key: cord-1017904-0qoc4qu8
authors: Orlowski, Edmund W.; Friedlander, Myrna L.; Megale, Allison; Peterson, Emily K.; Anderson, Shayne R.
title: Couple and family therapists’ experiences with Telehealth during the COVID-19 pandemic: a phenomenological analysis
date: 2022-04-04
journal: Contemp Fam Ther
DOI: 10.1007/s10591-022-09640-x
sha: 149969ff9be9ccb7f8df61d8baf5d259317383c5
doc_id: 1017904
cord_uid: 0qoc4qu8

In designing this study, we aimed to obtain a rich, phenomenological understanding of the experiences of couple and family therapists who transitioned their practice to telehealth due to the COVID-19 pandemic. Twelve experienced therapists from the U.S., Spain and Australia were interviewed in depth about their experiences of this transition, particularly how they developed and maintained therapeutic alliances in a virtual context with couples and families suffering pandemic-related hardships. The qualitative analysis identified 40 themes reflecting participants’ initial impressions of telehealth and their positive and negative reactions and adjustments to practicing remotely. Upon overcoming some initial wariness about providing services virtually, many participants described advantages to this way of working with families. Indeed, participants were creative in adjusting to this novel therapy modality, finding new ways to connect emotionally with their clients, to work meaningfully with children, to assess in-session dynamics, and to ensure their clients’ privacy and safety. Notably, several participants commented on the relatively slower development of alliances with new cases and the challenge of repairing split alliances between family members. Many of these difficulties were described as due to having minimal access to their clients’ raw emotions and the inability to use typical systemic interventions, such as moving family members around physically. Participants also reflected on being a “participant observer” to the upheaval caused by the pandemic, a distressing experience they shared with the families in their care.

the phenomenological experiences of CFT therapists using telehealth for the first time. That is, we sought to understand how therapists adjusted to working remotely during the COVID-19 pandemic and how they viewed the advantages and disadvantages of doing so compared to the more familiar experience of conducting therapy face-to-face. Particularly in light of the robust association between alliance and CFT outcomes (Friedlander et al., 2018) , we were interested in how therapists experienced alliance building and maintenance when working remotely with multiple clients simultaneously.

The purposive sample of 12 experienced therapists (8 women, 4 men), recruited through the authors' professional acquaintances, were licensed in their specialty field for at least three years and were practicing couple and family therapy remotely. We only recruited therapists who had used a video-based telehealth platform with 3 or more couples and/ or families at the time of the interview.

Nine therapists were living in the U.S.; one participant lived in Spain, and two lived in Australia. On average, participants were aged 51.92 years (SD = 15.48) and selfidentified as White (n = 9), Black (n = 1), Asian (n = 1), and Hispanic (n = 1). In terms of clinical experience, participants (50% psychologists, 25% marriage and family therapists, and 25% social workers) had been licensed for an average of 17.50 years, SD = 11.41, and worked primarily in independent practice (45.5%). Other settings included hospitals (18.2%), community agencies (4.5%), and college/university counseling centers (4.5%). At the time of the interview, participants had seen between 4 and 40 CFT cases using a telehealth platform, some of which had transitioned from inperson to remote therapy at the start of the pandemic.

The semi-structured interview protocol (available from the first author) was developed from the relevant literature on the therapeutic alliance in CFT (Friedlander et al., 2006) and on two of the authors' experiences conducting CFT in a telehealth setting for the first time since the start of the pandemic. The initial set of questions was refined and expanded by a research team of four counseling psychology PhD students and further modified following a pilot interview (not included in the sample).

A few general questions about the pandemic's impact on the therapist's current caseload were followed with Simpson & Reid, 2014) , we reasoned that clinical outcomes could nonetheless be hindered by a therapist's negative attitude toward online therapy (Reese et al., 2016; Tonn et al., 2017) .

Recognizing the critical importance of understanding how couple and family therapists made the transition to telehealth, we interviewed experienced practitioners to understand their experiences of unique benefits and challenges of conducting conjoint couple and family therapy (CFT) remotely during the pandemic. Of particular interest was the perceived impact of telehealth on the development and maintenance of therapeutic alliances with clients seen conjointly for relationship and familial difficulties. We were especially interested in the alliance due to its well-established association with retention and clinical change in CFT (Friedlander et al., 2018) , its importance as a common factor across psychotherapy approaches (Cuijpers et al., 2019) , and the challenge of forming a strong alliance in the absence of live interaction.

Unfortunately, there was little literature to guide therapists in their transition to telehealth at the start of the pandemic. Nonetheless, some evidence suggests that strong therapeutic relationships can be built remotely (Irvine et al., 2020) and that they tend to be just as important for success in an online environment (Reese et al., 2016; Simpson et al., 2021) as they are in face-to-face CFT (cf. Friedlander et al., 2018) .

