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Behavior Therapy 43 (2012) 61 – 76
Couple-Based Interventions for Medical Problems Donald H. Baucom University of North Carolina–Chapel Hill
Laura S. Porter Duke University Medical Center
Jennifer S. Kirby Jasmine Hudepohl University of North Carolina–Chapel Hill
The current paper discusses general principles, therapeutic strategies, common factors, and domains commonly addressed in the treatment of couples who have a partner with a medical condition. Couple-based interventions for medical problems are contrasted with couple therapy and relationship education in that the emphasis is on assisting the patient in addressing the medical disorder, along with being attentive to the patient's partner and their relationship. Guidelines are provided showing how knowledge and understanding of medical disorders and couple functioning are integrated in order to conduct such interventions. Five common domains addressed during intervention are elaborated upon: (a) psychoeducation about the disorder, (b) sharing thoughts and feeling regarding the disorder, (c) making decisions focal to the medical disorder, (d) implementing relationship changes that are nonmedical but that result from the disorder, and (e) addressing relationship functioning unrelated to the disorder. The importance of empirically demonstrating the utility of each domain in future investigations is noted.
Address correspondence to Donald H. Baucom, Ph.D., University of North Carolina, Chapel Hill, Chapel Hill, NC; e-mail: [email protected]
0005-7894/xx/xxx-xxx/$1.00/0 © 2011 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.
Keywords: couple-based interventions; couples and medical problems; spousal support
AS EVIDENCED BY OTHER PAPERS in this special section, over the past several decades couple-based interventions have almost exclusively focused on couple therapy for relationship distress and relationship education to prevent the development of relationship discord or to enhance currently healthy relationships. (We use the term "couple-based intervention" to refer to any psychosocial intervention in which the two partners in a committed, romantic relationship are seen together by a therapist, interventionist, or health educator for assistance.) What couple therapy and relationship education have in common is that the primary emphasis is upon the couple's relationship, either for remediation, prevention, or enhancement. In the current paper, we discuss the use of couplebased interventions for a very different reason—to assist the couple when one of the partners is experiencing a health concern or medical condition. In this instance, the primary reason for intervention is not to remediate relationship distress or enhance overall relationship functioning but, instead, to assist the "patient" who has a medical problem, while also attending to the well-being of the other partner and the couple's relationship. (In the current paper, we use the term “patient” to refer to the partner with a medical condition with no presumption that this individual is the sole focus of intervention.)
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Reciprocal Associations Between Individual and Relationship Functioning in the Context of a Medical Problem As Epstein and Baucom (2002) have noted, there are strong reciprocal associations among individual functioning, relationship functioning, and environmental factors. This means that (a) it is important for two partners to work effectively for the well-being of the relationship, and (b) central to the current paper, each partner and their relationship also have the potential to contribute to an individual's well-being, particularly when that individual encounters medical difficulties. Whereas the primary emphasis is upon assisting the individual with medical problems, the well-being of the other partner is also important to address, given that medical problems affect the partner as well as the patient. For example, partners of individuals with cancer often demonstrate as many psychological symptoms in response to the cancer as the patients themselves experience (Baider & Kaplan De-Nour, 1988; Ben-Zur & Gilbar, 2001; Dorros, Card, Segrin, & Badger, 2010; Hagedoorn, Sanderman, Bolks, Tuinstra, & Coyne, 2008; Northouse, 1992). Likewise, medical disorders can be a primary stressor on the couple as a unit. Roles and responsibilities within the relationship often change; physical limitations may restrict what the couple can do, and medical bills can place a strain on the couple's relationship. Whereas many couples navigate these required changes effectively, other couples do not. Interestingly, the two genders might be differentially prepared to address these medical problems. Recent evidence indicates that when women have significant medical problems, the divorce rates are six times higher than when men have significant medical problems (Glantz et al., 2009). The basis of these differential divorce rates are of concern and might well indicate the different roles that women and men typically play in family life and the struggles that some men experience when these roles become disrupted. Helping couples understand and adapt to changing roles within the relationship related to medical problems can be beneficial not only to the success of the relationship but the wellbeing of each individual as well. Not only does a medical condition typically affect both partners as individuals and their relationship, but in a reciprocal manner, the partner and the relationship can significantly influence a patient's adaptation to a medical disorder. For example, many medical problems call for health behavior changes (alterations in a patient's behavior that can help to facilitate rehabilitation or minimize further health complications) such as dietary change, increased
exercise, medication compliance, or stopping smoking. Given that these health behavior changes occur in a social context, gaining cooperation or assistance from intimate partners can facilitate needed changes. For example, one of the best predictors of whether an individual continues to stop smoking long term is whether that person's partner is a smoker (Palmer, Baucom, & McBride, 2000); that is, being around a loved one on a daily basis who smokes predicts that an individual will resume smoking. Thus, enlisting a partner in smoking cessation might be of importance. Other medical conditions such as breast cancer are less focused on health behavior changes, but the partner can be quite important as a woman comes to grips with changes in her body image or fears of death. In fact, women with breast cancer report that emotional support from their partners in addressing such issues is one of the most important factors in their adaptation to breast cancer (Ell, Nishoimoto, Mediansky, Mantell, & Hamovitch, 1992; Helgeson & Cohen, 1996). Hence, there might be multiple ways that a partner and the relationship can assist a patient with medical problems, even within the context of an overall happy relationship. Elsewhere we have noted that these same reciprocal influences between individual and relationship functioning are central when considering how to develop couple-based interventions when one partner has notable psychological difficulties or psychopathology (Baucom, Kirby, & Kelly, 2009; Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998; Epstein & Baucom, 2002), and there is strong empirical support for such couple-based approaches (see Whisman & Baucom, 2010, for reviews). As with individual medical conditions, individual psychopathology can be a significant stressor on relationships. In fact, as Whisman (2007) has noted, rates of marital distress are elevated when one partner has any one of a number of types of psychopathology. Although the co-occurrence between relationship distress and medical problems versus psychopathology has not been formally evaluated, the seeming strong association between psychopathology and relationship distress has resulted in couple-based interventions that emphasize the relationship when one partner has psychopathology. For example, in a meta-analysis of 12 randomized controlled trials for couples who were experiencing relationship distress and in which one partner had a substance use disorder, Powers, Vedel, and Emmelkamp (2008) reported that behavioral couple therapy that put a major emphasis on the couple's relationship was more effective than individual therapy with respect to frequency of substance use, consequences of use, and relationship discord. Hence, many of the principles discussed below are relevant when intervening with
couple-based interventions for medical problems couples in which one partner experiences psychopathology.
