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THE IMPACT OF ATTACHMENT AND COPING ON POST-
SURGICAL RECOVERY IN OLDER ADULTS

presented by

ELLEN MARIE O'TOOLE

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THE IMPACT OF ATTACHMENT AND COPING ON POST-SURGICAL
RECOVERY IN OLDER ADULTS

By

Ellen Marie O’Toole

A THESIS

Submitted to
Michigan State University
in partial fiilfillment of the requirements
for the degree of

MASTER OF ARTS
Department of Psychology

2003

ABSTRACT
THE IMPACT OF ATTACHMENT AND COPING ON POST-SURGICAL
RECOVERY IN OLDER ADULTS
By

Ellen Marie O’Toole

States of dependency in 70 older men (age 55 to 83) were examined as a key mechanism
in the recovery from a coronary bypass procedure. Attachment traits and coping
strategies were hypothesized to be important predictors of health, anxiety and depression
in this population. Coping was hypothesized to act as a mediator on the relationship
between attachment and mental and physical health. In general, coping did not mediate
attachment on the outcome variables. However, emotion-focused coping was shown to
mediate preoccupied traits on anxiety. More general predictions regarding the impact of
attachment traits and coping on depression, anxiety, physical functioning, and general
health were partly supported. Medium effect sizes were calculated for the relationship
between emotion-focused coping and anxiety, and for planning coping on physical
functioning. A medium to large effect size resulted for the relationship between
preoccupied traits and anxiety. Notably, secure attachment traits were significant

predictors of general health, although the effect was small to medium in size.

ACKNOWLEDGMENTS

I would like to acknowledge the efforts of the many people who enabled me to
accomplish this project. First of all, I want to thank my advisor and mentor, Anne Bogat,
for her guidance and encouragement throughout the entire process of creating this
research project as well as writing the thesis. I have especially appreciated her support of
my desire to pursue an independent project and her creative input in the practical
application of my ideas. Thank you for supporting me through a difficult yet rewarding
process. I would also like to thank Alytia Levendosky and Clare Collins, my two other
committee members, for their excellent suggestions and assistance in a variety of matters.
Their expertise in different areas greatly added to my understanding of the research
process in both a practical as well as a conceptual sense. I would also like to thank my
mentor from Mills College, Carol George, who graciously and promptly answered all of
my questions about attachment theory throughout this period.

For help in recruiting subjects, I would like to acknowledge the medical staff who
generously took time from their busy schedules to assist me: Steve Bush, P.A., Christine
Sampson, RN, and Jane Maxey, R.N. I would also like to thank the undergraduate
research assistants who helped conduct interviews: Janna Bartalone, Jason Coletta, Chris
Stickney, Paige Jones, and Brian Daniels. I would also like to thank the men who
consented to be interviewed for this project and to acknowledge their contribution to a
knowledge base that may help others in the future.

Finally, I would like to thank my partner, Holly Oppenheimer, whose support,

encouragement, and love sustained me throughout this undertaking.

iii

TABLE OF CONTENTS

LIST OF TABLES .............................................................................................................. vi
INTRODUCTION ............................................................................................................... 1
Attachment ............................................................................................................... 2
Attachment and Coping ........................................................................................... 5
Coping and Health Outcomes .................................................................................. 9
Attachment and Health .......................................................................................... 10
Depression and Anxiety ......................................................................................... 12
Coping and Psychological Outcomes .................................................................... 13
Attachment and Psychological Outcomes ............................................................. 14
Relevant Population Characteristics ...................................................................... 17
HYPOTHESES OF PRESENT STUDY ........................................................................... 20
METHOD .......................................................................................................................... 22
Participants ............................................................................................................. 22
Measures ................................................................................................................ 22
Procedures .............................................................................................................. 27
RESULTS .......................................................................................................................... 30
Missing Data .......................................................................................................... 30
Tests of Hypotheses ............................................................................................... 30
General Hypotheses ............................................................................................... 40
DISCUSSION .................................................................................................................... 42
Alternative Explanations ........................................................................................ 46
APPENDICES ................................................................................................................... 50
APPENDIX A: Demographics Questionnaire ...................................................... 51
APPENDIX B: Mini Mental State ........................................................................ 54
APPENDIX C: Reciprocal Attachment Questionnaire ......................................... 56
APPENDIX D: Revised scales for Reciprocal Attachment Questionnaire ........... 59
APPENDIX E: COPE Inventory .......................................................................... 60
APPENDIX F: Geriatric Depression Scale ........................................................... 63
APPENDIX G: State-Trait Anxiety Inventory ..................................................... 65
APPENDIX H: RAND SF-36 ............................................................................... 67
APPENDIX 1: Telephone Script ........................................................................... 71

iv

APPENDIX J: Consent Form ............................................................................... 72
APPENDIX K: Post-interview Letter and Community Resources ........................ 74

REFERENCES .................................................................................................................. 77

LIST OF TABLES

Table 1. Means, Standard Deviations, and Ranges for Study Variables .................. 31
Table 2. Intercorrelations of Variables ..................................................................... 32
Table 3. Mediating Effects of Planning Coping on Secure Traits and Depression..33
Table 4. Mediating Effects of Planning Coping on Secure Traits and Anxiety ....... 33

Table 5. Mediating Effects of Planning Coping on Secure Traits and Physical
Functioning .................................................................................................. 34

Table 6. Mediating Effects of Planning Coping on Secure Traits and General

Health .......................................................................................................... 34
Table 7. Mediating Effects of Emotion Coping on Preoccupied Traits and

Depression ................................................................................................... 35
Table 8. Mediating Effects of Emotion Coping on Preoccupied Traits and

Anxiety ........................................................................................................ 35
Table 9. Mediating Effects of Emotion Coping on Preoccupied Traits and

Physical Functioning ................................................................................... 36
Table 10. Mediating Effects of Emotion Coping on Preoccupied Traits and

General Health ............................................................................................ 36
Table 11. Mediating Effects of Disengagement Coping on Dismissing Traits

and Depression ............................................................................................ 37
Table 12. Mediating Effects of Disengagement Coping on Dismissing Traits

and Anxiety ................................................................................................. 37
Table 13. Mediating Effects of Disengagement Coping on Dismissing Traits

and Physical Functioning ............................................................................ 38
Table 14. Mediating Effects of Disengagement Coping on Dismissing Traits

and General Health ...................................................................................... 38
Table 15. Correlations Between Attachment Traits and Coping ............................. 40

Table 16. Effect Sizes for Attachment Traits and Coping as Predictors of Health
and Psychological Variables in Regression ................................................ 42

vi

INTRODUCTION

Attachment may be thought of as a complex process in which an individual’s
appraisal and response to a threat involves the use of a protective primary relationship. In
adults, this relationship is generally one’s romantic partner or a close friend, but it can
also apply to adult children caregivers of the elderly (F eeney, 1999; Hazan & Zeifman,
1999; Rickelman, Gallman, & Parra, 1994). Internal working models, which are mental
representations of the primary relationship, have been shown to be relatively stable and
consist of expectations of the responsiveness and availability of attachment figures as
well as beliefs regarding whether the self is valued or loved by the attachment figure.
Secure attachment encompasses beliefs of the self as valued and worthy of protection,
and attachment figures as accessible and likely to provide an appropriate and satisfying
response to the individual’s distress. Insecurely attached individuals have less optimal
views of self and attachment figure, resulting in less confidence when confronted by
significant stressors (George, West, & Pettem, 1999). Such expectations and beliefs guide
both the degree to which specific situations are considered threatening by an individual
and the response to that threat. Extant research has provided evidence that choice of
coping style varies by attachment classification (Birnbaum, Orr, Mikulincer & Florian,
1997; Feeney, 1995; Ognibene & Collins, 1998; Torquati & Vazsonyi, 1999).

These concepts are of interest in examining recovery during a state of dependence
in older adults. Such dependency may be found in those recovering fiom a major surgery
such as a coronary bypass operation. When an older adult becomes dependent on a
primary caregiver (and that caregiver is an attachment figure), aspects of attachment

become relevant shapers of coping styles, emotion regulation, strategies to obtain comfort

in the face of physical and emotional pain, and confidence in obtaining protection when
confronted with new physical limitations. If a newly disabled elder is successful and
confident in eliciting instrumental help from an attachment figure, this deactivates the
attachment system by removing the source of potential distress. Both attachment groups
and coping styles have been linked to both psychological well being and health outcomes.
Therefore, research on attachment classification and the resultant ability to predict coping
style, is an important area of research with an older population vulnerable to states of
dependency. This study examined whether coping was a mediator between attachment
traits and two kinds of outcome: psychological difficulties (anxiety and depression) and
health.
Attachment

Attachment theory was originally developed by John Bowlby to define the human
behavioral system providing protection for children (Bowlby, 1969; Ainsworth, Blehar,
Waters, & Wall, 1978). This system works through the interaction between the child and
his or her primary caregiver whenever threatening situations arise. This perceived threat
begins a cycle (or activation of the attachment system) whereby the child seeks contact
with or expresses distress, and a timely, sensitive response from the caregiver soothes the
child (Ainsworth et al., 1978; Goldberg, 1995). Such comfort affirms for the child the
sensitivity of the caregiver to such expressed needs, and a feeling of safety is therefore
associated with proximity to this caregiver. It follows that the attachment behaviors of
the child are no longer necessary when an appropriate response is provided; the
attachment system shuts down, or deactivates, and the child’s behavior and physiological

arousal returns to a normal state (Fox & Card, 1999; Hofer, 1995). The caregiver thus

acts as a secure base for the child, offering protection and comfort when needed, and
enabling the child to balance the need for security with the need to explore his or her
environment (George & Solomon, 1999).

One of Bowlby’s collaborators, Mary Ainsworth, created the basis of the
classification scheme still in use today by analyzing patterns of behavior observed when
the attachment system is activated. Using a laboratory task involving separation and
reunion (the Strange Situation), Ainsworth distinguished between three qualitatively
different types of attachment relationships: secure, avoidant, and ambivalent/resistant
(Ainsworth et al., 1978). Infants in the most frequently occurring attachment type,
secure, engage in exploration in the mother’s presence, maintain proximity checks, show
a variety of distress responses upon her leaving, yet respond to her return in a positive
manner. Avoidant children tend to focus on their surroundings and objects therein, do
not check proximity of the mother as the secure child will, and most saliently, will mask
emotional response to both the mother’s departure and return. Those in the ambivalent
category tend to cling to the mother, avoiding exploration, and show great distress when
the mother leaves and returns. Upon reunion, ambivalent children may show both angry
and contact seeking behavior, and will take much longer to be comforted than secure
children (Ainsworth et al., 1978; George & Solomon, 1999; Goldberg, 1995). The rates
of occurrence within the population estimated from research findings are as follows:
secure, 55-65%, avoidant, 20-25%, and ambivalent, 10-15% (Goldberg, 1995).

In adults, a comparable use of a protective primary relationship is accomplished
with an attachment figure who is usually one’s partner or a close friend (Feeney, 1999;

Hazan & Zeifman, 1999), but this person may also be a sibling (Hazan & Zeifman, 1999)

or an adult child caregiver to an older parent (Rickelman etal., 1994). Attachment
researchers have identified several criteria that differentiate adult attachment
relationships from other social relationships: seeking contact with the attachment figure
when contending with stress; decreased anxiety through use of the attachment figure as a
haven of safety (either through contact or by use of mental representation); a substantial
increase in anxiety and searching behavior if threatened by separation from the
attachment figure; expectations that the relationship will last over time; and a reciprocity
appropriate to adult relationships, based on a mutual sharing of comfort and protection
(George et al., 1999; West, Sheldon, & Reiffer, 1987). Feeney (1999) explicates the
nature of the events that arouse the adult attachment system: “stressful conditions in the
social or physical environment; conditions that appear to threaten the future of the
attachment relationship; and conditions of the individual, such as ill health” (Feeney,
1999: p.371).

