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Couples Therapists’ Attitudes Toward Online Therapy During the COVID‐19 Crisis

The measures adopted by governments around the world to control the spread of the COVID‐19 virus (e.g., social distancing) have propelled a rapid transition from face‐to‐face to online therapy. Studies on online individual therapy indicate that therapists often have favorable attitudes toward this modality. To date, there is scant work on couples therapists’ attitudes, despite the fact that the provision of online couples’ therapy poses unique challenges (e.g., dealing with escalating conflict remotely). To provide a snapshot, in real time, as to how therapists experience the transition to online therapy, we surveyed 166 Israeli couples’ therapists during April 2020, when lockdown orders prevented therapists from seeing couples face‐to‐face. A few weeks later, when the stay‐at‐home policy was lifted, a subsample (N = 60) of these therapists completed a follow‐up assessment. The results suggest that couples therapists had limited experience using the online modality prior to COVID. The therapists reported experiencing online couples’ therapy as somewhat successful and that their experience of providing therapy during the COVID‐19 crisis had an overall positive impact on their attitudes toward online work. Establishing a strong therapeutic bond with both partners, dealing with escalating conflict, and treatment dropout were identified as the issues of most concern when conducting online couples therapy. The perceived difficulties with online therapy prospectively predicted lower usage of online couples’ therapy, as well as less intention to continue online treatment once the crisis is over.

In light of the sudden transition to online therapy, it is imperative to examine mental health providers' attitudes with respect to online therapy. Previous work has shown that therapists' attitudes can shape treatment outcomes (Sandell et al., 2007). In addition, therapists' attitudes toward online therapy were found to predict their intention to use this modality (e.g., Sucala, Schnur, Brackman, Constantino, & Montgomery, 2013). Therefore, understanding couples therapists' attitudes toward delivering therapy online is imperative today to identifying obstacles to the pressing need to move from face-to-face to online treatment.
A recent review revealed that most mental health providers appreciate the accessibility and flexibility of online therapy (Cipolletta & Mocellin, 2018;Connolly, Miller, Lindsay, & Bauer, 2020). These positive attitudes were associated with therapists' previous experience with online therapy (Connolly et al., 2020). In contrast, technological barriers and the perception of online therapy as impersonal were associated with unfavorable attitudes. Safety and legal issues were also identified as potential concerns (Cipolletta & Mocellin, 2018;Connolly et al., 2020).
There is little empirical data on couples therapists' attitudes toward online treatment (Doss, Feinberg, Rothman, Roddy, & Comer, 2017). This is unfortunate since online couples therapy presents a number of unique challenges. For example, couples' therapists face the complex and delicate task of simultaneously forming a strong alliance with two partners who often enter therapy with disparate narratives, coping styles, and fears (Carlson & Dermer, 2016). Achieving a balanced alliance may be more complicated on an online platform, which can be experienced as less personal (Wagnild, Leenknecht, & Zauher, 2006). In addition, during couples' therapy, partners are often in close physical proximity; among those couples with reactive and volatile relationships, negative interactions can escalate quickly. When the therapist is conducting remote therapy, it is more difficult to help the couple downregulate during these escalations (Wrape & McGinn, 2019). Furthermore, the widely adopted stay-at-home policies make it more difficult to maintain treatment boundaries, since interruptions by family members during sessions are very likely to occur (Wrape & McGinn, 2019). Therefore, conducting couples therapy online may be more intimidating and thus, therapists' attitudes to online couples therapy may be more negative.
The main goal of the current study was to provide a snapshot of how Israeli couples therapists viewed and reacted to the transition to online therapy during the COVID-19 global health crisis. We sought to examine couples therapists' attitudes, beliefs, and expectations with respect to online therapy as therapists transitioned to this modality. Specifically, we explored (a) therapists' experiences of online couples therapy; (b) the difficulties they face when delivering online therapy in comparison to face-to-face therapy; and (c) therapists' concerns with respect to online couples therapy. To this end, we surveyed Israeli couples' therapists. The data were collected during April 2020, when the health measures adopted by the Israeli government were the most stringent, and seeing clients face-to-face was forbidden. About a month later, when most restrictions were lifted, we were able to reach a subsample of these same therapists who provided follow-up data. We used the data from these assessments at two time points to examine whether therapists' attitudes toward online couples therapy at the first assessment point would prospectively predict therapists' usage and experience of online couples therapy, as well as their intention to continue seeing couples online when the COVID-19 crisis is over.
Given the paucity of research on couples therapists' attitudes, the study was exploratory in nature. Nevertheless, some tentative a priori hypotheses were formulated. Older therapists often had less exposure and familiarity with online technology during their  (Brooks, Turvey, & Augusterfer, 2013); therefore, we expected older therapists to report less favorable attitudes toward online couple therapy (Hypothesis 1). Relatedly, and in line with previous studies (Cipolletta & Mocellin, 2018), we also expected to find a positive association between previous experience with online therapy and favorable attitudes toward it (Hypothesis 2).