Knowledge and Understanding Required to Design and Implement Couple-Based Interventions for Medical Problems Given the reciprocal associations between individual and relationship well-being, it is important to develop a conceptualization of these associations that can then be used to guide the creation of efficacious couple-based interventions. An appropriate conceptualization of individual and relationship factors in response to medical problems requires several types of understanding. First, it is important to understand the medical condition and its physical and psychological effects on the patient, along with any health behavior changes that are needed by the patient to optimize functioning. For example, it is important to know that following a heart attack, a notable number of patients experience a clinical level of depression. Although there might be multiple reasons for depression at this time, the notion of loss is central in almost all psychological theories of depression, and individuals experiencing heart attacks often experience a wide range of actual and anticipated losses such as lowered energy level and anticipated shortened life expectancy. Also, in order to recover from a heart attack from a medical perspective, many patients need to change their diets, exercise more extensively, and take their medications consistently. Thus, any couple-based intervention for individuals experiencing heart attacks must address these psychological and medical factors that are central to the patient's recovery. Second, it is essential to understand how the disorder influences the couple's relationship. For example, many individuals who have had heart attacks and their partners are fearful that sexual activity may place detrimental physical stress on the individual. Or one or both partners might hold the person responsible for the heart attack, given the individual's prior lack of exercise and poor eating habits, thus resulting in blame, anger, and guilt. Therefore, a couple-based intervention for heart attacks should provide needed information about what behaviors are safe and encouraged medically, as well as help the couple address negative emotions and cognitions that arise from the disorder. Third, the therapist must have an in-depth understanding of general couple functioning and couple therapy interventions (e.g., interventions to facilitate mutual social support) that can then be adapted for use in assisting the couple with medical problems. That is, although there are unique stressors that a couple must face when one partner experiences a medical problem, general principles of
healthy relationship functioning still apply to these couples, and many couple therapy interventions are beneficial. For example, effective communication is needed both to address disease-related issues and broader nonmedical issues in the relationship. Likewise, social support is important when either partner experiences a notable stressor whether it be medical, psychological, professional, or some other domain of life; hence, helping both members of the couple learn how to support each other in addressing a medical problem is paramount. Furthermore, while not ignoring or minimizing the medical condition, it is important that couples maintain a healthy perspective such that life is not totally dominated by the medical condition. Consequently, couples are encouraged to maintain some semblance of normality in their lives, which calls for all of the relationshipmaintaining processes that are important for couples in general, as well as couple therapy principles for couples who are relationally distressed (see Benson, McGinn, & Christensen, this issue; Halford et al., 2012-this issue; Snyder & Balderrama-Durbin, 2012-this issue, for discussion of such principles). Finally, the therapist must be able to integrate the above factors into a coherent intervention that is responsive to a particular couple. More specifically, armed with an understanding of the medical condition, what the patient must do to recover or adjust to the disorder, and how the disorder affects the partner and the couple, the therapist adapts commonly employed individual and couple intervention principles to address the medical disorder from a couple perspective as described below.
Universal Processes in Couple-Based Interventions for Medical Problems In discussing universal processes in couple-based interventions for medical problems, it is important to understand the empirical status of the field and limitations in our current knowledge. Whereas empirical demonstrations of the efficacy of cognitivebehavioral couple therapy for relationship distress and prevention began in the 1970s, application of these principles to medical conditions is much more recent, with almost all treatment outcome investigations being published since the mid-1990s. As noted throughout this paper, a number of couple-based interventions for medical conditions have demonstrated efficacy, and virtually all of these treatment packages target multiple domains of functioning with a variety of interventions. Given that demonstrating the overall efficacy of treatment packages has been the primary focus of these trials, the field still awaits investigations that isolate the effectiveness of specific interventions. Hence in the discussion of universal processes in these interventions, it is
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important to recognize that they are parts of multicomponent interventions, and the efficacy of each specific element has not yet been investigated. Hopefully by recognizing the common foci in these intervention packages, investigators can be encouraged to undertake the next generation of treatment outcome trials to clarify the most effective and efficient elements to include in assisting couples confronting these stressful situations. Based upon the common experiences that couples have when confronting medical disorders, most efficacious psychosocial couple-based interventions include some or all of the five following treatment components or address the following issues. (a) The couple typically is provided some level of psychoeducation about the medical condition, often including symptoms, etiology, treatment, prognosis, and health behavior changes that can assist in rehabilitation or adaptation to the medical disorder. (b) The couple typically is encouraged and assisted in sharing a wide range of emotional reactions and thoughts about the disorder and its implication for the patient, partner, couple, and other individuals involved in their lives. (c) Typically, couples have decisions to make about treatment and recovery or other issues that are focal to the medical disorder, and these decisions need to be implemented. Thus, helping the couple with these important treatment decisions (e.g., whether to have reconstructive surgery following a mastectomy) and associated behavior changes about the medical disorder (e.g., eating a heart-healthy diet) is central to couplebased interventions. (d) In addition to making decisions that are explicitly about the medical disorder, the presence of the disorder has implications for the couple's relationship more broadly, such as changes in work or leisure activities. Thus, relationship issues that stem from the medical disorder typically are addressed. (e) Finally, medical conditions develop and persist within the context of a couple's overall relationship that, in many instances, preceded the medical disorder. In order to provide the optimal social environment for the patient to recuperate or adapt to the disorder, creating the most positive, supportive broad relationship for the couple is a worthy goal. At the other end of the spectrum, a highly distressed relationship is a chronic, diffuse stressor that also makes it difficult for the couple to address the above issues that are more focal to the medical condition. Therefore, addressing the couple's general relationship functioning unrelated to the medical disorder can be valuable both to provide an optimal ongoing social context for the patient and to facilitate effective couple functioning in addressing medically related issues. A more detailed description of how these five
common elements can be implemented with a variety of medical conditions is described below.
