What is Communal Coping?

Introduction

Communal coping is the collective effort of members of a connected network (familial or social) to manage a distressing event (Lyons, Michelson, Sullivan and Coyne, 1998). This definition and the scope of the concept positions communal coping as an offshoot of social support.

According to Lyons et al. (1998), the communal coping conceptual framework emerged for two reasons. First, to expand the research that supports the claim that the coping process sometimes requires individual and collective effort (e.g. Fukuyama, 1995). Second, the need for a specific framework for investigating the cooperative characteristic of coping. To support the need for a framework which explores the social aspect of coping as a combined effort, the authors argued that the communal coping conceptual framework emphasizes the connectedness and reliance on personal network for coping. Developments to the communal coping framework include the explanation of the complex nature of the communal coping process (Afifi, Helgeson & Krouse, 2006) and specific personal outcomes (Helgeson, Jakubiak, Vleet, & Zajdel, 2018) following a communal coping process.

Background

Lyons et al. (1998) introduced the communal coping framework. The first model Lyons et al. (1998) proposed mainly distinguished between communal coping and existing perception of coping as an individualistic or prosocial process. Also, the model provided a lens for examining other aspects of coping such as the benefits, cost and influential factors. Afifi, Hutchinson, and Krouse (2006) noted some of the achievements of the model is that it accounts for the relational process within coping and shifts the focus of researchers from treating the phenomenon as mainly a psychological process but also a relational or communication.

However, despite the contributions of the model to the coping research, some questions still need an answer and a couple of research challenges remained unaddressed. For instance, Afifi et al. (2006) noted some researchers confused the process of communal coping for collective coping, types, provision and seeking of social support. The scholars attributed the lack of conceptualisation of communal coping as one of the factors responsible for the confusion. To address this gap in research and advance the existing model by Lyon’s and colleagues, Afifi et al. proposed a theoretical framework. The scholars anticipated the model will serve as a template for measuring communal coping.

The goals for designing the new model were specifically to understand the communal coping process within naturally occurring groups (e.g. post-divorce families). Through the new model, Afifi et al. (2006) attempted to:

  1. Provide a description of the complexities that characterise relying on other people to cope with a stressful event;
  2. Expand the discourse on the dynamic and interactive nature of the coping process;
  3. Explore the various factors that contribute to stressors within groups;
  4. Identify how characteristics of the group such as its structure, the beliefs, norms, and perspectives of its members are likely to influence the coping process; and
  5. Examine how context, source, and nature of the stressor impact the coping process.

The refinement of the model addressed the problems Lyon and colleagues’ model could not account for. Nonetheless, one question remained unanswered ‘how does communal coping influence coping outcome?’. Thereby still leaving a gap in research. Helgeson, Jakubiak, Vleet, and Zajdel (2018) attempted to fill this gap by proposing a model that acknowledges the adjustment process and outcome of communal coping.

Similar to prior models, Helgeson et al’s (2018) framework identified supportive communication as a significant aspect of communal coping that is linked to individual adjustment to a stressor (e.g. illness). A core tenet within the model is that communication enhances coping outcomes. In this vein, Helgeson et al’s model purports the outcomes of communal coping for stressed individuals include:

  1. A high sense of control over the stressor;
  2. Perception of the stressor as less stressful;
  3. Enhanced feeling of self- regulatory capacity; and
  4. Experiencing quality relationships.

Components of Communal Coping

The existing research on coping (Lazarus & Folkman, 1984) served as a backdrop for the development of the communal coping framework. Zimmer-Gembeck and Skinner (2009, p.333) defined coping as:

“how people of all ages mobilize, guide, manage, coordinate, energize, modulate, and direct their behavior, emotion, and orientation (or how they fail to do so) during stressful encounters”.

From this definition, one can infer coping researchers consider the management of a stressor as an individual effort. In addition, despite the significant contribution of coping studies to empirical knowledge in research areas such as coping resources (Lazarus & Folkman, 1980) and maintaining these resources (Hobbfall, 1989) it is still important to understand how collective coping efforts could make a difference in coping outcome of collective stressors such as the death of a breadwinner, natural disasters, environmental hazards, and epidemics. During these kinds of events, the desire to cope may not necessarily be for self-interest but the preservation of existing relationships and promoting the wellbeing of others that are affected. In these cases, collectively coping as part of a community or family supersedes individual effort to manage the distress. In this vein, Lyons et al. (1998) suggested the components of communal coping are salient and activated in such situations where at least one person treats the distressing event as ‘our problem’. Therefore, the components of the communal coping process require a communal coping orientation, communication about the stressor and cooperative action to address the stressor.

The components of communal coping may be defined as active steps towards achieving a positive coping outcome as part of a social unit. Lyons et al. (1998) proposed these active steps begin with one person adopting a communal orientation about how to manage the distressing event. The outcome of this action is the individuals involve share a mutual understanding of how to manage and overcome the stressor as a social unit versus ‘your problem’ where a specific individual is responsible for managing and overcoming the stressor. The actualisation of this first step largely depends on and is completed through communication. In other words, the individuals involved need to communicate about the stressor.

Communication allows for a conversation about the situation, circumstances, and likely solutions. The conversations at this point may be controlled by the individual experiencing the stressor to inform members of their network who are willing to share responsibility for the stressor on how the issue should be addressed. Or, the conversation may be controlled by members of the personal network of the individual experiencing the stressor to negotiate their involvement in how to manage the stress. Irrespective of the direction the communication takes, the primary goal is to share a common sense of responsibility for the stressor as “our problem” among the people involved.

The outcome of the first two steps le toad the emergence of a sense of cooperative action. At this point, everyone works cooperatively to create strategies for alleviating the problem or stressor. Given that there is a likelihood for the processes of the three components of communal coping to unfold differently across situations and for affected individuals, it is not unusual to find differences in communal coping styles. Some of the factors responsible for these differences include the sense of obligation experienced by the connected individuals (Stack 1974) or compassion for others (Nussbam, 1990); the type and purpose of the relationship as well as the characteristics of the individual in the leadership role and personalities of members within the communal coping network (Lyon et al. 1998). However, despite these differences in coping styles, communal coping is beneficial for the management of and recovery from a distressing event.

Influences on Communal Coping

Lyon et al. (1998) suggested four factors that influence how people use communal coping – situation, cultural context, characteristics of the personal relationship and sex. For instance, in a study on the role of marriage on health behaviours, Lewis, McBride, Pollak et al. (2006) discovered the transformation of motivation influenced how one chooses to help the other cope through a stressor. The scholars argued that in the case of romantic relationships, one partner’s mere realization that a stressor (e.g. health treat) poses a danger to relationship quality could motivate the need for communal coping.

In addition, the perceived salience of communal coping within certain situations is defined by the severity of the stressor. Therefore, the ways individuals define the severity of a problem are likely dependent on:

  • The priority or relevance attached to the problem;
  • If they are directly or indirectly affected; and
  • The decision whether to employ an individual or collective coping strategy.

In this vein, following their studies on communal coping within post-divorce families, Afifi, Hutchinson, and Krouse (2006, p.399) argued the “specific demands or requirement of a stressor” influence the communal coping process.

The cultural context in which the distressing event occur also influence the salience of communal coping in alleviating the stressor. The concepts of collectivism and individualism are often used in cultural comparative studies about a phenomenon. Cultures that promote group interest (collectivist cultures) over personal goals (individualist culture) are more likely to invest in communal coping (refer to Bryer, 1986). Given that culture is a way of life, it reflects in the performance of our relationships such as how we define close relationships and depend on these relationships (Lyons et al., 1998). Therefore, one can conclude that relationships in which strong relational ties exist will perhaps guarantee better performance of communal coping than relationships without strong relational ties.

Moreover, the language of the affected individual also influences the coping process. Researchers (e.g. Rohrbaugh, Shoham, Skoyen, Jensen, and Mehl, 2012) labelled communal coping language as ‘we – talk’. In their studies of addiction and cessation (cigarette and alcohol) due to health threats, Rohrbaugh and colleagues discovered the pronoun used by couples in their study influenced the communal coping outcomes. In the cases where couples defined the addiction as “our problem” versus “your problem” or “my problem”, there were implicit adaptive problem-solving outcomes.

