Dilemmas of talking about lifestyle changes among couples coping with a cardiac event

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Social Science & Medicine 63 (2006) 2079–2090 www.elsevier.com/locate/socscimed

Dilemmas of talking about lifestyle changes among couples coping with a cardiac event Daena J. Goldsmith, Kristin A. Lindholm, Jennifer J. Bute University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA Available online 21 June 2006

Abstract Persons who have experienced a myocardial infarction (MI) and/or coronary artery bypass graft (CABG) surgery may benefit from a low-fat diet, regular exercise, smoking cessation, and stress management. Yet many patients do not make these changes. A spouse or partner’s attempts at support may facilitate or interfere with patient behavior change. The present study explores dilemmas that may arise when couples talk about lifestyle changes following one person’s MI or CABG. In interviews carried out in Urbana-Champaign, Illinois, and surrounding communities with 25 patients and 16 partners we found communicating support for lifestyle change may be interpreted as undesired control or criticism. The caring conveyed by talking may be viewed positively but can also threaten patient autonomy and entrap partners in unwanted expectations and obligations. Finally, lifestyle change conversations may reflect empowered patients collaborating with partners to take control of health but can also serve as potent reminders of loss. These multiple, potentially conflicting meanings give an account for why talking with a partner does not always facilitate patient lifestyle change. Understanding these dilemmas also suggests practical implications for helping patients and partners. r 2006 Elsevier Ltd. All rights reserved. Keywords: Marital communication; Lifestyle change; Coronary heart disease; United States; Social support; Illness identity

Introduction Coronary heart disease (CHD) continues to be a leading cause of death worldwide, despite convincing evidence that controllable lifestyle factors contribute significantly to risk for men and women of all ages, races, and regions of the world (Rosengren et al., 2004; Yusuf et al., 2004). Lifestyle modification is especially important for those who have already experienced a cardiac event (defined Corresponding author. Tel.: +1 217 333 4263;

fax: +1 217 244 1598. E-mail addresses: [email protected] (D.J. Goldsmith), [email protected] (K.A. Lindholm), [email protected] (J.J. Bute). 0277-9536/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2006.05.005

here as myocardial infarction, MI, or coronary artery bypass graft surgery, CABG). For example, Zafari and Wenger (1998) review findings that postMI patients who stopped smoking reduced their risk of another MI by 50% after 1 year and patients who engaged in exercise training and risk factor modification programs had as much as a 20% survival advantage in the 3 years following an MI. Several expert task forces and panels in the United States, Canada, and Europe concur that quitting smoking, eating a heart-healthy diet, engaging in regular physical activity, and managing stress improve a person’s chances of recovering from a cardiac event, returning to valued activities, and reducing the risk of future events (American Association of

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Cardiovascular and Pulmonary Rehabilitation, AACVPR, 2004; Smith et al., 2001; Stone et al., 2001). Lifestyle modifications hold out the promise of improved health but they may entail difficult changes in behaviors and attitudes. CHD patients have low levels of adherence to recommendations for exercise, dietary change, smoking cessation, and prescription medications (for reviews, see Haynes, 2001; Oldridge, 2001). Despite the potential benefits, only one-third of coronary disease patients implement lifestyle changes, and more than half who initially participate discontinue the lifestyle changes within a year (AACVPR, 2004). Communication between a patient and spouse or partner (hereafter referred to as ‘‘partners’’) may improve the likelihood that a patient adopts a hearthealthy lifestyle (for reviews, see Daly et al., 2002; Sher & Baucom, 2001). Partners may encourage patients to exercise, praise their weight loss, remind them to take medication or avoid certain foods, or criticize their unhealthful actions. However, a partner’s good intentions do not always produce the desired results. Partner support for lifestyle change can also result in overprotection, patient resistance, and reduced patient self-efficacy with negative consequences for patient behavior change and health (Coyne, Wortman, & Lehman, 1988). Problem behaviors, such as smoking, may be so ingrained in a couple’s interaction patterns that cessation threatens relational intimacy or couples may find themselves caught in ironic processes such that the behavior one partner employs to encourage cessation is the very behavior that drives the other partner to continue smoking (Rohrbaugh et al., 2001). Franks, Stephens, Rook, Franklin, and Keteyian (2002) found that partner social support (e.g., listening to concerns about protecting health, encouraging healthy choices) during cardiac rehabilitation was not systematically associated with lifestyle changes 6 months later. However, partner social control (e.g., prompting or reminding, trying to stop the other from doing unhealthful things) was associated with worse adherence to a heart-healthy lifestyle 6 months later. Partners can affect patient behavior but much remains to be learned about the conditions under which that influence facilitates rather than hinders lifestyle change. In the present study, we examine talk about lifestyle change as a central process through which partner influence occurs. Partners can influence patient lifestyle in ways that do not