psychoeducation regarding the medical disorder When one member of a couple is diagnosed with a medical condition, both partners often respond with a wide range of negative emotions including anxiety, depression, and anger (Lederberg, 1998). Frequently there is an experience of shock as they attempt to absorb the news and experience that their sense of reality has immediately changed, often to a significant degree. Life can feel out of control with a lack of understanding about the implications of the disorder for the present and the future. For many people, information and understanding are major factors that can contribute to regaining a sense of control. Thus, providing psychoeducation about a medical condition in terms of the symptoms, etiology, treatment, prognosis, and potentially beneficial health behavior changes can be of value to both partners. Consistent with this perspective, our recent meta-analysis of psychosocial interventions for cancer demonstrated that, across a number of studies, psychoeducation is beneficial in the psychological adjustment of cancer patients (Zimmermann, Heinrichs, & Baucom, 2007). Although the utility of providing psychoeducation to both partners together has not been widely researched, our experience is that it can be beneficial in a number of ways predicated upon the notion that “psycho”education involves the integration of information with psychological responses to that information. That is, the psychoeducation process involves addressing highly subjective emotional, cognitive, and behavioral reactions to information about the disorder. First, providing psychoeducation to the two partners together can help to ensure that they have a shared understanding of the disorder, its seriousness, treatment, prognosis, and any needed health behavior changes. Soon after diagnosis, patients often do not fully absorb information provided by the medical staff because they are in a state of high distress. Consequently, it may not be enough to provide information orally, through pamphlets, or via the Web; instead, having a conversation with the couple to answer their questions, correct misinformation, and develop a shared perspective can be valuable. Understandably, people's beliefs and expectations about medical disorders are not solely a function of facts and statistics. Thus, some people might consider a diagnosis of heart disease or cancer as a death sentence, even though earlier detection and improved interventions provide a much more positive prognosis. Similarly, some people conclude that statistics do
couple-based interventions for medical problems not apply to them, and that they are doomed or, on the other hand, that they need not be concerned because everything always turns out for the best. Therefore, eliciting both partners’ emotions and cognitions about the prognosis of a medical disorder is an important part of psychoeducation. Second, couples have beliefs not only about prognosis but also about the etiology of disorders that can have interpersonal implications. In some instances, partners may inappropriately blame the patient for developing a disorder, which can lead to anger and resentment toward the patient. For example, one wife told her husband, "You have let your anger eat away at you for years, and now your cancer is eating away at your body. I don't know exactly how it works, but I have to believe that they are connected. I've asked you for years to get help, and now we both are going to pay the price." There are no data linking the development of cancer to specific negative emotions; thus, educating the partner may be of assistance. In addition, because information alone often does not alter emotional responses, it may be necessary to attend to any feelings of resentment throughout the intervention. On the other hand, the couple might believe that heart disease is fundamentally hereditary and that exercise or eating a heart-healthy diet really will not help the patient. Addressing these individual- or couple-level beliefs about the disorder through motivational interviewing (Miller & Rollnick, 2002) or other couple-based cognitive interventions (Epstein & Baucom, 2002) can be critical for the initiation and long-term maintenance of health behavior changes as discussed below.
sharing thoughts and feelings about the medical disorder and its implications The ability to communicate effectively and be able to share one's thoughts and feelings with one's partner and feel heard is central to long-term healthy relationships in general. In fact, the overall quality of communication is one of the most consistent predictors of long-term relationship functioning (Karney & Bradbury, 1995). This ability to communicate effectively is of paramount importance when major life changes or crises occur, including the development of medical disorders. Discussing one's reactions and experiences on an ongoing basis can be important because individuals’ reactions to the disorder change over time as they process their new circumstance and as ongoing treatment and recovery/disease progression present different challenges and opportunities. Consistent with this perspective, it appears that for women with breast cancer, having a highly supportive partner is one of the most important factors in their psychosocial
adjustment to the disorder (S. L. Manne, 1994; Peters-Golden, 1982). And while both instrumental and emotional support are of assistance, emotional support, which typically includes sharing feelings and thoughts, appears to be of greatest benefit to these women (Dunkel-Schetter, 1984). Furthermore, S. Manne et al. (2004) found that women with breast cancer felt closest to their male partners not only when the male partners were good listeners when the women were speaking but also when the men disclosed their own worries and concerns about the cancer. This finding demonstrates the importance of both persons sharing their subjective experiences, even when one person has the medical disorder. Whether couples engage in conversations in which they share their feelings and thoughts about the medical disorder is likely influenced by at least two factors: (a) the way the couple typically shares their thoughts and feelings more broadly within the relationship, as well as (b) their perspective on how the medical disorder should be addressed. If couples typically do not share their thoughts and feelings with each other on other matters, they are likely to be ill equipped to address more difficult and perhaps threatening aspects of the medical disorder. However, even for couples who typically discuss their thoughts and feelings, the seeming overwhelming nature of the medical disorder and beliefs about the most effective way to approach the disorder can result in couples avoiding conversations about the medical problem (Porter, Keefe, Baucom, Hurwitz, & Moser, 2009). For example, some partners avoid sharing their worries and concerns, believing it will burden the other individual and add to the stress of an already difficult situation. This avoidance approach has been referred to as "protective buffering" because one partner is attempting to protect or buffer the other individual from one's own distress or concerns (Coyne, Ellard, & Smith, 1990; Coyne & Smith, 1994). In general, the literature indicates that such strategies, although perhaps well intended, are often counterproductive. Findings from our own couples and breast cancer sample indicate that men who attempt to distance from the cancer and avoid discussions about the breast cancer have wives who are more depressed and experience higher levels of fatigue (Paprocki & Baucom, 2010). In a study of patients with gastrointestinal cancer and their spouses, we found that patients and spouses who reported holding back from discussing cancer-related concerns with their partner reported significantly poorer individual and relationship functioning (Porter, Keefe, Hurwitz, & Faber, 2005). The above findings point to the overall value of addressing concerns about the medical disorder; yet,
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there might be times when it is most effective to focus upon what needs to be done pragmatically to get through treatment or a difficult time without focusing upon emotions. Unfortunately, research has not addressed the contexts within which a more task-oriented approach to medical concerns versus an emphasis on emotional reactions is most helpful to couples. However, in instances when the patient does want to discuss the disorder with his or her partner but does not feel free to do so, it is likely to be problematic. For example, we conducted a couplebased emotional disclosure intervention study for gastrointestinal cancer in which couples were taught communication skills for sharing thoughts and feelings about the cancer, along with listening skills (Porter et al., 2009). The findings revealed that patients who reported at the beginning of treatment that they typically held back from discussing their cancer but wanted to be able to discuss it with their partner responded most positively to the emotional disclosure intervention. The discussion thus far focuses upon the importance of addressing negative emotions that are evoked during the course of the medical disorder. In addition, a large number of individuals with medical disorders report that there are positive consequences that result from confronting their illness, often referred to as posttraumatic growth (Tedeschi, Park, & Calhoun, 1998) or benefit finding (Affleck & Tennen, 1996; Antoni et al., 2001). Such positive benefits can take on various forms but often include a recognition of strength within oneself as a result of coping with the illness, appreciation of support from other individuals, and gaining a new perspective or greater appreciation of life (Affleck & Tennen, 1996; Tedeschi et al., 1998). Not all individuals have such experiences, and these perspectives typically evolve over time after the initial diagnosis and intense medical treatment have subsided. Furthermore, experiencing positive consequences from the disorder cannot be forced. Yet, it can be valuable to provide both partners with an opportunity to express this more balanced perspective, including what positive consequences have come from the illness experience. This is in keeping with an overall therapeutic approach to acknowledge and address the seriousness of medical disorders while also encouraging a realistic, balanced perspective in which positive aspects of the couple's life and relationship are emphasized as well. Whether addressing concerns or positive feelings about treatment progress or new perspectives on life, helping couples express their thoughts and feelings in some manner is important. Metaanalyses of couple therapy demonstrate that a variety of theoretical approaches are of assistance
