4 Discussion
In this investigation on heart patients and their spouses more than two thirds
of the patients are male. Correspondingly, more than four fifths of the relatives are
female. This is reason enough that there should be differences on psychological
variables between patients and relatives.
Turning to the differences in general it is worth mentioning that relatives score much higher on Physical Symptoms than patients do, and they are significantly younger. The first finding seems astonishing at first, but makes sense when considering that females in general report more physical symptoms than male persons do.
On further four out of seventeen variables patients and relatives differ, namely on loneliness and optimism, and on Self Regulation Competence (SRC) subscales ‘Indecisiveness’, and ‘Motivation Control’. Relatives always show the more favourable scores. Compared to patients, relatives are found to feel more secure in their decisions, to be able to motivate themselves better, to feel more optimistic, and less lonely.
This finding is similar to the findings for differences between male and female relatives: Female subjects again show the more favourable scores on loneliness, perceived social support, and on the three Self Regulation Competence (SRC) subscales ‘Goal-Directed SRC’, ‘Conflict Avoidance’, and again on ‘Motivation Control’, whereas pertaining to physical symptoms they suffer more from headache, and more from troubled sleep than their male counterparts.
Thus, neither patients compared to relatives, nor male compared to female relatives differ on the Self Regulation Competence (SRC) ‘Readiness to Feel Resigned’, thus indicating that for both roles (patient and caregiver) stamina is a crucial characteristic. On the other hand, there are significant differences on the other Self Regulation Competence (SRC) scales, indicating that relatives in general (who are mainly female), as well as female relatives are overall better able to regulate themselves when performing an action.
An important result, especially for the paper in hand, is the difference between male and female relatives on social support, and on loneliness as an indicator of vulnerability in the social domain.
The difference on social support is also found in distinguishing between patients who are living alone, and those who are living with a partner. In the latter case, social support is even able to explain 22% of the variance between those two groups.
At first glance this might seem trivial, but actually the strength of the influence is striking, since it should be supposed that in case of severe illness people living without a partner will mobilize their social net, thus making them feel well-supported.
From the results in examining the differences between male and female relatives it can be concluded that male persons have greater difficulties in caring for a severely ill partner. They feel less supported, but more lonely, they do not behave as much in a goal-directed manner than their female counterparts, they rather avoid conflicts, and they are not able to motivate themselves that well. Also on all other variables (with the exception of physical symptoms) they have less favourable scores.
Almost the same is true for patients compared to relatives: With the only exception of physical symptoms they score lower on positive variables, and higher on negative variables than relatives do.
It might be useful to take into account that the average age of patients is 60 years; in other words, most of them were born around 1935. Male persons of that generation are socialized in a different way so that it might not be surprising to find them a bit helpless when facing serious illness, or having to care for a seriously ill partner, respectively, presumably because they are not used to it.
Concerning the influence of age it would be useful to compare the results of the investigation in hand with results of investigations looking at persons suffering from other diseases such as cancer, for example, for which the onset of the illness is more variable pertaining to age.
For the comparison between patients living alone or with a partner, besides from the difference on the perception of support and on loneliness, there are several other significant differences. The consistent finding is a more favourable pattern for people living with a loved person. Apart from higher scores on the Self Regulation Competence subscales ‘Readiness to Feel Resigned’, ‘Motivation Control’, and the sum score of all SRC scales, persons who are not living alone are also less sad (Profile of Mood States (POMS)), they are not looking for support in religion as much, and they even suffer from less physical symptoms.
The prevailing pattern in examining group differences continues when looking at
differences between male and female patients, and male and female relatives. In
differentiating between those for groups of subjects, for eight major variables
significant statistical interactions were obtained which all show the more favourable
characteristics for male patients, and for female relatives, the latter showing the best
scores of all.
Apart from such group differences, patients and relatives also differ in the emerging pattern of correlations between major variables.
When discussing the correlations it might be useful to keep in mind that most of the patients are males, and most of the relatives are female, since this often might contribute to an explanation of the results.
