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Coping with Cancer Interventions for the Family
Cancer & Family  continuing education counselor CEUs

Section 24
Martial Attachment and Cancer

CEU Question 24 | CE Test | Table of Contents | Cancer
Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs

Many cancer patients are living and surviving long after their initial diagnoses and treatments (Andersen et al., 1994). Cancer treatment has expanded its concerns for patients' survival to include the ongoing adjustment of patients and their families. While many people are able to weather the storm of the diagnosis and treatment of cancer with few negative consequences, a sizable minority of patients and family members experience ongoing relational, psychological, and health-related distress. The struggles are especially salient for older couples managing cancer. The treatment of cancer frequently involves aggressive, invasive procedures such as surgery and chemotherapy followed by extensive monitoring of the patient for signs of recurrence. Such procedures place a burden on patients and family members (Zarit et al., 1998). Marital and family relationships may be affected by the presence of cancer and may in turn serve as a resource to buffer the effects of cancer on patients' and family members' quality of life (Smith & Nicassio, 1995; Weihs & Reiss, 1996).

Attachment theory has historically been concerned with individuals' responses to separation or threats of separation from or loss of their attachment figures (Bowlby, 1969). In response to a threat, individuals seek proximity to their attachment figures. From an attachment theory perspective, cancer represents a threat to the attachment relationship between spouses. This causes people to seek proximity to their partner. Those with more secure attachment styles are thought to be more successful in gaining and maintaining proximity because they are more aware of their own and their partner's emotional needs and use open communication with their partners.

Marriage and cancer                                                       
In this section, we review the literature on marriage and cancer. Most of the studies of marital factors and cancer have been done on small samples. We will describe studies that included 20 or more couples. Our literature review will show the following. In response to cancer, patients and spouses may seek increased closeness to each other (attachment behavior). The diagnosis of cancer may affect couples' marital satisfaction. However, factors that might explain the variance in marital satisfaction have not been studied. Marital functioning, especially open communication and emotional support, may affect emotional distress in patient and spouse. In most of these studies, marriage remains a black box, its internal functioning unexamined. None of these studies has employed a theoretical model of marital functioning in the face of a threat such as cancer.

Seeking proximity in response to cancer
Patients and spouses of both sexes experience simultaneously an increase in the desire for physical closeness.

Leiber et al. (1976) found that husbands and wives seek to gain and maintain proximity (attachment behavior) when their relationship is threatened by cancer. Thirty-eight patients and 37 spouses with mixed cancer diagnoses reported that they wanted to be physically closer even though they reported a decreased desire for sexual intercourse. Studies that are more recent have reported similar findings. In a study of 57 women with breast cancer, Friedman et al. (1988) found that those with the highest levels of psychological and marital adjustment also reported levels of cohesion (closeness) higher than published norms. In addition, no women desired less closeness, while 34% desired increased closeness. These studies offer support for the attachment theory notion that the diagnosis of cancer may propel couples to engage in attachment behavior, i.e. couples may engage in proximity-seeking in response to the threat of separation.

Cancer and marital satisfaction
Only a few studies have examined the impact of cancer on marital satisfaction. In a sample of 22 couples, Hannum et al. (1991) used the Locke-Wallace marital adjustment scale (Locke & Wallace, 1959) and found scores for marital satisfaction to be similar to published norms. In a sample of 78 breast cancer patients and their husbands, Lichtman et al. (1987) found similar results. Hoskins (1959) examined changes in marital satisfaction in a sample of breast cancer patients and husbands and found that husbands were less satisfied than wives 10 days after surgery, but at follow-up, patients were less satisfied than their husbands. None of these studies attempted to account for the variance in marital satisfaction by assessing other aspects of the marital relationship. It would appear that some couples, but clearly not all, experience decrements in marital satisfaction. These studies do not address the factors that may place some couples more at risk of experiencing marital distress.

Both patients and spouses experience emotional distress
Baider et al. (1998) found that both marital partners experience a similar level of distress, whether only one or both of them were diagnosed with cancer. In a study of 77 spouses of patients receiving cancer treatment, Rodrigue & Hoffmann (1994) found that almost one-third (29%) reported clinically significant levels of emotional distress. Goldberg et al. (1984) studied 21 cancer patients and their spouses and found depression scores decreased for both partners over time. Cassileth et al. (1985) found that patients reported more psychological distress than did spouses in a study of 201 cancer patients and relatives. Northouse & Swain (1987) found that patients and spouses had similar scores on mood problems and that both partners reported improved scores 1 month after surgery. In a sample of 41 breast cancer patients and spouses who were followed for 18 months after surgery, Northouse (1989) found that both reported psychological distress, though their scores decreased over time. Keitel et al. (1990) examined a sample of 43 cancer patients pre- and post-surgery and found that the spouses reported higher distress both before and after the surgery and that both partners reported lower distress levels over time. Ell et al. (1988) found, in a longitudinal study of 143 newly diagnosed breast cancer patients and spouses, that spouses' distress declined over time. Spouses who maintained a high level of emotional distress were married to patients who had higher levels of physical symptoms. Most studies found that distress levels of patients and spouses were similar and that they declined over time. However, a small percentage of patients and spouses remain emotionally distressed even after the immediate crisis of diagnosis and the beginning of treatment has passed.

Communication problems are associated with emotional distress
Even couples that report high marital satisfaction (Lichtman et al., 1987) admit to having communication problems, with the primary problem being the avoidance of discussions of cancer. Baider & Sarell (1984), in a study of 25 couples, found that even though 19 of 25 patients reported that they had discussed their cancer with their spouse, none of the spouses reported such conversations. Spouses reported isolation due to the lack of communication. In a study of 54 couples, Vess et al. (1985) found that couples who reported open communication reported more successful negotiations of role changes in the marriage. Spiegel et al. (1983) found that the open discussion of family and problems with a minimum of conflict was associated with less mood disturbance for patients in 1-year follow-up. It seems that, for a variety of reasons, some couples attempt to manage the stress of coping with cancer by not communicating. Insecurely attached spouses, especially those classified as avoidant, would be expected not to engage in open communication.

