The authors investigated emotional (empathy) and problematic (minimizing) support exchanges between 243 women experiencing a lupus flare-up and their husbands. Husbands and wives reported the amount of support they provided to each other and the extent to which they felt the support they received

from partners was emotionally responsive (validating). The authors expected individuals' perceptions of spouses' emotional responsiveness to mediate the relationship between support and psychosocial well-being. As predicted, more spousal emotional support was interpreted as being more emotionally responsive, which in turn was associated with better well-being. In contrast, more problematic support was interpreted as being less emotionally responsive, which in turn was associated with poorer well-being. Couples who are able to meet each others' emotional needs may experience better adjustment when coping with chronic illness.

Keywords: emotional support, emotional responsiveness, depression, marital satisfaction, chronic illness

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The incidence of chronic illness is rising in the United States, with more than half of chronically ill individuals being middle aged (Hoffman, Rice, & Sung, 1996). It has long been acknowledged that chronic illness significantly affects the well-being of both patients and their families. In particular, the marital relationship has been shown to exert positive effects on individuals' psychological and physical well-being during times of chronic stress, such as the stress of chronic illness (Burman & Margolin, 1992). Theory and research have suggested that when faced with a chronic or life-threatening illness, the extent to which marital partners feel that their emotional needs are being met is associated with each partner's psychological well-being and marital satisfaction (Cutrona, 1996). The present study examines how feeling understood and respected in response to spousal support (i.e., perceived emotional responsiveness) may mediate the relationship between support and psychosocial adjustment (i.e., depressive symptomatology and marital satisfaction) in couples living with wives' systemic lupus erythematosus (lupus).

EMOTIONAL AND PROBLEMATIC SUPPORT

Emotional support can be defined as attempts to alleviate or prevent another's negative affect (Heller & Rook, 1997). When providing emotional support, individuals will often express empathy, understanding, care, and concern (Stephens & Clark, 1997). Research has consistently shown that individuals who receive higher levels of emotional support have better psychological and physiological health (DeLongis, Capreol, Holtzman, O'Brien, & Campbell, 2004; Uchino, 2006). Moreover, emotional support has been linked to lower rates of morbidity and mortality (Berkman & Syme, 1979).

Although emotional support is most often provided with benevolent intentions, it is not always perceived as such by those who receive it (Coyne, Wortman, & Lehman, 1988). In this way, emotional support attempts may sometimes backfire and become problematic. Problematic support involves one person minimizing, criticizing, ignoring, or withdrawing in response to another's problems or feelings. As a result of these behaviors, receiving problematic support often has adverse effects on individuals' well-being, especially when the support underestimates or minimizes their stress (DeLongis et al., 2004; Manne & Glassman, 2000). Although problematic support typically occurs less frequently than emotional support, it often has a stronger impact on adjustment than emotional support (Rook, 1990).

EFFECTS OF CHRONIC ILLNESS ON COUPLES

As a result of their illness, chronically ill patients often experience elevated levels of stress. Patients' daily activities are often limited by their illness, many patients experience frustration about the unpredictable course of the illness and its symptoms, and many have fears about their future (Revenson & Majerovitz, 1990). Research has consistently shown that patients experience better well-being when they receive support from a significant other that conveys empathy for and understanding of the stress of their illness. Across a variety of chronic conditions (e.g., cancer, arthritis, stroke, and diabetes), patients who receive emotional support from their spouses have better psychological well-being, whereas patients who receive problematic support have poorer well-being (Helgeson, 1993; Revenson, Schiaffino, Majerovitz, & Gibofsy, 1991; Stephens & Clark, 1997; Trief et al., 2003).

Spouses of chronically ill patients often take on most of the responsibility of caring for the patient (Revenson & Majerovitz, 1991). As such, spouses often have increased distress from the emotional toll of coping with their partners' illness (Revenson & Majerovitz, 1991). In addition, caregiving spouses experience many lifestyle alterations such as having to take over the patient's household and family responsibilities and having less time for social activities and personal health care (Schulz & Beach, 1999). Thus, the spouses of chronically ill patients tend to have more health problems and more psychological distress and are at an increased risk of mortality when compared with spouses of healthy individuals (Bigatti & Cronan, 2002; Schulz & Beach, 1999). Research has shown that spousal caregivers tend to be less depressed when they receive support (Revenson & Majerovitz, 1990, 1991). Although many spouses receive support from family members and friends, they also rely on their ill partner as a primary source of support (Ptacek, Pierce, Dodge, & Ptacek, 1997).

