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P1: GRA Journal of Behavioral Medicine [jobm]

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Style file version Feb 25, 2000

C 2003) Journal of Behavioral Medicine, Vol. 26, No. 1, February 2003 (°

The Effects of Dyadic Strength and Coping Styles on Psychological Distress in Couples Faced With Prostate Cancer Rajni Banthia,1 Vanessa L. Malcarne,2,7 James W. Varni,3,4 Celine M. Ko,1 Georgia Robins Sadler,5,6 and Helen L. Greenbergs5 Accepted for publication: August 20, 2002

Dyadic adjustment and coping styles have been shown to predict levels of psychological distress following cancer diagnoses. This study examined the relationship between coping and distress in couples faced with prostate cancer, considering dyadic functioning as a third variable that potentially moderated or mediated the relationship. To investigate its influence on the success of patients’ and spouses’ coping efforts, both moderational and mediational models were tested using couples’ composite dyadic adjustment scores. Only the moderational model was supported for patients: dyadic strength moderated the effects of avoidant coping and intrusive thinking on mood disturbance. Despite maladaptive coping, patients that were members of stronger dyads reported less distress than those in more dysfunctional relationships. Findings suggest that the relationship between coping and distress depends on the quality of dyadic functioning. Being part of a strong dyad may serve as a

1SDSU/UCSD

Joint Doctoral Program in Clinical Psychology, San Diego, California. of Psychology, SDSU, San Diego, California. 3UCSD School of Medicine, San Diego, California. 4Children’s Hospital and Health Center, San Diego, California. 5UCSD Cancer Center, La Jolla, California. 6UCSD School of Medicine, La Jolla, California. 7To whom correspondence should be addressed at SDSU/UCSD Joint Doctoral Program in Clinical Psychology, 6363 Alvarado Ct #103, San Diego, California 92120; e-mail: malcarne@ psychology.sdsu.edu. 2Department

31 C 0160-7715/03/0200-0031/0 ° 2003 Plenum Publishing Corporation


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Banthia, Malcarne, Varni, Ko, Sadler, and Greenbergs

buffering factor, implying the need for psychosocial intervention for couples in maladjusted relationships. KEY WORDS: prostate cancer; spouses; coping; marital/dyadic functioning; distress.

INTRODUCTION The high prevalence of prostate cancer among elderly males in the United States suggests the need for broad ranging research with this population. In 2002, an estimated 189,000 American men are projected to be diagnosed with this disease making the prostate the leading site of new cancer cases in males (American Cancer Society, 2002). Fortunately, mortality rates are low when compared to other cancer sites and an increasing number of patients are living with prostate cancer rather than dying from it (American Cancer Society, 2002). The need for psychosocial research in coping and adjustment with this group is critical since individuals diagnosed with prostate cancer will have to incorporate ongoing disease-related experiences into their lives and are considered to be at risk for health-related quality of life (HRQOL) challenges (Gray et al., 1999). Patients and their spouses typically face the challenges presented by a cancer diagnosis together. Disease onset and entailing coping response commonly occur within the interpersonal context of a significant relationship (Giunta and Compas, 1993). Spouses of ill patients may assume the role of caregivers, take on added household responsibilities, attend medical visits, and help make treatment decisions (Manne and Zautra, 1989). They also are left with the burden of knowing that their loved one has a potentially life-threatening illness (Jacobs et al., 2002). Common side effects of prostate cancer and/or its treatment, including incontinence, erectile dysfunction, and decreased libido, can directly affect aspects of a couple’s relationship (Gray et al., 1999). In both empirical protocols and everyday practice, prostate cancer frequently has been regarded as a “relationship disease” because of the impact it can have on patients’ partners (Gray et al., 1999). It even is said that the “couple has cancer” (Gray et al., 1999). Thus, prostate cancer is suggested to be an optimal disease process within which to study psychological functioning in couples faced with chronic illness. Introducing a cancer diagnosis into a relationship unleashes a stressor for both members of a dyad; this disease often has been understood best as an “interpersonal experience” due to the tremendous effect that it has on relatives of a patient (Ey et al., 1998). When compared with control subjects who were not facing cancer, members of couples experiencing malignant disease reported distress levels that were significantly higher than those found in healthy populations (Hagedoorn et al., 2000; Northouse et al., 1998).


