ChapterPDF Available

Straight to the heart: Romantic relationships, attachment, and the management of cardiac disease

Authors:

Abstract

The link between the quality of couple relationships and cardiac health is well established. For instance, the results of empirical research conducted over the past three decades have revealed that the experience of isolation, loneliness, conflict, and distress within the context of committed couple relationships is related to increases in pulmonary hypertension (Smith et al., 2012) and to the development of cardiac disease leading to premature death (Eaker et al., 2007; House et al., 1988). On the other hand, the perception of a romantic partner's emotional accessibility and responsiveness is associated with reductions in blood pressure, the attenuation of cardiac reactivity (Gottman, 2011), and decreases in the neural perception of threat in stressful environments (Johnson et al., 2013). Couple relationships in which there are high levels of satisfaction also appear to protect against relapse and death in patients who develop cardiac disease. In light of these findings and of the recent call in the literature for greater attention to the interpersonal mechanisms of health outcomes (Pietromonaco et al., 2013), this chapter briefly outlines recent research on couple relationships as a risk or protective factor in the etiology and course of heart disease. We then discuss attachment theory as an organizing theoretical framework for the available data on the relation between couple functioning and heart disease, and conclude with the presentation of pilot data of a study of attachment and the management of heart disease in a sample of patients in cardiac rehabilitation.
Chapter
STRAIGHT TO THE HEART:
ROMANTIC RELATIONSHIPS, ATTACHMENT,
AND THE MANAGEMENT OF CARDIAC
DISEASE
Paul S. Greenman
1,2,3, Vanessa Tassé1,2
and Heather Tulloch4
1Université du Québec en Outaouais, Gatineau, Québec, Canada
2Institut de recherche de l’Hôpital Montfort, Ottawa, Ontario, Canada
3Ottawa Couple and Family Institute, Ottawa, Ontario, Canada
4University of Ottawa Heart Institute, Ottawa, Ontario, Canada
ABSTRACT
The link between the quality of couple relationships and cardiac
health is well established. For instance, the results of empirical research
conducted over the past three decades have revealed that the experience
of isolation, loneliness, conflict, and distress within the context of
committed couple relationships is related to increases in pulmonary
hypertension (Smith et al., 2012) and to the development of cardiac
disease leading to premature death (Eaker et al., 2007; House et al.,
Please address all correspondence concerning this chapter to Dr. Paul Greenman, Université du
Québec en Outaouais, Département de psychoéducation et de psychologie, 283, boul.
Alexandre-Taché, Gatineau, QC J8X 2X7 Canada (paul.greenman@uqo.ca).
Paul S. Greenman, Vanessa Tassé and Heather Tulloch
2
1988). On the other hand, the perception of a romantic partner’s
emotional accessibility and responsiveness is associated with reductions
in blood pressure, the attenuation of cardiac reactivity (Gottman, 2011),
and decreases in the neural perception of threat in stressful environments
(Johnson et al., 2013). Couple relationships in which there are high levels
of satisfaction also appear to protect against relapse and death in patients
who develop cardiac disease. In light of these findings and of the recent
call in the literature for greater attention to the interpersonal mechanisms
of health outcomes (Pietromonaco et al., 2013), this chapter briefly
outlines recent research on couple relationships as a risk or protective
factor in the etiology and course of heart disease. We then discuss
attachment theory as an organizing theoretical framework for the
available data on the relation between couple functioning and heart
disease, and conclude with the presentation of pilot data of a study of
attachment and the management of heart disease in a sample of patients in
cardiac rehabilitation.
Over the past thirty years, scientific research in health psychology,
psychobiology, neurology, and other disciplines has confirmed something that
most sage, astute grandmothers and happily (or unhappily) married people
already knew: The quality of one’s intimate connections to significant others
can have profound effects on one’s health in a variety of ways through diverse
mechanisms. There is now a great deal of empirical support for the notion that
people who feel isolated, alone, and cut off from the world are more likely to
develop and die from chronic illnesses such as heart disease and cancer than
are those who maintain close ties to others. In contrast, those who enjoy the
presence and support of those around them are less likely to develop chronic
illnesses and if they do, they are more likely to recover (Cacioppo & Patrick,
2008; Holt-Lunstad, Smith, & Layton, 2010; House, Landis, & Umberson,
1988; Uchino, 2004).
As House, Landis, and Umberson (1988) so eloquently stated in their oft-
cited landmark study of social relationships and health, “social relationships,
or the relative lack thereof, constitute a major risk factor for health rivaling the
effects of well-established health risk factors such as cigarette smoking, blood
pressure, blood lipids, obesity, and physical activity” (p. 540). Their findings
were confirmed in a more recent meta-analysis of relationships and mortality
risk: The strength of social relationships (measured by “structural” variables
such as marital status and “functional” ones such as social support) was a
significant, independent predictor of long-term survival in 148 independent
studies (N = 308,849) of risk factors for mortality around the world (Holt-
Straight to the Heart
3
Lunstad et al., 2010). The principal message of this scientific inquiry is that
the maintenance of close ties to significant others is vital to a long, healthy life
(Uchino, 2004).
Unfortunately, despite the preponderance of data that suggest powerful
basic needs for closeness and connection in human beings (Baumeister &
Leary, 1995) and the aforementioned dangers of emotional solitude, people
living in industrialized societies have become increasingly disconnected from
their larger communities and social support networks over the past century;
they generally have fewer close relationships than their parents or
grandparents did (Cacioppo & Patrick, 2008; Putnam, 2000; McPherson,
Miller, Smith-Lovin, & Brashears, 2006). Romantic partners have thus
become the principal attachment figures for a majority of individuals
(Johnson, 2013; McPherson et al., 2006). Stated differently, people in Western
societies now tend to live in dyadic communities, with spouses or romantic
partners (we use these terms interchangeably throughout the text) representing
their primary, and in many cases only, sources of emotional closeness and
social support. It follows logically, then, that the health benefits and health
risks attributed to social support might be particularly salient in the spousal
dyad, an inference for which there is indeed scientific evidence (Kiecolt-
Glaser & Newton, 2001).
As cardiovascular disease is the leading cause of death in industrialized
nations (Uchino, 2004), the link between social support and the progression of
cardiovascular disease has been extensively studied. Researchers have recently
emphasized the impact of couple relationships on the etiology and course of
various cardiac diseases and conditions (e.g., King & Reis, 2012; Sher, Braun,
Domas, Bellg, Baucom, & Houle, 2014) in an effort to better understand how
they might affect cardiac health. Some researchers have also examined the
effects of heart disease on patients’ spouses (e.g., Fosbøl et al., 2013; Mahrer-
Imhof, Hoffmann, & Froehlicher, 2007; So & La Guardia, 2011) and ways in
which couples can effectively cope with the diagnosis in order to increase
cardiac patients’ chances of survival and quality of life (e.g., King & Reis,
2012). The ultimate goal from a clinical standpoint is to utilize current
information on the effects of couple relationships on the etiology and course of
heart disease to help cardiac patients manage their illness more effectively or
to help prevent it altogether through evidence-based interventions.
