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Original Article

In-session intimacy processes and treatment outcomes for 2 couple-focused interventions for prostate cancer patients and their spouses

Manne, Sharon L.a,∗; Kashy, Deborah A.b; Kissane, Davidc; Zaider, Taliad; Heckman, Carolyn J.e; Virtue, Shannon Myersf; Penedo, Frankg

Author Information
Journal of Psychosocial Oncology Research and Practice: June 2020 - Volume 2 - Issue 2 - p e19
doi: 10.1097/OR9.0000000000000019

Abstract

The specific long-term treatment effects of prostate cancer such as impaired sexual, urinary, and bowel functioning[1,2] can adversely affect psychological and relationship outcomes for both patient and partner.[3–6] Sharing concerns and reactions with one's partner about the cancer experience followed by a caring and empathic response fosters more effective management of prostate cancer-related stressors and can ultimately reduce adverse effects on the marital relationship. Both qualitative[7] and quantitative studies[4,8] have described the importance of open communication between men with prostate cancer and their spouses. Nevertheless, couples hold back sharing cancer-related concerns. Patients are more likely to hold back sharing concerns about finances and their job than spouses, and spouses are more likely to hold back sharing concerns about physical symptoms, cancer treatment, emotional reactions to cancer, and fears about disease progression.[9]High levels of holding back for patients have been noted for concerns about the sexual relationship with the spouse, and high levels of holding back for spouses have been noted for fears about patient disease progression.[9] It is possible that the focus on disclosure and responsiveness did not solve or address the concerns that couples identified in IET, and that increasing understanding and validation is only the first step in an effective couple-focused treatment for men who are experiencing sexual dysfunction and couples who are dealing with worries about cancer recurrence.

Among the few empirically based couple-focused interventions, 2 studies targeted patients’ communication about sexual concerns and did not show improvements in relationship satisfaction or quality of life.[10,11] Another study illustrated a reduction in illness uncertainty and an increase in relationship communication, but there were no benefits on patients’ quality of life.[12] We developed and evaluated an intimacy-enhancing therapy (IET) for men diagnosed with localized prostate cancer and their spouses[13,14] IET is primarily based on the interpersonal process model of intimacy15; and the Relationship Intimacy Model of couples’ psychosocial adaptation to cancer.[16] These models propose that intimacy is fostered when couples’ interactions are characterized by one's own and the perception of one's partner's disclosures that are followed by validating, caring, and understanding responses.[8,15,17,18] IET content focused on improving couples’ ability to openly share thoughts and feelings regarding cancer, promote mutual understanding and support, facilitate open discussion about cancer concerns, and developing strategies to maintain relationship intimacy. IET was compared with a General Health and Wellness intervention (GHW) and Usual Care (UC).[14]Results indicated that spouses enrolled in IET had greater increases in relationship satisfaction than spouses in GHW and UC between the baseline and 5-week follow-up. Treatment effects on all other outcome variables (psychological adjustment, depression, cancer-specific distress, and cancer concerns) were not significant. For couples in shorter relationships, patients in IET reported an increase in psychological adjustment, whereas patients in GHW did not. However, patients in UC also reported increases in their psychological adjustment over time. For spouses, both GHW and UC were superior to IET. Among couples in longer relationships, patients in IET reported greater increases in psychological adjustment than patients in UC, whereas patients in GHW reported similar gains. For spouses, psychological adjustment actually declined in GHW, whereas there were increases in adjustment for IET and UC. In sum, IET was superior to UC only for patients in longer relationships, and GHW was inferior to both IET and UC for spouses. Taken together, these findings suggest that IET had limited effects on couples’ psychological adjustment and relationship satisfaction.

To build more effective psychological therapies, it is important to understand reasons why treatments do not work. The most common approach to evaluate this is examining proposed mechanisms of change, which has traditionally consisted of assessing communication and conflict either during sessions or mid-treatment (eg, 19–24). Toward this end, we have begun examining the key intimacy processes targeted by IET. In a previous study, we evaluated levels of and changes in self-disclosure, perceived partner disclosure, perceived responsiveness, and closeness as experienced during therapy sessions.[25] Findings indicated that self-disclosure and perceived partner disclosure were higher, on average, during IET sessions than GHW sessions, but partner responsiveness and closeness during sessions did not differ. The findings suggest that IET enhanced disclosure more than GHW, but IET did not have a stronger impact on couples’ responsiveness or closeness during treatment sessions.

