Support Care Cancer (2011) 19:15391548 DOI 10.

1007/s00520-010-0981-z

ORIGINAL ARTICLE

Examination of couples attachment security in relation to depression and hopelessness in maritally distressed patients facing end-stage cancer and their spouse caregivers: a buffer or facilitator of psychosocial distress?
Linda M. McLean & Tara Walton & Andrew Matthew & Jennifer Michelle Jones

Received: 4 September 2009 / Accepted: 16 August 2010 / Published online: 27 August 2010 # Springer-Verlag 2010

Abstract Purpose The purpose of this study is to determine levels of depression and hopelessness and to explore the relationship between attachment security and psychosocial distress in patients with metastatic/recurrent cancer and spousecaregivers, experiencing marital distress.
L. M. McLean (*) Department of Psychosocial Oncology and Palliative Care 16-755, University Health Network, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada e-mail: lmmclean@rogers.com L. M. McLean : A. Matthew : J. M. Jones Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada A. Matthew e-mail: andrew.matthew@uhn.on.ca J. M. Jones e-mail: jennifer.jones@uhn.on.ca T. Walton : J. M. Jones Department of Psychosocial Oncology and Palliative Care, University Health Network, 200 Elizabeth Street, 9EN-233, Toronto, Ontario M5G 2C4, Canada T. Walton e-mail: twalton@uhnresearch.ca A. Matthew Princess Margaret Hospital, The Prostate Centre, 4-922, University Health Network, 620 University Avenue, Toronto, Ontario M5G 2M9, Canada A. Matthew Department of Surgery, University of Toronto, Toronto, Ontario, Canada

Methods Couple-participants were from a pilot study and a larger clinical trial prior to randomization. Participation required that one partner endorsed marital distress on the Revised Dyadic Adjustment Scale (RDAS). Outcome measures included the Beck Depression Inventory-II (BDI-II), Beck Hopelessness Scale (BHS), and Experiences in Close Relationships Inventory. Results Caregivers, compared with their matched illpartners, had significantly higher scores on the RDAS (<distress) after taking sex, avoidance, and anxiety into account. Fifty-two percent of patients and 33% of caregivers scored above the BDI-II cut-off (15) for depression, with patients and females reporting higher levels of depression compared to caregivers and males. Thirty-three percent of patients and 24% of caregivers scored above the BHS cut-off (8) for hopelessness, with males and patients displaying significantly higher mean scores compared with females and caregivers. There was a significant interaction effect of sex and avoidance for RDAS; as the male avoidance subscale score increased, the female caregiver RDAS declined (>distressed). Conclusions Marital distress may be amplified within insecure attachment bonds, especially among avoidant male patients and their female caregivers, which may influence caregiving/care-receiving. We offer unique, preliminary support for identifying couples at risk to help reduce suffering and complicated bereavement in the terminal cancer population. Further research that include larger studies, are needed to determine relationships among attachment and psychosocial outcomes. Keywords Metastatic/recurrent cancer . Marital distress . Attachment security . Depression . Hopelessness . End-of-life

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Introduction A cancer diagnosis has a significant impact on the patient and the spouse caregiver [1]. Patients are confronted with a life-threatening diagnosis and a difficult treatment regimen, while their partners are often required to fulfill the demanding role of a spouse caregiver [2]. These difficulties are amplified during the terminal phase of cancer when patients experience more disease-related factors [3]. Individuals with cancer are at an increased risk for persistent depressive symptoms when compared with the general population [4, 5]. Feelings of hopelessness are also common in patients approaching end-stage cancer [6]. A general feeling of hopelessness may reflect end-of-life despair, or in extreme cases, may develop into a desire for hastened death or suicidal ideation, loss of dignity, and intimate dependency [6, 7]. A reported 1550% of adult cancer patients and their spouses present with clinically significant psychological distress, including depression and hopelessness, and this increases as death approaches [8, 9]. The majority of studies report that patients and their spouse caregivers have similar levels of distress over time [10], consistent with the view that common factors impact both partners, and affect the entire family system [11]. There is now emerging research highlighting the need to identify couples most at risk for psychological distress during end-stage cancer [12, 13]. Studies investigating predictors or correlates of patient and spouse distress vary in their sample size, the variables assessed, and the populations they have considered [37]. Consequently, there are few predictors that have consistently been linked with patient and spouse distress. Risk may be related to the patients condition, as well as demographic and psychological factors, and social support and resources [14]. Relational factors, such as level of marital satisfaction, and the quality of family functioning may also play an important role [15]. In this regard, couples who report good marital functioning endorse lower levels of psychosocial distress and morbidity [8], and a positive emotional environment may buffer the overall impact of terminal disease [16]. In contrast, negative, avoidant, and hostile marital interactions can amplify couple distress resulting in estrangement at end-of-life and a deleterious impact on the patient facing end-stage cancer and the bereaved spouse caregiver following patient death [3]. In one recent study of patients with metastatic lung and gastrointestinal cancer and their spouse caregivers, Braun and colleagues [1] found that a greater proportion of spouse caregivers (39%) endorsed symptoms of depression (Beck Depression Inventory-II (BDI-II) 15) [17] when compared with their ill partners (23%) and significant predictors of spouse caregiver depression were subjective experience of caregiving burden, caregivers insecure attachment (anxiety and avoidance), and marital satisfaction.

