When Spouses Disagree: A Predictor ofCardiac Rehabilitation

Dan Bar-On, Ph.D., and Solly Dreman, Ph.D.

Congruent uersus incongruent causal attributions of spouses were

testid as A mectsure of marital agreement in the rebabilitation ofmale coronary itatients. Sixty-nine male married patients, 50 andunder, admitted at the central medical ceflter in southern lsraelafter their first beart attack, and their wiues were interuiewed tbree

times within a four- to six-month period for their subiectiue causal

attributions and eualuations of the euent. Two similar patterns ofcausal attributibns were identified in patients' and spouses' chaices

of a Q sort at the end of the patient's bospitalization: externaluncontrollable (EUC) and denial (D). Spouses' congruence withpatients' denial accounted for sbort-term conualescence. Hotueuer'

after patients' return to utork and functioning ruas measured frturto six and 18 months after tbe infarct, spouses'incongruence withpatients' denial correlated significantly with long-term rehabili-tation. A similar trend was found with regard to the exter:"al

uncontrollable pattern. These results contribute to the theoreticalknowledge concerning successful uersus unsuccessful family cog-

nitiue coping mechanisms and suggest a model for researcb and

interuention in auersiue life euents.

A number of investigators have explored the issue of how interpersonalrelationships influence people's responses to aversive life events. Many ofthese studies have clearly demonstrated a relationship between perceived

social support, especially of family members, and effective adjustment to the

event (15). It is widely accepted that marital support involves the expression

Dan Bar-On, Ph.D., is a lecurer in the Department of Behavi<.tral Sciences, Ben Gurion Univer-sit1".

Sollv Dreman, Ph.D.. is a senior lecrurer in the Department of Behavioral Sciences, and director of the

Steiners' Center for Single Parent Families, Ben Gurion University, lsrael.

This paper is based Ln Dan Bar-On's unpublished Ph.D. dissertation at the Hebrew University-' Je-

rusalem. Th. pr.r.n, analysis *'", .rpported by a grant of Ben Curion Universitv. I r,r'ish to thank Dr.

N. Crisral, Prirfessor P. Hare, Profess& Z. Klien, and D.. E. Orr for their helpful comments on earlier

versions of this paper, and Ms. C. Galai and lv{s. Z. Barneis for their helpful editing and wping.

Family Systems Medicine, Vol. 5, No. 2,7987 O FSM, Inc'

\(hen Spouses Disagree: A Predictor of Cardiac Rehabilitatkm 229

of positive affect and respecr (5). However, rhe data concerning the cognitivecomponent of marital support is inconclusive. Some researchers emphasizethe importance of agreemenr and acceptance (7). others stress rhe possibledeleterious effect of processes rhar encourage false hopes or denial. This, inturn, makes it difficult ro accepr reality and may impede effective recovery(17).

The present study will focus on how interspouse agreement on attributionof control over external events of the male patienr accounts for rehabilitationafter myocardial infarcrion.

certain family theorists identify families according ro rhe rype of psycho-logical "contract" between the partners: Is it based on congruence, com-plementarity, or conflict (13)? Subjective interpretation of the critical eventby its victims may determine the merit of a congruent versus complementaryor conflicting (incongruent) opinion of the spouse. Ir is not, for example,the same to agree (be congruent) with a spouse who denies an event's con-trollability as it is to agree with a spouse who sees the same event as con-trollable.

In contrast, there are certain aversive events with an initial acute phasein which a person struggles for his life, and in which a cerrain amount ofdenial and feelings of unconrrollability are functional (8, 12). In this phase,agreement with the victim may be helpful. Larer on, during long-term re-habilitation, such congruence can become dysfunctional and hinder recovery(18).

In order to invesrigate these questions, the setting of first myocardialinfarction (MI) was chosen. It is usually a sudden crisis, with an acure anddangerous phase of two to three weeks, followed by a short period ofconvalescence (one month) and further rehabilitation (four to six months)(6). In an earlier study (3), causal attributions of coronary patienrs at theend of hospitalization were found to be related to consequent rehabilitationoutcomes, even when other independent variables were controlled (level ofeducation, severity of the MI). It was reporred (2) that patients' denialaccounted for short-term convalescence. However, in the long run, patientswho attributed their infarct to external unconrrollable factors or who deniedit were less likely to return ro work and to adequate physical and sexualfunctioning after six monrhs and one-and-a-half years. The above study didnot consider, however, that the MI of the husband is an aversive life eventfor the wife, too (9). She is afraid of losing her husband, her security isthreatened, and her sexual life becomes stressful. It is difficult for her todecide when to accepr and agree with her patient-husband and when toconfront and disagree with his attitudes. For example, under certain cir-cumstances, the heart patient might present amributional patterns that provedetrimental to the victim's recovery and need to be balanced by the incon-gruent recovery-amenable attitudes of his spouse.