Participants and Procedures
Couples therapists were recruited via posts on maillists and online social network groups of Israeli mental health professionals. The post included a brief presentation of the study and a link to a secure online questionnaire. Two hundred and forty-eight therapists began filling in the questionnaire. Of these, 166 completed the entire questionnaire and were included in the analysis. Data were collected during the month of April, 2020, when the stay-at-home policy was enforced in Israel. The survey was anonymous, though we invited therapists to leave their personal email address for future contact. About four weeks after completing the first survey, those 85 therapists who indicated their interest were re-contacted and asked to complete a follow-up questionnaire. Sixty therapists (36.1% from the original sample) completed the follow-up questionnaire. The follow-up was completed on average 39.1 days (Range = 29-49) after the first assessment. The study was approved by the university's Institutional Review Board.

Measures
An online questionnaire was designed for the present study. Some of the items were inspired by previous studies on therapists' attitudes (e.g., Glueckauf et al., 2018). In addition, the fourth author, a licensed couples' therapy supervisor, led a supervision group focusing on the challenges involved in the transition to online therapy during the COVID-19 crisis. The concerns and difficulties raised by therapists who participated in this group were used to develop some of the items included in the survey. The questionnaire comprised 34 items. Therapists first provided information regarding their demographics and professional background. Then, they rated their previous experience with online therapy as (i) an individual therapist, (ii) a couples' therapist, (iii) a family therapist, (iv) a supervisee, and as (v) a client. Items were rated on a scale ranging from 1 ("none at all") to 5 ("extensive experience").
To evaluate the experience with online couples therapy during the COVID-19 crisis, therapists reported (i) the number of couples they were seeing in online couples therapy during the COVID-19, and (ii) how many new couples they have begun seeing online since the COVID-19 crisis outbreak. In addition, they rated (iii) their perceived success with online therapy, using a scale ranging from 1 ("unsuccessful") to 5 ("very successful").
www.FamilyProcess.org 148 / FAMILY PROCESS We then asked therapists to report on the extent to which they perceived online couples therapy as more difficult than face-to-face therapy on seven common couples therapy therapeutic tasksnamely, (i) Forming a therapeutic bond, (ii) Dealing with escalations, (iii) Helping partners come in contact with feelings, (iv) Encouraging partners disclosure of feelings, (v) Helping partners to respond supportively, (vi) Helping partners with problem solving, and (vii) Helping partners to accept each other. Items were rated on a scale ranging from 1 ("online therapy is easier") to 5 ("online therapy is more difficult"). We averaged the seven items to compute a composite score (Cronbach's alpha = 0.84) representing perceived difficulty with online therapy in comparison with face-to-face therapy.
In addition, therapists rated the extent to which they had concerns regarding online couple therapy. Their responses were given using a 9-item questionnaire, ranging from 1 ("not at all") to 5 ("very much"). The following items were included: (i) maintaining information security, (ii) ethical/legal issues, (iii) escalating conflict, (iv) dropout, (v) therapy ineffectiveness, (vi) technological problems, (vii) personal-life exposure, (viii) difficulty in forming a therapeutic alliance, and (ix) creating an alliance split. We averaged the nine items to compute a composite score (Cronbach's alpha = 0.78, M = 2.32, SD = 0.58, Range = 1-3.77) representing therapists' concerns with respect to online couple therapy.
We also adopted items from Glueckauf et al.'s work (2018), to assess general attitudes toward online couples' therapy. The following four items, rated on a scale ranging from 1 ("not at all") to 4 ("very much"), were used: To what extent (i) do feel comfortable delivering online therapy? (ii) do feel confident providing online therapy without an initial in-person assessment? (iii) do you believe you will continue providing online therapy after the crisis? and (iv) has the experience of providing online therapy during the crisis had a positive impact on your perceptions and attitudes towards online therapy? Finally, we also included the Ten-Item Personality Inventory (Gosling, Rentfrow, & Swann, 2003) to assess therapists' personality traits. In the current study, online therapy was defined as real-time synchronous therapy provided via Internet platforms (e.g., Zoom), video conference, or phone call. The questionnaire used in this study was in Hebrew. The English version of the questionnaire and the data file can be found in the online supplementary materials (OSM; https://osf.io/9cn5y/).