Adult attachment has been measured by developmental psychologists through
narrative analysis of semistructured interviews asking subjects questions about their early
relationships with attachment figures. The Adult Attachment Interview (AAI; George,
Kaplan & Main, 1984/ 1985 / 1996) is a significant predictor of both measures of
parental responsiveness and actual attachment classifications of subjects’ children (Hesse,
1999; Main, 1996). Adult classifications have been developed which correspond to the
established categories for children: Secure/autonomous (secure), dismissing (avoidant),
and preoccupied (ambivalent) (George & Solomon, 1999; Hesse, 1999). Secure adults
give evidence of valuing attachment relationships while being able to discuss events in a

coherent and consistent manner. Dismissing subjects will describe early relationships

with normalizing language (often idealizing parents) while offering contradictory
evidence during specific vignettes. Subjects in the other insecure category, preoccupied,
offer incoherent discourse with salient angry, passive or fearful content; their narratives
contain long, rambling sentences with repeated or excessive detail. (George et al., 1999;
Hesse, 1999; Main, 1996). These descriptions of differential responses to stress based on
attachment classification provide a foundation for understanding the impact of attachment
on coping.
Att_achment and Coping

Bowlby (1973) first postulated that early attachment experiences precede a
development of what he termed internal working models of attachment figures and self.
Children who are securely attached develop a model of self as worthy and valued by
attachment figures and a model of attachment figures as responsive and available.
Insecure children establish representations of self as rejected or unloved and views of
attachment figures as rejecting or inconsistent in response (Bowlby, 197 3; Dozier,
Stovall, & Albus, 1999; F eeney, 1999). Such internalized representations are the
dominant mechanism of the attachment system by adulthood (Bowlby, 1973). Pertaining
to this, Bowlby discussed how secure attachment for an individual pervasively colors his
or her world view: when confronted by life stressors or difficulties, such a secure person
will carry an internal assurance that trustworthy attachment figures are available for
comfort or protection. Thus, a securely attached person will “approach the world with
confidence and, when faced with potentially alarming situations, is likely to tackle them

effectively or to seek help in doing so” (Bowlby, 1973; p. 208).

Therefore, in those situations seen as threatening or potentially harmful,
attachment should intrinsically shape coping responses of an individual (Feeney, 1995).
Empirical evidence supports the concept that different classification groups respond
differentially to stressful situations, as seen in infant response to separation in the Strange
Situation (Ainsworth et al., 1978; Main, 1996). The limited research on the impact of
attachment on coping offers results extending such findings to differential choices of
coping styles by classification groups (Bimbaum et al., 1997; Feeney, 1995; Ognibene &
Collins, 1998; Torquati & Vazsonyi, 1999). Unfortunately, such findings are
complicated by inconsistency in the coping literature in defining coping styles (Strack &
Feifel, 1996) as well as the use of psychometrically weak or untested instruments
(Endler, Parker, & Summerfeldt, 1998).

Coping is defined as a process of appraisal and behavior in response to stress.
Lazarus & F olkrnan (1984) initially identified two main coping functions, emotion-
focused coping (regulation of emotions associated with the stressor) and problem-focused
coping (acting on the source of the stress). Parker and Endler (1996) define these two
constructs thus:

“the problem-focused coping dimension involves strategies that

attempt to solve, reconceptualize, or minimize the effects of a stressful

situation. The emotion-focused coping dimension...includes strategies that

involve self-preoccupation, fantasy, or other conscious activities related to

affect regulation” (p. 8).

Lazarus (2000) notes that these two styles of coping are generally used in tandem,

although one or the other may predominate. Past research has provided much evidence

linking problem-solving approaches with better psychological well-being and emotion-
focused approaches with worse (Aldwin & Revinson, 1987; Downe-Wambolt &
Melanson, 1995; Zeidner & Saklofske, 1996), but contradictory findings have also been
reported (Bolger, 1990; Baum, Fleming, & Singer, 1983). Downe-Wambolt and
Melanson (1995) report a significant negative relationship between emotion-focused
coping and levels of psychological well-being on the Mental Health Inventory (MHI) in a
sample of 78 older adults diagnosed with chronic rheumatoid arthritis. Zeidner and
Saklofske (1996) describe emotion-focused approaches as helpful (in terms of providing
an outlet for emotional release) when used along with the more active problem-focused
approaches which enable the individual to maintain a sense of mastery in the situation.
Other coping researchers affirm that some use of emotion-focused coping enhances
problem-focused coping (Aldwin & Brustrom, 1997; Lazarus, 2000) but point out that
dependence upon emotion processing as a strategy is ineffective in facing many stressors
(Aldwin & Brustrom, 1997). Downe—Wambolt and Melanson (1995) also report a
significant positive relationship between optimistic coping (a form of problem-focused
coping) and well-being; as with most coping studies, the levels of problem-focused
coping here are analyzed separately from amount of emotion-focused coping engaged in.
Another coping style commonly measured is the avoidant dimension. This is
characterized by a diversion of attention away from the problem, which may be in the
form of seeking social diversion or by immersion in other tasks (Parker & Endler, 1996).
Health researchers have found an avoidant coping style to be somewhat beneficial over
the short term although linked to poor outcomes when used as a long term strategy (Suls

& Fletcher, 1985). This finding appears to generalize to an older, disabled population, as

suggested by a study examining older adults with reduced immobility (with 62% of the
sample reporting mobility difficulties for at least seven years); the researchers reported a
significant positive correlation between escape-avoidance coping and level of depression
(Landreville, Dube, Lalande, & Alain, 1994).

Coping style has been reported to vary significantly by attachment classification
(Birnbaum et al., 1997; F eeney, 1995; Ognibene & Collins, 1998; Torquati & Vazsonyi,
1999). The literature provides support for a proposed relationship between secure
attachment and problem-focused strategies when individuals are faced with a variety of
stressors. Adults who endorse statements reflecting current secure attachment are more
likely to engage in support seeking during stressful life experiences (Ognibene & Collins,
1998), including combat training (Mikulincer & Florian, 1995), to focus on tasks during
stressful moments in relationships (Lussier, Sabourin, & Turgeon, 1997), and to engage
in active coping when held as prisoners of war (Solomon, Ginzburg, Mikulincer, Neria,
& Ohry, 1998). An exception was reported by Birnbaum et a1. (1997), who did not find a
relationship between secure attachment and the coping strategies of problem-solving and
support seeking in their divorce sample. However, based on ratings of stressor appraisal,
the authors concluded that the secure group did not perceive (and thus, react to) divorce
as a threat compared to the other groups classified as insecure.

Findings for the insecure attachment subgroups (preoccupied and dismissing) are
less clear. Adults endorsing preoccupied statements to describe their current attachment
status appear more likely to use emotion-focused coping than other groups (F eeney,
1995; Lussier et al., 1997; Mikulincer & Florian, 1995). What might be expected to

clearly differentiate the dismissing group from the preoccupied, namely the dismissing

group’s tendency to use avoidance or distancing coping (Birnbaum et al., 1997; Lussier et
al., 1997; Mikulincer & Florian, 1995), is also reported for adult subjects who
characterize their current attachment as preoccupied, in some studies (Birnbaum et al.,
1997; Lussier et al., 1997; Ognibene & Collins, 1998). Some research is thus difficult to
interpret because of coping outcomes that fail to make a distinction between the
dismissing and preoccupied groups (Birnbaum et al., 1997 ; Lussier et al., 1997).
However, not all research has been unable to make such a differentiation. Vetere and
Myers (2002) treated coping as a stable trait rather than a situational or time-specific
strategy, and found a significant link between avoidant attachment and a repressor coping
style (low anxiety and higher defensiveness), with results showing the ambivalent
attachment group significantly higher on anxiety.
Coping_and Health Outcomes

An examination of the literature shows a clear link between attachment and
coping style; within the arena of coping research, relationships between coping and
outcome variables such as health are well-established. A current review of coping
strategies and their impact on health for older adults concluded that cognitive
restructuring of stressors (a problem solving approach) has a positive relationship to
health outcomes, where avoidant coping predicts negative health outcomes (Arbuckle,
Pushkar, Chaikelson, & Andres, 1999). This conclusion cannot be considered definitive
due to the small number of studies analyzed (seven) and the fact that these studies used
various health and coping strategy measures, many of which Arbuckle and colleagues
found too dissimilar to compare. Interestingly enough, Arbuckle et a1. present their own

study in the same article, with cognitive coping resulting in no significant predictions

regarding self reported health or illness scores over five years for a sample of World War
II veterans. Echoing Arbuckle and colleague’s findings, Day and Livingston (2001)
reported nonsignificant results for problem-focused coping and health symptoms in their
sample of military personnel. They also reported finding both emotion-focused and
avoidant coping styles significantly linked to higher reporting of symptoms.
Attachment and Health

The current study hypothesizes that coping style acts as a mediator between
attachment and health. In the attachment literature, some research exists that suggests
such a relationship between attachment and health outcomes. Within the last decade, a
few studies can be found which have assessed the relationship between physiological
stress responses and attachment, although most of this research has been limited to
children. Empirical evidence using protocols such as the Strange Situation reveal
differences in behavioral response to stress according to attachment classification; such
differences imply related physiological responses which may impact health. Cortisol is a
stress hormone released by the hypothalamic-pituitary-adrenocortical (HPA) system
which has been used as an index of stress by health researchers. Nachiamas and
colleagues (1996) found a significant positive relationship between behaviorally inhibited
insecure l8 month-olds and cortisol levels. One tentative conclusion from this study was
that secure attachment may act as a buffer against stress, especially in those children
determined to be shy or inhibited. Nachiamas et a1. (1996) also report that maternal
behavior, particularly intrusive acts indicative of insensitive or untimely caregiving, is
significantly related to increased levels of cortisol in insecure and disorganized children.

Spangler and Grossman (1993) found significantly higher levels of cortisol in groups of

10

infants classified as disorganized or insecure, when compared to secure infants, after
administration of the Strange Situation protocol. In the area of health psychology,
chronic stress is known to result in elevated cortisol levels (Schaeffer & Baum, 1984).
Such high adrenocortical response has been linked to higher reports of health symptoms
(Kirschbaum et al., 1995). Chronic stress has also been significantly related to levels of
respiratory illness (Boyce et al., 1995). Researchers in psychoimmunology suggest that
long term stress may impact health through decreased levels of immune system
functioning (Bachen, Cohen, & Marsland, 1997). Insecure or unresolved attachment may
be thought of in terms of nonoptimal responses to stress, with an extended period of
anxiety (or, a longer activation of the attachment system when stressors occur) in
comparison to those persons who are securely attached. This implies a compounding of
the amount of stress experienced. Considering this, it is not surprising that in one of the
few studies examining attachment and health in adults, preoccupied women reported
significantly more health symptoms on the Diagnostic Interview Schedule than secure
subjects (Ciechanowski, Walker, Katon, & Russo, 2002). However, the clinical relevance
of this difference is questionable, since the means of both groups fell below the cutoff (3
or more symptoms) indicating a significant level of symptoms (secure group M=1.89;
preoccupied group M=2.36). In addition, women who were preoccupied also reported
more physician visits and higher health care costs than secure subjects.

Clearly, the empirical findings on the relationship between attachment and health
are not yet substantial enough to provide definitive statements. The theoretical basis of
attachment and previous research points to unregulated emotion states (thus, prolonged

distress) in response to stress in insecure children. Longitudinal studies have established

11

that attachment classifications are stable characteristics (Urban, Carlson, Egeland, &
Sroufe, 1991; Waters, Merrick, Treboux, Crowell, & Albersheim, 2000), and can
therefore be conceived of as predictive of long-term typical responses to stressors. This
fits well with the body of knowledge from health psychology pertaining to chronic stress
in postulating an impact of attachment classification on health outcomes. The
aforementioned empirical work which supports links between attachment and coping,
attachment and health, and coping and health outcomes, is suggestive of a mediating role
for coping.
Depression and Anxiety

As psychological outcome variables, depression and anxiety have an impact on
the lives of older adults that varies from the rest of the adult population. Rates of
depression and anxiety in older adults may be underestimated when using criteria derived
from the DSM-IV for diagnosis; research has shown that significant depressive
symptoms are found in about 15 percent of older adults (Gallo & Lebowitz, 1999) while
significant symptoms of anxiety have been estimated to range from 0.7% to 21% in older
adults (Himmelfarb & Murrell, 1984; Flint, 1994). De Beurs and colleagues (1999)
found significantly higher levels of disability and lower ratings of well-being for older
adults with either an anxiety disorder or subclinical levels of anxiety, as compared to
nonanxious controls. While De Beurs et al. describe anxiety symptoms as having “grave
consequences for the quality of life” (p.583), it should be noted that anxiety (and
especially subclinical anxiety) is an understudied area of research among older adults

(Flint, 1994; Gallo & Lebowitz, 1999; Wetherell, 1998).

12

Comparative studies have found that rates of depressive symptoms are higher in
an older population (Flint, 1994). Older adults with depressive symptoms are vulnerable
to decreases in functional abilities (Gallo & Lebowitz, 1999), and both depressive and
anxious symptoms are linked to difficulties with cognitive performance in the general
population (Eysenck & Calvo, 1992). Yaretsky and colleagues (1998) generalized these
findings to state anxiety and older adults, reporting that those hospitalized elders with
higher levels of state anxiety showed significantly lower ability to successfully complete
a Clock Completion Test measuring psychomotor speed, attention, concentration,
learning, and memory.

The research on the impact of anxiety and depression on older adults suggests that
these are two psychological outcomes with implications for significant disability and
decline. More research is thus needed that specifically aims to understand the
mechanisms underlying the development of such symptoms in older adults, particularly
those facing physical illness (Aldwin & Brustrom, 1997; Flint, 1994; Gallo & Lebowitz,
1999; Wetherell, 1998). This discussion of the unique role depression and anxiety play in
the lives of older adults establishes the importance of defining the relationship of
attachment and coping to these variables for this population.

