Hold me tight : A Couples Group Intervention for Cancer Patients and Their Partners

1. Session A6a (Period 6: 3:30-4:30; 25 minutes) Saturday, October 17, 2015 Hold me tight: A Couples Group Intervention for Cancer Patients and Their Partners Maureen Davey, PhD, LMFT Associate Professor Drexel University Department of Couple and Family Therapy Laura Lynch, PhDCollaborative Healthcare Clinical Practice Educator Drexel University Department of Couple and Family Therapy Collaborative Family Healthcare Association 17thAnnual Conference October 15-17, 2015 Portland, Oregon U.S.A.

2. Disclosures The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

3. Learning Objectives • At the conclusion of this session, participants will be able to: • Describe an adapted brief (5-sessions) couple support group intervention for couples coping with cancer in a partner or a spouse • Describe findings from a program evaluation study designed to evaluate effectiveness of the intervention (Hold Me Tight; HMT) adapted for diverse samples of couples coping with cancer • Describe strategies for improving engagement and retention of diverse samples of couples coping with cancer and improving collaboration with oncology providers and cancer centers.

4. Selected References • Badr, H. & Krebs, P. (2012). A systematic review and meta-analysis of psychosocial interventions for couples coping with cancer. Psycho- Oncology. DOI: 10.1002/pon.3200 • Fitzgerald, J., & Thomas, J. (2012). A report: Couples with medical conditions, attachment theoretical perspectives and evidence for emotionally-focused couples therapy. Contemporary Family Therapy, 34(2), 277-281. doi:10.1007/s10591-012-9184-8 • Johnson, S. (2009). The Hold Me Tight Program: Conversations for Connection. International Centre for Excellence in Emotional Focused Therapy: Ontario, Canada. • McLean, L. M., Walton, T., Rodin, G., Esplen, M. J., & Jones, J. M. (2013). A couple-based intervention for patients and caregivers facing end-stage cancer: Outcomes of a randomized controlled trial. Psycho-Oncology, 22(1), 28-38. doi:10.1002/pon.2046 •  Regan, T. W., Lambert, S. D., Girgis, A., Kelly, B., Kayser, K., & Turner, J. (2012). Do couple-based interventions make a difference for couples affected by cancer? A systematic review. BMC Cancer, 12(1), 279-279. doi:10.1186/1471-2407-12-279

5. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted during and at the end of this presentation.

6. Prevalence How many couples are coping with cancer? • In 2012 • Over 7.8 million male-female unmarried couple households • Over 61 million male-female married couple households • Over 6 million same-sex couple households(US Census Bureau, 2012) • In 2014 • Over 1.6 million new cases of cancer (American Cancer Society, 2014)

7. Racial Cancer Health Disparities • Black men and women have highest cancer-related mortality rates of any racial group in the U.S. for the most common types of cancer (CDC, 2010) • Latina women have the highest incidence of cervical cancer, followed by African American/Black women (NCI, 2008) • Asian Americans and Pacific Islanders have the highest rates of liver and stomach cancer, and mortality rates twice that of White individuals (NCI, 2008)

8. Socioeconomic Cancer Health Disparities • Counties where 20% percent or more of residents are below the poverty line tend to have cancer mortality rates 13% higher than individuals who live in wealthier counties (Ward et al., 2004) • Individuals with lower SES are more likely to smoke, be obese, and have a higher alcohol intake (cancer risk factors), and are also less likely to get screened for cancer (NCI, 2008)

9. Adult Attachment • Based on attachment theory (Bowlby, 1980) • Importance of a secure attachment (responsive, attuned) between primary caregiver and infant/child • Linked to improved social and emotional adjustment across the lifecycle; Impacts intimate relationships in adulthood (Hazan & Shaver, 1987) When a couple experiences a stressor like cancer, attachment behaviors are activated similar to how they are activated in childhood

