A support group can be defined as a small group of from 6 to 10 people who are in similar circumstances that pose an adaptive challenge, and who are convened and led by a professional who provides education and/or training over a period of several weeks, and who facilitates a process of mutual aid among the participants for the purpose of fostering their health and well-being. Support groups differ from self-help groups by virtue of three characteristics: the direct involvement of professionals in the group sessions, their time-limited nature, and the tendency of support groups to look inward rather than outward, generally eschewing advocacy and social action. Support groups differ from conventional group therapy as well. In support groups, professionals do not make psychological interpretations or keep case records, and the members come for information, guidance, emotional validation, and skill training, not for psychotherapy.
While acknowledging the differences between support groups and other similar vehicles of social influence, it is also necessary to highlight the similarities. Like self-help groups, support groups aim to animate a process of mutual aid from similar peers and there
Support Groups by to temporarily enrich and specialize, if not compensate for deficiencies in the support available from the participants' natural networks. Like psychoedu-cational groups, support groups provide extra information and training that professionals believe will shore up the participants' coping efforts. Like therapy groups, support groups provide a context that promotes emotional catharsis, social comparison, and mutual identification.
The structural properties of support groups are highlighted in Table I. These properties can be altered in accordance with practical or logistical constraints, and to meet the adaptive challenges faced by the group members. More important, since the support process is likely to be affected by the ways in which the group is structured, practitioners should consider these properties carefully when they design the group. For example, in planning the group's membership (see criteria for matching in Table I), they must consider how the support process would be affected by including spouses in a group for men who are recovering from heart attacks. Would their inclusion preclude discussion of interspousal conflict about the timing of the husbands' return to work? Would the wives express emotions that might threaten the men? Similarly, in designing the individual sessions (see format in Table I), would it be better to adopt a fixed format involving a predetermined series of didactic presentations during the first half of each meeting, followed by experience swapping on any topics during the second half? Or would the members' needs be served better by opening each session with a free-floating discussion and introducing the educational or skill-training component only if and when its subject matter is raised by the group members?
The group's composition should be of paramount importance to those planning support groups since members have to be chosen in a way that will optimize their identification with one another and their participation in the group process. If they do not perceive one another as similar along certain valued dimensions, and if they do not have a common basis for comparing the feelings, actions, and thoughts that arise out of their circumstances, then the group will have little appeal to them and could actually intensify the stress they experience. For example, in composing a support group for the family caregivers of persons with dementia, practitioners must carefully weigh the importance of similarity with respect to the stage and
Table I The Design and Processes of Support Groups
Design Features: The Structural Properties of the Support Group Venue or setting
• Geographic proximity to participants
• Informal or agency/institutional setting
• Total number, length, and duration of sessions
• Interval between sessions Leadership and facilitation
• One or more professionals only
• Co-led by a participant and a professional
• Rotating professional leaders Composition
• Number of participants
• Open or closed membership
• Geographic proximity of participants to one another Criteria for matching, including
• Gender, age, socioeconomic, ethnic, racial, and verbal skill factors
• Severity of the stressor
• Stage of coping with stressor
• Intensity of distress and emotional expression
• Extent of mobilization of personal coping skills Format
• Structured vs. unstructured agenda and allocation of time
• Balance between expert input and experience swapping
• Rotating or continuous leadership
• Use of contracts vs. no contract
• Homework assignments (e.g., skill practice) vs. none
• Prescribed extra-group contacts among participants or not
• Instructions regarding extra-group exchanges of support or not
• Occasional participation of network associates or not Mechanisms of Action: Processes Linking Support to Outcomes
• Catharsis: emotional ventilation
• Normalization of emotions
• Validation: affirmation of valued role and identity
• Helper-therapy: helping others helps oneself
• Reduction of uncertainty in novel circumstances
• Modeling of coping strategies
• Hope and a positive outlook
• Making meaning of the adversity and consolidating a new or changed identity
• Predictability and anticipatory coping
• Social comparisons severity of the disease (e.g., early- versus late-stage Alzheimer's), the relationship between the caregiver and relative (e.g., spouses versus daughters and daughters-in-law), and the two parties' living arrangement (e.g., living in the same or different households). Other stressor related, demographic, and contextual variables may also affect the members' rapport and ease of communication, such as their education, ethnicity,
Support Groups income, and gender, their family and occupational contexts, and their level of physical and emotional functioning at the time they join the group.
