Jamie S. Ostroff
Gary Winkel
Kevin Fox
Generosa Grana
Eric Miller
Cooper Hospital
Stephanie Ross
Thomas Frazier
Evanston Healthcare
This study examined the efficacy of a couple-focused group intervention on psychological adaptation of
women with early stage breast cancer and evaluated whether perceived partner unsupportive behavior or
patient functional impairment moderated intervention effects. Two hundred thirty-eight women were
randomly assigned to receive either 6 sessions of a couple-focused group intervention or usual care.
Intent-to-treat growth curve analyses indicated that participants assigned to the couples group reported
lower depressive symptoms. Women rating their partners as more unsupportive benefited more from the
intervention than did women with less unsupportive partners, and women with more physical impairment
benefited more from the intervention group than did women with less impairment. Subgroup analyses
comparing women attending the couple-focused group intervention with women not attending groups and
with usual care participants indicated that women attending sessions reported significantly less distress
than did women receiving usual care and women who dropped out of the intervention.
Keywords: psychological intervention, breast cancer, couples group
worries about future cancer recurrence, as well as deal with managing family responsibilities and social plans. Even after treatment
is completed, patients negotiate the transition back to normal
life. These experiences can take an emotional toll on some patients, both in the short- and long-term. Between 7% and 46% of
women with early stage breast cancer report clinically significant
levels of anxiety or depressive symptoms within the first 6 months
of diagnosis (Gallagher, Parle, & Cairns, 2002).
A number of psychological interventions have been developed
and evaluated to reduce distress among early stage breast cancer
patients. The majority of randomized clinical trials evaluating
psychosocial interventions for women diagnosed with early stage
breast cancer have examined the efficacy of patient-focused treatments (e.g., Antoni et al., 2001; Helgeson, Cohen, & Schulz,
2000). Although many of these approaches have proven effective,
they do not take advantage of the family context of cancer and a
key source of support for patients, namely the partner (Pistrang &
Barker, 1995). In the clinical trials incorporating partners in psychological interventions, there is considerable variation in the
manner that partners have been incorporated. Studies have used
couple-focused interventions (e.g., Christensen, 1983), individualfocused interventions delivered to both patient and partner at the
same time (e.g., Donnelly et al., 2000), and interventions targeting
COUPLE-FOCUSED INTERVENTION
635
by helping the person learn to tolerate aversive feelings, by provision of support and encouragement of effective coping, and by
direct assistance in finding meaning and benefit in the experience.
Conversely, not being able to talk about a difficult experience with
family and friends because one perceives ones family or friends as
unsupportive may place individuals at higher risk for adverse
psychological reactions. Barriers to sharing the cancer experience
with ones partner may be particularly problematic because of the
level of importance the partner has as a source of support (Pistrang
& Barker, 1992). Thus, our intervention promoted open communication and processing of the cancer experience in the marital
dyad.
When evaluating the efficacy of an intervention, it is important
to consider that interventions may not prove efficacious for all
patients, and thus it may be important to identify subgroups of
participants benefiting more than others. In the present study, we
evaluated two potential moderators: partner unsupportive responses and patient physical impairment. As described above,
cognitivesocial processing theory suggests that an unsupportive
social environment is detrimental to patients adaptation. Women
who have a particularly unsupportive partner are likely to benefit
more from an intervention facilitating improved communication
with and support from the partner. A second factor that may
moderate the efficacy of a couple-focused intervention is the level
of physical impairment experienced. Women coping with a higher
level of disease-related physical impairment may benefit more
from a communication and support-based intervention. Thus, we
proposed that participants with higher levels of physical disability
would benefit more from the couple-focused intervention than
would participants with lower disability levels.
The main goal of the present study was to evaluate the efficacy
of a couple-focused group (CG) intervention on the psychological
adaptation of women with breast cancer. The intervention was
designed to enhance support exchanges and coping skills. We
hypothesized that women assigned to the intervention group would
evidence less distress and greater well-being. Our second aim was
to determine whether our intervention would be more effective for
particular subgroups of women. To this end, we examined two
moderators: perceived partner unsupportive behaviors and patient
physical impairment at the preintervention assessment. We hypothesized that women with higher perceived partner unsupportive
behavior at the preintervention assessment would show greater
benefit from the intervention, which had a primary focus on
couples communication. We predicted that women with more
functional impairment would benefit more from the intervention.
