Couples and Concealable Chronic Illness: Investigating Couples’ Communication, Coping, and Relational Well-Being Over Time

Abstract

Couples managing chronic illnesses—the leading causes of death and disability in the U.S.—can experience challenges in their daily lives and relationships. Both couple members have reported lower satisfaction, greater burden, and communication difficulties. Many of these illnesses are nonvisible or concealable, increasing fear and uncertainty when sharing illness information, and reducing self-disclosure. These challenges can leave couples vulnerable to dissatisfaction and distress. In this longitudinal study, we integrated dyadic coping frameworks to examine how couples’ communication and coping predicted relational well-being over time. Couples, where one partner was diagnosed with a concealable chronic illness, completed three online surveys 6 months apart (ns = 242 couples at baseline, 146 couples at 6 months, and 123 couples at 12 months). Couples were recruited from university settings. Actor-partner interdependence mediation models using within-person multilevel dyadic path modeling tested the theoretical model. For patient and partner actor effects, at times when they saw the illness as shared and something that they could manage together, the more they talked about the illness and used dyadic coping strategies (ps<0.001). In turn, when using dyadic coping strategies more often, patients and partners felt more satisfied, close, and sexually satisfied than they typically felt that year (ps<0.001). For cross-partner effects, when patients talked about the illness more than usual, their partners also used dyadic coping strategies more often (p=0.01). Patients’ open communication may not only benefit themselves but also their partners. This multifaceted approach offers new insight into promoting relational well-being while managing concealable chronic illness.

Introduction

Chronic illness is among the most common health issues and leading causes of death and disability in the United States (Bauer et al., 2014). Nearly half of American adults have at least one chronic illness, and one in four adults has multiple chronic illnesses (Ward et al., 2014). Many chronic illnesses, defined as health conditions with prolonged durations that do not resolve spontaneously and are rarely cured (Bauer et al., 2014), are nonvisible or concealable, meaning their symptoms are not visibly detected by others; such illnesses include diabetes, arthritis, and cardiovascular disease. This invisibility can create a unique set of challenges, such as individuals going unnoticed or untreated to avoid the label or stigma (Link & Phelan, 2006).

Individuals experience significant limitations across their daily routines and activities, as well as difficulty maintaining intimate relationships (Bayliss et al., 2003). Partners of those with chronic illness are often the main source of social support yet can feel burdened when restricting their behaviors, limiting their social activities, or providing care (Berg & Upchurch, 2007; Bodenmann, 2005). Individuals with chronic illness can also feel like a burden when involving their partners in coping (Jeon et al., 2010). These challenges can leave both partners and their relationship vulnerable to dissatisfaction and distress (Shrout, 2021).

In this longitudinal study, we examined how couples maintain their relationships while managing chronic illness. Drawing on several dyadic coping frameworks, we assessed couples’ underlying communication and coping processes to understand how each partner sees, talks about, and copes with the illness. Given the invisibility and concealability of many chronic illnesses, it might be important that each partner feels comfortable talking openly to understand the illness, its severity, and the necessary care. In turn, we examined how these communication and coping processes informed multiple aspects of each partner’s relational well-being. This dyadic perspective provided a window into how partners work together to manage chronic illness and maintain satisfying relationships. Taking this multifaceted approach may offer new insight into promoting relational well-being and reducing illness-related relationship risks.

Dyadic Coping and Chronic Illness

Dyadic coping frameworks, such as the systemic-transactional model (Bodenmann, 2005), developmental-contextual coping model (Berg & Upchurch, 2007), and dyadic illness management theory (Lyons & Lee, 2018), suggest partners mutually influence each other during stress and when managing chronic illness. Given partners’ interdependence, they engage in dyadic coping to relieve stress from the relationship and each partner (Bodenmann, 2005). As with individual-level models, these frameworks identify stress-related appraisals, communication, and coping as three important elements of managing stress and chronic illness. Extending to a couple-level perspective, the coping process is conceptualized as dyadic, suggesting that partners influence each other’s appraisals, communication, and coping efforts (Berg & Upchurch, 2007; Shrout, 2021). When faced with a stressor, such as a chronic illness, partners (1) appraise the stressor, such as who is responsible for and in control of the illness; (2) talk about the stressor, for instance how the illness affects them; and (3) use strategies to reduce each other’s stress, such as stress related to the illness (Berg & Upchurch, 2007; Bodenmann, 2005). Figure 1 shows the conceptual integrated dyadic coping model that guided the present research, while the following sections explain the model’s various components.

Figure 1.

Theoretical integrated model predicting relationship satisfaction, relationship closeness, and sexual satisfaction in couples coping with chronic illness. WI = within-person

Appraisals and Communication

Even among happy couples, communication problems can arise when managing a nonvisible chronic illness. Due to the invisible nature of these health conditions, partners need to talk openly about the illness to better understand it, including how it affects each partner and the relationship (Manne & Badr, 2008). Yet, disclosing illness-related information can increase feelings of helplessness and anxiety (Braitman et al., 2008). In one study, individuals reported feeling fearful and uncertain when sharing illness-related information, and the invisibility further reduced their willingness to self-disclose (Blixen et al., 2016). These concerns can contribute to patient concealment, such as avoiding talking about the illness and hiding worries related to their emotions, sexuality, and future plans (Lee & Lyons, 2019; Lyons et al., 2021). For example, 56% of breast cancer patients expressed difficulty talking about sexual issues (Kornblith et al., 2006). Even after talking about the illness, partners might not fully understand how the illness affects one another. In a study on cancer patients and partners, both couple members experienced distress when well-intentioned partners’ communication behaviors were unsupportive (Manne et al., 2007).

As discussed in stress communication and communal coping models (Lyons et al., 1998; Manne et al., 2014), shared stress appraisals can increase positive communication in couples. The more partners see the stressor as shared—a “we-stressor”—the more likely they are to think and talk about it in relational terms. For instance, seeing a stressor as “our” issue rather than “your” or “my” issue. This relational perspective helps couples take “we”-based action by working together to tackle stress. In Manne and colleagues’ (2014) work on couples with cancer, partners with a greater shared illness appraisal, meaning they saw cancer as something that could be managed together, reported greater positive communication strategies (Manne et al., 2014). Couples engaged in more frequent illness-related relationship talk, such as talking about how cancer affected their relationship and what partners needed from each other; they also engaged in more mutual self-disclosure, sharing personal information, thoughts, and feelings about cancer. In turn, couples using these communication strategies reported greater relationship closeness and intimacy. Despite research illustrating the importance of shared illness appraisals in couples with cancer, their relational benefits in couples with nonvisible chronic illness have not been examined. Longitudinal studies examining how both partners see and talk about the illness would help understand how couples maintain their relationships.

