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. Author manuscript; available in PMC: 2019 Apr 1.
Published in final edited form as: J Fam Psychol. 2018 Apr;32(3):412–418. doi: 10.1037/fam0000390

Disclosure and Holding Back: Communication, Psychological Adjustment and Marital Satisfaction among Couples Coping with Osteoarthritis

Ruixue Zhaoyang 1,*, Lynn M Martire 1,2, Ashley M Stanford 1,2
PMCID: PMC5922768  NIHMSID: NIHMS920549  PMID: 29698013

Abstract

This study examined two types of illness-related communication (disclosure and holding back) and their associations with psychological adjustment and marital satisfaction in patients with knee osteoarthritis (OA) and their spouses. A sample of 142 couples reported on disclosure and holding back of OA-related concerns, marital satisfaction, and depressive symptoms at two time points across one year. Results from dyadic analyses indicated that holding back was associated with decreases in one’s own marital satisfaction for patients and spouses and increases in one’s own depressive symptoms for spouses over one year. In addition, increases in disclosure were associated with increases in marital satisfaction for patients and spouses over time. Holding back and disclosure did not have significant interpersonal effects on the partner’s psychological adjustment or marital satisfaction. These results provide support for the hypothesized intrapersonal effects of disclosure and holding back on marital satisfaction and psychological adjustment over time for both OA patients and their spouses, and highlight the importance of open communication for dyadic coping among couples dealing with chronic illness.

Keywords: disclosure, holding back, psychological adjustment, marital satisfaction, osteoarthritis

Chronic illness is among the most common, costly, and preventable of all health problems in the United States (Centers for Disease Control and Prevention [CDC], 2016). Chronic illnesses such as osteoarthritis (OA) often cause concern and stress to patients and their spouses, and thus affect both partners’ individual and relational well-being (Porter, Keefe, Wellington, & de Williams, 2008). One important strategy for coping with the challenges caused by chronic illness is to communicate one’s illness-related concerns effectively with the partner (Manne, Badr, Zaider, Nelson, & Kissane, 2010). However, both patients and spouses often face a number of barriers that cause them to hold back from disclosing their concerns with their partner (Porter et al., 2008). In this study, we used a dyadic approach and longitudinal design to examine how knee OA patients’ and spouses’ disclosure and holding back from discussion of OA-related concerns impact the psychological adjustment and marital satisfaction of both partners over time.

Communication in Couples Coping with OA

Osteoarthritis (OA), caused by cartilage and subchondral bone degeneration, is a chronic illness that imposes ongoing challenges for patients and their spouses in their daily lives. For example, persistent symptoms of OA such as pain, stiffness and fatigue may cause limitations in daily responsibilities and activities, negative thoughts or feelings, and financial burden to patients, which in turn have significant impacts on their psychological and relational well-being (Porter et al., 2008). At the same time, spouses may experience distress due to partners’ symptoms and the burden associated with providing daily support, which may compromise spouses’ own psychological and relational well-being (Stephens, Martire, Cremeans-Smith, Druley, & Wojno, 2006). Given the considerable impact of OA symptoms on patients and spouses in their daily lives, effective communication with each other about illness-related concerns is particularly important for couples’ adaptation and well-being.

According to the relationship intimacy model (Manne et al., 2010), two types of communication between patients and spouses are influential for couples coping with chronic illness: disclosure (relationship-enhancing communication) and holding back concerns (relationship-compromising communication). As other researchers have noted, holding back is not the absence of disclosure but rather the active inhibition of a desire to express concerns (Porter et al., 2009). Indeed, correlations between disclosure and holding back in previous research have either been not statistically significant (e.g., Manne et al., 2010) or significant but moderate in magnitude (Manne et al., 2010; Porter, Keefe, Hurwitz, & Faber, 2005). Therefore, it is important to examine disclosure and holding back as distinct communication strategies and understand their unique influences on partners’ psychological and relational well-being.