As a next step in examining intimacy processes’ role in treatment, we evaluated the associations between post-treatment outcomes and intimacy process variables reported during treatment. We used the actor–partner interdependence model (APIM) as a framework for this study. According to this model, when 2 individuals are in a relationship, and so are interdependent, each person's outcomes can be predicted from their own inputs (called actor effects) as well as their partner's inputs (called partner effects).[26] More specifically, this study aimed to: evaluate actor effects of intimacy processes (Do my average intimacy process ratings, and my changes in intimacy process ratings across therapy sessions predict my outcomes after therapy is completed? ie, actor effects) and partner effects of intimacy processes (do my partners average intimacy process ratings and his/her changes over therapy predict my post-therapy outcomes? ie, partner effects); examine whether self- and partner disclosure, perceived responsiveness, and closeness felt during sessions had stronger associations with post-treatment outcomes among couples enrolled in IET as compared with GHW. The primary outcomes examined in the initial therapy trial[14] were included. To address impact on relationship intimacy, a key component of the intimacy process, general relationship intimacy, was added as a treatment outcome.

1 Method

1.1 Participants

Men diagnosed with localized prostate cancer and their partners were recruited from 5 cancer centers in the Northeastern United States and 3 community hospital settings. The eligibility criteria were: treatment for nonmetastatic prostate cancer within the last 18 months; Eastern Cooperative Oncology Group[27] performance status score of 0 or 1; cohabitating for a year or more with a significant other of either gender; either patient or spouse had elevated cancer-specific distress reflected by a score at recruitment >16 (patient) or >17 (spouse) on the Impact of Events Scale (IES[28]); >18 years of age; no self-reported hearing impairment, and; lived within a 1-hour commuting distance of the center. The study was approved by each site's Institutional Review Board. Full recruitment details and the study CONSORT are provided for the intervention outcomes publication.[14]

Owing to the constraints of the analytic approach, couples were included in the present analyses if they attended at least 2 therapy sessions. Thus, of the 156 couples who were randomized to one of the treatments, 19 couples were excluded (N = 137). Comparisons of 137 participating couples with 19 couples who did not complete 2 sessions suggested that patients who completed ≥2 sessions reported significantly higher baseline psychological adjustment (t [154] = 3.51, P < .01) and lower depressive symptoms (t [154] = 2.79, P < .01). Spouses who completed ≥2 sessions reported significantly lower depressive symptoms at baseline (t [154] = 3.09, P < .05). There were no differences with regard to demographic or medical variables or other outcomes.

1.2 Procedures

Participants completed post-session measures of level of self- and partner disclosure, partner responsiveness, and closeness experienced during sessions. Participants also completed surveys at home at 2 assessment time-points: Preintervention (baseline) and 6 months post-baseline (Follow-up). To improve clarity, we use the term “spouse” in this manuscript to refer to the patient's partner, whether legally married or not. This decision was made to distinguish this role from the term “partner” in the actor-partner interdependence statistical approach used.

1.3 Interventions

Detailed information about IET and GHW, treatment attendance, fidelity, and evaluation can be found in Manne et al.[14]

1.4 Measures

1.4.1 Intimacy processes rated after each session

Self-disclosure. Three items assessed the degree to which participants disclosed thoughts (“How much did you disclose your thoughts to your partner?”), information and facts (“How much did you share information and facts to your partner?”), and feelings (“How much did you share your feelings and concerns with your partner?”) during the session on a 7-point Likert scale (1 = not at all, 7= very much). The measure was adapted from Laurenceau et al's work[17] and has been used in our previous work.[13] Across sessions, internal consistency as calculated by Cronbach alpha ranged from .92 to .96 for patients and .86 to .93 for spouses.

Perceived Partner Disclosure. Three items assessed the degree to which participants perceived their partner disclosed thoughts (“How much did your partner disclose thoughts to you?”), information and facts (“How much did your partner share information and facts?”), and feelings (“How much did your partner share feelings and concerns with you?”) during the session on a 7-point Likert scale (1= not at all, 7 = very much). The measure was adapted from Laurenceau et al's work[17] and has been used in our previous work.[13] Across sessions, internal consistency as calculated by Cronbach alpha ranged from .93 to .97 for patients and from .92 to .96 for spouses.

