This article was downloaded by: [University of Connecticut] On: 13 April 2015, At: 02:20 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Journal of Psychosocial Oncology Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wjpo20

Social Support and Adjustment Among Wives of Men with Prostate Cancer a

b

Benjamin H. Gottlieb PhD , Scott B. Maitland PhD & Jamie Brown PhD

a

a

Department of Psychology , University of Guelph , Guelph , Ontario , Canada b

Family Relations & Applied Nutrition , University of Guelph , Guelph , Ontario , Canada Accepted author version posted online: 24 Oct 2013.Published online: 15 Jan 2014.

Click for updates To cite this article: Benjamin H. Gottlieb PhD , Scott B. Maitland PhD & Jamie Brown PhD (2014) Social Support and Adjustment Among Wives of Men with Prostate Cancer, Journal of Psychosocial Oncology, 32:1, 16-36, DOI: 10.1080/07347332.2013.855962 To link to this article: http://dx.doi.org/10.1080/07347332.2013.855962

PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &

Downloaded by [University of Connecticut] at 02:20 13 April 2015

Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions

Journal of Psychosocial Oncology, 32:16–36, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0734-7332 print / 1540-7586 online DOI: 10.1080/07347332.2013.855962

Social Support and Adjustment Among Wives of Men with Prostate Cancer BENJAMIN H. GOTTLIEB, PhD Department of Psychology, University of Guelph, Guelph, Ontario, Canada

Downloaded by [University of Connecticut] at 02:20 13 April 2015

SCOTT B. MAITLAND, PhD Family Relations & Applied Nutrition, University of Guelph, Guelph, Ontario, Canada

JAMIE BROWN, PhD Department of Psychology, University of Guelph, Guelph, Ontario, Canada

This study aims to understand how wives’ mental health and life enjoyment are affected by their perceptions of the sufficiency of the support they render to their husbands who have prostate cancer. Its specific purpose is to determine whether these outcomes accrue more strongly to wives who perceive their husbands coping in avoidant ways. Drawing on data from an interview study of 51 wives of men diagnosed with prostate cancer, the authors employ heiarchical regression analysis to examine the wives’ adjustment in relation to their provision of support to their husbands. Our findings reveal a significant moderating effect of the husbands’ avoidant coping; consistent with cognitive dissonance theory, wives who provided sufficient support to more avoidant husbands demonstrated better mental health and life enjoyment than wives of men who were less avoidant. In addition, the perceived sufficiency of the support provided by the wives’ social networks had a stronger bearing on their adjustment than the support provided by their husbands. These findings add to our understanding of the psychological benefits that support providers derive when they communicate support in ways that suit the recipient’s style of managing threat. KEYWORDS social support, avoidant coping, prostate cancer, mental health

Address correspondence to Benjamin H. Gottlieb, PhD, Department of Psychology, University of Guelph, Guelph, Ontario N1G 2W1, Canada. E-mail: [email protected] 16

Support Among Wives of Men with Prostate Cancer

17

INTRODUCTION

Downloaded by [University of Connecticut] at 02:20 13 April 2015

He doesn’t accept the fact that I want to help him do things.. . . I think he thinks that I’m nagging. If I were to burst into tears, he would probably say, “Don’t be so silly,” or “Grow up.” I can’t nurse him, which is not easy. I think a lot of wives get lost in the rush to help the person with the disease.

The remarks of these two wives of men affected by prostate cancer epitomize the frustrations associated with their efforts to render practical help and emotional support to their all-too-stoic husbands, and to gain support for themselves. The second comment spotlights a particularly familiar pattern whereby the wife supporter’s own needs for support are left unmet. In the tumult that follows the diagnosis of prostate cancer, the wives have two evident needs: to support their partners and to gain support. However, one formidable obstacle to meeting both needs is well documented in the literature on gender differences in coping, namely, that men handle adversity by emotionally insulating and distancing themselves from uncontrollable stressors, whereas women tend to employ more approach-oriented ways of regulating their emotions, relying heavily on social support (Hamilton & Fagot, 2002; Pearlin & Schooler, 1978; Stone & Neale, 1984; Tamres, Janicki, & Helgeson, 2002). It follows that the wives face the formidable challenge of supporting husbands whose styles of coping are likely to be all the more avoidant due to the particular threat to their masculinity posed by prostate cancer. In addition, the wives’ own needs for support may not be met if their husbands’ shame and embarassment insulate them from their wives (Burns & Mahalik, 2007; Gray, Fitch, Phillips, Labrecque, & Fergus, 2000). This study is broadly motivated by our interest in the contingencies that affect the expression and receipt of support in close relationships that are subjected to serious and uncontrollable stressors (Gottlieb & Wagner, 1991). The specific contingency we investigate is a style of coping that is more typical of men than women when they face uncontrollable stressors, namely an avoidant coping style (Gross, 1998; Lazarus & Folkman, 1984; Zeidner & Endler, 1996). Whereas there are numerous behavioral expressions of avoidant coping, our definition and measurement gauges cognitive avoidance and distancing, mental efforts to distract oneself from the stressor by turning attention elsewhere and avoiding reminders and thoughts of the stressor (Ebata & Moos, 1994; Horowitz, Field, & Classen, 1993). Our primary aim is to understand how the wives’ mental health and life enjoyment are affected by their own perceptions of the sufficiency of the support they render to their husbands, and to determine whether these outcomes hinge on the extent to which they perceive their husbands coping in avoidant ways. Secondarily, we are interested in the wives’ adjustment as a function of the

18

B. H. Gottlieb et al.

sufficiency of the support they gain from their husbands and from members of their social networks. In what follows, we review literature relevant to the main hypothesis we test, namely, that wives who report having provided sufficient support to husbands who they perceive to be more highly avoidant will demonstrate better adjustment than the wives of men who are perceived to be low in avoidance. We also marshall empirical evidence to test the hypothesis that the perceived sufficiency of the support they receive from their social network associates will have a stronger influence on the wives’ adjustment than the sufficiency of the support they receive from their husbands.