Research has maintained that especially when coping with the stress of illness, couples who are able to reciprocate each others' support efforts are more satisfied with their marriages and are better adjusted to the patients' illness (Cutrona, 1996; Hagedoorn et al., 2000; Manne et al., 2004; Stephens & Clark, 1997). Thus, even though only one partner is ill, both partners are in need of support and both partners are primary sources of support for each other (Coyne & Fiske, 1992; Revenson, 1994). However, most research has examined support that spousal caregivers provide to patients and how this support affects patients' adjustment to illness. A paucity of research has examined the support that patients provide to spousal caregivers and how patients' support relates to caregivers' well-being.

PERCEIVED EMOTIONAL RESPONSIVENESS

Within the marital relationship, social interactions, including support exchanges, are inherently transactional such that one partner's feelings and behaviors influence the other partner's feelings and behaviors. Theory and research have suggested that social interactions are the basis for the development of intimacy (Reis & Shaver, 1988). Intimacy develops through the process of an individual expressing his or her thoughts and feelings to his or her partner and subsequently feeling validated and understood as a result of his or her partner's reactions (Reis & Patrick, 1996; Reis & Shaver, 1988).

One way to explain how social support from one partner manifests itself in the well-being of another partner may be through individuals' interpretations of and affective responses to receiving support. Much research has found that perceived emotional responsiveness is a key component in the quality of interpersonal interactions (Berg & Archer, 1982) as well as the maintenance of intimacy within a relationship (Laurenceau, Feldman Barrett, & Pietromonaco, 1998; Laurenceau, Feldman Barrett, & Rovine, 2005). Individuals are often perceived by their partners as being emotionally responsive when they attend to the communications, needs, wishes, and actions of their partners (Miller & Berg, 1984).

Individuals' perceptions of their partners' emotional responsiveness may be more important in maintaining the relationship than their partners' actual behaviors (Lippert & Prager, 2001; Reis & Shaver, 1988). Women diagnosed with breast cancer who perceived their partners to be more responsive to their needs felt a higher amount of intimacy in their relationship (Manne et al., 2004). In addition, individuals who perceived their partners to be understanding, validating, and caring tended to experience better well-being, less distress, and more relationship satisfaction (Harter, 1999; Reis & Shaver, 1988). Despite this research linking perceived emotional responsiveness to couples' psychological well-being and relationship satisfaction, little attention has focused on the linkages between social support, perceived emotional responsiveness, and psychosocial adjustment.

CURRENT STUDY

Our study focused on women diagnosed with lupus and their husbands. Like many other chronic illnesses, lupus affects all aspects of patients' lives, including psychological well-being and interpersonal relationships (Seawell & Danoff-Burg, 2004). Thus, lupus presents a rich context in which to study marital support interactions. Lupus is an inflammatory, autoimmune disorder that affects the connective tissue and has the potential to damage organ systems that are critical to survival (Hall & Stickney, 1984). The disease is more prevalent in women than in men, and its onset is usually between the ages of 20 and 40 years (Hall & Stickney, 1984). The course of lupus is highly unpredictable and episodic. Patients have periods of remission followed by periods of symptoms that can range from mild to severe in intensity. The most common lupus symptoms include arthritis, fever, and fatigue (Lupus Foundation of America, 2006).

The overarching aim of our study was to examine perceived emotional responsiveness as a mediator of the relationship between spousal support efforts and psychosocial adjustment among married couples living with lupus. Most research on social support in the context of chronic illness has relied solely on patients to report the support they receive as well as their own psychosocial adjustment. Therefore, it is possible that patients' recall of spousal support efforts could be biased by their mood at the time of assessment (Bower & Forgas, 2001).

