Navigating a Diagnosis of Cancer in Relationships – Couples Therapy Inc.

Serious medical conditions, like cancer challenge the very core of relationships, altering the dynamics between partners in unforeseen ways. Illness not only affects the diagnosed individual but also reshapes the landscape of commitment and support within the relationship. Whether coping with cancer, heart disease, or psychological afflictions, the strain on couples can be profound, demanding a nuanced approach to navigate the complexities of the relationship under such duress.

Various types of couples therapy offer different approaches and coping strategies.

Traditional wedding vows include a promise to stay together in sickness and in health. But cancer, heart disease, major depression, substance abuse, and other types of serious medical illnesses can create stress in a marriage or in any type of committed relationship. Illness affects not only the person who receives the diagnosis, but his or her partner as well.

For example, a woman receiving treatment for breast cancer may be physically uncomfortable, constantly tired, and worried about her sexuality and body image. Likewise, a man undergoing treatment for prostate cancer may experience unpleasant side effects such as impotence and incontinence. Both are likely to worry about the future and their mortality. Although these concerns may surface at various times during cancer treatment, they can become especially troublesome once treatment ends, as couples make the transition to a “new normal.”

When the diagnosis is diabetes or heart disease, one or both partners may need to make significant lifestyle changes such as quitting smoking, losing weight, and adopting new dietary habits. Although some couples function as a team in response to these challenges, others may find themselves at odds over food choices, leisure activities, and the like.

Many couples are able to manage the challenges of illness reasonably well and can find ways to cope on their own, but some will need help. For those who do, couples therapy can enable partners to cope with the stress of medical illness or addiction. The methods are similar to those employed in individual therapy: interpreting emotional conflicts and the influence of the past; understanding fixed patterns of relating; encouraging insight and empathy into how those patterns may derive from early life experiences of each partner; assigning exercises for behavior change; challenging beliefs; offering advice, reassurance, and support; and teaching social skills and problem solving. All of these skills may be useful in helping couples to deal more productively with a serious illness.

The evidence of efficacy is thin, partly because so few studies evaluating the use of couples therapy for medical illness have been published. As one commentator put it, the area is “under-studied and under-reported.” Nevertheless, some of the following options have been proposed by experts working with couples who are dealing with medical issues.

Interventions for Couples

Given that coping with cancer should be characterized as a dyadic affair, a growing amount of literature involving couple-based interventions came up over the past 2 decades. Nevertheless, the majority of these studies were published only in the last decade. The most promising results in enhancing the well-being of both partners are shown by interventions with multiple targets (e.g., improvements in communication and sexuality, reduction of emotional distress, strategies to enable partners to express their distress [25], and stress communication (e.g., expressing worries, needs, and feelings regarding cancer- or relationship-related topics), supportive behavior, and effective dyadic coping [15]). Intimacy emerged as a key component of relationship quality and could serve as a buffer for psychological distress [26].

Women with cancer who are in committed relationships express a great need for support from their partners, even more than from others [27]. Although partners show high motivation to offer this support, they may have difficulties in providing social support because of their own distress or because they do not know how to be the type of support person the woman needs. In addition, the needs of the patient change across time, making support even more complicated. Hence, many women feel disappointed by their interactions with their partners when addressing cancer. This dissatisfaction can occur even within the context of an overall high relationship satisfaction. The challenges are likely to persist beyond the completion of treatment, but are most salient during the treatment phase, due to the acute burden of the diagnosis and treatment these couples have to confront.

Components of Couple Interventions

The content of interventions for couples coping with cancer is heterogeneous. A combination of skill training and psycho-educational intervention is recommended [28]. The components can be discussed according to the development-contextual model of couples coping with chronic illness [29] in 3 dimensions: dyadic appraisal, dyadic coping, and dyadic adjustment. Dyadic appraisal was conceptualized at the individual and dyadic levels and contains the appraisal of disease, self-efficacy, and communication [28]. How do both partners perceive and understand their coping abilities and their emotional state? How do they appraise the disease as a unit? In this process, the quality of communication influences the couple’s appraisal of their disease and efficacy [28]. Dyadic coping supports couples in coping with the disease as a team [15]. Enhancing communication skills, self-efficacy, and dyadic coping should influence the dyadic adjustment measured in quality of life and mental, physical, and relationship satisfaction [30]. Dyadic coping may reduce stress but, even more importantly, may increase intimacy, cohesion, and mutual confidence [24].

