Your best interests at heart?
‘I’M afraid you’re suffering from a lack of social support,’ said
the physician in a grave tone. ‘Consequences of this malady include
heart disease, complications during pregnancy and childbirth, a whole
host of infectious diseases, as well as higher blood-pressure and
heart-rate reactivity to acute stress. I have scheduled you for a
course of socially supportive interactions, which will begin
immediately. These interventions will take place during acutely
stressful events in your life, such as traffic jams and work
situations, and will serve to reduce your blood-pressure and heart-rate
reactivity at these times.’
The above exchange is unlikely to be heard in many contemporary,
biomedically focused healthcare settings. But a body of
epidemiological, experimental and intervention research has highlighted
the positive impact of social support on cardiovascular health. Does
this state of affairs reflect a worrying disconnection between medical
practice and the latest psychological research? Or is it simply
the case that we psychologists have been premature in promoting the benefits of social support for the cardiovascular system?
The concept of social support
Psychologists have long examined the impact of social relationships
from a variety of theoretical perspectives, including social exchange
theory, social comparison theory, evolutionary theory, attribution
theory, and psychodynamic theory. However, by far the most empirical
work has taken place within the domain of coping theory, particularly
as represented by Lazarus’s transactional model of stress (1975).
According to this model, a stress response is elicited when an
individual appraises that they do not have sufficient resources to cope
with a given situation. One such coping resource is social support. The
suggestion that social support exerts a beneficial effect by
influencing the individual’s appraisals of potential stressors and
coping resources is known as the ‘stress-buffering hypothesis’ of
social support (Cohen & Wills, 1985). This compares with the
‘direct effects hypothesis’, which purports that all social support is
good, regardless of the individual’s perception of stress in the
environment (Barrera, 1986). Whichever theory is favoured, however, the
coping perspective requires that a variable called ‘social support’ can
be constructed and measured.
However, neither a universally accepted definition, nor a coherent,
widely applied measurement approach exists. Taylor (2003) summarised
past attempts at defining social support as follows:
information from others that one is loved and cared for, esteemed and
valued, and part of a network of communication and mutual obligations
from parents, a spouse or lover, other relatives, friends, social and
community contacts such as clubs, or even a devoted pet. (p.235)
Even this reasonably comprehensive description fails to encompass all
aspects of the social support construct that have been examined to
date. For example, many authors have proposed taxonomies of social
support types. House (1981) distinguished different functions of
support: emotional, instrumental, informational and appraisal. Sarason
et al. (1990) separated tangible, informational and emotional support.
Importantly, Sarason et al. suggested that it is the perception that
support is generally available, whatever its specific nature or
function, that affects personal working models of social support, and
presumably, health and other outcomes.
Other authors (e.g. Tardy, 1985) have recommended that a useful
distinction can be drawn between ‘available’ support and ‘enacted’
support, highlighting the potential for perceived availability of
support to be just as effective as support that has already been
received.
The impact of social support
In spite of the absence of a consensual or consistently applied
definition of social support, a body of research spanning two decades
has nonetheless documented a robust association between constructs
related to social support and better physical health. Strong
epidemiological evidence links social support to lower risk for
all-cause morbidity and mortality (House et al., 1988). Particularly
strong evidence supports a link between high social support and lower
coronary heart disease rates. Social support is inversely related to
cardiovascular morbidity (Cohen, 1988) and mortality (Orth-Gomer, 1994).
However, population-based surveys have failed to clarify important
questions concerning causation and causal direction in the relationship
between social support and health. In other words, epidemiological
research does not shed light on whether social support enhances health,
or whether people with better health simply attract more social
contacts. Such uncertainties have been particularly influential in
stimulating the development of experimental methods for analysing the
effects of social support on health parameters.
Social support and stress in the laboratory
One common way of studying the effects of social support on stress
responses involves examining the effects of social support on
cardiovascular reactivity (CVR) to psychological stress in the
laboratory. This approach is based on a theory known as the ‘reactivity
hypothesis’, which proposes that excessive cardiovascular response to
episodic stress contributes to the development of hypertension and
coronary heart disease (Krantz & Manuck, 1984). People with high
levels of CVR are believed to be at increased lifetime risk of of
developing high blood pressure and heart disease (Lovallo & Gerin,
2003).
In the majority of social-support studies, CVR is measured by recording
blood pressure and heart rate. CVR is relatively stable over time
(Sherwood et al., 1997) and, as with other physiological measures, is
less contaminated by social desirability factors than psychometrically
assessed dependent variables such as questionnaire measures of stress
and anxiety. The ability to measure and interpret such a variable
generates an attractive context for researchers to examine the impact
of social support in controlled laboratory settings. Recent
social-support research employing CVR
as a dependent variable displays much experimental sophistication and
has yielded some useful empirical evidence that has the potential to
guide the design of socially supportive interventions.