We reasoned that aside from alliance formation and maintenance in virtual CFT, the telehealth setting poses other challenges for couple and family therapists. In particular, client safety while discussing problems and conflicts at home with other family members may be compromised. Indeed, for some partners and family members, the home is not a safe environment. We reasoned that due to the increase in domestic violence since the start of the pandemic (Kofman & Garfin, 2020), therapists have had to be acutely aware of safety issues when working remotely with couples and families.

We reasoned, further, that other aspects of conducting therapy are challenging in a telehealth. Due to limited visibility, therapists conducting CFT online need to make significant adjustments. Burgoyne and Cohn (2020) recommended meeting separately with subsystems to orient clients to telehealth gradually, requesting that clients position their camera so that everyone would be visible on the screen, addressing safety concerns directly, being directive in goal setting and explicit and flexible with in-session tasks, and using a screen sharing function to structure the therapy session.

While these suggestions and those of other authors (e.g., Goldstein & Glueck, 2016) offered therapists valuable ideas for working remotely, our objective was to discover other behaviors might be less useful or would decrease in frequency due to technological limitations, particularly nonverbal behaviors such as making eye contact. The coders expected participants to describe greater difficulty and discomfort resolving family conflicts while using telehealth compared to working in person.

Both auditors had conducted only a few couple therapy cases using telehealth when the study was being designed. At that time, one auditor viewed telehealth as impeding the process of couple therapy, while the other auditor had a more mixed reaction. Both auditors were finding alliance development to be considerably more challenging when working remotely. One auditor was particularly concerned about addressing heated conflicts between partners.

We followed Creswell's (1998) recommendations for phenomenological qualitative research by using open coding of meaning units to yield the broadest understanding of participants' lived experiences. Constant comparison (Glaser & Straus, 1965) was used, in that research team members repeatedly reviewed previously coded transcripts as each new code was identified. This iterative process allowed themes to surface from the narratives rather than being imposed on the data. In developing themes inductively, consensus and minority views were recorded and provided to the primary auditor for feedback.

Before the analysis began, the second author, who has extensive experience with qualitative analyses, trained the primary coding team using the first transcribed interview. For the next two transcripts, the team of three coders worked consensually. From that point on, the coders worked in pairs to analyze the remaining transcripts.

Throughout the process, the primary auditor reviewed ambiguous codes and recommended adjustments to the coding team as needed to ensure that all meaning units in the data were represented accurately. When all the transcripts had been analyzed, the auditors provided feedback on the congruence between illustrative data and the themes, which were returned to the coders for negotiation, as needed.

Dependability was addressed by memoing (Creswell, 1998) during the interview process and by the first author's maintenance of an audit trail throughout the analysis. These materials were referred to in the final compilation of thematic results.

To assess the credibility and validity of the themes identified in the coding process, we solicited all participants' feedback on the initial list of themes. From the sample of 12 questions about the therapist's experience conducting CFT remotely compared to in person. The interviewers followed the therapists' lead with prompts and reflections to obtain the richest possible description of the participant's internal processing. The questions covered a variety of topical areas, including the participant's experience transitioning to telehealth, how the participant's approach to new telehealth cases compared to in person therapy (e.g., "Before taking on new cases remotely, how do you typically screen couples or families for appropriateness? To what extent has the pandemic influenced this process?"), how therapists had adapted their approach to a telehealth setting, and how this setting may have affected the participant's ability to develop and maintain multiple alliances with romantic partners and/ or family members. Throughout the interview, we encouraged participants to reflect on their conduct of specific cases or sessions in response to our questions.

Upon approval from the university's Institutional Review Board, we recruited potential participants individually whom we believed met the inclusion criteria (4 therapists who were contacted had not seen at least three couples or families and were therefore omitted from the sample). Recruitment took place August 2020 to March 2021. Therapists who agreed to take part completed a demographic survey and provided informed consent online before an interview was scheduled. No incentive was offered for participation.

The interviews were conducted using Zoom.com by the first author or an advanced doctoral student. Transcripts of the video recorded interviews, which lasted between 60 and 90 min, were checked for accuracy by the interviewer.

Recruitment continued until the research team believed that data saturation had been achieved. That is, we continued to conduct and analyze interviews until it was determined that interviews were not producing any new codes (Mason, 2010) .

The narrative data were analyzed by five of the co-investigators, three counseling psychology doctoral students (two women, one man) and two Ph-D level auditors (one woman and one man, faculty members in counseling psychology and marriage and family therapy, both experienced CFT therapists). The primary coders, two of whom had experience conducting individual therapy using telehealth, expected that some alliance building and maintaining behaviors that are meaningful in face-to-face therapy (i.e., making empathic statements, collaborating on client goals, etc.) would also be relevant in a telehealth setting, whereas how their initial reservations dissipated with time: "… I did have reservations…So, there was a lot of, you know, reservation, but I think pretty quickly it felt kind of natural."