To test the above hypotheses, we conducted a randomized clinical
trial comparing a CG intervention with a usual care (UC) control
condition. Women were followed with two assessments, 1 week
and 6 months after the group intervention.
Method
Participants
Participants were women with early stage breast cancer who had undergone breast cancer surgery within the last 6 months and were married or
cohabiting, and their significant others. This study took place at three
comprehensive cancer centers in two major cities and four community
hospitals in New Jersey and Pennsylvania. Criteria for study inclusion were
as follows: (a) participant had a primary diagnosis of ductal carcinoma in
636
MANNE ET AL.
Procedure
Eligible women were identified and approached by the research assistant
either after an outpatient visit or by telephone. The study design and
procedures were described in detail during this contact. Participants were
given a written informed consent and the study questionnaire to complete
and return by mail. All participants signed an informed consent approved
by an institutional review board. After informed consent and preintervention surveys were received, couples were randomly assigned to either the
CG condition or a UC control condition. Randomization was performed in
blocks of 14 to allow for the formation of couples groups. Assessment
time points were preintervention (baseline), 1 week postintervention, and 6
months postintervention. Participants in the UC condition were sent
follow-up surveys at the same point in time as CG participants within their
same block of 14 couples in order to equate for time since baseline in the
two conditions. Patients were paid $20 per set of questionnaires returned,
and patients assigned to the intervention condition were paid $15 for each
session attended to cover travel and parking expenses. Recruitment began
in April 2000 and ended in October 2003.
As shown in Figure 1, 710 couples were approached for study participation. Two hundred thirty-eight couples consented and completed the
baseline survey (33% acceptance). The most common reason for refusal
provided was that the group would take too much time. The majority
(46%) did not provide a reason. Comparisons were made between the 238
patient participants and the 472 refusers with regard to available data (i.e.,
age, ethnicity, cancer stage, performance status). Results indicated that
study participants were significantly younger (Mparticipants 49.4, SD
10.6; Mrefusers 52.1, SD 10.8), t(708) 3.1, p .01; and had higher
performance status ratings on the ECOG scale (91% of participants had a
score of 0 [no symptoms]; 77% of refusers had a score of 0), 2(708, N
710) 17.3, p .001. There were no differences between participants and
refusers in terms of ethnicity (Caucasian vs. non-Caucasian) or cancer
stage.
Measures
Intervention Conditions
CG condition. The intervention consisted of six weekly 90-min sessions. Session content focused on enhancing support exchanges and coping
skills. The goals of Session 1 were to orient participants to the group,
establish rapport with the group leaders, foster connections among group
participants, and facilitate expression of feelings in the group. Exercises
were adapted from multiple family group techniques developed by Ostroff,
Steinglass, Ross, Ronis-Tobin, and Singh (2004). Session 2 focused on
couple-level stress management (e.g., recognizing stress in one another,
respecting differences in coping styles) and relaxation techniques (e.g.,
listening to a relaxation tape together). Session 3 covered couple-focused
coping (e.g., problem solving as a team) as well as sexuality and breast
cancer (e.g., sensate focus as homework). Session 4 focused on basic
communication concepts and skills (e.g., constructive and destructive communication). Basic communication skills techniques were adapted from the
Prevention and Relationship Enhancement Program (Markman & Floyd,
1980) and from Gottman and colleagues (Gottman, Notarius, Gonso, &
Markman, 1976) communication intervention and were adapted to the
context of dealing with cancer. Session 5 focused on constructive ways to
General distress. Participants completed the Mental Health Inventory18 (MHI18; Ware, Manning, Duan, Wells, & Newhouse, 1984).
This scale consisted of three distress subscales, Anxiety (4 items), Depression (4 items), and Loss of Behavioral and Emotional Control (BEC) (4
items), and a Well-Being subscale (6 items). Participants used a 5- or
6-point Likert scale to rate their feelings over the past month. Internal
consistency coefficients for the three time points were excellent (Anxiety,
.85, .85, .90; Depression, .88, .85, .91; Loss of Behavioral and
Emotional Control, .81, .80, .90; Well-Being, .87, .86, .91).
