Rheumatoid arthritis patients' perceptions of mutuality in conversations with spousespartners and their links with psychological and physical health.код для вставкиСкачать
Arthritis & Rheumatism (Arthritis Care & Research) Vol. 59, No. 7, July 15, 2008, pp 921–928 DOI 10.1002/art.23821 © 2008, American College of Rheumatology ORIGINAL ARTICLE Rheumatoid Arthritis Patients’ Perceptions of Mutuality in Conversations With Spouses/Partners and Their Links With Psychological and Physical Health SHELLEY KASLE,1 MARI S. WILHELM,1 AND ALEX J. ZAUTRA2 Objective. Mutuality, measured as subjects’ perceptions of responsiveness in conversations with their spouse/partners, is linked with women’s psychological health. Our objectives were to examine physical and psychological health outcomes of married/partnered patients with rheumatoid arthritis (RA) in relation to their perceptions of their own responsiveness (self-mutuality), their partner’s responsiveness (partner-mutuality), and combined responsiveness (overall mutuality), and to examine potential sex differences in the links between mutuality and depressive symptoms. Methods. Symptoms of depression and anxiety, physical disability, and arthritis impact reported by RA patients were examined in correlation matrices with their perceptions of overall mutuality, partner-mutuality, and self-mutuality in conversations with spouses/partners in the whole sample (n ⴝ 148) and separately for men (n ⴝ 34) and women (n ⴝ 114). Sex moderation of the links between mutuality and depression was tested in hierarchical regressions. Results. In the whole sample and among women, all mutuality measures had signiﬁcant inverse correlations with all health outcomes. In men, physical disability was unrelated to mutuality measures, but otherwise correlations approximated those in the whole sample and for women. Sex (being female) interacted with self-mutuality, but not overall or partner-mutuality, in predicting fewer depressive symptoms. Conclusion. RA patients’ perceptions of mutuality in conversations with spouses/partners predicted better health across a spectrum of outcomes. Overall mutuality and partner-mutuality predicted fewer depressive symptoms for both men and women, but self-mutuality appeared more important for women than for men. The clinical relevance of ﬁndings and their implications for behavioral interventions with RA patients are discussed. INTRODUCTION Supportive close relationships are important for health (1). In general populations, the absence of close ties has been shown to predict morbidity and mortality as strongly as obesity, smoking, and hypertension (2), and marital quality has been shown to predict both initial health and changes in health over 3 years (3). Because psychosocial factors inﬂuence immune-mediated disease activity in Supported by a New Investigator grant from the Arthritis Foundation and a Health Professional New Investigator award from the Research and Education Foundation of the American College of Rheumatology. 1 Shelley Kasle, PhD, Mari S. Wilhelm, PhD: University of Arizona, Tucson; 2Alex J. Zautra, PhD: Arizona State University, Tempe. Address correspondence to Shelley Kasle, PhD, Arizona Arthritis Center, University of Arizona College of Medicine, 1501 North Campbell Avenue, PO Box 245093, Tucson, AZ 85724-5093. E-mail: email@example.com. Submitted for publication July 13, 2007; accepted in revised form January 28, 2008. rheumatoid arthritis (RA) via neurohormonal mechanisms (4,5), the quality of interpersonal relationships may have even more long-term importance for the health of RA patients than for nonclinical populations. Longitudinal studies of RA patients have found that social network size and perceived available support at diagnosis predict disease activity, pain, and disability at 3- and 5-year followup (6,7). The acceptability of social support may hinge on its consequences for the recipient’s identity and self-esteem (8). Looking beyond support as assistance and resources, some perspectives frame increasingly relationship-oriented questions about the support process within the conduct, meaning, and course of human relationships (9 –12). Problematic support that is not truly responsive to the needs of the recipient (e.g., ill-ﬁtting or unrequested assistance) may itself be stressful, and has been linked with increased depression (13). In turn, interpersonal stress and depression have been associated with greater disease activity for women with RA (5,14). These considerations suggest the value of adopting a relational perspective in health re921 922 search to examine qualities of interpersonal relationships that are linked with RA health rather than assessing social contexts in terms of available assistance. Couples’ relationship quality may play a particularly signiﬁcant role in the social support of RA patients due to the frequency and intensity of interactions between partners and the importance of the relationship to identity. Moreover, the negative effect of RA pain, joint involvement, and disability on the availability and adequacy of social support in more diffuse social relationships (15) may increase reliance on the partner relationship for social support and amplify its impact. Couples’ relationships have usually been investigated as a source of stress rather than a source of strength in studies of patients with RA. In these studies, couple relationship quality is often measured as spouse criticisms or negative responses to patients’ pain. For example, more spousal criticism and less spousal support have been associated with depression and poorer coping (16), and with larger increases in anxiety and disease activity during stressful episodes in women diagnosed with RA (17). Negative spouse behavior (avoidance and critical remarks) predicted depressive symptoms and pain at 1 year for women with RA (18). Negative spouse responses were associated with poorer self-esteem for men and women with arthritis but not for healthy controls (19). Similarly, spouse negative responses to RA patients’ pain were associated with anxiety and depression for women and with anxiety for men (20). These studies provide fairly clear descriptions of the stressful aspects of couple relationships (e.g., spousal criticism, avoidance, and negative responses to patients’ pain) associated with ill health in patients with RA. However, comparatively little is known about positive aspects of couple relationships that are associated with better health in patients with RA. The present study investigated relational mutuality, a positive relationship quality of connectedness described in a theory of women’s psychological development, self-in-relation theory (21). In this theory, successful development for women is characterized by an increasing capacity to create and maintain close and complex interpersonal connections. This theory contrasts with prior theories of development based on a male model in which autonomy is viewed as the critically important developmental outcome (22). Mutuality, a central construct of the self-in-relation theory, is deﬁned as the reciprocated interest in bidirectional sharing of thoughts and feelings in close relationships, permitting partners to truly know and be known by each other. Mutuality is reﬂected in communications characterized by engagement, interest, empathy, validation, and authenticity. Mutual partners respond in ways that encourage authentic expression within the relationship, and can even disagree on issues while maintaining close connection. Mutuality is believed to promote self-awareness and the emergence of identity, a “self-in-relation,” through mutual psychological cultivation and growth (21). Mutuality is theorized as essential for women’s psychological development and ongoing health (23). Empathy is an essential feature in both mutuality and Reis and Shaver’s process model of intimacy (24), in Kasle et al which personal disclosures are met with empathic responses that encourage further intimations by the discloser, who thus ultimately comes to feel understood and valued. However, the intimacy model places emphasis on the discloser coming to feel understood and valued by the empathic listener. In contrast, the conceptualization of mutuality places equal weight on the listener’s and the discloser’s experiences in the empathic exchange; both partners are empowered by their shared understanding (25). A validation study of a mutuality measure found that mutuality correlated with couples’ relationship satisfaction and cohesion, and was inversely associated with women’s depressive symptoms but was unrelated to men’s depressive symptoms (26). Additional studies in all-female samples found that mutuality is reliably linked with better psychological health in women. For example, perceived mutuality in couple relationships was associated with less depression and anger suppression for women (27). Perceived mutuality was also associated with marital satisfaction, self-esteem, and less depression in women (28). In breast cancer patients, perceived mutuality in couple relationships was associated with less depression, better quality of life, and more self-care agency (29). Similarly, perceived mutuality in couple relationships was associated with less depression and discriminated between women with eating disorders and healthy controls (30). The theoretical and empirical relevance of mutuality for women’s psychological health argue for examining the associations of mutuality with health in patients with RA. Except in preliminary studies, mutuality has not been examined as a predictor of physical health outcomes, much less in patients with RA. Preliminary data suggested that mutuality is associated with fewer symptoms of depression and anxiety (31,32) and may be a protective factor relative to physical disability and overall health in patients with RA (33,34). Given the theoretical emphasis on both listener and discloser roles, separate investigations of health in relation to subjects’ perceptions of their own responsiveness (self-mutuality) and of their partners’ responsiveness (partner-mutuality) are of interest, along with combined (overall) mutuality. To date, the separate links of self-mutuality and partner-mutuality with health have not been examined. Our ﬁrst objective was to examine psychological and physical health outcomes of married/partnered patients with RA in relation to their perceptions of mutuality in important conversations with spouses/partners. We hypothesized that overall mutuality, partner-mutuality, and self-mutuality would all be associated with better psychological and physical health in the whole sample and in men and women. Our second objective was to examine potential sex differences in the association of mutuality with health outcomes. Studies of dyadic communication behaviors suggest that women are more emotionally intimate in dyadic relationships (35) and are more empathic, skilled, and take a more proactive role in maintaining relationships than men (36). Accordingly, we anticipated that role-congruent sex differences might emerge in the linkage of depressive symptoms with self-mutuality, i.e., respondents’ percep- Mutuality and RA Health tions of their own responsiveness in couple conversations. We expected that overall mutuality and partner-mutuality would be inversely associated with depressive symptoms for all RA patients. However, we hypothesized that selfmutuality would play a larger role in women’s depressive symptoms than in men’s. PATIENTS AND METHODS Participants and procedures. A survey study of couple relationship quality and health outcomes in patients with RA was approved by The University of Arizona Institutional Review Board and conducted in accordance with the Declaration of Helsinki. A total of 148 RA patients (114 women, 34 men; 87% white, 83% non-Hispanic) were recruited through rheumatology clinics. This sample provided power ranging from the 0.85 level (to detect an effect as small as 0.25 with ␣ ⫽ 0.05) to the 0.99 level (to detect an effect size ⱖ0.40 with ␣ ⱕ 0.01). Participants were adults (age 18 years or older) who were diagnosed with RA at least 6 months prior to enrollment, married or partnered for at least a year, and not limited in usual self-care or vocational abilities (except 1 male RA patient who was no longer able to perform physically strenuous tasks). Participants gave informed consent and completed mailed questionnaires. Measures. Sample characteristics. Demographic information was collected, including age, sex (binary coded 0 ⫽ male, 1 ⫽ female, for use in tests of sex moderation), highest education level (1 ⫽ grade school, 2 ⫽ some high school, 3 ⫽ high school or general equivalency diploma, 4 ⫽ technical school, 5 ⫽ some college, 6 ⫽ college degree, 7 ⫽ postgraduate training, 8 ⫽ masters, and 9 ⫽ MD, PhD), and years partnered/married. Years of RA duration was calculated from patient-reported dates of RA diagnosis. Antidepressants/anxiolytics use was coded from medication lists to reﬂect use of antidepressant and/or anxiolytic medications (0 ⫽ none, 1 ⫽ use of either or both types of medications). Positive affect was assessed with the 10-item positive affect scale from the Positive and Negative Affect Scales (37). Respondents rated the degree to which they experienced positive emotions (e.g., interested, strong, enthusiastic) during the past week using response options ranging from 1 (very little/not at all) to 5 (extremely). Scores were obtained as the mean of items. This measure of positive affect was included as a control variable for its anticipated effects on both depression and mutuality. Predictors. Overall mutuality and its subscales, partnermutuality and self-mutuality, were measured using the Mutual Psychological Development Questionnaire (MPDQ) (38). To capture the bidirectional nature of mutuality, the MPDQ uses 2 stems with 11 items each to elicit respondents’ perceptions of their partners’ and their own engaged, validating, empathic, and authentic responses in important couple conversations during the past month: “When we talk about things that are important to me, my spouse/partner is likely to . . .” and “When we talk about things that are important to my spouse/partner, I am likely 923 to. . . .” Response options ranging from 1 (never) to 6 (always) are used to rate items such as “pick up on my feelings,” “share similar experiences,” “show an interest,” “respect my point of view,” “feel moved,” “get involved,” and “express an opinion clearly.” After reverse coding indicated items, scores were obtained as means, with possible scores ranging from 1 to 6. Items from both stems were scored in aggregate to yield an overall mutuality score. Items from the stems were also scored separately, yielding scores of partner-mutuality (respondents’ perceptions of their partners’ responsiveness) and self-mutuality (respondents’ perceptions of their own responsiveness). Health outcomes. Depressive symptoms were measured using the 20-item Center for Epidemiologic Studies Depression Scale (39). Respondents rated the frequency during the past week that they experienced symptoms of depression, including depressed mood, feelings of guilt and worthlessness, helplessness and hopelessness, psychomotor retardation, loss of appetite, and sleep disturbance, on a scale of 0 (less than a day) to 3 (5–7 days). Items were summed, with possible scores ranging from 0 to 60. Scores ⱖ16 indicate signiﬁcant depressive symptoms in community samples, but an optimal cutoff of 27 was suggested for use in patients with chronic pain to adjust for construct overlap in somatic items (40). One man and 10 women in the current sample (7.43%) scored ⱖ27. Anxiety symptoms were measured with the Beck Anxiety Inventory (41) as self-reports of subjective fear, somatic nervousness, neurophysiologic symptoms, muscular/motor symptoms, and respiratory symptoms. Respondents rated the degree to which they experienced anxiety symptoms (e.g., heart pounding or racing and fear of dying) during the past week on a scale of 0 (not at all) to 3 (severe, “I could hardly stand it”). Items were summed, with possible scores ranging from 0 to 63. Physical disability was measured with the 24-item Health Assessment Questionnaire (HAQ) disability scale (42). The HAQ elicits respondents’ ratings of their abilities to perform activities of daily living (e.g., dress, get in/out of bed, walk on ﬂat ground, climb up 5 steps) on a scale of 0 (with no difﬁculty) to 3 (unable to do). Items were scored as the mean, with possible scores ranging from 0 to 3. Arthritis impact was measured with the Arthritis Impact Measurement Scales 2 Short Form (43), a 26-item measure of arthritis impact across multiple domains. Respondents rated their arthritis symptoms, affective states, and abilities during the preceding month to perform activities of daily living, work, and socialize. Response options range from 1 (all days/always) to 5 (no days/never). After indicated items were