Clinical Vignette

Liz and Phil, a married couple in their mid-thirties, present to you for treatment of relationship distress. Liz reaches out to make the initial appointment, and reports that they have been struggling lately and need to work on their communication. They have been married for 8 years and have two children, ages 6 and 4. Both Liz and Phil have demanding jobs and she states they both feel overwhelmed with household tasks and childcare when they come home. They find it difficult to connect and it seems like they can’t talk about anything anymore without it turning into an argument. Liz tells you that she hasn’t felt fulfilled in the relationship for approximately two years and while she and Phil have discussed therapy in the past, they have found it too difficult to work into their schedule. She wonders if you would be able to treat them via telehealth.

Clinical Challenge

Even prior to the pandemic, accessibility has been a considerate barrier to treatment for couple therapy (Doss et al., 2017; Wrape & McGinn, 2019). Difficulties in finding overlapping availability for both members of the couple and therapist as well as childcare scheduling may preclude couples from engaging in in-person treatment. Couple therapy delivered via telehealth is one method of increasing accessibility and empirical research supports its efficacy (Borcsa & Pomini, 2019; Treter et al., 2021; Wrape & McGinn, 2019). It is worth noting that cost is also a significant obstacle for many couples as insurance companies rarely cover treatment for relationship distress (Doss et al., 2017). Although this barrier is not automatically addressed through remote treatment, it would be remiss to leave this issue out of a discussion on access to care for couple therapy. The COVID-19 pandemic has increased these barriers with many couples facing increasing financial instability, the abrupt need for homeschooling children, and a lack of work/life boundaries (Pietromonaco & Overall, 2021, 2022). Given that the pandemic has also created additional stress for romantic couples, including lack of outside childcare, separation from support systems, and health-related stresses, effective, flexible couple therapy is currently of paramount importance (Pietromonaco & Overall, 2021, 2022).

It is important to note that while many clinicians offer couple therapy services, few have received formal training in couple therapy as a modality. Dyadic intervention and case conceptualization are specialized skills that require didactics beyond common individual therapeutic tools. Many evidence-based couple therapies have formal training and credentialing processes that may be completed in person or online and there are several excellent texts that may help provide a foundation to approach couples work (e.g., Christensen et al., 2020; Epstein & Baucom, 2002; Johnson, 2019). Developing a dyadic approach may be useful for health service psychologists more broadly as couple-based interventions for individual treatment may be more effective than individual treatment alone for many health conditions. Dyadic treatments for health concerns as varied as anorexia nervosa, breast cancer, smoking cessation, and alcohol use disorder (AUD) have garnered empirical support and the list continues to grow (Baucom et al., 2017; Brandão et al., 2014; Epstein & McCrady, 2002; Haskins et al., 2021).

As therapists have transitioned to telehealth platforms during the pandemic, many practitioners report that remote therapy has been a positive experience and that they plan to continue offering telehealth options in addition to in-person treatment in the future (Hardy et al., 2021; Machluf et al., 2021). Preliminary research suggests that perceptions of the difficulties of couple therapy via telehealth influence the likelihood of conducting such treatment (Machluf et al., 2021), and therapists frequently cite concerns about how to effectively navigate issues of safety, build rapport, and manage high-conflict couples during remote treatment (Glass & Bickler, 2021; Hardy et al., 2021; Machluf et al., 2021). The goal of this paper is to provide suggestions for effective couple therapy via telehealth particularly within these main areas of concern.

The most significant difference between conducting couple therapy via telehealth as opposed to in person is control over the therapy room. During a telehealth session, you are often remotely joining two people who are in the same physical location making it more difficult to interrupt interactions or manage disruptive behaviors than if you were all in the same space together. Consequently, many of the suggestions presented here will be focused on setting expectations and preventing problem behaviors before they occur. Suggestions are presented in chronological order: pre-treatment, session one, and treatment.

