COVID Couple Therapy: Telehealth and Somatic Action Techniques.

In March of 2020, during the global COVID-19 pandemic, therapists quickly transitioned to telehealth platforms to provide their services. Teletherapy, while subject to some constraints, presents unique opportunities to work creatively with couples, particularly during these uncertain times. This paper offers a case study of work with a couple using systemic, developmental attachment, dialogical, and somatic trauma theories. Action techniques, including doubling, ideal futures creation, and a foam roller trust exercise are employed to facilitate change processes as couples face the chaos and unknowns of the pandemic and the difficulties that have become triggered between them. These exercises help to open perspective, increase awareness, and lower resistance to change. Couples are able to physically enact and metabolise alternative realities while discharging excess energies in familiar surroundings.

The pandemic, while traumatic in many ways, has offered unique opportunities for innovative couple work via telehealth.

Establishing safety is extremely important in telehealth couple work during the pandemic.

Action techniques can be used creatively while engaging in virtual couple therapy.

It is helpful to develop a repertoire of techniques that are able to soothe our nervous systems and physically activate us toward growth, compassion, and forgiveness.

Several action techniques are described along with case study examples.

There was a YouTube video widely circulating in the United States during the COVID‐19 pandemic that depicted a woman with a flashlight hiding in a closet and whispering, ‘I want a man in life, just not in my house … Hook up my DVD player, my printer maybe, help me flip the mattress now and then, and then get out!’ (Enss, 2020). The woman was humorously struggling with the virus restrictions and the forced intimacy with her husband that she was experiencing during lockdown. Sarah is similarly struggling as she shelters at home with her husband Dan. She is feeling ‘trapped,’ ‘constantly triggered,’ and says that she ‘doesn't like herself’ in her interactions with him; their relationship is deteriorating. She and Dan would like some help with handling the stresses of the pandemic and with exploring how to improve their relationship during these extraordinary times.

COVID‐19 globally impacted family systems as we were required to stay at home, work from home, educate our children from home and, for many essential workers, separate ourselves from our families to try to protect them from becoming infected with the virus. Many faced economic stresses in addition to grief, loss, isolation, depression, and anxiety, and couples had to navigate multiple external demands as they accommodated new and ever‐changing parameters placed upon them while facing the unknown.

This pandemic is a trauma that many of us have experienced together, as we have become overwhelmed and sometimes unable to cope. Trauma is defined by van der Kolk (2014) as an event that overwhelms the central nervous system and alters the ways in which we process and recall memories. Collective trauma is said to occur when an entire society experiences an intense threat or overwhelming amount of stress exceeding their coping ability (Hirschberger, 2018). ‘The COVID‐19 pandemic is considered collective trauma due to the intense threat experienced by many that we or our loved ones will become seriously ill and die and are experiencing related concerns about our ability to access resources, maintain employment, care for others, and manage ongoing physical isolation’ (Holmes, Rentrope, Korsch‐Williams, & King, 2021, p. 496). Many of us experienced a ‘shared traumatic stress’ (Saakvitne, 2002; Tosone, 2011; Tosone, McTighe, Bauwens, & Naturale, 2011; Tosone, Nuttman‐Schwartz, & Stephens, 2012) that impacted our therapeutic work together. Not only did we need to adjust to working remotely, we also needed to adjust to the fact that therapists and their clients were negotiating similarly difficult terrain.

This paper offers a case study of telehealth couple work with Sarah and Dan as they face the chaos and unknowns of the pandemic and the processes of handling difficulties that are triggered between them. These factors combine with her pre‐existing childhood trauma, compromised immune system, and his history of substance misuse to present complex issues that they must address together to be able to deal with the stresses facing them. Crises offer opportunities for significant growth and evolution of self (Lindemann, 1944). Using action techniques of couple therapy (Chasin, Roth, & Bograd, 1989; Weiner, 2009, 2015, 2017; Wile & Kaufmann, 2021), we work to develop skills to cope with the challenges of the current moment.

