Love in the Time of the Coronavirus: PACT and Telehealth

As PACT therapists, we are trained to be ready to move with our couple. The COVID-19 pandemic is an exceptional virus that has compelled health professionals around the world to adapt best practices and improvise. By using telehealth sessions, they continue to provide care during this unprecedented moment in history. In this article, we share our thoughts and suggestions about how you may consider moving with your clients and adapting your practice of PACT to serve your couples through telehealth.

This introductory guide does not address the legal and ethical issues regarding telehealth. Each clinician must research and follow their specific state and professional membership regulations and codes. Nor is this an exhaustive list of ways that PACT can and should be adapted. It is a work in progress as we make this big transition. 

PACT Therapist Concerns About Telehealth

Many practitioners with whom we have spoken have expressed deep concern about not being in the room with their couples while conducting PACT video sessions. We are trained to focus our attention on the many rich and varied data streams that real-time, face-to-face interactions allow. Others worry about being able to successfully contain a couple who may escalate into very challenging territory. Some of us are anxious about being able to provide adequate care over video remotely and worried that the adaptations will limit what can be achieved. 

After careful consideration of these concerns and an honest appraisal of the limitations of telehealth, we believe that staying true to PACT theory and practice yields good results, regardless of whether we provide therapy in our offices or online. With firm grounding in our secure-functioning principles, we turn our attention to special considerations for providing PACT therapy online. 

Taking on New Couples

People require our services, especially at this time (and increasingly so in the weeks and months ahead), so don’t be afraid of taking on new telehealth cases. Always perform a thorough and formal intake with the couple while online, and carefully observe their behavior while doing so.

We are first and foremost investigators, always gathering detailed information and never assuming we know what's going on or what is true. Therefore, a thorough intake is the must do whether or not we're doing telehealth. Our PACT inquiries are mostly in the form of cross-questioning and, when necessary, we go direct. Pay attention to their level of collaboration and cooperation. If partners demonstrate an unwillingness or inability to fully cooperate with the intake process, reconsider their suitability for working in this medium. 

Self-Regulation: Our Cornerstone for Success

Therapist self-care only becomes more important when we are in a novel online environment. It is critical to take care of ourselves prior to and during the session to ensure we are as regulated and present as possible. Now, more than ever, both the PACT Serenity Prayer and reminder that the couple is in each other’s care  are important to remember. Breath work, internal resets, and stretching can help us remain calm and present with our couples.

Determining Client Eligibility for Telehealth Sessions

Consider the suitability of video therapy on a couple-by-couple basis. Use your judgement, training, and any needed consultation to determine whom to see over video, based on your work with these couples outside of telehealth. Make the determination based on their safety. 

Who May Not be Ready for Telehealth Sessions?

Couples with certain clinical presentations and situations may be problematic to work with via telehealth. These may include:

Disorganized Couples and/or Couples with Significant Trauma Histories: Attempting to work with these couples over video carries the potential for causing harm to an already damaged system.

High-Arousal and High-Conflict Couples with Unpredictable Arousal Patterns: Because we cannot see as much over video, these couples could escalate before we could catch or contain and assist. 

NOTE: It may be possible for therapists to work with the couples listed above by engaging them in conversation about the guidelines of the telehealth sessions and getting their agreement in advance. Provide guidelines to these couples at the beginning of your work and frequent reminders throughout the session. Let them know that the guidelines make it possible for you to work with them via telehealth and for their work together to have a greater chance of success.  

Setting Guidelines

Practical Telehealth Considerations

Inform couples in advance that they must be present together in the same physical location and without distractions for the sessions. Their equipment must be sufficiently powerful: their internet connection, lighting, and sound must be good; their screen sufficiently large and clearly visible. Online sessions will not work well if these conditions aren’t met. Let clients know you count on their help with these details to ensure the success of your virtual session.  

Make sure your internet is strong, your camera is good, your computer is sufficiently powered, and your lighting allows your face to be fully lit. Be sure to wear the best USB headset possible with a mic. This is both for confidentiality and for good sound reception. A headset with both ears covered is highly recommended. 

If you customarily do long sessions, consider breaking them down to 1 1/2 or 2 hours and taking breaks. Screen fatigue will impair your effectiveness. You may experience voice fatigue as well, so have water ready. 

Consider more frequent sessions during this stressful time, especially if sessions are shorter. 

Making Agreements with Your Couple

When each session begins, inform your couple of the limitations that come with this medium and set up whatever ground rules you deem necessary to maintain safety and efficiency during the session. Remember, you are in charge of treatment! Your couples must comply with your conditions or you should terminate online sessions with them. 

Deciding How Much to Intervene

Next, get an agreement with both partners on how you will intervene during the session. Remind them of the limitations of online sessions. Get them to agree from the onset that you must intervene when necessary and they MUST allow you to do so. Failure on their part to hold to this agreement may result in termination of the online session.

Ask them how much they would like you to be involved. By determining how tightly they would like you to coach/help/intervene — and getting their agreement upfront — you will have more permission to do your job. This approach models what you expect them to do with their own agreements. 