necessarily involve talk, but interactions in which couples discuss lifestyle changes are one important means of conveying approval, advice, encouragement, and validation (as well as disapproval, misinformation, discouragement, and criticism). We examine the meanings of talk about adherence and the dilemmas that may arise from conflicting meanings with the aims of (1) explaining previous findings on the inconsistent effects of couple talk on patient lifestyle change and (2) identifying the challenges to which successful couple communication is adapted. A communication framework for studying talk about lifestyle change Our emphasis on meanings and dilemmas of talk derives from Goldsmith’s (2004) theory of communicating social support (see also O’Keefe, 1988). To understand when and how communication between relational partners can facilitate a desired outcome, we must examine not just the frequency of talk, but also what is said, how it is said, and the meanings participants typically attribute to particular ways of saying things. Some conversations are especially challenging because the purpose of talking threatens valued identities and relational qualities, thus creating dilemmas. For example, encouraging a patient to place a healthful order in a restaurant may be challenging if it implies criticism of the patient’s efforts to recover, an accusation of ignorance, an undesired balance of power between partners, or a failure to respect autonomy. Even if both partners agree a heart-healthy diet is important and know what menu items are healthful, a partner’s well-intentioned suggestion may fall on deaf ears or meet with resistance if it undermines the way a patient views his or her own identity and the relationship. In Goldsmith’s model, some conversations are more satisfying and successful than others because some ways of communicating do a better job of accomplishing the task (e.g., encouraging lifestyle change) while also managing what talk means for identities and relationship. Cardiac patients’ healthrelated decisions are grounded in their understandings of how physical symptoms and medical prognoses interrelate with their own sense of identity and with the opinions expressed by significant others (Jensen & Petersson, 2003; Wiles, 1998). Influence attempts that are interpreted as supportive, encouraging, and motivated by concern

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have a better chance of bringing about healthful behavior (or at least may avoid evoking resistance, reactance, or deception by the patient) whereas influence attempts that are interpreted as controlling and critical tend to be less successful (Franks et al., 2002; Ka¨rner, Dahlgren, & Bergdahl, 2004). Goldsmith’s model explains these findings as follows: influence attempts that encourage behavior change while also validating identities and relational qualities are more likely to succeed than attempts that threaten identities and relationships. This model is especially appropriate for understanding couple communication about lifestyle changes following a cardiac event. Patients may feel uncertain about whether they will continue to enact valued identities (Johnson, 1991). They may wonder about resuming paid employment, household responsibilities, sexual performance, or hobbies. Loss of self-confidence, challenges to selfimage, or family obligations may hinder participation in cardiac rehabilitation (Clark, Barbour, White, & MacIntyre, 2004; Jackson, Leclerc, Erskine, & Linden, 2005). Physical dependence on partners immediately following a cardiac event may raise concerns about relational equity and lead to an ongoing renegotiation of relational closeness and power as the patient gradually recovers (or does not recover as expected) (Thompson, Ersser, & Webster, 1995). In other words, valued identities and relational qualities may be particularly vulnerable, salient, and uncertain for couples coping with a cardiac event. All communication entails task, identity, and relational meanings, but the particular tasks, identities, and relational qualities that matter are specific to various social contexts. For example, persuading a stranger to sign an organ donor card and influencing a partner to stop smoking both involve a persuasion task and both involve identity and relational considerations; however, the particular configuration of challenges, and the strategies that are more or less successful for meeting those challenges, take shape in light of the different relationships, actions targeted, social situations, and so on. Consequently, a first step in understanding successful couple communication about lifestyle changes is description of the common meanings and dilemmas couples experience in pursing this particular communication task while honoring the identities and relational qualities that are implicated in that task. The present study was guided by two research questions: (1) What task,

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identity, and relational meanings do patients and partners attribute to talking about lifestyle changes? (2) How do multiple meanings of talk create dilemmas for couples? Description of the strategies couples use to manage these meanings and dilemmas are described elsewhere (Goldsmith, Lindholm, & Bute, in press). Method Forty-one participants were interviewed in Urbana-Champaign, Illinois, and surrounding communities: 25 patients who had experienced an MI (n ¼ 6), CABG (n ¼ 8), or MI and CABG (n ¼ 11); 15 partners of these same patients; and one partner of a patient who did not participate in the study. Our sample included 21 male patients, 4 female patients, and 16 female partners. Participants ranged in age from 37 to 81; average age was 66 for patients and 63 for partners. Most participants were white. Education and occupation were varied. All participants were married except one who was involved in a committed romantic partnership. The average length of relationship was 36 years (range ¼ 3–55 years). Four participants had children under age 18 currently living with them and 36 participants had grown children. Participants were recruited through flyers in cardiologists’ offices, announcements at support group meetings and cardiac rehabilitation classes, posters at local churches, and referral by other study participants. All patients mentioned one or more lifestyle modifications they had (or believed they should) undertake for their CHD: all mentioned diet, 24 exercise, 8 stress management or relaxation, and 5 smoking cessation. In addition, 17 reported activity restrictions (usually these were temporary restrictions immediately following the event). All patients and partners had talked at least once about one or more of these recommendations. Participants engaged in a 60–90-min interview about changes they had experienced since the patient’s cardiac event; topics that were easy to discuss, difficult to discuss, and sources of argument; and recall of an especially good conversation about the heart condition and an especially bad conversation. The interviewer also asked participants about their experience of some common challenges associated with recovery from a cardiac incident (e.g., changing diet, physical activity, concerns about recurrence, sex, depression). Two different interviewers spoke to each member of a

