Psychiatry can promote growth amid chronic illness
Questions to ask during therapy
While working with these couples, assess their motivation to develop dyadic coping, by asking:
• “Do either of you feel that the patient should do this alone?” If the answer is yes, it will be difficult, if not impossible, to move the couple to a dyadic coping style.
• “Do your efforts to work together result in greater conflict?”
• “How much do you want this to change?” This questions clarifies their motivation to work together.
• “When you think about problems related to your heart condition, to what extent do you view those as ‘our problem’ [shared by the patient and the spouse equally] or mainly as ‘your own problem?’ ”
• “When a problem related to your heart condition arises, to what extent do you and your partner work together to solve it?”
• “When you both talk about the illness, how much do you use ‘we-talk’?”
• “It is important that you both agree about what is causing the illness. Can I answer any questions that might help you reach this understanding?”
• “Are there times in the past where you have successfully solved difficult problems? How did you do that?”
• “How do you respond when your spouse becomes ill?”
• “What can your spouse do that will help you get better?”
• “Can you ask your spouse for help and support?”
• “Can you work on your spouse’s health problem together?”
‘Benefit finding’ and PTG
Benefit finding emerges later in the adjustment to chronic illness. For example, caregivers may develop a greater appreciation of their own health and ability to enjoy their own pursuits. Family connectedness is a frequent source of meaning, and a critical aspect of well-being and benefit finding. Seven factors make up benefit finding: compassion/empathy, spiritual growth, mindfulness, family relations growth, lifestyle gains, personal growth, and new opportunities (Psychol Health. 2009 Apr;24[4]:373-93). Benefit finding is associated with higher marital adjustment, improved life satisfaction, and a more positive affect, especially at high levels of stress.
Post-traumatic growth, or PTG, refers to positive changes that occur after traumatic life events. People who experience PTG are transformed by their struggles with adversity. It is the struggle after the trauma, not the trauma itself, that produces PTG. In contrast to resilience, PTG refers to changes that go beyond pretrauma levels of adaptation and beyond benefit finding. Relational benefits in the aftermath of a cancer diagnosis are well recognized. An instrument used to assess these outcomes is called the Post-traumatic Growth Inventory, or PTGI (J Trauma Stress. 1996 Jul;9:455-71).
Interventions for couples coping with cancer resulted in improvements in communication, dyadic coping, quality of life, psychosocial distress, sexual functioning, and marital satisfaction (Psychooncology. 2014 Apr;23[7]:731-9). PTG may, however, be more apparent in patients than spouses.
Potential interventions
Promoting dyadic coping is effective if the couple wants to engage in intervention. According to one study, a partner-assisted emotional disclosure improved relationship functioning and intimacy (J Marital Fam Ther. 2012 Jun;38 Suppl 1:284-95). Couples therapy improves relational functioning in couples coping with cancer, at 1-year follow-up (Psychooncology. 2009 Mar;18[3]:276-83). Most important, as a first step, the couple must agree that they want to develop dyadic coping. The concept of individual versus dyadic coping may be novel for couples, and it is worth spending time on this review before offering couples intervention.
A psychoeducational program also can teach dyadic coping. The Resilient Partners discussion group developed in collaboration with the Multiple Sclerosis Society focused on developing couples’ strengths in coping with multiple sclerosis (Rolland, J., McPheters, J., and Carbonell, E., 2008). This multifamily group program is based on the Family Systems Illness Model, which integrates the demands of multiple sclerosis over time within a family developmental framework. In a comparison of a couple skills intervention with a psychoeducation program, women in the couple skills intervention benefited more in terms of their relationship functioning (Ann Behav Med. 2012 Apr;43[2]:239-52).
Dr. John S. Rolland’s Family Systems Illness (FSI) model provides a framework for the psychoeducation, assessment, and intervention with families dealing with chronic illness. This model, developed in clinical experience with more than 1,000 families, views families as valued partners and resources, and emphasizes resilience and growth. The FSI model takes into account the interaction of an illness with the individual’s development and the family’s development, the multigenerational ways of coping with illness, the family’s health/illness belief system, available resources, and relationships between health care providers.
The PTGI includes five domains: improved relationships, new possibilities for one’s life, a greater appreciation for life, a greater sense of personal strength, and spiritual development. Several family oriented themes within the PTGI can be used by the psychiatrist to inquire about positive change. These themes are:
