Journal of Psychosomatic Research 61 (2006) 187 – 196
Cognitive–behavior group intervention for relatives of cancer patients:
a controlled study
Miri Cohena,T, Abraham Kutenb
a
Faculty of Social Welfare and Health Studies, School of Social Work, Haifa University and Social Work Department, Rambam Medical Center, Haifa, Israel
b
Oncology Department, Rambam Medical Center, Haifa, Israel
Received 3 December 2004
Abstract
Objective: The objective of this study was to assess the effect
of cognitive–behavior (CB) group intervention on the psychological distress and adjustment of relatives of cancer patients with a
primary disease. Methods: A total of 52 relatives of cancer patients
participated in a CB group intervention, whereas another 52 served
as control subjects. All participants completed preintervention and
postintervention measures and a 4-month follow-up questionnaire
consisting of the Brief Symptom Inventory (BSI), the Psychological Adjustment to Illness Scale (PAIS), the Mini Sleep
Questionnaire, and the Multidimensional Scale of Perceived Social
Support; participants in the group intervention also reported
compliance with home practice. Results: Participants in the
intervention group scored significantly lower than the control
subjects on the BSI and the PAIS, recorded fewer sleep difficulties
in the postintervention and follow-up measures, and reported
higher perceived support in the follow-up measure. By contrast, no
significant change was observed in the control group during the
study period. On the reliable change index, 30.8% of the
intervention participants but only 3.9% of the control subjects
had statistically significant improvements in their psychological
distress. Improvement in the intervention group was associated
with higher compliance with home practice. Conclusion: This
study provides evidence for the positive effect of a CB group
intervention for family members, which lasted for 4 months after
the intervention ended.
D 2006 Elsevier Inc. All rights reserved.
Keywords: Relatives; Cancer patients; Cognitive–behavior group intervention; Compliance; Home practice
Introduction
The impact of cancer on patients’ relatives, especially their
spouses, has been widely studied [1– 6], with general
confirmation of the notion that they experience high levels
of psychological distress [3,5,6] resembling those of the
cancer patients themselves [4,7]. Even higher distress levels
in relatives than in patients have been reported [8,9]. Other
studies found impaired psychosocial adjustment of relatives
to cancer illness [2,10,11].
Despite these information, surprisingly few studies report
psychosocial interventions with cancer patients’ relatives.
Some early reports described group interventions [12 –14]
with small numbers of participants and without control
groups. The still fewer controlled studies that could be
T Corresponding author.
E-mail address: [email protected] (M. Cohen).
0022-3999/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.jpsychores.2005.08.014
located were conducted in the United States. Goldberg and
Wool [15] provided an unstructured supportive intervention
for the spouses and adult children of lung cancer patients.
They found no difference in the levels of psychosocial
adjustment or in psychological distress between the 23 participants and the control subjects. A more recent randomized
controlled study involved 66 spouses and included a followup [16]. A problem-solving intervention based on a standardized protocol was offered to the intervention group. No
difference in psychological distress, perceived health, or
perceived social support was found between the intervention
and the control groups. Manne et al. [17] evaluated the effects
of a six-session psychoeducational group intervention on
distress levels in 60 spouses of prostate cancer patients in a
randomized clinical trial. This was a structured group, and a
different topic was presented each session. Information was
provided on medical issues, nutrition, stress management and
coping skills, communication, intimacy, and posttreatment
188
M. Cohen, A. Kuten / Journal of Psychosomatic Research 61 (2006) 187 – 196
concerns. Again, no difference between the intervention and
control groups with regard to general distress or cancerspecific distress was noted.
A cognitive – behavior (CB) model of intervention with
cancer patients was developed by Moorey and Greer [18]
based on the cognitive theory of Beck [19]. The model
proposes that the negative appraisals, interpretations, and
meanings that individuals attribute to cancer and its treatments determine their emotional and behavioral reactions and
the way they adjust to the situation. CB therapy aims to create
a realistic interpretation of the stresses involved in adjusting
to cancer, eliciting ways to cope effectively with them and to
acquire and mobilize efficient coping behaviors [18,20].
Additional cognitive techniques are mental distraction,
reframing, problem solving, and decision-making strategies
[18]. The behavioral component consists of learning and
exercising relaxation and guided imagery and is aimed at
reducing levels of stress and anxiety. In addition, techniques
such as distraction and establishing a daily schedule and
activities are used [18,19].
The growing trend to provide cancer patients with CB
intervention with favorable outcomes [18,21,22] is lacking
from reports on interventions with relatives [18,23]. Moorey
and Greer [18] reported using the CB model with couples;
however, to the best of our knowledge, no report on group CB
therapy for relatives has been published.
