Differences in adjustment between women with breast cancer and their spouses: Implications for nursing interventions

Differences in adjustment between women with breast cancer and their spouses: implications for nursing interventions C. Noll Hoskins The aims of the study were to examine differences between partners in: (a) emotional and interaction support within the marital relationship, and (b) adjustment outcomes. Data were collected at 7-10 days, at I, 2, 3 and 6 months, and I-year postsurgery. A t each data collection point, the respondents completed the Partner Relationship Inventory (Hoskins 1998), the Psychosocial Adjustment to Illness Scale (Derogatis & Lopez 1983) and the Profile of Adaptation to Life Clinical Scale (EIIsworth 198 I). Intact data series were available for 128 patients and 121 spouses. The effect of cancer accentuated a complementary pattern for both emotional and interaction needs.The t-tests of differences between means were significant at all phases. For the adjustment variables, there was a consistent pattern of change over time for Negative Emotions, Psychological Distress and Psychological Well-being for both partners. Performance of roles in the vocational, domestic and social environments also improved significantly over time. BACKGROUND

Carol Noll Hoskins PhD, RN, FAAN, Professor of Nursing, NewYork University,429 Shlmkin

Hall.Washington Square. NewYork. NY 10003, USA

Cancer as a life-threatening illness produces high stress in both patients and families as they attempt to understand its meaning and cope with events at critical points (Krouse & Krouse 1982). The demands on a couple for coping with the stressful events associated with breast cancer while functioning in traditional roles tend to accentuate the dynam]'cs of ordinary interaction and intensify problems that already exist (Minuchin &,Minuch-in 1985). Ineffective adaptive behaviors include high negative emotions disproportionate to the conditions of the illness and a decrease in well-being. The influence of cancer on each partner has its own unique set of demands and effects. The enormous need for emotional support and communication between the patient and her spouse play an important role in adjustment to breast cancer (Hannum et al 1991). As a pivotal source of support for the woman with breast cancer (Bransfield 1982), the crisis may provide a stimulus for developing more effective communication, affection and support

Clinical Effectiveness in Nutting (1997) I, 105-111 © 1997PearsonProfessionalLid

(Wellisch 1985). Among male spouses, however, the increased demands related to the illness may negatively affect their ability to meet the patient's needs (Zahlis & Shands 1991) and, therefore, the couple's marital adjustment (Lewis et al 1989; Zahlis & Shands 1993). Morris (1979), in a review of adjustment to mastectomy, noted that 25-33% of patients manifested severe difficulties in adjustment and concluded that lack of support may be an especially important variable. Partners who report better marital adjustment are more flexible in their expectations of one another (Wollner 1983), provide higher quality support (Wellisch et al 1978), and experience less psychological distress (Wollner 1983). If patients perceive fewer expectations of active role performance by their spouse, they tend to have less psychological distress (Wollner 1983). Therefore, adjustment appears to require a re-evaluation of established roles and expectations (Baider & Kaplan-DeNour 1988; Friedman et al 1988; Northouse & Swain 1987) across the diagnostic, treatment and recovery phases.

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Phase-specific illness-related events have individual effects on role performance in the vocational, domestic and social environments (Baider & Kaplan De-Nour 1988; Northouse 1989), particularly in the postsurgery phase. Although high emotional distress occurs in both partners, spousal ratings may exceed those of patients at some points. While disfigurement is predictive of distress in both partners at various phases (Kemeny et al 1988) the long-term effect of different surgical procedures on the marital relationship is not clear (Lichtman 1982). Adjuvant therapy contributes to high stress in the relationship (Wilson & Morse 1991). Although adjuvant radiation therapy causes distress among patients (Graydon 1988; Levy et al 1992; Silberfarb et al 1980), chemotherapy leads to distress in both partners (Northouse 1989). Even though relief comes with completion of adjuvant therapy, preliminary evidence suggests that some of the same concerns of previous phases are experienced during the stable phases (Lewis 1990). In the present study, a longitudinal design permitted the study of differences in perceived emotional and interaction support within the marital relationship. Differences in adjustment outcomes at each phase of illness, considered separately and over time also were assessed. Adjustment outcomes included measures of negative emotions, psychological well-being, psychological distress, and role performance.

