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1. Nature And Use Of Self-Help And Support Groups
As psychosocial interventions, support groups and mutual aid, self-help (MASH) groups have a great deal in common. Their members share a similar health concern, life event, role transition, or chronic stressor, and they exchange a variety of types of support through face-to-face interaction, bringing to bear their experiential knowledge to gain an understanding of their personal and collective predicament and of ways of coping with it. The diﬀerences between these two small group structures are that support groups are organized, governed, and led by professionals who provide supplementary expert knowledge or skill training, whereas MASH groups are self-governing, and led by individuals who are peers by virtue of sharing the group’s problem or concern. In addition, support groups tend to have a closed membership whereas MASH groups are open, and support groups tend to have a ﬁxed duration whereas MASH groups are indeﬁnite in duration. Finally, some MASH organizations engage in advocacy eﬀorts on behalf of marginalized or vulnerable segments of the population (Reissman and Carroll 1995), whereas support groups tend to look inward rather than outward. Both support and MASH groups diﬀer quite dramatically from therapy groups; the leader does not engage in any clinical activities, such as psychological assessment, and the members are not assigned to a group on the basis of their symptomatology, diagnostic label, or prognosis.
A recent national US survey revealed that approximately 7 percent of adults had participated in a MASH group in the prior 12 months, and 18 percent had done so at some point in their lifetime (Kessler et al. 1997). A similar study in Canada, also based on a national probability sample, revealed a much lower prevalence of 2 percent of adults who had participated in a MASH group in the prior 12 months (Gottlieb and Peters 1991). Perhaps the self-help ethos is stronger in the US than in Canada, where a national healthcare system may also serve as a disincentive to MASH participation. Humphreys and Klaw (1998) report that, in the US, there are MASH organizations for almost every major chronic condition and leading cause of mortality. Examples of the former include groups for arthritis suﬀerers, people diagnosed with ischemic heart disease, cancer patients, diabetics, and people with hearing and visual impairments. MASH organizations are heavily utilized by people with substance abuse and emotional problems, Alcoholics Anonymous (AA) being the most widely used of all MASH organizations and probably the most widely accepted by professional referral agents such as family physicians and addictions counselors. AA also has been subjected to more evaluation research than other MASH groups, one recent study ﬁnding that, over three years, participants decreased their daily alcohol intake by 75 percent while also eﬀecting substantial cost savings relative to those receiving professional outpatient treatment (Humphreys and Moos 1996).
Although no corresponding census has been taken of public participation in support groups, prior reviews of the literature have spotlighted the abundance of groups for cancer patients (Fawzy et al. 1995, Helgeson and Cohen 1996), family caregivers of older adults, particularly those suﬀering from dementia (Bourgeois et al. 1996, Lavoie 1995, Toseland and Rossiter 1989), and people coping with loss through death or divorce (Hughes 1988). The fact that support groups have been subjected to far more research than MASH groups testiﬁes to the greater ease of access they provide, due in part to their professional sponsorship and more casual attitude toward maintaining anonymity.
Both support and MASH groups function as specialized personal communities that supplement or compensate for deﬁciencies in the participants’ natural networks (Helgeson and Gottlieb 2000). These deﬁciencies may stem from the natural network’s inability to comprehend or tolerate the thoughts, feelings, and behaviors that arise from relatively novel stressors, the network’s impatience with or exhaustion from lengthy periods of rendering support and aid, or from other interpersonal dynamics that compromise the network’s prosocial behaviors, such as conﬂicts about appropriate ways of coping (Gottlieb and Wagner 1991) and emotional overinvolvement (Coyne et al. 1988). In some circumstances, coparticipants substitute for a natural network that has proved destructive, such as when the fellowship oﬀered by AA supercedes former drinking buddies (Humphreys and Noke 1997). In some contexts coparticipants serve functions complementary to the natural network’s, such as when a weight loss group helps to maintain the gains eﬀected by dietary changes at home.
