The diagnosis and treatment of cancer can be stressful and upsetting. Patients deal with several challenges, including the emotional consequences of being diagnosed with a life-threatening illness1–3; medical treatments with sometimes debilitating side effects, such as nausea and vomiting, pain, urinary incontinence, fatigue, bodily disfigurement, sexual dysfunction, neuropathies, difficulties breathing, eating, and/or swallowing4–11; and existential and spiritual concerns.12, 13 However, the diagnosis of cancer in a member of the family can have significant repercussions for the entire family. Partners in particular cope with challenges, such as worry about the potential loss of their life partner and their ability to provide emotional and practical support to the patient.14 In addition to these emotional concerns, experiences throughout the cancer continuum can result in several practical issues that both patient and partner must cope with together. For example, in the months after a new diagnosis, these stressors include negotiating changes in occupational and family roles, interference with future life plans, and managing household and childcare responsibilities.15–18 For couples dealing with advanced disease, cancer causes additional life stresses, such as declining functional abilities that bring about the necessity for couples to discuss how care and assistance with daily activities will be provided to the ill partner.19, 20 Couples also typically negotiate difficult choices regarding end-of-life treatments and care, cope with anticipatory grief regarding the loss of one's partner, manage child and family reactions, and talk about the ill partner's legacy in psychologic and practical matters.21, 22 For couples who enter the survivorship phase, the primary challenge is negotiating the transition to “normal” life.23 For most of these couples, the main tasks include resuming a sexual relationship, discussing changes in life plans, discussing health behavior changes, dealing with disease and treatment-related late effects that may influence the patient's functioning, managing worry about disease recurrence, and discussing the meaning of the cancer experience for themselves and the relationship.24–31 One common challenge couples encounter is that each partner may have a different “pace” with regard to their desire to return to normal life.23 In summary, regardless of the stage along the cancer continuum, cancer can pose unique challenges for the marital relationship. Thus, from a couples' perspective, successful adaptation may not be as dependent on the circumstances of the illness but rather on how well the couple integrates cancer into their lives.
In writing this article, we sought to advance an understanding of the role of the marital relationship in cancer adaptation first by describing different approaches to understanding cancer in the marital context and then by reviewing some of the major theoretical frameworks that have guided an understanding of the role of relationship processes in couples' psychosocial adaptation. Next, we integrated the different perspectives into a new model that we believe can serve as an initial framework for future work on couples' psychosocial adaptation to cancer. In this report, we also describe preliminary results from a couple-focused, intimacy-enhancing intervention for patients with early-stage breast cancer and their partners that provides initial empiric support for this new model, and we discuss strengths and weaknesses of the model as well as directions for future research.
Approaches to Understanding Cancer in the Marital Context
Traditional approaches to understanding the psychosocial impact of cancer have sought to describe the level of distress experienced by the patient.2, 3 However, over the last 20 years, researchers and clinicians working in oncology have recognized the importance of viewing cancer in the family context. This realization has lead to a burgeoning literature assessing and comparing patient and partner distress levels3, 31–42 as well as sex differences in distress.43–47 With a few exceptions,32 these studies suggest that patients report higher levels of clinically relevant distress than partners3 and that women who are patients and partners report higher levels of distress than men who are patients and partners.43 Recent reviews have suggested that the difference in distress levels between patients and partners can be accounted for by sex differences in the reporting of psychologic distress rather than role differences.46 One exception may be partners of patients with end-stage disease who are providing home care; among these partners, evidence suggests that partners of both sexes may have higher levels of distress than patients.20
A second focus of this literature has been to study the psychologic impact of caregiving on spouses. The primary focus of these studies has been on quantifying caregiving demands47 and identifying correlates of caregiver burden.48 For a review of this literature, please see the article by Kim and Given in this supplemental issue of Cancer.49
A third focus has been to evaluate the impact of cancer on the general quality of the marriage. Although clinical lore suggests that partners, particularly partners who are men, may be more likely to abandon their marriage during and after cancer, there is no evidence to support this contention. In fact, studies indicate that marital satisfaction after diagnosis is not significantly different from population norms,50–52 and recent work suggests that nearly half of women with breast cancer and their husbands report that cancer brought them closer together.53
Previous work on couples dealing with cancer has been important in that it has quantified the psychologic impact of cancer both on partners and on marital quality. What we believe has been missing largely from this literature is the adoption of a couple-level perspective whereby the cancer experience is viewed in relational terms. Implicit in this couple-level perspective is that the illness is something that happens to the couple and that the focus on patient and partner separately may not be as beneficial from a theoretical and clinical perspective as a focus on the relationship. Another important assumption is the belief that the marital relationship is a resource for partners to draw from during difficult times but that it is equally important to study the ongoing contributions that partners make to preserve and improve relationship quality. Partners in satisfying relationships are aware of the important functions of their relationship, make purposeful efforts to maintain it during difficult times, and are open to finding opportunities to improve it. From this perspective, cancer can serve as an opportunity for couples to forge a more intimate bond. Viewing cancer as an opportunity for enhancing the couple's relationship, as opposed to a challenge for individual partners, entails a refocusing of scholarship and attention onto the interactions between partners and how these interactions affect the couple's sense of closeness and adaptation to cancer. From this perspective, relationship processes, or the ties that bind patients and partners together as they cope with cancer, are key. We believe that identifying and targeting key relationship processes can facilitate the design of efficacious, couple-focused interventions aimed at improving psychosocial adaptation to cancer for both members of the couple. To this end, we reviewed some of the major theoretic frameworks that have guided an understanding of the role of relationship processes in couples' psychosocial adaptation to cancer.