Attachment theory, caregiving, and care-receiving Attachment theory [18, 19] provides a framework for understanding close relationships and studying caregiving and care-receiving with adult couples [1]. The concept of adult attachment refers to internalized expectations and preferences regarding proximity to significant others and protection in times of need [20]. Attachment security refers to the way people relate to others and feel within close relationships [18]. Individuals can view themselves as worthy or unworthy of love and support and others as available/ trustworthy, or unreliable/rejecting [21]. Those individuals with attachment security may be more protected from psychological distress because they have a greater capacity to regulate their experience of affect and to seek support in times of need [20]. Insecure attachment has been represented as dimensions of anxiety (i.e., the degree to which individuals worry about rejection, abandonment or being unloved by significant others) and avoidance (i.e., the degree to which individuals may avoid intimacy and interdependence with significant others) [22]. Individuals who endorse low levels of anxiety and avoidance are secure in their attachment. The theoretical concepts of attachment security, caregiving and care-receiving are salient in the case of terminal cancer [23, 24]. End-stage cancer poses a threat to the continuity of self and to the marital relationship, resulting in activated attachment systems and separation distress [25]. Attachment security allows the caregiver to be able to respond to the needs of their spouse and facilitates highly attuned and compassionate caregiving [19, 23, 24]. Attachment security enables patients to seek and accept care and to effectively communicate their emotions [26]. In the context of an insecure marital bond, attachment insecurities and behaviors may be expressed in maladaptive patterns of interaction, maintaining separation distress, inhibiting compassionate caregiving, and negatively impacting the provision of care [23, 24, 27, 28]. Anxious individuals experience separation from attachment figures as catastrophic and have a strong need for support and affection from their partner, and may exhibit intense emotions. Avoidant individuals desire intimate connection, yet because of their deep distrust of others ability to care for them, resent having to rely on others for care, and react more negatively to care-receiving [23], which may result in significant relationship distress. Avoidant individuals tend to be compulsively reliant on themselves [23, 24, 29]. Insecure caregivers within an insecure attachment bond may provide care that is low on responsiveness and/or high on compulsiveness which may be negatively perceived by the care receivers [23, 24]. A handful of studies have examined the impact of attachment in adult cancer populations [1, 25, 30, 31], and these results suggest that either anxious or avoidant attachment is associated with lower marital satisfaction

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and responsive caregiving [23, 25] that may contribute significantly to levels of distress (depression, hopelessness, and anxiety) in both patients and caregivers [1, 30, 31]. Compatible with these studies, Rodin and colleagues [32] found that attachment security buffered the disease-related factors in depression in the metastatic gastrointestinal and lung cancer population. The primary objective of the present study was to explore attachment and distress in couples experiencing marital distress and facing the challenge of metastatic or recurrent cancer. Specifically, we investigated the levels of depression and hopelessness among patients and spouse caregivers and we explored the relationship between attachment security of patients and spouse caregivers and their experience of distress.

physical and emotional support throughout illness; this was confirmed by the spouse. Patients and spouse caregivers were considered eligible if the patient had recurrent or metastatic cancer, a Karnofsky Performance Status score (KPS) [33] of 60, if they were in an intimate relationship of 1 year, and were fluent in English, and that at least one partner endorsed marital distress on the Revised Dyadic Adjustment Scale (RDAS) (<48) [34]. The couple was then considered martially distressed [10, 35, 36]. Potential participants were considered to be ineligible if either partner had a significant cognitive deficit as indicated by a Short-Orientation-Memory-Concentration Test (SOMC) [37] score below the cutoff (<20, equivalent to >10 errors), presented with a major psychiatric illness (e.g., psychosis), or if they were currently in marital therapy. Procedures