Lastly, gender roles influence the performance of communal coping. Wells, Hobfoll and Lavin (1997) suggested the multiple roles some women take on tend to result in stressors. However, Women tend to be the fervent giver of social support making members of this gender community an active performer in the communal coping process (Vaux 1985, Bem 1993). Lyon et al. (1998) noted women’s tendency to give social support to others supersedes receiving support as maintaining relationship quality is important for this group. The downside to this sense of responsibility is women manage and overcome their stressor alone which take an emotional and psychological toll.

Benefits of Communal Coping

Adapting the communal coping strategy after a distressing event is beneficial for the coping process itself, the self and relationships (Afifi, Helgeson & Krouse, 2006). As a beneficial strategy for the coping process communal coping holds the potential to allow connected individuals to increase their resources and ability to deal with the situation. For example, a single stressful event may require reliance on other people or the exploration of others’ financial resources to cope with the situation.

Another significant benefit of communal coping as a coping strategy is the facilitation of emotional social support which in turn facilitates psychological wellbeing. Individuals who can share their emotional distress with others are less likely to experience depression and burnout (Williamson & Shultz, 1990)or commit suicide (LaSalle, 1995).

Under certain circumstances, the constant encouragement of communal coping among connected individuals promotes a likelihood of consistent availability of social support. In these cases, communal coping may serve as a form of long-term investment. The last two statements are not intended to categorise communal coping and social support as the same phenomenon but rather to argue that the former creates a conducive social and relational climate for the later. According to Lyons et al. (1998), some of the long-term investments of communal coping may result in rewards such as food and money.

Moreover, in the event of a common disaster such as earthquakes and wars, communal coping allows the people involved to experience a sense of ‘solidarity’ or a feeling of ‘I am not the only victim’. This realisation promotes mutual disclosure among all the affected individuals, a behaviour found to buffer stress as well as ameliorate negative feelings and concerns (Pennebaker & Haber, 1993). In their study on how the process of communal coping unfolds after social support resources have diminished, Richardson and Maninger (2016) discovered that a sense of mutuality and shared problem increased.

Taken together, there is enough evidence that communal coping has a significant impact on relationships. These impacts are evident in the development and maintenance of relationships; the desire or obligation to cater to the wellbeing of others and the collective good (Lyon et al., 1998). Perhaps, in well-established relationships, communal coping is likely to strengthen relationship characteristics such as trust. For instance, the confidence that people within a connected network will exchange support during or after a distressing situation promotes a sense of dependence which may improve the quality of a relationship.

Lyons and colleagues argued the actualisation of relationship development and maintenance regarding relational trust or improving relationship quality emerge from a sense of compassion (empathy-driven) or obligation (responsibility – driven) towards the wellbeing of others in the relationship. Although empathy-driven and obligation – driven motives are distinct based on the type of relational tie, in most cases the end goal is for the collective good.

The benefits of communal coping described to this point focus on the intention to meet the emotional need of others during a stressful life event. However, the self can also benefit from participating in the process. There is a likelihood for the person offering empathy-driven or obligation – driven support to experience a sense of fulfilment. Lyons et al. (1998) used social integration and excitement to explain self-benefits of communal coping. In their explanation of social integration as a benefit of communal coping, Lyons et al. noted people who consider themselves resourceful in the coping process of others consider themselves competent, valued, loved and indispensable. In the same vein, communal coping fosters a sense of togetherness and cooperation. Excitement usually results from a sense of togetherness and cooperation that yield positive results.

Given that people and resources such as money, time and goods are exchanged in the process of communal coping during certain stressful events, there is a likelihood for some of the individuals involved to experience discomfort. Lyons et al. (1998) alluded to this discomfort as costs of communal coping.

Costs of Communal Coping

A significant characteristic of communal coping is ‘dependency’. Cultural (collectivism versus individualism) and social factors play into how we expect others to depend on us and how much we are willing to depend on others. Communal coping will perhaps be perceived as a cost in situations where there is a lack of mutual understanding and expectation within a social unit consisting of members experiencing a common or personal stressful event. In such instances, Lyon et al. (1998) noted individuals in the social unit will need to deal with issues such as equity and individual-adaptation.

The equity problem arises from a lack of agreement or existing social norms on the expectation of individual efforts channelled towards communal coping. In a comparison of gender roles after a distressing event, women specifically wives and mothers were expected to hold higher responsibility for helping others manage and recover from a stressor. More so, given that communal coping requires significant reliance on other people, individuals who are used to this style of coping during or after a stressful event may experience trouble adapting to a situation or circumstance in the absence of someone to rely on. There is evidence for this in studies about how people embedded in a strong community experience difficulty after a change of location for the pursuit of life goals.

One drastic consequence of communal coping is the possibility of stress contagion to occur. In this case, rather than working towards alleviating the stressor, connected individuals wallow in negative emotions and feelings. This behaviour escalates old and fosters new stressors for all the people involved. These factor provide evidence that the communal coping process follows a complicated pattern likely to yield contradictory results. Even more, some complex factors influence how people use communal coping. The complex nature of these factors is evident in how they are not universal or consistent.

Concept Application

The communal coping framework is relatively new and there has not been much variation in the context to which the concept has been applied. Mickelson, Lyons, Sullivan and Coyne (2001) argue for the need to apply the communal coping conceptual framework to less collective stressors such as recovery from natural disaster (e.g. Richardson & Maninger, 2018) to more individualistic stressors such as job loss and illness (e.g. Vleet, Helgeson, Seltman, Korytwoski, Hausmann, 2018). Scholars who have attempted to apply the communal coping framework to context outside of illness and natural disaster have looked at the concept in relation to relational transgression (Pederson & Faw, 2019); the experience of athletes and members of their family (Nelly, McHugh, Dun & Holt, 2017) and ; the experience of refugees (Afifi, Afifi, Merill & Nimah, 2016).

Concept Critique

The communal coping framework is very dynamic in the sense that it can be applied to distinct research contexts yet facilitate empirical and general knowledge that aligns with the tenets of its models. This strength also lies in the weakness of the framework. Some scholars within the distinct field to which the concept has been applied propose models for communal coping with little to significant variations. For instance, Lyons and colleagues (1998) from the field of psychology proposed the first model. Their model served as a backdrop for the emergence of other models from experts in communication (Afifi, Helgeson & Krouse, 2006); sociology and anthropology (Helgeson, Jakubiak, Vleet, & Zajdel, 2018). Keefe, LeFevbre, Egert, et al. (2000) also advocated for a communal coping model of pain catastrophising. With the growth in the application of the conceptual framework, it might be beneficial to consider developing a model for studying the phenomenon that can be used across all fields or areas of research. A probable benefit of this suggestion is the promotion of jointly agreed conceptualisation of the communal coping phenomenon.

