Dr. Carmilla Solomon
Does online couples therapy work? Before I can fully answer this question, let’s first talk a little about what couples therapy is.
A Definition of Online Couples Therapy
By its very nature, the definition of couple’s therapy is a form of mental health counseling used to treat relationship distress, such as poor communication skills, incompatibility or a wide variety of other psychological disorders. Its purpose is to restore functioning to the coupled relationship and address the reasons for the distress in the first place.There are several different theories of couples-based therapy treatments that have proven to be effective in various forms. According to the Encyclopedia of Mental Disorders (www.minddisorders.com) below are some of the more commonly used models for treating couples.
This is by no means an exhaustive list of all of the different schools of thought related to couples therapy, but just an idea of what types of therapeutic practices your particular therapist might employ.
- Traditional behavioral therapy which focuses on behavioral change, communication, and problem-solving.
- Psychoanalytic therapy where the focus is on unresolved childhood conflicts with parents and how these are part of the current relationship problems
- Emotionally focused therapy that assists couples in learning how to acknowledge and express emotions that are related to their distress
- Integrative behavior therapy helping couples to improve behavior exchange and communication; examines problems and interactions that are repetitious that cause marital problems
- Cognitive behavioral therapy which helps relationships improve by increasing positive interactions between the couple.
Perissuttie and Barraca (2013) state that traditional behavior therapy isn’t really effective for severely distressed or emotionally disengaged couples. Rather than change, a more effective treatment would be an emphasis on emotional acceptance and tolerance. What is acceptance within couple’s therapy?’
It’s empathic joining (partners expressing their pain without blaming or accusations) and unified detachment (helping each partner detach self from conflict and emotionally laden discussions) (Perissutte et al, 2013). This is typically used with couples who are working through infidelity issues.
In the past, online or “e-therapy” was frowned upon and in some states, was illegal. There was concern that electronic connections did not allow for effective therapy or as effective as in-person therapy (Heitler, 2014). In addition, most licensing boards did not recognize online therapy and all therapists must be licensed in the state they lived in.
In recent years, however, these restrictions have slowly been lifted to allow for more access to therapy in an online format. For example, if one does a basic Google search, you can find several different online platforms in which therapists are able to connect with clients who specifically want an online therapist.
Individuals are now able to connect with a therapist outside of where they live, at a lower cost, with a stronger perceived sense of privacy. Individuals like the convenience of therapy in the privacy of their homes or now, via email. Yes, one can do therapy via email. I’ll explain this a little more later!
In couple’s therapy, there are ongoing yet subtle non-verbal and verbal cues that a therapist must be aware of and take note of, such as difficulty maintaining eye contact with each other and the therapist on a computer screen. In my own private practice, having worked with 2 couples in an online format, I found this to be one of the most difficult aspects of doing therapy. Couples and therapists can easily become distracted by what is happening around them.
One of my couples typically had the children in the same room in which the session was taking place and the other couple typically sat in the kitchen in the evening for everyone in the family to hear. While this made me as the therapist uncomfortable, this was the desire of the couples. It very quickly became apparent that we were not making progress and they have now come into my office.
Other times couples forget they in a therapy session and find themselves arguing without hearing the therapist on the computer screen. I’ve had this experience with both of my previous couples, which was another reason both couples have rolled into my private in-person practice.
But its effectiveness is dependent upon the client knowing and believing they are in therapy. A boundary has to be established, in terms of the most appropriate setting in the home for the session to take place.
This brings raises the question of what is appropriate for online couples’ therapy or therapy in general? Attridge (2011) finds that there have been positive outcomes for online therapy with people who have disorders such as depression, anxiety, eating disorders, panic disorders, PTSD and social phobias.
Online therapy is never appropriate or effective for anyone experiencing an active crisis or suicidal thoughts. In my own practice, any clients in need of immediate crisis care are not accepted until they have become stable for therapy treatment.
Couples come into therapy because they are in distress and more often than not, that distress is related to infidelity. According to Marin, Christensen, and Atkins (2014), the prevalence of marital affairs is between 20-40% with approximately 42% of relationships ending in divorce. Infidelity causes conflict, shame and hurt.
Addressing these issues within the context of online therapy can be difficult but not impossible. It involves more rapport building, engagement, and the connection between the therapist and clients.
Trust in a therapist that is not in the room is key. Attridge (2011) calls into question the effectiveness of the clinician due to the missing piece of being face to face with the clients. I think it is possible to make this connection online just as effectively and easily as I would face to face. Does it take skills? Yes. Does it take more patience? Yes.
Online Therapy Sites
There are potential opportunities for misunderstandings and missed cues because of site rebuffering. However, there are several online counseling formats that are HIPAA compliant and confidential that don’t have this issue. Those sites are easy and comfortable for clients to sign up and use.
There are clients who want to do therapy via email. This is not something I practice, but according to Attridge (2011), some individuals like email therapy because of its ability to be more therapeutic in nature due to the level of personal reflection and the reinforcement of prompt feedback from the therapist.