Methods Study participants and setting The current study included participants from a small pilot study and a larger randomized controlled trial (RCT) involving patients diagnosed with metastatic or recurrent cancer and their spouse caregiver. Data analysis included the baseline data obtained for the total pilot sample and the RCT prior to randomization. Participants were recruited from Princess Margaret Hospital (PMH), Canadas largest comprehensive cancer center that is part of the University Health Network (UHN), and located in Toronto, Canada. These studies were approved by the Research Ethics Board of the University Health Network (UHN). Health care providers (nurses and physicians in PMH outpatient clinics), psychiatrists, psychologists, and social workers of the Psychosocial Oncology and Palliative Care Program (POPC) served as a referral source for the studies. These clinicians would identify any potential patients from the outpatient clinics (i.e., patients who reported marital problems), determine if they had an eligible spouse caregiver, advise them of the study and then offer them an invitation letter. The invitation letter explained the study and the opportunity for referral to the clinical research assistant (RA) for further information about the study. Patients who expressed interest in participating were then screened by the RA to confirm eligibility. The recruitment period was finite: recruitment for the pilot study occurred between March 2006 and January 2007, while recruitment for the RCT occurred between January 2008 and October 2008. Participants who described marital distress represented a sub-group of the patient population. They were adult (18 years) patients with confirmed diagnoses of metastatic or recurrent cancer and their spouse caregivers. The spouse caregiver was defined as the significant partner identified by the patient as his or her primary source of Forty-nine potential couple-participants were identified by clinicians in outpatient clinics and by members of the multidisciplinary POPC team at PMH and referred to the RA for information about the study. Of those approached, there was a 6% refusal rate: three couples declined participation, two due to lack of interest, and one due to the patients disease progression. Those who declined were made aware of POPC services and referred as needed. All participants provided written informed consent, and then the RA administered the screening instruments (SOMC, RDAS, (KPS patient only)) and documented demographic and medical information. Baseline questionnaire packages were then mailed to all participating couples, with return addressed and stamped envelopes included. Measures Marital distress was measured by the RDAS [34], a standardized 14item self-report measure of marital functioning and relationship quality. The RDAS consists of three subscales: the Consensus Subscale, the Satisfaction Subscale, and the Cohesion Subscale, which are summed to obtain an overall individual or dyadic marital functioning score. Total scores range from 0 to 69 with a reliable cutoff score of 48 [34]. Lower scores on this measure reflect higher marital distress. Internal consistency of the total RDAS is =0.90, and its validity has been established [38]. Psychological distress (depression and hopelessness) was assessed using two measures. (1) the BDI-II [17], a 21-item self-report measure of depressive symptoms that is consistent with the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision [39] for major depressive disorder. Total scores range from 0 to 63, with scores of 15 on the BDI-II being clinically significant in screening for depressive symptoms [40]. It has been used

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extensively in cancer populations [40]; and (2) the Beck Hopelessness Scale (BHS) [41] is a 20-item true/false scale developed to quantify hopelessness and negative expectancies. Positively worded items are reversed scored, then summed to yield a total score ranging from 0 to 20, with higher scores reflecting increased hopelessness. The BHS has high internal consistency and validity, and has been used in terminally ill cancer populations [42]. A cut-off score of 8 has been recommended for cancer populations in screening for symptoms of hopelessness [5, 13, 41]. Attachment security was assessed using the Experiences in Close Relationships Inventory (ECR) [22], a 36-item selfreport scale tapping attachment anxiety and avoidance in romantic and marital relationships. Participants rate the degree to which items describe their feelings in close relationships on a 7-point Likert scale that ranges from 1 disagree strongly to 7 agree strongly. Eighteen items measure attachment anxiety (e.g., the fear of rejection and abandonment) and 18 items measure avoidance (e.g., discomfort with dependence on others and closeness) [22, 43]. For each subscale, a total score is computed by averaging the relevant 18 items [22]. Attachment security is operationalized as lower scores on both anxiety and avoidance subscales (see reference [22], pp. 260 for overview of attachment scales and the construction of the ECR). Patients medical information was obtained through semi-structured interview and confirmed through medical chart review. Patient and spouse caregiver demographics were recorded from a brief demographic questionnaire. Statistical analyses Frequencies, measures of central tendency, and dispersion were calculated to describe patient and caregiver demographics as well as scores on outcome measures using SPSS 16.0, 2008 for Windows (SPSS; SPSS Inc, Chicago, IL). Using SAS 9.2, 20022008 (SAS Institute Inc., Cary, NC), we employed two-tailed t tests to compare means on the outcome measures between patients and spouse caregivers. We conducted one- and two-way analyses of covariance (ANCOVAs) to examine the effects of sex and patient/ caregiver status on measures of marital distress, depression, and hopelessness, using avoidance and anxiety subscale scores as covariates. TukeyKramer was the multiple-testing procedure used. The alpha level for this study was 0.05.

