Family Process - 2023 - Aviram - I Miss Not Being Able To Offer My Couples A Box of Tissues Couples and Therapists

15455300, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/famp.12853 by Cochrane Israel, Wiley Online Library on [31/01/2023].
See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Received: 17 August 2022 Revised: 13 November 2022 Accepted: 26 December 2022
DOI: 10.1111/famp.12853
ORIGINAL ARTICLE
“I miss not being able to offer my couples a box of

tissues…”: Couples' and Therapists' perspectives on
the therapeutic Alliance with the transition to online
couple therapy
Alon Aviram | Yochay Nadan
The Paul Baerwald School of Social Work

and Social Welfare, The Hebrew University of Abstract
Jerusalem, Jerusalem, Israel The purpose of this study is to advance theory concern-
ing the experiences of couples and therapists involved
Correspondence
in online couple therapy and the meanings they assign
Alon Aviram, The Paul Baerwald School of
Social Work and Social Welfare, The Hebrew to them, with a particular focus on the therapeutic alli-
University of Jerusalem, Jerusalem, Israel. ance. Using constructivist grounded theory methodol-
Email: alon.aviram1@mail.huji.ac.il ogy, in-depth semi-structured online interviews were
conducted with 36 individuals, including 18 couples
who had participated in online couple therapy via
videoconference. Additionally, 15 couple and family
therapists were interviewed in four online focus groups.
Our analysis indicates three dimensions that impact the
formation of the therapeutic alliance in online couple
therapy: (1) emotional closeness, as a conduit for estab-
lishing physical or emotional space; (2) limited care,
due to the therapist's difficulty providing comfort and
security; and (3) body language, as reflected in the lack
of physical presence and the close inspection of the
face, at two opposite ends of a continuum. We discuss
our findings through the lens of the closeness-distance
dynamic, which posits that therapists' ability to regulate
themselves depends on their clients' emotional needs.
We conclude with implications for clinical practice.
KEYWORDS
couple therapy, online therapy, telepsychology, teletherapy, therapeu-
tic alliance
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and repro-
duction in any medium, provided the original work is properly cited.
© 2023 The Authors. Family Process published by Wiley Periodicals LLC on behalf of Family Process Institute.
Family Process. 2023;00:1–13. wileyonlinelibrary.com/journal/famp 1

