Are patients with chronic illness motivated to learn how to protect their relationships as a benefit to their health and well-being? Can clinicians teach what we know about the complex connections between health and our intimate relationships in a practical way? Those questions led me to propose a six-session class, "Flourishing with Love and Health," for active seniors through the University of Montana Osher Lifelong Learning Institute (MOLLI) in Missoula.
The class drew on the best recent research supporting the health benefits of positive relationship interactions and the damage to health and well-being that can occur with negative ones, which Theodora Ooms and I described in a Families & Health blog post, and have written about extensively for the National Healthy Marriage Resource Center. The class included evidence-based strategies for maintaining couple well-being under stress, and for working as a couple team with health providers.
Here's the outline of the six 90-minute sessions.
· Intimate Couple Relationships in the Last Phase of Life: 21st Century Couple Lifespans
· Love on the Brain: Neuroscience Findings on Human Love and Attachment
· Evidence for the Health Dangers of Relationship Discord, Negativity and Withdrawal
· Intimacy and Touch: Does it Matter Now? What the Science Says
· Managing Your Health as a Couple Team, Part I
· The Couple Team, Part II: What to Do and What Not to Do
The participants who signed up for this class were active seniors ranging in age from late 50's to 85. There were 4 couples (the 84-year old pair sat right up front so they could hear) and 17 single partners, the "well" caregiving spouses. They brought to the class their current experience with various cancers, heart disease, Parkinson's, and dementia. One individual was in a long-standing same-sex partnership, and there was one widower beginning to envision a new relationship for himself after his wife's death from cancer. None were Pollyannaish about what lies ahead.
After the first session, a woman in her early 60's, married some 30 years, came up and said:
"You know, I always imagined that someday I would be moving to New Mexico with some girlfriends, to live in an adobe casita where we could write, paint, hike (long pause) -- that's not going to happen, is it?"
No, it's not likely. She's in the generation already experiencing the demographic shift from "couple mortality" by age 70, to "couples aging together" well into their 80's and 90's.1 Her husband didn't come with her. But I imagine that like many men in Western Montana, he may have his own fantasy about how his life will play out:
"Someday I'll be out on Rock Creek, the salmon flies will be hatching, and I'll cast one more time into that big pool --and suddenly drop dead of a heart attack, right in the best blue-ribbon trout stream in America."
That's not likely to happen either.
As this woman realized, she's in the growing generation of still-coupled patients in their 70's and 80's They are the accessible and motivated ones we can and should be reaching and educating now. They want answers to the following questions: How do couple interactions affect physical health? What kinds of behaviors cause harm? What can we do to protect our relationship from the stresses of illness and treatment? Is it worth the investment of our time and energy?
When I started looking for 'what works,' I found far more useful, practical strategies in peer-reviewed research journals than I expected -- encouragement for those of us who want to rely on evidence-based interventions. RCT studies provide specific descriptions of what to say and not say to partners, in order to encourage adherence to medical regimens. There are specific communication strategies and behaviors that strongly correlate with health consequences (negative and positive) in major national surveys such as the National Social Life, Health and Aging Project (NHSAP)2-4, and the MidLife in the US (MIDUS)5. I found couple-focused strategies for planning doctor visits beforehand, and excellent new video tutorials for how to ask questions and to become active participants as a team..
Participants said that understanding the research gave them the confidence to talk with health care providers about what matters as a team and they valued the research basis for practical tips. They liked the new neuroscience research on how the body and mind are inextricably linked. They were motivated by understanding Kiecolt-Glaser's research on the 'cascade' from relationship conflict & distress to chronic physiological arousal, to lowered immune system response, to injury or infection, to higher inflammatory response6-7. Everyone appreciated Session 4, about why maintaining an intimate love life is good for both partners' health, why the oxytocin release from touch and intimacy is so critical to well-being, and how to "enlarge your repertoire" when performance falters (Yes, I really did talk about this).
By the 5th session, class participants were willing to write down and share their own stories of successes and failures in managing their health care encounters. So we developed our own "Best Practices" list of everyday activities and strategies to protect relationships from the damaging effects of serious/terminal illness, to bolster the health of both couples, and to maintain couple well-being even in the face of a terminal diagnosis. And I learned that there's real payoff in teaching just one partner how to protect a relationship and avoid damaging interactions (remember, 17 of the participants were there without partners). A common response on the evaluations was 'I learned so much." So did I, by having to research and develop this class.
