Introduction

In recent years, the field of family and couple therapy has witnessed a mounting trend of transitioning 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 functioning (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 information 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 characteristics 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 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 legitimize 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 alliance. 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?

Method

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 participants construct the theoretical model collaboratively. This position lies between the realist and post-modernist positions by assuming “limited reality,” while also assuming multiple perspectives 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 participation 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 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. Participants 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?), contending 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 interviews, which lasted between 50 and 90 min (mean 67.5 min), were digitally recorded and transcribed 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 facilitate 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' experiences to develop a data-grounded theoretical model regarding video-conferenced online couple 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 merging 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 analysis 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 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 partner 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 previous 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 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 closeness 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 automatically 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 represents 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 therapy, 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 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 physical 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 communication; 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 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 information…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 clinical 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 relationship, 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 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 regarding 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 example, 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 dimensions 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 interviewees 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 perception of closeness/distance may vary. In our study, a favorable therapeutic alliance with the therapist 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 alliance 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 experience a diminished sense of caring, which may result in a greater effort on the part of the therapist 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, participants 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 therapeutic 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 opportunity to avoid the experience of limited care, and help focus on the information gathered from facial expressions, thereby strengthening the therapeutic alliance.