Yet a CB therapy may be helpful in relieving psychological distress in relatives too. It may help them reduce
psychological distress through restructuring negative
appraisals of cancer and its impact on their lives and of the
demands and strains of caring. Another possible target of CB
therapy for relatives should be to teach them how to have their
support needs met and improve appraisals of the support they
receive from their family and their social network. Several
studies reported that relatives who perceived receiving
greater support coped better with the strain of caring for a
cancer patient [10,24,25], whereas other studies suggested
that positive support has no effect on psychological distress
(reviewed in Ref. [1]).
Psychological distress is often associated with the onset or
worsening of sleep difficulties, which has a negative impact
on quality of life (e.g., impairments in concentration and
memory, coping capacity, mood, and physical health [26]).
Studies have suggested that CB techniques can produce a
meaningful improvement in the quality of sleep [26,27]. The
improvement may be caused by the lowering of levels of
anxiety and depression [28,29]. Moreover, research has
demonstrated that relaxation improves quality of sleep [30]
by reducing autonomic arousal [29–31] or raising melatonin
levels [32]. Relaxation techniques can be used as a direct
means for falling asleep as well [23].
Accordingly, this study was designed to assess the
effect of a CB group intervention for relatives on their
psychological distress, sleep difficulties, perceived support,
and psychosocial adjustment to cancer in the ill family
member, as compared with a nonintervention group.
Our first hypothesis was that participants in the CB
group would score lower than the control subjects on
psychological distress, sleep difficulties, and adjustment
and higher on perceived social support by the end of
the sessions.
Most studies on the effect of group interventions have
measured statistically significant changes, from pretreatment
to posttreatment, by means of the studied variables and their
effect size. Recently, researchers have noted that a statistically significant change, even with a considerable effect
size, may not be a clinically significant change; they have
devised other ways to identify the significance of change.
The statistical approach to evaluate the clinical significance
of change by Jacobson and Truax [33], known as the
reliable change index (RCI), was used in this study. Based
on this approach, the change from pretreatment to posttreatment undergone by each individual was examined and
determined significant if the observed change was beyond
the limits of chance variation. A major advantage of the RCI
is that it accounts for error variance owing to measurement
[33]. This allows a more precise evaluation of change in
individual patients. Thus, our second hypothesis was that
more participants in the CB group would exhibit a clinically
significant change in the studied variables posttreatment,
which would persist in a follow-up.
Methods
Participants and procedure
From 2001 to 2004, relatives of cancer patients with a
primary and localized disease receiving either chemotherapy
or radiotherapy treatment, regardless of time elapsed since
diagnosis, were invited to participate in the study. They
were recruited by social workers and nurses in the outpatient
unit of the oncology department of the Rambam Medical
Center in Haifa, Israel, after the patients’ permission was
obtained. Stipulations for eligibility were that participants be
aged between 24 and 75 years, spoke fluent Hebrew, were
not receiving psychiatric medication, and were themselves
not present or past cancer patients. Only one relative from
each patient’s family participated in the study. Relatives
received information about the study and its aims and gave
their informed consent to participate.
The control group consisted of relatives who had initially
agreed to participate in the group intervention but before it
started found that they could not attend because of practical
reasons (e.g., time of the sessions and small children at
home). This way was chosen because the number of relatives
wishing to participate was too low for a random selection.
The high rates of refusal and dropout from groups for cancer
patients’ relatives have been previously noted [23]. Although
not chosen at random, all participants in the control group had
initially wished to join the therapy group, so, presumably,
they constituted a satisfactory control group.
M. Cohen, A. Kuten / Journal of Psychosomatic Research 61 (2006) 187 – 196
Of the 552 eligible relatives approached, 409 refused to
participate in this study. Of the final sample, 80 relatives
were assigned to the intervention group and 63 relatives
were assigned to the control group. Of the intervention
participants, 18 declined to continue participating after the
group started (7 participants opted out because of their ill
relative’s medical complications, 6 could not adjust
themselves to the group schedule, and 5 resigned after
the group started because they felt that the group
intervention did not suit their needs). Another 10 patients
from the intervention group missed more than two meetings and were not included in the study, and 4 participants
failed to complete the questionnaires at one or more of the
time points and were excluded from the study. Finally,
the intervention group consisted of 52 participants. Of the
control subjects, 11 failed to complete all questionnaires,
which resulted in 52 participants too.
Eight CB groups, meeting for nine sessions of 90 min
each, were conducted consecutively. Each group had five to
seven participants. Relatives in the control group received the
standard psychosocial care from a multiprofessional team.
189
This care consisted of support from a social worker and
nurses in the oncology unit and mediation in receiving
tangible aid from sources in the community. They were invited
to attend a new group intervention when the study ended.
All participants completed questionnaires at three time
points: Time 1, preintervention; Time 2, after 9 weeks after
the intervention ended (postintervention); and Time 3,
4 months after the intervention ended (i.e., the 25th week
of the study). The study was approved by the hospital’s
ethics committee.
CB group intervention
The intervention was conducted according to a manual
for CB group intervention prepared in our psycho-oncology
unit. The manual was based on the cognitive theory of Beck
[19], the CB model of Moorey and Greer [18], and the
model of relaxation and guided imagery of Baider et al.
[34]. The model was implemented at the Rambam Medical
Center’s Oncology Department, and clinical experience with
the intervention was acquired prior to the study. Groups
Table 1
Structure and content of CB sessions and home practice
Session
Content
Home practice for the following week
1
Acquaintance, expectations, group contract
Introduction to the program and to CB
(start of making distinctions between emotions and thoughts)
Primary experience with relaxation and guided imagery
Introduction to the concept of automatic thoughts and their
relation to emotions through working on examples from
participants’ lives; emotional expression
Relaxation and guided imagery with focus on learning to relax
the head and face muscles
Introduction to the concept of challenging thoughts and thought
distortions; relaxation and guided imagery with focus on the nape,
shoulders, and hand muscles
Identifying and challenging beliefs
Learning problem-solving and coping skills
Relaxation and guided imagery with focus on the back,
bottom, and legs
Continue work on thoughts, beliefs, and problem solving
Learning cognitive and behavioral distracting techniques
Practicing relaxation and guided imagery with focus on chest and
abdominal muscles and learning deep breathing
Using the CB model with focus on issues of anxiety and arousal
Introduction to techniques for sleep problems
Practicing complete relaxation and guided imagery
Identifying and rating the intensity of emotions
during the week
2
3
4
5
6
7
8
9
Using the CB model with focus on issues of communication
and managing anger
Practicing complete relaxation and guided imagery; learning
immediate relaxation techniques for daily situations of arousal in
anxiety, stress, or anger
Using the CB model with focus on issues of depressed mood
Practicing complete relaxation and guided imagery and immediate
relaxation techniques
Setting goals and reinforcement of strategies
Overview of the group, feedback, and ending
Monitoring and recording emotions and thoughts;
practicing relaxation and guided imagery
Monitoring and recording emotions, thoughts,
alternative thoughts, change in emotions;
practicing relaxation and guided imagery
Continued recording of the complete model
(described above); practicing problem solving;
practicing relaxation and guided imagery
Continued recording of the complete model
Practicing problem solving and distracting
Practicing relaxation and guided imagery
Continued monitoring of the complete model
Practicing problem solving and distracting
Practicing relaxation and guided imagery
(handing out relaxation and guided imagery audio disc/cassette)
Continued monitoring of the complete model
Practicing problem solving and distracting
Practicing relaxation and guided imagery
Continued monitoring of the complete model
Practicing problem solving and distracting
Practicing relaxation and guided imagery
190
M. Cohen, A. Kuten / Journal of Psychosomatic Research 61 (2006) 187 – 196
were conducted by a senior social worker who had extensive
experience and training in psycho-oncology, group therapy,
and CB therapy. The sessions were structured, and each
consisted of cognitive and behavioral components (Table 1).
The cognitive techniques focused on learning to elicit
negative thinking patterns, learning to identify and monitor
automatic thoughts and beliefs and to challenge and
restructure them in more adaptive patterns, and finding
alternative responses for recurrent stressful situations. In
addition, reframing and problem solving were taught.
Behavioral techniques consisted of systematic learning of
relaxation, guided imagery, and deep breathing. Cognitive
and behavioral distraction strategies were likewise introduced. Expression of emotions and building mutual support
were encouraged too, although these were not the focus of
the intervention.
The participants gradually learned the CB skills (Table 1).
They began by identifying emotions and grading their
intensity and then moved on to identifying and monitoring
negative thought and beliefs, challenging them, and grasping the cognitive distortions caused. Next, they elicited
alternative thoughts and tracked the successive intensities of
their emotions.
