The purpose of this study was to determine the effectiveness of a couple-based intervention on the quality of life (QOL) of early-stage breast cancer patients and their partners. A randomized controlled design was used to assign couples to either the hospital standard social work services (SSWS) or a couple-based intervention, the Partners in Coping Program (HCP). QOL was measured at three times during the first year after the diagnosis. A series of analyses of covariance revealed that QOL of patients and partners in the HCP arm improved at time 2 and time 3 and was consistently higher than the QOL of couples in the SSWS arm, controlling for QOL at time 1. However, differences between the two arms on QOL were not statistically significant. Patients in the HCP who were in relationships of shorter lengths and were receiving chemotherapy made the greatest gains in their QOL, suggesting that these types of patients would benefit more from a couple-based approach to their illness. On the basis of the findings, the authors suggest future directions for intervention research and for social work practitioners who are looking for efficient and effective ways to deliver psychosocial services to cancer patients.
KEY WORDS: breast cancer; couples; psychosocial intervention; quality of life
Women with breast cancer do not cope with their disease in isolation but, instead, within the context of their interpersonal relationships. Little attention, however, has been given to the partners of breast cancer patients, from whom the women seek support and who are also affected by the illness. Indeed, social work interventions for breast cancer have often excluded the partners. The shift of health care from professionals primarily caring for cancer patients during hospital stays to reliance on family members for provision of care at home underscores the highly compelling need to include partners in the total treatment of the breast cancer patient.
Breast cancer patients commonly experience emotional and psychological distress in relation to their diagnosis and treatment. Approximately 45% of women newly diagnosed with breast cancer report mild to severe symptoms of anxiety, and 28% of the women report mild to severe symptoms of depression (Dausch et al., 2004). Similar rates of psychological distress have been found when comparing early-stage and advanced breast cancer patients (Kissane et al., 2004). Although breast cancer patients may not have higher rates of psychiatric disorders as defined by DSM-IV (American Psychiatric Association, 1994) than a community sample, they still experience symptoms of anxiety and depression that affect their physical, medical, and sexual quality of life (QOL) (Dausch et al., 2004). The behavioral manifestations of this anxiety and depression can include insomnia, inability to concentrate, loss of appetite, greater use of alcohol and tranquilizers, thoughts of suicide, sexual dysfunction, and disruption of daily activities (Irvine, Brown, Crooks, Roberts, & Browne, 1991). The diagnosis of post-traumatic stress disorder is more commonly found among breast cancer patients than among the general population (Baum & Posluszny, 2001; Dausch et al., 2004). Breast cancer patients are likely to experience stress-related symptoms including repeated, disturbing memories and dreams of their cancer treatment, fears of recurrence, fears of death, and physical reactions when something reminds them of cancer treatment or their experience with cancer (Cordova et al., 1995).
The cancer's effect on psychological well-being also extends to partners or spouses. Breast cancer can often expose partners to heightened anxiety, depression, feelings of being unprepared to help their partners, fear of losing their partner, and somatic preoccupations (Given & Given, 1992; Lethborg, Kissane, & Burns, 2003; Northouse & Peters-Golden, 1993; Omne-Ponten, Holmberg, & Sjoden, 1994; Sabo, 1990;Walker, 1997). Baider and Kaplan DeNour (1984) found that husbands whose wives were eight to 34 months postmastectomy reported that the mastectomy created nearly as many adjustment problems for them as it did for the women. Other researchers have found that the postsurgical period has been especially distressing to the husbands, and many men have expressed problems concerning sexual intimacy at this time (Harwood & O'Connor, 1994; Sabo, 1990). Significant positive correlation between patients' and husbands' adjustment scores indicate that when patients adjust poorly, the husbands adjust poorly also.