Coping_and Psychological Outcomes

Studies investigating coping and depression have established clear links between
dependence on either emotion-focused coping or avoidance coping and depressive
outcomes (Summerfeldt & Endler, 1996). The few studies in this area using an older
adult sample confirmed this for avoidance coping and depressive symptomalogy as

measured with self report scales: the Mental Health Inventory (MHI; Veit & Ware, 1983)

13

(Downe-Warnbolt & Melanson, 1995) and the Geriatric Depression Scale (GDS; Brink et
al., 1982) (Landreville et al., 1994). Arbuckle and colleagues (1999) reported avoidance
coping as a strong predictor of anxiety and somatization in their sample of older men (as
measured by the neuroticism subscale of the Eysenck Personality Inventory; EPI;
Eysenck & Eysenck, 1968). A discussion of the general literature on coping and anxiety
by Summerfeldt and Endler (1996) confirms that avoidance coping has been empirically
related to higher levels of anxiety. The authors explore this by considering how the
avoidance of problems or stressors may be related to the vigilance and preoccupation
with threat associated with higher levels of anxiety. Differentiating between this and a
tendency toward passive and ruminative worry (as an extreme tendency toward emotion-
focused coping may be described) could explain predictions of depression via coping
style. However, given high rates of comorbidity of depression with anxiety reported in
both the general population as well as in older adults (Flint, 1994), a distinction between
pathways is more challenging to determine.
Attachment and Psychological Outcomes

In their meta-analysis of thirty-three studies using AAI protocols, van IJzendoorn
& Bakermans-Kranenburg (1996) report a significant relationship between parental
groups classified as either insecure or unresolved and the clinical status of their children.
The authors report a strong representation of preoccupied parents (with a somewhat
smaller degree of dismissing parents) in groups of children with psychiatric diagnoses.
This study cited a variety of psychological diagnoses examined, including anxiety and
mood disorders, but did not conclude any further differentiation based on attachment

classification (van IJzendoom & Bakermans-Kranenburg, 1996). There is, however,

14

some support from both longitudinal and correlational research that insecurity and
disorganization are related to greater anxiety and depression in both adults and children.
From their work with the Minnesota Parent-Child Project, Warren and colleagues (1997)
reported that ambivalent attachment in infancy predicted a modest but significant
relationship to anxiety disorders at age 16 (using diagnoses obtained with the KSADS-
III-R-MPE). In their high-risk group, the potential for developing an anxiety disorder if
the subject was classified as ambivalent was more than twice that of other subjects.
Lyons-Ruth and colleagues (1997) followed a low-income sample from the ages of 18
months to 7 years, and reported a significant positive relationship between avoidant
children and internalizing problems (as measured by the Child Behavior Checklist).
Studies on attachment classification and levels of depression in adults have found
significant links between the insecure and unresolved groups and mood disorders (Dozier
et al., 1999). In their study on eating disorders and depression in women, Cole-Detke and
Kobak (1996) found a significant positive relationship between depression (as measured
by the Beck Depression Inventory) and preoccupied classification. Another study on
hospitalized adolescents (Rosenstein & Horowitz, 1996) compared three groups
differentiated by psychiatric disorder: affective disorders, conduct disorder and affective
disorders comorbid with conduct disorder. Those diagnosed with just affective disorders
were significantly more often classified as preoccupied, and unresolved classification was
significantly related to both affective disordered subjects and the comorbid group.
Patrick and colleagues (1994) reported in their sample of women inpatients a
significantly higher link between dysthymia and a dismissing classification. However,

this study divided the sample into groups diagnosed with either dysthymia or borderline

15

personality disorder, without further identifying those in the borderline group who may
have had depressive symptomology. West and colleagues (1999) report a significant
relationship between depression (measured with the CBS-D) and endorsement of
behavior linked to the preoccupied classification. These behaviors were high proximity
seeking coupled with both fear of loss of the attachment figure and inability to use the
attachment figure in the face of stress. West et. a1 explain this in terms of living in a state
of continual anxiety over whether one’s need for security can be met via an important,
protective relationship. Behavior undertaken with the goal of proximity to an attachment
figure coupled with awkwardness in approaching that person leads to further failure and
reinforcement of such insecurity. Hence one can see how a sense of helplessness and
even depression may result.

The research on anxiety and attachment in adults and adolescents is even more
scarce. Rosenstein and Horowitz (1996) report that 65% of preoccupied subjects and
35% of dismissing subjects showed elevated scores on the anxiety scale of the Millon
Multiaxial Personality Inventory. Fonagy and colleagues (1996) report that a majority of
subjects diagnosed with anxiety disorders were also determined to have a preoccupied
classification. In their study using the Behavior Symptom Checklist to measure anxiety
and depression, Cooper, Shaver, & Collins (1998) reported significant differences
between each of the secure, preoccupied and dismissing groups (measured via self
endorsement of statements pertaining to current attachment) on depression (preoccupied
having highest levels and dismissing showing moderate levels), and significantly high
levels of anxiety in both of the insecure groups when compared with the secure group.

The authors report that the preoccupied and dismissing groups did not differ significantly

16

on the subscale of general anxiety. Cooper et a1. (1998) also state that attachment status
accounted significantly for the variance in each of the eight subscales of psychological
symptomology, as well as for over 5% of the overall variance in the model after including
demographic variables. These studies suggest that insecure and internal working models
are significantly linked to higher levels of both anxiety and depression.

Sroufe (1997) comments on how ambivalence in children is typified by a chronic
vigilance in tracking an inconsistent caregiver, and how avoidant children learn to move
their focus to the environment when painful or stressful attachment needs are aroused,
due to rejecting caregivers. These patterns of behavior have been shown to be consistent
over time (Urban, Carlson, Egeland, & Sroufe, 1991; Waters, Merrick, Treboux, Crowell,
& Albersheim, 2000); therefore, in the face of a stressor such as coronary bypass surgery,
it is predicted that subjects with insecure traits will report higher rates of anxiety and
depression.

Relevant Population Characteristics

Coronary bypass patients are expected to enter a state of short-term dependency
due to their surgery. Such a dependent state provides an avenue to examine the
mechanisms involved in coping with a stressor significant enough to activate subjects’
attachment systems. In a current review of research on contributions of coping and
control processes to health outcomes in older adults, Arbuckle and colleagues concluded
that “the most striking effects of control or coping on health were obtained in samples
that were under the stress of declining health” (Arbuckle et al., 1999, p.308). Tienari
(1994) states that in 25-40% of coronary bypass patients, well-being remains at low

levels post-surgery, and such distressed patients tend to cope poorly and may not return

17

to previous levels of activity due to fears about how physical exertion may impact their
heart. This suggests the importance of understanding the mechanisms which significantly
predict coping strategies in such a population. Research also suggests that surgical
success is not related to the emotional well-being of the coronary bypass patient (Magni,
Unger, & Valfie, 1987). In their review of the psychosocial literature on coronary heart
disease (CHD) patients, Krantz and McCeney (2002) note that persons with low social
contact have an approximately 50% higher risk for CHD. They also report that close
relationships have a salient impact on the quality of life for CHD patients, and urge
researchers to include more measures examining the nature of such relationships.

Research on the effects of coping on health status provides evidence that use of
specific coping strategies, such as problem-focused coping, is linked to better outcomes
(Arbuckle et al., 1999). However, it should be noted that much of the coping research
has been conducted on young adults. Addressing this point, Arbuckle and colleagues
note that with

“age-related change in the type of stressors that people experience,

previously favoured strategies may no longer be as effective, and

persistence in their use may negatively affect healt ” (Arbuckle et al.,

1999, pp. 308-309).

Successful adaptation to aging may mean learning new ways to cope with
stressors that can no longer be resolved through behavioral intervention (Heckhausen &
Schulz, 1995). A few researchers have pinpointed increased use of cognitive
restructuring (redefining one’s perception of the problem in such a way that associated

anxiety is reduced) as related to age (Arbuckle et al., 1999; Diehl, Coyle, & Labouvie-

18

Vief, 1996; Heckhausen & Schulz, 1995). Another relevant aspect of coping is whether
gender impacts choice of coping strategy. Although the current research does not provide
clear answers to this for the general population, at least one study concluded that men
with heart disease may adopt different coping styles than women (Weidner, 2000).
Controlling for gender is therefore an additional consideration in answering questions
about coping in the coronary bypass population. Thus, identifying effective coping
strategies for older adults facing, for example, an acute health condition, is important in
order to refine current knowledge of the processes as well as the predictors involved in
successful recovery.

Thus, it is important to examine potential predictors of outcomes of depression,
anxiety, and quality of relationships for this group. This population was targeted by this
study in order to better investigate the impact of coping strategy as a mediator of

attachment on health and psychological outcomes.

19

HYPOTHESES OF PRESENT STUDY

The aim of this study was to investigate the impact of attachment classification
and coping strategy on the psychological and physical outcomes of older men who have
undergone a coronary bypass procedure.

Although research on attachment in various domains provides good evidence that
attachment significantly predicts coping strategy as well as levels of anxiety and
depression, no studies have yet integrated this knowledge into an explanatory model of
the mechanisms of the process. Furthermore, previous research has provided
physiological evidence that attachment classification is significantly related to levels of
stress, such as cortisol. Health psychologists have established an inverse relationship
between cortisol level and health status, but few studies have examined the impact of
attachment on health, particularly in adults.

Based on both theory and empirical findings, it was proposed that coping strategy
would act as a mediator of attachment on both health and psychological outcomes. It was
predicted that higher levels of secure attachment traits would be significantly associated
with successful, problem-focused forms of coping, which in turn would be linked to
higher levels of perceived health functioning as well as lower levels of self-reported
anxiety and depression. It was also predicted that dismissing attachment traits would be
positively associated with avoidance coping strategies, which have been associated with
good health outcomes in previous short term studies on coronary patients. However,
levels of depression and anxiety were hypothesized to be higher for dismissing

individuals. Preoccupied attachment traits were hypothesized to be associated with the

20

least successful coping strategies (emotion-focused and or avoidance) and have the worst

outcomes on all psychological and health indices. Specific hypotheses are listed below:

Hypothesis 1: Planning Coping will mediate the relationship between Secure Traits and
Depression

Hypothesis 2: Planning Coping will mediate the relationship between Secure Traits and
Anxiety

Hypothesis 3: Emotion Coping will mediate the relationship between Preoccupied Traits
and Depression

Hypothesis 4: Emotion Coping will mediate the relationship between Preoccupied Traits
and Anxiety

Hypothesis 5: Disengagement Coping will mediate the relationship between Dismissing
Traits and Depression

Hypothesis 6: Disengagement Coping will mediate the relationship between Dismissing
Traits and Anxiety

Hypothesis 7: Planning Coping will mediate the relationship between Secure Traits and
Physical Functioning

Hypothesis 8: Planning Coping will mediate the relationship between Secure Traits and
General Health

Hypothesis 9: Emotion Coping will mediate the relationship between Preoccupied Traits
and Physical Functioning

Hypothesis 10: Emotion Coping will mediate the relationship between Preoccupied
Traits and General Health

Hypothesis 11: Disengagement Coping will mediate the relationship between Dismissing
Traits and Physical Functioning

Hypothesis 12: Disengagement Coping will mediate the relationship between Dismissing
Traits and General Health.

21

METHOD

Participants

Participants in the study were 70 male subjects who were interviewed three to ten
weeks (M =5.80, S_D =1.73) following their coronary bypass surgery. Subjects ranged in
age from 55 to 83 years (M = 68.13, SI; =7.7l). Ethnicity of subjects was largely
Caucasian (93%), with a small minority identifying as Afiican American (4%), Asian
American (2%), or Native American (1 %). Approximately one-half of the sample
reported having a 12th grade education or less (49%), while the rest reported having some
college or vocational/skilled trades training (31%), or earning graduate degrees (10%),
undergraduate degrees (9%) and professional degrees (1%). Seventy-six percent of the
sample were married, 13% were widowed, 9% were divorced, 1% were unmarried, living
with a partner, and 1% were single. Median annual household income was $30,000 to
$39,999. Although 63% of the subjects reported not being employed, the rest reported
varying degrees of hours worked per week: 40 or more hours (11%), 30 to 40 hours
(10%), 20 to 30 hours (10%), or less than 20 hours (6%). Participants underwent
coronary bypass surgery involving between 1 to 5 grafts (single bypass, 7%; double
bypass, 13%; triple bypass, 30%; quadruple bypass, 31%; and quintuple bypass, 19%).
Measures

Demographics. Subjects completed a demographics questionnaire that asked
about their age, ethnicity/race, marital status, employment status, household composition,
income level, years of education, and number of bypass grafts. See Appendix A.

