Attachment-oriented psychological intervention for couples facing breast cancer: protocol of a randomised controlled trial

Attachment in Couples Coping with Cancer: Associations with Observed Communication and Long-Term Health

Cancer poses a threat to well-being that may activate the attachment system and influence interpersonal dynamics, such as communication. Research indicates that avoidant and anxious attachment, as well as communication, are independently associated with poorer psychosocial well-being, yet studies examining links between attachment, communication, and long-term physical well-being are lacking. We examined (a) associations between patient and partner attachment (measured with the adult attachment scale [AAS-Revised]) and observed communication (across affect [the Relational Affective Topography System (RATS) coding system] and behavior [the Asymmetric Behavior Coding System (ABCS) coding system]) and (b) the extent to which attachment and communication independently predicted long-term physical well-being (measured by the Functional Assessment of Cancer Therapy-General Population [FACT-GP]). Participants were 134 couples [mean age 53.9 (SD = 13.4), 86.2% Caucasian, 66% of patients, 36% of partners female]. Patient participants had either breast, colorectal, or lung cancer. Couples individually completed self-report measures of attachment (baseline) and physical well-being (baseline and 4, 8, and 12 months later). At baseline, couples engaged in a 15 min videorecorded cancer-related conversation coded for communication behavior and affective expression. Patients and partners with higher anxious and avoidant attachment exhibited more negative affect and negative approach behaviors. A greater avoidant attachment was associated with less positive affective expression. Attachment insecurity and affective expression were prospectively linked with physical well-being. Findings indicate that attachment is associated with overt communication behaviors and that insecure attachment and affective expression may be risk factors for poorer health outcomes.

Psychosocial interventions for informal caregivers of people living with cancer

BACKGROUND

Increasingly, cancer is recognised as a chronic condition with a growing population of informal caregivers providing care for cancer patients. Informal caregiving can negatively affect the health and well-being of caregivers. We need a synthesised account of best evidence to aid decision-making about effective ways to support caregivers for individuals 'living with cancer'.

OBJECTIVES

To assess the effectiveness of psychosocial interventions designed to improve the quality of life (QoL), physical health and well-being of informal caregivers of people living with cancer compared with usual care.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, ProQuest, Open SIGLE, Web of Science from inception up to January 2018, trial registries and citation lists of included studies.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials comparing psychosocial interventions delivered to adult informal caregivers of adults affected by cancer on a group or individual basis with usual care. Psychosocial interventions included non-pharmacological interventions that involved an interpersonal relationship between caregivers and healthcare professionals. We included interventions delivered also to caregiver-patient dyads. Interventions delivered to caregivers of individuals receiving palliative or inpatient care were excluded. Our primary outcome was caregiver QoL. Secondary outcomes included patient QoL, caregiver and patient depression, anxiety, psychological distress, physical health status and intervention satisfaction and adverse effects.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently screened studies for eligibility, extracted data and conducted 'Risk of bias' assessments. We synthesised findings using meta-analysis, where possible, and reported remaining results in a narrative synthesis.

