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Cancer as a "we-disease": examining the process of coping from a relational perspective.

This paper presents findings on how breast cancer patients and their partners cope together with the cancer diagnosis and treatment. It expands on earlier frameworks of dyadic coping by presenting a model that views dyadic coping as a process that varies according to how couples appraise the illness-related stress, communicate about it, coordinate their coping efforts, and make meaning from the illness experience. In-depth analyses were conducted on interviews with 10 couples who were coping with breast cancer. A qualitative method that comprises a series of "listenings" to the couples' experiences was used to examine how couples talked about their stress and coping efforts. Two patterns of relational coping were identified: mutually responsiveness and disengaged avoidance. The relational qualities of relationship awareness, authenticity, and mutuality were identified as important ingredients for dyadic coping. Suggestions for future research that furthers our understanding of relational coping are offered.

Keywords: dyadic coping, relational coping, mutuality, relationship awareness, authenticity

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It is becoming an accepted fact that models of stress and coping need to incorporate a relational perspective. Major life stressors affect not only individuals but the lives of their intimate partners, spouses, children, friends, and others in their social networks. However, research on couples and families still focuses almost entirely on the coping efforts used by individuals. To understand fully the relationship between stress and health or mental health, we need to examine coping as it occurs within the context of significant relationships.

Recently several theoretical frameworks, empirical research, and interventions that focus on how couples cope together with life stress have been developed. Theoretical approaches such as relationship-focused coping (Coyne & Fiske, 1992), interpersonal regulatory processes (DeLongis & O'Brien, 1990; O'Brien & DeLongis, 1997), coping congruence (Revenson, 1994, 2003), communal coping (Lyons, Mickelson, Sullivan & Coyne, 1998), and the systemic-transactional coping (Bodenmann, 1995, 1997, 2005) have expanded the original stress and coping theories of the 1970s and 1980s (e.g., Lazarus & Folkman, 1984; Pearlin & Schooler, 1978). Furthermore, they have recently been applied to the development of psychosocial interventions with couples facing cancer (Kayser, 2005; Scott, Halford, & Ward, 2004). Dyadic coping, another term for this process, is seen as the interaction between the stress signals of one partner and the coping reactions of the other. A shortcoming of many of these models is the focus on only one aspect of the coping process, namely, the individual coping strategies that partners use in managing the stress.

This paper presents a framework of dyadic coping that expands on previous models by viewing coping as a process that involves how couples appraise the illness-related stress, react to each other's responses, use behavioral and cognitive strategies to manage stress, and make meaning of the illness. First, we review the studies related to couples coping with cancer that use a dyadic perspective. Second, we present findings from an interpretive analysis using qualitative data from a clinical research study with breast cancer patients and their partners. Third, recommendations for future research and theory development are discussed.

PREVIOUS RESEARCH: COUPLES COPING WITH CANCER

Several studies on couples' coping with cancer focus on how the coping strategies used by one partner affect the other partner's adjustment to the stress of the illness. Wives' adjustment to breast cancer has been associated with their husbands' use of more problem-focused coping (Ptacek, Ptacek, & Dodge, 1994) and husbands' use of active engagement coping Strategies (Kuijer, Ybema, Buunk, DeJong, Thijs-Boer, & Sanderman, 2000), Cancer patients were more likely to feel distressed when their husbands used wishful thinking (Ptacek, Ptacek, & Dodge, 1994), external control-resignation types of coping (Hannum, Giese-Davis, Harding, & Hatfield, 1991), and were overprotective toward them (Kuijer et al., 2000).

In a similar vein, breast cancer patients' coping strategies also affect their husbands' adjustment. Hannum et al. (1991) found that wives' use of optimism as a way to cope was negatively related to their husbands' distress. In another study (Ptacek et al., 1994), husbands reported more relationship satisfaction and higher levels of mental health when their wives reported using more problem-focused coping and less avoidance. The wife's use of wishful thinking was related to her husband's mental health (Ptacek et al., 1994). These studies illustrate the significant crossover associations between the coping reported by one spouse and the other spouse's adjustment outcomes. A limitation of these studies is that the couple is not the unit of analysis--an individual's coping is the unit of analysis.

Two qualitative studies have analyzed coping as a couple phenomenon. Skerrett (1998) interviewed 20 couples about their coping with breast cancer as a couple, focusing on factors such as communication, beliefs regarding illness and health, problem-solving techniques, feelings of loss and disfigurement, and other topics related to their experience. Based on the interview data, couples were categorized as either resilient or problematic. The majority of couples were seen as resilient: They had a philosophy of coping that was mutual and served as a basis for dealing with the ongoing illness demands. They strongly believed that they were "in it together" and served as each other's confidante, advisor, and sounding board. Most talked openly about cancer but did not allow the talk of the illness to dominate their daily living.