References and Further Reading

  • Afifi, T. D., Afifi, W. A., Merrill, A. F., & Nimah, N. (2016). ‘Fractured communities’: uncertainty, stress, and (a lack of) communal coping in Palestinian refugee camps. Journal of Applied Communication Research, 44(4), 343-361doi:10.1080/00909882.2016.1225166
  • Afifi, T. D., Hutchinson, S., & Krouse, S. (2006). Toward a theoretical model of communal coping in postdivorce families and other naturally occurring groups. Communication Theory, 16(3), 378–409.
  • Berg, C. A., Meegan, S. P., & Deviney, F. P. (1998). A social-contextual model of coping with everyday problems across the lifespan. International Journal of Behavioral Development, 22(2), 239–261.
  • Coyne, J. C., & Fiske, V. (1992). Couples coping with chronic and catastrophic illness.
  • Fiske, Veronica; Coyne, James C.; Smith, David A. (1991). “Couples coping with myocardial infarction: An empirical reconsideration of the role of overprotectiveness”. Journal of Family Psychology. 5(1): pp.4-20.
  • Fukuyama, F. (1995). Trust: The social virtues and the creation of prosperity (Vol. 99). New York, NY: Free press.
  • Lyons, R. F., Mickelson, K. D., Sullivan, M. J., & Coyne, J. C. (1998). Coping as a communal process. Journal of Social and Personal Relationships, 15(5), 579–605.
  • Keefe, F. J., Lefebvre, J. C., Egert, J. R., Affleck, G., Sullivan, M. J., & Caldwell, D. S. (2000). The relationship of gender to pain, pain behavior, and disability in osteoarthritis patients: the role of catastrophizing. Pain, 87(3), 325–334.
  • Helgeson, V. S., Jakubiak, B., Van Vleet, M., & Zajdel, M. (2018). Communal coping and adjustment to chronic illness: Theory update and evidence. Personality and Social Psychology Review, 22(2), 170–195.
  • Hobfoll, S. E., & London, P. (1986). The relationship of self-concept and social support to emotional distress among women during war. Journal of Social and Clinical Psychology, 4(2), 189–203.
  • Hobfoll, S. E. (1989). Conservation of resources: A new attempt at conceptualizing stress. American psychologist, 44(3), 513.
  • Lazarus, R. S., & Folkman, S. (1984). Coping and adaptation. The handbook of behavioral medicine, 282325.
  • Lewis, M. A., McBride, C. M., Pollak, K. I., Puleo, E., Butterfield, R. M., & Emmons, K. M. (2006). Understanding health behavior change among couples: An interdependence and communal coping approach. Social science & medicine, 62(6), 1369–1380.
  • Lyons, Renee F.; Mickelson, Kristin D.; Sullivan, Michael J.L.; Coyne, James C. (October 1998). “Coping as a Communal Process”. Journal of Social and Personal Relationships. 15 (5): 579–605.
  • Rohrbaugh, M. J., Shoham, V., Skoyen, J. A., Jensen, M., & Mehl, M. R. (2012). We‐talk, communal coping, and cessation success in a couple‐focused intervention for health‐compromised smokers. Family process, 51(1), 107–121.
  • Nussbaum, M. C. (1990). Love’s knowledge: Essays on philosophy and literature. OUP USA.
  • Skinner, E. A., & Zimmer‐Gembeck, M. J. (2009). Challenges to the developmental study of coping. New directions for child and adolescent development, 2009(124), 5–17.
  • Pennebaker, J. W., & Harber, K. D. (1993). A social stage model of collective coping: The Loma Prieta earthquake and the Persian Gulf War. Journal of Social Issues, 49(4), 125-145
  • Richardson, B. K., & Maninger, L. (2016). “We were all in the same boat”: An exploratory study of communal coping in disaster recovery. Southern Communication Journal, 81(2), 107–122.
  • Stack, C. B. (1975). All our kin: Strategies for survival in a black community. Basic Books.
  • Wells, J. D., Hobfoll, S. E., & Lavin, J. (1997). Resource loss, resource gain, and communal coping during pregnancy among women with multiple roles. Psychology of Women Quarterly, 21(4), 645–662.
  • Vaux, A. (1990). An ecological approach to understanding and facilitating social support. Journal of social and personal relationships, 7(4), 507-518
  • Van Vleet, M., Helgeson, V. S., Seltman, H. J., Korytkowski, M. T., & Hausmann, L. R. (2019). An examination of the communal coping process in recently diagnosed diabetes. Journal of social and personal relationships, 36(4), 1297–1316.
  • Wellman, B., Carrington, P., & Hall, A. (1983). Networks as personal communities. Centre for Urban and Community Studies, University of Toronto.
  • Williamson, G. M., & Schulz, R. (1990). Relationship orientation, quality of prior relationship, and distress among caregivers of Alzheimer’s patients. Psychology and Aging, 5(4), 502.

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What is Invisible Support?

Introduction

In psychology, invisible support is a type of social support in which supportive exchanges are not visible to recipients.

There are two possible situations that can qualify as acts of invisible support. The first possibility entails a situation where “recipients are completely unaware of the supportive transaction between themselves and support-givers”. For example, a spouse may choose to spontaneously take care of housework without mentioning it to the other couple-member. Invisible support also occurs when “recipients are aware of an act that takes place but do not interpret the act as a supportive exchange”. In this case, a friend or family member may subtly provide advice in an indirect manner as a means to preserve the recipient’s self-esteem or to defer his or her attention from a stressful situation. Invisible support can be viewed on both ends of an exchange, in which the recipient is unaware of the support received and the provider enacts support in a skilful, subtle way.

Background

It is known that perceptions of social support availability predict better adjustment to stressful life events; it has been found that the perception of support availability is inherently comforting, and can serve as a psychological safety-net that motivates self-reliant coping efforts in the face of stress. Although the perception of support availability is associated with better adjustment, the knowledge that one has been the recipient of specific supportive acts has often been unhelpful to effectively reduce stress. The knowledge of receiving help may come at a cost with decreased feelings of self-esteem and self-efficacy, because it increases recipients’ awareness towards their personal difficulties to manage stressors. People’s well-intentioned support attempts may also be miscarried, and their efforts could either fail or even worsen the situation for a person under stress. Since supportive acts benefit recipients but their actual knowledge of receiving support is sometimes harmful, it has been theorised that the most effective support exchange would involve one in which the provider reports giving support but the recipient does not notice that support has occurred. From a cost-benefit point of view, invisible support would be optimal for the recipient because the benefits of provision are accrued while the costs of receipt are avoided. Using the same idea, it also implies that the least effective type of support would be one in which the provider does not report providing support but the recipient reports receiving it.

The first investigation of invisible support involved a couples study in which one member was preparing for the New York State Bar Exam. Support receipt and provision were measured by having both couple members complete daily diary entries. Over the course of one month, stressed individuals who reported low frequency of received support (but whose partner ranked their own actions as highly supportive) rated themselves low on anxiety and depression compared to other individuals who reported high frequency of received support.

Compared to Visible Support

A substantial body of work has evidence to suggest that support is most effective when it is invisible or goes unnoticed by recipients. While invisible support has been shown to benefit recipients over visibly supportive acts in some cases, there have also been instances where recipients have benefitted from visible support as well. For example, greater observed support enacted by intimate partners during couples’ support-relevant exchanges have been shown to build feelings of closeness and support, boost positive mood and self-esteem, and foster greater goal achievement and relationship quality across time.

It has been recently suggested that acts of invisible support and visible support may be beneficial or costly depending on different circumstances. To investigate this idea, a recent study in 2013 compared the short-term and long-term effects of visible and invisible support reception during romantic couples’ discussions of each partner’s personal goal. It was found that either type of support was more beneficial depending on the emotional distress that recipients felt at the time. Visible emotional support (support through reassurance, encouragement, and understanding) was associated with perceptions of greater support and discussion success for recipients who felt greater distress during the discussion. In contrast, invisible emotional support was not associated with recipients’ post-discussion perceptions of support or discussion success. For long-term support effects, it was found that only invisible emotional support predicted greater goal achievement across the following year.

When put together, these findings suggest that visible support and invisible support have unique functions for well-being. When people are under distress, visible support appears to be a short-term remedy to reassure recipients that they are cared for and supported. These benefits are only present when recipients are actually distressed during the time that the supportive act takes place. On the other hand, while invisible support tends to go unnoticed by recipients, it seems to play an integral role in the long-term success of goal-maintenance. This increasingly complex view of the implications of support visibility is reinforced by a growing body of research suggesting the effects of invisible social support – as with visible support – are moderated by provider, recipient, and contextual factors such as recipients’ perceptions of providers’ responsiveness to their needs, or the quality of the relationship between the support provider and recipient.

Effects on Support Providers

Refer to Social Support, Psychology, Stress (Psychological; Eustress and Distress), Coping (Psychology), Self-Esteem, and Self-Efficacy.

The effects of invisible support on recipients have been extensively investigated, but the consequences of invisible support on providers are less known. One study in 2016 investigated the benefits and costs of invisible support on couple-members who enacted supportive behaviours by differentiating the processes of invisible emotional support (support through reassurance, encouragement, and understanding) from processes of invisible instrumental support (providing tangible aid such as sending money or childcare). No costs of support-giving were found for providers when they demonstrated acts of invisible emotional support. The effects for invisible instrumental support told a different story, where providers who reported high relationship satisfaction were unaffected, but providers who reported low relationship satisfaction were negatively affected by their acts of invisible instrumental support with an increase in negative mood. These findings suggest that emotional comfort may be a more central function to maintain close relationships than instrumental support. Therefore, providing invisible emotional support may lead to less perceptions of a costly inequity than providing invisible instrumental support on average. However, since invisible instrumental support did not incur costs for providers who reported high relationship satisfaction, it implies that high relationship satisfaction may buffer potential costs that would otherwise be felt by support-providers. The differential results between invisible instrumental and emotional support indicate that a solid distinction between instrumental and emotional social support may be useful to take into account when investigating effects of invisible support as a whole.