From the second session, each meeting started with a
review of the home practice. Next, a new topic was
introduced, discussed, and experienced. In this part of the
session, participants shared and explored their emotions with
the group and used the opportunity to apply the strategies to
their personal situation. In subsequent sessions, common
issues such as managing stress, anxiety, anger, and sleep
difficulties were addressed. Also, distancing and problemsolving techniques were introduced and exercised. This
activity covered the first hour of each session. The last half
hour was devoted to progressive learning of deep relaxation
and guided imagery [34].
In each session, a different guided imagery was suggested
(e.g., a seashore, a spring, an open field). The participants had
the opportunity to experience and discuss various sensations
and reactions to different elements of the relaxation and
guided imagery. Feedback was given in the last part of the
session and home practice was assigned. Participants
gradually acquired the experience needed to conduct relaxation and guided imagery successfully on their own and to
implement it for specific situations (e.g., anxiety arousal and
sleep difficulties).
Participants were provided with written materials and
home practice at every session. The handouts included an
explanation of CB techniques, sheets for successive recording of identified emotions (type and intensity), thoughts and
beliefs underlying the emotions, alternative thoughts, and
changes in emotion intensity. Participants were asked to
practice the cumulatively learned CB techniques. Participants received written instructions for relaxation and guided
imagery for the week following each session according to the
techniques practiced during the session; at the sixth session,
by which the whole model of relaxation/guided imagery had
been learned, they were given the relaxation/guided imagery
audiocassettes or compact discs for further practicing.
Instruments
Brief Symptom Inventory
The Brief Symptom Inventory is a shortened (53 items)
version of the SCL-90-R [35]. It is a well-tried instrument
designed to assess psychological distress and has been
shown to possess good psychometric properties [36]. It was
found appropriate for the Israeli population [37]. It is
composed of nine symptom dimensions: somatization,
obsessive– compulsive, interpersonal sensitivity, depression,
anxiety, hostility, phobic anxiety, paranoid ideation, and
psychoticism. Each item is scored on a 5-point scale ranging
from 0 (not at all) to 4 (extremely). In our study, a Global
Severity Index (GSI) was calculated as the mean of all item
scores. The GSI is a sensitive indicator of psychological
distress because it reflects information on both the number
and severity of symptoms [36]. The internal consistency (a)
values of the GSI at the three time points were .91, .87, and
.90, respectively.
Psychological Adjustment to Illness Scale–Self-Rating
The Psychological Adjustment to Illness Scale–SelfRating (PAIS-SR) [38] contains 46 items that cover seven
domains of psychosocial adjustment: health care orientation,
vocational environment, domestic environment, sexual relations, extended family relationships, social environment, and
psychological distress. The PAIS has been proven to have
good psychometric properties. Its validity and reliability have
been established in relatives of cancer patients [39]. Items are
rated on a 4-point scale from 0 (no problems) to 3 (a multiplicity of problems). The total score of psychosocial adjustment was used in this study; a higher total score reflected
worse overall adjustment. The internal consistency (a)
values of the PAIS-SR at the three time points were .87,
.84, and .85, respectively.
Mini Sleep Questionnaire
The Mini Sleep Questionnaire [40] is a 10-item self-report
that measures problems with falling asleep, restless sleep,
and early awakening in the morning. Answers are given on a
7-point scale from 1 (never) to 7 (always). Higher
scores reflect more sleeping difficulties. A total sleep
difficulties score is calculated. There are four categories of
sleep difficulties: 10 –24 points, good sleep quality;
25 –27 points, mild sleep difficulties; 28 –30 points, moderate
sleep difficulties; and z31 points, severe sleep difficulties. In
our study, the internal consistency (a) at the three time points
ranged from .87 to .89.
Multidimensional Scale of Perceived Social Support
The Multidimensional Scale of Perceived Social Support
[41] is a 12-item instrument designed to measure perceived
M. Cohen, A. Kuten / Journal of Psychosomatic Research 61 (2006) 187 – 196
social support from three sources: a significant person, the
family, and friends. The items are rated on a seven-point
Likert scale. Higher scores reflect higher perceived support.
Internal consistency (a) ranged from .92 to .95 for the
three subscales.
Compliance with Home Practice
Compliance with home practice was assessed by two
questions: (1) how many times a week (average of the
2 previous weeks) participants performed the relaxation and
guided imagery exercise (at least 10 min) and (2) how many
times a week participants performed the written automatic
thought monitoring. Answers ranged from 0 (none) to
7 (everyday or more often).
