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. Author manuscript; available in PMC: 2026 Feb 1.
Published in final edited form as: Psychol Serv. 2024 Feb 26;22(1):158–166. doi: 10.1037/ser0000836

Examining Veterans’ Preferences for How to Deliver Couples Based Treatments for PTSD: Home-based Telehealth or In-Person?

Stephanie Y Wells 1,2, Kayla Knopp 3,4, Gabriella T Ponzini 1, Shannon M Kehle-Forbes 5,6,7, Rosalba M Gomez 8, Leslie A Morland 3,4,7, Eric Dedert 2,9, George L Jackson 1,10, Kathleen M Grubbs 3,4
PMCID: PMC11345872  NIHMSID: NIHMS1963206  PMID: 38407069

Abstract

Understanding the modality by which veterans prefer to receive couples-based 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

Less than 25% of Veterans with posttraumatic stress disorder (PTSD) receive one or more sessions of a PTSD evidence-based psychotherapy (EBP) in Department of Veterans Affairs (VA) outpatient clinics and, of those who initiate care, less than 10% receive an adequate dose of eight sessions (Maguen et al., 2020; Mott et al., 2014). One avenue to improve engagement in PTSD treatment is to understand veterans’ treatment preferences. Studies have found that when individuals with PTSD receive a preference concordant treatment, they receive more sessions (Mott et al., 2014), and report greater adherence and clinical outcomes compared to those who do not (Zoellner et al., 2019). Understanding delivery modality preferences (e.g., telehealth, in-person) can increase collaboration and patient-centered care, and inform system-level decision-making about resource allocation and staffing (e.g., telehealth or in-person care).

To date, treatment-related beliefs, such as perceived credibility and effectiveness (Chen et al., 2013; Zoellner et al., 2009) have predicted preference for treatment type (e.g., psychotherapy vs. pharmacotherapy), whereas demographic variables have not reliably predicted treatment preferences (Chen et al., 2013; Markowitz et al., 2016; Zoellner et al., 2009). Studies examining preferences for how care is delivered (e.g., in-person, home-based telehealth [HBT]) have mixed findings. Many patients do not report a clear preference (Spence et al., 2011) or are open to telehealth (Whealin et al., 2015); however, other studies show a preference for in-person PTSD treatment, while also being open to telehealth interventions (Gutner et al., 2018). When compared to office-based telehealth, Veterans preferred HBT (Morland et al., 2019). There is little research examining the reasons for veterans’ delivery modality preferences, although one study found that military sexual trauma (MST) survivors may be hesitant to seek care in-person at VA due to trauma triggers (Gilmore et al., 2016) and sexual harassment that commonly occurs at VA Medical Centers (Klap et al., 2019). Taken together, these studies demonstrate variability in treatment modality preferences and a lack of understanding of why individuals choose their preferred modality.

No studies have examined modality preferences for couples-based interventions, which may have unique considerations. PTSD has significant negative impacts on intimate relationships (Taft et al., 2011) and may erode social support for veterans (Zalta et al., 2021). Encouragingly, a meta-analysis found couples-based trauma-focused interventions are associated with significant improvements in PTSD symptoms and relationship difficulties (Sijercic et al., 2022). As a result, couples-based interventions are rolling out across VA Clinics (VHA Directive for Family Services 1163.04). The logistical barriers (e.g., childcare and travel for both partners) and interpersonal considerations (e.g., relationship dynamics) associated with couples-based PTSD treatments may have a greater impact on modality preferences than individual PTSD treatments.

Thus, our 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.

Method

This study used data collected at a baseline assessment in a parent randomized clinical trial (Morland et al., 2022) examining couples-based PTSD therapies delivered in person and through HBT. This study was approved by the San Diego VA Institutional Review Board and informed consent was obtained from all participants.

Procedure

This study occurred through the San Diego VA Medical Center, which recruited couples from November 2015 to March 2020. All data for the present study were collected prior to the COVID-19 pandemic, with the last baseline assessment in early March of 2020. Following informed consent, couples completed baseline self-report measures and clinician-administered diagnostic interviews (see Morland et al., 2022 for more information). This study only utilized veterans’ data as the study aimed to understand veterans’ preferences for how to receive couples-based PTSD treatment, and veterans’ partners did not complete preferences questionnaires.

