Featured Article
Article Title
Examining Veterans’ Preferences for How to Deliver Couples-Based Treatments for Posttraumatic Stress Disorder: Home-Based Telehealth or In-Person?
Authors
Stephanie Y. Wells; Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, United States; Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina, United States
Kayla Knopp; Veterans Affairs San Diego Healthcare System, San Diego, California, United States; Department of Psychiatry, University of California San Diego
Gabriella T. Ponzini; Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, United States
Shannon M. Kehle-Forbes; Center for Care Deliver and Outcomes Research, Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota, United States; Department of Medicine, University of Minnesota, Minneapolis; National Center for Posttraumatic Stress Disorder Women’s Health Sciences Division, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, United States
Rosalba M. Gomez; Durham Veterans Affairs Health Care System, Durham, North Carolina, United States
Leslie A. Morland; Veterans Affairs San Diego Healthcare System, San Diego, California, United States; Department of Psychiatry, University of California San Diego; National Center for Posttraumatic Stress Disorder Women’s Health Sciences Division, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, United States
Eric Dedert; Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina, United States; Department of Psychiatry and Behavioral Sciences, Duke University
George L. Jackson; Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, United States; Department of Public Health, Peter O’Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center
Kathleen M. Grubbs; Veterans Affairs San Diego Healthcare System, San Diego, California, United States; Department of Psychiatry, University of California San Diego
Abstract
Understanding the modality by which veterans prefer to receive couples-based posttraumatic stress disorder (PTSD) treatment (i.e., home-based telehealth, in-person) may increase engagement in PTSD psychotherapy. This study aimed to understand veterans’ preferred modality for couples-based PTSD treatments, individual factors associated with preference, and reasons for their preference. One hundred sixty-six veterans completed a baseline assessment as part of a clinical trial. Measures included a closed- and open-ended treatment preference questionnaire, as well as demographics, clinical symptoms, functioning, and relational measures, such as relationship satisfaction. Descriptive statistics and correlations examined factors associated with preference. An open-ended question querying veterans’ reasons for their preferred modality was coded to identify themes. Though veterans as a group had no clear modality preference (51% preferring home-based telehealth and 49% preferring in-person treatment), veterans consistently expressed high levels of preference strength in the modality they chose. The presence of children in the home was associated with stronger preference for home-based telehealth. Veterans who preferred in-person care found it to be more credible and had more positive treatment expectancies. Veterans who preferred home-based telehealth believed it was flexible and increased access to care. For both preference groups, veterans’ preferred modality was viewed as facilitating interpersonal relations and being more comfortable than the alternative modality. Veterans expressed strong preference for receiving their desired treatment modality for couples-based PTSD treatment. Results suggest that it is important to offer multiple treatment delivery options in couples-based PTSD treatment and matching couples to their preferred modality supports individualized, patient-centered care.
Keywords
Posttraumatic stress disorder; couples therapy; telehealth, preferences; veterans
Summary of Research
“Less than 25% of veterans with posttraumatic stress disorder (PTSD) receive one or more sessions of a PTSD evidence-based psychotherapy in Department of Veterans Affairs (VA) outpatient clinics and, of those who initiate care, less than 10% receive an adequate dose of eight sessions. One avenue to improve engagement in PTSD treatment is to understand veterans’ treatment preferences. No studies have examined modality preferences for couples-based interventions, which may have unique considerations” (p. 159).
The “first aim was to identify veterans’ treatment modality preferences and strength of preference for couples-based PTSD treatment. Our second aim was to evaluate individual factors associated with veterans’ treatment modality preferences. Demographic variables that may be related to modality preferences (e.g., age, income, children in the home) and MST history were examined. Additionally, we examined factors that could practically or theoretically influence modality preferences such as physical health factors (e.g., vision impairment, hearing impairment), accessibility factors (e.g., distance and travel time to clinic, preferred appointment times), relational factors (e.g., relationship satisfaction, psychological aggression), and clinical factors (e.g., PTSD severity, trauma type). Our third aim was to explore reasons for veterans’ delivery modality preferences” (p. 159).
“This study occurred through the San Diego VA Medical Center, which recruited couples from November 2015 to March 2020… Participants (N = 166) were veterans who completed a baseline assessment as part of enrollment in a randomized clinical trial examining couple-based treatment for PTSD. Eligibility to be invited to complete the baseline assessment for the parent trial included (a) a veteran 18 or older; (b) meeting criteria for a likely PTSD diagnosis based on the Life Events Checklist–5 (Weathers et al., 2013a) and PTSD Symptom Checklist for Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) (Weathers et al., 2013b); (c) not currently in another PTSD treatment; (d) a stable dose of medication for at least 2 months; (e) well-managed psychotic or dementia symptoms; (f) no suicide attempts or perpetrated assaults in the past year; and (g) willing/able to attend treatment with a partner either in-person or over video telehealth” (p. 159).