Although there are now a number of studies of couples and heart disease,
no theoretical framework has been tested that would explain the apparent
impact of relationship variables such as marital satisfaction or spousal support
on cardiac health outcomes, and there is sparse information on how clinicians
Paul S. Greenman, Vanessa Tassé and Heather Tulloch
4
might apply the knowledge that is available. For these reasons, we present an
overview of recent research findings on couple relationships as a risk or
protective factor for the onset and progression of heart disease, followed by
the proposition of attachment theory as an organizing theoretical framework to
explain the data gathered from cardiac patients and their spouses. In order to
illustrate the potential usefulness of attachment theory in predicting and
preventing the course of heart disease, we discuss preliminary results of a
study that we conducted on attachment and the management of cardiac illness.
We conclude with a discussion of the clinical implications of these findings.
For the purposes of this chapter, we refer to “heart disease” as any cardiac
condition (e.g., atherosclerosis, congenital heart disease, angina, congestive
heart failure, myocardial infarction (heart attack), cardiac arrest) that
necessitates medical intervention and significant lifestyle change.
COUPLE RELATIONSHIPS AND HEART DISEASE:
RISK AND PROTECTIVE FACTORS
As previously mentioned, various aspects of the marital relationship can
compound risk factors for developing heart disease such as poor diet, lack of
exercise, and tobacco use. In some cases, relationship variables even represent
direct, independent risk factors for cardiac disease.
These include lack of perceived social support and feelings of isolation or
loneliness within the couple relationship, relationship distress (e.g., high levels
and frequency of conflict, dissatisfaction with the couple relationship), and
interpersonal hostility. On the other hand, couple relationships high in
perceived support, low in conflict, high in satisfaction, and low in
interpersonal hostility appear to protect against the onset and nefarious
progression of cardiac illness. In this section, we present scientific evidence
generated over the past decade that substantiates these claims.
SOCIAL SUPPORT WITHIN THE SPOUSAL DYAD
Although there is now a sizable body of research on social support in
general (i.e., from friends, colleagues, immediate family members, extended
family members, and health care providers) and its effects on health outcomes
(e.g., Uchino, 2004; Holt-Lunstad et al., 2010; House et al., 1988), researchers
Straight to the Heart
5
have only recently concentrated more specifically on social support within the
spousal dyad and its link to recovery from heart disease. Three recent studies
conducted over the past ten years illustrate this trend.
The first study was a fascinating investigation of spouses’ confidence in
their partners’ ability to recover from congestive heart failure, conducted with
191 patients (74 % male, 26% female, mean age = 52 years) and their spouses
(Rohrbaugh, Shoham, Coyne, Cranford, Sonnega, & Nicklas, 2004). The
researchers asked patients and their spouses to indicate their level of
confidence in their spouse’s ability to effectively manage their weight,
medications, and exercise regimen using Likert scales that ranged from 1 (“not
at all confident”) to 10 (“completely confident”) (Rohrbaugh et al., 2004, p.
186). Interestingly, they found that spouses’ confidence in their partners’
ability to engage in healthy behaviors following the detection and treatment of
congestive heart failure was a better predictor of patients’ long-term survival
than were the patients’ own perceptions of their health-related self-efficacy
(Rohrbaugh et al., 2004). Patients whose spouses reported less confidence in
their ability to manage their illness effectively were more likely to die in the
four years following data collection. The reverse also held true (Rohrbaugh et
al., 2004). The authors interpret this finding as evidence that spouses’ beliefs
might affect their partners’ ability to overcome cardiac illness. They highlight
the fact that recovery takes place in an interpersonal context.
The second study was conducted in Israel with 86 male patients and their
partners following acute coronary syndromes including heart attacks or
unstable angina (Vilchinsky, Dekel, Leibowitz, Reges, Khaskia, & Mosseri,
2011). In this investigation, couples completed a number of measures
immediately following the cardiac event, one month later, and six months
later. The researchers measured type of support given by spouses and
perceived by patients following the cardiac incident: protective buffering,
active engagement, or overprotection. Patients also reported on their smoking
behavior and had their cholesterol checked during the study. Results showed
that patients whose wives were “actively engaged” (i.e., who talked to them
about how they felt about their illness and who tried to help them solve their
problems) and whom they perceived as such were more likely to stop smoking
than were patients who perceived less active support on the part of their wives.
In contrast, “overprotection” on the part of romantic partners, which involved
wives’ underestimation of their husbands’ ability to overcome their cardiac
illness, predicted higher levels of harmful cholesterol in patients (Vilchinsky et
al., 2011). It is clear from these findings that spouses’ expressed interest in
Paul S. Greenman, Vanessa Tassé and Heather Tulloch
6
patients’ emotional well-being plays a role in the recovery from heart disease
and lifestyle management, whereas a lack thereof hinders such progress.
Finally, the results of a recent study of ambivalence in couple
relationships (N = 136 couples, mean age = 63 years, mean years of marriage
= 36) revealed that people who perceived their spouses as significant sources
of both upset and help and whose spouses perceived them as significant
sources of both upset and help were more likely to exhibit dangerous levels of
coronary-artery calcification than were people whose experiences of spousal
support (both given and received) were more consistent (Uchino, Smith, &
Berg, 2014). Based on their findings, the authors suggest that relationships
which are high in ambivalence (i.e., both partners perceive each other as
helpful and upsetting when giving support) might pose a risk for heart disease,
even when controlling for traditional risk factors such as smoking, alcohol use,
and sedentary lifestyle (Uchino et al., 2014). They highlight the importance of
considering the dynamics and types of social support that are present in couple
relationships, above and beyond the overall quality of the marital bond. It thus
appears that this type of ambivalence, and both partners’ perceptions of it, can
affect cardiac health over the long term.
RELATIONSHIP QUALITY
The recent research cited above has shed some light on the impact of
couple relationships on the recovery from and management of cardiac disease.
In this section, we explore the association between relationship quality and
cardiac health, with an emphasis on the impact of relationship variables on the
etiology of heart disease.
