Interventions for Couples Coping with Cancer-related …

Implications for Psychosocial Care ... Similarity in adjustment to cancer continues over time. ... Individual Coping in Stress Theory (Lazarus & Folkm...

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Interventions for Couples Coping with Cancer-related Stress Karen Kayser, MSW, Ph.D. University of Louisville

Cancer Pole Ile-de-France Paris, France

6 May 2014

King Louis XVI – Namesake of Louisville, KY

Other Notable Things: Horse-Racing

Cancer in Kentucky

Patterns in Lung Cancer Death Rates by State, 2002-2006

Medical advances have changed our experience with cancer Living longer with cancer

Lower death rates Shorter hospital stays

Implications for Psychosocial Care More complicated caregiving responsibilities for families Complex medical centers to navigate Cost of treatment with devastating financial consequences More emphasis on the total patient

Growing Concern for Quality of Life “Cancer care today often provides state-of-the-

science biomedical treatment, but fails to address the psychological and social (psychosocial) problems associated with the illness.”

Institute of Medicine (IOM). 2008. Cancer Care for the whole patient: Meeting psychosocial health needs. Nancy E. Adler & Ann E.K. Page, eds. Washington, DC: The National Academies Press.

Overview of Presentation  Why do we study couples and cancer?

 What do we mean by dyadic coping?  How do we screen and assess for relationship distress?  How can we intervene to promote effective coping with cancer?

Why do we study couples and cancer?

Couples and Illness  Early research focused on marital status and health  Later research focused on quality of relationships and health  Relationship distress related to physical health  For married women, poor relationship related to mortality  Marital distress and slower recovery from physical illness Ren, X.S. (1997). Marital status and quality of relationships: The impact on health perception. Social Science and Medicine, 44, 241-249. Hibbard, J.H. & Pope, C.R. (1993). The quality of social roles as predictors of morbidity and mortality. Social Science and Medicine, 36, 217-225.

Relationship distress has adverse effects on partners’ cardiovascular, endocrine, immune, and neurosensory

systems. Examples: Satisfaction with spouse support and cortisol response during conflict Simple act of holding hand helped women with cancer adapt to stressful situation

Heffner, K.L., Kiecolt-Glaser, J.K., Loving, T.J., Glaser, & Malarkey (2004). Spousal support satisfaction as a modifier of physiological responses to marital conflict in younger and older couples, Journal of Behavioral Medicine, 27 (3), 233-254. Lieber. L., Plumb, M.M., Gerstenzang, M.L., & Holland, J. (1976). The communication of affection between cancer patients and their spouses. Psychosomatic Medicine, 38, 379-389.

Interdependence of Partners’ Responses to Cancer  Spouses report similar levels of stress in cancer

 Hopelessness and emotional distress are transferred from one partner to the other  Similarity in adjustment to cancer continues over time

Effect of illness-related Stress on Relationships  Shift in focus from effect of relationship on health to effect of illness-related stress on relationships  Form of dyadic stress  Stressful event or encounter that concerns both partners either directly or indirectly  Origin of stress is internal or outside the relationship

 Hence, coping with the stress becomes dyadic coping

Cancer-related Stresses Physical/medical: hospitalizations, lower functioning,

treatment side-effects, pain Emotional: anxiety, depression, uncertainty, sadness Social stress: accessing social support, telling people about

illness Practical: work, family and treatment demands, financial

hardship Existential: meaning of life, finding benefits

Dyadic Coping What do we mean by dyadic coping?

Individual Coping in Stress Theory (Lazarus & Folkman, 1984)

Stress Event

Cognitive Appraisal

Emotional Reaction

Coping Behavior


Theoretical Model of Individual Coping Process (Folkman & Greer, 2000)

Moving from Individual Coping to Dyadic Coping  Relationship-focused (Coyne)

 Empathic Coping (DeLongis)  Coping Congruence Model (Revenson)

 Systemic-Transactional (Bodenmann)  Relational-Cultural (Kayser)

Coping as a Couple Patient: Coping to him and me is that we talk about the breast cancer and we deal with it. Husband: We share decisions; we share the research. One of us isn‘t running off saying, ‘This is what I’m doing. I don’t care it‘s my disease.’ It's shared. It's a we-disease.