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couple individually to facilitate forthright expression of positive and negative reactions to what their partners said or did. Procedures were approved by university and hospital Institutional Review Boards. Interviews were transcribed verbatim. Identifying information was obscured, and each participant was assigned a pseudonym. The authors engaged in a comprehensive review of audiotapes and transcripts and used open coding methods of grounded theory (Strauss & Corbin, 1990) to identify challenges, difficulties, and rewards associated with talking about lifestyle change. We acknowledge limitations to our study. Although we solicited participants through several channels, rehabilitation classes were our most effective recruitment site. This may over-represent patients who had made lifestyle changes (though it shows talking can be difficult even for those who have had some success in making changes). Our interview data were well-suited to our questions about how participants interpreted talk but reliance on self-reported behavior does not provide a firm basis for making claims about causes and effects. Our sample is racially homogeneous, and couples reported high levels of relational satisfaction. Our sample size and distribution of patient and partner sex do not permit gender comparisons.

Findings In the analyses that follow, we identify three dilemmas that can arise from the multiple meanings couples attribute to talking about lifestyle change. Dilemmas were experienced when an individual attributed conflicting meanings to talk or when the two members in a couple interpreted their talk differently. Not all individuals or couples reported dilemmas: Some participants felt comfortable with the frequency and tenor of their talk about lifestyle change either because they did not talk or because they had constructed a positive meaning for their talk. However, the potential for these dilemmas exists within the system of meanings participants revealed as they made sense of their experience (cf. Baxter & Montgomery, 1996). Dilemmas are challenges to which couples adapt as they use available social meanings to interpret their communication practices. If couples are to succeed in defining their interactions as supportive rather than unsupportive, these are some of the cross-currents they navigate.

‘‘I Don’t Want to Nag Buty.’’ Talking about lifestyle changes may be heard as unwanted attempts at control (Franks et al., 2002) and as criticism, invoking relational power dynamics and claims to the moral high ground. Our participants used negatively valenced or ambiguous terms to describe talk as ‘‘pressure’’, ‘‘control’’, ‘‘demand’’, ‘‘dependence’’, ‘‘policing’’, and ‘‘gatekeeping’’. Making lifestyle changes involves knowing what to do, making judgments about how to apply general guidelines to particular situations, and having motivation to change habits and forego pleasures. Consequently, commenting on behavior may be taken as not only questioning the specific behavior but also criticizing the lack of knowledge, judgment, or motivation that produced it. For example, some patients reported that they responded to their partner’s comments with rejoinders such as ‘‘I know what I’m doing’’ or ‘‘I’m not stupid’’. In contrast, some said they did not mind talking with their partners about diet, for example, because their partner did have greater knowledge of nutrition or will-power to resist temptation. Whether accepted or resisted, talk about lifestyle change can imply claims about partners’ relative power, knowledge, and virtue. Sometimes conversations did have the explicit purpose of getting a patient to do something or of negatively evaluating some action; however, couples were vigilant of the possibility that even ‘‘innocent’’ comments or genuine questions might be heard as controlling or critical. These meanings crystalize around the term nagging, as in the following excerpts: ywe like talk it out and that’s it. But I don’t nag him about it. I figured, you know, he’s old enough to know better. (Rita, wife of MI/CABG patient) I was watching a program y and they were nagging at each other and I said [to her], ‘‘you don’t push buttons like thaty’’And it’s just that there is a difference between somebody that wants to get on you all the time and somebody that just puts up with you and doesn’t get back on youy(Matthew, CABG patient) He likes it really [when I ask how he feels after physical exertion], I think. ‘Cause it’s not all the time. It’s not like a nagging thing. (Barbara, Matthew’s wife) As this sampling of quotations suggests, nagging is undesirable. In contrast to ‘‘talking it