“The present study aimed to better understand veterans’ preferences between in-person and HBT-delivered couples-based PTSD therapy. Veterans were split on their preferences, roughly half selecting in-person and the other half selecting HBT. There were few demographic and clinical differences among those who selected each modality. Age was the only significant predictor of preference, with veterans who preferred the in-person modality being slightly older. This is not surprising as younger mental health consumers report feeling more comfortable and open to video-technology-supported mental health treatment. However, the effect was quite small, with only a 4-year average age difference (i.e., 44.9 vs. 40.5). Given this small effect, age may not be the best factor to assist veterans in determining their preferred treatment modality in clinical settings. It is notable that none of the other clinical or demographic variables we examined were significantly related to modality preference, even with the liberal lack of correction for multiple tests. This may suggest that other factors, such as individuals’ beliefs, may have a stronger impact on preferences or that quantitative measures may not be sufficient to understand preferences. Among demographic variables associated with preference strength, only the presence of children in the home was associated with a stronger preference for HBT. Qualitative data suggest that telehealth reduces some of the logistical difficulties and costs of coordinating childcare while both parents attend an appointment” (p. 163 - 164).
Translating Research into Practice
“Overall, these findings suggest that treatment planning should include options for both HBT and traditional office-based care for all veterans seeking PTSD couples-based therapies. The strength of preference was high among both those who preferred telehealth and those who preferred in-person, even among a sample of veterans willing to be randomized to either modality further emphasizing the importance of choice for veterans and the benefits of allocating staff time to both HBT or in-person care to accommodate veterans’ preferences.
Open-ended short-answer questions offered insight into other factors that veterans consider when making treatment decisions that expanded upon our quantitative findings. “Perceived credibility
and expectancy” of the treatment modality was identified as a primary theme among short-answer responses, particularly for veterans who preferred traditional in-person care. This builds on prior research that found that perceived credibility was associated with preferred treatment type (e.g., psychotherapy, pharmacotherapy). Aligning patients with a modality that they find credible and judge as likely to benefit their symptoms could lead to better treatment outcomes.
‘Increased accessibility and flexibility of care’ was a theme that was common for veterans who preferred HBT. Veterans predicted that receiving couples-based PTSD treatment through HBT would overcome logistical barriers to treatment. This is consistent with the literature on individual PTSD therapy which recognizes the benefits of flexible access afforded by telehealth. Logistical barriers may be especially salient when two people are attempting to travel to physically travel to the VA for an appointment. Offering couple- and family-based care via HBT can support VA directives (Veterans Health Administration Directive for Family Services 1163.04) by creating a more accessible option to receive care. Veterans stated that HBT reduces the need to find and pay for childcare during appointments. HBT can also reduce the time it takes to transport kids to childcare before and after therapy. Ease of childcare is more critical if both caretakers are attending the appointments. This supports Whealin et al.’s (2017) findings that veterans used HBT for individual PTSD treatment because it overcame childcare barriers. While veterans stated they preferred HBT due to easier childcare, there may be potential challenges for couples to actively engage in therapy sessions with enough privacy and few distractions if unattended children are at home, particularly if the children require greater care. Given the number of children in the home was associated with a stronger preference for HBT, it may be particularly important for therapists to discuss how to create an environment free of distractions and adequate privacy.
The “interpersonal process” was another important factor for veterans in both groups. Regardless of preference, veterans predicted that their preferred modality would improve their connection with the therapist or their partner. Fortunately, a recent meta-analysis examining individual PTSD treatments via HBT or in-person found no differences in therapeutic alliance following therapy and 3 months later. This suggests that veterans’ initial preferences may be based on their perception of what modality will be better for forming a connection with their therapist, but a strong therapeutic alliance can occur with either modality. The “therapeutic environment” influenced veteran’s preferred modality in both groups. Veteran’s identified their preferred modality as supportive of comfort and safety during couples-based PTSD therapy. In PTSD treatment, these can be complex. On the one hand, safety, privacy, and comfort could create conditions that facilitate the therapeutic process, while on the other hand, avoidance can interfere with treatment outcomes and can maintain PTSD symptoms. Reducing avoidance while supporting engagement is particularly important for couples-based PTSD treatment; given studies have found that 30–48% of veterans drop out from cognitive-behavioral conjoint therapy and that avoidance is associated with dropout from trauma-focused PTSD treatment. Clinicians may discuss at the outset of therapy how to create a safe therapy environment while also considering how to minimize avoidance” (p. 164).
Other Interesting Tidbits for Researchers and Clinicians
“The present study had limitations worth noting. The data were collected prior to the COVID-19 pandemic when HBT was less routinely offered. Therefore, the proportion of veterans that prefers HBT to in-person care and their opinions about the merits of each may be different after the pandemic. The present study also required veterans to be willing to be randomized to in-person or telehealth modalities, so this sample may not be representative of veterans who are unwilling to receive couples-based PTSD treatment through either modality. Additional data from a more representative sample on veterans’ preferences for the delivery of couples-based therapies post COVID-19 would be informative to further direct clinical care (i.e., proportion of veterans’ preferred delivery modalities, reasons associated with treatment preference). Given that nearly all couple and family care was provided via telehealth during the first wave of the pandemic (McKee et al., 2023), it is possible that even more veterans now feel comfortable with telehealth for couples-based PTSD treatments; alternatively, veterans may prefer a return to in-person treatment following the necessity of telehealth appointments during the pandemic. There is no reason to believe that the reasons cited by patients for preferring a given modality would not also be important considerations following the height of the COVID-19 pandemic. Additionally, while short-answer data provide some insight, these brief responses do not allow for in-depth analysis. Future studies should explore modality preferences with greater depth to generate a richer understanding of the array of considerations that veterans use to determine treatment preferences. Additionally, we were unable to examine partners’ preferences” (p. 164).