Cancer-specific distress. Participants completed the Impact of Event
Scale (IES; Horowitz, Wilner, & Alvarez, 1979), which is a 15-item
self-report measure focusing on intrusive and avoidant ideation associated
with a stressorin this case, breast cancer and its treatment. The IES has
been used in studies of women with cancer (e.g., Baider et al., 2003). Using
a 4-point Likert scale, participants rated how true each statement had been
for them during the past week. Cronbachs alphas were .89, .89, and .91,
at Times 1, 2, and 3, respectively.
Partner unsupportive behaviors (Manne & Schnoll, 2001). The Partner
Unsupportive Behaviors Scale consisted of 17 items assessing critical
COUPLE-FOCUSED INTERVENTION
responses, such as criticism of the womans ways of handling the cancer
and appearing uncomfortable when she talked about her cancer. Items were
rated on a 4-point response scale. Internal consistency was .88, .89, and .91
at Times 1, 2, and 3, respectively.
Physical impairment. Physical impairment was assessed with the
Functional Status subscale of the Cancer Rehabilitation Evaluation System
(CARES; Schag & Heinrich, 1988). Twenty-six items assessed functional
disability caused by the cancer and its treatment. Participants rated difficulty during the past month from 0 (not at all) to 4 (very much). Higher
scores indicated greater impairment. Internal consistency was .93 at Times
1, 2, and 3.
Treatment expectancy. A modified Expectancy Rating Form (Borkovec & Nau, 1972) was administered to group participants at the end of
Session 1. Participants used 4-point Likert scales to rate how logical the
treatment seemed, whether they would recommend it to others, and expectations for the treatments success (e.g., 1 not at all logical/successful,
4 extremely logical/successful). The coefficient alpha for this measure
was .80.
Treatment evaluation. A 20-item expanded version of Borkovec and
Naus (1972) scale was administered after the last session. Using 5-point
Likert scales, participants rated whether they learned anything new;
whether the sessions improved the marital relationship; their satisfaction
with the group; how helpful the therapist was; whether the participant used
any of the skills or believed she would use the skills in the future; the
helpfulness of each session; whether the participant would recommend the
sessions to another patient; the ease of attending sessions; the convenience
of the sessions; whether the topics covered were important; and whether
the materials were clear and easy to understand, tuned into her needs, and
helpful (1 not at all, 5 a great deal). Items were summed. The
coefficient alpha for this measure was .94.
Psychosocial care use. Participants completed a survey assessing any
psychosocial care (e.g., support group, formal psychological contacts)
obtained at each assessment time point.
Medical variables. Data regarding disease stage (1 to 3a), treatment
status, and ECOG symptom ratings were obtained from the medical chart
pretreatment and at the two follow-up time points. ECOG ratings were
made by the attending physician.
Group Leaders
Each group was co-led by a therapist team. Twenty therapists provided
the intervention. Therapists underwent 6 hours of training in the manualbased couples group protocol. To facilitate treatment fidelity, we structured the manual with suggested text for leaders and co-leaders and
in-session handouts for participants. Ongoing supervision was provided.
Sessions were audiotaped, and treatment fidelity was rated.
Results
Sample
Figure 1 illustrates the study flow. Two hundred thirty-eight
women consented to the study and completed a preintervention
survey. Of these 238 participants, 118 were assigned to UC and
120 were assigned to the CG condition. Among the 120 couples
assigned to the CG condition, 42 couples did not attend any group
sessions. Participants who did not attend group sessions were
offered the opportunity to complete follow-up surveys.
Survey attrition. Survey completion is shown in Figure 1. Of
the 238 participants who completed Time 1 surveys, 187 completed postintervention surveys (79%), and 163 completed
6-month follow-up surveys (68%). As can be seen in Figure 1,
survey completion rate was significantly higher among CG partic-
637
Treatment Fidelity
A random subset of 44% of sessions was rated for treatment
fidelity. The fidelity checklist was created by Sharon L. Manne
from the Couples Group Intervention manual. Fidelity criteria
consisted of topics covered in each session, whether in-session
exercises were conducted, and whether home assignments were
given. Raters coded whether each topic was addressed in the
session, whether exercises were conducted, and whether home
assignments were given. A fidelity score consisted of the percentage of topics, exercises, and home assignments completed in each
session, divided by the total number of possible fidelity criteria.