Thus, given the challenges that breast cancer poses for the couple’s relationship, in addition to the central importance of the couple’s relationship to the patient’s and partner’s adjustment, it is critical to determine the most efficacious way to assist couples in facing a breast cancer diagnosis. There is increasing recognition that the quality of marital interactions, rather than global social support, the mere presence of a partner, or even overall marital satisfaction, is essential to achieve positive patient outcomes. Patientpartner interaction patterns that have been associated with positive patient adaptation include candid communication about cancer-related issues, the ability to express emotions to a partner who is able to listen supportively, and effective problem-solving skills. For instance, in patients with breast cancer, high levels of empathy from spouses were a stronger predictor of patient psychological adjustment than overall marital satisfaction [31]. In addition, the ability to express emotions and to communicate openly with partners about cancer has been associated with fewer emotional and physical complaints and higher levels of self-esteem and perceived control [32], in addition to higher relationship satisfaction [33, 34]. Conversely, negative or unhelpful interaction patterns, such as partner avoidance and criticism, hiding concerns from each other, mutual denying of worries, and avoidance of shared discussion, are associated with poorer patient adjustment, including increased distress, maladaptive coping strategies, and intrusive thoughts about the illness [15] along with lower relationship functioning [21]. A recent review illustrates the importance of stress communication, supportive behavior and effective dyadic coping for relationship satisfaction in couples coping with cancer [15]. In addition, the scope of communication should be enlarged from cancer-related issues to the couple’s life in general [34]. Helping couples to maintain relationship normalcy and quality during the cancer trajectory and to cope as a unit may lead to better communication and enhanced relationship intimacy [26].

An often neglected subject of couple-based interventions is the caregivers’ self-care [28]. Partners often put their own needs on hold, resulting in less time spent on maintaining their own mental, social and physical health [35]. This behavior could affect the partners’ own health.

Effectiveness of Interventions for Couples

The benefit of psychosocial interventions for couples coping with cancer still remains unclear. Some reviews and meta-analyses report that these interventions are effective in improving individual and dyadic functioning and have beneficial effects on relationship quality and psychosocial adjustment, albeit with small to medium effect sizes [19, 36, 37]; others show heterogeneous evidence [38]. An often expressed critique is that the studies have only small sample sizes and are therefore underpowered to examine changes in the multiple outcomes measured, which results in only small to medium effect sizes [39]. For example, in a recent meta-analysis [19] with 20 randomized controlled trials, 9 studies included in the meta-analysis had 35 or less couples per group. One reason for the small sample size could be the challenging recruitment process. Badr and Krebs [19] reported refusal rates ranging from 3 to 82%. Indeed, only few studies report a detailed description of the reasons for refusal. Distance from the study center, fear of randomization, and the perceived burden of study participation are documented barriers. Timing or scheduling issues and age (i.e., younger couples are more likely to participate than older ones) emerged as key factors [19, 37]. More research is required to identify barriers and obstacles for couples to participate in couple-based interventions (e.g., by approaching couples at routine clinic visits, scheduling study-related appointments with medical appointments, decreasing the number of sessions, expanding the delivery methods by conducting trials by phone, the Internet or in the couples’ homes, enhancing the cooperation with physicians or clinic staff, and increasing the perception that psychosocial interventions are an important part of overall medical care) [19, 40] and to identify the couples’ preferences for interventions considering factors such as disease stage, age, feasibility, and cost effectiveness [19].

Another reason for the heterogeneity of evidence could be that only a subgroup of patients with cancer and partners suffers from increased distress [20]. Given that most interventions were offered to all patients regardless of their distress level, floor effects occur [38]. In addition, there is a strong association between baseline and outcome distress [41]. Badr and Krebs [19] suggest the identification of profiles of couples at risk who may benefit from couple-based interventions. Moreover, screening for relationship and/or psychological distress can be useful. In a recent meta-analysis, only 19 of 198 retrieved studies preselected patients according to their psychological distress, but these interventions reported large effects [38].