METHOD Sample The subjects were accrued from the practices of breast surgeons at three major medical centers in the New York City metropolitan area. The criteria for inclusion were: a. the patient was diagnosed with breast cancer b. the patient had a spouse or male partner who lived with the patient and agreed to participate c. both the patient and partner could read English. The criteria for exclusion were: a. the patient had a previous history of cancer b. either the patient or partner had a history of psychiatric hospitalization or drug abuse. Data were collected from 174 couples In the main study. Of these, 128 patients had no missing values for the primary variables in two time periods in a row or more than three time points in total. The mean age for patients and spouses, respectively, was 51.0 years (SD = 9.9) and 54.2 years (SD = 10.3) and all were married. Eighty-six percent had combined household incomes greater than US $20 000 per year and 47% had combined household incomes greater than US $40 000 per year. At the outset of the study, 68% of the patients and 78% of the spouses were employed outside the home.

Instruments At each data point, the respondents completed the following standardized inventories: the Partner Relationship Inventory (Hoskins 1988); the Psychosocial Adjustment to Illness Scale (Derogatis & Lopez 1983); and the Profile of Adaptation to Life Clinical Scale (Ellsworth 1981). Each partner received a separate set of inventories with written instructions at each data collection time. Respondents were instructed to complete each item on all inventories according to their perception since the previous data collection time, and not to consult with their partner. A pre-stamped envelope was provided for return of the inventories. The Partner Relationship Inventory (Hoskins 1988) is a measure of need fulfillment in the marital relationship. Role theory provides the framework which suggests that a satisfactory and mutually supportive relationship is based on congruency between partners in perceptions of one another's role in providing for needs to be met. Major discrepancies, whether in the perception of one another's role, expectations of the other, or actual satisfaction of needs, are role strain and conflict. The Emotional Needs subscale consists of 15 items and the Interactional Needs subscale, 25 items. The two subscales together are comprised of eight categories, each of which focuses on a specific domain of need. The Partner Relationship Inventory is selfadministered, has a 4-point scale in Likert format and requires the respondent to answer each item according to current feelings, thereby tapping percepti0ns.at a particular phase of illness. Two alternate forms with equivalent reliability permit repeated measurement. Construct validity of the Partner Relationship Inventory was assessed by administering the short form of the Marital Adjustment Scale (Locke & Wallace 1959) to the standardization sample of 52 couples along with an original'90-item form of the Partner Relationship Inventory. The Pearson product-moment correlation coefficients between the Locke and Wallace marital adjustment score and scores for each of the Partner Relationship Inventory categories ranged between - 0.40 and - 0.75. Less satisfaction with need fulfillment, as reflected in higher scores, was related to lower marital adjustment. A varimax rotated factor analysis supported a clear division of categories between two factors or subscales. Test-retest reliability when the inventory was administered on two occasions was supported by correlation coefficients between category scores which ranged between 0.84 and 0.95. For the present sample, the coefficients alpha exceeded 0.90 at all data collection times for both Emotional Needs and Interactional Needs. The Psychosocial Adjustment to Illness Scale (Derogatis & Lopez, 1983) is designed to measure domains of psychosocial adjustment to illness. The