None of the programs I list below offer email therapy as an option. I support journaling in both the electronic and analog formats, which is really what many who want to use email as a form of journaling are seeking.
There are several online therapy platforms in which couples therapy can be facilitated. I have listed a few below.
- TheraLink – HIPAA compliant and supports group and family session.
- DoxyMe – another popular and HIPAA compliant platform. It’s free for the client to connect with their therapist.
- VSee – another HIPAA compliant platform that has (according to their website) been used by NASA and the Navy Seals.
- Wecounsel – HIPAA compliant with very strong encryption standards.
In my own practice, I use DoxyMe and I really love the platform. I have a very stable platform in which to work with remote and even local clients who cannot come into the office. I have used Skype and WhatsApp in the past but those platforms are not HIPAA compliant nor stable to work with. One of the main reasons I like DoxyMe is the fact that it’s a download for both my iPhone and iPad. The signup for both clients and therapist is free and easy.
What about the ethical, professional and pragmatic issues to consider with online couple’s therapy, or any therapy, for that matter?
Online therapy is not the same as in-person therapy and so there potentially won’t be the same level of client/therapist connection. There is a need for specialized training on how to be more effective in doing the work. And finally, the ethical considerations of providing online therapy over the Internet involve being compliant with HIPAA and confidentiality (Murphy, MacFadden and Mitchell, 2008).
So how effective is couple’s therapy, online couples’ therapy? While there is limited research available on the efficacy of online couple’s therapy, there is a plethora of research available for review on the general concept of couple’s therapy.
There is evidence to support couples being successful in navigating through their distress. In the past, when couples felt relationship distress, only one member of the couple sought out therapy. Recently, couples therapy is the preferred treatment method for relationship distress (Perissuttie and Barraca, 2013).
Expectations for Online Couples TherapySo let’s talk about expectations within the realm of online couples therapy. Everyone has expectations and we have to manage those expectations, even within the therapy setting. Often, couples come to the session thinking and believing that therapy is a magic treatment and that the therapist themselves are going to solve the problem and make things better.
This is not true. My role is to facilitate change, to call into question the reasons behind the need to change and what that change should look and feel like. Client expectations are a significant contributor to successful outcomes in therapy.
Tambling, Anderson, and Wong (2016) highlight the fact that couple’s therapy is generally more effective and efficacious in creating positive change in clients, decreasing divorce and improving individual and family health. But even with these positive outcomes, there is still an issue with the early or premature termination of couple’s therapy. Sometimes, whether online on in-person, some couples do fail to get better and improve during treatment.
As a therapist, early termination without success is problematic. It’s important for me to have an understanding of my client’s expectation and needs. I ask each client during my intake session about their expectations for treatment and what their goals are. Why is this important? Because we must manage expectations, both what the client is seeking and the service I am providing.
Sometimes treatment failure is due to not understanding this dynamic and sometimes this is made more difficult when clients are in online therapy and this is not made clear. Positive therapeutic outcomes and expectations are in part related to positive feelings about therapy and successful engagement (Tambling et al, 2016).
One of the things I highlight in my own practice in working with clients is individual and couple goals. The reason I break this down is because each party might have a different goal for therapy. Goal setting is a must for any therapeutic process, individual or couples.
Is it really counseling if it’s done through email? I look at this as more journaling and not counseling. To me, counseling involves relationships. I question whether it’s really counseling via email.
Is it appropriate for a client to email their thoughts to a therapist? Sure. And these can be items brought up in session. But I wonder about the effectiveness of email counseling. So for me, more research is needed.
Attridge, M. (2011) The emerging role of e-therapy: online services proving to be effective. The Journal of Employee Assistance, p. 10+. Psychology Collection
Heitler, S. (2014). What’s up with online therapy and marriage counseling? Psychology Today
Marin, R., Christensen, A., & Atkins, D. (2014). Infidelity and behavioral couple therapy: relationship outcomes over 5 years following therapy. Couple and Family Psychology: Research and Practice. American Psychological Association. 3(1) p.1-12
Murphy, L. J., MacFadden, R. J., & Mitchell, D. L. (2008). Cybercounseling online: The development of a university-based training program for e-mail counseling. Journal of Technology in Human Services, 26(2/4), 447-469.
Perissutti, C., & Barraca, J. (2013). Integrative Behavioral Couple Therapy vs. Traditional Behavioral Couple Therapy: A theoretical review of the differential effectiveness. Clinica Y Salud, 24(1), 11-18. doi:10.5093/c12013a2
Pinsof, W. M., Wynne, L. C., & Hambright, A. B. (1996). The outcomes of couple and family therapy: Findings, conclusions, and recommendations. Psychotherapy: Theory, Research, Practice, Training, 33(2), 321-331. doi:10.1037/0033-3188.8.131.521
Tambling, R. B., Anderson, S. R., & Wong, A. G. (2016). Expectations about couple therapy over time. Contemporary Family Therapy: An International Journal, 38(4), 353-360. doi:10.1007/s10591-016-9390-x
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