Theoretical Background

Milan Systemic Theory

In my work with couples, I use an integrative approach blending different theories and practices to meet the particular situations and needs of my clients. Milan Systemic Theory (Boscolo, Cecchin, Hoffman, & Penn, 1987) serves as a foundation for my work. The recursive circular patterns that clients engage in, as well as the interactions of therapist and client systems, are important to how I frame things and position myself. The use of telehealth during the pandemic offers a certain perspective and distance that is reminiscent of working with a team behind a one‐way mirror. There is a screen between us, and I have the psychological distance away from the ‘force field’ of their energies to take my time and think more clearly as I facilitate the couple's process.

Developmental attachment theory

Couples have widely different developmental attachment styles, and it is important to understand and negotiate them as we work together. Pearlman and Courtois (2005) offer a useful summary of four adult styles of attachment: those with secure attachment styles have a solid internal world and are able to engage in mutually satisfying relationships with others; those who have insecure preoccupied attachment styles become flooded with feelings and engage in emotionally explosive, difficult, and unhealthy interactions with others to whom they cling; those with insecure dismissing attachment styles minimise feelings, deny their need for relationships, and appear falsely independent; and those with insecure fearful avoidant unresolved attachment intermittently approach and avoid relationships. Wallerstein (1994, 1996) identifies one of the developmental tasks of couples as moving from the enmeshed attachment of beginning romance to more individual differentiated positions in the relationship.

Dialogical theory

Dialogue is communication that seeks to understand meaning and connect with others. Anderson (2007) characterises dialogue as ‘social exchange and the generation of meaning and understanding through it’ (p. 34). According to Bakhtin (1984), all of living is participating in dialogue with others, with events, with thoughts. In couple therapy, the ‘here‐and‐now dialogical regulation of the relationship, that is, living together from moment to moment, and jointly producing and renewing the relationship’ (Laitila et al., 2019, p. 686) underscores everything. Seikkula and Trimble (2005) speak of dialogue as the ‘embodiment of love.’ Much of couple work focuses on listening to understand and developing dialogical skills.

Somatic trauma theory

Somatic trauma theory posits that traumas live in the body unless they are provided the opportunity to be discharged or resolved (Levine, 2010; van der Kolk, 2014). Somatic experiencing (SE) (Levine & Frederick, 1997; Levit, 2018) and sensorimotor psychotherapy (SP) (Masero, 2017; Ogden & Fisher, 2015) are forms of therapy that focus on healing through the language and intelligence of the body, the place where trauma and attachment issues are said to reside. SP uses a combination of traditional talk therapy and body‐oriented interventions that include ‘helping clients to become aware of their bodies, to track their bodily sensations and to implement physical actions that promote empowerment and competency’ (Ogden & Fisher, 2015, p. 14). SE's ‘major interventional strategy involves bottom‐up processing by directing the client's attention to internal sensations, both visceral (interoception) and musculo‐skeletal (proprioception and kinesthesis), rather than primarily cognitive or emotional experiences’ (Payne, Levine, & Crane‐Godreau, 2015, p. 1). These somatic therapies help clients discharge bodily memories and alter physical actions and postures that have kept them stuck in the past. They are replaced with gestures and positioning that facilitate flexibility and choice. Somatic action techniques in couple work offer wonderfully creative ways to viscerally experience and alter difficult interactions.

Shared Traumatic Stress

In these uncertain times, as the entire world grapples with the virus and its prolonged effects, we are faced with a shared grief and loss and a shared traumatic stress that many of us must navigate together. Globally, as of 28 April 2022, there have been 509,531,232 confirmed cases of COVID‐19, including 6,230,357 deaths, reported to the World Health Organization (2022). The losses are profound and unfathomable. While the world is no longer in acute crisis mode and many restrictions are being lifted in various countries including the United States, many continue to choose to wear masks and shelter in their homes, particularly those who are immunocompromised.