Disclosure and Individual and Relational Well-Being

The vital importance of disclosure in relationships has long been recognized. Disclosure provides opportunities for people to understand and validate their partner’s thoughts and feelings and support each other’s needs, thereby increasing intimacy and relationship satisfaction (Reis & Shaver, 1988; Rimé, 2016). For couples dealing with chronic illness, communications about one’s concerns about illness and symptoms may entail emotional disclosure, recruit emotional support, and build intimacy (Cano & Williams, 2010). In addition, it is widely believed that disclosure may facilitate individuals’ own psychological well-being by allowing them to free their mind of unwanted thoughts, desensitize upsetting events, and improve connections with relationship partners (Pennebaker, Zech, & Rimé, 2001). One partner’s disclosure may also facilitate the other partner’s psychological adjustment by reducing social constraints on disclosure and facilitating cognitive processing (Robbins, Lopez, Weihs, & Mehl, 2014).

Even though the influence of disclosing illness-related concerns on couples’ well-being has not been examined within the context of OA, previous studies on cancer provide some evidence to support the positive effects of disclosure on psychological and relational well-being for both patients and spouses. For example, disclosure was associated with less psychological distress and greater relationship intimacy for cancer patients and spouses (Porter et al., 2005), as well as greater relationship intimacy and decreases in depressive symptoms for their partners (Porter et al., 2005; Robbins et al., 2014).

Holding Back and Individual and Relational Well-Being

Notwithstanding the potential benefits of disclosure, OA patients and spouses often face a number of barriers that hold them back from disclosing their concerns with their partner. For example, OA patients may worry that expressing concerns will increase spouses’ stress and burden or elicit unhelpful responses (Porter et al., 2008). Spouses may withhold discussing their concerns to protect patients’ feelings, avoid under- or overestimating patients’ pain, or because they are uncertain of how to be supportive (Wilson et al., 2013). However, the act of inhibiting or holding back one’s concerns may increase intrusive thoughts and cause chronic physiological arousal and stress (Pennebaker et al., 2001), thereby compromising one’s psychological adjustment. Furthermore, one person’s holding back may prevent the partner from understanding the situation and offering support, thus causing more distress to the partner and diminishing feelings of belonging and intimacy for both partners.

In line with this idea, holding back was found to be associated with higher levels of psychological disability and catastrophizing for OA patients and more caregiver strain for spouses (Porter et al., 2008). Some studies among couples coping with cancer also found that holding back was associated with increased distress and decreased relationship functioning for oneself (Manne et al., 2007; Langer, Brown, & Syrjala, 2009) and lower perceived intimacy for the partner (Porter et al., 2005), suggesting the detrimental influence of holding back for patients and spouses in the context of chronic illness.

The Current Study

Although theory and previous research highlight the importance of openly communicating illness-related concerns for couples dealing with chronic illness, no prior study has simultaneously examined the influences of disclosure and holding back on well-being for OA patients and spouses over time. In this study, we used longitudinal data collected at two time points over one year to examine the simultaneous effects of disclosure and holding back discussing OA-related concerns in the same model. We adopted a dyadic analytic approach to examine how disclosure and holding back affected one’s own and the partner’s well-being, and hypothesized that each person’s (patient or spouse) disclosure of concerns would be positively associated with changes in one’s own and the partner’s psychological adjustment and marital satisfaction over time (Hypothesis 1) whereas holding back from discussing such concerns would be negatively associated with changes in one’s own and the partner’s psychological adjustment and marital satisfaction over time (Hypothesis 2).

Method

Participants and Procedures

Data for the current study were from a larger observational (i.e., nonintervention) study designed to capture individual and marital processes in couples dealing with knee OA. The larger study combined in-person interviews conducted over an 18-month period (i.e., T1, T2 at a 6-month follow-up, and T3 at an 18-month follow-up; see Martire et al., 2013 for details). The University of Pittsburgh Institutional Review Board (IRB) approved this study. Written informed consent was obtained when trained staff interviewed patients and spouses separately in the couples’ homes. The data relevant to the current analyses were collected in T2 and T3 interviews, which had a 1-year interval. Therefore, the current analyses included data from these two assessments (referred to as initial and one-year follow-up assessments).