Participants

Participants (N = 166) were veterans who completed a baseline assessment as part of enrollment in a couple-based treatment for PTSD. Eligibility to be invited to complete the baseline assessment for the parent trial included: 1) A veteran 18 or older 2) meeting criteria for a likely PTSD diagnosis based on the Life Events Checklist-5 (LEC, 5; Weathers et al., 2013a) and PTSD Symptom Checklist for DSM-5 (PCL-5; Weathers et al., 2013b); 3) not currently in another PTSD treatment; 4) a stable dose of medication for at least two months; 5) well-managed psychotic or dementia symptoms; 6) no suicide attempts or perpetrated assaults in the past year, and 7) willing/able to attend treatment with a partner either in-person or over video telehealth. The sample was 81.3% male, 42.6 years old on average, 72.9% married, and 78.3% had children living in the home. In terms of race, 18.8% identified as African American or Black, 2.5% as American Indian /Alaska Native, 3.1% as Asian, 0.6% as Middle Eastern, 3.1% as Native Hawaiian / Pacific Islander, 62.0% as White, and 7.5% selecting the option “Other.” In terms of ethnicity, 36.0% identified as Hispanic or Latino. See Table 1 for full demographic details.

Table 1.

Demographic Characteristics and Veterans’ Preferences.

Veteran Characteristic Range M (SD)
or n (%)		 Correlation with Preference Correlation with Strength of Preference
Telehealth In-Office
Strength of preference 0–4 3.31 (0.79) −.007 - -
Age 21–75 42.6 (14.2) −.157* −.059 .127
Gender 0/1 135 (81.3%) .004 .084 .107
Ethnicity (Hispanic/Latine vs Not) 0/1 58 (34.9%) −.012 −.059 −.036
Race (African American/Black vs Not) 0/1 30 (18.1%) −.012 .125 .063
Race (White vs Not) 0/1 103 (62.0%) .084 −.176 −.220
Married 0/1 121 (72.9%) −.026 −.032 −.062
Children in the home 0/1 91 (54.8%) .107 .243* .100
Income 1–8 5 ($60k-$75k) −.026 −.106 −.122
Student 0/1 35 (21.1%) −.001 −.017 .195
Full-time Employed 0/1 57 (34.3%) .148 .073 −.110
Physical Health 1–5 2.71 (1.02) .066 −.042 −.162
Vision Impairment 0/1 50 (30.1%) −.042 .032 .176
Hearing Impairment 0/1 115 (69.3%) .003 .047 .035
Preference for Morning Appointment 0/1 64 (38.6%) −.095 −.061 −.026
Preference for Afternoon Appointment 0/1 43 (25.9%) −.028 −.028 −.011
Preference for Evening Appointment 0/1 57 (34.3%) .123 .083 −.039
Travel Time to VA Clinic 1–4 1 (0–20 min.) −.113 −.030 .091
Distance from VA Clinic (miles) 0.4–72.6 17.5 (14.3) −.111 −.155 −.022
MST History 0/1 33 (19.9%) −.086 .101 .067
Psychological Aggression (toward partner) 0–12 4.57 (2.22) .013 .106 −.110
Psychological Aggression (from partner) 0–12 3.69 (2.29) −.050 .137 −.096
Relationship Satisfaction 0–161 105.6 (35.5) .074 .129 −.053
CAPS Total Severity Score 0–80 35.7 (10.1) .054 −.051 −.116
CAPS Re-Experiencing Severity Score 0–20 8.45 (3.25) .006 .120 −.011
CAPS Avoidance Severity Score 0–8 4.33 (1.65) .040 −.016 −.172
CAPS Negative Cognitions/Mood Severity Score 0–28 12.48 (4.89) .063 −.206 −.163
CAPS Hyperarousal Severity Score 0–24 10.44 (3.37) .043 .022 −.017
Psychosocial Functioning 0–100 48.6 (23.7) −.019 −.101 −.086
Interpersonal Trauma1 0/1 45 (27.1%) −.029 .012 −.003
Military-Related Trauma1 0/1 119 (71.7%) .047 −.056 −.008
Combat Trauma1 0/1 91 (56.2%) .034 −.026 −.065
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Note. Telehealth preference is coded 0 = prefer in-person and 1 = prefer telehealth. Correlations between one continuous and one dichotomous variable are point-biserial correlations; correlations between two dichotomous variables are phi coefficients.

1

Trauma types are not mutually exclusive.

*

p < .05.