Saakvitne and Tosone (2011), Tosone, McTighe, Bauwens, and Naturale (2011), and Tosone, Nuttman‐Schwartz, and Stephens (2012) wrote about the traumatic stress that was shared by clinicians and their clients in New York City following the events of 9/11. They identify several themes that include a shared sense of grief and horror. Saakvitene acknowledges that during this time ‘I did not particularly feel like a therapist’ (p. 444). What does a therapist feel like? And what does a therapist feel like during a pandemic in which all of us have been required to retool and flexibly accommodate the changing contexts within which we position ourselves in our work with clients? This is definitely new territory for all of us, and the need to offer our services virtually has many pros and cons. There is a shared vulnerability and humanness as we peer into computer cameras and enter our clients' homes while they are also entering ours. There is a close personal intimacy that wasn't there before, a heightened attention to visual cues (Balmbra & Raimundo, 2021; Shapiro, 1968) as well as an energetic distance as we lose some of our capacity to ‘read’ one another (Burgoyne & Coyne, 2020). So many of my clients are asking, ‘are you all right?’ They have never asked before. I am, and I am not, probably in many of the same ways that they are and are not all right.

Telehealth

Video conferencing has been found to be ‘a viable alternative to in‐person care’ (Wrape & McGinn, 2018, p. 296) and is being used widely during this pandemic. It is likely that telehealth will continue to be an option for clients once the pandemic is over, making therapy more accessible for certain populations (Burgoyne & Coyne, 2020; Rivett, 2020). Salivar, Rothman, Roddy, and Doss (2020) offer evidence that an online version of integrative behavioural couple therapy is as effective as face‐to‐face therapy. Caldwell, Bischoff, Derigg‐Palumbo, and Liebert (2017) developed a useful ‘best practices guide’ to telehealth couple and family therapy as part of an online therapy workgroup comprised of members of the American Association for Marriage and Family Therapy prior to the pandemic, outlining legal and ethical issues of practicing in this way. It includes such practices as signed consent attending to privacy and confidentiality, identifying the couple, ensuring that licensing requirements are met, technology issues (bandwidth, access), and a crisis intervention plan.

The Couple

Sarah, Dan, and I meet on Zoom, with the couple sharing a screen. This is triggering for Sarah, who needs physical distance in their marriage and reacts strongly to sitting close to Dan. The video platform raises issues of abandonment and feeling unsafe for her, given her disorganised and insecure attachment style; she feels out of control and uncomfortable in ways she cannot articulate or understand. While they have no history of domestic violence, she says that she feels disempowered and threatened.

Sarah and Dan have been married for 20 years. Both are in their late fifties and are retired.

Sarah's career was with the federal government, and Dan's was in engineering. Dan is an alcoholic in recovery for four years. Sarah is a survivor of childhood sexual abuse perpetrated by her father. She also had to be evacuated from the Pentagon during the 9/11 attack and has survived multiple sexual assaults. Their own individual issues, combined with the shared traumatic stress of the pandemic, have led to a heightened vulnerability and volatility for both Sarah and Dan as they shelter together. The couple moved to the Boston area from Virginia 10 years ago. This is a second marriage for each, and each brought a child from a previous marriage to this one. Dan's 24‐year‐old daughter and Sarah's 28‐year‐old son recently moved out of the house to begin their young adult lives, and the couple is alone together for the first time.

Sarah's trauma history and memories had not surfaced until the former U.S. President Trump took office. While it is important to acknowledge the challenges of working with recovered trauma, given the malleability of memory, I tend to accept and honour my clients' recovered memories at face value as they are embodied in and significant to their lived experiences and I find it useful to work with them as such. In January of 2017 Sarah began having flashbacks, nightmares, and panic attacks after she heard about the multiple allegations of Trump's sexual assaults on the news. She began recovering memories of her father's abuse of her. Sarah's father was a dentist who performed her dental work when she was a child. She recovered vivid memories of his inappropriately touching her beginning at age three, and more vague memories of him raping her while she was under anaesthesia in his dental chair beginning at age eight. She described her mother as ‘abandoning of her,’ saying that she was self‐absorbed, absent, and disengaged as a parent. She did not know if her mother knew what was happening and did not think that her father abused her younger brother and sister. She sought individual treatment and was referred from there for couple therapy to help with the difficulties that surfaced in the marriage.

