Support Groups Research Paper

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A support group is composed of from 6 to 10 people who share a similar life stressor, transition, affliction, or noxious habit, and who receive expert information and training, and exchange mutual aid for a predetermined period of time in order to foster improved coping and adjustment. This research paper will present the rationales for and core characteristics of support groups, it will review evidence concerning their impacts on participants, and it will discuss the varied ways in which the groups’ structures and formats affect the support process.

Outline

I. Introduction

II. Definition and Overview

III. Rationales for the Implementation of Support Groups

IV. Core Characteristics of Support Groups

V. The Impacts of Support Groups

A. Support Groups for Caregivers of Elderly Relatives

B. Support Groups for Cancer Patients

VI. Linking Group Structure, Processes, and Composition to Outcomes

A. Documenting Support Group Processes

B. Support as a Means or as an End

C. Group Composition and the Bases of Similarity

D. Adapting the Group to Personal Coping Styles

VII. Potential Risks and Shortcomings of Support Groups

VIII. Conclusion

I. Introduction

Jimmy Armstrong’s Mom knows that every Tuesday she is to pack a double dessert in Jimmy’s lunch pail because that’s the day he attends his K.O.P.S. group in Pioneer Elementary School. The acronym stands for Kids of Parental Separation, but none of the eight sixth-grade students who attend this weekly support group would recall that. All they know is that, halfway through the hour, they get to dump the extra desserts in a pile on the table, and then pick numbers from a hat to determine the order of choosing the desserts. On this, the fifth of eight meetings, the hat will do extra duty because each of the children is supposed to deposit a question, an upset, or a happiness in it, and then, one by one, each child will choose a slip of paper, read it aloud, and discuss it with the group. Ms. James, the social worker from the local community mental health center, and Todd Williams, a high school senior whose parents separated when he was in grade six, will help lead the discussion of each note. They have a way of getting the group to talk about the things they feel angry, sad, and glad about without anyone getting too upset. Last Tuesday, when Jimmy’s Mom picked him up from school, she was amazed because, for the first time, Jimmy told her how much he missed Dad, but not the fights she and Dad always had after he went to bed.

Carol Swenson, 48-year-old mother of two active teenagers, and daughter of Sylvia, who was recently pronounced to have Alzheimer’s Disease, attends a support group called ‘‘Coping with Caregiving.’’ So far, the best thing that has happened in the group is that the leader taught the members some very practical techniques of managing their anger toward their relative and of relaxing by using their imagination and their muscle control. The worst thing that has happened is that, 2 weeks ago, one group member’s demented relative actually died from the disease. What made the death so hard to understand is that the deceased was only 63 years old and in perfect physical health. Carol knew this because the group members bring pictures of their relatives to each meeting, and this relative’s picture displayed a vital gentleman wearing a pair of shorts that showed off his muscular legs. But as Dr. Morton, the group facilitator, pointed out, there was nothing that could have been done to prevent or postpone the death, and it surely was softened by the love and compassion of a dutiful wife. In fact, although frightening, the death seemed to draw the group members closer together, and some members were beginning to call one another and even get together between meetings. It looked like more lasting friendships were being formed.

At 7:30 a.m., in the Hotel Excelsior’s fitness center, 10 middle-aged men sit around a treadmill, 8 of them sitting in pairs while pouring over the results of their latest stress tests. One of the men is their physician and another is an occupational therapist. The members of this ‘‘Heart Club’’ have met together on a biweekly basis for the past 6 months. After the first few meetings in the cardiac rehabilitation unit of the hospital, the group’s venue changed to the hotel’s fitness center because it was located within easy striking distance of each member’s workplace. They had also formed a buddy system so that each of them had a partner to call if he wanted to work out with someone or just talk about how to deal with a boss who had forgotten to ease up on the pressure or with a spouse who was afraid of the exertion required by lovemaking and lawn mowing. Today, the topic was called ‘‘Stress: Body and Soul.’’ The format was always the same, beginning with a lecturette by the doctor on the body’s response to stress, followed by a half hour of experience swapping among the participants. After the hour meeting, the Heart Club adjourned to the bagelry downstairs to enjoy the food and camaraderie.