MANNE ET AL.
638
Table 1
Preintervention Demographic and Disease Information for Participants by Intervention Group
Variable
N
Age (years)
Race
White
Black
Asian
Hispanic
Years of education
college
college
Median family income
Relationship length (years)
Baseline ECOG ratings
0
1
Stage of disease
0
1
2
3a
Type of surgery
Mastectomy
Breast-cons surgery
Current treatment
None
Chemotherapy
Radiation
Psychosocial care (yes)
UC
CG full sample
CG attenders
CG attrition
118
49.76 (10.5)
120
49.25 (10.4)
78
49.68 (11.2)
42
48.5 (8.8)
107 (90.7)
4 (3.4)
4 (3.4)
3 (2.5)
106 (88.3)
7 (5.8)
2 (1.7)
5 (4.1)
67 (85.9)
4 (5.1)
2 (2.6)
4 (5.1)
39 (92.8)
3 (7.2)
0 (0)
0 (0)
39 (33.1)
79 (66.9)
$90,000
23.29 (12.56)
41 (34.2)
79 (65.8)
$85,000
21 (14.1)
26 (33.3)
52 (66.6)
$89,000
21.16 (14.1)
15 (35.7)
27 (64.3)
$85,000
20.7 (14.1)
114 (96.6)
4 (3.4)
101 (85.6)
17 (14.4)
73 (93.5)
5 (6.4)
42 (100)
0 (0)
14 (11.8)
38 (32.2)
63 (53.4)
3 (2.5)
8 (6.7)
47 (39.2)
61 (50.8)
4 (3.3)
5 (6.4)
29 (37.1)
41 (52.6)
3 (3.8)
3 (7.1)
18 (42.9)
20 (77.6)
1 (2.4)
27 (22.8)
91 (77.1)
31 (25.8)
89 (74.1)
23 (29.48)
55 (70.5)
8 (19.0)
34 (81.0)
25 (21.22)
68 (57.6)
12 (10.2)
65 (55.1)
24 (20)
74 (61.7)
15 (12.5)
71 (59.2)
18 (23.0)
45 (5.8)
10 (12.8)
47 (60.3)
6 (14.2)
29 (69.0)
5 (11.9)
24 (57.1)
Note. Numbers in parentheses are percentages for categorical variables and standard deviations for continuous variables (age, relationship length). Sample
sizes are preintervention figures. UC usual care control condition; CG couples group intervention condition; ECOG Eastern Cooperative Oncology
Group; Breast-cons surgery breast-conserving surgery.
Statistical Plan
The longitudinal data from this study were analyzed by using a
growth curve models approach (Moskowitz & Hershberger, 2002;
Singer & Willett, 2003). Growth curve analyses are designed to
understand group and individual rates of change in outcome variables over time and require a minimum of three assessments.
Growth curve analyses involve a mixed linear model approach,
which is also referred to as a random effects or hierarchic linear
model (Bryk & Raudenbush, 2002; Singer & Willett, 2003).