Dan was an only child who was raised in a ‘dramatic and fiery’ Italian family. He was doted on by both parents and considered to be ‘God's gift,’ although in many ways he felt that they abandoned him emotionally as they emphasised his achievements and did not seem interested in who he was. His father was a doctor, and his mother worked with him as an office manager in his small family practice office. Dan began drinking with his friends when he was an adolescent and his use increased gradually, becoming significant after he retired in his early fifties. He entered a substance abuse program and became sober after Sarah and the children confronted him about his alcohol use and emotional absence from them.

Sarah did not respond well to Dan's sobriety and found his increased presence and availability difficult. She was irritated by his ‘following me around like a puppy and trying to be me.’ She preferred his aloofness when he was drinking and longed for ‘the Old Dan.’ Sarah is an extremely social person who is involved in many activities outside of the home (yoga, a book group, a singing group, friendships, volunteer activities). Dan is involved in Alcoholics Anonymous meetings daily and tends to otherwise keep to himself or spend time with Sarah. Sarah and Dan both walk five miles each day; she prefers to walk alone while he prefers to walk with her. On the developmental attachment continuum, I would place Sarah somewhere between insecure dismissing and insecure fearful avoidant unresolved. Dan seems to have a relatively secure attachment style, though he can at times become insecure, preoccupied, and clingy.

During the pandemic Sarah spent part of an inheritance she had received when her father died 12 years ago to buy herself a rowboat so that she could exercise and spend some time alone on the river near their house. This boat has a sail and has special significance, as she spent much of her childhood sailing; her father taught her how to sail and they shared a love of sailing. Boats represent freedom for Sarah, as well as memories of positive times with her father. This boat became a point of contention between Sarah and Dan during quarantine. Sarah needed a new anchor for the boat and knew exactly what she needed. She had been researching where to order the anchor online and went outside one day to find that Dan had had an anchor delivered as a surprise for her. While she secretly liked what he had chosen for her, she was outwardly angry at his intrusion and experienced his surprise as an attempt to control her as her father had. Dan follows Sarah to the river when she goes out to row and stands on the dock watching her; a trigger for her, as her father always watched her. (I think of the scene in The Great Gatsby (Fitzgerald, 1925) where Gatsby stares at the green light at the end of Daisy's dock, dreaming of reuniting with her; Sarah thinks ‘stalker.’) Sarah experiences Dan's attentions as invasive and would like him to focus elsewhere. Dan says that he is showing Sarah how much he cares for her, and he does not understand how she can see his expressions of caring as stalking.

Sarah says that she is often triggered by Dan's size (he is 6′3″, as was her father) and presence in the house. She has asked that he keep his distance and respect her autonomy. Their differing attachment styles are some of what we work on. We have developed tools that the couple can use when they are wanting more closeness or needing more distance, to facilitate their negotiation of the optimal distance that they find difficult to talk about. Sarah has opted to leave a sign in the kitchen saying ‘space’ when she would like to be alone. Dan says he never needs to be alone and, while he is trying to be respectful of Sarah's need for space, ventures in and then asks if it is ok, leaving him often feeling rejected and alone when she says ‘no,’ though he appears good natured about it.

The Work

Safety first

As we are meeting via telehealth, it is perhaps more important than when meeting face‐to‐face to be clear about professional boundaries and safety issues. The energetic field is different, the therapist has less of a sense of control over what happens in a session, and it may be more difficult to read non‐verbal cues (Wrape & McGinn, 2018). Wrape and McGinn suggest that the couple protect their own privacy if there are other people in the home during telehealth sessions. They also recommend individual screenings for intimate partner violence, either in separate telehealth sessions or via telephone, and the development of agreed‐upon time‐out cues in case things get out of hand during a session. They say that it is important to collect periodic individual self‐report measures via email or telephone to check in and make sure that clients are feeling safe.