Theoretic Frameworks for Studying Relationship Processes and Empiric Support
Traditionally, there have been distinct bodies of literature examining couples' psychosocial adaptation to cancer. The divide is caused primarily by the differentiation between the social psychology literature, which emphasizes underlying psychologic and relationship processes, and the clinical psychology literature, which emphasizes evaluating psychologic interventions. The disconnect between these literatures in the area of relationship support processes among couples coping with cancer is unfortunate, because there is considerable overlap in component relationship processes, and much can be learned from integrating this knowledge base. From a theoretical perspective, identifying broad theoretical constructs to include in an overarching model of relationship processes will inform programmatic research. From a clinical perspective, this information can facilitate the design and testing of effective, couple-focused interventions. In the section below, we have provided an overview of some of the major theories that have guided research on couples and cancer. These theories are summarized in Table 1, which also provides illustrative empiric work adopting each theory. That overview is followed by a description of our new integrative relationship-level model of couples' adaptation to cancer.
Table 1. Summary of Key Theoretical Approaches to Studying Cancer and the Marital Relationship
Representative studies in the oncology literature
The partner/relationship is viewed primarily as a resource for the patient
Cognitive social processing theory
Talking with the spouse can facilitate cognitive and emotional processing; members of the social network can constrain disclosure by being critical or unsupportive
Disclosure, cognitive and emotional processing, social constraints
Focusing greater attention onto the relationship by incorporating the relationship into one's self-concept, viewing cancer as a ‘we’ disease, talking with a partner specifically about the relationship, or engaging in other communication behaviors aimed at maintaining or enhancing the relationship is associated with greater psychological and marital adjustment
Badr & Carmack Taylor in press103; Badr 2007108; Badr 2008110
Interpersonal process model of intimacy
For an interaction to be perceived as intimate, the speaker needs to interpret the listener's statements as being responsive (eg, the speaker needs to perceive that the listener has understood the content of the individual's disclosure and, thus, feels accepted and cared for)
Reciprocal self-disclosure and perceived partner responsiveness
Applying behavioral principles, such as reinforcement and punishment, to marital exchanges; the ratio of positive to negative behaviors determines marital satisfaction; believes that marital dissatisfaction is caused primarily by poor communication, which can be strengthened
Theories such as cognitive-social processing theory, social support theories, and equity theory adopt the view that the marital relationship is a resource for individuals to draw on for assistance during difficult life events. Most of these theories draw from family systems theory and communication theory, which originate from seminal early work conducted by Jackson54, 55 and by Jackson and Weakland56 on communication theory and work by Haley57, 58 and by Spiegel59 on family systems theory.