Communication and Dyadic Coping

In dyadic coping frameworks, each partner’s stress communication affects how they cope with the stressor (Bodenmann, 2005). Partners send each other verbal and non-verbal messages about the stressor’s severity and how to handle it. Partners then use various dyadic coping strategies, defined as the process of collaborating and sharing resources to manage a mutual stressor (Bodenmann, 2005). These dyadic coping strategies include both positive techniques, such as managing stress together or taking stress off each other’s plate, and negative techniques, like helping each other unwillingly or sincerely. In a study of patients with advanced cancer, patients used more negative coping strategies when their spouses were critical during communication (Manne, 1999). In contrast, patients and partners who felt more confident talking about the illness also reported enhanced coping (Magsamen-Conrad et al., 2015). In addition, heart failure patients and their care partners used more positive dyadic coping strategies when they both talked about the illness and rated talking about the illness as important (Bouldin et al., 2019). In contrast, those not talking openly and feeling frustrated when discussing the illness used more negative coping strategies. These findings illustrate how couples’ communication strategies influence their dyadic coping. Assessing links between communication and coping longitudinally may offer new insight into how these dyadic processes change over time and enhance both illness management and couples’ relationships.

Dyadic Coping and Relational Outcomes

The link between dyadic coping and relational well-being is well-documented. A meta-analysis of 13 studies showed partners using positive dyadic coping strategies had higher relationship satisfaction, with 30% to 40% of the variance in relationship satisfaction explained by dyadic coping (Bodenmann, 2005). When coping with cancer, patients and partners using positive dyadic coping had greater relationship satisfaction, closeness, and intimacy (Manne, Ostroff, et al., 2004; Manne, Sherman, et al., 2004). In contrast, cancer patients and partners using more negative dyadic coping strategies reported poorer relationship functioning and lower satisfaction in both patients and partners (Kayser et al., 2007; Rottmann et al., 2015). Other studies have demonstrated dyadic coping’s relational benefits in those with chronic obstructive pulmonary disease (COPD; Vaske et al., 2015) and diabetes (Schokker et al., 2010). In breast cancer survivors, greater partner support has also been associated with fewer sexual difficulties and greater relationship satisfaction concurrently and 6 months later (Kinsinger et al., 2011). Though fewer studies have examined links between dyadic coping and sexual satisfaction in couples with chronic illness, theoretical and qualitative work have shown that poor illness management can negatively impact sexual intimacy and well-being (Verschuren et al., 2010; Weber & Solomon, 2008). In addition, daily diary research among those without chronic illness demonstrated that individuals’ sexual satisfaction was higher on days with greater dyadic coping (Bodenmann et al., 2010; Schwenck et al., 2022).

Also, cross-sectional work illustrates the indirect effects of shared illness appraisals on better relational outcomes through communication and coping. For example, cancer patients and partners with greater shared illness appraisals engaged in more illness-related communication and, in turn, reported greater emotional closeness (Manne et al., 2014). Among physically healthy couples, greater communication predicted higher relationship satisfaction through dyadic coping (Levesque et al., 2014). Recent reviews on dyadic coping have shown that when couples see stressors as shared, they use more constructive communication and coping and, in turn, enjoy greater sexual and relationship satisfaction (Bertschi et al., 2021; Falconier & Kuhn, 2019). These findings and reviews provide initial evidence of both the direct and indirect benefits of shared appraisals on couples’ relationships through greater communication and dyadic coping.

A Developmental Context

Given that one in two American adults has a chronic illness (Ward et al., 2014), it is important to investigate how dyadic appraisal, communication, and coping processes help couples maintain their relationships while managing chronic illness. Prior work has shown that relationship and sexual satisfaction declined over time, particularly among young and middle-aged adults (McNulty et al., 2016), those with chronic stress (Lavner & Bradbury, 2010), and those low in dyadic coping (Falconier & Kuhn, 2019). Illness management can also interfere with relationship maintenance, contributing to declines in dyadic coping and relational well-being (Falconier & Kuhn, 2019). Indeed, among couples with COPD, dyadic coping decreased over three years (Vaske et al., 2015). The developmental stage of couples is also important. Young adult and middle-aged couples managing a chronic illness may be non-normative, posing challenges to each partner’s ability and expectations to manage a life-long illness (Berg & Upchurch, 2007). Couples may experience more limitations and burdens in daily life than anticipated. Likewise, rather than serving as a spousal or partner caregiver, partners may have a unique role in co-managing an illness. Investigating how couples develop and use relational resources to cope with chronic illness in early developmental stages may inform prevention and intervention efforts. Helping couples identify and apply dyadic coping skills early on may help them manage chronic illness and maintain strong relationships throughout adulthood.

The Present Study

This longitudinal study integrated stress communication and dyadic coping frameworks to gain a comprehensive understanding of how individuals with chronic illness (hereafter referred to as “patients”) and their partners (hereafter referred to as “partners”) cope with concealable chronic illness. By applying multiple perspectives, we examined how key elements of the coping process contributed to each partner’s relationship well-being, including their relationship satisfaction, closeness, and sexual satisfaction. Our dyadic and longitudinal sample allowed us to examine patients’ and partners’ coping over time, as well as how changes in coping were related to changes in relational well-being (i.e., within-person effects). These within-person processes are important in understanding how changes in a person’s own experiences impact how they and their partners cope with the illness.