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out’’ or ‘‘putting up with you’’, nagging involved talking frequently in a way that aroused irritation in response to implied control and/or condescension. Partners can sometimes avoid coming off as nagging if they do not comment too frequently or if they watch their tone and wording. However, partners said even their best efforts might be interpreted differently by the patient. As Kathy, wife of an MI/CABG patient, explained: ‘‘I don’t have to nagy Although he probably thinks I do [nag].’’ Some partners said that talking about lifestyle changes not only ran the risk of nagging but also was likely to be ineffective at bringing about change anyway. Lois said that when she tried to talk about diet with her husband, Roger, ‘‘He just laughs at me. He knows I’m concerned and he agrees. ‘Oh yeah. I guess I’d better.’’’ After a recent doctor’s appointment in which Roger learned he had gained weight, Lois reported that his diet improved: ‘‘He saw a need and he fulfilled that need. But he has to see it himself, you know, I can’t do all that. And I don’t want to nag at him. I can’t do it all.’’ Roger’s characterization of their conversations also revealed a view that the final decision to make changes was his own. At several points in his interview, he characterized his wife’s talk about changes in diet and exercise as ‘‘reminders’’. Asked by the interviewer, ‘‘Would you say those are gentle little reminders, or does she kind of get after you?’’ Roger replied: ‘‘Oh, she gets after me with gentle reminders. See, when we got married I had her put in the vow that ‘I would obey.’ So, when it comes down to it, I am the boss.’’ Just as talking about lifestyle change could connote control and criticism, refraining from talk could be construed as respecting autonomy. To talk suggests a right to be involved and a stake in the matter. Several patients expressed appreciation that their partners had given up talking about a contested lifestyle change and said this showed acceptance of the patient’s right to decide. For example, Nathan reported that his decision to manage stress by cutting back at work was not something he had discussed with his partner: ‘‘There’s nothing to talk about. It’s my decision.’’ Likewise, Nathan had stopped drinking alcohol following his MI, but he said that he and his partner had not discussed it, even though he characterized his previous consumption as excessive. He explained, ‘‘There wasn’t any point in

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talking about it. I wasn’t going to quit until it was time to quit.’’ For Nathan, lifestyle changes were his alone to make on his timetable and to discuss them with his partner would be to suggest otherwise. If talking about lifestyle changes risks negative meanings such as control, criticism, and futility, we might wonder why couples ever do raise these topics. The countervailing rationale for talking despite the risks was implied in the very same quotations about nagging that were given above. Though it may be interpreted as nagging, talking about lifestyle change is often motivated by laudable desires to protect and encourage. It may be part of ‘‘talking it out’’, noticing one another, and ‘‘putting up with’’ one another. Donna explained: My husband dearly loves to eat!y[I] try to at least help him instead of maybe just keeping my mouth shut about it completely. But I don’t want to be a harper on it either because I think that would be worse. It’s one of those situations where you’re not sure sometimes what you ought to do. Thus, talk about lifestyle change can create a dilemma for partners, who wish to avoid being seen as nags and who recognize the limits to their own control over the patient’s behavior but who worry about the patient’s health and fear that not talking is tantamount to not helping. It can also create a dilemma for patients who recognize their partner’s good intentions but wish to retain their autonomy to make changes. Couples may be able to manage the dilemma by regulating how often they talk or the tone they take (Goldsmith et al., in press), but the balancing act may be a delicate one and partners may end up disagreeing. Rather than assuming that nagging always originates in something the partner says or does, we also observed self-reinforcing cycles in which patient behavior made possible some kinds of partner comments, which, in turn, were consistent with particular lines of action for the patient. Each person’s way of talking about the issues reinforced the other’s, sometimes in ways they found satisfactory and sometimes in ways they found unsatisfactory. For example, when patients enthusiastically make lifestyle changes, there may be less need and fewer opportunities for talk that could be perceived as nagging. Simon reported that his wife never nagged

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him about what he ate. When asked why he thought that was, he replied with a laugh, ‘‘‘Cause I’m a good boy!’’ He then reflected: ‘‘Now I don’t know if I was bad if she would, I don’t know. I think she probably would.’’ Lisa also said Simon had been ‘‘really, really good’’ about his diet. As a consequence, Lisa reported, ‘‘Yes, so I do catch him but it’s- He’s so good that it’s not a problemyfortunately, I was never tested earlier because I think I would have been really bad.’’ Simon’s and Lisa’s accounts show how it is easier for a partner to avoid strong social control attempts when the patient is making changes on his or her own. Ben and Kathy reported a self-reinforcing cycle around his resistance to changing his diet. Kathy described several examples of her husband’s dietary infractions, including eating french fries in restaurants and drinking whole milk. When asked if she ever said anything to him about this, she said, ‘‘I really don’t think I do. But he always acts like I am. I think he feels guilty enoughyI used to say a little bit and [now] I just go, ‘whatever!’ You know, it’s his lifey’’ When asked in his interview if there were topics related to his heart condition that he and his wife argued about, Ben replied, ‘‘Diet’’ and went on to explain: ‘Cause I want to eat everything and she doesn’t want me to. [laughter] I think it’s that simple. [laughter] And I suppose because I want to win. [laughter] y It comes up particularly when we’re eating out. Because there are things that I really should just never order. And I find it hard to pass up some of those things. And then I, she would not say that I get scolded. But I’d say I get scolded. Both Ben’s and Kathy’s descriptions suggest rather limited and specific instances of consuming high fat foods, and they laugh as they describe their arguments. Nonetheless, their example suggests a self-reinforcing cycle in which failing to stick to a low-fat diet leads to partner control attempts which are met with resistance, some resentment, and a determination to continue with the dietary infractions. Their example also shows how social control attempts that a partner might perceive to be rather tame can be interpreted by a patient as ‘‘scolding’’ within a cycle of infraction, guilt, and resentment. Once such a pattern is established, even when the partner believes she no longer comments, the patient may still infer disapproval.