Data analysis
Data were analyzed by means of the SPSS 12 program
for Windows. Repeated-measures analysis of variance
(ANOVA) was used to determine the changes over the three
time points for each outcome variable (GSI, PAIS, sleep difficulties, and perceived support). This was a 2 (group: intervention, control) 3 (time point: Time 1=preintervention,
Time 2=postintervention, Time 3= 4 months after) model.
Contrast analyses were used to test for changes in the outcome measures from pretreatment through posttreatment
to follow-up. Within-subject effects for each group were assessed for each pair of time points. Requirements of homogeneity of variance and compound symmetry (assessed by
the Mauchly Test of Sphericity) were met for the perceived
support and sleep difficulties scales. For GSI and PAIS,
the requirements were not met, and the Greenhouse– Geisser
epsilon correction was used [42]. A P value V.05 was used for
statistical significance; all probability values were two tailed.
Regression analysis was conducted for the intervention
group only, in which the total change at Time 3 in each of the
outcome variables was the dependent variable. The initial
score was entered first, then sex, time since diagnosis, and
compliance (at Time 3) with home practice.
Effect size estimates (partial D2) were reported to indicate
the proportion of variance that was accounted for by an effect
[43]. In general, effect size values for partial D2 are regarded
as small at .01, medium at .06, and large at .14 [43]. In addition, we assessed whether the psychological distress in
participants had eased to a clinically significant degree by
calculating the RCI for each participant using the method
suggested by Jacobson and Truax [33]. The RCI indicates
whether a change in scores between the measurement times
reflects more than incidental fluctuations of measurement.
The RCI was calculated using the equation RCI=X 2X 1/S diff.
The preintervention and postintervention score difference
was divided by the standard error of difference between the
two test scores, which was calculated from the standard
errorffi
qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
2
of measurement (S.E.) by the formula Sdiff ¼ 2ðS:E:Þ .
When the RCI is N1.96, the change is considered statistically
significant [33].
191
Results
Sociodemographic characteristics
The demographic characteristics of the intervention
participants, the control subjects, and those who declined
to participate are shown in Table 2 (for those who declined,
only age, sex, education, and kinship variables are presented
because they did not give informed consent to have the
medical files of their family member looked into or to fill
any other questionnaire). m2 test, t test, or ANOVA was
conducted to compare demographic and patients’ illnessrelated differences between the intervention, control, and
refusal groups (Table 2). The characteristics of the three
groups were not statistically different.
Psychosocial measures
Table 3 presents the mean values and standard deviations
of the scores of the study and control groups for the
psychosocial measures across the three time points (pretreatment, posttreatment, and follow-up), the repeated-measures
analyses, and the effect sizes of results.
Table 2
Demographic and clinical characteristics
Age
Mean
S.D.
Range
Education
Mean
S.D.
Range
Sex [n (%)]
Female
Male
Kinship [n (%)]
Spouse
Son/daughter
Parent
Other
Patient’s disease [n (%)]
Breast
Colon
Prostate
Gynecological
Other
Marital status [n (%)]
Married
Single
Divorced
Widower
Employed
Religiosity [n (%)]
Secular
Mildly religious
Very religious
Intervention
(n=52)
Control
(n=52)
Refused to
participate
(n= 409)
53.3
14.7
25 –72
52.6
12.1
24 – 69
53.9
16.5
27–73
12.3
3.5
8 –17
12.9
2.3
8 –18
13.2
3.1
8 – 20
36 (69.2)
16 (30.8)
33 (63.5)
19 (36.5)
265 (64.8)
144 (35.2)
24
12
9
7
(46.2)
(23.1)
(17.5)
(13.5)
27
9
8
8
(51.9)
(17.3)
(15.4)
(15.4)
208
78
56
67
21
14
4
6
7
(40.4)
(26.9)
(7.7)
(11.5)
(13.5)
22
12
5
8
5
(42.3)
(23.1)
(9.6)
(15.4)
(9.6)
–
–
–
–
–
40
3
7
2
40
(76.9)
(5.8)
(13.5)
(3.8)
(76.9)
41
2
6
3
38
(78.8)
(3.8)
(11.6)
(5.8)
(73.1)
–
–
–
–
–
33 (63.4)
16 (30.8)
3 (5.8)
–
–
–
28 (53.8)
21 (40.4)
3 (5.8)
(50.9)
(19.0)
(13.7)
(16.4)
192
M. Cohen, A. Kuten / Journal of Psychosomatic Research 61 (2006) 187 – 196
Table 3
Mean values (S.D.) of outcome variables (by time and group)
Variable
GSI
Time 1
Time 2
Time 3
Sleep difficulties
Time 1
Time 2
Time 3
PAIS
Time 1
Time 2
Time 3
Perceived support
Time 1
Time 2
Time 3
Intervention
Control
0.66
0.41
0.52
0.34
0.46
0.49
0.64
0.72
0.73
0.33
0.48
0.50
30.33
22.58
22.31
11.47
10.05
11.26
29.31
28.52
29.77
12.28
12.26
11.52
1.79
1.29
1.32
0.98
0.86
1.07
1.65
1.82
1.84
0.81
0.85
0.83
5.80
6.02
6.58
3.41
4.26
3.92
6.03
5.82
5.18
4.25
4.19
4.22
Group (1, 101)
Time (1, 101)
Group Time (1, 101)
Effect size
9.09T
0.09
21.74TT
0.18
4.86T
3.92T
11.64TT
0.11
4.49T
6.24T
11.54TT
0.11
2.93
2.27
11.82TT
0.13
T Pb.01.