10. Limitations of Existing Interventions for Couples Coping with Cancer • Lack of racial and socioeconomic diversity in samples (Badrand Krebs , 2013; Baik & Adams, 2014; Li & Loke, 2014) • Most are cognitive-behavioral and/or educational interventions versus focusing on emotion or targeting couple attachment (secure) • Most studies have not measured relational outcomes(some only measured patients’ outcomes and not partners’ outcomes) • Included partners were typically an assistant, coach, or support person for the cancer patient

11. Hold Me Tight Intervention • Hold Me Tight (HMT) Couple Intervention Program: Conversations for Connectiondeveloped by Dr. Susan Johnson (2009) • Helps couples repair and strengthen relationship by targeting emotions and facilitating secure attachment in smaller support group settings • Based on empirically-supported Emotionally Focused Couples Therapy (EFT)

12. Why Hold Me Tight? • Couples coping with cancer tend to have less intimacy and lower relationship satisfaction (Hagedoorn et al., 2008) • HMT targets couple attachment to improve relationship satisfaction • Elevated rates of depression and anxiety (Couper et al., 2006) among cancer patients andtheir partners/spouses • Emotionally Focused Therapy (EFT), model underlying HMT associated with decreased depressive symptoms

13. Why Hold Me Tight? • Sexual issues (e.g., libido, sexual dysfunction, body image, pain) are commonly reported by female and male cancer patients, but not often addressed by oncology providers In HMT session # 4 is dedicated to facilitating more open communication between partners about these sensitive intimacy issues • Compared to traditional couples therapy (up to 20 sessions), a structured short-term couple support group intervention is more feasible and also provides social support HMT group facilitators help partners openly share concerns about cancer treatment, coping, and adjustment and receive support from other couples

14. Adaptation of Hold Me Tight Intervention for Couples Coping with Cancer • First adaptation (first cohort) • Reduced from 8 to 6 sessions (2 hours per session every other week over 12 weeks) • Final Adaptation (second and third cohorts) • 5 sessions (2 hours per session every other week for 10 weeks) • Reduced from 8 to 5 sessions so adapted HMT intervention is more feasible for couples navigating cancer treatment • Decreased content in first session to prevent fatigue, after completing baseline psychosocial assessments • During assessments (baseline and post-intervention), graduate student volunteers read each question aloud to participants (participants could also opt out)

15. Final Adapted HMT Intervention Session 1:Group Introductions • Join with group members & overview of HMT Session 2:Recognize Demon Dialogues • Negative interactional cycles, underlying feelings, unmet attachment needs, attachment behaviors Session 3:Finding the Raw Spots & Becoming Open and Responsive • Accessibility, responsiveness, and engagement Session 4:Bonding through Sex & Touch Session 5:Caring for Yourself & Your Relationship

16. Program Evaluation Study • Assess intervention acceptability and feasibility • Recruitment and retention rates • Participants’ reasons for refusal or dropout • Participant (couple) satisfaction after completing the intervention • Pilot-test treatment efficacy • Compared pre-intervention and post-intervention measures for couple participants • Psychological (BDI-II) • Relationship satisfaction (RDAS) • Attachment (BARE) • Impact of cancer and Quality of Life (IES and FACT-G for patients only)

17. Procedures • IRB approval of Adapted HMT intervention delivered by 2 White female senior (EFT-certified therapists) group facilitators and 2 African American assistant group facilitators (preliminary EFT training) • All senior and assistant facilitators trained in adapted treatment manual, prior to first cohort by Dr. Ting Liu (EFT-certified therapist and master EFT trainer) • All sessions rated with fidelity checklist by 2 coders; Dr. Liu provided ongoing clinical supervision • Assessments conducted at baseline immediately prior to first session and at end of intervention • Data entered, checked, and analyzed using SPSS 20.0