@gnitive Status. A brief measure of cognitive status, the Mini-Mental State

(MMS; Folstein, Folstein, & McHugh, 1975) was employed to screen for those subjects

22

too impaired to take part in the study. The MMS is a widely used 21-item mental status
examination requiring subjects to answer questions (such as “what is today’s date?” and
“what floor are we on?”) and perform simple tasks (for example, correctly following the
command to “take the paper in your right hand, fold it in half and put it on the floor”).
Folstein and colleagues reported high test-retest reliability (r = .89). This protocol
successfully identifies subjects with moderate to severe mental impairment using cutoff
scores of 23 points or less out of 30 total points (Folstein et al.). Lezak’s (1995)
recommendation to alter the cutoff to 19 points for subjects with an 8th grade education or
less was employed as well. Therefore, subjects had to score 24 points or higher to
continue the interview, except for those who reported lower education completion (8th
grade or less), who had to score 20 points or higher in order to stay in the study. Scores in
the current study ranged from 20 to 30, with a mean of 27.17 (SD=1.94). See Appendix
B.

Attachment. Adult attachment was measured by the Reciprocal Attachment
Questionnaire (RAQ; West et al., 1987). The RAQ is a 43 item questionnaire developed
to measure nine individual dimensions of attachment: proximity seeking, use of the
attachment figure, perception of availability of the attachment figure, angry withdrawal,
separation protest, feared loss, compulsive care-giving, compulsive self-reliance, and
compulsive care-seeking. Each subject was asked to consider the questions in terms of his
relationship to his attachment figure, who is defined as “the person you have been most
likely to turn to or depend on for comfort or help when facing stress.” Questions were
phrased in terms of this relationship (for example, “I feel it is best not to depend on my

attachment figure”) and answered on a 5-point Likert scale (ranging from 1, strongly

23

agree, to 5, strongly disagree). West et al. (1994) reported coefficient alpha ranging from
.74 to .85, and test-retest reliability over a four month period ranging from .76 to .82,
across the nine scales (see Appendix C).

In order to analyze the data using the most well-known global concepts associated
with adult attachment, namely, autonomous, preoccupied and dismissing traits, principal
components factor analysis with varimax rotation was employed to force the items into
three factors, which were refined by omitting items that had loadings less than +/- .500,
or that loaded higher than +/- .300 on any other factor. The items in each factor were then
examined and determined to fit well theoretically, as traits associated with the three
attachment groups. Scales were derived by summing the items. The preoccupied traits
scale contained 7 items with a range of 7-35, and both the secure traits and dismissing
traits scales had 4 items each and ranged fiom 4-20 (see Appendix D). Higher scores
corresponded to greater levels of each attachment trait. The preoccupied traits and secure
traits scales had good internal consistency, with a coefficient alpha of .86 for both
measures. The dismissing traits scale demonstrated lower reliability, with a coefficient
alpha of .68.

Mg. The COPE inventory (Carver, Scheier, & Weintraub, 1989) is a 52-item
measure with 13 scales. Five scales reflect problem-focused coping (planning, active,
suppression of competing activities, use of instrumental social support, and positive
reinterpretation/ growth), three are related to emotion-focused coping (focus on and
venting of emotions, use of emotional social support, humor), two are related to
acceptance coping (restraint, acceptance), and four are related to avoidant type strategies

(mental disengagement, denial, behavioral disengagement, substance use). Subjects rate

24

statements from 1 (I usually didn’t do this at all) to 4 (I usually did this a lot) in reference
to coping with their health condition. Examples of statements are “I get upset and let my
emotions out,” “I refuse to believe that it has happened,” and “I do what has to be done,
one step at a time.” Scales were derived by summing the items. Each scale had a range of
4-16, with higher scores indicating greater use of a particular coping strategy. Cronbach’s
alpha are reported to vary from 0.62 to 0.92 for the subscales, with the exception of
Mental Engagement, with an alpha coefficient of 0.45 (Carver et al., 1989). See
Appendix E.

In this study, one scale from the three more widely used categories (emotion-
focused, problem—focused, and avoidant coping) was chosen based on content-theory
match and strength of coefficient alphas. From the problem-focused coping scales,
planning was chosen, with a coefficient alpha of .87. The focus on and venting of
emotions scale (emotion) was chosen fiom the emotion-focused coping scales, showing
adequate internal consistency with a coefficient alpha of .77. From the avoidant coping
scales, denial (the avoidant scale with the highest alpha at .70) was rejected for use
because the distribution was significantly skewed and violated the assumption of
normality (Kolmogorov-Smimov g=1.77, p=.00). The behavioral disengagement scale
did not have a skewed distribution and was used in the analyses, although reliability was
low (Cronbach’s alpha=.52).

Pgsvchological outcomes. Depression was measured using the Geriatric
Depression Scale (GDS; Brink et al., 1982). The GDS, developed by Brink and
colleagues, is a widely used self-report screening test for depression developed especially

for older adults, taking into consideration the tendency of this group to indicate their

25

depressive symptomology as somatic in nature, rather than psychological. It consists of
30 yes-no questions. Examples of questions are : “Do you often feel helpless?” and “Do
you feel full of energy?” Scores are derived by summing all the items, some of which are
reverse coded. The range of scores is from 0-30, with higher scores indicating greater
depression. The authors’ reliability reports are high, with a Cronbach’s alpha of .94, split-
half reliability coefficient of .94, and one-week test-retest reliability of .85. Convergent
validity with the Beck Depression Inventory (BDI) resulted in correlations of 0.73. In the
current study, internal consistency was high on this measure (Cronbach’s alpha=.87). See
Appendix F.

Anxiety was measured using the State-Trait Anxiety Inventory (STAI;
Spielberger, Gorsuch, & Lushene, 1970). The STAI consists of two forms of 20 items
each, answered on a 1-4 Likert-type scale, ranging from 1, not at all, to 4, very much so.
Subjects rate such statements as “I feel jittery” and “I am relaxed.” This instrument
measures both state anxiety (a fluctuating characteristic dependent on circumstance) and
trait anxiety (a stable characteristic dependent on the individual). Test-retest reliability is
high for the trait anxiety scale (ranging from .73 to .86), but low for state anxiety (.16 to
.54), which is congruent with both operational definitions given (Finney, 1985). The Trait
scale was chosen for the analyses in order to measure anxiety as a stable attribute rather
than a situation-dependent characteristic. Subjects’ scores were obtained by summing the
items [tom the Trait measure, some of which are reverse coded. Scores range from 20-80,
with higher scores indicating greater levels of anxiety. Internal consistency for the Trait

scale in the current study was high (Cronbach’s alpha=.91). See Appendix G.

26

mlth outcomes. The RAND SF -36 (Ware & Sherbourne, 1992) is a commonly
employed self-report measure of general health and physical functioning. This measure
is an ll-item questionnaire requiring subjects to report health self-perception with a
variety of Likert-like scale choices for different items (for example, “In general, would
you say your health is:” offers five answers ranging from “excellent” to “poor”).
McHomey (1996) reports good reliability with this instrument using cognitively intact
older subjects (Cronbach’s alpha ranges from .82 to .91 on seven of the subscales; for the
General Health Perception subscale, Cronbach’s alpha = .78). This measure was
developed to measure health concepts with four different scales (physical fimctioning,
bodily pain, role-physical, and general health). The two more general scales of health
were used for analysis, physical functioning and general health, with respective
coefficient alphas of .90 and .57. Scores were obtained by summing the items
corresponding to each scale; the physical functioning scale had a range of 10-30, and the
general health scale had a range of 5-24. Higher scores indicate better health on both
scales. See Appendix H.
Procedures

Recruitment of subjects was conducted through four Lansing area cardiovascular
medical practices. Recruitment efforts were changed after 17 subjects were interviewed,
due to the difficulty of obtaining participants. This change consisted of the student
investigator obtaining names from the medical office and calling patients directly; prior
to this, nurse managers in each practice asked patients for consent to release their names
and telephone numbers to the investigator. Subjects were contacted by telephone three to

four weeks post-surgery and asked to participate in the study (see Appendix I for

27

telephone script). Those agreeing to do so were given the choice of being interviewed in
their home or at our office on campus. The majority of subjects were interviewed in their
homes (97%). Participants were recruited fi'om nine counties located in the Southwest
(74%), East Central (19%), and West Central (7%) regions of Michigan.

At the beginning of the interview, informed consent was obtained (see Appendix
J), then participants filled out a demographics questionnaire and were given the Mini-
Mental State (MMS; Folstein et al., 1975). The MMS served to screen out cognitively
impaired patients, using point cutoffs recommended by Lezak (1995): 19 for those with
an 8th grade education or less, and 23 for those with a 9th grade education or higher. Two
subjects were screened from the study in this manner. Interviewers read instructions for
each measure, and all but two subjects (due to visual difficulties) then read and marked
the questionnaires’ self-report items to themselves (see Appendices A, and C through H).
The entire interview protocol lasted approximately 90 minutes. At the end of the
interview, participants were thanked for volunteering their time. The student investigator
sent each subject a thank-you letter containing community resources for older cardiac
patients (see Appendix K).

Interviewers were five undergraduate student volunteers and the graduate student
investigator. Training on the interview protocol consisted of three weeks of supervised
practice administration, including meetings devoted to issues such as interviewer bias and
standardized test administration. Interviewers then administered the protocol with an 85%
accuracy rate or better on two practice and two supervised interviews, consisting of
scoring accuracy on the MME and reading all directions correctly. Subjective feedback

about overall interview administration, including handling questions from subjects, was

28

provided as well. Weekly meetings and feedback continued throughout the interviewing
process. Furthermore, after interviewers had completed five interviews on their own, they
were observed again, with each earning an 85% accuracy rate or better on interview

administration.

29

RESULTS

Missing Data

Two methods of dataset adjustment were employed due to missing information.
For subjects missing items from otherwise complete measures, mean substitution fiom
the scale in question was used. Six data points were accounted for in this manner. For
missing data that could not be replaced using mean substitution, values were imputed
from the dataset with the EM algorithm method, using the SYSTAT 10.2 statistical
analysis program. Data was imputed for nine subjects who declined to answer the income
question, one subject who refused to answer the attachment questionnaire, and one
subject who refused to answer the health questionnaire.l
Tests of Hypotheses

Mediation was tested with regression analyses using the method suggested by
Baron and Kenny (1986). The authors recommend three steps to establish mediation.
The first is to regress the dependent variable on the independent variable; the second is to
regress the mediator on the independent variable; and the third is to regress the dependent
variable on both the mediator and the independent variable. Evaluation of the steps is
used in order to provide support for mediation: the first two analyses must result in
significance; if, in the last regression, the mediator variable remains significant, and the
effect of the independent variable on the dependent decreases to zero, full mediation
occurs. Partial mediation may be shown by a decrease in the effect of the independent
variable on the dependent variable. The Sobel test (Sobel, 1982), recommended by Baron

and Kenny (1986), was used to determine whether such decreases were significant.

 

1See Table 1 for means, standard deviations, and ranges of study variables. See Table 2 for
intercorrelations of study variables.

30

Table 1

Means, Standard Deviations, and Ranges for Study Variables

 

 

 

 

 

Variable M SD Rgge
__Secure fill 3_.41 m
Dismissing 1_0_.5_5_ 349 1_5_
Preoccupied fi_._9_5_ ifl 1_9_
Emotion 116 289 g
__gPlannin 19.99 ass .12
Disengagement 6,52 Q6 __9
Depression E M _2_6_
Anxiety M £9. 19
Physical Functioning 12.14 514 Q
General Health 1139 3_2_6 15
A393 ELI}. 110. E
Education 12161 1_89 __9
Yearly Income 4_5_9_ Q m
Weeks post surgery m u; _7

 

 

For the current analyses, an alpha level of .05 was used for all statistical tests.
The regressions performed covaried for demographic variables that extant literature has
shown to influence levels of psychological and health outcomes: age, education level,
yearly income (Adler et al., 1994; Syme & Berkman, 1997; Thoits, 1995). The number
of weeks between surgery and the interview were also controlled for in analyses.