TT Pb.001.
At pretreatment, the psychosocial measures (GSI, PAIS,
sleep difficulties, PAIS and perceived support) were similar
in both groups, with no significant difference between them.
The participants’ mean GSI scores were similar to those of
the spouses of breast cancer patients in a previous study in
Israel [2]. Participants in both our groups reported having
sleep difficulties at the upper end of the moderate score [40].
PAIS scores were worse than those previously reported for
relatives (parents of adult cancer patients) [44]. However,
participants in both groups perceived fairly high support
from their social network (a score of 5.9 of a maximum of 7).
Repeated-measures ANOVA indicated that significant
Group Time interactions existed for all the psychosocial
variables, pointing to a significant reduction in GSI, PAIS,
and sleep difficulties and an increase in perceived support in
the intervention group, but not in the control group, over
time. Group main effects were significant for GSI, PAIS,
and sleep difficulties but not for perceived support. Time
main effects were significant for sleep difficulties and PAIS.
The overall effect size of between-group differences ranged
from .11 to .18 (Table 3), which indicates a medium-to-high
effect [43].
Contrast analyses revealed that for GSI, the Group Time
interactions were significant for Time 2 scores as against
Time 1 scores [ F(2, 101)=34.61; Pb.0001] and for Time 3
scores as against Time 2 scores [ F(2, 101)=5.09; Pb.05].
This indicates that the differences in mean scores between
Time 1 and Time 2 and between Time 2 and Time 3 were
significant for the intervention group but not for the control
group. The Time 2 score was found to differ significantly
from the Time 1 score for PAIS [ F(2, 101)=11.36; Pb.01]
and for sleep [ F(2, 101)=15.14; Pb.001]. For perceived
support, only the Time 1 and the Time 3 scores differed
significantly [ F(2, 101)=14.30; Pb.0001].
Compliance with practicing thought monitoring
and relaxation
At Time 2, the mean home practice of relaxation with
guided imagery was 3.4 (S.D.= 3.8) times per week; at Time
3, it was 2.3 (S.D.=2.9) times per week. Written thought
monitoring was performed, on average, 2.7 (S.D.=2.5) times
per week at Time 2 and 1.9 (S.D.=1.7) times per week at
Time 3. At Time 3, women performed relaxation and guided
imagery significantly more times per week (mean=3.8 times,
S.D.=2.6) than men (mean=1.8 times, S.D.=2.0) (t=3.1,
Pb.01). Thought monitoring was performed, on average,
2.3 (S.D.=1.7) times per week by men and 1.6 (S.D.=1.2)
times per week by women, but the difference was not statistically significant.
Regression analysis for the outcome variables
Regression analysis was conducted on the total change in
psychosocial variables at Time 3 for the intervention group
(Table 4). Independent variables entered were sex, initial
scores, time since diagnosis of the ill relative, and compliance
at Time 3 with practice of thought monitoring and of
relaxation/guided imagery. Higher GSI preintervention scores
and higher compliance with thought monitoring and with
relaxation/guided imagery were significant predictors of the
total change in GSI. The independent variables accounted for
37% of the variance of GSI. The independent variables
accounted for 45% of variance of sleep difficulties. Being
male, scoring higher in preintervention, longer time since
diagnosis, and complying more with both modalities were
significant predictors. Thirty-five percent of the PAIS variance
was accounted for by the dependent variables; of these, higher
preintervention scores, longer time since diagnosis, and
M. Cohen, A. Kuten / Journal of Psychosomatic Research 61 (2006) 187 – 196
Table 4
Multiple regression and analysis for mean total change in outcomes
variables for the intervention group (n=52)
Variable
Total change – GSI
Sex
Preintervention score
Time since relative’s diagnosis
Compliance to thoughts monitoring
Compliance to relaxation/imagery
Total change–sleep difficulties
Sex
Preintervention score
Time since relative’s diagnosis
Compliance to thoughts monitoring
Compliance to relaxation/imagery
Total change –PAIS
Sex
Preintervention score
Time since relative’s diagnosis
Compliance to thoughts monitoring
Compliance to relaxation/imagery
Total change –perceived support
Sex
Preintervention score
Time since relative’s diagnosis
Compliance to thoughts monitoring
Compliance to relaxation/imagery
h
R2
Adjusted R 2
.43
.37
.48
.45
.41
.35
.28
.26
.12
.38***
.16
.29**
.24*
.09
.36***
.28**
.24*
.28**
.13
.35**
.24*
.27*
.18
.23*
.27*
.09
.06
.10
* Pb.05.
