Spirituality and Relationship: A Holistic Analysis of How Couples Cope With Diabetes

SPIRITUALITY AND RELATIONSHIP: A HOLISTICANALYSIS OF HOW COUPLES COPE WITH DIABETES

John Cattich and Carmen Knudson-MartinLoma Linda University

This study explores how couples’ spirituality and relationship processes holistically inter-act to inform diabetes management. Qualitative analysis of interviews with 20 hetero-sexual couples identified five spiritual coping styles based on the spiritual meaning theyascribed to the situation and the nature of their relationships with God and each other:(a) opportunists approach the illness as an opportunity for growth; (b) mutual problemsolvers collaborate with their partners to respond to their disease; (c) individualistic prob-lem solvers take personal responsibility for managing their disease; (d) accepters enduretheir disease; and (e) victims take a hopeless, discouraged approach. Results suggest thatspirituality and couple communication and problem-solving patterns appear intertwinedand integral to the practice of family therapy.

Researchers and clinicians increasingly recognize the important role of spirituality whenworking with people facing stressful situations (e.g., Hodge, 2005; Marsh & Dallos, 2001;Miller, Korinek, & Ivey, 2006; Moules, 2000). Several have explored its role in relation tocoping with diabetes (Paterson, Thorne, Crawford, & Tarko, 1999; Polzer & Miles, 2007;Rapaport, 1998). However, spirituality is usually discussed as an individual or additionaldimension for assessment and consideration, and is not yet integrated into a holistic under-standing of family processes. Holistic approaches suggest that spiritual, physical, and relationaldimensions of health care are interrelated and should not be isolated from each other (Patter-son, 1998). However, how spirituality and intimate relationships work together to organizeresponses to illness has not been well articulated. In this article we examine how these dimen-sions are integrated among couples managing the diabetes of at least one partner. We focus inparticular on the couple relationship as the relational unit through which diabetic patients cometo terms with the disease and adapt to it on a day-to-day basis.

BACKGROUND

Diabetes is a common chronic illness faced by 20.8 million persons in the United States(American Diabetes Association, 2006). Coping with this disease demands significant lifestylechanges in such areas as exercise, diet and nutrition, as well as routine monitoring of bloodglucose levels. Adherence to the recommended regime is a common problem (Campbell, 2003).Patients diagnosed with diabetes also have increased risks for developing mental health problemssuch as depression and anxiety (Kruze, Schmitz, & Thefeld, 2003; Thomas, Jones, Scarinci, &Brantley, 2003). Perhaps most important from a psychological and behavioral perspective is thatpatients must adhere to the demanding requirements of diabetes management while knowing thateventual onset of complications is almost inevitable (Thomas et al., 2003). The strain of diabetescare and the associated effects on the patient’s mental health have also been shown to significantlystress patients’ families (Auslander, Bubb, Rogge, & Santiago, 1993). In fact, Fisher, Chesla,

John Cattich, MS MFT, MDiv, is a Doctoral Candidate in Marriage and Family Therapy at Loma Linda

University and a Child and Family Therapist at Daymark Recovery Services, Lexington, North Carolina;

Carmen Knudson-Martin, PhD, is a Professor in the Department of Counseling and Family Sciences, Loma

Linda University.

Address correspondence to John Cattich, Daymark Recovery Services, 220 E. First Ave. Ext., Suite 10,

Lexington, North Carolina 27292; E-mail: [email protected]

Journal of Marital and Family TherapyJanuary 2009, Vol. 35, No. 1, 111–124

January 2009 JOURNAL OF MARITAL AND FAMILY THERAPY 111

Skaff, Mullan, and Kanter (2002) found that the partners of diabetic individuals experienced levelsof psychological distress as high, or higher, than patients—especially if the partner was female.

Couples’ Relationships and Adaptation to DiabetesDiabetes becomes intricately embedded in the emotional life of a couple (Rapaport, 1998).

Fisher et al. (2004) report that stable, cohesive families with high marital quality and low con-flict show greater ability to manage chronic disease. Intimate couple relationships have beenshown to play an important role in a person’s ability to cope with diabetes and related stressors(Fisher et al., 2002; Trief, Himes, Orendorff, & Weinstock, 2001; Trief, Wade, Britton, &Weinstock, 2002). Trief et al. (2002) found that among insulin-treated adults with diabetes,quality of marriage prospectively predicted diabetes-related quality of life. More precisely,better marital adjustment predicted lower diabetes-related stress, and greater satisfaction witha patient’s diabetes care regimen was predicted by better marital adjustment and greaterperceived marital intimacy. The patient’s ability to make significant lifestyle changes isenhanced when a supportive spouse is willing to participate in this endeavor.