In general, couples who experience a great deal of conflict in their
relationships tend to be less satisfied with them, which is indicative of poorer
relationship quality. On the other hand, couples with less conflict tend to feel
closer to each other and to be more satisfied with their relationships, which is
indicative of better relationship quality (Metz & Epstein, 2002). For this
chapter, we have adopted Robles, Slatcher, Trombello, and McGinn’s (2014)
operational definition of “relationship quality” because it encompasses many
key elements typical of adult love relationships, including the frequency and
intensity of conflict. According to them, “high marital quality is typically
operationally defined by high self-reported satisfaction with the relationship,
predominantly positive attitudes towards one’s partner, and low levels of
hostile and negative behavior. Low marital quality is characterized by low
Straight to the Heart
7
satisfaction, predominantly negative attitudes towards one’s partner, and high
levels of hostile and negative behvior” (Robles et al., 2014, pp. 140-141).
In the first extensive review of the literature on marital functioning and
physical health, Kiecolt-Glaser and Newton (2001) examined and discussed
the findings of 64 studies conducted between 1990 and 1999, of which 21
pertained to elevated heart rate and blood pressure, which are established risk
factors for heart disease. Results revealed a link between marital discord (as
measured by standardized instruments of marital satisfaction) and strain on the
heart, with significant, reliable associations between marital disagreement and
high blood pressure and heart rates in men and women (Kiecolt-Glaser &
Newton, 2001). Simply stated, the more conflict that was present in the marital
relationship, the greater the toll on people’s hearts.
Numerous studies have expanded on the findings summarized in Kiecolt-
Glaser and Newton’s (2001) article. For example, Eaker and colleagues (2007)
discovered in their longitudinal, epidemiological study of 1769 men and 1913
women in Massachusetts that over a ten-year period, certain types of marital
strain predicted the development of coronary heart disease and mortality, even
after controlling for variables such as age, blood pressure, and body mass
index. Specifically, women who tended to “self-silence” during conflicts (i.e.,
the stifling of one’s own feelings and thoughts) were four times more likely to
die than were women who aired their grievances with their partners (Eaker,
Sullivan, Kelly-Hayes, D’Agostino, & Benjamin, 2007). Eaker and associates
also found that men who perceived that their wives’ work intruded on the
marital relationship because it made her angry or upset were almost three
times as likely to develop coronary heart disease as were men whose wives did
not work or who reported that their wives were satisfied with their work.
Similarly, in a cross-sectional investigation of 671 couples between the ages of
52 and 79 in England, Whisman and colleagues (2010) found that women who
indicated a preponderance of negative interactions with their husbands, in
which they felt criticized, were at greater risk of meeting criteria for metabolic
syndrome (i.e., central obesity, dyslipidemia, elevated blood pressure, and
dysglycemia) than were women who rated their interactions with their
husbands more positively (Whisman, Uebelacker, & Settles, 2010). When
female partners in this study felt supported and understood by their husbands,
they exhibited significantly fewer risk factors for heart disease than did their
less satisfied counterparts. In this case, perceived lack of connection to their
spouses appeared to be linked to heart disease risk, particularly for women.
Other recent studies reiterate the link between marital conflict and cardiac
health risk for both men and women. Smith and colleagues (2009) discovered
Paul S. Greenman, Vanessa Tassé and Heather Tulloch
8
in their study of 300 middle-aged and older couples in the United States that
conflict discussions in a laboratory setting were related to more significant
increases in blood pressure, cardiac output, and activation of the sympathetic
nervous system than were collaboration tasks that participants completed.
Conflict predicted physiological reactions known to contribute to the onset of
heart disease. Members of the same research group later studied 150 healthy
couples engaging in conflict discussions. Those who demonstrated high levels
of hostility and low levels of warmth during their interactions (as measured by
the Structural Analysis of Social Behavior (SASB), a standardized coding
scheme for social interactions) reported higher levels of marital dissatisfaction
and had greater coronary artery calcification than did couples who
demonstrated warmth and openness (Smith, Uchino, Berg, & Florsheim,
2012). Taken together, these findings suggest that conflict might put men and
women at risk for heart problems, but this risk may be attenuated by the
manner in which they discuss their differences.
The results of another study, conducted by King and Reis (2012) in
Rochester, New York (U.S.A.), make a cogent argument for the effects of
marital quality on cardiac health over the long term. These researchers found
that marital quality predicted survival in the 15 years following coronary
artery bypass grafting. Men who rated their marital relationships as highly
satisfying in the year following surgery were 2.7 times as likely as men who
rated their marital relationships as less satisfying to be alive 15 years after
their surgery. Women who rated their relationships as highly satisfying were
3.9 times more likely to survive over a 15-year period post-bypass than were
women who did not rate their relationships as highly satisfying. These results
were robust even when controlling for age, sex, history of heart disease, and
tobacco use, which suggests that marital quality might make a direct,
independent contribution to long-term survival.
ATTACHMENT: A THEORETICAL FRAMEWORK
FOR UNDERSTANDING THE LINK BETWEEN COUPLE
RELATIONSHIPS AND HEART DISEASE
Although the link between couple relationship functioning and cardiac
health is now considered a robust finding in the scientific literature, it is still
not entirely clear why or how close relationships, and couple relationships in
particular, exert the influence they do on the heart. Theorists have posited the
Straight to the Heart
9
existence of direct paths of influence, by which the stress created by martial
strife and feelings of loneliness in general increase blood pressure and cardiac
reactivity, as well as indirect pathways that involve engaging in health-risk
behaviors such as smoking and alcohol use as coping strategies for the distress
caused by relationship problems and isolation (Cacioppo & Patrick, 2008;
Robles et al., 2014). There seems to be agreement that both paths affect
cardiac health, but in different ways (Robles et al., 2014).
But why is this so? And how might the interested clinician be able to
intervene effectively on an interpersonal level to help prevent heart disease or
to aid in patients’ recovery from it? For the answers to these questions,
researchers and clinicians are drawing with increasing frequency upon
attachment theory. From a theoretical perspective, attachment theory shows a
great deal of promise in helping understand why and how the events that take
place in close relationships have the impact they do on physical health. From a
practical perspective, it can inform clinical interventions and serve as a guide
for therapists. There is an extraordinary amount of empirical support for the
validity of the basic tenets of attachment theory (Mikulincer & Shaver, 2007),
and that support is now starting to extend to the realm of health psychology
(Pieteromonaco, Uchino, & Dunkel Schetter, 2013).
OVERVIEW OF ATTACHMENT THEORY
Attachment theory was developed by the British psychiatrist John Bowlby
in the second half of the twentieth century (Bowlby, 1969, 1973, 1980). Based
on his extensive study of Charles Darwin’s theory of evolution, his
observations of emotional behavior between offspring and caregivers across a
range of species, and his own clinical work with children with behavior
problems who had been abandoned by or lost contact with their mothers, he
came to several conclusions about emotional ties among human beings. First,
Bowlby stipulated that all human beings have innate tendencies to seek out
emotional support and comfort in times of stress or perceived threat, and that
all human beings fear isolation and abandonment.. Consequently, people make
a concerted effort to establish and maintain intimate relationships with
significant others. During childhood, these “attachment figures” tend to be the
child’s parents or primary caregivers.
