APOS PSYCHOSOCIAL
POCKET GUIDE

Relationship Issues

Introduction

Cancer patients who are in an intimate relationship identify their spouses/partners as their most important source of practical and emotional support.¹ There is also evidence that a higher quality marital relationship may facilitate psychosocial adaptation to cancer. ²  However, the diagnosis and treatment of cancer can affect every aspect of patients’ and partners’ quality of life (QOL). Indeed, patients must cope with the role changes and distress brought about by the physical side effects and increased functional disability associated with their disease and treatment. Partners must confront the potential loss of their life partner and quickly become adept at providing instrumental and emotional support during a time when they themselves are under extreme stress. Coping with cancer treatment can also challenge a couple’s established communication patterns, roles, and responsibilities. Thus, while many couples report that cancer brought them closer together, many others experience significant physical/functional, psychological, and interpersonal challenges that contribute to feelings of decreased intimacy, greater interpersonal conflict, and even divorce.^3-5

Screening/Risk Factors

• Cancer may increase risk of separation and divorce compared with the general population– particularly for female patients ^5-7 however, findings have been inconsistent.
• Researchers have identified a variety of factors that have either positive or negative associations with couples’ psychosocial adaptation to cancer. These include:
• Individual-level Factors. Younger age, female gender, higher levels of cancer and treatment-related distress,⁸ and depression,^8,9 have all been associated with increased risk for relationship distress.
• Communication Patterns.
  • The Relationship Intimacy Model (RIM)¹⁰ of couples’ adaptation to cancer proposes that communication can either be relationship-enhancing or compromising and that spousal communication can influence cancer adaptation through its effects on relationship intimacy.
    • Relationship-enhancing communication includes reciprocal self-disclosure, partner responsiveness, and mutual constructive communication (e.g., mutual discussion and expression of feelings about cancer-related concerns).
    • Relationship-compromising communication adversely affects relationship intimacy and includes: 1) mutual avoidance, a pattern whereby both partners avoid talking about cancer-related problems or withdraw from one another after discussing an issue; 2) demand-withdraw communication (i.e., one or both partners pressures the other to talk about a cancer-related issue or concern while the other partner withdraws or becomes defensive); 3) criticism; and, 4) protective buffering, a process by which one partner holds back negative feelings, denies worries, or avoids disagreements so as not to burden the other partner.
  • Relationship talk is another adaptive communication strategy that has received attention in cancer. Research has shown that patients and partners who talk together about their relationship, what each person needs from their partner, and the relationship implications of cancer report less distress and greater relationship adjustment.¹¹
  • Relationship maintenance strategies include: (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 messages of commitment and love; (4) social networks, which entails relying on or interacting with common relatives/friends; and (5) shared tasks, which involves engaging in everyday activities such as housework together. Research in lung cancer has shown that regardless of gender, patients and partners who engaged in these strategies during the initial treatment period experienced better relationship functioning up to 6 months later.¹²
• Dyadic Coping. The Systemic-Transactional Model (STM) posits a model of common dyadic coping in which, faced with a shared stressor such as cancer, partners work together as a team to jointly manage their stress and restore balance in their relationship. Research has shown that couples who engage in common dyadic coping strategies (e.g., joint problem solving, coordinating everyday demands, relaxing together, sharing, expressing solidarity) report greater relationship satisfaction. In contrast, couples who engage in mutual avoidance and withdrawal to cope with cancer-related stress report greater relationship dissatisfaction.¹³ Common therapeutic elements of interventions grounded by the STM include: 1) education; 2) intrapersonal skills training to address individual coping needs; and, 3) interpersonal skills training (e.g., communication) to improve common dyadic coping. Findings suggest that both patient and partner psychological and relationship outcomes may be improved by enhancing couples’ dyadic coping.

Evaluation/Assessment

• Psychosocial clinicians should consider the individual-level psychosocial needs of both patients and partners, as well as their relationship needs when formulating supportive care protocols. Few validated cancer-specific measures of relationship issues in cancer exist. However, The 7-item short form of the Dyadic Adjustment Scale (DAS-7) has been used to assess relationship functioning in cancer patients and their romantic partners and has an established cut score to indicate relationship distress.¹⁴
• Routinely assess patients for distress and extend distress screening to partners as an important first step in providing comprehensive psychosocial care. The NCCN Distress Thermometer and Problem list (https://www.nccn.org/home) is a free validated screening tool that is available in 71 languages to help providers identify and address the unpleasant experiences that may make it harder to cope with having cancer, its symptoms, or treatment. The Distress Thermometer is a graphical representation of thermometer marked from 0 to 10 representing the intensity of distress (0 = no distress and 10 = extreme/severe distress). It can be used independently or in conjunction with the problem checklist which comprises 43 items that are divided into five different categories (physical, emotional, social, practical, and spiritual/religious concerns). Although the problem checklist is geared toward patients, the Distress Thermometer can be used to assess caregiver distress. Indications for the assessment of caregiver distress include feeling overwhelmed or constantly worried, withdrawal from friends/family, loss of interest in activities previously enjoyed, feeling sad, irritable, or hopeless, changes in appetite/weight or sleep patterns, and getting sick more often than usual.^15,16
• Assess the survivor and caregiver’s relationship at key junctures and transitions of care (e.g., diagnosis, during treatment, post-treatment survivorship, metastatic/recurrent disease).
• Evaluate how couples’ communication and coping patterns may be affecting each partners’ psychosocial adjustment. If they are, target interventions to help them. 

