CDPXXX10.1177/0963721416667444Slatcher, SelcukClose Relationships and research-article6674442017

Current Directions in Psychological Science A Social Psychological Perspective on 2017, Vol. 26(1) 16­–21 © The Author(s) 2017 Reprints and permissions: the Links Between Close Relationships sagepub.com/journalsPermissions.nav DOI: 10.1177/0963721416667444 and Health www.psychologicalscience.org/CDPS

Richard B. Slatcher1 and Emre Selcuk2 1Department of Psychology, Wayne State University, and 2Department of Psychology, Middle East Technical University

Abstract The association between the quality of people’s close relationships and their physical health is well established. But from a psychological perspective, how do close relationships impact physical health? This article summarizes recent work seeking to identify the relationship processes and psychological mediators and moderators of the links between close relationships and health, with an emphasis on studies of married and cohabitating couples. We begin with a brief review of a recent meta-analysis of the links between marital quality and health. We then describe our strength and strain model of and health, homing in on one process—partner responsiveness—and one moderator— adult attachment style—to illustrate ways in which basic relationship science can inform our understanding of how relationships impact physical health. We conclude with a brief discussion of promising directions in the study of close relationships and health.

Keywords marriage, health, marital quality, relationships,

There is a long tradition of studies investigating the links intimate, satisfying, and committed relationships. At the between social relationships and health. This area of same time, there has been considerable theoretical and research received a shot in the arm with House, Landis, and empirical work on the mechanisms linking social relation- Umberson’s article “Social Relationships and Health,” which ships to health (Cohen, 1988; Lewis & Rook, 1999; Miller, appeared in Science in 1988. That article used several epi- Chen, & Cole, 2009; Pietromonaco, Uchino, & Dunkel demiological studies to illustrate a consistent link between Schetter, 2013; Uchino, Cacioppo, & Kiecolt-Glaser, 1996). stronger social ties and greater longevity. The authors con- However, much of the existing theoretical work is based cluded that “social relationships, or the relative lack thereof, primarily on broad social networks, including family, constitute a major risk factor for health—rivaling the effects friends, and acquaintances. Yet research in social psychol- of well-established risk factors such as cigarette smoking, ogy suggests the possibility that our closest relationships— blood pressure, blood lipids, obesity, and physical activity” those with a spouse or long-term romantic partner—have (p. 541). That claim was definitively supported in a meta- particularly potent effects on health. Moreover, a growing analysis of over 300,000 participants across 148 studies, literature on the development of close relationships pro- indicating a 50% increased likelihood of survival for people vides us with a blueprint for addressing the psychological with stronger social bonds (Holt-Lunstad, Smith, & Layton, processes by which relationships are linked to physical 2010). Thus, the question of whether social relationships health. impact physical health has been answered with a resound- The goal of this article is to provide a concise sum- ing “yes.” But from a psychological perspective, how do mary of the work that we (and others) have been doing social relationships impact physical health? A logical place where researchers have looked for answers to this “how” question is social psychology. Over Corresponding Author: Richard Slatcher, Department of Psychology, Wayne State University, the past three decades, relationship scientists have made 5057 Woodward Ave., Detroit, MI 48202-3489 numerous breakthroughs in identifying factors that lead to E-mail: [email protected] Close Relationships and Health 17 to identify the relationship processes and psychological term “strength” is meant to capture the range of positive mediators and moderators of the links between close processes in relationships (e.g., intimacy, capitalization, relationships and health, with a particular focus on long- support) that have increasingly been the focus of rela- term romantic relationships. We begin with a brief review tionship scientists (Reis & Gable, 2003). It is this greater of a recent meta-analysis of the links between marital emphasis on positive relationship processes (beyond just quality and health. We then describe our strength and in stressful contexts) that distinguishes our strain model of marriage and health, homing in on one model from most prior models of marriage and health. process—partner responsiveness—and one potentially Although both marital strain and marital strength are pro- important moderator—adult attachment style—to illus- posed to moderate the effects of outside stressors on trate ways in which basic relationship science can inform health, only marital strength should buffer or protect our understanding of how relationships impact physical against the negative health effects of stress—whereas health. We conclude with a brief discussion of promising marital strain should intensify or exacerbate those effects. directions in the study of close relationships and health. This model also presupposes that individual differences, including , personality traits, and attachment style, Meta-Analysis of Marital Quality and should moderate the effects of marital quality on health. However, as indicated by our recent meta-analysis Health (Robles et al., 2014), almost no studies have tested mod- A recent meta-analysis showed robust associations erators. The field is thus ripe for consideration of these between the quality of people’s and their phys- factors. Below, we describe a process (partner respon- ical health (Robles, Slatcher, Trombello, & McGinn, 2014), siveness) and a moderator (adult attachment style) as including lower risk of mortality. Although the reported examples of key parts of the strength and strain model. effect sizes generally would be considered small by con- ventional standards in psychology (rs between .07 and Partner Responsiveness, Attachment, .21, depending on the type of health outcome), they are and Health similar to the effect sizes of typical behavior interventions (e.g., increasing fruit and vegetable intake, decreasing Partner responsiveness refers to the extent to which indi- sedentary activity) for improving health. viduals are caring, understanding, and validating of their Perhaps most surprising about our meta-analysis was partners (Reis, 2013). Numerous influential relationship how little we could glean about the specific aspects of theories (attachment theory, interdependence theory, marriage—positive aspects (e.g., intimacy, understand- social support theory) ascribe a central role to partner ing), negative aspects (e.g., conflict, hostility), or both— responsiveness in linking relationships to health and well- that matter most for physical health. Further, almost no being. Among these, attachment theory is probably the studies examined moderators of the links between mari- one that most prominently features responsiveness as the tal quality and health. Below, we describe our theoretical core aspect of close relationships “from the cradle to the model, which provides a starting point for investigating grave” (Bowlby, 1988). Perceiving partners—the proto- the mediators and moderators of marriage-health links. typical attachment figures in adulthood (Hazan & Shaver, 1987)—as responsive brings a sustained sense of security, The Strength and Strain Model which in turn is thought to promote health and well-being in the long run. Failures to perceive partners as respon- The theoretical model that guides our work (shown in sive, on the other hand, lead to two types of attachment Fig. 1) illustrates the hypothesized effects of marital qual- insecurities. Attachment anxiety (characterized by worries ity on physical health (originally described in Slatcher, of rejection and abandonment) is linked to inconsistent 2010, but refined here). In this model, marital strengths partner responsiveness, where the partner is sometimes (positive aspects of marriage) and marital strains (nega- responsive and sometimes not, or responsive only to per- tive aspects of marriage) both have main effects on sistent distress signals and excessive reassurance seeking health, as well as moderating effects on links between (Mikulincer & Shaver, 2007). Attachment avoidance (char- outside stressors (e.g., work stress) and health. Our acterized by discomfort with depending on relationship model shares many common elements with earlier mod- partners) is linked to consistent partner unavailability and els of marriage and health (e.g., Burman & Margolin, unresponsiveness (Mikulincer & Shaver, 2007). Both 1992; Kiecolt-Glaser & Newton, 2001), models of stress attachment insecurities are thought to increase the likeli- and marriage (e.g., Karney & Bradbury, 1995), and mod- hood of later physical health problems. els of social support and health (Cohen & Wills, 1985; Recent work investigating attachment-related health Uchino et al., 1996), with a key difference that we use the effects using diverse methodologies (e.g., experiments, term “strength” over the more widely used “support.” The longitudinal follow-ups, daily-experience designs) has 18 Slatcher, Selcuk