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Patient–Spouse Concordance A relationship between patient and spouse adjustment to cancer has been demonstrated throughout the oncology literature. Several studies have found spouse functioning to be the most pervasive determinant of patient functioning (Manne, 1998; Manne et al., 1997). Other studies have found no differences in psychological distress, intrusiveness, and avoidance levels whether individuals were cancer patients themselves or their spouses (Baider et al., 1998a). Patients’ and spouses’ mood states can have mutual influence on each other. Scores on measures of social support, distress, hopelessness, and uncertainty have been found to account for a significant portion of the variance in the other spouse’s adjustment (Northouse et al., 1995). The relationship between cancer and patient/spouse adjustment may not necessarily be direct; mediating and moderating factors have been suggested (Kurtz et al., 1995; Manne, 1999). Kurtz and colleagues found that the cognitive response displayed by cancer patients’ caregivers mediated caregivers’ psychological reaction to disease-related burdens. Manne reported that relationship factors moderated the association between thought patterns and distress in married cancer patients. Uncovering latent or qualifying variables may contribute to a better understanding of the cancer–distress association, and also have implications for the development of interventions aimed at reducing or preventing elevated distress scores in couples with cancer. Two specific variables have consistently emerged in psychosocial oncology literature and will be the focus of the present study: coping processes and dyadic adjustment (Revenson, 1994). Coping Processes The diagnosis of cancer activates coping processes that affect patients’ psychological distress outcomes (Ey et al., 1998). Coping strategies employed by patients and spouses in response to the stressors posed by chronic illness have been strongly linked to quality of life (Giunta and Compas, 1993). In studies of cancer-affected populations, coping initiatives that incorporate problem-solving and open communication are correlated with positive adjustment, while practices such as denial and social withdrawal have been related to symptoms of anxiety and depression (Ey et al., 1998). Coping styles that are characterized by helplessness and self-isolation also have been connected to increases in bodily complaints, anxiety, and sadness (Hoekstra-Weebers et al., 1998). Intrusive thoughts and avoidant coping consistently have been found to predict distress levels in cancer patients and their spouses (Baider et al., 1998b; Manne, 1999; Manne and Glassman, 2000).


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Furthermore, spouses’ coping styles have been shown to affect their own mood states as well as the distress levels of their partners (Manne and Zautra, 1989). Ey et al. (1998) found that male cancer patients’ avoidance uniquely predicted greater distress in their partners. Another study showed that female spouses’ coping behaviors, e.g., avoidance, were the best predictors of mood disturbance in male cancer patients (Gray et al., 1999). In a protocol conducted with marital dyads from the general population, escape– avoidance coping by wives predicted their own as well as their husbands’ emotional and somatic distress (Giunta and Compas, 1993). Dyadic Adjustment Social support has been well established as a buffer against negative HRQOL outcomes, as it facilitates emotional exchanges, healthy behaviors, and the sharing of resources (Carter and Carter, 1994; Manne et al., 1999). Even in the absence of any stressors, social support can have a direct effect on mood (Revenson, 1994). In a less optimal situation, high levels of support are linked to enhanced coping, decreased distress, and improved immune functioning in both cancer patients and their spouses (Ey et al., 1998). A romantic dyadic relationship is often a primary, most accessible, and valuable source of social support (Manne et al., 1999; Manne and Glassman, 2000). The correlation between social support and effective coping becomes even stronger when the support is provided by a spouse because of the extended availability of this resource (Gray et al., 1999). Incidence of prostate cancer is correlated with age; and members of elderly couples, particularly those that are postretirement, are likely to spend most of their time with their partners (Revenson, 1994). The spousal relationship may become especially salient following the introduction of cancer when the probable need for support increases dramatically. The partners of cancer patients assume a dual role as they become the primary providers of support for their loved one who has cancer while experiencing their own needs for support (Hagedoorn et al., 2000; Revenson, 1994). Gender differences exist in social support utilization and dyadic functioning. Men tend to be less likely than women to seek outside social support or psychological services (Nicholas, 2000), and are more apt to rely on their spouses for support (Hoekstra-Weebers et al., 1998; Revenson, 1994). In contrast, women are inclined to use several different sources of support simultaneously (Nicholas, 2000). In accordance with gender disparities, there may be distinctions in dyadic adjustment outcomes for female partners of prostate cancer patients. Members of married couples tend to adapt better physically and mentally to chronic disease as their relationship helps ameliorate the