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What is the Social Support Questionnaire?

Introduction

The Social Support Questionnaire (SSQ) is a quantitative, psychometrically sound survey questionnaire intended to measure social support and satisfaction with said social support from the perspective of the interviewee.

Degree of social support has been shown to influence the onset and course of certain psychiatric disorders such as clinical depression or schizophrenia. The SSQ was approved for public release in 1981 by Irwin Sarason, Henry Levine, Robert Basham and Barbara Sarason under the University of Washington Department of Psychology and consists of 27 questions. Overall, the SSQ has good test-retest reliability and convergent internal construct validity.

Refer to Peer Support.

Overview

The questionnaire is designed so that each question has a two-part answer. The first part asks the interviewee to list up to nine people available to provide support that meet the criteria stated in the question. These support individuals are specified using their initials in addition to the relationship to the interviewee. Example questions from the first part includes questions such as “Whom could you count on to help if you had just been fired from your job or expelled from school?” and “Whom do you feel would help if a family member very close to you died?”.

The second part asks the interviewee to specify how satisfied they are with each of the people stated in the first part. The SSQ respondents use a 6 -point Likert scale to indicate their degree of satisfaction with the support from the above people ranging from “1 – very dissatisfied” to “6 – very satisfied”.

The Social Support Questionnaire has multiple short forms such as the SSQ3 and the SSQ6.

Brief History

The SSQ is based on 4 original studies. The first study set out to determine whether the SSQ had the desired psychometric properties. The second study tried to relate SSQ and a diversity of personality measures such as anxiety, depression and hostility in connection with the Multiple Affect Adjective Checklist. The third study considered the relationship between social support, the prior year’s negative and positive life events, internal-external locus of control and self- esteem in conjunction with the Life Experiences Survey. The fourth study tested the idea that social support could serve as a buffer when faced with difficult life situations via trying to solve a maze and subsequently completing the Cognitive Interference Questionnaire.

Scoring

The overall support score (SSQN) is calculated by taking an average of the individual scores across the 27 items. A high score on the SSQ indicates more optimism about life than a low score. Respondents with low SSQ scores have a higher prevalence of negative life events and illness. Scoring is as follows:

  1. Add the total number of people for all 27 items (questions). (Max. is 243). Divide by 27 for average item score. This gives you SSQ Number Score, or SSQN.
  2. Add the total satisfaction scores for all 27 items (questions). (Max is 162). Divide by 27 for average item score. This gives you SSQ Satisfaction score or SSQS.
  3. Finally, you can average the above for the total number of people that are family members – this results in the SSQ family score.

Reliability

According to Sarason, the SSQ takes between fifteen and eighteen minutes to properly administer and has “good” test-retest reliability.

Validity

The SSQ was compared with the depression scale and validity tests show significant negative correlation ranging from -0.22 to -0.43. The SSQ and the optimism scale have a correlation of 0.57. The SSQ and the satisfaction score have a correlation of 0.34. The SSQ has high internal consistency among items.

Linkages

The SSQ has been used to show that higher levels of social support correlated with less suicide ideation in Military Medical University Soldiers in Iran in 2015. A low level of social support is an important risk factor in women for dysmenorrhea or menstrual cramps. Low Social Support is the strongest predictor of dysmenorrhea when compared to affect, personality and alexithymia.

Related Surveys

SSQ3

The SSQ3 is a short form of the SSQ and has only three questions. The SSQ3 has acceptable test-test reliability and correlation with personality variables as compared to the long form of the Social Support Questionnaire. The internal reliability was borderline but this low level of internal reliability is as expected since there are only three questions.

SSQ6

The SSQ6 is a short form of the SSQ. The SSQ6 has been shown to have high correlation with: the SSQ, SSQ personality variables and internal reliability. In the development of the SSQ6, the research suggests that professed social support in adults may be a connected to “early attachment experience.” The SSQ6 consists of the below 6 questions:

  1. Whom can you really count on to be dependable when you need help?
  2. Whom can you really count on to help you feel more relaxed when you are under pressure or tense?
  3. Who accepts you totally, including both your worst and your best points?
  4. Whom can you really count on to care about you, regardless of what is happening to you?
  5. Whom can you really count on to help you feel better when you are feeling generally down-in-the-dumps?
  6. Whom can you count on to console you when you are very upset?

Interpersonal Support Evaluation List (ISEL)

The Interpersonal Support Evaluation List includes 40 items (questions) with four sub-scales in the areas of Tangible Support, Belonging Support, Self-Esteem Support and Appraisal Support. The interviewee rates each item based on how true or false they feel the item is for themselves. The four total response options are “Definitely True”, “Probably True”, “Probably False”, and “Definitely False”.

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What is Social Support?

Introduction

Social support is the perception and actuality that one is cared for, has assistance available from other people, and most popularly, that one is part of a supportive social network. These supportive resources can be:

  • Emotional (e.g. nurturance);
  • Informational (e.g. advice);
  • Companionship (e.g. sense of belonging);
  • Tangible (e.g. financial assistance); and/or
  • Intangible (e.g. personal advice).

Social support can be measured as the perception that one has assistance available, the actual received assistance, or the degree to which a person is integrated in a social network. Support can come from many sources, such as family, friends, pets, neighbours, co-workers, organisations, etc.

Government-provided social support may be referred to as public aid in some nations.

Social support is studied across a wide range of disciplines including psychology, communications, medicine, sociology, nursing, public health, education, rehabilitation, and social work. Social support has been linked to many benefits for both physical and mental health, but “social support” (e.g. gossiping about friends) is not always beneficial.

Social support theories and models were prevalent as intensive academic studies in the 1980s and 1990s, and are linked to the development of caregiver and payment models, and community delivery systems in the US and around the world. Two main models have been proposed to describe the link between social support and health: the buffering hypothesis and the direct effects hypothesis. Gender and cultural differences in social support have been found in fields such as education “which may not control for age, disability, income and social status, ethnic and racial, or other significant factors”.

Refer to Social Support Questionnaire, Communal Coping, and Invisible Support.

Categories and Definitions

Distinctions in Measurement

Social support can be categorised and measured in several different ways.

There are four common functions of social support:

  • Emotional support is the offering of empathy, concern, affection, love, trust, acceptance, intimacy, encouragement, or caring. It is the warmth and nurturance provided by sources of social support. Providing emotional support can let the individual know that he or she is valued.
  • Tangible support is the provision of financial assistance, material goods, or services. Also called instrumental support, this form of social support encompasses the concrete, direct ways people assist others.
  • Informational support is the provision of advice, guidance, suggestions, or useful information to someone. This type of information has the potential to help others problem-solve.
  • Companionship support is the type of support that gives someone a sense of social belonging (and is also called belonging). This can be seen as the presence of companions to engage in shared social activities. Formerly, it was also referred to as “esteem support” or “appraisal support,” but these have since developed into alternative forms of support under the name “appraisal support” along with normative and instrumental support.

Researchers also commonly make a distinction between perceived and received support. Perceived support refers to a recipient’s subjective judgement that providers will offer (or have offered) effective help during times of need. Received support (also called enacted support) refers to specific supportive actions (e.g. advice or reassurance) offered by providers during times of need.

Furthermore, social support can be measured in terms of structural support or functional support. Structural support (also called social integration) refers to the extent to which a recipient is connected within a social network, like the number of social ties or how integrated a person is within his or her social network. Family relationships, friends, and membership in clubs and organisations contribute to social integration. Functional support looks at the specific functions that members in this social network can provide, such as the emotional, instrumental, informational, and companionship support listed above. Data suggests that emotional support may play a more significant role in protecting individuals from the deleterious effects of stress than structural means of support, such as social involvement or activity.