range, 1 to 48), with 80.5% having a child or children. Nineteen percent (n =9) of the couples reported a history of marital discord that pre-dated the patients diagnosis of cancer. Ninety-four percent of the couples had a household income of greater than $60,000 per year. Participant characteristics and patient information are reported in Table 1. Marital distress Participation in this study required that minimally one partner endorsed marital distress on the RDAS. Of the 46 total couples who participated, marital distress was endorsed by both the patient and the caregiver for 24 of the couples, by only the patient for 15 of the couples, and by only the caregiver for 6 of the couples. Overall, the patients had an RDAS mean of 44.4 (SD=6.98; range, 2962) and the caregivers had a mean of 46.5 (SD=6.4; range, 2759). A paired t test for patients versus matched spouse caregivers revealed that spouse caregivers had statistically higher scores on the marital distress measure (RDAS), indicative of less marital distress than their ill partners (t(45) =2.67, P =0.01). Depression and hopelessness Mean depression scores (BDI-II) and hopelessness (BHS) scores are reported in Table 2. Patients had significantly higher mean BDI-II scores than their matched spouse caregivers (t(45) =3.4, P =0.001). Fifty-two percent of patients and 32.6% of matched spouse caregivers were above the BDI-II cut-off (15), indicative of depression (P =0.09). Although 32.6% of patients and 23.9% of matched spouse caregivers were above the BHS cut-off (8), indicative of hopelessness, this difference was not significant (P =0.48). Marital distress, depression, and hopelessness as functions of sex, patient/caregiver status, avoidance, and anxiety We performed two-way ANCOVAs to explain the variation in the three main scores. The two factors were sex and patient/caregiver status. Avoidance and anxiety were covariates, and couples were treated as dyads. All two-way interaction terms were tested, however only the significant results are presented. Caregivers had statistically significantly higher RDAS scores (less distress) than patients, after taking sex, avoidance, and anxiety into account. Mean depression scores (BDI-II) were significantly higher for females than males and higher for patients than caregivers. BDI-II is highly dependent on both the avoidance and the anxiety subscale scores. The results are in Table 3 (see Fig. 1). Moreover, mean hopelessness (BHS) scores were significantly higher for males than females and higher for caregivers than patients, but these relationships are con-

Results Study participants Forty-six couples participated in this study. Participating couples were married on average 18.7 years (SD=12.8;

Support Care Cancer (2011) 19:15391548 Table 1 Patient demographics and medical information and spouse caregiver demographics Age (years) Mean Standard deviation Range Sex Male Female Primary language English Highest level of education Graduate Undergraduate or college Trade or professional school Grade school/high school Currently working Yes First marriage Yes Type of cancer Breast Head and neck Blood Gynecological Central nervous system Gastrointestinal Genito-urinary Lung Melanoma Cancer recurrence/metastasis Cancer recurrence Metastatic Treatment active? Yes Treatment history Surgery and radiation Surgery and chemotherapy Surgery, radiation, and chemotherapy Chemotherapy and bone marrow transplant Patients (N =46) Number Percentage Caregivers (N =46) Number

1543

Percentage

49.66 11.53 2770 18 28 43 10 26 5 5 29 32 12 8 7 6 4 3 3 2 1 22 10 32 2 15 25 4 39.13 60.87 93.48 21.74 56.52 10.87 10.87 63.0 69.57 26.09 17.39 15.22 13.04 8.70 6.52 6.52 4.35 2.17 47.8 21.7 69.6 4.3 32.5 54.5 8.7

49.34 11.75 2774 28 18 44 10 22 6 8 13 32 60.87 39.13 95.65 21.74 47.83 13.04 17.39 28.3 69.57