Learning to use technology. Many participants described a learning curve with technology use when transitioning to telehealth. One of the most common considerations described by participants concerned their physical presence on the screen. Specifically, participants carefully considered the virtual background for their sessions, were careful about looking into the camera, adjusting so that clients could see their hand gestures. Participants also mentioned using humor to cope with technological limitations, such as the lack of body language due to their camera's limited perspective. One participant spoke about the importance of upgrading their equipment:

…. it's important that you can see what you see here [referring to their presence on screen] …and so I wanted to do that so … they could connect with me… in the best possible way, they could actually really see me and hear me and engage in the best possible manner.

Changes in work-life balance. In addition to adjusting to the technological changes, participants typically described personal adjustments to working remotely. Many participants felt the need to create structure to their day, such as having a lunch break, going for walks, even pretending to go home to help them separate their work from their personal life. "Zoom fatigue" was also discussed by multiple participants. When first transitioning, participants consulted their colleagues and attended webinars to help them develop telehealth specific protocols and to aid with the transition. Participants also mentioned missing the social aspects of working in person, such as meeting their friends after work, which added to the isolation of the pandemic. One participant described re-creating an office their home and sharing the office space with their romantic partner, who also was working remotely:

…we bought a new chair; we sort of re decorated the office because we were using it. Until then, maybe two, three hours a week because … we both work outside and now we were having to share the spaces, maybe even book the [home] office because I needed from 9 − 2 but then I need it from 3 to 5.

Different orientation of clients. Some participants described how telehealth changed how they typically oriented clients to therapy, particularly in terms of addressing expectations. One participant emphasized this change as follows:

…earlier on in the pandemic, I would be more clear about talking about virtual work … and I wonder if it was my own discomfort, like, hey, I know this kind of weird, but, you know, we'll get we'll get comfortable together.

therapists, one individual responded to the email request for feedback. This participant's response was simply a general positive comment, with no suggested changes.

In the first stage of coding, the research team identified 1098 codes within 6 broad categories, with 40 themes. Using the terminology of consensual qualitative research (Hill & Knox, 2020) , we identified themes as general when they reflected the narratives of all 12 participants, typical (4 to 11 participants), or variant (two or three participants). As summarized in Table 1 , five themes were general, 24 were typical, and 12 were variant.

Adjustment was needed. Participants typically mentioned the rapid and necessary adjustment to telehealth due to the urgency of the pandemic. According to participants, many clients were initially reluctant to try remote therapy and were adamant about only wanting to be seen in person, although the majority of participants' clients eventually switched to telehealth. The transition was typically described as difficult; for example, one couple reportedly dropped out of therapy due to "Zoom-fatigue." Adjustment was also needed due to logistical challenges, such as deciding whether to use a single screen for the whole family or a separate screen for each individual. One participant, unable to use physical touch, began giving "virtual hugs." Another participant explained that participating in family therapy virtually required adjustment when technological problems were encountered: …when one of the kids, for example, when we had conjoint sessions [with a family] was silent, she [the mother] would start in the middle, for example, screaming, 'Oh this one disappeared'…she got mad and she left and the [describes parent reaction to child's screen disappearing].

[Therapist response:] No, no, she's there. Your screen just made her…disappear because she was silent for a while, but she's still here, [she] says she's listening and she's still here.

Greater comfort over time. Multiple factors contributed to participants becoming more comfortable with telehealth over time. Typically, participants began to recognize telehealth as an effective approach to treatment despite the limitations, particularly when they received positive feedback from their clients. One participant explained that they simply "powered through" their anxiety with telehealth, which led to an increase in comfort. Another participant discussed to move their office furniture and seating as they would typically do when working with families in person. Further, participants noted the need to ask family members to look at one another during a telehealth session, which did not occur naturally when people are facing a screen. As one participant explained, "I think…it's mostly the physical thing, you know, like I can't prearrange chairs in the room. Also, they can't move as much in the room, right. Like if they're trying to stay in the screen. I can't move closer to one or the other. So, it's a lot of it is about…[the] physicality, you know." Different in-session dynamics. Some participants indicated that the dynamics of the session seemed different. Namely, these participants noted that their clients were able to remove outside influences (e.g., parenting responsibilities) by changing their location for a session. Further, participants noted that the presence of family members not involved in the therapy, such as children or in-laws, affected the dynamics of the session. This theme was reflected in one participant's description: "…I don't want people having to titrate their capacity to go to any kind of emotional depth with the fact that they may have kids or in-laws or somebody just kind of around the house at certain times a day that make it hard to, to really go to that level." As this participant indicated, the presence of extraneous people made it challenging to focus solely on the clients.

Greater need for directiveness. Some participants noted feeling more confident about being directive in telehealth sessions. Specifically, these participants explained that the reduced emotional intensity of a telehealth session made it less challenging for them to interrupt clients. One participant noted that because technological limitations at times made it difficult to identify which client was speaking, more directiveness was needed in order to manage the session effectively: I think … with family therapy is that's way more challenging on Zoom because in person, if people were speaking over each other … I actually have what I call the talking stick. And so, if I can't get people to listen to each other, I will actually give them a physical item…to help them get to a place where they can communicate better…I can't do that over Zoom so … I'm often doing more like 'timeout,' 'hold on,' 'stop talking'….