Though fewer studies have examined links between dyadic coping and sexual satisfaction in couples with chronic illness, we anticipated similar beneficial effects of coping on patients’ and partners’ relationship satisfaction, closeness, and sexual satisfaction. As shown in Figure 1, we hypothesized that when patients and partners saw the illness as more shared than usual, they would each talk more about the illness than usual. This greater stress communication, including illness-related relationship talk and mutual self-disclosure, would in turn be associated with greater than typical dyadic coping in patients and partners. Patients’ and partners’ greater use of dyadic coping strategies would ultimately be associated with higher than their own average relationship satisfaction, closeness, and sexual satisfaction. Moreover, we hypothesized indirect effects throughout the model: patients’ and partners’ greater shared illness appraisals would be linked to better than usual relationship outcomes through greater stress communication and dyadic coping.

Method

Participants

Couples, where one partner (i.e., “patients”) had a nonvisible diagnosed physical chronic illness (e.g., autoimmune diseases, cardiovascular disease, chronic pain), were recruited to participate in a longitudinal study on how couples cope with chronic illness. Couples were recruited from several universities and colleges in the western United States through email advertisements about the study. Emails with eligibility requirements and an online screening questionnaire were sent to a campus-wide random sample of graduate and undergraduate students who agreed to release their email addresses with each university. Nonvisible chronic illnesses were defined as chronic health conditions that are not visually detectable by others, such as autoimmune diseases, cardiovascular disease, chronic pain, sleep disorders, etc. The screening questionnaire included a list of chronic illnesses from which participants could select, including the option to specify conditions not listed. Additional eligibility requirements included: (1) the person’s partner must also participate in the study and know about the health condition; (2) their relationship length must be at least 3 months; and (3) given the convenience sample of college students, individuals must have been at least 26 years and older to examine coping process in those beyond emerging adulthood (Arnett, 2007). In the screening questionnaire, individuals provided their partner’s name and email address so that each person could provide consent and receive the surveys via email. A total of 84 partners (34.7%) also had a chronic illness, which served as a covariate in the analyses. This study was approved by the University of Nevada, Reno Institutional Review Board.

Informed by an Actor Partner Interdependence Model a priori power analysis to detect small to medium-sized actor and partner effects (actor effect size = .20, partner effect size = .15, power of β = .85, and α = .05), we recruited a minimum of 186 couples. A total of 242 couples (484 individuals) completed the first survey, 146 couples (292 individuals) completed the 6-month survey, and 123 (246 individuals) couples completed the 12-month survey. Sociodemographic data at wave 1 are shown in Table 1.

Table 1.

Sociodemographic Data of Patients and Partners at Wave 1 (N = 242 couples)

	Patients		Partners
	M (SD), range	%	M (SD), range	%
Age	33.94 (7.95), 26 to 59 years		34.48 (8.41), 26 to 63 years
Gender
Women		71.7		30.0
Men		27.4		69.6
Non-binary or gender non-conforming		0.8		0.4
Race
White		78.8		78.8
Multi-racial		10.6		4.3
Asian or Pacific Islander		4.2		6.5
Black or African American		3.0		6.9
Native American or Alaska Native		2.1		1.7
Another race		1.3		1.7
Hispanic/Latinx		14.0		14.6
Sexual orientation
Straight/heterosexual		90.3		83.5
Bisexual		2.5		8.9
Gay or lesbian		5.1		5.9
Prefer to self-describe (pansexual, queer)		2.1		1.7
Current student status		100		16.9
Undergraduate student		51.4		8.5
Graduate student		48.6		8.5
Years of education		48.6
≤ Some college or completed college		59.09		71.90
> College		40.91		28.10
Employment status
Part-time		25.7		13.6
Full-time		36.7		69.5
Custodial parent of children		37.6		36.7
Relationship length (years; patient rated)	7.50 (6.13), 3 months to 35 years
Married/domestic partner		58.2
Engaged		11.0
Dating, living together		19.8
Dating, not living together		11.0

Measures

Shared Illness Appraisal

The 6-item Couple Identity subscale of the Commitment Inventory Scale (Stanley & Markman, 1992) was adapted to assess how partners view the health condition (e.g., “I am more comfortable thinking in terms of "my" [“his/her”] health condition than "our" health condition). Response options range from 1 (strongly disagree) to 7 (strongly agree). The items were averaged together (patient αs = .86 to .89; partner αs = .83 to .86). Higher scores represent a higher shared illness appraisal, meaning respondents viewed the illness as more shared (a “we-disease”) than solely the patient’s responsibility.

Illness-Related Communication

Communication was assessed with Manne and colleagues’ (2014) adapted measures of illness-related relationship talk, self-disclosure frequency and breadth, and perceived partner disclosure frequency and breadth. Measures were used to create a composite variable for each partner’s illness-related stress communication.

Illness-Related Relationship Talk.

A 7-item measure was used to measure the extent to which partners have talked to each other about how the illness impacts their relationship (e.g., “We have talked about how the health condition has affected our relationship”). Items were rated on a 7-point Likert scale ranging from 1 (not at all) to 7 (very much) and averaged together so that higher scores represent higher illness-related relationship talk (patient αs = .88 to .93; partner αs = .90 to .91).

Illness-Related Self-Disclosure.

Six items were used to measure illness-related self-disclosure. Three items assessed frequency of disclosed thoughts, feelings, and information about the health condition to their partners (e.g., “How often have you talked to your partner about your feelings about the health condition?”). Items were rated on a 7-point Likert scale (1 = very rarely, 7 = very often). Likewise, three items assessed the depth of disclosures (e.g., “Thinking about when you have talked to your partner about the health condition, how in-depth (e.g., how open, how complete) have you talked about your feelings about the health condition?”). Response options ranged from (1 = not at all deep, 7 = very deep). The items were averaged together, with higher scores indicating more frequent and deep illness-related self-disclosure (patient αs = .93 to .95, partners αs = .92 to .94).

Perceived Partner Illness-Related Disclosure.

The same items used for illness-related self-disclosure were adapted to measure perceived partner disclosure. Three items measured how often participants perceived that their partners have disclosed thoughts, feelings, and information about the health condition to them (e.g., “How often has your partner talked to you about his/her feelings about the health condition?”). Items were rated on a 7-point Likert scale (1 = very rarely, 7 = very often). Three items measured perceived partner disclosure depth (e.g., “Thinking about when your partner has talked to you about the health condition, how in-depth (e.g., how open, how complete) has your partner talked about their feelings about the health condition?”). Response options ranged from (1 = not at all deep, 7 = very deep). The items were averaged together with higher scores indicating more frequent and deep perceived partner illness-related disclosure (patient and partner αs = .95 to .96).