Measures

Treatment Preferences Questionnaire

The study team developed a 15-item questionnaire to assess veterans’ treatment preferences that examined preferences for a range of PTSD treatments and delivery modalities, including how to deliver couples-based PTSD treatments. This study utilized three items from the measure. The questionnaire gave a brief description of both office-based and HBT modalities and then asked two closed-ended questions about which treatment delivery modality they preferred for couples-based PTSD therapy (e.g., “Select which treatment delivery method you would prefer to receive for PTSD-focused couples treatment: traditional office-based care or HBT”). Participants were then asked how strongly they preferred their selected modality on a scale from 0 (not at all) to 4 (extremely) based on literature indicating strength of preference is associated with clinical outcomes (Raue et al., 2009). Veterans also answered an open-ended, short-answer question asking them to describe their reasons for choosing their preferred delivery modality for couples-based PTSD therapy.

Demographics Questionnaire

Veterans completed a demographics questionnaire that included questions about their age, gender, ethnicity, race, marital status, income, student status, and employment status. The demographics questionnaire also included information about self-reported physical health and potential telehealth accessibility considerations, such as their preferred appointment time, distance (i.e., miles), and travel time from their house to their typical VA clinic. See Table 1 for all demographic variables examined in Aim 2.

Military Sexual Trauma History

A modified version of the Life Events Checklist (Weathers et al., 2013a) was used that included an item about experiences of MST which was used to categorize veterans who had experienced MST. This variable was examined separately in Aim 2 from the trauma type variable described below.

Conflict Tactic Scale-Short Form

Four psychological aggression items were used from the CTS-2 Short Form (Straus & Douglas, 2004). These included two questions about verbal and physical aggression on the part of the veteran and two equivalent questions about their partner. The CTS2S uses an ordinal scale to measure the frequency of occurrence of each item, from 0 (this has never happened) to 6 (more than 20x in the past year) and there are many possible ways to score CTS2S subscales (Straus & Douglas, 2004). Among the scoring options for the CTS2S, we used sum scores capturing frequency of past-year psychological aggression based on the score distributions in the current sample.

Couples Satisfaction Index (CSI-32)

The 32-item Couples Satisfaction Index (Funk & Rogge, 2007) measures relationship satisfaction. Sum scores range from 0 to 161 with higher scores indicating greater relationship satisfaction. Internal consistency in the current sample was α = .98.

Clinician-Administered PTSD Scale for DSM-5 (CAPS-5)

The CAPS-5 (Weathers et al., 2013b) was used to diagnose and determine PTSD severity at baseline. The CAPS-5 includes 20 items that correspond to each PTSD symptom and assessors rate each item on a 5-point Likert scale ranging from 0 (absent) to 4 (extreme/incapacitating). The present study utilized the overall total severity score and total scores for each of four symptom clusters. Internal consistency in the current sample was α = .77.

Brief Inventory of Psychological Functioning (B-IPF)

The B-IPF (Marx et al., 2020) is a 7-item questionnaire that includes one item to assess functioning in the past 30 days across seven domains: romantic relationships, family relationships, parenting, friendships and socialization, work, education and training, and daily activities and responsibilities. Items are not all applicable to all participants, therefore scores are calculated as the sum of completed items divided by the maximum possible sum of completed items, then multiplied by 100, the resultant score represents a percentage out of 100. Higher scores indicate more dysfunction (see Bovin et al., 2018). Internal consistency in the current sample was α = .82.

Trauma Type

Traumatic events reported for Criterion A of the CAPS-5 diagnostic interview were categorized into different types based on prior research showing that different kinds of trauma lead to differences in clinical presentation and treatment response. The literature lacks consensus on a specific taxonomy; however, most studies separate combat experiences and non-combat assault into separate categories (e.g., Straud et al., 2019). For the purposes of the current study, categories included interpersonal trauma, military-related trauma, and combat trauma. Military-related traumas included combat and non-combat traumas that occurred during participants’ military service, such as vehicle accidents and MST. To distinguish interpersonal trauma – typically conceptualized as any trauma involving interaction with other people – from military combat, person-on-person violence that occurred during expected military duties (e.g., shooting an enemy combatant) was not categorized as interpersonal, whereas interpersonal violence or crime that occurred in civilian or other settings was coded as interpersonal. We coded a total of 16 trauma types for Criterion A events (e.g., childhood physical or emotional abuse; unexpected or violent non-combat death), but the remaining 13 categories included less than 10% of the sample and were therefore not included in analyses.

