Is ‘Hold Me Tight’ Relationship Enhancement Program Effective in Reducing Fear of Progression in Iranian Married Women with Breast Cancer?

Introduction

Cancer is a chronic and potentially terminal illness characterized by the growth of mutated cells in the body (American Cancer Society [ACS], 2019). The quality of life of cancer patients has been investigated through a variety of studies in the last decade, with the majority of them focusing on women with breast cancer (Naughton & Weaver, 2014). Breast cancer is one of the most common cancers in women worldwide, and the second leading cause of cancer deaths among women (Sun et al., 2017). According to the World Health Organization (WHO), breast cancer is the top cancer in women (International Agency for Research on Cancer [IARC], 2018).

Breast cancer is the most common cancer and the primary cause of cancer-related mortality among women in Muslim countries. The incidence in Muslim countries is low compared to the incidence in the US. However, breast cancer incidence is increasing in Muslim-majority countries (Noor et al., 2016). Also, it is important to note the significance of shame and the Hijab in Muslim countries, and the impact it may have on early screening. Iranian women are suffering from breast cancer a decade earlier, and 70% of the patients are diagnosed at an advanced stage (Farma et al., 2014). Breast cancer, or more specifically, Invasive Ductal Carcinoma (IDC), is reportedly the most common cancer in the country (Nafissi et al., 2018).

With rising early detection and more successful treatment, breast cancer survival rates continue to increase rapidly; as a result, many women find themselves troubled with the psychosocial effects of breast cancer, such as fear of progression or recurrence (Ziner et al., 2012). One of the most frequent distress symptoms of cancer survivors, and most commonly reported psychological problem, is Fear of Progression (FoP) (Herschbach & Dinkel, 2014; Mehnert et al., 2006). FoP is a life-long challenge for most survivors of breast cancer, the prevalence of which indicates that to identify its construct and prevalence, and to help survivors cope with this problem, there is a need for related interventions examination (Ziner et al., 2012).

FoP is defined as “fear, worry, or concern relating to the possibility that cancer will come back or progress” (Götze et al., 2019) and is considered one of the most prevalent and stable long‐term psychological consequences of cancer survival (Simard et al., 2013; Lebel et al., 2016).

Psychological treatments for FoP are becoming more widely studied. However, treatments that are both easily accessible and cost-effective are still uncommon (Sharpe et al., 2017; Simard et al., 2013; Maheu & Galica, 2018). There are a limited number of effectiveness studies on FoP: Cognitive-Behavioral Group Therapy (CBT) (Sabariego et al., 2011), CBT-based online self-help training (an Helmondt et al., 2016), Supportive-Experiential Group Therapy (Herschbach et al., 2010), and Acceptance and Commitment Therapy (ACT) (Hasannezhad Reskati et al., 2020). However, no study has explored the effectiveness of Emotionally Focused Couples Therapy (EFT) on FoP reduction in women with breast cancer. It is suggested that dysfunctional fear of progression can be effectively treated with brief group therapies (Herschbach & Dinkel, 2014).

Emotionally Focused Couples Therapy (EFCT or, more commonly, EFT), an intervention based on couples’ relational correction (Johnson, 2008) is a short-term, semi-accessible, cost-effective couple therapy that can be either applied to groups or separate couples (Johnson, 2005; Burgess Moser & Johnson, 2008; Johnson, 2004). It is understood that the experience of chronic diseases such as cancer is happening rather interpersonally and within a duo pattern of interactions with most loved ones. Dealing with the effects of cancer has been increasingly seen in marital relationships as both influencing and being influenced by that relationship (Wiebe & Johnson, 2016).

As explained, cancer is an illness that affects not only patients but also their partners. Thus, there is a need for more couple-based psychological or psychosocial interventions designed to help patients and their partners cope with the diagnosis and treatment of cancer. Although EFT-based treatments are unlikely to be beneficial for every cancer survivor, they do provide several advantages, including convenience, cost-effectiveness, and targeting a new sphere of treatment. Therefore, this study investigates the effectiveness of the Hold Me Tight (HMT) Relationship Enhancement Program on FoP in Iranian married women with breast cancer, with an Emotionally Focused Couple Therapy-based approach.