Illness-Related Communication Composite.

We then conducted confirmatory factor analyses (CFAs) for illness-related stress communication to assess how well the measures loaded together across waves. Though fit indices were uninformative because there were three items and the model was fully saturated (i.e., df = 0; CFI and TLI = 1.00, RMSEA and SRMR = 0.00), the indicators showed high standardized factor loadings. Patient loadings: illness-related relationship talk = .76, illness-related self-disclosure = .82, perceived partner illness-related self-disclosure = .82. Partner loadings: illness-related relationship talk = .72, illness-related self-disclosure = .87, perceived partner illness-related self-disclosure = .76. There was no measurement invariance between patients and partners (Δχ²(2) = 1.89, p=0.39) or by wave (Δχ²(4)= 3.34, p=0.50). Given the high loadings, and our conceptual model’s complexity, we averaged the measures together to create a composite observed variable for illness-related stress communication for each individual in the analyses.

Illness-Related Dyadic Coping

Dyadic coping was assessed with the Dyadic Coping Inventory (Bodenmann, 2008; Randall et al., 2016). Participants were asked to think about how they and their partners cope with the stress related to the health condition. The 16-item measure assessed dyadic coping that was supportive (5 items; e.g., “I show empathy and understanding to my partner”), delegated (2 items; e.g., “I take on things that my partner would normally do in order to help him/her out”), common (5 items; e.g., “We help one another to put the problem in perspective and see it in a new light”), and negative (4 items; e.g., “I blame my partner for not coping well enough with stress” and “I do not take my partner’s stress seriously”). Response options ranged from 1 (very rarely) to 5 (very often). Items were reverse coded and averaged so that higher scores indicate more positive dyadic coping (patient and partner αs = .86 to .88).

Relationship Satisfaction

The 3-item Kansas Marital Satisfaction Scale (KMSS; (Schumm et al., 1983, 1986) was adapted to assess romantic relationship satisfaction rather than marital satisfaction (e.g., “How satisfied are you with your relationship?”). Items were rated on a 7-point Likert scale (1 = very dissatisfied, 7 = very satisfied) and averaged so that higher scores indicate higher relationship satisfaction (patient and partner αs = .95 to .98).

Relationship Closeness

Relationship closeness was measured with the Inclusion of Other in the Self scale (IOS; (Aron et al., 1992). The IOS consists of 7 Venn diagrams that depict self and partner as circles with different degrees of overlap (perceived closeness). Participants selected the diagram (1 through 7) that best represented their degree of closeness in their current relationship, with higher scores reflecting greater closeness.

Sexual Satisfaction

We assessed sexual satisfaction using a five-item semantic differential scale (MacNeil & Byers, 2009). Using the stem, “In general, how would you describe your sexual relationship with your partner?” participants responded to 7-point bipolar scales: pleasant-unpleasant, positive-negative, worthless-valuable, satisfying-unsatisfying, and bad-good. Three items were reverse-coded, and all items were averaged so that higher values indicated greater sexual satisfaction (patient and partner αs=.93 to .94).

Analysis Plan

For descriptive analyses, we examined the nature of patients’ chronic illnesses, including the type of illness and the illness length, severity, and daily management. We also examined correlations between the main study variables at each wave and between waves for patients and partners. Then we conducted dyadic multilevel growth curve models to examine changes in the main study variables over the three waves and differences by role (patients vs. partners) and gender (women vs. men), along with their two- and three-way interactions. Non-significant interactions were removed when interpreting main effects, and the models corrected for multiple comparisons. Models specified that individuals were nested within couples and wave was a repeated factor across couples (Kenny et al., 2006). Models included random intercepts using a variance components covariance structure, and accounted for the similarity in the residuals of the partners’ variables across the specific time points using an unstructured covariance matrix. All descriptive analyses were conducted in SPSS version 26, and multilevel analyses were performed using the MIXED MODELS procedure with restricted maximum likelihood estimation.

Next, we examined study hypotheses. To address how changes in one variable related to changes in another variable, we conducted actor-partner interdependence mediation models (APIMeM) using multilevel dyadic path modeling (Bolger & Laurenceau, 2013; Ledermann et al., 2011); analyses were conducted using Mplus version 8.8. The model specified patients’ and partners’ outcome variables as a function of their own (i.e., an actor effect) and each other’s (i.e., a partner effect) predictor and mediator variables. This modeling approach accommodated the dyadic longitudinal data (i.e., wave crossed with patients and partners nested within dyads) and teased apart within- and between-person effects. Random intercepts and, when possible, random effects for the slopes were estimated. Wave was included as a fixed covariate. Patient and partner variables were person-mean centered to obtain within-person effects, and the person-mean centered variables were grand-mean centered to obtain between-person effects. Thus, within-person variables indicated how much participants’ scores at each wave deviated from their average across the study.

Within-person centering also allowed for within-person serial mediation hypothesis testing (i.e., level 1-1-1-1) using the following formula: a₁*a₂*a₃ + a₁*Cov(β₂, β₃) + a₂*Cov(β₁, β₃) + a₃*Cov(β₂, β₁), where a_i = E(β_i) (Asparouhov & Muthén, 2021; Bolger & Laurenceau, 2013); indirect effects were tested using 95% confidence intervals (CI). We examined the indirect effects of patients’ and partners’ shared illness appraisal on each relationship outcome through their own and each other’s illness-related communication followed by dyadic coping. Several actor and partner effects, as well as covariances, were similar in magnitude; thus, to reduce model complexity, patients’ and partners’ effects and covariances were constrained to be equal if deviance tests supported such constraints.

Prior to the main analyses, we assessed if missing data across the waves differed by key sociodemographic data, including gender, race, ethnicity, sexual orientation, having children, employment, income, and relationship status. Results showed missing data across waves differed by relationship status and race. First, participants of color were more likely to have missing data at waves 2 and 3 compared to white participants (wave 2: χ²(1)=11.45, p<0.001; wave 3: χ²(1)=8.31, p=0.004). Second, participants dating exclusively but not living together were more likely to have missing data at wave 3 compared to married/domestic partners (χ²(3)=8.81, p=0.03). No other variables differed across waves. Race and relationship status were included as covariates in the analyses, along with relationship length, relationship status, partner illness status, and patient symptom severity. Analytic code and data are available upon request from the first author; this study was not preregistered. We report how we determined our sample size, data exclusions, manipulations, and all measures in the study.