15455300, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/famp.12853 by Cochrane Israel, Wiley Online Library on [31/01/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2 FAMILY PROCESS
INTRODUCTION
In recent years, the field of family and couple therapy has witnessed a mounting trend of tran-
sitioning from in-person to online environments (Machluf et al., 2021), raising questions about
the virtual arena's influence on aspects of the therapeutic alliance. While scholars have explored
different elements of the unique framework of online couple therapy, such as telepresence, ethics,
and telesupervision (Aviram & Nadan, 2022b; de Boer et al., 2021; Hardy et al., 2021), little
attention has been paid to the therapeutic alliance in online couple therapy. The purpose of
this article is to explore the concept of the therapeutic alliance in the context of online couple
therapy. We begin by examining the concept, with a focus on its role in online setting. We then
offer a description of the methodology that guided our research and the three sub-categories that
emerged from our analysis. We conclude with a discussion of the study's theoretical contribution
and a review of the clinical implications for clinicians working with couples online.
A therapeutic alliance is a type of partnership between a client and their therapist that allows
to achieve goals by working together (Berger, 2017). Although the concept can be traced back
to Sigmund Freud (1949), its meaning has changed as the therapeutic alliance evolved over the
years, both in form and significance, into a pantheoretical conceptualization. For example,
Rogers (1951) describes the ideal characteristics of a therapeutic relationship as acceptance,
empathy, understanding, and congruence, whereas, Bordin (1979) conceptualizes the therapeutic
alliance as consisting of three components: agreement on goals, assignment of tasks, and the
development of bonds.
What began as an analytical construct has evolved into an integrative variable and a common
factor (Bartle-Haring et al., 2012), with evidence demonstrating that the therapeutic alliance is the
most empirically supported common factor, both in individual therapy (Flückiger et al., 2018)
and in couple and family therapy (Friedlander et al., 2011). Family therapy has emphasized
the therapeutic alliance since its early days. For example, the term “joining” depicts the process
by which the therapist copies and adapts the family's style, language, and manner of function-
ing (Minuchin, 1967). To be able to alter the structure of the family, trust must be established
through joining. It has been argued that therapeutic alliance makes a greater contribution to
therapeutic change in couple and family therapy than in individual therapy, due to the combined
momentum generated by connectedness with family members and the ripple effect on the entire
relational system (D'Aniello & Fife, 2020).
One aspect of the therapeutic alliance is related to the closeness–distance dynamic between
the therapist and the client/s. The idea of therapeutic distance can be traced back to the work of
Mallinckrodt (2010), Mallinckrodt et al. (2015) and is defined as therapists' ability to regulate
themselves based on their client's emotional needs during a session. Using therapeutic distance
increases the scaffolding of the therapeutic alliance, as it creates a dynamic of closeness and
distance between client and therapist (Egozi et al., 2021).
Tremain et al. (2020) suggest that for people with serious mental illnesses, therapeutic alliance
can be fostered through digital interventions (technology-based interventions providing infor-
mation and support, as well as emotional, decisional, behavioral, and neurocognitive therapy
for physical and mental health problems), but that such an alliance may have unique character-
istics that have yet to be confirmed in digital settings. A digital therapeutic alliance may increase
adherence and engagement with digital interventions. Although the therapeutic alliance appears
to have lesser impact on outcomes in digital interventions than in-person interventions (Germain
et al., 2010), two reviews of therapeutic alliances in internet-based interventions have concluded
that client-related alliance scores were high (Berger, 2017; Simpson & Reid, 2014). These reviews
call for further research to identify unique characteristics of the therapeutic alliance in different
treatment formats.
Research focusing on the therapeutic relationship in the context of online couple and family
therapy is scarce. In a recent study (Machluf et al., 2021), therapists reported difficulty forming
AVIRAM and NADAN 3
therapeutic alliances online, but little data exist regarding clients' perspectives. Additionally, we
do not have any data pertaining to the virtual domain's effect on closeness-distance dynamics.
A growing body of literature demonstrates the importance of the therapeutic alliance in
achieving therapeutic engagement in online therapy (Berger, 2017; Simpson et al., 2021), although
this body of knowledge has not focused on couple therapy. Moreover, whereas studies pertaining
to the therapeutic alliance have demonstrated the feasibility of establishing an alliance to legiti-
mize internet interventions (Cook & Doyle, 2002; Tremain et al., 2020), they have not produced
a deeper qualitative understanding of the factors that may help construct the therapeutic alli-
ance. The present study aims to start filling this lacuna by offering further insights into elements
that may scaffold the therapeutic alliance, based on interviews with couples and therapists who
engage in online couple therapy. Our inductive exploration was guided by the following research
questions: (1) What are the perceptions, experiences, and meanings that spouses assign to online
couple therapy? (2) How do spouses experience, interpret, and perceive the online dimension in
the context of the therapeutic alliance?, and (3) How do couple and family therapists experience,
interpret, and perceive the online dimension in the context of the therapeutic alliance?
METHODOLOGY
This qualitative study employed the inductive and comparative bottom-up approach
(Glaser & Strauss, 1967) of Constructivist Grounded Theory methodology (hereafter: CGT;
Charmaz, 2017). Broadly, social construction theory maintains that the researcher and partici-
pants construct the theoretical model collaboratively. This position lies between the realist and
post-modernist positions by assuming “limited reality,” while also assuming multiple perspec-
tives on such reality (Charmaz, 2017).
Participants
Clients
Interviews were conducted with 36 individuals, comprising 18 couples. The participants were
selected using purposeful, criteria-based sampling (Patton, 2015). The main criteria for partic-
ipation in the study was for couples to have attended online couple therapy for a minimum
number of 10 sessions. In addition, the selection criteria specified Hebrew or English-speaking
adult couples living in Israel or abroad (Israelis and non-Israelis). Participants were recruited
through the personal connections of the researcher (first author), who introduced the study to
colleagues and asked them to refer it prospective interviewees. Furthermore, an advertisement
targeting therapists was posted on Facebook to encourage them to refer their clients for the study.
Overall, there were no major age differences between the men and women participants (men's
mean age = 40.7 years; women's mean age = 38.6 years). The couples were all in relationships
of between two and 26 years (mean 11.1), ten of the couples were married (mean duration of
marriage 6.7), and 12 of the couples had children (mean 1.7). Most couples were opposite-sex
couples (n = 16). The majority of participants held a university degree (four doctoral degrees,
17 masters degrees, and 13 bachelor degrees), and two participants possessed only a high school
education. Participants were mostly middle- and upper-class secular Jews, with two religious
Jewish participants and one secular Muslim participant. The sampling was relatively diverse
in terms of the geographical location of the interviewed couples. Half of the sample switched
