Social Ambivalence and Disease (SAD): A Theoretical Model Aimed at Understanding the Health Implications of Ambivalent Relationships

Acute and chronic disease outcomes

Robust data have linked social relationships to acute and chronic disease outcomes, yet the majority of studies on morbidity and mortality do not assess relationship positivity and negativity—let alone their joint contribution. Although relatively limited data exist relative to other relationship conceptualizations, some of the first evidence has emerged linking ambivalence to actual cardiovascular disease outcomes (Uchino, Smith, & Berg, 2014). In one study, the level of coronary artery calcification (CAC) was higher primarily when both individuals in the marriage viewed each other as sources of ambivalence compared with when only one member of the dyad saw his or her spouse as supportive or ambivalent or both viewed the dyad as supportive (Uchino et al., 2014). Note that CAC is a marker of an artery with atherosclerotic disease. CAC is a strong and independent predictor of coronary events in both symptomatic and asymptomatic individuals and an independent predictor of death.

Health-relevant biological processes

According to the SAD model, ambivalent relationships can influence acute and chronic health conditions via health-relevant biological processes (i.e., central nervous system, autonomic, endocrine, immune functioning). Current evidence has primarily focused on autonomic functioning because of its relative feasibility in assessment and relevance to cardiovascular disease. Examining the effect of ambivalence on cardiovascular functioning is a compelling first step in establishing the health relevance of ambivalence given that coronary heart disease (CHD) is the number one cause of death in the United States and most industrialized countries for both men and women. One way in which relationships might influence risk for CHD is through elevation in blood pressure (BP), either during the time of the interaction or as a long-term consequence of repeated interactions. If such alterations in cardiovascular function are chronic or pervasive, this could presumably affect CHD risk. Thus, to address this hypothesis, researchers have primarily used two different methodological techniques: (a) examining interactions within a tightly controlled laboratory setting and (b) examining interactions in daily life via ambulatory and diary methods.

Health behaviors and treatment adherence

The salubrious effects of social relationships on health have been linked to their influence on health behaviors and lifestyle factors. For instance, individuals with positive social relationships engage in less risky health behaviors (Jessor, Turbin, & Costa, 1998). However, relationship factors have also been linked to poorer health behaviors, including weight gain and barriers to exercise and nutrition (Porter, Bean, Gerke, & Stern, 2010) and excessive alcohol consumption (Peirce, Frone, Russell, Cooper, & Mudar, 2000; Steptoe, Wardle, Pollard, Canaan, & Davies, 1996). Currently, very little systematic research has specifically examined the influence of ambivalent relationships on health behaviors. In one community sample, perceptions of relationship ambivalence were unrelated to sleep quality (Kent, Uchino, Cribbet, Bowen, & Smith, 2015). There is also evidence that among college students, engaging in hook-ups (engagement in sexual or physical intimacy without the expectation of a relationship) was associated not only with mental-health outcomes (psychological distress, depression, anxiety) and physical-health outcomes (sexually transmitted diseases) but also with relationship processes (greater perceptions of ambivalence; Bachtel, 2013). There is some evidence, albeit limited, to suggest that perceptions of ambivalence may influence health-relevant behaviors, and health-relevant behaviors may influence perceptions of relational ambivalence. However, more data are needed on whether such health behaviors are important pathways linking perceptions of relationship ambivalence to subsequent health.

Treatment adherence has significant influences on health outcomes (DiMatteo, Giordani, Lepper, & Croghan, 2002). Aid or support from others influences adherence and may help explain the associations between social relationships and health outcomes. Currently, little research has specifically examined the effect of relational ambivalence on medical adherence. However, in a meta-analysis of 122 studies, adherence was found to be 1.53 times lower in patients from families in conflict and 1.74 times higher in patients from cohesive families, and family conflict has a more detrimental effect on adherence in studies using more than one method to measure adherence than in studies using only one method of measuring adherence (DiMatteo, 2004). These data suggest the potential importance of considering the influence of concurrent negativity (ambivalence) within relationships for treatment adherence.

