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

The transition to Teletherapy: Experiences of emotionally focused therapists

Emotionally focused therapy (EFT) is an evidence-based treatment for relational distress based on experiential, humanistic, and attachment theories. Despite the empirical support for EFT, there are no studies on EFT delivered via teletherapy. In this study, we aimed to understand therapists' experiences delivering EFT through teletherapy using open-ended questions on a web-based survey of certified EFT therapists (n = 69). Reflexive thematic analysis identified five themes: (1) Delivering EFT via teletherapy is similar to in-person therapy, (2) Delivering EFT via teletherapy is more challenging than in-person therapy, (3) Delivering EFT via teletherapy is more challenging with certain clients, (4) therapists adapted EFT for teletherapy, and (5) teletherapy and the COVID-19 pandemic changed therapy practice. The themes illustrated the mixed experiences of EFT therapists using teletherapy. Whereas some found it straightforward to use EFT via teletherapy with couples, others experienced exhaustion and barriers. Practice recommendations for delivering EFT via teletherapy are outlined, including modifying assessment strategies, implementing new safety protocols, and providing additional psychoeducation.

Lost in translation: Therapeutic Alliance as a mediator in the relationship between teletherapy and marital satisfaction

The global impact of the SARS-COV-2 pandemic necessitated a rapid shift to online/teletherapy psychotherapy services. While research suggests the feasibility and efficacy of teletherapy, there is limited investigation into couple teletherapy's impact on satisfaction and therapeutic alliance. This study aimed to address this gap by examining changes in couple satisfaction during tele- and in-person therapy sessions over 12 sessions and exploring whether therapeutic alliance development mediates these changes. Using growth curve modeling in a sample of 416 couples, it found that teletherapy participants initially reported higher couple satisfaction, but improvement in this domain was slower than in-person therapy recipients. The development of the therapeutic alliance mediated this effect via two indirect paths. Implications include the need for focused attention on alliance development in teletherapy and more empirically-informed approaches in couple teletherapy.

Evaluation of Online Counseling through the Working Experiences of Mental Health Therapists Amidst the COVID-19 Pandemic

This study aimed to reflect on mental health professionals' experiences with online counseling during the COVID-19 pandemic, as well as their perceptions and recommendations for the future. The method of qualitative research with semi-structured interviews was used. The sample consisted of 17 mental health professionals working in the public or private sectors. A framework analysis revealed four main themes, namely (a) the evaluation of online counseling; (b) comparing in-person and online counseling; (c) factors influencing the effectiveness of online counseling; and (d) suggestions for the future use of online counseling. Most therapists reported that their overall experience with online counseling was positive. The main advantages cited were the accessibility for everyone and the reductions in time, money, and distance. Its primary drawbacks included less nonverbal communication, the inability to employ certain therapeutic tools, problems with confidentiality, lack of experience, and technical difficulties during online sessions. Its effectiveness depends on contextual factors and factors related to the therapeutic process itself. Organizational planning, training, and a solid implementation strategy may help ensure that this communication medium is used to its fullest potential. In addition, the possible utilization of remote counseling combined with in-person psychotherapeutic intervention methods will provide solutions for the future, especially in crisis situations.

Tele-psychotherapy during the COVID-19 pandemic: a mini-review

The COVID-19 pandemic has dramatically changed psychotherapy practices. Psychotherapy around the world has shifted from predominantly face-to-face settings to overwhelmingly online settings since the beginning of the pandemic. Many studies have been published on this topic, but there has been no review of the literature focused on the experience of psychotherapists. Our goal was to identify the challenging issues of teletherapy, including the efficiency of online consultations and the extent to which they are accepted by therapists and patients. A PubMed literature search using the [("Teletherapy" OR "Telebehavioral health" OR "telepsychotherapy") AND ("COVID-19")] search string retrieved 46 studies focused on mental health professionals, as detailed in a PRISMA flow diagram. Two reviewers independently screened the abstracts and excluded those that were outside the scope of the review. The selection of articles kept for review was discussed by all three authors. Overall, the review contributes to the description and evaluation of tele mental health services, including teletherapy, online counseling, digital mental health tools, and remote monitoring.