In summary, the present study focuses on the congruence of causal attri-butions of spouses with rhose of coronary victims as a measure of marital

230 Family Systems Medicine, Vol. 5, No. 2, Summer 1987

agreement, and on its influence on the rehabilitation process and outcome.

More specifically, it is hypothesized that:

1) Attributions of lack of control over one's environment by the patient,

accompanied by incongruent spouse attributions, will in the long run be

positively related to patients' rehabilitation.2) lnterspouse congruence with regard to attributions of high control over

.rternil events will be positively related to patients' long-term rehabili-

tation.3) In the acute stage (one month), the congruence mode between patients'

and spouses' aft;ibutions will predict better convalescence, regardless ofthe subjective interpretation of the critical event's controllabiliry.

METHOD

Subiects

The subjects were 69 male married patients, aged 34-60, with no previous

history of chronic disease, who were admitted to the Intensive Coronary-Care iJnit (ICCU) of the Soroka Medical Center in Beer Sheva, Israel, be-

tween 1978 and 1980, with their first MI. These were all the male marriedpatients who came to the check-up clinic after six months out of a totalsa*ple of 79 married patients, and out of the 96 patients who were admitted

to the ICCU during this period. No significant differences were found be-

rween the 59 married patients and the other 27 patients in any of the variables

(e.g., physical risk factors, severiry of the MI, level of education, attribution,oriehabilitarion measures): The range of chi square values was .A05-2.44(df : 1, N : 59, 27). Lll the wives of these patients, aged 32-57, were

also interviewed. In 35 of the couples, both partners were of 'Western origin;in 29 couples both partners were of Eastern origin; and five couples were

mixed. The average education of the patients was 10.24 years of schooling,

while the spouses' level of education was significantly lower-8.9 years on

the average (r{571 : 2.20,p < .001). while all of the patients worked priorto the infarct, only 29 of the spouses were employed (part- or full-time) at

the same time.

lnstruments : D ependeni Measures

Sbort-term conualescence measure (STC): Physicians, at the first check-

up clinic, about one month after the patients' release from the hospital, were

"ik.d to rate their patients according to their physical condition on a five-

point scale (1 : much worse compared to pre-Ml, 3 : about the same, 5

: much better).Rehabilitation outcome medsurei A factor analysis of 13 patients on dif-

ferent rehabilitation measures yielded one predominant factor, which we

\\'/.,c1 .\pr;rr,ir,-s l)i-s.r.grcc: .4 Pretlictor oi (..trdr,tc Rcltaltilitttiotr

defined as return ro work and functioning (RWF) (see Appendix A fordetails). The return ro work and functioning measures were composed pre-dominantly of the patienrs' self-rating of phvsical, sexual, and work-loadfunctioning, compared w,ith the functioning before the MI, on three nine-point scales ranging from "much better" through "same as before" to "muchworse." It also included a five-poinr scale of self-rating rhe exrent to whichthe patient returned to work (1 : does not work atall,2: srarred to workbut had to stop because of my heart, 3 : work about four hours daily,4: w'ork about eight hours daily, 5 : wor,k extra hours dailv).

lnstruments: lndependent Measures-Causal Attributions

A special Q sort was developed for the heart-attack research. It consisredof 20 answers to the question "!7hv did it happen ro you?", and another20 answers to the question "Whar will help you cope with it?" Answerswere formulated on rhe basis of responses ro these questions gathered atpretest interviews with post-Ml patients. Four independent rarers agreedthar each of these items could be identified by a specific combinarion of thefollowing categories: 1) internal-exrernal, conrrollable-unconrrollable (19),- nd 2) denial-acknowledgement of the MI. An idenrical Q sort was srrucuredfor the patients' spouses ("!fhy did it happen ro him?", "Whar will helphim cope?", etc.).