There is an interesting difference between patients and relatives pertaining to social support, for example. Patients who are high on perceived support have partners who score high on all Self Regulation Competence (SRC) subscales, and on optimism, and who score low on all negative affect Profile of Mood States POMS subscales, and on loneliness, most of these being highly significant and comparably high correlations. Relatives who perceive much support, on the other hand, are living with partners who have only high scores on the Self Regulation Competence (SRC) subscale ‘Motivation Control’, on the Profile of Mood States POMS subscale ‘sadness’, and on optimism, self-efficacy, and scoring low on loneliness. Based on the assumption that a good deal of the perception of social support should be connected to a person’s life partner, it can be stated that feeling well-supported as a relative is linked to rather self-efficacious patients who are able to motivate themselves well, and who do not feel depressed. For a patient, on the other hand, a life partner need not only be little depressed, but also little discontent, and little tired to feel well-supported; and, moreover, the partner should not only be able to motivate himself or herself well, but should also behave in a goal-directed manner, should not avoid conflict, should be secure in his or her decisions, and should not give up easily. Only a relative’s self-efficacy is not important for a patient to feel well-supported.
This result seems to make sense: First, because a patient is more vulnerable, needing care and support in more domains than the caregiver does. Second, it could be suggested that the patient is more dependent on the spouse as a source of social support, whereas the spouse, the majority being female, has access to more sources of support. For a spouse it might be a relief to care for a person who feels rather self-efficacious, who can motivate himself or herself rather well referring to the demands of the illness, and who is not feeling too depressed, thus getting also support from the patient.
Another such differential result is found for the Self Regulation Competence (SRC) subscale ‘Motivation Control’. For patients, there are significant correlations emerging with almost all relatives’ variables; relatives’ ability to motivate themselves, on the other hand, shows similar results, but it is not significantly related to patients’ Profile of Mood States (POMS), except to ‘sadness’ again. As far as emotional well-being is concerned, relatives who are able to motivate themselves well are only related to patients who are little depressed. Vice versa, patients with a good motivation control are linked to relatives who show an overall pattern of emotional well-being.
For the Self Regulation Competence (SRC) subscale ‘Readiness to Feel Resigned’ the opposite pattern emerges: Patients who do not give up easily are only associated significantly with relatives who are little discontent; relatives who do not give up easily, however, are associated with patients who are rather optimistic, and who feel well-supported. Whereas patients’ and relatives’ ‘Motivation Control’ is at least moderately correlated, the correlation between the two ‘Readiness to Feel Resigned’ variables equals almost zero, showing that both should be able to motivate themselves well, but that only one of the couple shows stamina, either the patient or the caregiver.
Thus, for patients there might be a unfavourable influence from a discontent partner on their stamina, for relatives, on the other hand, it is important to have an optimistic, and well-supported partner to show stamina.
The lack of any correlation between patients’ and spouses’ stamina is striking. Interestingly in general patients’ and relatives’ Self Regulation Competence (SRC) scales show only moderate correlations if any at all.
A last noteworthy result in this context is the one for patients’ coping behaviour ‘Seeking Information and Exchange of Experience’: Patients who are trying to get information about how to cope with their illness, who are actively trying to get into touch with other patients to exchange experience are strongly related to less optimistic, and rather discontent, anxious, and little self-efficacious partners.
This might be an important finding, since it might shed light on some negative
aspects of intimate relationships: It could be considered that spouses of a seriously
ill patient want their partner to be rather passive. Taking into account spouses’
high anxiety this finding points into the same direction as the finding of Ewart (1995),
that spouses are unable to appraise their partner’s physical capability in the
rehabilitation process. Moreover, it might soothe relatives’ feeling of little
self-efficacy if they deprive their partner from responsibilities, and tasks.
Some of the patients’ time 1 characteristics also show interesting multiple associations to relatives’ time 1 characteristics. The coping strategy ‘Search of Social Integration’ is related to spouses’ Quality of Life, and their Profile of Mood States (POMS) subscale ‘vigour’, thus indicating that vigorous spouses who perceive a high quality of life are associated with patients who are looking for social integration.
Spouses’ Quality of Life, as well as their Self Regulation Competence (SRC) scale ‘Motivation Control’, has also a strong relation with patients’ Profile of Mood States (POMS) subscale ‘sadness’, linking patients’ degree of sadness negatively to spouses’ quality of life, and positively to their ability to motivate themselves well.
Spouses’ gender seems to be a prominent variable among those multiple correlations: Whether a relative is female or not is related to patients’ self-efficacy, their perceived support, and their motivation control. Also this finding matches expectations, like the other multiple associations.
Unfortunately, there are almost no results for the association between relatives’ variables at point in time 1, and patients’ Recovery Items at point in time 2. This is mainly due to the restricted variance within the Recovery Items.