Data Analysis

Aim 1 – Identify Veterans’ Treatment Modality Preferences and Strength of Preference for Couples-based PTSD Treatment

Veterans’ reports of preference for either HBT or in-person modalities for couple-based PTSD treatment and the strength of these preferences were examined using descriptive statistics.

Aim 2 – Evaluate Individual Factors Associated with Veterans’ Treatment Modality Preferences

To determine if theoretically important variables were associated with modality preference, bivariate correlations were tested between preference (in-person, coded as 0, versus HBT, coded as 1) and each variable of interest (point-biserial for continuous variables and phi coefficients for dichotomous variables). The following variables were considered due to associations with research in prior literature or potential theoretical relevance to preference: demographic variables (i.e., age, gender, ethnicity, race, marital status, children in the home, income, student status, employment status), physical health factors (i.e., vision & hearing impairment), accessibility factors (i.e., preference for appointment times, travel times to clinic, distance from VA clinic), relational factors (i.e., psychological aggression, relationship satisfaction), and clinical factors (i.e., MST history, PTSD symptom severity, psychosocial functioning, and index trauma type). Next, among each preference group, we tested correlations between strength of preference (0 to 4, with higher scores indicating stronger preference) and the aforementioned variables. Because these analyses were exploratory and hypothesis-generating rather than hypothesis-testing, we did not correct for multiple tests.

Aim 3 – Explore Veterans’ Stated Reasons for Their Treatment Modality Preferences

Short answer questions were coded to identify relevant themes for why veterans selected their preferred delivery modality. Two independent coders (SYW, KMG) developed a codebook based on 25% of responses. The coders then met to compare codes and came to a consensus on preliminary codes. Before finalizing, the two coders met with co-authors (LAM, SKF, GTP) for input on the final codebook. All responses were then coded using the final codebook, including the initial 25% of responses. All short-answer responses were double coded by SYW and KMG and all discrepancies reconciled so there was 100% agreement on all codes. The sample size for this aim was N = 148 due to some veterans not completing the short-answer response or giving an unclear answer that was difficult to interpret and code. Once coding was complete, the authors (SYW, KAG, LAM, SFK, GTP) met to review codes and identify overarching themes that unified them. A constant comparison approach (Boeije, 2002) was used to compare differences in themes across conditions (i.e., HBT, in-person).

Results

Aim 1 – Identify Veterans’ Treatment Modality Preferences and Strength of Preference for Couples-based PTSD Treatment

Approximately equal numbers of veterans preferred each modality, with 51% preferring HBT and 49% preferring in-person treatment. Veterans had a relatively strong preference overall, with a mean of 3.31 on a 4-point scale (SD = 0.79; 3 anchored to “quite a bit,” and 4 anchored to “extremely”). Strength of preference was not different among those who preferred HBT versus those who preferred in-person care (r = −.007, p = .329).

Aim 2 – Evaluate Individual Factors Associated with Veterans’ Treatment Modality Preferences

See Table 1 for full results for Aim 2. Age was the only variable that was significantly associated with preference (r = −.157, p = .043). The effect was small: those who preferred HBT were 40.4 years old on average (SD = 12.5), while those who preferred in-person care were 44.9 years old on average (SD = 15.6).

Among those participants who endorsed a preference for HBT, the presence of children in the home was significantly associated with the strength of this preference (r = .243, p = .026), such that participants with children at home reported an average preference strength of 3.43 out of 4 (SD = 0.74) whereas participants without children at home reported an average preference strength of 3.16 (SD = 0.83). No characteristics were significantly associated with strength of preference among those who preferred in-person treatment.

Aim 3 – Explore Veterans’ Stated Reasons for Their Treatment Modality Preferences

Four themes were identified after coding the short-answer open-ended questions assessing veterans’ reasons for their preferred modality: Perceived Credibility and Expectancy, Accessibility and Flexibility of Care, Interpersonal Processes and Relations, and the Therapeutic Environment. See Table 2 for examples of illustrative quotes from each theme.

Table 2.