Procedure

Subjects were inrerviewed three times: toward the release from the hos-pital, about two to three weeks afrer the infarctl after the first check-upclinic, about one month later, when patients came to find out about theirpossible return to work; and at a regular check-up clinic, about four to sixmonths after the infarct. During the first inrerview, rhe Q sorr was admin-istered to all 69 parients and their wives. At the second inrerview, parienrsand their physicians were interviewed for the short-term convalescence meas-ure. Sixty-four patients and 11 physicians-each of whom treated four ro11 patients-were interviewed at this srage. At the third inrerview, data weregathered about the rehabilitation ourcome measure (R\fF), and the inter-viewer asked the patient about the rehabilirarion process: Did he inrroduceany changes after the infarct? Did he use rhe help of wife or other familymembers in this process?, etc. Sixry-nine patients and 69 wives came ro thischeck-up clinic. All subjects were asked ro reporr by mail 18 months later,following their return to work, to update information on rheir functioningcriteria. Thirty-five patients senr back rhis report.

The author, together with two of his undergraduate psvchology srudenrs,conducted all rhe inten iews.

2lt

232 Family Systems Medicine, Vol. 5, No. 2, Summer 1987

RESULTS

Dependent Measures

Physicians' and patients' ratings correlated significantly on'both the STC(r : +.66, p. <.001) and the RWF 1r : +.85, p <.001). The intercor-relation between STC and RWF was also significant (r : *.37, p. <.005).

lndependent Measures

Subjects' choices on the Q sort were factor-analyzed. Two similar factors"external controllable" (EUC) and "denial" were identified in both the pa-

tient and the spouse populations in which the highly loaded items wereidentical. The patients' denial cluster correlated positively and significantlywith short-term convalescence measure (r : +.35, p<.01). However, a

negative correlation was found between EUC and the rehabilitation criteria

groups, according to their score split at the median on each cluster. Spouses'attributions on a given cluster were defined "congruent" when both scoredhigh or low on that cluster. Their attributions were defined as "incongruent"when they were assigned to opposite high/low groups on a given cluster.

The effect of the different attribution measures on the to criteria was

tested in a stepwise multiple-regression annalysis. Patients' and spouses'attribution clusters accounted independently for 1.3.6% of the STC and 13%of the R'\J7F variance.

Marital Agreement : Sbort-Term Conualescence

In a one-way analysis of variance, significant relations were found betweencongruency of spousal attribution patterns and STC (p <.008 for denial,and p < .05 for EUC). It was found by utilizing planned comparisons thatwhen patient and spouse were congruent (high-high denial scores), they hadbetter STC scores than high-low, low-low or low-high spousal denial attri-butions (p < .05). With regard to EUC attributions, congruence of spousevs. patient attributions, whether high or low, yielded marginally significanthigher STC scores (p < 0.81).

Marital Disgreement: Long-Term Rehabilitation

Incongruence of denial attributions had diametrically opposed irnplica-tions for long-term rehabilitation (RWF) versus short-term convalescence(STC). At four to six months incongruent modes yielded marginally higher

Note: A detailed description of the statistical procedure and relevant tables can be obtained by writingdirectly to Dan Bar-On, Ph.D., at the Department of Behavioral Sciences, Ben Gurion Universiry, Beer

Sheva, lsrael 84105.

t

lilhen Spouses Disagree: A Predictor of Cardiac Rehabilitation 233

RWF mean scores (p<0.10) when compared to the congruent modes of highor low denial. In contrast to the STC findings, the patient "high"denial/spouse "low" denial mode yielded significantly higher R\UF scores(p<.05) than the "high-high" mode. Spouses' congruent attributions of low'denial yielded significantly higher R'S7F scores as compared to congruenthigh denial (p<.001.) Similar trends were found after one year.

As for EUC attributions, significant effects were found for the mean R'S7F

scores measured four to six and 18 months after the infarct (p<.01 andp<.003, respectively). These trends, while not as strong as for the denialattributions, showed that spouses agreeing about low external uncontroll-ability (EUC), or disagreeing as reflected in high-low (patient-spouse) EUC,demonstrated higher RSTF scores.