Challenges addressing split alliances. All participants addressed the different process of identifying and repairing split alliances in telehealth compared to working in person. Participants explained that the lack of nonverbal cues made handling split alliances more difficult. For example, one Other participants explained that they addressed clients' expectations in the same way they typically did when working in person. Participants mentioned that as they became more comfortable with remote therapy, they spent less time orienting clients to the telehealth format.

Initial reservations or concerns. Many of the therapists interviewed for this study reported some initial reservation or concern when first transitioning to telehealth. Frequently discussed was the concern that telehealth sessions would be awkward, in that they would not be able to have a therapeutic presence online, that clients might not "buy-in" to telehealth, and that unfamiliar technology might be a problem. For example, one participant explained, "I had some imposter syndrome about how I could have a therapeutic presence… through this online mode modality."

Initial impressions of the benefits of telehealth. While many participants reported concerns, others described having a positive first impression of the modality. Participants described being most encouraged when their clients were able to navigate the technology and attend sessions with minimal difficulty. Further, many participants also recalled having more positive impressions when their clients appeared to be engaged during the transition to telehealth. One participant described their initial success with telehealth as, "… just finding that [the pandemic] could happen and that everything didn't get canceled so there was initially a little bit of triumph of we're actually making this work…".

Therapist optimism. Many participants reported having positive experiences and were optimistic about conducting therapy using telehealth. These participants saw telehealth as having enormous potential. Indeed, they described being pleasantly surprised by the benefits of working remotely. For some participants, offering telehealth services was seen as a useful skill; these participants explained that they planned to continue seeing clients virtually even when in-person service could resume. One participant described telehealth as part of a "new age" given its many benefits. Another participant explained, "This has a lot of potential, I think. It's different and it has got different strengths, but it's got a lot of very similar strengths."

Challenging to use physical space as an intervention. Some participants noted that the inability to adjust the physical space of the therapy session affected the therapeutic process. Specifically, these participants missed the opportunity

Increased confidence addressing clients' conflicts and problematic relationships. In contrast to the typical category described above, a few participants felt more confident in addressing family conflicts in telehealth due to being more removed from partners' or family members' intense emotions. These participants recognized the increased objectivity afforded by telehealth. As an example, one participant appreciated feeling separated from the emotional "rawness," saying, "…I have felt it easier to intervene, especially if the conflict is being played out right in front of me.

Emotions are quite intense…something about the fact that I'm a little removed…the intensity of the emotion allows me to intervene…".

Pandemic effects on alliance formation. A few participants explained that the COVID-19 pandemic had an impact on how they formed therapeutic alliances remotely with CFT cases. Specifically, one participant explained that discussing matters related to the pandemic and exchanging information with clients was a unique way to join with families.

Another participant noted that due to lockdowns and quarantines during the pandemic, many clients needed to rely on their computers for other aspects of their life (i.e., remote work, entertainment, etc.). Clients' excessive reliance on their computers made this participant recognize the need to make a greater effort to form working relationships with clients when working remotely.

Similarities to alliance formation in person. In contrast, a few participants noted similarities in how they formed alliances in person and via telehealth. Similar techniques mentioned by participants included empathy, active listening, reflecting, validation, and humor. One participant noted that goal setting seemed similar in the two modalities. As one participant explained, "I think once you get rolling, I don't think it's any different [with] goal setting and issues that we're working on."

Difficulty maintaining the relationship. A few participants explained having more difficulty maintaining strong therapeutic alliances when working remotely compared to their experience in person. Some participants noted that the alliance continued to grow with clients who transferred to telehealth from in person therapy, whereas the alliance tended to stagnate over time with clients who were only seen remotely.

Along with initial impressions about telehealth, participants also indicated general benefits that extended beyond initial impressions about potential benefits to the therapy process person said, "…the difference with that, if it's [split alliances] in-person or online. …it comes down to…the difference in the more non-verbal or the necessity of more verbal expressiveness of the emotional aspect of it."

Further, it was noted that the necessary changes to scheduling during the transition to telehealth also posed a problem to balance alliances with multiple clients. For example, one participant noted:

…if we're emailing that everybody is on that email, if it's texting, we do a group text, but sometimes that hasn't happened. …sometimes people have forgot to add the other person, or the group text wasn't working. And so, it just adds another layer of maintaining the balance. In the relationship there are no points where someone thinks "oh my therapist is having private communications with my partner that I don't have access to," as it may lead to a split in their relationship with the couple system.

Alliance slower to develop. Most participants noted feeling that the alliance with couples and families was slower to develop in telehealth. One participant commented, for example, "So, one of my three couples was new…and there isn't the same level of comfort and openness as there are with the other two couples who I've known before…".

Further, several participants working with families with children and/or adolescents noted that telehealth seemed to hinder alliance development. For example, one participant said, "I don't get the sense that teens that I've started with remotely… feel uncomfortable, but it does feel like it takes longer to build that rapport with them because in my office I can really be myself and, and I think they kind of let their guard down a little bit…quicker."