to online couple therapy following Israel's first lockdown in early 2020, whereas the other half
opted for online couple therapy. Most couples participated in couple therapy for 12 months, with
a maximum of 36 months and a minimum of 3 months. For the first half of the sample, who
4 FAMILY PROCESS
switched to online therapy, the duration of treatment included a period of offline therapy. The
couples interviewed were treated by certified couple therapists (n = 15), clinical psychologists
(n = 2), and a licensed clinical social worker (n = 1).
Couple and family therapists
To acquire a deep understanding of the phenomenon under study, a focus group was selected to
facilitate discussion and debate among homogeneous members (Kitzinger, 1995). Such a setting
provides an opportunity to express different worldviews and paradigms (Guba & Lincoln, 1994).
In a focus group setting, the researcher also promotes or moderates a group discussion among
the participants rather than between the researcher and the participants.
We interviewed 15 couple and family therapists in four different online focus groups
(3–6 participants). The participants were selected using purposeful, criteria-based sampling
(Patton, 2015). The selection criteria specified Hebrew and English-speaking couple therapists
living in Israel or abroad who took part in online couple therapy through a video call. Partici-
pants were recruited through the personal connections of the researchers (both authors of this
article), who introduced the study to colleagues with a request that they participate in a focus
group. In addition, a Facebook post was directed to couple and family therapists.
Data collection
Clients
Individual, in-depth, semi-structured online interviews were conducted in Hebrew and English
between September 2020 and April 2021 by the first author. Each interview commenced with
the narrative question: “Could you tell me the story of your couple therapy?” The interview
guide contained questions related to the background of the interviewee and his or her marital
relationship; the reason/s for engaging in couple therapy; and expectations, feelings, thoughts,
and concerns prior to, during, and following therapy. The interview guide covered the following
topics: the use of technology in the therapy (e.g. Did you have any concerns about the use of
technology in couple therapy through video conferencing?), the therapeutic relationship (e.g. To
what extent did you feel that a relationship developed between you and the therapist?), contend-
ing with marital disagreements and arguments in therapy (e.g. Did you have heated arguments
with your partner during therapy?), and other topics brought up by the interviewees. The inter-
views, which lasted between 50 and 90 min (mean 67.5 min), were digitally recorded and tran-
scribed verbatim.
Couple and family therapists
Data collection occurred between November 2021 and January 2022. The interview guide
contained questions pertaining to the clinician's experience with online therapy (How would
you describe your experience with online therapy?), with therapeutic alliances (How would you
describe your formation of a bond with your client?), and with the technology required to facil-
itate online therapy in general and therapeutic alliances in particular (How would you describe
the effect of technology on your clinical work?). The focus groups, which lasted between 90 and
120 min (mean 105), were digitally recorded and transcribed verbatim.
Data analysis
Data analysis followed the steps of CGT with the goal of conceptualizing participants' experi-
ences to develop a data-grounded theoretical model regarding video-conferenced online couple
AVIRAM and NADAN 5
therapy (Charmaz, 2017). Data collection and analysis was conducted simultaneously, through
a circular process. Analysis was carried out mostly by the first author with the assistance of the
second author, who is the study's research advisor. The first step was to acquire familiarity with
the data (immersion) by reading and re-reading the interviews. Coding was done line-by-line or
incident-with-incident, helping the researchers remain open to the data and search it for nuances.
Coding was also done by looking for actions in each sentence and using gerunds. This type of
open coding reduces the tendency to categorize people, allowing the researcher to focus on the
data and not the type of person delivering it (Charmaz, 2017).
After the conclusion of the initial coding phase, the focused coding phase began. In this phase,
constant comparative analysis was employed to analyze and compare data collected within and
between interviews to confirm similarities and differences. For example, the code “home visit”
appeared several times throughout the text in many different formats. Some were described as just
a “visit,” others as a therapeutic visit, and others as a home visit. This method entailed breaking
down the data into “incidents” (Glaser & Strauss, 1967) or “bones” (Charmaz, 2017) and then
coding the “incidents” into categories. The categories emerged from the participants' language
and from data identified by the researcher as significant to the phenomena of interest. The merg-
ing of the codes “home visit” and “the experience of hosting” resulted in the sub-category of
“emotional closeness.” This process was conducted for each interview, followed by a dyadic anal-
ysis of each couple (Eisikovits & Koren, 2010). This type of analysis entails greater clarity by
comparing spouses and refining the codes. Data analysis was conducted by ATLAS.ti qualitative
data analysis and research software.
Researchers' reflexivity and positionality
Reflexivity is fundamental to CGT (Charmaz, 2017). In conducting the research, the first author
was aware of the impact of his identity as a married Israeli cisgender man, a father, a social
worker, and an online couple therapist had on the process (Dwyer & Buckle, 2009). As an insider
and a member of the online couple therapy community, the researcher may have been affected
by the research process; this requires paying attention to perceptions and attitudes at the various
stages of the research to ensure that they do not affect the findings (Bryant & Charmaz, 2019).
One example of this dynamic may be found in the interviewing process, as the researcher, who
is also a clinician, had to ensure that boundaries were maintained between these two complex
positions. The second author—a married Israeli cisgender gay man specializing in couple and
family therapy and psychotherapy research—served as the study's research advisor. The first
author maintained a field diary throughout the study, recording study phases in detail. Further,
the authors engaged in consultations, peer debriefings, and reflexive thinking to understand
personal concepts, values, and social positioning (Patton, 2015). The process of “bracketing”
was also employed (Husserl, 1977) to avoid biases and assumptions on the part of the researcher
by explaining a phenomenon in terms of its own system of meaning.
Ethical considerations
Ethical approval was granted by the Ethics Committee of the Hebrew University's School
of Social Work. The study was conducted in accordance with Ethics Committee guidelines:
participants signed an informed-consent form and confidentiality was ensured throughout the
study, including by the use of pseudonyms and the omission of all identifying details from the
final report and this article. Furthermore, it was made clear to participants that participation was
voluntary and that they could stop at any time and refuse to answer any question. As all of the
interviews were conducted online, efforts were made to ensure proper information security, and
6 FAMILY PROCESS
all recordings, transcripts, and comments regarding the interviews were kept secure (Janghorban
et al., 2014).
FINDINGS
In this section, we report on one key category identified in our analysis: distant closeness. This
category is divided into three sub-categories relating to elements of distant closeness between the
couples and the couple therapists interviewed in the study: emotional closeness, limited caring,
and body language.
Emotional closeness: “What is more intimate than having a deep conversation