Perceived responsiveness. Three items assessed the degree to which participants felt accepted (“To what degree did you feel accepted by your partner?”), understood (“To what degree did you feel understood by your partner?”), and cared for (“To what degree did you feel cared for by your partner?”) during the session on a 7-point Likert scale (1 = not at all, 7= very much). The measure was adapted from Laurenceau et al's work[17] and has been used in our previous work.[8] Across sessions, internal consistency as calculated by Cronbach alpha ranged from .88 to .92 for patients and .90 to .95 for spouses.

Closeness. Participants rated how close they felt to their partner during the session using 2 items: “How close did you feel to your partner?” and “How emotionally intimate did you feel toward your partner?”, on a 7-point Likert scale (1 = not at all, 7= very much). Across sessions, internal consistency as calculated by Cronbach alpha ranged from .84 to .91 for patients and .85 to .96 for spouses.

1.5 Treatment outcomes (baseline and follow-up)

1.5.1 General psychological adjustment

The Mental Health Inventory, (MHI)29 is a 38-item measure in which items assess both well-being (eg, “How happy, satisfied, or pleased have you been with your personal life?”) and distress (eg, “How much of the time have you been a very nervous person?”). Higher scores indicate better adjustment. At baseline, coefficient alpha was .97 for both patients and spouses. At follow-up, coefficient alphas were .97 for patients and .96 for spouses.

1.5.2 Depressive symptoms

The Patient Health Questionnaire-9 item version (PHQ-9) is the 9-item depression module from the full PHQ.[30] At Baseline, coefficient alphas were .84 for patients and .85 for spouses. At follow-up, coefficient alphas were .86 for patients and .80 for spouses.

1.5.3 Cancer-specific distress

Patients and spouses completed the Impact of Events scale,[28] which is a 15-item scale measuring the severity of intrusive thoughts, worries, and feelings about having (or one's spouse having) cancer, avoidance, and numbing. At baseline, coefficient alpha was .91 for patients and .93 for spouses. At follow-up, coefficient alphas were .92 for patients and .93 for spouses.

1.5.4 Cancer-related concerns

Patients and spouses rated the degree to which they were concerned about 10 cancer-related problems. Ratings ranged from 1 = not at all concerned to 5 = extremely concerned. Items were averaged. At baseline, coefficient alpha was .83 for patients and .93 for spouses. At follow-up, coefficient alphas were .83 for patients and .85 for spouses.

1.5.5 Relationship satisfaction

Patients and spouses completed the 32-item Dyadic Adjustment Scale, which is the most widely used measure of relationship functioning and satisfaction.[31] Scores can range from 0 to 151; scores <97 indicate relationship distress. Higher scores indicate greater satisfaction. At baseline, coefficient alphas for patients were 93 and spouses were .94. At follow-up, coefficient alphas were .95 for patients and spouses.

1.5.6 General Relationship Intimacy

The Personal Assessment of Intimacy in Relationships[32] was used. Ratings ranged from 1 = does not describe me/my relationship very well at all to 5 = describes me/my relationship very well. Items were averaged. At baseline, internal consistency was .87 for patients and .89 for spouses. At follow-up, coefficient alphas were .87 for patients and .85 for spouses.

1.6 Covariates

1.6.1 Demographic information

Age, ethnicity, sex, education level, income, occupational status, relationship (married, cohabitating), and length of marriage/relationship were collected.

1.6.2 Medical Information

Gleason score, disease stage, treatment type, and time since the initiation of treatment were collected from the medical chart. Patients completed the Bowel function (IIEF-BF) subscale of the International Inventory of Erectile Function (IIEF-ED).[33] Coefficient alpha was .85 for the Bowel Function scale.