Illustrative Quotes for Each Theme from Aim 3

Theme Illustrative Quotes
Perceived Credibility and Expectancy “I feel that in person care is more effective.” (preferred in-person)
“Face to face is always better in my view.” (preferred in-person)
Accessibility and Flexibility of Care “Places less strain on spouse while providing a longer period of availability. Ease of access makes it possible to attend sessions in other home settings if traveling.” (preferred home-based telehealth)
“ It also helps alleviate inflexibilities in my partners’ schedule.” (preferred home-based telehealth)
Interpersonal Processes and Relations “It feels more personal and easy to communicate.” (preferred in-person)
“We would be able to spend more time with each other in less stressful situations like dealing with traffic and dropping off our daughter with different caretakers.” (preferred home-based telehealth)
Therapeutic Environment “With two little kids at home, it would be easier (and less distracting) to meet in an office.” (preferred in-person)
“We are both private people and I don’t have to walk in public after I have been crying.” (preferred home-based telehealth)
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Perceived Credibility and Expectancy.

Veterans’ perceived credibility (i.e., how valid they perceive the modality to be) and expectancy (i.e., how well they think the modality would work) of the delivery modality was identified as a primary theme. Perceived credibility and expectancy was primarily described by veterans who preferred office-based care and was rarely mentioned by individuals who preferred HBT as a reason for their preference.

Veterans who preferred traditional office-based care stated that they believed in-person couple’s therapy was more credible and effective than HBT. Many veterans who preferred traditional office-based care said that being “face to face” would allow them to be more open with their partner and therapist, feel personal or intimate, and felt it was easier to read non-verbal cues (e.g., body language) and get “immediate feedback” from their environment. They also noted that it would facilitate making eye contact, and they believed it would be easier to communicate in-person. Further, some veterans who preferred traditional office-based care indicated a preference for the therapist to be physically in the room with them to facilitate the therapy process and mediate between the veteran and their partner. Some veterans who preferred traditional office-based care also said that being in person would hold them more accountable to the therapy process (e.g., less likely to not reschedule or not attend, especially due to avoidance) and felt in-person therapy would be more helpful than telehealth because it would require them to get out of their house or “comfort zone” by going to the office.

Accessibility and Flexibility of Care.

Increased accessibility (e.g., ease of obtaining care) to engage in therapy and increased flexibility (e.g., ability to accommodate unique needs) was identified as a primary theme for why veterans preferred HBT.

Veterans described that HBT was generally more convenient for them, and makes it easier to access care, primarily through overcoming common barriers to engaging in therapy. For example, veterans shared that HBT overcame common logistical barriers such as travel time and costs, driving difficulties and traffic, lack of transportation, and finding parking at the VA. Further, Veterans with physical health limitations that make it harder to access care shared that HBT minimizes the impact of these health issues. For example, some veterans with back problems or who were legally blind shared that being able to do therapy in home would be easier than visiting the office.

Veterans also described HBT as being more flexible, particularly for increasing the ability to accommodate scheduling and childcare considerations. Veterans shared that HBT makes scheduling appointments more flexible in several ways, such that they can better fit appointments into their own schedules when needed, can better match their schedule with their partners, their partners can fit appointments into their own schedule, and they can respond to children’s schedules. A few veterans shared that HBT increases flexibility to attend therapy from different locations, such as when they are on vacation or traveling for work. Finally, veterans shared that HBT would make it easier for childcare purposes due to not needing to find a babysitter or drive to drop off their children.

Interpersonal Processes and Relations.

The importance of individual connection and the therapy processes were mentioned by veterans who preferred both traditional office-based care and HBT. This theme overlapped with perceptions of credibility and expectancy as veterans viewed these interpersonal processes with their provider and partner to be important to the success of the therapy.

For veterans who preferred traditional office-based care, they believed interpersonal connection with their partner or therapist to be improved because of in-person treatment. Veterans expressed that traditional office-based care feels more personal, is more intimate, is easier to read body language and make eye contact, increases ease of communication, allows them to open-up more easily, and interactions are more immediately visible. Overall, a sense of intimacy and closeness with the therapist or partner was important for individuals who preferred traditional office-based care.

A few veterans mentioned that their preferred modality would improve their relationship during therapy. Some veterans who preferred traditional office-based care felt that being outside of the house at predetermined times would help them to improve their communication and listening skills with their partners. A couple of veterans who preferred HBT also thought that it would be easier for them and their partner to “feed off of” each other’s emotions and that they would be able to spend time together in less stressful situations, such as driving and dropping their child off at childcare.

For both modalities, a few veterans believed their preferred modality would support better conflict resolution. A veteran who preferred traditional office-based care said that the modality itself would make it harder to leave or disengage during conflict in therapy. A couple of veterans who preferred HBT said that the modality would allow the couple to have space from the other person, if needed, whereas that would not be possible if they had to drive home from an appointment together. Similarly, another veteran said that HBT would help the couple avoid fights that could start while driving to and from the VA.

