1 Theory go1.1 Introduction go
1.1.1 Coping with Losses Due to Serious Illnessgo
Serious illness such as experiencing a myocardial infarction or having to undergo bypass surgery has the potential to change a persons life to a large extent. It affects not only a body but also a mind, and a consciousness. That also implies adjustment to the changes caused by the illness in a variety of physical, and psychological domains.
At first, the two different stages of illness should be differentiated. First, a person has to face the acute phase of a serious illness. The paramount concern then is survival. Choices about a patients treatment in the acute phase can have a lasting impact on the individuals long-term survival, and on the quality of the persons future life.
On the part of the patient, this acute phase of medical care is most likely characterized by negative emotions such as fear, confusion, and pain.
The next stage then is the rehabilitation phase, in which the patient is not longer bedridden, or only passively cared for by the medical personnel. After bypass surgery, for example, patients are to return to normal everyday activities as soon as possible; starting with sitting up in bed, and ending up in walking unassistedly along the corridors, and staircases of the hospital.
To achieve as high a level of health and independent functioning as possible the patient must learn to adjust to limitations, and to come to terms with an altered self-image.
Rehabilitation either leads to complete recovery, or it leads to the third stage of chronic
The perception of rehabilitation changed gravely over the last centuries. It is fairly recent in history. As late as during the 1800s the first institutes for the care of ill, and crippled people were founded in Europe. And it was not before World War I that a rehabilitation movement started, which in the beginning was only directed at the physical recovery of patients. Only very recently we know about the psychological impacts of severe injuries, and illness. A patients depression, and hopelessness, for example, may block a persons motivation to take the necessary steps towards rehabilitation, and well-being.
1.1.1 Coping with Losses Due to Serious Illness
The sudden focus on one part of ones own body that has stopped working properly, and even endangers ones life may cause a loss of body integrity. The patient has to overcome this first dissociation from his body, and try to integrate the altered body image, what may well take some time. Denial is found to be a common response to such alterations in heart attack patients (Krantz & Deckel, 1983). As a short-term defense strategy it can be very useful in maintaining ones identity, and self-esteem while slowly coming to terms with the alterations.
A less well functioning body may also raise fears about resulting changes in social relationships, in particular intimate relationships with a loved person. Concerning these problems, providing the patient with information about the recovery process, and possible outcomes can be of great help for a realistic evaluation of the future time. This makes the future more predictable for the patient, and thus reduces fears, and worries.
Illness and hospitalization in general can put a strain on the relationship with others. Apart from limiting privacy, and reducing the amount of interactions there are many obligations for a patients carepersons. These additional obligations over a longer period of time may lead to burnout symptoms in relatives and/or spouses (Croog & Fitzgerald, 1978; Methorst, 1994).
Another important point is the possibility to lose ones job. Some people derive a strong sense of identity from the work that they are doing. Apart from this threat to a persons self-definition it can also be a threat to ones self-esteem in case the person cannot gain a living any longer. It is even worse if others are relying on the patient as a breadwinner. This can raise severe fears and worries, and may lead to depression.
Apart from the financial support, it might also be hard to rely on others for physical and/or emotional support all of a sudden.
To suffer from a heart disease means to lose a great deal of control over ones own life. At first, others have the responsibility for a patients survival during the acute phase. Next, a patient is forced to a certain passivity after surgery that one can either fight against, or resign to. In the latter case, passivity may become a habit. A patient might accept to get things done for him he could easily do by himself. That shows to what extent the limits of independence are defined and redefined, and how much depends on the way a patient copes with these challenges.
The adjustment to illness and disabilities in general can be strongly influenced by a patients resources. In particular, social support is important in the form of physical assistance as well as in the form of emotional support. It has been found that well-supported patients cope better than patients lacking social support (e.g., Wortman, 1984).
On the other hand, too much support might be experienced by a patient as being overprotected and controlled, so that the patient may stop trying to develop his own abilities, or trying to regain his former standards of functioning. The crucial point is the maintenance of reciprocity. That means, the patient should give as much support to the caregiver as possible (i.e., emotional support such as being interested, and involved in the caregivers concerns).
Persons who tend to be uncommunicative and depressed usually receive less social
support if any at all (Coyne, & Downey, 1991). So people have to be optimistic to some
extent and have to maintain their social network, otherwise they deprive themselves of an
important resource in the process of adjustment to illness.
The aim of this investigation is to explore the conditions that cause a differential process of readjustment after bypass surgery. Since it is not only the physical condition of patients that would allow to predict recovery, the investigation focuses on psychological factors that influence readjustment. Being aware of the impact of the domain of social relationships, also patients spouses were asked to participate in the investigation. Thus, it was possible to have direct access to some aspects of the patients social relationships, and to closely examine their effects.
In general, this investigation might contribute to efforts to prepare patients, and their close social network members for the critical life event of heart surgery, and the subsequent problems they have to face in the course of recovery, and readjustment.
1.1.2 Psychological Factors in Recovery from Serious Illness
From a biological point of view, it might still makes sense to view stress only as a kind of output of a body, a simple physiological reaction to certain stimuli.
In psychology this biological standpoint fitted to a behaviouristic theory. After the cognitive revolution in the 70s, however, this model has proved to be insufficient.