In summary, in the short term, spouses' congruence with patients' high-denial attributions or congruence to either high or low EUC accounted forpatients' convalescence. In the long term, marital disagreement, measured

by attributional incongruence, accounted for patients' rehabilitation. Incon-gruence of the spouses' attributions with the patients' high denial or highEUC score was found to be a predictor of long-term coronary rehabilitation.

DISCUSSION

Congruent versus incongruent causal attributions of spouses were tested

as a measure of marital agreement in the convalescence and rehabilitationof patients after a first heart attack. As predicted, the short-term conva-lescence was more affected by the degree of congruence between the patientsand their spouses, regardless of attributions' content, while the time-ex-tended rehabilitation outcome was more affected by the content (adaptivity)of the patients' attributions. Thus, in the long run, incongruence of spouses'attributions were of merit when the patients tended to deny the infarct orto attribute it to external-uncontrollable factors. This difference was clearlydemonstrated in the denial attributions. Thus, in the short run, the spouses'congruence with "high" denial attributions of their husbands was relatedto better convalescence. In the longer rehabilitation period, however, thiseffect was reversed and incongruence of the couples' denial pattern waspositively related to patients' return to work and functioning, especiallywhen the patient denied the aversive event. This finding supports the findingsof earlier studies concerning the relative values of patients' denial in differentstages of the illness (2,4,8). They emphasize the positive function of denialin the acute early phase. They also emphasize the relative dysfunction of thedenial mechanism in the later rehabilitation process, when patients have tocope with the more realistic implications of their illness. Our findings addto this model of denial that patients' inability to be flexible with his/herdenial attributions may be modified by a spouse's incongruent (in this case

low denial) attributions.For the "maladaptive" (EUC) attributional style, congruence of scoring

: )a L.lrrih,.\1,-(r.,,//-s l\Iedicitre. \'r.r/. .i, \o. 2. \untnrer lt)g7

"low" on rhis scale (e.g., high conrrollabiliry of the event) was positivelyrelated to both short-term convalescence and iehabilitation measures. Again,this finding is.-supported by earlier works on rhe negarive effeo of exrernaland uncontrollable attributions on the well-being ofiicrims of crirical aver-sive life evenrs (15, 16).

.A previous report (3) stressed the importance of padents, ..theories,, about

critical events on their3ubsequent rehibilitation. ih. present analysis shedssome new light on.rhe influence of spousal attributions a.rd rgreement ona specific critical life event. The idca of measuring congruenr versus incon-gruent spousal attributions to a critical event anJtheir"effects on rehabili-tation rnay lead ro some important more general distinctions.

The above research _suggests that mariial agreement does not necessarily

lead ro "general well-being" in the long .unl r$7hile it may provide som!short-term "harmony" and feeli.gs of "well-being,', the long-iange realidesmav cancel out short-term benefits. A recent ..poit about lorig-term survivalof.dialvsis patients (11) found rhar noncoordinating families and noncom-pliant padents survived longer. Reiss et al. conclude"that

recent studies suggest thatmost families dealing rvith the firsr phase ofsevere illness tend to coalesce around the illiess and become morecloseli, integrated and ried together to deal with its pervasive and pro-tean demands- However, high coordination, through an affecdve re-sponse ro an acure medical emergency, if it persists miy make the familymore vulnerable in the. long run. If family -e*beis remain highlyengaged with one anorher, particularry if ihey focus heavily on"th!needs of rhe chronically ill members, irrdependent needs of others inrhe family go unanswered (11, p. 802).

satir (14), in discussing_couples and communicarion, suggesrs that rhereare. many couples in which one parrner expecrs the other l-urrn., to rhinkand act the wav they do in a variety of situations. such ,gr..-..r, is oftenadaptive. and helps the couple live together and develop. Th"e problem is thartoo much agreement or a "clutch" situation, as Satir describei it, may crowdout.social or objective realities and lead to maladaptarion and'perhaps pa_thology in the family. For example, a coupre that insists rhat their 1g'-y.rr-old daughrer come home at 11 o'clock on saturday night may in the ihortrun be satisfied about their decision. However, if the iaughter runs awaybecause. the. exisring social reality in the communiry permitf one A.M. as anacceptable hour, the long-range resulr of the parinial acrion is obviouslycounterproductive. on rhe physiological objective level, this is parallel to thecouple's congruenr short-term denial of the cardiac infarct, *hi.h may leadto short-term improvement and harmony, but ultimarely will result in long-term pathological dererioration because of nor dealing with the physicllrealities and dangers of the cardiac situation.