Downloaded by [University of Connecticut] at 02:20 13 April 2015

Prostate Cancer as a Shared Stressor Numerous studies of couples affected by cancer report that the diagnosis constitutes a shared stressor that poses a number of daunting challenges, ranging from decision making about the type of treatment to select, to navigating through and selecting appropriate community health and support services, to dealing with the undesirable side effects of the treatment on sexual and urinary function, to managing disclosure of the disease to family members and close associates, and to regulating their anxieties about the cancer metastasizing (Gray et al., 2000). On the latter score, in a survey of the support needs of 210 men with prostate cancer, 44% identified “fears about cancer spreading” as the most common source of stress (Lintz et al., 2003). Complementing that statistic, a review of studies examining the psychosocial adjustment of the wives of men with prostate cancer concluded that they experience higher levels of distress than the patients themselves. They also perceive their husbands as being more distressed by the disease and its ramifications than the husband patients report, and they are less concerned about their husbands’ sexual functioning than the husbands (Couper et al., 2006; Reis, 1998). The vast literature on caregiving in the context of family illness underscores the finding that women are the most likely occupants of the caregiving role and the most likely to be their male partner’s main confidants (Henderson, 1977). The National Caregiver Alliance in the United States reports that women engage in 50% more of the family caregiving than men (Family Caregiver Alliance, 2007). Caregiving reflects the cultural definition of gender-appropriate behavior for women (Brewer, 2001), exposing them to intimate facets of the illness ordeals their husbands, parents, or children experience, thereby eliciting their hands-on care and support (Gilligan, 1982; Helgeson, 1993). Moreover, because prostate cancer typically occurs following retirement in later life, the wives can spend a great deal of time with their husbands, providing more opportunities for them to render and potentially receive support. In addition, the husbands can legitimately make claims on their wives’ support because, as the patients, they directly experience the pain, fatigue, and adverse effects on their sexual and urologic function. For

Support Among Wives of Men with Prostate Cancer

19

all these reasons, the wives will expect themselves and be expected by their associates to make their own needs for emotional support subordinate to their husband’s needs. It follows that the wives’ adjustment and well-being will rest more strongly on their provision of support to their husbands than on their receipt of support from them.

Downloaded by [University of Connecticut] at 02:20 13 April 2015

Wives’ Social Support and Husbands’ Avoidant Coping Studies examining the dynamic support process reveal that it can miscarry and go awry for a number of different reasons. There are social-psychological impediments to the tendering of support, its acceptance, and its usefulness (Coyne, Ellard & Smith, 1990; Fisher, Nadler & Witcher-Alagna, 1982). However, to date, the caregiving and informal helping literatures have largely ignored situations in which the provision of support is hampered or subverted by the would-be recipient’s ethic of self-reliance, independence, and stoicism that, in threatening circumstances, manifests as a pattern of avoidant coping. Prior research testifies to men’s greater reliance on avoidant forms of coping, especially when they face highly threatening stressors that signify the actual or anticipated loss of valued standing or male self-defining resources (Burns & Mahalik, 2007; Ey, Compas, Epping-Jordan, & Worsham, 1998; Gray, Fitch, Phillips, Labrecque, & Klotz, 1997). Hegemonic masculinity is the prototypical and most desirable view of manhood, characterized by feelings of power and invulnerability that preclude help seeking, particularly for problems related to their sexual function (Connell & Messerschmidt, 2005). Stoicism and self-reliance are the order of the day, especially for older men who have already lost some of the defining attributes of masculinity (e.g., retirement, aging bodies), and who were born in an era when gender roles were far more traditional (for a review, see Roesch et al., 2005). Moreover, by denying or repressing their fearful emotions and vulnerability, men do not express the cues that are typically reliable triggers for support from their wives confidants. As one of the wives in this study observed about her husband, “He was pretty cool about the whole thing – ‘we’ll do what we have to do’: I tried to get him to talk about it – ‘there’s nothing to worry about, don’t worry about it’ – that’s his attitude.” Their stoicism may be further reinforced by engaging in what Coyne and Smith (1994) have called “protective buffering” of their wives, meaning that they avoid discussion of the illness and their anxieties and fears to insulate their wives from worry. The highly charged context of prostate cancer therefore calls for the wives to take a delicate and strategic approach to the provision of support, an approach that communicates caring and solidarity without disrupting or derogating their husbands’ style of coping. The challenge is to moderate the recipient’s distress by marshalling sufficient support while avoiding direct or implied criticism of his or her ways of coping (Gottlieb & Wagner, 1991). Particularly in the context of a shared and uncontrollable stressor that poses

Downloaded by [University of Connecticut] at 02:20 13 April 2015

20

B. H. Gottlieb et al.

significant threat, interactions between husbands and wives can become particularly complicated and tense because women are predisposed to a style of stress appraisal and coping that has been characterized as more approachand sensitization oriented than the avoidant, blunting style typically adopted by men (Vaux, 1985; Vingerhoets & Van Heck, 1990). In the words of one of the wives who participated in this study: “He likes to do things himself. He gets mad when I talk, so I feel like I can’t talk. He likes time to himself. So I would just go for tea with my friends and that was good for both of us.” In short, the provision of support is a delicate and strategic process that depends on the wives’ instincts and experience regarding their husbands’ “supportability.” It follows that wives who perceive their husbands coping in more avoidant ways face a substantially greater challenge than the wives who view their husbands relying less on that style of coping. However, dissonance theory (Festinger, 1957) postulates that substantial psychological benefits can arise from perceived success in overcoming the challenge. Dissonance theory maintains that the achievement of goals that require greater effort will make those goals more valuable as a way to justify the energy expended. In the current context, those wives who believe that they have provided sufficient support to husbands they perceive as highly avoidant are likely to attach greater subjective value to the achievement of that goal than wives who perceive their husbands as less avoidant. Further, by magnifying the outcome’s value to make it more congruent with their efforts, the wives are likely to derive a greater sense of self-satisfaction, interpersonal competence, and well-being. Hence, wives who perceive their husbands as highly avoidant in their style of coping and report providing sufficient support, regardless of its amount and character, are likely to experience better adjustment than the wives who do not perceive their husbands to be highly avoidant. Finally, if the wives’ well-being depends more strongly on their provision of sufficient support to their ill husbands than on its receipt from them, especially from those perceived as avoidant, then they may get the support they need from alternative sources. This is because women are generally far more likely than men to seek help for their life stressors (Addis & Mahalik, 2003; Oliver, Pearson, Coe, & Gunnell, 2005), to show significantly less stoicism and less concern about stigma than men (Hayward & Bright, 1997), and to turn to their social network to discuss matters that men are loathe and less equipped to discuss (Baxter & Wilmot, 1985). The latter applies with extra force to the current context of prostate cancer, marked by shame, fear, and significant threat to conventional conceptions of masculinity. Futhermore, there is evidence that women value and benefit from support more than men (Barbee et al., 1993) and that they actually receive more support than men because they disclose more to more people, usually other women, than do men (Dindia & Allen, 1992). We therefore hypothesize that the wives’

Support Among Wives of Men with Prostate Cancer

21

perceptions of their networks’ support will contribute more strongly to their well-being than their perceptions of the support provided by their husbands.