In one of the common psychological views, stress is seen as an input into an individual. This input may be a complex situation, or a certain event that can be described as a stressor. In contrast to this stressor theory, a strain theory has been formulated that views stress as the reaction to novel, difficult, or dangerous events (Selye, 1956).
The most prominent proponent in recent stress research, however, is Richard S. Lazarus with his Cognitive Transactional Theory of Stress (Lazarus, 1990; Lazarus & Folkman, 1984, 1987). In his view, stressors can be critical life events, but as well they can only be daily hassles. Moreover, they have a transactional relation with an individual who is experiencing them.
Transactional in this context means that there is not only an unidirectional influence, a stimulus leading to a stress reaction, for example, but that there is a relationship between a changing situation, and an individual with all its cognitions, emotions, and actions.
That implies that a stressor is not stressful as such, but that the person who experiences the stressor appraises it as being either challenging, threatening, or harmful. These cognitive appraisals are a crucial component of the transactional stress model. In Lazarus words: "Stress is a postappraisal state" (Lazarus, 1990, p. 4).
Lazarus distinguishes between two kinds of appraisals: The term primary appraisal refers to a persons estimate of the severity of the stressor (What is at stake?). As a result, a stressor can be classified as a challenge, or as a threat, and/or harm/loss. The perception of challenge or threat will be followed by coping attempts that are directed to the future, the appraisal as a harm/loss, however, is followed by efforts referring to a past event so that coping strategies for both will differ.
Secondary appraisal pertains to a persons estimate of his or her resources to cope with the stressor. These two processes occur more or less at the same time. They can also be denoted as a persons situation model, and self model (Schwarzer, 1996), this is a persons perception of events, and a persons perception of his or her resources.
Of course, there may be several stressors at the same time, but the primary appraisal of all stressors present will lead to one dominant classification so that the person can focus on a certain coping effort to deal with the most prominent, or most important stressor.
This makes clear that the perception of a stressor is a highly subjective process. It implies that people differ in their appraisals of stressors. A patient having undergone a bypass operation, for example, might perceive the rehabilitation demands shortly after surgery as a threat, because he or she does not have the idea to dispose of the physical resources, or the stamina to be able to comply with the demands, but he or she might as well perceive them as a challenge to prove ones own stamina, and physical resources. Those different appraisals will consequently lead to different actions -- and, of course, to different emotions, and to a different level of stress.
1.2 Social and Personal Resources of Coping with Stressful Events
In general, there are two prominent kinds of resources for an individual, namely personal resources, and social resources. Apart from these two which are most important in psychology, there are also financial resources which do not have much intrinsic value in a psychological context, but they can help people to maintain other valuable resources (Hobfoll, 1988).
The term personal resources refers to a persons beliefs about his or her competences in several domains. Among these dispositional variables -- such as optimism (Scheier & Carver, 1985), hardiness (Kobasa, 1979, 1982), internal locus of control (Wallston & Wallston, 1981), or Self Regulation Competence (Schröder, 1993) -- self-efficacy beliefs are considered as highly important for secondary appraisal processes (Bandura, 1977, 1986, 1990). Since the existence of resources can either be objective or subjective, it is important in how far a person perceives resources being available for him or her. If there is a subjective lack of availability of effective strategies to cope with stressful events, this leads to a persons vulnerability (see Jerusalem, 1990a, 1990b). Thus, the reverse to the medal in the field of personal resources are dispositional factors that make persons vulnerable, such as anger (Schwenkmezger & Hodapp, 1993), anxiety, or external locus of control.
A persons social resources consist of social integration, and social support. What makes them vulnerable is a lack of social resources, coming forward in a persons loneliness, for example.1.2.1 Optimism
Optimism as a psychological construct does not mean the same as the everyday usage of the word implies. Optimism is defined as a persons generalized outcome expectancies. In other words, a person perceives the relation between his or her action, and the outcome as rather positive in general (Everything will turn out well). This must be distinguished from specific outcome expectancies which refer to a specific action. That implies that generalized outcome expectancies are meant to be able to predict a variety of personal characteristics, and not only specific ones. Thus, assessing optimism should yield a variety of results, for example for predicting somebodys chance to give up smoking, or for predicting readjustment after surgery.
In a study on heart patients who had to undergo a bypass operation, for example, it was found that optimistic patients recovered more quickly, and that they stated to be more content with their situation (Scheier et al., 1989). In this investigation, optimism was assessed with the Life Orientation Test (LOT) by Scheier and Carver (1985). This is an eight-item scale which was also used in the present investigation. Patients were examined shortly before surgery, about one week afterwards, half a year later, and eventually five years after the bypass operation. The study yielded impressive results: Already during the operation optimistic subjects had better physiological characteristics than non-optimistic patients. One week after the operation, optimistic patients showed a different behaviour: They were more vivid, less long bedridden, and they were walking around earlier, and more often than pessimistic patients. Six months after surgery optimists lifes had normalized more or less; they had returned to their jobs, and to their leisure activities, they reported less pain, and a more healthy nutrition than did pessimists.