** Pb.01.
*** Pb.001.
greater compliance were significant predictors of the change
in PAIS scores. Twenty-six percent of the variance of
perceived support was accounted for by the dependent
variables, of which significant predictors of the change were
only being male and having lower preintervention scores.
Significance of change
The RCI calculation (RCI= 6.5) showed a clinically
significant improvement in psychological distress from
preintervention to follow-up in 30.8% (n=16) of the
participants in the intervention group, in contrast to that in
only 3.9% (n=2) of the subjects in the control group. All
participants who experienced significant change had initial
GSI scores higher than the norm. The change in the other
measured variables was also clinically significant for the
intervention group (for PAIS, RCI=2.2; for sleep difficulties,
RCI=14.8; for perceived support, RCI=3.2).
Discussion
This study evaluated the effectiveness of short-term CB
group intervention with relatives of cancer patients receiving treatment for primary cancer. The results indicated the
presence of an intervention effect for psychological distress,
sleep difficulties, and psychological adjustment to illness.
The effect was maintained over the 4-month follow-up. A
193
significant effect for perceived support was observed only
on follow-up. Thirty percent of the participants in the
intervention groups with high initial GSI scores achieved a
clinically significant improvement.
These results are of importance in light of the small
overall number of controlled studies on interventions with
relatives of cancer patients; these generally reported no
change in psychological distress [16,17] or adjustment
problems [15] as a result of the intervention. Our study is
likewise especially significant considering the dearth of
research evaluating CB interventions for relatives of cancer
patients. High refusal and dropout rates in groups for cancer
patients’ relatives were previously described [23]. However,
the results are in line with previous reports on the positive
effect of CB therapy for cancer patients (reviewed in Refs.
[21,45,46]) and for other groups of distressed individuals
[47– 49], although other studies reported no difference in
outcomes of CB groups and various control groups [50].
The positive effect of the present CB group intervention
suggests that this mode may be effective for relatives too.
Most of the decreases in psychological distress and sleep
difficulties were observed during the intervention period. The
positive effect of CB interventions on psychological distress
was previously widely studied and confirmed with different
populations [21,45– 47]. The positive effect of CB interventions on sleep difficulties was only recently empirically
confirmed [26,27], supporting the present findings. Reducing
sleep difficulties may significantly improve positive coping
with and adjustment to life stress, so it should be an important
goal of interventions with relatives [26].
Although increasing the level of perceived support was
among the main aims of the intervention, by its end, the
change in perceived support was not significant. However,
perception of support continued to improve in the intervention group and appeared significantly better in the
follow-up as compared with the preintervention reports.
Ogrodniczuk et al. [51] likewise found that changes in
perceived support were evident only at the follow-up period
of the group intervention, not immediately at the end of
sessions. A possible explanation may lie in the nature of
perceived support, which, in addition to being reactive to the
situation of coping with cancer in a relative, carries elements
of a core belief. Moorey and Greer [18] already suggested
that core beliefs can be changed even in short-term CB
interventions, but in a somewhat longer process and after a
patient feels less distressed. In addition, a process of
learning and assimilating the cognitive techniques may
have to occur before the techniques can be implemented into
actual coping and before they have a significant effect on
perceptions such as social support. In addition, it could be
that during the group sessions, support received from group
members overshadowed support received from others, and
only at follow-up was the change in the perception of
support from family and significant others evident.
In contrast to the intervention group, the control group
showed no change and even a nonsignificant trend of
194
M. Cohen, A. Kuten / Journal of Psychosomatic Research 61 (2006) 187 – 196
deterioration in perceived support between the time points;
this accords with the findings of previous studies indicating
the growing sense of isolation among cancer patients and
their relatives over time [52].
