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Rheumatoid arthritis patients' perceptions of mutuality in conversations with spousespartners and their links with psychological and physical health.

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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: shelley@u.arizona.edu.
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[146] 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
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