sager (13) also speaks abour marital agreement and how expecrations and

When Spouses Disagree: A Predictor of Cardiac Rehabilitation

attributions in the marital dyad may affect both short- and long-term ad-justment of the respective partners. Agreement does not necessarily meana congruent behavior or belief system. Thus, in many complementary re-lations, we may have a situation where one spouse is realistic while the otheris romantic, one spouse is assertive while the other is more passive, one ismore sadistic while the other is the sufferer, etc. In such cases, where acouple "agrees to disagree" or to be different and where mutual benefit isinvolved, this often works out well. 'lfhere there is no agreement, implicitor overt, between the spouses, we may have real conflict and trouble. Aparallel to this situation may exist in the findings of the presenr research.Thus the wives' incongruent attributions were of merit in long-term reha-bilitation when the husbands tended to deny the severity of the cardiaccondition. This might be similar to the realist and the romanric comple-mentary dyad in which one partner's deficiencies are made up for by theother's merits. One might hypothesize that incongruency or disagreementwould be more adaptive when a couple "agrees to disagree" than in a

situation where the couple disagrees but there is no agreement ro do so, inwhich case we would have what Sager (13) describes as a conflict situation.

Thus, agreement is a multidimensional variable and dependent on suchvariables as 1) the type of agreement,2) the type of disagreement,3) social(including psychological) realities, and 4) objective (including physical) real-ities. We must consider all of these in determining under what conditionswill marital agreement be effective in the couple's life space. Also, the cor-onary setting can be seen as a conflict situation in which patients have toaddress themselves simultaneously to two conflicting messages: "You candie from it" and "calm down, you can be careful-return to normal lifewithin a few months." While emphasis on the first message by the dyadmight lead to maladaptive attributions of one kind (high-high-EUC), srress-ing the second message might lead to a different kind of maladaptive attri-bution (high-high-denial), especially in the long run.

"Effectiveness" of cognitive sryle in aversive life events can, therefore, bedefined as the flexibility to move from one style to another according to thechanging demands of the situation (16). Once the situation is more carefullydefined, one can suggest a specific mode, or husband-wife "fit" of attri-butions, and test their relationship with the criteria. Such a paradigm willenable researchers to move ahead in answering the question concerning whattype of spousal behavior is effective in different settings, as opposed to themore questionable generalizations such as "agreement" or "help" (15).

This paradigm can also be useful for planning and evaluating interventionsin aversive life events. A differential model of intervention might be devel-oped that would suggest different levels of intervention in the particularsetting (acute, chronic), content of the dominant attributional style ("adap-tivity" to the setting, flexibility), and mode (congruence versus incongruence)between the victims and their close social supporters. Certain combinationsmight need no interventions at all (congruence of low-low-EUC). Others

2t5

235 Family Systems Medicine, Vol. 5, No' 2, Summer 1987

might need mild interventions (helping couples move from congruent high-high denial to incongruent high-low denial when the setting changes). Stillothers might need intensive therapeutic intervention (congruent high-high-EUC).

These results should be carefully replicated and cross validated with a

larger sample. Some of the issues that future research should address include:

relarions between different attributions within subjects, the different effect

of the two forms of incongruence (high-low, lo'v-high) in spouses' attri-butions, and the specific process through which causal attributions of pa-

tients and their spouses at an early stage of the illness may affect the

consequent rehabilitation of patients. The previous report suSgests that the

planning and implementation of changes by the patients and the involvementof the spouse in this process may intervene between the early attributionsand forthcoming rehabilitation outcomes.

APPENDIX

Factor Analysis of Rehabilitation Measures

Return to work6< functioning'

RehabilitationFactor

Eigenvalue

Reh abilitation measure s

1. No. of referrals to hospital due toheart condition

2. No. of rehospitalizations due to

(41%h)

5.82

heart conditionNo. of reinfarctionsLevel of medicationChest painBreath shortagePhysical functioningSocial functioningSexual functioningLevel of functioning at workReturn to work (in hours)

Evaluation of physical condition since

hospitalizationEvaluation of mental condition since

hospitalization

"Name given to factor according to the high loaded iterns.hPercentage of explarned variance of factor anal,vsis.