Most studies include couples with newly diagnosed patients with early-stage cancer (patients with poor prognosis are underrepresented) [20] and only short-term follow-up. Therefore, the influence of the length or timing of the intervention on the outcome remains unclear, besides the need of booster sessions to maintain the positive impact of the intervention.

Researchers criticize the variation or absence of theoretical models or frameworks, the variation in the intervention approaches, and the diversity of reported outcomes [19, 28]. The majority of interventions were modified from marital therapy interventions developed for healthy people or couples with relationship problems, or from existing cognitive behavioral therapy (CBT) interventions developed for individuals. Thus, it remains unclear whether this approach is appropriate or whether couple-based intervention may be best applied in different ways, depending on the difficulties and issues encountered by the couple [42]. For example, for a dissatisfied couple, the focus of the intervention could be on the relationship and techniques from couple therapy, whereas in couples who are satisfied with their relationship it may be more helpful to focus on the medical and psychosocial challenges of the cancer by providing, e.g., information on the medical treatment and side effects and on how to manage the challenges together.

Other aspects that could influence the efficacy of interventions for couples could be the timing, dosage, and delivery of the intervention and program flexibility. Couples often experience the time immediately after the diagnosis as the most emotionally taxing [43], whereas others emphasize the time when the medical treatment has ended and the transition back to ‘normal’ life is expected, including reprioritizing life goals and management of healthy lifestyle changes [31, 44]. Thus, the content of an intervention should vary depending on the couple’s needs at different time points during the cancer journey [37]. Li and Loke [28] and Regan et al. [37] recommended an appropriate dosage of sessions (e.g., 6 sessions), delivery by trained professionals (higher effect sizes for professionals with mental health background [19]), and greater variation in the contents and mode of delivery of couple-based interventions. Furthermore, more studies are needed to identify gender differences to tailor interventions to the specific wants and needs of women with breast cancer and their partners. Table Table11 gives an overview of useful components for couple-based interventions emerging from existing research, which provide flexible modularity

Women with early stage breast cancer face numerous emotional concerns. Distress can occur as the cancer impacts a patient’s daily life, such as nausea, hair loss, and weight gain, along with impacting career, social life, household and family responsibilities, and relationships. Patients often turn to a spouse or significant other to manage this stressful experience.

“In this new study, we wanted to compare [a 6-session, couple-focused, skills-oriented group intervention] to traditional support group therapy in which couples attend the group session together and both receive emotional support and validation from group members,” explained Sharon Manne, PhD, Rutgers Cancer Institute Associate Director for Cancer Prevention, Control and Population Science and a professor of medicine at Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, and lead author of the study.

For the study, 302 women with early stage breast cancer and their significant others (including 2 female spouses) were recruited from the outpatient clinics of 3 comprehensive cancer centers in the Northeastern United States, as well as community hospital oncology practices. Half of the patients were assigned to traditional support group therapy sessions and the other half was assigned to the couple-focused, enhanced skill-based intervention.

“We found that depression, anxiety, and cancer distress declined and well-being improved for couples enrolled in both interventions; that is, neither treatment was superior to the other,” said Manne. “Each group intervention was more effective for patients depending on their personal and relationship characteristics.”

Manne explained that patients with high levels of cancer-related stress prior to starting the intervention did better at the 1-year follow-up regarding stress, depression, and anxiety if they were in the traditional couples’ support group, while those with low cancer-related stress did better at 1 year if they were in the couple-focused, enhanced skill-based couples’ group intervention.

Distressed patients with breast cancer benefit most from couple-focused supportive group therapy, while less distressed patients benefit more from a structured, skills-based, couples-focused group therapy.¹

Reference

1. Manne SL, Siegel SD, Heckman CJ, et al. A randomized clinical trial of a supportive versus a skill-based couple-focused group intervention for breast cancer patients [published online May 26, 2016]. J Consult Clin Psychol. http://psycnet.apa.org/?&fa=main.doiLanding&doi=10.1037/ccp0000110. Accessed June 13, 2016.

Emotionally focused couples therapy

This form of couples therapy is a short-term, structured approach that addresses patterns of communication, action, and reaction that create and reinforce a family environment. A core concept of this therapy is that such patterns are dynamic and reciprocal. (This concept is also key to psychodynamic couples therapy, discussed later in this article.)