with our therapist in our living room?”
One way in which distant closeness was perceived and constructed by the interviewees in the
context of online couple therapy was according to its merit in creating emotional closeness.
The participants largely linked the creation of emotional closeness to the “home visit” effect
of online couple therapy. Since the inception of therapy, emotional closeness, as described by
Becky, a 42-year-old woman who has been in a relationship for 16 years, has been regarded as a
fundamental aspect of the process:
Interviewer: Describe your first meeting with the therapist.

Becky: …It was very innovative, and I felt that this alone—I could do couple therapy and be
sitting in my slippers (laughs)…. created intimacy, a lightness…
Interviewer: What about it was intimate for you?
Becky: …I suppose the fact that we were in our living room was significant. We hosted him in
our home, and it was nice. It felt like a conversation with friends…It felt like something very
non-clinical, very much unlike going to someone's office…We had been to couple therapy
before, and there it felt like going to the doctor. There was a sense of alienation that caused us
to leave after a few sessions. If I compare the two, here there was no alienation whatsoever…I
think that this really delineated our entire relationship with him from that point on.
Becky's words draw a connection between the therapeutic relationship that she and her part-
ner had begun to develop with the therapist and the effect of this being like a home visit. She
uses words that emphasize the personal—our living room, my slippers, our house—employing
possessive pronouns to signify ownership of the therapy process (Pennebaker, 2011). The result
is greater intimacy and a stronger therapeutic alliance. Furthermore, by contrasting a previ-
ous experience of in-person couple therapy, which she described as alienating, to online couple
therapy, she may have been situating emotional closeness and alienation at the two ends of a
continuum, creating a sense that offline and online couple therapy reside at opposite ends of the
spectrum.
The couples interviewed tended to compare and contrast in-person and online therapy, but
the reality of therapists is not as binary; online therapy is simply another way by which emotional
closeness is created through the therapist's invitation into the couple's natural space. This feeling
was expressed by Sharon, a 45-year-old certified couple therapist with 12 years of experience:
When a couple come to me, I am responsible for their couple relationship…Meaning,

they too will have an alliance regarding their couple relationship. Online [therapy] is
wonderful…If they are on the same screen, then that is the picture they see; they see
their couple relationship, in their living room, in their bedroom. I am extraterritorial
AVIRAM and NADAN 7
to their couple relationship; I am being hosted in their home, which is intimacy