Primary sources of recruitment were research registries for rheumatology clinics and for older adults interested in research, flyers distributed at the University of Pittsburgh, and word of mouth. To be eligible for this study, patients had to be diagnosed with knee OA, experience usual knee pain of moderate or greater intensity, be at least 50 years of age, and be married or in a long-term relationship and living with their spouse or partner. Exclusion criteria for couples included: (1) patient had a comorbid diagnosis of fibromyalgia or rheumatoid arthritis; (2) patient planned to have hip or knee surgery in the next six months; (3) spouse had arthritis pain of moderate or greater intensity, or required assistance with personal care activities; (4) either patient or spouse used a wheelchair to get around; and (5) either patient or spouse was not cognitively functional as indicated by the accuracy of their answers to questions regarding the current date, day of the week, their age, and birth date.

A total of 606 couples were screened for eligibility. Of these, 221 couples declined to participate; the most frequent reasons were lack of interest (N=87) and illness in the family (N=55). An additional 233 couples were ineligible for the study; the most frequent reasons were lack of OA of the knee (N=55) and OA pain that was mild (N=47). A total of 152 couples were enrolled in the study. Approximately 94% (N=143) of the initial couples participated in the 6-month interview and 89.5% (N=136) participated in the 18-month interview. Common reasons for dropping out were health issues, lack of time, and inability to contact. Missing data analyses suggested that couples who dropped out of the study were not significantly different from those who did not regarding demographics, OA history and symptom severity, marriage duration and baseline scores on marital satisfaction, depressive symptoms and life satisfaction. Due to missing data on one or more study variables, sample sizes for the current analyses were 142 couples for initial assessment and 132 couples for one-year follow-up assessment.

Table 1 displays demographic information and descriptive and reliability information for each measure at the two assessments for patients and spouses respectively.

Table 1.

Descriptive Information on Demographics and Key Study Variables

Patient Spouse
Mean S.D. α Mean S.D. α Paired-t
Gender (% Men) 41% 59%
Age 65.78 9.99 65.32 12.02 0.89
Race (% White)a 87% 85%
Years of Education 16.00 2.03 15.84 2.05 0.87
Years of OA 16.42 12.56
Overall OA Pain 3.57 0.87
Years Married 34.71 16.89
Initial Disclosure 3.19 1.25 .87 3.13 1.15 .89 0.49
Follow-up Disclosure 3.26 1.32 .88 3.17 1.18 .89 0.64
Initial Holding Back 2.63 1.19 .87 2.41 1.09 .88 1.65
Follow-up Holding Back 2.74 1.29 .87 2.38 1.07 .86 2.64**
Initial Marital Satisfaction 39.10 5.91 .81 38.29 6.06 .83 1.78
Follow-up Marital Satisfaction 39.68 5.68 .81 38.66 5.97 .83 2.10*
Initial Depressive Symptoms 0.70 0.53 .82 0.66 0.54 .82 0.86
Follow-up Depressive Symptoms 0.69 0.56 .85 0.67 0.53 .81 0.21
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Note. N=142 for demographics and baseline measures, N=132 for 1-year follow-up measures.

a

Among the 13% non-White patients, 11% were Black, 1.4% were Asian or other Pacific Islander, and 0.6 % were other. Among the 15% non-White spouses, 12% were Black, 2.7% were Asian or other Pacific Islander and 0.3% were other. Range for scales: Overall OA Pain (1–5), Disclosure and Holding Back (1–6), Marital Satisfaction (0–50), Depressive Symptoms (0–3).

*

p <.05.

**

p < .01.

Measures

Disclosure and holding back from discussion of OA-related concerns

The extent to which participants (patients and spouses) disclose and hold back from discussing their concerns related to the patient’s arthritis was measured with a 9-item scale adapted from Porter et al. (2008). Participants rated how much they talk to their partner (1 = Talk about none of what I felt, 6 = Talk about all of what I felt) and how much they hold back from talking to their partner (1 = Not at all, 6 = A lot) about their concerns in each of nine domains: patient pain; other symptoms (e.g., swelling, stiffness, fatigue); limitations of activities caused by OA; treatment; fear or worry about progression of disease; their own negative feelings; relationship with spouse; relationship with others; and financial concerns. Average scores were created for disclosure and holding back respectively.

