A thematic analysis of open-ended survey questions was conducted on responses from 25 participants, resulting in the identification of several common telehealth themes. One such theme, “Making do”, referred to the fact that the majority of participants identified their preference to “make do” with what was available (online therapy), rather than go without therapy altogether during the pandemic. Participants also identified benefits of telehealth within the themes of “Safe therapeutic space” and “Convenience”, emphasizing the comfort, authenticity, and expediency of receiving therapy while in their own homes. The authors provide interpretation and recommendations related to these themes and others uncovered in the responses of the study participants. This article provides some interesting insight into how telehealth is perceived by patients, a resource that many providers may find helpful in making decisions about entering or continuing telehealth for couples in the future, even beyond the COVID-19 pandemic.

As more information filters in from both providers and patients who have been engaged in online therapy for couples over the past year, the availability of information on the experience and effectiveness of the modality will no doubt continue to grow. These early resources and studies provide a solid starting place for those interested in exploring questions about telehealth with couples, including “Does it work?” and “Should we keep doing it?” once the pandemic passes.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Jenny Phillips, Ph.D., is the Assistant Director of Evaluation for the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, MD.

Wrape, E. R & McGinn, M. M. (2019) Clinical and ethical considerations for delivering couple and family therapy via telehealth. Journal of Marital and Family Therapy, 45(2), 296-308.
Burgoyne, N., & Cohn, A. S. (2020). Lessons from the transition to relational teletherapy during COVID‐19. Family Process, 59(3), 974-988.
Hardy, N.R., Maier, C.A., Riger, D., & Gregson, T.J. (2021). “It’s splendid once you grow into it:” Client experiences of relational teletherapy in the era of COVID-19. J Marital Fam Ther, 47(2), 1–16.
Maier, C.A., Riger, D., & Morgan-Sowada, H. (2021). “It’s splendid once you grow into it:” Client experiences of relational teletherapy in the era of COVID-19. J Marital Fam Ther, 47(2), 1–19.