Cohen, M., & Kuten, A. (2006). Cognitive-behavior group intervention for relatives of cancer patients: A controlled study. Journal of Psychosomatic Research, 61, 187–196.

To compare the effectiveness of a cognitive behavioral (CB) group intervention for relatives of patient with cancer with a control group
 

The cognitive behavioral (CB) intervention consisted of nine structured, 90-minute group sessions. Individual groups had five to seven participants and were conducted by a senior social worker with psycho-oncology experience as well as training in group therapy and CB therapy. Participants were provided written materials at every session and audiocassettes or compact discs for home practice of relaxation with guided imagery. The CB intervention had a cognitive and a behavioral component. Cognitive techniques were taught to identify and challenge negative and automatic thinking patterns and beliefs. Participants were taught to restructure thoughts into more adaptive patterns, reframe, problem-solve, and find alternative strategies to use with recurrent and stressful situations. Behavioral techniques taught were relaxation, guided imagery, and deep breathing.

• The sample was comprised of 104 participants assigned to a CB intervention group (n = 52) or a control group (n = 52).
• Mean age of participants was 53 years (range = 24 to 72 years).
• The sample was 66% female and 34% male.
• Caregivers did not have a present or past cancer diagnosis.
• Participant relatives were mainly spouses (49%), children (20%), parents (16%), or others (14%).
• Participant relatives’ diagnoses of cancer were breast (41%), colon (25%), prostate (9%), gynecologic (16%), and other (12%).

• Single site  
• Outpatient setting
• Haifa, Israel

Active antitumor treatment

A repeated measures, controlled trial design was used.

• Global Severity Index (GSI) was calculated as the mean of all item scores on the Brief Symptom Inventory (BSI) to assess psychological distress. Internal consistency was good, ranging from 0.87 to 0.91.
• Psychological Adjustment to Illness Scale–Self Rating (PAIS-SR): Internal consistency was good, ranging from 0.84 to 0.87.
• Mini Sleep Questionnaire was used to measure problems with falling asleep, restless sleep, and early awakening in the morning. Internal consistency was good, ranging from 0.87 to 0.89.
• Multidimensional Scale of Perceived Social Support was used to measure social support from significant others, family, and friends. Internal consistency was good, ranging from 0.92 to 0.95.
• Compliance with home practice was assessed with two questions.
   

There were significant group X time interactions for all of the psychosocial variables in the CB group but not in the control group. Significant main group effects were for psychological distress, psychosocial adjustment, and sleep problems but not for perceived support in the CB group but not the control group. Significant main time effect was for sleep difficulties and psychosocial adjustment. The between group effect size difference was 0.11–0.18.

There were significant improvements in perceived support from time 1 to time 3 (p < 0.0001) for the CB group but not for the control group.

Reliable Change Index (RCI) is a measure of clinical significance. RCI (6.5) showed clinically significant improvement in psychological distress from preintervention to follow-up in 30.8% (n = 16) of the participants in the CB  group as compared to  3.9% (n = 2) of the participants in the control group. Psychological adjustment, sleep problems, and perceived support levels for the CB group were also clinically significant (for PAIS, RCI = 2.2; for sleep difficulties, RCI = 14.8; for perceived support, RCI = 3.2).

On average, the amount of  thought monitoring was performed 2.7 (SD = 2.5) times per week at time 2 and 1.9 (SD = 1.7) times per week at time 3. Relaxation with guided imagery  was performed 3.4 (SD = 3.8) (time 2)  to 2.3 (SD = 2.9) times per week (time 3).

The results from this study indicate that the CB group intervention was effective in reducing psychological distress and sleep problems, and improving psychological adjustment for relatives of patients with cancer who participated. The CB intervention had a long-term effect that was maintained over the four-month follow-up.

Greater preintervention distress and a greater amount of  home-practice thought monitoring and relaxation/guided imagery compliance were significant predictors of the total change in participants’ level of distress.

The CB intervention was administered by a social worker who was highly experienced and familiar with psycho-oncology, group therapy, and CB therapy. Consequently, the study social worker was highly prepared to administer this CB group intervention. This indicates that the individual administering the CB intervention should be highly trained to replicate the successes of this research.
 

• The study has risk of bias due to no blinding, no randomization, and no appropriate attentional control condition. 
• Subject withdrawals were 10% or greater.
• The study had self-selection of control group participants in that they initially agreed to participate in the group intervention but could not attend due to other obligations.
• The study had a high refusal rate and losses to follow up.

The CB group intervention can be effective for improving psychological distress, psychological adjustment to illness, and sleep difficulties of relative caregivers of patients with cancer. This intervention can have both short-term and long-term psychosocial effects. Nurses can provide referrals for a CB intervention for highly distressed caregivers or those who are having sleeping problems and issues with adjustment to their relatives’ illness.

Further research is needed to replicate this study using a randomized controlled design. Additionally, an abbreviated CB intervention for relatives of patients with cancer needs to be developed for caregivers who have time constraints.