1.7 Approach to analyses

A 2-step approach was taken for these analyses. The first step involved using SAS Version 9.4 to estimate separate growth model parameters for each person (ie, both patients and spouses) in the study. These growth models used couple-mean centered weeks since session 1 as the predictor and each intimacy process variable as the outcome. Thus, these analyses generated separate intercepts and slopes for each of the 4 session variables (self-disclosure, perceived partner disclosure, perceived responsiveness, and closeness) for each person. For example, the intercept for a person's self-disclosure estimates the person's average disclosure over the sessions and the slope estimates the degree to which a person's disclosure changes over time for that person. We then used these intercepts and slopes as predictors of the 6-month treatment outcomes using an APIM approach with MLM.[26] Thus, using session self-disclosure predicting psychological adjustment as an example, predictors included the person's own intercept and slope for self-disclosure, as well as the person's partner's intercept and slope for self-disclosure. The actor intercept effect measures whether the person's average level of self-disclosure during the sessions predicts adjustment 6 months after the end of treatment, and actor slope effect measures whether the person's change in disclosure over the sessions predicts the person's adjustment. The partner intercept effect measures whether the partner's average self-disclosure predicts the person's adjustment, and the partner slope effect measures whether the partner's change in disclosure predicts the person's adjustment. These models included role, treatment condition, and all 2- and 3-way interactions for each actor or partner effect with role and condition. Covariates included in each of these models were the person's age, ethnicity (coded White Not-Hispanic = 1, other = −1), income (coded in units of $10,000), work status (full or part-time = 1, other = −1), cancer stage, and score on the bowel function measure. Finally, because these are dyadic models, separate residual variances were included for patients and spouses, and these residuals were allowed to correlate across partners.

The actor and partner slopes measuring change in the intimacy process variables over therapy sessions had very high kurtosis values because there were a substantial number of individuals whose linear change was either 0 or very close to 0 over the sessions. Therefore, when analyzing the simple slopes for interactions involving actor or partner slopes for the intimacy process variables, rather than giving +1 andosure over time had significantly lower well-being at fol −1 standard deviation (SD), we give simple slopes at 25th and 75th percentiles (Table 1). Note that, because the percentiles are <1 SD from the means, this represents a relatively conservative approach. We do the same when breaking down interactions involving actor and partner intercepts to maintain a consistent approach throughout the article.

Table 1
Table 1:
Descriptive statistics for the intercepts and slopes from person-by-person growth models in which couple-mean centered weeks since session 1 is the predictor and each intimacy process variable is the outcome.

2 Results

Table 2 shows the sample descriptive information. The mean age of patients and spouses respectively was 61 and 57 years. Most participants were White, had completed a college degree or higher education, and were married, and the average relationship length was >27 years. The majority of patients were diagnosed with stage 2 cancer and the majority underwent surgery.

Table 2
Table 2:
Descriptive information on the study sample.

We report below on associations between intimacy processes (self-disclosure, partner disclosure, perceived responsiveness, and closeness) and each of the main outcomes studied in the larger trial. Within each outcome, we first report on the effects for all individual (regardless of role and condition), then on effects for patients, and then spouses. As noted previously, we use the term spouse here to refer to the patient's partner, whether legally married or not, and to distinguish this role from the term partner in the actor–partner interdependence statistical approach we used.

2.1 In-session intimacy processes and general psychological adjustment

Table 3 presents the results for the intimacy process intercepts and slopes during therapy predicting the MHI scores at follow-up. Results show that, overall, individuals who reported higher average intimacy processes over sessions reported higher post-treatment adjustment. A 3-way interaction with moderation by condition and role emerged for this outcome (see top panel of Fig. 1). For patients in IET, higher ratings of spouse disclosure were associated with higher post-treatment adjustment (P < .001). For patients in GHW, and for spouses in either condition, this association was not statistically significant (all P >.17). There was also a significant 3-way interaction between role, condition, and the partner intercept for perceived responsiveness. In this case, none of the simple slopes were significantly different from zero (see the bottom panel of Fig. 1). Finally, the significant main effect of the actor slope for partner disclosure, along with the significant role by actor slope interaction, indicate that across both conditions, spouses who reported that patients showed increases in disclosure over time had significantly lower well-being at follow-up, b = −20.045, se = 4.936, t[102] = 4.061, P < .001, but there was no such association for patients who reported that spouses disclosed more over time (P > .30).