Pierre & Marie Curie

Stress Communication Process and Dyadic Coping (Bodenmann) Communication of stress by Partner A

Perception of A’s stress by B

Partner A Perception and attribution of Partner B’s reaction by A

Partner B Interpretation of Partner A’s stress signs (decoding) by B

Types of Dyadic Coping Positive


Common Coping

Hostile Coping

Supportive Coping

Ambivalent Coping

Delegated Coping

Superficial Coping

Relational Coping Model Gender Roles Family Boundaries

Outcome: Relational & individual growth

Cultural Context Appraise stressor as a dyadic stress

Relationship awareness, authenticity, mutuality

Coordinate problem-focused & emotionfocused coping

Personal Control Interdependence

Emotional response to stressor & response from partner

Screening for Relationship Distress How do we screen for relationship distress?

Distress Thermometer

Screening Questions 1.

On a scale from 1 to 10 how happy are you in your relationship?


Do you and your partner have difficulty communicating?


Do your arguments ever lead to pushing, slapping or hitting?


Do relationship problems contribute to you or your partner feeling depressed, anxious, or lonely?  Having more difficulty in dealing with your children?  Feeling less able to deal with such stresses as work, financial problems or health problems?  Drinking alcohol or using other drugs more than you should?

Rating of Distress Scoring of Questions



Unlikely to need couple therapy 5-7, significant communication problems, depression, anxiety, loneliness Relationship enhancement 1-4, physical aggression or relationship affects other areas Referral to couple therapist

How can we intervene to promote effective coping with cancer?

Partners in Coping Program  Phase I: Design a couples-based intervention for breast cancer patients  Series of single-subject designs with seven couples

 Phase II: Evaluate the effectiveness of intervention on couple’s adjustment to breast cancer  Randomized group design

Description of Program  Couple meets privately with social worker

 Social worker follows treatment manual  Nine sessions are completed during the first year of diagnosis  Each session lasts approximately one hour and is audiotaped

Topics of Sessions  Building social support network  Reallocating family tasks  Caring for children  Identifying dyadic coping patterns  Learning new coping skills  Facilitating supportive communication  Enhancing intimacy and sexuality

 Living with cancer

Structure of Sessions 1. Taking stock of previous week

2. Follow-up on assignments from previous session 3. Day’s Theme

4. Assignment and planning for next session

Assessment  Becoming Acquainted with the Couple and their Social Support Network

Assessment Questions What is the most important change in your life as a couple since the diagnosis? What things are you handling best as a couple? What things are you handling less well? Rating of Coping as a Couple: Scale from 1 to 10

Is there any good for you as a couple that may have resulted from the illness?

Have you as a couple experienced any other major illness?

Their Support Network: Genogram Nuclear Family

Extended Family

Case Illustration: Adam and Susan’s Genogram

Support Network Whom have you told about illness? From whom do you get best help?

With whom have relations changed? Contact with other couples with breast cancer?

Genogram: Extended Support Network (outside family)

Session 1: How the Couple does their Work

Role Assignments & Negotiation Procedures Step 1 List things couple is currently doing to keep the family and household going.

Step 2 Record current allocation of tasks under columns headed by: Primary



Step 3

Who is responsible for each task and who helps?

Step 4 What assignment changes would ideally make situation better?

Step 5 Reach agreement on what distribution would work effectively

Session 2: Enhancing Couple Supportive Communication

Instructions for 10-minute Conversation Step 1: Patient is “discloser;” partner is “helper” Step 2: Ask patient to think of topic she would like to discuss (something with personal meaning but is not a conflict with partner)

Step 3: Clinician sets up recorder and timer. Step 4: Start conversation with discloser telling helper what topic he/ she has chosen. Proceed with conversation in natural way.

Step 5: Couple talks for 10 minutes until clinician returns to room. Step 6: Clinician returns to the room and asks for general feedback: “How typical was this of conversations you normally have?” “Was there anything that sticks in your mind that was particularly helpful?” “. . Or that was particularly unhelpful?”

Tape-assisted Recall Step 7: Play back segment of tape and ask discloser to rate empathy on scale of 1 to 5 Step 8: Are there parts of the conversation that were particularly helpful or unhelpful?

Questions for Discloser: 1. How did you feel at that point? 2. In what way did you feel understood/not understood? 3. What was it about your partner’s response that made you feel understood/not understood? 4. How would you have liked him to respond to you at that point?

Questions for Helper: 1. How did you feel at that point?

2. What were you trying to do in making your response? 3. To what extent did you feel you understood what your partner was feeling or experiencing? 4. Was there anything that got in the way of your being able to understand your partner’s feelings at that point?

Role Reversal After reviewing the taped conversation with the patient as the discloser, reverse roles so that the partner becomes the discloser.

Future Directions for Couplefocused Interventions  What are the key ingredients for intervention?

 Are there couples for which the intervention will be more effective?  How can we make our interventions adaptable to the real world?