Challenges addressing problematic relationships and conflicts. Many participants discussed difficulties addressing problematic relationships and in-session conflicts between family members. These participants noted that the process of resolving in session conflicts took longer in remote sessions in the absence of nonverbal cues that are typically used to maintain safety. As an example, one participant explained:

…I did eventually try to address some of the problematic things…and I think it would have been easier if that were inperson because … there's the full body language. …I could soften the challenge by providing certain kinds of nonverbal cues or leaning … That's harder to do via the screen. So, I think it just made that more challenging.

… there's a way to go, but …, he and his family are doing much better and many of the kind of breakthroughs that he's made where he's actually been able to be more reflective, … a capacity for reflectiveness enormously, powerfully linked with our capacity to feel safe.

Practical benefits. In addition to the therapeutic benefits, many participants commented on the practical benefits of remote therapy, including less drop out. Clients were described as more reliable and on-time for sessions since their travel time was reduced and they did not need child care, for example. Generally, providing services over telehealth was seen as offering clients more flexibility and convenience.

More natural assessment of family dynamics. Most therapists reported using the unique aspects of telehealth to assess family dynamics. Several therapists described noting session interruptions to observe parents' style of interacting with one another and their children in a natural setting. One participant valued the ability in telehealth to observe family members' conflicts in real time and more quickly than typically occurred when conducting therapy in person. One participant described the unique aspects of assessing distress in a telehealth session:

It's an opportunity… to discuss maybe a parenting issue that's acted out … Sometimes I'm using this opportunity to understand better what's going on and how that might precipitate conflict between a couple or how they handle it. We can see it in real time, real action.

More opportunity to work with individual family members. Many participants incorporated individual sessions into their teletherapy work with families and couples. These therapists explained that building relationships with each family member before working with the family system helped them to establish rapport and safety more quickly. One participant would typically not begin in-person sessions without all family members present, but felt differently about engaging with individual family members remotely:

In the past…well, 'If you're not both here, I'm not going to see you, I'm going to wait for the other person to be here.'

[Waiting] seems like the respectful thing to do. And [in telehealth] I'm not so worried about that. You know, if anything, it's an opportunity to engage the person. Different interventions. Most therapists discussed using alternate interventions in telehealth. Several participants expressed surprise after finding that the interventions relied on in their offices were just as effective in remote work. Frequently, therapists used shared screen functions to walk clients through written interventions. One participant described feeling pleasantly surprised by how well a visualization intervention worked online:

I was very reluctant of a visualization working as well through the screen. She [the client] said that maybe it was due to a telehealth context. These themes were seen as distinct from participants' initial impressions about telehealth as they included benefits that were identified after a number of telehealth sessions.

Working in clients' natural environment. Many participants considered that a major advantage of telehealth is the opportunity to see how partners and family members interacted in their natural environment. That is, participants were able to observe personal aspects of family life that could not be seen when providing services in person, such as seeing the family pet and various rooms in clients' homes. Additionally, many participants noted that their clients were more relaxed and comfortable. For example, one participant explained, "It's sort of deep, and enriches the counseling experience by getting to see them in their comfort zone … a kid will show me their Lego project or their trophy from baseball." This participant also noted how much they learned about their clients by working remotely:

Certainly, it gives you more information. I've met, … client's pets. I've met the children; … I've interacted with children online and so clearly these things are things that could not happen if I were meeting them in person. So, … it's given me more of an appreciation of the context of the alliance.

Interestingly, one participant noted that allowing clients to see them in their home was a form of self-disclosure.

People are also seeing you know my space or my spaces as I rotate around. … So, … there's just a little bit of an exchange that people, I think, will ask more like, how is it going and really mean it, you know or, oh, I see you're in a different room is everything okay.

Positive client reactions. Many participants described their clients' positive reactions to telehealth, such as the increased flexibility in scheduling and not needing to rush to sessions. In fact, some clients spontaneously requested that their therapy remain remote even after restrictions lift. One participant discussed a particular advantage when working with adolescents, saying, "…they're in their bedrooms, right, and like, you know, it's just very relaxed and in some ways that's really cool."

Increased client safety/comfort. Some participants explained that using a telehealth platform increased their clients' sense of safety and comfort in, for example, carrying out a risky in-session task, such as an adolescent reading a letter aloud to a parent. Participants also commented on the greater sense of comfort since the therapist could see their home environment. One participant reflected on how a client has become more reflective as a "courtesy" of having remote sessions: communication. One participant, for example, explained as follows:

…dress…physical reactions, talking earlier about…couples, where do they sit? Do they look at their partner? Don't they look at their partner? Do they look at their shoes all the time? Do they look up in the ceiling?… Is there affection? Do they show affection towards each other? I don't know, you lose some of that in the telehealth.

Several participants described strategies used to compensate for the loss of nonverbal information, including asking more questions about emotions and attending to facial expressions. Another participant reported a heightened awareness of tone of voice:

But I found that you know the brain is funny and the brain will compensate where it needs to, … I find I'm paying much more attention to tone of voice. I don't have the whole cue of the body language, but tone of voice has become really, really, important to me in terms of my online work.