Table 3
Table 3:
Predicting psychological adjustment at the 6-month follow up with the person's own intercepts and slopes for intimacy process variables and the person's partner's intercepts and slopes for intimacy process variables.
Figure 1
Figure 1:
Predicting psychological adjustment at the six month follow-up as a function of condition (IET vs GHW), Role (PT = patient, SP = spouse), and actor intercepts for perceived responsiveness across the therapy sessions (top panel) and partner intercepts for perceived responsiveness across the therapy sessions (bottom panel). GHW = General Health and Wellness, IET = intimacy-enhancing therapy.

2.2 In-session intimacy processes and depressive symptoms

Table 4 presents the results predicting depression, and as shown, there were no effects for self-disclosure. Overall, individuals (patients or spouses) who perceived greater average disclosure from their spouse reported lower depressive symptoms. The significant role by actor-slope coefficient shows that spouses who reported increases in perceived patient disclosure over the sessions had higher depressive symptom scores at follow-up (b = 2.000, se = .878, t[106] = 2.275, P = .025), but this was not the case for patients (b = −.197, se = .446, t[100] = .442, P = .659). In addition, the actor slopes for both perceived responsiveness and for perceived closeness were significant and positive predictors of depressive symptoms. Thus, across conditions and roles, individuals whose relationship closeness increased over sessions, and those who perceived that their spouse increased in responsiveness over sessions, reported higher depressive symptoms at follow-up.

Table 4
Table 4:
Predicting depression at the 6-month follow-up with the person's own intercepts and slopes for intimacy process variables and the person's partner's intercepts and slopes for intimacy process variables.

Finally, there were significant role by condition interactions with both the actor and partner intercept effects for perceived responsiveness (see the top panel of Fig. 2 for the interaction with actor intercept and the bottom panel for the interaction with partner intercept). As can be seen in the figure, spouses in IET who perceived the patient as highly responsive had significantly lower depressive symptoms (P = .031). No other simple slopes differed significantly from zero (all P > .10). The partner intercepts of perceived responsiveness showed a somewhat different pattern. In this case, when the patient reported high perceived responsiveness from the spouse, the spouse tended to report higher depressive symptoms (P = .092), and again no other simple slopes differed from zero (all P > .22).

Figure 2
Figure 2:
Predicting depression at the 6-month follow-up as a function of condition (IET vs GHW), role (PT = patient, SP = spouse), and actor intercepts for perceived responsiveness across the therapy sessions (top panel) and partner intercepts for perceived responsiveness across the therapy sessions (bottom panel). GHW = General Health and Wellness, IET = intimacy-enhancing therapy.

2.3 In-session intimacy processes and cancer-specific distress

Only actor intercepts were statistically significant predictors of cancer-specific distress (see supplemental Table 1, http://links.lww.com/OR9/A4 for full results). Individuals in both conditions who reported higher average intimacy processes during therapy sessions reported lower post-treatment cancer specific distress (self-disclosure b = −1.943, se = .688, P = .005; partner disclosure b = −2.011, se = .576, P = .001; perceived responsiveness b = −1.439, se = .626, P = .023; closeness b = −6.088, se = 2.507, P = .017).

2.4 In-session intimacy processes and cancer concerns

There were few significant predictors of post-treatment cancer concerns (see supplemental Table 2, http://links.lww.com/OR9/A5 for full results). Actor intercepts for both perceived partner disclosure (b = −.100, se = .025, P < .001) and perceived responsiveness (b = −.064, se = .026, P = .017) were significantly different from zero (ie, individuals who perceived greater spousal involvement on average reported lower concerns at follow-up). However, for perceived partner disclosure, there was also a significant interaction with treatment condition such that individuals in IET (patient or partner) who perceived higher partner disclosure on average over the sessions reported significantly lower concerns, b = −.164, se = .042, t (130) = 3.92, P < .001, but those in GHW did not show this association, b = −.037, se = .026, t(143) = 1.40, P = .163.