The first analysis focused on intent to treat (ITT), which included all participants who signed an informed consent and agreed
to be randomized. We also conducted subgroup analyses comparing participants who were assigned to the CG condition but did not
attend any intervention sessions (N 42; labeled CG attrition
[CG-A]), participants who were assigned to the CG condition and
attended at least one session (N 78), and the UC group (N
COUPLE-FOCUSED INTERVENTION
639
Table 2
Means and Standard Deviations for Study Outcomes by Intervention Group
UC
Variable
MHI depression
Preintervention
Postintervention
6-month follow-up
MHI anxiety
Preintervention
Postintervention
6-month follow-up
MHI loss of behavioral and emotional control
Preintervention
Postintervention
6-month follow-up
IES total
Preintervention
Postintervention
6-month follow-up
MHI well-being
Preintervention
Postintervention
6-month follow-up
CG full sample
CG attenders
CG attrition
SD
SD
SD
SD
9.10
8.90
8.95
2.52
2.77
3.90
9.37
8.60
8.14
2.85
2.69
2.98
9.10
8.10
7.70
2.53
2.25
2.33
9.88
10.07
9.72
3.23
3.43
4.34
10.08
9.81
10.28
3.57
3.56
4.87
10.34
9.86
9.21
3.50
3.40
3.17
10.08
9.54
8.77
3.57
3.26
2.99
10.83
10.91
10.78
3.35
3.67
3.41
8.88
8.04
8.52
2.82
2.82
4.26
8.82
8.06
7.73
3.02
2.84
2.93
8.88
7.55
7.23
2.82
2.38
2.41
8.73
9.72
9.50
3.38
3.55
3.91
23.30
20.89
17.57
15.02
14.74
15.53
24.18
19.26
16.77
14.82
13.71
13.88
23.30
19.35
15.72
15.01
13.86
13.89
25.82
19.00
20.61
14.47
13.54
13.54
24.54
25.63
25.58
4.94
4.90
6.18
24.12
25.98
26.52
5.12
4.96
5.20
24.54
26.65
27.28
4.94
4.65
4.53
23.36
23.82
23.83
5.42
5.42
6.55
Note. UC usual care control condition; CG couples group intervention condition; MHI Mental Health Inventory18; IES Impact of Events
Scale.
ITT Analyses
We examined preintervention differences on all outcomes reported below, and there were no significant differences.
Depressive symptoms. Results are shown in the first panel of
Table 3. The first step, which was a model with time as the only
explanatory variable, showed a significant decline in depressive
symptoms over time, t(344) 3.23, p .0014, as well as
significant individual differences among patients both in preintervention depressive symptoms (z 7.03, p .0001) and in the
rates at which depressive symptoms changed over the study course
(z 2.82, p .0024). The covariation between preintervention
levels of depressive symptoms and rates of change in depressive
symptoms was not significant, indicating that individual differences in rates of change were not due to individual differences in
preintervention depressive symptoms. The second step of the analysis yielded a significant intervention group effect in favor of CG,
MANNE ET AL.
640
Table 3
Intent-to-Treat Results for Growth Curve Model Predicting Psychological Outcomes
Covariance parameter estimates
Effect
Parameter
estimate
Confidence interval
Parameter
estimate
Confidence interval
df
0.39
0.63, 0.15
344
3.23
.0014
0.44
0.07
0.05
0.12
0.59
0.68, 0.20
0.09, 0.04
0.03, 0.08
0.07, 0.16
1.15, 0.03
330
226
226
226
226
3.57
5.17
4.85
5.40
2.09
.0004
.0001
.0001
.0001
.0376
0.46
0.07
0.05
0.11
0.54
0.02
0.04
0.07
0.05
0.79, 0.014
0.09, 0.04
0.03, 0.07
0.04, 0.18
1.16, 0.09
0.11, 0.07
0.08, 0.001
0.56, 0.41
0.11, 0.008
327
225
225
225
225
225
327
327