Pre-treatment

Screening

Effective telehealth work with couples begins before treatment officially commences. Many manualized couple therapies include an assessment period in the early stages of treatment (Benson et al., 2012). The information obtained during this period is typically used in two ways: (1) to determine if the couple is appropriate for the treatment being offered, and (2) to develop the couple’s case formulation and treatment plan. When seeing a couple for telehealth, it may be more beneficial to determine the couple’s fitness for treatment prior to session 1 to ensure that there are no safety concerns before engaging in a remote session (Wrape & McGinn, 2019). This screening should be relatively short, typically around 15 min at the most, and should be conducted with each partner separately. It is often most effective to schedule a time to talk to each person when they will already be alone or away from their partner. This brief screening conversation will cover several sensitive topics and speaking to each partner individually serves to protect their privacy and provide the opportunity to disclose more fully.

Pre-treatment screening for telehealth is similar to screening for in-person treatment. Always assess the presence of interpersonal violence (IPV) with each partner. IPV is contraindicated for some couple therapy modalities while others may be appropriate for only certain forms of IPV, such as low-level bidirectional IPV (Hurless & Cottone, 2018; Wrape & McGinn, 2019). Having a thorough understanding of how violence presents within each couple is crucial to determining if the couple is a good fit for remote treatment. This is best assessed through specific, behaviorally based questions presented without judgment. If either partner endorses historical violence in the relationship, gather additional details about the intensity, frequency, and directionality of the violence as well as when it last happened.

It is also necessary to assess cognitive capacity for treatment. Screen for active suicidal or homicidal ideation, as well as any active psychosis or cognitive issues. Finally, assess for any ongoing alcohol or substance use disorders. There are no specific guidelines to determine the level of alcohol or substance use that precludes individuals from engaging in treatment but, at a minimum, partners must be able to be sober during sessions and have the capacity to implement the skills being taught in therapy. If there are concerns, it may be more appropriate to refer individuals to treat the substance or alcohol use disorder before engaging in couple therapy. If alcohol use disorder (AUD) is of concern, they may benefit from Alcohol Behavioral Couple Therapy, an empirically supported couple-based treatment for AUD (Epstein & McCrady, 2002).

In addition to these common screening questions, there are some additional considerations for determining a couple’s appropriateness for telehealth. Ask each partner about any issues that may impede communication via telehealth. Possible concerns could be visual or hearing impairments, history of traumatic brain injury that may make excessive screen time difficult, or language barriers that may become more difficult in a telehealth setting. While these issues may not disqualify a couple from telehealth treatment, they may require advance planning. For example, clients with hearing impairments or who speak English as a second language may benefit from an interpreter for sessions. Overall, even though much of the screening process is the same for in-person and telehealth treatment, practitioners may consider lowering the threshold for exclusion for telehealth treatment vs. in person treatment. For example, a couple with moderate IPV may be appropriate for in-person treatment but could feel too risky to see via telehealth where the therapist is less able to control the room. Similarly, couples who are too volatile to engage in productive conversation on areas of conflict may not be appropriate for telehealth treatment. These are individual decisions based on each practitioner’s comfort level.

Setting the Stage for Treatment

Once a couple has been deemed appropriate for telehealth-based treatment, there are several additional steps that may be implemented to ensure a smooth start to treatment. First, consider preparing in advance for potential technological issues. New patients are often anxious and uncertain in the best of circumstances, let alone when factoring in the stress of starting the first session late due to issues with the appointment platform. To circumvent this, consider adding extra time to orient patients to telehealth. This can be in the form of a brief 10–15-min tech check prior to the first appointment or scheduling the initial session for 90 min (or adding 30 min to your usual appointment length). Let the clients know that this buffer will be built in to the first session when scheduling so even if there are difficulties connecting for the appointment, you will still have sufficient time to cover the session’s material together.

Another technological consideration prior to treatment is how to incorporate measurement-based care (Wrape & McGinn, 2019). Some options will depend on the software used for your therapy practice records. If this software is used to send and receive intake forms, it could be possible to send links to clients to complete their pre-session assessments the same way. When using this approach, consider keeping separate charts for each client so that each partner only has access to their own measures within their medical record. In this case, enter an identical note into each chart after each session as well. Alternatively, encrypted email may also be used for measures. If responses are going to be shared during the session for treatment purposes, partners may choose to read their responses aloud or print off the measure and hold it up to the camera.