The handful of dyadic studies in which both partners' reports of support exchanges were assessed have found that spouses do not always interpret each others' support attempts in the same way (e.g., Bolger, Zuckerman, & Kessler, 2000). Thus, our study used a dyadic design and examined the emotional and problematic support that husbands reported providing to wives, as well as the emotional and problematic support that wives reported providing to husbands. In addition, wives and husbands each reported on their own psychosocial adjustment (depressive symptoms and marital satisfaction) and perceptions of the extent to which their partner was emotionally responsive. On the basis of theory and research on emotional and problematic support exchanges in chronically ill couples and the importance of perceived emotional responsiveness, the current study had two hypotheses:

Hypothesis 1: Wives' perceptions of their husbands' emotional responsiveness will mediate the relationship between husbands' support efforts and wives' psychosocial well-being.

Hypothesis 2: Husbands' perceptions of wives' emotional responsiveness will mediate the relationship between wives' support efforts and husbands' psychosocial well-being.

For both of these hypotheses, we expected that emotional support would be associated with perceptions of greater emotional responsiveness. These perceptions, in turn, would be associated with less depression and more marital satisfaction. In contrast, we expected that problematic support would be associated with perceptions of less emotional responsiveness. These perceptions, in turn, would be associated with more depression and less marital satisfaction.

METHOD

Participants and Procedure

Participants were recruited through chapters of the Lupus Foundation of America. After wives were screened for eligibility, husbands were contacted for recruitment. Once recruited, couples were mailed questionnaires and instructed to fill them out independently. To encourage independent responding, separate packets were mailed to wives and husbands.

Because lupus patients who are experiencing an illness episode tend to experience more stress and poorer functioning than patients who are not experiencing an illness episode (Seawell & Danoff-Burg, 2004), wives had to be currently experiencing a lupus episode to be included in analyses reported in this study. An episode was defined as either (a) experiencing lupus symptoms that were serious enough for the woman to contact her physician or (b) having symptoms that persisted for more than 1 week even if a physician had not been contacted. In addition, wives had to be between the ages of 18 and 60, the age range representative of the majority of lupus patients (Hall & Stickney, 1984), and could not have been diagnosed with other chronic illnesses. Finally, wives were required to be married and living with their husbands. To be included in the analyses, we had to have complete data for both members of the couple.

Of the 349 couples who were eligible and participated in the study, data were obtained from 294 couples (84.2%). Of these couples, 51 (17.3%) were excluded because the wife was not currently experiencing an episode of lupus. The final sample consisted of 243 wives and their husbands. To determine whether the final sample of wives and husbands differed from the 51 couples excluded from the analyses, t tests were conducted on sociodemographic variables, and no significant differences were found. However, compared with wives excluded from the analyses (M = 2.14), wives included in the analyses felt that their lupus condition was more severe than the population of individuals diagnosed with lupus (M = 2.39), t(291) = -2.03, p < .05.

Wives were on average 39.4 years of age (SD = 7.8) and had at least some college education (M = 14.6 years, SD = 2.5). The majority of wives were Caucasian (89.0%) and fewer than half were employed (43.2%). Wives had been diagnosed with lupus for an average of 6.9 years (SD = 6.7), and the average length of wives' current lupus episode was 9 months (SD = 0.34). Husbands were on average 42.0 years of age (SD = 9.7) and had at least some college education (M = 15.1 year, SD = 2.8). The majority of husbands were Caucasian (91.0%), and most were employed (97.5%). Couples had been married for an average of 13.0 years (SD = 8.4) and had an average household income of $41,000 to $50,000.

Measures

Emotional and Problematic Support

Wives and husbands were asked how often they used emotional and problematic support efforts in an attempt to help their partner feel better when the partner was upset during wives' most current lupus episode. Measures of emotional and problematic support were adapted from prior research examining what support recipients deemed to be helpful or unhelpful (Stephens & Clark, 1997), such that the instructions were modified to be appropriate for couples coping with lupus. The emotional and problematic support measure has been shown to reliably predict psychosocial well-being in chronically ill patients and caregivers, with Cronbach's alpha levels ranging from .69 to .84 (Fekete, Stephens, Druley, & Greene, 2006; Stephens & Clark, 1997).