MAIN RESULTS

Nineteen trials (n = 3, 725) were included in the review. All trials were reported in English and were undertaken in high-income countries. Trials targeted caregivers of patients affected by a number of cancers spanning newly diagnosed patients, patients awaiting treatment, patients who were being treated currently and individuals post-treatment. Most trials delivered interventions to caregiver-patient dyads (predominantly spousal dyads) and there was variation in intervention delivery to groups or individual participants. There was much heterogeneity across interventions though the majority were defined as psycho-educational. All trials were rated as being at 'high risk of bias'.Compared to usual care, psychosocial interventions may improve slightly caregiver QoL immediately post intervention (standardised mean difference (SMD) 0.29, 95% confidence interval (CI) 0.04 to 0.53; studies = 2, 265 participants) and may have little to no effect on caregiver QoL at 12 months (SMD 0.14, 95% CI - 0.11 to 0.40; studies = 2, 239 participants) post-intervention (both low-quality evidence).Psychosocial interventions probably have little to no effect on caregiver depression immediately to one-month post-intervention (SMD 0.01, 95% CI -0.14 to 0.15; studies = 9, 702 participants) (moderate-quality evidence). Psychosocial interventions may have little to no effect on caregiver anxiety immediately post-intervention (SMD -0.12, 95 % CI -0.33 to 0.10; studies = 5, 329 participants), depression three-to-six months (SMD 0.03, 95% CI -0.33 to 0.38; studies = 5. 379 participants) post-intervention and patient QoL six to 12 months (SMD -0.05, 95% CI -0.37 to 0.26; studies = 3, 294 participants) post-intervention (all low-quality evidence). There was uncertainty whether psychosocial interventions improve patient QoL immediately (SMD -0.03, 95 %CI -0.50 to 0.44; studies = 2, 292 participants) or caregiver anxiety three-to-six months (SMD-0.25, 95% CI -0.64 to 0.13; studies = 4, 272 participants) post-intervention (both very low-quality evidence). Two studies which could not be pooled in a meta-analysis for caregiver physical health status found little to no effect immediately post-intervention and a small intervention effect 12 months post-intervention. Caregiver or patient satisfaction or cost-effectiveness of interventions were not assessed in any studies. Interventions demonstrated good feasibility and acceptability.Psychosocial interventions probably have little to no effect on patient physical health status immediately post-intervention (SMD 0.17, 95 % CI -0.07 to 0.41; studies = 4, 461 participants) and patient depression three to six months post-intervention (SMD-0.11, 95% CI -0.33 to 0.12; studies = 6, 534 participants) (both moderate-quality evidence).Psychosocial interventions may have little to no effect on caregiver psychological distress immediately to one-month (SMD -0.08, 95% CI -0.42 to 0.26; studies = 3, 134 participants), and seven to 12 months (SMD 0.08, 95% CI -0.42 to 0.58; studies = 2, 62 participants) post-intervention; patient depression immediately (SMD -0.12, 95% CI -0.31 to 0.07; studies = 9, 852 participants); anxiety immediately (SMD -0.13, 95% CI -0.41 to 0.15;studies = 4, 422 participants), and three to six months (SMD -0.22, 95% CI -0.45 to 0.02; studies = 4, 370 participants); psychological distress immediately (SMD -0.02, 95% CI -0.47 to 0.44; studies = 2, 74 participants) and seven to 12 months (SMD -0.27, 95% CI -0.78 to 0.24; studies = 2, 61 participants); and physical health status six to 12 months (SMD 0.06, 95% CI -0.18 to 0.30; studies = 2, 275 participants) post-intervention (all low-quality evidence).Three trials reported adverse effects associated with the interventions, compared with usual care, including higher distress, sexual function-related distress and lower relationship satisfaction levels for caregivers, higher distress levels for patients, and that some content was perceived as insensitive to some participants.Trials not able to be pooled in a meta-analysis did not tend to report effect size and it was difficult to discern intervention effectiveness. Variable intervention effects were reported for patient and caregiver outcomes.

AUTHORS' CONCLUSIONS

Heterogeneity across studies makes it difficult to draw firm conclusions regarding the effectiveness of psychosocial interventions for this population. There is an immediate need for rigorous trials with process evaluations and clearer, detailed intervention descriptions. Cost-effectiveness studies should be conducted alongside future trials.

The effect of an attachment-oriented couple intervention for breast cancer patients and partners in the early treatment phase: A randomised controlled trial

OBJECTIVE

Patients and partners both cope individually and as a dyad with challenges related to a breast cancer diagnosis. The objective of this study was to evaluate the effect of a psychological attachment-oriented couple intervention for breast cancer patients and partners in the early treatment phase.

METHODS

A randomised controlled trial including 198 recently diagnosed breast cancer patients and their partners. Couples were randomised to the Hand in Hand (HiH) intervention in addition to usual care or to usual care only. Self-report assessments were conducted for both patients and partners at baseline, postintervention (5 months), and follow-up (10 months), assessing cancer-related distress, symptoms of anxiety and depression, and dyadic adjustment. Patients' cancer-related distress was the primary outcome.

RESULTS

Cancer-related distress decreased over time in both patients and partners, but the intervention did not significantly affect this decrease at postintervention (P = .08) or follow-up (P = .71). A significant positive effect was found on dyadic adjustment at follow-up for both patients (P = .04) and partners (P = .02).

CONCLUSIONS

There was no significant effect of the HiH intervention cancer-related distress. The results suggest that most couples can cope with cancer-related distress in the context of usual care. However, the positive effect on dyadic adjustment implies that the HiH intervention benefitted both patients and partners. Future studies should investigate how to integrate a couple focus in usual cancer care to improve dyadic coping in the early treatment phase.