Two main approaches have been adopted in research examining the
support–CVR relationship: the study of the effects of laboratory
analogues of social support on CVR, and the study of the relationship
between psychometrically evaluated quantity and quality of day-to-day
(outside the laboratory) support and CVR.
Laboratory social support and CVR Studies of the effects of
laboratory social support on CVR have employed slight variations on the
following protocol. First, participants rest quietly while baseline
measures of blood pressure and heart rate are taken. Then, participants
complete some stressful laboratory task, such as speech-giving or
mental arithmetic, either alone or in varying social support
conditions, and their CVR is recorded. Operationalisations of
laboratory social support have included mere presence, verbal praise,
offers of information, and even videotapes of people behaving in a
supportive manner. In general, studies employing this protocol have
reported an attenuating effect for social support on CVR (e.g. Kamarck
et al., 1990). However, some researchers have actually found higher
reactivity in support conditions (e.g. Allen et al., 1991).
Do all types of support have the same effects, so that simply trying to
help is enough? Or do we need to be careful to match the support we
give to the problem at hand? It is likely that different types of
support are differentially effective for different types of problems
(Mitchell et al., 1982). For example, if the support that is needed in
a given situation is mere presence, then friends and family may be only
as effective as strangers. If instrumental support is necessary, then
an expert who is a stranger might be more effective. However, due to
the use of different stressors, varied populations and disparate
methodologies across laboratory social-support studies it it difficult
to draw conclusions about which types of support are most effective at
attenuating CVR in the laboratory.
A major methodological issue in laboratory social-support research
concerns the identity of the support provider. Studies of the effects
of laboratory social support on CVR have used either friends of the
participants, or else confederates employed by the researcher, to
provide support in the experiment. Studies employing friends of
participants as supporters have generally indicated an attenuating
effect for support on CVR (e.g. Kamarck et al., 1995). However, Allen
et al. (1991) reported that reactivity in the presence of a friend was
higher than reactivity when alone. This higher reactivity in the
presence of a friend may be attributable to anxiety about being
evaluated by the other person, commonly referred to as ‘evaluation
apprehension’ (Thorsteinsson & James, 1999).
On the one hand, friend support is likely to mirror support received by
people in their everyday lives; but on the other hand, there are
standardisation problems when employing friends as support providers in
experimental research, even when they are trained to formalise their
behaviour while in the laboratory. In most instances, friend supporters
have been recruited by asking participants to bring along their
same-sex best friend. It is possible that people who have a friend
available to come with them to the laboratory differ from people who do
not have such a friend available, and this might account for some
between-group differences.
As a result of such problems, many investigators have sacrificed some
external validity for greater experimental control. These researchers
have employed trained confederates to provide standardised support to
participants. Some of this research indicates an attenuating effect for
confederate support on CVR (e.g. Kamarck et al., 1990) but there have
been exceptions (e.g. Edens et al., 1992). Furthermore, despite the
fact that these confederates are trained to provide equivalent support
across all participants, it remains likely that there will be some
slight differences in their behaviour across participants. One group of
researchers has attempted to overcome this problem by operationalising
social support as a pre-recorded video of either a supportive or
non-supportive confederate (Thorsteinsson et al., 1998). These
researchers found a significant attenuating effect for social support
on heart rate.
In a further interesting development, a team of researchers attempted
to study social support processes by focusing on availability of social
support rather than on enacted social support (Uchino & Garvey,
1997). The researchers instructed participants either that support was
available or that support was not available while they were to perform
a speech task. Even though the setting and procedure were the same for
all participants, both heart-rate and blood-pressure reactions were
observed to be reduced when participants were led to believe that
support would have been available if needed. Of course, such research
needs to be replicated before definitive conclusions can be drawn.
The picture is further complicated by the suggestion that a number of
behavioural and personality factors influence the relationship between
support and CVR. As well as evaluation apprehension, such potentially
moderating variables might include hostility, self-efficacy,
neuroticism and optimism, all of which appear to be associated with
blood pressure. The difficulty for researchers is that the list of such
variables is potentially endless, and some of them (for example,
evaluation apprehension) might be impossible for researchers to
eliminate. Given the predictions of social comparison theories, the
importance of evaluation apprehension is potentially great, and this
variable warrants much more attention in research.
But does the research really mean anything? Can laboratory analogues of
stressful situations adequately represent the complex set of
behaviours, thoughts and emotions that people experience in their
everyday lives? Davig et al. (2000) report that CVR associated with a
laboratory speech task was not the best predictor of CVR to a natural
speech task in their study (an oral defence of a thesis or
dissertation). In fact, CVR while watching a frightening movie was a
better predictor of CVR during the oral exam. This study had a very
small sample, however, and as psychologists working in stress research,
we need to focus on maximising the validity of laboratory analogues of
stress.