J.

4.5.

6.7.

8.

9.

10.

1,1,.

12.

13.

.10

.04

.05

.11

.1,9

.t2

.57

.2s

.56

.74

.74

.24

.1.7

It.

2.

\\'ben Spouses Di,sagree,: A Prctlictor oi Carr!iac Rehabrlrtatton 237

NOTES

1. For details of the developmenr of the RWf scale and other instruments used in thisresearch, see Bar-On (198 I ).A^full description of the Q sorr appears in the appendix of Bar-on, Family physician,t981, 1 1, (2),220-232.

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Bar-On, D. The "wh)"' and "how" of a real life cnsis: Patients' causal attributions andpredictions ab<lut rheir first heart attack. Unpublished docroral disserration, HebrewUniversitv, Jerusalem, 198 l.Bar-on, D. Differenr types of denial account ior short- and long-term recovery of cor-onari- patients. lsraeli Journal of Psychiatr.v and Related Sciences, 1985,22, (3),t 5 5-17 2.Bar-On, D. Causal attributions and rehabilitation of heart attack victims. Journal ofSocial and Clinical Psychology, rn press.Breznitz, S. The seven kinds of denial. ln s. Breznitz (Ed.), The denial of s/ress. NewYork: lnternational Universitv Press, 1983.

5. Cobb, S. Socral support as a moderaror of life stress.J8, .100-.114.

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6. Croog, s. H., & Levine, s. Life after t heart attack. New york: Human sciences press.1982.

_Kah1, R L. Aging and social support. In \{. \X,hite Rilev (Ed.), Aging irom birth todeatb: lnterdisctplinart' perspectire. Boulder, CO: V,esrview Press, 19791Krantz. D. S.. & Schultz, R. Personal control and health: Some applications to crisis ofmrddle .rnd old age. ln J. srnger & A Baum tlF,ds.'t, Adt,ances in enL'tionmental psycbology.Hrllsdale. N.[: L;rr'rencc Frlhaunr Assocrates, 1980.\l;rou. R. S.. Foster. .\.. Er \\ illiamson. B. Psvchological and social effects of mvocardialrnlJrjtrun un \\r\es. Brrtt:1. .\fuJt;Ll l.,urrtil,l9-8, I.699--0 l.\.rrr:. R, \1.. tsrandt. P. U . T.. C;ughcr. D. E., Lee, A.J., S{ Scott, p. J. A ncw coronaryprognosrr. rnder. L,rircer. 1969. 1.l-4-2i8.Reiss. D.. Gonzalez. S.. & Kr:mer, N. Iamilv process, chronic rllness and dearh. Archit,esoi General Psychiatrt,.1986, 4J, i8r. -95-80,1.Rorhbaum, F., Vertz, J. R., & Sn'der. S. S. Changing the *.orld and changing the self:A. two-process model of internal vs. external control of reinforcernent. fsyihologicalMonographs, 1982, 8, (50), 196.sager, c. J. Marriage contracts and couple thelapv. New York: Brunner/Mazel, 1976.Satir, V. Peoplemakmg Palo Alro, CA: Scrence & Behavior Books, 1972.Srl'er, R. L., & $Iortman, C. B. Coping w,irh undesirable life events. ln J. Garber & NI.E. P. Seligrnan i,Eds.i, Hum.trr helplessness. New York: Academic press, 1980.Tavlor, S. E.. It could be worse. .Sr.scial lssues, rn press.Visotskr', H. N'1., Hamburg, D. A., Goss, M. E., & Lebovirs, B. Z. Coping behaviorunder extreme stress. Arcl:it.,es of General Pst,chiatry,,l961, i, 423448.Watzlau,rck, P., V'eakland, I. H., & Fish, R. Chaige, principles of problem formationand problem resolutions. New York: W. W. Norton. 1974.Weiner, B. Achieuement motit,atiotr and attribution theort.l\.1orristown, NJ: GeneralLearning Press, 1 974.

Requests for reprints should be sent to Dan Bar-On, Ph.D., Department of Behavioral Sciences, BenCurion Universitv, Box 553, Beer Sheva, lsrael 84105.

1.

2.

.1.

4.

8.

9.

10.

11.

12.

13.14.15.

16.17.

18.

19.

rI

I