"I miss not being able to offer my couples a box of tissues…": Couples' and Therapists' perspectives on the therapeutic Alliance with the transition to online couple therapy

The purpose of this study is to advance theory concerning the experiences of couples and therapists involved in online couple therapy and the meanings they assign to them, with a particular focus on the therapeutic alliance. Using constructivist grounded theory methodology, in-depth semi-structured online interviews were conducted with 36 individuals, including 18 couples who had participated in online couple therapy via videoconference. Additionally, 15 couple and family therapists were interviewed in four online focus groups. Our analysis indicates three dimensions that impact the formation of the therapeutic alliance in online couple therapy: (1) emotional closeness, as a conduit for establishing physical or emotional space; (2) limited care, due to the therapist's difficulty providing comfort and security; and (3) body language, as reflected in the lack of physical presence and the close inspection of the face, at two opposite ends of a continuum. We discuss our findings through the lens of the closeness-distance dynamic, which posits that therapists' ability to regulate themselves depends on their clients' emotional needs. We conclude with implications for clinical practice.

The Benefits and Challenges of Shifting to Telehealth During COVID-19: Qualitative Feedback from Kentucky's Sexual Violence Resource Centers and Children's Advocacy Centers

The onset of the COVID-19 pandemic presented novel challenges for service providers addressing mental health issues with a large shift to the utilization of telehealth. While previous research has examined the benefits and challenges of providing mental health and crisis services remotely through telehealth, little research exists examining the use of telehealth in children's advocacy centers (CACs) and sexual violence resource centers (SVRCs). CACs and SVRCs are multi-disciplinary agencies taking a holistic approach to addressing interpersonal violence, making them unique in that they provide a range of direct services beyond mental health counseling (e.g., legal advocacy, medical exams, and prevention education) but all geared toward public health and safety. The current study explored the experiences of direct service providers in Kentucky CACs and SVRCs and their opinions about the most significant challenges and benefits of adapting their practices at the onset of the COVID-19 pandemic. A total of 118 providers participated in the study, and 88 reported using telehealth (defined as communicating with clients via technology such as videoconferencing, phone calls, or email) since the onset of COVID-19. Qualitative data from those 88 respondents regarding the challenges and benefits of using telehealth were collected and coded using a thematic content analysis. 78.6% of the sample indicated that they served primarily rural areas. Benefits noted included increasing treatment access, increasing treatment flexibility, and advancing continuity of care, while challenges included difficulties with technology, client engagement, privacy, and logistical challenges. Responses highlighted that telehealth presented both a number of advantages and difficulties and that more formal guidance for providers at CACs and SVRCs was desired.

Couple therapy in the 2020s: Current status and emerging developments

This paper provides a critical analysis and synthesis of the current status and emerging developments in contemporary couple therapy. Its narrative centers on the evolution of couple therapy into a prominent intervention modality and coherent body of practice. The review begins with the consideration of the field's strong empirical underpinnings derived from research on couple therapy and basic relational science. Couple therapy comprises the widely accepted method for reducing relationship distress and enhancing relationship quality. Moreover, both as a stand-alone intervention and in conjunction with other treatment formats, couple-based interventions have garnered considerable empirical support for their effectiveness in addressing a broad spectrum of specific relational dysfunctions as well as individual emotional and physical health problems. We highlight the convergence of methods through common factors, shared strategies, and remarkably similar arrangements across approaches. Our review also points to key differences among approaches, the importance of recognizing respective strengths and limitations linked to these differences, and building on differences across models when selecting and tailoring interventions for a given couple. The discussion concludes with a consideration of recent trends in the field including the impact of telehealth and related digital technologies, the expansion of specific treatments for specific problems and diverse populations, the interface of couple therapy with relationship education, and enduring challenges as well as new opportunities addressing broader systemic and global dynamics.

Online clinical supervision in couple and family therapy: A scoping review

Online clinical supervision, or telesupervision, is a growing practice in couple and family therapy. This scoping review aims to identify and synthesize the existing body of knowledge regarding the utilization, experiences, and perceptions of telesupervision among the couple and family therapists and to highlight gaps in the literature. The review followed the five-step approach proposed by Arksey et al. (2005). Fifteen articles were included and their analysis yielded four themes: 1. telesupervision competence; 2. setting and boundary management; 3. advantages of telesupervision; and 4. challenges of telesupervision. Our review clearly demonstrates the dearth of available conceptual and empirical work. The rapidly growing use of online therapy and telesupervision in couple and family therapy has created a critical need to expand this body of knowledge by collecting evidence that can later be translated into practice. Moreover, we identified several gaps in the existing body of knowledge, including a lack of reports on the efficacy of telesupervision and on the experiences, processes, and ascribed meanings of the supervisors and supervisees. We also noted a lack of practice and ethical guidelines for telesupervision. We conclude our analysis by suggesting areas and directions for further investigation.