Attachment theory suggests that children develop particular schemata or
perceptions of themselves and the people around them depending on their
caregivers’ responses to their manifestations of distress and need for comfort.
Paul S. Greenman, Vanessa Tassé and Heather Tulloch
10
These “working models” of self and other represent another main tenet of
attachment theory: Consistent responses by caregivers to their children’s
signals of need for closeness and comfort tend to encourage a sense of oneself
as lovable (positive working model of self) and of the world as a safe place
(positive working model of other), which fosters independence and autonomy
in children (Bowlby, 1969, 1973). On the other hand, inconsistent caregiving
tends to breed a sense of insecurity about oneself and tenuousness about the
safety of the rest of the world.
In support of Bowlby’s theory, Ainsworth and colleagues found in their
seminal research on children’s responses to separation from their mothers that
children did indeed tend to react differently to the stress of the situation and to
their reunions with their mothers after a brief absence (Ainsworth, Blehar,
Waters, & Wall, 1978). Some children sought comfort and reassurance from
their mothers upon her return and resumed playing, some were practically
inconsolable throughout the entire procedure and exhibited a mixture of fear
and anger upon her return, and some appeared unaware or uninterested in her
departure and subsequent return. These attachment patterns, known as secure,
anxious-ambivalent, and avoidant, respectively, are related to the type and
consistency of caregiving provided to children. This finding has been
replicated and expanded upon throughout the years (see Cassidy & Shaver,
2010 for a collection of reviews).
Thus, attachment theory suggests that human beings are born with
powerful drives to seek emotional comfort and reassurance from attachment
figures during times of vulnerability and stress; that comforting, soothing
responses by attachment figures in such moments leads to the development of
strong emotional bonds; that perceived threats to the attachment relationship
are experienced as potentially traumatic events; and that people will go to
great lengths to establish and preserve interpersonal ties to others (Bowlby,
1979; Mikulincer & Shaver, 2007). According to attachment theory, all of
these innate tendencies help ensure the survival of the individual organism and
the propagation of the species. Secure bonds with significant others encourage
autonomy and independence, because they represent a “secure base” to which
people can return for comfort in times of need (Bowlby, 1988).
ATTACHMENT THEORY AND ADULT LOVE
Straight to the Heart
11
Since the late 1980s, a number of theorists and clinicians have been
conceptualizing romantic love between adults as an attachment process
analogous to the one observed by Bowlby, Ainsworth, and their
contemporaries in children. Hazan and Shaver (1987) published the first paper
on topic, in which they found that adults tended to construe and interact with
their romantic partners in ways that mirrored those that Ainsworth discovered
in young children in their relationships with caregivers. The large body of
research on adult love from an attachment perspective reveals that some adults
tend to turn toward their partners for love, support, and comfort and to give it
readily (secure attachment), some tend to fear the loss of their romantic
relationship intensely and constantly seek reassurance of their partner’s
presence and commitment, often while experiencing feelings of anger or
jealousy (anxious-ambivalent attachment), and some people tend to minimize
the importance of close emotional ties in their romantic relationships or to
avoid them altogether (avoidant attachment; Collins & Feeney, 2010; Fraley &
Shaver, 2000; Hazan & Shaver, 1987; Johnson, 2013; Mikulincer & Shaver,
2007). These findings are hardly surprising when one considers Bowlby’s
(1979) assertion that attachment needs and behaviors remain salient “from the
cradle to the grave” (p. 129). As people mature, other individuals beside
caregivers become important attachment figures. In Western cultures in the
present day, romantic partners tend to be primary attachment figures for most
people (Johnson, 2013).
ATTACHMENT AND MATTERS OF THE HEART
From an attachment perspective, then, the empirical findings presented
earlier in this chapter become more readily understandable. If one adheres to
the notions that attachment longings are innate drives that motivate behavior
throughout life, that threats or perceived threats to the integrity of attachment
relationships are highly distressing or even traumatic, and that romantic
partners tend to be people’s principal attachment figures, it makes sense that
chronic marital strife and discord would predict stress and strain on the heart
and that emotionally close and nurturing relationships would protect cardiac
health. Bowlby (1979) explained that little is more stressful or terrifying for
human beings than the prospect of isolation and disconnection, which happen
to be experiences that run rampant in distressed romantic relationships
(Johnson, 2004). It is also a known fact that prolonged fear, stress, and general
physiological hyperarousal are harmful to the heart, and nowhere do people
Paul S. Greenman, Vanessa Tassé and Heather Tulloch
12
tend to experience stronger emotions of this kind than in couple relationships
that are not going well (Johnson, 2013). Research reveals, in fact, that anxious
attachment style in adults is associated with high blood pressure, heart attacks,
and stroke (McWilliams & Bailey, 2010). The more people are afraid of not
being close to other people, the more dangerous it appears to be for their
hearts. Conversely, close emotional ties to significant others appear to help
regulate physiological stress responses in a variety of ways, notably through
the secretion of calming hormones such as oxytocin (Cacioppo & Patrick,
2008; Johnson, 2013).
In addition to providing directly calming and protecting effects on or
posing a risk to health, couple dynamics borne out of attachment tendencies in
the relationship might also have indirect, but extremely important, effects on
health outcomes. For example, Pietromonaco and colleagues (2013) devised a
theoretical model to explain detected links among attachment, dyadic
relationships, and physical health. They suggest that attachment strategies
(secure, anxious, or avoidant) in couple relationships may interact with
variables such as commitment, relationship quality, and responsiveness to
affect the frequency of health-related behaviors such as exercise, diet, alcohol
consumption, and tobacco use (Pietromonaco et al. 2013). These authors call
for more research on the relation between attachment and health as the
attachment construct is believed to improve our understanding of and ability to
treat an array of health problems, including heart disease.
PILOT DATA
In light of this call, we conducted a study of 201 patients (79.6% male,
20.4% female, mean age = 62 years) participating in cardiac rehabilitation at
the University of Ottawa Heart Institute in Ottawa, Ontario, Canada. Among
other variables, we examined patients’ attachment to romantic partners
(secure, anxious, or avoidant), engagement in exercise, tobacco use, and the
presence of specific cardiac symptoms. Patients completed self-report
questionnaires at cardiac rehabilitaiton intake and 3-months later.
Analyses of these data reveal fascinating links between attachment to
romantic partners (measured by the Experiences in Close Relationships Scale,
Revised) and a number of variables related to cardiac health and disease. The
strongest attachment predictor of health outcomes to emerge out of a series of
multiple regressions was anxious attachment to romantic partners.