First, not all items might be valid, in the sense of not pertaining to what they are supposed to assess. There is, for example, a difference in substance between the item asking for the first time someone could stand unassistedly beside his or her bed, and the item asking for the first time someone could eat with good appetite. Second, the intense medical care might reduce the variation to a certain extent.
Apart from the limited variance, it is not to be expected to find high correlations between patients’ physical condition shortly after a bypass operation, and psychological variables assessed on their spouses about a week before.
Thus, between patients’ Recovery Items time 2, and spouses variables time 1 there are almost no correlations found, not even a prevailing pattern of interrelations. There is an exception for relatives’ Profile of Mood States (POMS) subscale ‘sadness’: When it takes patients longer to recover from surgery, spouses are consistently less sad. A similar pattern evolves for relatives’ Physical Symptoms. With regard to the contents this does not seem to make sense: The better spouses’ well-being, the longer it takes patients to get onto their feet again. But on the other hand, here the same consideration might hold as above when discussing the surprising association between patients’ active coping behaviour, and spouses’ negative characteristics: Spouses might like and support a kind of helplessness in their partners, maybe even a forced helplessness.
At least, there is one consistent result emerging for patients’ interview data, and relatives’ time 1 variables, namely for Worries Related to Heart Disease. The item scale ‘Worries about the Future’ shows a prevailing pattern with all relatives’ variables, and even two significant correlations with anger, and perceived social support. Furthermore, patients’ worries referring to the possibility to suffer once more from a heart attack are strongly related to relatives’ anxiety. Both seems to make sense.
Thus, patients’ psychological characteristics shortly after surgery, like their worries, for example, are more likely to be associated with their spouses’ characteristics. Patients’ vigour after surgery -- a crucial characteristic for coping with serious illness -- also shows strong relations to spouses’ vigour, their decisiveness, and their perceived quality of life: Multiple associations of patients’ vigour at point in time 2 with relatives’ variables at point in time 1 show correlations with rather young spouses who are vigorous themselves, and perceive a high quality of life are emerging. For the third point in time, the predictors lead to rather female spouses this time, who apart from that show the same characteristics. This finding might rather pertain to the positive aspects of intimate relationships, since vigour in patients goes together with vigour in their spouses, who presumably have to be decisive when facing their new responsibilities, and tasks. And at the same time these spouses perceive a high quality of their life, indicating that it is more a pleasure than a strain to show vigour.
It is an interesting result that spouses’ Quality of Life at point in time 1, though just being a single item, is that strongly connected to patients’ characteristics at all points in time. It could be assumed that the perception of quality of life is highly dependent on the quality of a person’s intimate relationship. If this can be taken as an indicator of marital satisfaction, or quality of the intimate relationship, findings here are consistent with the literature.
Since the mere existence of an intimate relationship has often proved to make much of a
difference (e.g., Berkman & Syme, 1979), it was examined whether there is an impact
of intimate relationship on patients’ Recovery Items. Mean differences between
patients living alone, and patients living with a partner concerning the indicators of
recovery show a consistent pattern: Patients who have an intimate relationship spent
always less time in the intensive care unit, and they were quicker in recovery in terms of
every item.
Indeed there are not many associations between spouses’ characteristics, and the way patients pull through the operation, but pertaining to long-term adjustment a lot of associations are found. Actually it seems to be rather astonishing that relatives’ variables are able to predict patients readjustment, sometimes even their way of recovering (time 2, for example, patients’ vigour, or their sadness). The mere existence of such associations can be taken as proof of the importance of close social relationships for patients, and as proof of the overall importance of psychological factors in readjustment, and rehabilitation.
For a prediction of patients’ time 3 variables by relatives’ time 1 characteristics, findings in general showed only patients’ variables related to efficacy, or personal competence could be predicted.
Turning to the prediction of patients’ Quality of Life scales respectively factors at point in time 3, interesting results were found.
First, the three scales proved to assess different aspects of quality of life, since predictors were different. In regression analyses of the factors later on, the first factor referring to personal competences proved to be different from the remaining two in addition. But for both sets of predictions the general direction of influences was the same.
