Couples Therapy

To explore the effectiveness of psycho-oncologic interventions for patients and partners on anxiety, depression, psychopathology, and distress

Patients and partners who had been referred for psycho-oncologic service were recruited. Common interventions were psychoeducation, cognitive restructuring, behavior control techniques, guided imagery, relaxation, couples communication training, and other types of counseling in an individualized, nonstandard fashion. Patients and partners were grouped according to propensity scores calculated from variables shown to be significant in regression analysis for outcomes of interest, including gender, age, cancer site, stage of disease, baseline anxiety, and depression. Propensity matched control patients, and partners who did not receive the intervention were identified and used as control comparisons. Analysis was done in groupings according to the level of distress with propensity scores as low-, moderate-, or high-distress.

• N = 66 patients and 45 partners in ITT analysis; 43 patients and 27 partners completed the study  
• MEAN AGE = 57.8 years (SD = 14.2 years) for patients, 56 years (SD = 14.4 years) for partners in the intervention
• MALES: 60.6% for patients, 26.1% for partners; FEMALES: 39.4% for patients, 73.9% for partners
• KEY DISEASE CHARACTERISTICS: Multiple tumor types—hematologic, head and neck, and gastrointestinal most common; 63.6% of patients had stage 3 or 4 disease; 69.5% of partners were involved with stage 3–4 disease
• OTHER KEY SAMPLE CHARACTERISTICS: In most areas, patients in the control group did not have significant differences from those in the treatment groups. However, the majority of patients in the control group were highly educated, with 24% at the university level. Educational characteristics of patients and partners in the intervention group were not reported. Note: Sample characteristics are those who were moderately distressed. All characteristics of the full sample across all groups are not clearly provided.

• SITE: Single site  
• SETTING TYPE: Outpatient  
• LOCATION: Germany

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Palliative care 

• Naturalistic design
  • Quasi-experimental with matched control comparison

• Hospital Anxiety and Depression Scale (HADS)
• Symptom checklist (nine psychological symptoms)
• Global Severity Index for overall psychopathology

Time effects within patient groups showed significant decreases over time in depression and distress (p ≤ .05), but not for anxiety and psychopathology. No group effects were seen on outcomes over time. Among partners, no changes were seen over time and no significant effects of the intervention were seen on outcomes. The same pattern was seen in completer and intent to treat analysis. Pre- and post-intervention data showed that patients had significant declines in anxiety (effect size Cohen’s d = 0.32, p = .01), distress (d = .46, p = .001), and depression (d = 0.52, p = .001) at 12 months, and partners had significant declines in anxiety (d = 0.45, p = .01) and distress (d = .42, p = .02) within the highly distressed group. No significant differences were seen in the less distressed group over time.

Findings suggest that psychotherapeutic interventions can reduce anxiety, distress, and depression among patients and partners who are highly distressed. Little benefit may exist for individuals who are less anxious or distressed at baseline.

• Small sample (less than 100)
• Baseline sample/group differences of import
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Measurement/methods not well described
• Questionable protocol fidelity
• Other limitations/explanation: Distress measurement and definition are not described. The matched controls were not completely described but were highly educated; the education level of the comparison group is unknown. The intervention was not standardized or reviewed for content, so one cannot determine the similarities or dissimilarities of intervention sessions.

Psychotherapeutic interventions may be beneficial for patients and caregivers who are highly distressed. Nurses need to be aware of the overall level of patient and caregiver distress and identify those who are likely to benefit from referral for therapy.

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.

To (a) examine data collected eight weeks following participants’ completion of the intervention to determine whether treatment effects were maintained, and (b) process data to identify factors that might explain variability in response to the intervention 

After providing informed consent, participants were administered baseline measures and then randomly assigned to either a partner-assisted emotional disclosure intervention group or an education/support condition group. The partner-assisted emotional disclosure intervention protocol systematically trained couples in skills designed to help patients disclose their feelings and concerns related to the cancer experience.

Individual couples attended four in-person sessions with a master's-level therapist. Sessions included training in communication skills to help patients express their cancer-related thoughts and feelings and partners to encourage patients’ disclosure and communicate understanding and acceptance. The majority of sessions were devoted to couples’ conversations in which patients were given the opportunity to disclose their cancer-related thoughts and feelings to their partners.

Couples in the cancer education/support condition group attended four in-person sessions that centered on presenting information relevant to living with cancer. The therapists and scheduling sessions were the same as for the disclosure intervention. Couples in this condition group did not receive any training in communication skills, and patients were not encouraged to discuss their thoughts and feelings related to the cancer experience with their partners.

• The sample included 130 couples. 
• Mean age of patients was 59.4 years; mean age of partners was 59.3 years.
• The patient sample was 71% male and 29% female; the partner sample was 29% male and 71% female.
• Patient diagnoses were colorectal cancer (42%), pancreatic cancer (15%), esophageal cancer (11%), and other cancers (32%).
• The majority of patients were Caucasian, had stage IV disease, and had received chemotherapy; half were educated beyond high school.
• The majority of partners were Caucasian and were educated beyond high school (60%).

• Outpatient setting
• Duke University and University of North Carolina Hospitals

• End of life/multiple phases
• End of life; survivorship; sustained intervention effect

A randomized controlled trial design was used.

• Quality of Marriage Index (QMI): study Cronbach’s alpha average for both patients and partners = 0.90    
• Miller Social Intimacy Scale (MSIS): study Cronbach’s alpha average for patients and partners = 0.90
• Profile of Mood States (POMS): study Cronbach’s alpha average for patients and partners = 0.89
• Holding Back From Disclosure Measure: study Cronbach’s alpha for patients only = 0.88
• Positive and Negative Affect Scale (PANAS): noted to have reliability and validity
• Self-Feeling Awareness Scale (SFAS): inter-rater reliability previously established

The study experienced a 27.7% attrition rate due to patient death or declining health or conflicts between study completion and life issues. Analysis occurred according to an intent-to-treat model based on an initial randomized sample of 130 couples. For couples in which the patient initially reported high levels of holding back from discussing cancer-related concerns, the partner-assisted emotional disclosure intervention led to significant improvement in relationship quality (p = 0.002) and intimacy (p = 0.020) over an eight-week follow-up period compared to an education/support control condition. There was no treatment effect on mood. Overall, the benefits of disclosure intervention appeared largest for patients who were high in holding back.

In patients who were more expressive during disclosure sessions, patients and partners were significantly more likely to report increases in relationship quality and intimacy from baseline to post-treatment assessment. When patients reported more negative affect following the disclosure sessions, both patients and partners were significantly more likely to report decreases in psychological distress between baseline and post-treatment assessment.

The intervention showed a positive effect on couples’ relationships over the eight-week follow-up; however, there was no demonstrated effect on affect or mood disturbance for patients or their partners.

• Some couples were unable to complete the four sessions of the intervention due to the face-to-face structure of the intervention.
• The large amount of data collected by telephone contact at eight weeks postintervention may influence the accuracy of data.
• Whether partners were also caregivers for patients at the end of life is unclear. 
• Participants tended to be white, well-educated, heterosexual couples.
• The study's focus on patient emotional disclosure, with limited attention to caregiver disclosure, may affect relationship quality and intimacy issues.

Nurses have a role in assessing patient–partner coping during cancer treatment and referring couples to relevant resources to facilitate physical, spiritual, and psychosocial health of couples. Partner-assisted emotional disclosure in a structured supportive environment may benefit couples when patients have difficulty expressing cancer-related concerns.