Specifically, an anxious attachment bond to romantic partners was a
statistically significant predictor of inhibited physical functioning, pain, poor
Straight to the Heart
13
general health, and recurrent angina. Regression analyses also indicated that
the more patients were anxiously attached to their partners, the less they
exercised and the more they smoked cigarettes. Avoidant attachment to
partners was also a predictor of smoking behavior. Although these findings are
preliminary and there is much more research to be done, they do highlight the
strength of the association between attachment fears in the couple relationship
and a number of variables related to cardiac health. They support the
contention that attachment, and more specifically the quality of attachment in
the couple relationship, might be of great importance in understanding and
treating people with heart disease.
CONCLUSION
In light of this review and our empirical data, we call for increased
attention to couple dynamics and their impact on the onset and management of
cardiac disease, as well as for evaluations of relationship-based interventions
with an attachment focus integrated into mainstream cardiac care. Meta-
analyses and systematic reviews of the sparse evidence suggest that couple
interventions can help improve quality of life in patients with chronic illness,
including cardiovascular disease, and they appear to help manage risk of
recurrence (Martire, Schulz, Helgeson, Small, & Saghafi, 2010; Reid, Ski, &
Thompson, 2013). However, effect sizes for couple interventions tend to be
low and there is as of yet no evidence of their effects on long-term mortality
rates (Reid et al., 2013). Thus, it is clear that couple dynamics can affect
health, but it is not yet clear how to best go about helping people to improve
their health by improving their relationships.
One promising avenue might be the application of Emotionally Focused
Therapy (EFT) for couples (Johnson, 2004; Johnson & Greenman, 2006) to
people with cardiac disease and their partners. Unlike other couple
interventions, EFT has an explicit attachment focus; chronic couple difficulties
are construed as the result of insecure attachment bonds. EFT is an empirically
supported treatment for couple distress (Snyder, Castellani, & Whisman, 2006)
that has shown promise when applied to couples facing chronic illness in the
relationship and in family members (Couture-Lalande, Greenman, Naaman, &
Johnson, 2007; Clouthier, Manion, Gordon Walker, & Johnson, 2002). The
overarching goal of the intervention is to create a secure attachment bond in
the couple, in order to help them improve their ability to face life challenges
effectively. Given the established links between attachment and cardiac illness
Paul S. Greenman, Vanessa Tassé and Heather Tulloch
14
discussed in this chapter, we argue that EFT might be an essential intervention
for patients and partners coping with heart disease. It may be, in essence, the
right medicine for the heart.
REFERENCES
Ainsworth, M. D., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of
attachment: A psychological study of the strange situation. Hillsdale, NJ:
Lawrence Erlbaum Associates.
Bowlby, J. (1969). Attachment and loss. Vol.1. Separation. New York: Basic
Books.
Bowlby, J. (1973). Attachment and loss. Vol.2. Separation. New York: Basic
Books.
Bowlby, J. (1980). Attachment and loss. Vol.3. Loss. New York: Basic Books.
Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human
development. New York: Basic Books.
Baumeister, F. R., & Leary, M. R. (1995). The Need to Belong: Desire for
Interpersonal Attachments as a Fundamental Human Motivation,
Psychological Bulletin
, 117, 497-529, doi:10.1037/0033-2909.117.3.497
Cacioppo, J. T., & Patrick, W. (2008). Loneliness : Human nature and the
need for social connection. New York, NY, US: W. W. Norton &
Company.
Cassidy, J., & Shaver, P. R. (2008). Handbook of attachment: Theory,
research, and clinical applications (2nd ed). New York: Guilford Press.
Cloutier, P. F., Manion, I. G., Gordon Walker, J., & Johnson, S., M. (2002).
Emotionally focused interventions for couples with chronically ill
children: A 2-year follow-up. Journal of Marital and Family Therapy, 28,
391-398. doi : 10.1111/j.1752-0606.2002.tb00364.x
Collins, N. L., & Feeney, B. C. (2010). An attachment theorical perspective on
social support dynamics in couples: Normative processes and individual
differences. In K. Sullivan & J. Davila (Eds.). Support processes in
intimate relationships (pp. 89-120). New York: Oxford University Press.
Couture-Lalande, M., Greenman, P.S., Naaman, S., & Johnson, S.M. (2007).
La thérapie de couple axée sur l’émotion (EFT) pour traiter les couples
dont la femme a le cancer du sein: Une etude exploratoire. [Emotionally
focused therapy (EFT) for couples with a female partnerwho suffers from
Straight to the Heart
15
breast cancer: an exploratory study]. Psycho-Oncologie, 257-264. doi:
10.1007/s11839-007-0048-7.
Eaker, D. E., Sullivan, L. M., Hayes, K. M., D’Agostino, B. R., & Benjamen,
E. J. (2007). Marital status, marital strain, and risk of coronary heart
disease or total mortality: The framingham offspring study.
Psychosomatic Medicine 69, 509513. doi: 0033-3174/07/6906-0509
Fosbøl, E.L., Peterson, E.D., Weeke, P., Wang, T.Y., Mathews, R., Kober, L.,
Thomas, L., Gislason, G.H., & Torp-Pedersen, C. (2013). Spousal anxiety,
depression, and suicide after myocardial infarction. European Heart
Journal, 34, 649-656. doi:10.1093/eurheartj/ehs242
Fraley, C. R., & Shaver, P. R. (2000). Adult romantic attachment: Theoretical
developments, emerging controversies, and unanswered questions. Review
of general psychology, 4, 132-154. doi: 10.1037//1089-2680.4.2.132
Gottman, J. M. (2011). The Science of Trust: Emotional attunement for
couples. New York: W. W. Norton & Company.
Hazan, C., & Shaver, P. (1987). Romantic Love Conceptualized as an
attachment process. Journal of Personality and Social Psychology, 52,
511-524. doi: 10.1037/0022-3514.52.3.511
Holt-Lunstad, J., Smith, T. B., & Layton, J. B (2010). Social relationships and
mortality risk: A meta-analytic review. Plos Medicine, 7(7) e1000316.
doi:10.1371/journal.pmed.1000316
House J. S., Landis, K. R., & Umberson, D. (1988). Social relationships and
health. Science, 241, 540-545. doi: 10.1126/science.3399889
Johnson, S. (2013). Love sense: The revolutionary new science of romantic
relationships. New York: Little, Brown and Company.
Johnson, S. M. (2004). The practice of Emotionally Focused Couple Therapy:
Creating connection (2nd ed.). New York: Brunner-Routledge.
Johnson, S.M., Coan, J.A., Moser, M.B., Beckes, L., Smith, A., Dalgleish, T.,
Halchuk, R., Hasselmo, K., Greenman, P.S., & Merali, Z. (2013).
