Partner-assisted emotional disclosure for patients with gastrointestinal cancer: results from a randomized controlled trial

For patients with cancer who are married or in an intimate relationship, the relationship with their partner plays a critical role in adapting to their illness.1–3 Both patients and partners often perceive social support and family functioning to diminish in the year following a cancer diagnosis,3–5 suggesting that some couples may be at risk of relationship distress as a result of the burdens imposed by the cancer experience. One factor that may lead to deteriorations in patient-partner relationships is the challenge of communicating effectively about cancer-related concerns. Married cancer patients tend to rate their spouses as their most important confidant,6, 7 however, cancer patients often feel constrained in talking about their concerns with their partners, and partners often withdraw or distance themselves from the patient's emotional distress.2, 6, 8–10 These avoidant patterns are present even in even in relationships that are satisfying.11 Patients' inability to talk openly with their partners about their cancer-related concerns may ultimately compromise the quality of the patient-partner relationship as well as the patient's psychological adjustment Emotional disclosure – defined as the expression of information that is personal, private, and emotional in nature12 – is a central component of the emotional support (e.g. love, concern, and understanding) that partners provide to each other.13, 14 The construct of emotional disclosure has been operationalized as both (a) the degree to which individuals express their thoughts and feelings, and (b) the degree to which they hold back from doing so. While expression and holding back may be seen as opposites of each other, they are in fact only moderately negatively correlated (e.g., −.3215 to −.3816), suggesting that they may represent orthogonal constructs. Holding back may reflect active inhibition of expression rather than a general tendency towards inexpression. Prior studies suggest that high levels of holding back, more so than low levels of expression, are significantly associated with poorer relationship functioning and increased psychological distress.16, 7 To date, however, all of the studies in this area have been correlational, thus it is not possible to draw causal conclusions about the effects of disclosure or holding back. A number of studies, including several studies conducted with cancer patients,17–20 have shown that expressive writing protocols can produce improvements in psychological and physical well-being (e.g., improved affect, decreased psychological distress and self-reported symptoms).21, 22 In these protocols, participants typically write for 15–20 minutes over several sessions about their deepest thoughts and feelings regarding stressful experiences. In this paradigm, disclosure is private and anonymous; participants are alone when they disclose and their disclosures are not shared with anyone other than the researchers. When applied to patients with cancer, this intervention has been found to lead to improved sleep and vigor in patients with metastatic renal cell cancer17 and to significant reductions in physical symptoms and medical appointments among patients with breast cancer.18 In a separate tradition, increasing emotional disclosure between spouses is often a focus of cognitive-behavioral couple therapy23, 24 A large body of empirical literature demonstrates that in a variety of settings, cognitive-behavioral interventions for couples can significantly improve both individual adjustment and relationship functioning.25 Cognitive-behavioral couple interventions focus specifically on learning relationship skills such as communication. Increases in emotional disclosure that occur during the course of cognitive-behavioral couples therapy have been linked to enhanced intimacy and marital satisfaction.26 However, to our knowledge, the potential benefits of facilitating disclosure regarding cancer-related issues between cancer patients and their partners have not been addressed. There are several reasons why increasing emotional disclosure between cancer patients and their partners is likely to lead to benefits for couples' relationships. First, as noted above, increasing emotional disclosure may lead to increases in intimacy and relationship satisfaction.27 Second, helping couples to discuss their cancer-related concerns may help partners have a better understanding of patients' needs, and to provide more effective support. In addition, it is possible that patients may derive the same individual psychological benefits from disclosure to their partner as they do from private emotional disclosure protocols. Finally, partners may benefit from hearing the patients talk openly about their concerns. Often a partner senses when the patient has concerns and is not expressing them, and this can lead to increase distress for the partner; when the patient shares his/her concerns, the partner may experience this as a relief. The purpose of this study was to evaluate the efficacy of a new partner-assisted emotional disclosure protocol for patients with GI cancer. GI cancers make a particularly good model in which to study the effects of this protocol for several reasons. First, they are common, with colorectal cancers being the third leading site of cancer occurrence and cancer mortality for both men and women. 28 Second, they are often discovered at advanced stages when the prognosis for survival is poor. 28, 29 While treatments have been shown to improve survival, tumor control, and quality of life due to relief of tumor-related symptoms, these treatments are often associated with significant toxicities. Patients report multiple disease and treatment-related side effects including fatigue, pain, difficulty eating, weight loss, problems with bowel function, and sexual problems.29–32 Many patients also experience significant emotional distress including disturbances in body image, anxiety and worry, depression, and fears of disease progression and death.3, 29–32 Thus, the diagnosis and treatment of GI cancer poses numerous physical and psychological challenges for patients as well as their loved ones. The partner-assisted emotional disclosure intervention was designed to systematically train patients and partners in strategies to facilitate the patients' disclosure and give the patient the opportunity to talk about their cancer-related concerns to their partner. We hypothesized that the intervention would lead to improvements in relationship quality, intimacy, and psychological distress for patients and their partners relative to an attention control condition. In addition, we conducted exploratory analyses examining whether intervention effects differed by gender or by the degree to which patients reported holding back from disclosing cancer-related concerns to their spouse at baseline.