Cognitive-social processing theory
Cognitive-social processing theory emanates from the vast literature on the effects of the social context on individuals' psychologic adaptation after a traumatic or stressful event.60, 61 According to this perspective, successful cognitive processing involves actively assimilating or accommodating a stressful experience into an individual's “world view,” which typically involves finding some meaning or purpose in it.62, 63 Although some processing is done on an individual level, the social network can aid or interfere with effective processing.64 Talking with others may facilitate successful processing by allowing the disclosure of emotions, helping the individual learn to tolerate aversive feelings, providing support for adaptive coping, and providing direct assistance in finding meaning and benefit in the experience, as discussed by Tait and Silver.65 Conversely, not being able to talk about a difficult experience because an individual perceives their family or friends as critical, unreceptive, or uncomfortable with the topic may place individuals at higher risk for adverse psychologic reactions. On the basis of this theory, the spouse can serve as a resource for the patient in terms of providing assistance in cognitive processing. The spouse also can serve as a barrier to effective processing if he or she is either unavailable or unsupportive. Barriers to sharing the cancer experience with a spouse may be particularly problematic because of the level of importance the spouse has as both a confidante and primary source of support.66
To our knowledge, few studies to date have adopted the cognitive-social processing theory perspective to examine how couples deal with cancer. In our previous work, we evaluated the role of spouse unsupportive responses in how patients cognitively process cancer. We observed that unsupportive spouse responses moderate the association between intrusive thoughts and distress67 and that avoidance mediates the association between spouse unsupportive responses and psychologic distress.68
In summary, cognitive-social processing theory views the marital relationship as an important resource in adaptive cognitive processing on the part of the individual with the disease. Key constructs are disclosure, processing, and how others facilitate an individual's processing of an event. However, it is important to note that this theory adopts an individual-level conceptualization of the role of the marital relationship, because the focus is on individual partner distress, and there is little attention given to couples' interaction.
Social support theories
By far the most common relationship process studied in the cancer context is the provision of social support from partner to patient. Traditionally, social support has been viewed as a personal resource, and the theoretical conceptualization guiding this work has been either stress and coping theory69 or stress-buffering theory.70 Stress and coping theory has viewed support provided by others as 1 method individuals use to deal with a stressful life event. Most theories of how coping works suggest that the practical and emotional support that individuals receive from others facilitates adaptive coping.71 Similarly, stress-buffering theory proposes that social support protects against the deleterious effects of negative life events on health and well being.70, 72 Although social support provided by an individual's partner is considered an important determinant of a satisfactory marriage,73–75 to our knowledge only a small number of studies in the social support literature have focused on the role of social support in the marital relationship.76–78
The majority of studies evaluating the role of emotional and practical support provided by the partner have reported that higher levels of spousal support are associated with lower levels of distress as reported by the cancer patient.79–82 However, Bolger et al.78 observed that reported changes in partner support were not related to reductions in distress among women with early-stage breast cancer. The role of the provision of support from the individual with cancer to the healthy partner has been studied less. Limited research has suggested that husbands of women with early-stage breast cancer believe their needs are attended to less.83
When evaluating the role of social support, it is important to consider that all interactions between couples are supportive. Some behaviors that are intended as supportive on the part of the healthy partner are not perceived as such by patients.84–86 Examples are attempts to avoid discussing concerns or topics that may cause the patient distress (typically labeled “protective buffering”) and giving advice when the patient was not asking for advice. Cross-sectional67 and longitudinal studies87, 88 indicate that attempts to avoid discussing concerns or topics are associated with increased distress for both partners. There also is evidence that responses that are perceived as overtly critical (eg, criticizing how the partner is coping) are associated with patient distress.67
In summary, social support theories view marriage as a resource for individuals with cancer. This literature has been successful in identifying behaviors engaged in by others that are perceived as either supportive or unsupportive. This viewpoint is similar to the cognitive-social processing theory perspective, because it adopts an individual-level conceptualization of the role of the marital relationship.
Equity theory has conceptual overlap with social support theories. Some researchers have argued that, for support to have beneficial effects, it must be reciprocal.89 However, in the context of cancer, relationships may be affected by changes in the balance of give and take between partners.90, 91 Whereas support may have flowed back and forth between partners before the onset of illness, the exchange may become more unidirectional, with the healthy spouse's contributions to the relationship far exceeding those of the patient.
According to equity theory, when the ratio of contributions to rewards for 1 partner differs from that of the other, the relationship is out of balance; individuals in inequitable relationships are more likely to become distressed,92 regardless of whether they are overbenefited or underbenefited.93–95 Kuijer et al.96 compared couples coping with cancer with healthy couples and observed that cancer patients felt more overbenefited and experienced more guilt about being overbenefited than healthy individuals.97 Among patients, the perception of not giving enough to the partner also was related to depressive symptoms.98 Although the majority of partners of cancer patients reported feeling that they were treated as equitably as healthy individuals reported, those who reported feeling underbenefited had greater depressive symptoms98 and greater relationship distress.96
In summary, equity theory adopts an individual-level perspective on the role of the marital relationship by focusing on individual psychologic adaptation. However, a key advantage of this theory is that it acknowledges the exchange of support between partners and the value that partners place on the level of equity in their support-related exchanges.