METHOD

Downloaded by [University of Connecticut] at 02:20 13 April 2015

Participants The structured, private, in-home interview was completed by 53 participants, two of whom were removed from the data set due to having a Mahalanobis distance that classified them as statistically significant multivariate outliers. The interviewees averaged age 69 (SD = 7.94 years), 49% being retired, and 40.6% engaged in some form of employment. The couples had relatively lasting marriages averaging 37 years, and the patients were undergoing various forms of active treatment: 57% of the men had received a radical prostatectomy, 29% were undergoing radiation treatment, and the remainder opted for watchful waiting and hormone therapy. Based on Idler and Benyamini’s (1997) three-item self-report general health scale, the wives reported a mean of 8.85 (SD = 2.00, range = 3–12), with higher scores reflecting better health.

Procedure Following clearance from the Institutional Ethics Board, study participants were recruited from two urology practices by gaining the urologists’ permission to work with their office staff to identify patients (the husbands) who met the following study eligibility criteria: (1) a firm diagnosis of prostate cancer within the past 6 months but no more recently than 6 weeks earlier, (2) married or living as married for at least the past 6 months, and (3) fluent in English and living with a partner who is fluent in English. After reviewing medical files to identify eligible patients, a nurse at the urology practice contacted patients by phone, provided a brief description of the study, and sought verbal consent from the patients to have their names, contact information, and selected medical information (e.g., date of diagnosis, type of treatment elected) released to the researcher. The researcher, who declared no conflict of interest regarding the study, then called the wives of patients who consented to describe the study and to solicit their verbal consent to participate in an interview. Written consent was obtained at the interview.

Measures Psychosocial adjustment. Wives’ psychosocial adjustment to cancer was measured using two separate tools: (1) The mental health scale of the SF-36 Health Survey (SF-36; Ware, Snow, Kosinski, & Gandek, 1993) and (2) The Positive States of Mind Scale (PSOM; Adler, Horowitz, Garcia, & Moyer, 1998). The SF-36 mental health scale is composed of four subscales that

Downloaded by [University of Connecticut] at 02:20 13 April 2015

22

B. H. Gottlieb et al.

assess general mental health with five items, vitality with four items(both of the preceding on 6-point Likert-tye response formats), social functioning with two items (on a 5-point Likert-type response format), and role limitations due to emotional problems with three items (rated dichotomously). Total scores range from 14 to 70, with higher scores reflecting better adjustment. Ware et al. (1993) examined the alpha reliability of all the subscales across 14 studies and found a median alpha reliability that exceeds .80, except for the two-item social functioning scale (α = .76). The internal consistency for the mental health scale in the current study was α = .90. The PSOM scale (Adler et al., 1998) was used to assess positive mental health. It measures the extent of difficulty, if any, participants experienced in trying to achieve positive states of mind (including focused attention, productivity, responsible caretaking, restful repose, pleasure, and sharing). Participants were asked how easy or difficult it had been to experience each of the six positive states of mind during the preceding month, using a 4-point scale (1 = unable to experience this even though you have wanted to, 2 = difficult to experience, 3 = able to experience with only a little difficulty, 4 = easy to experience). Participants also had the option to indicate that the item was not relevant to them if they had not wanted to experience a particular state of mind. Items reported as not relevant were not coded. One item from the original scale, referring to sexual pleasure, was removed to prevent participant distress and embarrassment. Total scores for the adapted scale could range from 0 to 24, with higher scores reflecting greater success in achieving desired positive states of mind. Wives had a mean of 19.04 (SD = 3.37). Preliminary validation of the scale, using a version of the PSOM scale that had been modified in the same manner as in the present study, had a Cronbach’s alpha of .77 (Siewert, Antoniw, Kubiak, & Weber, 2011). The internal consistency in this study wasα = .78. Sufficiency of support provided to and received from husband. The social support literature distinguishes between descriptive and evaluative reports concerning its expression and mobilization (Barrera, 1986; Gottlieb & Bergen, 2010). Descriptive reports address the amount of support conveyed, whereas evaluative reports guage its perceived sufficiency. To date, the weight of the evidence is that judgments of sufficiency have a stronger bearing on morale and well-being than purely descriptive information about its amount (Dehle, Larsen, & Landers, 2001; Gardner & Cutrona, 2004). This is because recipients of support have different needs and preferences for the amount of support they want to receive, and some types of support are wanted more than others and experienced as more beneficial. The same applies to providers of support except that their judgments of the sufficiency of support are influenced not only by their own capacities, but also by their appraisal of the kinds and amount of support that will be well received by the recipient.

Downloaded by [University of Connecticut] at 02:20 13 April 2015

Support Among Wives of Men with Prostate Cancer

23

To assess the sufficiency of emotional, informational, and instrumental support wives provided to and received from their husbands, items from the Berlin Social Support Scales (BSSS; Schulz & Schwarzer, 2003) were slightly adapted to suit the present research. Originally designed for patients coping with cancer surgery, the BSSS comprises two parallel content scales, one assessing cognitive and behavioral types of received support and one assessing the same types of provided support. In this study the instructions and items were adapted to examine wives’ reports of the sufficiency of the support they provided to and received from their husbands, and six items were added (four on the support provision scale and two on the support receipt scale) to capture types of partner support relevant to the prostate cancer context (e.g., provision of health care information and resources). Specifically, to assess the sufficiency of the support the wives received from their ill husbands, the following instructions were provided: I’d like you to think about how your husband has been behaving toward you during the past month. For each of the following kinds of support, did your husband do this as much as you would have liked him to, less than you would have liked him to, or more than you would have liked him to?

