Couple-based communication interventions for cancer: Moving beyond a “one size fits all” approach

We are writing in regard to the review article “New frontiers in couple-based interventions in cancer care: refining the precription for spousal communication.” [1] We commend Dr. Badr for writing a comprehensive and thought-provoking review of this topic, and we agree with her assessment that there is much to be learned about the nuances of couples’ communication and the development of more efficacious interventions for couples facing cancer. We disagree, however, with Dr. Badr’s statement that couples-based interventions to date have provided a “unilateral and generic prescription to talk openly about cancer” (p. 139). Furthermore, we are concerned that her description of the findings of a 2009 study that we conducted along with our colleagues is not correct.

With regard to the first point, Dr. Badr portrays current couple-based interventions as using a “one size fits all approach”, i.e. simply recommending that couples talk more openly about their feelings. This approach may be beneficial for some patients. [2] However, as Dr. Badr suggests, there may also be some downsides to this approach, including couples’ reluctance to talk about cancer-related issues, their lack of skills to communicate effectively in ways that lead to increased intimacy, support, and understanding, and the potential benefits of addressing a range of topics in addition to emotions.[3]

We have developed an alternative approach which we have used in multiple protocols [4–8]. This approach is multifaceted and more flexible than that described by Dr. Badr, and individualized to address each couple’s unique needs. It is informed by general principles of healthy relationship functioning and includes components to assist couples in communicating effectively, provide each other with support, and maintain some semblance of normality in their lives.[3]

We address couples’ motivations for avoidance of cancer-related discussions through (a) asking the couple about their communication style, including the challenges they have faced in discussing cancer-related issues and their motivations for engaging in protective buffering and other forms of avoidance; (b) providing a rationale for more open communication which includes validation and normalization of the couple’s concerns along with an explanation of the benefits that can result from addressing difficult topics; and (c) emphasizing that cancer-related conversations can be brief and focused and need not dominate the couples’ interactions. In addition, we provide training in communication skills for both sharing one’s thoughts and feelings, and for listening to one’s partner and responding in a supportive manner. We individualize the skills training by incorporating information gathered from the couple about their communication style and challenges, focusing on the components that may be most relevant and helpful to them. Finally, we encourage couples to address a range of topics regarding the cancer experience, including medical decision-making, symptom management, and family- and relationship-focused concerns. We do promote the expression of emotions (both positive and negative) about the topics they choose to discuss, as a discussion of emotional reactions is often not intuitive for couples but can provide important information as to the impact of their experiences. However, we do not suggest that expression of emotions should be the sole purpose of the conversations. Ultimately, we believe that these strategies encourage increased disclosure but, more importantly, decreased avoidance (i.e., holding back) of important cancer-related issues that couples may be reluctant to address.

Regarding the second point of this letter (the inaccurate description of results of our 2009 study), Badr reported that our intervention led to increases in marital quality but not significantly more than an attention control group. This is incorrect. In fact our results showed that the patients and partners in the disclosure intervention reported significant improvements in overall relationship quality and intimacy relative to those in the attention control condition.[5, 9] In addition, couples in the disclosure intervention in which the patient initially reported higher levels of holding back at baseline benefited more from the intervention. These findings have led us to target communication interventions specifically to couples who report higher levels of holding back, who we believe are most likely to benefit. [8]

In summary, we believe that the literature supports the notion that efficacious couple-based interventions should do more than provide a prescription for increased disclosure of feelings related to the cancer experience. Rather, they should provide couples with an understanding of the ways in which communication can facilitate adjustment to cancer, the potential benefits of addressing important cancer-related issues that they have been avoiding, and training in skills that help them talk about these issues and promotes increased mutual understanding and support. Interventions should also be individualized to address couples’ specific concerns about communication and their unique communication styles.

These observations in no way negate Badr’s conclusion that we need to know more about couple communication processes. Important directions for future research include both descriptive and intervention studies designed to elucidate the mechanisms by which couple communication leads to better individual and relationship adjustment, as well as identifying couples who are most likely to benefit from intervention. Researchers should also move beyond reliance on global self-report measures of communication. The vast literature on general (non-cancer) couple relationship functioning can provide valuable guidance on methodologies likely to be fruitful. For example, one novel objective approach to studying couple communication is the assessment of expressed emotional arousal during couples’ interactions via measurement of a vocal feature, fundamental frequency (f₀). F₀, is a physical property of speech associated with psychophysiological measures of arousal including heart rate, blood pressure and cortisol.[10, 11] It has a unique advantage for the measurement of expressed emotional arousal in couple conversations in that vocal features are part of how emotional information is communicated between individuals.[11, 12] Findings from a recent study examining associations between f₀ and social support in the context of conversations between women with breast cancer and their partners found meaningful associations between both patient and partner f₀ and the patient’s support-seeking behaviors. [13] Use of these types of novel methodologies, along with those suggested by Dr. Badr, are likely to lead to a better understanding of the specific features of couple communication that are most likely to enhance adaptation to cancer, leading to the refinement of couple-based interventions to improve their efficacy.