Documenting Support Group Processes

There is no dearth of hypotheses about the mediating processes or mechanisms at work in support groups. Biological pathways include alterations in immune system function, blood pressure, and urinary cortisol, whereas behavioral changes range from improved adherence to recommended dietary and drug regimens to changes in modes of coping, including the use of community services. The psychological factors that have been cited most frequently as potential mediators include the 10 listed at the bottom of Table I. At present, little is understood about the complex ways in which psychological, biological, and behavioral changes interact to produce durable and important outcomes such as the improvements in mood and survival of the cancer patients who were involved in the support groups organized by Spiegel, Bloom, Kraemer, and Gottheil in 1989.

It is therefore necessary to begin documenting aspects of the process of support groups, and systematically varying their structure and emphasis to determine how the process is altered and how it affects the observed outcomes. In addition to varying the proportion of time that is devoted to education and peer discussion, group planners can vary the emphasis they place on various goals. For example, Lavoie maintains that those who have organized support groups for family caregivers have aimed to reduce the participants' stress, whereas the participants themselves have typically aimed to improve and gain confidence in their caregiving skills. Obviously, some attention should be paid to participants' goals at the outset of the intervention, and different groups can be formed to address different goals. Even when support groups are designed to blanket all the principal sources of stress and to foster improved coping, as is the case in groups for children whose parents are divorcing or for recently bereaved people, large differences among individuals in the salience of certain stressors and in their need for supplemental coping resources may call for

Support Groups more specialized groups. It is also important to acknowledge that even when groups are initially structured along the same lines, each will develop its own culture and participants who are in the same group will experience the support process differently (J.-P. Lavoie, personal communication, August 19, 1996).

In addition, as Lavoie and Bourgeois, Schulz, and Burgio observe, implementation evaluation that involves assessment of the intervention process and structure is so rare that the details regarding the psy-choeducational maneuvers, the leadership, the balance between mutual aid, skill training, and education, and the group's composition are not available for the purpose of replication or verification that the intervention is faithful to its blueprint. Without knowing what actually transpired over the life of the group, it is impossible to determine whether the process accurately reflected the theory that links the intervention's content to its intended outcomes. For example, if support groups for the family caregivers of persons with dementia concentrate on the acquisition of anger management skills, then it is necessary to adopt outcome criteria that reflect this specific goal, and to ensure that the requisite amount of time is spent on effectively teaching these skills and proficiently applying them at home. Similarly, if the intervention aims mainly to decrease stress and uncertainty by disseminating authoritative information about the nature and typical course of dementia, and by introducing the specialized support of similar peers, then measures of knowledge and of global stress or subjective burden should be adopted as outcomes, and members' perceptions of their similarity, the support they exchange, and the information they receive should be tapped through formative evaluation.

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