These different types of social support have different patterns of correlations with health, personality, and personal relationships. For example, perceived support is consistently linked to better mental health whereas received support and social integration are not. In fact, research indicates that perceived social support that is untapped can be more effective and beneficial than utilised social support. Some have suggested that invisible support, a form of support where the person has support without his or her awareness, may be the most beneficial. This view has been complicated, however, by more recent research suggesting the effects of invisible social support – as with visible support – are moderated by provider, recipient, and contextual factors such as recipients’ perceptions of providers’ responsiveness to their needs, or the quality of the relationship between the support provider and recipient.

Sources

Social support can come from a variety of sources, including (but not limited to): family, friends, romantic partners, pets, community ties, and co-workers. Sources of support can be natural (e.g. family and friends) or more formal (e.g. mental health specialists or community organisations). The source of the social support is an important determinant of its effectiveness as a coping strategy. Support from a romantic partner is associated with health benefits, particularly for men. However, one study has found that although support from spouses buffered the negative effects of work stress, it did not buffer the relationship between marital and parental stresses, because the spouses were implicated in these situations. However, work-family specific support worked more to alleviate work-family stress that feeds into marital and parental stress. Employee humour is negatively associated with burnout, and positively with, stress, health and stress coping effectiveness. Additionally, social support from friends did provide a buffer in response to marital stress, because they were less implicated in the marital dynamic.

Early familial social support has been shown to be important in children’s abilities to develop social competencies, and supportive parental relationships have also had benefits for college-aged students. Teacher and school personnel support have been shown to be stronger than other relationships of support. This is hypothesized to be a result of family and friend social relationships to be subject to conflicts whereas school relationships are more stable.

Online Social Support

Social support is also available among social media sites. As technology advances, the availability for online support increases. Social support can be offered through social media websites such as blogs, Facebook groups, health forums, and online support groups.

Early theories and research into Internet use tended to suggest negative implications for offline social networks (e.g. fears that Internet use would undermine desire for face-to-face interaction) and users’ well-being. However, additional work showed null or even positive effects, contributing to a more nuanced understanding of online social processes. Emerging data increasingly suggest that, as with offline support, the effects of online social support are shaped by support provider, recipient, and contextual factors. For example, the interpersonal-connection-behaviours framework reconciles conflicts in the research literature by suggesting that social network site use is likely to contribute to well-being when users engage in ways that foster meaningful interpersonal connection. Conversely, use may harm well-being when users engage in passive consumption of social media.

Online support can be similar to face-to-face social support, but may also offer convenience, anonymity, and non-judgmental interactions. Online sources such as social media may be less redundant sources of social support for users with relatively little in-person support compared to persons with high in-person support. Online sources may be especially important as potential social support resources for individuals with limited offline support, and may be related to physical and psychological well-being. However, socially isolated individuals may also be more drawn to computer-mediated vs. in-person forms of interaction, which may contribute to bidirectional associations between online social activity and isolation or depression.

Support sought through social media can also provide users with emotional comfort that relates them to others while creating awareness about particular health issues. Research conducted by Winzelberg et al. evaluated an online support group for women with breast cancer finding participants were able to form fulfilling supportive relationships in an asynchronous format and this form of support proved to be effective in reducing participants’ scores on depression, perceived stress, and cancer-related trauma measures. This type of online communication can increase the ability to cope with stress. Social support through social media is potentially available to anyone with Internet access and allows users to create relationships and receive encouragement for a variety of issues, including rare conditions or circumstances.

Coulson claims online support groups provide a unique opportunity for health professionals to learn about the experiences and views of individuals. This type of social support can also benefit users by providing them with a variety of information. Seeking informational social support allows users to access suggestions, advice, and information regarding health concerns or recovery. Many need social support, and its availability on social media may broaden access to a wider range of people in need. Both experimental and correlational research have indicated that increased social network site use can lead to greater perceived social support and increased social capital, both of which predict enhanced well-being.

An increasing number of interventions aim to create or enhance social support in online communities. While preliminary data often suggest such programmes may be well-received by users and may yield benefits, additional research is needed to more clearly establish the effectiveness of many such interventions.

Until the late 2010s, research examining online social support tended to use ad hoc instruments or measures that were adapted from offline research, resulting in the possibility that measures were not well-suited for measuring online support, or had weak or unknown psychometric properties. Instruments specifically developed to measure social support in online contexts include the Online Social Support Scale (which has sub scales for esteem/emotional support, social companionship, informational support, and instrumental support) and the Online Social Experiences Measure (which simultaneously assesses positive and negative aspects of online social activity and has predictive validity regarding cardiovascular implications of online social support).

Links to Mental and Physical Health

Benefits

Mental Health

Social support profile is associated with increased psychological well-being in the workplace and in response to important life events. There has been an ample amount of evidence showing that social support aids in lowering problems related to one’s mental health. As reported by Cutrona, Russell, and Rose, in the elderly population that was in their studies, their results showed that elderly individuals who had relationships where their self-esteem was elevated were less likely to have a decline in their health. In stressful times, social support helps people reduce psychological distress (e.g. anxiety or depression). Social support can simultaneously function as a problem-focused (e.g. receiving tangible information that helps resolve an issue) and emotion-focused coping strategy (e.g. used to regulate emotional responses that arise from the stressful event) Social support has been found to promote psychological adjustment in conditions with chronic high stress like HIV, rheumatoid arthritis, cancer, stroke, and coronary artery disease. Whereas a lack of social support has been associated with a risk for an individuals mental health. This study also shows that the social support acts as a buffer to protect individuals from different aspects in regards to their mental and physical health, such as helping against certain life stressors. Additionally, social support has been associated with various acute and chronic pain variables (for more information, see Chronic pain).

People with low social support report more sub-clinical symptoms of depression and anxiety than do people with high social support. In addition, people with low social support have higher rates of major mental disorder than those with high support. These include post traumatic stress disorder, panic disorder, social phobia, major depressive disorder, dysthymic disorder, and eating disorders. Among people with schizophrenia, those with low social support have more symptoms of the disorder. In addition, people with low support have more suicidal ideation, and more alcohol and (illicit and prescription) drug problems. Similar results have been found among children. Religious coping has especially been shown to correlate positively with positive psychological adjustment to stressors with enhancement of faith-based social support hypothesized as the likely mechanism of effect. However, more recent research reveals the role of religiosity/spirituality in enhancing social support may be overstated and in fact disappears when the personality traits of “agreeableness” and “conscientiousness” are also included as predictors.

In a 2013 study, Akey et al. did a qualitative study of 34 men and women diagnosed with an eating disorder and used the Health Belief Model (HBM) to explain the reasons for which they forgo seeking social support. Many people with eating disorders have a low perceived susceptibility, which can be explained as a sense of denial about their illness. Their perceived severity of the illness is affected by those to whom they compare themselves to, often resulting in people believing their illness is not severe enough to seek support. Due to poor past experiences or educated speculation, the perception of benefits for seeking social support is relatively low. The number of perceived barriers towards seeking social support often prevents people with eating disorders from getting the support they need to better cope with their illness. Such barriers include fear of social stigma, financial resources, and availability and quality of support. Self-efficacy may also explain why people with eating disorders do not seek social support, because they may not know how to properly express their need for help. This research has helped to create a better understanding of why individuals with eating disorders do not seek social support, and may lead to increased efforts to make such support more available. Eating disorders are classified as mental illnesses but can also have physical health repercussions. Creating a strong social support system for those affected by eating disorders may help such individuals to have a higher quality of both mental and physical health.

Various studies have been performed examining the effects of social support on psychological distress. Interest in the implications of social support were triggered by a series of articles published in the mid-1970s, each reviewing literature examining the association between psychiatric disorders and factors such as change in marital status, geographic mobility, and social disintegration. Researchers realised that the theme present in each of these situations is the absence of adequate social support and the disruption of social networks. This observed relationship sparked numerous studies concerning the effects of social support on mental health.

One particular study documented the effects of social support as a coping strategy on psychological distress in response to stressful work and life events among police officers. Talking things over among co-workers was the most frequent form of coping utilized while on duty, whereas most police officers kept issues to themselves while off duty. The study found that the social support between co-workers significantly buffered the relationship between work-related events and distress.