327
2.78
5.21
4.60
3.08
1.70
0.49
2.02
0.31
1.70
.0058
.0001
.0001
.0023
.0912
.6219
.0444
.7605
.0910
0.28
0.52, 0.03
344
2.21
.280
0.27
0.06
0.05
0.15
0.53
0.52, 0.02
0.10, 0.03
0.03, 0.07
0.10, 0.19
1.23, 0.19
330
226
226
226
226
2.16
3.66
4.19
6.45
1.45
.0311
.0003
.0001
.0001
.1491
5.8797
0.5494
1.0907
4.53, 7.94
1.43, 0.33
0.60, 2.54
7.03
1.22
2.82
.0001
.2230
.0024
9.4865
0.5596
0.9618
7.54, 12.31
1.60, 0.48
0.49, 2.71
8.02
1.05
2.38
.0001
.2939
.0085
6.0708
0.6896
1.2388
4.55, 8.50
1.77, 0.39
0.64, 3.35
6.31
1.25
2.47
.0001
.2104
.0068
0.38
0.64, 0.12
344
2.83
.0049
0.42
0.05
0.05
0.12
0.50
0.69, 0.16
0.08, 0.02
0.02, 0.07
0.08, 0.16
1.10, 0.11
330
226
226
226
226
3.14
3.76
3.53
6.04
1.61
.0018
.0002
.0005
.0001
.1090
0.47
0.05
0.05
0.17
0.41
0.05
0.08
0.14
0.09
0.80, 0.015
0.08, 0.02
0.02, 0.07
0.10, 0.23
1.10, 0.27
0.04, 0.14
0.13, 0.04
0.66, 0.38
0.15, 0.03
327
225
225
225
225
225
327
327
327
2.88
3.65
3.50
5.24
1.18
0.98
3.68
0.52
2.75
.0042
.0003
.0006
.0001
.2375
.3272
.0003
.6063
.0063
COUPLE-FOCUSED INTERVENTION
641
Table 3 (continued )
Covariance parameter estimates
Effect
Parameter
estimate
Confidence interval
Parameter
estimate
Confidence interval
df
3.33
4.38, 2.28
348
6.24
.0001
3.50
0.29
1.22
0.20
0.28
1.98
4.64, 2.35
0.09, 0.49
0.40, 2.03
0.07, 0.32
0.06, 0.49
5.08, 1.11
313
209
209
209
209
209
6.01
2.83
2.95
3.05
2.57
1.26
.0001
.0051
.0036
.0025
.0108
.2080
3.53
0.52
0.28
1.20
0.08
0.24
2.02
0.21
4.67, 2.38
0.78, 0.26
0.08, 0.48
0.38, 2.02
0.09, 0.25
0.02, 0.46
5.10, 1.06
0.44, 0.02
313
208
208
208
208
208
208
208
6.07
3.96
2.76
2.89
0.96
2.19
1.29
1.76
.0001
.0001
.0063
.0042
.3386
.0296
.1977
.0793
1.01
344
3.38
.0008
0.68
0.09
0.07
0.20
0.26
0.30, 1.06
0.05, 0.14
0.11, 0.03
0.27, 0.13
0.78, 1.31
330
226
226
226
226
3.54
4.25
3.71
5.72
0.50
.0005
.0001
.0003
.0001
.6180
0.98
0.09
0.09
0.23
0.09
0.06
0.03
0.06
0.67
0.11
0.51, 1.45
0.05, 0.14
0.13, 0.05
0.32, 0.14
1.22, 1.04
0.20, 0.08
0.003, 0.06
0.01, 0.13
0.05, 1.40
0.03, 0.19
326
225
225
225
225
225
326
326
326
326
4.12
4.27
4.37
4.92
0.16
0.88
2.24
1.58
1.82
2.62
.0001
.0001
.0001
.0001
.8706
.3807
.0261
.1140
.0701
.0093
161.08
21.7098
20.0119
127.58, 209.83
40.10, 3.31
11.32, 44.58
7.91
2.31
2.94
.0001
.0207
.0016
18.9820
1.4149
2.6232
15.05, 24.69
3.59, 0.76
6.00, 9.24
7.96
1.28
3.11
.0001
.2021
.0009
0.64
0.27,
Note. MHI Mental Health Inventory18; CARES physical impairment as assessed by the Functional Status subscale of the Cancer Rehabilitation
Evaluation System; Unsupp. beh. partner unsupportive behavior; IES Impact of Event Scale.
642
MANNE ET AL.
COUPLE-FOCUSED INTERVENTION
Subgroup Analyses
Subgroup analyses compared women attending the couplefocused intervention group with women who did not attend the
group (CG-A) and women assigned to UC. In each subgroup
analysis that follows, the first step involving time as the only
explanatory variable yielded the same results as in the ITT analysis. In addition, the sociodemographic and medical variables in
the ITT continued to be significant in the subgroup analyses. We
examined preintervention differences on all outcomes reported
below, and there were no significant differences. Coefficients for
these analyses can be obtained from the authors as they are not
presented in tabular format here.