to distressed couples, including variations on cognitive-behavioral approaches, insight-oriented approaches, and emotion-focused approaches (Shadish & Baldwin, 2003, 2005). While these different theoretical approaches vary in the manner in which they help couples address emotions, all of these approaches facilitate couples’ expression of their feelings. It is likely that these various approaches can be adapted to address medical problems. To date, most couple-based intervention studies for medical concerns have been conducted from a cognitive-behavioral perspective, building on the strong empirical support of cognitive-behavioral couple therapy. Within cognitive-behavioral approaches, couples typically are provided with a set of communication guidelines for sharing thoughts and feelings that are then used to address various issues related to the medical disorder (Epstein & Baucom, 2002). We have employed such communication guidelines in the treatment of a wide range of couple-based interventions for medical disorders and health-related concerns including breast cancer (Baucom, Porter, et al., 2009), gastrointestinal cancer (Porter et al., 2009), lung cancer (Porter et al., 2011), heart disease (Sher & Baucom, 2001), osteoarthritis (Keefe et al., 2004, 1996), chronic obstructive pulmonary disease (Blumenthal et al., 2009), and smoking during pregnancy (McBride et al., 2004). Overall, there is still a great deal to be learned about the degree and timing of sharing thoughts and feelings about the medical disorder, which is further complicated by two partners perhaps having different needs and desires for such processing. Yet, helping couples clarify what each person needs with regard to sharing thoughts and feelings can be valuable, along with providing them the needed guidelines and safe environment within which such conversations can occur.
making and implementing decisions focal to the medical disorder Couple therapists have long recognized that it is important for couples to be able to make decisions or resolve problems across a broad range of issues that arise throughout the course of a committed relationship (see Benson et al., 2012-this issue; Snyder & Balderrama-Durbin, 2012-this issue; Wadsworth & Markman, 2012-this issue, for a broader discussion of problem solving in intimate relationships). In addressing medical problems from a couple perspective, one large class of decisions confronting couples involves treatment for the disorder itself. Although patients vary in the degree to which they want to be involved in making decisions about their medical care and treatment versus having physicians make the decisions (Benbassat, Pilpel, &
couple-based interventions for medical problems Tidhar, 1998), a growing trend appears to be soliciting patients’ input regarding decisions about their medical treatment. This might include decisions regarding initial treatment alternatives when empirical data do not indicate a clear treatment (e.g., whether to have a radical mastectomy vs. breast-conserving surgery) or whether to undergo extreme experimental procedures in late stage disease. Helping couples address these issues and make thoughtful decisions is an important aspect of couple-based interventions for medical problems. Whereas there is no absolute way that these decisions should be made, addressing how couples think about medical decisions in terms of an individual versus interpersonal perspective can be a valuable discussion that can help to clarify the decision-making process. At times, partners express the viewpoint that the medical decisions are clearly the patient's decisions and that the partner will fully support whatever the patient decides. In an attempt not to be intrusive, these partners may be reluctant to offer their own perspectives or opinions. This stance might be preferred by the patient. Alternatively, the patient may prefer to make joint decisions or at least take the partner's perspective into account, even if the patient ultimately makes the medical decision. For example, when medical decisions are primarily cosmetic, often the patient wants to understand the partner's perspective because the patient wants to be attractive or appealing to the partner (e.g., many women want to know about their partners’ perspectives on reconstructive breast surgery following a mastectomy). Having open and honest discussion of such issues can be difficult because partners often want to maintain a stance that the patient's well-being and happiness is of foremost importance and expressing one's own wishes or preferences is selfish. Similarly, women might be reluctant to discuss their worries about potential sexual complications resulting from more extensive treatment of prostate cancer, believing that their sexual relationship should not be of importance when considering their male partner's health. Whereas there are times when the patient might make decisions about treatment for the medical problem, there also are contexts in which the partner often takes the lead regarding medical treatments, such as interacting with the medical team. Often there are many details to address with different professions and health care providers, and it can be taxing for the patient to remember all of these issues or make contact with all needed staff members. Therefore, some couples decide that the partner will take the lead in interacting and raising questions with health care staff or asserting him- or herself on behalf of the patient. In addition to decisions about medical treatments, a second important realm of medically related
decisions involves behavioral changes that the patient needs to make to optimize recovery, prevent recurrences, or adapt to new physical realities resulting from the medical disorder. Disorders vary in the degree to which specific health behavior changes have been documented as physically or psychologically beneficial for rehabilitation or disease management. For example, diet and exercise are important in rehabilitating and managing disorders such as heart disease and diabetes. Yet, behavioral change over the long term is difficult, and nonadherence rates for lifestyle change recommendations for primary, secondary, or tertiary prevention often exceed 50% (Fappa et al., 2008; Sackett & Snow, 1979). Given that these health behavior changes occur within a social and interpersonal context, it can be important to consider how to employ the partner and the couple as a unit to facilitate these health behavior changes. Elsewhere we have referred to these interventions as partnerassisted interventions because the emphasis is on how the partner can assist the patient in making needed changes focal to the medical disorder (Baucom, Kirby, et al., 2009). In these instances, the focus is not on changing the couple's relationship in a notable way but rather on promoting individual change in the patient. The partner is assuming the role of a substitute or surrogate therapist in some ways, or a coach and cheerleader in helping the patient make important changes. One example of a medical condition in which partner-assisted interventions can be helpful is osteoarthritis. Osteoarthritis is a common condition that often afflicts the elderly and that can be associated with significant pain, physical disability, and psychological distress. Effective behavioral interventions for osteoarthritis include teaching the patient strategies for coping with the pain, including relaxation and distraction from the pain, as well as alternating activities with rest (rest–activity cycles) to promote moderate exercise without excessive strain to the patient. Along with Keefe and colleagues (1996, 2004, 2005), we have developed partnerassisted interventions to facilitate these health behavior changes for individuals with osteoarthritis. These interventions include, for example, the couple going on outings in which they schedule moderate activity and build in a rest period prior to the patient experiencing pain. Similarly, both partners might learn and practice relaxation exercises together, enjoying the relationship aspects of this joint activity, at the same time as decreasing the partners' pain. The findings from these partner-assisted interventions for osteoarthritis have been promising and demonstrate the importance of teaching the partner how to be helpful in the treatment of this painful
