This chapter has explored the impact skin disease has on couples and how attachment styles can influence the process of adjustment. It is evident that altered appearance, difficulties in communication, shifts in social networks and decreased sexual intimacy are triggers for acute and chronic stress that can threaten relationship functioning. Despite the aforementioned difficulties, the process of adjustment also provides couples with opportunities to discover untapped potential in their relationship and to deepen their commitment and intimacy (Story & Bradbury, 2004). The advantage of using an attachment-based theoretical perspective in skin disease is that, whilst explaining normative relational processes, it considers the variation of adults' experiences in romantic relationships and highlights how couples become and remain distressed in the course of coping with the demands and consequences of various skin diseases.
The attachment perspective also incorporates tenets of social and personality psychology, which are having an increasing influence in psychodermatological research; firstly, by acknowledging that a set of mechanisms (working models) contribute to individual stability and secondly, by highlighting that social and environmental factors can powerfully influence attachment behaviour (Feeney & Noller, 1996). The notion of relationship-focused coping (De Longis & O'Brien, 1990) expands understanding of dyadic influences in skin disease by stressing that successful adjustment is not solely dependent on the ability to problem-solve or regulate emotions, but also on the regulation of intimate relationships. An interesting point to consider is that since attachment patterns are relatively stable in 70% of individuals, (Baldwin & Fehr, 1995; Fuller & Fincham, 1995) it can be conjected that the 30% who change their attachment style may be doing so as a result of a romantic relationship. By extension, individuals who potentially might have been devastated by skin disease may be coping successfully because of their partner. Currently, investigators are calling for greater attention to relational factors in coping with chronic illnesses, however a comprehensive model that addresses the stresses, strategies and outcomes of relationship-focused coping is still evolving (Feeney & Noller, 1996). Lawrence et al. (1998) have proposed that attachment styles can change through couple therapy. For example, couples prone to escalating negative exchanges in times of stress could benefit from improved conflict resolution. Couples in which one partner is prone to depression may benefit from learning how to provide greater emotional support. Further research on relationship-focused coping could thus explore what processes protect couples from the stresses of skin disease and examine how the interplay of dyadic coping and individual adjustment changes over the course of a relationship. Maintaining this focus of investigation is fundamental in that, medical care that neglects how individual's feel in the 'real world' (Goleman, 1995) and in the 'reality' of their most intimate relationships, is no longer adequate for the 'comprehensive' treatment of skin disease.
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