Clients' worries/discomfort. Several participants reported that one or more of their couple and family clients dropped out of therapy during the transition to telehealth due to discomfort with online treatment. Other clients agreed to try telehealth after discussing their discomfort with technology. Initial teletherapy sessions were typically described as awkward, especially for clients who were less familiar with technology. One participant noted that in one case, the children seemed less concerned than their parents about attending therapy remotely.

Increased likelihood of interruptions. Many participants commented on the increased frequency of outside interruptions during teletherapy sessions. One participant observed that without having an office waiting room and door, they lost some capability to manage who enters the session. Parents with children were sometimes interrupted by knocking on doors or requests for attention, while clients sometimes experienced interruptions from texts, calls and emails. One participant explained that interruptions "hijack" the therapy. Other participants agreed that interruptions reduced their focus during session, but also noted that meeting children and partners offered information about their clients' lives beyond what could be seen in an office setting. One participant summarized their experience with increased distraction and interruptions in this way:

You know people still get phone calls, sometimes they have to answer them… but it's, a different vibe … via telehealth or virtual session, you know there is the likelihood of so many more distractions…They might be driving their car or walking around in a store or at the doctor's office or because she was wearing headphones and I was in her head. Literally, that she felt my voice. I was … trying to use a very relaxing voice. And she described that session almost in magical terms of how she felt so relaxed …. But, … yeah, … very successful in that sense and I was very surprised.

Potential for innovation. Pointing out the need for innovation when providing therapy virtually led therapists to become more creative in terms of different ways of listening to and connecting emotionally with clients, such as asking children to share a video of doing something special. One participant explained, "It's the Zoom is offering us, the bottom line of it is that we never would have come up with this [intervention] if it hadn't been for Zoom or, you know, online and telehealth."

Location issues. Most participants discussed the need to manage clients' locations during telehealth sessions. Participants who worked primarily with families reported requesting clients to attend the session in separate rooms so that everyone would be visible. Some participants found that "squeezing family members together" on one screen was uncomfortable for clients. Further, one participant asked partners and family members to attend sessions from different locations when it seemed that safety might be compromised if the clients sat together.

When working with couples, many participants preferred that partners be in the same room on a single screen, although several therapists reported seeing couples on separate screens in different locations. One participant explained their reasoning as follows:

When it's families… I think it's easier for everybody to kind of be in their own bubble. But couples have always been home together sitting in the same room and I do think that that does make a difference. That does feel as close as it can be to like being in in the room together, being [in] an office together.

Loss of nonverbal information. All participants discussed losing access to nonverbal information, body language and eye contact, in telehealth sessions because they were only able to view a client's face and shoulders. Participants also noted the inability to observe how couples and families would naturally choose seating since everyone needed to be seen on a screen. Three participants noted that because it was more difficult to convey empathy and attention nonverbally, they worried about this lost aspect of the impact of telehealth on treatment effectiveness. As one participant explained:

I do wonder if couples therapy is as effective with telehealth. It's a lot about watching them, watching their body language, like seeing how attuned they are to one another, I do think a lot is missed. I've been surprised at how effective it's been, but I can't say for sure that it's not, it's not as effective, though, and I can't say that for my own caseload it, it has been significantly less effective.

Technology problems. Many therapists described technology problems as a significant disadvantage of telehealth. Although being able to establish strong, reliable internet connections, some of their clients had difficulty with Wi-Fi reception, which negatively affected the therapeutic work. Participants described frustration with needing to help their clients troubleshoot their technological problems.

Reduced session impact. A few participants discussed their sense that telehealth sessions were less serious and impactful. For example, some children tended to act silly in front of a camera, which disrupted the therapy process. One participant noted that while telehealth can increase safety for some clients, the use of screens also created a distance that lessened the impact of therapy sessions.

Different type of client resistance. Different experiences with client resistance were also described. One participant found that attendance in telehealth was more "all or nothing," since clients did not show resistance by coming to sessions late or leaving early, as they might do in an office setting. This "all or nothing" attitude may make the task of addressing alliance ruptures in telehealth sessions more challenging as clients who do not show up to therapy will not be present to address potential ruptures.

On clients' problems. All participants mentioned that their clients were affected by the pandemic, particularly the loss of alone time and the greater challenge of childcare. One participant explained that parenting and family conflicts tend to be exacerbated. On the other hand, one participant explained that the ability to have more family time decreased the distress and isolation of some clients. Work life was also described as a source of tension for participants' families, specifically the loss of an income or resentment when one parent could leave for work while the other parent needed to stay home with the children.

unexpectedly… their kids are home that day or their partner is home that day or whatever the workman is there. And some of its just like oh okay, you know you can't predict every aspect of life, but I think people give themselves a little bit more permission to multitask and they don't necessarily protect the therapy hour.