2.5 In-session intimacy processes and relationship satisfaction

As can be seen in Table 5, actor and partner intercepts for each intimacy process variable predicted relationship satisfaction at follow-up. Individuals who reported higher average self- and perceived partner disclosure, responsiveness, and closeness across sessions reported higher post-treatment relationship satisfaction, and individuals whose partners reported higher self- and perceived partner disclosure, responsiveness, and closeness across sessions reported higher relationship satisfaction. However, the actor effects were qualified by interactions with condition for self-disclosure, perceived partner disclosure, and closeness. For self-disclosure, the association between the person's average disclosure and his or her post-treatment relationship satisfaction was relatively large and statistically significant in IET (b = 5.129, se = 1.010, t [153] = 5.08, P < .001), but it was smaller and nonsignificant in GHW (b = .978, se = .716, t[134] = 1.37, P = .174). The actor intercept effect for perceived partner disclosure was similar in that the effect was large and significant in IET (b = 4.770, se = .876, t [157] = 5.45, P < .001), but in this case although the coefficient was smaller, it was also statistically significant in GHW (b = 1.182, se = .560, t [166] = 2.11, P = .036). Finally, similar results emerged for closeness, such that individuals in IET who reported higher average closeness during treatment reported higher average post-treatment relationship satisfaction (b = 12.763, se = 2.502, t [110] = 5.10, P < .001), but this was not the case for those in GHW (b = 1.581, se = 2.912, t [126] = .54, P = .588). Notably, the effect of the partner's intercepts for the intimacy process variables (ie, people whose partners reported higher average intimacy processes reported higher relationship satisfaction at follow-up) did not differ across conditions.

Table 5
Table 5:
Predicting relationship satisfaction at the 6-month follow-up with the person's own intercepts and slopes for intimacy process variables and the person's partner's intercepts and slopes for intimacy process variables.

There were indications that changes in intimacy processes over sessions also predicted relationship satisfaction. There was a significant interaction between role and actor slope for perceived partner disclosure, such that spouses who perceived that their partners increased in their disclosure over the sessions tended to report lower relationship satisfaction at Time 2 (b = −9.206, se = 3.379, t [111] = 2.72, P = .007), but this was not the case for patients (b = .371, se = 2.171, t [102] = .171, P = .865). In addition, there were interactions between condition and the actor slopes for both perceived responsiveness and closeness. For responsiveness, individuals in IET who reported increases in their partner's responsiveness over time reported significantly lower relationship satisfaction at follow-up (b = −8.940, se = 4.150, t [144] = 2.15, P = .033), but this was not the case in GHW (b = 2.424, se = 3.126, t [148] = .78, P = .439). Likewise, for session closeness, the association between the actor slope and relationship satisfaction was significant and negative in IET (b = −34.759, se = 11.015, t [160] = 3.16, P = .002), but not in GHW (b = −.430, se = 11.314, t [134] = .04, P = .970).

There were also significant condition by partner slope, and role by condition by partner slope, interactions for session closeness predicting relationship satisfaction at follow-up. As is illustrated in Figure 3, interactions are driven primarily by spouses: spouses in IET whose partners (ie, the patient) reported increases in closeness over the sessions tended to report lower relationship satisfaction (P = .015). However, in GHW, spouses whose partners reported increases in closeness over the sessions reported higher relationship satisfaction (P = .024).

Figure 3
Figure 3:
Predicting relationship satisfaction at the 6-month follow-up as a function of condition (IET vs GHW), role (PT = patient, SP = spouse), and partner slopes for closeness across the therapy sessions (bottom panel). GHW = General Health and Wellness, IET = intimacy-enhancing therapy.

2.6 In-session intimacy processes and general relationship intimacy

There were significant effects for the actor intercepts on all session variables (Table 6). Individuals who reported higher average self-disclosure, perceived partner disclosure, perceived responsiveness, and closeness during sessions had higher post-treatment relationship intimacy. These actor intercept effects were moderated by condition for self-disclosure and perceived partner disclosure. In both cases, the effect of higher average self-disclosure on relationship intimacy was significantly stronger for individuals in IET relative to those in GHW. For self-disclosure, the actor intercept effect in IET was b = .216, se = .058, t (133) = 3.70, p < .001. In GHW, the actor intercept was b = .053, se = .041, t(134) = 1.30, P = .196. For perceived partner disclosure, the actor intercept effect in IET was b = .239, se = .049, t (142) = 4.91, P < .001. In GHW, it was b = .091, se = .031, t (147) = 2.88, P = .005.

Table 6
Table 6:
Predicting general relationship intimacy at the 6-month follow-up with the person's own intercepts and slopes for intimacy process variables and the person's partner's intercepts and slopes for intimacy process variables.