18. Demographic Profile of Couples • 7 eligible couples completed study (N=14 participants) • Primarily African American (12 African American; 1 White; 1 Asian) • Most Baptist (71.4%) • Lower to middle class; all heterosexual • Most married (n=5 couples), 1 engaged, 1 committed relationship • Years married ranged from 0.33 to 41 years • Age (average= 50 years old) • Patients: 27 to 63 years; mean age of 48.6 years • Partners: 31 to 64 years; mean age of 49.0 years • Only one couple was under age of 40

19. Demographic Profile of Patients • Breast cancer most common type (n=3); stomach (n=1); prostate (n=1); gynecological (n=1) • Stage 1 (n=3); stage 2 (n=2), stage 3 (n=1), stage 3a (n=1) • Most cancer patients had cancer for the first time (n=5), not recurrence • All cancer patients (n=7) were in treatment (chemotherapy, radiation) at pre-intervention

20. Film Clip

21. Aim 1: Acceptability and Feasibility • Adapted HMT (5 sessions) acceptable based on participants’ positive CSQ and HMTCRS scores (high scores for both patients and partners) and narrative feedback • 25 couples recruited over 13 months (slow rate of recruitment at one clinic) • 2 couples referred each month and 1 out of 2 couples recruited each month (50% rate of recruitment) • Out of 25 referred couples, 12 volunteered (N=24) (1 couple excluded because not in a relationship with each other) • 4 out of 11 eligible recruited couples dropped out after baseline assessments and first session (work conflict, side effects from treatment): (64% retention rate) • Retention rate significantly increased after first cohort (3 couples dropped out of 1st cohort; only 1 couple dropped out of second cohort, 0 couples dropped out of third/last cohort)

22. Aim 2: Pilot Test Treatment • Patients’ and partners’ scores on all outcome measures changed in positive/improved direction at post-intervention; only a few measures significantly changed over time • Repeated measures ANOVA (2 factors): total RDAS and IES scores for all participants combined significantly improved from pre-intervention to post-intervention (medium to large effects); no partner effects, only time • Relationship satisfaction (RDAS total) and negative impact of cancer (IES total) improved for both patients and partners after completing HMT • Results suggest HMT positively impacts both patients’ and partners’ outcomes and targets the relationship

23. Limitations Open trial one-arm design • No control group to control for time Generalizability • Primarily African American sample, low to middle income, and heterosexual Multiple cancer stages and types • Could be differences in effectiveness due to stage and type of cancer Possible during each iteration group facilitators became more skilled • 1st cohort: slightly different adaptation (6 sessions) • 2ndand 3rd cohort experienced more cohesive HMT treatment team

24. Clinical Implications • Positive feedback and findings for relationship satisfaction and traumatic impact of the cancer diagnosis suggest adapted HMT intervention is a promising intervention for couples coping with cancer • Intervention acceptable for primarily African American low to middle income sample of couples living in an urban area • Medical and mental healthcare providers should routinely screen and assess quality of the couple relationship at diagnosis and throughout cancer treatment • Partner also impacted by cancer: importance of treating the couple, and not just focusing on patient’s quality of life

25. Future Research Cancer Health Disparities • Evaluate HMT with more underserved populations • Larger samples of couples followed over time(6 month, 1 year follow-up) • Analysis of multiple key factors (covariates) • Stage and type of cancer, gender of ill partner • Two-group comparison to control for time • Treatment-as-usual group vs. different couple-based interventions for cancer patients and their partners/spouses • Include couples with mild to moderate distress & cancer survivors

26. Strategies to Improve Engagement & Retention of Diverse Samples of Couples Build Trust and Join Starting with First Phone Call • Engaging recruitment style • Build trust at first contact using letters, texts, phone calls • Check in throughout care Remove Treatment Barriers • Child Care at Groups • Convenient Time and location • Help with transportation, provide refreshments Consideration of How Treatment is Disseminated • Acceptable to diverse populations of patients and their families • Provided in a wide variety of clinical settings, for example, primary care, community health centers, private practice settings (D’angelo et al., 2009; Gladstone et al, 2015).

27. Questions and Comments

28. Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!