Other studies have examined the social support systems of single mothers. One study by D’Ercole demonstrated that the effects of social support vary in both form and function and will have drastically different effects depending upon the individual. The study found that supportive relationships with friends and co-workers, rather than task-related support from family, was positively related to the mother’s psychological well-being. D’Ercole hypothesizes that friends of a single parent offer a chance to socialise, match experiences, and be part of a network of peers. These types of exchanges may be more spontaneous and less obligatory than those between relatives. Additionally, co-workers can provide a community away from domestic life, relief from family demands, a source of recognition, and feelings of competence. D’Ercole also found an interesting statistical interaction whereby social support from co-workers decreased the experience of stress only in lower income individuals. The author hypothesizes that single women who earn more money are more likely to hold more demanding jobs which require more formal and less dependent relationships. Additionally, those women who earn higher incomes are more likely to be in positions of power, where relationships are more competitive than supportive.

Many studies have been dedicated specifically to understanding the effects of social support in individuals with post traumatic stress disorder (PTSD). In a study by Haden et al., when victims of severe trauma perceived high levels of social support and engaged in interpersonal coping styles, they were less likely to develop severe PTSD when compared to those who perceived lower levels of social support. These results suggest that high levels of social support alleviate the strong positive association between level of injury and severity of PTSD, and thus serves as a powerful protective factor. In general, data shows that the support of family and friends has a positive influence on an individual’s ability to cope with trauma. In fact, a meta-analysis by Brewin et al. found that social support was the strongest predictor, accounting for 40%, of variance in PTSD severity. However, perceived social support may be directly affected by the severity of the trauma. In some cases, support decreases with increases in trauma severity.

College students have also been the target of various studies on the effects of social support on coping. Reports between 1990 and 2003 showed college stresses were increasing in severity. Studies have also shown that college students’ perceptions of social support have shifted from viewing support as stable to viewing them as variable and fluctuating. In the face of such mounting stress, students naturally seek support from family and friends in order to alleviate psychological distress. A study by Chao found a significant two-way correlation between perceived stress and social support, as well as a significant three-way correlation between perceived stress, social support, and dysfunctional coping. The results indicated that high levels of dysfunctional coping deteriorated the association between stress and well-being at both high and low levels of social support, suggesting that dysfunctional coping can deteriorate the positive buffering action of social support on well-being. Students who reported social support were found more likely to engage in less healthy activities, including sedentary behaviour, drug and alcohol use, and too much or too little sleep. Lack of social support in college students is also strongly related to life dissatisfaction and suicidal behaviour.

Physical Health

Social support has a clearly demonstrated link to physical health outcomes in individuals, with numerous ties to physical health including mortality. People with low social support are at a much higher risk of death from a variety of diseases (e.g. cancer or cardiovascular disease). Numerous studies have shown that people with higher social support have an increased likelihood for survival.

Individuals with lower levels of social support have: more cardiovascular disease, more inflammation and less effective immune system functioning, more complications during pregnancy, and more functional disability and pain associated with rheumatoid arthritis, among many other findings. Conversely, higher rates of social support have been associated with numerous positive outcomes, including faster recovery from coronary artery surgery, less susceptibility to herpes attacks, a lowered likelihood to show age-related cognitive decline, and better diabetes control. People with higher social support are also less likely to develop colds and are able to recover faster if they are ill from a cold. There is sufficient evidence linking cardiovascular, neuroendocrine, and immune system function with higher levels of social support. Social support predicts less atherosclerosis and can slow the progression of an already diagnosed cardiovascular disease. There is also a clearly demonstrated link between social support and better immune function, especially in older adults. While links have been shown between neuroendocrine functionality and social support, further understanding is required before specific significant claims can be made. Social support is also hypothesized to be beneficial in the recovery from less severe cancers. Research focuses on breast cancers, but in more serious cancers factors such as severity and spread are difficult to measure in the context of impacts of social support. The field of physical health often struggles with the combination of variables set by external factors that are difficult to control, such as the entangled impact of life events on social support and the buffering impact these events have. There are serious ethical concerns involved with controlling too many factors of social support in individuals, leading to an interesting crossroads in the research.

Costs

Social support is integrated into service delivery schemes and sometimes are a primary service provided by governmental contracted entities (e.g. companionship, peer services, family caregivers). Community services known by the nomenclature community support, and workers by a similar title, Direct Support Professional, have a base in social and community support “ideology”. All supportive services from supported employment to supported housing, family support, educational support, and supported living are based upon the relationship between “informal and formal” supports, and “paid and unpaid caregivers”. Inclusion studies, based upon affiliation and friendship, or the conversely, have a similar theoretical basis as do “person-centred support” strategies.

Social support theories are often found in “real life” in cultural, music and arts communities, and as might be expected within religious communities. Social support is integral in theories of aging, and the “social care systems” have often been challenged (e.g. creativity throughout the lifespan, extra retirement hours). Ed Skarnulis’ (state director) adage, “Support, don’t supplant the family” applies to other forms of social support networks.

Although there are many benefits to social support, it is not always beneficial. It has been proposed that in order for social support to be beneficial, the social support desired by the individual has to match the support given to him or her; this is known as the matching hypothesis. Psychological stress may increase if a different type of support is provided than what the recipient wishes to receive (e.g. informational is given when emotional support is sought). Additionally, elevated levels of perceived stress can impact the effect of social support on health-related outcomes.

Other costs have been associated with social support. For example, received support has not been linked consistently to either physical or mental health; perhaps surprisingly, received support has sometimes been linked to worse mental health. Additionally, if social support is overly intrusive, it can increase stress. It is important when discussing social support to always consider the possibility that the social support system is actually an antagonistic influence on an individual.

Two Dominant Models

There are two dominant hypotheses addressing the link between social support and health: the buffering hypothesis and the direct effects hypothesis. The main difference between these two hypotheses is that the direct effects hypothesis predicts that social support is beneficial all the time, while the buffering hypothesis predicts that social support is mostly beneficial during stressful times. Evidence has been found for both hypotheses.

In the buffering hypothesis, social support protects (or “buffers”) people from the bad effects of stressful life events (e.g. death of a spouse, job loss). Evidence for stress buffering is found when the correlation between stressful events and poor health is weaker for people with high social support than for people with low social support. The weak correlation between stress and health for people with high social support is often interpreted to mean that social support has protected people from stress. Stress buffering is more likely to be observed for perceived support than for social integration or received support. The theoretical concept or construct of resiliency is associated with coping theories.

In the direct effects (also called main effects) hypothesis, people with high social support are in better health than people with low social support, regardless of stress. In addition to showing buffering effects, perceived support also shows consistent direct effects for mental health outcomes. Both perceived support and social integration show main effects for physical health outcomes. However, received (enacted) support rarely shows main effects.

Theories to Explain the Links

Several theories have been proposed to explain social support’s link to health. Stress and coping social support theory dominates social support research and is designed to explain the buffering hypothesis described above. According to this theory, social support protects people from the bad health effects of stressful events (i.e. stress buffering) by influencing how people think about and cope with the events. An example in 2018 are the effects of school shootings on the well being and future of children and children’s health. According to stress and coping theory, events are stressful insofar as people have negative thoughts about the event (appraisal) and cope ineffectively. Coping consists of deliberate, conscious actions such as problem solving or relaxation. As applied to social support, stress and coping theory suggests that social support promotes adaptive appraisal and coping. Evidence for stress and coping social support theory is found in studies that observe stress buffering effects for perceived social support. One problem with this theory is that, as described previously, stress buffering is not seen for social integration, and that received support is typically not linked to better health outcomes.

Relational regulation theory (RRT) is another theory, which is designed to explain main effects (the direct effects hypothesis) between perceived support and mental health. As mentioned previously, perceived support has been found to have both buffering and direct effects on mental health. RRT was proposed in order to explain perceived support’s main effects on mental health which cannot be explained by the stress and coping theory. RRT hypothesizes that the link between perceived support and mental health comes from people regulating their emotions through ordinary conversations and shared activities rather than through conversations on how to cope with stress. This regulation is relational in that the support providers, conversation topics and activities that help regulate emotion are primarily a matter of personal taste. This is supported by previous work showing that the largest part of perceived support is relational in nature.