The internal consistency in the present study was α = .86. Scoring was dichotomous; the support sufficiency score was computed by counting the number of items a participant rated receiving support “as much as you would have liked to.” Hence, total scores for the sufficiency of support receipt could range from 0 to 11 (11 items), with higher scores representing judgments of more sufficient received support. Wives reported a mean for the sufficiency of support received of 7.87 (SD = 3.40). Parallel instructions were provided for completing the 15 items describing the support the women may have provided to their husbands (e.g. “You have looked after a lot of things for him”). Items duplicated the types of support included in the received support scale, with the addition of four items designed to capture support activities that were deemed inappropriate for the support receipt scale (e.g. “You have taken care of daily duties that he could not fulfill on his own”). The response format was identical to the support provision format except that the question was whether the wives had provided each type of support as much as, less than or more than they had wanted to, with the eighth and 14th items reverse scored. Calculation of the alpha and the scale score was identical to the support receipt measure. Total scores for the sufficiency of support provision scale could range from 0 to 15, with higher scores reflecting judgments of more sufficient support provided. Wives reported a mean for the sufficiency of the support they provided of 10.52 (SD = 3.54). Alpha reliability for this measure was α = .77.

Downloaded by [University of Connecticut] at 02:20 13 April 2015

24

B. H. Gottlieb et al.

Sufficiency of network support received. Drawing on Procidano and Heller’s (1983) Perceived Social Support from Friends (PSS-Fr) and from Family (PSS-Fa) scales, six items assessed the sufficiency of the emotional and practical support provided by the wives’ network (e.g., “People have given you the moral support you need”), plus a seventh item created to tap informational support (“People have given you useful information about cancer and health resources”). Participants received the following instructions: “Now I’m going to ask you about how other people in your social circle have been behaving toward you during the past month.” For each of seven kinds of support, participants were asked to evaluate whether the support they received was much less than you would like, a little less than you would like, as much as you would like, a little more than you would like, or much more than you would like. A score for network support sufficiency was identical to the scoring of the sufficiency of the support received and provided by the wives, namely by counting the number of items rated as much as you would like. Scores for the total scale could range from 0 to 7, with higher scores reflecting greater sufficiency of the network’s support. The alpha for this measure was .82. Perceived avoidant coping. Participants’ perceptions of the extent of their husbands’ avoidant coping in dealing with prostate cancer were assessed using 10 items drawn from well-validated coping scales including the Brief COPE (COPE; Carver, 1997), the avoidance subscale of the Impact of Events scale (IOE-A; Horowitz, Wilner, & Alvarez, 1979), the MiniMental Adjustment to Cancer Scale (Mini-MAC; Watson et al., 1994), and the Ways of Coping Questionnaire (WOC; Lazarus & Folkman, 1984). Participants were asked to report how often their husband had engaged in cognitive (e.g., “Been keeping busy with work or other activities to take his mind off things”) and affective (e.g., “Been expressing or letting out his negative feelings”) avoidance during the past month. Items were rated on a four-point response format (1 = not at all, 2 = a little bit, 3 = quite a bit, 4 = a lot), with the first, fifth, and seventh items reverse scored. Total scores for the scale could range from 10 to 40 with higher scores indicating higher frequency of avoidant coping. Wives reported a mean of 22.69 (SD = 5.82) for their husbands’ avoidant coping. The internal consistency for this measure was α =.78.

RESULTS Variance inflation factors (VIF) and tolerance levels were checked for all variables included in the models and found to be well within acceptable levels (Allison, 1999; Fox 2008). These two statistics quantify the level of multicollinearity by providing a standardized index of the effects of possible collinearity on the variance of the coefficients in a

25

Support Among Wives of Men with Prostate Cancer

Downloaded by [University of Connecticut] at 02:20 13 April 2015

TABLE 1 First-Order Correlations Among Study Measures

1. 2. 3. 4. 5. 6.

SF-36 Mental Health Scale Positive States of Mind Scale Husband’s Avoidance Coping Network Support Sufficiency Sufficiency of Support Provided Sufficiency of Support Received

∗p

< 0.05,

∗∗ p

1

2

3

4

5

6

1.00 .74∗∗ −.01 .35∗∗ .42∗∗ .29∗

1.00 0.08 0.23 .38∗∗ .31∗

1.00 −0.12 0.15 0.20

1.00 0.09 0.21

1.00 .42∗∗

1.00

< 0.01.

multiple regression. Table 1 displays the first-order correlations for all study measures. To test the main hypotheses, two multiple hierarchical regressions were performed, one predicting the SF-36 mental health scale and the other predicting the PSOM scale. As we were interested in the independent effect of the perceived sufficiency of the social network’s support and expected it to influence the wives’ adjustment above and beyond the influence of the perceived support provided by and to the husbands, we entered it in the initial step of the two hierarchical models. The sufficiency of the support received from and provided to the husband, the perceived extent of the husband’s avoidant coping, and the interaction of the latter two were then entered in the second block. This order of entry allowed us to test our main hypothesis that the wives who perceived providing sufficient support to husbands they perceived as highly avoidant would show superior adjustment. The three support scores were centered to control for collinearity in computing interaction terms. In predicting the SF-36 mental health scale and the PSOM, the results of the two hierarchical multiple regression analyses show similar patterns (see Tables 2 and 3); both analyses reveal that the sufficiency of the support provided by the wives’ networks is the strongest predictor of their adjustment, and the interaction of the sufficiency of the support provided to the husband and the husband’s perceived avoidant coping was also a significant predictor of both criterion measures. The sufficiency of the support received from the husbands had a significant influence on the wives’ mental health but not on their life enjoyment. In terms of the predictors’ relative and combined influence on adjustment, in Step 1, the sufficiency of the network’s support accounted for 27.4% of the variance in SF-36 mental health scores and 21% of the variability in PSOM scores. In Step 2, when the sufficiency of the support provided and received by the wife, the avoidant coping style of the husband, and their interactions are added, an additional 21.9% of the variation in SF-36 scores is explained and an additional 14.7% of the variance in the PSOM is explained. Together, the final models predicted 50.7% of the variance in the SF-36 and