In contrast, there was a small cluster of "problematic" couples, for whom breast cancer had a devastating impact on their lives. The illness seemed to color every aspect of their interaction. The "problematic" couples were unable to formulate a common coping philosophy regarding the many illness demands. Their communication took the form of one of two patterns: individual retreat into withdrawal and silence or reactive, anxiety-driven, tell-all communication. They struggled to find ways to understand and make meaning of the experience.

In another qualitative study, Zunkel (2002) identified four relational or dyadic processes in which each partner contributed to the coping with breast cancer. These included: (a) sharing in the patient's recovery, (b) helping her, (c) normalizing the household, and (d) moderating or minimizing the intrusion of the cancer. Zunkel (2002) concluded that there were two distinct types of processes: an acknowledging type and a moderating or minimizing type. The acknowledging process attempted to incorporate the illness into the family life; couples openly expressed their feelings about its presence and acknowledged their partners' responses to the cancer and recovery. In contrast, the moderating or minimizing process attempted to limit the cancer's impact on the family. Both processes utilized problem-focused strategies and emotion-focused strategies.

In summary, the research indicates that both the patient and partner are affected by the stress of breast cancer. How each partner copes with the multiple stressors posed by the illness, its treatment, and its meaning will affect the other partner's coping and psychosocial adjustment. The Skerrett (1998) and Zunkel (2002) studies conceptualize coping as dyadic processes which define how patients and partners can (or cannot) handle the disease together.

DEFINING DYADIC COPING

The systemic-transactional theory (Bodenmann, 1995, 1997, 2005), proposes that coping is a stress management process where partners either ignore or react to each other's stress signals to maintain a level of stability in the relationship (in this case, a preillness level of well-being) on the individual and the dyadic levels. Each partner's well-being mutually depends upon the other's well-being, as well as upon the couple's ability to use resources in the social environment during the stress management process. Assuming that each partner is willing to invest in the relationship and is committed to the relationship, they will be motivated to help each other deal with stressful encounters. This framework draws from Lazarus and Folkman's (1984) interpersonal stress and coping theory that conceptualizes coping as involving (a) cognitive appraisal, (b) emotional reaction, (c) coping behavior, and (d) adjustment. In Bodenmann's theory (1995, 1997, 2005), a stress communication process triggers both partners' coping responses. One partner's stress signals are sent to the other partner, who perceives, interprets, and decodes them, and then responds with some form of coping (that might involve ignoring these stress signals). Stress can be communicated verbally or nonverbally (e.g., voice tone, sighs, or facial expression). Several cognitive processes are involved in the stress communication process: the appraisal of who is concerned by the stress (partner A, partner B, both partners), the appraisal of the causes for the stress event (the partner, others, external causes) and the responsibility (e.g., guilt of the partner or not) as well as the appraisal of controllability (by partner A, partner B, both). Depending on the stressor under consideration and what is at stake for the individual and the dyad, both partners make efforts to maintain or restore the well-being of the relationship. The systemic-transactional theory offers a framework in which the couple is the unit of analysis. Most theorists have conceptualized dyadic coping as coping in relation to another person. For example, relationship-focused coping may involve a person actively engaging a partner by discussing his or her own stress but it does not include the response from the partner (Coyne & Fiske, 1992). We do not know if the efforts of engaging the partner lead to the partner's empathic response or withdrawal or some other reaction.

Although the focus of our analysis was not specifically to validate the systemic-transactional theory, this theory influenced our thinking about dyadic coping as a process that involves more than the coping strategies that each partner uses to manage a dyadic stress. Our research questions were:

1. How do couples describe their coping?

a. How do they appraise the stress related to the cancer?

b. Do they attempt to use the same or complementary coping strategies?

c. Do they identify benefits from their coping experience?

