Abstract

Coping with a chronic illness in adulthood takes place in the context of social relationships (Revenson and Delongis, 2011).  Despite the well documented positive outcomes of partners' support (Kiecolt-Glase & Newton, 2001; Fisher, Nadler & Whitcher-Alagna , 1982; Pfiffner & Hoffmann, 2004; Vilchinsky et al., 2011), recent findings have shown that support provided by partners is not always beneficial for the recipients, and in times might even worsen recipient's outcomes (Burg & Seeman, 1994; Bolger, Zuckerman & Kessler, 200o; Martire & Schulz, 2001).

Contemporary studies suggest that in order to reveal the circumstances under which support is found beneficial for the recipient it is not enough to focus on either the provider or on the recipient characteristics. However, it is the interaction between the specific manner in which support is provided by the caregiver on the one hand and the personal ability of the recipients to accept the offered support, on the other hand, which may explain the effects of provided support (e.g., Cutrona, Shaffer Wesner & Gardner, 2007; Martire, Druley, Stephens & Wojno, 2002; Vilchinsky et al., 2010, 2011).

            Thus, the current dissertation conceptualizes dyadic support transactions as an interpersonal process that occurs at the intersection of two elements: the sense of relational entitlement, or the extent to which an individual feels that his needs should be fulfilled by the partner (Tolmacz & Mikulincer, 2011), and the other is care giving style, or the way in which the spouse responds to the partner who needs his support (Kunce and Shaver, 1994). The present research advances prior studies by investigating the sense of relational entitlement and caregiving styles in a dyadic context and in a prospective longitudinal design of couples coping with a major life crisis (i.e., Acute Coronary Syndrome- ACS). The dissertation primary goals are to establish the concepts of sense of relational entitlement and caregiving styles in a dyadic context and to examine the contribution of the interplay between the two concepts to patients coping with acute coronary syndrome relational, psychological and behavioral outcomes. 

            In order to accomplish the study goals three sub-studies were performed: 1) the first study further validated the Sense of Relational Entitlement Scale (SRE) among 120 healthy middle-aged partners in long-term dyadic relationships and assessed its contribution to relationship satisfaction. The couples were recruited via a convenience sample (“snowball” procedure). Sense of relational entitlement was measured using the Sense of Relational Entitlement Scale (SRE; Tolmacz & Mikulincer, 2011) and relationship satisfaction was measured using the ENRICH scale (Fowers & Olson, 1993; Olson, Fournier, & Druckman, 1987). The questioners were administrated to both partners at one sitting. Factor analyses revealed that the SRE scale consisted of two major dimensions: conflicted entitlement and assertive entitlement. Applying an Actor-Partner-Interdependence Model (APIM) analysis indicated that the more conflicted one felt with regard to what one was entitled to, the less satisfaction one felt with the relationship. Additionally, the higher one’s entitlement expectations were of one’s partner (a subfactor of the assertive entitlement dimension), the more one’s partner was satisfied with the relationship.

            2) The second study included a comparative design and focused on the caregiving system among 131 couples coping with ACS during the acute phase of the illness versus a matching group of 68 healthy couples and examined the activation of the two caregiving styles: sensitive and compulsive in times of daily life versus acute stress context. The matched group of 68 healthy couples was selected from the dataset of the 120 couples of the first study. The ACS group was recruited from the Cardiac Care Units (CCU) of Sheba Medical Center and Meir Medical Center and included male patients diagnosed with a first ACS and their females' partners. Both partners from both groups completed the study's questioners. Depression and anxiety symptoms were measured using the Brief Symptom Inventory (BSI; Derogatis & Melisaratos, 1983) and caregiving styles were measured using the Adult Caregiving questionnaire (Kunce & Shaver, 1994).  Structural equation modeling revealed that contrary to the activation hypothesis, neither the sensitive nor the compulsive caregiving styles intensified in the high-stress context. Also, no partner effects of caregiving styles on emotional distress were found.  Nevertheless, high levels of one’s own compulsive caregiving were associated with higher levels of one’s own depression and anxiety, across contexts and genders.

            3) The third study focused on couples coping with ACS during the acute and chronic phase of the illness and examined the moderating role of partners' caregiving styles on the associations between patients' sense of relational entitlement and patients' outcomes after ACS (anxiety, relationship satisfaction and medication adherence). The sample consists of the 131 couples from the ACS group participated in the second study. The couples completed the questioners at two time points: during patients' hospitalization and at the follow up, six month after the hospitalization. During hospitalization patients' sense of relational entitlement was measured using the SRE and partners' caregiving styles were measured using the Adult Caregiving questionnaire. At hospitalization and at follow up patients' anxiety levels were measured using the BSI and patients' relationship satisfaction was measured using the ENRICH scale. At follow up patients also completed the Medication Adherence Report Scale (MARS) (Horne & Weinman, 2002) in order to assess their medication adherence levels. As expected, hierarchical regression analysis revealed that the interaction between partners' caregiving styles and patients' sense of relational entitlement was more substantial in explaining patients' outcomes, than the main effects. It was found that the higher patients were on excessive entitlement the more anxious they felt, but only when their partners provided lower levels of sensitive caregiving. With regard to relationship satisfaction, it was found that patients high on excessive entitlement felt more satisfied with the relationship, but only when their females' partners' compulsive caregiving was low.  Finally, the findings showed that the higher patients were on restricted entitlement the less they tended to adhere to the medication prescribed, but only when their partners provided them higher levels of compulsive caregiving.

            Overall the findings of the current study shed light on the important role of the interplay between providers' support and recipients' personality in explaining the beneficial effects of provided support. Also, the results strengthen the postulation that the construct of sense of relational entitlement, which only recently was subjected to empirical investigation, is relevant to the context of dyadic relationships and thus is worth further attention. From the clinical point of view, helping couples master the challenge of providing and receiving support may contribute to patients' well being as well as to their relationship satisfaction. In such trying times as coping with illness this may even contribute to enhanced levels of adherence among patients which, in turn, may lead to improved health and maybe even saved lives. These clinical and theoretical implications are further discussed.

 

 

Sense of Relational Entitelment and Support Study