2. Group Design And Dynamics
From the perspective of an observer, meetings of MASH groups and support groups would be virtually indistinguishable except for two diﬀerences. First, the support group would devote a portion of its time to education or training provided by an expert, whereas the MASH group would devote the entire meeting to the swapping of experiences and the exchange of support. Second, many, but not all MASH groups would operate on a 12-step model or a variation thereof, which consists of quite elaborate ideological formulations about the cause and source of diﬃculty and about the ways members need to think about their situations in order to come to terms or resolve them (Antze 1976). Underlying the 12-step belief system are the ideas of spiritual surrender and personal struggle, along with the need for moral cleansing and mutual aid. In contrast, support groups rarely import an ideology but develop their own norms, with whatever cognitive restructuring occurring as a result of the resources introduced by the professional leader and the inﬂuences arising from the members’ interactions.
Aside from these two diﬀerences, the same set of structural elements need to be considered in designing both MASH and support groups. These include: (a) the setting and scheduling of the group sessions, including their number, length, duration, and intervals; (b) the leadership, which may be consistent or rotating, and involve one or two (co-led) facilitators; (c) the group composition, taking into account demographic (e.g., age, gender, socioeconomic status), stressor-related (e.g., stage, severity), and copingrelated (e.g., extent of distress and resource mobilization) criteria; and (d) the format, including the extent of meeting structure, extra-group contacts among members, and behavioral training. To date, there has been relatively little research comparing the eﬀects on both the process and outcomes, as well as attrition, resulting from systematic manipulation of these structural elements. For example, little is known about ways of composing the groups to optimize the social comparisons that members make, and whether aspects of the social mix or of the problem they share more strongly aﬀect members’ attraction, participation, social learning and supportive exchanges in the group (Gottlieb 1998).
The beneﬁcial psychosocial dynamics that underlie the mutual aid occurring in both support and MASH groups include the emotional venting along with the validation and normalization of emotions that are gained from contact with similarly aﬄicted peers, the opportunity to enhance one’s sense of worth and control by providing support to others, a process that has been called helper-therapy (Riessman 1965), and the opportunities for self-enhancement and self- improvement that derive from the social comparisons that members make. These latter comparisons may take an upward, downward, or lateral direction, ideally respectively serving self-improvement, self- enhancement, and normalizing functions. For example, in a widely cited study, Taylor (1983) found that the vast majority of women with breast cancer found a real or imagined dimension on which they compared more favorably to other women with the same diagnosis.
These psychosocial dynamics have yet to be integrated within a comprehensive model of the process through which support and MASH groups exert an impact on health outcomes, whether psychiatric or medical. That is, to understand the mechanisms of action through which these psychosocial dynamics inﬂuence health and morale, competing theoretical models should be speciﬁed and tested. Cohen (1988), Stroebe et al. (1996), and Wills and Filer (1999) have described several potential direct and indirect pathways through which social support may aﬀect health, including physiological mechanisms, appraisal and reactivity mechanisms, and behavioral mechanisms of action. For example, it is presently unknown whether the increased survival time documented by Spiegel et al. (1989) and Fawzy et al. (1993) for women with metastatic breast cancer and malignant melanoma respectively resulted from mediating improvements in their immune and endocrine function, the enhancement of positive health behaviors such as diet, exercise, and compliance with their therapy regime, or a purely psychological process involving hope and a sense of being needed by interdependent group members. Naturally, there may also be a complex interaction among these mechanisms. The important point is that support and MASH groups that are informed by these models should be designed to impact the hypothesized mediating processes, and measures that are sensitive to change in these processes must also be included.