Contact frequency

How pervasive is the potential influence of ambivalent relationships? Given the potential detrimental influence of ambivalent relationships, it may be important to understand the potential extent of their influence. Presumably, if we have few ambivalent relationships and/or rarely interact with these individuals, their influence would be quite minimal. Perhaps the social psychological and health influence would be mitigated if such relationships were avoided. However, there is growing evidence that ambivalent relationships are pervasive. Ambivalent relationships appear to be so common that the vernacular term frenemy has become commonplace. A systematic examination of social networks in both undergraduate and community samples reveals that ambivalent relationships are found among all relationship types (e.g., spouse, family members, friends, coworkers, and social acquaintances), and individuals report roughly equivalent proportions of supportive and ambivalent relationships (Campo et al., 2009; Uchino et al., 2001). Prior research has also demonstrated that supportive and ambivalent ties occur much more frequently in individuals’ networks than do aversive ties (Fingerman, Hay, & Birditt, 2004; Newsom et al., 2005; Uchino, Holt-Lunstad, Smith, & Bloor, 2004; see also Rook, 2001). Likewise, the length of the relationship and frequency of weekly contact was similar among ambivalent relationships and supportive relationships (Gramer & Supp, 2014; Holt-Lunstad & Clark, 2014; Holt-Lunstad et al., 2007; Reblin et al., 2010).

Likewise, data suggest that individuals do not outright avoid ambivalent ties (Campo et al., 2009). Ambivalent ties were found in young, middle-aged, and older adult populations, and it was consistently found that close to half of important network members are viewed as ambivalent (Campo et al., 2009; Uchino et al., 2004, 2012). Note that ancillary analyses of these existing data sets have not shown age-related differences in ambivalent ties, suggesting that people toward whom one will feel ambivalent appear to be present throughout the life span.

Perceptions of ambivalence toward a spouse may be particularly relevant to examine given the importance of such relationships for the aging adult. In three separate studies, between 47% and 86% of individuals report feeling ambivalent toward their spouse (Birmingham et al., 2015; Uchino, Bosch, et al., 2013; Uchino et al., 2014). Given that contact between spouses is typically very frequent (i.e., daily), these findings further reject the notion that ambivalence is associated with low contact frequency. Taken together, it appears that contact with ambivalent ties is voluntary and frequent. Thus, exposure to and potential influence of relational ambivalence may be high.

Stress enhancement

Are ambivalent relationships a significant source of stress? The answer to this question appears to be affirmative. For instance, the number of ambivalent ties is typically correlated with greater interpersonal conflict from social networks (Campo et al., 2009; Uchino et al., 2001). In addition, other results suggested more subtle ways in which ambivalent friends may be stressful. State anxiety was elevated for individuals who were with an ambivalent friend throughout the entire study, including during relaxation/baseline periods (Holt-Lunstad & Clark, 2014; Holt-Lunstad et al., 2007). In addition, analyses of baseline levels of cardiovascular activity showed that participants anticipating interacting with ambivalent friends had significantly higher HR, an effect driven by lower parasympathetic control of the heart as indexed by RSA. Such reductions in RSA may signify decreases in self-regulatory ability (Thayer, Hansen, Saus-Rose, & Helge Johnsen, 2009). In another study, participants randomly assigned to bring in an ambivalent friend had higher BP before, during, and after a stressor task relative to participants who brought in a supportive friend—although the friend was in a separate room and they were not actually interacting with the friend (Holt-Lunstad & Clark, 2014). Thus, these data may indicate a reduced ability to regulate aspects of the cardiovascular system in the mere presence and anticipation of interacting with such ambivalent ties. This finding appears evident even at a less conscious level given that subliminal activation of ambivalent relationships was related to greater HR reactivity and parasympathetic withdrawal (RSA) during a subsequent self-relevant stressor (Carlisle et al., 2012).

Support interference

Are we less likely to benefit from social support from an ambivalent relationship? The stress-buffering hypothesis suggests that relationships may be beneficial in the context of stress by altering perceptions of stress or helping one cope with stress and thereby damping one’s stress response; however, some evidence suggests that social support from an ambivalent relationship may not have a buffering effect. To examine the support-interference hypothesis, studies have examined support during stress (a) contrasting support from ambivalent and supportive relationships and (b) contrasting interactions with ambivalent relationships during stress and nonstressful contexts. Finally, studies have examined whether individuals are less likely to seek support from their ambivalent friends.