There was also evidence that changes in a person's intimacy process variables over therapy sessions predicted post-treatment relationship intimacy. For perceived partner disclosure and responsiveness, there were interactions between role and the actor slope. Patients who perceived increases in their partner's disclosure and responsiveness over sessions reported nonsignificantly higher post-treatment relationship intimacy (partner disclosure: b = .171, se = .119, t [85] = 1.43, P = .155; perceived responsiveness: b = .262, se = .199, t [84] = 1.32, P = .191). However, spouses who reported greater increases in their partner's disclosure and responsiveness over sessions reported lower relationship intimacy at follow-up (partner disclosure: b = −.375, se = .177, t [87] = 2.12, P = .036; perceived responsiveness (b = −.321, se = .219, t [83] = 1.47, P = .146).

More complex results emerged for closeness across therapy sessions. In addition to an overall negative actor slope effect, there was a significant 3-way interaction between treatment condition, role, and the actor slope. As can be seen in Figure 4 (top panel), this interaction indicates that patients in IET (P = .003), and spouses in both conditions (IET, P = .316; GHW, P = .073), who reported increases in closeness across sessions reported lower intimacy at follow-up. However, patients in GHW who reported increases in closeness over sessions reported (nonsignificantly, P = .198) higher intimacy at follow-up. Finally, there was also a condition by role by partner slope interaction for closeness predicting relationship intimacy (see Fig. 4 bottom panel). Although none of the simple slopes differed significantly from zero, the pattern indicates that patients in GHW and spouses in IET whose partners reported increasing closeness over therapy sessions tended to report lower intimacy at the 6-month follow-up, but spouses in GHW whose partners (the patient) reported increases in closeness reported higher relationship intimacy at the 6-month follow-up.

Figure 4
Figure 4:
Predicting general relationship intimacy (PAIR) at the 6-month follow-up as a function of condition (IET vs GHW), role (PT = patient, SP = spouse), and actor slopes for closeness across the therapy sessions (top panel) and partner slopes for closeness across the therapy sessions (bottom panel). GHW = General Health and Wellness, IET = intimacy-enhancing therapy.

3 Discussion

The results of this study underscore the complexity of examining treatment processes to determine why interventions do not have their proposed effects, particularly when comparing treatment approaches. Overall, when actor effects are considered, the pattern of results provides support for the intimacy process models.[16,15] Across both treatments, patients who disclosed more during sessions perceived that their partner disclosed back in return, and reported that the partner conveyed a sense of understanding and acceptance, such that they felt close to their spouse and reported better post-treatment outcomes. However, there was little evidence to support partner effects, which were only seen for relationship satisfaction. Individuals whose partners reported higher self- and perceived partner disclosure, responsiveness, and closeness across sessions reported higher post-treatment relationship satisfaction.

Surprisingly, there was less evidence to support the hypothesis that increases in intimacy processes during sessions would be associated with better post-treatment outcomes. Increases in self-disclosure were not significantly predictive of treatment outcomes. Patients who perceived increases in their partner's disclosure and responsiveness in sessions reported higher post-treatment relationship intimacy, but spouses who reported greater increases in the patient's disclosure and responsiveness in treatment reported lower post-treatment relationship intimacy. Some results were contrary to our predictions. Spouses who reported that the patient's self- disclosure increased over sessions had lower post-treatment well-being and more depressive symptoms. Spouses who reported that the patient's disclosure and responsiveness increased over sessions reported lower post-treatment relationship satisfaction and relationship intimacy. Individuals (patients and spouses) who reported increases in relationship closeness over sessions and individuals who perceived that their partners increased in their responsiveness to them during sessions also reported more post-treatment depressive symptoms. These findings are in contrast with therapy process evaluations of other types of couples’ therapy, which have shown that changes in communication and relationship processes targeted in treatment are associated with better therapy outcomes.[34,20] One explanation is that 6 intervention sessions were not sufficient to resolve the concerns couples disclosed in treatment sessions.

Comparing the associations between intimacy processes and post-treatment outcomes across treatments revealed a number of findings that were consistent with predictions. Individuals in IET who disclosed more, perceived their partner disclosed more, and perceived more closeness in treatment reported higher relationship satisfaction as compared with GHW. Individuals in IET who perceived higher partner disclosure in treatment reported significantly lower cancer concerns as compared with GHW. Finally, patients in IET reporting more perceived partner disclosure reported higher post-treatment adjustment, and these associations were not statistically significant for patients in GHW and spouses in both conditions. Unfortunately, spouses in IET whose partners (the patient) reported increasing closeness in treatment tended to report lower post-treatment intimacy, and spouses in IET whose partners (the patient) reported more responsiveness tended to report higher depression.