Soothing the threatened brain: Leveraging contact comfort with
Emotionally Focused Therapy. PLoS ONE, 8 (11). e79314.
doi:10.1371/journal.pone.0079314
Johnson, S.M., & Greenman, P.S. (2006). The path to a secure bond:
Emotionally Focused Couple Therapy. Journal of Clinical Psychology,
62, 597-609.
Kiecolt-Glaser, J. K., & Newton, L. T. (2001). Marriage and health: His and
hers. Psychological Bulletin, 127, 472-503. doi:10.1037/0033-
2909.127.4.472
Paul S. Greenman, Vanessa Tassé and Heather Tulloch
16
King, B. K., & Reis, H. T. (2012). Marriage and long-term survival after
coronary artery bypass grafting. Health Psychology, Vol 31, 55-62. doi:
10.1037/a0025061
Marher-Imrof, R., Hoffman, A., & Froelicher, E. S. (2007). Impact of cardiac
disease on couples’ relationships. Journal of Advanced Nursing, 7, 513-
521.doi: 10.1111/j.1365-2648.2006.04141.x
Martire, L.M., Schulz, R., Helgeson, V.S., Small, B.J., & Sghafi, E.M. (2010).
Review and meta-analysis of couple-oriented interventions for chronic
illness. Annals of Behavioral Medicine, 40, 325-342. doi: 10.1007/s12160-
010-9216-2
McPherson, M., Smith-Lovin, L., & Brashears, E. M. (2006). Social Isolation
in America: Changes in Core Discussion Networks over Two Decades.
American Sociological Review, 71, 353-375. DOI:
10.1177/000312240607100301
McWilliams, L.A., & Bailey, J. S. (2010). Associations between adult
attachment ratings and health conditions: Evidence from the National
Comorbidity Survey Replication. Health psychology, 29, 446-453. doi:
10.1037/a0020061
Metz, E. M., & Epstein, N. (2002). Assessing the Role of Relationship Conflict
in Sexual Dysfunction. Journal of Sex and Marital Therapy, 28, 139-164.
doi:10.1080/00926230252851889
Mikulincer, M., & Shaver, P. R. (2007). Attachment in adulthood: Structure,
dynamics, and change. New York: The Guilford Press.
Pietromonaco, P.R., Uchino, B., & Dunkel Schetter, C. (2013). Close
relationship processes and health: Implications of attachment theory for
health and disease. Health Psychology, 32, 499-513. doi:
10.1037/a0029349
Reid, J., Ski, C.F., & Thompson, D.R. (2013). Psychological interventions for
patients with coronary heart disease and their partners: A systematic
review. PLoS ONE, 8(9): e73459. doi:10.1371/journal.pone.0073459
Robles, T.F., Slatcher, R.B., Trombello, J.M., & McGinn, M.M. (2014).
Marital quality and health: A meta-analytic review. Psychological
Bulletin, 140, 140-187. doi:
Rohrbaugh, M., J., Shoham, V., Coyne, J. C., Cranford, A. J., Sonnega, J. S.,
& Nicklas, J. M. (2004). Beyond the self in self-efficacy: spouse
confidence predicts patient survival following heart failure. Journal of
Family Psychology,18, 184-193. doi: 10.1037/0893-3200.18.1.184
Straight to the Heart
17
Sher, T., Braun, L., Domas, A., Bellg, A., Baucom, D. H., & Houle, T. (2014).
The Partners for Life Program: A couples approach to cardiac risk
reduction. Family process, 53, 131-149. doi: 10.1111/famp.12061
Smith, T. W., Uchino, B. N., Berg, A. C., & Florsheim, P. (2012). Marital
discord and coronary artery disease: A comparison of behaviorally defined
discrete groups. Journal of consulting and clinical psychology, 80, 87-92.
doi:10.1037/a0026561
Smith, T. W., Uchino, B. N., Berg, C. A., Florsheim, P., Pearce, G., Hawkins,
M., Henry, N. J. et al. (2009). Conflict and collaboration in middle-aged
and older couples: II. Cardiovascular reactivity during marital interaction.
Psychology and Aging, 24, 274-286. doi: 10.1037/a0016067
Snyder, D.K., Castellani, A.M., & Whisman, M.A. (2006). Current status and
future directions in couple therapy. Annual Review of Psychology, 57,
317-344. doi: 10.1146/annurev.psych.56.091103.070154
So, S.S. & La Guardia, J. G. (2011). Matters of the heart: Patients’ adjustment
to life following a cardiac crisis. Psychology and Health, 26, Suppl.1, 83-
100. doi: 10.1080/08870441003690456
Vilchinsky, N., Dekel, R., Leibowitz, M., Reges, O., Khaskia, A., & Mosseri,
M. (2011). Dynamics of support perceptions among couples coping with
cardiac illness: The effect on recovery outcomes. Health Psychology, 30,
411-419. doi: 10.1037/a0023453
Uchino, B. N., Smith, S. T. W., & Berg, A. C. (2014). Spousal relationship
quality and cardiovascular risk dyadic perceptions of relationship
ambivalence are associated with coronary-artery calcification.
Psychological Science, 25, 1037-1042. doi : 10.1177/0956797613520015
Uchino, B. N. (2004). Social support and physical health : Understanding the
health consequences of relationships. New Haven, CT: Yale University
Press.
Putnam, D. R. (2000). Bowling alone: The collapse and revival of American
community. New York: Touchstone Books/Simon & Schuster.
Whisman, M.A., Uebelacker, L.A., & Settles, T.D. (2010). Marital distress and
the metabolic syndrome: Linking social functioning with physical health.
Journal of Family Psychology, 24, 367-370. doi: 10.1037/a0019547
SCH
... In conjunction with cognitive restructuring, therapists who followed our treatment manual also engaged patients in relationshiporiented behavioral activation. In all cases, behavioral activation involved a heavy emphasis on increasing the quality of patients' social networks, given the well-documented effects on physical and emotional health of emotional ties to others [59][60][61][62]. Therapists worked to help patients increase not only the number of meaningful social contacts in their daily lives, but also the emotional intimacy characteristic of their social interactions. ...
... In some ways, this type of interpersonal behavioral activation was similar to the supportive components of Albus and colleague's [21] treatment, which was highly successful. Given known links between interpersonal functioning and cardiac health [59], this emphasis on personal relationships might be one of the reasons that the results in the present study were as positive as they seemed to be. ...