Caring can be a double-edged sword As we have seen already, talking about lifestyle changes can be interpreted as a desirable expression of relational caring, closeness, and responsibility. We observed many instances when patients and partners expressed these connotations: I think I have said to him, ‘‘I know you probably don’t like to hear me say things [about diet] but I just do it because I love you and I want to make sure you’re around for awhile.’’ (Donna, wife of MI/CABG patient) He’ll say, ‘‘You shouldn’t be doing that.’’y It shows that he cares. I don’t listen. But it shows that he cares. (Renee, CABG patient) Conversely, when couples did not discuss lifestyle change, it could be construed as a lack of care. After her MI, Ruth’s husband did not say anything about her diet or exercise and she concluded, ‘‘It’s like he isn’t concerned.’’ Meanings of caring were typically seen positively. However, when talk about lifestyle is equated with caring, partners may feel obligated to talk (cf. Lukkarinen & Kyngas, 2003). George said his wife’s comments did not bother him because ‘‘I figure that’s her job,’’ and Paul described his wife’s comments as ‘‘just normal wifely concerns,’’ each revealing a view that wives are expected to talk about lifestyle changes. A partner may be expected (by him- or herself, by the patient, or by others in the social network) to take some responsibility for a patient’s behavior. As a result, partners may feel caught in a ‘‘gatekeeping’’ role they do not desire but nonetheless feel obligated to enact. Rose said she had told her husband Ken that if she didn’t care so much for him, she wouldn’t comment on his diet. Ken understood, saying, ‘‘She feels that she has a responsibility, she’s told me that, to sort of keep me on the path.’’ Rose described the mixture of frustration and appreciation Ken expressed toward the responsibility she had taken for his diet and exercise, saying, ‘‘I think he appreciates very much what I’m doing. He sometimes will act like maybe this isn’t what he wants, but I think that in reality he is.’’ Ken recognized that ‘‘we do discuss diets quite a bit, and of course I am much more lenient than she is, so she’s the gatekeeperyAnd that puts the load on her and sometimes she gets a little bit unhappy about that.’’ Whether the partner desired it or not, talking about lifestyle changes implied the partner sharing some responsibility for patient behavior and

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patients might react with a mixture of appreciation and resistance. Interpreting talk about lifestyle as caring created a bind for some patients, who wished to disagree with the substance of their partner’s comments without invalidating the relational caring their talk conveyed. For example, Matthew felt constrained about expressing his frustrations when his wife Barbara was concerned about resuming sexual intercourse soon after his CABG: ‘‘And I know that she was just being careful. . .what can you do? You can’t get mad, you know, she’s worried about you.’’ Likewise, 4 months after his surgery, Matthew said that when Barbara comments about lifting or other activities: I feel like she has her place saying that, but I feel like I know where my limits are. And you know, it’s good for her to want to watch out for me, just like she would with the kids, or whatever. But being, I know what my muscles feel likey [emphasis added] Caring occurs within various roles, and partners’ reminders may risk crossing the line from partner behavior to parental behavior. Because he recognized his wife’s caring intentions, it was more difficult for Matthew to complain, even though her comments made him feel like a child and failed to recognize his own judgment. The expectation that talking is a caring partner’s responsibility also created a bind for some partners. For example, Dot was concerned about how much her husband, Paul, depended on her to tell him what to eat. When she told Paul he should take some responsibility for these choices rather than always asking her, ‘‘he kind of gets his feelings hurty.and he’ll say, ‘Okay, I’ll do it myself if you don’t want to do this for me.’’’ Because Paul interpreted Dot’s comments about his diet as caring, it became difficult for her to question that pattern of communication. One way partners may manage their own distress following a cardiac event is to take on responsibility for actions that patients could do for themselves (Coyne, Ellard, & Smith, 1990) and these individual affective processes may be present in our couples. However, our examples show communicative processes may also contribute to overinvolvement. Dot recognizes a potentially problematic pattern yet one part of its perpetuation is the way positive, caring meanings of talk about lifestyle change constrain what can be said within those conversations.