Depressive symptoms. Results from the second step, a main
effect model, yielded a significant intervention group effect, F(2,
225) 8.37, p .0003, in favor of CG (adjusted M 8.39)
compared with UC (adjusted M 9.42) and CG-A (adjusted M
9.74) after covariate adjustment. Means for women in the UC and
CG-A groups did not differ from one another. Results from the
643
third step, the moderator analyses, indicated a significant firstorder interaction between intervention group and partner unsupportive behavior, F(2, 223) 4.68, p .0102. For women one
standard deviation above the mean on partner unsupportive behavior, mean depressive symptoms were significantly lower among
women in the CG condition (adjusted M 8.85) compared with
the UC (adjusted M 10.56) and CG-A groups (adjusted M
11.31). The latter two means did not differ from one another. For
women one standard deviation below the mean on partner unsupportive behavior, there were no significant mean differences (adjusted MCG 7.99; adjusted MUC 8.23; adjusted MCG-A
8.25). There were no significant moderator effects involving physical impairment.
Anxiety. In the second step, the main effect for intervention
group was examined by controlling for significant demographic
and medical covariates. Results indicated a significant main effect
for intervention group, F(2, 25) 4.14, p .0171. After covariate
adjustment, average anxiety for CG participants (adjusted M
9.58) was significantly lower than for UC participants (adjusted
M 10.51) and CG-A participants (adjusted M 10.80). Means
for women in the UC and CG-A groups did not differ. The third
step indicated that there were no significant moderator effects
involving intervention group, partner unsupportive behaviors, or
physical impairment.
Loss of BEC. In the second step of the analysis, after the
effects of sociodemographic, medical, and moderator (physical
impairment, unsupportive partner behavior) were included, the
main effect for intervention group yielded significance, F(2,
225) 3.90, p .013, in favor of CG (adjusted M 8.00)
compared with UC (adjusted M 8.78) and CG-A (adjusted M
8.90). The latter two means did not differ. In the third step,
examination of first-order moderator effects indicated a significant
interaction, F(2, 325) 3.94, p .0054, between time and
intervention group. Examination of the means for the three groups
prior to the intervention indicated no differences. However, at the
first assessment postintervention, mean BEC score for those participants in CG (adjusted M 7.93) was significantly lower than
the mean for those in the UC (adjusted M 8.78) or in the CG-A
(adjusted M 9.33) groups. Means for the UC and CG-A groups
did not differ. At the second postintervention assessment, the mean
BEC score for those in CG (adjusted M 7.15) was significantly
lower than mean BEC for those in the UC (adjusted M 8.44) or
the CG-A (adjusted M 9.90) groups. Again, UC and CG-A
means did not differ from one another.
The interaction between intervention group and physical functioning, F(2, 221) 3.51, p .0315, was also significant. Examination of the interaction indicated that for women in the CG
condition, as physical impairment increased, there was a slight
increase in BEC, although this increase was not significant,
t(221) 0.83, p .05. However, for women in the CG-A or UC
groups, greater physical impairment was associated with a significant increase in BEC, tCG-A(221) 4.30, p .0001; tUC(221)
2.36, p .01. A slightly different way of looking at this interaction
is to note that for women who were one standard deviation below
the mean on physical impairment, there were no significant differences among the means (adjusted MCG 7.70; adjusted MUC
7.98; adjusted MCG-A 7.98). However, for women one standard
deviation above the mean on physical impairment, mean BEC was
significantly lower for women in the CG condition (adjusted M
MANNE ET AL.
644
Discussion
This article is the first to report the results of a randomized,
controlled CG intervention designed to reduce distress and improve well-being in women treated for localized breast cancer. As
predicted, the CG intervention had a positive impact on depressive
symptoms. We found some evidence to suggest that the intervention tended to be more beneficial to women rating their partners as
more unsupportive and to women reporting more physical impairment preintervention. Among women rating their partners as more
unsupportive preintervention, women assigned to the CG intervention reported lower loss of BEC symptoms and greater well-being
at follow-up than did women in the UC group. In addition, women
randomized to the intervention group who rated their partners as
more unsupportive reported marginally lower depressive symp-
COUPLE-FOCUSED INTERVENTION
645
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