In couples dealing with serious illness, a previously stable pattern of interaction may become maladaptive under stress. For example, an ill partner may want to maintain a feeling of control over some aspects of life — such as continuing to work during treatment — but the other person may try to act as a “savior” and step in and try to take responsibility for everything. A couples therapist works with both individuals to understand the emotions and motivations contributing to these interactions. For example, “saviors” may see how adopting this role helps them deny their own sense of helplessness. The therapist works with a couple to help each partner recognize and escape from entrenched cycles. In one common pattern, an angry, critical, complaining partner confronts one who is defensive and withdrawn. Therapists help the angry partner to feel his or her desperation about not being heard and the resulting fear of abandonment, while supporting the withdrawn partner in the effort to temporarily set aside the feeling of being attacked, to listen to the other person’s concerns, and to be responsive rather than defensive.

The therapist also helps partners recognize and appreciate their interdependence and need for attachment, and to reframe problems in terms of emotional needs. The premise is that a safe emotional bond with another person is a basic human need, and that a secure attachment provides comfort and confidence.

Case reports and one pilot study attest to the value of emotionally focused couples therapy when one partner is dealing with cancer, whether diagnosed early on or at a more advanced (and terminal) stage. In a study of 16 couples in which one partner was diagnosed with advanced cancer, for example, the investigators reported that eight weekly sessions of emotionally focused couples therapy significantly improved mood (as measured by a standard clinical instrument) and helped improve relationships.

Cognitive behavioral couples therapy

This approach differs from behavioral couples therapy mainly in that it addresses cognitive distortions and emotions as well as behaviors that may be disrupting a couple’s relationship — and adding to the stress of illness. CBCT principles have been adapted to create couple-based interventions to assist couples in which one partner has individual psychopathology or medical problems.Similar to individualized cognitive behavioral therapy, this approach involves skill-building sessions during therapy, supplemented by homework assignments. The goal is to help couples become cognizant of specific ways the stress of an illness strains the relationship. The therapist can then help them find more positive ways to communicate about their differences.

Systemic couples therapy

This approach examines a couple’s rules and roles, particularly dysfunctional ones. For example, one partner may behave as the take-charge person, while the other tends to be accommodating. This type of therapy may be particularly helpful when serious illness results in couples having to reverse roles.

A therapist using this approach works with couples to understand how habitual patterns shape how each partner acts in a relationship. The goal is to help the partners negotiate and make their plans more flexibly, so that they can avoid recurring problems and respond more effectively when circumstances change.

Gottman method couples therapy

This approach, developed by Dr. John Gottman, now a professor emeritus of psychology at the University of Washington, is based on his observation that happy couples have two things in common: they behave like good friends (providing respect, affection, and empathy to each other), and they handle conflicts in gentle, positive ways instead of becoming defensive, critical, or withdrawn.

During this therapy, a clinician helps partners to develop more positive and less negative expressions of conflict. Gottman method therapists target the “four horsemen” that can derail relationships: excessive criticism, defensiveness, caustic sarcasm defined as contempt, and stonewalling. Couples learn instead to cultivate positive interactions.

Gottman method has demonstrated that the four horsemen negatively impact the nervous system which in turn, taxes the immune system. I like to say that you are better off having an affectionate pet than a contemptuous spouse if you have an illness like cancer.

Psychodynamic couples therapy.

This type of therapy is based on the assumption that couples treat each other in ways that are strongly influenced by childhood experience. For example, an individual who feels a great need to control a partner may not realize this stems from having felt powerlessness in an early relationship. One of the most important goals of psychodynamic couples therapy is to help partners separate current feelings about each other from feelings and responses related to their past and families of origin.

Psychodynamic therapists work with each partner in a relationship to recognize how they may be disavowing their own feelings by attributing them to the other person or behaving in ways to elicit the responses that validate their own biases. For example, one partner may tend to disavow dependent feelings and criticize the partner’s dependency, while at the same time acting in ways that make the partner more dependent.

Integrative approaches. 

Given the strains on couples who are dealing with a serious medical illness or substance use, the most productive approach — and probably the most common one in practice — may be for therapists to combine psychotherapeutic techniques. For example, a clinician may utilize both emotional and behavioral strategies. Some experts believe that therapists who are more eclectic, who make use of more diverse tools, are better able to help couples in conflict meet, rather than succumb to, the challenges they face.