Privacy concerns. Most participants described concerns about not having the same level of privacy in telehealth sessions than during in-person therapy, explaining that clients with children or housemates seemed not to be able to express themselves as freely if they could be overheard by others. Participants also reported privacy as an issue, since they needed to work around family members' schedules. One participant explained:

[Couples] don't seem to feel as comfortable speaking candidly, openly, and honestly about their relationship, even if they're behind a closed door because they're not sure who maybe, can hear them… I really do feel a difference in their level of guardedness at home, sometimes they get in their car to do the session, and it seems a little better.

More challenging to work with children. Several therapists discussed unique aspects of working with children via telehealth, such as having more difficulty engaging them remotely due to "Zoom fatigue" from long days of online school. One participant stated that working virtually with children required "vastly more creativity" to keep them clients engaged and focused:

It's really hard to do telehealth or video work with … younger kids. And I have done a little bit of puppet work; I've got an assortment of games that I might play with them but it's not as effective with younger children, as being in the room ….

Limited kinds of interventions. Other therapists described difficulty using some kinds of interventions in telehealth, such as modulating their tone of voice, leaning toward a client, or requesting partners to move closer to one another or to touch each other. One participant pointed out that fewer interventions tend to be effective over a screen: "…I don't think I'm trying to do things differently. I think maybe some of the things that I want to do I'm not fully able to. So, I guess, in that sense, yes. I'm just not doing the full repertoire of things that I might do."

Uncertainty about comparative effectiveness. Some participants shared their thoughts on the general effectiveness of telehealth with couples and families. While some participants described telehealth and in-person therapies as roughly similar, others found telehealth with families to be less effective. One participant pointed out the difficulty intervening effectively when several family members spoke at once. Some participants observed that they had lower retention rates with clients and had been concerned about

In conducting the present analysis, we found 40 qualitative themes within 6 categories representing the phenomenological experiences of 12 experienced CFT practitioners who discussed in depth their experiences transitioning to telehealth during the COVID-19 pandemic. Despite most participants' initial wariness or outright disdain for conducting CFT remotely, they nonetheless found some creative ways to adjust to this novel modality. Notably, most participants were able to describe their adjustment to telehealth in specific terms, not only their own attitudes but also their modifications to in-session interventions. Moreover, most participants described the advantages of virtual therapy compared to traditional in-person clinical work, as well as innovative ways they had found to work around the exigencies of conducting conjoint therapy remotely.

While we anticipated some of these findings prior to beginning the study, such as the relative lack of nonverbal information that typically guides therapists' interventions, we encountered an unexpected level of optimism for telehealth among our participants, many of whom commented on the advantages of seeing their clients in their home environment. That is, despite their initial reservations about telehealth, most participants were able to describe some positive aspects of working remotely. Indeed, many participants seemed quite adept at working around the limitations of the technology to join with children, parents and couples by, for example, disclosing their personal reactions to the pandemic and enforced lockdowns.

Due to abundant evidence about the critical importance of developing and maintaining strong therapeutic alliances in conjoint couple and family therapy (e.g., Friedlander et al., 2018) , we were particularly interested in this aspect of remote clinical work. Indeed, many of our participants described numerous alliance differences in telehealth, including its slower development with new cases and the challenge of rebalancing split alliances. Participants explained many of these difficulties as due to the lack of access to the raw emotion of the session and the inability to communicate empathy in the same nonverbal ways (e.g., leaning forward) that they typically use to deepen their bonds with clients. Similarly, participants needed to make adjustments when addressing within-family conflicts due to not being able to move clients physically closer or more distant from one another, as they typically would do when working in person.

On the other hand, some participants noted similarities in the process of forming alliances in telehealth as in an office setting. These similarities included empathic listening, validation, expressing an accurate understanding of the family's problems. Since these behaviors rely on verbal Other participants noted positive effects of the pandemic, such as some couples experiencing a "honeymoon phase" due to being able to spend more time together. Another participant noted that the increased family time decreased one adolescent's suicidal ideation and self-harm. Effects on families were described by one participant as follows:

…everybody is always kind of isolated and doing their own thing and … sometimes kids never really see their parents and, … sometimes, I feel like …, they're doing, maybe …, somewhat better like families are doing better because they're closer, they're spending more time with each other.

On the therapeutic process. The pandemic was also described as affecting in-session dynamics. Participants noted that some couples were focused on the crisis situations rather than on their relational dynamics. One participant described being both a "witness and a participant" of the pandemic, which created a similar experience with their clients. Since the pandemic was a universal stressor for both clients and therapists, participants also noted that they had to make decisions about whether to disclose their own experiences with the pandemic. One participant described a peak in anxiety:

…there was a bit of a pause, … because everybody felt like a brick hit them over the head when the pandemic first hit. And I was very anxious about that. Oh my gosh, where's my practice going to go?… all that.

On the therapist. The transition to telehealth typically altered how participants conducted their practice and dealt with their personal struggles. One participant noted the need to reduce the fee for therapy due to the pandemic, while another participant began advertising their services online. Another participant began taking on more cases, while another participant reflected on the need to turn down referrals due to being overloaded.