26

B. H. Gottlieb et al.

TABLE 2 Hierarchical Regression Results for SF-36 Mental Health Scale Step 1

Downloaded by [University of Connecticut] at 02:20 13 April 2015

Dependent Variable: SF-36 Mental Health Variable Intercept Sufficiency of network support Sufficiency of support provided by wife Sufficiency of support received from husband Husband’s avoidance coping Husband’s Avoidance Coping × Sufficiency of Support Provided Model R 2 Adjusted R 2 F ∗∗ p

< 0.01,

∗∗∗ p

Step 2 Times New Roman

β

b 14.51 1.46

.33∗∗∗

28.8% 27.4% 19.87∗∗∗

β

13.16 .99 .14

.37∗∗ .11

5.29

.36∗∗

−.07 .17

−.04 .33∗∗

50.7% 45.2% 9.26∗∗∗

< 0.001.

37.4% of the variance in the PSOM. The significant predictors in Step 2 that were common for the SF-36 mental health subscale and the PSOM were the sufficiency of the wives’ network support and the interaction between the perceived extent of the husband’s avoidant coping and the sufficiency of the support provided to him; the latter (two-way) interaction suggests that the more sufficient they perceive the support they provide to their husbands, the better the wives’ adjustment when they perceive their husbands as more avoidant. When the husbands are perceived to have lower levels of avoidant coping, the wives’ adjustment decreases with increases in the sufficiency of the support she provides. For the SF-36, the interaction accounts for 9.5% of the variance, and for the PSOM it accounts for 7.5% of the variance. TABLE 3 Hierarchical Regression Results for PSOM Scale Dependent Variable: PSOM Variable Intercept Sufficiency of network support Sufficiency of support provided by wife Sufficiency of support received from husband Husband’s avoidance coping Husband’s Avoidance Coping × Sufficiency of Support Provided Model R 2 Adjusted R 2 F Note: PSOM = Positive States of Mind Scale. ∗ p < 0.05, ∗∗ p < 0.01, ∗∗∗ p < 0.001.

Step 1 b −5.21 .95

22.7% 21.1% 14.39∗∗∗

Step 2 β .48∗∗∗

b

β

−4.71 .63 .21 1.60

.32∗ .22 .15

.13 .11

.12 .29∗

37.4% 30.4% 5.37∗∗

Support Among Wives of Men with Prostate Cancer

27

Downloaded by [University of Connecticut] at 02:20 13 April 2015

DISCUSSION Calling on the social support and coping literatures, this study tested hypotheses about the perceived adequacy of the support the wives of men with prostate cancer receive and provide, and its bearing on their adjustment. As providers of support, the wives’ adjustment was not significantly influenced by the sufficiency of the support they provided; we found no main effect on their mental health and ability to experience positive states of mind of the support they tendered to their husbands. However, when the wives’ ratings of the extent to which their husbands coped in an avoidant manner were taken into account, its interaction with the sufficiency of the support provided to them by the wives had a significant influence on both our positive measure of life enjoyment (PSOM) and our measure of mental health. The interaction uniquely accounted for 9.5% of the variance in the SF36 and 7.5% of the variance in the PSOM. Moreover, drawing on postulates from dissonance theory that justify greater effort by assigning greater value to goal achievement, wives who reported that they provided sufficient support to more avoidant husbands had significantly better adjustment than wives who provided sufficient support to less avoidant spouses (see Figures 1 and 2). Moreover, the consistent direction of these significant interaction effects adds to the reliability of our findings. The latter interaction suggests that the support process can be quite delicate in stressful circumstances that elicit certain patterns of coping on the part of the would-be recipient. In the present context, the wives who view their husbands as more avoidant in their style of coping must rise to the challenge of supporting them in ways that contribute to the wives’ own adjustment. In other words, the wives’ well-being rests in part on their skill in coping with their husbands’ coping, including their ability to regulate their own emotions. After all, social support is itself a coping resource that needs to be expressed in ways that buttress the recipient’s coping responses or at least do not undermine or disrupt them. Given their relatively lasting marriages, averaging 37 years together, the wives have probably learned a great deal about how to convey support in ways that are effective and validating for both parties. Especially for the wives who view their husbands as more avoidant, to the extent that they have learned to be strategic in the words and deeds they use to console, reassure, or protect their husbands, they can gain satisfaction from demonstrating their reliable alliance with them in the context of a serious, shared, and largely uncontrollable stressor. The social support literature provides numerous accounts of the contingencies that affect its mobilization and its acceptance (Wortman & Lehman, 1985), but relatively little information about how it is communicated in ways that are tailored to the recipient’s personality, ways of managing threat, social norms, and psychological needs. One example of the latter is Bolger, Zuckerman, and Kessler’s (2000) study of invisible support, meaning support

Downloaded by [University of Connecticut] at 02:20 13 April 2015

28

B. H. Gottlieb et al.

FIGURE 1 Effect of wives’ support and husbands’ avoidant coping on positive states of mind (Color figure available online).

that the recipient is unaware of or behaviors that the recipient does not interpret as support because they do not call attention to the recipient’s distress or deficient coping skills. Another contingency affecting the expression of support are the social norms to which people subscribe. Glidewell, Tucker, Todt, and Cox’s (1982) study of exchanges among high school teachers in their lunch room showed that support took the form of experience swapping about how they managed a variety of student and administrative problems. By sharing accounts of the emotions they experienced and how they had coped with these varied irritants, all the time withholding any advice, guidance, or prescriptions, they were able to exchange practical and emotional support in ways that were well aligned with the teaching profession’s norms of independent decision making and autonomous practice. Here too support was rendered subtly so as to mitigate self-esteem costs or other pejorative self-attributions. Together, these two studies and our own findings suggest that the delivery of support requires careful consideration of what is psychologically at stake for the would-be recipients, and an approach that neither

Downloaded by [University of Connecticut] at 02:20 13 April 2015

Support Among Wives of Men with Prostate Cancer

29

FIGURE 2 Effect of wives’ support and husbands’ avoidant coping on the SF-36 Mental Health Scale (Color figure available online).

undermines their confidence in their own handling of matters nor augments their distress. The wives’ observations of their husbands’ emotional and behavioral reactions to their diagnosis, treatment, and side effects suggest that they were aware of the need to take a strategic approach to supporting them, one that calls for a high degree of sensitivity and self-regulation. One wife remarked, He was pretty cool about the whole thing – “We’ll do what we have to do.” I tried to get him to talk about it – there’s nothing to worry about, don’t worry about it – his attitude. In the end he said I hope we’re doing the right thing.