Life-span theory is another theory to explain the links of social support and health, which emphasizes the differences between perceived and received support. According to this theory, social support develops throughout the life span, but especially in childhood attachment with parents. Social support develops along with adaptive personality traits such as low hostility, low neuroticism, high optimism, as well as social and coping skills. Together, support and other aspects of personality (“psychological theories”) influence health largely by promoting health practices (e.g. exercise and weight management) and by preventing health-related stressors (e.g. job loss, divorce). Evidence for life-span theory includes that a portion of perceived support is trait-like, and that perceived support is linked to adaptive personality characteristics and attachment experiences. Lifespan theories are popular from their origins in Schools of Human Ecology at the universities, aligned with family theories, and researched through federal centres over decades (e.g. University of Kansas, Beach Centre for Families; Cornell University, School of Human Ecology).

Of the Big Five Personality Traits, agreeableness is associated with people receiving the most social support and having the least-strained relationships at work and home. Receiving support from a supervisor in the workplace is associated with alleviating tensions both at work and at home, as are inter-dependency and idiocentrism of an employee.

Biological Pathways

Many studies have tried to identify biopsychosocial pathways for the link between social support and health. Social support has been found to positively impact the immune, neuroendocrine, and cardiovascular systems. Although these systems are listed separately here, evidence has shown that these systems can interact and affect each other.

  • Immune system: Social support is generally associated with better immune function. For example, being more socially integrated is correlated with lower levels of inflammation (as measured by C-reactive protein, a marker of inflammation), and people with more social support have a lower susceptibility to the common cold.
  • Neuroendocrine system: Social support has been linked to lower cortisol (“stress hormone”) levels in response to stress. Neuroimaging work has found that social support decreases activation of regions in the brain associated with social distress, and that this diminished activity was also related to lowered cortisol levels.
  • Cardiovascular system: Social support has been found to lower cardiovascular reactivity to stressors. It has been found to lower blood pressure and heart rates, which are known to benefit the cardiovascular system.

Though many benefits have been found, not all research indicates positive effects of social support on these systems. For example, sometimes the presence of a support figure can lead to increased neuroendocrine and physiological activity.

Support Groups

Refer to Support Group.

Social support groups can be a source of informational support, by providing valuable educational information, and emotional support, including encouragement from people experiencing similar circumstances. Studies have generally found beneficial effects for social support group interventions for various conditions, including Internet support groups. These groups may be termed “self help” groups in nation-states, may be offered by non-profit organisations, and in 2018, may be paid for as part of governmental reimbursement schemes. According to Drebing, previous studies have shown that those going to support groups later show enhanced social support… in regard to groups such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), were shown to have a positive correlation with participation in their subsequent groups and abstaining from their addiction. Because correlation does not equal causation, going to those meeting does not cause one to abstain from divulging back into old habits rather that this been shown to be helpful in establishing sobriety. While many support groups are held where the discussions can be face to face there has been evidence that shows online support offers the same amount of benefits. Coulson found that through discussion forums several benefits can be added such as being able to cope with things and having an overall sense of well being.

Providing Support

There are both costs and benefits to providing support to others. Providing long-term care or support for someone else is a chronic stressor that has been associated with anxiety, depression, alterations in the immune system, and increased mortality. Thus, family caregivers and “university personnel” alike have advocated for both respite or relief, and higher payments related to ongoing, long-term care giving. However, providing support has also been associated with health benefits. In fact, providing instrumental support to friends, relatives, and neighbours, or emotional support to spouses has been linked to a significant decrease in the risk for mortality. Researchers found that within couples where one has been diagnosed with breast cancer, not only does the spouse with the illness benefit from the provision and receipt of support but so does the spouse with no illness. It was found that the relationship well being was the area that benefited for the spouses of those with breast cancer. Also, a recent neuroimaging study found that giving support to a significant other during a distressful experience increased activation in reward areas of the brain.

Social Defence System

In 1959 Isabel Menzies Lyth identified that threat to a person’s identity in a group where they share similar characteristics develops a defence system inside the group which stems from emotions experienced by members of the group, which are difficult to articulate, cope with and finds solutions to. Together with an external pressure on efficiency, a collusive and injunctive system develops that is resistant to change, supports their activities and prohibit others from performing their major tasks.

Gender and Culture

Gender Differences

Gender differences have been found in social support research. Women provide more social support to others and are more engaged in their social networks. Evidence has also supported the notion that women may be better providers of social support. In addition to being more involved in the giving of support, women are also more likely to seek out social support to deal with stress, especially from their spouses. However, one study indicates that there are no differences in the extent to which men and women seek appraisal, informational, and instrumental types of support. Rather, the big difference lies in seeking emotional support. Additionally, social support may be more beneficial to women. Shelley Taylor and her colleagues have suggested that these gender differences in social support may stem from the biological difference between men and women in how they respond to stress (i.e. flight or fight versus tend and befriend). Married men are less likely to be depressed compared to non-married men after the presence of a particular stressor because men are able to delegate their emotional burdens to their partner, and women have been shown to be influenced and act more in reaction to social context compared to men. It has been found that men’s behaviours are overall more asocial, with less regard to the impact their coping may have upon others, and women more prosocial with importance stressed on how their coping affects people around them. This may explain why women are more likely to experience negative psychological problems such as depression and anxiety based on how women receive and process stressors. In general, women are likely to find situations more stressful than males are. It is important to note that when the perceived stress level is the same, men and women have much fewer differences in how they seek and use social support.

Cultural Differences

Although social support is thought to be a universal resource, cultural differences exist in social support. In many Asian cultures, the person is seen as more of a collective unit of society, whereas Western cultures are more individualistic and conceptualise social support as a transaction in which one person seeks help from another. In more interdependent Eastern cultures, people are less inclined to enlist the help of others. For example, European Americans have been found to call upon their social relationships for social support more often than Asian Americans or Asians during stressful occasions, and Asian Americans expect social support to be less helpful than European Americans. These differences in social support may be rooted in different cultural ideas about social groups. It is important to note that these differences are stronger in emotional support than instrumental support. Additionally, ethnic differences in social support from family and friends have been found.

Cultural differences in coping strategies other than social support also exist. One study shows that Koreans are more likely to report substance abuse than European Americans are. Further, European Americans are more likely to exercise in order to cope than Koreans. Some cultural explanations are that Asians are less likely to seek it from fear of disrupting the harmony of their relationships and that they are more inclined to settle their problems independently and avoid criticism. However, these differences are not found among Asian Americans relative to their Europeans American counterparts.

Different cultures have different ways of socials support. In African American households support is limited. Many black mothers raise their children without a male figure. Women struggle with job opportunities due to job biases and racial discrimination. Many Black women face this harsh reality causing them to go through poverty. When there is poverty within home, the main focus is to make sure the bills are paid. Sometimes causing children to play adult roles at a very young age. Women trying to balance the mom and dad role, takes away from the moral support certain kids need.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Social_support >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What is Communal Coping?

Introduction

Communal coping is the collective effort of members of a connected network (familial or social) to manage a distressing event.

This definition and the scope of the concept positions communal coping as an offshoot of social support. The communal coping conceptual framework emerged for two reasons:

  • First, to expand the research that supports the claim that the coping process sometimes requires individual and collective effort.
  • Second, the need for a specific framework for investigating the cooperative characteristic of coping.

To support the need for a framework which explores the social aspect of coping as a combined effort, the authors argued that the communal coping conceptual framework emphasizes the connectedness and reliance on personal network for coping. Developments to the communal coping framework include the explanation of the complex nature of the communal coping process and specific personal outcomes following a communal coping process.

Background

Lyons et al. (1998) introduced the communal coping framework. The first model Lyons et al. (1998) proposed mainly distinguished between communal coping and existing perception of coping as an individualistic or prosocial process. Also, the model provided a lens for examining other aspects of coping such as the benefits, cost and influential factors. Afifi, Hutchinson, and Krouse (2006) noted some of the achievements of the model is that it accounts for the relational process within coping and shifts the focus of researchers from treating the phenomenon as mainly a psychological process but also a relational or communication.

However, despite the contributions of the model to the coping research, some questions still need an answer and a couple of research challenges remained unaddressed. For instance, Afifi et al. (2006) noted some researchers confused the process of communal coping for collective coping, types, provision and seeking of social support. The scholars attributed the lack of conceptualization of communal coping as one of the factors responsible for the confusion. To address this gap in research and advance the existing model by Lyon’s and colleagues, Afifi et al. proposed a theoretical framework. The scholars anticipated the model will serve as a template for measuring communal coping.