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consequences of stress (Baider et al., 1998b; Northouse et al., 2000). Women in long-standing, supportive marital relationships reported positive adjustment ratings following cancer treatment; hence, positive marital history is suggested to be a buffer against negative reactivity to cancer (Northouse and Swain, 1987). Relationships may not always take on buffering roles; when marital adjustment is poor, higher rates of depression and anxiety have been found in cancer populations (Baider et al., 1998a; Nijboer et al., 1999). Marriages characterized by conflict and strain can reduce the level of social support that is available to a patient from a spouse. Studies with cancer patients also have demonstrated that less satisfying relationships were associated with distress, while closeness with one’s partner was linked with better quality of life (Manne et al., 1999). Moreover, negative aspects of close relationships can have a greater impact on psychological well being than positive aspects (Manne, 1998; Manne et al., 1997). In these investigations, positive responses from spouses of cancer patients had domain-specific effects while negative responses’ effects were present across mood domains. Positive spousal responses were not significantly associated with patients’ global ratings of distress while negative responses, in contrast, were related. Much of the existing behavioral medicine literature focuses on positive aspects of social support; further research that examines negative dimensions of significant relationships is needed (Manne et al., 1997). Cancer may change the way spouses interact with one another and affect marital satisfaction and stability as chronic illness can alter couples’ finances, division of responsibilities, and even the overall structure of their relationship (Burman and Margolin, 1992). Couples experiencing malignant disease reported greater decline in marital functioning over time when compared to control subjects who were not facing cancer (Northouse et al., 1998). Moreover, when perceived demand burden is high, spousal caregiving can result in negative dyadic interaction and subsequent social withdrawal (Manne et al., 1999), unsupportive behaviors (Manne and Glassman, 2000), resentment (Gilbar, 1999), and increased criticism (Manne and Zautra, 1989). These factors contribute to the variability in dyadic adjustment outcomes in response to health concerns.

Coping Processes and Dyadic Adjustment Individual patient and spouse coping factors have predictive implications for relationship adjustment when dealing with cancer, and dyadic functioning likewise influences coping processes (Revenson, 1994). Both


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of these variables have interpersonal and intrapersonal effects, and may work in conjunction to influence psychological adjustment outcomes. Gray et al. (1999) reported that prostate cancer patients’ coping behaviors and marital ratings were the best predictors of their wives’ psychological distress. Relatedly, marital strain often occurs when patients and partners have different views of how to best cope with the disease (Northouse and Swain, 1987). Dyadic dysfunction, marked by spousal criticism or withdrawal, for example, may promote ineffective coping strategies such as cognitive and behavioral avoidance (Manne, 1999). An unsupportive relationship may inhibit open communication with one’s partner, which can lead to further marriage disturbance in a cyclical fashion (Manne, 1999). Previous research suggests coping and marital variables may explain a significant portion of the variance in adjustment to chronic illness (Manne and Zautra, 1989). However, most studies use dyadic functioning as a predictor of coping adaptation. The mediational effects of relationship quality on the coping–distress association have yet to be explored fully in chronic illness populations, and could have implications for members of couples dealing with prostate cancer. The support derived from a strong marriage may enhance, or even in part be responsible for, the results of coping mechanisms employed in response to this stressor, and subsequently enable individuals to reduce emotional distress (Baider et al., 1998b). Alternatively, few studies have considered marriage as a buffering factor that potentially moderates the relationship between patient and/or spouse coping response and psychosocial adjustment to cancer. Ey et al. (1998) reported that avoidant coping by patients was associated with greater spousal distress when it was manifested in the context of a poor marital relationship. In addition, spousal criticism was found to moderate the relationship between intrusive thoughts and psychological distress (Manne, 1999). It is suggested that those individuals with either greater or poorer marriages, in interaction with either better or worse coping skills, adjust differently (Manne, 1999). The relation between coping and distress in fact may change as a function of dyadic strength (Manne, 1999). Additional empirical evidence could provide clues for how best to conceptualize the effects of marriage on coping and adjustment, and how to help couples approach the disease process together. Present Study The present study examined the following research questions surrounding the variables: dyadic adjustment, coping style, and psychological distress,