Article
Full-text available
People who suffer from depression, post-traumatic stress, or anxiety following cardiac events and treatment are more likely to have further cardiac complications resulting in death than are people who do not. Although there have been advances in psychological techniques to elicit behavior and lifestyle changes in heart patients [1], there is currently a dearth of information on how to address the psychological sequelae of heart disease effectively. The goals of this pilot study were therefore to develop and test a cognitive-behavioral psychological treatment that was specifically tailored to the needs of people with cardiac disease and symptoms of psychological distress. Fifteen men and 12 women between the ages of 35 and 85 who exhibited clinically significant symptoms of depression, anxiety, or post-traumatic stress following a diagnosis of heart disease participated in a maximum of 20 sessions of cognitive-behavioral therapy. By the end of treatment, there were statistically significant reductions in all symptoms of psychological distress, as measured by the Beck Depression Inventory Fast Screen for Medical Patients [2], the Beck Anxiety Inventory [3], the Hospital Anxiety and Depression Scale [4], and the Impact of Event Scale, Revised [5]. We present the treatment protocol in detail and discuss our results in terms of the utility of the integration of psychological services into cardiac care.
... A healthy couple relationship (ie, one in which partners feel loved, emotionally supported, respected, and cared for) is a significant protective factor, particularly against cardiac disease incidence and outcomes [1][2][3][4][5]. Healthy relationships can influence positive cardiac outcomes in direct and indirect ways. ...
Article
Full-text available
Unstructured: Supportive couple relationships are associated with reduced risk of chronic illness development, such as cardiovascular disease, as well as improved secondary prevention. Healing Hearts Together (HHT) is an 8-week couples-based intervention designed to improve relationship quality, mental health, quality of life, and cardiovascular health among couples in which one partner has experienced a cardiac event. A randomized controlled trial (RCT) began in October 2019 to test the efficacy of the in-person, group-based HHT program as compared to usual care. In March of 2020, all recruitment, assessments, and interventions halted due to the COVID-19 pandemic. Guided by optimal virtual care principles, and Hom and colleagues' (2020) four-stage framework (consultation, adaptation, pilot testing, and test launch), this paper is a tutorial for the step-by-step transition planning and implementation of a clinical research intervention from in-person to a web-based platform, using the HHT program as an example. Clinical and research considerations are reviewed, including; (1) privacy; (2) therapeutic aspects of the intervention; (3) group cohesion; (4) research ethics; (5) participant recruitment; (6) assessment measures; (7) data collection; and, (8) data analyses. This tutorial can assist clinical researchers transitioning their research programs to a web-based format during the pandemic and beyond.
... A healthy couple relationship (ie, one in which partners feel loved, emotionally supported, respected, and cared for) is a significant protective factor, particularly against cardiac disease incidence and outcomes [1][2][3][4][5]. Healthy relationships can influence positive cardiac outcomes in direct and indirect ways. ...
Preprint
UNSTRUCTURED Supportive couple relationships, are associated with reduced risk of chronic illness development, such as cardiovascular disease, as well as improved secondary prevention. Healing Hearts Together (HHT) is an 8-week couples-based intervention designed to improve relationship quality, mental health, quality of life, and cardiovascular health among couples in which one partner has experienced a cardiac event. A randomized controlled trial (RCT) began in October 2019 to test the efficacy of the in-person, group-based HHT program as compared to usual care. In March of 2020, all recruitment, assessments, and interventions halted due to the COVID-19 pandemic. Guided by optimal virtual care principles, and Hom and colleagues’ (2020) four-stage framework (consultation, adaptation, pilot testing, and test launch), this paper is a tutorial for the step-by-step transition planning and implementation of a clinical research intervention from in-person to a web-based platform, using the HHT program as an example. Clinical and research considerations are reviewed, including; (1) privacy; (2) therapeutic aspects of the intervention; (3) group cohesion; (4) research ethics; (5) participant recruitment; (6)assessment measures; (7) data collection; and, (8) data analyses. This tutorial can assist clinical researchers transitioning their research programs to a web-based format during the pandemic and beyond.
... The importance of social relationships for health (e.g., Greenman, Tassé, & Tulloch, 2015;Holt-Lunstad, Smith, & Layton, 2010) is often examined in terms of the number of social relationships we have, that is, social network size (Chan & Lee, 2006;Zhu, Woo, Porter, & Brzezinski, 2013), and the functional social support (emotional and tangible acts of support) we receive from them (Bokhorst, Sumter, & Westenberg, 2010;Chu, Saucier, & Hafner, 2010). Research shows that both social network size (Kim & Lee, 2011) and social support (Cohen & Syme, 1985;Thoits, 2011) are beneficial for our psychological well-being (Holt-Lunstad et al., 2010). ...
Article
Full-text available
It is well established that stressful life events (e.g., family bereavements or moving to a new country) are damaging to psychological health and well‐being. Indeed, social relationships are often noted as an important factor that can influence well‐being and buffer the negative effects of stress. However, the quality and source of these relationships, particularly for adolescents, are often overlooked. Using the Growing Up in Ireland Survey, a population‐based study of 13‐year‐old Irish adolescents (N = 7,525; 51.1% female), the current study examines the quality of both parent and peer relationships as potential mechanisms explaining the association between stressful life events and psychological well‐being indices in adolescents. As expected, results showed that stressful life events negatively impacted the psychological well‐being of adolescents. Parallel mediation analyses indicated that both parent and peer relationship quality mediated this association. Further exploratory analyses found that for girls, greater numbers of stressful life events were associated with poorer quality relationships with both their parents and peers, and in turn, these were linked to lower levels of psychological well‐being. For boys, this effect was only evident for parental relationship quality, but not peers. The implication of these findings for adolescent's psychological well‐being, particularly for girls, are discussed. This article is protected by copyright. All rights reserved.
... Also, even if we did not assess attachment style in our study, due to the fact that at adult age the partner is often the main attachment figure, emotionally focused therapy could also be implemented: this type of therapy would aim to create a secure attachment bond within the couple, helping the patient and her spouse to face disease as well as other life challenges in a more efficient way. This type of therapy has already been assessed with success in chronic disease [61,62]. ...
Article
Aim: Evaluate the influence of emotional distress of young women with breast cancer and their spouses on their daily subjective experience of the disease, through application of the Actor-Partner Interdependence Model. Patients & methods: A total of 112 women under 45 years of age were diagnosed with nonmetastatic breast cancer and their spouses answered self-reported measures of anxiety, depression and subjective experience of the disease and its treatment. Results: The patient's emotional distress influenced more the subjective experience of her spouse than the spouse's emotional distress influenced the patient. The spouse's difficulties depended as much on his own distress level as on the patient's distress level. Conclusion: These data confirm the importance of implementing couple-focused interventions.