Marital Satisfaction

The Dyadic Satisfaction subscale of Spanier’s (1976) Dyadic Adjustment Scale was used to assess participants’ marital satisfaction. An example question is “In general, how often do you think that things between you and your partner are going well?” A sum score of marital satisfaction was created, ranging from 0 to 50.

Depressive Symptoms

The Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977; Andresen, Malmgren, Carter, & Patrick, 1994) was used to assess depressive symptoms. Participants rated 10 statements of ways they might have felt or behaved in the past week on a 4-point scale (0 = Rarely or none of the time, 3 = Most of the time). Example items include “I felt depressed” and “I was bothered by things that don’t usually bother me.”

Data Analysis

Actor-Partner Independence Models (APIMs, Kenny, Kashy, & Cook, 2006) were estimated with structural equation modeling using Mplus V7.0 (Muthen & Muthen, 1998–2012). Full information maximum likelihood estimation with robust standard errors was used to handle missing data and adjust against minor violations of the assumption of normality. The APIM takes into account the interdependence between the partners and simultaneously estimates the intrapersonal effects of a person’s predictor on one’s own outcome (referred to as actor effects), and the interpersonal effects of a person’s predictor on the partner’s outcome (referred to as partner effects). The dyadic analyses were conducted in three steps. First, a saturated APIM model was constructed, in which the patient and spouse within a couple were treated as distinguishable and all paths were estimated freely. Second, we tested the equality of corresponding effects across patients and spouses by using the Satorra-Bentler scaled χ2 difference test (Satorra & Bentler, 2010), and imposed equality constraints for effects that did not significantly differ across patients and spouses. Finally, the overall model fit of the final parsimonious model was assessed by (non-significant) Satorra-Bentler scaled χ2 tests and several well-established fit indices: the comparative fit index (CFI > 0.95), root mean square error of approximation (RMSEA < 0.08) and Standardized Root Mean Square Residual (SRMR < 0.08, Hu & Bentler, 1999). Following these steps, lagged APIMs were first fit to predict one year follow-up relational or psychological well-being from the initial disclosure and holding back while controlling for the initial levels of well-being (M1, Kenny et al., 2006). Then the changes of holding back and disclosure from initial to follow-up assessments were added into M1 to test the associations between changes in disclosure/holding back and changes in psychological and relationship outcomes over time (M2, Finkel, 1995). Covariates in all models included: patients’ gender, age, race, OA duration and overall knee pain severity (or changes in overall knee pain severity in M2); spouses’ age and race; and the couples’ marriage duration.

Results

Preliminary Analysis

Before testing our hypotheses, we conducted preliminary analyses. As shown in Table 1, on average, patients and spouses reported moderate levels of disclosure and low levels of holding back at both assessments. The correlations between holding back and disclosure were low to moderate (rs ≤ −.35 for patients, r ≤ −.06 for spouses). Initial levels of disclosure and holding back were not significantly different between patients and spouses but patients reported significantly higher levels of holding back than spouses at follow-up. Moreover, examining the nine domains of concerns revealed that patients’ pain and other physical symptoms, OA treatment and financial situation were the domains in which participants shared their concern with the partner to the greatest extent across the two assessments. The domains in which participants held back from their partner to the greatest extent were patients’ pain and other physical symptoms, limitations in patients’ activities caused by OA, and one’s own negative emotions. Paired-sample t-tests further suggested that patients shared concerns regarding pain (t = 2.15, p =.033) and limitations to activities (t = 2.58, p =.011) more than spouses did, whereas spouses shared relationship concerns with patients (t = −2.43, p =.016) more than patients did. In addition, compared with spouses, patients held back more on sharing concerns about their pain (t = 3.66, p =.000), other symptoms (t = 4.78, p =.000), limitations in activities (t = 4.41, p =.000) and OA treatment (t = 3.69, p =.000). Finally, none of the key study variables changed significantly over time.

Following the recommendation by Kenny et al. (2006), we tested the non-independence between two partners by calculating the partial correlations between partners’ scores on each outcome (e.g., marital satisfaction or depressive symptoms) controlling for predictors from both partners (i.e., disclosure and holding back). The significant partial correlations between patients’ and spouses’ outcomes (rs ≥ .24, p < .01) supported the importance of using a dyadic analytic approach.