II. Definition and Overview

These are only three examples of a vast and growing number of support groups that have been organized by virtually every health and human service organization in North America. As the examples reveal, support groups have been convened on behalf of people of all ages who face a wide range of adaptive challenges that call for more specialized or intensive support than is naturally available to them. The groups are typically led or co-led by professionals who meet with from 6 to 10 people who are facing similar stressful events, transitions, or circumstances, or who have in common an affliction, disability, noxious habit, or problem in living. Typically, once composed, the support group is closed to new members, and meets on a regularly scheduled basis for a predetermined period of time and number of sessions. Although there are innumerable variations, the standard format involves the transmission of information and skills by one or more professionals, and exchanges of information and mutual aid among the participants. In principle, the combination of expert and experiential knowledge in the context of a supportive peer culture creates optimal conditions for improved coping and adaptation.

This research paper sets out the distinguishing characteristics of support groups, including their basic structural properties and formats. It explains the theoretical justification for this type of psychosocial intervention, and delves into the social influence processes that arise during the course of the intervention. Drawing on recent reviews of support groups for cancer patients and family caregivers of elderly persons, it weighs the empirical evidence concerning the mental health impact of such groups, spotlighting aspects of their design, composition, and process that deserve greater attention in the future.

III. Rationales for the Implementation of Support Groups

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 prospectively 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 stressbuffering 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 mutual 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.

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 Lichtman 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 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.

IV. Core Characteristics of Support Groups

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 thereby to temporarily enrich and specialize, if not compensate for deficiencies in the support available from the participants’ natural networks. Like psycho-educational 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?

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

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 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, 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 Gerrard 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 subsequent support groups, and it can enrich social comparison theory by adding knowledge based on intervention.

V. The Impacts of Support Groups

To properly assess the impacts of support groups, it is necessary to adhere to the requisites of a scientific evaluation. This means that ideally, a reasonably large number of participants should be randomly assigned to support and control or comparison groups, and outcomes should be standardized and examined well after the formal intervention concludes. In addition, it is desirable to carefully document the actual substance of the intervention so that any observed effects can be appropriately attributed to the intervention maneuvers. For example, if the process of experience swapping consumes virtually all the group’s time, then any effects can be reliably attributed to this component of the intervention. However, few investigators have been able to devote the resources and develop the tools needed to gauge the differential impact of the several components that typically comprise support groups. These components may include educational input from expert sources, skill training, supportive contact among members within and between group sessions, homework assignments, and more general group discussion and problem solving. Hence, to date, evaluations of this multifaceted social intervention have not isolated the effects of its components.

As one might expect, it is impossible to offer any general conclusions about the mental health impact of support groups because of the sheer volume of studies that have been completed and the many differences in the characteristics of the participants and their stressful predicaments, the structure, format, and content of the group sessions, the ‘‘dosage’’ (number, length, and duration of the group sessions), as well as the measures used to tap outcomes. Although there are many individual reports of support groups that have had impressive and relatively lasting desirable mental health effects, there are also many articles reporting marginal or null effects.

There have been three critical reviews of the literature on the effects of support groups for family caregivers of elderly relatives (Bourgeois, Schulz, and Burgio in 1996, Lavoie in 1995, and Toseland and Rossiter in 1989), and two concerning their effects on cancer patients (Fawzy, Fawzy, Arndt, and Pasnau in 1995, and Helgeson and Cohen in 1996). Generally, the evidence strongly suggests that the typical, short-term support group that meets on a weekly basis for 6 to 10 sessions does not have a comparative edge in terms of its mental health effects. The impact of longer term groups, specifically, groups that meet for at least 6 months, shows more promise. However, as discussed later, the group’s duration is not the only factor that affects its success.

A. Support Groups for Caregivers of Elderly Relatives

Although the evidence is mixed, the general consensus is that groups for the caregivers of elderly family members have a negligible impact on mental health outcomes, measured by widely accepted psychiatric symptom, general distress, and burden scales, and by indices of socioemotional functioning. Toseland and Rossiter’s careful review of this literature led them to conclude that the groups should be composed of more homogeneous subgroups of caregivers, such as separate groups for spouses and adult children, and that they should last longer, gauge more specific behavioral changes, and experiment with alternative formats and curricula. Finally, both Lavoie and Bourgeois, Schulz, and Burgio suggest that support groups may not address the unique circumstances and needs of individual caregivers, and therefore in many cases the outcomes that are measured are not relevant.