Table 2 Mean patient and caregiver depression and hopelessness Patient BDI-II (mean, SD) BHS (mean, SD) 16.5 (SD=8.2) 5.7 (SD=3.8) Caregiver 11.5 (SD=7.9) 5.7 (SD=3.8) Significance *P =0.001 P =0.9

BDI-II Beck depression inventory-II, BHS Beck hopelessness scale *P 0.001, two-tailed

1544 Table 3 Results of two-way ANCOVAs for three scores Score RDAS BDI-II Sex F(1,43.6) =0.53 P =0.4692 F(1,44) =4.56 P =0.0384 PT/CG F(1,42.7) =5.69 P =0.0215 F(1,43) =9.95 P =0.0029 Avoidance subscorea F(1,57.6) =0.26 P =0.6143 F(1,79.8) =7.98 P =0.0060 Anxiety subscoreb F(1,71.7) =0.00 P =0.9694 F(1,86.7) =7.31 P =0.0083

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Interactions None None

Least square means CG=46.43 PT=44.46 F =15.43 M =12.58 CG=11.92 PT=16.09 F =8.17 M =9.08 CG=8.70 PT=8.55

BHS

F(1,52.6) =5.55 P =0.0222

F(1,46.9) =4.75 P =0.0344

F(1,52.6) =0.01 P =0.9210

F(1,65.1) =0.12 P =0.7263

Sexvoidance PT/CGanxiety

Table 3 entries are values of F and P with degrees of freedom RDAS Revised Dyadic Adjustment Scale, BDI-II Beck Depression Inventory-II, BHS Beck Hopelessness Scale, M male, F female, PT patient, CG caregiver
a b

Experiences in close relations avoidance dimension Experiences in close relations anxiety dimension

founded by avoidance and anxiety subscale scores, respectively (see Table 3 and Fig. 1). Patient marital distress, depression, and hopelessness as functions of sex and matched caregiver avoidance and anxiety We employed one-way ANCOVAs to examine the impact of spouse caregiver avoidance and anxiety scores on the matched patient mean scores for the three outcome scores.
Fig. 1 Marital distress, depression and hopelessness as functions of sex, patient/ caregiver status, avoidance, and anxiety
Females Males

We did not find significant differences among the means for the three patient outcomes based on patient sex or spouse caregiver avoidance or anxiety subscale scores. The results are reported in Table 4. Caregiver marital distress, depression, and hopelessness as functions of sex and matched patient avoidance and anxiety We employed one-way ANCOVAs to examine the impact of patient avoidance and anxiety scores on the matched
Linear fit Linear fit Caregivers Patients Linear fit Linear fit

20

20

15

15

BHS

BHS
1 2 3 4 5 6

10

10

Avoidance Subscale

Anxiety Subscale

Support Care Cancer (2011) 19:15391548 Table 4 Results of one-way ANCOVAs for three scores for patients with matched caregiver avoidance and anxiety subscales Score RDAS BDI-II BHS Sex F(1,42) =0.06 P =0.8071 F(1,42) =0.39 P =0.5383 F(1,42) =0.73 P =0.3991 Avoidance subscale scorea F(1,42) =0.89 P =0.3501 F(1,42) =0.18 P =0.6726 F(1,42) =0.04 P =0.8455 Anxiety subscale scoreb F(1,42) =0.00 P =0.9969 F(1,42) =1.45 P =0.2358 F(1,42) =1.40 P =0.2433 Interactions None None None Least square means

1545

No significant differences No significant differences No significant differences

Table entries are values of F and P with degrees of freedom BDI Beck Depression Inventory-II, BHS Beck Hopelessness Scale, M male, F female,
a b

Experiences in close relationships avoidance dimension Experiences in close relationships anxiety dimension.

spouse caregiver mean scores for the three outcome scores. We did not find significant differences among the means for the caregiver outcomes of BDI-II and BHS based on caregiver sex or patient avoidance or anxiety subscale scores. However, there is a significant interaction effect of sex and avoidance for marital distress (RDAS): as the female patient avoidance subscale increases, the male caregiver RDAS stays about the same, and as the male patient avoidance subscale increases, the female caregiver RDAS declines. The results are in Table 5. Figure 2 illustrates the linear fit of this interaction.