reverse coded, items were scored as the mean, with possible scores ranging from 1 to 5. Statistical analysis. Descriptive statistics and scale reliabilities were calculated for all variables in the whole sample and in men and women, with independent sample t-tests of differences between the means for men and women. A correlation matrix of all variables was calculated to reveal associations of overall mutuality and its subscales with health outcomes in the whole sample and 924 Kasle et al Table 1. Rheumatoid arthritis (RA) sample characteristics and scale reliabilities* Whole sample (n ⴝ 148) Sample characteristics Age† Education Years partnered† RA duration, years† Antidepressants/anxiolytics Positive affect Predictors Overall mutuality Partner-mutuality Self-mutuality Health outcomes Depression† Anxiety Physical disability Arthritis impact Men (n ⴝ 34) Women (n ⴝ 114) Mean ⴞ SD ␣ Mean ⴞ SD ␣ Mean ⴞ SD ␣ 56.6 ⫾ 12.3 5.1 ⫾ 1.8 26.3 ⫾ 16.2 7.7 ⫾ 5.8 0.24 ⫾ 0.42 3.3 ⫾ 0.78 – – – – – 0.90 62.5 ⫾ 12.2 4.9 ⫾ 2.2 34.5 ⫾ 16.6 11.0 ⫾ 8.7 0.15 ⫾ 0.36 3.5 ⫾ 0.70 – – – – – 0.90 54.9 ⫾ 11.8 5.2 ⫾ 1.7 23.8 ⫾ 15.2 6.8 ⫾ 4.1 0.26 ⫾ 0.43 3.2 ⫾ 0.79 – – – – – 0.90 4.5 ⫾ 0.59 4.4 ⫾ 0.66 4.6 ⫾ 0.61 0.91 0.84 0.87 4.6 ⫾ 0.46 4.5 ⫾ 0.51 4.6 ⫾ 0.53 0.87 0.78 0.80 4.5 ⫾ 0.62 4.4 ⫾ 0.70 4.6 ⫾ 0.64 0.92 0.85 0.88 10.8 ⫾ 8.9 8.4 ⫾ 7.2 0.54 ⫾ 0.46 1.96 ⫾ 0.48 0.89 0.86 0.94 0.87 7.3 ⫾ 6.0 7.2 ⫾ 7.1 0.43 ⫾ 0.46 1.90 ⫾ 0.48 0.83 0.84 0.96 0.85 11.9 ⫾ 9.4 8.8 ⫾ 7.2 0.57 ⫾ 0.45 1.98 ⫾ 0.49 0.90 0.86 0.93 0.87 * Reliabilities are the Cronbach’s alpha internal consistency coefﬁcients. † Men’s means differ from women’s means; t(146) ⱖ 2.79 for all, P ⱕ 0.008 for all. to aid the selection of control variables for subsequent sexmoderation regressions. Correlations of health outcomes with mutuality and its subscales were also calculated separately for men and women. Finally, hierarchical regressions testing for sex-moderated effects of overall mutuality, partner-mutuality, and self-mutuality on depressive symptoms were conducted following the recommendations of West et al (44). Interaction terms were calculated as the product of the binary-coded sex variable and deviation scores of overall mutuality, partner-mutuality, and self-mutuality. Variables associated with mutuality and its subscales and/or with health outcomes were entered as control variables in the regressions, including education level, years partnered/married, use of antidepressants/ anxiolytics, and positive affect. After main effects of sex, overall mutuality, self-mutuality or partner-mutuality, and control variables were entered, the interaction terms were entered in the second step to examine any additional explanation of variance in depressive symptoms. The meaning of signiﬁcant interaction terms was “unpacked” in separate regressions of men’s and women’s unadjusted depression scores on mutuality subscales to examine slope differences (44). RESULTS Preliminary analyses. Sample and measure descriptions and scale reliabilities in the whole sample and separately in men and women are reported in Table 1. Compared with women, men were older, had been married longer, had longer RA disease duration, and reported fewer depressive symptoms (t ⱖ 2.79 for all, P ⱕ 0.01 for all). The means for all other measures (including overall mutuality, partner-mutuality, and self-mutuality) did not differ by sex. Internal consistencies, measured as Cron- bach’s ␣, were acceptable for all measures, with reliabilities ranging between 0.78 and 0.96 across sample subgroups (Table 1). Associations among variables in the whole sample. As hypothesized, RA patients reporting higher levels of overall mutuality, partner-mutuality, and self-mutuality reported better psychological and physical health, as reﬂected by inverse correlations with symptoms of depression, anxiety, physical disability, and arthritis impact (r ⫽ ⫺0.233 to ⫺0.488, P values ranged from ⬍0.01 to ⬍0.001) (Table 2). Mutuality and its subscales were related to positive affect (r ⫽ 0.314 to 0.383, all P ⬍ 0.001) but were unrelated to education level, use of antidepressants/ anxiolytics, and years partnered/married. All health outcomes were associated with antidepressant/anxiolytic use (r ⫽ 0.216 to 0.293, all P ⱕ 0.01) and inversely