RESULTS
The descriptive statistics for the variables are presented in Table 1. Information regarding items' response endorsement frequency, zero-order correlations, and pairwise comparisons with Bonferroni corrections are presented in the online supplementary materials (OSM). Most of the therapists in the sample reported having limited previous experience with online couples' therapy. Specifically, 32.7% reported having no experience, 26.7% reported having slight experience (refer Table S2 in the OSM). They also reported limited experience with online therapy as a family-therapist, a supervisee, and a client. The therapists reported slightly more experience in conducting online individual therapy. In addition, therapists reported that since the COVID-19 crisis outbreak, they had begun seeing, on average, approximately one new couple online (M = 0.90, SD = 1.60, Range = 0-10) who was not on their caseload before the outbreak.
Therapists reported experiencing online therapy as somewhat successful (M = 3.49, SD = 0.95); that is, most therapists rated their success as "reasonable" (30.0%) or "good" (38.7%). In general, the therapists rated online couples therapy as slightly more difficult than face-to-face therapy (refer also Table S4 in the OSM). The two therapeutic tasks that therapists perceived as the most difficult to conduct in online couples' therapy were dealing with escalating conflict and forming a strong therapeutic bond. Experiential emotionfocused tasks (i.e., encouraging partners to get in touch with and reveal their feelings, encouraging partners to respond empathically to each other) were also rated as somewhat difficult (refer OSM Tables S3 and S4). In addition, therapists reported being most concerned about potential dropout, technological problems, and escalating conflict (refer OSM  Tables S6 and S7). Most therapists reported that they feel relatively comfortable with online couples therapy (e.g., 56.6% reported feeling comfortable "to a certain extent", 28.9% reported "to a large extent"). However, only moderate confidence was reported in treating couples online without a prior face-to-face assessment (e.g., 34.8% reported confidence "to a small extent", 37.2% reported "to a certain extent"). Finally, most therapists indicated that the experience of providing online therapy during COVID-19 had a positive impact on their attitudes (30.5% reported a positive change "to a certain extent", 40.9% "to a large extent"). However, they were not enthusiastic about continuing to see couples online after the COVID crisis is over (e.g., 42% reported they would continue to provide online "to a small extent"; refer OSM Table S8).

Therapists' Age and Experience
In contrast to expectations, no associations were found between therapists' age and their attitudes or experience with online couples therapy. Specifically, therapists' age was associated with perceived success with online couples therapy (r = .02, p = .847), the difficulty of delivering online therapy (r = .03, p = .698), concerns about online couples therapy (r = À.15, p = .060), and the four items assessing therapists' general attitudes toward online couples therapy (rs = À.09 to .06, ps > .270). In line with predictions, therapists' previous experience with online couples' therapy was associated with favorable attitudes and experience with online couples' therapy during the COVID-19 crisis. Specifically, therapists' previous experience with online couples therapy was associated with higher perceived success with online couples therapy (r = .25, p = .002), less difficulty delivering online therapy (r = À.29, p < .001) and concerns about online couples therapy (and r = À.21, p = .007). In addition, previous experience with online couples therapy was associated with therapists' comfort (r = .29, p < .001) and confidence (r = .21, p = .007) with online therapy during the pandemic, as well as their belief that they would continue to see couples online when the COVID-19 crisis is over (r = .23, p = .003). However, previous experience with conducting couples online therapy was not associated with therapists' reports as to whether their current experience during the COVID-19 crisis had changed their attitude toward online therapy in a positive direction (r = À.04, p = .565).

Follow-up Assessment
Finally, we examined whether therapists' attitudes toward online couples therapy at the first assessment prospectively predicted therapists' usage and experience of online couples therapy, as well as their intention to continue seeing couples online when the COVID-19 crisis is over. We ran a set of regressions in which therapists' perceived difficulty delivering and concerns about online couples' therapy on the first assessment were used to predict therapists' reports on the follow-up assessment. In all models, we included the outcome level on the first assessment as a covariate, so that the outcome can be considered a change score. Missing data were handled by pairwise deletion. The results of these analyses are shown in Table 2. Therapists' perceived difficulty with online couples' therapy predicted fewer online couples, as well as lesser intention to continue seeing couples online when the COVID-19 crisis is over. Therapists' concerns about online couples therapy were not associated with any of the predicted outcomes. 1