Associations between Communication of Concerns and Marital Satisfaction

We first tested the effects of initial disclosure and holding back on changes in marital satisfaction (M1) and then tested the effects of changes in disclosure and holding back on changes in marital satisfaction over time (M2). In line with our hypothesis on intrapersonal effects of holding back, and as shown in Figure 1A, initial holding back significantly predicted decreases in one’s own marital satisfaction over time for both patients and spouses (b = −0.11, p =.011). In addition, a significant intrapersonal (i.e., actor) effect was found for changes in disclosure, such that increases in disclosure was associated with increases in marital satisfaction for both patients and spouses (b = 0.12, p =.020). However, no evidence was found to support the hypothesized interpersonal (i.e., partner) effects of disclosure or holding back on partner’s marital satisfaction in either model.

Figure 1.

Figure 1

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Actor–partner independence model predicting changes in (A) marital satisfaction and (B) depressive symptoms. Statistically significant paths are depicted by solid lines and non-significant paths are depicted by dashed lines. Standardized path coefficients before the semicolon represent effects of initial predictors (M1); coefficients after the semicolon represent effects of changes of predictors (M2). Model fit for marital satisfaction: χ2 [16] =23.03, p =0.113, RMSEA=0.06; CFI=0.97; SRMR=0.02 for M1; χ2 [20] =24.33, p =0.229, RMSEA=0.04; CFI=0.98; SRMR=0.02 for M2; for depressive symptom: χ2 [15] diff=12.17, p =0.666, RMSEA=0.00, CFI=1.00, SRMR=0.02 for M1; χ2 [20] diff=21.10, p =0.392, RMSEA=0.02, CFI=0.99, SRMR=0.02 for M2. *p <.05. **p < .01.

Associations between Communication of Concerns and Psychological Adjustment

Next, we examined the effects of initial disclosure and holding back (M1) and changes in disclosure and holding back (M2) on changes in psychological adjustment as indicated by depressive symptoms. As shown in Figure 1B, we found a significant actor effect of initial holding back for spouses but not for patients (χ2 [1] diff=4.61, p =.032) in M1. That is, spouses who initially held back more experienced more increases in depressive symptoms over one year (b = 0.15, p =.009), partially supporting our hypothesis regarding the intrapersonal effect of holding back. No evidence was found to support the intrapersonal effect of disclosure, or the interpersonal effects of disclosure and holding back on the partner’s depressive symptoms.

Discussion

The current study examined the influences of two ways of communicating illness-related concerns with the partner—disclosure and holding back—on changes in marital satisfaction and psychological adjustment over time in couples coping with knee OA. Consistent with previous studies (e.g., Langer et al., 2009; Manne et al., 2010; Porter et al., 2005), we found evidence to support the hypothesized intrapersonal effects of holding back on changes in one’s own marital satisfaction and psychological adjustment. Specifically, an initial level of holding back was associated with decreases in marital satisfaction for both patients and spouses, as well as increases in depressive symptoms for spouses over one year. In addition, we found evidence for hypothesized intrapersonal effects of disclosure on marital satisfaction, but not on depressive symptoms. Finally, no evidence was found to support the interpersonal effects of holding back or disclosure on the partner’s psychological and relational well-being, contrary to our hypothesis.

Previous theory and research have suggested that disclosure and holding back are conceptually distinct communication strategies (Manne et al., 2010; Porter et al., 2009). Holding back reflects the inhibition of discussing one’s concerns with the partner when there is a desire or need to share, whereas the lack of disclosure may reflect the lack of such a desire to share, or a dispositional tendency towards inexpression. Consistent with previous studies, we found that the correlations between holding back and disclosure were low to moderate, suggesting that these two concepts do reflect different dimensions of communication behavior rather than opposite ends of one continuum. More importantly, results from models examining holding back and disclosure simultaneously revealed different predictive effects. Specifically, holding back and disclosure both predicted changes in marital satisfaction for patients and spouses, whereas only holding back predicted increases in spouses’ depressive symptoms.