between me and their couple relationship, and between the two of them. It greatly
strengthens their ability to be a couple, to see themselves as a couple…
Sharon expresses a professional creed: it is her responsibility to create an alliance between herself
and the couple and between the partners that constitute the couple. In her opinion, the screen is a
tool to accomplish this, as it serves as a mirror for the couple's relationship in its natural setting.
This emphasis on the space of the relationship is interesting, as Sharon makes two main points:
firstly, it creates a sense of intimacy between her and the couple and between the two partners
by being extraterritorial to their relationship while still being hosted in their home. Secondly,
Sharon notes that the emotional closeness created, and the image of the couple they view on their
screen, serves to empower them. According to the interviewees, it appears that emotional close-
ness can be achieved in various ways. Both couples and therapists, it is evident, view emotional
closeness as a conduit that can be established through space, whether within the couple's home
or between the couple and the therapist.
Limited caring: “I really wanted her to console me, and no matter what she did
that damn screen was still between us”
Another element of the distant closeness that emerged from the interviews with both the couples
and the therapists relates to the inability to console or be consoled during emotional distress.
Interestingly, this element was often symbolized by offering a box of tissues, a well-known act by
therapists that signifies comfort and care. The effect of this limited caring is explained by Chris,
a 35-year-old man who has been in a relationship for 10 years:
I cannot describe how frustrating it is. Shirley [his spouse] really cried…and I auto-
matically started looking for a tissue for her. And I remember being very angry…I
understood that I was angry at our therapist. Why wasn't she giving her a tissue?
Why do I now need to put my feelings aside and again take care of Shirley? It was
also a moment at which I suddenly understood how much distance there is on
Zoom. Until that moment it worked great for us, but that moment was so hard that
something cracked in my relationship with this format…In later conversations with
the therapist, I told her that I feared that something like that would happen again…
The incident that Chris describes is challenging and highly emotional. The box of tissues repre-
sents two ideas for him. The first is the fact that he is angry at the therapist for not offering care
or compassion, creating a rupture in their relationship. As seen through Chris' eyes, this rupture
may also represent what is known as an empathic failure (Doss et al., 2004) on the part of the
therapist. Second, Chris extends this rupture to his relationship with the modality of online ther-
apy, which limits the extent to which the therapist could offer care. Chris experiences this as a
chasm between himself and online therapy as a tool for change.
Couple therapists, too, have addressed the concept of the tissue box as a symbol for limited
care, a missing experience, and the development of rapport with the couples, as reflected in the
words of Amy, a therapist with 10 years of experience:
I feel that the experience [in online therapy] is lacking, partial, superficial…I make
no preparations before people come to my home, and there is also something in my
joining, not just that of the patients…in the therapeutic alliance, in that place, that
truly facilitates my connection. Not only how the patients feel, but also how I feel in
that place, and I think it is missing…And certainly, when they are in a whirlwind or
8 FAMILY PROCESS
a storm, my experience is very difficult. It is very hard for me that I cannot move my
chair toward them, that I cannot hand them a tissue or a glass of water. Somewhere
I truly feel emasculated, sitting on the chair facing the screen and unable to move. It
is a very difficult experience.
According to Amy, developing a therapeutic alliance with couples is based on participating in the
act of joining and hosting them. She describes her experience when these basic conditions are not
met and the couple is in an emotionally challenging situation: her professional position becomes
stagnant making it difficult to employ therapeutic techniques, such as offering them a glass of
water or a box of tissues. As a result, her ability to offer care or form therapeutic relationships
with clients is compromised.
In sum, both couples and therapists experienced a form of compromised care that was limited
by the characteristic features of the online modality. Cases of limited care have been highlighted
by the need for a physical connection, whether to receive (or offer) a box of tissues or a glass of
water, or to facilitate a sense of closeness between the therapist and the clients.
Body language: “Without a doubt, body language takes a blow. But I see them so
close up that it makes up for it”
Another element of the distant closeness that emerged from the analysis was the conviction that
body language plays a significant role in creating it. This, too, was a common topic in interviews
with both couples and therapists when they talked about the lack of bodily presence, as reflected
in the words of Lizzy, a 45-year-old woman who has been in a relationship for 13 years:
Lizzy: I was telling Benjamin that I do not know what the therapist smells like, what cologne
he wears, or how tall he is. I do not know if he has legs (laughs). As far as I am concerned,
he might finish a session with us and roll off in a wheelchair. I would not know…There is
something in this…that really makes the connection with him difficult.
Interviewer: And how is the connection with him in reality?
Lizzy: I am very ambivalent. He is truly a wonderful therapist. He is a person who is able to
mediate between us…On the other hand, there is [the fact that]…I do not know if I am able
to trust him completely. Even today.
Lizzy makes a critical point regarding trust, as she creates a link between the amount of phys-
ical information she can gather about the therapist and her level of trust in him. Interestingly, she
points out the ambivalence that is inherent in online couple therapy. On the one hand, therapy
works by successfully mediating between a couple and helping them improve their communica-
tion; on the other hand, the therapist is merely a picture on a screen, a “talking head” as opposed
to a full-size person. The idea of a therapist as a subjective being based on the physical data the
client can acquire is mentioned in other interviews as well.
While some interviewees were more concerned with the physical absence, others focused on
the close examination of the face. For Adam, a 34-year-old man who has been in a committed
relationship for 5 years, seeing the therapist closer than is feasible in an office makes up for the
physical absence:
Interviewer: How did you feel the connection between you and the therapist?…
Adam: That is one of the things that surprised me from the outset…The fact that she is very
sensitive, that she knows and feels us regardless of what we say…There is something about
looking a person in the eyes or seeing a face…that is a bit more difficult over Zoom. But on
the other hand, we see her so close up…we can really look into her eyes. And her eyes speak
AVIRAM and NADAN 9
amazingly [well]. We knew she was attentive…when she was seeing us…At times she teared