Generally, family caregivers report high levels of satisfaction with their group experience, and deeply regret the fact that the group must terminate after the prescribed number of sessions. This suggests that a short-term model of practice is inappropriate for a population that is dealing with a host of chronically stressful demands that change over time. Most family caregivers require continuing support, training, and guidance, in addition to a range of community services that can alleviate the objective burdens they shoulder. As Lavoie observed in 1995, ‘‘To expect to change well-established behaviors such as personal coping styles, or deep-seated dynamics such as anxiety or depression over the illness of a loved one and the need to care for that person, by means of a limited number of group meetings with peers could seem like wishful thinking’’ (p. 589).

Even more fundamental questions can be raised about the nature and meaningfulness of the mental health outcomes that have been gauged. Is it appropriate to reduce feelings of sadness and loss when such feelings are to be expected under the harsh circumstances imposed by dementia? Should a statistically significant reduction in anxiety or depressive affect be considered meaningful apart from its clinical significance? Are there other mental-health-related variables that may be more important to the subjective wellbeing of family caregivers, and more amenable to the influence of a support group? For example, through group discussion and social comparisons, the members may come to adopt a more sanguine perspective on their situation, normalize their feelings of frustration and loss, and even rid themselves of the guilt they anticipate experiencing if they were to avail themselves of respite programs and solicit more help from other family members. These are important potential contributions of the support group, yet they have not been systematically addressed in evaluations of its effects.

B. Support Groups for Cancer Patients

Reviews of the mental health effects of support groups for cancer patients have also yielded mixed results. In 1995, Fawzy, Fawzy, Arndt, and Pasnau identified 15 ‘‘group interventions’’ for cancer patients, the majority of whom were women who participated in heterogeneous groups composed of patients with mixed diagnoses and with both initial and recurrent /metasticized disease. With one exception, the groups met from 4 to 11 times over a period of from 2 to 8 weeks, and typically included education, stress management (coping; relaxation) training, and mutual aid. In 1996, Helgeson and Cohen identified seven evaluations of support groups that involved various degrees of peer discussion and education from expert leaders, as well as four studies that compared the effects of group discussion only to the effects of education only or combined education and group discussion. Both reviews underscore the fact that many of the studies did not meet the requirements of a formal randomized controlled trial (RCT).

Fawzy and colleagues concluded that separate support groups should be convened for cancer patients who are newly diagnosed or in the early stage of treatment versus those who have advanced metastatic disease. They suggest that the former population benefits most from a structured, multifaceted, short-term program that combines didactic education, skill training, problem solving, and mutual support, whereas the latter population benefits most from a long-term, weekly support group that concentrates on shoring up the participants’ daily coping and pain management skills, while offering the empathic understanding and emotional validation of peers. Both reviews cite the support groups for metastatic breast cancer patients that Spiegel, Bloom, and Yalom organized in 1981, as exemplary of the kind of long-term program of support that appears to be needed by and of benefit to patients with advanced disease. It consisted of weekly, 90-minute sessions that lasted for 1 year and focused on ‘‘. . . the problems of terminal illness, including improving relationships with family, friends, and physicians and living as fully as possible in the face of death’’ (p. 527). Each of the three groups they organized was co-led by a psychiatrist or a social worker and a counselor whose breast cancer was in remission. The group’s main emphasis was on the development of an emotionally sustaining culture, not on educational material supplied by the leaders. Finally, participants also had supportive contact with one another outside the formal group sessions, and after the 1-year mark of data collection, the survivors continued to meet as a group for a second year and informally thereafter.

The findings of this RCT underscore the importance of offering a relatively long-term program of support, and of measuring various intervention effects at several points in time. Specifically, compared to the control group, those in the three support groups reported better adjustment after a year but not at the 4-month or 8-month time points. That is, the effects of the intervention on total mood disturbance, and on the subscales of tension-anxiety, vigor, fatigue, and confusion appear to have been cumulative in nature. Moreover, in 1989, Spiegel, Bloom, Kraemer, and Gottheil presented a 10-year follow-up of the study participants that revealed that the intervention increased survival by 18 months.