Over time, most couples dealing with breast cancer experience an improvement in emotional adjustment (Hannum, Giese-Davis, Harding, & Hatfield, 1991). However, fear of recurrence tends to remain for both patients and their spouses. The limited literature suggests that patients may openly express their fears of recurrence, but spouses are more likely to keep these fears to themselves, hoping to spare their wives additional burden or worry (Germino, Fife, & Funk, 1995). As a result, partners can experience two conflicting responses--the fear of recurrence and the need to be optimistic and cheerful for the patient. When asked, women with breast cancer indicate that they would like to hear about their spouses' fears (Germino et al., 1995). If breast cancer reoccurs, family members' mental health can be significantly worse than that of the normal population, and their emotional well-being scores can be slightly worse than even the patients' scores (Northouse et al., 2002).
Role of Partner Support in the Adjustment to Breast Cancer
Numerous studies report better emotional adjustment for women after a diagnosis of breast cancer if their husbands or partners are highly supportive (Baider et al., 2004; Baider, Ever-Hadani, Goldzweig, Wygoda, & Peretz, 2003; Kayser, Sormanti, & Strainchamps, 1999; Northouse,Templin, & Mood, 2001; Vacek, Winstead-Fry, Secker-Walker, Hooper, & Plante, 2003). A growing literature on posttraumatic stress growth also finds a strong correlation between benefits from the breast cancer experience and spousal support (Calhoun & Tedeschi, 1998; Weiss, 2004b). This finding holds true for both patients and their husbands (Weiss, 2004a). Furthermore, support from family and friends can significantly affect the mental and physical functioning of women with breast cancer for several years after the diagnosis (Helgeson, Snyder, & Seltman, 2004). Breast cancer patients often identify their husbands or partners as their most important confidant (Figueiro, Fries, & Ingram, 2004; Maunsell, Brisson, & Deschenes, 1995). Although women may seek support from other sources (friends, neighbors, coworkers), these alternative sources often do not compensate for the lack of marital support when coping with a life-threatening illness (Cutrona, 1996).
Likewise, for partners of breast cancer patients, there is evidence that spousal support plays a critical role in their psychosocial adjustment. In a longitudinal study of 121 husbands of breast cancer patients, marital support was a significant predictor of both emotional and physical adjustment among patients' husbands (Hoskins et al., 1996). The husbands who were dissatisfied with the emotional support they received experienced significantly more negative emotions--worry, tension, and uneasiness--which continued throughout the 12-month study. In contrast, husbands who felt supported by their wives experienced fewer negative emotions and a sense of psychological well-being--enjoyment in talking with others, finding work and other things of interest, and feeling needed and useful. Coping with breast cancer is indeed a dyadic affair for those patients in intimate partnerships.
Psychosocial Interventions for Breast Cancer Patients
Despite the correlational studies showing a strong association between partner support and adjustment to breast cancer, in a review of outcome studies on psychosocial interventions in cancer, only seven out of 76 studies evaluated interventions that included a spouse or family member (see Kayser, 2005). Most of the studies assessed interventions such as behavioral training, educational groups, individual counseling, and support groups for patients. Although support groups appear to be the most common intervention offered to cancer patients, recent studies have questioned their efficacy (Bordeleau et al., 2003; Goodwin et al., 2001). Some researchers have found not only minimal psychosocial benefits from peer support groups for early-stage breast cancer patients, but even adverse effects of peer discussion for some subgroups of women (Helgeson, Cohen, Schulz, & Yasko, 2001). Of the seven studies that included a spouse or significant other as a participant in the psychosocial intervention, only two studies evaluated a couple-based intervention, and both of these studies used randomized group designs (Christensen, 1983; Scott, Halford, & Ward, 2004). In both of these studies, couples in the intervention groups experienced lower levels of psychological distress and depression than couples in the control groups after participating in a couple-based intervention.
In sum, the strong relationship between adjustment to breast cancer and emotional support from spouses, husbands' reports of high distress levels related to their wives' breast cancer, and the positive effects of couple-based interventions for both patients and spouses collectively formed the basis for the development of the Partners in Coping Program (HCP). In this article, we report the results of a randomized trial that tested whether a series of couple-based interventions provided by HCP can enhance the QOL of breast cancer patients and their partners. We hypothesized that quality of life would be significantly higher among members of couples who received the conjoint counseling than among members of couples who were assigned to the standard social work services (SSWS) arm. We also...