Multiple studies have found evidence of a stress-buffering effect of supportive relationships that is not evident for ambivalent relationships when participants are engaging in a laboratory stressor (e.g., Carlisle et al., 2012; Holt-Lunstad & Clark, 2014; Uchino et al., 2001). Likewise, studies that mimic support exchanges (discussing a stressful event) find greater cardiovascular reactions among discussions with an ambivalent friend relative to a supportive friend (Holt-Lunstad et al., 2007). Individuals also reported that ambivalent friends were more distressing in the past when they needed support from them (Holt-Lunstad et al., 2007). Moreover, independent judges rated ambivalent friends as providing less emotional support and engaging in more negative behaviors (Reblin et al., 2010). Among a sample collected in Austria by an independent lab (Gramer & Supp, 2014), it was found that participants who brought in an ambivalent friend had heightened cardiovascular responses (SBP reactivity) during anticipation of the interaction and while receiving active support during a stressor, but slower recovery compared with participants who brought in a supportive friend; the active-support condition was associated with the greatest response. Moreover, participants who received active support from an ambivalent friend did not perceive it as supportive. Note that recovery from the stressor was equivalent among participants who brought in an ambivalent friend and those in a no-support condition. These findings suggest that active support from an ambivalent friend was not only less effective relative to a supportive friend but had no stress-buffering effect.

Given that we turn to our relationships in a variety of contexts, not just in times of stress, comparing these contexts may help elucidate any effects specific to stress interference. When examining responses to supportive and ambivalent relationships beyond the support contexts (nonstressful; i.e., positive, neutral), the data are strongest in terms of interactions in a stressful (social support) context. For instance, cardiovascular reactivity was highest when discussing a stressful event with an ambivalent friend even compared with discussing a positive (social capitalization; see Gable & Reis, 2010) or neutral event (daily life; Holt-Lunstad et al., 2007; Reblin et al., 2010). ¹ However, ambivalence in other contexts was less consistently related to physiological responses (inflammation), although ambivalence in a capitalization context was related to one of several inflammatory markers (Uchino et al., 2012). Thus, these data start to delineate the crucial contexts (e.g., stress/support) in which ambivalent ties may be most consequential (Uchino, Bosch, et al., 2013). In general, these associations may be evident in a support context because it is a context with high resource value (e.g., advice) and is linked to intimacy and self-worth (e.g., putting your problems and trust on the line; Gable & Reis, 2010; Reis & Shaver, 1988; Uchino, 2004).

Evidence suggests that individuals also may be somewhat less likely to turn to their ambivalent relationships in times of stress for support. For instance, when individuals are asked to rate how likely they are to turn to their ambivalent and supportive friends for support during stressful, positive, and neutral contexts, ratings were relatively higher for supportive friends. Note that despite relative differences, subjects were highly likely to seek support from both supportive and ambivalent friends (Holt-Lunstad et al., 2007). However, in a study using experience sampling, ambivalence toward a spouse was related to lower ratings of self-disclosure (Birmingham et al., 2015). Likewise, another study found that participants reported using more emotional distancing among ambivalent compared with supportive friendships (Bushman & Holt-Lunstad, 2009). Taken together, these data suggest that although individuals may be likely to seek support from ambivalent relationships, albeit less so than from supportive relationships, they may be less open and more guarded during support seeking.

Stress enhancement and support interference

Note that the stress-enhancement and support-interference hypotheses may not be independent and may be interrelated as a result of reciprocal interpersonal relationship processes (as reflected in the bidirectional arrow in the SAD model). To examine this potential bidirectionality further, studies have attempted to tease apart the actual behaviors (supportive/positive; negative/upsetting) of the ambivalent relationship partner and the perceptions (supportive/positive; negative/upsetting) of the individual toward the ambivalent partner. In one study, friends were preselected on the basis of ratings of ambivalence or supportiveness, and researchers had them interact with participants in a neutral or negative context (Reblin et al., 2010). Interactions were behaviorally coded using the social support interactional coding system (Pasch & Bradbury, 1998). As noted earlier, friends viewed as sources of ambivalence were rated as providing less emotional support and more negative behaviors such as criticizing and blaming. Of course, these latter behaviors are likely to be associated with stress enhancement in its own right.