Dyadic level theories
Whereas resource theories focus on the individual as the unit of study and conceptualize the relationship as a source of support for partners to draw on, dyadic-level theories focus on the couple as the unit of study and examine the ongoing contributions that both make to preserve or improve the quality of their relationship as they strive to cope together with the cancer experience. Below, we consider the dyadic-level models that have been influential in shaping research on couples coping with cancer.
Relationship resilience models
Marital resilience refers to the strategies partners engage in to strengthen and/or maintain their relationship and promote adaptation to life challenges.99 Stafford and Canary100 identified 5 such strategies: 1) positivity or interacting with one's partner in a cheerful and optimistic manner; 2) openness, which refers to discussing and disclosing information about the relationship with one's partner; 3) assurances, which are statements of commitment and love; 4) social networks, which entail relying on or interacting with common relatives/friends; and, 5) shared tasks, which involves engaging in everyday activities together. These strategies promote positive feelings and commitment to the relationship99 and prevent the relationship from decaying.101, 102 Theory and research suggest that these strategies help promote resilience.99 By applying this framework to how couples cope with cancer, Badr and Carmack Taylor103 reported that couples' efforts to maintain or enhance their relationship when 1 partner was recently diagnosed with lung cancer affected their psychologic and marital adjustment over time.
A construct related to relationship maintenance is relationship awareness, which is defined as the focusing of attention on the relationship.104 Relationship awareness consists of 2 key components: viewing oneself as part of a couple105 and talking with one's partner about the relationship.106 Greater relationship awareness is associated with higher levels of happiness, commitment, and love between married couples107 as well as the psychologic adjustment of individual partners.108 For example, it has been demonstrated that seeing oneself as part of a couple facilitates a couples' level of cooperation109 and minimizes the negative effects of a chronic illness on spouse mental health.108 Badr et al.110 recently demonstrated that couples who reported engaging in more frequent discussions about their relationship within 1 month of the patient's initiation of treatment for lung cancer had greater marital adjustment and less psychologic distress up to 6 months later. Such discussions include talking about relationship memories, plans for the future, and problem solving about cancer-related issues that have impacted the relationship.111
In summary, relationship resilience models propose that viewing the cancer as a stressor that affects both partners and making efforts to maintain and/or enhance the relationship may play an important role in couples' psychologic and marital adaptation. Thus, understanding the behaviors that help couples maintain and enhance the quality of their relationship is important.
Interpersonal process model of intimacy and intimacy theory
Intimacy is considered a primary psychologic need112 and is a widely studied construct in social and clinical psychology. Recent conceptualizations of intimacy have included components such as attentive listening and the conveyance of understanding.113 Nearly all conceptualizations focus on the role of disclosure. Indeed, the degree to which patients disclose concerns has been a focus of several recent studies in the psycho-oncology literature.114, 115
We have adopted the conceptualization of intimacy described by Reis and Shaver116 that has been labeled the interpersonal process model of intimacy. In this model, intimacy is defined as a process whereby an individual expresses important self-relevant feelings and information to another and, as a result of the other's response, comes to believe that they are understood, validated, and cared for.116, 117 This conceptualization is unique both because interactions are the basis for intimacy and because intimacy is defined in interactive terms. This model emphasizes 2 key components in intimate interactions: self-disclosure and partner responsiveness.116, 117 Self-disclosure is the communication of personally relevant and revealing information to another individual and can contain facts, thoughts, or feelings as well as nonverbal communication. The listener then responds by disclosing personally relevant facts, thoughts, or feelings. The process then proceeds to the perceptions and appraisals by the speaker regarding what the listener has said. For the interaction to be intimate, the speaker needs to interpret the listener's statements as responsive. That is, the speaker needs to perceive that the listener has understood the content of the individual's disclosure and, thus, believes that they are accepted and cared for. Laurenceau et al.118 expanded the interpersonal process model of intimacy to include perceived partner disclosure as well as self-disclosure. According to this model, both self-disclosures and partner disclosures contribute to the development of intimacy through the degree to which the speaker believes that their partner is responsive.