Scheier and Carver state that the effects of optimism are mediated via influencing a persons choice of coping strategies. In the investigation reported about above, for example, optimistic persons started already before the operation to make plans for the future, and work on concrete goals pertaining to the recovery process, also asking medical staff for good advice. Pessimistic persons, however, focused more on present emotions, and tried to supress thinking about their symptoms.
Since the choice of a certain coping strategy is dependent upon the previous appraisal of the situation, and of ones own perceived resources the question arises to which of the two the optimistic outcome expectancies are referring: To action-outcome-expectancies, or to situation-outcome-expectancies. Are optimistic persons optimistic because they believe they can manage situations well, or just because they believe everything will turn out to be fine anyway? In the theory of Scheier and Carver there is no distinction made between the two.
1.2.2 Locus of Control
Since the term locus of control refers to generalized expectancies, too, it is a rather broad construct, and could thus be regarded as a compilation from a variety of specific action-outcome-expectancies.
Taking into account the differences between the action component, and the situation component, it has to be distinguished between first, expectancies about the consequences of a persons action, second, about a persons beliefs in his or her competence to act, and third, expectancies about the situation factors which cannot be controlled by the person.
Referring to the consequences of an action, from the point of view of a person, Krampen (1987) speaks of a persons control beliefs. Control beliefs can further be specified by defining them for a certain domain, for example health. In the investigation in hand the concept of a specific health locus of control (Wallston et al., 1976; Wallston & Wallston, 1978; Ferring & Filipp, 1989) was used to assess patients beliefs about their perceived locus of control over health consequences.
A personal resource in coping with heart disease in this respect is the internal locus of control. That means, people believe that they have a good deal of influence on their physical condition, and well-being. An external locus of control, attributing control to either chance, or other people, on the other hand, increases a persons vulnerability.
Again, the perception of a certain locus of control influences the choice of coping strategies. If a person believes that it makes sense to invest energy and time in an effort to enhance his or her physical condition, coping strategies will be chosen accordingly; for example, taking physical exercise, or asking for advice. If a person believes, however, that his or her physical well-being is only dependent on the expertise of the medical staff, and/or only dependent on chance, the person will rather be passive, not taking any action, nor any effort of own free will.
To make a judgment about the efficacy of certain consequences of an action it is necessary that a person believes that he or she is able to carry out the action at all. This leads to the other action component, to a persons self-efficacy beliefs (with which will be dealt in the following section). A persons estimate about personal competences is as important as his or her estimate of consequences. In a study of Kaplan, Atkins and Reinsch (1984), for example, it was examined what makes patients succeed in increasing their physical activity level. They found a significant relation between self-efficacy, and an increase of activity only in case patients perceive an internal health locus of control.
The hierarchy of expectancies was presented this way because expectancies stem from experience, since persons learn certain contingencies (Bandura, 1977).
A persons perception of his or her self-efficacy is the central psychological construct in Albert Banduras social cognitive theory (Bandura, 1977, 1991, 1992a). Stemming from learning theory, social cognitive theory is an approach to understand human motivation, affect, thought, and action. It assumes that persons are capable of self-reflection, and self-regulation, and that they are actively shaping their environment (see Maddux, 1995). Moreover, self-efficacy is regarded as one of the most important personal resources in coping with stress (see Schwarzer, 1993).
Especially in an investigation about heart patients it is interesting to notice that the cognitive appraisal of stress is mainly determined by a persons self-efficacy beliefs (Jerusalem, 1990; Kavanagh, 1992; Krohne, 1990, 1993; Lazarus, 1991). Much more so when taking into account that the subjective experience of stress is mirrored in physiological changes pertaining to heart-rate, blood pressure, or immune parameters, for example. In a study of Wiedenfeld, OLeary, Bandura, Brown, Levine, and Raska (1990) it was shown that components of the immune system (like the total number of lymphocytes, for example) changed during a training in coping self-efficacy. Most of the changes ranged between 15% and 20% increase compared to the baseline.
It should be distinguished again between specific self-efficacy beliefs, and generalized self-efficacy beliefs. In general, self-efficacy beliefs influence the way people think, feel, and act. Referring to the emotional domain, for example, low self-efficacy is related to depression, anxiety, and low self-esteem (see Bandura, 1991). Referring to the cognitive domain, low self-efficacy beliefs lead people to underestimate their own achievements, and their own abilities. High self-efficacy in this domain, on the other hand, makes people perceive difficult tasks rather as a challenge (see Schwarzer, 1993). Self-efficacious persons invest more energy in difficult tasks, and they show more stamina, too. Also set-backs do not bother self-efficacious persons as much as little self-efficacious persons (Bandura, 1992a). All these personal characteristics related to self-efficacy are also crucial for patients who have to recover, and readjust after surgery.
In a study of 400 cardiac patients, and their wives on physical and psychophysical recovery Waltz and Badura (1988) found that perceived self-efficacy influences the stability of well-being . The authors conclude that perceived self-efficacy should be suggested as a salient factor in causal models of the effect of life events on well-being.