In another study (Holt-Lunstad & Clark, 2014), these questions were examined by manipulating the behavior of the friend. As in previously described protocols, participants were randomly assigned to bring in either a supportive or ambivalent friend (i.e., support or ambivalence was based on prior ratings). Friends provided the participant with positive, negative, ambivalent, or ambiguous feedback following a speech task. Unbeknownst to the participant, the feedback was randomly assigned and standardized. Blood pressure reactivity was higher among participants who brought in an ambivalent friend compared with participants who brought in a supportive friend. Higher BP reactivity was also found among participants who received ambivalent feedback compared with participants who received positive or ambiguous feedback. However, there was no significant interaction between the friend’s feedback and the relationship quality. Thus, both broad relationship perceptions and their objective behavior appear to independently contribute to enhance stress. Taken together, these studies suggest that interpersonal processes associated with both partners may contribute to support interference and stress enhancement.

Conflicting societal norms

At a broad level, it has been argued that conflicting societal norms may be at the heart of the development of relationship ambivalence, especially to the degree that these norms relate to developmental transitions (Hillcoat-Nalletamby & Phillips, 2011; Luscher, 2011; Luescher & Pillemer, 1998). These conditions are most evident when examining intergenerational relationships such as older parents and their adult children. Although most of this prior research on intergenerational relationships has focused on the emergence and importance of solidarity (e.g., affection, cohesion; Bengtson & Harootyan, 1994), this approach has been criticized as not acknowledging the significant levels of conflict that can coexist with solidarity in intergenerational relationships (i.e., ambivalence; Luescher & Pillemer, 1998).

There are at least two well-documented examples of how societal norms in the context of developmental transitions may contribute to the formation of relationship ambivalence. First, parents have expectations for their children that stem from societal norms regarding successful development. That is, parents expect that their children will generally transition from a state of dependence to both financial and familial independence (Luescher & Pillemer, 1998). When adult children fail to meet these expectations, perceptions of relationship ambivalence are heightened (Birditt, Fingerman, & Zarit, 2010; Kiecolt, Blieszner, & Savla, 2011; Pillemer et al., 2007; Pillemer, Munsch, Fuller-Rowell, Riffin, & Suitor, 2012; Pillemer & Suitor, 2002; Wethington & Kamp Dush, 2007). For instance, one longitudinal study over a 14-year period found that as children moved from adolescence to early adulthood, marriage was related to decreases in parents’ perception of ambivalence toward an adult child (Kiecolt et al., 2011). In general, when adult children are able to meet societal expectations for normative development, relationship ambivalence tends to decrease (Luescher & Pillemer, 1998).

A second example of how societal norms can set up conditions that facilitate relationship ambivalence can be found when adult children become caregivers for an older parent with health problems (Luescher & Pillemer, 1998). There are strong societal norms that family members should take care of their aging parents (Willson, Shuey, & Elder, 2003). This norm can lead to perceptions of relational ambivalence for both caregivers and care recipients (Spitze & Gallant, 2004; Van Gaalen, Dykstra, & Komter, 2010; Willson, Shuey, Elder, & Wickrama, 2006). Older parents may feel ambivalence toward their adult children because of their need for independence apart from the child (Spitze & Gallant, 2004), whereas adult children may feel ambivalence toward the parent because of conflicting norms regarding caring for a parent in contrast to caring for one’s own “new” family (their own children; Van Gaalen et al., 2010; Willson et al., 2006).

Early family environment

A second important factor contributing to the development of ambivalence is the early family environment. More specifically, harsh and inconsistent family environments (e.g., rejection, hostility, punishment) are related to greater perceptions of ambivalence toward the parent (Surjadi, Lorenz, Conger, & Wickrama, 2013; Willson et al., 2003). One study used data from the Family Transitions Project, which is an ongoing study of 550 individuals followed from early adolescence to young adulthood (Surjadi et al., 2013). This study found that early reports of harsh family environments were related to adult children’s later reports of ambivalence toward parents as well as increased externalizing behavior. Note that these factors in turn were related to perceiving a subsequent spouse ambivalently (Surjadi et al., 2013). Of course, the early family environment is also shaped by child-related factors (e.g., disposition, mental-health status). One study reported that child behavioral problems (e.g., expulsion from school, troubles with law) were related to greater parental perceptions of ambivalence toward the child (Kiecolt et al., 2011). Overall, these data are consistent with models highlighting the critical importance of the early family environment in shaping social and behavioral processes that can facilitate or impede relationship functioning (Bryant & Conger, 2002; Repetti, Taylor, & Seeman, 2002; Uchino, 2009a, 2009b).