We evaluated this model in a study of women diagnosed with breast cancer who were in active treatment and their partners. Couples participated in 2 discussions and then rated perceived self-disclosure, partner disclosure, partner responsiveness, and intimacy experienced during the discussion.119 When the partner's perspective was evaluated, our findings were consistent with the interpersonal process model of intimacy. However, when the patient's perspective was evaluated, the findings were only partially supportive of the Interpersonal Process Model. Patient self-disclosure did not predict patients' feelings of intimacy over and above perceptions of partners' responsiveness. Rather, partner disclosure was a more important determinant of perceived closeness than patient disclosure. Although these findings suggest that patient self-disclosure may not play a strong role in relationship closeness, our observational work suggests that partners' responses—particularly partner's reciprocal self-disclosures—play a role in patients' distress.119
Behavioral marital theory
We include behavioral marital theory because it is a hallmark of the vast majority of couple-focused interventions in the marital literature and has guided some of our recent approaches to understanding relationship processes in cancer. Behavioral models evaluate how relational partners influence one another. Behavior exchange approaches attempt to increase the ratio of positive to negative behaviors exchanged by partners.120 Behavioral exchange, improving adaptive communication, conflict resolution, and problem-solving skills are considered important processes of relationship functioning and satisfaction and, as such, are targeted in behavioral approaches to marital therapy.121, 122 These skills are brought by couples to each of their interactions, and both partners influence and are influenced by these interactions.123
In terms of marital interaction, Christensen and Shenk,124 used a 1984 communication patterns questionnaire from the University of California-Los Angeles to identify 3 patterns. They defined pressure-withdraw as a maladaptive interaction pattern in which 1 or both partners pressure the other to discuss a problem, and the other partner withdraws. Traditionally, the woman in the couple is the pursuer, and the man is the withdrawer.125 The pressure-withdraw interaction dynamic is associated with marital dissatisfaction.124 Mutual avoidance of discussing problems is a second dynamic that is predictive of marital dissatisfaction.124 Finally, mutual constructive communication, which involves mutual engagement in discussing a problem and attempting to find a solution, is associated with greater marital satisfaction.124
Behavioral marital theory has not been used widely in the study of cancer patients and their partners. In a study of women with early-stage breast cancer and their spouses, we evaluated the role of the communication patterns described by Christensen and Shenk in couples' distress and marital satisfaction.126 Our findings suggested that less pressure-withdraw communication, less mutual avoidance, and greater mutual constructive communication of cancer-related problems were associated with less distress and greater marital satisfaction on the part of both partners.
Each of the theoretical perspectives outlined above has contributed new thoughts and a greater understanding of the role of relationship processes in couples' psychosocial adaptation to cancer. For example, resource theories illuminate the importance of the marital relationship as a source of support for both partners to draw on during the cancer experience, describe partner supportive and unsupportive responses, and capture the importance of equitable support exchanges. However, they do not view marriage as a relationship in which partners invest and draw from, they do not treat the couple and their interaction as the unit of study, and they do not view cancer in relationship terms. The strength of dyadic-level theories is that they conceptualize the couple as a unit and treat cancer as a relationship issue. Specifically, relationship resilience models emphasize the importance of partners' focus on the relationship as an attempt to maintain and/or enhance relationship quality. These theories also suggest that openness to relationship enhancement during difficult experiences may be important. The interpersonal process model of intimacy, which also is a dyadic-level model, highlights the importance of reciprocal self-disclosure, responsiveness, and intimacy. Its primary strength is the focus on specific interactions and how the other partner responds. However, it does not describe dysfunctional processes or other beneficial behaviors, and psychologic adaptation is not included in the model. Thus, the main gap in dyadic-level theories is that they do not fully capture and interrelate key elements and outcomes of relationship processes. Finally, behavioral marital theories emphasize interaction patterns and the role of acceptance and commitment in relationship satisfaction. However, they do not focus on intimacy processes.