The Efficacy of Couple-Based Interventions on Health-Related Quality of Life in Cancer Patients and Their Spouses: A Meta-analysis of 12 Randomized Controlled Trials

BACKGROUND

Couple-based interventions on health-related quality of life (HRQoL) of cancer patients and their spouses have received increasing attention in recent years, but the findings of previous studies are inconsistent.

OBJECTIVE

The aim of this study was to investigate the effects of couple-based interventions on the HRQoL of cancer patients and their spouses using a meta-analysis approach.

METHOD

English- and Chinese-language publications were collected from PubMed, EBSCO, EMBASE, CMB, and CNKI. The outcome measures included physical health, depression, anxiety, hopelessness, and marital satisfaction (MS). Pooled, weighted mean differences and 95% confidence intervals were estimated using fixed- and random-effects models. Publication bias and sensitivity analyses were performed.

RESULTS

Twelve randomized controlled trials were included in this study. Compared with the control groups, the weighted mean differences of depression, anxiety, and MS were significantly improved in the intervention groups. However, improvements in the measures of physical health and hopelessness were nonsignificant. Psychoeducational interventions yielded a larger effect size than did skill training and blending interventions. Publication bias was not significant, and a sensitivity analysis indicated that the results were robust.

CONCLUSIONS

Couple-based interventions can improve anxiety, depression, and MS among cancer patients and their spouses, and psychoeducational interventions may be an effective approach. Given the small number of studies utilized in this analysis, the results should be considered preliminary and interpreted with caution.

IMPLICATIONS FOR PRACTICE

Couple-based interventions may be an adjunctive method for cancer patients and their spouses to improve HRQoL. Further study concerning couple-based skill training and blending intervention are needed to better understand intervention effects.

Couple-based treatment for sexual problems following breast cancer: A review and synthesis of the literature

PURPOSE

Although there are many physical and psychological impacts on women's sexuality following breast cancer diagnosis and treatment, sexual problems often remain unaddressed in these cancer survivors. Given the crucial role of the partner in sexual issues, couple-based sex therapy would appear to be a logical first-line treatment for this population, but there is scant research on the efficacy of couple-based treatments and/or sex therapy in breast cancer survivors.

METHODS

A review of the literature was conducted using the PMC, PsycINFO, EMBASE, and MEDLINE databases. Articles were included that presented the results of an experimental or quasi-experimental clinical trial evaluating a psychosexual intervention for couples, targeted women diagnosed with breast cancer and their partners, and included outcome measures of sexual function and sexuality. Studies were excluded if the primary intervention was not focused on sexual problems or if they were published in a language other than English.

RESULTS

From 2231 records, five articles met criteria for inclusion in the present review. Couple-based sex therapy appears to be an effective and highly accepted treatment for addressing sexual problems in breast cancer patients. These interventions were associated with improvements in sexual physiology, sexual functioning, sexual self-image, and sexual relationships, as well as improved psychological well-being of both breast cancer patients and their partners.

CONCLUSIONS

Based on this review, the authors address clinical implications, particularly incorporating psychological treatment for sexual problems in comprehensive cancer care, and provide recommendations for further study.

Experiencing an Intimate Partner's Breast Cancer: Attachment, Caregiving, and Burden in Men

OBJECTIVE

This study examined interrelationships among adult attachment orientations, caregiving, and caregiver burden in men of female partners with breast cancer, and tested whether caregiving patterns mediated associations between men's attachment orientations and their self-reported caregiver burden.

METHOD

The participants were 124 male partners of women with breast cancer. These participants completed assessments related to attachment, caregiving, and caregiver burden. Path models examined the associations between constructs and tested mediational effects.

RESULTS

Findings demonstrated significant associations between men's adult attachment orientations and their experience of caregiver burden. In addition, the maintenance of proximity in caregiving completely mediated the respective associations of attachment security and attachment avoidance to caregiver health problems, on one hand, and to the caregiver's self-esteem (e.g., another indicator for caregiver burden), on the other. Moreover, we found a direct effect of attachment avoidance on health problems.

CONCLUSIONS

This study highlighted the importance of addressing adult attachment dispositions and caregiving to understanding the relational processes implicated in caregiver burden. The results support the conclusion that men's adult attachment orientations and caregiving patterns toward their female partners with breast cancer are relevant contributors to men's perceptions of caregiver burden.