Discussion This research examined two novel objectives in martially distressed patients with metastatic or recurrent cancer

and their spouse caregivers: (1) we investigated the levels of depression and hopelessness, and (2) we explored the relationship between attachment security of patients and matched spouse caregivers and their experience of distress. We found that spouse caregivers were significantly less martially distressed than their matched ill partners (P =0.01). Caregivers continued to have significantly higher scores on the marital distress measure (less distress) after taking sex, avoidance and anxiety into account, than patients. We also found a significant interaction effect of sex and avoidance for marital distress. Female caregivers level of marital distress increased as the male patient avoidance subscale score increased, such that the more avoidant the male patients were, the more the female caretakers marital distress increased. Patients reported significantly higher mean depression (BDI-II) scores than their matched

Table 5 Results of one-way ANCOVAs for three scores for caregivers with matched patient avoidance and anxiety subscale scores Score RDAS Sex F(1,41) =6.43 P =0.0151 F(1,42) =0.52 P =0.4752 F(1,42) =0.13 P =0.7230 Avoidance subscorea F(1,41) =5.26 P =0.0270 F(1,42) =0.81 P =0.3727 F(1,42) =3.78 P =0.0585 Anxiety subscoreb F(1,41) =1.12 P =0.2956 F(1,42) =3.70 P =0.0613 F(1,42) =0.00 P =0.9513 Interactions Sexavoidance F(1,41) =7.08 P =0.0111 None None Least square means F =46.75 M =46.74

BDI-II BHS

Table entries are values of F and P with degrees of freedom BDI Beck Depression Inventory-II, BHS Beck Hopelessness Scale, M male, F female
a b

Experiences in close relationships avoidance dimension Experiences in close relationships anxiety dimension

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60 55

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Caregiver RDAS

50 45 40 35 30 25

Females Males Linear fit for females Linear fit for males
1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0

Patient Avoidance Subscale

Fig. 2 Interaction effect of sex and avoidance for Revised Dyadic Adjustment Scale

spouse caregivers (P =0.001), relevant in screening for clinical depression. The patients rate of depression was higher than that of their matched spouse caregiver (52% vs. 32.6%; P = 0.09). Moreover, higher mean depression scores were found in females than males. This rate of spouse caregiver depression is consistent with the prevalence reported by other studies [e.g., 1, 2], but is not compatible with the findings of Braun [1] who reported caregiver depression as being almost twofold that of their ill partners. Higher rates in our study may be in part accounted for by the inclusion criteria that represented a sub-sample of the patient population reporting marital and psychosocial distress. Mean hopelessness scores were found to be higher for males than females and for caregivers than for patients. In keeping with the oncology literature, a general feeling of hopelessness may reflect end-of-life despair, loss of dignity, and intimate dependency [6, 7]. Of note, the rate of hopelessness in our patient sample is greater (33% vs. 23%; P = 0.48) than that reported by Rodin and colleagues [5], but is consistent with the findings of Rodin and colleagues [32] of higher levels of depression and hopelessness in end-stage cancer patients. It is interesting that males and caregivers showed higher mean scores of hopelessness; this may be influenced by their anticipation of loss of the marital bond through patient death [3, 44, 45], and the feeling of helplessness in being able to save their significant other. The measure of

depression was highly dependent on the anxiety and avoidance subscale scores. This study provides new information about patients and matched spouse caregivers attachment security and the possible association with levels of marital distress in couples who are challenged with end-stage cancer. Our results support the notion that an avoidant attachment in male patients may add to the experience of marital distress in female caregivers. Individuals with this attachment view themselves as unworthy of love, and expect that others will reject them. They have difficulty trusting that others can provide care in their time of need, and tend to remain detached and disengaged [21]. Avoidant attachment has been associated with lower marital satisfaction and responsive caregiving [23, 25]. Our findings add to the oncology literature in identifying an avoidant attachment in martially distressed couples as especially salient to the marital satisfaction of the female caretaker, as well as the potential overall well-being of the couple and the caretakers ability to responsively care for the ill male patient [23, 27, 28]. There are several limitations that should be taken into account in interpreting the findings of this study. To begin, the sample size limited the statistical tests that could be performed and also limited power in examining group differences. Moreover, it is possible that another factor that we did not measure may have contributed to our findings. Attachment security is thought to be an enduring trait, characteristic of the individual and imperious to the mental state of the individual. In the case of facing end-of-life, it may be argued that attachment security is threatened and thereby a measure of reactive response to the threat of loss of life and the marital bond. Due to the limitations in our sample size and study design, we are limited in making assumptions in this regard. Because of these limitations, future studies with a longitudinal prospective design and a larger sample are warranted. In conclusion, attachment security may impact psychosocial distress in couples where one is facing terminal cancer, specifically; marital distress may be amplified within insecure attachment bonds and influence the quality of both caregiving and care-receiving. Our findings offer unique, preliminary support for the need to identify those couples at risk in order to reduce suffering and complicated bereavement in this population. Finally, our results underscore the need for interventions for couples where one has metastatic or recurrent cancer and is facing end-of-life [12, 13].