The Relationship Intimacy Model of Couple Psychosocial Adaptation to Cancer
Although the review described above demonstrates a growing body of literature examining not only the psychosocial adjustment of cancer patients and their partners but also the role of relationship processes in partners' coping and adjustment, to date, there is no well articulated, integrative theoretical framework for such research. We propose that more could be achieved from both a theoretical perspective and a clinical perspective by adopting a meta-analytic, dyadic-level approach to understanding marriage after cancer. We believe that this can be achieved by focusing on intimacy as a primary mechanism for promoting couples' adaptation and by integrating key relationship processes that contribute to intimacy into an overarching, heuristic model. We propose the relationship intimacy model of couples' psychosocial adaptation to cancer, which is an overarching, heuristic model that we believe can help begin to organize the conceptualization of the marital relationship after cancer, because it integrates key component relationship processes and outcomes (see Fig. 1). We focus on component relationship processes that contribute to intimacy in 2 categories: “relationship-enhancing” and “relationship-compromising” behaviors. We have selected 3 relationship-enhancing processes to include in the integrative model. The first is disclosure of concerns and feelings regarding the cancer experience (reciprocal self-disclosure). Self-disclosure is a component of social support theory, the interpersonal process model of intimacy, cognitive-social processing theory, and the relationship resilience models. The second process is partner responsiveness, which is defined as feeling understood, cared for, and accepted by one's partner. Responsiveness is a component of social support theory, the interpersonal process model of intimacy, and the relationship resilience models. The third process is relationship engagement, which is an overarching term that we define as viewing cancer in relational terms (ie, viewing cancer as having implications for the relationship as well as for each partner individually) and engaging in behaviors that are aimed at either sustaining or enhancing the relationship while coping with cancer. Relationship engagement is characterized by 1) an awareness of the challenges cancer poses to the couples' relationship and an openness to discussing these changes with one's partner, 2) a willingness to address aspects of the relationship that either have changed or need to change after cancer (ie, relationship priorities and roles), and 3) efforts to maintain components of the relationship that are important to either partner during the illness (eg, treating one another as spouses rather than adopting caregiver-patient roles). Relationship engagement combines elements of the relationship resilience models (eg, relationship awareness and maintenance), which our research suggests are relevant in the cancer context.
We have categorized relationship-compromising behaviors, which consistently have been associated with reduced marital quality and/or psychologic distress into 3 broad categories: avoidance, criticism, and pressure-withdraw. Avoidant responses are more subtle insensitive behaviors, such as conveying discomfort when a partner is attempting to talk about the illness, as well as well intentioned efforts to hide worries, deny concerns, and yield to one's partner to avoid disagreement and reduce the other partner's upset and/or burden.88 Critical behaviors are intentionally unsupportive reactions, such as the spouse criticizing how the patient is coping with cancer,64 and a less commonly studied response, which is the patient criticizing how the partner is coping with cancer.111 Finally, pressure-withdraw occurs when a partner pressures the other to discuss a cancer-related problem and the other partner withdraws.126 Relationship-compromising behaviors can be viewed as including components of social support, social-cognitive processing, and behavioral marital theories.
We chose relationship intimacy as the primary way that relationship-enhancing and relationship-compromising behaviors exert their effect on couples' adaptation. We realize that there may be individual-level variables, such as how couples cope with the illness, which also may be affected by engaging in either relationship-enhancing or relationship-compromising behaviors; however, this model focuses primarily on the role of the relationship in couple adaptation. There are many ways to define relationship intimacy. We adopt a situation-specific approach whereby intimacy is the experience of feeling close to and cared for by a partner with regard to the cancer experience. We distinguish intimacy from attachment, which we view as a set of expectations about oneself and others that develop in the context of early childhood experiences that influence how individuals interpret interpersonal experiences. Research has demonstrated that the attachment can influence how couples establish intimacy (eg, the degree of disclosure and perceptions of responsiveness) (Schaeffer & Laurenceau, unpublished observations). Although attachment may be amenable to change and can influence intimacy, it is viewed primarily as a dispositional characteristic,127 whereas intimacy is viewed as amenable to change.118
The primary outcome in our model is couple-level psychologic and marital adaptation. We include marital adaptation along with distress in our conceptualization of couples' adaptation because a dyadic perspective is carried into all aspects of the relationship intimacy model.
Couple-focused Interventions Using the Relationship Intimacy Model
There have been several recently published couple-focused interventions for individuals with cancer.22, 128 None have focused on enhancing intimacy or have targeted all of the key elements of our integrative model. We recently developed and pilot tested an Intimacy-Enhancing Couples' Therapy (IECT) for women diagnosed with early-stage breast cancer and their partners.129 The relationship intimacy model was used to guide the development of IECT. This intervention targets relationship-enhancing behaviors by enhancing reciprocal disclosure and responsiveness, assisting couples in viewing the illness in relationship terms, enhancing relationship maintenance activities, and encouraging the couple to consider changes in the priorities in their relationship both precancer and postcancer. Relationship-compromising behaviors also are addressed through structured training and practice in adaptive communication skills with therapist feedback. IECT consists of 5 weekly 1-hour sessions with the individual couple and a therapist. The intervention is manualized with in-session practice, handouts, and home assignments.