In terms of their personal lives, participants described their own anxiety about the pandemic, which led them to feel a greater need for their own social supports. Some participants also experienced mental health difficulties, aside from work stress, due to the pandemic. One participant explained as follows:

… the pandemic really rocked my socks … because all of a sudden, everything halted to a stop. And I didn't really know what to do with myself, so I struggled a lot, my own mental health, …, in the spring, for sure. Big time. And that's gotten better. But it does feel like it's getting a little bit hairy again now like with the holidays and the end of the year. making in-person treatment untenable. With the real-world experience of the advantages and challenges delivering telehealth services during the pandemic, a therapist may be more comfortable offering telehealth services to the family in this circumstance. On the other hand, a CFT therapist might be able to better identify cases that are poor candidates for telehealth treatment more effectively after having experienced remote work during the pandemic. In sum, CFT therapists' telehealth experiences during the pandemic may make them more knowledgeable about how virtual treatment might be a good option for some couples or families due to their unique circumstances.

In terms of limitations, it is possible that participants may have overlooked or forgotten aspects of their experience that were critically important to their transition to telehealth. Similarly, some therapists seemed to change their opinion about telehealth while answering an interview question, suggesting that they may not have reflected deeply on their experiences prior to the interview. Additionally, our recruitment of participants began during the transition period where people were actively learning how to do teletherapy, so that our findings may be pertinent primarily to the transition to telehealth. Finally, we have no information on how the couples and families seen by our participants experienced the transition to telehealth. Due to evidence that therapists are not always aware of what their clients consider to be more or less effective (e.g., Hill et al., 1993) , the present findings need to be considered as solely the perspective of therapists, which is likely to differ from the perspectives of their clients.

Along with the practical ways our participants described adjusting to telehealth, our findings suggest several directions for future research endeavors. For example, interviewing clients about their telehealth experiences, particularly when shifting from in-person therapy, seems particularly important. From another perspective, observational research could be conducted to discover how telehealth may be similar to or different from in-person CFT in terms of the kinds and frequencies of clients' and therapists' alliance-related behaviors. Additionally, it may be valuable to explore the psychological effect of therapists being "participant observers" of the pandemic, which can have implications for training and supervision. Indeed, many therapists reported becoming more comfortable as they spent more time in telehealth settings. Finally, researchers might investigate how the experience of transitioning to telehealth during the pandemic affects therapists' future work now that the pandemic is waning, and in-person therapy returns to the norm.

As therapists, we encourage the couples and families in our care to be flexible and open to new experiences. For most of us, the transition to telehealth was a new and highly challenging experience, which was further complicated by communication, their increased relevance to the alliance is understandable for remote therapy.

Aside from comments on the relative difficulty of alliance formation and maintenance, a number of participants noted concerns about the effectiveness of telehealth for family concerns, particularly client buy-in and increased difficulty sustaining the attention of children. That said, most participants reported positive client reactions to modifying their usual way of working, such as sharing the screen to watch a family video or to collaborate on a task. In fact, participants noted that many of their clients indicated a preference for continuing telehealth even after restrictions are lifted.

In considering the themes that emerged from the interviews, we concluded that many participants seemed to find it difficult to separate their experiences with telehealth from their experiences of the COVID-19 pandemic. Indeed, our participants had a good deal to say about the effects of the pandemic on themselves as well as on their approach to therapy, such as the "Zoom fatigue" of working so many hours online, an experience they shared with clients who also worked remotely from home. In fact, one participant described their relationship to the pandemic as a "participant observer."

In terms of clinical implications, the present study's findings suggest a number of ways that therapists conducting CFT via telehealth can adjust their behavior to better engage clients. First, it seems that therapists should consider the ways that telehealth might benefit their clients (e.g., more comfort, increased ease in accessing sessions, etc.) and work to facilitate these benefits in a way that minimizes some of the challenges that clients may encounter. Further, it may be necessary for clinicians to adjust their expectations for alliance formation and maintenance as it may take longer to form a strong alliance with a couple, or a family and it may not be as easy to maintain once formed. As such, a therapist may need to consider adjusting the timing of their interventions to match this change in pace. Finally, therapists should also be mindful of the limitations of telehealth platforms when selecting and implementing interventions with couples and families. In brief, it seems that telehealth affords some unique opportunities to be innovative in their choice and implementation of effective interventions.

Aside from practical implications for therapists conducting couple and family therapy solely due to the pandemic, it is also necessary to consider the role in which telehealthbased treatment may be used as in-person services have now become an option. Our findings suggest a constellation of advantages and disadvantages that a CFT therapist should consider when decided whether a case should be online or in-person. In some instances, it may be beneficial to seeing a couple or a family online. For example, a family with adult children may reside in different geographic locations, the effects of the pandemic on our personal lives. Despite widespread initial apprehension, we seem to have adjusted admirably, even with some cautious optimism about this novel way of working with distressed families.

Conflict of interest The authors declare that they have no conflicts of interest.

Ethical approval All procedures described in the present manuscript were in accordance with the institutional/ national ethical standards. 

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