Finally, the same best practices for telehealth with individuals apply to couples as well. Choose a neutral background for your video if possible and consider adding some sort of ring light or other computer light source so that you are well lit. Wearing headphones may make patients feel that their privacy is more protected. Additionally, if you are working from home or in a shared office space, it may be worth investing in a white noise machine to ensure privacy for the session. Finally, remember to engage in self-care practices throughout the day (Hardy et al., 2021). This may include brief hourly screen breaks, longer scheduled screen-free periods, incorporating movement throughout the day, or spacing sessions further apart.

Session One

Early Expectation Setting and Troubleshooting

As previously discussed, the one significant disadvantage when providing couple therapy via telehealth is that it is more difficult to control the room remotely. As such, one of the overarching goals in this paper is to provide more structure early in treatment so that disruptive behaviors and patterns do not have a chance to develop. Once therapy begins, consider explicitly discussing expectations and best practices for engaging in therapy. Many patients will have never participated in therapy of any sort, let alone therapy through telehealth. Thus, it is important to help clients identify and troubleshoot common issues that may arise before they become a concern.

First, help identify common behaviors that may impact full engagement in treatment. Clients may feel more casual in their home than they would in your office, but it is important that the couple treat these sessions as they would any in-person appointment. Some points to emphasize may be that clients should be fully dressed (casual clothing is appropriate, but not pajamas or bare torsos), and seated upright. Although couples may need to conduct session in their bedrooms for privacy, discourage lying in bed during session. Lastly, ask the couple to minimize any potential distractions within their setting. This means no eating meals or drinking alcohol during session and all screens should be turned off with phones put away. If a couple is particularly concerned about being able to be reached during session, perhaps one person can leave their phone on in a far corner of the room. Or perhaps the couple can give their babysitter your office phone number in case of emergency. The goal for these guidelines is not to be rigid but to encourage maximally productive sessions. As such, feel free to be creative or make adjustments on a case-by-case basis. For example, for some tobacco-using couples, smoking cigarettes during session may encourage engagement by reducing nicotine withdrawal, but for others cigarettes may be used as a distraction or tool for withdrawal from difficult conversations. Engage the couple in problem-solving potential distractors as well.

Similarly, allot a few minutes early in treatment to troubleshoot possible privacy disruptors with clients. Having a plan to deal with any children in the home during session is of particular importance. Ultimately, the ideal solution will both preserve the privacy of the session for the couple and protect children from hearing any discussions or conflicts they may find upsetting (van Eldik et al., 2020). Depending on their age, children may need a babysitter. Otherwise, children may engage in an activity while wearing headphones but try to avoid planning an activity for the children that involves streaming any sort of entertainment if possible so wifi speed is preserved for the session. Using a white noise machine or a white noise app on a phone placed outside of the door will provide additional privacy. If needed, couples can be creative about their location. As mentioned previously, many couples choose to complete therapy sessions in their bedrooms, but they could also go to a garage or shed area, or even sit in a parked car outside the house for session depending on the weather. In addition to making a plan to deal with children in the home, plans should be made for pets in the house as they may also be a source of distraction during session. If possible, pets should be kept out of the room during session and walks or feeding times should be adjusted to better ensure an interruption-free session.

In couple therapy, attending to nonverbal cues is extremely important, particularly when gauging one partner’s reaction to the other partner speaking (Benson et al., 2012; Wrape & McGinn, 2019). As such, some additional tips may help ensure optimum video quality. First, the device with the camera should be resting on a stable surface rather than handheld. In addition to creating poor video quality, the client holding the device will be more distracted during session. Adjust the camera angle so that you can see both partners in the same frame as much as possible before session begins. Finally, make a backup plan with clients for what will happen if there are connectivity issues. Although turning off video can help with internet stability, we want to preserve our view of the patients whenever possible. If connectivity becomes an issue, try leaving the video on mute and calling the client on speakerphone for audio. Only disable the camera if absolutely necessary. While an audio-only session may merely be an annoyance when working with some couples, it is also possible that not being able to see the clients over video is a reason to cancel the session. For example, some partners will give only nonverbal signals they are becoming activated during a discussion prior to an outburst. In such a case, engaging in a session without visuals could be iatrogenic.