When either or both members of a couple have experienced trauma, the couple relationship is fraught with relational minefields and much of the work of nurturing the relationship must involve accommodation, acceptance, empathy, and forgiveness (Hill, Hasty, & Moore, 2011).

Despite (or perhaps because of) all of their troubles, Sarah and Dan appear to be very skilled at employing all of these skills. Throughout their long marriage they have negotiated many difficulties related to their differences in attachment styles and trauma responses and say that they are ‘best friends.’ Their current issues seem more related to the pandemic and Sarah feeling isolated and ‘trapped with this large man’ as her recently recovered trauma memories have exacerbated tensions in the marriage.

In an article on trauma, dissociation, and shame, Codrington (2017) reports on an interview with trauma expert Kathy Steele who says, ‘Helping clients understand that not a single step forward can happen unless both feel safe might help them understand the importance of pausing and focusing on safety. It can even become an exercise for the couple, that they find ways to support each other to feel safe’ (p. 677). While Sarah has not communicated much with Dan about what she is remembering, both appear open to developing ways to safely do this. Sarah describes herself as a kinesthetic person who finds safety through somatic ways of ‘feeling things out.’ She is very active physically, and often will go into the woods and literally hug a tree to ground herself when she is feeling triggered. And so, in addition to traditional talk therapy, we engage in somatic exercises that are geared toward altering the couple's interactions and their lived experiences together.

Dramatic enactments/exercises

Dramatic enactments and exercises help Sarah and Dan to feel things out. Kinesthetic experiences increase awareness and open perspective during sessions. They are cemented with homework to pursue during the week. These enactments are based in a ‘theatrical application of psychodrama that develops perspective, promotes empathy, lowers resistance to being invalidated by disagreement and points the way to novel resolutions’ (Weiner, 2015, p. 7). The physical performance of the exercises offers an experience that concretises their learning in a visceral way (Chasin, Roth, & Bograd, 1989). The exercises also offer elements of SE and SP, as the couple is able to physically enact and metabolise alternative realities while discharging excess energies. The exercises below instill resources that were not available to Sarah and Dan prior to this work.

Optimal distancing

In this exercise I ask Sarah and Dan to move to the far sides of the room they are in and take turns walking toward each other, stopping when each is at what feels like an optimal distance. Sarah stops when she is several feet away from Dan, and Dan stops when his body is touching Sarah's. This offers each a kinesthetic experience of the other's spatial comfort levels and needs, and addresses their differences in developmental attachment styles. The somatic experiencing of their differences cuts through their defences, and each can respond more empathically to the other's comfort levels.

While Sarah knew that Dan wanted to be closer to her, her physical experience of how close he wanted to be helped to dispel some of her irritation and she was able to tolerate more closeness.

Likewise, the exercise helped Dan to become more aware of the extent of Sarah's need for distance and he was able to respectfully offer her more space. This carried into their lives outside of the virtual sessions and they described the changes as ‘profound.’ They were surprised that ‘something so simple could have such a strong impact.' My role in this exercise was simply to verbally direct their interactions and facilitate their discussion. I leaned into the camera, making my presence larger than it would have been had I been in the room, and Sarah's and Dan's openness and willingness to step into the interaction helped it to be successful.

Communication

Back‐to‐back listening to connect

I ask Dan and Sarah to sit on the floor back‐to‐back and each take a turn talking for two minutes without interruption about what is important for them to have the other know. I then have each repeat what they heard the other say and have the other respond and clarify what was misunderstood or missed. This is an adaptation of Harville Hendrix's Imago Dialogue (Hendrix & Hunt, 2019, pp. 260–263) that I have developed for couples who have trauma histories and have difficulty with face‐to‐face interactions. The physical contact and shared breath work that back‐to‐back communication offers can be grounding, supportive, and soothing for both members of the couple. Careful attention to dialogue improves communication and offers an ‘embodiment of love’ (Seikkula et al., 2018), helping each to feel more attended to, cared for, and understood.

