The theoretical rationale that usually introduces studies on the use of support groups to maintain and promote mental health is based on the broad fabric of evidence, reviewed by Cohen and Wills in 1985, revealing that the support of one's personal community of associates has health protective effects. They concluded that it is largely perceived support that cushions the impact of a wide range of stressful life events and transitions. In addition, in 1988, House, Landis, and Umberson reviewed a number of epidemiological studies that showed that social integration was pro-
Support Groups spectively linked to lower morbidity and mortality. That is, the stress moderating function of social support appears to rest on people's belief that they are reliably allied with certain associates who are prepared to provide needed practical assistance and emotional support. From an epidemiological perspective, the advantage that social support confers on health and survival stems from more abundant contact with family members and friends, as well as from participation in voluntary associations. Support groups therefore cannot be justified on the basis of either the stress-related or epidemiological findings. Such groups do not concentrate on conditioning a psychological sense of support, nor do they intensify or enlarge contact with natural network members.
Instead, support groups are artificial and temporary systems of mutual aid. In large part, they involve the disclosure of personal problems, fears, and doubts to a set of strangers, collective problem solving, and the sharing of coping strategies. Yet evidence for the protective effect of actually receiving support is mixed, with null or negative effects resulting from the damaging psychological implications of seeking help from others or from a miscarried support process. In short, the weight of the empirical evidence suggests that the adaptive value of support derives largely from the perception that one has worth and importance to others and can count on them when needed, rather than from actual exchanges of help and support.
This distinction between perceived and received support generally has not been recognized by those who have mounted support groups. Since the stress-buffering effect of social support is mainly predicated on perceived rather than received support, the most appropriate intervention would be to persuade people that they can gain the support they need from others rather than involving them in a process of mutual aid. On the other hand, it is possible that involvement in the process of mutual aid is a precondition of perceived support, giving rise to perceptions of caring and belonging. In fact, whatever beneficial effects of support groups may occur could result from the psychological sense of support that the group instills rather than from its helping processes. This is why it is particularly important to compose the group in a way that will enable the members to perceive one another as similar peers who are "in the same boat'' since this will magnify feelings of connection and mu tual responsiveness. This may also help to explain why support group members generally agree that the most beneficial aspects of their group experience were that they felt less emotionally alone, and gained comfort from learning that their thoughts, feelings, and behaviors were normal and validated by others.
A second rationale for introducing support groups is based on the supposition that certain stressful events and transitions create rends in the affected parties' natural networks or overtax the resources or tolerance of network members. In circumstances that call for prolonged help from family members and friends, when stigma and embarrassment surround the affected parties, or when the victims of life events express threatening emotions, close associates are often incapable of providing needed support. In addition, there are instances when the stressor is so severe or pervasive that it restricts social participation, such as when family caregivers withdraw from employment and become homebound in order to supervise a demented relative. Similarly, people with certain medical conditions, diseases, or disabilities must often limit or surrender their social activities, with the attendant loss of valued relationships. [See Coping with Stress.]
Short of losing touch with their natural network, people may feel that their associates simply do not understand what they are experiencing or that their difficulties are compounded by their associates' own efforts to cope with the difficulty or by their misguided helping efforts. For example, there is evidence that a spiral of conflict can occur when spouses clash with one another in their ways of coping with a shared stressor, such as a child's serious illness. In 1988, Coyne, Wortman, and Lehman identified several other ways in which support can miscarry and undermine close relationships.
Hence, support groups have been introduced to compensate for absent, insufficient, or irrelevant support from the members' natural networks. For example, based on the findings of their survey of 667 cancer patients, Taylor, Falke, Shoptaw, and Licht-man found in 1986 that 55% wished "very much or somewhat'' that they could talk more openly to family members, and 50% said the same thing about friends. More than a third agreed with the sentiment that family members did not truly understand their experience of cancer. However, it is important to note that those patients who had participated in a support group did not differ from those who had not with respect to
Support Groups their network's support, suggesting that other factors come into play in spurring support group participation. In fact, Taylor and colleagues discovered that support group users generally disclosed their cancer-related concerns to a larger number of informal and professional resources than the nonusers, and also had a more extensive help-seeking history than the nonusers. Support group users, or perhaps those who benefit most from such groups, may therefore be particularly disposed to cope by seeking information and feedback, a point that is discussed in greater detail later.
Another rationale for introducing support groups has more to do with the transmission of information, education, and skills to the participants than with the emotional support provided by the group. There are several reasons why a support group is a desirable context for learning new information and skills. First, there may be a significant amount of technical information that all participants want and need to know to improve their comprehension and handling of their situations. The sheer volume of information may require it to be divided into consumable chunks that can be disseminated more efficiently en masse than individually. For example, support groups for cancer patients typically cover the following topics: the causes of cancer; explanation of the diagnoses, tests, and prognoses of the various subtypes of the disease; explanation of the various components of the treatment plan, such as surgery and chemotherapy, and their side effects; discussion of the personal and social impacts of treatment, such as changes in body image and sexuality; education about diet, exercise, and any other life-style changes; explanation and demonstration of the use of prostheses; instruction about relaxation and visualizing techniques; and discussion of issues that arise in communicating needs and problems to both health care providers and network members.
Second, it is widely understood that discussion facilitates the learning of new information, an advantage that is offered by the group context. Moreover, since the group meets over a period of several weeks, the information can be divided into manageable units and time can be set aside to practice, review, and reinforce any skills that are taught. For example, in 1994, Gallagher-Thompson described two different cognitive-behavioral group programs for the family caregivers of persons with dementia, one focused on the alleviation of depression and the other on anger management. In each case, she has planned eight sessions plus two additional booster sessions at 3-month intervals, beginning with an overview of the model, progressing to the acquisition and practice of component skills in the group and at home, and culminating with continued implementation and monitoring of outcomes.
Third, aside from their cost-effectiveness compared to individual education and skill training, support groups offer other advantages over individual counseling. The group members can serve as role models for each other, sharing methods of solving problems and coping. In these ways, they are at once being helped and helping others, the latter counteracting feelings of helplessness and enhancing feelings of self-worth and usefulness to others. In addition, the support group can lead to the formation of friendships that endure beyond the formal group sessions, helping to populate the participants' natural networks with similar peers.
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