Results

Descriptive Analyses

Patients self-reported the following types of nonvisible chronic illness: rheumatologic (31.4%), endocrine (17.4%) digestive (11.6%), neurologic (11.6%), other (e.g., addiction, chronic fatigue syndrome; 10.3%), urologic (8.3%), pulmonary (5.4%), hematologic (2.5%), and cardiovascular (1.7%). Nearly half of patients were diagnosed within the last 5 years (46.1%), followed by more than 10 years ago (29.9%) and then between 6 and 10 years ago (24.1%). On a 1-5 scale, patients reported a mean of 3.46 (SD = 1.07) for experiencing symptoms, with most indicating sometimes (32.6%) and often (31.1%), followed by very often (18.3%), rarely (14.0%), and very rarely (4.0%). Their symptom severity in the last two weeks was on average 2.59 (SD = 0.87) on a 1-5 scale, with most patients stating moderate (41.8%) and mild (36.0%) symptom severity. Patients’ average daily management was 3.05 (SD = 0.91) on a 1-5 scale, with most patients stating somewhat (42.9%) to quite a bit (23.3%) of daily management. These findings suggest that patients experienced symptoms sometimes and often, had mild to moderate symptom severity, and somewhat to quite of bit of daily management.

Table 2 shows the correlations between study variables at each wave, separately for patients and partners. Correlations were in line with our hypotheses: all variables were positively correlated at each wave, across the three waves, and between patients and partners.

Table 2.

Correlations Between Study Variables Within Each Wave

	Shared illness appraisal	Illness- related comm.	Illness- related dyadic coping	Rel. sat.	Rel. close.	Sexual sat.
Shared illness appraisal
Baseline	0.23 **	0.52***	0.42***	0.29***	0.29***	0.23**
6 months	0.28 ***	0.48***	0.39***	0.31***	0.35***	0.20*
12 months	0.15	0.51***	0.52***	0.40***	0.36***	0.35***
Illness-related communication
Baseline	0.21*	0.36 ***	0.62***	0.38***	0.41***	0.25**
6 months	0.29***	0.32 ***	0.52***	0.39***	0.34***	0.17*
12 months	0.21*	0.34 ***	0.56***	0.40***	0.29**	0.34***
Illness-related dyadic coping
Baseline	0.48***	0.37***	0.31 ***	0.50***	0.40***	0.35***
6 months	0.43***	0.50***	0.33 ***	0.47***	0.37***	0.38***
12 months	0.35***	0.46***	0.48 ***	0.58***	0.28**	0.43***
Relationship satisfaction
Baseline	0.29***	0.23**	0.38***	0.48 ***	0.50***	0.51***
6 months	0.29***	0.35***	0.57***	0.29 ***	0.40***	0.54***
12 months	0.31***	0.30**	0.63***	0.44 ***	0.49***	0.66***
Relationship closeness
Baseline	0.32***	0.20*	0.24**	0.27***	0.36 ***	0.20*
6 months	0.26**	0.29***	0.33***	0.45***	0.40 ***	0.19*
12 months	0.31***	0.30***	0.39***	0.48***	0.36 ***	0.39***
Sexual satisfaction
Baseline	0.28***	0.24**	0.25**	0.43***	0.34***	0.56 ***
6 months	0.29***	0.33***	0.44***	0.57***	0.24**	0.43 ***
12 months	0.32***	0.26**	0.49***	0.58***	0.34***	0.37 ***
Patient mean (SD)	4.02 (1.38)	4.60 (1.44)	3.84 (0.58)	6.05 (1.18)	4.95 (1.60)	5.70 (1.39)
Partner mean (SD)	5.49 (1.12)	4.64 (1.31)	3.90 (0.53)	6.03 (1.23)	4.95 (1.55)	5.76 (1.35)
Range	1-7	1-7	1-5	1-7	1-7	1-7

Note. Correlations on the upper diagonal are for patients, and correlations on the lower diagonal are for partners. Correlations on the diagonal are between patients and partners. Baseline n = 242 couples, 6 months n = 146 couples, 12-months n = 123 couples. Com. = communication; Rel = relationship; Sat. = satisfaction; Close. = closeness.

^*p < 0.05

^**p < 0.01

^***p < 0.001

Changes Over Time in Study Variables

Dyadic multilevel growth curve models showed patient and partner illness-related appraisal (AIC = 2381.55, BIC = 2400.19), communication (AIC = 2523.17, BIC = 2541.82), dyadic coping (AIC = 1101.04, BIC = 1119.70), relationship satisfaction (AIC = 2324.91, BIC = 2351.54), and closeness (AIC = 2780.87, BIC = 2799.51) decreased over time; see Table 3 for means, standard errors, and F tests. Patients’ and partners’ shared illness appraisal (b=0.23, SE=0.06, p=0.001), communication (b=0.22, SE=0.07, p=0.01), dyadic coping (b=0.08, SE=0.03, p=0.047), relationship satisfaction (b=0.26, SE=0.08, p=0.002), and closeness (b=0.37, SE=0.09, p<0.001) were higher at baseline compared to 12 months. Relationship satisfaction (b=0.24, SE=0.08, p=0.01) and closeness (b=0.35, SE=0.10, p=0.002) were also higher at 6 months relative to 12 months. Sexual satisfaction (AIC = 2447.19, BIC = 2465.82) did not change over time (p = 0.06).

Table 3.