For Sarah, this exercise is extremely useful, as somehow the kinesthetic experience of being physically connected and supported by Dan without having to look at him offers a reparative experience. She tells him things she has never told him (many of them memories that are newly recovered) with less shame. His nonverbal response of just being, breathing in synchrony, and conveying empathy is deeply healing, and she sheds many tears as she discharges her tightly held anxieties. Dan, on the other hand, has the new experience of thinking before he speaks, measuring his words in a heartfelt way, and being held and listened to at a deeper level of intimacy. New pathways are laid down to be expanded upon in their day‐to‐day lives.

Doubling

Doubling is a powerful psychodramatic exercise developed by Moreno (2020) and expanded upon by Wile and Kaufmann (2021) as described in their book, in which the therapist stands slightly behind and beside a member of the couple and speaks from their inner voice to deepen the couple's conversation. The protagonist then repeats what has been said, if they agree, or corrects what has been said if they disagree. The therapist moves back and forth beside/behind each member of the couple as they dialogue about an issue they are struggling with.

This exercise works well online, though I am not able to stand behind or beside them, and some of the nonverbal communication may be lost. The good news is that, as in any systemic work, the focus is more on developing the couple relationship than on the relationship between therapist and client(s). Although I am not in the room, and do not have access to their energies in the same way, I lean into the screen and carefully read body language and facial expressions. As with a blind person whose other senses become heightened, I am developing other ways of observing small differences. I notice micro‐movements; small changes in tensions held in the jaw, differences in posture, eye movements, breath. In many ways I feel closer and more connected than I might in the room, as our faces on the screen are larger than life.

We begin with Dan:

I don't know how to be close to you anymore.

I feel like I am always doing things wrong and being rejected by you.

Yes, I do feel like I am always wrong and rejected. I get frustrated and hurt all the time.

I feel lonely. I miss you.

I feel angry, then lonely. I DO miss you.

You just seem to be always there. I need space. This is hard for me. I need you to back off.

I don't think you understand how deeply the traumas have impacted me. I need to withdraw and pull inside. It is the only thing I have ever been able to count on. It's not personal. I don't mean to hurt you. I love you.

I do love you. And I do need to withdraw. It is the only thing I have ever been able to count on. I don't mean to hurt you.

This is all new to me and it scares me. I hope you can be patient and put up with me while I go through this. I am afraid of losing you, but I can't afford to lose myself again.

Yes, I did lose myself before. I am afraid. Of the trauma AND of losing you. I can't afford to lose myself again. I don't want to lose you.

Sarah and Dan are both moved to tears during this exercise, as am I. They seem to understand one another more and feel closer as we move through it. The doubling exercise helps to move their conversation to a deeper level as they are able to recognise that both are afraid of losing the other.

Ideal futures creation

Chasin, Roth, and Bograd (1989) developed this technique to help couples move out of ‘stuck places,’ suspend their disbelief that things can change, and imagine and communicate their way into new futures. In this exercise each member of the couple creates and then enacts a simple scene with their partner that shows their ideal future relationship, a related past negative scene (usually from their family of origin), and a demonstration of that scene as they would have liked it to have gone. Each then talks about what the current issue is that they are having with the relationship. My role as facilitator/director is to keep things moving in an even‐handed and neutral way.

Sarah begins by saying that she would love it if Dan ignored her and gave her more space. Very simply, she asks that he not come into the kitchen when she is making her breakfast, a request that he says will be easy to honour. Dan says that he would like Sarah to be more affectionate with him, a big ask at this point, as Sarah is struggling with physical contact with anyone while she is recovering memories of sexual abuse. She agrees to try to touch him more often and to hug him when she feels she can.

Each returns to scenes from their childhood and enrols the other to play out what happened, and then what they would have liked to have had happen. As they play out the scenes assuming different roles, they experience them in embodied ways. Sarah's narrative is about her father's objectification and sexual abuse of her for years during her childhood. Dan's is about the loneliness and isolation he felt as his parents emotionally abandoned him during his early years. The reparative scenes become the basis for the current ideal futures.