Differences in adjustment to breast cancer

self-report formats for patients and for spouses consist of 46 items with a close match between content and phrasing of items. The items for the spouse are designed to assess the effects of the patient's illness on the spouse's ability to function within designated roles, including vocational, domestic and social roles. The other domain of interest in the present study is perceived psychological distress. Although norms, validity and reliability have been developed for small samples of breast cancer patients, they have not been reported for spouses. In the present study, the range in coefficients alpha across all data collection times for patients and spouses, respectively, were 0.64-0.75 and 0.59-0.66 for role performance in the Vocational Environment, 0.660.77 and 0.63-0.79 for Domestic Environment, 0.83-0.85 and 0.63-0.79 for Social Environment, and 0.86-0.89 and 0.87-0.91 for Psychological Distress (Murphy 1994). The Profile of Adaptation to Life Clinical Scale (Ellsworth 1981) also measures domains of psychological adjustment and physical outcomes. The scale is a 41-item self-report inventory sensitive to variations over time and to counseling intervention. The initial scale (PAL-R) consisted of 154 items to reflect a wide range of adjustment and functioning (Ellsworth 1979). It was administered initially and 3 months later to groups receiving various treatments or training in such modalities as conscious control of internal states through guided imagery (n = 1738). The items retained in the clinical form of the scale (PAL-C) were selected according to the criteria of sensitivity to pre- and post-treatment change, ability to distinguish between groups known to differ in adjustment (discriminant validity) and salience of the item for measuring an adjustment domain as determined by factor analyses. A series of factor analyses performed on the groups separately identified the dimensions of adjustment common to all groups (Ellsworth 1979). In studies of discriminant validity, the subscales of Negative Emotions and Psychological Well-being were among the best discriminators between groups. Criterion validity was established by significant correlations between self and other ratings, ranging between 0.20 and 0.86. Test-retest reliabilities were 0.80 and above. In the present study, the coefficients alpha across all data collection times exceeded 0.90 for Negative Emotions and 0.75 for Psychological Well-being.

Procedure Data were collected at three medical centers in the New York City metropolitan area at the following times: 7-10 days postsurgery and 1, 2, 3, 6 months and 1 year postsurgery. Surgeons who agreed to refer couples to the study screened them for the inclusion criteria; the initial contact by an investigator occurred either in the surgeon's office or hospital. A case management approach was used in the

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interest of maintaining rapport with the couples, awareness of the medical status of the patient and minimal attrition. The investigator who made the initial contact with the couple followed the couple throughout the 1-year period of data collection. The investigators mailed the inventories with a personalized letter at each data collection time.

Prelinffnary preparation of data Two of the standardized inventories completed by respondents at each data collection point, the Psychosocial Adjustment to Illness Scale and the Partner Relationship Inventory, contained items differing in directionality and were reverse-scored. The constitutent subscales of the inventories were scored for each respondent at each data collection point. Due to the problems of collecting self-report data for a large number of subjects at several times, some scores on the psychometric measures were missing for some respondents at some testing times. When a score was missing for a subject at a testing time, but was present at the time before and the time after, the missing score was supplied by linear interpolation. A total of 2.6% of the variable values were obtained through linear interpolation taking into account the uneven intervals between data collection points.

Data analyses The data analyses proceeded in two steps. First, means and standard deviations for all the variables for both patients and spouses across all data collection "points were calculated. In the case of all subscales, with the exception of Psychological Well-being, the higher the score, the more negative the perception. Pearson correlation coefficients between patient-spouse scores and t-tests of differences between means were computed (Winer 1971). They are presented in Figures 1-6. Second, mixed-model analyses of variance were used to construct tests for differences between patients and partners over time (Scheffe 1959). These models take into account correlations between measures within couple by defining a random effect comprising of couple-to-couple variance. In addition, the models take into account the fact that differences between patients and their partners may vary over couples. To account for this, a random interaction effect of couple by patient vs partner difference was included in the models. Thus, the analysis of variance model contained three random effects: couples, couple by patient vs partner interaction, and residual error. Fixed effects included the main effect of patient vs partner difference in means, time, and time by patient vs partner interaction. Initially, the significance of the fixed interaction effect (time by partner difference) was assessed using P < 0.05. The null hypothesis tested was that

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30

60

28

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~" 26

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:~ 24

30

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ZU patent mean Spouse mean Sample sirs Correla6c~ S~J. of diff. Sk3.of con'.

7-10~,ay$ 42.42 51.61 112 0.:00~1

1-n~thl 2on~ths 50.09 41.45 113 0.12 0.0001

4003 52.87 113 0.26 0.0001 0J~6

3-n~s 6-n~tt~ 51.45 40.g6 40.95 54.21 113 113 0.40 0.2g 0.00Q1 0.0001 0.CC01 0.0~2

l-year 52.48 42.11 108 0.40 0.0~1 0.~01

Fig. I Interaction Needs subscale. Means for patients (C]) and spouses (A). Higher score = greater unmet needs; scale range: 25-100.