Spouses of diabetics walk a fine line between trying to support their spouses and avoidingconflict (Rapaport, 1998; Trief et al., 2003). The experience of marital emotional support‘‘clearly hinges on open communication of feelings and ability to problem-solve when difficul-ties arise’’ (Trief et al., 2003, p. 65). Feeling emotionally supported within the marriage is par-ticularly significant in maintaining adherence to various aspects of the diabetic regimen(exercise, diet, medication, blood glucose monitoring). Fisher et al. (2004) found that whiledegree of overt emotional expressiveness was not related to diabetes management, appraisals ofmarital morale and conflict were directly linked to disease management. These findingsappeared to apply across different ethnic groups.

Spirituality and Disease ManagementThere is considerable research evidence demonstrating a positive link between reli-

gious ⁄ spiritual factors and health and well-being (Charmaz, 1995; Gall & Grant, 2005; Gordonet al., 2002; Rowe & Allen, 2004). Spiritual beliefs involve an understanding of a power greaterthan self and a sense of relationship with this power (Gall & Grant, 2005). However, ‘‘spiritualbeliefs can also exist without a belief in a higher power as an individual can draw upon his orher own meaningful life experiences’’ (p. 522). In their comprehensive literature review of theconnection between spirituality and coping with illness, Kaye and Raghavan (2002) identifiedthe common thread of transcendence, that is, ‘‘a level of awareness that exceeds ordinary,physical boundaries and limitations, yet allows the individual to achieve new perspectives andexperiences’’ (p. 232). Though the stress of illness often leads to disequilibrium of mind, body,and spirit, spirituality can help ‘‘the person make some sense out of pain and suffering’’(p. 237) and can turn disability and illness and their associated stress into an opportunity forspiritual growth. According to Rapaport (1998) the ability to find positive spiritual meaning isvery helpful to the lifetime nature of coping with diabetes.

Paterson and colleagues’ (1999) qualitative study of individuals with diabetes illustrated acapacity to experience a transformation experience ‘‘as the result of a conscious decision toidentify and interpret a challenge and, in so doing, to create a new relationship with the illnessand with those who provide health care’’ (p. 799). Their findings pointed to ‘‘transformation asa means of mediating the impact of disease by altering one’s cognitive and affective response toit’’ (p. 799). In a similar study with an African American sample, Polzer and Miles (2007)found that the strategies employed for managing diabetes depended on how patients experi-enced their relationships with God. For some, God was the major actor; for others God was inthe background or a collaborator.

Gordon et al. (2002) found that patients who functioned at a higher level of coping oftenused their religious beliefs to better cope with their illness and found meaning or strength from

112 JOURNAL OF MARITAL AND FAMILY THERAPY January 2009

their beliefs. According to Gall and Grant (2005), how a person copes depends on the ability tomobilize resources such as faith and hope. However, they conclude that believing in God,alone, does not contribute to health. Rather, the kinds of causal attributions patients make arecritical. These are related to motivation, locus of control, and personality and family of originfactors such as attachment. Similarly, Rowe and Allen (2004) found that persons who measuredhigh in spirituality reported varying kinds of coping styles, including intrusive positivethoughts, intrusive negative thoughts, problem focused, and avoidance. Though not all thesecoping styles were positive or active, persons rating high on spirituality were more likely thanother respondents to report coping with a stressful situation through a positive outlook.

A Holistic Systems PerspectiveSignificant inroads have been made in the study of spirituality and couple relationships as

separate resources for coping with illness. Couples who are able to communicate clearly andopenly with each other, problem-solve, and resolve conflict are clearly at an advantage in deal-ing with a chronic stressor such as diabetes. Transcendent spirituality appears to enhance thepossibility of making positive meaning out of an otherwise difficult situation. However, spiri-tual people cope in many different ways. How spirituality is expressed in couple relationships isthus complex and varied (Baucom, 2001; Giblin, 1997).

A systemic perspective suggests that these two aspects of disease management, relationshipand spirituality, are holistically interconnected. Our purpose in this study is to begin to identifyand describe these connections. Thus we use qualitative interviews with couples to access partic-ipants’ meaning and experience in relational context.

METHOD

We apply a philosophical hermeneutic framework to the research process that places anemphasis on how participant couples’ narratives explain and negotiate their mutual experience ofliving with diabetes. According to this framework, the meaning of parts of their dialogue is deter-mined in context of the whole (Barton, 2004; Whitehead, 2004). Meaning is negotiated as theresearcher engages with the text (Schwandt, 2003). A ‘‘clear understanding’’ of the data is a nego-tiated activity not separate from the researchers themselves (p. 301). Validity is thus determinedby the degree to which we were able to systematically contextualize pieces of the data within acoherent whole and bring multiple perspectives to the analytic process (Janesick, 2003).

Our interest and understanding of the topic of spirituality and illness have been shaped bya variety of lenses. We are family therapists with a practical interest in how couples cope withstressful situations. We believe that individual meaning and experience are negotiated withininterpersonal relationships and the larger social context, including the spiritual. We work in asetting that emphasizes the integration of mind, body, and spirit. Though each of us is embed-ded within Christian tradition, our practices and conceptions of the sacred vary considerably.As much as possible, we attempted to identify and ‘‘bracket’’ our previous knowledge andopinions on the research topic so that we could develop new knowledge based on the experi-ence of the participants (e.g., Richards & Morse, 2007). The differences in our individualperspectives helped us to approach this research with enhanced curiosity and a shared commit-ment to questioning our assumptions.