Secure Attachment. With regard to Hypothesis 1, regression analyses showed a
decrease in significance for the effect of secure traits on depression when planning
coping was added to the equation. However, in the third regression, planning coping was
not a significant predictor, which is a required condition for testing mediation (see Table
3). For Hypothesis 2, a nonsignificant effect of secure traits on anxiety did not fulfill the
criteria for step 1 of mediation testing (see Table 4). In testing Hypothesis 7, results

showed that secure traits were not significantly related to physical functioning (B=. 13,

31

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32

Table 3

Mediating Effects of Planning Coping on Secure Traits and Depression

 

Predictor Planning Coping Depression
13 t p AR2 13 t p AR2
Hypothesis 1
Step 1
Block 1: (demog) .10
Block 2: .05
Secure Traits -.23 -2.01 .05

Step 2
Block 1: (demog) .08

Block 2: .06
Secure Traits .25 2.10 .04

Step 3
Block 1: (demog) .10

Block 2: .09
Planning Coping -.21 -1.69 .10
Secure Traits -.19 -1.56 .12

Table 4
Mediating Effects of Planning Coping on Secure Traits and Anxiety

 

Predictor Planning Coping Anxiety
13 - t p AR2 13 t p AR2
Hypothesis 2
Step 1
Block 1: (demog) .14
Block 2: .02
Secure Traits -.13 -l.10 .28

Step 2
Block 1: (demog) .08

Block 2: .06
Secure Traits .25 2.10 .04

Step 3
Block 1: (demog) .14

Block 2: .03
Planning Coping -. 12 -.98 .33
Secure Traits -.10 -.82 .42

33

Table 5

Mediating Effects of Planning Coping on Secure Traits and Physical Functioning

 

Predictor Planning Coping Physical Functioning
_B t p AR2 13 t p AR2
Hypothesis 7

Step 1
Block 1: (demog) .21

Block 2: .02
Secure Traits .13 1.15 .25

Step 2
Block 1: (demog) .08

Block 2: .06
Secure Traits .25 2.10 .04

Step 3
Block 1: (demog) .21

Block 2: .16
Planning Coping .41 3.79 .00
Secure Traits .03 .29 .78

Table 6

Mediating Effects of Planning Coping on Secure Treits and General Hea_ltp

 

Predictor Planning Coping General Health
[3 t p AR2 13 t p AR2
Hypothesis 8
Step 1
Block 1: (demog) .05
Block 2: .06
Secure Traits .26 2.12 .04

Step 2
Block 1: (demog) .08

Block 2: .06
Secure Traits .25 2.10 .04

Step 3
Block 1: (demog) .05

Block 2: .12
Planning Coping .26 2.06 .04
Secure Traits .20 1.60 .17

34

Table 7

Mediating Effects of Emotion Coping on Preoccupied Traits and Depression

 

Predictor Emotion Coping
.8 t p AR2 l3
Hypothesis 3

Step 1
Block 1: (demog)

Block 2:
Preoccupied Traits .26

Step 2
Block 1: (demog) .20

Block 2: .13
Preoccupied Traits .39 3.48 .00

Step 3
Block 1: (demog)

Block 2:
Emotion Coping .19
Preoccupied Traits .18

Table 8

Mediating Effects of Emotion Coping on Preoccupied Traits and Anxieg

 

Depression

1

2.10

1.41
1.38

p AR2

.10
.06

.04

.10
.08

.17
.17

 

Predictor Emotion Coping

.8 t p ARZ .13
I-Iygothesis 4

Step 1

Block 1: (demog)

Block 2:

Preoccupied Traits .47

Step 2
Block 1: (demog) .20

Block 2: .13
Preoccupied Traits .39 3.48 .00

Step 3
Block 1: (demog)

Block 2:
Emotion Coping .30
Preoccupied Traits .35

35

Anxiety
p AR2

t

4.25

2.52
3.05

.14
.19

.00

.14
.25

.01
.00

Table 9

Mediatig Effects of Emotion Coping on Preoccupied Traits and thsicflmctioning

 

Predictor Emotion Coping Physical Functioning
.6 t 9 AR2 13 t p AR2
Hypothesis 9
Step 1
Block 1: (demog) .21
Block 2: .02
Preoccupied Traits -. 14 -1.19 .24

Step 2
Block 1: (demog) .20

Block 2: .13
Preoccupied Traits .39 3.48 .00

Step 3
Block 1: (demog) .21

Block 2: .02
Emotion Coping .08 .57 .57
Preoccupied Traits -. 17 -1.32 .19

Table 10

Mediating Effects of Emotion Coping on Preoccupied Traits and General Hea_lt_h_

 

Predictor Emotion Coping General Health
13 t p AR2 13 t p AR2
Hypothesis 10
Step 1
Block 1: (demog) .05
Block 2: .06
Preoccupied Traits .12 .95 .35

Step 2
Block 1: (demog) .20

Block 2: .13
Preoccupied Traits .39 3.48 .00

Step 3
Block 1: (demog) .05

Block 2: .08
Emotion Coping .30 2.1 1 .04
Preoccupied Traits .01 .05 .96

36

Table 11

Mediating Effects of Disengagement Coping on Dismissing Traits and Depression

 

 

 

Predictor Disengagement Coping Depression
13 t p AR2 13 t p AR2
Hypothesis 5

Step 1
Block 1: (demog) .10

Block 2: .00
Dismissing Traits .02 . 12 .91

Step 2
Block 1 : (demog) . 16

Block 2: .02
Dismissing Traits .16 1.32 .19

Step 3
Block 1: (demog) .10

Block 2: .04
Disengagement Coping .23 1.76 .08
Dismissing Traits -.02 -.17 .87

Table 12

Mediating Effects of Disengagement Coping on Dismissing Traits and Anxiety

 

Predictor Disengagement Coping Anxiety
13 t p AR2 13 t p AR2
Hypothesis 6
Step 1
Block 1: (demog) .14
Block 2: .01
Dismissing Traits .1 1 .86 .40

Step 2
Block 1: (demog) .16

Block 2: .02
Dismissing Traits .16 1.32 .19

Step 3
Block 1: (demog) .14

Block 2: .07
Disengagement Coping .27 2.14 .04
Dismissing Traits .06 .52 .60

37

Table 13

Mediating Effects of Disengagement Coping on Dismissing Traits and Physical
Functioning

 

 

Predictor Disengagement Coping Physical Functioning
13 t p AR2 13 t p AR2
Hypothesis 11

Step 1
Block 1: (demog) .21

Block 2: .02
Dismissing Traits .17 1.42 .16

Step 2
Block 1: (demog) .16

Block 2: .02
Dismissing Traits .16 1.32 .19

Step 3
Block 1: (demo g) .21

Block 2: .03
Disengagement Coping -.71 -.59 .56
Dismissing Traits .18 1.49 .14

Table 14

Mediatirpg Effects of Dismgement Coping on Dismissing Traits and General Health

 

Predictor Disengagement Coping General Health
B t 1: AR2 13 t 13 AR2

_ v ‘-

Hypothesis 12

Step 1

Block 1: (demog) .05

Block 2: .04
Dismissing Traits -.21 -1.62 .1 1

Step 2
Block 1: (demog) .16

Block 2: .02
Dismissing Traits .16 1.32 .19

Step 3
Block 1: (demog) .05

Block 2: .04
Disengagement Coping .04 -.31 .76
Dismissing Traits -.21 -1.63 .l 1

38

1:1.15, p=.25). See Table 5. Regressing general health on secure traits did show a
significant relationship (13=.26, 1=2.12, p=.04). The second and third regressions met
Baron and Kenny’s criteria as well, with a change in significance for secure traits on
general health with the addition of the mediator, planning coping (see Table 6). The
Sobel test was conducted and determined the decrease in the impact of the independent
variable on the dependent variable to be nonsignificant (Sobel significance test-11.45,
p=.15). Therefore, only partial support was provided for Hypothesis 8.

Preoccupied Attachment. Preoccupied attachment traits were not mediated by
emotion-focused coping for depression (see Table 7). Although a decrease occurred in
the effect of preoccupied traits on depression, the effect of emotion coping on depression
did not remain significant in the final regression (13:.19, 1:1.41, p=. l 7), providing no
support for the prediction of mediation in Hypothesis 3. Partial mediation was supported
in the regression outcomes for Hypothesis 4 with the effect of preoccupied traits on
anxiety decreasing when emotion coping was entered into the analysis during step 3 (see
Table 8). The Sobel test determined that the decrease was significant (Sobel significance
test=2.04, p=.04). For Hypotheses 9 and 10, the preoccupied traits measure was not a
significant predictor of either physical functioning or general health when covarying for
demographic variables (see Tables 9 and 10). Thus, tests of mediation did not provide
evidence for these two hypotheses.

Dismissing Attachment. Unexpectedly, dismissing attachment traits were not
significantly related to any of the dependent variables: depression (13:.02, 1=.12, p=.91),
anxiety (13=.l 1, 1:86, p=.40), physical functioning (13:.17, _t_=1.42, p=.16), or general

health (13=-.21, 1=-1 .62, p=.11). By not meeting the first condition in testing mediation,

39

these results did not demonstrate support for Hypotheses 5, 6, 11, or 12 (see Tables 11,
12, 13 and 14).

General Hypotheses

Analyses provided partial support for general predictions regarding level of secure and
preoccupied attachment traits. The secure traits variable was significantly positively
related to planning coping (r=.24, p=.05), a problem-focused coping strategy, while the
preoccupied traits variable was significantly associated with higher levels of both
emotion coping (p=.47, p=.00) and disengagement coping (p=.46, p=.00), an avoidant
strategy. Although dismissing attachment traits were expected to be significantly related
to avoidance coping, analyses showed that the measure of dismissing traits was not

related to any of the coping styles. See Table 15.

Table 15

Correlations Between Attachment Traits and Coping

 

 

 

Coping
Traits Planning Emotion Disengagement
Secure .24* .07 .05
Preoccupied -.12 .47*** .46***
Dismissing -.01 -.01 .17

 

note: *_p<.05, **_p<.01, ***p<.001

Linear regression analyses were conducted to evaluate whether attachment traits
and coping strategies were significant predictors of psychological and health outcomes.

Some evidence was provided to support general hypotheses, but overall results were

40

mixed. Neither preoccupied nor dismissing attachment traits were significant predictors
of health, but higher levels of secure traits were associated with better general health (see
Table 16). The lack of 'secure traits was associated with higher depression, while greater
amounts of preoccupied traits predicted higher levels of both depression and anxiety.
Low planning coping was associated with high depression and lower scores on both of
the health measures. As was also predicted, both emotion coping and disengagement
coping is positively related to higher reports of depression and anxiety. While
disengagement coping was not significantly related to the health outcomes, higher scores
on emotion coping predicted lower general health. These analyses consisted of linear
regressions controlling for demographic variables (age, income, education, and number
of weeks between surgery and the interview), with predictor variables entered in a second
block alone to determine the unique variance they accounted for. Effect sizes are
reported in Table 16 as a f2 test statistic, calculated from ARZ. Although many of the
effect sizes are modest (falling between small and medium), the effect size for the
relationship between preoccupied attachment and anxiety is medium to large (f =.24),
and two other analyses show effect sizes that are medium (emotion coping on anxiety, 1’2

=.l9; planning coping on physical functioning, f2 =.19) (see Table 16).

41

DISCUSSION
This study examined the impact of attachment traits and coping on psychological

and health outcomes in older male coronary bypass patients. Evidence was provided to
partially support the general hypotheses that traits associated with two attachment groups,
secure and preoccupied, are significantly related to psychological and health outcomes.
Secure attachment was negatively related to depression, but results showed no significant
relation to anxiety. Preoccupied attachment was positively related to both anxiety and
depression variables. Surprisingly, dismissing attachment traits were not significantly

related to any of the outcome variables.

Table 16

Effect Sizes for Afizghment Traits and Copingms Predictors of Health an_d
Psychological Variables in Regression

 

Dependent Variables

 

Predictors Depression Anxiety Physical General
Functioning Health

 

Secure .06 (.05) ns ns .07 (.06)
Preoccupied . .06 (.06) .24 (.19) ns ns
Dismissing ns ns ns ns
Planning .06 (.06) ns .19 (.16) .09 (.09)
Emotion .06 (.06) .19 (.16) ns .08 (.07)
Disengagement .04 (.04) .07 (.07) ns ns

 

Note. The values represent the f2 effect size statistic: small=.02,
medium=.15, large=.35. AR2 is reported in parentheses.

42

Although evidence generally supported broad hypotheses concerning preoccupied
and secure attachment, tests of mediation failed to establish coping as a mediator of
attachment traits on health and psychological outcomes. Only one of the hypotheses was
supported, with results showing emotion-focused coping partially mediating preoccupied
traits on anxiety (Hypothesis 4). This is consistent with previous research establishing a
positive relationship between preoccupied attachment and both emotion-coping and
levels of anxiety (Cooper et al., 1998; Fonagy et al., 1996; Ognibene & Collins, 1998;
Lussier etal., 1997; Mikulincer & Florian, 1995; Rosenstein & Horowitz, 1996; van
Ijzendoom & Bakerrnans-Kranenburg, 1996; Warren etal., 1997). However, given an
alpha of .05 and 36 regressions employed, it is likely that one or two regressions would
be significant purely by chance.

Both preoccupied and secure traits were predictors of depression, and results of
the test of mediation saw a decrease in significance for these variables, but the mediator
variables did not remain significant. Secure traits did not significantly predict anxiety.
The outcomes of the regression analyses with health and preoccupied attachment were
unexpected. Significant relationships between preoccupied traits and the health variables
did not remain once the demographic variables (age, income, level of education and
nmnber of weeks between surgery and interview) were covaried. Planning coping
appeared to fulfill the three steps of Baron and Kenny’s (1986) tests of mediation (of
secure traits on general health), but was not significant on the Sobel test (1982). No
significant relationship resulted from regressing physical functioning against secure
attachment. These results show that coping is a poor mediator of attachment on

psychological and health outcomes.