Orienting the Couple to Treatment

Now that the couple has created plans for dealing with distractions and disruptors, the last piece of the puzzle is to provide the couple a framework for treatment. The first, and perhaps most surprising suggestion, is to ask each partner to speak to you directly rather than to their partner during session. Additionally, when each partner is speaking, there is a firm “no interrupting” policy. This certainly does not mean that partners are not allowed to address each other at all during the treatment. However, particularly in early sessions, couples may be too distressed to work through their conflict productively with one another. The inability to engage in productive communication is often a driving force behind couples seeking treatment in the first place. One of the primary goals of couple therapy is to break unhelpful communication patterns in which the participants have become stuck (Benson et al., 2012; Davis et al., 2012). If the couple has the same frustrating experience of trying to communicate with their partner and making no progress during session, that may create a feeling of hopelessness and a belief that therapy will not be effective. Early in treatment, the primary goal is for the therapist to gain a full understanding of what is driving each partner’s behavior and for each partner to feel heard, understood, and validated by the therapist. The long-term goal of treatment is for partners to fulfill this role for each other, and having this process modeled by the therapist is a principal mode of teaching these behaviors. The suggestion to have partners speak to the therapist rather than each other becomes more salient in telehealth appointments. As discussed throughout this paper, it is much more difficult to interrupt a couple who has begun to engage in an unproductive communication pattern with each other via telehealth. When each partner is primarily speaking to the therapist, this becomes much easier to manage. It is important to set this guideline at the outset while providing the reasoning behind this request.

Since this approach means one person will be listening to their partner and the therapist talk for portions of the therapy, it is helpful to underscore the importance of listening when the partner is talking. Well-meaning individuals may think of those interactions as being their partner’s “time” and start to do other things instead of actively listening to what is happening. Be clear that this is not a time to do other tasks or to disengage from the conversation. Also set the expectation that session will be paused if both partners aren’t present. If one partner is speaking, that is not a good time for the other partner to take a bathroom break or check on the children. If something like that needs to take place, the session will be paused until both partners are back in the room. While this could seem like an arbitrary boundary, speaking to one partner without the other present can create rapport issues during treatment. If one partner leaves the room, both the therapist and the remaining partner can engage in activities on their own until the partner returns. Exceptions to this rule may be made for high-conflict couples. These exceptions are discussed in detail in the “Adjustments for High-Conflict Couples” section.

Safety Considerations

Telehealth treatment necessitates additional safety considerations, which require additional planning early in treatment. You may already have this in your records from your pre-treatment screening, but be sure to obtain contact information for each partner when treatment begins. In the rare case of an emergency or a turbulent session, you may need to be able to check in with participants separately. Similarly, if the patient record has been created in one partner’s name, make sure there is a signed release on file for the other partner so both have access to their treatment file. Finally, ask in advance if there is a family member the couple wants contacted in case of emergency. If so, have them sign a release of information and provide contact information for that person.

At the start of each session, ask for a physical address for the couple, or each partner if they are in separate locations. Gathering this information serves multiple purposes. In case of an emergency, you will be able to call the appropriate emergency services. Remember that using 911 will connect to local services only. If the clients are in a different county or state, look up their local law enforcement and call them directly in case of emergency. Asking for a physical address also ensures that participants are in one fixed location rather than trying to engage in a therapy session while driving. Attending a session while driving decreases engagement in the session, increases risk of accidents, and impedes sending emergency services if needed. Finally, depending on the state of licensure, you may or may not be able to conduct session with clients in other states. Participants aren’t often aware of these restrictions and may not inform their provider they will be joining session from a new setting. Obtaining a physical location at the start of session will prevent any accidental breach of state regulations.