2. What relationship qualities facilitate couples' coping?

METHODS

Procedure

Qualitative data were collected through interviews with couples who were part of a clinical research study of the Partners in Coping Program (PICP) (see Kayser, 2005, for a description of this study). Patients were approached for study participation from the outpatient clinics at a cancer institute and large medical center in New England. Criteria for study inclusion were as follows: (a) a diagnosis of nonmetastatic breast cancer within the last 3 months; (b) currently receiving treatment such as chemotherapy, surgery, radiation, or a combination of treatments; and (c) married or in an intimate relationship. Both partners needed to agree to participate to be involved in the study. Eligible patients were identified by an on-site research coordinator who contacted the patient during an outpatient visit or by letter or telephone. Couples who agreed to participate were randomly assigned to the intervention (PICP) arm or the standard services arm. All participants completed questionnaires with measures of dyadic coping, mutuality, communication, and quality of life but only the couples in the intervention arm (N = 25) were interviewed. Hence, the data that we analyzed for this study were collected from the couples who were receiving the intervention.

The interview was part of the initial session with an oncology social worker during the Partners in Coping Program. The social worker used a semistructured interview schedule that consisted of questions related to their coping and their social support network. The couples were asked the following questions: (a) What is the most important change in your life as a couple since the diagnosis? (b) What are you handling best as a couple? (c) What are you handling less well as a couple? (d) Is there anything good for you as a couple that has come from this diagnosis? Because this was a couples-based, clinical intervention, the patient and partner were interviewed together by the social worker. Informed consent was obtained from both members of the couple. The interviews were audiotaped and lasted approximately 1 hour. Because we were interested in the various ways that couples would communicate about their coping, open-ended and unguided questioning was used. The interviewer directed the questions to the couple and did not explicitly encourage each person to comment on what the other said. However, the interviewer was instructed to make sure that each member of the couple had the opportunity to answer the question.

Because the purpose of the study was to explore in-depth these couples' experiences of a particular phenomenon, namely the stress of breast cancer, and the interpretive analysis is very labor intensive, a small sample of 10 interviews were selected for the analysis. The interviews were chosen based on the clarity of the recordings (some of the interviews had missing data because of poor quality recording). To insure that the interviews represented people across the different ages, three patients were in the 35- to 45-year-old age group, four in 46- to 55-year-old age group, and three in 56- to 65-year-old age group.

The sample consisted of primarily Euro American, middle-class couples with household incomes averaging $90,000. Their ages ranged from 32 to 69 years (M = 50.9) and the lengths of their relationships were from 2 to 42 years (M = 24.3). Except for one woman, all of the women were receiving chemotherapy and the chemotherapy had been combined with either radiation (60%) or a mastectomy (40%). The woman who did not receive chemotherapy had radiation and a lumpectomy. All of the couples were heterosexual and married except for one lesbian couple. All of the married couples had children with the average number of children being two.

Data Analysis

The interviews were transcribed and read by the three coauthors. We used the "Listening Guide" as the qualitative method for an interpretive analysis of the couple's experience (Gilligan, Spencer, Weinberg, & Bertsch, 2003). This method of analysis is based on relational psychologies with assumptions that human development and the sense of self occur in relationship with others and with the cultures within which we live (Spencer, 2000). The method was selected because it emphasizes the voice of the research participants, the attempt to understand the meaning-making process and its use in other studies of relational research (e.g., Doucet, 1995; Mauthner, 2000). For each step, we used different colored pencils to underline the content of each "listening." The readers followed four steps as described by Gilligan et al. (2003).

Step 1: Listening for the Plot

The first listening consisted of two parts: (a) listening for the plot and (b) the listener's response to the interview. First, we read through the text and listened for the plot by attending to what was happening or what stories were being told. Repeated images and metaphors and dominant themes were noted and the social context within which these stories were experienced. Because we were reading stories from a couple, we also recorded a comparison of the two stories we heard from each partner. During this step, we attended to our own responses to the narrative, bringing our own subjective views into the process of interpretation.

Step 2: I Poems and We Poems

The second listening focused on the voice of the "I" who is speaking by following the use of this first-person pronoun with the verb. The purpose of this step was to listen to the participant's first-person voice and to hear how this person speaks about him- or herself (Gilligan et al., 2003). With I poems there is the possibility that a feeling or thought not stated directly but central to the meaning of what is being said will emerge (Gilligan et al., 2003). The I Poems were constructed by underlining every first-person "I" within the passage along with the verb and any important accompanying words and maintaining the sequence in which these phrases appear in the text. It is called a poem because it is then recorded with each "I" and verb on a separate line to look like stanzas of a poem. Similarly, Linguistic Inquiry and Word Count (LIWC; Pennebaker, Francis, & Booth, 2001) counts the number of first person singular references but does not place the "I's" in stanzas like a poem. Pennebaker analyzes the frequency of the first person singular references in relation to other social and psychological responses (Cohn, Mehl, & Pennebaker, 2004).