~,U 7-10 ~ays P~ent n~an 24.18 Samp~ size • Correlation Sig. Of diff.

t SI~I.Ofcorr.

0.41 0.02 0.0001

Z-month 25.43 23.81 113 0.23 0.05 0.003

2-~U',sl 3-m~t~s 23.51 25.g9 25.42 23.48 113 113 0,46 0.39 0.0003 0003 0 . C ~ 0 1 0.0001

6-/1~0~s 24.31 25.71 113 0,44 0.006 0 0001

1-y~r 27,07 24,36 108 0.50 0.01 0.0001

Fig. 2 Emotional Needs subscale. Means for patients (~) and spouses (A). Higher score = more unmet needs; scale range: 15-60.

15 14

13 12

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11 P a ~ t mean Spouse mean Sample size Cormla~on Sig. of d~ff. Sig. of con'.

7-10~lays

1-n~n~

14.35 14.25 112 0.17

13.69 13.28 113 0.23

2 - m ~ t h s 3-n".o~ths 6.montl~ 12.96 12.65 113 0.3;'

12.97 12.72 113 0.28

13.11 1.265 113 0.32

l-year 13.32 12.57 108 035

0.01

0.0001

0.003

0.0006,

0.0003

Fig. 3 Negative Emotions subscate. Means for patients ([3) and spouses (t 0. Higher score = more negative emotions; scale range: 5-20.

the difference between the patient and partner means is constant over time. If this hypothesis was accepted, the fixed interaction was removed from the model. Then, the main effects of patient vs partner and time were examined in the reduced model. The null hypothesis for the former test was that there was no difference in mean values between partners and patients. The null hypothesis for the latter test was that the means are constant over time. Paired t-tests (Winer 1971) were used to compare mean values between patients and partners. The use of paired t-tests permits the filtering out of couple-to-couple variation when comparing patients and spouses.

RESULTS The subscale scores for both the Emotional and Interaction Need dimensions reflect dissatisfaction with the extent to which a partner was meeting the respondent's needs. At the initial 7-10-day phase, spouses reported greater dissatisfaction with the extent to which the patients agreed with their thinking, were open in communicating feelings and perceptions, were sensitive, insightful and considerate of their feelings, and shared in their needs for companionship (Interaction Needs). At each subsequent phase the position on dissatisfaction was reversed between patients and spouses (Fig. 1). The t-tests of

differences in mean scores were significant at all phases. A similar pattern emerged for Emotional Needs (Fig. 2). Spouses again reported greater dissatisfaction with the expression of affection, less emotional security and stability in the relationship, and less recognition and appreciation from the patients at the 7-10-day post-surgery phase. Similar to the pattern for Interaction Needs, the position on dissatisfaction was reversed for patients and spouses at each subsequent phase and all t-tests of differences were significant. In terms of adjustment outcomes, Negative Emotions, conceptualized as feelings of worry, gloom, tension, unhappiness and being uneasy or troubled, are high immediately following surgery for both patients and spouses. When the surgery was successfully completed and recovery underway (1-2 months), a decline in the intensity of these emotional responses was observed in the mean scores for both partners (Fig. 3). It is interesting to note the consistent parallel between the means for 'negative' behavioral responses of spouses with those of patients, the patients' ratings always exceeding those of spouses. The correlations between patients and spouses are significant from 1 month through to 1 year. There was a significant couple by patient vs spouse random interaction (Fiil.lt08 = 8.3, P < 0.0001) for Negative Emotions. There was more variation in the difference between patients' and spouses' scores than could be accounted for by residual variation. In this model, the factor of time by patient vs spouse was not significant (P = 0.67 (NS)), e.g. there was no evidence that the difference between patients and spouses changed over time. Also, there was no evidence of overall difference in mean values between patients and spouses (P = 0.2 (NS)). In contrast, the main effect of time was significant (Fs.tlm3= 19.5, P < 0.0001), e.g. among both partners, negative emotions declined significantly between 7-10 days postsurgery and 1 year. Psychological Well-being, conceptualized as enjoyment in talking with others, finding work interesting and feeling involved, needed and useful,

Differences in adjustment to breast cancer

18

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p~ttient me#J1 Spouse mean Sample s~ze Correla~orl Sig. of d~. Sig. o# corr.