Personality and individual differences

Personality and individual differences that arise from this early family environment may also be important as antecedent processes to the development of relationship ambivalence. Although there is less evidence to this point, several studies suggest that general attachment style may be related to ambivalence in specific relationships. Individual differences in attachment style are thought to arise from early infant–caretaker interactions and set the basis for working models of the self and others as reliable or secure (Bowlby, 1982). However, if these interactions are inconsistent or negative, infants may develop more ambivalent or avoidant attachment systems (Ainsworth, Blehar, Waters, & Wall, 1978). Several studies have found that more secure attachment styles were related to lower perceptions of ambivalence toward parents and spouses (Levy, Blatt, & Shaver, 1998; Maio, Fincham, & Lycett, 2000; Uchino, Bosch, et al., 2013). Other preliminary studies focusing on trait negative affect/neuroticism and hostility have not found links to ambivalence across a broad range of network members (Uchino et al., 2001). Individual differences in emotional intelligence or wisdom may also influence the capacity to experience ambivalence. For instance, given that in reality each person has varying degrees of positive and negative qualities, the ability to see other’s variegated qualities and be able to handle this judiciously and empathetically may be related to less ambivalence. Indeed, higher trait emotional intelligence and social skills have been associated with less emotional and behavioral difficulties (Poulou, 2014). Another possibility is that individuals who do not regulate their emotions well in social interactions are more likely to report ambivalent feelings for their relationship partners because of a history of mixed experiences with these individuals. Researchers have not directly examined this idea, but it may be a fruitful line of inquiry that should be considered in future research.

Interpersonal transactions

A pattern of mixed interpersonal transactions or interpersonal tensions in the context of a previously positive relationship can also lead to relationship ambivalence in both familial and nonfamilial relationships. In fact, simply knowing that another liked individual has discrepant attitudes or conflicting traits is related to greater feeling of ambivalence toward that person (Gebauer, Maio, & Pakizeh, 2013; Priester & Petty, 2001). Duffy, Ganster, and Pagon (2002) also found that coworkers are often a source of both supportive behaviors (e.g., emotional support, advice) and undermining behaviors (e.g., talked behind your back, belittled you). Moreover, relatively high levels of both support and undermining (ambivalence) from a supervisor were related to participants being more counterproductive at work and experiencing lower levels of work self-efficacy, commitment, and well-being (Duffy et al., 2002).

Consistent with the importance of interpersonal transactions in the development of ambivalence, research focused on the family environment also suggests that adult children’s current emotional and behavioral problems were related to greater parental perceptions of ambivalence toward the adult child (Birditt et al., 2010; Ingersoll-Dayton et al., 2011). Individuals coping with stressful situations also report problematic interactions, including poor or misguided support attempts that can lead to perceptions of ambivalence toward friends and family (Lehman, Ellard, & Wortman, 1986). For instance, individuals with chronic diseases (e.g., cardiovascular, cancer, diabetes) may experience problematic social interactions related to social control or poor quality/quantity of support (Dakof & Taylor, 1990; Franks et al., 2006; Helgeson, Novak, Lepore, & Eton, 2004; Martire, Schulz, Helgeson, Small, & Saghafi, 2010). More generally, acts of betrayal in a previously positive relationship may be important contributors to perceptions of relationship ambivalence. Hansson, Jones, and Fletcher (1990) found that about 50% of older adults were able to recount significant acts of betrayal by members of their immediate family or support network. As noted by Hansson and colleagues, many of these incidents occurred more than 20 to 30 years earlier but still maintained their significance in later life.

Transference

Finally, transference can also contribute to the development of ambivalence in new relationships (Andersen & Przybylinski, 2012). The conceptualization of transference comes for early models that recognized the importance of relationships for the development of the self (e.g., Sullivan, 1953). Basically, transference occurs when another person resembles a close, important other (e.g., appearance, mannerisms, traits; Andersen & Chen, 2002). This resemblance leads to automatic activation of the important-other representation that then influences one’s sense of self, emotions, and behavior toward that person. In a seminal program of research, Andersen and Chen (2002) and Andersen and Przybylinski (2012) showed that transference is quite common and has important downstream consequences on interpersonal perception and interactions, in some cases leading to a self-fulfilling prophecy in which individuals elicit responses consistent with the important-other representation (e.g., Berk & Andersen, 2000). Of particular relevance for this review, it has also been shown that transference can occur for more mixed or ambivalent relationships (Berenson & Andersen, 2006; Berk & Andersen, 2008). In these studies, individuals who experienced transference stemming from an ambivalent relationship (e.g., loved parent but a history of abuse) showed signs of positivity (e.g., implicit affect, affection seeking) toward the relevant new relationship but also viewed that person more negatively (rejecting, less trust; Berenson & Andersen, 2006; Berk & Andersen, 2008).