To provide preliminary feasibility and efficacy data, we conducted a small, nonrandomized trial with 16 women who were diagnosed with early-stage breast cancer and their partners. On average, patients were aged 53 years (standard deviation [SD], 10.2 years; range, 32–69 years), and partners were aged 54 years (SD, 10.2 years; range, 32–69 years). The majority of partners were men (92%). Most patients (48%) and partners (44%) had completed college. The majority of patients (80%) and partners (80%) were Caucasian. The median household income was $75,000 (range, $26,000–$188,000). Among married couples (N = 13), the average relationship length was 21 years (SD, 13.8 years; range, 2–50 years). Among nonmarried, cohabiting couples (N = 3), the average relationship length was 13.3 years (SD, 5 years; range, 8–18 years). Approximately 8% of patients were diagnosed with ductal carcinoma in situ, 88% were diagnosed with stage I or II breast cancer, and 4% were diagnosed with stage IIIA breast cancer. The average time since original cancer diagnosis was 6.5 months (SD, 4.4 months; range, 1–12 months). Patients had undergone breast-conserving surgery (68%) or modified radical mastectomy (32%). Approximately 96% of patients had an “asymptomatic” rating on the Eastern Cooperative Oncology Group performance status subscale.130 Primary study outcomes were general psychologic distress (38-item Mental Health Inventory)131 and cancer-specific distress (Impact of Events Scale [IES]).132 Measures of relationship-enhancement processes included perceived partner disclosure,119 partner responsiveness,119 partner criticism and avoidance,68 cancer-specific relationship intimacy,119 and general relationship intimacy (the Personal Assessment of Intimacy in Relationships inventory).133 Measures were administered to both partners preintervention and 1 week postintervention.
Of the 16 couples who completed preintervention surveys, 14 completed all 5 sessions and the follow-up survey (88%). Preintervention and postintervention means and SDs are shown in Table 2. Pretest and posttest comparisons of patient and partner psychologic outcomes indicated that IECT significantly reduced patient psychologic distress (F1,14 = 7.56; P < .05) and significantly increased patient-perceived partner responsiveness (F1,14 = 7.87; P < .05) and patient cancer-specific closeness (F1,14 = 6.65; P < .05). Marginally significant reductions in patient IES intrusions (F1,14 = 4.09; P = .06) and marginally significant increases in general relationship closeness (F1,14 = 3.44; P = .08) also were noted.
Table 2. Preliminary Results of the Intimacy-enhancing Pilot Intervention Trial (N = 15)
SD indicates standard deviation; MHI, Mental Health Inventory; IES, Impact of Events Scale.
Our preliminary data suggest that IECT has promise as a couple-focused intervention in that it increased relationship-enhancement behaviors, reduced relationship-compromising behaviors, increased relationship intimacy, and reduced couples' distress. However, it should be noted that this was not a controlled clinical trial, and we did not assess other constructs in the relationship intimacy model, such as relationship maintenance behaviors, relationship awareness, patient criticism of the partner, patient avoidance of the partner, and pressure-withdraw behaviors.
Directions for Future Research
We divide our discussion of future directions into methodological issues, future empiric and clinical challenges, and limitations of our model. First, it is important that future research studying couples' adaptation to cancer not only include both partners but also make sure that the couple is the unit of analysis throughout the research process. This dyadic perspective should be reflected when conceptualizing the research question, choosing a study design, selecting methodology and measures, and by using dyadic-level statistical approaches to analyze and interpret the data.134–136 Second, it will be important to use multimethod approaches to measure marital processes by including observational137 and daily diary methods138 that can capture the interactional nature of these processes. Measures of some relationship-enhancement behaviors, such as relationship awareness, need to be developed and validated for the cancer context. Definitions of marital distress in cancer also may need to be refined. The effects of cancer on what are primarily long-term, stable relationships may be more gradual and may erode different components of marital quality (eg, sexuality, efforts at relationship maintenance).
It will be important for investigators to study couples dealing with different types and stages of cancer so that the effects of illness status (eg, patient vs partner) can be disentangled from the effects of sex. The study of couples dealing with different types of cancer also may illuminate the differences in relationship issues. For example, sexual problems and/or the pressure-withdraw dynamic as barriers to relationship intimacy may be more important for couples coping with prostate cancer. Social isolation and blame for substance use may be a more common intimacy barrier for couples dealing with head and neck cancers, and partner criticism for smoking may be a key relationship issue and barrier to intimacy among couples dealing with lung cancer. Finally, although previous research provides initial support for components of the relationship intimacy model, the examination of proposed linkages using model-building statistical approaches such as structural equation modeling is needed.
