Examination of positive and negative aspects of close relationships and mortality over time provides an opportunity to achieve a better understanding of the complex and sometimes paradoxical nature of social relationships. This study provides support for the main and buffering hypotheses but also indicates that contextual factors must be considered. Although baseline relationship quality was not associated with mortality, the pattern of relationship quality over time was associated with survival. In addition, the quality of relationships at baseline buffered the effects of chronic conditions on mortality. Relationship quality appears to affect survival because of its cumulative effects as well as by buffering current stressful circumstances. In addition, positive and negative relationships may have beneficial as well as detrimental effects on survival depending on the types of support, type of relationship, and life circumstances. These findings provide further evidence of the complexity of relationships and suggest a more differentiated conceptualization of the buffering model.
Examination of the main effect of relationship quality on mortality yielded mixed results. Overall, the patterns of relationship quality over time were more highly associated with survival than baseline relationship quality. Spouses and children had a greater effect on survival than did friends/relatives. Participants who felt their spouse or child did not listen consistently over time had lower survival rates. In addition, those who reported an increase in criticism from spouse or child had lower survival than those who had consistently critical relationships. Thus, it appears that the consistent lack of emotional support or an increase in criticism may have cumulative negative effects on health/survival. On the other hand, findings regarding baseline spousal love and the pattern of love in the spouse and friend/relative relationships and mortality might be considered counterintuitive. Participants who reported greater love from spouses or friend/relatives at baseline had higher mortality rates. Similarly those who reported consistently low levels of love over time from spouses or friends/relatives had better survival than participants who reported other patterns of love over time. This finding appears to be consistent with Carstensen and her colleagues (Carstensen, Isaacowitz & Charles, 1999
) view that increases in positive aspects of relationships may occur before death and Cutrona’s (1996)
review indicating that over protectiveness can be harmful to health.
The findings regarding patterns of relationship quality and mortality have implications for the literature. Although overall network support is associated with reduced mortality rates (Blazer, 1982
; Ceria et al., 2001
; Lyyra & Heikkinen, 2006
), studies testing the main effect of specific relationships on mortality have been less consistent (Dalgard & Haheim 1998
; Sugisawa et al., 1994
). Chronic relationship history or convoys of social relationships over time may be more important for well-being than relationships assessed at one time point (Antonucci, 2001
; Seeman et al., 2002
). These findings are in line with Life Course Theory and the Biopsychosocial Model which suggest that cumulative experiences over time influence health (Seeman et al., 2002
). Thus, early work may have provided an interesting but incomplete picture of these associations over time and life circumstances. It may be that more specific and more frequent indicators of relationship quality are needed to gain a comprehensive and accurate understanding of relationships and mortality.
Consistent with the stress buffering model and our hypothesis, negative and positive relationship quality with spouse and child significantly predicted mortality among people with physical illnesses. However, the findings, again, might be considered somewhat paradoxical. In particular, among people with chronic illnesses, those who reported higher spousal demands or criticism and child demands at baseline survived longer than people with chronic illnesses who reported lower levels of negative relations at baseline. In addition, people with a chronic illness who reported higher levels of spousal love had lower survival rates than those with lower spousal love at baseline. Although an increase in love from children appeared to be beneficial for survival among this same group. These findings indicate that relationships are particularly important for well-being when under stress (Cohen & Wills, 1985
; Uchino, 2004
). It appears, however, that negative relations and a lack of support may sometimes actually be beneficial
for survival among people with chronic illnesses. Although this finding is inconsistent with some literature indicating that averse relationships are associated with health problems and depression (Koopman, Hermanson, Diamond, Angell, & Spiegel 1998
), it is similar to other literature indicating that negativity has dual effects of increasing distress while leading to better health outcomes (Fukukawa, Nakashima, Tsuboi, Niino, Ando & Kosugi, 2004
Interestingly positive aspects of relationships appear to be more important for main effects on health whereas the negative aspects of relationships had buffering effects. This may be explained by the concept of the health continuum in which certain types of support are beneficial but only under certain circumstances. The type of support provided must match the circumstances. Thus, while it is generally good for individuals’ health to have others who are willing to listen, these types of support may not be as important or have different effects in the context of chronic illness. For example, when a person is ill, social partners who avoid being over protective and are a little demanding may promote health and self-efficacy.