In line with previous studies [34,53], higher initial
distress predicted higher total change in all outcome
variables. In addition, being male predicted higher change
in perceived support. The role of sex may be explained by
the lower initial perceived support among the males and the
positive relationship between lower initial scores and greater
increase during the intervention and follow-up.
Compliance with home practice of the cognitive and
behavioral techniques learned in CB sessions was also a
significant predictor of the total change in outcome
variables. The role of such compliance was only seldom
measured in past studies, which did not include this
variable in the evaluation of outcomes [21,54,55]. The
present results indicate that compliance was not very high
and was even lower at follow-up. However, it was
associated with the degree of improvement in the psychosocial variables; compliance with relaxation and guided
imagery was associated with improvement in GSI scores
and sleep difficulties, whereas compliance with automatic
thought monitoring was associated with the degree of
change in GSI and PAIS scores and sleep difficulties. On
the other hand, increase in social support was not
associated with frequency of practice. This finding also
relates to the slower pattern of change in social support as
compared with the other variables, which appeared after
relief in psychological distress and assimilation of the new
approach [18].
The measuring of compliance, which was based on selfreports of frequency of performance, had some drawbacks.
This measure may have been liable to recall inaccuracy or to
social desirability bias [56]. In addition, patients may have
needed to use written monitoring less when they became
more acquainted with the cognitive techniques. It is important
to expand research on the effects of compliance with home
practice on results of CB interventions using more accurate
ways of measuring compliance. Writing a diary of compliance is a possibility, although it too has disadvantages such as
being time consuming, requiring high commitment from
participants, and involving problems ensuring validity.
The effect of the intervention lasted for 4 months after
it ended, which is in accordance with previous reports on
CB interventions [45– 48], although other studies reported
that the difference between intervention and control groups
had diminished by the time of the follow-up [21]. The
significance of the changes in outcome variables was
examined using effect size and RCI. Effect size indicated a
medium-to-high effectiveness of the CB intervention; RCI
indicated a significant clinical change in 30.8% of the
patients. The results are similar to those of other studies
that measured the effect of CB group interventions [57].
Participants in the control group also showed a decrease in
GSI scores over time, but only 3.9% showed a clinically
significant improvement. Studies found RCI to be a more
reliable indicator of treatment outcomes than other
statistical measures [33,58]. RCI has not yet been used
to measure the clinical significance of change in interventions with cancer patients and their relatives. Its
significance and necessity in the realm of psycho-oncology
should be further studied.
Several limitations of our study need to be underscored.
In the first place, we did not randomly assign participants to
intervention and control groups. This was because all the
relatives who were wished for CB intervention experienced
some level of psychological stress and felt in need of
immediate professional help. Ethically and professionally,
we could not assign them to the control group and delay
giving them professional help at precisely the time they
needed it most. Note, however, that the intervention and
control participants were equally anxious to take part in the
intervention and that no demographic difference was found
between them. Nevertheless, the possibility that those who
moved to the control group were different in several
respects cannot be ruled out. For example, the control
subjects who wanted to participate in the intervention but
were unable to do so for various reasons might have been
less motivated to experience the intervention or had to cope
with additional stresses and commitments in their lives.
They perhaps had had less previous exposure to group
interventions. However, the effect sizes and the RCI results
indicate that the differences measured between the groups at
Time 2 and Time 3 were apparently not caused by chance.
Furthermore, a meta-analysis that compared psychotherapies for patients with schizophrenia found similar effect
sizes for studies that used randomization and those that did
not [59].
Another limitation of the study was the relatively small
sample size, although it was similar to [53] or even higher
than [21] the size used by other studies evaluating group
interventions. Taking these limitations together, generalization from the present results to other groups of relatives
should be done with caution.
In conclusion, this study demonstrated the effectiveness
of a CB group intervention in reducing psychological
distress and increasing the psychosocial adjustment of
relatives of cancer patients. Further studies are needed to
replicate this one with different populations of relatives,
such as those of patients with advanced or metastatic
cancer, or with different kinds of cancer. CB interventions
should be assessed with randomized groups, and the
follow-up period should be longer. Furthermore, the
instruments used for the present study measured the outcome variables; it may be helpful to use instruments that
focus on the process of change in automatic thoughts to
understand better the processes occurring in the CB groups
and the way they affect the outcomes. Further research
focused on mediational factors and on identifying successful elements in CB interventions with relatives of cancer
patients is suggested.
M. Cohen, A. Kuten / Journal of Psychosomatic Research 61 (2006) 187 – 196
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