up with emotion or sadness from stories we told her…A person's face contains so much infor-
mation…There is body language, which is missing…But I did not feel like something was
lacking…I felt that this zoom-in on her face compensated for what we were losing, perhaps
in terms of the body language.
Despite being mediated through a computer screen, Adam and his partner express a sense of
physically closeness to the therapist, which may lead to the formation of emotional closeness and
emotional bonding. Adam also emphasizes the importance of the emotional mutuality reflected
in the therapist's self-disclosure. Through the use of facial expressions, they can share emotions
and feelings and even synchronize themselves. Although Adam and his partner acknowledge
the loss of physical presence, they also feel that this is compensated for by the zoom-in on the
therapist's face.
Returning to the therapist's point of view, Anna and Amalia, therapists with 23 years and
20 years of experience respectively, elaborate on the sub-category of body language from a clin-
ical perspective. In a focus group interview, they provide insights into how focusing on a client's
face may compensate for the lack of physical presence:
Anna: Another challenge is that we see part of the body, and, at the same time, we see the
face…This is also a major feat of magic…I am an Imago therapist…Closeness, the look
in the eyes…It is measured in centimeters…Precisely the distance between the face of the
mother and the face of the baby when it is nursing. I cannot achieve this closeness with
patients in the clinic. I can only achieve it online….So, it is true…The body is lost, but we
increase the closeness immensely.”
Amalia: That's true, it's…intimate, as I see it. It can be on the other side of the globe, but
it is…intimate…The source of the voice is also much closer…The experience of the echo is
different. There are background sounds, breaths, weeping…It is really impossible to achieve
this in the clinic.
Anna: I think that there is a great advantage to online in terms of the spaces with which the
media provides us, and of course the experience of two bodies in a space is irreplaceable. It is
a unique and magical experience.
Amalia: I very much agree, Perhaps we can say that these are two different experiences…
They do not need to be compared.”
Anna and Amalia each express different benefits of online therapy in terms of the proximity
between the client and the therapist and the ability to zoom in on facial expressions. As in the
case of the other sub-categories, both therapists discuss online therapy as another tool in their
clinical arsenal. They also both agree that this is a factor that contributes to the therapeutic rela-
tionship, resulting in emotional closeness, and even a feeling similar to that which exists between
a mother and a child. In addition, both agree that the experience of being in a single space—
together as a couple, as in traditional couple therapy—is unique and offers distinct advantages.
In sum, body language is crucial to creating a therapeutic alliance. Both therapists and
couples discussed the lack of physical presence on the one hand, and the close inspection of the
face on the other hand, at opposite ends of a continuum: the absence of the body was seen as
detrimental to the therapeutic alliance, whereas the ability to zoom-in on the face was regarded
as enhancing the therapeutic alliance.
DISCUSSION
This study aimed to explore how couples and therapists experience, interpret, and perceive
the online dimension in the context of therapeutic alliances or distant closeness. Our findings
10 FAMILY PROCESS
revealed three dimensions that work to the benefit (or the detriment) of a therapeutic alliance in
online couple therapy, from both sides of the virtual sofa: emotional closeness, limited care, and
body language. However, we argue that although these elements were presented here as separate
dimensions, they are closely intertwined and offer insights into how one (client or therapist)
may work toward establishing a therapeutic alliance. For example, the experience of intimacy
may result in a positive perception of the body language dimension—focusing on one's face—
whereas limited care may result in the opposite. As we have seen, the couples interviewed tended
to compare and contrast in-person and online therapy. This may also have implications regard-
ing a fusion between emotional closeness and body language, as one informs the other often in
the therapy room. Lastly, the inability to provide care, by offering your client a tissue, for exam-
ple, has an impact on the ability to create emotional closeness.
Adopting a meta position vis-a-vis the research findings enables us to view the three dimen-
sions identified through the lens of the closeness-distance dynamic. Through closeness, one
becomes intimate with the other by entering their private space. In this shared space, there is
the possibility of hosting—creating a space where two or more people can feel safe and at ease
together, lower their defenses, and share their worlds (Panichelli, 2013). For example, the inter-
viewees indicated that the experience of hosting the therapist in their homes made them feel
closer with/to them. In addition, creating a shared space through hosting makes it possible for
the couple to take responsibility for the setting and, by extension, for the therapeutic space.
Emotional closeness may also decrease anxiety and create a sense of comfort for both parties.
On the other end of the continuum, however, distance can lead to limited care, which reduces
the closeness between the couple and their therapist. From the perspective of the concept of a
“stable object” (Levite & Cohen, 2012), this may be explained by the couple's lack of an object of
stability. Our findings indicate that this can lead to ruptures in the alliance, as anxiety increases
and the sense of safety is compromised (Eubanks et al., 2019). Body language is also identified
as affecting the closeness-distance dynamic in conflicting ways. For some couples and therapists,
the ability to zoom-in on facial expressions adds to the sense of closeness to the therapist, and
vice-versa, and enhances the therapeutic alliance. For others, the absence of non-verbal cues
creates distance, which in turn is detrimental to the therapeutic alliance.
Our findings add to and strengthen previous findings on the effect of non-verbal cues
(Downing et al., 2021; Henry et al., 2017). However, whereas previous studies have focused on
the creation of distance by their absence, the current study sheds new light on the subject by
noting the closeness/distance axis that emerges from the personal preferences of couples and
therapists. It is unclear, at this stage, what influence therapists' and clients' preferences have on
distance or closeness, and further research is required on this aspect. One possible explanation
may be found in the limitations of the modality. As online therapy is two-dimensional, it creates
a mediation effect between the therapist and couple; communication is dependent on technology.
Due to differences in technical proficiency and adaptation to online environments, the percep-
tion of closeness/distance may vary. In our study, a favorable therapeutic alliance with the thera-
pist was experienced by those who successfully adapted to the virtual environment. At this stage,
it is unclear what influences therapists' and clients' preferences regarding distance or closeness,
and further research is needed.
