McLean, L.M., Walton, T., Rodin, G., Esplen, M.J., & Jones, J.M. (2011). A couple-based intervention for patients and caregivers facing end-stage cancer: Outcomes of a randomized controlled trial. Psycho-Oncology, 22, 28–38.

To examine the hypothesis that following an emotionally focused therapy (EFT), the intervention group for patients with metastatic cancer and their caregivers would demonstrate a greater increase in marital functioning postintervention when compared to the control group

To examine whether the intervention group would have a greater decrease in depression, hopelessness, and spousal caregiver burden scores and greater increase in patients’ perceptions of spousal caregiver empathic behaviors as compared to the control group

Potential participants included those who had requested a psychosocial referral for couple distress or those whom doctors had referred to the Psychosocial Oncology and Palliative Care Program. Couples were assigned to the EFT intervention or the control standard of care group. Randomization was stratified by sex.

The EFT intervention, which was adapted for use with couples experiencing metastatic cancer, was delivered over eight sessions. The modified manualized EFT addressed particular issues that challenge such couples and were used in prior research. These included ways to facilitate marital relationships by changing habitual and distressing patterns of interaction, increase mutual understanding and emotional engagement, and strengthen the marital bond. Couples had a one-hour weekly session delivered by a trained psychologist in a clinic outpatient or other convenient location over a period of two to three months.

The control group received standard of care from the institutional Psychosocial Oncology and Palliative Care Program. Social work consultation in that facility accounts for two-thirds of psychosocial care and usually involves practical and instrumental care or supportive interactions to relieve patient and family psychological distress. Patients and their partners facing metastatic cancer may be followed by a multidisciplinary team on a weekly, biweekly, or until end-of-life basis and as defined by patient/clinician assessment.

• The sample included 42 patient/caregiver dyads (22 in the EFT group and 20 in the control group).
• Mean age of patients was 51 years; mean age of caregivers was 50 years.
• The patient sample was 45% male and 55% female; the caregiver sample was 55% male and 45% female.
• Patients mainly had breast (23%), blood (17%), gynecologic, (14%), and head and neck (10%) cancers.
• Of the patients, 42% had some college education or a college degree, spoke English, and were not in active treatment. Similar results were noted in caregivers.

• Outpatient
• Home setting
• Toronto, Ontario, Canada

• End-of-life phase
• Caregiver burden; depression; marital functioning

A randomized, controlled, two-group trial design was used.

• Beck Depression Inventory II: Used extensively in cancer populations; Cronbach’s alpha in prior studies = 0.92
• Beck Hopelessness Scale: Used in terminally ill populations; prior Cronbach’s alpha = 0.88
• Caregiver Burden Scale: “Demand” subscale prior Cronbach’s alpha = 0.92; “difficulty” subscale prior Cronbach’s alpha = 0.93
• Relationship-Focused Coping Scale: Measured patient’s perception of caregiver empathic behavior; prior Cronbach’s alpha = 0.89
• Revised Dyadic Adjustment Scale (RDAS): Used to screen couples for study inclusion; Cronbach’s alpha in current study = 0.90; has validity from prior studies  

Patients with metastatic disease and their spouses who received the modified EFT had significant improvements in martial functioning compared with those couples who received standard care (p < 0.0001). Additionally, patients in the EFT intervention group reported significant improvement in their assessment of perceived caregivers’ empathetic behaviors when compared with the control group (p = 0.02). On the basis of initial RDAS scores, 91% of the intervention patients improved RDAS scores as compared to 28% of control patients (p < 0.0001). Fifty percent of EFT caregivers improved their RDAS scores as compared to 11% of control caregivers (p = 0.01). The study had a high participation rate and retention of couples. After the EFT and control interventions, there was no difference between groups in caregiver burden, hopelessness, or depression.

A modified EFT intervention was beneficial for patients with advanced cancer and their caregivers and improved both quality of martial functioning and patients’ perceived experience of being empathically understood by their caregivers. There were no apparent effects on caregiver strain and burden.

• The study had a small sample.
• Couples were referred by their clinical team and met a cutoff for marital distress, thereby limiting generalizability (no attentional control).
• The control intervention standard of care varied because of clinician decision of care deemed suitable for the client.
• Participants were not blinded to the intervention.

Recent trends toward longer survival and home care for patients with advanced cancer place emotional, relationship, and physical demands (burden) on the primary caregiver, who in many cases is the spouse or partner. An intervention that improves martial functioning may impact terminal care and patient satisfaction with spousal care, as well as reduce caregiver burden. Nursing assessment of marital or patient–caregiver relationships and referral to relevant resources may enhance the quality of life of both patients and caregivers and meet a standard of care for holistic nursing care.