SampleParticipants for this study were volunteers recruited from patient groups at a diabetes treat-

ment center and by word of mouth. To qualify for the study, participants needed to be adultscurrently married or living together for two years or more and at least one partner was required tohave been diagnosed with Type II diabetes during adulthood. Because of our interest in relationalprocesses, both partners had to be willing to be interviewed together. Potential participants were


told that we were interested in learning about their experiences of living with diabetes. Thoughsample selection was not based on spiritual beliefs or religious affiliation, all participants in thisstudy reported spiritual views. Though it is unclear how participants who volunteered for thestudy may differ from the many who did not, the sample seems to us to generally reflect the kindsof persons who attend diabetes education groups in our diverse community. Procedures for pro-tecting participants were approved by the Loma Linda Institutional Review Board.

The sample consisted of 20 heterosexual couples. All but one was married. Length of rela-tionships ranged from 3 years to 56, with an average of 29 years. Ages ranged from 24 to 78,with an average of 53.7 for women and 55.8 for men. The sample was ethnically diverse. Four-teen of the 40 respondents were Hispanic, 12 were Caucasian, 9 were Asian, 4 were AfricanAmerican, and 1 was Native American. Fifteen had college degrees, 16 reported attending somecollege, and 9 had high school diplomas. All but two of the participants reported some type ofChristian affiliation. Fourteen were Roman Catholic, 11 were Protestant ⁄nondenominational,10 were Seventh Day Adventist, and 3 were Mormon.

InterviewsSemi-structured interviews were based on an interview guide that included questions

regarding the nature of their relationship, such as how they communicate and resolve problems,how they deal with the diabetes and changes they have made since the diagnosis, and how theirspiritual beliefs and experiences factored into their experience of diabetes. The primary ques-tions regarding spirituality included ‘‘How is religion a part of your life together?’’ ‘‘What doyour religious beliefs suggest about health and healthcare?’’ and ‘‘Is religion ⁄ spirituality a helpto you in dealing with stress and illness?’’ Interviewers followed responses to these general ques-tions with probes for additional information about areas that seemed salient to them. Forexample, when participants cited religious teachings regarding health and nutrition, interviewersasked them to explain how they applied these to their illness.

The study reported here represents the first 20 interviews conducted by a diverse team offamily therapy doctoral students as part of a Loma Linda Department of Counseling and Fam-ily Sciences project studying diabetes and relationships. Partners were interviewed together intheir own homes in order to promote greater research understanding of how the couples relateto each other in their own environment. The interviews, which lasted 1½–2 hr, were audiotapedand transcribed eliminating all names and personal identifying material. Names in this reportare pseudonyms. Three of the interviews were conducted in Spanish and translated intoEnglish.

AnalysisEach of us independently read each interview with an eye toward understanding the nature

of each couple relationship, how they coped with diabetes, and their spiritual beliefs and prac-tices. We began with no predetermined analytic categories and used the coding procedures devel-oped by Strauss and Corbin (1998) to help categorize the data and conceptualize it at a moreabstract level (pp. 105–110). Our analytic process was collaborative and interactive with Johnprimarily taking the lead and Carmen questioning and challenging his interpretations. We beganwith open, line-by-line coding to label and describe what was happening in each of these areas ofinterest. For example, one couple believed that their circumstances occurred ‘‘by design, becauseit really helped in the way it brought us closer together.’’ This was labeled ‘‘optimism.’’ Othersbelieved that regardless of whether or not you believe in God, ‘‘there are certain things you haveresponsibility to take care of and certain things you can’t do anything about no matter what youdo.’’ This was coded as ‘‘acceptance’’ and ‘‘personal responsibility.’’ Items that seemed similarwere given the same label. To contextualize this information we wrote brief summaries of whatwas happening within each couple relationship and identified the conditions that informed theircoping and its consequences and compared and debated our impressions.


Next, axial coding was used to group the labels and identify distinct categories such asspiritual meaning, communication styles, connection to each other, and diabetes managementstrategies. As we explored the dimensions around each category and their variations and range,we could group these into categories and subcategories. For example, communication becamea subcategory under connection to each other. Connection to God had five subcategories ordifferent ways that people described their connection to God.

The final level of analysis involved understanding how these categories worked togetherwithin the narratives of each couple’s experience. This required that we go back to each individ-ual interview to recontextualize how categories were linked to each other in their accounts.Through this process we continued to refine categories in the context of their relational mean-ing and asked questions that deepened and fine-tuned our interpretation of the data. Interpreta-tions were continuously compared and contrasted amongst ourselves and peer reviewed bymembers of our departmental research group.

‘‘Couples’ spiritual coping styles’’ became the core category through which all the otherscould be linked. Differences in three aspects—spiritual meaning, connection to each other, andconnection to God—coalesced to form spiritual coping styles within the relationship. Theresults that follow describe five different spiritual coping styles with direct implications for howpartners make sense of and manage the disease.