Estimated Marginal Means and Standard Errors of Variables Across Waves

	Intercept	Baseline	6 months	12 months	F	M (SE) by role
						Patient	Partner	p
Shared illness appraisal	5.83	5.05 (0.28)a	4.92 (0.28)a,b	4.80 (0.28)b	F(2, 254) =7.96***	4.20 (0.29)	5.65 (0.28)	<0.001
Illness-related comm.	4.90	5.01 (0.31)a	4.91 (0.31)a,b	4.78 (0.31)b	F(2, 250) =4.45*	4.95 (0.32)	4.85 (0.31)	0.25
Illness-related dyadic coping	4.48	4.08 (0.12)a	4.07 (0.12)a,b	4.01 (0.12)b	F(2, 255) =3.26*	4.02 (0.13)	4.08 (0.12)	0.18
Relationship satisfaction	6.35	6.10 (0.26)a	6.07 (0.26)a	5.84 (0.26)b	F(2, 251) =6.89**	6.06 (0.27)	5.95 (0.26)	0.29
Relationship closeness	5.65	5.31 (0.35)a	5.29 (0.35)a	4.95 (0.35)c	F(2, 255) =8.32***	5.20 (0.35)	5.17 (0.35)	0.83
Sexual satisfaction	5.92	6.03 (0.29)a	6.04 (0.29)a	5.87 (0.29)a	F(2, 256) =2.92+	5.92 (0.29)	6.04 (0.29)	0.27

Note. Within each row, means that do not share the same superscript differ at p<0.05 (e.g., the means for shared illness appraisal differed at baseline compared to 12 months; 6 months was not different from baseline or 12 months). The average means and standard errors across waves are reported for patients and partners given that there were no role differences by wave. Comm. = communication.

⁺p < 0.10

^*p < 0.05

^**p < 0.01

^***p < 0.001.

As shown in Table 3, on average, partners reported greater shared illness appraisals (b=−1.45, SE=0.12, p<0.001) than patients. There were no differences in patients’ and partners’ illness-related communication, relationship satisfaction, or sexual satisfaction (ps>0.08). There were no gender differences in study variables (ps>0.06) except men reported greater illness-related communication than women (M_men=4.83, SE_men=0.13; M_women=4.54, SE_women=0.13; b=−0.29, SE=0.09, p=0.006). There were no significant two- or three-way interactions between role (patient vs. partner), wave, and gender (ps>0.25).

For covariates, white participants had greater shared illness appraisals than participants of color (b=−0.33, SE=0.14, p=0.02). Compared to those dating exclusively and not cohabiting, married/domestic partners were more satisfied with their relationships and felt closer to each other (satisfaction: M_married=6.30, SE_married=0.27, M_dating=5.79, SE_dating=0.29, b=0.51, SE=0.17, p=0.02; closeness: M_married=5.67, SE_married=0.35, M_dating=5.02, SE_dating=0.38, b=0.65, SE=0.23, p=0.02). Patients’ symptom severity was associated with lower relationship satisfaction (b=−0.11, SE=0.05, p=0.04) and sexual satisfaction (b=−0.13, SE=0.06, p=0.02). No other covariates were significant (ps > 0.12)

Integrated Within-Person Models Predicting Relational Well-Being Outcomes

Next, we examined the within-person models predicting relationship satisfaction, relationship closeness, and sexual satisfaction (see Figure 2). Across the three models, for actor effects, when patients and partners saw the illness as more shared than usual, they also reported talking about the illness more than usual (ps<0.001). In turn, patients’ and partners’ higher illness-related communication was associated with higher than typical illness-related dyadic coping (ps<0.001). When they used more dyadic coping strategies than usual, they were more satisfied with their relationships (ps<0.001). For cross-partner effects, when patients talked about the illness more than usual, their partners also used dyadic coping strategies more often (ps=0.007). There were no other cross-partner effects for patients or partners (ps>0.17).

Figure 2.

Integrated models predicting (A) relationship satisfaction, (B) relationship closeness and (C) sexual satisfaction. Only significant paths are shown; all paths are reported in text. Residuals were estimated but not depicted. WI = within-person. Baseline n = 242 couples, 6 months n = 146 couples, 12-months n = 123 couples.

*p < 0.05, **p < 0.01, ***p < 0.001.

For indirect effects, there were significant indirect actor effects from patients’ and partners’ shared illness appraisal to their own relationship satisfaction (indirect effect=0.09, SE=0.04, 95% CI [0.03, 0.15]) and sexual satisfaction (indirect effect=0.09, SE=0.04, 95% CI [0.02, 0.15]) through illness-related communication and dyadic coping. The indirect actor effect from patients’ and partners’ shared illness appraisal to their own relationship closeness through illness-related communication and dyadic coping was not significant (indirect effect=0.02, SE=0.04, 95% CI [−0.05, 0.09]). These findings support the sequential theoretical model.

Given significant links in study variables, we also tested all potential paths throughout the models (e.g., how shared appraisal directly related to dyadic coping and each relational outcome; how communication directly predicted each relational outcome; all cross-partner effects). Across the three models, for patients (ps<0.001) and partners (ps=0.02), when they saw the illness as more shared, their own dyadic coping was higher than usual; partners’ greater shared illness appraisals were also associated with their own higher than usual relationship satisfaction (p=0.03) and sexual satisfaction (p<0.001). Also, patients’ illness-related communication was related to their own higher sexual satisfaction (p<0.001), whereas partners’ illness-related communication was related to patients’ lower sexual satisfaction (p=0.004). There were no other actor or cross-partner effects (ps>0.05), and estimates were similar to those in the initial model. The deviances of the hypothesized models and the models with these additional paths differed, (relationship satisfaction: Δχ²(3)=29.72, p<0.001; relationship closeness: Δχ²(2)=24.16, p<0.001; and sexual satisfaction Δχ²(5)=58.03, p<0.001), suggesting the additional paths improved model fit and thus are provided in Figure 2. Across the models, patient and partner covariates were not significant for relationship satisfaction (ps>0.80), relationship closeness (ps>0.79), or sexual satisfaction (ps>0.76).

Discussion

In this longitudinal study, we integrated and applied several dyadic coping frameworks to examine communication and coping with concealable chronic illness among couples from university settings. The findings supported the integrated model, demonstrating that each partner’s appraisals, communication, and coping predicted greater relationship well-being, including satisfaction, closeness, and sexual satisfaction. For patients and partners, at times when they saw the illness as shared and something that they could manage together, the more they talked about the illness and used dyadic coping strategies. In turn, when using dyadic coping strategies more often, patients and partners felt more satisfied, close, and sexually satisfied than they typically felt that year. Additionally, when patients talked openly about the illness more than usual, their partners also used dyadic coping strategies more often. Patients’ open communication may not only benefit themselves but also their partners. The findings illustrate how each partner’s positive communication and coping strategies may help couples maintain their relationships while managing concealable chronic illness.