Methods

Procedure

Following the approval of research in IRB of Hormozgan University of Medical Sciences, we selected a sample of Muslim couples visiting three renowned oncologists working with BDRC. In the second stage, 71 couples were assessed for their eligibility. After a brief presentation of EFT intervention and the purpose of the study, a total of 22 couples gave consent to participate in the study. In the third stage, based on the participants’ ages and psychological characteristics, the couples were assigned into experimental and control groups (each containing 11 couples). The sample size was determined using MedCalc Ver. 19.8 software based on a comparison of two means, Type I error (alpha) 0.05 and Type II error (beta, 1-power) 0.1, as well as Power 90%. Equal participants were placed in two groups (1:1 ratio). The normality was tested using the Kolmogorov-Smirnov and Shapiro-Wilk tests. Both groups were tested for normality at a confidence level of 5%, which showed the normality hypothesis of both groups was confirmed in Kolmogorov-Smirnov and Shapiro-Wilk tests. Other statistical quantities were as follows: Difference of mean score (2); Standard deviation in group 1 (1.5), and group 2 (1); Number of samples in the experimental group (n=11) and the number of samples in the control group (n=11). The mentioned software uses Cohen’s “d” for Effect Size (ES) calculation. We selected alpha 0.05 for sample size calculation. The Intra-class Correlation Coefficient (ICC) is used as a measure of the reliability of measurements. For the purpose of assessing ICC, MedCal software analyzed four rates of study subjects. The intervention group received a 6-session HMT intervention (one 120-minute session per week in two 60-minute shifts). Before and after the program, the women in both groups completed the Fear of Progression Questionnaire (FoP-Q) pre-test and post-test. The consort diagram of the study is indicated below (See Figure 1).

Figure 1. Study Consort Diagram

Results

The study was based on 22 couples (44 individuals) that were equally divided to the experimental and control groups, each containing 11 couples (22 individuals). As shown in Table 1, the largest number of participants (approximately 41%) were those above the age of 51. The mean age of participants in the experimental and control groups were 48.2% and 49.6% years respectively. Fifty percent of the experimental and control groups’ participants had a high school diploma; 9% had an associate degree; 30% had a B.A. or B.Sc.; and 11% had a Master’s or Ph.D. As for employment status, 64% of the participants were employed.

Table 2 shows FoP test results for both experimental and control groups in pre-test and post-test. The mean scores of the subjects in the pre-test for the experimental group (28.70 ± 88.63) and the control group (40.15 ± 93.81) were not significantly different (t(20)=-0.87, p=0.392). A comparison of the difference between post-test scores of the experimental group (35.13 ± 82.63) and the control group (41.77 ± 102.00) for FoP did not reveal a significant difference (t(20)=-0.695, p=0.495), and this indicates that the implementation of HMT program did not have a significant effect on FoP in the subjects.

Due to our small sample size, normality was checked using the Shapiro-Wilk test. The distributions were normal for the experimental group (W=0.956, p-value=0.725) and the control group (W=0.944, p-value=0.569). Based on the obtained results and the visual inspection of the histogram X and Q-Q plot, it was decided to recruit a parametric test.

Before performing the analysis of covariance, we tested the homogeneity of variance assumptions and the slope of regression. Evaluations indicated that normality, homogeneity of variance, linearity, and homogeneity of regression slopes were all satisfactory. Particularly, the hypothesis of homogeneity of regression slopes was examined by independent variables and pre-test interaction, and the results showed that the variances of the two groups were equal (F=0.27, p=0.60).

Table 3 shows the mean and standard deviation of the components/dimensions of FoP variables for the control and experimental groups before and after the intervention. According to the results, none of FoP components revealed a significant change in the post-test.

As the results of Table 4 show, the difference between the pre-test–post-test scores of the experimental and control groups is not significant for the FoP variable with a value of F = 0.022 at the level of p<0.05. Therefore, HMT intervention did not affect reducing FoP in married women with breast cancer.