Individual Differences • Attachment style • Personality • Gender • Culture Main Effect Strength and Strain Model of Marital Quality and Physical Health Marital Strain • Hostility • Conflict Main Effect • Attention to alternatives Moderating Effect • Demand/withdraw Psychological Biological Physical Health • Criticism Main Effect Mechanisms Mechanisms Outcomes • Physical abuse • Cognitions • Endocrine (e.g., • Mortality Stress-Intensifying Effec - Attributions of cortisol) • Heart partner behaviors • Cardiovascular • - Cognitive (e.g., blood • Asthma Marital Strength appraisals of stress pressure, heart • Arthritis and • Social support • Affect rate variability) other • Self-disclosure - Positive affect • Immune (e.g., inflammatory t • Partner responsiveness Main Effect - Negative affect pro-inflammatory • Capitalization - Depression cytokine • Autoimmune production) diseases • Intimacy Stress-Buffering Effect • Health Behaviors • Commitment - Sleep • Gene expression • Diabetes • Satisfaction - Diet (e.g., - Exercise glucocorticoid - Medication receptor adherence expression) - Hygiene Outside Stressors - • Work • Child-rearing • Interpersonal tensions • Housework • Financial pressures • Chronic disease

Fig. 1. Theoretical model illustrating how marital quality influences physical health directly via psychological and biological pathways and indi- rectly via its moderating influence on the effects of outside stressors (either stress-intensifying or stress-buffering). Also included in the model are individual difference factors, which can moderate the health effects of relationship processes or, alternatively, can directly impact relationship pro- cesses (main effects). shown that differences in partner responsiveness are married and cohabiting adults in a 10-year longitudinal likely to influence later health by way of regulating phys- study. We found that partner responsiveness predicted a iological responses to stress, promoting health behaviors, “healthier” diurnal cortisol profile (as indicated by steeper reducing pain, and moderating the effectiveness of social declines in daytime cortisol) a decade later (Slatcher, support. Selcuk, & Ong, 2015). This long-term association between responsiveness and diurnal cortisol was partially mediated Alteration of stress regulatory systems by a psychological mechanism, namely negative affect, as suggested in Figure 1. To the best of our knowledge, this Prior developmental work showed that during childhood, is the only evidence so far in humans suggesting the excit- maternal responsiveness leads to sustained changes over ing possibility that adult romantic relationships may lead time in the functioning of the hypothalamic-pituitary- to long-term alterations in the HPA axis, potentially result- adrenocortical axis (HPA), the body’s major stress-regulation ing in beneficial changes in cortisol production and, thus, system, and its hormonal product, cortisol (Gunnar & physical health. Quevedo, 2007). Is such a long-term fine-tuning of the HPA system possible in adulthood? If romantic partners Immune functioning are capable of inducing such changes, then this would probably be one of the most critical pathways through Our findings indicate that relationships with unrespon- which close relationships affect later health. Our research sive partners may be linked to dysregulated cortisol pro- group investigated this question in a large sample of files. This is particularly true for anxiously attached Close Relationships and Health 19 individuals, whose chronic worries about abandonment (Uchino, 2009). In a recent examination of partner respon- and intense signaling of distress to get partner support siveness in moderating the association between partner result in increased cortisol production in daily life (Jaremka support and physical health, we found that received part- et al., 2013). Overproduction of cortisol, in turn, is associ- ner support predicted a higher risk for all-cause mortality ated with alterations in the . Recent work a decade later for individuals who perceived their partner has linked attachment anxiety with indicators of weaker as unresponsive (Selcuk & Ong, 2013). However, this par- immune functioning, including lower T-cell counts adoxical association disappeared for individuals who per- (involved in activating immune cells and responding to ceived their partner as responsive. infections; Jaremka et al., 2013), higher levels of latent her- In sum, accumulating evidence has started to uncover pesvirus reactivation (Fagundes et al., 2014), and exacer- a network of processes linking partner