Results: Spiritual Connection and Coping in Couple RelationshipsWe define a couple’s spiritual coping style as the manner through which they appear to

organize themselves to optimize their relational and spiritual resources. Each style is associatedwith particular coping strategies. Spiritual coping styles include (a) opportunists, who approachthe illness as an opportunity for growth; (b) mutual problem solvers, who collaborate with theirpartners to respond to their disease; (c) individualistic problem solvers, who take personalresponsibility for managing their disease; (d) accepters, who learn to endure their disease; and(e) victims, who take a hopeless, discouraged approach to the illness.

We first briefly review the variations in three components that work together to form spiri-tual styles of coping: spiritual meaning, connection to God, and connection to each other. Wethen use case examples to illustrate how, in our interpretation, each spiritual coping style isutilized by the couples as they manage diabetes in the context of their relationship.

COMPONENTS OF SPIRITUAL STYLES

Spiritual coping frames how partners attribute spiritual meaning to the disease and guidesthe way they use their relationships with God and each other in their attempts to cope withdiabetes. Though individuals within a relationship may not always experience spirituality inexactly the same way, we found that we could classify couples as a unit on each of these com-ponents. Table 1 shows how we classified each couple.

MeaningWe identified four different categories that describe how these couples attribute spiritual

meaning to their circumstances:Opportunity. Three couples viewed their circumstances as an opportunity for personal,

relational, or spiritual growth. These couples seemed to have the ability to identify a ‘‘silver lin-ing’’ amidst trying circumstances. Susan, who says her whole life turned around for the betterwhen she was diagnosed, echoes this sense of purpose: ‘‘Maybe you kinda needed for that tohappen for some reason.’’

Test. These couples view their circumstances as a test of faith. They believed that throughthese challenges God would prove to be faithful and able to help them overcome their difficul-ties. It is a test of their ability to endure. According to Roxanne, ‘‘You know what, you don’t


question . . . He allowed it to happen. A lot of stuff happened to Job just to show his faith.’’Dallyna laments, ‘‘I don’t rebel. I say, ‘Thanks, God. You know what you’re doing, but don’tremember me so much.’ ’’

Punishment. These couples expressed belief that their diabetes and other difficulties maybe the result of divine punishment, or a just consequence for not living their lives in a proper,healthy manner. In response to an inquiry about the effect of his illness on his relationship withGod, Angel says, ‘‘Something happened to you because maybe you deserve it.’’

Just life. Almost half the sample did not appear to attribute positive or negative value to theircircumstances. They said it was ‘‘just life’’ or part of the reality of living in an imperfect world.

Connection With GodConnection with God was described in five different ways. Both partners typically used

similar language to portray the nature of their relationship with God. In a few cases couplesused more than one of these categories.

God as anchor. For these people God appears to be a steady source of stability that main-tains personal meaning and purpose. Eun sees ‘‘God’s hand’’ in everything that she experiencesand in times of crisis experiences the ‘‘presence of God.’’

Table 1Categorization of Spiritual Coping Styles

Spiritual copingstyles

Coupleconnection

Connectionto God

Spiritual meaningof illness

Opportunists (3)Couple 2 Engaged Anchor OpportunityCouple 7 Engaged Anchor OpportunityCouple 11 Engaged Guide Opportunity

Mutual problem solvers (5)Couple 12 Engaged Guide TestCouple 16 Discontinuous Guide TestCouple 4 Engaged Guide Just lifeCouple 8 Engaged Provider Just lifeCouple 9 Engaged Guide Just life

Individual problem solvers (5)Couple 21 Resigned Refuge TestCouple 23 Discontinuous Guide TestCouple 13 Resigned Guide Just lifeCouple 18 Discontinuous Guide PunishmentCouple 19 Resigned Judge Just life

Acceptors (6)Couple 1 Resigned Provider Just lifeCouple 3 Resigned Judge Just lifeCouple 5 Resigned Provider ⁄ Judge Just lifeCouple 10 Resigned Refuge TestCouple 14 Discontinuous Refuge ⁄ Judge Just lifeCouple 17 Resigned Rules Just life

Victims (1)Couple 6 Hostile Judge Punishment


God as guide. Here God is experienced as a source of wisdom that can be accessed whenneeded. God is described as a map that they pull out when they are lost or needing direction.For example, June describes how she turns to God: ‘‘I do ask Him . . . to help me find outhow to control it.’’ Similarly, Guadalupe says that she and her husband turn to God ‘‘to under-stand more of what we’re going through.’’

God as provider. In this case people look to God to fix the problem. For example, Corinnesays, ‘‘I always pray to God that he [her husband] gets well as soon as possible.’’ Like God asa guide, God is accessed when needed. However, people who see God as a provider seem totake a more passive role in relation to God and their circumstances.