Besides the generalized self-efficacy beliefs specific beliefs can be assessed. Since specific expectancies are better able to predict specific outcomes, also in the investigation in hand specific self-efficacy beliefs, and specific outcome-expectancies, plus the corresponding intentions were assessed, for example pertaining to nutrition. That means, patients were asked about their intentions concerning healthy nutrition, they were asked about their appraisals referring to their ability to behave according to their intentions, and third, they were asked in how far they believe that a healthy nutrition can enhance their physical well-being. At the same time it was assessed, what kind of food they were really eating at that time, and what kind of food they were eating six months later. The intention at that time, as well as the kind of nutrition six months later could be predicted by self-efficacy beliefs, and specific outcome-expectancies (Ruschke, 1996).
In general, serious and/or chronic illness demands active coping to readjust to a level as high as possible. To build up the suitable health behaviours the corresponding self-efficacy beliefs are crucial. For rehabilitation after myocardial infarction this was demonstrated by Ewart (1992, 1995). And also to maintain these health behaviours (and minimize risk behaviours) is easier for self-efficacious people (Bandura, 1992b). For increasing physical activity, for example, -- important in rehabilitation of heart patients -- specific self-efficacy beliefs are crucial (Dzewaltowski, Noble & Shaw, 1990; Feltz & Riessinger, 1990; McAuley, 1992; Weiss, Wiese & Klint, 1989).
1.2.4 Social Support
First, the construct of social support should be clearly distinguished from social integration (see Schwarzer & Leppin, 1991a, 1991b). The term social integration refers to being embedded in a social network; as opposed to being socially isolated. The construct pertains to quantitative, and structural aspects of social relationships, whereas social support pertains to qualitative, and functional aspects. Indicators of social integration are marital status, number of relatives, friends, and acquaintances, or frequency of social contacts. Furthermore, social integration is an important condition for receiving any social support at all, since it requires social contacts.
Turning to social support it should be mentioned in the beginning that a lot of research has been done on the benefits of social support on physical, and psychophysical well-being. Social support seems to be associated with lower cardiovascular reactivity (Karmarck, Manuck & Jennings, 1990), and it improves the immune system (Jemmott & Magloire, 1988; Kiecolt-Glaser et al., 1984; Kiecolt-Glaser et al, 1987; Kiecolt-Glaser et al, 1988). Moreover, it was found beneficial for recovery, and readjustment to serious illness (Dunkel-Schetter, 1984; Mumford, Schlesinger & Glass, 1982; Trelawny-Ross & Russell, 1987; Wortman, 1984), and it even reduced mortality (Berkman & Syme, 1979; Blazer, 1982; Ruberman, Weinblatt, Goldberg & Chaudhary, 1984).
Since the construct of social support is rather broad, and complex, a lot of research has worked on the question what specific conditions there are under which social support can unfold its beneficial effects. Research led to three important distinctions, first, the distinction among the different functions of support, second, the distinction referring to the source of support, and last the distinction between the perception of support, and the actual receipt of support.
The latter distinction denotes two constructs that do not seem to be closely related (Dunkel-Schetter & Bennett, 1990; McCormick, Siegert & Walkey, 1987). Receipt of support is mainly assessed as a retrospective estimate of actually received help or support, whereas the perception of support pertains to a persons estimate if in case certain help is needed there were someone to provide him or her with this kind of support.
Pertaining to the classification of different functions of social support there are three kinds of support that have to be distinguished: Emotional support, instrumental, or tangible support, and informational support. An example for emotional support is showing compassion, or providing someone with warmth, and care. Tangible support refers to helping someone with household chores, for example, or doing the shopping, or taking somebodys children to the kindergarten. The last category informational support can be taken literally as providing someone with information; that means, telling someone the address of a famous doctor, or giving good advice what to do against a bad headache. It depends on the situation which of the three kinds of support has the best effects (stressor-support specificity model, Cutrona & Russell, 1990).
Although researchers have considered emotional support to be the primary component (Cohen & Hoberman, 1983; House, 1981; Schaefer, Coyne & Lazarus, 1981), at least as far as coping with serious illness is concerned the greatest beneficial effect depends on the situation-specific needs that arise (Cohen & McKay, 1984; Cohen & Wills, 1985; Cutrona, 1990). Conducting an investigation on heart attack patients and their spouses, Helgeson (1993a), for example, found emotional support highly important during the onset of chronic illness for both patient, and spouse; but after that, the kind of stress as well as the needs of patient and spouse diverge in a way that patients found informational support most helpful, whereas spouses found instrumental support most helpful to cope with their particular stressors.
The source of social support is an important factor for the positive effects of support. Videka-Sherman and Lieberman (1985) demonstrated, for example, that the most beneficial source of support for parents coping with the loss of a child is the spouse. On the other hand, spouse support in a situation of stressful problems at someones working place is not as helpful as support given by colleagues, for example (Kobasa & Puccetti, 1983).
Next, the question arises how social support can bring about beneficial effects. There are two prominent models, one concerning the main effect of support, the other concerning its buffering effect. Main effect denotes a direct effect of perceived or received support, for example improving well-being, or depression. Buffering effect, on the other hand, refers to resources that protect against the negative effects of stress by meeting specific needs that are created by a certain stressful event. In case of increased work stress it might be a relief to have someone to take care of ones children so that this act of instrumental support reduces the overall amount of stress, and is thus beneficial, whereas the same kind of support would be negligible if no work stress was present.