The coping process was shaped by illness-related shared appraisals: when patients and partners saw the illness as shared and as something they could manage together, they talked more about the illness. Thus, those who saw the illness in relational terms, or as a we-disease (Kayser et al., 2007), were more likely to (a) talk about how the illness impacts their relationship, (b) share personal thoughts, feelings, and information about the illness, and (c) perceive that their partners also share personal thoughts, feelings, and information about the illness. Prior work has shown that in couples coping with cancer, seeing cancer as more shared was linked to more frequent cancer-related communication (Manne et al., 2014). Our findings demonstrate these associations at the within-person level in couples with concealable chronic illnesses. Such chronic illnesses are particularly difficult to co-manage because invisibility increases uncertainty and vulnerability, and also reduces openness and self-disclosure (Blixen et al., 2016; Braitman et al., 2008). Seeing the illness in more relational terms may promote openness and self-disclosure, facilitating necessary yet difficult conversations when managing chronic illness.

Furthermore, patient and partner illness-related stress communication promoted dyadic coping. At times when patients and partners both talked about how the illness affects them and their relationships, the more likely they were to use positive aspects of dyadic coping. For instance, they were more likely to help or provide support to one another, rather than use helping unwillingly or insincerely. Moreover, when patients engaged in greater illness-related stress communication, their partners helped with illness management more often than usual. Partners may feel more comfortable using and suggesting various coping strategies when patients talk more openly and freely about their illnesses (Lyons et al., 2021). Patients’ openness may help partners understand different aspects and severity of the illness, and how partners can provide support. Extending prior research connecting communication to dyadic coping (Bodenmann, 2005), the findings demonstrate the importance of continued stress communication in promoting dyadic coping over one year when managing a concealable illness. In addition, although the correlations demonstrated that illness-related communication was associated with greater sexual satisfaction, the within-person analyses showed when partners talked more about the illness than usual, patients reported lower sexual satisfaction. Too much discussion or focus on the illness may interfere with more physically intimate aspects of patients’ relationships (Verschuren et al., 2010; Weber & Solomon, 2008). There may be a sweet spot for patients and their preferred amount of illness communication.

When patients and partners used more positive and fewer negative dyadic coping strategies than usual, they also felt more satisfied, close, and sexually satisfied. Prior work revealed connections between dyadic coping and relationship well-being during the cancer trajectory (Manne, Ostroff, et al., 2004; Manne, Sherman, et al., 2004). Our findings highlight similar patterns and demonstrate dyadic coping’s beneficial relational effects for couples managing various health conditions. Patients and partners might have felt more supported and cared for when couples worked together to manage the illness, possibly reducing burden and relational distress (Berg & Upchurch, 2007). As couples navigate the challenges associated with many chronic illnesses, such as restricting their behaviors, limiting their social activities, or providing care (Bodenmann, 2005; Manne & Badr, 2008), working together particularly during difficult times, may help nurture their relationships.

The indirect effects showed that, for patients and partners, greater shared illness appraisals were associated with greater relationship satisfaction through illness-related stress communication and then dyadic coping. Thus, at times when patients and partners saw the illness as more shared (a we-disease), the more they talked about the illness and used positive dyadic coping strategies than usual, and in turn were more satisfied. Notably, these effects were shown at the within-person level, illustrating appraisals, communication, and dyadic coping—key components of the coping process—fluctuate together to predict satisfaction. Supporting theoretical models (e.g., Berg & Upchurch, 2007; Falconier &Kuhn, 2019), this work provided evidence that illness-related communication and coping are mechanistic pathways connecting shared appraisals to satisfaction. Though direct effects were shown throughout the models predicting relationship closeness and sexual satisfaction, the indirect effects were not significant. Although shared illness appraisals may have stronger indirect ties to relationship satisfaction than closeness or sexual satisfaction, seeing the illness as shared helped initiate the dyadic coping process. Partner shared illness appraisals and both patient and partner communication predicted sexual satisfaction. Various aspects of the coping process may be more directly rather than indirectly linked to the sexual aspects of couple relationships.

In addition to findings related to the conceptual model, the results showed that partners reported greater shared illness appraisals compared to patients. Partners who saw the illness as shared may have also seen the illness in a more positive light (Berg et al., 2020). These more relational appraisals may be particularly important for partners to feel comfortable and capable of providing support and care. Consistent with prior work, dyadic coping and satisfaction declined over time (Falconier & Kuhn, 2019); extending these findings, both patients’ and partners’ shared illness appraisals, illness communication, and closeness also declined over one year. Thus, couples were less likely to see the illness as shared, talk about and cope with the illness together, and feel satisfied and close over time. In contrast, patients’ and partners’ sexual satisfaction remained stable. In this way, even though their illness-related appraisals, communication, and coping decreased over time, couples still maintained their sexual satisfaction. These relational processes help couples manage chronic illness and protect them from stress (Manne et al., 2014); declines in such processes may increase relationship dissolution and dissatisfaction risks. These findings illustrate that a chronic illness can take a toll on relationships over time. Accordingly, it is important to strengthen couples’ illness-related appraisals, communication, and coping so that they gain the most relational benefits.

Theoretical Implications

These findings contribute to the dyadic stress and coping literature, most notably in the context of concealable chronic illness. We identified shared illness appraisals and multiple aspects of illness-related communication as key mechanisms facilitating dyadic coping and enhanced relational well-being. Seeing the illness as shared not only predicted greater illness communication, but also greater dyadic coping, relationship satisfaction, and sexual satisfaction. These effects illustrate the relational benefits of each partner seeing the illness as “our” illness rather than “yours” or “mine” (Manne et al., 2014). Given the invisible nature of these illnesses, seeing the illness as shared and talking about how the illness affects them and their relationship may be an essential part of the coping process. This study also provides new evidence for dyadic coping’s salutary effects across multiple relational domains: relationship satisfaction, closeness, and sexual satisfaction. These findings advance theory and research on how the dyadic coping process strengthens relationships while navigating chronic illness.