Internal barriers

If ambivalent relationships are characterized by interpersonal conflict, why do people not end these relationships? Clearly some relationships (e.g., family, work) are not easy to exit because of strong external or social pressures; however, similar frequency distributions of supportive and ambivalent classifications have been found among friendships (Holt-Lunstad et al., 2007), which are presumably voluntary relationships, suggesting internal factors may be relevant. The role of internal and external relationship factors that might maintain ambivalent relationships was examined in a study by Bushman and Holt-Lunstad (2009). External factors included variables outside the individual such as physical proximity, financial dependency, and involvement in social groups, whereas internal factors originated from the individual, such as their beliefs and sense of commitment (Hess, 2000). Participants were randomly assigned to rate either a supportive or ambivalent friend on these measures of relationship maintenance. The main results suggest that ambivalent relationships are not maintained primarily because of obligation or external barriers but rather are viewed as voluntary associations maintained primarily because of internal factors (Bushman & Holt-Lunstad, 2009). The two most important internal factors included a personal commitment to the relationship and the positive aspects of ambivalent friendships that were viewed as either redeeming or impeding termination. Although internal barriers far outweighed external barriers in maintaining friendships among younger adults, additional research is needed to determine whether external barriers may be more influential among other types of relationships (e.g., family, coworkers) and among older adults.

Coping strategies

Although ambivalent relationships appear to be voluntarily maintained, how they maintain these relationships may differ. Of course, individuals often attempt to cope with ambivalent relationships to reduce the uncomfortable nature of such perceptions (Sawicki et al., 2013). This finding presents challenges given the mixed nature of such relationships. In one study, it was found that relational distancing—both physical (not spending time with the individual) and emotional (not self-disclosing)—was used significantly more frequently as a coping technique with ambivalent friendships than with supportive friendships (Bushman & Holt-Lunstad, 2009). More generally, individuals report a range of coping strategies to handle ambivalent ties, including lying, withholding information, excusing their behavior, reducing expectations, adjusting help giving, and confronting (Ingersoll-Dayton et al., 2011; Nordgren, van Harreveld, & van der Pligt, 2006; Spitze & Gallant, 2004). Note that most of these coping strategies decrease the transformative potential within ambivalent relationships (Hillcoat-Nalletamby & Phillips, 2011). That is, these coping strategies are such that the person viewed as a source of ambivalence is not aware of his or her behavior, which may inadvertently maintain such ambivalent relationship perceptions over time. Although confronting can potentially be beneficial, even it does not guarantee positive changes because in some cases it can lead to increased interpersonal tension within the relationship (e.g., feelings of not being appreciated; Duck & Wood, 1995; Spitze & Gallant, 2004). In addition, motivation to cope and resolve ambivalence may depend on one’s level of commitment and knowledge about the person (Sawicki et al., 2013; van Harreveld, Rutjens, Rotteveel, Nordgren, & van der Pligt, 2009). When a person is knowledgeable about a relationship (as is likely with our close ties), ambivalence may be maintained because individuals are less likely to seek information that might reduce that ambivalence (Sawicki et al., 2013).

Ongoing interpersonal transactions

Given the coping strategies reportedly used with ambivalent ties, it is perhaps not surprising that the behavior of the person continues to maintain such perceptions over time. In one study, individuals were asked to bring in a randomly selected ambivalent or supportive friend (as rated on the SRI) and interact with them in a support context (i.e., discussing problems; Reblin et al., 2010). The behavior of the friend viewed as a source of ambivalence was then coded by independent judges (blind to relationship condition) using the social support interactional coding system (Bradbury & Pasch, 1997). Note that friends viewed as a source of ambivalence were rated as providing less emotional support and engaging in more negative behaviors (Reblin et al., 2010). These results suggest that friends viewed as ambivalent continue to act in ways that reinforce that perception, perhaps because of a lack of feedback about their behavior.