Healthcare Professionals' Experience of Performing Digital Care Visits-A Scoping Review

The use of digital care visits has been increasing during the COVID-19 pandemic. Learning more about healthcare professionals' technology experiences provides valuable insight and a basis for improving digital visits. This study aimed to explore the existing literature on healthcare professionals' experience performing digital care visits. A scoping review was performed following Arksey & O'Malley's proposed framework using the Preferred Reporting Items for Systematic reviews and Meta-Analyses. The collected data were analyzed using thematic content analysis. Five main themes were identified in the literature: positive experiences/benefits, facilitators, negative experiences/challenges, barriers, and suggestions for improvement. Healthcare professionals mostly reported having an overall positive experience with digital visits and discovered benefits for themselves and the patients. However, opinions were mixed or negative regarding the complexity of decision making, workload and workflow, suitability of this type of care, and other challenges. The suggestions for improvement included training and education, improvements within the system and tools, along with support for professionals. Despite overall positive experiences and benefits for both professionals and patients, clinicians reported challenges such as physical barriers, technical issues, suitability concerns, and others. Digital care visits could not fully replace face-to-face visits.

Intimate Relationships and Coronary Heart Disease: Implications for Risk, Prevention, and Patient Management

PURPOSE OF REVIEW

Research and clinical services addressing psychosocial aspects of coronary heart disease (CHD) typically emphasize individuals, focusing less on the context of intimate relationships such as marriage and similar partnerships. This review describes current evidence regarding the role of intimate relationships in the development, course, and management of CHD.

RECENT FINDINGS

Having an intimate partner is associated with reduced risk of incident CHD and a better prognosis among patients, but strain (e.g., conflict) and disruption (i.e., separation, divorce) in these relationships are associated with increased risk and poor outcomes. These associations likely reflect mechanisms involving health behavior and the physiological effects of emotion and stress. Importantly, many other well-established psychosocial risk and protective factors (e.g., low SES, job stress, depression, and optimism) are strongly related to the quality of intimate relationships, and these associations likely contribute to the effects of those other psychosocial factors. For better or worse, intimate partners can also affect the outcome of efforts to alter health behaviors (physical activity, diet, smoking, and medication adherence) central in the prevention and management CHD. Intimate partners also influence-and are influenced by-stressful aspects of acute coronary crises and longer-term patient adjustment and management. Evidence on each of these roles of intimate relationships in CHD is considerable, but direct demonstrations of the value of couple assessments and interventions are limited, although preliminary research is promising. Research needed to close this gap must also address issues of diversity, disparities, and inequity that have strong parallels in CHD and intimate relationships.

The Feasibility of Providing Remote Functional Family Therapy with Adolescents During the COVID-19 Pandemic: A Mixed-Method Study

Background

Due to the recent COVID-19 pandemic, mental health care has largely transferred its services to online platforms, using videoconferencing (VC) or teletherapy. Within the field of family therapy, however, there is little evidence on the feasibility of using VC, especially when working with whole families at the edge of care.

Objective

This study investigated the feasibility of remote Functional Family Therapy (FFT), using a mixed-method approach.

Method

Study 1 consisted of semi-structured interviews with 23 FFT professionals (18 female) about their experience of providing remote FFT during the COVID-19 pandemic. Study 2 included monitoring data of 209 FFT clients (46% female, M age  = 14.00) who participated in FFT during the pandemic. We compared families who received mainly in-person, mainly remote or a mix of remote and in-person on client-reported alliance, drop-out, therapist-rated outcomes, and treatment intensity using MANCOVA's and chi-square tests.

Results

In Study 1 two themes emerged around experienced challenges, namely 'Feeling in control' and 'Engagement and alliance'. Two other themes emerged around adaptations, namely 'Being more on top' and 'Connecting in different ways'. In Study 2, we found that the therapeutic alliance was not related to using VC. Also, families had less between-session contact during the Engagement and Motivation Phase when receiving mainly VC, but had more sessions and longer therapy when receiving a mix of in-person and remote therapy.

