examination of couples’ attachment security in relation to depression and hopelessness in...

7/27/2019 Examination of couples attachment security in relation to depression and hopelessness in maritally distressed pat

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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 spouse-

caregivers, experiencing marital distress.

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 ill-

partners, had significantly higher scores on the RDAS

(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

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: [email protected]

L. M. McLean : A. Matthew : J. M. Jones

Department of Psychiatry, University of Toronto,

Toronto, Ontario, Canada

A. Matthew


J. M. Jones


T. Walton : J. M. Jones

Department of Psychosocial Oncology and Palliative Care,


200 Elizabeth Street, 9EN-233,

Toronto, Ontario M5G 2C4, Canada

T. Walton


A. Matthew

Princess Margaret Hospital, The Prostate Centre, 4-922,


620 University Avenue,

Toronto, Ontario M5G 2M9, Canada

A. Matthew

Department of Surgery, University of Toronto,

Toronto, Ontario, Canada

Support Care Cancer (2011) 19:15391548

DOI 10.1007/s00520-010-0981-z


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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 whenpatients experience more disease-related factors [3]. Indi-

viduals 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 tothe 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 withsignificant 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 inti-

mate 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 respon-

siveness 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

1540 Support Care Cancer (2011) 19:15391548
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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 expectan-

cies. 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 of8 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 self-

report 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., discom-

fort with dependence on others and closeness) [22, 43]. Foreach 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 demograph-

ics 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. Tukey

Kramer was the multiple-testing

procedure used. The alpha level for this study was 0.05.

Results

Study participants

Forty-six couples participated in this study. Participating

couples were married on average 18.7 years (SD=12.8;

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 scoreson 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 cova-

riates, and couples were treated as dyads. All two-way

interaction terms were tested, however only the significant

results are presented. Caregivers had statistically signifi-

cantly 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-

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Patients (N=46) Caregivers (N=46)

Number Percentage Number Percentage

Age (years)

Mean 49.66 49.34

Standard deviation 11.53 11.75

Range 2770 2774

Sex

Male 18 39.13 28 60.87

Female 28 60.87 18 39.13

Primary language

English 43 93.48 44 95.65

Highest level of education

Graduate 10 21.74 10 21.74

Undergraduate or college 26 56.52 22 47.83

Trade or professional school 5 10.87 6 13.04

Grade school/high school 5 10.87 8 17.39

Currently working

Yes 29 63.0 13 28.3First marriage

Yes 32 69.57 32 69.57

Type of cancer

Breast 12 26.09

Head and neck 8 17.39

Blood 7 15.22

Gynecological 6 13.04

Central nervous system 4 8.70

Gastrointestinal 3 6.52

Genito-urinary 3 6.52

Lung 2 4.35

Melanoma 1 2.17

Cancer recurrence/metastasis

Cancer recurrence 22 47.8

Metastatic 10 21.7

Treatment active?

Yes 32 69.6

Treatment history

Surgery and radiation 2 4.3

Surgery and chemotherapy 15 32.5

Surgery, radiation, and chemotherapy 25 54.5

Chemotherapy and bone marrow transplant 4 8.7

Table 1 Patient demographics

and medical information and

spouse caregiver demographics

Table 2 Mean patient and caregiver depression and hopelessness

Patient Caregiver Significance

BDI-II (mean, SD) 16.5 (SD=8.2) 11.5 (SD=7.9) *P=0.001

BHS (mean, SD) 5.7 (SD=3.8) 5.7 (SD=3.8) P=0.9

BDI-II Beck depression inventory-II, BHS Beck hopelessness scale

*P0.001, two-tailed

Support Care Cancer (2011) 19:15391548 1543


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founded by avoidance and anxiety subscale scores, respec-

tively (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.