The Emotional Support scale included 11 items (e.g., "listened to your spouse talk," "asked your spouse to explain when you did not understand," "asked your spouse to share his or her feelings," "tried to put yourself in your spouse's shoes," "showed your spouse affection," "let your spouse know how much you love and care for him/her"), and the Problematic Support scale included 5 items (e.g., "changed the topic," "encouraged your spouse to stop dwelling on his or her problems," "told your spouse that he or she worries too much," "found a way to avoid discussing the problem"). Items were rated on a 4-point scale ranging from 1 (rarely) to 4 (all of the time). Scores were summed and could range from 11 to 44 for emotional support and from 5 to 20 for problematic support. The mean level for wives' reports of the emotional support they provided to husbands was 33.6 (SD = 5.3, range = 17-43, [alpha] = .78), and the mean level of problematic support provided was 9.4 (SD = 2.9, range = 5-20, ([alpha] = .60). The mean level for husbands' report of the emotional support they provided to wives was 31.5 (SD = 5.1, range = 17-42, [alpha] = .78), and the mean level of problematic support provided was 9.7 (SD = 3.1, range = 5-18, [alpha] = .68).

Perceived Emotional Responsiveness

Wives and husbands indicated perceptions of their partners' emotional responsiveness when wives and husbands were upset during wives' most current lupus episode. Each partner rated eight positive and eight negative cognitive and affective responses (e.g., feeling validated, understood, ignored, or rejected) on a 4-point scale ranging from 1 (not at all) to 4 (very much). The Perceived Emotional Responsiveness scale was developed for the current study from prior research on the conceptualization of emotional responsiveness during intimate interactions (Laurenceau et al., 1998; Reis & Shaver, 1988).

Negative items were reverse scored, and a factor analysis was conducted. Results from the factor analysis revealed that all items loaded onto one factor with all factor loadings being greater than .45. Factor loadings of .45 are considered to be adequate for retaining an item on a measure (Comrey & Lee, 1992). Thus, items were summed and could range from 16 to 64. The mean level of wives' perceived emotional responsiveness was 52.5 (SD = 9.6, range = 25-64, [alpha] = .93), and the mean level of husbands' perceived emotional responsiveness was 51.3 (SD = 9.4, range = 27-64, [alpha] = .93).

Marital Satisfaction

Marital satisfaction was assessed with one item from the Dyadic Adjustment Scale (Spanier, 1976). Both wives and husbands were asked to rate their degree of happiness in their marriage, all things considered, on a 7-point scale ranging from 0 (extremely unhappy) to 6 (perfect). The selection of this item was based on prior research indicating that this item is sufficient for classifying persons on a continuum of dyadic adjustment (Sharpley & Cross, 1982). The mean level of wives' marital satisfaction was 4.0 (SD = 1.3, range = 1-6), and the mean level of husbands' marital satisfaction was 3.7 (SD = 1.3, range = 0-6).

Depressive Symptomatology

The Center for Epidemiologic Studies--Depression Scale (CES-D; Radloff, 1977) was used to assess depressive symptoms. The CES-D is a 20-item scale that asks respondents to indicate how frequently they experienced symptoms and feelings associated with depression in the past week. Scores can range from 0 to 60, with higher scores reflecting more depressive symptomatology. A score of 16 or higher on the CES-D is an indicator of risk for clinical depression in the general population (Radloff, 1977). However, research has indicated that a score of 27 or higher on the CES-D is a more appropriate indicator of risk for clinical depression in medical patients (Schulberg et al., 1985). In the present sample, approximately 44% of wives and 34% of husbands could be classified as being at risk of developing a depressive disorder, based on this more conservative cut-off point. The mean for wives' depressive symptomatology was 25.5 (SD = 12.3, range = 0-55, [alpha] = .91), and the mean for husbands' depressive symptomatology was 13.0 (SD = 10.3, range = 0-49, [alpha] = .92).

Covariates

A variety of sociodemographic and health characteristics were examined as potential covariates. Potential sociodemographic covariates included wives' and husbands' age, ethnicity, education, employment status, income, and length of marriage. Potential health covariates included husbands' self-rated health, time since wives' lupus diagnosis, severity of wives' symptoms, and the extent to which lupus interfered with wives' daily goals and activities (i.e., illness interference).