Can these findings elucidate possible reasons why IET was not superior to GHW? First, higher intimacy processes were associated with beneficial outcomes for both treatments. As was noted in our previous publication,25 couples’ interactions which fostered intimacy also occurred in GHW sessions. Although this treatment did not specifically address cancer-related relationship concerns or communication about cancer, couples discussed healthy eating, planning meals, relaxation, and exercise in their sessions, and supervision of therapy sessions indicated that many couples engaged in dietary changes and physical activities such as walking outside together. These shared activities have brought about deeper closeness and intimacy. Second, increases in closeness reported by patients participating in IET sessions may not have had their intended beneficial effect on spouses’ relationship outcomes, whereas increases in closeness among patients had a positive effect for spouses in GHW: spouses of patients who reported increasing closeness over therapy sessions tended to report lower post-treatment relationship satisfaction and less relationship intimacy.

4 Strengths and limitations

As has been noted previously,[14] this study had strong attention to treatment fidelity, which ensured that both treatments were delivered as intended. Our statistical approaches were sophisticated. Both partners’ perspectives on intimacy processes were assessed after each session. There are a number of limitations. A key weakness was the high study refusal for the parent study, which raises concerns about how representative this sample is of the patient population. A related weakness is that couples who dropped out of the interventions were more distressed, which also may bias the results of this study toward less distressed patients and spouses. Average scores on the PHQ scale were in the minimal depression range (≤4). Conclusions regarding the clinical meaning of these findings must be interpreted with caution because levels of depressive symptoms were not clinically elevated for most couples. We did not assess other potential mechanisms of change, such as higher acceptance of partner issues and problems (in this care, acceptance that intimacy may need to be focused less on erectile function) and negative communication (eg, criticism) during treatment, which may have played a role in explaining why IET was not effective. These factors have been shown to be mechanisms for positive impact from other couples therapies (eg, Hawrilenko et al[21]). Finally, and most importantly, we did not assess couples enrolled in Usual Care condition at the same time points using the same measures, which would help explain why neither IET nor GHW were superior to UC.

5 Conclusions and implications

The pattern of results provides support for the intimacy process models and some limited support that the intimacy processes targeted in IET were associated with better post-treatment outcomes. However, increases in disclosure, responsiveness, and closeness were not predictive of better post-treatment outcomes in either IET or GHW, which may partially explain the lack of a significant treatment effect in the larger study. It is possible that the focus on disclosure and responsiveness did not solve or address the concerns that couples identified in IET, and that increasing understanding and validation is only the first step in an effective couple-focused treatment. Future work might benefit from developing an intervention that fosters constructive communication that includes problem-solving regarding concerns that patients and spouses hold back sharing. Given patients and spouses hold back sharing concerns about their sexual relationship, and spouses hold back sharing concerns about disease recurrence[9], a focus on these concerns may enhance treatment impact. Reducing holding back and enhancing couples’ efforts to develop effective ways to cope with sexual dysfunction may enhance treatment efficacy. Finally, future work may develop and test more intensive interventions for couples who have a history of psychological distress and/or relationship problems deficits that pre-dates the cancer diagnosis. These couples are more likely to drop out of couple-focused interventions and may need more intensive treatment.

Conflicts of interest statement

The authors declare that they have no conflicts of interest.

Acknowledgements

The authors acknowledge Project Managers Tina Gajda, Sara Frederick, Shira Hichenberg, Kristen Sorice, and Research Study Assistants Joanna Crincoli, Katie Darabos, Arielle Schwerd, and Sloan Harrison, and the study participants, their oncologists, and the clinical teams at Rutgers Cancer Institute of New Jersey, Memorial Sloan Kettering Cancer Center, Fox Chase Cancer Center, Hospital of the University of Pennsylvania, Thomas Jefferson University, Morristown Medical Center, and Cooper University Hospital.

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Keywords:

Couple-focused interventions; Couples; Intimacy processes; Prostate cancer

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