Support Care Cancer (2011) 19:15391548 Acknowledgements We appreciate the patients and spouse caregivers time and contribution to this study. We thank members of the psychosocial Oncology and Palliative Care Program for their assistance with the referral process. We extend appreciation to the Department of Statistics, University of Toronto, for their contribution to data analysis. Disclosures None.

1547 patients facing advanced cancer and their spouse caregivers: outcomes of a pilot study. Psychooncology 17:11521156. doi:10.10021/pon1319 Banthia R, Malcarne VL, Varni JW, Ko CM, Sadler GR, Greenbergs HL (2003) The effects of dyadic strength and coping styles on psychological distress in couples faced with prostate cancer. J Behav Med 26:3152 Baider L, Ever-Hadani P, Goldzweig G, Wygoda MR, Peretz T (2003) Is perceived family support a relevant variable in psychological distress? A sample of prostate and breast cancer couples. J Psychosom Res 55:453460 Steinglass P (2000) Family processes and chronic illness. In: Baider L, Cooper C, De-Nour A (eds) Cancer and the family. Wiley, West Sussex, pp 315 Beck AT, Steer RA, Brown GK (1996) Manual for the beck depression inventory-II. Psychological Corporation, San Antonio Bowlby J (1969) Attachment and loss, volume 1: attachment. Basic Books, New York Bowlby J (1988) A secure base: clinical applications of attachment theory. Routledge, London Goldberg S (2000) Attachment and development. Arnold Publishers, London Bartholomew K (1990) Avoidance of intimacy: an attachment perspective. J Soc Pers Relat 7:147178 Brennan K, Clark C, Shaver P (1998) Self-report measurement of adult attachment: an integrative overview. In: Simpson JA, Rholes WS (eds) Attachment theory and close relationships. The Guilford Press, New York, pp 4676 Feeney JA, Hohaus L (2001) Attachment and spousal caregiving. Pers Relatsh 8:2139 Westmaas JL, Silver RC (2001) The role of attachment in responses to victims of life crises. J Pers Soc Psychol 80:425438 Shields CG, Travis LA, Rousseau SL (2000) Marital attachment and adjustment in older couples coping with cancer. Aging Ment Health 4(3):223233, Publisher Routledge, part of the Taylor & Francis Group Slade A (1999) Attachment theory and research: implications for the theory and practice of individual psychotherapy with adults. In: Cassidy J, Shaver PR (eds) Handbook of attachment. Gilford Press, New York, pp 575594 Mikulincer M, Shaver PR (2005) Attachment security, compassion, and altruism. Curr Dir Psychol Sci 14:3438 Feeney JA (1996) Attachment, caregiving, and marital satisfaction. Pers Relatsh 3:401416 McLean LM, Nissim R (2007) Marital therapy for couples facing advanced cancer: case review. Palliat Support Care 5:303313 Kayser K (2005) Enhancing dyadic coping during a time of crisis: a theory-based intervention with breast cancer patients and their partners. In: Revnson TA, Kayser K, Bodenmann G (eds) Couples coping with stress: emerging perspectives on dyadic coping. American Psychological Association, Washington, pp 175194 Hunter MJ, Davis PJ, Tunstall JR (2006) The influence of attachment and emotional support in end-stage cancer. Psychooncology 15(5):431444 Rodin G, Walsh A, Zimmermann C, Gagliese L, Jones J, Shepherd FA, Moore M, Braun M, Donner A, Mikulincer M (2007) The contribution of attachment security and social support to depressive symptoms in patients with metastatic cancer. Psychooncology 16(12):10801091 Karnofsky DA, Burchenal JH (1949) The clinical evaluation of chemotherapeutic agents in cancer. In: Macleod CM (ed)

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15.

Funding This study was funded by the Faculty of Medicine, Deans Fund, University of Toronto, and the University Health Network, Allied Health Grant, Toronto, Ontario, Canada.

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