This second listening also included identifying all instances in which either partner referred to the relationship or a situation in the form of "we." These were compiled into "we poems." These poems consisted of every "we" with the verb in sequence and were recorded separately for each partner.

Step 3: Listening for Contrapuntal Voices

This step brought the analysis back into relationship with the research question. We read through the transcript again and identified strands in the interview that may speak to the research question. The researcher's questions guided this listening, which may be based on the theoretical framework guiding the research, or the questions raised by the previous listenings, or both. Our overall research question was "how would you describe the couple's coping?" Because Bodenmann's systemic-transactional framework was guiding our analysis, we were attuned to looking at coping as a process-involving appraisal, emotional response, coping efforts, and outcome.

Step 4: Composing an Analysis

At this step, we pulled together all of our stories and what we had learned about each couple in relation to the research question. Based on all of our listenings as recorded in the previous steps, we wrote interpretive summaries of each couple's coping. Then we looked across the interpretive summaries to look for relationship qualities that were emerging from the data.

The Listening Guide was chosen as our approach to the analysis because it facilitated an examination of the relational process and not simply the content of the material. We were interested in how the couple talked about cancer and how they communicated with each other during the interview. Others have used this approach in analysis of dyads (cf. Spencer, 2005). In addition, the clarity of the steps of the Listening Guide enhanced the reliability and integrity of the method. A shortcoming of many qualitative analyses is unclear and vague procedures. Each coauthor followed the first three steps of analysis for every interview. The fourth step involved checking our individual interpretations for reliability and composing a summary. If any disagreements among the interpretations occurred, the three readers discussed the couple's interview until a consensus was reached.

RESULTS

The couples in the study appeared to follow a process of coping that is similar to the stress and coping process as developed by Lazarus and Folkman (1984). Figure 1 illustrates the process of couples appraising the dyadic stress, responding to the stress and validating each other's response, coordinating their coping strategies, and finding benefits or growth from the experience. The process is drawn in the shape of a wheel to illustrate the circular nature of this process in that a couple can experience the phases of coping repeatedly. Coping with a chronic illness like cancer may require the couple to proceed through a number of these cycles as they first cope with the acute stress of the diagnosis and then later cope with the demands of living with cancer over subsequent years. Furthermore, the outcomes of the initial coping process will likely influence the subsequent coping processes.

Three relational qualities that facilitated the process of coping were identified (see Table 1). These included relationship awareness (sensitivity of stress as "our stress"), authenticity (honest self-disclosure of feelings), and mutuality (the ability to empathize with each other). Depending on the extent to which couples have or do not have these qualities, their coping processes looked different. Through our analyses, we were able to distinguish two patterns in the relational coping process: mutual responsiveness and disengaged avoidance.

Mutual Responsiveness

Appraisal

We listened for indications of how the stressor was appraised, in particular, whether the breast cancer was defined as a dyadic stressor or individual stressor. There were several couples who assessed the stress as "ours" and talked about the breast cancer changing their lives as a couple. Notice how the following patient and partner used "we" language in describing the breast cancer.

[FIGURE 1 OMITTED]

Patient. Coping to him and me is that we talk about the breast cancer and we deal with it.

Partner. We share decisions, we share the research. One of us isn't running off saying "this is what I'm doing. I don't care--it's my disease." It's shared--it's a we-disease.

Patient.... that was the most impressive thing he said to me. He calls it a we-disease. He just said it to me a couple of weeks ago.

Partner. Isn't that what it is?

Patient. It is but it doesn't mean that everyone thinks that way.

The appraisal of the disease as a "we-stress" does not necessarily mean that both partners were identifying the same aspects or changes as being the most stressful. In fact, in most of the cases each patient and partner identified different changes. For example, one patient's immediate response to the question about the most important change due to the diagnosis was a change in their sex life. The husband was surprised and disagreed by saying, "I worry a lot about how she's feeling--I think that's the biggest change because it is all the time. The sex life thing has changed but I don't think to me it's the greatest thing--not something you worry about every day." Although these partners did not refer to the breast cancer as explicitly as a "we-stress," they did identify how the cancer affected their intimacy as a couple. In addition, their disagreeing on the most important change does not necessarily mean that they were not coping together or were less relational in their coping. An important characteristic of partners in an intimate relationship is their ability to accept differences in their perspectives.

