Findings from this study suggest that a brief, couple-based intervention that specifically targeted communication of cancer-related thoughts and feelings in patients with GI cancer led to improvements in relationship quality and intimacy for couples in which the patient initially reported higher levels of holding back from discussing cancer-related concerns. This finding is noteworthy in light of the brevity of the intervention, the length of marriage among couples in the study (mean=24 years), and the severity of the patient's illness (two-thirds of the patients were diagnosed with Stage 4 cancer). Improving the quality of the couple relationship is particularly important in this population due to their shortened life expectancy and the vital role that spouses play in patients' care at the end of life. This study had a number of methodological strengths including comparing the partner-assisted emotional disclosure intervention to a couples cancer education/support condition that controlled for time and attention given to the patients and partners, and the use of sophisticated data analytic techniques (e.g., multilevel models) that are uniquely suited to analyzing data from couple-based interventions.40, 41
“Holding back” likely reflects patients' active inhibition of disclosing their cancer-related concerns with their partners rather than a general tendency towards inexpression. Thus, patients who report high levels of holding back may want to discuss these concerns but may be reluctant to do so. It is interesting to note that, on average, patient's levels of holding back as assessed at baseline were quite low (mean=0.82, SD=0.99, range=0–4). Thus, even patients considered “high” in holding back did not indicate that they held back from discussing their cancer-related concerns with their spouse to a large degree. These levels of holding back are similar to what we found in a previous study with the same patient population.16
However, even this relatively modest degree of holding back was associated with significantly poorer individual and relationship functioning.16
Results from this study suggest that helping patients to overcome their reluctance to express their concerns may lead to significant improvements in the quality of their marital relationships and in the amount of intimacy they share with their spouse. This is consistent with research indicating that disclosure of personal, vulnerable information is a central component of intimacy13, 14
which is in turn closely linked to relationship satisfaction.27
Contrary to our hypotheses as well as to the literature on private emotional disclosure, the intervention did not lead to improvements in psychological distress among patients or partners. One possible explanation for this lack of findings is that, although the intervention was designed to facilitate patient disclosure, patients may have been unable to disclose their thoughts and feelings to their partner (and in the presence of a therapist) to the extent that they would have in a private disclosure protocol. Some patients may have felt inhibited about sharing their thoughts and feelings with their partner and/or the therapist. Alternatively, the sessions' dual focus on both the patient's disclosure and on the dyad's communication processes may have distracted the patient from expressing and processing their thoughts and feelings to the same extent that they would have in a private disclosure protocol. Another possibility is that patients may have felt that their disclosure was burdensome to their partners, and that this sense of burden off-set any psychological benefits of disclosure. Importantly, however, there was no evidence that the partner-assisted emotional disclosure sessions led to increased psychological distress for patients or partners. Finally, it is possible that the effects of the intervention were dampened by the fact the many couples did not receive all four sessions. Future studies of partner-assisted emotional disclosure should consider strategies to increase retention in the intervention, such as offering home-based sessions or targeting patients with less advanced disease. It may also be necessary to increase the number of sessions so that patients become more comfortable with the setting and the communication guidelines and have more opportunity to disclose. In addition, future studies should explore the possibility that the two formats of disclosure – partner-assisted versus private – have different effects. Partner-assisted protocols in which patients disclose their concerns to their partner may be more effective in enhancing couples' relationships, whereas private disclosure protocols in which patients write about their thoughts and feelings may be more effective in reducing patient's psychological distress. If so, then treatment can be targeted according to the specific needs of the patient and the couple.
Due to the focus of the intervention on patient disclosure, it is perhaps less surprising that partners did not benefit in terms of reduced psychological distress. While many partners expressed appreciation for the opportunity to hear the patient discuss his/her concerns, it was also at times difficult for them to listen to the patient describe painful experiences and emotions, particularly because partners were asked to refrain from reassuring the patient or giving advice or suggestions. Thus, any benefits for partners may have been off-set by increased burden from listening to the patient's concerns. However, as noted above, partners did not experience increases in distress as a result of the partner-assisted emotional disclosure intervention. Given the high burden of cancer caregiving43, 44
, particularly when the patient has advanced disease45, 46
, particular attention should be given to developing interventions that may help alleviate partner distress. Enhancing cancer-related communication between partners may ultimately benefit both patients and partners if it leads to increased relationship functioning and a shared understanding about the meaning of the illness experience. One interesting direction for future research would be to explore the relative benefits for patients and partners of including a more reciprocal approach to disclosure (e.g. partners disclosing to patients as well as patients to partners). In addition, longer-term effects of the partner-assisted emotional disclosure intervention should be examined as it is possible that short-term improvements in relationship satisfaction could potentially lead to improvements in individual psychological well-being for patients and/or partners.