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

Table 3 Results of two-way ANCOVAs for three scores

Score Sex PT/CG Avoidance subscorea Anxiety subscoreb Interactions Least square means

RDAS F(1,43.6)=0.53 F(1,42.7)=5.69 F(1,57.6)=0.26 F(1,71.7)=0.00 None CG=46.43

P=0.4692 P=0.0215 P=0.6143 P=0.9694 PT=44.46

BDI-II F(1,44)=4.56 F(1,43)=9.95 F(1,79.8)=7.98 F(1,86.7)=7.31 None F=15.43

P=0.0384 P=0.0029 P=0.0060 P=0.0083 M=12.58

CG=11.92

PT=16.09

BHS F(1,52.6)=5.55 F(1,46.9)=4.75 F(1,52.6)=0.01 F(1,65.1)= 0.12 Sex voidance F=8.17

P=0.0222 P=0.0344 P=0.9210 P= 0.7263 PT/CG anxiety M=9.08

CG=8.70

PT=8.55

Table 3 entries are values of F and P with degrees of freedom

RDASRevised Dyadic Adjustment Scale, BDI-IIBeck Depression Inventory-II, BHSBeck Hopelessness Scale, Mmale, Ffemale, PTpatient, CG

caregivera

Experiences in close relations avoidance dimensionb

Experiences in close relations anxiety dimension

1 2 3 4 5 6

0

5

10

15

20

1 2 3 4 5 6

0

5

10

15

20

Females Linear fitMales Linear fit

BHS

Avoidance Subscale

Caregivers Linear fitPatients Linear fit

BHS

Anxiety Subscale

Fig. 1 Marital distress,

depression and hopelessness

as functions of sex, patient/

caregiver status, avoidance, and

anxiety

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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 martial-

ly 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 Sex Avoidance subscorea Anxiety subscoreb Interactions Least square means

RDAS F(1,41)=6.43 F(1,41)=5.26 F(1,41)=1.12 Sexavoidance F=46.75

P=0.0151 P=0.0270 P=0.2956 F(1,41)=7.08 M=46.74

P=0.0111

BDI-II F(1,42)

=0.52 F(1,42)

=0.81 F(1,42)

=3.70 None

P=0.4752 P=0.3727 P=0.0613

BHS F(1,42)=0.13 F(1,42)=3.78 F(1,42)=0.00 None

P=0.7230 P=0.0585 P=0.9513

Table entries are values of F and P with degrees of freedom

BDI Beck Depression Inventory-II, BHS Beck Hopelessness Scale, M male, F femalea

Experiences in close relationships avoidance dimensionb

Experiences in close relationships anxiety dimension

Table 4 Results of one-way ANCOVAs for three scores for patients with matched caregiver avoidance and anxiety subscales

Score Sex Avoidance subscale scorea Anxiety subscale scoreb Interactions Least square means

RDAS F(1,42)=0.06 F(1,42)=0.89 F(1,42)=0.00 None No significant differences

P=0.8071 P=0.3501 P=0.9969

BDI-II F(1,42)=0.39 F(1,42)=0.18 F(1,42)=1.45 None No significant differences

P=0.5383 P=0.6726 P=0.2358

BHS F(1,42)=0.73 F(1,42)=0.04 F(1,42)=1.40 None No significant differences

P=0.3991 P=0.8455 P=0.2433

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

Experiences in close relationships avoidance dimensionb

Experiences in close relationships anxiety dimension.

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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 incl usion criteria thatrepresented 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 col-

leagues [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 interest-

ing 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 the ir sig nifica nt oth er. 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 maritaldistress 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 forthe 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, i t 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 psy-

chosocial 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 popula-

tion. 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].

1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0

25

30

35

40

45

50

55

60

Females

Males

Linear fit for females

Linear fit for males

Careg

iverRDAS

Patient Avoidance Subscale

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

Adjustment Scale

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Acknowledgements We appreciate the patients and spouse care-

givers time and contribution to this study. We thank members of the

psychosoc ial Onco logy and Palliat ive Care Program for thei r

assistance with the referral process. We extend appreciation to the

Department of Statistics, University of Toronto, for their contribution

to data analysis.

Disclosures None.

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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