Treatment

Altering Treatment for Telehealth

As treatment begins, it may be helpful to consider changing some elements of treatment to encourage productive telehealth sessions. For example, Integrative Behavioral Couple Therapy (IBCT) treatment usually focuses on acceptance work early in treatment rather than change-based behavioral strategies (Benson et al., 2012; Jacobson et al., 2000). However, given that it is harder to regain control of the session in telehealth, it may be more beneficial to review some behaviorally based skills, such as rules for effective and ineffective communication, early in treatment. Adjustments may be needed to keep both partners engaged throughout a telehealth session. For example, consider keeping each partner’s talking turn shorter in telehealth than you would in an in-person session, or check in to get the partner’s response to what they’re hearing more frequently. Additionally, therapeutic common factors (e.g., therapeutic alliance, positive regard, empathy, and collaboration) are a significant factor in couple therapy success and some small adjustments may increase their benefit in telehealth settings (Davis et al., 2012). It may be helpful to increase validation of the partner who isn’t speaking, particularly if they tend to withdraw when they are upset. Implement this strategy early rather than waiting until the listening partner is visibly upset since it may be difficult to see subtle nonverbal cues on video. The goal is to avoid having someone withdraw from the conversation completely or become so agitated they have an outburst. Finally, it may be helpful to spend more time building rapport early in treatment before pushing for discussion on sensitive topics. Although it is important to not help couples engage in avoidance, the barrier to exit is much lower for a telehealth session than in person. In other words, it may take less for a client to decide to close their laptop than to walk out of a therapist’s office.

Adjustments for High-Conflict Couples

It cannot be overstated that the main difference between seeing couples via telehealth vs. in person is that the therapist has less ability to control a room they are not in. This is especially difficult when working with high-conflict couples. One common scenario that can present when treating a high-conflict couple remotely is that the couple will turn to each other during session and engage in a conflict while the therapist tries to interrupt from a computer screen. For couples where this is a common issue, consider instituting some sort of signal to halt the conversation. This could be a hand signal (e.g., time out sign, waving hands), a specific word, or a noise (e.g., a whistle, bell, gong sound). When this signal is employed, all conversation stops and both partners look at the therapist. If this strategy does not work, it may be helpful to have participants join the session from separate rooms. This guarantees all communication is occurring through the screen and the therapist may have an easier time intervening when needed.

If a couple is still struggling to make it through sessions without being sidelined by unproductive conflict, consider implementing separate sessions for each partner or breaking out from session with each partner. When using this method, it is imperative that time spent with each partner is balanced. In other words, if you meet with one partner individually, you must at least offer to meet with the other partner individually for the same amount of time. Set ground rules for the confidentiality in individual sessions at the outset. Any individual communication with either partner is in the service of couple therapy. As such, make it clear that you will not keep secrets between partners and anything said to you in an individual discussion may be referenced in a conjoint session. If someone wishes to tell you something they don’t want shared with their partner, they must tell you in advance and you can work with them to develop a plan to share this in session with their partner.

On rare occasions, a conflict may become so intense during session that it becomes appropriate to separate the couple and speak to them each individually. If this happens, the same guidelines apply and you should speak with both partners. Be intentional about who you choose to speak to first. It is usually advisable to start by speaking to the more dysregulated partner to avoid the risk of increasing dysregulation while you speak to their partner. If possible, this individual conversation should be used to provide some emotion regulation techniques so that both partners can rejoin the conjoint session. If this is not possible, discuss a strategy for what will happen after the session ends. Will they take a time out before talking again? Will one person engage in an activity to cool off such as a walk around the block? If this happens more than once and the couple is unable to regulate enough to stay engaged in session, they may not be a good fit for telehealth and instead may be encouraged to attend in-person sessions. As their communication improves, you may decide they can resume remote sessions if they prefer.

Clinical Application

Pre-treatment

Returning to Liz and Phil, the couple from our opening vignette, Liz has just asked if seeing she and Phil for remote therapy may be an option.

Therapist: I do offer telehealth sessions. If you have a few minutes, I can ask you some basic questions to see if it seems like you and Phil may be a good fit for remote therapy with me. Is now an ok time? Are you in a private setting where we can chat?

Liz: This is a good time to talk.

Therapist: Sometimes when couples are very distressed, things can get pretty intense during arguments. What is the worst it’s gotten for you? Has anyone yelled, thrown things, slapped, or hit?

Liz: Phil and I have raised our voices or called each other names, but our fights have never become physical.

Therapist: Have the police ever been called due to an argument?

Liz: No, never.

Therapist: Do you have any ongoing child protective service investigations?

Liz: No.

You continue with the screening questions and Liz doesn’t report anything of concern to you. You let her know that based on your discussion it’s possible that she and Phil could be good candidates for telehealth. You ask Liz to have Phil call you at his convenience and leave you some times that he will in a private location and available to answer questions. After speaking with Phil, you decide to schedule the couple for their first telehealth appointment.