Our findings also entail recommendations for clinical practice. Our main recommendation
relates to involving clients in collaborative therapeutic discussions regarding the therapeutic alli-
ance in the online setting. Therapists and couples share responsibility for building a therapeutic
alliance, but the therapist has an increased obligation to initiate conversations about feelings,
emotions, and thoughts. Engaging in conversations may increase the level of emotional closeness
in the therapeutic space and therefore deepen the therapeutic relationship. This is consistent
with collaborative and postmodern approaches that view human reality as a product of social
construction and dialogue (Anderson, 2012; Gergen, 2015). Furthermore, couples may experi-
ence a diminished sense of caring, which may result in a greater effort on the part of the therapist
AVIRAM and NADAN 11
to correct or repair the situation. Questions such as “How would it be if I were there with you
in person at this moment?” can begin a dialogue regarding the clients' need for care and have a
mediating impact on the feeling of limited care. Additionally, it is recommended that, in inner
and therapeutic dialogue, therapists inquire what information is collected (or missed) when using
online technologies, to make non-verbal communication as noticeable as possible. It may be
helpful to integrate the body into the therapeutic encounter by asking questions related to clients'
somatic experience such as: Focus on your body right now—how does it feel when you say these
words to your partner? Where in your body do you feel it? Additionally, therapists have discussed
the idea of hospitality as a means of creating emotional closeness; this idea is related to the
concept of joining, which is of crucial importance in therapy. A good definition of joining, which
may be useful for online use, is the “penetrating” of the world of the participants in dialogue to
see reality through their eyes and through the emotions they are experiencing (Andolfi, 1983).
When done appropriately, joining may be manifested through asking question regarding what
one sees. For example, what is that drawing behind you? What room are you located in? Are your
kids asleep? By asking these types of questions, a therapist may learn about and experience the
couple's views, feelings, and thoughts regarding the therapeutic act in an online setting.
This study suffers from several limitations. Firstly, the relatively small and homogeneous
sample of Israeli therapists and highly educated couples limit interpretations to the dominant
middle-class discourse, making any conclusions less transferrable. Second, since this analysis
focuses on couples within a specific social and cultural context, its findings are also limited to the
Israeli context, although some aspects may also be applicable to other contexts. Thirdly, partic-
ipants were recruited in conjunction with Israeli therapists, most of whom practice privately.
Their clients—those who participated in this study—may have possessed different coping skills
and competencies than other clients. Lastly, couples who began their work in person and then
shifted to online therapy may have experienced a different effect on their therapeutic alliance than
couples who engaged exclusively in online therapy. Considering these limitations, more research
on couples who participate in online couple therapy in different contexts with broader and more
diverse samples, as well as studies that examine the impact of therapeutic alliances, is needed.
Such research, we believe, could help generate a better understanding of the phenomenon and
increase the transferability of findings and interpretations. In addition, it is expected that future
research will refine our understanding of the similarities and differences between online therapy
and face-to-face therapy.
CONCLUSION
This study sought to contribute to the understanding of the experiences and perceptions of
couples and therapists involved in online couple therapy, with a focus on the concept of the
therapeutic alliance. Our analysis highlighted three aspects of the therapeutic alliance from the
perspectives of the couples and the therapists interviewed in the study: emotional closeness,
limited caring, and body language. These aspects were considered through the closeness/distance
dynamic. Therapists and clients can feel closer by creating emotional closeness (by sharing a ther-
apeutic space via the act of hosting) or by focusing on body language (such as facial expressions).
Alternatively, couples and clinicians may feel distant when there is a rupture in their alliance, as
in the absence of body language or tissues. However, it is important to note that the three aspects
presented here are not fixed notions but rather flexible constructs that may be transformed as
they are explored in therapy. Furthermore, the change in therapeutic environment is important,
for both couples and clinicians (Aviram & Nadan, 2022a).
We therefore recommend not being blind to the online setting, but rather to acknowledge
it and to invite couples in therapy to engage in collaborative conversations about it. Such
acknowledgment and exploration of the here and now may deepen emotional closeness, offer an
12 FAMILY PROCESS
opportunity to avoid the experience of limited care, and help focus on the information gathered
from facial expressions, thereby strengthening the therapeutic alliance.
ORCID
Alon Aviram https://orcid.org/0000-0002-1436-9226
REFERENCES
Anderson, H. (2012). Collaborative relationships and dialogic conversations: ideas for a relationally responsive practice.
Family Process, 51(1), 8–24. https://doi.org/10.1111/j.1545-5300.2012.01385.x
Andolfi, M. (1983). Behind the family mask: Therapeutic change in rigid family systems. Brunner-Routledge.
Aviram, A., & Nadan, Y. (2022a). Couple's experiences and meanings in online couple therapy: Rethinking telepres-
ence. In M. Borcsa & V. Pomini (Eds.), Handbook of online systemic therapy, supervision, and training. Springer
International.
Aviram, A., & Nadan, Y. (2022b). Online clinical supervision in couple and family therapy: A scoping review. Family
Process, 61(4), 1417–1436. https://doi.org/10.1111/famp.12809
Bartle-Haring, S., Knerr, M., Adkins, K., Delaney, R. O., Gangamma, R., Glebova, T., Grafsky, E., McDowell, T., &
Meyer, K. (2012). Trajectories of therapeutic alliance in couple versus individual therapy: Three-level models. Jour-
nal of Sex & Marital Therapy, 38(1), 79–107. https://doi.org/10.1080/0092623X.2011.569635
Berger, T. (2017). The therapeutic alliance in internet interventions: A narrative review and suggestions for future
research. Psychotherapy Research, 27(5), 511–524. https://doi.org/10.1080/10503307.2015.1119908
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory,
Research & Practice, 16(3), 252–260. https://doi.org/10.1037/h0085885
Bryant, A., & Charmaz, K. (2019). The SAGE handbook of current developments in grounded theory. SAGE Publications
Ltd. https://doi.org/10.4135/9781526485656
Charmaz, K. (2017). The power of constructivist grounded theory for critical inquiry. Qualitative Inquiry, 23(1), 34–45.
https://doi.org/10.1177/1077800416657105
Cook, J. E., & Doyle, C. (2002). Working alliance in online therapy as compared to face-to-face therapy: Preliminary
results. Cyberpsychology & Behavior The Impact of the Internet, Multimedia and Virtual Reality on Behavior and
Society, 5(2), 95–105. https://doi.org/10.1089/109493102753770480