The most striking finding emerged in the prediction of patients’ Competence-Related Quality of Life factor since relatives’ factor Social Embedding yielded a negative relation, whereas in the remaining two regressions it had a positive sign as should be expected. One reason could be the additional strain on a spouse who has to take care of a severely ill patient since the caregiving is time consuming and exhausting, thus leaving not much time for other social contacts (see Methorst, 1994). In addition, the patient might not only be unable to support the spouse very much because of illness-related handicaps, but patients high on Competence-Related Quality of Life might also be rather self-centered in their efforts to cope with the illness, thus making the spouse feel rather lonely. The correlational associations between the three patient factors and the single items of the third factor show that the Competence-Related Quality is only related to less close social relationships, whereas for the remaining two factors correlations only emerge for the intimate relationships (namely with spouse, and family).
It might be an interesting approach to rather examine different aspects of perceived quality of life than focusing only on the quality of marital relationship. It seems to be rather trivial that also in the present study patients’ quality of their social life is most strongly allied with their satisfaction in their intimate relationships; the same is true for the strong relation between relatives’ feeling of being socially embedded, and patients’ satisfaction with intimate relationships. Both refer to marital quality. But the overall perception of a high quality of life is surely dependent on more than the intimate relationship. In case, high quality of life, or satisfaction in many respects has an influence on physiological, and psychological well-being, as many studies suggest, the focus should be laid on the broader scope. As the results show, there is a relation between relatives’ Social Embedding, and patients’ perception of their Health-Related Quality of Life, for example, indicating that it is not only necessary that a patient perceives his or her marriage as satisfactory to make him or her feel better, but that in addition the spouse feels well-supported, and not lonely to make the patient feel better.
Also in examining patients’ social support, no correlation was found for Competence-Related Quality of Life, only correlations for the other two patient factors evolved.
The focus on a broader construct seems to be even more important when looking at the results for patients’ Competence-Related Quality of Life: It seems to be counterintuitive to find patients’ satisfaction with their personal competences unrelated to their intimate relationship. This includes their satisfaction with their independence in everyday functioning, which might be influenced by illness-related handicaps, but also their satisfaction with their abilities, with their self-esteem, and with themselves as a person in general which could be expected to have a relation to marital quality. A quarter of the variance in patients’ Competence-Related Quality of Life, however, is explained by other spouses’ variables, apart from the quality of marital relationship.
In this context it might be beneficial to look at associations with negative social relationships, which unfortunately have not been assessed in the present investigation, though several cues have been found indicating their importance.
That the quality of interpersonal relationships can affect well-being seems to be a
common finding (Coyne & Bolger, 1990; Coyne & DeLongis, 1986; Rook, 1984).
According to Rook’s social strain model (1990), however, it is mainly the
negative interaction that impedes well-being. Negative aspects of social relationships are
often found to be more robust predictors of well-being (Helgeson, 1993a; Manne &
Zautra, 1990). Moreover, they were found to covary with less effective communication
(Gottman, Markman, & Notarius, 1977; Margolin, Burman, & John, 1989). Also these
finding support the idea to take a broader approach as suggested above.
With respect to social support, Helgeson (1993b) mentioned that after the onset of serious illness in one spouse both partners will no longer alternate in the roles of support provider and support recipient, but most likely the patient will hold the role of the recipient most of the time. Though of course it could be argued that an ill spouse is still able to emotionally provide the partner with support, and also informational support might be possible. In the investigation in hand, the source of social support unfortunately was not assessed. Also the question about reciprocity is thus not to be answered from the data.
Research mainly is concerned with the impact of social relations and social support on adjustment, but it has neglected the impact of adjustment on social relationships. Johnson (1991) demonstrated a transactional relation between social environment and mental health. Also in the present investigation the data allow to examine the direct influence of spouses’ adjustment on patients’ physical and mental well-being, and the findings are consistent with the literature.
For social support this means, a person’s well-being might have an influence on the provision of support. Since the data of this study do not contain items about the reception of support, it cannot be examined whether well-being and high provision of support are associated. With respect to this question, Helgeson (1993b) found patients’ adjustment unpredictable by spouses support; but patients received less support from maladjusted spouses (spouses adjustment predicted support).
In the present paper, patients’ perceived support does not only refer to the support provided by the spouse, but it can only be predicted by spouses’ characteristics. In all three regressions of patients’ perceived support, relatives’ variables could make up for approximately one quarter of the variance. The predictors always include gender, indicating that female spouses provide more support, and one of the Self Regulation Competence (SRC) subscales, either ‘Motivation Control’ (before surgery), or ‘Readiness to Feel Resigned’ (for support time 3). Moreover, correlational results relate patients who feel well-supported to spouses who are little tired, discontent, and sad, who do not feel lonely, nor angry, but optimistic, they are female, and they are able to regulate themselves well.