DISCUSSION
The policies adopted by governments around the world to deal with the COVID-19 pandemic (e.g., social distancing) have imposed a rapid transition from traditional face-to-face to online therapy. This study constitutes one of the first attempts to probe couples therapists' attitudes and experiences with online couples' therapy in general and particularly during this challenging period. The results indicate that couples therapists had very little previous experience with online therapy. Most therapists rated their current experience working with couples online as reasonable or good. They also reported feeling somewhat confident delivering and comfortable with online couples therapy. Most therapists (71.4%) reported that their experience of providing online couples therapy during the COVID-19 crisis changed their attitudes positively toward online couples therapy to a certain or large extent. Interestingly, despite this improvement, the therapists reported that once the crisis is over, they do not plan to continue using this modality to a large extent.
The critical barriers to therapists' willingness to utilize online couples therapy appear to be their concerns about establishing a strong therapeutic bond with each partner, managing escalating conflicts, and preventing potential dropouts. Unfortunately, we failed to ask therapists what they had found to be the most useful in mitigating the challenges associated with seeing couples online. However, some of the recommendations suggested recently by Wrape and McGinn (2019) may be pertinent here. For example, an initial in-office visit and individual sessions with each partner may help strengthen the therapeutic bond. In order to deal with escalations, it might be beneficial to create a "time out" procedure, agreed upon at the beginning of therapy, or thinking together with the couple on ways to calm down without the presence of the partner (e.g., walk around the room or deep breathing; Wrape & McGinn, 2019). Another possible strategy when working with highly volatile couples would be to have them log into the session from different rooms and different computers to maintain some degree of physical distance.
The current study also sought to explore factors that promote therapists' positive attitudes toward online couples' therapy. We predicted that older therapists' attitudes would be less favorable due to their limited exposure to technology during their training years. However, despite the wide range of therapists' ages in the current sample, no association was found between therapists' age and their attitudes. What did seem to matter was their actual previous experience with online therapy. Consistent with our hypothesis, and previous findings (e.g., Aafjes-van Doorn, B ek es, Prout, & Hoffman, 2020), couples therapists' past experience with online couples therapy was associated with greater comfort, confidence, and perceived success with online therapy. It was also associated with the actual usage of online therapy during the COVID-19 crisis, and their intention to keep on using this modality once the current pandemic is over. In addition, therapists with more previous experience with online therapy reported fewer difficulties delivering and concerns about online couples' therapy. This association between previous experience and therapists' willingness to try as well as use online therapy highlights the crucial need to integrate practice in online therapy into training programs (Aafjes-van Doorn et al., 2020).

Limitations and Summary
One major limitation of the current study is that perceived success with online couples therapy was not rated in comparison with other times (e.g., prior to the pandemic) or forms of therapy (e.g., face-to-face). Without this information or a comparison group, no conclusions can be drawn as to whether the difference between the experience with online and in-person therapy was meaningful. In addition, to assess the obstacles to online therapy, we constructed a list of nine potential concerns. However, this list was not exhaustive, and there are probably other factors affecting therapists' willingness to continue www.FamilyProcess.org 152 / FAMILY PROCESS using an online platform when the restrictions on seeing couples in-person is lifted. Anecdotal information suggests that therapists experience social isolation with working online, and that the online modality demands greater emotional and physical investment in order to bond with clients.
It should also be noted, in this regard, that we surveyed therapists at the start of the COVID-19 outbreak in Israel (from April to June 2020). Therapists' attitudes toward couples' online therapy may have changed when the current stressful situation became more chronic. During the early stages of the pandemic, therapists might have been highly motived to shift to providing online therapy. However, with time, therapists could become emotionally drained; for example, from attempting to compensate for the emotional aspects of therapy that are more difficult to convey in online work (Connolly et al., 2020;Wrape & McGinn, 2019). Therefore, future studies should monitor couples therapists' attitudes over longer time frames.
Another major limitation of the current study is that it relied solely on the therapists' perspective. Though understanding therapists' subjective experiences, satisfaction, and concerns is important, this method did not consider the couples' experience or whether therapists' attitudes were associated with their actual efficacy in delivering treatment using the online modality. In addition, we did not ask therapists to assess the extent to which their client couples were experiencing COVID-related stressors. External stressors associated with the pandemic (e.g., financial strain, health concerns) often lead to destructive relational behaviors (e.g., poor communication, violence; Pietromonaco & Overall, 2020). It is thus likely that couples facing greater levels of stressors would react more poorly to treatment (though refer Rathgeber et al.,2019). This, in turn, may negatively impact therapists' attitudes toward delivering couples therapy online. Therefore, future studies should assess couples' stressors and examine therapists' attempts to address them within the therapy session. This may help identify constructive as well as ineffective means of dealing with these challenges.
These limitations notwithstanding, the data collected provide a unique opportunity to capture therapists' attitudes toward online therapy as they transitioned in real time to using this modality. The results indicate that most couples' therapists had limited experience with this modality prior to COVID-19, reported experiencing the use of this modality as somewhat successful and a little more difficult than in-person therapy. These encouraging results suggest that couples therapists are willing to provide online therapy and thus to make this service accessible to more couples. This is especially important in times in which public health restrictions necessitate using this modality. During such stressful times, many couples are in tremendous need of professional help to deal with relational hardships (Goldenberg & Goldenberg, 2013). The current study results show that having previous experience with online therapy lessens therapists' concerns and thus may facilitate therapists' willingness to provide this much-needed assistance.