In comparing the effects of short-term groups that concentrate on discussion and support with the effects of groups that concentrate on education, Helgeson and Cohen tentatively conclude that the latter demonstrate superior adjustment benefits. This is not to say that the support and discussion component is superfluous, but that the education component is necessary to achieve desired effects. It may be that people who have been diagnosed with cancer need the technical information that professionals provide, and gain a stronger sense of security from the professional’s presence and special interest in the group members. It is also possible that feelings of control and predictability are uniquely predicated on the authoritative information and skill training professionals provide. In contrast, Helgeson and Cohen suggest that groups that concentrate strictly on peer support may undermine feelings of control if they disrupt denial or other emotionally avoidant modes of coping. In addition, they may adversely affect participants’ reactions to their illness by exposing them to peers who are losing their battle with cancer, or who raise frightening topics that are not worked through with professional guidance, or whose cancer site and stage are so different that they cannot validate one another’s emotional experience. In the future, more careful measurement will be needed to identify these and other potential mediating processes associated with the peer and professional sources of influence in the group.

VI. Linking Group Structure, Processes, and Composition to Outcomes

There is a tight interdependence among the structure, composition, and process of support groups. Leaders can place varying emphases on the experience-swapping, behavioral-training, and information-dissemination functions of the group, thereby affecting the group’s cohesion, intimacy, and overall social climate. Leaders can concentrate on either the emotional or the instrumental coping assistance offered by the group, and establish norms governing the extent and style of disclosure, confrontation, and affective release. There are also vast differences in the training and orientation of leaders themselves, a factor that is rarely taken into account in interpreting and comparing the effects of the groups. Moreover, the credentials and style of the leaders can play a critical role in recruiting and retaining group participants. For example, experience shows that support groups for male cardiac patients are more successful when the leader is a staff member with medical training in heart disease, the group is introduced as a routine aspect of medical care, and is called a rehabilitation group rather than a support or therapy group, and when wives are not included in the same group because they would interfere with their husbands’ tendency to resist discussing their feelings about the threatening aspects of their condition. Hence, the group’s composition can powerfully affect its process.

A. 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 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 psychoeducational 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.

B. Support as a Means or as an End

When program planners consider participants’ needs for supplemental coping resources, they must assess not only the kind of resources that are needed, but also how long they will be needed. Earlier, evidence was presented in favor of the efficacy of longer term groups for patients with advanced cancer and for family caregivers. It stands to reason that the duration of the support group should be matched to the duration of the adjustment demands faced by the participants. Chronic disorders, disease, and life difficulties may require ongoing or prolonged support, whereas time-limited acute life events and transitions may be addressed through a short-term group. Moreover, those designing support groups may wish to use the group as a way of permanently adding similar peers to people’s natural social networks. This may be called for when existing network members are unable or unwilling to extend the kinds of practical help and emotional support that are needed because they feel helpless, drained or threatened, or because they have become critical, emotionally overinvolved, or overprotective. Among the techniques that can be used to accomplish this is to explicitly state this goal at the outset of the group, informing members that they can choose to continue to meet on their own following the final formal group meeting, and that a resource person can be made available to them when needed. In addition, members can be encouraged to have contact with one another between the group sessions, either informally or by setting up a rotating or permanent buddy system with or without a specific agenda. For example, buddies can be encouraged to simply call one another when they need extra support and dialogue, or to practice together the skills they have learned in the group. Naturally, to examine the impact of such supplemental support, records must be kept of the kind and amount of extra-group contact. Evaluation researchers should also keep in mind that social support may be an end in itself, rather than a means to an end. That is, the goal of some groups may be to combat social isolation by establishing durable and intimate dyadic or group ties among the members, as in the case of support groups for chronically mentally ill persons or teenaged, sole-support parents. Other groups may concentrate on mobilizing support as a resource for resisting stress-induced disease, illness, or maladjustment, or for promoting more positive functioning.

As discussed earlier, as long as the members perceive one another as similar peers, social comparison will be an ongoing covert process throughout the course of the group. Ideally, in composing the group, some thought should go into ways of exploiting this psychological process to the best advantage of the participants. For example, in most self-help groups there is a ‘‘veteran sufferer’’ who serves as a model of effective coping and thereby instills hope and motivation to comply with the group’s behavioral prescriptions. Social comparison theory also postulates that, to accomplish its stress-reducing effect, the companions must be perceived to be reacting relatively calmly to their situation, suggesting that support groups are not appropriate during periods when people are feeling emotionally overwhelmed. It is therefore advisable to recruit participants only after they have recovered from the initial shock of a crisis, and are ready to commence a structured and paced social support program.