Conclusions

The current study suggests that providing systemic family teletherapy to families on the edge of care is feasible. Further development of systemic family teletherapy is warranted.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10566-022-09692-y.

Conducting Couple Therapy via Telehealth: Special Considerations for Virtual Success

Couples may experience any number of barriers to in-person couple therapy, including scheduling difficulties, childcare needs, and stigma. Providing couple treatment via telehealth can address these obstacles and improve accessibility. However, couple therapists considering the transition to telehealth may be unsure of how to alter their current treatment approach for remote delivery. Further, there are often specific concerns of how to handle safety concerns or high-conflict couples via telehealth. The goal of this paper is to provide concrete suggestions, from pre-treatment screening through treatment, for how to conduct successful couple therapy via telehealth.

"There is Just a Different Energy": Changes in the Therapeutic Relationship with the Telehealth Transition

The therapeutic relationship (TR), including its therapeutic frame, is the foundation of the therapeutic endeavor. In response to the COVID-19 pandemic and the rapid transition to videoconferencing for therapeutic encounters, we employed a cross-sectional exploratory survey with 1490 respondents to understand how practitioners adapted to the changes. In this secondary analysis focused on the TR, we analyze the clinicians' (N = 448) spontaneous narratives about facets of the TR. Temporally, we focused on how these adaptations occurred during the initial part of the pandemic before vaccination was available and while the TR was still adapting to teletherapy videoconferencing under the duress of pandemic crises. We find three broad themes: (1) It is a "much more remote relationship"; (2) The "connection…remains surprisingly strong"; and (3) It is "energetically taxing." Each reflects clinicians' views of the TR as altered, but surprisingly resilient. Although grateful for the safety of virtual therapeutic encounters, clinicians mourned the loss of an embodied encounter, experienced depletion of energy beyond Zoom fatigue, and nonetheless recognized their clients' and their own abilities to adapt.

Continuation of teletherapy post COVID-19: Survey data from licensed mental health professionals (Preprint)

Background

The use of teletherapy has exponentially increased in the context of the ongoing COVID-19 pandemic. Studies on teletherapy documented substantial benefits of accessibility and convenience even before the start of the pandemic. Although recent studies show that this modality of therapy delivery is here to stay, few have studied who will most benefit from this trend.

Objective

In this paper, we report predictors of continued teletherapy usage in a sample of licensed mental health professionals in the United States during a time period when pandemic-related restrictions began diminishing. As such, it is one of the first studies to examine factors related to continued benefits of teletherapy postpandemic.

Methods

Participation from licensed mental health professionals was sought on listservs of national organizations of multiple mental health organizations. Data were collected via an anonymous link to a survey on Qualtrics between January 2021 and April 2021. Participants responded to questions on therapist demographics, practice setting, experiences of shifting to teletherapy, perspectives on continued use of teletherapy, and their client characteristics. Findings related to client characteristics that predicted continued teletherapy usage are presented here.

Results

A total of 186 individuals consented to participate in the survey, with a final sample of 114 with complete data. A majority of participants identified as female (92/114, 80.7%), White (94/114, 82.5%), and having a master's degree (75/114, 65.5%) from a nationally accredited program (106/114, 93%). Data were analyzed using heteroskedastic regression modeling with client-related factors as predictors. Two models were run with and without distance travelled by clients as a control variable. Model estimates from both models showed that continued use of teletherapy postpandemic was predicted by the following factors: higher percentage of clients from rural areas, younger and older adult clients, clients with Medicare, and clients with marginalized gender and religious/spiritual identities. Significantly, having a higher percentage of clients from lower socioeconomic status, a higher percentage of those with Medicaid coverage, and a higher percentage of couples and families as clients predicted decreased use of teletherapy postpandemic.

Conclusions

Findings from the study suggest that while some groups of clients are more likely to continue to receive benefits of teletherapy, vulnerable groups such as those in lower socioeconomic conditions, Medicaid beneficiaries, and those who seek couple and family therapy may be less likely to be served by it. These differences point to a need to address factors driving telehealth care disparities such as access to technology, housing, and childcare issues, as well as the need for continued training for licensed professionals.