Husbands' self-rated health (M = 1.7, SD = 0.65, range = 1-4) was measured with one item asking husbands to rate their current health on a scale ranging from 1 (excellent) to 4 (poor). Illness interference (M = 3.1, SD = 0.82, range = 1-4) was also assessed with one item asking wives to what extent their lupus episode interfered with their daily goals and activities on a scale ranging from 1 (has not interfered at all) to 4 (has interfered a great deal). Severity of lupus symptoms (M = 45.2, SD = 16.6, range = 4-85, [alpha] = .86) was assessed by asking wives the severity of 18 different lupus symptoms (e.g., nausea and muscle aches and pains) during their most current lupus episode on a scale ranging from 0 (did not experience) to 5 (very severe). Items were summed to create a measure of the severity of wives' symptoms and could range from 0 to 90. The most severe lupus symptoms reported by wives were extreme fatigue and tiredness (86.0%), joint aches and pains (67.5%), muscle aches and pains (61.3%), difficulty sleeping (48.1%), and headaches (42.0%).

Analysis Plan

To test our hypotheses, we conducted structural equation modeling using the EQS 5.7 package (Bentler & Wu, 1995). Maximum likelihood estimation was used to generate standardized parameter estimates, and multiple fit indices were used to determine the fit of each model to the observed data. A model with a nonsignificant chi-square value, a comparative fit index (CFI) value of .90 or above, and a root mean square error of approximation (RMSEA) value of less than .08 was considered to have a good fit with the observed data (Bentler, 1992; Browne & Cudeck, 1993).

Criteria set forth by Baron and Kenny (1986) were used in tests of mediation. Perceived emotional responsiveness can be assumed to be a full mediator of the relationship between spousal support efforts and psychosocial well-being if the direct relationship between support and well-being is not significant, yet the indirect paths from support to perceived emotional responsiveness and then from perceived emotional responsiveness to well-being are significant. Perceived emotional responsiveness can be considered to at least partially mediate the relationship between social support and well-being if both the direct relationship between social support and well-being and the indirect paths from support to perceived emotional responsiveness and from perceived emotional responsiveness to well-being are significant (Baron & Kenny, 1986).

To determine whether any covariates should be used in the analyses, bivariate correlation coefficients were examined between potential covariates and the two indicators of psychosocial well-being. Next, each dependent variable (i.e., depressive symptoms and marital satisfaction) was regressed on all sociodemographic variables with which it was significantly correlated. Only variables that remained significant in the regression equation were used in the structural equation models as covariates (Weisberg, 1979). For wives, husbands' health, illness interference, and severity of lupus symptoms were retained as covariates. For husbands, husbands' health and husbands' age were retained as covariates. In the initial structural equation modeling analyses, covariates were free to affect all variables in the model. This procedure allowed us to assess the unique effects of the key study variables by ensuring that any initial inequalities among participants were accounted for.

RESULTS

Table 1 presents the bivariate correlation coefficients between all study variables for the 243 couples. As shown in the table, wives' and husbands' reports of the emotional support they provided to each other were positively correlated. In addition, wives' and husbands' reports of the problematic support they provided to each other were also positively correlated. However, the amounts of emotional and problematic support provided were not correlated within person (i.e., wives' reports of emotional and problematic support) or across couple (i.e., wives' reports of emotional support and husbands' reports of problematic support). These findings are similar to prior research suggesting that emotional and problematic support are separate dimensions of social interactions that do not exist on a continuum (Rook, 1990).

Hypothesis 1: Wives' Perceptions of Husbands' Emotional Responsiveness as a Mediator of Husbands' Support and Wives' Psychosocial Well-Being

In the preliminary analyses for Hypothesis 1, the Lagrange multiplier test was used to determine how the covariates were associated with the main study variables. The Lagrange multiplier is a modification index used to alter structural models by adding paths and ultimately achieving a better model fit (Kline, 2005). On the basis of the Lagrange multiplier test, paths were added from husbands' health to wives' perceived emotional responsiveness ([beta] = 0.43, p < .05) and to husbands' provision of emotional support ([beta] = 0.13, p < .05). Paths were also added from illness interference to wives' depression ([beta] = 0.10, ns) and from severity of lupus symptoms to wives' depression ([beta] = 0.40, p < .05).

After the addition of the paths from the covariates to the study variables, an initial test of the hypothesized model was conducted. This initial model fit the observed data well, [chi square] (14, N = 243) = 15.75,p = .33, CFI = 0.99, RMSEA = .02. The initial model indicated that when husbands provided more emotional support, wives tended to perceive their husbands as being more emotionally responsive. More perceived emotional responsiveness, in turn, was associated with wives' higher marital satisfaction and lower depressive symptoms. In addition, the initial model indicated that when husbands provided more problematic support, wives tended to perceive their husbands as being less emotionally responsive. Lower perceived emotional responsiveness, in turn, was associated with poorer psychosocial well-being.