Facing cancer together – 8 tips

More often than not, the reality of “sickness” materializes out of nowhere. When your spouse is diagnosed with a chronic illness, you begin to realize that your life, your spouse’s life and your marriage will never again be the same. It’s easy to let thoughts such as, “Will this affect his lifespan?” and “Will we still be able to have kids?” torment you.

Below are eight tips for dealing with a diagnosis as a couple.

1. Accept offers of help. If you’re involved with a church or a close-knit group of friends, you’ll likely receive more assistance than you know what to do with. Casserole dinners and offers of free babysitting won’t ameliorate your condition or mend your broken spirit, but they will allow you to focus on healing and coping as a couple.
2. Find a support group. Contact your doctor’s office or church for support-group referrals. If possible, find a group where spouses and family members are welcome. If a support group doesn’t exist in your area, consider starting one. Or, find an online forum where you can receive and give encouragement.
3. Find a good counselor. If the prospect of seeing a psychiatrist daunts you, don’t. Instead, find a certified, Biblically based counselor both you and your spouse can speak with. Your pastor may be a certified counselor; if not, he should be able to point you to one. You can also call 800-A-FAMILY for a local referral.
4. Continue to make intimacy a priority. Physical intimacy is one of the greatest tangible bonds between a married couple. Besides fulfilling physical cravings, sex builds relational and spiritual intimacy between a husband and wife, allowing them to release emotions. If sex is still possible, continue to make love regularly. If it isn’t, seek to fulfill each other’s needs in other creative ways.
5. Reach outside yourself. It’s possible for you and your spouse to spiritually and emotionally “drown” in hopelessness if you constantly focus on your situation. Reach out to others in need – individuals with a similar medical condition, shut-ins who could use a warm meal or widows who’d appreciate a listening ear. Helping others brings true joy – a rare commodity at times like these.
6. Realize it’s OK to question God. If you have a belief in God, now is the time to strength that relationship. God understands if you’re angry at the doctors, angry at Him and angry at the world in general. Don’t let Satan trick you into thinking anger is a sin. It’s not, though sinful behavior includes acting in anger towards others or turning your back on God. Present Him with your questions and uncertainties. Wrestle through this time with Him, and expect additional clarity as the end result.
7. Reflect. Life is a journey, and you know it won’t be an easy one. You may not have answers to why you were diagnosed with your condition – not now, not in this life. Take comfort in knowing you will have these answers someday. In the meantime, if you have faith, now is the time to ask for clarity for your purpose for your life – and your life with this condition. Journal your thoughts, feelings and reflections. Share them with your spouse. Open yourselves individually and corporately to what life or God has in store for your life together.
8. Refuse to be owned by your condition – or hopelessness. Life, no matter how painful or confusing, is precious and worth living. Do your best to make lemonade out of lemons, and rest when you’re wrung-out.

In Closing

The realm of couples therapy presents a diverse array of strategies tailored to confront the unique challenges posed by illness such as cancer within relationships. While evidence for their efficacy may be limited due to sparse research, approaches like emotionally focused therapy, cognitive behavioral therapy, systemic therapy, and the Gottman method offer promising avenues to fortify relationships under the weight of medical crises. As couples navigate the unfamiliar terrain of illness together, seeking external support, engaging in open communication, and cultivating mutual understanding become pivotal steps in weathering the storm while keeping the bond intact and resilient.

References

Gurman AS, ed. Clinical Handbook of Couple Therapy (The Guilford Press, 2008).

 Manne SL, Siegel SD, Heckman CJ, et al. A randomized clinical trial of a supportive versus a skill-based couple-focused group intervention for breast cancer patients [published online May 26, 2016]. J Consult Clin Psychol. http://psycnet.apa.org/?&fa=main.doiLanding&doi=10.1037/ccp0000110. Accessed June 13, 2016.

Naaman S, et al. “Coping with Early Breast Cancer: Couple Adjustment Processes and Couple-Based Intervention,” Psychiatry (Winter 2009): Vol. 72, No. 4, pp. 321–45.

Powers MB, et al. “Behavioral Couples Therapy (BCT) for Alcohol and Drug Use Disorders: A Meta-Analysis,” Clinical Psychology Review (July 2008): Vol. 28, No. 6, pp. 952–62.