Spouse emotional support is correlated with patients' emotional distress
Emotional support from one's spouse is associated with lower psychological distress, especially at follow-up. Quinn et al. (1986), in a study of male lung cancer patients, found that patients who reported receiving greater levels of emotional support from their spouses reported lower levels of psychological distress on follow-up. Roberts (1994) found that emotional support from husbands was associated with lower emotional distress and fewer depressive symptoms in breast cancer patients. Northouse et al. (1995), in study of 108 women with recurrent breast cancer, found that emotional support from husbands was related to better role adjustment. Emotional support from all sources, including their husbands, was associated with lower levels of psychological distress for patients.

Social interaction in marriage is not solely positive. While the marital research literature has closely examined negative interactions, only a few studies have examined negativity in relationships of couples coping with cancer. Vinokur & Vinokur-Kaplan (1990), in a study of 274 women with breast cancer, found that receiving negative emotional support or undermining responses from their spouses was related to patients' depressive symptoms. Pistrang & Barker (1995), in a study of 113 breast cancer patients, found that openness and empathy in communication were related to lower levels of psychological distress. Manne et al. (1997) examined the positive and negative responses by spouses in a cross-sectional study of 158 mixed cancer patients. They found two types of negative responses: withdrawal and over critical statements. Husbands of female patients engaged in more withdrawal. The pattern of patients engaging in withdrawal and spouses engaging in criticism was more related to psychological distress than were reports of positive emotional support.

Attachment theory
Attachment theory has a long history of scholarship and research in cognitive and representational aspects of relationships. Bowlby (1969) first posited the development of internal working models in children of their relationship with their attachment figures. Main et al. (1985) was one of the first studies to specify the mental representational aspects of attachment, which were seen as the hallmark of adult attachment research. Main and her colleagues developed the Adult Attachment Interview (George et al., 1985) to assess cognitive representational aspects of attachment. Bartholomew & Horowkz (1991) also developed an interview and coding system to assess self and other relationship schemas. Collins & Read (1994) and Kobak & Hazan (1991) have also used similar interviews to assess cognitive aspects of attachment using Q sorts and other systems for coding the interviews. These systems attempt to assess the cognitive models individuals have of themselves and others (parents, peers, partners, or spouses) in relationships. Typically, they assess, to broad factors, the positively or negativity of the models and the level of awareness or 'meta-cognition' (Main et al., 1985) individuals have about their own working models. Attachment coding systems assess these cognitive aspects of working models and use them to classify individuals as having secure or insecure attachment.

Marital attachment and coping with cancer
Marital attachment has not been examined in older couples, let alone older couples coping with cancer. In studies of younger couples, attachment has been found to be related to open communication and less negativity (Kobak & Hazan, 1991) and to greater marital satisfaction (Feeney, 1996, 1999; Noller & Feeney, 1994). In studies with the other populations, attachment style has been found to covary with emotional distress (Birnbaum et al., 1997; Roberts et al., 1996).

Bowlby's (1969) theory emphasizes that working models need to accommodate change. During times of crisis, working models need to be flexible enough to incorporate and accommodate new experiences. Bowlby (1980) described this as revising or updating internal working models. We hypothesize that individuals whose working models are more accessible, and who engage in more perspective-taking, will be better able to accommodate new experiences, will engage in more open communication, and will be better able to manage negative emotions when they arise. Individuals who have more secure marital attachment styles will report greater marital satisfaction, fewer depressive symptoms, and greater perceived health. In addition, we conceptualize the diagnosis and treatment of cancer as a threat to the attachment relationship. In the face of cancer, individuals' marital attachment systems should be more activated than those of individuals who are not coping with a life-threatening illness. Therefore, we hypothesize that secure attachment will be especially salient for couples coping with cancer as compared to a group of couples not coping with an active life-threatening illness.

- Shields, C. G., Travis, L. A., Rousseau, S. L.; Marital attachment and adjustment in older couples coping with cancer. Aging and Mental Health; August 2000; Vol. 4, Issue 3

Personal Reflection Exercise #10
The preceding section contained information regarding martial attachment and cancer. Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Friedlander, M. L., Escudero, V., Welmers-van de Poll, M. J., & Heatherington, L. (2018). Meta-analysis of the alliance–outcome relation in couple and family therapy. Psychotherapy, 55(4), 356–371.

Müller, F., Hagedoorn, M., Soriano, E. C., Stephenson, E., Smink, A., Hoff, C., DeLongis, A., Laurenceau, J.-P., & Tuinman, M. A. (2019). Couples’ catastrophizing and co-rumination: Dyadic diary study of patient fatigue after cancer. Health Psychology, 38(12), 1096–1106.

Soriano, E. C., Otto, A. K., Siegel, S. D., & Laurenceau, J.-P. (2017). Partner social constraints and early-stage breast cancer: Longitudinal associations with psychosexual adjustment. Journal of Family Psychology, 31(5), 574–583.

Soriano, E. C., Pasipanodya, E. C., LoSavio, S. T., Otto, A. K., Perndorfer, C., Siegel, S. D., & Laurenceau, J.-P. (2018). Social constraints and fear of recurrence in couples coping with early stage breast cancer. Health Psychology, 37(9), 874–884.

Online Continuing Education QUESTION 24
What two negative response types were found most frequently among martial couples coping with cancer? Record the letter of the correct answer the CE Test.

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