43

The current study contributes to the sparse current literature on attachment and
anxiety in adult subjects, confirming findings that preoccupied tendencies are strongly
associated with higher levels of anxiety (Cooper, Shaver, & Collins, 1998; Fonagy et al.,
1996; Rosenstein & Horowitz, 1996). The lack of an association between secure traits
and anxiety presents a challenge to research that has suggested a protective role for
secure attachment (Cooper, Shaver, & Collins, 1998; Fonagy et al., 1996). This appears
to be consistent, however, with other research reporting fewer significant results for
secure attachment and psychopathology, although most studies in this area have
consistently reported findings linking insecure attachment and poor psychological
outcomes (Cole-Detke & Kobak, 1996; Dozier et al., 1999; Rosenstein & Horowitz,
1996; West et al., 1999). One interpretation of this is that much of the previous research I
has been with psychiatric clinical and inpatient populations, from which it may not be
possible to generalize about secure attachment, and in which higher levels of insecure
attachment are found (Fonagy, 1996).

As predicted, secure traits were positively associated with one of the health
outcomes, general health, but not physical functioning. Preoccupied traits were not
related to general health, and were not significant predictors of physical functioning once
demographic variables were covaried in regression analyses. The latter findings are
inconsistent with Ciechanowski et al.’s (2002) results that preoccupied persons reported
more health symptoms and physician visits. These different results may be related to
sample size as well as power and effect size. For example, effect sizes for relationships
between the general health variable and the predictor variables in this study all fell within

the small to medium range. It is possible that our sample size of 70 was not adequate to

detect a relationship between the preoccupied variable and health outcomes. In contrast,
Ciechanowski and colleagues’ sample size of 701 subjects provided ample power for
detecting even small effects. One argument to counter this is that the difference cited by
Ciechanowski et a1. appears to be clinically irrelevant in terms of health status. As more
research becomes published in this area, coupled with researchers’ growing tendency to
report effect sizes, estimation of needed sample size for research projects will become
easier.

Although analyses failed to provide support for the specific hypotheses of the
study, other results offer a unique contribution to the limited research in this area. Linear
regression provided further support to the general hypotheses of the impact of attachment
and coping on health and psychological outcomes. Effect sizes calculated fiom AR2
revealed that attachment traits and coping styles frequently continued to have a
significant impact on the outcome variables when demographic variables were covaried.
Although most of the effect sizes were modest and fell somewhere between the
conventional delineation of small and medium, three more substantial relationships were
noted: a medium to large effect size for preoccupied traits and anxiety, and medium
effect sizes for emotion coping and anxiety, and planning coping and physical
functioning. Although the effect size was in the small to medium range for general health
regressed on secure traits, it is a notable finding that secure attachment contributes
significantly to predicting health outcomes in a sample of vulnerable older adults. The
sparse prior research on health and attachment supports the latter finding, although also
reporting significant relationships between insecure attachment and worse health

outcomes (Feeney, 1995). A reasonable explanation for this difference may lie in how

45

Feeney measured health (health locus of control, health behavior, and lifestyle choices),
versus the more physically and functionally related nature of our health measure, the SF-
36. Feeney’s measures may more closely approximate functions associated with
attachment: self care, appraisal of stress, and sense of efficacy in the face of stressors,
whereas our aim was to more closely examine and measure the sphere of physical
functioning and overall health.
Alternative Explan_ati_rms,
Currently, the strict dichotomization (emotion-focused versus problem-focused) of the
coping process is under criticism by researchers who cite some inconsistency in results
and call for different ways of conceptualizing coping: analyzing combinations of coping
strategy use rather than coding predominant strategies only (Aldwin & Brustrom, 1997;
Lazarus, 2000; Steiner, Erickson, Hernandez, & Pavelski, 2001); use of both general and
specific types of coping (Martin et al., 2001); and clearly distinguishing between whether
the scale being used reflects a stable attribute or a situation-specific response (Day &
Livingstone, 2001 ). It may well be the latter issue which led to the current results. The
situation our subjects were confronted with was (typically) a time-limited recovery from
major surgery. Instructions were added to the COPE measure, asking subjects to refer to
their most recent illness as they filled out the questionnaire. However, it is conceivable
that subjects were coping with the aftermath of open-heart surgery in ways they typically
did not with other, more commonly encountered stressors, and that this was not
adequately captured by the COPE scales.

The lack of results with dismissing traits is surprising, as it is contrary to previous

research showing higher levels of depression and anxiety (Cole-Detke & Kobak, 1996;

46

Cooper, Shaver, & Collins, 1998; Patrick et al., 1994; Rosenstein & Horowitz, 1996).
This may be explained in terms of the measure used in the current study. The
reformulation of the RAQ into traits reflecting preoccupied, secure and dismissing
attachment, although based on theory and factor analytic methods, is not the scoring
system originally developed by the authors (West et al., 1987). West and his colleagues
conceived the RAQ with continuous dimensions of attachment in mind. In the current
study we revised the scale to reflect the three most commonly researched attachment
categories (preoccupied, secure and dismissing), using principal components factor
analysis. While such a revision may be theoretically accurate and methodologically solid,
it may fall short of providing a complete picture of each group. In other words, while the
traits appear to have been categorized accurately here regarding attachment group
characteristics, the items were not originally chosen to create a holistic portrait of each
group. It is probable that traits essential to defining the dismissing group were simply not
present in the measure. Another pertinent difference regarding the measurement of the
attachment variable is the present study’s use of continuous scores rather than
categorizing subjects according to classification group, the method used in the cited
studies (Cole-Detke & Kobak, 1996; Cooper, Shaver, & Collins, 1998; Patrick et al.,
1994; Rosenstein & Horowitz, 1996). It is possible that our results did not support our
hypotheses due to not using attachment categories. However, a strong argument for the
use of continuous variables for our study is that it provided greater statistical power for
the analyses, decreasing the number of subjects needed and thus allowing us to

investigate a medical population that is difficult to recruit and interview shortly after

47

surgery. Further research with categorical measures is needed to clarify our results with
this population.

Limitations of the current study include its cross-sectional methodology, which
disallows us from making definitive causal statements about our results. Given that
attachment is considered a trait that is stable, we might, with caution, infer causation in
the present study. However, it is not clear whether life events typically encountered by
coronary patients who are older (i.e., major surgery, bereavement, chronic health
difficulties) are of a nature stressful enough to impact and subsequently alter attachment
itself. It is imperative that future research employ longitudinal methods in order to
comprehensively understand the direction of the relationships we have reported.

Although the noted limitations should be kept in mind when interpreting the
results of the current study, it is also one of the few studies examining the mechanisms of
attachment, coping, health and mental health. Furthermore, it has been conducted with a
population noted for different vulnerabilities linked to cardiac condition, age, and general
health. Strengths of our methodology include the use of rigorous statistical analyses (the
Baron & Kenny method of testing mediation, as opposed to using partial correlations), in-
person interviews, instruments with good psychometric properties, and controlling for
cognitive impairment with a pre-interview screening measure. Several contributions to
the literature on attachment were provided by this study. First, this research
demonstrated a significant impact of attachment and coping on health outcomes. Second,
this study investigated attachment in a population with sparse empirical work to date,
older adults, and showed that coping is not a good mediator between attachment and

health outcomes. Finally, this study examined these variables in a population difficult to

48

recruit and interview, coronary bypass patients. Thus this study provides a first,
important step towards comprehending the patterns of both risk and resilience in older
male coronary bypass patients. Future research employing longitudinal methodology is
needed in order to make causal statements about this population. Other suggestions for
future research include the use of coping measures specifically targeting the coronary
bypass experience, examination of gender, and using categorical attachment measures, all
of which may provide a clearer picture of the underlying mechanisms of states of

dependency.

49

APPENDICES

50

Demographics Questionnaire Subject #

APPENDIX A

 

Date:

 

Interviewer:

Please answer the following questions about yourself:

1.

menepp‘er)

3.

Age: Date of birth:

 

Education -- indicate highest level attained: (Circle one)
elementary school grade: 1 2 3 4 5 6 7 8

high school grade: 9 10 11 12 13=GED

vocational training/trade school/nursing

college -- (AA degree)

college -- undergraduate degree (BA/BS)

college -- graduate degree (MA/MS/PhD)

professional degree (MD/JD)

other (please indicate type):

 

Ethnicity:
Afiican American

Asian American

Caucasian

Hispanic
Native American

4.

Other (please indicate):

 

Marital status:

A. Married

B. Partnered (unmarried, living together)
C. Single

D. Divorced

E. Widowed

51

5. Household members.
A. How many people live in your household?
B. List your relationships to them (Such as Spouse/Partner,
Daughter/Son, Brother/Sister, Friend, etc.):

 

 

 

6. What is your total yearly income reported for the last year

for tax purposes? (Circle one)
under $10,000
$10,000-$19,999
$20,000-$29,999
$30,000-$39,999
$40,000-$49,999
$50,000-$59,999
$60,000—$69,999
$70,000-$79,999
$80, GOO-$89, 999
$90, ODD-$99, 999
K. $100, 000 and over

“reeaepcw?

7. A. Are you currently employed? Yes/No
B. If so, do you work:
a) 40 hours/week or more
b) between 30-40 hours/week
c) between 20-30 hours/week
(1) less than 20 hours/week

8. Have you experienced any of the following in the past 3
years? (Circle all that apply)

a. Death of a spouse/partner

b. Death of a close family member
c. Death of a good fiiend

(1. None of the above.

52

9. Identify attachment figure.

We would like you to identify your attachment figure for us. By
attachment figure, we mean:

0 The person you have been most likely to turn to or
depend on for comfort or help when facing stress.

This person may be a spouse/partner, a fiiend, a family member
or someone else. You may have several people in your life
whom you are close to in different ways, or it may be difficult
to think of one person who means that much to you. Think of
th_eperson you feel closest to right now. This person is your
attachment figure. Please report the relationship you have to
your attachment figure (circle one):

Spouse/romantic partner
Daughter

Son

Brother

Sister

Friend

Other (specify):

NQMPP’P!‘

 

7. Surgery information
1. Date of your coronary bypass surgery:
2. Type of procedures you had done:

 

 

 

3. Have you had a repeat admission since the original
surgery? Yes/No
4. Have you had other major medical illnesses / difficulties
since your surgery? If so, what illnesses?

 

 

53

APPENDIX B

Mini Mental State
Subject #
Date:
1. What is today’s date? Date
2. What is the year? Year
3. What is the month? Month
4. What day is today? Day
5. Can you also tell me what season it is? Season
6. Can you also tell me the name of this school? School
7. What floor are we on? Floor
8. What town or city are we in? Town or City
9. What country are we in? County
10. What state are we in? State
11. I’m going to test your memory now.
“Ball” (one second pause) Ball
“Flag” (one second pause) Flag
“Tree” (one second pause) Tree
Can you repeat what I just said?
12. Now I would like you to start with 100 and count backwards by 7. 93
86
79
( Stop after 65; Score total # of correct answers) 72
65
(If subject cannot or will not perform the counting task, ask him D
or her to spell backwards) L
Can you spell the word “world” backwards for me? R
O
W
13. Can you recall the three words I just asked you to remember? Ball
Flag
Tree
14. What is this? (show watch) Watch
15. What is this? (show pencil) Pencil

16. Please repeat after me: “No ifs, ands, or buts.”
17. Do exactly as I say: Take the paper in your right hand, fold it in half,
and put it on the floor.
18. (Present Close Your Eyes sheet). Read this and do what it says.
19. (Give paper to subject) Write a sentence on this paper for me
(Scoring: sentence must contain a subject and a verb and be sensible;
correct grammar and punctuation are not necessary)
20. Copy these figures exactly.
(Cutoff: must be 24 or higher.) Total score:

54

CLOSE

YOUR

EYES

APPENDIX C
Reciprocal Attachment Questionnaire

In this questionnaire, you will find questions about your relationship to your attachment

figure. Remember, your attachment figure is:

o The person you have been most likely to turn to or depend on for comfort or
help when facing stress.

Please circle a number to indicate how you feel each statement applies to you.

1 2 3 4 5

Strongly Disagree Somewhat agree Agree Strongly

disagree and somewhat agree
disagree

1. I turn to my attachment figure for many things, including comfort

and reassurance. l 2 3 4 5
2. I wish there was less anger in my relationship with my attachment figure.

1 2 3 4 5
3. I put my attachment figure’s needs before my own.

1 2 3 4 5

4. I get frustrated when my attachment figure is not around as much as

I would like. 1 2 3 4 5
5. I feel it is best not to depend on my attachment figure.

1 2 3 4 5
6. I want to get close to my attachment figure but I keep pulling back.

1 2 3 4 5
7. I often feel too dependent on my attachment figure.

1 2 3 4 5
8. I can’t get on with my work if my attachment figure has a problem.