Therapeutic Environment.

The therapeutic environment was identified as an important theme regarding veterans’ preferred delivery modality. Veterans identified aspects of the environment of each modality decision, although there were some differences between modalities.

Veterans who preferred traditional office-based care expressed that they thought that the modality would be less distracting than if they were at home. Veterans said that being home would have too many distractions (e.g., kids), which would make it difficult to focus. Across preferences for in person and HBT, veterans noted the modality they preferred increased privacy. For example, a couple of veterans who preferred traditional office-based care said that the office would be more private because other people were often at home. In contrast, veterans who preferred HBT thought being home was more private because if they cried in a session, they would not be seen in public afterwards by others. One veteran worked at the VA and wanted to be home to do therapy.

Veterans who preferred traditional office-based care and HBT also perceived their preferred modality to be more comfortable than the alternative. Increased comfort was more commonly stated among those who preferred HBT, yet it was also mentioned by individuals who preferred office-based care. Veterans who preferred traditional office-based care said they found the office environment to be more comfortable because they felt safer face-to-face, preferred a neutral space for therapy, and found it easier to discuss things with their partner. Veterans who preferred HBT found their home to be more comfortable because it is their safe space, is more familiar, and just found their home to be a more comforting environment overall.

Discussion

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, with 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 (Karimi et al., 2022). However, the effect was quite small, with only a 4-year average age difference (i.e., 44.9 versus 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 suggests that telehealth reduces some of the logistical difficulties and costs of coordinating childcare while both parents attend an appointment.

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; Zoellner et al., 2009). Aligning patients with a modality that they find credible and judge as likely to benefit their symptoms, could lead to better treatment outcomes (Litz et al., 2019; Tarrier et al., 2000).

“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 (Slightam et al., 2020; Whealin et al., 2017). Logistical barriers may be especially salient when two people are attempting to travel to physically travel to the VA for an appointment (see Doss and Hatch, 2022). Offering couple- and family-based care via HBT can support VA directives (VA 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 and colleagues’ (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 three months later (Scott et al., 2022). 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 30–48% of veterans dropout from CBCT (Morland et al., 2022; Pukay-Martin et al., 2022) and that avoidance is associated with dropout from trauma-focused PTSD treatment (Wells et al., 2022). Clinicians may discuss at the outset of therapy how to create a safe therapy environment while also considering how to minimize avoidance.

The current 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 prefer HBT to in-person care and their opinions about the merits of each may be different after the pandemic. The current 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., 2022), 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 provides 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 preference. Additionally, we were unable to examine partners’ preferences.

The pandemic resulted in a sudden and dramatic shift to HBT services for nearly all mental health visits in the VA, including couple therapy (Connolly et al., 2021; McKee et al., 2022; Rosen et al., 2021). However, our data suggest that even before the pandemic, equal numbers of veterans preferred in-person services and HBT services for couples-based PTSD. The current study highlights the value of offering both for couples-based PTSD treatments in VA. This study also suggests that the use of various question formats (i.e., closed vs. open ended) or mixed methods (e.g., quantitative and qualitative) can yield more comprehensive information about choice. Couples-based PTSD treatment modality preferences are based on a variety of individual and personal priorities and should be explored further to optimize treatment matching.

Impact Statement.

Approximately half of Veterans prefer to receive couples-based posttraumatic stress disorder (PTSD) treatment in-person and half prefer home-based telehealth. Veterans’ preferences for receiving their care are strong. Multiple options to deliver care should be available to Veterans to allow matching Veterans with their preferred delivery modality to promote patient-centered care.

Acknowledgments

This project was funded by Award 1I01RX002093-01 from the Rehabilitation Research and Development Service of the VA Office of Research and Development.

Dr. Wells was supported by a Career Development Award (IK2HX003539) from the Health Services Research and Development Service of the VA Office of Research and Development (VA ORD). Drs. Wells and Jackson were also supported by Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), (CIN 13-410) at the Durham VA Health Care System.

Dr. Knopp was supported by a Career Development Award (IK2RX003777) from the Rehabilitation Research and Development Service of the VA Office of Research and Development (VA ORD).

Dr. Grubbs was affiliated with VA San Diego Health Care System and University of California San Diego at the time of the trial and manuscript development and is currently affiliated with Central Arkansas VA Healthcare System and University of California San Diego

Footnotes

To our knowledge, there are no conflicts of interest.

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