Coping Behaviors

The couples using mutually responsive coping attended to each other's emotional and physical needs in a coordinated manner to manage the illness. They used coping strategies that were either problem-focused (dealing directly with demands of the stress) or emotion-focused (managing or processing feelings about the stress). Problem-focused coping efforts such as driving to medical appointments or researching treatments on the Internet may have been divided between the partners or delegated primarily to one of the partners. An example of a couple using the same coping strategies simultaneously was the couple who defined their illness as "we-disease" in the earlier excerpt. When trying to make a decision on treatment, they both read about the doctors, they gathered information on the treatment protocols, and they attended religious services together. However, some couples used different types of coping--one using problem-focused and the other using emotion-focused--but they coordinated their efforts so that the behaviors complemented each other.

Partner. I think that's one of the things that we handle the best is the information and synthesizing it.

Patient. You do that very well, you share it with me, but I can't say I do it well.

Partner. But we're doing designated roles around it really well.... you have all the books all lined up, and you're using it on a just needed basis ... and everything's there, and all arranged and you pull it out when you need it.

Patient. Yes.

Partner. We make an effort to keep talking about everything, and make sure that you take time to be sad. Um, I tried to carve out time for that to happen, because there's a tendency to do not much of that. And, um.

Partner. To have you be sad with me.

The partner is problem-focused and task-oriented in her coping by gathering and organizing a large body of information on breast cancer. The patient is more emotion-focused by needing to express her feelings and communicate her stress with her partner. What is noteworthy about this couple is their relational capacity to accept and support each other's coping efforts even if they are different. Without the partner's support for the patient's need to express her feelings (emotional-focused coping), the patient would have needed to use other coping strategies or have gone outside the relationship for emotional support.

Some couples learned through the experience of the cancer how to transform their individual coping behavior into a mutual or relational coping. Note how the following couple describes the movement from an individualistic coping to a mutual coping:

Partner. I think the stress level is tremendous.... As a couple, being together, supporting each other, spending rime together, trying to understand the illness, being involved in all aspects of the treatment, emotional and physical.

Patient. I think in the beginning we had a hard time. And what he says is true. I am a strong person but when we first came here to the oncologist, he owns his own business and his cell phone was ringing. I was going to kill him. I was going to throw the phone out the window ... he said he wanted to be here but he's here in body, not mind. I told him, "If your phone calls are that important, don't come. I'll do it myself or I'll bring someone who wants to be here ...

Partner. She's right. I wanted to be there, I blocked the day and that's it. Going through it together has helped me. I hope it has helped you.

Through the wife's confrontation with her husband and his listening and responding to her needs, this husband was able to support her coping efforts in managing the demands of her treatment. The relationship was transformed to one in which he was present both physically and emotionally.

Outcome

Through the mutually responsive coping there was growth--individually and as a couple. When asked if there was anything positive that came from the illness, these couples often identified a strengthening of the relationship or a change in their priorities to become more focused on the relationship. One partner stated:
   I also did see it (the cancer) in some way as guaranteed to be
   relationship building, we were bound to learn a lot, and have to
   deal with a lot and that's another kind of gift in this that to
   deal with crisis and build through it--is good for the relationship
   we want.


Disengaged Avoidance

Appraisal

Couples who used disengaged avoidance to cope tended to appraise the breast cancer as an individual stressor. They frequently made "I statements" in response to the question about the most important change since the diagnosis. This occurred even though the question specifically asks what are the changes "as a couple." The following response from a partner refers almost totally to his own emotional reaction to the stress. Notice the "I Poem" indicated in italics in this passage:

Interviewer. What is the most important change in your life as a couple since the diagnosis?

Partner. I think it's a lot of different levels. Physically, it's the surgery. I met her in college. We were the same age and I had seen her around a couple of years. I was always attracted to her, so but then when I got to know her, there was a spiritual side to her so I think the physical implications of breast cancer--surgery they put her through and what her body has been through--and then the hair loss. It's almost like I don't want to look because I don't want to destroy the image I have of her. So I'm not dying to see her without her hair. I helped her with her scarring but it's not something I'm racing in to see. I'm definitely keeping a visible distance.

The most important change as cited by this husband was the difference in his wife's physical appearance. He mourns the loss of the way his wife looked in the past when they first met. The verbs in the I Poem are in the past tense indicating memories and a sense of loss. They also convey an avoidance of his wife's illness and its consequences and his attempts to maintain a preillness image of her.

There were some couples in this group who did not appraise the breast cancer as stressful--they could not think of a change in their lives since the diagnosis. Typically, these couples were dealing with other stressors like the recent birth of a child and understandably, were not primarily focused on the cancer.