Some authors link the main effect model mainly to social integration, or the structural aspects of social support. Berkman and Syme (1979), for example, found in a classical epidemiological study a strong negative relationship between social ties and mortality, even though they did not control for the quality of the social ties.
Although the term support hints at a thoroughly positive resource, effects of social support can sometimes be negative. Not only to provide someone with a kind of support that is neither needed, nor desired can yield negative effects, also if support is not wanted by the recipient it may lead to an increase of stress, and a sense of forced helplessness or inferiority since the recipient might get the impression that others do not give him or her credit for solving problems by himself or herself.
A large social network means on the one hand that one would be provided with help if needed, on the other hand a persons own problems might be multiplied, and stress might be increased since one is exposed to the social network members problems in addition, so that their stressors become ones own stressors to a certain extent, too (Lazarus & Folkman, 1984; Solomon, Mikulincer & Hobfoll, 1987).
Another negative aspect of social support is related to the principle of reciprocity (There is no free lunch). In case someone only has few resources accepting social support may be a kind of luxury one cannot afford (The rich get richer, the poor get poorer). Social support was found to be associated with strong positive effects for women with good resources such as education, income, and also favourable psychological characteristics, but none for those who lack these resources (Riley & Eckenrode, 1986; Solomon, Mikulincer & Hobfoll, 1987).
What must a person do to be supported? In a huge field of research the characteristics of the recipient of social support are examined.
Dunkel-Schetter and Skokan (1990) list three factors of a recipient that make it more easy for others to help: First, a mean level of stress in the person who needs help seems to evoke more support; if too much support is needed, or if it is needed over an extremely extended period of time, potential sources of support will not be as willing to provide someone with help. Second, the person in need should actively try to cope with his or her problems, and should also actively try to get support (see Schwarzer & Weiner, 1990). Third, a recipient should have good personal resources such as self-esteem, competence, optimism, and/or an internal locus of control, since these characteristics make him or her more attractive for potential providers of social support (see Hobfoll & Freedy, 1990).
On the part of persons who give support several cognitions, and emotions were identified that are crucial. Among them, a prominent cognition pertains to the cause of a problem: Is the cause attributed to reasons that are controllable or uncontrollable for the recipient? For heart patients with an infarction, for example, there was found a correlation between controllability, and compassion of r = -.32 (Schwarzer & Weiner, 1991). Thus, only if providers of support have the impression that the recipient could not help getting into trouble he or she feels compassion; this positive emotion influences the providers intention, and may then lead to supportive behaviour (Weiner, Perry & Magnusson 1988).
Another important factor is the quality of the relationship between provider and recipient of support. If a person perceives a high degree of intimacy, and satisfaction in a relationship he or she will be more likely to help (see Coyne, Ellard & Smith, 1990).
Following the transactional stress model of Lazarus (1990), events can be perceived as more or less stressful, depending on a persons appraisal of the situation, and the appraisal of his or her resources. If a person knows from previous experiences that there was support available in case of need the overall level of stress will be lower. But social support can also have a beneficial effect on a persons ability to cope with the stressor. Thus, the following section will deal with the reaction to a stressful event, in other words: Coping.
1.3 Coping Behaviours
In Lazarus transactional stress model, based on the transactional relationship between a person and a situation, coping is the major component beside the cognitive processes (cognitive appraisals). Resuming to Chapter 1.1, primary cognitive appraisals mainly pertain to environmental information (that is the demands of the situation or of the person, or the aversive stimuli), secondary appraisals, however, mainly pertain to a persons characteristics (personal resources), like personal competences, beliefs, goals, but also to environmental information about the availability of a social net, or of social support (social resources), or financial resources.
The result of the cognitive appraisal determines the choice of appropriate coping strategies. Lazarus (1990) in general distinguishes between problem-focused coping, and emotion-focused coping. Problem-focused coping aims at solving the problem at issue, emotion-focused coping refers to an effort to soothe the emotional strain. Both strategies can be beneficial in certain situations.
It is important to distinguish between the function of a certain coping strategy, and its effect. In recent research it has been shown that there is no such thing as a good strategy. When facing an examination, for example, it will be little appropriate to only soothe oneself with thoughts like It is not that important. It does not matter if I fail (emotion-focused), instead of being well prepared (problem-focused). When facing a bypass operation, however, this may be the right strategy, since a patient cannot do anything to solve the problem.
Many authors have developed psychometric scales to assess different coping strategies. One of them is the Ways of Coping Scale by Folkman and Lazarus (1989), which consists of 66 items that can be subdivided into eight subscales (see Lazarus, 1990).
Another way to classify coping strategies was suggested by Krohne (1990) who states two dimensions of coping in his Model of Coping Modes. These two are vigilance, that is the search for and the cognitive processing of threatening information, and cognitive avoidance, which pertains to turning away from threatening thoughts to calm oneself down. These two dimensions of coping can be assessed with the Coping with Anxiety Inventory (ABI) by Krohne, Rösch, and Kürsten (1989).