God as refuge. Rather than asking God to fix the problem, these people turn to God as asource of comfort and solace, like a child may turn to a parent. According to Mario, [God]‘‘provides a certain amount of peacefulness and serenity . . . a relief, a diversion from stress . . .makes me feel better.’’ Amar says you can ‘‘flee to [God] and ask for help and comfort . . . Itis just like talking to a psychologist or psychiatrist.’’

God as judge. These couples rarely express affinity toward God. God seems to be a distantauthor of rules and arbiter of one’s ability to satisfactorily adhere to them. Unlike the othercategories, God is seldom described as a source of provision, direction, wisdom, peace, or com-fort.

Connection With Each OtherIn our analysis, the couples in this study maintain four different types of connection with

each other:Engaged. Many couples in this study describe maintaining interpersonal connection even

as they deal with difficulties. They express confidence in their ability to understand each otherand to compromise. According to Amar, ‘‘We have always solved every problem . . . We talkabout it and we overcome it by reaching common ground.’’ Similarly, Benjamin speaks of thecloseness and reciprocity that he shares with his wife: [It’s] ‘‘giving up part of yourself andtrusting the other partner . . . there is less confusion because you allow each other into yourinner space, so to speak.’’ This mutuality is experienced as validating and supportive. Carlottasays, ‘‘It feels so great . . . It doesn’t matter that you disagreed, as long as you are honest andcaring.’’ We distinguished engaged couples by their satisfaction and pride in their ability tocommunicate with each other and their sense of sustained connection.

Discontinuous. These couples appear to alternate between connecting and giving each otherspace. They describe some difficulty maintaining engagement, particularly around differences.They express concern for each other and take steps to be supportive, but when faced with conflictor disagreement, they back off and exercise individual autonomy. For example, Patrick handlesdifferences by letting Sophie do things her own way: ‘‘I know her likes and dislikes, so basically, Ileave her alone.’’ When Patrick gets upset she lets him ‘‘cool off,’’ saying, ‘‘You have no choice.You can’t do anything about it.’’ Yet, Sophie does what she can to support his diabetes. Patrickexplains, ‘‘She is on top of it. So it’s a team effort.’’ Though couples with discontinuous connec-tion report some frustration with their communication and need to take breaks from each other,there appears to be an underlying trust in their ability to reconnect.

Resigned. In contrast to the retreat to individual space among the discontinuous couples,resigned couples express difficulties in their communication with each other, but appear tomaintain a delicate sense of connection. They tolerate each others’ shortcomings, without mak-ing an issue of them. For example, Philippe says, ‘‘We don’t do too much talking . . . If youdon’t like it, it’s ok.’’ Similarly, the wife is resigned to her inability to discuss issues with herhusband: ‘‘I wish we could talk it out . . . We don’t argue.’’ Despite their limited communica-tion, these couples seem to experience themselves as mutually supportive and engaged in day-to-day routines together. For example, when Philippe says that he walks four miles, his wife,Corinne, says, ‘‘I even go with him.’’


Hostile. These couples appear to have difficulty engaging each other without raising theirvoices and making hurtful accusations. Leila and Elias (the only couple we placed in thiscategory) describe themselves as ‘‘dogs and cats.’’ During this interview they engaged in thiscontentious exchange as the husband tried to describe the physical effects of his diabetes:

Elias: Affects my heart, affects my kidneys, affects my legs . . .

Leila: Everything.

Elias: Be quiet for a minute I’m talking.

Leila: Yeah.

Elias: That’s what makes me upset and angry.

This couple does not speak of shared activities or ways that they support each other.Attempts to communicate tend to produce conflict and dealing with diabetes is a source ofcontention in their relationship.

SPIRITUAL COPING STYLES

Meaning, connection with God, and connection with each other come together to form acouple’s spiritual coping style. The process of determining whether there is a positive or nega-tive spiritual meaning is relational and occurs within ongoing conversations. Couples filter themeaning of the diabetes through spiritual styles that appear to evolve over the course of theirlives together. Each of the styles described below provides a very different context throughwhich diabetes management is approached. The first three styles seem to emphasize taking per-sonal responsibility for finding solutions that enable them to live with or transcend the diabetes.The fourth style seems to place less emphasis on personal action in response to the disease, andmore emphasis on acceptance of it. The fifth style involves hopelessness. These spiritual copingstyles were also expressed in the nature of the couple relationship.

OpportunistsThree couples utilize the opportunist spiritual coping style. They seem to give diabetes a

positive spiritual purpose that empowers them to seek and recognize opportunities for personaland relationship growth through the disease. They also report engaged relationships with eachother. This means that diabetes is a shared problem for which they seek solutions. These cou-ples describe a spiritual anchor that facilitates personal responsibility. They report considerableadversity in their lives with positive outcomes. Maintaining connection to each other and toGod characterizes their stories of positive change.