The prospective finding that both holding back and disclosure had a significant influence on changes in marital satisfaction provided robust evidence to support the importance of open communication between partners for one’s own relationship satisfaction. In addition, holding back also predicted increases in depressive symptoms over time for spouses. Spouses may withdraw discussing their concerns to protect patients’ feelings, or to avoid unsupportive responses. However, inhibition of the desire to share concerns may prevent spouses from fulfilling their expected role as a caregiver and confidante, and thus cause increased distress for themselves over time (Manne et al., 2007).

In contrast, we did not find evidence for the intrapersonal effects of disclosure on one’s depressive symptoms. Though inconsistent with theoretical prediction, some studies among couples dealing with cancer also failed to find evidence for the role of disclosure in reducing psychological distress (Hagedoorn et al., 2011; Manne et al., 2010). One possible explanation is that the most salient function of disclosure is to increase intimacy of the relationship, and thus the influence of disclosure on individuals’ depressive symptoms is less direct and prominent. Individuals’ depressive symptoms may be more strongly influenced by other factors, such as health status, pain, disease severity, physical disability or other stressful life events (Rosemann et al., 2007). The extent to which disclosure can be beneficial for individuals’ psychological well-being may also depend on perceived listener’s responsiveness to the disclosure (Cano, Corley, Clark, & Martinez, 2017; Reis & Shaver, 1988). In addition, reciprocal disclosure or mutual constructive communication rather than disclosure alone was found to be linked with less distress in couples dealing with cancer (Manne et al., 2010).

Finally, we did not find evidence to support the interpersonal effects of holding back or disclosure on the partner’s well-being. It is likely that partner’s perception of disclosure or holding back, more so than the behavior per se, would influence his or her well-being. For example, the perception that the partner is holding back, rather than the partner’s report of holding back significantly predicted relationship and psychological well-being for cancer patients and spouses (Langer et al., 2009). Additionally, communication behaviors may be most beneficial for the partner when they match the partner’s need for support (Cano & Williams, 2010).

The findings from our study have important theoretical and clinical implications. Our prospective findings provide strong evidence to support the crucial role of open communication in affecting psychological and relational well-being for patients and spouses. While our findings were based on couples dealing with OA, for whom communicating illness-related concerns is particularly critical for dyadic coping, disclosure and holding back discussion of personal concerns may also be influential for healthy couples given the importance of constructive communication within a satisfying and supportive relationship (Reis & Shaver, 1988). In addition, our dyadic findings highlight the importance for family research to understand the relationship context through which individual’s health and well-being can be influenced.

Our findings also point to the need for psychological interventions that involve both partners because such interventions may not only benefit each partner individually, but also set the stage for a healthier relationship for both partners (Cano et al., 2017; Martire, 2013; Porter et al., 2009). Future couple-oriented interventions should help partners to fully realize the harms of holding back their concerns, identify the barriers that hold them back from sharing (e.g., patients’ worries about upsetting or burdening the partner, partners’ worries of under- or overestimating patients’ pain) and develop skills for constructive communication. Recent work on couple- interventions suggests that training in how to share constructively, how to give the partner the opportunity to respond, and mindful or reflective listening could effectively help couples improve their communication and relationship quality, especially for couples in which partner(s) hold back to a greater extent (Cano et al., 2017; Porter et al., 2009).

There are limitations of the present study that present promising avenues for future research. First, our sample was limited to couples who were in long-term, highly satisfying marriages and had been coping with patients’ OA for many years. Future research is needed to examine the generalizability of our findings to couples with different characteristics or coping with other diseases. Second, our measures of holding back did not assess the reasons for holding back. Future research should explore the specific barriers that cause people to hold back sharing their concerns. In addition, future research could benefit from examining partners’ responses to disclosure and its subsequent influences on both partners’ well-being. Another important topic for future research is to understand the bidirectional associations between disclosure/holding back and well-being, and how these associations may be influenced by other factors, such as patients’ symptom severity, partners’ demographics, and relationship characteristics. In conclusion, the current study demonstrates the importance of openly communicating illness-related concerns with partner for couples dealing with OA and suggests that holding back from sharing such concerns has long-term detrimental influences for one’s psychological and relational well-being.

Acknowledgments

This research was supported by NIH grants R01 AG026010 and K02 AG039412 awarded to Lynn M. Martire.

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