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disease, even among nondistressed couples. That is, the findings demonstrated an important association between the couple's relationship quality and the patient's long-term adjustment, varying as a function of whether the couple was treated together or the patient was treated individually. For couples who were treated together in the partner-assisted intervention, there was a positive association between the quality of the relationship and the patient's adjustment; that is, the better the marriage, the better the long-term adjustment of the patient in dealing with pain. However, for patients who were treated individually in pain-coping skills, the better the marriage, the worse the long-term adjustment for the patient (Keefe et al., 1996). These findings suggest that well-intended partners in a good relationship may inadvertently behave in maladaptive ways when trying to be of help if they are not trained in how to best assist the patient. As can be seen from the above discussion, there are many ways in which problem-solving or decisionmaking strategies that are commonly involved in couple therapy or relationship education are appropriate in couple-based interventions for medical problems. What is important to note is that there are aspects of medical disorders that lead to a consideration of certain types of issues that are less commonly addressed in couple therapy and relationship education. These differential emphases stem from the fact that one partner has the medical condition, and it often is ambiguous as to whether medical decisions should be considered to be individual or couple decisions. Similarly, health behavior changes can be adaptive for both partners but result from the patient's medical condition, and at times it is complicated to consider whether partners should be asked to change their own behavior (e.g., dietary changes) in order to facilitate changes in the patient's behavior. In contrast, the focus of couple therapy and relationship education more often involves concerns or ways to facilitate the couple's relationship per se, rather than a focus upon one individual.
addressing relationship issues stemming from the medical disorder In addition to decisions about medical treatment, rehabilitation, and management, and important health behavior changes, many medical conditions have broader implications for how a couple conducts their daily lives and the roles and responsibilities that each person assumes, both during treatment and on a long-term basis. Elsewhere, we have entitled these interventions “disorder-specific interventions” in that they involve making changes in the couple's relationship but only in domains that are related to,
or result from, the patient's disorder (Baucom et al., 1998). In these interventions, the therapist helps the couple identify ways that they need or want to alter their relationship as a result of the medical disorder, but the issues being addressed are not medical per se. There are several relationship themes that recur in the context of medical conditions that many couples address. First, during active treatment, the patient may feel sick, have less energy, or be unable to maintain daily roles and responsibilities both at work and at home due to medical appointments. Consequently, many couples need to discuss realignment of roles and responsibilities during the treatment process, ranging from meal preparation to transporting children to altering or ceasing work obligations on a short-term or permanent basis. Changes for the patient in these domains typically have reciprocal implications for the partner as well, resulting in the need for numerous decision-making conversations. Because individuals’ self-worth often is based in part upon their contributions and roles within the family and society at large, these decisions need to consider not only practical and pragmatic aspects of changing roles and responsibilities resulting from the medical disorder but also how to help the patient maintain a sense of self-worth as roles become altered. Likewise, taking the needs of the partner into account also is important so that the partner does not become overwhelmed and depleted. If there is an imbalance in the relationship, with the healthy partner's contributions to the relationship exceeding those of the patient, both partners are likely to experience increased negative emotion and lower relationship satisfaction (Kuijer, Buunk, De Jong, Ybema, & Sanderman, 2003). A second common relationship theme evolving from the medical disorder involves the couple's finances. If the patient has to limit work or take a less lucrative position, or the partner needs to spend less time at work in order to care for the patient or assist with children and other family matters, the couple's income might decrease. Also, the treatment of many medical conditions is expensive, and even if couples have medical insurance, it often is inadequate to cover expenses. Not only does this lead to stress for couples but they often need to compensate by reducing spending in other domains, ranging from discretionary spending such as entertainment or vacations, which can help to alleviate stress, to purchasing cheaper, less healthy food. There are also cognitive and emotional implications if one or both partners believe that they have failed to provide adequate finances to address their current needs. Thus, many couples need time in treatment to address financial issues stemming from the medical condition, both from a practical perspective as well
couple-based interventions for medical problems as how they view finances from a cognitive and emotional perspective. A third common theme for many couples confronting a medical disorder involves a reevaluation and reprioritization of how they spend their time as individuals and as a couple. This is a component of posttraumatic growth or benefit finding, as discussed above. More specifically, many individuals report that confronting serious medical complications leads them to address important existential issues regarding the meaning of life, what is important to them, and how to allocate their time and resources. Consequently, couple-based interventions can assist couples in having conversations about these topics and making thoughtful decisions about what to maintain and what to change in their current and future lives. Because these reevaluations often occur initially on an internal, individual level, it cannot be assumed that both partners are having similar experiences in reevaluating life. As a result, it can be valuable for partners to discuss both persons’ perspectives regarding desires for change in life goals or how time and resources are allocated, stemming from the medical condition. For example, in our couple-based intervention for breast cancer, we help couples discuss what aspects of their lives they would like to maintain and what they want to change on an individual and couple level as a result of reevaluating life due to the cancer (Baucom, Porter, et al., 2009). In addition to the broad themes noted above, there are a myriad of other topics related to life changes stemming from the medical disorder that may need to be addressed according to each couples’ circumstances. For example, many couples discuss what to share about the medical condition with children, friends, and family. Similarly, many couples discuss the degree and what types of support and assistance they would like or are willing to receive from other people in their lives and how to respond when various offers of support are made by others. By employing frequently used couple intervention strategies such as sharing thoughts and feelings and decision-making conversations to address unique issues raised by medical conditions, the therapist can be of assistance to couples as they explore individual and relationship issues that are influenced by the medical condition but extend far beyond treatment and rehabilitation. The stage of the disease also can have a notable impact on relevant issues to address with the couple. For example, couples faced with a late stage or terminal illness may have some unique concerns, including existential issues as noted above. In general, attending to family relationships is vitally important to patients and their family members at the end of life (Steinhauser et al., 2000). Thus, couple-
based interventions may be particularly relevant during this time. More specifically, patients with late stage disease are often coping with high levels of symptom burden and disability, which profoundly impacts their partners and their relationships as well (McLean & Jones, 2007). These couples are also dealing with anticipatory grief and struggling to make meaning of their lives and their relationships. Couple-based interventions focused on coping skills and symptom management strategies have been found to be helpful for patients and partners at end of life (Keefe et al., 2005; McMillan et al., 2006). Couple-based interventions that include a focus on communication around existential issues such as meaning, value and spiritually may also be particularly pertinent (McLean & Jones, 2007). Overall, the stage of the patient's disease can have a notable impact on the content and the tenor of treatment sessions, and clinicians and researchers should be sensitive to stage of illness in designing optimal treatments.