15.74 14.55 113 0.14 0.003

15,77 1505 113 0.34 0.04 0.0002

16.00 15.33 113 0.29 0.002

18.62 15,47 113 0~4 OJX)3 0.009

16.69 15.44 113 0.18 0.002

17.11 15.78 108 0.33 0.0001 0.0006

Fig. 4 Psychological Well-being subscale. Means for patients ([:3) and spouses (6) Higher score = m o r e wellbeing; scale range: 5-20.

11 lo ¢cl 9

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8 ~ 7-10aa,~J 1-mon~ I PaOent mean 11.81 Spcx~e mean 923 Sat~le sizo ' 103 Correlation ,I 0.23 Sig. of diff. I 0.0001 $k$. of corr_ I 0.02

1124 8.79 108 021 0.0~1 0.03

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2-m~t~s!3-~ths 9.70 8.18 108 0.10 0.0001

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8.07 7.75 106 027

0.46 0.0005

0.(X:OI

0.009

Fig. 6 Performance in Vocational Roles subscale. Means for patients (13) and spouses (~). Higher score = impaired performance; scale range: 1-24.

increased for both patients and spouses over time. Patients had higher mean values at every point in time than spouses (Fig. 4). The couple by patient vs spouse interaction was significant (Fro..0 s = 8.8, P < 0.0001). Again, there was more variation in the difference between patients' and spouses' scores than could be accounted for by residual variation. The patient vs spouse differences did not depend on time (P = 0.21 (NS)) so the interaction term was removed from the model. In the reduced model, both the time effect (Fs.m3 = 14.3, P < 0.0001) and the patient vs spouse differences (Fuu m = 1.9, P < 0.0003) were significant. The pattern in Psychological Distress is similar to that of Negative Emotions, as might be expected since the items tap feelings of anxiety, depression, hostility, worry, self-devaluation and body image distortion. The t-tests of differences between partners were significant from the 2-month period through 6 months (Fig. 5). The interaction of time by spouse vs couple was not significant (P = 0.38 (NS)). In the reduced model, the main effect of time (Fs.uu = 19.0, P < 0.0001) and of patient vs partner were significant (Fum = 4.2, P < 0.04). The values in both groups declined over time and the mean values for patients were consistently higher than those for partners. In terms of ability to perform roles in the workplace, home and social environments, patients had a less satisfactory adjustment than partners. The items

pa6errt mearz I Sp
109

13.34 12.76 113 0.12

12.56 11.60 113 0.18

12.42 11.38 113 027 0.02 0.004

12~J 11.37. 113 029 004 0.002

"° " ~ . . . . . . . . .

12.~ 11.14 113 0.27 0.0C8 0.004

Z~

11.44 11.14 108 0.37 0.0001

Fig. 5 Psychological Distress subscale. Means for patients (~) and spouses (A). Higher score = more distress, scale range: 1-28.

for Vocational Environment tap evaluation of personal performance, time lost on the job, vocational investment and interpersonal conflicts; for Domestic Environment, items tap quality of relations for both the principal and other cohabitants in the household, family adaptability and communication, domestic impairment, physical disability and dependency, and financial resources; and for Social Environment, both interest in leisure activities and actual activities. For performance in the vocation environment, the mean scores decline over time for both patients and spouses, indicating an improvement in performance (Fig. 6). However, patients had a much larger decline due to a larger mean value at 7-10 days postsurgery. By 1 year the differences between patients and spouses almost vanished. There was a similar 15attern for performance in the domestic and social environments. Differences between partners significantly varied among couples (Fl~j037 = 7.7, P < 0.0001). Differences between patients and spouses changed significantly over time (F5.1037 = 13.7, P < 0.0001).