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as measured by the Dyadic Adjustment Scale, Impact of Events ScaleRevised, and Profile of Mood States, respectively. 1 Does dyadic adjustment predict individual psychological distress that presents in response to prostate cancer in patients and their spouses? (Direct effect) 2 How does dyadic adjustment relate to individual coping efforts that are extended in response to prostate cancer? Could it potentially serve as a mediator (a) or moderator (b) of psychological distress outcomes? (Indirect effect) (a) Does dyadic adjustment serve as an intervening variable through which individual coping styles predict psychological distress levels? Can individual coping styles be used to predict the strength of a significant relationship, which in turn predicts distress levels? (b) Can a strong dyadic adjustment enable patients and spouses to overcome the limitations posed by maladaptive coping regimens by moderating the effect of maladaptive coping on psychological distress? Two competing conceptual models were tested in exploration of the relationship(s) between coping processes, dyadic adjustment, and psychological distress. The first model was mediational and tested the role of dyadic adjustment as a latent variable/mechanism that influences the effect of coping response on distress. The hypothesis was that in individuals who respond to prostate cancer with negative coping processes, the resulting increase in psychological distress is in part mediated by a poor dyadic adjustment with one’s spouse/partner. The second model was moderational and examined the role of dyadic adjustment as a buffering factor that moderated the strength of the relationship between coping processes and distress outcomes. Here, it was hypothesized that the psychological distress level that results from individual coping efforts would depend upon the dyadic adjustment of a couple. Both models were tested separately for patients and spouses. Conceptual Model # 1: Dyadic Adjustment as a Mediator


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Conceptual Model # 2: Dyadic Adjustment as a Moderator

METHOD Sample One hundred and fifty-four males who were recently diagnosed with prostate cancer and their spouses/partners (all female) were asked to complete the same set of baseline self-report measures as part of a longitudinal randomized clinical trial (Malcarne et al., 2002). To be included in the study, patients had to be recently diagnosed with prostate cancer, be either married or cohabitating with a partner, speak English, and live in San Diego County. Demographical information for all 308 participants, including age, ethnicity, highest level of education completed, marital status, combined household income, months since diagnosis at the time of enrollment into the study, and stage of cancer, can be found in Tables I and II. Nine couples from the original sample were not included in the present analyses. Two couples were excluded because patients had been diagnosed with cancer over 5 years previously, one was left out because of limited English proficiency, and six were dropped due to incomplete assessment data. For the remaining 154 couples, complete data were obtained for both patients and spouses. It was not possible to collect demographical data from nonparticipants due to Human Subjects Committee guidelines on patient confidentiality. Procedures Participants were primarily recruited from local medical centers, support groups, media coverage, and community organizations over a period of 2 years. Several couples declined participation for various reasons including time constraints and unwillingness of both members of the couple to take part in the study. It was not possible to document the total number of couples that were approached for participation as proxy and passive methods of recruitment were employed to respect patient confidentiality. Prostate cancer diagnosis and self-reported medical information were verified through office


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Table I. Spouse Demographical Information Characteristic Age M = 62 SD = 10.27 Range = 32–86 Combined income Zero–$4999 $5000–$10,000 $10,001–$20,000 $20,001–$30,000 $30,001–$50,000 $50,001–$75,000 >$75,000 Education $75,000 Stage of cancer A B C D Unknown Education