associated with positive affect (r ⫽ ⫺0.379 to ⫺0.648, all P ⬍ 0.001) (Table 2). Prediction of men’s and women’s health outcomes by overall mutuality, partner-mutuality, and self-mutuality. Correlations of overall mutuality, partner-mutuality, and self-mutuality with health outcomes were examined separately for men and women, with similar results in each group generally supporting the hypotheses. Men. Overall mutuality was inversely associated with depressive symptoms, anxiety symptoms, and arthritis impact (r ⫽ ⫺0.448 to ⫺0.544, all P ⬍ 0.01), but was unrelated to physical disability (Table 3). A similar pattern emerged in men’s associations of partner-mutuality and self-mutuality with depressive symptoms, anxiety symptoms, and arthritis impact (r ⫽ ⫺0.326 to ⫺0.523, all P ⱕ 0.06) (Table 3). Women. As hypothesized, overall mutuality was inversely associated with all health outcomes (r ⫽ ⫺0.269 to Mutuality and RA Health 925 Table 2. Correlations among variables (n ⴝ 148) Variables 1 2 3 4 5 6 7 8 1. Overall mutuality 1 0.925* 0.912* ⫺0.488* ⫺0.328* ⫺0.254† ⫺0.433* ⫺0.038 2. Partner-mutuality 1 0.688* ⫺0.441* ⫺0.261* ⫺0.233† ⫺0.407* ⫺0.059 3. Self-mutuality 1 ⫺0.454* ⫺0.345* ⫺0.233† ⫺0.389* ⫺0.010 4. Depression 1 0.631* 0.502* 0.674* ⫺0.110 5. Anxiety 1 0.629* 0.680* ⫺0.100 6. Physical disability 1 0.810* ⫺0.189‡ 7. Arthritis impact 1 ⫺0.191‡ 8. Education level 1 9. Years married/partnered 10. Antidepressants/anxiolytics 11. Positive affect *P †P ‡P §P ⱕ ⱕ ⱕ ⱕ 9 10 11 ⫺0.030 0.022 ⫺0.080 ⫺0.185‡ ⫺0.142§ ⫺0.013 ⫺0.079 ⫺0.056 1 ⫺0.063 ⫺0.041 ⫺0.076 0.216† 0.293* 0.252† 0.273* ⫺0.170‡ ⫺0.064 1 0.380* 0.314* 0.383* ⫺0.648* ⫺0.406* ⫺0.379* ⫺0.526* 0.134 0.127 ⫺0.144§ 1 0.001. 0.01. 0.05. 0.09. ⫺0.497, all P ⬍ 0.01) (Table 3). A similar pattern emerged for associations of partner-mutuality and self-mutuality with women’s health outcomes (r ⫽ ⫺0.218 to ⫺0.496, all P ⬍ 0.05) (Table 3). Sex differences in linkage of depressive symptoms with overall mutuality, partner-mutuality, and self-mutuality. Results from 3 parallel hierarchical regression analyses of depressive symptoms supported hypotheses that overall mutuality and partner-mutuality would comparably predict depressive symptoms for men and women, and that self-mutuality would exert a larger effect for women. The regression equation testing sex moderation of overall mutuality (data not shown) revealed signiﬁcant main effects of positive affect (␤ ⫽ ⫺0.483, P ⬍ 0.001) and overall mutuality (␤ ⫽ ⫺0.300, P ⬍ 0.001), and the sex by overall mutuality interaction approached statistical signiﬁcance (␤ ⫽ ⫺0.280, P ⫽ 0.073). The regression equation testing sex moderation of partner-mutuality (data not shown) revealed signiﬁcant main effects of positive affect (␤ ⫽ ⫺0.516, P ⬍ 0.001) and partner mutuality (␤ ⫽ ⫺0.216, P ⬍ 0.001); the sex by partner-mutuality interaction was not signiﬁcant (␤ ⫽ ⫺0.190, P ⫽ 0.246). The regression equation testing for sex moderation of self-mutuality (Table 4) revealed signiﬁcant main effects of positive affect (␤ ⫽ ⫺0.492, P ⬍ 0.001) and self-mutuality (␤ ⫽ ⫺0.270, P ⬍ 0.001). Here, the signiﬁcant sex by self-mutuality interaction term (␤ ⫽ ⫺0.326, P ⫽ 0.025) indicated a larger inverse effect of self-mutuality on depression for women than for men. This sex difference is shown in Figure 1 as slopes of self-mutuality on unadjusted depressive symptoms for men and women. DISCUSSION This study joins a growing body of literature evidencing the importance of social support for health in general and clinical populations (2,3,6,7,16 –18,45). Speciﬁcally, ﬁndings suggest that mutuality, measured as perceptions of responsiveness in couples’ communications, is linked with better physical and psychological health in both men and women with RA. Study ﬁndings are consistent with earlier studies linking mutuality with better psychological health in non-RA samples (26 –30), and they extend the relevance of mutuality to physical health outcomes in patients with RA, including the ability to perform activities of daily living and physical symptoms of arthritis. Study ﬁndings are also congruent with prior studies linking negative spouse/partner responses with poorer outcomes in patients with RA (5,16 – 20), and extend this understanding by linking positive Table 3. Correlations of health outcomes with overall mutuality, partner-mutuality, and self-mutuality for men and women Men (n ⴝ 34) Women (n ⴝ 114) Health outcomes Overall mutuality Partnermutuality Selfmutuality Overall mutuality Partnermutuality Selfmutuality Depressive symptoms Anxiety symptoms Physical disability Arthritis impact ⫺0.460* ⫺0.448* ⫺0.184 ⫺0.544‡ ⫺0.497* ⫺0.445* ⫺0.179 ⫺0.523‡ ⫺0.326† ⫺0.359§ ⫺0.149 ⫺0.452* ⫺0.497‡ ⫺0.303‡ ⫺0.269* ⫺0.411‡ ⫺0.424‡ ⫺0.218§ ⫺0.236* ⫺0.380‡ ⫺0.496‡ ⫺0.348‡ ⫺0.262* ⫺0.379‡ *P †P ‡P §P ⱕ ⱕ ⱕ ⱕ 0.01. 