DISCUSSION

Investigations of the effects of illness on the family, and specifically the spouse, have emerged only in the last several decades. Differential effects between patient and spouse have been rarely studied. Assessments of spouse adjustment have been studied indirectly by examining social support as it mitigates the negative effect of illness, as well as directly by evaluating the impact of illness on the lifestyle of the partner. Since breast cancer affects one in eight women in the USA within a broad age range, the effect on families, particularly those most closely involved in the events associated with its diagnosis and treatment, is critical. The present study considered the dynamics of the relationship between patients and their spouses at different phases in the course of diagnosis, treatment and recovery from breast cancer. The partners

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Clinical Effectiveness in Nursing

alternated in the extent to which their needs were perceived as being met. The pattern was definitive and consistent. According to communication theorists (Watzlawick et al 1967), it could be characterized as complementary with one partner occupying a relatively superior position and the other a corresponding secondary position, a relationship that is more prone to rigidity. According to theorists, the stability and strength of the family system depend on flexibility (Minuchin 1974), and during the course of treatment for breast cancer, adjustment requires re-evaluation of established roles and expectations (Baider & Kaplan-DeNour 1988; Friedman et al 1988; Northouse & Swain 1987). Since the demands and effects of the illness are unique for each partner at each phase, this needs to be a dynamic process. In the present sample, however, it appears that the effects of cancer accentuated the dynamics of a rather rigid complementary pattern in interaction as a means of coping with the experience. As a life-threatening illness, cancer requires treatment that has both physical and emotional sideeffects. While flexibility in responding to changing events is desirable from an adjustment point of view, difficulty in redefining expectations of one another in the relationship may occur, particularly if this has not been a pattern prior to the cancer. Marital support, as conceptualized and measured in the present study, has not been measured in other works, although Silberfarb et al (1980) and Vess (1985) alluded to the importance of valid observations of the impact of illness on role expectations and functioning. Others (Lewis et al 1985; Wilson & Morse 1991) have found that spouses of women with breast cancer tend to restructure their role and accommodate their lifestyle to the treatment regimen. In later work, Lewis et al (1989) noted a relationship between demands associated with the illness and spousal depression, the depression in turn affecting marital adjustment. It is increasingly evident that partners are not insulated from the experience of cancer. In some respects, the impact of the diagnosis and treatment may be more pronounced. Lower levels of psychological well-being among spouses relative to their wives may be suggestive, in fact, of an uncertainty and fear of recurrence (Gotay 1984) that continues over time. In the present study, patients' scores on Psychological Well-being were consistently higher, a finding consistent with those of other investigators (Baider & Kaplan De-Nour 1984; Lewis 1990; Oberst & James 1985). The crisis of cancer draws attention to the needs of the patient while the spouse may be left to cope with the demands of the illness with little or no support (Lewis et al 1989; Wilson & Morse 1991). The ability to meet his partner's needs may be substantially compromised over time. Although patient's ratings on Negative Emotions and Psychological Distress exceeded those of the

spouses throughout the data collection period, the overall difference in mean values between patients and partners for Negative Emotions was not significant. Both partners may have been experiencing the worry and uneasiness that characterize cancer (Gotay 1984), particularly in the postsurgery phases. Finally, the ability to perform traditional roles in the vocational, domestic and social environments improved consistently for both partners over time. The differences in impaired function for all three areas were significant with patients' impairments exceeding those of spouses throughout the illness experience. The findings from the present study have a number of implications for increasing the effectiveness of nursing practice. Assessments by health professionals need to focus on the spouse, as well as on the patient. It may not be assumed that the concerns and needs of the spouse are the same as those of the patient. Second, differences between a spouse and the patient need to be acknowledged. Decisionmaking and resolutions ought to be based on recognition of differences in immediate and long-range objectives. Third, assessments of both the woman with breast cancer and her spouse need to be comprehensive, including resources for support and level of functioning in all facets of life. Fourth, interventions should be planned to be responsive to the needs of both patients and spouses as they vary over time. The physical impact of illness-related stress may emerge at later points when the acute crisis has passed. Fifth, both patients and spouses who are at ~sk in terms of a satisfactory adjustment need to be identified for possible intervention. Nurses are in an advantageous position for implementing these recommendations. It may be concluded that the findings from the present study should serve as a basis for anticipating events along the illness trajectory for more effective care. In general, family members experiencing cancer can be assisted in identifying their needs as they vary over time, and in setting realistic, flexible expectations. As noted by Zahlis and Shands (1991), the phase-specific events of breast cancer require time, intrapersonal resources and energy. In the study sample, a more normal lifestyle returned as the demands lessened and both partners could resume their usual roles. In the initial phases, explanations of treatment options and procedures are basic to decision making. Accurate information is a prerequisite. During adjuvant therapy, if families are guided in anticipating the nature and duration of side effects, they can more effectively implement measures for control. At all phases, inclusion of family in the decision making process as appropriate tends to enhance a sense of control and mitigate feelings of powerlessness. Finally, strategies for early detection and prevention, e.g. importance of breast self-examination and medical check-ups,