The current study found fewer cross-partner effects than anticipated. These findings highlight the importance of patients’ and partners’ own perceptions of dyadic coping and relational well-being. Fewer cross-partner effects may have been shown because the constructs examined were inherently dyadic and incorporated perceptions of each partner. We assessed perceptions of how relational they see the illness, how often each person talks about the illness, and what each person does to manage the illness. Although there were relatively few cross-partner effects, the findings underscore the importance of a partner’s involvement and dyadic coping as part of the care process.

Practical Implications

In this study, seeing the illness as something that couples can manage together, and talking openly and honestly about the illness, promoted dyadic coping strategies that benefited both patients and partners. Clinical intervention, prevention, and couple education programs could include partners in illness management, including at diagnosis and during treatment and routine care. For example, helping partners see the value in managing illness as a team, such as picking up and organizing prescriptions, scheduling doctor’s appointments, and showing understanding when patients’ symptoms flare up. When couples have trouble managing chronic illness, healthcare providers and educators can help couples express their concerns and identify the necessary changes in their illness management; they can also provide space for couples to talk about symptoms and illness management to help offset the silence and avoidance that are common with concealable illnesses (Lyons et al., 2021). For example, partners may want to help patients in their daily management but worry about imposing themselves, whereas patients may prefer partners step in but are afraid of the burden. Providers and educators can help patients and partners talk about how and when to ask each other for help, and about how the illness affects them individually and as a couple to prevent long-term relationship consequences. Importantly, the findings suggest that talking about the illness may not provide uniform benefits to couples’ sexual relationship. It may be important to help patients and partners identify and establish boundaries so that they are each comfortable with their illness-related communication. Knowing which processes are adaptive may help patients and partners learn how to effectively manage the illness together and implement these techniques.

Strengths, Limitations, and Future Directions

A strength of this study is that we integrated key theoretical frameworks to provide a more comprehensive understanding of how couples cope with concealable chronic illness. By integrating and applying tenets from stress communication, dyadic coping, and illness management models, we identified specific relationship resources in the coping process, how couples use these resources, and the mechanisms through which these resources promote relationship well-being. In addition, by including both couple members, the current research demonstrated key coping processes couples use, as well as how certain mechanisms functioned differently for patients than partners. Focusing on concealable chronic illness allowed us to identify notable communication behaviors to convey information and feelings about an illness that partners cannot visibly see. This study examined coping processes across several chronic illnesses, providing support for the integrated model across a wide range of health conditions. The longitudinal design allowed for within-person examination, which demonstrated that changes in patients’ and partners’ coping processes, rather than how they compared to others, were important for how their own relationship well-being changed throughout the study. This design also showed how couples’ coping processes changed over time.

One limitation of this study is that it relied on retrospective and self-report measures, which might have led to biased recollections. Observational communication methods could reveal how specific behaviors and couple dynamics facilitate dyadic coping and enhanced relational well-being. In addition, the model complexity did not allow for standardized results to be produced. This study examined change over time rather than changes on a day-to-day basis; daily dairy methods could illustrate how ongoing discussions of the illness relate to patients’ and partners’ everyday coping strategies. Daily studies could explore if talking about illness every day is helpful or harmful, and if there is a point at which illness communication does more harm than good; such examination might help explain why partners’ illness-related stress communication contributed to patients’ lower sexual satisfaction. Likewise, this study examined dyadic coping as a multidimensional construct, but daily studies may consider examining how the various strategies—supportive, delegated, common, and negative dyadic coping—predict daily relational well-being. Though this study examined how deep and open couples were when talking about the illness, we did not examine the degree to which patients concealed or hid symptoms from their partners; addressing both illness disclosures and concealment is an important next step to understanding how couples’ communication patterns contribute to relational well-being while managing chronic illness.

In addition, both couple members were also required to participate. Those opting into couple research may have been in happier relationships. Though recruiting dissatisfied couples with chronic illness is difficult, future work could focus exclusively on couples experiencing relationship problems while managing an illness to identify intervention points. This study focused on how couples manage one partner’s chronic illness, yet in 34.7% of couples, both partners had a chronic illness. Though the partner’s illness status was not significant across the models, it may be more difficult for couples to manage multiple illnesses together and maintain their relationships and health (Polenick et al., 2021). Importantly, compared to white participants and married/domestic partners, participants of color and those dating exclusively but not cohabiting were more likely to have missing data; thus, the findings may be biased, especially because participants of color were less likely to see the illness as shared compared to white participants, and those dating exclusively but not cohabiting had lower relationship satisfaction and closeness than married/domestic partners. It is important to recruit and retain couples of color and those not cohabiting, to address barriers to participation in longitudinal research, and to ensure their inclusion in research on coping with concealable chronic illness.

Also, couples were recruited from multiple university settings rather than medical institutions, and most participants were young or middle-aged adults, limiting the generalizability to non-student and older samples with more severe illnesses. Because older couples are more likely than younger couples to see stress as shared and in relational terms (Seider et al., 2009), they may also see the illness as more shared and thus use positive communication and coping strategies. Yet, illness severity and disability worsen with age, increasing the difficulty of managing chronic illness and its potential consequences for couples’ relational well-being. Indeed, in this study, symptom severity was associated with lower relationship and sexual satisfaction. It is important for future couple studies to recruit from medical institutions and healthcare facilities to represent broader demographics such as older adults, and to capture experiences of those with greater illness severity. Nevertheless, it is worthwhile to understand how younger and middle-aged couples develop and use relational resources to cope with chronic illness effectively. Intervening and learning these skills early on may help couples not only manage chronic illness but also maintain strong relationships throughout adulthood.

Conclusion

Given the seriousness and pervasiveness of chronic illness, this longitudinal study applied and integrated key theoretical frameworks to better understand the relational effects of how couples cope with concealable chronic illness. In couples recruited from university settings, viewing the illness as shared, talking about the illness, and using coping strategies that involve one another were all key components of managing a concealable health condition. At times when patients and partners saw the illness as more shared, talked more about the illness, and used more dyadic coping strategies than usual, they also were more satisfied, close, and intimate than usual. This research identifies processes that both promote adaptive coping and inform interventions for couples to strengthen their relationships while managing chronic illness. This multifaceted approach offers new insight into promoting adaptive coping for couples to not only manage chronic illness but grow closer by navigating it together.