0.06. 0.001. 0.05. 926 Kasle et al Table 4. Hierarchical regression predicting depression with sex moderation of selfmutuality (n ⴝ 148)* Model R2⌬ Step 1: control and main effects Education level Years married/partnered Antidepressants/anxiolytics Positive affect Sex Self-mutuality Step 2: sex by self-mutuality interaction Education level (step 2) Years married/partnered (step 2) Antidepressants/anxiolytics (step 2) Positive affect (step 2) Sex (step 2) Self-mutuality (step 2) Sex by self-mutuality interaction 0.514 b weight ␤ ⫺0.288 ⫺0.060 2.06 ⫺5.64 2.36 ⫺3.93 ⫺0.058 ⫺0.109 0.097 ⫺0.492 0.112 ⫺0.270 ⫺0.319 ⫺0.067 2.13 ⫺5.70 2.17 0.414 ⫺5.18 ⫺0.065 ⫺0.120 0.100 ⫺0.497 0.102 0.028 ⫺0.326 0.017 P ⬍ 0.001 0.336 0.081 0.111 ⬍ 0.001 0.075 ⬍ 0.001 0.025 0.281 0.051 0.095 ⬍ 0.001 0.097 0.846 0.025 * Model adjusted R2 ⫽ 0.508, P ⬍ 0.001. responsiveness, speciﬁcally mutuality, with RA health. Moreover, along with perceptions of their partners’ responsiveness, the importance of health for RA patients’ own responsiveness emerged from the separate examinations of self-mutuality and partner-mutuality in relation to health. These ﬁndings underscore the importance of communicative responses that mutually engage partners in conversations, and suggest that asking RA patients whether they are able to truly engage in conversations with partners may have clinical relevance. Finally, study ﬁndings extend the relevance of mutuality for women’s health to that of men diagnosed with RA. This noteworthy ﬁnding contrasts with a ﬁnding from a nonclinical sample, wherein men’s depression was unrelated to mutuality (26). This contrast invites speculation that spouse/partner relationship quality may be more closely linked with well-being for men diagnosed with RA than for men in the general population. The examination of overall mutuality and its components (partners’ responsiveness and one’s own responsiveness) in relation to depressive symptoms revealed both similarities and differences between the sexes. Perceptions Figure 1. Slopes of self-mutuality on unadjusted depressive symptoms for men and women. Solid diamonds represent men (n ⫽ 34); open squares represent women (n ⫽ 114). of overall mutuality and of partners’ responsiveness inversely predicted depressive symptoms for both men and women. However, responsiveness to one’s partner (selfmutuality) was more predictive of women’s psychological health than of men’s. Although men’s scores on the mutuality scales did not differ from women’s scores, it is conceivable that the observed sex difference in the link of self-mutuality with depressive symptoms is an artifact of the larger variance for women in both of these variables (see Table 1). However, the variances of overall mutuality and partner-mutuality were likewise larger for women, yet no sex differences emerged in their links with depressive symptoms. Furthermore, the observed sex difference for self-mutuality is congruent with the ﬁnding by Revenson and colleagues that women with RA provide more positive and less problematic support to their healthy spouses than do men with RA (10). Such sex differences may be of interest because they might moderate effectiveness of supportive interventions involving these relational behaviors. However, further research would be necessary to conﬁrm and elucidate this observation before applications are considered. Some important study limitations warrant consideration. First, the current sample of men was small; results focusing on sex differences should be conﬁrmed in a sample with a larger proportion of men. Second, these crosssectional data preclude any inference of causality in the links between mutuality and health; a