Susan and Bill, married 19 years, illustrate the opportunist coping style. According toSusan, being diagnosed with diabetes was ‘‘the best thing that ever happened to me.’’ She saysthat before the diabetes she and Bill had ‘‘bad communication’’ and she was depressed. Dealingwith the diabetes ‘‘caused us to have to talk about things that I have never even talked about.’’The diagnosis was particularly fearful because she had witnessed her grandmother suffer legamputations as a result of diabetes. Yet, experiencing connection to her husband and sonsimmediately following the diagnosis was transformative. ‘‘The look on his face, his eyes kinda,you know, teary. And it just struck, oh my God . . . I felt like he cared about me.’’

The spiritual meaning they attribute to her disease contains a note of optimism. Susansays, ‘‘We’ve had some pretty interesting things happen in our past that looked really bad atthe time, but now you look at it and think, ‘this one was a good thing.’ ’’ She sums up herview: ‘‘God didn’t mean for this to happen . . . but I always knew somehow something good isgonna come out of it. You know, maybe you kinda needed for that to happen for some


reason.’’ Both agree that to make the most of the opportunity it is necessary to let go of somecontrol while retaining personal responsibility.

Bill shares responsibility for managing her diabetes. Bill says, ‘‘We just plan ahead a littlebit, we could have a margarita on Wednesday night, or we could wait till Saturday when wecould really enjoy it . . . You only get one a week.’’ He describes how figuring out how to copetogether required talking:

. . . thinking she’s going to get a salad, and trying to figure out if you’re OK with thator should I feel guilty? You sit and talk about it . . . let’s figure out what to do andhow we’re going to live with it and move on.

Mutual Problem SolversMutual problem solvers take a similar shared approach to dealing with diabetes. Like

Susan and Bill, they report maintaining connection and open communication as they deal withstress. However, two viewed their diabetes as a test of their faith, while three considered theircircumstances merely a reality of life. Mutual problem solvers turn to God for guidance andwisdom as they actively seek solutions to the problem of diabetes. We classified five couples asmutual problem solvers.

Mario and Winetta, married 37 years, illustrate mutual problem solvers. During thepreceding year Mario was diagnosed with diabetes and Winetta’s sister died of cancer. Mariocompares this stressful period with how they coped when he was in Viet Nam early in theirmarriage. They do not appear to attribute positive or negative value to the situation and believethat people must take personal responsibility in order to make it through. However, Mario andWinetta appear to believe God provides guidance:

It’s like the guy who is in the middle of a flood and he’s on top of his house and ahelicopter comes and he waves it off, and a boat comes and he waves it off, andanother helicopter comes and the floods come and he dies and goes to heaven and heasks God, ‘‘Why didn’t you save me?’’ And God says, ‘‘Well I sent two helicoptersand a boat!’’ . . . So it’s that kind of thing, you have free will, you have the ability toknow what you have to do.

Winetta and Mario report trust in their communication processes. They say they feel freeto ‘‘dialogue’’ about anything. Both are actively involved in finding ways to overcome his dia-betes. Winetta was instrumental in taking the steps to find a specialist: ‘‘He wasn’t getting anybetter . . . and I stayed home that day and I stayed on the phone ’til I got what I wanted.’’Their problem-solving attitude is evident as Mario describes his approach: ‘‘[It’s] helped me touse a slogan that ‘I am going to manage this disease, this disease is not going to manage me.’ ’’Winetta agrees: ‘‘Just trying to be strong, and saying that this is going to pass, it’s going to getbetter . . . you don’t think you’re going to be able to survive, but you do.’’ She views God as aresource: ‘‘God never gives you any more than you can survive, even though you think youcan’t handle it . . . somehow or another, you pool those resources that you didn’t even knowyou had.’’ As mutual problem solvers, both plan around his diabetes. Winetta also helps moni-tor his eating and exercises with him.

Individual Problem SolversThese five couples typically look to God primarily for guidance and refuge while the dia-

betic takes personal responsibility for managing the disease. Three individual problem solversappear to have resigned couple connections and two have discontinuous connections. This spiri-tual coping style is consistent with the tendency among discontinuous connection couples to


respect each other’s autonomy, particularly during times of disagreement. Spouses often expressconfidence in the other’s ability to determine the best course of action for managing theirdiabetes. However, when attempts to be supportive (reminders, warnings, etc.) fail to communi-cate respect for autonomy, the diabetic spouses can interpret their partners’ behavior as con-trolling or nagging. While two of the individual problem-solving couples did not attributepositive or negative value to their diabetes, two viewed it as a test of their faithfulness and abil-ity to accept God’s will. For instance,

Roxanne: A lot of stuff happened to Job but God didn’t do it to him, but he allowedit to happen just to show his faith and all that . . . so, it’s like, you know what . . .there are things that I can do to beat this . . . No matter the obstacle, I can overcome.

Roxanne’s husband, Shelton, expressed frustration over failed attempts to help her monitorher food intake and seemed to finally determine that he could be most supportive by respectingher autonomy and giving her some space:

. . . they have to live their lives themselves and you have to blend in and go with theflow . . . who am I to say ‘‘Hey!’’ I just try to let her live her life and really be sup-portive. When she is doing the right thing, or when she’s not, just stay cool.