More generally, in the context of familial and romantic relationships, some interpersonal transactions may reinforce perceptions of relationship ambivalence (Braiker & Kelley, 1979). For instance, from a parent’s perspective, tensions related to past and current emotional problems of a child are related to increased perceptions of ambivalence (Birditt et al., 2010; Kiecolt et al., 2011), as are tensions regarding the adult child’s continuing decisions about romantic relationships and child rearing (Peters, Hooker, & Zvonkovic, 2006). Birditt, Miller, Fingerman, and Lefkowitz (2009) also examined the link between relationship ambivalence and tensions at the relationship level (e.g., personality differences, unsolicited advice) and at the individual level (e.g., lifestyle, finances). Results showed that relationship tensions were more strongly linked to ambivalence compared with individual tensions. These data suggest that interpersonal tensions directly tied to the relationship are strong factors that maintain relationship ambivalence. These ongoing interactions with ambivalent ties also prime underlying positivity and negativity and thus sustain ambivalence toward social network ties (Bell & Esses, 2002; de Liver, van der Pligt, & Wigboldus, 2007).

Self-related processes

Finally, self-related processes can maintain perceptions of ambivalence. This idea is consistent with the importance of relationship representations in activating and reinforcing self-relevant processes as a result of reciprocal cognitive links between self and other (relationship) representations (Aron, Aron, Tudor, & Nelson, 1991; Baldwin, 1992; Holmes, 2000; Leary, 1999; Ogilvie & Ashmore, 1991). When activated, such relationship representations can influence self-relevant processes (e.g., self-esteem) via spreading activation to aspects of the self that are most closely linked to such social ties and thus influence what aspects of the self-concept are accessible in working memory (Baldwin, 1997; Ogilvie & Ashmore, 1991). In one study, ambivalent friends were more closely linked to one’s feared and disliked selves compared with more positive friends (Gabriel, Carvallo, Jaremka, & Tippin, 2008). Moreover, priming ambivalent friendships was related to greater self-liking for individuals with an avoidant attachment style (Gabriel et al., 2008).

The links between ambivalent ties and the self may help maintain ambivalent ties because individuals are motivated to verify aspects of the self (Kwang & Swann, 2010; Swann, 2012). Thus, spouses report greater commitment and are more likely to remain in a relationship when their partners see them as they see themselves, even for negative aspects of the self (Swann, De La Ronde, & Hixon, 1994; Swann, Hixon, & De La Ronde, 1992). In addition, ambivalent ties may be reinforced over time via social synchronization. Negative social synchronization occurs when individuals change the self to match negative attributes of a partner in an attempt to increase the probability of a positive social connection (Gabriel, Kawakami, Bartak, Kang, & Mann, 2010). In a series of studies, it was found that negative social synchronization was especially likely to occur for individuals high in attachment security (Gabriel et al., 2010).

Support interference

Although the majority of the existing data tends to support the support interference hypothesis in the context of stress—finding that individuals display greater cardiovascular reactivity when receiving support from an ambivalent friend and that ambivalent friends exhibit more negative behaviors—less is known about how relationships may interfere with support during positive events (social capitalization). A growing body of literature suggests that social relationships are important in both good times and bad and that perceptions of relationship responsiveness (e.g., enthusiasm and supportiveness) to positive disclosures is associated with both personal and relationship growth and well-being (Gable, Gonzaga, & Strachman, 2006). Gable and Reis’s (2010) recent review of the evidence in support of social capitalization suggests responsive capitalization was associated with increased positive emotions, subjective well-being, and self-esteem and decreased loneliness for the recipient. Relationship benefits were also demonstrated, including satisfaction, intimacy, commitment, trust, liking, closeness, and stability (Gable & Reis, 2010). However, perceived responsiveness to a positive event (social capitalization) may be influenced by relationship quality or the security of the relationship (Gosnell & Gable, 2013). Because little is known about how social capitalization is linked to long-term health or health-relevant outcomes, this will be another important avenue of future research.

Stress enhancement and coping options

The current data suggest that despite similar levels of positivity among supportive and ambivalent relationships, ambivalent relationships not only are less effective at helping individuals cope with stress but also may be sources of stress themselves. An important next step will be to determine effective coping strategies. The identification of effective coping strategies may be particularly important given that there is reason to believe that people do not exit these relationships. Although emotional distancing was used more often in ambivalent relationships than it was in supportive relationships, it is possible that this strategy may not be effective in reducing negative health effects. For example, multiple studies have shown that individuals were more anxious and less able to relax in the mere presence of their ambivalent friends (Holt-Lunstad & Clark, 2014; Holt-Lunstad et al., 2007). Therefore, if individuals are not limiting contact with ambivalent relationships, it is possible that despite such strategies, relationships still have an effect through cognitive processes (e.g., rumination and emotional suppression). Future studies that directly test these issues may be able to identify and elucidate the most effective coping methods.