addressing relationship issues unrelated to the medical condition Addressing the issues stemming from the medical condition described above is most effective when couples have good communication and are able to work together as a unit in approaching these important domains of individual and couple life. If the couple is highly distressed, then it can become difficult for them to discuss the topics described throughout this paper. Therefore, helping couples work more cooperatively as a team can be important in order to help them address the issues that emanate from the medical problem. In addition, relationship distress can be a chronic, diffuse stressor on individuals that can compromise the functioning of both the patient and the partner who already are confronting numerous stressors related to the medical condition. Consequently, in order to reduce stress and provide an optimal social context for both individuals and the couple as a unit, minimizing relationship discord can be valuable. In clinical contexts, several factors influence whether broad relationship issues unrelated to the medical condition are addressed during the intervention. First, the reason that the couple seeks assistance clearly influences the scope of the intervention. Many psychosocial interventions for medical conditions occur in hospitals and other medical settings, and when couples seek or agree to receive services, often their goal is to address psychosocial issues related to the medical condition per se in a limited number of sessions. Thus, a therapist must be cautious in venturing into broad relationship issues if this focus is not part of the
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couple's initial understanding or "contract" in seeking assistance. Second, even if the couple and therapist intend to focus almost exclusively on issues related to the medical condition, if the couple is unable to address these issues successfully because of relationship discord, then the therapist should raise this issue with the couple and decide whether broader relationship themes need to be addressed so that they can work cooperatively around medically related issues. On the other hand, some couples who are seeking couple therapy for relationship discord more broadly have medical conditions that complicate their relationship and merit attention; in these instances, integrating a focus on medical issues and other relationship concerns is appropriate. A discussion of strategies for addressing general relationship discord is beyond the scope of this paper (see Christensen; Snyder & BalderramaDurbin, 2012-this issue; Davis, Lebow, & Sprenkle, 2012-this issue, for a discussion of general principles in couple therapy). However, some comments on sequencing or integrating a focus on the medical problem along with nonmedically related issues merit brief attention. First, the recency of diagnosis and seriousness of the medical condition will likely influence whether it is addressed early in intervention. Given that both partners are often highly distressed soon after diagnosis, attending to the medical condition early in the intervention can be helpful in these contexts. Likewise, the more serious or distressing the disorder is in terms of impacting the couple's life or as a threat to mortality, the sooner the clinician is likely to address medical issues. On the other hand, the extent to which broader relationship concerns interfere with addressing medical issues, the sooner broad relationship issues need to be addressed. In particular, couples who behave in hostile, punishing ways are likely to struggle when attempting to discuss medical problems, so focusing on broader relationship functioning is appropriate in these cases. However, couples who are unhappy in their relationships but are not as punitive toward each other, at times can focus on the medical problem as a common concern that is less relationally distressing to them. In these instances, the couple might successfully focus on the medical problem early in treatment as a way to learn to work together as a team for a common cause. Hence, whereas some interventions are intended to be circumspect in addressing only limited areas of functioning related to the medical disorder (e.g., pain management at the end of life; Keefe et al., 2003), there are other contexts that allow for, or require, that broader aspects of relationship functioning be
addressed in order to be of assistance in addressing medical problems.
Do All Couples With a Medical Problem Need or Benefit From Couple-Based Interventions: The Search for Moderators Because couple-based interventions typically have been equated with strategies for improving relationship functioning, clinicians and couples alike often have assumed that couple-based interventions for medical problems are unnecessary if a couple has a good overall relationship. Whereas we have argued in this paper that even happy couples might benefit from assistance in addressing issues unique to medical problems, at present investigators are only beginning to explore the question of which couples are responsive to couple-based interventions for medical problems. Given the widespread prevalence of disease, particularly with individuals’ increasing lifespan, it is impractical to consider offering these interventions to all couples experiencing medical issues. To some degree, this problem is lessened because many couples are unlikely to participate in such interventions, even when they are offered. In fact, recruitment rates for couple-based interventions for medical problems in research contexts are rather low overall (Fredman et al., 2009). In part, this low rate of involvement might result from the somewhat heavy research burden that is common in such investigations, at a time when couples might be overwhelmed with medical concerns. Whether couples would be more likely to participate in couplebased clinical services without research commitments is unclear. An even more important question involves which couples are likely to elect such services. As Sullivan and Bradbury (1997) note when discussing relationship education, if those at highest risk of difficulties volunteer (which they termed a compensation effect in recruitment), then interventions might be cost-effective. On the other hand, if low-risk couples volunteer (which they called an attenuation effect), then interventions might make little difference. At present, these issues have not been explored among couples with medical problems, and a first step is to identify which couples are likely to benefit from these interventions. Then treatment can be appropriately targeted, and couples whose lives are already complicated by medical problems can use their time and resources well. At present, we can turn to two sources to assist in these beginning efforts to identify potential moderators of treatment efficacy: basic research and existing treatment outcome investigations. First, basic research is beginning to identify which individuals have particular difficulty adjusting to specific medical problems, and such groups could
couple-based interventions for medical problems be targeted for couple-based interventions. For example, it appears that younger women have more difficulty adjusting psychosocially to breast cancer than do older women (see Baucom, Porter, Kirby, Gremore, & Keefe, 2005, for a discussion of relevant factors). Given their increased risk, young women with breast cancer and their partners might be a population of emphasis for couple-based interventions. Also, as noted earlier, divorce rates are notably higher when women develop medical problems than when men have medical problems (Glantz et al., 2009), indicating that these relationships are at higher risk of dissolution. Although the bases for these differential divorce rates are unclear, the findings should alert both clinicians and researchers that the gender of the individual with the medical problem might impact who responds to treatment or how interventions need to be delivered. Given that women typically play the role of “family manager” in coordinating and scheduling many family activities and chores, even in dual-career families (Epstein & Baucom, 2002), serious medical problems among female partners might require more family reorganization than medical problems among their male counterparts. Thus, gender of patient might to some degree be a proxy for the degree or type of family disruption caused by the disease, which is important to take into account in treatment planning. Furthermore, the