responsiveness to bated inflammatory response to cardiac surgery (Kidd health. Importantly, studies have also indicated that part- et al., 2014), suggesting that failures to perceive one’s part- ner responsiveness has a discriminant role in predicting ner as responsive may lead to impairments in the immune health-related biology, since the effects of responsiveness system. hold even after partialling out potential confounds, including other positive or negative aspects of relation- Health behaviors ships (Slatcher et al., 2015), psychological symptoms (Selcuk & Ong, 2013; Slatcher et al., 2015), personality The associations between partner responsiveness and traits, and physical health indicators (e.g., chronic symp- health behaviors have not been studied extensively, but toms; Selcuk & Ong, 2013). attachment theory can guide future investigations of rela- We should note that much of the work reviewed here tionship effects on health behaviors. An excellent exam- focused on middle-aged or older adults with established ple is research on adult sleep (Troxel, 2010). High-quality long-term relationships, when much of the protective sleep requires down-regulation of arousal and anxiety, health benefits are realized. Early-stage romantic relation- which is precisely what partner responsiveness serves to ships, which are more commonly studied in young adult- alleviate. Recent data from our group indicate that part- hood, do not always demonstrate the typical characteristics ner responsiveness indirectly predicts increased subjec- of full-blown attachment bonds (e.g., partners being tive sleep quality and objective (actigraph-assessed) sleep secure bases for each other; Zeifman & Hazan, 2008). We efficiency through decreased anxious arousal (Selcuk, speculate that although perceptions of responsiveness in Stanton, Slatcher, & Ong, 2016). Corroborating these find- early-stage relationships would promote the develop- ings, both types of insecure attachment styles have also ment of attachment and intimacy, the effects on health been linked to poorer sleep (Adams, Stoops, & Skomro, are likely to be conferred over a much longer time period. 2014). Of course, only future empirical work will tell whether and how the health effects of romantic relationships Pain regulation change with age and relationship development. Responsive interactions with partners result in the release Moving Forward With Greater of endogenous opioids, which not only instill a sense of Interdisciplinary Integration security and contentment but also reduce feelings of pain (Machin & Dunbar, 2011). Indeed, one of the first studies Although many relationship researchers (including our- on the health implications of partner responsiveness selves) were influenced by developmental attachment showed that greater partner responsiveness predicted theory, work on childhood and romantic attachment have lower levels of knee pain 3 months after knee replace- progressed relatively separately from each other. Integra- ment surgery (Khan et al., 2009). Conversely, failure to tion of these fields will help us better understand life-span appraise partner behaviors as responsive, as in the case of effects of relationships on health. Early life stress, particu- those who are anxiously or avoidantly attached, increases larly unresponsive caregiving, is associated with insecure vulnerability to developing chronic pain (Meredith, attachment (Ainsworth, Blehar, Waters, & Wall, 1978), Ownsworth, & Strong, 2008). which in turn affects developing stress neurobiology and health (Loman & Gunnar, 2010). Growing evidence shows that these early effects extend well into adulthood (e.g., Moderation of received support Taylor, Karlamangla, Friedman, & Seeman, 2011). Early A counterintuitive research finding is that receiving sup- caregiving environment shapes not only later health port from loved ones is sometimes associated with poorer but also later romantic attachment experiences (Fraley, well-being (Bolger, Zuckerman, & Kessler, 2000) and Roisman, Booth-LaForce, Owen, & Holland, 2013). The physical health outcomes, including early mortality question, then, is whether romantic attachment experiences 20 Slatcher, Selcuk would in turn affect offspring care and health, a possibil- References ity that has not yet been studied much. To help bridge this Adams, G. C., Stoops, M. A., & Skomro, R. P. (2014). Sleep gap, we have started examining the implications of part- tight: Exploring the relationship between sleep and attach- ner responsiveness for the health of offspring. 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