1 2 3 4 5
9. I enjoy taking care of my attachment figure.

1 2 3 4 5
10. I don’t object when my attachment figure goes away for a few days.

1 2 3 4 5
11. I’m confident that my attachment figure will try to understand my

feelings. I 2 3 4 5
12. I wish that I could be a child again and be taken care of by my

attachment figure. 1 2 3 4 5

56

l 2 3 4 5

Strongly Disagree Somewhat agree Agree Strongly
disagree and somewhat agree
disagree

13. I worry that my attachment figure will let me down
1 2 3 4 5

14. I wouldn’t want my attachment figure relying on me.

1 2 3 4 5

15. I resent it when my attachment figure spends time away from me.

1 2 3 4 5

16. I have to have my attachment figure with me when I’m upset.

I 2 3 4 5

17. I rely on myself and not my attachment figure to solve my problems.

1 2 3 4 5
18. When I’m upset, I am confident my attachment figure will be there

to listen to me. 1 2 3 4 5
19. I usually discuss my problems and concerns with my attachment figure.

1 2 3 4 5
20. I feel abandoned when my attachment figure is away for a few days.

1 2 3 4 5

21. I have a terrible fear that my relationship with my attachment figure

will end. 1 2 3 4 5
22. I do not need my attachment figure to take care of me.

1 2 3 4 5

23. My attachment figure only seems to notice me when I am angry.

I 2 3 4 5
24. I talk things over with my attachment figure.

1 2 3 4 5
25. It’s easy for me to be affectionate with my attachment figure.

1 2 3 4 5

26. I expect my attachment figure to take care of his/her own problems.

1 2 3 4 5
27. I’m afraid that I will lose my attachment figure’s love.

1 2 3 4 5
28. I feel lost if I’m upset and my attachment figure is not around.

1 2 3 4 5

57

1 2 3 4 5

Strongly Disagree Somewhat agree Agree Strongly
disagree and somewhat agree
disagree

29. I’m furious that I don’t get any comfort from my attachment figure.
1 2 3 4 5
30. I’m so used to doing thing on my own that I don’t ask my attachment
figure for help. 1 2 3 4 5
31. I’m confident that my attachment figure will always love me.
1 2 3 4 5
32. I’m never certain about what I should do until I talk to my
attachment figure. 1 2 3 4 5
33. I would be helpless without my attachment figure.
1 2 3 4 5
34. Things have to be really bad for me to ask my attachment figure for help.
1 2 3 4 5
35. I get really angry at my attachment figure because I think he/she could
make more time for me. 1 2 3 4 5
36. I often feel angry with my attachment figure without knowing why.
1 2 3 4 5
37. I feel that the hardest thing to do is to stand on my own.
1 2 3 4 5
38. I feel that there is something wrong with me because I’m remote from

my attachment figure. 1 2 3 4 5
39. I don’t make a fuss over my attachment figure.

1 2 3 4 5

40. I don’t sacrifice my own needs for the benefit of my attachment

figure. 1 2 3 4 5
41. My attachment figure is always disappointing me.

1 2 3 4 5

42. When I am anxious I desperately need to be close to my attachment

figure. 1 2 3 4 5
43. It makes me feel important to be able to do things for my attachment
figure. 1 2 3 4 5

58

APPENDIX D
Revised scales for Reciprocal Attachment Questionnaire:

Secure Attachment Traits:

1. I turn to my attachment figure for many things, including comfort
and reassurance

11. I’m confident that my attachment figure will try to understand my
feelings.

18. When I’m upset, I am confident my attachment figure will be there
to listen to me.

31. I’m confident that my attachment figure will always love me.

Preoccupied Attachment Traits:

4. I get fi'ustrated when my attachment figure is not around as much as
I would like.

16. I have to have my attachment figure with me when I’m upset.

20. I feel abandoned when my attachment figure is away for a few days.

21. I have a terrible fear that my relationship with my attachment figure
will end..

28. I feel lost if I’m upset and my attachment figure is not around.

37 . I feel that the hardest thing to do is to stand on my own.

Dismissing Attachment Traits:

14. I wouldn’t want my attachment figure relying on me.
22. I do not need my attachment figure to take care of me.
34. Things have to be really bad for me to ask my attachment figure for help.
39. I don’t make a fuss over my attachment figure.

59

APPENDIX E

The COPE Inventory

We are interested in how people respond when they confront difficult or
stressful events in their lives. There are lots of ways to try to deal with stress.
This questionnaire asks you to indicate what you did and felt, when you

experienced stressful events during your last illness. Obviously,
different events bring out somewhat different responses, but think about
what you usually did when you were under a lot of stress during this period.

Then respond to each of the following items by marking one number on your
answer sheet for each, using the response choices listed just below. Please
try to respond to each item separately in your mind from each other item.
Choose your answers thoughtfully, and make your answers as true FOR
YOU as you can. Please answer every item. There are no "right" or
"wrong" answers, so choose the most accurate answer for YOU--not what
you think "most people" would say or do. Indicate what YOU usually did

when YOU experienced a stressful event during your last illness.

1 2 3 4
I usually don't I usually do I usually do this I usually do this
do this at all this a little bit a medium amount a lot

1. I try to grow as a person as a result of the experience.

I turn to work or other substitute activities to take my mind off
things.

I get upset and let my emotions out.

I try to get advice from someone about what to do.

I concentrate my efforts on doing something about it.

I say to myself "this isn't real."

I put my trust in God.

I laugh about the situation.

I admit to myself that I can't deal with it, and quit trying.
10. I restrain myself from doing anything too quickly.

11. I discuss my feelings with someone.

12. I use alcohol or drugs to make myself feel better.

13. I get used to the idea that it happened.

14. I talk to someone to find out more about the situation.

 

.N

 

9°

 

:P‘

 

S"

 

9

 

>‘

 

9°

 

.xo

 

 

60

p—i

2 3 4

I usually don't I usually do I usually do this I usually do this
do this at all this a little bit a medium amount a lot

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I keep myself from getting distracted by other thoughts or
activities.
I daydream about things other than this.

. I get upset, and am really aware of it.

. I seek God's help.

. I make a plan of action.

. I make jokes about it.

. I accept that this has happened and that it can't be changed.

. I hold off doing anything about it until the situation permits.
. I try to get emotional support from friends or relatives.

. I just give up trying to reach my goal.

. I take additional action to try to get rid of the problem.

. I try to lose myself for a while by drinking alcohol or taking

drugs.

. I refuse to believe that it has happened.

. I let my feelings out.

. I try to see it in a different light, to make it seem more positive.
. I talk to someone who could do something concrete about the

problem.

. I sleep more than usual.
. I try to come up with a strategy about what to do.
. I focus on dealing with this problem, and if necessary let other

things slide a little.
I get sympathy and understanding from someone.

. I drink alcohol or take drugs, in order to think about it less.
. I kid around about it.

I give up the attempt to get what I want.

. I look for something good in what is happening.

I think about how I might best handle the problem.

. I pretend that it hasn't really happened.
. I make sure not to make matters worse by acting too soon.
. I try hard to prevent other things from interfering with my efforts

at dealing with this.

61

1 2 3 4
I usually don't I usually do I usually do this I usually do this
do this at all this a little bit a medium amount a lot
43. I go to movies or watch TV, to think about it less.

 

44.
45.
46.

 

 

 

47.
48.
49.
50.
51.

 

 

 

 

52.
53.
54.
55.
56.
57.
58.
59.

60.

I accept the reality of the fact that it happened.

I ask people who have had similar experiences what they did.
I feel a lot of emotional distress and I find myself expressing
those feelings a lot.

I take direct action to get around the problem.

I try to find comfort in my religion.

I force myself to wait for the right time to do something.

I make fun of the situation.

I reduce the amount of effort I'm putting into solving the
problem.

I talk to someone about how I feel.

I use alcohol or drugs to help me get through it.

I learn to live with it.

I put aside other activities in order to concentrate on this.

I think hard about what steps to take.

I act as though it hasn't even happened.

I do what has to be done, one step at a time.

I learn something from the experience.

I pray more than usual.

62

APPENDIX F

Geriatric Depression Scale

Instructions: Choose the best answer for how you felt over the
past week.

1.

2.

9.

Are you basically satisfied with your life? YES / NO

Have you dropped many of your activities and interests? YES/NO

. Do you feel that your life is empty? YES / NO
. Do you often get bored? YES / NO
. Are you hopeful about the future? YES / NO

. Are you bothered by thoughts you can’t get out of your head?

YES / NO
Are you in good spirits most of the time? YES / NO

Are you afraid that something bad is going to happen to you?
YES / NO

Do you feel happy most of the time? YES / NO

10.Do you often feel helpless? YES / NO

11.Do you often get restless and fidgety? YES / NO

12.Do you prefer to stay in your room, rather than going out and

participating in new activities? YES / NO

13.Do you frequently worry about the future? YES / NO

63

14.Do you feel you have more problems with memory than most?
YES /NO

15.Do you think it is wonderful to be alive now? YES / NO

16.Do you often feel downhearted and blue? YES / NO

17.Do you feel pretty worthless the way you are now? YES / NO

18.Do you worry a lot about the past? YES / NO

19.Do you find life very exciting? YES / NO

2015 it hard for you to get started on new projects? YES / NO

21.Do you feel full of energy? YES / NO

22.Do you feel that your situation is hopeless? YES / NO

23.Do you think that most people are better off than you are?
YES / N O

24.Do you frequently get upset over little things? YES / NO
25.Do you frequently feel like crying? YES / N O

26.Do you have trouble concentrating? YES / NO

27.Do you enjoy getting up in the morning? YES / NO
28.Do you prefer to avoid social gatherings? YES / NO
29.Is it easy for you to make decisions? YES / NO

30.18 your mind as clear as it used to be? YES / NO

64

APPENDIX G

State-Trait Anxiety Inventory (STAI Y1)

Directions: A number of statements which people have used to describe
themselves are given below. Read each statement and then circle the
appropriate number to the right of the statement to indicate how you feel
right now, that is, at this moment. There are no right or wrong answers. Do
not spend too much time on any one statement but give the answer which
seems to describe your present feelings best.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not at Some- Moder— Very
all what ately much

so so
1. Ifeel calm [1] [2] [3] [4]
2. Ifeel secure [1] [2] [3] [4]
3. I am tense [1] [2] [3] [4]
4. Ifeel strained [1] [2] [3] [4]
5. Ifeel at ease [1] [2] [3] [4]
6. Ifeel upset [1] [2] [3] [4]
7.1 am resentl wo n over
possiblepmisfortrIInesfryi g [I] [2] [3] [4]
8. Ifeel satisfied [1] [2] [3] [4]
9. Ifeel frightened [1] [2] [3] [4]
10. I feel comfortable [1] [2] [3] [4]
1 1. I feel self-confident [1] [2] [3] [4]
12. I feel nervous [I] [2] [3] [4]
13. I am jittery [l] [2] [3] [4]
14. I feel indecisive [1] [2] [3] [4]
15. I am relaxed [I] [2] [3] [4]
16. I feel content [1] [2] [3] [4]
17. I am worried [I] [2] [3] [4]
18. I feel confused [1] [2] [3] [4]
19. I feel steady [l] [2] [3] [4]
20. I feel pleasant [1] [2] [3] [4]

 

 

65

STAI-Y2

DIRECTIONS: A number of statements which people have used to describe

themselves are given below. Read each statement and then circle the
appropriate number to the right of the statement to indicate how you

generally feel. There are no right or wrong answers. Do not spend too

much time on any one statement but give the answer which seems to

describe how you generally feel.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

concerns and interests

 

 

 

 

Almost Some- 0 ft Almost
never times en always
21. I feel pleasant [1] [2] [3] [4]
22. I feel nervous and restless [1] [2] [3] [4]
23. I feel satisfied with myself [1] [2] [3] [4]
24. I wish I could be as ha as
others seem to be ppy [I] [2] [3] [4]
25. I feel like a failure [1] [2] [3] [4]
26. I feel rested [1] [2] [3] [4]
27.1 am “calm, cool, and collected” [1] [2] [3] [4]
28. I feel that difficulties are ilin
up so that I cannot overcomelfhenf [1] [2] [3] [4]
29. I wo too much over some-
_thi__r_r_g thatrrrilaally doesn’t matter [I] [2] [3] [4]
, 30. I am happy [1] [2] [3] [4]
31. I have disturbing thou ts [1] [2] [3] [4]
32. I lack self-confidence [1] [2] [3] [4]
33. I feel secure [1] [2] [3] [4]
34. I make decisions easily [1] [2] [3] [4]
35. I feel inadequate [1] [2] [3] [4]
36. I am content [1] [2] [3] [4]
37. Some unim ortant thou ht runs
through my mirIfd and bothegrs me [I] [2] [3] [4]
38. I take disa ointments so keenl
that I can’t putlfiiem out of my mindy [I] [2] [3] [4]
39. I am a steady person [1] [2] [3] [4]
40. I get in a state of tension or
turmoil as I think over my recent [1] [2] [3] [4]

 

66

 

APPENDIX H

RAND SF-36

1. In general, would you say your health is:
Excellent

Very good

Good

Fair

 

 

 

 

 

 

 

 

AWN-t

 

 

2. Compared to one year ago,
how would your rate your health in general now?

Much better now than one year ago
Somewhat better now than one year ago
About the same

Somewhat worse now than one year ago
Much worse now than one year ago

 

 

 

 

 

Ul-bbJNi—t

 

 

 

 

3. The following items are about activities you might do during a typical
day. Does your health now limit you in these activities? If so, how much?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Circle One Number on Each Yes, Yes, No, Not

Line) Limited Limited limited at
a Lot a Little All

a) Vigorous activities, such as

running, lifting heavy objects, [1] [2] [3]

participating in strenuous sports

b) Moderate activities, such as

moving a table, pushing a vacuum [1] [2] [3]

cleaner, bowligg, or playing—golf

c) Lifting or carrying_groceries [1] [2] [3]

d Climbin several fli hts of

82,,“ g g [11 [21 131

e) Climbing one flight of stairs [I] [2] [3]

f) Bending, kneeling, or stooping [1] [2] [3]

g) Walking more than a mile [1] [2] [3]

h) Walking several blocks [1] [2] [3]

i) Walking one block [1] [2] [3]

j) Bathing or dressingourself [l] [2] [3]

 

 

67

4. During the past week, have you had any of the following problems with
your work or other regular daily activities as a result of your physical
health?