Most of the various scales that exist to assess coping behaviours have one thing in common: They all differentiate between a class of strategies that is characterized by being attentive, and confronting the problem, and another class that summarizes strategies of avoidance. In a meta-analysis, Suls and Fletcher (1985) found avoidance strategies to be beneficial in the short run, and confronting, attentive strategies to be beneficial in the long run.
In the context of the relation between stress and health it is important to notice that it is not the stress as such that can have negative influences on well-being, but that it is the coping process. Coping with a stressful event can last for a long period of time, and even if it leads to a positive adjustment coping efforts cause costs which can have severe effects on health.
1.4 Patients and Spouses
In an article about the benefits of supportive social relationships, Michael Argyle (1992) summarizes the effects of marriage (or close intimate relationships) on health. He notes that the quality of marriage is a crucial factor indeed, but only the marital status (also referred to as structural support by Cohen & Wills, 1985) alone makes a big difference as far as well-being is concerned. Married people show, for example, smaller numbers of heart attacks, strokes, lung cancer, tuberculosis, and cirrhosis.
One of the most prominent results in this field is the finding of Berkman and Syme (1979) on the relations between marital status, and mortality (see Campbell, 1986; House, Robbins & Metzner, 1982). But this does not answer the question about causality: Is there a direct effect of marriage on mortality, or an indirect one.
Also Verbrugge (1979, 1985, 1989) found married people to be the healthiest, followed by single people, the widowed, divorced and separated persons, who were the least healthy. This hierarchy points to the importance of the kind of marital status, which proves to have more than two categories to be useful. There might be different explanations for these results. It could be hypothesized that differential health statuses are associated with marital roles, and life-style behaviours, respectively, in a way that singles, for example, show more risk behaviours such as smoking, drinking, drugs etc. (Feist & Brannon, 1988), or in a way that singles do not have access to the social support that is available for married people. It may also be assumed that married persons evaluate their physical symptoms differently, in a way that a married person may rather not call himself or herself ill, for example, because it also has negative effects on the spouse.
The finding that the marital status is associated with well-being can be interpreted within the above mentioned main-effect model of social support. Marital status then is considered evidence of social support, and high amounts of support promote well-being regardless of stress. In the stress-buffering model the negative effects of stress are diminished by support (Landerman, George, Campbell & Blazer, 1989; Thoits, 1982), so that a positive marital relationship buffers against effects of stress. The latter kind of support is called functional support (as opposed to structural support) by Cohen and Wills (1985), denoting a persons appraisal of available support, for example marital quality. In short: the existence of a social network enhances well-being, whereas the perception of availability of support is necessary to buffer the negative effects of stress. Thus, the main-effect model would lead to the suggestion that married persons are in better health, whereas the stress-buffering model would predict persons in non-distressed marriages to be in better health than those in distressed marriages.
These models of social support come with an important limitation: They do not explicitly refer to the specific mechanisms that cause reciprocal influences between marital interaction and health, nor do they refer to whether marriage affects health directly, or in an indirect way. Marital status, for example, might be linked to other variables such as gender, age, race, or life-style behaviour, that actually make the difference.
With Weakland (1977) three possible ways of the influence of marital interaction on health may be assumed: Direct influence by effecting physiological parameters, indirect influence by increasing susceptibility to noxious agents, or in case of existing health problems there might be an influence on the course or on the outcome.
In the investigation in hand, quality of marriage was only indirectly assessed by an item of the Munich Quality of Life Dimensions List. Moreover, it is dealt mainly with the third path of influence, that is the influence of marital status on the course, and outcome of adjustment after surgery.
But also the question of a relationship between marital variables, and the etiology of disease is, of course, an interesting topic. In other words: Does marital interaction directly affect physiological responses? Studies by Levenson and Gottman (1983, 1985), for example, give evidence of a relationship between marital interaction, marital quality, and physiological arousal, leading even to predicting a decrease in marital satisfaction over three years by high physiological arousal at the first point in time.
McEnroe, Blechman, and Shieber (1988) could not only replicate these results, but could further show an inverse relationship between heart rate and effective conversation.
These findings suggest a link between marital interaction, and health problems, showing that negative affect, or ineffective communication is related to increased physiological arousal. Distressed couples are characterized by more negative affect, and less effective communication (Gottman, Markman & Notarius, 1977; Margolin, Burman & John, 1989). Though the present investigation did indeed not deal with the quality of marital communication, measures of negative affect were assessed at all points in time.
An interesting finding to elucidate the mechanisms of influence of marital factors is presented by Waltz, Badura, Pfaff, and Schott (1988), who followed 372 male myocardial infarction patients, and their wives over several years. Since marital quality as either a source of support, or a source of stress was regarded as highly important, they examined a complex model of psychosocial variables, cognitive appraisals, subjective, and objective health measures, and psychological distress to gain further insight in its effects. Marital conflict predicted anxiety, as well as depression at the four year follow-up. When cognitive appraisals, and subjective perceptions of health (assessed after one year) were entered in the model, however, marital conflict was no longer significant. Thus, low quality of marital relationship seems to be linked to patients subjective perception of their impairment, or losses, which in turn relate to subsequent depression, and anxiety. On the other hand, high marital intimacy was negatively related to depression, but it did not relate to anxiety. This might be interpreted in a way that a positive marital relationship can only buffer specific kinds of distress, but not distress in general.