When given the choice, partners will often choose to have the most input and guidance from us, because anything less is a waste of their money and time. Under tighter conditions, exercises will be much more stressful, but valuable, for them. Expect to see improvement in each session as a result.

While you can allow the couple “to run at times without a leash” over telehealth, you will need to control the amount of slack they have as the session progresses in order to get things done. You may want to start a bit looser in the beginning and gradually tighten up with holding them in very tightly toward the end. This serves to help them focus on the task they have set for the session and hold them to the agreements they have made. 

Adapting PACT Interventions to Telehealth 

Session Tasks

The following are our recommended tasks for online therapy. Only one of these tasks should be considered for any single session. Each is vital to couple well-being, and each is sufficient to fill a session. Attempting to do more than one of these tasks over telehealth may risk overwhelming the couple or therapist. 

From Therapist to Coach/Mentor

You may notice that these tasks change the therapist’s role, in some measure, to that of coach and educator. It is our opinion that this alteration may be more appropriate to the online medium as well as more rewarding for most couples. 

This is not meant to be an exhaustive list of all PACT interventions that are appropriate for telehealth. Our goal is to highlight certain ones to provide a sense of how these may be used over video. 

Top-Down Tasks

During in-person sessions, we collect and make use of as much raw, unedited information from the body, brainstem, and limbic brain as possible. In telehealth, much of this data will be less visible to us so this is an opportunity to employ more concrete, top-down interventions. These can provide relief and support to our couples in working on foundational aspects of their relationship. This will yield a positive and helpful process over video as well as concrete tools to help them support each other outside of sessions.  

Below we provide multiple examples of top-down processes to help couples focus on the foundation of their relationship. Doing so helps provide structure to the telehealth session and helps couples build and maintain the fundamental components, which will strengthen their relationship during difficult times.  

• Creating a Shared Purpose: Focus partners on their purpose or mission in being a couple. This must be something greater than themselves individually and most certainly more than simply about love, attraction, children, etc. Helping them understand that purpose-centered couples do better in the long run will support their commitment to the process. Positive feelings such as love and attraction come and go, yet shared purpose is significantly more stable. Consider this task as hierarchically vital. Without a shared purpose, partners will be unable to use any of the tools we provide when they bottom out. Every task below this one depends on this one and each depends on the task above it. For instance, if no shared purpose, how are they to hold onto a reason to stay together?
• Creating a Shared Vision: Where are they going? Are they going into the future together, pointing in the same direction? Where do they wish to be as a couple in five years? 
• Creating Principles of Governance: Following the creation of a shared vision, help your couple focus on their agreements or shared principles of governance and have them articulate and process them. What are their shared rules for protecting each other and their partnership? Secure-functioning partners agree to ensure both survival and thriving. They must operate according to civilized rules of fairness, justice, and sensitivity. These principles of governance will help partners care for each other and maintain commitment through the difficult times in their relationship. 

Top-down interventions engage the upper-left hemisphere of the brain and quiet the lower brain structures, thereby regulating our higher-arousal couples and helping them state-shift when things begin to escalate. This can help safeguard partners from getting over-activated when we cannot be there to step in. 

Top-down interventions, such as psychoeducation, are an excellent choice for telehealth sessions. By contrast, bottom-up interventions, while effective, elicit strong feeling states that can be difficult for the couple to manage. The use of bottom-up interventions therefore runs the risk of requiring external regulation through the physical presence of the therapist in the consulting room, something which we do not have the luxury of providing during telehealth sessions. 

Instead, we can provide a more detailed road map of secure-functioning principles. Although we recognize that learning is state-dependent and therapists must facilitate problematic states of arousal in order to create change in those states, psychoeducation benefits the couple by informing the couple of important relationship components within the safety of a tightly held container. 

Consider educating partners about any of the following topics:

• Threat perception. Help partners pay close attention to one another when discussing stressful material. Educate and use real time examples of how our brains continuously scan for threat in the environment and how threat cues radically increase under conditions of stress and distress. Introduce them to how long-term and short-term memory play a significant role in threat perception as well as how subcortical recognition systems are lightning fast and highly error-prone. Use this education to help them see each other differently. 
• Mutual accountability and taking an active role in reducing threat. Each must learn how to shift the other’s state to that of safety, and they must learn to accomplish that state shift as quickly as possible. That means each member of the couple must learn what works and does not work with their partner.
• You cannot influence or persuade the other under conditions of threat. Conditions of safety must be present for each partner to be heard or to get what they want. If they want to get anything accomplished, both partners will have to maintain each other’s sense of safety and security at each moment or they will remain stuck. 
• Work on the problem, not on each other. Use psychoeducation and intervention when necessary to get the couple to work on the problem — not on each other. The latter will always lead to war. It is neither collaborative, cooperative, nor wise. Everyone must learn to do what we’re teaching and expecting; they are no exception. 
• Lead with relief and disarm the other before proceeding with their own point. Show partners that, while under stress, distress, or threat, neither view the other as friendly. Help partners to disarm the other first, check their face for confirmation, and only then continue with an explanation, counter comment, or process while protecting from counterthreat. Remind partners that this formality of threat elimination or disarmament of the threat response is due to a core survival issue between human beings. 
• Negotiation. Guide them toward the use of bargaining, negotiating, and persuading. Both partners must learn to broker win-win outcomes if they are to move forward without accruing resentment and face paybacks. 