Differences in adjustment to breast cancer need to be reinforced as the treatment phase is completed.

ACKNOWLEDGEMENTS The study was funded by The Walter Langer Foundation, 1990-1994. The author gratefully acknowledges the assistance of Greg Maislin, MS, MA, Principal Biostatistician, Biomedical Statistical Consulting, Wynnewood, PA, USA.

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Lewis FM, Woods NF, Bensley LS, Hough EE 1989. The family's functioning with chronic illness in the mother: the spouses' perspective. Social Science and Medicine 29:1261-1269 Lichtman RG 1982 Close relationships after breast cancer. Unpublished doctoral dissertation, Univer. of California, Los Angeles, CA Locke H, Wallace K 1959 Short marital adjustment and prediction tests: Their reliability and validity. Marriage and Family Living 21:251-255 Minuchin P, Minuchin S 1985 A preliminary report on the study of adaptation of families and patients in the Cooperative Care Unit. (Unpublished manuscript, New York Univer. Medical Center at New York) Minuchin S 1974 Families and family therapy. Cambridge, MA: Harvard Univer. Press. Morris T 1979 Psychological adjustment to mastectomy. Cancer Treatment Review 6:4 !-61 Murphy G 1994 Psychosocial adjustment to illness: an examination of measures. (Unpublished doctoral dissertation, New York University, N.Y.) Northouse LL 1989 A longitudinal study of the adjustment of patients and husbands to breast cancer. Oncology Nursing Forum 16:511-516 Northouse LL, Swain M A 1987 Adjustment of patients and husbands to the initial impact of breast cancer. Nursing Research 36:221-225 Oberst MT, James R 1985 Going home: Patient and spouse adjustment following cancer surgery. Topics in Clinical Nursing 7:46-75 Scheffe H 1959 The analysis of variance. Chichester, UK: Wiley Silberfarb PM, Maurer LH, Crouthamel CS 1980 Psychosocial aspects of neoplastic disease. I. Functional status of breast cancer patients during different treatment regimens. American Journal of Psychiatry 137:450-455 Vess JD 1985 A longitudinal study of families facing cancer. Doctoral dissertation. Ohio State University Watzlawick P, Beavin JH, Jackson DD 1967 Pragmatics of fiuman communication. A study of interactional patterns and paradoxes. New York: Norton WellischDK 1985 The psychologicalimpact of breast cancer on relationships.Seminars in Oncology Nursing h 195--199 Wellisch DK, Jamison KR, Pasnau RO 1978 Psychosocial aspects of mastectomy: II: The man's perspective. American Journal of Psychiatry 135:543-546 Wilson S, Morse JM 1991 Living with a wife undergoing chemotherapy. Image 23:78-84 Winer BJ 1971 Statistical principles in experimental design. New York: McGraw Hill. pp. 44---48 Wollner ME 1983 The influence of role expectations on the psychological and marital adjustment for the patient and spouse living with cancer: An investigation of illness and psychosocial correlates. Unpublished doctoral dissertation, Univer. of Texas, Austin Zahlis Ett, Shands ME 1991 Breast cancer: Demands of the illness on the patient's partner. Journal of Psychosocial Oncology 9:75-93 Zahlis EH, Shands ME ! 993 The impact of breast cancer on the partner 18 months after diagnosis. Seminars in Oncology Nursing 9:83-87