Coping Behaviors

With the disengaged avoidant couples, at least one or both of the partners coped by avoiding or denying the stress of the disease. This denial of the cancer may be functional to some degree, but it does not allow partners to engage each other in support of the other's coping with cancer. Note how the following couple coped in a disengaged way:

Partner.... I think we need to be forced to talk. At some point during the summer between work and going home, I just said "I don't feel like talking." I don't know if she has turned to her mother, I don't know.

Patient.... He works very long hours and when he comes home he doesn't want to hear again.... I began to realize that he really wasn't interested in and I don't really blame him and in a way those are things that it's better for me talk to my mother about. She's interested in every little detail, "What have you done?" "What did they say?

In the example above, the partner was acknowledging that the breast cancer was stressful but wanted to avoid dealing with it directly. When partners do not acknowledge the stress of the breast cancer, it is very unlikely that they will be engaged in coping together with it. These couples, also, tend to be committed to the idea of not allowing the cancer to take a primary focus in their lives. Again, sometimes this tendency to avoid cancer-related stress is because of stressors other than cancer that are taking priority in their lives, such as, caring for an infant. Their coping behaviors are confined to problem-solving, rather than sharing of emotions. They rarely communicate about existential issues or the future but are focused on the practical demands of daily living.

This relational coping pattern was poignantly demonstrated in an interview with a couple who recently had a baby and stated that caring for the baby took priority. They were not talking about the emotional issues around the cancer and seemed to show very little support of each other in their coping. The husband at one point in the interview described in detail a very difficult time for him around the diagnosis and the uncertainty of it. At the end of his lengthy and emotional response, his wife simply said to the interviewer, "I forgot the original question." She did not acknowledge his feelings or what he had said.

This couple's avoidance of dealing with the cancer directly also carried over to not talking about it to their families. The patient's mother had lost her own mother at a young age. The patient stated, "... probably I just try to gloss it over so that it wouldn't be as difficult hopefully for her." Just as the partners were protecting each other from their stress, they were also buffering their parents and siblings. Their own disengagement led to disengagement from others.

Outcomes

When disengaged avoidant couples were asked if anything positive had come from this diagnosis, the typical answer was either nothing or something related to each individual. The following illustrates this type of response:

Patient. Yeah, I hear a lot of people saying that cancer makes them stronger but I'm not convinced.... When I first heard the diagnosis, I thought we would come out the other end better people--but now that we are almost near the end--I don't think it's any different--I mean I hope we were already good people going in ...

Rarely, did these disengaged couples mention how the cancer strengthened their relationship. If they were closer, they would not attribute it to going through the cancer experience.

Patient. Good? [long pause] No, not at all. We could have gotten here, slowing down and spending more time together in another way.... I don't see any good from that.

In summary, the relational qualities of the couples seemed to play a pivotal role in the type of pattern of coping the couples described. The mutually responsive couples had the relational qualities of relationship awareness, authenticity, and mutuality. Partners did not always respond perfectly with the support they desired from each other, but their authenticity and mutuality allowed them to make the necessary changes to cope more effectively as a couple. These characteristics facilitated a type of relational coping that included the participation of both partners together in the coping process. In contrast, the couples who used a disengaged avoidant style of coping in relation to the cancer seemed to have developed a mutual respect for each other's individual response to the illness that did not necessarily include the demonstration of the relational qualities of relationship awareness, authenticity, and mutuality.

DISCUSSION

The first purpose of our study was to examine how couples describe their coping with breast cancer. Our analysis revealed that couples followed a process of coping that was similar to the Lazarus and Folkman (1984) model of stress and coping and Bodenmann's (1995, 1997) systemic-transactional model. The couples described a process of coping that involved appraising and responding to the stress, coordinating their coping efforts, and finding meaning out of the experience. When listening to their narratives, we identified two patterns of relational coping. The first pattern, mutual responsiveness, involved the couple defining the cancer experience as a dyadic stressor--a "we-stress"--that affected both of them. The partners communicated their response to the stress to each other and they listened and supported each other's response. Talking openly about their stress allowed them to approach managing the disease in a coordinated way that involved both emotion-focused and problem-focused types of coping strategies. As one participant had expressed it, each partner was not running off "doing their own thing" to cope with the disease. Couples who coped in this way identified benefits to the cancer experience both as building the strength and resilience of the individual and enhancing the closeness of their relationship. These findings are consistent with earlier studies that found resilient couples had a philosophy that they were "in it together" and talked openly about cancer (Skerrett, 1998). Similarly, Manne, Ostroff, Rini, Fox, Goldstein, and Grana (2004) found that open communication positively affected the psychological adjustment for both cancer patients and their spouses.