I want to encourage clinicians working in medical and health care systems and those training new clinicians for health care practice not to wait for the health policy makers to understand what we already know about the importance of intimate relationships for older patients. Can we go beyond crisis interventions, assessments and counseling to share what is already known in seminars, classes or in individual consultations? I believe we can teach the specific communication skills needed to discuss illness and work together as a health care team, to be advocates for each other's health, to block negativity and discord, and to protect their relationship even as severe health conditions are encountered. As health systems move toward paying for outcomes rather than treatments, patient education will only increase its value, particularly by improving adherence rates. The health benefits of increasing adherence to medical regimens is a good issue to start with8, but we don't need to stop there.
Months after this class ended, I encountered the wife of a local health provider (he and his wife were one of the 4 couples). He's still active while struggling with advancing Parkinson's. Her face just glowed as she described how much better their most recent physician visit went. "It was SO different! I knew how to ask questions, knew I needed to speak up and be involved. And my husband and I were able to talk about it ahead of time, so he didn't get upset with me." (This from someone who's already had years of coping with Parkinson's). She said their doctor (a neurologist specializing in Parkinson's) was surprised at first, but seemed pleased, and the result was that he spent more time talking with them.
Jana Staton, has her doctorate in counseling psychology, and currently works as a marriage and family therapist and couples educator in Montana. She is author of A Few Months to Live: Different Paths to Life’s End, with Roger Shuy & Ira Byock. If there are clinicians offering similar interventions or training family therapists for health care settings, who are interested in, or already incorporating this perspective into curriculum, she would be glad to share the "Flourishing" syllabus, research basis and practical tips. You can contact her directly at firstname.lastname@example.org
1. Jacobson, L.A., Kent, M., Lee, M., & Mather, M. 2011. America's Aging Population. Population Bulletin. Wash, DC: Population Reference Bureau, Vol. 66, No. 1. http://www.prb.org/pdf11/aging-in-america.pdf
2. Hui, L. & Waite, L. 2014. Bad Marriage, Broken Heart: Age and Gender Differences in the Link between Marital Quality and Cardiovascular Risks among Older Adults. Journal of Health and Social Behavior, 55(4) 403–423. DOI: 10.1177/0022146514556893. http://hsb.sagepub.com/content/55/4/403.abstract
3. Iveniuk, J., Waite, L.J., Laumann, E., McClintock, M.K., Tiedt, A D. 2014. Marital conflict in older couples: Positivity, personality, and health. Journal of Marriage and Family, 76, 130–144. DOI: 10.1111/jomf.12085. http://onlinelibrary.wiley.com/doi/10.1111/jomf.12085/abstract
4. Wong, J. & Waite, L. 2015. Marriage, social networks, and health at older ages. Population Ageing, 8, 7-25. DOI 10,.1007/s12062-014-9110-y. http://link.springer.com/article/10.1007/s12062-014-9110-y#page-1
5. Bookwala, J. 2005. The role of marital quality in physical health in the mature years. Journal of Aging and Health, Vol. 17, No. 1, 85-104. DOI: 10.1177/0898264304272794. http://www.midus.wisc.edu/findings/pdfs/129.pdf
6. Kiecolt-Glaser, J.K. & Newton, T.L. 2001. Marriage and health: His and hers? Psychological Bulletin, 127, 4, 472-503. DOI: 10.I037//0033-2909.127.4.472. http://pni.osumc.edu/KG%20Publications%20(pdf)/142.pdf
7. Kiecolt-Glaser, J.K. et al, 2005. Hostile marital interactions, proinflammatory cytokine production, and wound healing. Archives of General Psychiatry, 62:1377-1384. http://pni.osumc.edu/KG%20Publications%20%28pdf%29/171.pdf
8. DiMatteo, M.R. 2004. Social support and patient adherence to medical treatment: A meta-analysis. 2004. Health Psychology, 23, 207–218. DOI: 10.1037/0278-618.104.22.168 http://www.robindimatteo.com/uploads/3/8/3/4/38344023/meta_social_support_.pdf