Some couples with resigned connection also utilize the individual problem solver spiritualstyle. This may be due to their difficulty with communication and seems consistent for coupleswho are resigned to accepting their spouses’ shortcomings rather than working toward improve-ments. Sarah, a nurse, trusts in ‘‘a higher power’’ for comfort and support: ‘‘[God’s] not gonnazap me and say you’re gonna be perfect . . . but it helps to know you have somebody you cango to that you can talk to personally about anything . . . And it’s helpful . . . to believe inGod, to have hope for tomorrow, and in the future.’’ Sarah does not expect God to solve theproblem. Instead, she emphasizes the importance of becoming educated about diabetes,‘‘because the more I know about it, the better I can take care of it.’’ For instance, she haslearned that ‘‘if you’re gonna eat something sweet, it’s better to eat it with your food than inbetween [meals], because otherwise, if you eat in between your sugar spikes up.’’ Sarah’shusband, Freddie, is not engaged in her diabetes, reasoning that since his wife is a nurse, hedoesn’t need to get involved in the treatment of her diabetes.

AcceptorsAcceptors appear to describe a process of learning to live with the disease and thus primar-

ily seek peace through their spirituality or relationship with God. God is experienced as a pro-vider, refuge, or judge in times of trials and tribulations. Only one of the six acceptors viewedtheir circumstances as a test. The others did not attribute any positive or negative value to theircircumstances. None of these couples experience engaged connections with their spouses ⁄part-ners. We coded all but one in the resigned couple category. The other is in the discontinuouscategory.

Dallyna and Juan illustrate the acceptors. They are resigned to their marriage of 25 years,which they agree is ‘‘rocky.’’ Dallyna is disappointed that Juan is not more emotionally avail-able: ‘‘Even though he is nice, emotionally he is not in the relationship.’’ Juan responds that he‘‘would like to be different.’’ He can do it for two days ‘‘and after then I come back to thesame situation.’’ He also believes that ‘‘she doesn’t understand me.’’ Neither partner sees anylikelihood that their relationship will change.

Though Juan says he wants to support his wife, who also has other medical problems, heexplains that he ‘‘was more attentive in all her illnesses,’’ but over time has gotten used to it.‘‘Now . . . it doesn’t affect me as much as it did before.’’ Dallyna also accepts her condition.She does not seek out information about the diabetes or actively problem-solve: ‘‘I don’t listen


nor read much about diabetes . . . I know I have it, but I don’t want to know . . . I don’t checkmy sugar daily.’’ She tries to watch her eating and exercise, but has not seen that it makesmuch difference.

Dallyna accepts that ‘‘suffering’’ is part of life that must be endured and serves as a test ofher faith. She describes an example of how her relationship with God (through scenes from ThePassion of the Christ) helped her to experience peace and comfort during a recent medical crisis:‘‘They found I have stones in the [kidneys] . . . I have never felt any pain as big as this pain.When I was in the hospital, everything came to my mind . . . the Passion of the Christ, no?When he was walking with his cross and everything . . . and that alleviated my pain.’’

Unlike the opportunists or problem solvers, acceptors do not seem to seek wisdom fortreatment or ascribe a positive value or silver lining to the disease. Their difficulties workingwell together as couples may prohibit a more assertive or optimistic approach to diabetes man-agement. Instead they ‘‘learn to live with it,’’ sometimes praying for each other’s health andusing rituals that help them to experience a sense of emotional acceptance toward their ill-nesses: According to Stephan, a retired Mormon in his 70s:

Whenever she gets really sick I have the power to give her a blessing and stuff likethat. That provides peace for her and provides peace for me because I’m doing thebest that I can and then it’s beyond me if something is going to happen to her becauseI already did what I was supposed to have done.

VictimWe placed only one couple in the category of victim. This was also the only couple with a

hostile couple connection. Elias and Leila seem to struggle to engage each other in a constructivemanner. When describing how his diabetes affects their relationship, Elias says his conditionresults in conflict ‘‘a lot . . . for every small thing. For everything. For every movement. Every-thing.’’ Leila agrees that ‘‘it’s never good.’’ She wishes he would ‘‘do something with his temper’’because he will often ‘‘speak in a rough tone, or act aggressively.’’ Similarly, he expressesfrustration because ‘‘whatever you tell her, she doesn’t listen. She does her own way. That’s it.’’

Elias and Leila describe both their spirituality and their approach to diabetes managementas a series of behavioral rules. They experience God as a judge, the arbiter of rules. Accordingto Elias, religious people generally ‘‘say good things, sleep on time, keep your health . . . youknow? And uh, they go to church.’’ While nonreligious people ‘‘don’t care about it.’’ Theyengage in ‘‘drinking, and uh, cursing, fighting, you know, those kinds of things.’’ Similarly, hedescribes his medical condition as the result of ‘‘not following all the rules . . . I was eatingwhatever I had to eat . . . People warned me, but I didn’t take them seriously and thought thatthe worst wouldn’t happen to me. But then it happened.’’ The spiritual meaning they ascribe totheir circumstances expresses a sense of being unfairly punished. According to his wife, ‘‘All thetime he curses, and says [to God], ‘Why do you give this sickness to me?’ ’’ Though Elias sayshe prays daily, he insists he’s not a very religious person, and that he prays only ‘‘because I’ma sick person.’’ Elias gives no indication that his spirituality is a source of peace and comfort(associated with acceptors) or wisdom (associated with problem solvers and opportunists). Noris his wife a source of support.

