During this pandemic when people are being asked to stay home, many clinicians are moving their practices to an online format. Providing telemental health is not new; however, prior to this pandemic, many therapists and clients still preferred in-person therapy. Since that is rarely an option right now, behavioral health providers must find ways to transition to using technology to provide clinical services. Offering clinical services online has the potential to increase access to mental health support during a time when it is especially needed. While providing individual therapy using technology presents many challenges, it becomes even more complex when providing it to couples. For a number of reasons, attending to the needs of two people in an online format presents challenges that clinicians should evaluate prior to engaging in it.
As a licensed clinical social worker, the majority of my clinical practice has focused on work with couples and families. I have predominantly worked in outpatient clinics on military bases, as well as in private practice settings specializing in couples work. I have seen the positive changes that can emerge from successful couples therapy and believe it is a critical need right now given the issues many couples face as they are forced to stay home. Issues such as economic stress, unexpected home-schooling, health concerns and uncertainty about the future require couples to navigate and communicate in effective ways to support one another.
Many aspects of couples therapy are the same whether in an online environment or not. However, there are differences which should be evaluated and understood. First, logistical challenges arise such as determining ways to have clients complete and return intake paperwork and self-report measures. Also, identifying an electronic format that is cost-effective, HIPAA-compliant, and comfortable for both therapists and clients may be difficult. Next, clinicians must be well-versed in the legal and ethical issues involved in telemental health. Consulting laws governing the provision of services using electronic means - especially across state lines – as well as being familiar with published professional standards and guidelines are important first steps. Finally, couples therapists should plan for the clinical differences which may arise using this format.
I recently came across an article discussing some important clinical and ethical issues involved in telehealth couples therapy. Interestingly, this article was published a year ago – long before anyone could have imagined the circumstances we are currently experiencing. It was written by two psychologists, Drs. Wrape and McGinn who worked in Veterans Administration healthcare systems. The authors present a number of considerations and suggestions which can be implemented by couples therapists.
First and foremost, the issue of safety is addressed in the article. As with any relationship counseling, clinicians should be alert for any signs of intimate partner violence (IPV). During this pandemic when people are mostly staying home, victims may be at increased risk due to being forced to stay inside with those who have abused them. When working with couples in an office, it is possible to follow best practices of meeting individually with each partner to determine if they feel safe in their relationship. Asking about IPV with both partners in the room potentially places a victim at increased risk if they disclose information that angers or upsets their partner. If a therapist is transitioning to online counseling, careful consideration should be given to ways to assess for and address safety.
In their article, Wrape and McGinn (2019), offer a number of suggestions to address this. They suggest that if it is not possible to have the couple attend an in-office session where confidentiality can be assured, an alternative would be to ask one partner to leave the room and then have the remaining partner utilize headphones and ask them “yes” or “no” questions about safety. This allows confidelitality even if the other partner is listening. While partners are using headphones, safety plans can be verbally discussed and resources can be provided. The authors also recommend that clinicians verify the physical location of the couple if the need arises for emergency services to be dispatched.
Managing high-conflict couples
Another recommendation is for clinicians to have a plan to manage couples that tend towards rapid escalation of conflict. For couples where IPV is not present, but where couples exhibit high degrees of conflict, the authors suggest spending time at the beginning of therapy to collaboratively discuss and establish plans for taking “time outs” during sessions. Plans regarding having visual cues (such as the therapist signaling a “T” with their hands indicating a “time out”) or having a word stated by either partner or therapist signaling a need for a break should be determined before beginning therapy and should be reviewed prior to each session. Cool-down activities should also be discussed and practiced – things such as listening to music, playing a game on a phone or walking/stretching.
One concern raised by therapists moving to online couples therapy is the possibility of decreased connection between therapist and clients. Similarly, concerns have been raised about changes in the therapeutic process that could negatively impact therapy outcomes.
With regard to the connection between therapist and couple, the authors suggest therapists should be aware of the possibility that the therapeutic alliance could be less robust and take steps to guard against this. Simply acknowledging the differences presented in telemental health and being intentional about developing a therapeutic alliance is important. Regularly checking in with partners to ask about their experience in the online setting conveys care and concern about this issue and communicates intention to avoid it becoming a barrier.
Regarding the therapeutic process, Wrape and McGinn suggest providing structure around the therapy sessions. To this end, they recommend encouraging partners to treat telehealth sessions as they would in-person sessions by emphasizing the importance of beginning on-time and ensuring (as much as possible) a quiet time with few interruptions and both partners present for the entire session. Also, asking both partners to remain on camera throughout the entire session allows the therapist to observe their behavioral interactions. If established sessions guidelines are not followed, the authors encourage therapists to have a problem-solving discussion about it. It’s possible that non-adherence to guidelines could indicate some type of resistance to the therapy process or simply that the couple may not have anticipated some of the logistical challenges presented. Using this as part of the therapy can be a useful intervention.
To address decreased access to non-verbal information and cues especially around emotions and cognitions, the authors suggest asking questions such as “What are you feeling now?”, “What is coming up for you right now?” and “What thoughts are you having?” more frequently than one might during in-person sessions. Also, slowing down interactions and conversations and allowing each partner to respond helps keep both partners engaged. The authors suggest using each partner’s name when directing questions or comments to them. In the absence of eye contact and other non-verbal cues, being clear who the therapist is addressing can be a useful technique.
Benefits of online therapy with couples
Other than the obvious benefit of being able to access services during a time when in-person therapy is not available, Wrape and McGinn point out a number of additional benefits of online couples therapy. Drawing from research on context-dependent learning indicating that a person is better able to remember and use information when it’s presented in the same environment where it is first learned, the authors point out the advantages of learning skills while in the home. Use of telemental health may increase the likelihood that couples will utilize new skills learned in sessions because they feel more natural when they have first been practiced in an online session from home.
Also, numerous case studies and some small trials suggest that clients generally prefer the convenience online therapy provides and report feeling like it offers good benefits. It also has the ability to support couples who are physically separated from each other either in long-distance relationships or even military couples separated due to military duties. Offering telehealth couples counseling can expand the reach of therapy and accessibility of services.
Overall, telehealth therapy may be an important resource for many couples who are struggling now. Having therapists create a plan ahead of time to manage the issues and challenges that arise may be the key to ensuring the most effective outcomes.
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.
April Thompson, LCSW, is a clinical social worker currently working as a Cognitive Behavioral Therapy Trainer at the CDP at the Uniformed Services University of Health Sciences (USU) in Bethesda, Maryland.
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. https://doi.org/10.1111/jmft.12319