To date, there has been little experimentation with alternative ways of composing groups and virtually no follow-ups of people who have dropped out of groups in order to determine the social dimensions that impede and facilitate communication and exchanges of information and support. Nor have prospective group members been canvassed about who they would and would not prefer to meet with. Consequently, there is no empirical basis for deciding how to compose a support group to optimize members' attraction, active participation, and social learning and support.
As for a theoretical rationale for the group's composition, social comparison theory offers abundant but inconsistent predictions about the benefits and risks of both downward and upward comparison processes, leaving considerable ambiguity about how to engineer a social milieu that will lower distress, and maintain or increase self-esteem as well as other bases of self-evaluation. Specifically, as Gibbons and Ger-rard pointed out in 1991, there is a vast literature testifying to the esteem-enhancing functions of downward social comparison or comparisons to people or even imaginary targets perceived to be worse off than oneself on certain dimensions. There is also an extensive list of papers documenting that self-esteem is bolstered when people assimilate their status to that of upward targets, and that they gain useful information from their observations of superior others. As Collins observed on the basis of her 1996 review of the social comparison literature, "Ultimately, positive self-regard depends on striking the proper balance between the number of people who are better than oneself and the number who are worse'' (p. 65). Unfortunately, her conclusion provides little guidance regarding the optimal composition of a support group.
Even if the literature yielded more consistent propositions about the dimensions of comparison that enhance self-appraisals and mood, it contains no information about how the social comparison process might affect group cohesion and the exchange of support. For example, it is conceivable that exposure to a target who is perceived to be coping less effectively than oneself might raise one's self-esteem, but it may also result in rejection of the target due to the distressing affect that he or she is displaying. Indeed, most people who refuse invitations to join a support group or who drop out explain that they do not want to expose themselves to others' distress and complaints.
A second factor that militates against systematic experimentation with group composition is logistical. Those who convene support groups usually do not have the luxury of selecting the optimal membership because there are too few candidates for the groups to match people on the relevant dimensions, and most agencies do not have the resources or know-how to screen prospective participants in advance. For example, if the local chapter of the Alzheimer Disease Association attracts only 10 caregivers who are interested in attending a support group, half of whom are elderly spouses and half middle-aged daughters, and their demented relatives range from mild to severe cases, then the organization is ethically bound to offer them a group despite these apparent differences. Moreover, even when a large number of prospective group participants is available for group assignment, if a formal evaluation is in the offing, then random allocation of participants to experimental and control or comparison conditions may preclude appropriate matching within groups.
In sum, although there is little doubt that the social comparisons that occur both overtly through discussion and covertly through observation constitute a fundamental process whereby support groups influence adaptation, there exist no guidelines regarding ways of structuring the group's membership to optimize the support process and beneficial outcomes arising from it. Short of exploring how the support process and its outcomes are affected by systematically varying certain dimensions of comparison, such as the stage and severity of the members' stressful experience or their apparent mastery of their circumstances, researchers can gather information directly from members about their preferences for and reactions to their fellow sufferers. If an individual with a mild case of Multiple Sclerosis does not wish to see and hear from someone who is confined to a wheelchair due to the disease's progression, then they can report this before or after their first group session. Similarly, if a teenager who is acutely distressed by his parents' recent separation finds it reassuring to talk to youths who are calmer now that their parents have concluded the divorce and each has established a new household, then they can report this. Such information can be immensely helpful to other practitioners by informing their decisions about the composition of
Support Groups subsequent support groups, and it can enrich social comparison theory by adding knowledge based on intervention.
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