Results for the changes in patients’ and relatives’ emotions show that patients feel the more supported the less sad, and discontent, and the more vigorous the relatives feel. Taking also into account the findings for Profile of Mood States (POMS) stability and for mean differences it can be stated that sadness and vigour are major indicators of adjustment, the two assessing a kind of opposite of each other. For both emotions the results show clearly: The better adjusted relatives become, the better supported do patients feel.
Thus, it can be concluded that -- like in the study of Helgeson (1993b) -- in the study in hand good readjustment in spouses is allied with high perception of support in patients.
It might also be concluded that relatives’ emotional well-being, and thus their
ability to provide patients with support, is more important for patients than is
patients’ emotional well-being for relatives, who can more easily turn to other
sources of social support and social integration (since the change in patients’
emotions is not correlated to relatives’ perception of support). The common principle
of reciprocity in support provision and support reception might not hold to the
usual extent for a relation between an ill partner and a caregiver. At least not for the
first six months after surgery.
Concerning the question of the predictability of patients’ adjustment and the amount of support spouses provide the patient with, the present data do not allow a direct answer, since the reception of support was not assessed, nor the source of support. Thus, only associations between patients’ adjustment indicators and their perception of social support can be mentioned here, taking the latter as a measure for support provided by the spouse, which makes sense with regard to the findings in this study.
In data analysis all indicators of patients’ adjustment show a relation to patients’ perception of support, thus at least indicating that good adjustment in patients is linked to a high amount of perceived support. In case this perceived support, as assumed, is really provided mainly by the spouse, this means that high provision of support by the spouse is associated with good adjustment in patients.
Besides, also for the reverse question there is clear evidence in the data: The better adjusted patients are, the more support do spouses perceive.
A noteworthy result in the correlational examination of the data is the correlation between patients’ perceived support and one of the Coping with Everyday Problems subscales: A rather strong correlation emerges between perception of support and the subscale ‘Psyche’. It indicates the importance of being well-supported for accepting oneself, and for caring for one’s own appearance, thus underlining the social dimension of a person’s self-perception. This emphasizes the importance of feeling well-supported when having to come to terms with the changes and losses due to the illness.
Also correlations between patients’ support and the Health Locus of Control
subscales show a clear result: Only internal control beliefs are related to high
perception of support. This result remains stable for a six months period.
The examination of group differences on social support led to the most interesting result pertaining to support. First, well-supported couples are related to the following relatives’ characteristics: Optimism, loneliness, ‘sadness’, ‘displeasure’, and ‘Motivation Control’; they are moreover related to the following patients’ characteristics: Optimism, loneliness, self-efficacy, ‘sadness’, and to Coping with Everyday Problems subscales ‘Psyche’, and ‘Social Integration’, and astonishingly also to patients’ External Powerful Other Locus of Control. The latter result might point to a negative aspect of social relationships again, namely indicating that patients might feel rather overprotected and deprived of their responsibilities, thus turning to powerful others instead of relying on themselves.
The most crucial characteristics to distinguish between high supported and low supported couples are yielded by the discriminant analysis: Most prominent is both partners’ loneliness, as to be expected, but furthermore relatives’ ‘fatigue’ can contribute to the explained variance.
The distribution of gender within the four groups of support reveals that
couples of the high support group consist of male patients and female relatives.
Taking into account all the results about differences between patients and relatives, and male and female subjects in addition to the consistent findings just mentioned, it can be concluded that coping with serious illness should rather be referred to as Dyadic Coping, at least in case a patient has got an intimate relationship with a loved person.
Coyne and Smith (1991) found coping with a myocardial infarction is a ‘thoroughly dyadic affair’. Referring to Lazarus’ stress model they argue that it narrowly focuses on the effort of the individual. Though the concept ‘social support’ is, however, the main acknowledgment that adaptation to stress occurs within a social context of relationships with other people, it is most of the times still reduced to the cognitive component of perception of support. Thus it would be beneficial to assess the reception and the source of social support as well. System theorists, on the other hand, often exaggerate the role of marriage and the family according to Coyne and Smith. Often, only satisfaction with the marital relationship is taken into consideration, as already criticized above.