D'Aniello, C., & Fife, S. T. (2020). A 20-year review of common factors research in marriage and family therapy: A
mixed methods content analysis. Journal of Marital and Family Therapy, 46(4), 701–718. https://doi.org/10.1111/
jmft.12427
de Boer, K., Muir, S. D., Silva, S. S. M., Nedeljkovic, M., Seabrook, E., Thomas, N., & Meyer, D. (2021). Videoconfer-
encing psychotherapy for couples and families: A systematic review. Journal of Marital and Family Therapy, 47(2),
259–288. https://doi.org/10.1111/jmft.12518
Doss, B. D., Simpson, L. E., & Christensen, A. (2004). Why do couples seek marital therapy? Professional Psychology:
Research and Practice, 35(6), 608–614. https://doi.org/10.1037/0735-7028.35.6.608
Downing, L., Marriott, H., & Lupton, D. (2021). “‘Ninja’ levels of focus”: Therapeutic holding environments and the
affective atmospheres of telepsychology during the COVID-19 pandemic. Emotion, Space and Society, 40, 100824.
https://doi.org/10.1016/j.emospa.2021.100824
Dwyer, S. C., & Buckle, J. L. (2009). The Space Between: On Being an Insider-Outsider in Qualitative Research. Interna-
tional Journal of Qualitative Methods, 8(1), 54–63. https://doi.org/10.1177/160940690900800105
Egozi, S., Tishby, O., & Wiseman, H. (2021). Client–therapist closeness–distance dynamics as a pathway for understand-
ing changes in the alliance during psychodynamic therapy. Counselling and Psychotherapy Research., 22, 784–794.
https://doi.org/10.1002/capr.12490
Eisikovits, Z., & Koren, C. (2010). Approaches to and outcomes of dyadic interview analysis. Qualitative Health Research,
20(12), 1642–1655. https://doi.org/10.1177/1049732310376520
Eubanks, C. F., Muran, J. C., & Safran, J. D. (2019). Repairing Alliance ruptures. In Psychotherapy relationships
that work: Volume 1: Evidence-based therapist contributions (pp. 549–579). Oxford University Press. https://doi.
org/10.1093/med-psych/9780190843953.003.0016
Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-an-
alytic synthesis. Psychotherapy (Chicago, Ill.), 55(4), 316–340. https://doi.org/10.1037/pst0000172
Freud, S. (1949). An outline of psychoanalysis. W.W. Norton & Company, Inc.
Friedlander, M. L., Escudero, V., Heatherington, L., & Diamond, G. M. (2011). Alliance in couple and family therapy.
Psychotherapy (Chicago, Ill.), 48(1), 25–33. https://doi.org/10.1037/a0022060
Gergen, K. J. (2015). An invitation to social construction. SAGE Publications Ltd. https://doi.org/10.4135/9781473921276
Germain, V., Marchand, A., Bouchard, S., Guay, S., & Drouin, M.-S. (2010). Assessment of the therapeutic alliance in
face-to-face or videoconference treatment for posttraumatic stress disorder. Cyberpsychology, Behavior and Social
Networking, 13(1), 29–35. https://doi.org/10.1089/cyber.2009.0139
AVIRAM and NADAN 13
Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research (observations)
(1st ed., p. 271). Aldine Pub Co.
Guba, E. G., & Lincoln, Y. S. (1994). Competing paradigms in qualitative research. In Handbook of qualitative research
Vol 2. SAGE Publications, Inc.
Hardy, N. R., Maier, C. A., & Gregson, T. J. (2021). Couple teletherapy in the era of COVID-19: Experiences and recom-
mendations. Journal of Marital and Family Therapy., 47, 225–243. https://doi.org/10.1111/jmft.12501
Henry, B. W., Block, D. E., Ciesla, J. R., McGowan, B. A., & Vozenilek, J. A. (2017). Clinician behaviors in telehealth
care delivery: A systematic review. Advances in Health Sciences Education : Theory and Practice, 22(4), 869–888.
https://doi.org/10.1007/s10459-016-9717-2
Husserl, E. (1977). Cartesian Meditations (pp. 20–21). Springer. https://doi.org/10.1007/978-94-009-9997-8
Janghorban, R., Latifnejad Roudsari, R., & Taghipour, A. (2014). Skype interviewing: The new generation of online
synchronous interview in qualitative research. International Journal of Qualitative Studies on Health and Well-Be-
ing, 9, 24152. https://doi.org/10.3402/qhw.v9.24152
Kitzinger, J. (1995). Qualitative research. Introducing focus groups. BMJ, 311(7000), 299–302. https://doi.org/10.1136/
bmj.311.7000.299
Levite, Z., & Cohen, O. (2012). The Tango of Loving Hate: Couple Dynamics in High-Conflict Divorce. Clinical Social
Work Journal, 40(1), 46–55. https://doi.org/10.1007/s10615-011-0334-5
Machluf, R., Abba Daleski, M., Shahar, B., Kula, O., & Bar-Kalifa, E. (2021). Couples Therapists' attitudes toward
online therapy during the COVID-19 crisis. Family Process., 61, 146–154. https://doi.org/10.1111/famp.12647
Mallinckrodt, B. (2010). The psychotherapy relationship as attachment: Evidence and implications. Journal of Social and
Personal Relationships, 27(2), 262–270. https://doi.org/10.1177/0265407509360905
Mallinckrodt, B., Choi, G., & Daly, K. D. (2015). Pilot test of a measure to assess therapeutic distance and its association
with client attachment and corrective experience in therapy. Psychotherapy Research, 25(5), 505–517. https://doi.
org/10.1080/10503307.2014.928755
Minuchin, S., Montalvo, B., Guerney, B., Rosman, B., & Schumer, F. (1967). Families of the Slums. Basic Books.
Panichelli, C. (2013). Humor, joining, and reframing in psychotherapy: Resolving the auto-double-bind. The American
Journal of Family Therapy, 41(5), 437–451. https://doi.org/10.1080/01926187.2012.755393
Patton, M. Q. (2015). Qualitative Research & Evaluation Methods 4th ed (p. 832). SAGE Publications, Inc.
Pennebaker, J. W. (2011). The secret life of pronouns. New Scientist, 211(2828), 42–45. https://doi.org/10.1016/
S0262-4079(11)62167-2
Rogers, C. R. (1951). Client-centered therapy (p. 560). Houghton-Mifflin.
Simpson, S. G., & Reid, C. L. (2014). Therapeutic alliance in videoconferencing psychotherapy: a review. The Australian
journal of rural health, 22(6), 280–299. https://doi.org/10.1111/ajr.12149
Simpson, S., Richardson, L., Pietrabissa, G., Castelnuovo, G., & Reid, C. (2021). Videotherapy and therapeutic alliance
in the age of COVID-19. Clinical Psychology & Psychotherapy, 28(2), 409–421. https://doi.org/10.1002/cpp.2521
Tremain, H., McEnery, C., Fletcher, K., & Murray, G. (2020). The therapeutic alliance in digital mental health interven-
tions for serious mental illnesses: Narrative review. JMIR Mental Health, 7(8), e17204. https://doi.org/10.2196/17204
How to cite this article: Aviram A., & Nadan Y. (2023). “I miss not being able to offer
my couples a box of tissues…”: Couples' and Therapists' perspectives on the therapeutic
Alliance with the transition to online couple therapy. Family Process, 00, 1–13. https://
doi.org/10.1111/famp.12853

Family Process - 2023 - Aviram - I Miss Not Being Able To Offer My Couples A Box of Tissues Couples and Therapists

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Family Process - 2023 - Aviram - I Miss Not Being Able To Offer My Couples A Box of Tissues Couples and Therapists

Uploaded by

Copyright:

Available Formats

15455300, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/famp.12853 by Cochrane Israel, Wiley Online Library on [31/01/2023].

“I miss not being able to offer my couples a box of

Alon Aviram | Yochay Nadan

The Paul Baerwald School of Social Work

Family Process. 2023;00:1–13. wileyonlinelibrary.com/journal/famp 1

Couple and family therapists

Couple and family therapists

Researchers' reflexivity and positionality

Emotional closeness: “What is more intimate than having a deep conversation

Interviewer: Describe your first meeting with the therapist.

When a couple come to me, I am responsible for their couple relationship…Meaning,

to their couple relationship; I am being hosted in their home, which is intimacy

You might also like