Possible adaptiveness of ambivalent relationships?

From an evolutionary perspective, why would ambivalent relationships thrive (perhaps like weeds) despite such detrimental consequences? Is it possible that such relationships may be adaptive? Is it possible that ambivalent relationships are adaptive because they allow one to maintain access to valued resources and prevent loneliness and social isolation? Although it is difficult to experimentally test whether having ambivalent relationships is better than having no or few relationships, it may be possible to compare people who have social networks filled with ambivalent relationships with people who are socially isolated. For example, one study showed that low-income men who were in a high-conflict marriage had lower risk for mortality than never married or previously married men (Choi & Marks, 2011)—suggesting some potential benefit of a poorer quality relationship relative to no relationship. Nonetheless, additional studies would be needed to more directly test hypotheses specific to ambivalence and to begin to tease apart their relative and unique health-relevant pathways. Although both have been linked to detrimental outcomes, we have a much larger body of evidence for the detrimental influence of social isolation and loneliness. Expanded research efforts are needed to begin to answer these questions.

Methodological approach

As evidenced from preliminary data, it will be important to take an interdisciplinary multimethod/level approach to understanding the antecedents, processes, and consequences of ambivalent social relationships. We must take both a relationship science perspective (individual or dyad as the level of analysis) as well as a social network perspective (network level of analysis). The social relationships and health literature span many disciplines. In an effort to advance the broader science of understanding the association between social relationships and health, ambivalence needs to be integrated into existing theoretical and methodological approaches across these disciplines. This model needs to be broad enough to be relevant to those engaged in relationship science, biological sciences, medicine, epidemiology, and public health to guide future research in this area. This would allow researchers to simultaneously model multiple pathways and processes in the SAD model that would allow for stronger inferences.

Developing intervention approaches

We believe our model provides a more comprehensive approach to understanding links between social relationships and health and has implications for intervention attempts. One important insight is that more complex relationships such as ambivalent ties, despite their positivity, tend to be associated with worse health outcomes. In addition, such ambivalent ties make up a relatively large portion of important network members across different domains such as spouses, friends, coworkers, and other family members (Campo et al., 2009; Uchino et al., 2004). Data generated from this model thus suggest that intervention attempts need to be (a) specific to social relationships and (b) effective across diverse social network ties that differ in their underlying positivity and negativity. In this context, general cognitive-behavioral stress management may not be as effective because it is not specific to relationships. Furthermore, more focused relationship therapy (i.e., marital) may be too narrow given the diversity of types relationships and social roles involved.

Given prior data suggesting ambivalence relationships are closely maintained as well as the physiological consequences of these ties even when not physically present, interventions may need to go beyond interpersonal coping strategies and instead focus on increasing positivity and decreasing negativity within a relationship. A promising set of interventions based on meditation practices from the Buddhist tradition attempts to cultivate nonjudgmental awareness, openness, and acceptance (Grossman, Niemann, Schmidt, & Walach, 2004) and could potentially be applied to relationships. Loving-kindness meditation (LKM; Kok et al., 2013) specifically focuses on relationships and seeks to increase feelings of love, caring, and compassion for the self and others—including more conflicted relationships (Salzberg, 1995). LKM’s focus on relationships makes it a distinct form of mediation, and studies suggest differential mechanisms might be operating between LKM and mindfulness meditation, such as increased feelings of social connectedness and positive affect compared with more basic mechanisms of attentional control (e.g., decreased rumination; Feldman, Greeson, & Senville, 2010; Hofmann, Grossman, & Hinton, 2011; Kok et al., 2013; Lee, Rogge, & Reis, 2010). Although meditation interventions have been related to positive outcomes (Chiesa & Serretti, 2009; Grossman et al., 2004; Hofmann, Sawyer, Witt, & Oh, 2010; Piet & Hougaard, 2011) future research is needed to determine whether interventions might be effective in both reducing perceptions of ambivalence and health outcomes.