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We don’t want to dwell on illness Numerous studies have shown how chronic illness can challenge an individual’s identity and biography (e.g., Charmaz, 1987; Corbin & Strauss, 1987). When chronic illness entails risk behavior modification, this, too, can challenge identities (Becker, 1997). A couple’s talk about lifestyle changes is a potent reminder that life has changed, and the patient’s identity and illness trajectory are implicated in the frequency and content of that talk. Participants spoke of their desire to see their CHD as ‘‘fixed’’ by surgical procedure, medication, and/ or risk modification and of their desire to return to normal activities. Adopting a healthy lifestyle entails enacting an ‘‘at risk’’ identity that differs both from the ‘‘sick role’’ one plays as an acutely ill patient and from the ‘‘well’’ or ‘‘normal’’ identity (Baric, 1969). Talk about one’s lifestyle can cast the person whose behavior is under discussion as someone who may no longer take those behaviors for granted. Several participants commented that the cardiac event had made them more aware of their mortality and more appreciative of life. Yet food, participation in sports, taking care of one’s yard or house, smoking and other risk-related activities may be woven into life’s enjoyable moments. The same cardiac event that inspires a desire to live fully may also require redefinition of a full life. Talking about lifestyle change can cast a patient or partner in the role of kill-joy, or one who puts an end to participation in activities that make life worth living. Patients and partners expressed a desire not to dwell on negative aspects of life with CHD and explicitly or implicitly associated some kinds of talking with dwelling. Nathan described his and his partner’s orientation: ‘‘She’s optimistic, I’m optimistic. I think that’s the way you have to live your life. I couldn’t be with anybody that wasn’tyThey sit around and worry about my health, it’d be ‘byebye honey.’’’ When CHD-related recommendations disrupt everyday life, talking about the changes may only add to the disruption. Talk about physical activity was especially likely to reflect upon patients’ identity and illness trajectory. Some activities were prohibited immediately following the cardiac event but became acceptable again as a patient recovered. During this transition, patients said their health care providers told them to monitor their sensations and to stop if something hurt. This advice created uncertainty, especially for

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partners who had no direct access to a patient’s bodily sensations and who had variable access to the health care provider’s instructions (some accompanied patients to appointments while others heard the instructions relayed by the patient). Kirby recognized that 2 months after his MI his wife ‘‘still worries’’ about his exertion: Occasionally, she’ll go, ‘‘Are you, you okay?’’ Just concerned. ‘Cause she knows that I’ll hide stuff. She knows that I’ll try to hide fear. She knows that I’ll hide painyso she tries to keep in check, ‘‘Are you okay?’’ Partners may wish to talk about how patients are feeling in order to reassure themselves, but these inquiries are a reminder that recovery is still in progress and ordinary activities are not yet ordinary for the patient. Donna reported: I probably was real protective during that time, trying to make sure that he didn’t or trying to do, you know, but now that I’ve finally decided that he’s away from it like he is, he seems to be doing good, and so maybe I should just try to let him see what he can do and hopefully he’ll know. In contrast, Victoria said she wished her husband would talk about her rehabilitation program and exercise plans. She attributed his unwillingness to talk to a desire to deny that she had CHD: My husband does not want me to be ill. And that’s out of love. It’s not out of ‘‘I can’t be bothered.’’ It’s out of, ‘‘there’s no way I could do without you’’ and ‘‘there’s no way you can be ill.’’ y He was certainly very consumed and very caring when it happened. But now, it’s history. For some, lifestyle changes are empowering and talking about them with a partner is a way for the couple to negotiate a new sense of ‘‘normal’’ and take control over an uncertain illness trajectory. For Simon and Lisa, talk about lifestyle changes was a positive step toward recovery when it revealed acceptance of a new reality and a desire to be proactive in safeguarding Simon’s health and quality of life. Simon recalled that right after his MI, their conversations were about ‘‘Am I going to be able to do this?’’ Lisa recalled how her husband was ‘‘just being introspective and thinking’’ during the first month, whereas later, ‘‘I could see him really focusing on the future, you know. This is what happened and you kind of had dealt with it.’’ A particular conversation she viewed as a positive