These findings build on the literature on private emotional disclosure which has found that writing about cancer concerns can lead to benefits for patients with cancer17–19
. To our knowledge, this is the first study of cancer patients that has applied a disclosure paradigm in the context of a patient disclosing to their spouse or intimate partner. There are several reasons that partner-assisted disclosure is particularly appropriate for cancer patients and their partners. The diagnosis and treatment of most cancers places major demands not only on patients but their partners as well. Although patients and partners must work together to meet these demands, communication particularly about emotionally related topics can be challenging even in relationships that overall are strong. The results of the current study are promising in showing that a brief intervention targeting patient disclosure to their partner can be beneficial for couples' relationships. Future studies are needed to replicate these findings in patients and partners who are coping with other types of cancer (e.g. breast cancer, prostate cancer, or lung cancer).
From a clinical perspective, the findings of this study suggest that psychologists, social workers, and other mental health professionals working with GI cancer patients may want to identify patients who tend to hold back from expressing their cancer-related thoughts and feelings to their partners, and work with them and their partners to help facilitate communication. In the current study, the only demographic or medical variable associated with holding back was age, indicating that younger patients were more likely to hold back. This is consistent with clinical impressions that younger patients often have more difficulty coping cancer. Overall, despite the fact that most couples reported having strong relationships at baseline, many commented on the fact that the treatment sessions were helpful in enhancing their relationship further in that they gave them the opportunity to discuss important issues that they had previously avoided. Similar to what has been reported in previous studies,6–8
patients often noted that their biggest need was for someone to listen to them, and that it was helpful to be able to express their concerns more openly to their partner. Partners, on the other hand, often found it difficult not to respond to the patient's concerns with reassurance or problem-solving, but over the course of the sessions learned to appreciate that validating the patient's concerns was more helpful to the patient and also resulted in a higher degree of patient disclosure.
Several limitations need to be kept in mind when interpreting the results of this study. First, the participation rate in this study (25%) is somewhat lower than that obtained in other recent couple-based or caregiver-assisted studies with cancer patients (range= 34% 47, 48
), possibly due to the fact that many of the patients approached about participation were quite ill. Patient illness was a significant factor in attrition as well. Recruitment and retention were also likely hampered by the fact that participation required that couples attend four, face-to-face sessions. Future studies could test the efficacy of telephone- or internet-based interventions that could be made available to a wider population of couples. A second limitation is that the couples who participated in this study on average reported high levels of relationship quality. The findings may not generalize to couples who are more distressed who quite likely need a more lengthy and intensive intervention. Third, the results of the study likely reflect the sample of patients who participated who tended to be well-educated and have advanced disease. The gender composition of the sample (more male than female patients), may have also influenced the pattern of results. Women have been found to self-disclose more than men, although this difference diminishes in the context of heterosexual relationships14, 50
and was not evident from the baseline data of the current study. Gender differences in response to written emotional disclosure interventions have also been found.22
Thus, it is possible that the results would not generalize to samples of female patients, or to contexts other than heterosexual romantic relationships
Taken together, the results of this study suggest that future research on partner-assisted emotional disclosure is warranted. This is a novel intervention that builds on both the private emotional disclosure and the cognitive-behavioral marital therapy literature. While the benefits in the current study were reflected primarily in indices of the quality of the couple's relationship, it is possible that these short-term improvements in relationship quality and intimacy could be associated with longer-term improvements in both patient and partner individual functioning. In addition to examining longer-term effects, future research could also explore methods of enhancing the effects of the intervention, such as using a mixture of lab-based and home-based partner-assisted disclosure sessions, increasing the number of sessions, and/or exploring the relative benefits of having partners disclose to patients as well as patients to partners. In addition, future research needs to focus on more distressed couples for whom more intensive approaches are likely necessary. Given the important role that partners play in patients' adaptation to cancer, it is critical to help patients and partners communicate effectively about their cancer-related concerns.
Partner-assisted emotional disclosure is a brief intervention focused on facilitating the cancer patient's emotional disclosure to his/her partner. Results from this study suggest that this intervention led to increases in relationship quality and intimacy for couples in which the patient initially held back from disclosing cancer-related concerns.