Coyne and Smith (1991, p. 405) state:"What needs to be done in coping with the infarction -- the tasks or issues that coping entails -- is shaped by what each partner does and how the other responds. To a large degree, such give and take, not just the couple’s perception of the event, determines how the event unfolds and reverberates in these people’s lives.".
They report about having identified two broad classes of so-called relations-focused coping strategies, that exist apart from emotion-focused and problem-focused coping: Namely, active engagement and protective buffering, the first pertaining to involving the partner in discussions, inquiring how the partner feels, and other constructive problem solving activities, the latter referring to hiding concerns, denying worries, and avoiding disagreements.
Regarding coping in this respect a different set of competencies in dealing with stress emerge. In the words of Coyne and Smith (1991, p. 405):"(...) How does one contribute to the partner’s well-being, avoid unnecessary conflict, and yet look after oneself, balancing concern for the partner with one’s own needs?".
Also Revenson and Majerovitz (1990) emphasize in their investigation on the
stress-buffering role of support the need to study social support processes by using a
dyadic, transactional approach, as well as to study patients and spouses within the larger
context of their social support network.
From the results, several conclusion might be drawn: First, it might be considered in how far the results allow to suggest some kind of specific support for patients and caregiver, provided by medical and/or psychological professionals. Second, suggestion for further research might be extracted. In particular, the following conclusions could be drawn:
(a) Obviously male caregivers have the greatest difficulties in coping with their spouses’ illness and the altered situation. This group of relatives should be most supported.
(b) Another vulnerable group consists of those patients who are living alone. In the psychological domain, they especially need to be supported in coping with depression and self regulation difficulties.
(c) It is a common finding in the literature that interactions with depressed people are unsatisfactory and easily lead to burnout (e.g., Coyne & Downey, 1991). Since patients’ depression or sadness also in this investigation has been found to have a major influence on spouses’ well-being, it might be suggested to support patients in this respect.
(d) For both patients and caregivers the variable ‘Readiness to Feel Resigned’ seems to be crucial. Since for all Self Regulation Competence (SRC) Scales almost no correlations are found between patients and relatives, at the same time, however, these characteristics seem to have a great impact on adjustment and well-being, it could be considered to develop a training: When improving the capability pertaining to this important personal resource for both patient and caregiver, there might be a great beneficial effect.
(e) In the prediction of patients’ recovery after surgery only their worries yielded relations with their spouses’ characteristics. It seems that worries are an important factor since they are consistently related to unfavourable spouses’ characteristics, in particular to higher anxiety. Considering a reciprocal influence between patient and caregiver, providing the spouse with information about changes due to the illness, and about the problems couples have to face during rehabilitation might reduce patients’ worries; thus improving quality of life and well-being for both partners.
(f) This also means, it could be instructive for further research to assess patients’ worries related to heart disease.
(g) Judging not only from the investigation in hand, it seems to make sense to assess also negative social interaction to gain further insight in the mechanisms that control the improvement or impediment of adjustment and well-being.
(h) Moreover, the scope should be broader in a sense that not only the quality of marital (or family) relationships should be examined, but a broader range of variables pertaining to the quality of life; always taking into account that coping with illness can also be understood as Dyadic Coping.
(i) Although it is true that caregivers have less time for social contacts in general, they do not rely completely on the patient to feel well-supported. Patients, on the other hand, are mainly dependent on the spouse as source of social support. Thus, providing the spouse with (professional) support might have beneficial effects on the patient.
(k) Also patients’ coping with changes and losses due to the illness, as well as their internal locus of control is strongly influenced by their perception of support; this is clearly another reason to care for spouses’ well-being.
(l) Since in the investigation in hand no differences at all were found for the three kinds of support (presumably due to the instrument, respectively the way of assessing support), it can only be concluded to provide patient and caregiver with all possible kinds of support. Informational support, for example, would be easy to offer for a doctor or for a hospital. But also emotional support, especially for the more vulnerable groups of patients and caregivers, should be provided by psychologists and/or therapists.
To resume the findings of this paper, the most important result seems to be the increasing evidence for a dyadic coping process. This has a lot of implications for both further research, and practical help in the aftermath of myocardial infarction and bypass surgery: Latest findings in the literature as well as the present results all point to a much broader scope when assessing the crucial mechanisms in coping with serious illness, and to a focus on dyadic coping to understand how people are able to return to satisfactory daily functioning and a high quality of life after myocardial infarction.
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