turning point was one in which they discussed the possibility he might give up racquetball: And something like, ‘‘Does it matter that much to you that you play racquetball?’’ He said, ‘‘Yeah, I really like it and I really need to exercise.’’ I said, ‘‘Will it bother you if you can’t play that for the rest of your life?’’ He said, ‘‘Yeah, it probably will, somewhat. But if I can’t, there’s a lot of other things I can do. I can do this. I can do that.’’ And I thought, ‘‘Well good.’’ He wasn’t just focusing in on ‘‘I can’t do something’’ but ‘‘I can do some other things.’’ Talk about Simon’s exercise reinforced that life had changed. However, when the topics of their talk changed from restriction to constructive action, they both saw this as a positive move in the recovery trajectory and a way to enact an identity empowered by lifestyle change. For other couples, lifestyle change had negatively changed identity and relationship and talking about it required some effort in order to put losses in the best possible light. For Joyce and Wendall, talk about lifestyle changes drew attention to an undesired illness trajectory that had required successive identity accommodations. Wendall had been through several MIs and two CABG surgeries and had been diagnosed with congestive heart failure, a condition in which the heart is unable to meet the body’s needs. Joyce said of the resulting lifestyle changes, ‘‘yI don’t make a big deal about it, that he doesn’t do the things that he used to do. I just go ahead and do it. You know, I don’t say anything about it.’’ Nonetheless, Wendall was clearly aware of changes in what he was able to do and of his wife’s accommodations. He said, ‘‘She’s more concerned about me all the time. She does more around the house, fights to do more than I do now. She won’t let me do things that I used to do.’’ Still, when asked if their relationship had changed, he responded: ‘‘I think in some ways it’s better. But I feel sorry for her having to put up with all that. And I appreciate her taking care of me all the time.’’ Joyce’s description of how she talks about her husband’s dietary restrictions reveals a balancing act between acknowledging the need for change and dwelling on restrictions. She said: I think that I care more now about his diet. You know. When we go out to eat I kinda make suggestions about ‘‘Oh, you know, that looks

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good.’’ Something like chicken instead of beef. But then I don’t do a whole lot of that because of, I figure he’s got to have some fun in life and his cholesterol is not high and mine is, and his isn’t. Although Joyce gave several examples of avoiding talk about lifestyle change in order to avoid drawing attention to Wendall’s illness, she described as a good conversation one in which he joked with her about shoveling snow: He said, ‘‘We’re gonna have to buy a snow shovel’’yAnd he said, ‘‘I won’t be able to shovel it.’’ And I said, ‘‘Oh, you’re gonna buy me a snow shovel.’’ [laughs] And I said ‘‘Okay, you let me pick it out,’’ you know. But, you know, he admitted that he should not be shoveling snowyOh, there were times in the past when I, you know, he wasn’t always as agreeable about this. I mean he had to learn to live within the parameters of his abilities. And he kinda needed a keeper. I think most men do. Joyce recognizes Wendall has a serious and debilitating condition, yet she believes he is like ‘‘most men’’ in needing a keeper. Joyce is mindful of the need for restrictions but she finds ways to talk about it so as to normalize his lifestyle. Talk about how to live with one’s CHD can reveal acceptance of a condition and a determination to make the best of it, but such talk also underscores the fact that there is a condition to accept. Lifestyle changes can both empower and undermine the self, and talking about it may bring this tension to the forefront. However, talking about lifestyle changes does more than just reveal patient and partner perceptions. Talk is relational and may also draw attention to dependence, inequity, and power. Joyce’s account shows she thinks about how to talk in order to avoid threatening an identity that has already been assaulted by illness and to downplay the degree to which changes in Wendall’s capabilities affect her as well. Even when a patient recovers to the point that household burdens and dependence are not an issue, tensions may arise from questions about the patient’s status as sick, at risk, or well and the comparative status of the partners. MI and CABG patient Mark said that when his wife, Irene, comments on his diet, he knows ‘‘she’s doing it for my own good’’ but that he gets ‘‘a little tired of hearing it all the time.’’ He observed that her eating habits were no better than

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his own, yet she commented freely upon his diet. He felt constrained from reciprocal comments on her choices: ‘‘Because it makes her mady So I, you know, no, I don’t say anything about how she eats.’’ The lack of reciprocity in commenting on one another’s lifestyle was a reminder that he was the one who was ‘‘sick’’. In her interview, Irene also reported some frustration with their talk about diet, saying, ‘‘When I think he’s doing something that he shouldn’t be doing, as he says I am probably a nag. I try not to be.’’ In contrast to his perception that he was ‘‘hearing it all the time,’’ Irene said she had stopped saying much about his diet, in part because his blood pressure had improved recently but also because ‘‘he just went ahead and did it. It probably went in this ear and right back out the other!’’ In fact, she reported encouraging an occasional splurge: ‘‘ya couple times, we’d been out eating. He says, ‘Well, I’m ordering what I’m supposed to be ordering.’ I says, ‘Now, Mark, if you want to eat steak, you go right ahead.’’’ Although the substance of her comment was to encourage him to enjoy a special dinner without constraints, it draws attention to the fact that Mark no longer eats what he likes whenever he wants and Irene, as a well person, is authorized to comment and even grant permission whereas he is not. Lifestyle change is infused with meanings derived from broader cultural discourses and dilemmas. Adopting a healthy lifestyle has taken on moral significance and may be charged with meanings of control, fatalism, rebellion, vitality, or virtue (Conrad, 1994; Crossley, 2000; Davison, Frankel, & Smith, 1992), thus creating conflicting demands for self-control, release, and consumption. Our findings show these meanings surface not only in public health campaigns but also in couples’ everyday talk. Among those who are demonstrably at risk by virtue of a cardiac event, these tensions are particularly salient and show up in mundane talk as couples decide what to eat, plan daily activities, or remark on one another’s behaviors. One impetus for studying couples’ talk about lifestyle changes comes from a desire to marshal partners in the effort to modify risk behaviors. However, we should consider the implications of drawing partners into the dilemmas intrinsic to this enterprise. Perhaps not surprisingly, participants in our study who experienced dilemmas of talking about lifestyle change did not locate these in contradictions of cultural discourse or in the nature of the cardiac recovery experience, but instead tended to see them