Once it is conceded that experiential similarity serves as a stronger basis for mutual identification and empathic understanding than structural similarity based on age or marital status, for example, questions arise concerning how similar the common experience must be in order for the participants to attend and compare themselves to one another, and to develop bonds of affection and belonging. For example, for a group of recent widows, their bereavement is probably not sufficient to level differences based on the cause and age of their partner’s death. It is unlikely that widows whose husbands had died of heart attacks would perceive themselves to be ‘‘in the same boat’’ as widows whose husbands had been murdered or killed in a traffic accident or who had died in the line of wartime fire or by taking their own lives. The same careful consideration of the bases of similarity is warranted in planning the composition of virtually every group for people who have undergone stressful life events and transitions, such as parental death or divorce, retirement, new parenthood, job loss, serious accidents, and illness diagnoses. Three factors in particular warrant consideration: (1) the contextual or situational parameters that are likely to be most salient to the participants; (2) factors that are known to affect people’s risk status; and (3) the probable trajectory the participants will experience. For example, in composing support groups for the family caregivers of elderly relatives, program planners should recognize that caring for a relative afflicted with dementia poses greater risk to the mental health of the caregiver than caring for a frail but cognitively intact relative, and that the future course of dementia is distinctly different from other disabilities and conditions. Hence, it would not be advisable to compose a group that combines caregivers in these contrasting situations. Of course, if the prospective participants are children or youth, it is necessary to ensure that the group content and composition is developmentally appropriate.

Finally, the similarity of the participants not only bears on their ability to relate and compare themselves to one another, but it also affects the substantive content of the educational component and ultimately, the impact of the intervention. As noted earlier, reviews of the support group literature have been consistent in their criticism of the heterogeneity of groups, arguing that interventions will impact differently on various subgroups of participants and suggesting that null results may mask differential effectiveness for such subgroups. In addition to structural and experiential differences among participants, they may also differ on the basis of the stage of the condition or problem they face, their use of both informal and formal supports in the community, and a number of personality and coping factors that affect their receptiveness to and benefit from this type of intervention.

D. Adapting the Group to Personal Coping Styles

This brings us to the larger question concerning the personal characteristics that distinguish those who gravitate toward support groups from those who decline participation, and those who are most likely to benefit from those who do not benefit or who may be adversely affected by joining such a group. Although only rarely reported, refusal rates for support groups are quite high, and to a lesser extent, attrition is a problem as well. Aside from the standard psychological (e.g., stigma and fear of disapproval or rejection) and logistical (e.g., access, scheduling, and coverage of competing demands such as childcare) impediments to participation in any social program, support groups pose some unique threats and offer a particular way of coping with one’s difficulties that does not have universal appeal or benefit.

The threats posed by support groups include a fear of becoming overwhelmed by attending to and disclosing one’s difficulties, and by exposing oneself to the more severe difficulties faced by other group members, especially if those difficulties preview one’s own possible fate. Although some members may benefit from this because of the anticipatory coping and sense of control such advance information may promote, others may cope most effectively by keeping such information out of conscious awareness. In short, differences in people’s coping styles may powerfully affect their interest in and the value they gain from participating in support groups. Specifically, differences in information and help seeking, and more generally, avoidant versus approach-oriented coping styles under threat, may distinguish between those who are attracted to and make good use of the group experience and those who do not. In plain language, some people deal with threat by seeking as much information about it as they can and by venting their fears and emotional distress, whereas others maintain their equilibrium best by avoiding threatening information and blunting their emotions. In their 1996 review of psychosocial interventions for patients with chronic physical illnesses, Devins and Binik cite numerous studies revealing that social programs that concentrate on imparting information are more effective when they are matched to the participants’ information processing style. Hence, ‘‘blunters’’ may fare better with more structured, task-centered, behavioral intervention protocols, whereas ‘‘monitors’’ may respond best to formats that provide plentiful details about the stressful context, and that allow them to discuss their feelings and experiences, and to ask questions.

Depending on how they are marketed and actually run, support groups may be more or less threatening or attractive to people with contrasting information and support-seeking coping styles. As noted earlier, if they smack of group therapy with all of its emotional trappings and disclosure requirements, or if their advertisements promise to deliver detailed information about the more threatening aspects of the present and future, then they are likely to be shunned by and maladaptive for those who tend to regulate their emotions by avoidance and distraction. Indeed, the combination of unbridled emotional expression among peers and abundant information from experts is likely to drive the blunters away, while appealing to the monitors whose emotional self-regulation and sense of control are augmented by these two components. It follows that, in both advertising and implementing groups, the format, emotional climate, and type of information supplied should be pitched differently, depending on the prospective participants’ coping styles. Where feasible, a measure of their information-processing style can be used as a screening and group placement tool. If this is not possible and people with different styles are assigned to the same group, then potential moderating effects of these coping styles can be tested to determine whether they have influenced intervention outcomes.