The paths from husbands' emotional and problematic support to wives' psychosocial well-being (i.e., direct effects) were not significant. As such, these results suggest that wives' perceptions of husbands' emotional responsiveness fully mediated the associations between husbands' support efforts and wives' psychosocial well-being. To examine whether the removal of these nonsignificant paths improved the model's fit, a revised structural model was tested in which these direct effects were eliminated. This revised model fit the data as well as the initial one, [chi square] (18, N = 243) = 19.45, p = .36, CFI = 0.98, RMSEA = .03. As shown in Figure 1, the final model accounted for 37% of the variance in patients' marital satisfaction and 27% of the variance in wives' depression.

[FIGURE 1 OMITTED]

Hypothesis 2: Husbands' Perceptions of Wives' Emotional Responsiveness as a Mediator of Wives' Support and Husbands' Psychosocial Well-Being

Again, the Lagrange multiplier test was used in preliminary analyses to determine how the covariates were associated with the main study variables. On the basis of the Lagrange multiplier test, paths were added from husbands' health to wives' provision of problematic support ([beta] = 0.17, p < .05), husbands' perceived emotional responsiveness ([beta] = -0.12, p < .05), and husbands' depression ([beta] = 0.19, p < .05). Paths were also added from husbands' age to husbands' perceived emotional responsiveness ([beta] = 0.16, p < .05) and husbands' depression ([beta] = -0.16, p < .05).

After the addition of the paths from the covariates to the study variables, an initial test of the hypothesized model for husbands was conducted. This initial model fit the data well, [chi square] (7, N = 243) = 2.94, p = .89, CFI = 0.93, RMSEA = .09. This model indicated that when wives provided more emotional support, husbands tended to perceive their wives as being more emotionally responsive. More perceived emotional responsiveness, in turn, was associated with husbands' higher marital satisfaction and lower levels of depressive symptoms. In contrast, the model indicated that when wives provided more problematic support, husbands tended to perceive their wives as being less emotionally responsive, which in turn was associated with poorer psychosocial well-being.

Similar to results from the wives' model, the paths from wives' emotional support to husbands' marital satisfaction and depression (i.e., direct effects) were not significant. In contrast to results from the wives' model, the direct effects of wives' problematic support on husbands' psychosocial well-being remained significant. These results suggest that husbands' feelings of emotional responsiveness fully mediated the associations between wives' emotional support and husbands' well-being, but only partially mediated the relationship between wives' problematic support and husbands' well-being.

To examine whether the removal of the nonsignificant paths would improve the model's fit, a revised structural model was tested in which the nonsignificant direct effects were eliminated. The revised model was a better fit for the observed data, [chi square] (9, N = 243) = 3.13, p = .96, CFI = 1.00, RMSEA = .00. As shown in Figure 2, the final model accounted for 36% of the variance in husbands' marital satisfaction and 34% of the variance in husbands' depression.

[FIGURE 2 OMITTED]

DISCUSSION

Importance of Perceived Emotional Responsiveness in the Social Support Process

Findings from the current study highlight the importance of perceived emotional responsiveness as part of the social support process, especially when coping with a chronic illness such as lupus. Our findings provide evidence that the meaning individuals attach to their partners' support efforts helps to explain how spousal support manifests itself in recipients' psychosocial well-being. When individuals perceived that their partners' support efforts were responsive to their emotional needs, individuals also experienced fewer depressive symptoms and were more satisfied with their marriage. In contrast, when individuals perceived that their partners' support efforts did not meet the demands of their emotional needs, individuals tended to experience more depressive symptoms and were less satisfied with their marriage. Thus, in addition to being important for the maintenance of relationship intimacy (Reis & Shaver, 1988), our results suggest that perceptions of partners' emotional responsiveness may play a role in the effectiveness of supportive interactions.

For the couples in our study, the more spouses reported listening to and expressing affection toward their partners when partners were upset about lupus (i.e., emotional support), the more partners reported feeling validated and affirmed by these support efforts. In contrast, for both husbands and wives, when spouses sought to help them through distraction or avoidance (i.e., problematic support), husbands and wives were less likely to feel understood and accepted. Thus, the degree to which individuals perceived that their partners were understanding and validating when they were upset about lupus determined, in part, how social support was associated with depressive symptomatology and marital satisfaction.