The second pattern of relational coping, disengaged avoidance, occurred when couples appraised the stressor as individual stress, affecting each of them individually and not as a couple. Disengaged avoidance also occurred when couples were not appraising that the cancer was stressful as was the case with some couples that stated there were other stressors in their lives that overshadowed the cancer. When couples were using this type of relational coping, they avoided talking about the cancer and their coping efforts were typically problem-focused coping behaviors that involved dealing with practical tasks of the cancer and not the emotional experience. Disengaged avoidant couples had difficulty finding any personal or relationship benefits from the cancer experience. Although the avoidance coping strategies may have been an effective way to deal with the pile-up stresses that some of the couples were experiencing, previous research has found that among breast cancer patients and their partners this type of coping may have some negative consequences including lower relationship satisfaction and mental health (Ptacek et al., 1994). Avoidant coping is also associated with unsupportive behaviors (Manne, Ostroff, Winkel, Grana, & Fox, 2005) and more distress for patients and partners (Manne, Ostroff, Norton, Fox, Goldstein, & Grana, 2006).

The second purpose of our analysis was to identify the relational qualities that facilitated the coping as a couple. Although previous research has primarily focused on the types of coping strategies and behaviors of the individual partners (such as problem-focused and emotion-focused), we wanted to investigate other aspects related to the relationship functioning that facilitated coping. In our analysis, we found that these relational characteristics were just as critical to the coping process as the particular strategies that each partner used. These important characteristics included relationship awareness, authenticity, and mutuality. The relational qualities facilitated the communication between the partners so that they could talk about the cancer experience and work out an agreeable way to manage both the emotional and physical demands of the cancer. This is particularly important for inexperienced couples who have not faced major illnesses or stressors in their lives together. Couples will not always know when they first receive the diagnosis how they will be coping over the long haul--a dyadic approach to coping with the illness will evolve over time. Previous research on coping among couples has focused almost exclusively on the coping strategies used by each individual, without acknowledging the qualities of the relationship that foster or hinder the coping process.

Relationship awareness, as we define it, involves thinking about one's relationship in the context of the illness. It includes thinking about the impact of the disease on the partner and the relationship and how to sustain one's relationship given the extra demands of the illness. Viewing the impact of the disease on the relationship helps partners to approach their coping in a common way--together not alone. Previous studies have found that women are more likely than men to be aware of the relational context (Acitelli, 1992). We found that with our couples in which the wife had an illness, the husbands were more likely than the wives to talk in reference to the relationship and engage in relational talk when appraising the stress. This may be a result of the stress being an indirect stress for the men (the women have the disease) and thus, the appraisal of the stress includes the wife (patient) in relation to themselves (husbands). For the wives, the focus is more likely on her own physical and emotional well-being because they are dealing directly with the stress. This is not to say that the women were not aware of the effects of their illness on their partners, but the stress (e.g., pain, surgery, treatment side effects) was experienced more directly by the patient and indirectly by the partner.

A worthwhile direction for future research may be the analysis of "relationship talk" of the couple to examine whether partners who talk more about their relationship are more likely to view cancer as a "we-disease" and coordinate their coping efforts together. In previous research with couples coping with lung cancer, patients and partners who talked with each other about their relationships reported fewer constraints and better communication about cancer (Badr & Taylor, 2006).

Authenticity was another relational characteristic that was identified as facilitating coping in the narratives of the couples. Because coping with a serious illness can be a new experience for couples, it is critical that each partner has the ability and desire to be honest and open with their feelings and needs. Authenticity has been defined as the disclosing of genuine feelings and not hiding them (Spencer, 2005). In the context of the cancer, authenticity appeared to facilitate the relational coping by allowing partners to be aware of each other's feelings and needs in relation to the cancer and ultimately, helped them to respond to these needs in an effective way.

The third relational quality identified in the narratives was mutuality. This characteristic involves empathy and a way of relating in which each of the partners is participating as fully as possible in a shared experience (Jordan, 1997). Mutuality fosters effective coping by providing the emotional support needed to deal with the anxiety, sadness, fears, and other emotions related to a serious illness. In a previous study, we found a woman's ability to cope with a stressor like breast cancer was positively reinforced and enhanced by mutuality in a close relationship (Kayser, Sormanti, & Strainchamps, 1999). When coping effectively, not only will a woman feel a greater ability to handle the stress, but her close relationships will move toward a greater sense of well-being.