 

Circle One Number on Each Line Yes No

 

a) Cut down the amount of time you spent on work or
other activities

b) Accomplished less than you would like
c) Were limited in the kind of work or other activities

d) Had difficulty performing the work or other activities
(for example, it took extra time)

 

 

 

Hi—i—si-t
NNNN

 

 

 

 

 

5. During the past week, have you had any of the following problems with
your work or other regular daily activities as a result of any emotional
problems (such as feeling depressed or anxious)?

 

 

 

 

 

 

 

 

(Circle One Number on Each Line) Yes N o

a) Cut down the amount of time you spent on work or 1 2
other activities

b) Accomplished less than you would like 1 2

c) Didn’t do work or other activities as carefully as usual 1 2

 

6. During the past week, to what extent has your physical health or
emotional problems interfered with your normal social activities with
family, fiiends, neighbors, or groups?

(Circle One Number)

Not at all Slightly Moderately Quite a bit Extremely
1 2 3 4 5

7. How much bodily pain have you had during the past week?

(Circle One Number)

None Very mild Mild Moderate Severe Very severe
l 2 3 4 5 6

68

8. During the past week, how much did pain interfere with your normal
work (including both work outside the home and housework)?
(Circle One Number)

Not at all A little bit Moderately Quite a bit Extremely
l 2 3 4 5

9. These questions are about how you feel and how things have been with
you during the past week For each question, please give the one answer

that comes closest to the way you have been feeling. How much of the
time during the past week: . . .
(Circle One Number on Each Line)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A
Good A
All of Most Bit of Some Little None
the of the the of the of the of the
Time Time Time Time Time Time
a) 971d you feel full of 1 2 3 4 5 6
P3P-
b) Have you been a very 1 2 3 4 5 6
nervous person.
c) Have you felt so down
in the dumps that nothing 1 2 3 4 5 6
could cheer you up?
(I) Have you felt calm
and peacefirl? 1 2 3 4 5 6
e) Did you have a lot of
1 met .2 l 2 3 4 5 6
1) Have you felt
downhearted and blue? 1 2 3 4 5 6
g) Did you feel worn out? 1 2 3 4 5 6
2) Have you been a 1 2 3 4 5 6
appy person.
i) Did you feel tired? I 2 3 4 5 6

 

69

 

10. During the past week, how much of the time has your physical health
or emotional problems interfered with your social activities (like visiting
with friends, relatives, etc.)?

 

(Circle One Number)
1 2 3 4 5
All of the Most of the Some of A Little of None of
Time time the Time the Time the Time

 

 

 

 

 

 

 

11. How TRUE or FALSE is each of the following statements for you.
(Circle One Number on Each Line)

 

 

 

 

 

 

 

 

 

 

 

Definitely Mostly ' Don't Mostly Definitely
True True Know False False

a) I seem to get sick a

little easier than other 1 2 3 4 5

people

b) I am as healthy as

anybody I know 1 2 3 4 5

c) I expect my health to

__get worse 1 2 3 4 5
d) My health is excellent 1 2 3 4 5

 

 

70

APPENDIX I

Telephone Script

My name is Peggy O'Toole and I’m with the MSU Coronary Bypass
Recovery Study. We received your name from Jane Maxey/ Christine
Sampson] Sherry / Steve Bush, the nurse manager/Physician’s Assistant
at TCI / CVT / Dr. Goldshlack’s office / Lansing Heart & Lung
Specialists, and she / he told us you might be interested in our study. We
are looking at how different characteristics of coronary patients impact
their recovery; in order to do this, we will be asking people questions
about social, emotional and physical aspects of their lives. The whole
interview will take about 1 1/2 hours to complete. You can either come in
to our office on campus for this or we can come out to your home if you
would prefer. Would you be interested in doing the interview?

Verify:

Age?

Coronary bypass on date?

(Y es)——Wou1d you prefer to come in to our office or for us to come out
to your home?

Office: give directions to Snyder (someone will be outside to meet them)
Home: Get address plus city/ driving instructions / estimate of driving time

(Schedule a time):These are the times we have open for interviews:

(List times here)

For the interview, we will need a quiet room with a table available to
set our materials up on. We will tape record part of the interview, and
it is especially important for this part that you not be distracted by
anything so you can concentrate on the interview.

Also, I’d like to leave my name and phone number in case you need to

call us: Peggy O'Toole @ 432-3684.
WE LOOK FORWARD TO MEETING YOU ON AT

 

71

APPENDIX J

Consent Form
Coronary Bypass Recovery Study
Consent Form

You are invited to participate in this study on recovery from
coronary bypass surgery. Your participation is completely
voluntary. This research is being conducted through Michigan
State University and is not associated with your cardiovascular
surgeon/cardiologist in any manner beyond recruitment for the
study. In consenting to take part in this study, you authorize your
physician to release only the following information about you to
the study investigators: pre- and post-surgery stress test (treadmill
rate), and information about the extent of your artery occlusion.
Whether or not you choose to participate, this will not affect your
medical service with Thoracic & Cardiovascular Healthcare
Foundation / Cardiovascular Thoracic Surgeons of Mid-Michigan/
Dr. Paul Goldshlack.

We are interested in the experiences of people who have
undergone coronary bypass surgery and how this impacts the ways
in which they recover from the surgery. You will be asked to fill
out some questionnaires as well as answer questions about yourself
and your health. The entire interview will take about 1 1/2 hours to
complete. All of your answers and responses will be kept
completely confidential. Your privacy will be protected to the
maximum extent allowable by law.

If at any time you decide that you cannot or do not want to
continue, you may withdraw from the study. You may also decline
to complete any item or portion of the interview. If you have any
questions about the project, feel free to ask them now.

page 1 of 2

72

Coronary Bypass Recovery Study

If you have any questions or concerns about this research
project, you may contact Peggy O'Toole at (517) 432-3 825, or
Professor Anne Bogat at (517) 353-0812. Further questions about
your rights as a research participant can be answered by David
Wright of the University Committee for Research Involving
Human Subjects at Michigan State University at (517) 355-2180.

Your signature indicates your voluntary agreement to
participate in this study. This decision may be changed at any
point during this interview.

 

 

Signature of subject Date

 

Printed subject name

 

 

Signature of examiner Date

Thank you very much for your help.

page 2 of 2

73

APPENDIX K

Post-interview Letter and Community Resources
Coronary Bypass Recovery Study
Department of Psychology
43 Snyder Hall
Michigan State University
East Lansing MI 48824
(517) 432-3684

Name
Street
City state zip

Date
Dear Mr. Name,

We would like to thank you for recently participating in our research project. Your
time and effort enable us to discover important elements of the process of
recovering from coronary bypass surgery. Once the study is completed, we will
share the information we have gathered with the scientific and professional
community. Your participation is an important part of helping us to understand
how social, emotional, and physical aspects play a role in the recovery process.

Many people find the aftermath of a major surgery to be a difficult time for them
in a variety of ways. It is common to want to talk to someone about these
difficulties or to be around other people who are going through similar problems.
We are sending out to all of our participants an information list that includes
available counseling services as well as cardiac health resources. We hope you
find this helpful.

Once again, your participation has been greatly appreciated. If you have any
questions about the research project, feel free to contact us at (517) 432-3684.

Anne Bogat, Ph.D. Peggy O'Toole
Director of Clinical Training Graduate student investigator
Department of Psychology

74

Counseling and therapy services
MICHIGAN STATE UNIVERSITY PSYCHOLOGICAL CLINIC

Olds Hall, MSU Campus Ph: 355-9564
Hours: 8am to 9pm (Mon-Thurs)

8am to 5pm (Friday)

10am to 2pm (Saturday)

Services: Individual, couples and family therapy. Psychological and neuropsychological
assessments. Memory assessments. Call for appointment and further information.
Cost: Fees based on ability to pay (sliding scale).

CLINTON COUNTY COUNSELING CENTER

1000 E. Sturgis St., Suite 3, St. Johns, MI 48879

Ph: (517) 224-6729 or 1-800-372-8460 (24 hour emergency)

Appointments: (888) 800-1559

Hours: 8:30 am. - 12 noon, 1:00 - 5:00 pm, Monday through Friday. Evenings by
appointment.

Services: Outpatient counseling services to individuals, couples and families. Also offers
substance/drug abuse and mental health counseling and treatment.

Eligibility: Clinton, Eaton or Ingham county residents.

Cost: Fees based on ability to pay (sliding scale).

EATON COUNTY COUNSELING CENTER

551 Courthouse Dr. ,Charlotte, MI 48813 Ph: (517) 543-5100

Hours: 8:00 am. to 5:00 pm, Monday through Friday. Evening hours available by
appointment.

Services: Counseling services to individuals, couples and families. Adult afier care, case
management, and medication clinic services.

Eligibility: Eaton county residents.

Cost: Fees are on a sliding scale basis.

FAMILY VIOLENCE PREVENTION HELPLINE

Gateway Community Services: P.O. Box 4152, East Lansing, MI 48826-4152
Ph: (800) NO-ABUSE or (800-996-6228) - Seniors & Adults

(800) 942-4357 - Parents & Caregivers
Hours: 24 hours a day, 7 days a week
Services: Provides confidential crisis counseling and referral in cases of elder abuse
(physical, emotional, financial exploitation). Also able to connect callers to local Adult
Protective Services.
Eligibility: Senior citizens and vulnerable adults or anyone with questions or
concerns regarding elder abuse.
Cost: No cost.

75

CARDIAC HEALTH

HEART WISE

Ingham Regional Medical Center

401 W. Greenlawn, Lansing, MI 48910 Ph: (517) 334-2405
Services: A support and educational group for surgical and medical cardiac patients.
Family and fiiends encouraged and welcome to attend.
Meetings: Meetings held monthly, September - J une. Call for meeting times and
locations.
Eligibility: Any interested party.

AMERICAN HEART ASSOCIATION - MIDWEST AFFILIATE

Capital Division
271 Woodland Pass, Suite 110, East Lansing, MI 48823
Ph: (517) 332-0385 or 1-800-968-2425
Hours: 8:30 am. to 5:00 p.m., Monday through Friday.
Services: Walking clubs meet in numerous pedestrian malls. CPR classes, speakers
bureau, film library, educational materials on heart disease, nutrition information, and a
stroke support club are also available.
Eligibility: Anyone.
Cost: None with exception of charge for large quantities of literature.

SPARROW LIFETIME

Sparrow Health System

1215 E. Michigan Ave. P.O. Box 30480 / Lansing, MI 48909-7980
Ph: (517) 483-3696 Nurse Line: (517) 483-3838
Hours: 8:00 am. to 5:00 pm. Monday through Friday
Services: Health screenings, bimonthly newsletter and discounts on health products and
to area stores. Also monthly "Lunch with a Doctor" series features discussions on
various health issues and "Pacers" walking and aerobics program at the Lansing Mall.
Eligibility: Free membership program for people age 50 and older
Cost: There are fees for some programs. Call for information.

WELLNESS CENTER

Hayes Green Beach Hospital

123 Lansing St., Charlotte, M148813
Ph: (517) 543-1050 ext. 315
Hours: 8:30 to 9:30 am. Tuesdays and Thursdays
Services: Senior Fitness Class. Includes stretching and low intensity exercise. Can use
a chair or stand.Fees: First week is free. Walk-ins $4.00 tickets are $3.00/non-
members

76

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