Another wife observed that her husband’s silence was consistent with his family socialization:

30

B. H. Gottlieb et al.

Downloaded by [University of Connecticut] at 02:20 13 April 2015

He doesn’t verbalize very well, he isn’t one that will voice every feeling. As a kid he and his family didn’t talk a lot about feelings. He worries and is making sure I know how to take care of things like our finances. He worries that it will kill him.

Because these observations are likely to form the basis of the wives’ supportive strategies, in future research it will be instructive to gain detailed information about the actual support process employed by wives who view their husbands as highly avoidant and wives who do not see their husbands that way. The possibilities range from certain forms of “protective buffering” (Coyne & Smith, 1994) whereby, unknown to their husbands, the wives handle vexing tasks and problems, accepting their husbands’ withdrawal into their work and pastimes, planning and engaging in more positive companionate activities with their husbands, to conversing with them about their future together and their personal and familial priorities. The study findings concerning the sufficiency of the support received by the wives and its influence on their adjustment also merit discussion. Our prediction that the wives’ adjustment would be more strongly influenced by their perceptions of the support provided by their social networks than by their perceptions of their husbands’ support received mixed evidence. Whereas these two perceived sources of support are approximately equivalent in their influence on the wives’ mental health, accounting for 10.7% and 10.3%, respectively, of the variance in the SF-36, the perceived support of the wives’ networks is a stronger predictor of their ability to achieve positive states of mind than the perceived support of their husbands’ (7.9% and 1.7%, respectively). Taken together, these findings suggest that the perceived sufficiency of their social networks’ support contributes more strongly to their positive affect (e.g., maintaining or boosting their ability to be productive, enjoy restful repose, and focus their attention) than the support provided by their husbands. Future research may help to explain why the husbands’ perceived support had a significant impact on the SF-36 but not on the PSOM whereas the social network had a significant impact on both measures of adjustment. It would be instructive to determine how the wives spend their time with network members, particularly the balance of time devoted to distracting conversations and pleasurable activities, and the time devoted to illnessrelated topics. Prior research has demonstrated that women cannot talk to male partners about numerous topics that they realize are taboo or that are known to predict tensions and arguments (Dehle et al., 2001; Gottlieb & Wagner, 1991). Instead, they turn to their natural network for dialogue, diversion, and support, mainly to their female peers and family members (Brady & Helgeson, 1999). In their networks they can foreground identities that are not predicated on their domestic and marital lives, pursue valued avocations, and enjoy more affectively positive experiences.

Support Among Wives of Men with Prostate Cancer

31

Downloaded by [University of Connecticut] at 02:20 13 April 2015

Taken together, our findings portray the wives’ adjustment as contingent upon their perceptions of having provided sufficient support to husbands they view as more avoidant, and having received sufficient support from their network associates. Moreover, the models in Tables 2 and 3 demonstrate the predictive strength of these support perceptions; they account for 35% of the variance in the wives’ mental health scores and 30% of the variance in their ability to experience positive states of mind. Other candidate predictor variables that could be investigated in future research include the wives’ own coping responses, their past experience in handling other illness -related stressors, and the self-efficacy they bring to their support-related interactions with their husbands.

CLINICAL IMPLICATIONS Medical advances in the therapies offered for prostate cancer have made decision making more complex for couples who are affected by the disease, requiring physicians to spend more time outlining their pros and cons for the near term and more distant future. Armed with this knowledge, couples can make more informed decisions about the path that is right for their own circumstances, taking into account the stage and aggressiveness of the diagnosis. In addition to that knowledge, this study suggests that the couple may benefit from periodic brief counseling sessions with their physician, with a focus on their support-related needs, preferences, and interactions. Couple counseling centered on improving sexual function after prostate treatment has already been instituted (e.g., Schover et al., 2012) and could be extended to include discussion of support and coping dynamics. There are also programs that teach proactive problem-solving and emotion regulation skills to the partners and caregivers of people affected by cancer (Malcarne et al., 2002). Support groups led by physicians, nurses, or mental health practitioners could also be of great benefit, allowing couples to compare their ways of coping and supporting their partners while also gaining the support of the group.

Limitations There are several study limitations that qualify these findings. First and foremost, the cross-sectional study design precludes causal inferences regarding the role of support in the wives’ adjustment. Short of designing an experimental study, a longitudinal design could help to unravel the temporal relationships between perceived support and subsequent adjustment. A second limitation is our exclusive reliance on the wives’ reports. Although there can be no substitute for subjective, evaluative reports regarding the sufficiency

Downloaded by [University of Connecticut] at 02:20 13 April 2015

32

B. H. Gottlieb et al.

of the support the wives provided and received, research is needed to investigate the husbands’ perspectives on the support they receive and provide: do they concur with their wives’ assessments of its sufficiency, and do those assessments influence the husband’s adjustment? Access to the husbands would also allow for direct measurement of the extent of their avoidant coping. Although error variance could be minimized by including the husbands in the research process, the two urologists with whom we collaborated expressed strong reservations about contacting the patients while they were undergoing active treatment; on ethical grounds they were concerned about the potentially negative reactive effects of probing the husbands’ coping and receipt of support, and on clinical grounds, their experience told them that few patients would agree to participate because of their embarassment and reluctance to discuss their situation and feelings. In fact, two literature reviews have shown that, in the vast majority of studies that have succesfully recruited couples who are coping with cancer, the patients are women and experience greater distress than their partner caregivers than when the patients are men (Hodges, Humphries, & Macfarlane, 2005; Manne, 1998). Moreover, a report issued by the Johns Hopkins Evidence-based Practice Center testifies to the difficulty of recruiting older men for participation in cancer-related trials and observational studies, including them with men who are members of racial and ethnic minorities as underrepresented research participants (Ford et al., 2008). The study’s generalizability is also limited by the relatively small number of participants and their lasting marriages, averaging 37 years. Such long marriages imply that the partners know one another’s preferences, likes and dislikes, and coping styles quite well, suggesting that they may have learned to accommodate one another more effectively than couples who have had less time together and fewer stressful alarms. It may take many years of marriage to learn about the extent and style of support provision that is acceptable and effective for the partners, and then to apply those insights. Hence, the current research needs to be extended to more diverse samples, including couples who have been together for shorter periods of time. Finally, other control variables may be confounded to some extent with the perceived support investigated here. Future research should take into account the strength of the marital relationship, concurrent use of any support services or counseling, and the extent, prognosis, and functional disability associated with the husband’s disease.