Pertaining to anxiety, Stengrevics, Sirois, Schwartz, Friedman and Domar (1996) report an interesting finding. They related preoperative anxiety, and anger to postoperative outcome in cardiac surgery patients. The results show no association between the outcomes, and trait anxiety and anger, but state anxiety and anger were associated with poorer postoperative outcomes. That hints at the necessity of different foci of attention for different perspectives, such as a focus on state measures for the short-term perspective of conditions shortly before surgery, and the immediate outcomes of the operation. The lack of a significant result for the trait measures might be interpreted in a way that it should thus not be the interaction with the spouse shortly before surgery that leads to high state anxiety and anger; it might be speculated that it is rather the medical personnel and/or the aversive, and threatening situation that begets high levels of anxiety and anger. On the other hand, it might be possible for a spouse to help preventing her or his partner from becoming anxious and angry.
The medical system is another factor that should be taken into account when scrutinizing couples adaptation. Thompson and Meddis (1990) found wives complaining frequently of a lack of information, and support from medical personnel after her husbands first myocardial infarction. This may hamper adaptation, and may cause unnecessary additional stress. These factors should be taken into account to prevent a misattribution of negative effects of medical condition, or lack of guidance from the medical system (see Coyne & Anderson, 1989; Gillis, 1984).
Besides from information, and medical guidance for spouses of heart patients one could go one step further and try to involve them actively in the rehabilitation process of the patient. Ewart (1995) points out that family members play a crucial role in determining how active a cardiac patient becomes in the first weeks after surgery. Spouses are frightened by their partners heart attack; the lack of information contributes to their feeling of helplessness, and anxiety. That often leads spouses to limit their partners activity, which is the wrong thing to do.
Since spouses are also frightened by their partners sometimes vigorous exercises during rehabilitation, Taylor, Bandura, Ewart, Miller, and DeBusk (1985) examined the possibilities to alter spouses appraisals of their partners efficacy. In their study, infarction patients wives had the chance to (a) wait outside in the lobby while their husbands were exercising on the treadmill, (b) to observe their partner exercising, and (c) to participate in the same kind of exercise. Wives ratings of their level of confidence in their husbands physical capabilities only matched their partners perceived self-efficacy in case they could exercise themselves so that they could make their judgment based on own experience. This indicates an easy, and effective method for creating a supportive social environment for a patient who suffered a myocardial infarction.
Beneficial effects of involving spouses into a patients treatment have also been demonstrated by Margolin and McIntyre-Kingsolver (1988): Educating the family (typically the spouse), for example, helped to improve treatment compliance, to reduce patients blood pressure, and to decrease mortality.
Apart from other social relationships of a patient, spouses surely belong to patients primary caregivers. As such they are of paramount importance for a patients physical, and psychological condition. This in mind, Methorst (1994) searched the literature between 1989 and 1994 for studies about health risks for patients spouses. She found 48 documents, among them 27 about spouses of somatic patients. Pertaining to spouses psychological well-being the overall result showed high distress, anxiety, and depression. Surprisingly, she did not find evidence for the common idea that women are more vulnerable to psychological disturbances in general. At least not for spouses of somatic patients such as heart patients.
Among spouses of the coronary bypass patients, more than two thirds reported current emotional problems before surgery. 44% of them scored above the GHQ index of psychiatric symptoms, 54% above the BDI index for clinical depressions, and one third had higher scores on anxiety than normative samples. Furthermore, depression scores were predictive of distress at a one-year follow-up.
An exception pertaining to psychological well-being was reported by Manne and Zautra (1990), who found general psychological well-being scores in 103 male spouses of rheumatoid arthritis patients higher than those of a normative sample. In this investigation, also a correlation emerged between low levels of communication, and poor adaptation to illness in both partners. The exception might be explained with the less frightening consequences of rheumatoid arthritis compared to the consequences of myocardial infarction. Thus, spouses are not likely to be overprotective, there should rather be no shift in responsibilities etc. Moreover, a heart attack is an unforeseeable event that comes all of a sudden, with a maximum of threat, and danger, whereas rheumatoid arthritis develops slowly, giving both partners more time to adapt and cope with the occurring changes.
Pertaining to spouses psychosocial functioning, Methorst (1994) found social contacts of spouses of somatic patients generally threatened. For wives of heart patients a common finding was that they stopped working temporarily; many reporting at the same time that their work was an important source of social support. Moreover, many wives strongly limited their leisure activities.
Almost all studies including quality of marital relationship found spouses less satisfied than before the patient had become ill -- with the exception among wives of heart patients, and dialysis patients, who reported more marital satisfaction, and more closeness towards their partners. Methorst claims that couples confronted with chronic illness suffer from communication problems, and from disturbing changes in marital and family roles, all that causing high levels of stress in spouses, related to inadequate coping, general distress, and poor adaptation. Referring to heart patients, relationships were characterized by less open communication, overprotectiveness on the part of the spouses, and changes in family roles between the spouses. Spouses participating in these studies -- mainly females -- took over their husbands roles in household chores, and towards their children.