study utilizing prospective data would help clarify the nature of these associations. Similarly, although we controlled for positive affect in the sex-moderation regressions, other selfselection or personality factors that we did not measure and control (e.g., neuroticism, interpersonal awareness, empathy, or similar traits) might underlie the observed link between relational behaviors and health by inﬂuencing both constructs. All measures of couple mutuality and health outcomes were self-reported; conﬁdence in the results would be increased if ﬁndings were conﬁrmed using observer-reported measures of mutuality and biomarker or Mutuality and RA Health other objective measures of health outcomes. Additionally, a study incorporating reports from spouses/partners would increase understanding of the links between mutuality and health in both RA patients and their spouses/ partners. Finally, the sample was not limited in self-care abilities, nor was it highly diverse ethnically; ﬁndings may not generalize to severely impaired populations or to all ethnicities. These limitations should not lead us to overlook the importance of these ﬁndings. Accumulating evidence that social support has long-term implications for RA patients’ health has prompted the development in recent years of cognitive– behavioral interventions containing modules to improve social relationships (46) and interventions to enhance RA patients’ social networks (47). Findings from this research may further the development of such interventions by providing potentially important insights into the “black box” of social support. Mutuality was captured here using a measure that elicits frequencies of communicative responding behaviors that operationalize the construct of mutuality (38). Therefore, the measurement items may provide valuable descriptions of potentially therapeutic communicative behaviors that are linked with RA health. Concomitantly, testing an intervention based on mutuality could provide evidence bearing on causal relations, if any, between mutuality and health. Health care professionals are becoming increasingly aware of biopsychosocial models of health (10,45), including family systems perspectives and dyadic coping (10 – 12), and of the clinical relevance of psychosocial contexts for immune-mediated disease activity in RA (6,7,14,17). This study contributes to that awareness by describing speciﬁc relational behaviors that are linked with better health for patients with RA: the mutual engagement of partners in conversations through responses characterized by empathy, authenticity, validation, and empowerment. Although this study focused on mutuality in couple relationships, mutuality in other close relationships may be similarly linked with health and deserves our attention. Ultimately, this linkage of relational behaviors with health encourages us to understand RA patients as active participants in couple relationships, families, friendships, and communities rather than as individual patients coping with illness. ACKNOWLEDGMENTS We are deeply indebted to Shannon Howe, MD, for her generous assistance in recruitment. We also thank an anonymous reviewer of an earlier version of this article for suggesting ways of characterizing the utility of this study, which we incorporated in the ﬁnal version. AUTHOR CONTRIBUTIONS Dr. Kasle had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study design. Kasle, Wilhelm. Acquisition of data. Kasle. Analysis and interpretation of data. Kasle, Wilhelm, Zautra. Manuscript preparation. Kasle, Wilhelm, Zautra. Statistical analysis. Kasle. 927 REFERENCES 1. Berkman LF. The role of social relations in health promotion. Psychosom Med 1995;57:245–54. 2. House JS, Landis KR, Umberson D. Social relationships and health. In: Salovey P, Rothman AJ, editors. The social psychology of health. Philadelphia: Psychology Press; 2003. p. 218 –26. 3. Wickrama KA, Lorenz FO, Conger RD, Elder GH Jr. Marital quality and physical illness: a latent growth curve analysis. J Marriage Fam 1997;59:143–55. 4. Sternberg EM, Chrousos GP, Wilder RL, Gold PW. Stress responses and the pathogenesis of arthritis. In: McCubbin JA, Kaufmann PG, Nemeroff CB, editors. 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