ACKNOWLEDGEMENTS The authors wish to thank the study participants and Dr. Tom Morris for their collaboration.

Support Among Wives of Men with Prostate Cancer

33

Downloaded by [University of Connecticut] at 02:20 13 April 2015

REFERENCES Addis, M. E., & Mahalik, J. R. (2003). Men, masculinity, and the contexts of helpseeking. American Psychologist, 58, 5–14. Adler, N. E., Horowitz, M., Garcia, A., & Moyer, A. (1998). Additional validation of a scale to assess positive states of mind. Psychosomatic Medicine, 60, 26–32. Allison, P. D. (1999). Multiple regression: A primer. Thousand Oaks, CA: Pine Forge Press. Barbee, A. P., Cunningham, M. R., Winstead, B. A., Derlega, V. J., Gulley, M., Yankeelov, P., & Druen, P. (1993). Effects of gender role expectations on the social support process. Journal of Social Issues, 49, 175–190. Barrera, M., Jr. (1986). Distinctions between social support concepts, measures, and models. American Journal of Community Psychology, 14(4), 413–445. Baxter, L. A., & Wilmot, W. (1985). Taboo topics in close relationships. Journal of Social and Personal Relationships, 2, 253–269. Bolger, N., Zuckerman, A., & Kessler, R. C. (2000). Invisible support and adjustment to stress. Journal of Personality and Social Psychology, 79, 953–961. Brady, S. S., & Helgeson, V. S. (1999). Social support and adjustment to recurrence of breast cancer. Journal of Psychosocial Oncology, 17, 37–55. Brewer, L. (2001). Gender socialization and the cultural construction of elder caregivers. Journal of Aging Studies, 15, 217–235. Burns, S. M., & Mahalik, J. R. (2007). Understanding how masculine gender scripts may contribute to men’s adjustment following treatment for prostate cancer. American Journal of Men’s Health, 1(4), 250–261. Carver, C. S. (1997). You want to measure coping but your protocol’s too long: Consider the Brief COPE. International Journal of Behavioral Medicine, 4, 92– 100. Connell, R. W., & Messerschmidt, J. W. (2005). Hegemonic masculinity: Rethinking the concept. Gender and Society, 19(6), 829–859. Couper, J., Bloch, S., Love, A., Macvean, M., Duchesne, G. M., & Kissane, D. (2006). Psychological adjustment of female partners of men with prostate cancer: A review of the literature. Psycho-Oncology, 15, 937–953. Coyne, J. C., Ellard, J., & Smith, D. (1990). Social support, interdependence, and the dilemmas of helping. In B. R. Sarason, I. G. Sarason, & G. Pierce (Eds.), Social support: An interactional view (pp. 129–149). New York, NY: Wiley. Coyne, J. C., & Smith, D. A. F. (1994). Couples coping with a myocardial infarction: Contextual perspective on patient self-efficacy. Journal of Family Psychology, 8(1), 43–54. Dehle, C., Larsen, D., & Landers, J. E. (2001) Social support in marriage. American Journal of Family Therapy, 29, 307–324. Dindia, K., & Allen, M. (1992). Sex differences in self-disclosure: A meta-analysis. Psychological Bulletin, 112, 106–124. Ebata, W., & Moos, R. (1994). Personal, situational, and contextual correlates of coping in adolescence. Journal of Research on Adolescence, 4(1), 99–125. Ey, S., Compas, B., Epping-Jordan, J., & Worsham, N. (1998). Stress responses and psychological adjustment in patients with cancer and their spouses. Journal of Psychosocial Oncology, 16, 59–77.