With a more nuanced experience of their partner's experience, it becomes relatively simple and easy for each to enact the other's ideal scene. Dan is able to treat Sarah as a subject whose past has impacted her capacities for intimacy, and he is more careful in his interactions with her, while pursuing more of his own activities and interests. He respectfully asks permission before he enters a room that she is in or touches her, and says he is no longer hurt by her limitations. Sarah, having learned about his abandonment issues (which mirror her own), is able to come forward more physically with him and invites him to join her more often on her walks and boating excursions.

Foam roller trust exercise

This is a powerful trust exercise that helps each member of the couple to experience taking a risk while being held and stabilised by the other. It is designed to be healing for people who have experienced trauma (D. Berger, personal communication, February 2010). One member of the couple climbs onto the roller and stands while the other helps to stabilise it. Dan steps up first, and it is not an easy feat for Sarah to support him as she is so much smaller than he. She manages to use her strength and strategy to help him stand and become still. She positions herself facing him so that her feet are straddling the roller, keeping it still, and holds onto his hips to steady him while he puts his hands on her shoulders. Sarah then takes her turn, climbing onto the roller and allowing Dan to get close and keep her steady.

They share some laughter and discharge some tension during this exercise. I am moved by the tenderness with which they hold and support one another.

Homework

All of these exercises offer Dan and Sarah new and different ways of being in relation with one another that help with the challenges of the present moment. The kinesthetic aspects offer changes experienced on a cellular level that can become concretised through completing specific homework assignments that further the work. The fact that they are completing the exercises in their own home helps with encoding (Wrape & McGinn, 2018) or metabolising, and may help it to feel more natural to continue these new and different ways of being.

At the end of each session, I suggest homework for the couple to complete during the time between sessions. For example, following the ideal futures session I suggest that Sarah initiate spending some time with Dan doing something that they both enjoy, and that Dan work on being less engaged and more focused on developing his life separate from Sarah's.

Discussion and Conclusions

The move to telehealth during the pandemic has offered opportunities to work creatively with couples as they face the stresses of sheltering together. Somatic action techniques can powerfully alter interactions on a visceral level and help couples to develop new and hopeful ways of being and communicating with one another. These exercises are a small sample of what is possible in remote work with couples. Interventions can be improvised to fit particular dynamics and situations, growing organically from the interactions they bring.

While not all couples will be able to work in this way, couples who are able to feel safe with one another, are particularly reflective and able to take risks, and actively step into new experiences together will benefit from engaging in somatic action techniques via telehealth. These creative ways of working with Sarah and Dan as they developed skills to negotiate the stresses of the current moment were invigorating and exciting for me as I witnessed and shared their vulnerability and commitment to growing together.

Telehealth offers convenience, accessibility, and continuity of care to clients and their therapists as we shelter at home and/or face geographic or transportation challenges. The pandemic has offered many opportunities, as licensing restrictions have been lifted in the United States and we have been able to engage in treatment across state lines, making the work more possible for couples and families who live in different areas (Burgoyne & Cohn, 2020). These lifted restrictions will need to be tracked ongoingly.

Couple therapy has always emphasised the relationship between the two partners over the relationship with the therapist (Lord, 2017), which is enhanced when we are separated by screens and working together in different spaces. The therapist is a facilitator of the couple's process and acts as a coach to their interactions. Couples who are in their own homes might be more relaxed and open about their issues; therapists can use their physical closeness on screen to help intensify interactions (Burgoyne & Coyne, 2020). Of course, safety is always an issue in this work and must be assessed carefully and ongoingly, as mentioned above.

Couples who are not safe, couples who are unwilling to take risks, and those who are less reflective or less interested in improving their relationships will not do as well with these action techniques. Technology may be an issue as either the therapist or the couple may run into difficulty with their equipment or their server, disrupting the work.

All of us are subject to the chaos and unknowns of the pandemic in these uncertain times. It is helpful to develop a repertoire of techniques that are able to soothe our nervous systems and physically activate us toward growth, compassion, and forgiveness as we embrace our shared humanity and face our future together.