3. Group Impacts
Evaluation of the eﬀects of MASH groups has consisted largely of feedback regarding consumer satisfaction, not randomized controlled trials that administer standardized outcome measures at several intervals following the intervention. Indeed, since most MASH groups are open-ended in nature, allowing members to ﬂexibly come and go as their needs dictate, it is virtually impossible to assess anything that resembles a uniform intervention. Moreover, many MASH groups are not oriented to personal change, recovery, or improved adjustment; instead, they oﬀer acceptance, support, and fellowship to people who feel marginalized (e.g., people with developmental disabilities) or who have been stigmatized (e.g., people with mental illnesses), or people who live with and care for someone who has one of those statuses. In short, many MASH groups view support as an end in itself rather than as a means to other ends, rendering conventional outcome evaluation irrelevant.
Those MASH groups that have been rigorously evaluated consist of both ad hoc groups designed along self-help principles and groups that are part of a MASH organization, such as AA. Examples of ad hoc groups are parents of premature infants (Minde et al. 1980), bereaved wives (Marmar et al. 1988), and older adult men who have diabetes (Gilden et al. 1992). All three of these studies report signiﬁcant desirable health eﬀects that lasted for several months after the group ended, compared to less eﬀective or equally eﬀective but more costly comparison interventions such as psychotherapy. Though limited in number, evaluations of groups that are part of a larger MASH organization show similar beneﬁcial eﬀects, including Humphreys and Moos’ (1996) study of participants in AA, and Lieberman and Videka-Sherman’s (1986) study of bereaved participants in THEOS (They Help Each Other Spiritually). One provocative ﬁnding of the latter study is that participants who developed friendships through their group experience achieved signiﬁcantly better adjustment than those who did not, suggesting that MASH group eﬀects are magniﬁed for those who have the social skills, personality, or motivation to convert a tie based on shared organizational membership and stressful circumstances into a strong personal tie.
As previously noted, there exist far more evaluations of the health impact of support groups than of MASH groups, including review papers on groups for cancer patients, the family caregivers of elderly persons with dementia, and the bereaved. Both within and across these three stressor contexts there is much variability in the characteristics of the participants, the structure, content, and format of the meetings, and the measures used to tap the intended eﬀects. The only constant is the ‘dosage,’ with the vast majority of groups meeting between 6 and 10 times for 1–2 h on each occasion. As for the impacts, there seems to be far more consensus about the limited impact of support groups for family caregivers than for the other two stressor contexts.
Speciﬁcally, the evidence shows that the mental health of family caregivers does not improve much from such a brief intervention, but that longer-term groups and groups that involve skill training that is tailored to situational demands and needs eﬀect larger gains, whether measured in terms of general (e.g., depressive aﬀect and anxiety) or domain speciﬁc (e.g., role performance and hostility toward the recipient of care) indicators (Gottlieb 1998, Lavoie 1995, Toseland and Rossiter 1989, Ostwald et al. 1999). It appears that a short-term intervention is not matched appropriately to the chronic character of the caregiving experience, and it is also hard to see how such a limited group experience can mitigate the distress that is a natural biproduct of helplessly witnessing the deterioration of a family member.
Fawzy et al. (1995) also concluded their review of the eﬀects of support groups for cancer patients with the recommendation that short-term groups were best suited to the needs of newly diagnosed patients who are early in their treatment, whereas long-term groups were better suited to those with advanced metastatic disease. An example of the latter is a year-long support group intervention that involved weekly 90-min meetings plus abundant extra-group contact among the members, women who had metastatic breast cancer. Co-led by a professional and a counselor whose breast cancer was in remission, the group achieved better adjustment (e.g., mood disturbance, tension-anxiety, vigor, confusion) than a control group by the 12-month measurement interval, but not by the two preceding 4-month and 8-month intervals. Moreover, by the time of the 10-year follow-up, the support group participants had increased their survival time by 18 months relative to the control group. Although this study gives reason for optimism about the health beneﬁts of longer-term support groups, the ﬁndings must be replicated before any deﬁnitive conclusions can be drawn. Moreover, future research should devote more attention to identifying the mechanisms underlying the group’s ameliorative eﬀects and determining which subgroups of participants and which disease diagnoses beneﬁt most from this type of psychosocial intervention. Clearly, people who are more extraverted, inclined to cope by seeking information and venting their feelings, and have the skills and motivation to form attachments with co-participants, are more likely to be attracted to this medium in the ﬁrst place and perhaps more prone to beneﬁt from the provisions it supplies. Conceivably, the group oﬀers a sense of belonging and being needed by others, and these perceptions may stimulate more active immune system functioning, which may account for the superior outcomes that have been observed.