From a clinical perspective, it will be important to develop couple-focused psychologic interventions for couples dealing with cancers other than early-stage breast cancer. These interventions should target specific issues for each population and adopt a relationship focus rather than using the partner as an “assistant” by addressing the relationship and the needs of both partners. More research also is needed to determine appropriate timing of couple-focused interventions. Whereas the best timing for working with couples may be at the time of diagnosis, the transition to survivorship also may be an appropriate time for couple-focused interventions. It also will be important to decide the degree to which couple-focused interventions can be adapted from efficacious marital interventions for nonphysically ill couples. Finally, it will be important to examine mechanisms for therapeutic change and to identify subgroups of couples who may benefit more from intervention approaches.
It is important to recognize that the relationship intimacy model proposed here is a first step in building an integrative framework for understanding how relationship factors influence psychosocial adaptation to cancer. This model has not yet incorporated several medical, relationship, and individual-level factors that we realize may impact both component processes and outcomes. For example, physical disability experienced by the partner clearly impacts relationship-enhancing and relationship-compromising behaviors.67 Sociodemographic variables, such as age, education, and culture, also may be important. For example, couples at different stages of the life cycle (childrearing, postretirement) may experience very different types of relationship stressors as a function of a cancer diagnosis and treatment and, thus, have different expectations regarding not only social support but also interaction with their partners. Likewise, cultural variables may affect the definition, salience, and importance of intimacy as a key mediating variable in couples' psychosocial adaptation to cancer. There are important differences between Western conceptualizations of disclosure and closeness and the viewpoints of other cultures,139, 140 and these differences also may have relevance for the applicability of our model to other cultures. For example, a recent cross-cultural study demonstrated that Asian-American breast cancer survivors valued family harmony over intimacy, whereas Euro-American women valued intimacy over harmony.141 Preillness marital intimacy, commitment, and satisfaction may influence both partners' motivations to use cancer as an opportunity to enhance their relationship. Individual factors such as attachment style (Schaeffer & Laurenceau, unpublished observations), personality, and interpersonal skills that partners bring to this situation also may influence relationship processes, as discussed above. For example, couples in which both partners have an insecure attachment style may experience more problems when it comes to disclosing feelings and/or responding appropriately to a partner's disclosures. Thus, these couples may need to work harder to enhance intimacy, which may be particularly important at the end of life.
In addition to influencing feelings of closeness, relationship-enhancing and relationship-compromising behaviors also may influence the coping strategies that patients and partners use.88 It is also important to note that this model ultimately will need to account for reciprocal relations between variables. For example, partners may influence one another's distress,142 and this distress may influence relationship-enhancing and relationship-compromising behaviors. Despite these limitations, we believe that intimacy is the most important component of a couple's relationship and that this initial framework can be used to build a more comprehensive framework to guide further theory development, research, and clinical approaches to understanding the marital relationship and cancer.
In this article, we have expressed the importance of viewing cancer from a relationship perspective. This perspective not only considers the marital relationship as a resource that individual partners draw on but also highlights the importance of focusing attention onto the relationship and engaging in communication behaviors aimed as sustaining and/or enhancing the relationship during stressful times. On the basis of existing conceptualizations and empiric research on couples and cancer, we have formulated the relationship intimacy model as a first step in building a framework for researchers and clinicians to inform their work in this area.
There are several innovations represented by this model. Most noteworthy, it emphasizes the importance of partners relating to each other as spouses rather than as “patient” and “caregiver.” Second, the model emphasizes the importance of partners' efforts to both maintain a level of stability in their relationship and enhance their relationship. Third, as noted above, the model combines social and clinical psychology literatures. Finally, our view that cancer can pose a relationship opportunity is novel. We believe that partners can draw on the intimate connection between them as a source of strength and support while forging a closer emotional bond, which, in turn, may open the door not only for relationship growth but also to promote psychologic adaptation and healing.
We thank Jamie Ostroff, PhD; Cindy Carmack Taylor, PhD; and Gary Winkel, PhD for their important contributions to this work. Maryann Krayger provided technical assistance. Jennifer Burden, Briana Floyd, and Erin Dougherty collected couples' intervention data.