Discussion

This study evaluated the effectiveness of the Hold Me Tight couple’s therapy program on FoP in Iranian married women coping with breast cancer. The results of statistical analysis indicated that the mean score of FoP decreased in the experimental group compared to the control group. However, the results revealed no significant difference between the means, showing that the implementation of the HMT intervention program had no significant decreasing effect on FoP dimensions in the intervention group women as compared to the control group (p<0.05).

Mental health is the most precious asset a cancer patient/survivor possesses to cope with the disease stressors, including Fear of Progression (FoP). For married patients, emotional recognition and social support from their spouse is an invaluable source. EFT and its adapted cost-effective short-form, HMT, are considered as a promising intervention model that has targeted attachment and emotion as primary mechanisms of change in couples coping with life-threatening illnesses. Furthermore, this study was conducted on Iranian Muslims, and it can be important to consider the impact of the Hijab and shame on early screening of breast cancer. Also, such studies can highlight the importance of cultural and religious factors and even political issues to physical health.

Some studies in Iran (Javidi 2014; Javidi et al., 2012; and Javidi et al., 2014) indicated the effectiveness of EFT-based interventions on improving marital satisfaction and communication patterns in couples. Furthermore, Guarino et al. (2020) indicated that EFT models of intervention are effective in improving psychological improvement and reducing psychological manifestations of stress in women with breast cancer. Lynch’s (2015) study on the effectiveness of the EFT-based HMT program on the improvement of mental health indicators attenuated due to the cancer control process. In addition, Wiebe & Johnson (2016) reviewed the effectiveness of EFT and concluded that EFT appeared to be an effective couple therapy for couples in distress who are coping with the effects of illness in their lives, such as parents of children with chronic illnesses who reported statistically significant improvements in relationship satisfaction, communication, and intimacy after EFT (Walker, Manion, Cloutier, & Johnson, 1992). EFT researchers have examined whether EFT can be effective for couples facing cancer who are also in relationship distress. They found that EFT might be effective to improve relationship satisfaction and quality of life for couples undergoing treatment for cancer (Naaman, 2008). Mclean, Walton, Rodin, Esplen, and Jones (2013) randomized 42 couples facing terminal metastatic cancer in distressed relationships to receive EFT, as well as standard care or standard care alone. At post-treatment, couples assigned to EFT reported significantly greater improvement in relationship satisfaction, and greater improvement in the patient’s experience of their caregiver’s empathic care as compared to couples assigned to standard care alone (Mclean et al., 2013). Taken together, there is preliminary evidence that EFT can be an effective treatment for relationship distress in couples experiencing illnesses in their lives or the lives of their children.

The results of our study, in contrast with the previous studies, didn’t indicate a significant difference between the experimental and control groups. However, there might be different explanation for these results. As indicated in these studies, most of the couples were in distressing relationship, and EFT helped their relationship. It seems that the improvement in their relationships might have helped them cope with their disease. Therefore, assessing couples’ relationship satisfaction beside FoP can be helpful. There is the possibility that the sample’s relationships were not distressing. And so, we suggest assessing relationship satisfaction beside individual factors like FoP before starting intervention.

In a study on Fear of Progression, the majority of the samples (76.4%) reported low FoP (Mehnert et al., 2009). This study indicated that FoP was significantly associated with younger age, having children, disease progress, and chemotherapy. Our study sample, similar to the previous study, had low FoP (M_e=88.63); and after intervention, their FoP score reduced (M_c=88.63). However, as explained in the Results section, it was not significant. The sample were relatively young (M_e=43.72, M_c=48.27), were in stage II, and had finished their chemotherapy. The sample’s low FoP could be due to the reassurance that was given to the patients in the medical center. Also, they completed their medical therapy before EFT intervention. Therefore, we suggest that addressing FoP in higher stages and simultaneously with physical therapy, such as chemotherapy, might be more useful.

Furthermore, the experimental group intervention was conducted during the COVID-19 outbreak. This unpredictable condition prohibited the face-to-face presentation, and on-line sessions might have reduced the effectiveness of the HMT program. Also, the anxiety of this outbreak may have affected mechanisms through which the HMT program is supposed to reduce emotional disturbance, and affect FoP through emotional regulation.