Helgeson and Cohen (1996) limited their review of psychosocial interventions for cancer patients to a comparison of peer support vs. education vs. combined support and education groups. The former concentrate on the provision of emotional support, whereas the latter mainly deliver informational support. Although their conclusions are hedged due to the numerous methodological weaknesses of the studies and diﬀerences in the samples and disease sites and stages, they oﬀer important insights into the mechanisms that may be implicated in psychological and physical adjustment to cancer. These mechanisms include enhanced self-esteem, gains in perceived control, optimism regarding the future, improved processing of emotions, and opportunities to derive meaning from their adversity. These and other pathways, including biobehavioral processes, deserve greater scrutiny in future intervention trials.
Support groups for people who have experienced losses through death or divorce have proved to speed the adjustment process, compared to people who have not used any professional or mutual aid resource (Bloom et al. 1985, Hughes 1988, Vachon et al. 1980, Silverman 1986). Groups for children whose parents have divorced have also been found to foster improved behavioral, academic, psychological and social adjustment (see Grych and Fincham, 1992, for a review). Support groups have also been oﬀered to adolescents with eating disorders and to children of varying ages who have a parent with a mood disorder (Beardslee et al. 1993) or with an alcohol or substance abuse problem (Emshoﬀ 1990).
Evaluation of support groups is complicated by the fact that these interventions usually consist of multiple active ingredients, not just the support that is exchanged among the members. In fact, in a rare comparison of support groups with and without a skill-training component, Stolberg and Mahler (1994) found that the group that lacked skills training was no more eﬀective than the control group for children whose parents had divorced. More studies that adopt such a dismantling design (West et al. 1993) need to be conducted in order to demonstrate that changes in social support are responsible at least in part for improved outcomes. This means that measures of support need to be taken and then related to the distal outcomes of the intervention as a strategy of conﬁrming the mediating role of support.
Finally, recognizing that many people who might be attracted to a support group live in geographically remote communities, have disabilities that limit their mobility, or prefer not to divulge their identity, a number of investigators have implemented computer mediated groups, using the technology that has recently become available at relatively low cost. For example, Dunham et al. (1998) trained 50 poor, young, single mothers to use a bulletin board system to post both private and network-wide messages to one another and to hold text-based teleconferences with up to eight mothers at a time. With the mothers’ permission, Dunham et al. (1998) analyzed the extent and nature of the participants’ communications, and found a signiﬁcant pre to post-test decrease in parenting stress for those mothers who participated consistently over the 6-month study period. Telephone support groups have also been implemented for family caregivers of persons with dementia (Goodman and Pynoos 1990), a vulnerable population that is largely home-bound. A distinct psychological advantage of support groups that use computer and telephone media is that they moderate the emotional intensity of the group experience, which in turn may decrease its threat. On the other hand, without direct exposure to the other group members, the social comparison process may be more limited and the possibility of friendship formation, which has proved to be so vital in the bereavement and cancer studies reviewed earlier, is diminished.
MASH and support groups are relatively low-cost and highly accessible helping resources that promote health and well being through many psychological processes. In the health ﬁeld, these groups have been employed both as an alternative and a complement to professional services. Moreover, as the actual and potential health beneﬁts of these groups become more widely recognized, mutual aid strategies are more likely to become integrated within health care and health promotion programs (Humphreys and Klaw 1998). More systematic investigation of diﬀerent ways of structuring the groups and tailoring them to the needs and coping styles of prospective members, promises to augment their attractiveness and health impacts.
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