Article
Full-text available
The quality of spousal relationships has been related to physical-health outcomes. However, most studies have focused on relationship positivity or negativity in isolation, despite the fact that many close relationships are characterized by both positive and negative aspects (i.e., ambivalence). In addition, most work has not accounted for the reciprocal nature of close-relationship processes that can have an impact on health. Using a sample of 136 older married couples, we tested whether actor-partner models of relationships that were either primarily positive or ambivalent (i.e., perceived as having both helpful and upsetting aspects) predicted measures of coronary-artery calcification. Results revealed an Actor × Partner interaction whereby coronary-artery calcification scores were highest for individuals who both viewed and were viewed by their spouse as ambivalent. These data are discussed in light of the importance of considering both positive and negative aspects of relationship quality and modeling the interdependence of close relationships.
Article
Full-text available
Morbidity and mortality are reliably lower for the married compared with the unmarried across a variety of illnesses. What is less well understood is how a couple uses their relationship for recommended lifestyle changes associated with decreased risk for illness. Partners for Life compared a patient and partner approach to behavior change with a patient only approach on such factors as exercise, nutrition, and medication adherence. Ninety-three patients and their spouses/partners consented to participate (26% of those eligible) and were randomized into either the individual or couples condition. However, only 80 couples, distributed across conditions, contributed data to the analyses, due to missing data and missing data points. For exercise, there was a significant effect of couples treatment on the increase in activity and a significant effect of couples treatment on the acceleration of treatment over time. In addition, there was an interaction between marital satisfaction and treatment condition such that patients who reported higher levels of marital distress in the individuals condition did not maintain their physical activity gains by the end of treatment, while both distressed and nondistressed patients in the couples treatment exhibited accelerating gains throughout treatment. In terms of medication adherence, patients in the couples treatment exhibited virtually no change in medication adherence over time, while patients in the individuals treatment showed a 9% relative decrease across time. There were no condition or time effects for nutritional outcomes. Finally, there was an interaction between baseline marital satisfaction and treatment condition such that patients in the individuals condition who reported lower levels of initial marital satisfaction showed deterioration in marital satisfaction, while non satisfied patients in the couples treatment showed improvement over time.
Article
Full-text available
Social relationships are tightly linked to health and well-being. Recent work suggests that social relationships can even serve vital emotion regulation functions by minimizing threat-related neural activity. But relationship distress remains a significant public health problem in North America and elsewhere. A promising approach to helping couples both resolve relationship distress and nurture effective interpersonal functioning is Emotionally Focused Therapy for couples (EFT), a manualized, empirically supported therapy that is strongly focused on repairing adult attachment bonds. We sought to examine a neural index of social emotion regulation as a potential mediator of the effects of EFT. Specifically, we examined the effectiveness of EFT for modifying the social regulation of neural threat responding using an fMRI-based handholding procedure. Results suggest that EFT altered the brain's representation of threat cues in the presence of a romantic partner. EFT-related changes during stranger handholding were also observed, but stranger effects were dependent upon self-reported relationship quality. EFT also appeared to increase threat-related brain activity in regions associated with self-regulation during the no-handholding condition. These findings provide a critical window into the regulatory mechanisms of close relationships in general and EFT in particular.
Article
Full-text available
Despite evidence that patients with coronary heart disease (CHD) and their partners report significant psychological distress, and suggestions that involving partners in interventions alleviates such distress, no systematic reviews have examined this. The objective of this study was to systematically review evidence on the effectiveness of psychological interventions for patients with CHD and their partners. CENTRAL, Medline, EMBASE, CINAHL and PsycINFO databases were searched through October 2012. Randomized controlled trials evaluating psychological interventions for patients with CHD and their partners were included. Selection of studies, study appraisal, data extraction and analysis were undertaken using standard methods. Seven studies comprising 673 participants were included, two of which indicated that psychological interventions result in modest improvements in patients' depressive symptoms, anxiety, knowledge of disease and treatment, and satisfaction with care, and in partners' anxiety, knowledge and satisfaction. In partners, there was a non-significant trend for improvements in depressive symptoms. One study showed a beneficial effect on blood pressure. There was no evidence of a significant effect on mortality, morbidity or cardiovascular risk factors for patients or social support for patients and partner. The small number of studies included in the review had generally poor methodology, as shown by the risk of bias, and were performed over 10 years ago. As only two of the seven studies resulted in modest improvements in outcomes, no firm conclusions can be drawn as to the effectiveness of such interventions in this population.
Article
This book is a revision and updating of the 1996 book titled Emotionally Focused Marital Theory. It is intended to serve as the basic therapeutic manual for Emotionally Focused Couple Therapy (EFT). As in the first edition, there is also one chapter on Emotionally Focused Family Therapy (EFFT).
Chapter
This chapter describes an attachment-based model of social support in couples, which emphasizes the interpersonal and transactional nature of support processes and focuses on the roles of both the care giver and the support seeker. The authors describe their ongoing programs of research on normative differences in care giving and seeking, as well as how individual differences in attachment security affect support processes.
Article
This article explores the possibility that romantic love is an attachment process--a biosocial process by which affectional bonds are formed between adult lovers, just as affectional bonds are formed earlier in life between human infants and their parents. Key components of attachment theory, developed by Bowlby, Ainsworth, and others to explain the development of affectional bonds in infancy, were translated into terms appropriate to adult romantic love. The translation centered on the three major styles of attachment in infancy--secure, avoidant, and anxious/ambivalent--and on the notion that continuity of relationship style is due in part to mental models (Bowlby's "inner working models") of self and social life. These models, and hence a person's attachment style, are seen as determined in part by childhood relationships with parents. Two questionnaire studies indicated that relative prevalence of the three attachment styles is roughly the same in adulthood as in infancy, the three kinds of adults differ predictably in the way they experience romantic love, and attachment style is related in theoretically meaningful ways to mental models of self and social relationships and to relationship experiences with parents. Implications for theories of romantic love are discussed, as are measurement problems and other issues related to future tests of the attachment perspective.
Article
This state-of-the-art book examines the effect of social relationships on physical health. It surveys and assesses the research that shows not only that supportive relationships protect us from a multitude of mental health problems but also that the absence of supportive relationships increases the risk of dying from various diseases. Bert N. Uchino discusses the links between social support and mortality from cardiovascular disease, cancer, and HIV/AIDS. He investigates whether social support is more effective for some individuals and within certain cultures. After evaluating existing conceptual models linking social support to health outcomes, he offers his own broader perspective on the issue. And he suggests the implications for intervention and for future research in this area.
Article
The authors review the theory of romantic, or pair-bond, attachment as it was originally formulated by C. Hazan and P. R. Shaver in 1987 and describe how it has evolved over more than a decade. In addition, they discuss 5 issues related to the theory that need further clarification: (a) the nature of attachment relationships, (b) the evolution and function of attachment in adulthood, (c) models of individual differences in attachment, (d) continuity and change in attachment security, and (e) the integration of attachment, sex, and caregiving. In discussing these issues, they provide leads for future research and outline a more complete theory of romantic attachment.