Treatment

Dyadic interventions that target the couple as the unit of care often include psychoeducational and skills training components (e.g., information about cancer and caregiving, self-care/self-management skills, stress management, training regarding caregiving tasks, and/or relationship-enhancement skills including communication skills training and dyadic coping).^17,18 Therapeutic techniques that have been employed include cognitive behavior therapy (CBT), education, interpersonal counseling, behavioral marital therapy, and emotion-focused therapy.¹⁷ The table below provides examples of dyadic or shared stressors experienced by couples at different phases along the cancer continuum along with recommended evidence-based approaches to address these issues.

Click here to view table as PDF

Cultural Considerations

Most research and interventions involving couples coping with cancer have included predominantly white participants, ignoring the possibility that race and culture may influence the importance of the couple relationship in patient adaptation. Study demographics also likely reflect who has access and ability to attend intervention programs and may have excluded patients who lived far away from their care center, had transportation problems, or had physical limitations that make travel difficult. Therefore, creating interventions that are culturally and linguistically appropriate and that can be easily and widely disseminated appears critical to advancing the field and providing equal access. Web-based and mobile technologies may allow for widespread dissemination. However, research is needed to determine whether such interventions are feasible, cost-effective, and efficacious.

Conclusion

Psychosocial clinicians are often optimally positioned to engage couples at critical moments throughout the cancer journey, with timely access to partners when they are most open to learning optimal ways to communicate and show support. The importance of screening for relationship distress and extending psychological distress screening to partners is an important first step in providing comprehensive psychosocial care. There is need to identify and assess survivors who are at higher risk for developing psychological problems and partners who may be at increased risk for experiencing strain or burden because of their caregiving role so that appropriate interventions can be targeted to them. When couple-based interventions are integrated into care couples have an opportunity to enhance their ability to cope with stressors, increase problem-solving skills, and feel emotionally connected.

References

1. Pistrang N, Barker C. The partner relationship in psychological response to breast cancer. Soc Sci Med. 1995;40:789-797.
2. Banthia R, Malcarne VL, Varni JW, Ko CM, Sadler GR, Greenbergs HL. The effects of dyadic strength and coping styles on psychological distress in couples faced with prostate cancer. J Behav Med. Feb 2003;26(1):31-52.
3. Baider L, Kaufman B, Peretz T, Manor O, Ever-Hadani P, Kaplan De-Nour A. Mutuality of fate: adaptation and psychological distress in cancer patients and their partners. In: Baider L, Cooper C, Kaplan De-Nour A, eds. Cancer in the Family. Wiley; 1996:173-186.
4. Ell K, Nishimoto R, Mantell J, Hamovitch M. Longitudinal analysis of psychological adaptation among family members of patients with cancer. J Psychosom Res. 1988;32:429.
5. Karraker A, Latham K. In sickness and in health? Physical illness as a risk factor for marital dissolution in later life. J Health Soc Behav. 2015;56(3):420-435.
6. Syse A, Kravdal Ø. Does cancer affect the divorce rate? Demographic Research. 2007;16:469-492.
7. Carlson RH. Study: women with brain tumors have 10 times rate of divorce as men with brain tumors. Oncology Times. 2001;23(8):63.
8. Langer SL, Jean CY, Syrjala KL, Schoemans H, Mukherjee A, Lee SJ. Prevalence of and Factors Associated with Marital Distress among Hematopoietic Cell Transplantation Survivors: Results from a Large Cross-Sectional Study. Transplantation and Cellular Therapy. 2022;
9. Nalbant B, Karger A, Zimmermann T. Cancer and Relationship Dissolution: Perspective of Partners of Cancer Patients. Frontiers in psychology. 2021;12
10. Manne S, Badr H. Intimacy and relationship processes in couples’ psychosocial adaptation to cancer. Cancer. 2008;112(S11):2541-2555.
11. Badr H, Acitelli LK, Carmack Taylor CL. Does talking about their relationship affect couples’ marital and psychological adjustment to lung cancer? J Cancer Surviv. 2008;2(1):53-64. 18648987.
12. Badr H, Carmack Taylor CL. Effects of relational maintenance on psychological distress and dyadic adjustment among couples coping with lung cancer. Health Psychol. 2008;27(5):616-627. 18823188.
13. Traa MJ, De Vries J, Bodenmann G, Den Oudsten BL. Dyadic coping and relationship functioning in couples coping with cancer: a systematic review. British Journal of Health Psychology. 2015;20(1):85-114.
14. Hunsley J, Best M, Lefebvre M, Vito D. The seven item short form of the dyadic adjustment scale: Further evidence for the construct validity. The American Journal of Family Therapy. 2001;29(4):325-335.
15. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines^â) for Distress Management V.2.2024. ã National Comprehensive Cancer Network, Inc. 2024. All rights reserved. Accessed April 3,2024. To view most recent and complete version of the guideline, go online to NCCN.org.
16. Donovan, K. A., Handzo, G., Corbett, C., Vanderlan, J., Brewer, B. W., & Ahmed, K. NCCN Distress Thermometer Problem List Update. Journal of the National Comprehensive Cancer Network. 2022; 20: 96-98
17. Badr H, Krebs P. A systematic review and meta-analysis of psychosocial interventions for couples coping with cancer. Psychooncology. 2013;22:1688-1704.
18. Hu Y, Liu T, Li F. Association between dyadic interventions and outcomes in cancer patients: a meta-analysis. journal article. Support Care Cancer. March 01 2019;27(3):745-761. doi:10.1007/s00520-018-4556-8