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as personal or relational problems they had to work out for themselves. Conclusion Couple talk about adhering to a heart-healthy lifestyle has meaning that goes beyond the literal content of the conversation, conveying desired personal and relational qualities such as caring, closeness, responsibility, recovery, and taking charge of one’s health as well as less desirable qualities such as control, criticism, sickness, loss, and futility. These multiple meanings can create dilemmas within and between partners so that good intentions do not always translate into positive interpretations. These dilemmas suggest an account for why previous research has not detected a consistently positive effect of partner support on a patient’s heart-healthy lifestyle: Whether or not a couple’s talk facilitates lifestyle change may depend upon how they manage meanings and dilemmas. Interaction patterns that capitalize on the desirable identity and relational meanings of lifestyle talk are more likely to be accepted and appreciated whereas patterns that are given undesired identity and relational meanings are more likely to be met with resistance and resentment. We describe couples’ strategies for managing dilemmas in greater detail elsewhere (Goldsmith et al., in press). Couple interaction is only one component involved in risk behavior modification. However, our findings give insight into why informed and motivated patients and well-intentioned partners may nonetheless run into difficulty in making and sustaining lifestyle change. In addition to explaining some of the challenges associated with the task of encouraging lifestyle change, our findings are also relevant to the broader study of chronic illness and identity. Identity changes that may occur in chronic illness occur in a relational context, and partners can be a significant source of validation or threat to a patient’s identity. Most previous research on illness identity has focused on how identities are revealed and enacted in personal narratives. We have shown that a couple’s conversations about what to do, what to eat, and how to change can have powerful implications for partner identity as well as patient identity and for their views of their relationship. Insofar as these everyday conversations involve dilemmas and require coordination with another person, the identity construction processes may differ from those observed in personal narratives.

Attention to couple interaction about lifestyle change reminds us that the identity-relevant meanings of illness and lifestyle change are not only a cognitive construct of patients but also an enacted performance in significant relationships. Our findings replicate a growing body of work that points to the salience of social support and social control as conceptually distinct provisions of personal relationships. However, support and control do not exhaust the meanings of talk about lifestyle change and to conceptualize these as different behaviors (i.e., rating the frequency of various behaviors that are categorized as either support or control) would not adequately capture the dilemmas we found. A particular conversation or a repeated style of interaction can mean multiple things simultaneously and therein lies the challenge. We also found that attempts at support and control have a relational history; it is not always clear that a partner’s behavior at one point in time is the cause of a patient’s later response. Was the partner supportive because the patient’s self-initiated changes provided more opportunities for praise than for nagging? Or was the patient able to make those changes because of the positive support of the partner? Finally, our findings have practical implications for how to assist patients and partners. For many couples, it may be useful to simply validate the experience of dilemmas and help patients who interpret adherence talk in one way realize that their partners may understand talk in quite a different way (and vice versa). Alerting patients and partners to dilemmas of talk about lifestyle change may help them to see they are not alone and to attribute the frustration they experience to the challenging situation in which they find themselves, rather than presuming that their relational partner is especially difficult or obstinate. Previous research has underscored the need to adequately support and inform partners if they are to serve as constructive facilitators of recovery and rehabilitation (e.g., Coyne & Smith, 1991; Stewart, Davidson, Meade, Hirth, & Makrides, 2000). To this we would add that couples may benefit not only from medically derived information about health risk but also from information about the relational dynamics of lifestyle change. Acknowledgments This research was supported by a grant from the University of Illinois Research Board. We wish to

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thank the cardiac rehabilitation staff at Carle Foundation Hospital and Provena Covenant Medical Center and the Champaign-Urbana chapter of Mended Hearts for their assistance in participant recruitment. We thank Virginia McDermott and Kristen Bauer for their assistance with interviews and transcription and Ruth Anne Clark for helpful comments on an earlier draft.

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