VII. Potential Risks and Shortcomings of Support Groups

If prospective participants are geographically dispersed, as is the case for people who reside in rural areas, then logistical difficulties may prevent them from attending a support group. Alternatives that have recently been initiated are to create telephone and electronic mail support groups. By means of teleconferencing and occasional face-to-face visits, much of the experiential knowledge and a substantial amount of emotional and esteem-relevant support can still be exchanged in such groups. A second shortcoming is that support groups do not allow for the individualization of helping. Thus, what is gained in cost efficiency through the group format is lost in personalized attention. However, in many instances, support groups are designed to supplement rather than to substitute for the individual counseling or treatment offered by mental health or medical practitioners, and so members’ unique needs are addressed. Moreover, when individual counseling precedes support group participation, the counselor may be able to make more judicious judgments about group assignments. As Gottlieb pointed out in 1988, there are also several types of one-to-one formats for marshaling support that may be better suited to people’s needs and preferences than a group intervention. Hence, practitioners should consider and even compare the effectiveness of alternative support strategies.

Third, support groups can have adverse social repercussions. They can threaten natural network members who perceive the group as an affront to the support they offer instead of recognizing that the support of similarly stressed peers is a vital complementary coping resource. The group leaders can guard against such resentment, injury, or backlash from the participants’ network members by not only advising the participants to explain the special value of the support group, but also by inviting key network members to attend a meeting of their own in which they can ask questions, air their concerns, and learn how they can optimize the group’s impact on their associate. A related social and ethical concern that has not received sufficient attention from group planners is the potential negative effect of withdrawing the peer support when the final group session has ended. In virtually every published report of support groups, the members lament the group’s termination. This suggests that many groups do, in fact, terminate prematurely and ought to have a longer course or at least offer the members the option of continuing to meet on their own as a mutual aid group or at least to socialize with one another. Naturally, this will not be possible if the participants are minors or if they are dealing with such sensitive or technical matters that they require professional guidance. In any case, it behooves the group leaders to carefully plan for the group’s termination, and to monitor any rebound effects that may result there from.

Finally, as is the case for all group interventions, there is the possibility that a negative emotional contagion will spread through the group, especially if the members face circumstances that are known to deteriorate over time or suffer from a condition that has a poor prognosis. Many practitioners question the wisdom of bringing together people with terminal diseases such as cancer because they fear that they will only exacerbate their distress and further demoralize them. Although this adverse development is certainly possible, its likelihood can be minimized by leaders who carefully monitor and control the group’s affective tone. Moreover, those who clinicians worry about most are usually people who suffer from both social and emotional isolation, and who therefore are most likely to benefit from the empathic understanding, companionship, and solidarity that a support group can offer. It is also important to keep in mind that people want to be well and that the support group can teach participants how to reinforce one another’s wellness rather than their distress.

VIII. Conclusion

If there is a single message that deserves emphasis it is that practitioners need to attend more closely to the composition and duration of support groups, and apportion the time allotted to expert information and peer interaction in a way that suits the participants’ needs and coping styles. Where possible, the group’s composition should be determined by taking into account at least three sets of similarity factors, namely, experiential similarity, structural similarity, and similarity in the members’ information-processing style of coping. Sustained rather than brief groups are called for and have proved more effective for chronic life difficulties, role strain, and other circumstances of unremitting demand, whereas short-term groups are called for during periods of crisis and transition.

Support groups have broad, although not universal, appeal. For people who tend to cope by seeking information and affiliation with similar peers, such groups can reduce distress and promote adjustment. Yet the processes implicated in the group’s ameliorative psychosocial impact are not well understood. For this reason, more careful documentation is needed of the physiological, behavioral, and psychological mechanisms that underlie this mode of intervention. In addition, there is a need for comparative studies that systematically vary the group’s structure, composition, and emphases, in order to discern how the process and outcomes are affected. Although mental health ranks among the most important of these outcomes, the support group may also give the participants a sense of reliable alliance and belonging that can dispel their feelings of emotional isolation. At bottom, the support group is a highly specialized personal community that gives full expression to the human impulse to care for others and to be cared for by them.

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