Psychometric social support and CVR As previously mentioned,
epidemiological research has implicated social support in the aetiology
of coronary heart disease. These epidemiological studies were based not
on laboratory manipulations of social support, but on sociological
constructions that represent the individual’s relationship with the
social network that has evolved around them in real life (Hughes,
2002). For that reason, studies that employ psychometric social support
as an independent variable may offer findings that are more
generalisable than those from laboratory social support and CVR
studies.
The experimental protocol employed in studies examining the effects of
psychometric social support on CVR is similar to that used in
laboratory social support studies. Participants perform some laboratory
task, which is designed to elicit a cardiovascular response.
Blood-pressure and heart-rate measures are generally recorded and
participants also complete questionnaires that assess social support.
Empirical evidence indicates that psychometric social support is an
individual difference variable, which is stable over time (Sarason et
al., 1986).
In the majority of such studies, the Social Support Questionnaire 6 (SSQ6: Sarason
et al., 1983) has been employed as a psychometric social support
measure. The SSQ6 yields scores for both quantity and quality of
psychometric social support (alternative questionnaires tend to measure
one or the other). Conceptually and empirically, it is important to
distinguish between these two facets of social support. A person who
reports having many friends may not be satisfied in their relationships
and indeed may not be in receipt of positive or usable forms of support
from them.
Despite offering an alternative perspective, the output of social
support and CVR research measuring social support psychometrically has
been low. The results of the five psychometric support and CVR studies
that have been conducted indicate no association between quality of
social support and reactivity. However, quantity tends to be positively
related with CVR. In other words, participants reporting higher levels
of psychometric social support show higher reactivity to laboratory
stressors (e.g. Hughes & Curtis, 2000; Roy et al., 1998). This
positive association between quantity of support and blood-pressure
responses to stress does not sit well with the epidemiological
findings. However, this paradox may result from conceptual issues
related to the definition of social support employed across the
different types of research.
One issue highlighted by research indicating negative effects of
psychometric social support on CVR is that our social relationships can
have negative, as well as positive, effects. Social exchange theorists
have long emphasised that social ties can have both negative and
positive consequences (e.g. Homans, 1974). We may receive instrumental
support in crises, emotional support for the ups and downs of daily
living and chances to appraise one’s situation relative to that of
others in ways that are beneficial for the self. But friendships can
also cause conflict, embarrassment, envy, invasion of privacy and
negative appraisals of one’s own life situation relative to the life
situation of others. Furthermore, having a greater number of people in
one’s social network increases the probability that one will have
friends and family members who become ill or die. Therefore, reports of
high quantities of social support (particularly with low ratings of
support quality) may well indicate, rather than attenuate, an increased
potential for life stress. Further research is required to clarify this
milieu.
Heartache and headaches
The emphasis on prevention in some recent healthcare initiatives suggests that
the establishment of risk factors for disease, and the design of
interventions (whether pharmacological or otherwise) to reduce the
prevalence of such risk factors is an important task. Lack of social
support, as we have noted, may be one such risk factor.
We have considered above the effects of social support on
blood-pressure and heart-rate reactivity to acute laboratory stress,
one aspect of the wider relationship between support and physical
well-being. Although much of this research is imaginative and its
findings enlightening, our understanding of the relationship between
social support and CVR remains far from straightforward. This shouldn’t
really surprise us: when it comes to aching hearts, friendship and love
are notoriously double-edged swords! It appears that those who wish to
do good – either paid professionals or just good friends – need to
tread carefully when offering social support in acutely stressful
situations.
- Aoife O’Donovan is in the Mental Health Research Unit, Department of Psychiatry, University College Dublin.
E-mail: [email protected].
- Brian M. Hughes is in the Department of Psychology, National University of Ireland, Galway.
Weblinks
Workplace social support and cardiovascular disease: www.workhealth.org/risk/rfss.html
Laboratory for the Study of Stress, Immunity and Disease: www.psy.cmu.edu/~scohen/
Information on cardiovascular reactivity: www.macses.ucsf.edu/Research/Psychosocial/
notebook/reactivity.html
Publications from the Whitehall II study: www.workhealth.org/projects/pwhitepub.html
Discuss and debate
Should social support be systematically incorporated into routine treatment programmes for cardiac and other patient groups?
What are the negative effects of social support?
Which aspects of social support are beneficial to physical health, and which aspects are detrimental to physical health?
Can we ever provide valid analogues of everyday social interactions in the controlled laboratory setting?
Have your say on these or other issues this article raises. E-mail
Letters on [email protected] or contribute to our forum via
www.thepsychologist.org.uk.
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(Please note that some pictures may have been removed for copyright reasons)
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