Session One

Therapist: Now that we have covered all of our housekeeping items, I want to give you some insight into how our sessions will operate. I know you told me that you currently feel frustrated with your communication and want to work on that. To do that, I am going to ask that each of you to talk to me rather than to each other when we are discussing a conflict. I want to make sure that I fully understand what was happening for you when the conflict happened and what is happening for you now as we talk about it. I know it may be a little awkward, and we won’t do it this way for the entire treatment, but for now it’s important that we change up the way you usually communicate. I promise I will save space in each session to hear from both of you so you will get your turn to share and respond to what’s being said. Although I may not be able to ensure that you both get to speak 50% of the time in each session, my goal is to make sure that you have equal time across sessions. Do you have any questions?

Phil: So we aren’t allowed to talk to each other at all during the session?

Therapist: Not exactly. I still want all three of us to work together in session. But when we are discussing conflict in particular, you will be explaining to me what happened along with your thoughts and feelings. It will be important for you to be able to explain how you felt, and it will be just as important for you to hear how your partner felt. It’s not uncommon for couples to assume they understand their partner’s thoughts and intentions. When couples start to feel distressed, they make increasingly negative assumptions about their partner’s motives. As you listen to your partner, you may learn new information about their own experience during your conflicts. This means it’s important for you to be as engaged when your partner is speaking as you are when you’re speaking. As we get further into treatment, you will be able to understand each other better and your communication will improve. As that happens, I will talk less and less in session and the two of you will talk to each other more and more.

Treatment

Early in treatment, Phil and Liz are quick to fall into their typical communication pattern and there is a session where it takes you several minutes to successfully interrupt a particularly heated argument. Once the argument has stopped, you discuss how important it is to not repeat this occurrence.

Therapist: I think that there is a lot of progress that we can make together in treatment. Unfortunately, that will be difficult to do if I am spending so much time in session trying to be heard. Let’s come up with some sort of signal to help you recognize when you have fallen into your pattern and I need you two to disengage. This could be anything—a word, a noise, a hand gesture—anything at all. What would you like to try?

Liz: A noise of some sort might be helpful. I don’t know if I would hear a specific word when I get that frustrated.

Phil: I agree. I wonder if we could try something silly or unexpected? That could help us snap out of it.

The three of you decide to use theme music from one of their favorite sitcoms as a signal that their conversation has become unproductive. You use this strategy in the next session and it not only successfully interrupts the conflict, it also eases the tension in the session.

After two more sessions, you no longer need to use the music and the couple is starting to lessen their emotional reactivity to their conflict. A few sessions later, each partner has become more skilled at understanding their own feelings and behaviors and they are learning how to explain their experience to their partner. As these communications improve, you are able to transition your role in session to providing support when needed as Liz and Phil work together to understand their roles in their conflict and problem solve as needed. By the time you finish therapy, Liz and Phil have reconnected with one another. Although they still don’t agree on everything, and occasionally experience conflict, they are able to approach these topics as a team, with the goal of understanding the other person’s position rather than hoping to win an argument.

Conclusions and Key Clinical Takeaways

Although working with couples via telehealth may require some adjustments to the typical in-person treatment, many of the skills and techniques that work well for in person couples still apply. The transition to telehealth is not a matter of reinventing the wheel, but rather taking what you already do and tweaking it for a new platform. When adjusting treatment for telehealth, be creative and flexible (Kendall & Frank, 2018). As discussed previously, because you will potentially have less ability to intervene and redirect behaviors in telehealth, it is important to be proactive rather than reactive. This goal can be achieved by investing more effort in the pre-treatment and early treatment stages of therapy to set expectations and implement guidelines. Key clinical considerations for the early stages of treatment are summarized in Table 1. Even with all of your preparation and planning, difficulties may still arise. When this happens, successful telehealth may require more flexibility and creativity in problem-solving. Engage the couple in brainstorming solutions as well. Finally, if you are working with a couple who really needs to be seen via telehealth but struggles to make it through sessions together in a productive way, consider seeing each partner separately with the ultimate goal of conjoint sessions.

Table 1 Summary Clinical Considerations