two genders might differ in the types of support they need when ill, as well as the types of support each gender is comfortable providing for the other. Such gender differences might call for different approaches to treatment. Strategies for providing support might differ not only by gender but cultural factors can play a role as well. For example, we recently collaborated in the United States and Germany to investigate crosscultural differences in support between partners when the female has breast cancer. Using the same social support conversation tasks for both American and German couples, and employing the same observational coding system with coders from the two countries trained together, the findings indicated that American couples are more emotional in their provision of support compared to German couples (Zimmermann, Baucom, Kelly, & Heinrichs, 2008). Applying couple-based interventions for breast cancer in different countries without taking such cultural differences into account could lead to less than optimal interventions. Second, in addition to basic research findings that can suggest who might need treatment or respond best to treatment, some intervention trials are beginning to explore moderators of treatment efficacy, and the results of these investigations can provide guidance for future efforts. As noted earlier,
we have found that among couples in which one partner has gastrointestinal cancer, a couple-based emotional disclosure intervention was particularly useful to couples in which the patient "held back" or wanted to discuss cancer-related concerns but was reluctant to do so (Porter et al., 2009). This result is understandable given that the couples were provided skills and guidelines to engage in conversations that certain patients desired. Also, we have found that for couples in which one partner has lung cancer, a partner-assisted coping skills intervention was more efficacious when the lung cancer was more advanced, perhaps when coping skills were more needed (Porter et al., 2011). In each of these instances, the moderator was a variable that was particularly relevant to the couples’ situations—either the patient desired or appeared to be in need of the intervention that was provided. Hence, as with other forms of psychosocial intervention, it will be important to identify which couples are likely to benefit from specific couple-based interventions for particular medical problems. It will also be important to identify and communicate to couples what domains of functioning are likely to be influenced by these interventions. At present, there has been little exploration as to whether couple-based interventions for medical problems alter the actual course of the disease or influence mortality. Even within the psychosocial realm of outcomes, it is unclear when such interventions are likely to be of primary benefit to the patient, the partner, or their relationship.
tailoring treatment to specific couples At present, empirical research is lacking regarding how to individualize treatment for specific couples, yet findings from basic research to date and clinical observation highlight several domains to consider in tailoring treatment to couple needs. Identifying important moderators of response to treatment is one major way to optimize treatment for specific couples. That is, high-risk couples might be targeted for treatment, whereas others are not. Similarly, potential moderators can suggest ways that treatments might be altered to optimize their effectiveness. In addition to moderating demographic variables such as gender and age/life stage of the patient or cultural factors affecting ways for providing support, there are individual and relationship nuances that characterize the ways a particular couple thinks about and addresses medical problems within their specific relationship that might call for altering the intervention. On the individual level, for example, patients vary in their attitudes about the degree to which they should be stoic about their medical symptoms and proceed with life as usual, attempting to fulfill their
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typical daily responsibilities. Whereas many couplebased interventions encourage patients and partners to express their concerns and avoid buffering the other person from one's distress, this focus of intervention must be tempered by the individual's characteristic ways of expressing emotions and their beliefs about illness. Although treatment research is lacking in this regard, clinical observations suggest that encouraging patients to express physical complaints or psychological distress beyond certain limits can undermine their sense of coping with adversity and potentially lower their sense of self-efficacy. Similarly, some alteration in roles often is necessary when one partner has a medical disease, but overly restricting a patient from responsibility beyond what is necessary and desirable for that individual also runs the risk of undermining a sense of self-efficacy and a sense of contributing to the family and societal well-being. Not only might individual differences within the “normal” range of functioning call for individualizing treatment, but type and level of psychopathology of the patient (or partner) can call for changes in the treatment. Whereas findings are somewhat scant, the efficacy of couple therapy for relationship distress appears to be more limited among couples in which one partner demonstrates psychopathology (Snyder & Whisman, 2004); individual psychopathology might have a similar complicating effect on couple-based treatments for medical problems as well. In addition, many couple-based interventions for medical problems are brief in nature (e.g., four to six sessions) and, thus, must be targeted in their focus. Given that medical illnesses are a significant stressor for both the patient and partner, individuals already experiencing or predisposed to psychological difficulties such as depression, might struggle to function given this added burden. Thus, treatment might need to be lengthened when one partner has significant individual psychological difficulties. The type of psychopathology might also influence how the couple addresses the medical problem. For example, if the patient is highly anxious or depressed, the partner might be reluctant to disclose the partner's own concerns for fear that the patient might not be able to cope with these concerns. Similarly, the partner might be less willing to encourage a depressed patient to explore the patient's worries about death or other life complications, having experienced that the patient “goes into a dark hole and gets lost when we've had those discussions in the past, even before the illness.” Thus, interventions might need to be extended or broadened to address the psychopathology as well as existing medical problems.
As noted earlier, couples vary also in how they as a unit address individual issues in a relationship context, and this can call for altering the treatment to some extent. For example, some couples consider medical problems to be the domain of the patient, and the partner's role is to support the patient. Other couples consider medical problems to be “our problem” and they address the problem as a couple in almost all ways. Whereas such distinctions might seem subtle, they can call for variations in how the therapist helps the couple make medically related decisions. Among couples with more of an “individual focus,” the partner might provide input and consultation, but the couple agrees that the final decision about the patient's body and medical treatment is up to the patient. For couples who view the disease as a “couple issue,” their decision making might mirror other couple decisions in which they find a solution that is mutually agreeable to both of them. Clarifying how the couple wants to think about medical problems as individual versus couple issues and adapting the treatment accordingly has the potential to optimize treatment. The above suggestions are only examples of how treatment might be selected and tailored to meet specific couple's needs in the context of medical disorders. They are noted because they are somewhat specific to medical disorders or become accentuated in the context of medical disorders. In addition, many of the same factors that a therapist would consider in individualizing treatment for couples with relationship distress are likely to be pertinent when addressing medical problems in a couple-based intervention.