Provide a conclusion for the session. Plan for sufficient time before you stop to provide a summation of what they are working on and to suggest concrete ways they can continue practicing between sessions. 

Create Optimal Frustration

When you continually insist that partners prioritize each other’s well-being before advancing their own personal agenda, they will become frustrated. Do your best to normalize that frustration. What they are learning is very difficult to do despite being simple to understand. You are supporting them to: 

• be effective with each other
• make collaboration possible and much easier to do
• help them get things done
• be understood
• spend much less time fighting 

The goal is to deal with distressing issues quickly, moving the ball forward even just a little, and providing mutual relief. 

Process Over Content

Unsuccessful interactions are almost always the source of the couple's problems, and it’s not the content material or the subject matter that causes them distress. It is the frequent, uncorrected errors in communication, perception, and appraisal that repeat and increase with stress that cause problems. Helping couples see those errors and process them in real time will help them create new state-dependent learning about this. 

Focus partners on their interactions while discussing an issue. Have them face each other while you watch and provide coaching. When working with partners and their current issue over telehealth, strongly consider the following guidelines:

Face-to-face, eye-to-eye: Have them face each other and make certain their eyes are up. Tracking one another’s face and eyes is critical for success over video sessions. Do not allow gaze-averting except for very brief moments. Explain that this is a fast-acting process that demands focus and attention to avoid trouble.  

Help partners slow down: Telehealth sessions provide an opportunity for us to zero in on the couple’s interactions that usually occur at lightning speed. This is an excellent time for the couple to learn how many critical errors they make. 

Slowing down the discussion helps partners notice how often they are missing the many errors that go unnoticed and uncorrected:

• misattuning
• misunderstanding each other
• misappraising each other’s thoughts, feelings, and intentions 
• wrongly anticipating each other
• talking about two different things 

If you hear communication errors, misunderstandings, or errors of appraisal, stop the interaction to point these out right away. Be sure to check your own communication and appraisal errors as you talk. Remember, partners are acting and reacting automatically and reflexively, according to memory. They are unwittingly amplifying each other’s threat response. As threat increases, so do errors.  

Focus closely on each partner: This will help you identify implicit threat signals (face, movements, gestures, utterances, etc.) so you can bring their awareness to it promptly. Listen closely for dangerous words and phrases. Address these immediately. Watch the receiving partner closely for signs of distress or threat, and stop the action quickly.  

Remind partners to pay attention to their partner when speaking. Remind them that they will both lose if they forget to create friendliness and safety whenever necessary. Help them understand how easy it is to go to war. 

Don’t allow partners to hold the stage too long: During stressful periods over telehealth, help them keep it short. Explain that, while discussing stressful matters, each must make their point as clearly and concisely as possible and allow the other to respond. 

Work with the couple on any of the above tasks. Make certain the couple sticks to the task at hand and only that task. If working with a recent issue, keep them to one topic or need. Instruct partners to self-monitor orderliness in their back and forth. 

Use of Bottom-Up Interventions 

PACT’s power lies in its bottom-up approach. Adapting these skills to telehealth will provide continuity to ensure the continued growth of our couples. The more dramatic interventions like King and Queen, Lover’s Pose, and Toward and Away are probably ill-advised for telehealth. 

However, if partners present you with a recent, troublesome interactive event, you can, for example, ask partners to “re-enact” a snippet. The replay will help you zero in on the problem by tracking the sequence as partners replay it. 

Recall that “bottom-up” also refers to the therapist’s use of their facial and vocal instruments. 

Voice, speech, and facial expressiveness. These are critical tools for video sessions. The prosody, tone, pitch, and volume of your voice can all be used to regulate your couple’s level of arousal. If partners are yelling at each other, practice matching their speed, intensity, and volume. This attunement will give you the opportunity to gradually slow them down without them necessarily being aware that you are doing so. 

Because video naturally decreases the couple’s ability to see you clearly, there is a greater likelihood that you will be perceived as threatening. Maintaining a neutral, friendly face during video sessions is therefore particularly important, allowing you to be experienced as helpful and non-threatening, which will further regulate your couple. 

Humor and playfulness. Have some fun with your couple. Your approach should carry a spirit of play, experimentation, and humor about the human condition.

Let’s Amplify the Positive

With couples cooped up indoors with each other, relationship stress has never been higher and our services have never been more needed. While all of us are feeling incredibly challenged by the personal and professional restrictions of this pandemic, telehealth is providing unique data and opportunities to learn more about our couples and to assist them in truly being in each other’s care. 

All five of us, as authors of this piece, are new to telehealth. We are already finding incredible adaptations and uses for this challenging and limited medium, and our couples are growing and grateful. While we will return to an in-person process as soon as the social distancing recommendations are over, may this time foster new growth and development for our couples and ourselves. 

We hope that this provides some ideas to help you support your couples through this incredible time.