IMPLICATIONS FOR FUTURE RESEARCH

A shortcoming of our study is that the small sample size limits the generalizability of the study findings. In addition, the homogeneity of our sample does not allow us to make conclusions about the influence of other cultural contexts on the coping process. However, we acknowledge that the differences in culture, family structure, and class determine the unique ways in which couples adapt in stressful situations (Genero, 1994). Empirical research on the cultural context of coping with stress is scarce and needs to be a direction for further research.

In considering the influence of culture, we recommend that researchers expand their thinking beyond categories of ethnicity or race to fundamental constructs that underlie cultures and shape the perceptions, beliefs, and social behaviors of members who share a common culture. These constructs are organizing principles and the basic structures that define the culture (Hardy & Laszloffy, 2000). (1) There are numerous organizing principles operating in cultures but one construct that would appear to influence dyadic coping is the concept of self as independent versus self as interdependent. This is a construct that distinguishes Western (American and European) from Eastern (Asian) cultures. A society or culture that fosters the independent self is known as individualistic, egocentric, separate, autonomous, or self-contained (Markus & Kitayama, 1991). The hallmark of individual growth is self-actualization (Maslow, 1999) or "developing one's distinct potential" (Markus & Kitayama, 1991, p. 226).

By contrast, cultures that promote an interdependent self assume that human beings are essentially connected to each other and that this connection among individuals must be maintained in order for "the self" to be complete. In other words, the person is fully human only in relation to others (Markus & Kitayama, 1991). This type of culture is also referred to sociocentric, holistic, collective, allocentric (Markus & Kitayama, 1991). Future research could examine how the cultural dimension of independent versus interdependent self affect the process of couples coping with stress.

In addressing the monocultural perspective of coping, we need to develop valid measures of coping that can be used with culturally divergent participants.

Researchers are often challenged by whether they are measuring true cultural differences on one variable or whether their instruments are measuring different variables as defined by the cultural context. Typically, researchers have two options--either using a measure from one culture and applying it to another (etic methodology) or developing indigenous measures for each culture (emic methodology). A third alternative is using an etic-emic procedure in which a standard coping measure is modified to include items especially relevant to participants from another culture (Tweed et al., 2004). This procedure allows the etic advantage of using the same measure in both cultures and the emic advantage of making the measure relevant for participants from the other culture.

Ethnographic methods may also be useful in investigating the influence of the cultural context on dyadic coping. Repetti and Bradbury's (2005) research in which they videotape dual earner couples in their homes is an example of this method. Specific questions to be explored in using ethnographic methods include: How do sociocultural influences foster or hinder relational coping? Do partners access support from different types of relationships? In what ways does the cultural context limit participating in the relational coping process? How is relational coping related to quality of life? What types of formal help could benefit couples from divergent cultures? Learning more about the context in which relational coping occurs will help further our understanding of the ways in which we can assist couples to manage cancer as a "we-disease."

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KAREN KAYSER, PHD

LISA E. WATSON, MSW, LICSW

JOEL T. ANDRADE, MSW

(1) To paraphrase Kluckhohn (1949/1985), culture is the total way of life of a group of people; a way of thinking, feeling, and believing; a theory about the way in which a group of people in fact behave; a set of standardized orientations to recurrent problems; and a set of techniques for adjusting both to the external environment and to others.

Karen Kayser, PhD, Lisa E. Watson, and Joel T. Andrade, Boston College.

This research was supported by a grant from the Massachusetts Department of Public Health Breast Cancer Research Program. We thank Renee Spencer, Jane Gilgun, and Tracey Revenson for their valuable comments on earlier drafts of the manuscript.

Correspondence concerning this article should be addressed to Karen Kayser, PhD, at the Graduate School of Social Work, Boston College, Chestnut Hill, MA 02467. E-mail: kayserk@bc.edu
Table 1
Relational Qualities Identified in Analysis

Characteristic     Definition

Relationship     Thinking about one's relationship in the context of
awareness          the illness; thinking about the impact of the
                   disease on the partner and the relationship and how
                   to sustain one's relationship given the extra
                   demands of the illness
Authenticity     Disclosing of genuine feelings to your partner; not
                   hiding feelings from partner
Mutuality        Empathic responding; a way of relating in which each
                   of the partners is participating as fully as
                   possible in a shared experience (Jordan, 1997)
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Author:Kayser, Karen; Watson, Lisa E.; Andrade, Joel T.
Publication:Families, Systems & Health
Article Type:Clinical report
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Date:Dec 1, 2007
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