Let’s picture a couple you’re seeing in your oncology practice. Susan is 52; Mike’s 54. They’re well educated, employed, and making a comfortable income. They’ve been married a long while; in fact, they recently celebrated their 25th anniversary.
About a month ago, Sue underwent surgery for early-stage breast cancer.
Photo AbleStock.com
Social constraint may be a major problem for a patient's adjustment to cancer and for how the marriage will adapt to this major life challenge.
They may seem to you to be doing okay as a couple, especially considering the physical and emotional adjustments they’ve had to make since the diagnosis, but if it were possible to order the equivalent of an fMRI or PET scan of your patient’s emotions, you would see that not all is well. In the report’s social-cognitive processing section, the diagnosis would be "Socially constrained."
What it means in a nutshell is that Sue doesn’t feel that she can openly share her thoughts or feelings about her cancer – or really, even about the more mundane events in her life – with Mike.
And that could be a major problem for her adjustment to cancer and for how the marriage will adapt to this major life challenge.
A recent study (J. Fam. Psychology 2012: 26:661-7) examined the concept of social constraints in 45 newly diagnosed breast cancer patients and their spouses or significant others, beginning about a month after surgery. They defined social constraints as "the extent to which the patient perceived that her spouse avoided, rebuffed, or appeared disinterested in the patient’s attempt to share or discuss her cancer-related concerns."
An example, taken from one questionnaire utilized in the study: "How often did your spouse change the subject when you tried to discuss your illness?"
The authors, led by Elizabeth C. Pasipanodya of the University of Delaware, emphasized that social constraints are in the eye of the beholder and don’t necessarily reflect "objective signs of negativity, disinterest, or withdrawal."
In other words, if Sue perceives that Mike doesn’t want to hear about her symptoms or concerns, she’ll respond in a socially constrained way, keeping those feelings to herself, regardless of how Mike truly feels.
Indeed, in the study, the authors found no correlation between patients’ and spouses’ perceptions of social constraint in their relationships, even though they were in agreement, on average, about the quality of their marriages.
Associations with social constraint were powerful.
While female partners shared the "best event of the day" with their spouses 86% of the time, high patient-reported social constraint made that positive conversation 71% less likely (P less than .001). Not surprisingly, perhaps, the effect lost significance when investigators controlled for patient-reported marital quality.
Patients’ self-reported "worst event of the day" was shared with spouses 78% of the time but was also significantly (P less than .001) less likely to be shared among patients with high levels of social constraint. This time, the significance held, even when controlling for patient-reported marital quality.
Finally, when a cancer-related event was the "worst event of the day," patients shared the experience with a spouse 71% of the time, but significantly less so in the context of social constraint (P less than .03). Marital quality mediated the significance.
Among patients, self-reported social constraint was significantly associated with daily negative affect and lower self-esteem, intimacy, and marital happiness.
Past research demonstrates an association between social constraints and negative emotional and health outcomes in bereavement and diabetes. Among amputees, social constraint predicts depressive symptoms and posttraumatic stress disorder. Among cancer patients in previous studies, it is linked with intrusive thoughts and depressive symptoms.
In the Delaware study, "the patient’s perceptions seem to matter more than what the partner says he is doing," the authors concluded.
"Given that the promotion of relationship enhancement is a predominant intervention approach for couples at the early stages of cancer, our results suggest that social constraints should also be considered as a possible target of intervention separate from improving overall marital quality," Ms. Pasipanodya and her associates said.
As an oncologist, you have much to consider as you meet with a couple a month after breast cancer surgery, and social constraint in the relationship may be better addressed by the mental health professionals associated with your practice.
But it would be helpful to keep an eye out for signs of constraint, to enable you to connect at-risk couples with help early on in their cancer experience.
When Susan describes her side effects and concerns, is Mike, by chance, averting his gaze?