DISCUSSION

A number of authors have argued that spirituality is an important clinical resource (e.g.,Carlson & Erickson, 2003; Walsh, 1999), yet how spirituality is connected to relational processeshas been virtually unexplored. This study suggests that spirituality is more than a set of beliefs orattitudes to be assessed. It appears to be an integral part of how couples respond to stressful life


situations woven into the very nature of their relationships. Previous research showed that thequality of marital relationships predicts adaptation to diabetes (e.g., Trief et al., 2001). In oursample, we found a link between the meaning that partners ascribe to their diabetes and the waysthey connect with each other and with God. We call the integration of these a spiritual copingstyle through which couples work together to deal with diabetes. Though these categories areheuristic constructions and couples may not always fit neatly into one category, they can providea useful guide for future research and practice. We draw three preliminary conclusions that caninform practitioners in helping people deal with chronic illness.

First, couples who maintain an engaged connection with each other also describe anempowering connection with the transcendent that helps them explore new options. Theyappear to be better equipped to actively create solutions to their problems and deal with stress.In some cases, they actually are able to use the illness to create new opportunities for growth.

Second, couples in this study whose spiritual coping style emphasizes emotional acceptanceof what is and ‘‘making it through’’ are usually resigned to their relationships and to enduringtheir disease. In these cases, God serves as a source of solace and sometimes judgment. Theability of these couples to problem-solve through communication appears limited. Nonetheless,they seem able to maintain a sense of commitment to each other and faith in God despite theirdifficulties. In contrast, the couple who is hostile with each other also seems unable to findcomfort with God.

Third, the spiritual style couples bring to their circumstances seems to determine howactively they approach their disease, the degree of their optimism, and the creativeness and skillthat they apply to diabetes management. We are not able to determine from our analysis ifrelationships with God determine the nature of the couple’s connection or vice versa. However,it seems likely that these evolve reciprocally in an ongoing way over time. Therefore, we viewspiritual coping styles as a reflection of the current stage of their relationships with God andeach other, and thus, potentially amenable to change.

Diabetes management is enhanced when couples can work together as a team (e.g.,Rapaport, 1998). Efforts to help couples improve their capacity for teamwork may require achange in their spiritual coping style as well. Thus, these conclusions suggest that therapists notonly draw on spiritual resources, but also potentially impact them. As we help people developthe communication and problem-solving skills required to effectively cope with their diseases,we seem also to enter into the spiritual context of the situation. Clinical and psychoeducationalapproaches that help people move from problem-focused perspectives toward identifying moreoptimistic views may be helpful.

Limitations and Future DirectionsOur findings regarding the transformative potential of diabetes (Paterson et al., 1999), the

link between diabetes management strategies and relationships to God (Polzer & Miles, 2007),and variations in spiritual coping styles and meanings (Gall & Grant, 2005; Gordon et al.,2002; Rowe & Allen, 2004) largely validate previous studies. However, this study provides aninitial examination of spiritual processes for coping with disease within couple relationships.Participants are ethnically and socioeconomically diverse. However, all participant couples hadat least some Christian family background and professed beliefs in some kind of God. Thesample is also limited to partners who are sufficiently engaged with each other to participatetogether in a volunteer interview. A larger sample that extends beyond these parameters mayidentify additional relational patterns.

Though participants talked about changes over time in their relationships and disease man-agement, the data were collected at only one point in time and cannot track change or deter-mine the processes through which spiritual coping styles evolve. We also cannot assume thateach couple consistently uses one spiritual coping style. By interviewing couples together wepurposefully focused on spirituality as a relational process. Our analysis may have been


considerably different if our focus was on individual spiritual experience. Furthermore, theserespondents were coping with the long-term lifestyle changes required by diabetes. Issues raisedby other kinds of stressors and illnesses could be different.

Future research should explore how persons from other faiths and nonreligious or inter-faith couples apply spirituality to their circumstances. We need to know more about spiritualprocesses among distressed couples and how other personal, social, or philosophical resourcescontribute to spiritual processes. Further exploration of the relationship between couple com-munication and spiritual perspectives is needed to validate our hypotheses and determine causalpathways. Integrative clinical models that incorporate spirituality into relationship therapyremain to be developed and tested. Since our findings suggest that there may be considerableconnections between couples’ communication and problem-solving processes and spirituality,work in this area appears to be fruitful for development in the field of family therapy and otherhealth-related disciplines.

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Documents

Spirituality and Relationship: A Holistic Analysis of How Couples Cope With Diabetes