Also Helgeson (1993b), investigating changes in the patient-spouse relationship after one has suffered a first myocardial infarction, and linking those changes to readjustment, found (at three months, and twelve months follow-ups) the marital dialogue centered around the patients illness, she found a shift in household responsibilities from patient to spouse, and she found changes in the support spouses provided patients with. For patients, the shift of responsibilities was adaptive at first, but maladaptive in a later phase of adjustment; the shift was always maladaptive for spouses. Surprisingly, spousal support did not predict patients adjustment. But spouses adjustment predicted patients support in a way that patients received less support from distressed spouses.
Croog and Fitzgerald (1978) studied 263 wives of patients who had suffered a first myocardial infarction, focusing on stability and change in wives subjective stress levels over one year. The findings indicate that spouses reported subjective stress is more strongly associated with a more general stress experience reflected in emotional volatility, and marital unhappiness, than with variables such as age, employment of wife, socioeconomic status, illness burdens in the household, or level of severity of husbands illness.
The findings of Methorst, of Helgeson, and of Croog and Fitzgerald show clearly that spouses who are caregivers of a seriously ill partner are at high risk for burn-out.
Revenson and Majerovitz (1990) demonstrated in a sample of rheumatoid arthritis patients, and their mainly male spouses the importance of support provision by social ties outside the marriage to buffer against depression in spouses: Spouses were found to provide more support to distressed (and depressed) patients, but they were also found to provide more problematic support when the spouses themselves were highly distressed.
In an analysis of the association between marital relationships, and health problems, Burman and Margolin (1992) mention the investigation on 103 female rheumatoid arthritis patients, and their spouses by Manne and Zautra (1989), who studied the relationship between marital variables, and psychological adjustment. In interviews with the husbands, numbers of critical remarks about their wives were rated, and furthermore wives were to report their perception of their husbands supportive behaviours. They found that husbands critical remarks were related to wives maladaptive coping behaviours, and thus to their poorer adjustment. Conversely, wives perception of supportive behaviours was related to adaptive coping behaviours, and thus better adjustment. That means, the negative or positive behaviour of the male spouses was not directly related to wives adjustment, but indirectly via wives choice of coping behaviours. Burman and Margolin suggest that this finding might shed a light on the mechanisms of how marital variables affect health outcomes.
Interestingly, Manne and Zautra (1989) furthermore did not find husbands positive (support), and negative (critical remarks) behaviours being correlated, but being separate predictors of wives coping and adjustment, thus indicating that support and stress are not merely the two sides of the same dimension.
The positive impact of supportive behaviour on the choice of adaptive coping strategies can be explained in a way that somebody who has to cope with a highly stressful life event is supported in his or her efforts to cope with the event (see Cohen & Wills, 1985; Thoits, 1986; Veiel & Ihle, 1993). Some authors assume that specific coping behaviours can be influenced by support more than others (see Monroe & Johnson, 1992). Especially coping strategies such as search of social integration, or exchange of experiences often are only made possible by social support. But also cognitive coping behaviours such as social comparison, or search of cause are most likely influenced by members of the social network.
Nolen-Hoeksema, Parker and Larson (1994) could demonstrate in a study on persons who had recently lost a close relation that a lack of support for a persons decisions, convictions, and beliefs by their social network members led to a higher level of rumination.
In an investigation on a sample of 103 cancer patients, Aymanns and Filipp (1995) found that the effectiveness of two cognitive coping modes (namely rumination, and threat minimization) on hopelessness of the patient is moderated by the amount of emotional support that the patient receives from his or her family: The effectiveness of threat minimization on hopelessness is increased by high amounts of support, whereas the dysfunctional effect of high rumination increases under a low support condition. The authors conclude that emotional support is of great relevance as a prerequisite for adaptive coping behaviour being able to take full effect.
Thus, also in coping research social support is found to be a crucial resource. In other words: The examination of influences of social network members, and intimate partners, respectively, is an important factor in research on coping with serious illness.
1.5 Research Questions
(a) How do patients and relatives compare in terms of their personal characteristics?
It seems to be an important question if patients and relatives differ; much more so since the dispersion of gender is highly heterogeneous.
To answer these questions, mean differences between patients and relatives
variables will be computed. Also the differences between male and female relatives are of
interest. Moreover, correlational associations between relatives and patients
variables will be examined.
(b) How do patients who have a spouse differ from those patients who live alone?
This seems to be the crucial point for the present paper. T-tests for paired-samples will be used to examine possible differences.
Since the majority of the patients are male, it will also be looked at the differences
between male and female patients living alone or with a partner.
(c) Are presurgery spouses characteristics related to postsurgery patients characteristics?
It would be very interesting to find associations between the way patients pull through the operation, and their partners characteristics.
Correlations between spouses time 1 variables and patients time 2
variables, as well as t-test for patients living alone vs. patients living with a partner
will be conducted.
(d) Are spouse characteristics able to predict patients recovery and readjustment?
After being concerned with a short-term adaptation (or recovery) shortly after the operation the question evolves, if relatives variables of point in time 1 are able to predict patients readjustment six months after surgery.
The indicator for patients readjustment will be measures of their quality of
life. Those indicators will be related to spouses variables.
(e) What is the particular role of social resources for couples who cope with stress?
© by Gerdamarie Schmitz