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Hold Me Tight: A Couples Group Intervention For Cancer Patients And Their Partners Collaborative Family Healthcare Association 17 th Annual Conference October 15-17, 2015 Portland, Oregon U.S.A. Session A6a (Period 6: 3:30-4:30; 25 minutes) Saturday, October 17, 2015 Maureen Davey, PhD, LMFT Associate Professor Drexel University Department of Couple and Family Therapy Laura Lynch, PhD Collaborative Healthcare Clinical Practice Educator Drexel University Department of Couple and Family Therapy Ting Liu, PhD, Lydia Kormanicky, MD, and Briana Bilkins, MA Slide 2 Disclosures The presenters of this session have NOT had any relevant financial relationships during the past 12 months. Slide 3 Learning Objectives At the conclusion of this session, participants will be able to: Describe an adapted brief (5-sessions) couple support group intervention (illustrated with DVD clips) for couples coping with cancer in a partner or a spouse Describe findings from a program evaluation study designed to evaluate the effectiveness of the intervention (Hold Me Tight; HMT) adapted for diverse samples of couples coping with cancer Describe strategies to improve engagement and retention of diverse samples of couples coping with cancer and how to improve collaboration with oncology clinics and cancer centers. Slide 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 Slide 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. Slide 6 Prevalence How many couples are coping with cancer? There were approximately 14.5 million Americans with a history of cancer were as of January 2014 (ACS, 2015) In 2014 there were over 1.6 million new cases of cancer (ACS, 2014) In 2012 there were 7,845,000 male-female unmarried couple households, 6,1,04700 male-female married couple households, and 594,000 same-sex couples (US Census Bureau, 2012; ACS, 2010) Slide 7 Cancer Health Disparities Racial 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) Slide 8 Cancer Health Disparities Socioeconomic 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 high alcohol intake (cancer risk factors), and are less likely to get screened for cancer (NCI, 2008) Slide 9 Adult Attachment Based in attachment theory (Bowlby) Importance of a secure attachment (responsive, attuned) between primary caregiver and infant/child Child exhibits attachment behavior when in distress Secure attachment linked to improved social and emotional adjustment at any age; also impacts intimate relationships in adulthood (Hazan & Shaver, 1987) When a couple experiences a stressor like cancer, attachment behaviors are activated Slide 10 Limitations of Existing Interventions for Couples Coping with Cancer Lack of racial and socioeconomic diversity in samples (Badr and Krebs, 2013; Baik & Adams, 2014; Li & Loke, 2014) Most interventions cognitive-behavioral and/or educational versus focusing on emotion or couple attachment Most studies did not measure relational outcomes (some even only measured the patients outcomes and not the partners) Included partners were typically an assistant, coach, or support person to the cancer patient Slide 11 Hold Me Tight Intervention Hold Me Tight (HMT) Couple Intervention Program: Conversations for Connection developed by Dr. Susan Johnson (2009) Helps couples repair and strengthen relationship by targeting emotions and facilitating secure attachment in smaller group settings Based on empirically-supported Emotionally Focused Therapy (EFT) Slide 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 increase relationship satisfaction Elevated rates of depression and anxiety (Couper et al., 2006) among cancer patients and partners Emotionally Focused Therapy, the model underlying HMT, has been shown to decrease depressive symptoms Slide 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 provides social support HMT group facilitators help partners openly share concerns related to cancer treatment, coping, and adjustment and receive support from other couples Slide 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 in the midst of cancer treatment Decreased content in first session to prevent fatigue, after completing baseline assessments During assessments (baseline and post-intervention), graduate student volunteers read each question aloud to participants (participants could also opt out) Slide 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 Slide 16 Fidelity Checklist and Review of Model Slide 17 Aims for Program Evaluation Study 1. Assess intervention acceptability and feasibility Recruitment and retention rates Participants reasons for refusal or dropout Participant satisfaction after completing the intervention 2. Pilot-test treatment efficacy Compare pre-intervention and post-intervention measures for couple participants Psychological (BDI-II) Relationship satisfaction (RDAS) Attachment (ECRS, BARE) Impact of cancer and Quality of Life (IES and FACT-G for patients only) Slide 18 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 Slide 19 Sample Demographics 7 eligible couples completed study (N=14 participants) Primarily African American (12 African American; 1 White; 1 Asian) Most Baptist (71.4%) Primarily lower to middle class; all heterosexual couples Most married (n=5 couples), 1 engaged, 1 committed relationship Years married ranged from 0.33 to 41 years Age (average approximately 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 Slide 20 Sample Demographics Cancer patient participants: 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 at pre-intervention Slide 21 Aim 1: Acceptability and Feasibility Adapted HMT (5 sessions) acceptable based on participants positive CSQ and HMTCRS scores (higher scores for both patients and partners) and narrative feedback Recruitment and retention of couples was somewhat feasible 25 couples recruited over 13 months On average 2 couples referred each month and approximately 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) 4 out of 11 eligible recruited couples dropped out after baseline assessments and first session:(64% retention rate) Retention rate significantly increased after first cohort (3 couples dropped out of 1 st cohort; only 1 couple dropped out of second cohort, 0 couples dropped out of third/last cohort ) Slide 22 Aim 2: Pilot Test Treatment Patients and partners scores on all outcome measures changed in the hypothesized positive/improved direction at post-intervention; only a few significantly changed over time Paired sample t-tests: partners RDAS total scores and patients IES Intrusion Subscale scores significantly improved from baseline to post-intervention 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 Slide 23 Limitations Open trial one-arm design No control group Generalizability Primarily African American sample, low to middle income, and heterosexual Multiple cancer stages and types Could be differences in effectiveness across stage and type cancer Possible for each iteration group facilitators became more skilled 1 st cohort: slightly different adaptation 2 nd and 3 rd cohort experienced more cohesive HMT treatment team Slide 24 Clinical Implications Positive feedback and positive 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 minority sample Medical and mental healthcare providers working with cancer patients should routinely screen and assess quality of the couple relationship at diagnosis and throughout treatment Partner also impacted by cancer and intervention: importance of treating the couple, rather than focusing on the patient and the partner as secondary Slide 25 Future Research Cancer Health Disparities Ready to be evaluated with larger samples and 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 couples-based group intervention for cancer patients and their partners Include couples with mild to moderate distress Evaluate intervention with cancer survivors Slide 26 Strategies to Improve Engagement & Retention of Diverse Samples of Couples Build Trust and Join Engaging recruitment style Build trust at first contact using letters, texts, phone calls Check in throughout care with phone calls, letters, notes 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 (Dangelo et al., 2009; Gladstone et al, 2015). Slide 27 Questions and Comments Slide 28 Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!