Downloaded by [University of Connecticut] at 02:20 13 April 2015

34

B. H. Gottlieb et al.

Family Caregiver Alliance. (2007). Family caregiving: State of the art, future trends. Report from a National Conference. San Francisco, CA: Author. Festinger, L. (1957). A theory of cognitive dissonance. Evanston, IL: Row, Peterson. Fisher, J., Nadler, A., & Witcher-Alagna, S. (1982). Recipient reactions to aid. Psychological Bulletin, 91, 27–54. Ford, J. G., Howerton, M. W., Lai, G. Y., Gary, T. L., Bolen, S., Gibbons, M. C., . . . Bass, E.B. (2008). Barriers to recruiting underrepresented populations to cancer clinical trials: A systematic review. Cancer, 112(2), 228–242. Fox, J. (2008). Applied regression analysis and generalized linear models (2nd ed.). Thousand Oaks, CA: Sage. Gardner, K. A., & Cutrona, C. E. (2004). Social support communication in families. In A. L. Vangelisti (Eds.), Handbook of family communication (pp. 495–512). Mahwah, NJ: Erlbaum. Gilligan, C. (1982). In a different voice: Psychological theory and women’s development. Cambridge, MA: Harvard University Press. Glidewell, J. C., Tucker, S., Todt, M., & Cox, S. (1982). Professional support systems: The teaching profession. In A. Nadler, J. Fisher, & B. DePaulo (Eds.), Applied research in help-seeking and reactions to aid (pp. 231–256). New York, NY: Academic Press. Gottlieb, B. H., & Bergen, A. E. (2010). Social support concepts and measures. Journal of Psychosomatic Research, 69, 511–520. Gottlieb, B. H., & Wagner, F. (1991). Stress and support processes in close relationships. In J. E. Eckenrode (Ed.), The social context of coping (pp. 165–188). New York, NY: Plenum. Gray, R. E., Fitch, M., Phillips, C., Labrecque, M., & Fergus, K. (2000). To tell or not to tell: Patterns of disclosure among men with prostate cancer. Psycho-Oncology, 9, 273–282. Gray, R. E., Fitch, M. I., Phillips, C., Labrecque, M., & Klotz, L. (1997). Presurgery experiences of prostate cancer patients and their spouses. Cancer Practice, 7, 130–135. Gross, J. J. (1998). The emerging field of emotion regulation: An integrative review. Review of General Psychology, 2, 271–299. Hamilton, S., & Fagot, B. (2002). Sex differences in coping behavior: A meta-analytic review and an examination of relative coping. Personality & Social Psychology Review, 6, 2–30. Hayward, P., & Bright, J. A. (1997). Stigma and mental illness: A review and critique. Journal of Mental Health, 6, 345–354. Helgeson, V. S. (1993). (1993). Implications of agency and communion for patient and spouse adjustment to a first coronary event. Journal of Personality and Social Psychology, 64, 807–816. Henderson, S. (1977). The social network, support and neurosis: The function of attachment in adult life. British Journal of Psychiatry, 131(6), 185–191. Hodges, L. J., Humphries, G. M., & Macfarlane, G. (2005). A meta-analytic investigation of the relationship between the psychological distress of cancer patients and their carers. Social Science and Medicine, 60, 1–12. Horowitz, M. J., Field, N. P., & Classen, C. C. (1993). Stress response syndromes and their treatment. In L. L. Goldberger, & S. Breznitz (Eds.), Handbook of stress: Theoretical and clinical aspects (pp. 757–773). New York, NY: Free Press.

Downloaded by [University of Connecticut] at 02:20 13 April 2015

Support Among Wives of Men with Prostate Cancer

35

Horowitz, M., Wilner, N. J., & Alvarez, W. (1979). Impact of events scale: A measure of subjective stress. Psychosomatic Medicine, 41, 209–218. Idler, E. L., & Benyamini, Y. (1997). Self-rated health and mortality: A review of twenty-seven community studies. Journal of Health and Social Behavior, 38, 21–27. Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York, NY: Springer. Lintz, K., Moynihan, C., Steginga, S., Norman, A., Eeles, R., Huddart, R., . . . Watson, M. (2003). Prostate cancer patients’ support and psychological care needs: Survey from a non-surgical oncology clinic. Psycho-Oncology, 12, 769–783. Malcarne, V. L., Banthia, R., Varni, J. W., Sadler, G. R., Greenbergs, H. L., & Ko, C. M. (2002). Problem-solving skills and emotional distress in spouses of men with prostate cancer. Journal of Cancer Education, 17(3), 150–154. Manne, S. (1998). Cancer in the marital context: A review of the literature. Cancer Investigation, 16, 188–202. Oliver, M. I., Pearson, N., Coe, N., & Gunnell, D. (2005). Help-seeking behaviour in men and women with common mental health problems: Cross-sectional study. British Journal of Psychiatry, 186, 297–301. Pearlin, L., & Schooler, C. (1978). The structure of coping. Journal of Health & Social Behavior, 19, 2–21. Procidano, M. E., & Heller, K. (1983). Measures of perceived social support from friends and from family: Three validation studies. American Journal of Community Psychology, 11(1), 1–24. Reis, H. T. (1998). Gender differences in intimacy and related behaviors: Context and process. In D. J. Canary & K. Dindia (Eds.), Sex differences and similarities in communication: Critical essays and empirical investigations of sex and gender in interaction (pp. 203–231). Mahwah, NJ: Erlbaum. Roesch, S. C., Adams, L., Hines, A., Palmores, A., Vyas, P., Tran, G., . . . Vaughan, A. (2005). Coping with prostate cancer: A metaanalytic review. Journal of Behavioral Medicine, 28, 281–293. Schover, L. R., Canada, A. L., Yuan, Y., Sui, D., Neese, L., Jenkins, R., & Rhodes, M. (2012). A randomized trial of Internet-based versus traditional sexual counseling for couples after localized prostate cancer treatment. Cancer, 118(2), 500–509. Schulz, U., & Schwarzer, R. (2003). Social support in coping with illness: The Berlin Social Support Scales (BSSS). Diagnostica, 49, 73–82. Siewert, K., Antoniw, K., Kubiak, T., & Weber, H. (2011). The more the better? The relationship between mismatches in social support and subjective well-being in daily life. Journal of Health Psychology, 16(4), 621–631. Stone, A. A., & Neale, J. M. (1984). New measure of daily coping: Development and preliminary results. Journal of Personality and Social Psychology, 46, 892–906. Tamres, L. K., Janicki, D., & Helgeson, V. S. (2002). Sex differences in coping behavior: A meta-analytic review and an examination of relative coping. Personality and Social Psychology Review, 6(1), 2–30. Vaux, A. (1985). Variations in social support associated with gender, ethnicity, and age. Journal of Social Issues, 41, 89–110. Vingerhoets, A., & Van Heck, G. (1990). Gender, coping, and psychosomatic symptoms. Psychological Medicine, 20, 125–135.

36

B. H. Gottlieb et al.

Downloaded by [University of Connecticut] at 02:20 13 April 2015

R Ware, J. E., Snow, K. K., Kosinski, M., & Gandek, B. (1993). SF-36 health survey manual and interpretation guide. Boston, MA: New England Medical Center, The Health Institute. Watson, M., Law, M., dos Santos, M., Greer, S., Baruch, J., & Bliss, J. S. (1994). The Mini-MAC: Further development of the Mental Adjustment to Cancer Scale. Journal of Psychosocial Oncology, 12(3), 33–46. Wortman, C. B., & Lehman, D. (1985). Reactions to victims of life crises: Support attempts that fail. In I. G. Sarason & B. R. Sarason (Eds.), Social support: Theory, research and application (pp. 463–489). Dordrecht, The Netherlands: Martinus Nijhoff. Zeidner, M., & Endler, N. S. (1996). Handbook of coping: Theory, research, applications. New York, NY: John Wiley.