There are several possible explanations for the reduced mortality rates among people with greater negative relations, less love, and chronic illnesses. Theorists have suggested that supportive and sympathetic behaviors can often ‘backfire’ in the context of physical illnesses (Cutrona, 1996
; Fordyce, 1976
). Overly solicitous relationships may reinforce sickness behaviors and increase dependencies. Thus, the lack of support and/or negativity may involve efforts to increase independence and reduce illness behaviors in people with chronic illness. In the context of illness, negative relations (especially demands) may also include efforts to control health behaviors (Krause et al., 1993
). For example, a spouse or child may remind (demand) a sick partner/parent to take medicine (Rook & Ituarte, 1999
). In addition to social control, negativity may signify the lack of detrimental types of support such as overprotection and protective buffering (Hagedoorn, Kuijer, Buunk, DeJong, Wobbes & Sanderman, 2000
), it may keep people actively engaged, or it may involve disguised or invisible support. Bolger, Zuckerman and Kessler (2000)
found that invisible support (support that is disguised so that the receiver is unaware or does not interpret the interaction as support) was more beneficial for well-being when couples were under severe stress. Negative aspects of relationships may also decrease before death. The literature suggests that as people perceive their time to be more limited (e.g., closer to death), they report fewer interpersonal problems and seek to resolve unfinished business and receive forgiveness (Carstensen et al., 1999
; Koenig, 2002
; Steinhauser, Christakis, Clipp, McNeilly, McIntyre & Tulsky, 2000
The majority of the previous explanations assume that relationships cause variations in health. However, people with illnesses often experience a decrease in support, become less socially active, and cause discomfort among their social partners (Bloom & Spiegel, 1984
; Wortman & Dunkel-Schetter, 1987
). For example, spousal support declines over time among women with breast cancer (Bolger et al., 1996
). This study considered whether health status may have led to differences in relationship quality and survival. Individuals who reported more positive and less negative relations generally reported better self rated health. Although lower quality relations may enhance survival, they may be associated with lower self reported health. Similarly, the dual effect hypothesis suggests that relationships may cause distress while simultaneously improving health behaviors (Hughes & Gove, 1981
Limitations and conclusions
There are several limitations to this study that should be noted and addressed in future research. First, it is unclear whether relationships changed in response to the diagnosis and severity of chronic illnesses. It is possible that negativity occurs in the beginning of an illness and decreases before people die. Although spouse and child were examined separately, other family and friends were included together in the same questions. This may be problematic because individuals often expect family members to provide instrumental support whereas they may seek certain types of emotional support from friends (Antonucci, 2001
). Future research should also consider a more detailed examination of the links between illness, relationships and mortality. For example, multiple waves of interactions among dyadic partners would permit a more complex assessment of the causal processes and dynamics that occur between individuals as they cope with illness.
Despite these limitations, this study offers a preliminary examination of negative and positive aspects of relationships over time and mortality. Our findings support the life course perspective and indicate that relationship patterns have a greater impact on mortality than do relationships at a single time point. The findings also support the notion of a health continuum in which the effectiveness of types of support varies by health status. Indeed, relationships that are less loving and more demanding may actually help individuals with chronic illnesses. Interventions should consider ways of teaching individuals to seek out and manage support in a way that matches their needs. For example, people with chronic illnesses may benefit from supportive relationships that are challenging and not too over protective. Future studies will benefit from a more detailed examination of relationships and need to examine these associations to assess whether these findings can be replicated. This study highlights the complex and psychological nature of close social relations. It suggests that the association between social relations and health varies by both type and quality of relationship as well as health status. Prior research at the aggregate level may have masked more detailed, relationship-specific dynamics. We believe that these findings provide important insight into the dynamic association between social relationships and mortality and suggest critical directions for future research.