Whereas wives' perceptions that husbands' support efforts were emotionally responsive explained the relationship between husbands' problematic support and wives' well-being, husbands' perceptions that wives were emotionally responsive only partially explained this relationship. Partial mediation suggests that there may be other mechanisms present through which problematic support from patients is manifested in husbands' psychosocial adjustment (Baron & Kenny, 1986). For example, husbands may have attributed wives' critical or insensitive behaviors to their wives' illness rather than to a lack of emotional responsiveness (Bradbury & Fincham, 1990). Alternatively, because men tend to be less aware of interpersonal difficulties, husbands may not have interpreted wives' insensitive communications as a lack of empathy or understanding (Holtzworth-Munroe & Jacobson, 1985).

Clinical and Practical Implications

The findings from the current study present many opportunities for clinical interventions and individual therapy for couples coping with chronic illness. Psychosocial interventions for chronically ill individuals are programs designed to positively affect individuals' emotional and physical well-being through both behavioral and psychological means such as patient education, stress management, and increasing social support (Martire, 2005). Across a variety of illness conditions, including lupus patients, psychosocial interventions have been shown to increase emotional well-being, lower stress, and increase physical functioning (Carrico et al., 2005; Greco, Rudy, & Manzi, 2004; Helgeson, Lepore, & Eton, 2006).

More recently, however, research has begun to acknowledge the importance that family members, including the spouse, play in patients' illness experience. It is becoming more common for group and individual interventions to include spouses or other family members as a part of the intervention process. Family or couple interventions have been shown to have beneficial effects for the well-being of both patients and their significant others (Martire, Lustig, Schulz, Miller, & Helgeson, 2004). In some cases, the family-oriented interventions are more beneficial for well-being than standard patient-oriented interventions (Martire, 2005).

The pattern of results in our study suggests that interventions or individual therapy aimed at improving communication and support exchanges among couples coping with chronic illness may have benefits for both emotional well-being and marital functioning. Teaching couples how to communicate their need for support, as well as how to provide feedback to each other about support exchanges, may help increase the amount and the effectiveness of support exchanges in couples. Couples coping with wives' cancer were able to increase their communication skills and lower their distress after attending couples-focused training sessions (Scott, Halford, & Ward, 2004). In addition, identifying support behaviors that are often construed as being problematic (e.g., minimizing or dismissing the problem) may decrease the occurrence of these events. A couples-focused intervention was successful in lowering depression in breast cancer patients who initially rated their partners as being unsupportive (Manne et al., 2005). Maintaining the emotional well-being, as well as the marital functioning, of couples will likely have an impact on couples' ability to cope with wives' lupus as partners rather than as individuals (Coyne & Fiske, 1992; Seawell & Danoff-Burg, 2004).

Strengths and Limitations

Findings from our study are consistent with the larger literature suggesting that emotional support has benefits for psychosocial adjustment and problematic support has deleterious effects on adjustment in couples coping with a chronic illness (Cutrona, 1996; Manne et al., 2004). In addition, our study identified perceived emotional responsiveness as a mechanism through which support is associated with well-being. Because of the dyadic nature of our study, our findings increase the confidence that can be placed on prior studies that have been limited by only examining the support recipients' perspective. In comparison to much of the research on marital support exchanges, we assessed providers' perceptions of their support efforts, recipients' perceptions of the emotional responsiveness of these efforts, and recipients' well-being. This dyadic approach reduced the potential for recipients' psychosocial well-being and reactions to support to be confounded with reports of support exchanges (Bower & Forgas, 2001).

Our study has several limitations that should be taken into consideration when interpreting the findings. Owing to the study's cross-sectional nature, the direction of the associations presented in our model cannot be confirmed. It is possible that husbands' and wives' well-being affected the types of support their spouses provided, rather than that spousal support affected husbands' and wives' well-being, as our results suggest. However, several longitudinal investigations have shown that, similar to our assertions, support efforts and perceptions of emotional responsiveness precede changes in relationship satisfaction and psychological well-being (Burman & Margolin, 1992; DeLongis et al., 2004; Laurenceau et al., 2005; Lippert & Prager, 2001).