common factors in couple-based interventions for medical problems The discussion thus far has focused on universal processes and the substantive issues involved in couple-based interventions for medical problems. We believe that these substantive issues are central to meaningful treatment, although they likely can be delivered from a variety of theoretical perspectives. As Davis et al. describe in this issue, there also are likely to be additional common factors that contribute to treatment effectiveness. As they also note, almost all research on common factors in psychotherapy has emanated from investigations of individual psychotherapy. Even couple therapy for relationship distress, which has been researched for over 35 years, has little empirical investigation of common factors, and no empirical investigations to our knowledge have addressed this issue in assisting couples with medical problems. Thus, our comments below draw from a synthesis of common
couple-based interventions for medical problems factors in individual psychotherapy, and how these issues might be experienced in assisting couples with medical problems. Such speculation is intended to stimulate both research and clinical attention to potential variables of importance in working with these couples. Client Variables One of the most important factors in effective therapy is clients’ motivation and engagement in the therapy being offered, with a belief that the treatment has the potential to be of assistance at this point in their lives (Davis et al., 2012-this issue). However, when one partner develops an individual medical problem, it is not necessarily intuitive that a psychosocial intervention for the couple will be of assistance. This seeming lack of fit can be accentuated if the couple is happy in their relationship and equates couple-based interventions with couple therapy or marriage counseling for distressed relationships. Thus, some explanation about the nature of the intervention being offered, how the couple might use it to support each other through a stressful time, and how it differs from couple therapy can be important to engage the couple in treatment. As part of this explanation, at times it can be important to clarify that a couple-based psychosocial intervention does not imply causation— either that the medical problem is “in the patient's head” or that the couple or partner caused the problem. Instead, intervention will focus upon how the couple might address the medical problems within the context of their relationship. Therapist Variables Therapist characteristics that are important in individual psychotherapy, such as being positive, friendly, flexible, and sensitive to the patient's worldview (Davis et al., 2012-this issue) also are likely to be important in assisting couples with medical problems. In addition, the therapist needs to be knowledgeable and appear credible to clients. This can be a challenge given the expertise that is optimal to provide couple-based interventions for medical problems. As described earlier, the therapist needs knowledge of the medical disorder; how the disorder affects the patient, the partner, and the couple's relationship; general couple intervention skills; and how to integrate these various factors. Thus, many couple therapists will likely need additional training about the medical disorder, and many health psychologists will need couple therapy training, to offer interventions optimally and gain the trust and confidence of the couple. Therapeutic Alliance An effective therapeutic alliance appears to be an important factor in efficacious psychotherapy. In
providing therapy to couples with medical problems, many of the same issues as couple therapy are relevant regarding therapeutic alliance (having a strong alliance with each partner individually and the couple as a unit). Compared to couple therapy for relationship distress, in addressing medical issues, the partners are less likely to be angry with each other or blame each other for the problem; hence, the therapist has less concern about taking sides, being a referee, of being asked to decide who is right and who is wrong. Yet, there are other issues that are pertinent to medical complications that must be handled carefully in maintaining a positive therapeutic alliance. For example, serious medical issues are quite frightening to many couples. In an attempt to control their distress and maintain a positive attitude, some couples avoid or minimize the seriousness of the issues they are confronting. While being sensitive to the couple's readiness to address implications of serious diseases, at times the therapist needs to encourage the couple to confront painful realities. Doing so with skill and timing is essential so that the couple does not “shoot the messenger” and direct their distress toward the therapist. Similarly, the therapist must carefully navigate a partner's desire to be totally focused on the patient's needs, resulting in extreme and excessive self-sacrifice and the potential for caregiver exhaustion. Otherwise, the therapist can appear to be out of tune with the partner's beliefs and values regarding how to be a good partner at such times, and the therapist can be viewed as suggesting that the partner be selfish or not appropriately responsive to the patient who is well loved. In essence, the medical condition creates a whole array of worries and concerns regarding mortality, loss and limitations, and how the couple's relationship can and should be altered as they progress through recovery or the disease process. Whereas such issues can be difficult to navigate for both the couple and the therapist, there is the potential for the therapeutic relationship to serve as an important support and source of safety in a landscape that the couple is traversing, often for the first time.
a research agenda for assisting couples with medical problems Couple-based interventions for medical problems are still in an early stage of development and evaluation. Therefore, a research agenda for this domain in many ways mirrors such an agenda for any area of psychotherapy research in the early stages, including the need for additional randomized controlled trials to establish the efficacy of the interventions for a host of medical conditions,
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dismantling studies to isolate effective components of treatment, and so on. Within this context, it is important to clarify the outcomes of interest; that is, is the goal of treatment to alter the course of the medical problem itself or improve medical symptomatology, optimize the individual psychological well-being of each partner, or improve the couple's relationship? At this early stage in conducting treatment outcome research with these populations, the impact of couple-based interventions across these domains is unclear and likely will vary depending on the medical issue being addressed and the specifics of the intervention. Also of great importance are comparisons evaluating whether a similar amount of therapeutic effort is best focused on intervening with the patient alone, the couple as a unit, or some combination of the two. Likewise, there might be instances where a broader family focus, including grown children, for example, would be most appropriate, but such variations in family involvement are yet to be explored. Also, it is impractical and likely unnecessary to think that all couples need intervention each time one partner has a notable medical complication, so it is essential to clarify which couples will benefit most from couplebased interventions for specific disorders. Finally, at a time in their lives when both partners might be frightened by the medical condition, the role of common factors such as a caring, supportive therapist who establishes a positive therapeutic alliance might be of particular importance; such investigations of common factors in couple-based interventions for medical problems still await.
Conclusions Within the field of couple-based interventions, interventions to assist couples with medical problems are in the early stages of development and evaluation. In large part, this is because this approach lies at the intersection of two disciplines, each of which have had somewhat different emphases. Traditionally, couple-based interventions have focused upon altering the couple's relationship rather than attending to individual difficulties of one person. On the other hand, behavioral medicine and health psychology have focused upon psychological interventions for medical problems, but typically from an individual perspective. The current approach integrates these two disciplines in what we believe is an exciting and potentially beneficial manner. In order for couple therapists and researchers to be maximally attuned to couples, they must be responsive to the wide range of experiences that couples will have over the course of their relationships. Given the almost inevitable development of medical complications
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R E C E I V E D : August 2, 2010 A C C E P T E D : January 28, 2011 Available online 30 May 2011