Another limitation is our one-item measure of marital functioning. It is possible that a different pattern of results would have emerged if more dimensions of marital satisfaction (e.g., marital conflict) were assessed. However, the one-item indicator of marital functioning used in the current study has been found to be a valid way of measuring overall dyadic adjustment (Sharpley & Cross, 1982).

Lupus differs from other chronic illnesses in that it can be characterized as highly episodic. Patients go through periods of remission in which they have no lupus symptoms and are not impaired by the illness and periods in which their condition flares up and may be so severe that they cannot function. Thus, it is unclear how these results would generalize to other illness populations (e.g., diabetes or arthritis) in which the illness symptoms and management were constant rather than episodic. Moreover, based on the average lengths of their lupus episode (M = 9 months), it is likely that the lupus condition of most women in the current study was more severe than that of most women with lupus. It is unclear how these results would generalize to women whose lupus episodes were more episodic and less severe. Finally, lupus is more prevalent in African American women (Lupus Foundation of America, 2006), but our sample consisted primarily of Caucasian women. Therefore, it is unknown how well these results would generalize to African American couples or couples of different ethnic backgrounds.

Conclusions

Our study contributes to the literature on support exchanges in couples coping with chronic illness in several important ways. First, the dyadic nature of the study underscores the importance of individuals' interpretations of spousal support efforts as being affirming and validating. Second, these perceptions of emotional responsiveness help explain how spousal support efforts manifest themselves in each partners' psychosocial well-being. Finally, taken together, our findings suggest that for couples coping with chronic illness, support exchanges that are responsive to recipients' needs are integral to maintaining the quality of the marital relationship, as well as individuals' well-being.

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ERIN M. FEKETE, PHD

MARY ANN PARRIS STEPHENS, PHD

KRISTIN D. MICKELSON, PHD

JENNIFER ANN DRULEY, PHD

Erin M. Fekete, PhD, Mary Ann Parris Stephens, PhD, and Kristin D. Mickelson, PhD, Department of Psychology, Kent State University; Jennifer Ann Druley, PhD, Department of Psychology, Cleveland State University.

Correspondence concerning this article should be addressed to Erin M. Fekete, PhD, Department of Psychology, University of Miami, 5665 Ponce de Leon Boulevard, Coral Gables, FL 33146. E-mail: efekete@psy.miami.edu

Table 1
Correlations Among Study Variables (N = 243)

Variable                          1          2          3

1. Emotional support (W)         --
2. Emotional support (H)        .19 **      --
3. Problematic support (W)      .02        .05         --
4. Problematic support (H)      .01        .02        .20 **
5. Perceived emotional          .40 ***    .32 ***   -.26 ***
     responsiveness (W)
6. Perceived emotional          .29 ***    .36 ***   -.16 ***
     responsiveness (H)
7. Depression (W)              -.08       -.06        .28 ***
8. Depression (H)               .11       -.08        .27 ***
9. Martial satisfaction (W)     .26 ***    .26 ***   -.25 ***
10. Marital satisfaction (H)    .18 **     .26 ***   -.20 **

Variable                          4          5          6

1. Emotional support (W)
2. Emotional support (H)
3. Problematic support (W)
4. Problematic support (H)       --
5. Perceived emotional         -.25 ***     --
     responsiveness (W)
6. Perceived emotional         -.26 **     .47 ***     --
     responsiveness (H)
7. Depression (W)               .06       -.28 ***   -.20 ***
8. Depression (H)               .21 ***   -.25 ***   -.49 ***
9. Martial satisfaction (W)                .61 ***    .46 **
10. Marital satisfaction (H)               .33 ***    .59 ***

Variable                          7          8          9       10

1. Emotional support (W)
2. Emotional support (H)
3. Problematic support (W)
4. Problematic support (H)
5. Perceived emotional
     responsiveness (W)
6. Perceived emotional
     responsiveness (H)
7. Depression (W)                --
8. Depression (H)               .18 **      --
9. Martial satisfaction (W)    -.28 ***   -.33 ***    --
10. Marital satisfaction (H)   -.22 ***   -.50 ***   .51 ***    --

Note. W = Wives' report; H = husbands' report.

* p <.05. ** p <.01. *** p<.001.