The goals for designing the new model were specifically to understand the communal coping process within naturally occurring groups (e.g. postdivorce families). Through the new model, Afifi et al. (2006) attempted to:

  1. Provide a description of the complexities that characterise relying on other people to cope with a stressful event;
  2. Expand the discourse on the dynamic and interactive nature of the coping process;
  3. Explore the various factors that contribute to stressors within groups;
  4. Identify how characteristics of the group such as its structure, the beliefs, norms, and perspectives of its members are likely to influence the coping process; and
  5. Examine how context, source, and nature of the stressor impact the coping process.

The refinement of the model addressed the problems Lyon and colleagues’ model could not account for. Nonetheless, one question remained unanswered ‘how does communal coping influence coping outcome?’. Thereby still leaving a gap in research. Hegelson, Jakubiak, Vleet, and Zajdel (2018) attempted to fill this gap by proposing a model that acknowledges the adjustment process and outcome of communal coping.

Similar to prior models, Hegelson et al’s (2018) framework identified supportive communication as a significant aspect of communal coping that is linked to individual adjustment to a stressor (e.g. illness). A core tenet within the model is that communication enhances coping outcomes. In this vein, Hegelson et al’s model purports the outcomes of communal coping for stressed individuals include:

  1. A high sense of control over the stressor;
  2. Perception of the stressor as less stressful;
  3. Enhanced feeling of self- regulatory capacity; and
  4. Experiencing quality relationships.

Components of Communal Coping

The existing research on coping (Lazarus & Folkman, 1984) served as a backdrop for the development of the communal coping framework. Zimmer-Gembeck and Skinner (2009, p. 333) defined coping as “how people of all ages mobilize, guide, manage, coordinate, energize, modulate, and direct their behaviour, emotion, and orientation (or how they fail to do so) during stressful encounters”. From this definition, one can infer coping researchers consider the management of a stressor as an individual effort. In addition, despite the significant contribution of coping studies to empirical knowledge in research areas such as coping resources (Lazarus & Folkman, 1980) and maintaining these resources (Hobbfall, 1989) it is still important to understand how collective coping efforts could make a difference in coping outcome of collective stressors such as the death of a breadwinner, natural disasters, environmental hazards, and epidemics. During these kinds of events, the desire to cope may not necessarily be for self-interest but the preservation of existing relationships and promoting the wellbeing of others that are affected. In these cases, collectively coping as part of a community or family supersedes individual effort to manage the distress. In this vein, Lyons et al. (1998) suggested the components of communal coping are salient and activated in such situations where at least one person treats the distressing event as ‘our problem’. Therefore, the components of the communal coping process require a communal coping orientation, communication about the stressor and cooperative action to address the stressor.

The components of communal coping may be defined as active steps towards achieving a positive coping outcome as part of a social unit. Lyons et al. (1998) proposed these active steps begin with one person adopting a communal orientation about how to manage the distressing event. The outcome of this action is the individuals involve share a mutual understanding of how to manage and overcome the stressor as a social unit versus ‘your problem’ where a specific individual is responsible for managing and overcoming the stressor. The actualisation of this first step largely depends on and is completed through communication. In other words, the individuals involved need to communicate about the stressor.

Communication allows for a conversation about the situation, circumstances, and likely solutions. The conversations at this point may be controlled by the individual experiencing the stressor to inform members of their network who are willing to share responsibility for the stressor on how the issue should be addressed. Or, the conversation may be controlled by members of the personal network of the individual experiencing the stressor to negotiate their involvement in how to manage the stress. Irrespective of the direction the communication takes, the primary goal is to share a common sense of responsibility for the stressor as “our problem” among the people involved.

The outcome of the first two steps le toad the emergence of a sense of cooperative action. At this point, everyone works cooperatively to create strategies for alleviating the problem or stressor. Given that there is a likelihood for the processes of the three components of communal coping to unfold differently across situations and for affected individuals, it is not unusual to find differences in communal coping styles. Some of the factors responsible for these differences include the sense of obligation experienced by the connected individuals (Stack 1974) or compassion for others (Nussbam, 1990); the type and purpose of the relationship as well as the characteristics of the individual in the leadership role and personalities of members within the communal coping network (Lyon et al. 1998). However, despite these differences in coping styles, communal coping is beneficial for the management of and recovery from a distressing event.

Influences on Communal Coping

Lyon et al. (1998) suggested four factors that influence how people use communal coping – situation, cultural context, characteristics of the personal relationship and sex. For instance, in a study on the role of marriage on health behaviours, Lewis, McBride, Pollak et al. (2006) discovered the transformation of motivation influenced how one chooses to help the other cope through a stressor. The scholars argued that in the case of romantic relationships, one partner’s mere realization that a stressor (e.g. health treat) poses a danger to relationship quality could motivate the need for communal coping.

In addition, the perceived salience of communal coping within certain situations is defined by the severity of the stressor. Therefore, the ways individuals define the severity of a problem are likely dependent on:

  • The priority or relevance attached to the problem;
  • If they are directly or indirectly affected; and
  • The decision whether to employ an individual or collective coping strategy.

In this vein, following their studies on communal coping within post-divorce families, Afifi, Hutchinson, and Krouse (2006, p.399) argued the “specific demands or requirement of a stressor” influence the communal coping process.

The cultural context in which the distressing event occur also influence the salience of communal coping in alleviating the stressor. The concepts of collectivism and individualism are often used in cultural comparative studies about a phenomenon. Cultures that promote group interest (collectivist cultures) over personal goals (individualist culture) are more likely to invest in communal coping (see Bryer, 1986). Given that culture is a way of life, it reflects in the performance of our relationships such as how we define close relationships and depend on these relationships (Lyons et al., 1998). Therefore, one can conclude that relationships in which strong relational ties exist will perhaps guarantee better performance of communal coping than relationships without strong relational ties.

Moreover, the language of the affected individual also influences the coping process. Researchers (e.g. Rohrbaugh, Shoham, Skoyen, Jensen, and Mehl, 2012) labeled communal coping language as ‘we – talk’. In their studies of addiction and cessation (cigarette and alcohol) due to health threats, Rohrbaugh and colleagues discovered the pronoun used by couples in their study influenced the communal coping outcomes. In the cases where couples defined the addiction as “our problem” versus “your problem” or “my problem”, there were implicit adaptive problem-solving outcomes.

Lastly, gender roles influence the performance of communal coping. Wells, Hobfoll and Lavin (1997) suggested the multiple roles some women take on tend to result in stressors. However, Women tend to be the fervent giver of social support making members of this gender community an active performer in the communal coping process (Vaux 1985, Bem 1993). Lyon et al. (1998) noted women’s tendency to give social support to others supersedes receiving support as maintaining relationship quality is important for this group. The downside to this sense of responsibility is women manage and overcome their stressor alone which take an emotional and psychological toll.

Benefits of Communal Coping

Adapting the communal coping strategy after a distressing event is beneficial for the coping process itself, the self and relationships (Afifi, Hegelson & Krouse, 2006). As a beneficial strategy for the coping process communal coping holds the potential to allow connected individuals to increase their resources and ability to deal with the situation. For example, a single stressful event may require reliance on other people or the exploration of others’ financial resources to cope with the situation.

Another significant benefit of communal coping as a coping strategy is the facilitation of emotional social support which in turn facilitates psychological wellbeing. Individuals who can share their emotional distress with others are less likely to experience depression and burnout (Williamson & Shultz, 1990)or commit suicide (LaSalle, 1995).

Under certain circumstances, the constant encouragement of communal coping among connected individuals promotes a likelihood of consistent availability of social support. In these cases, communal coping may serve as a form of long-term investment. The last two statements are not intended to categorise communal coping and social support as the same phenomenon but rather to argue that the former creates a conducive social and relational climate for the later. According to Lyons et al. (1998), some of the long-term investments of communal coping may result in rewards such as food and money.

Moreover, in the event of a common disaster such as earthquakes and wars, communal coping allows the people involved to experience a sense of ‘solidarity’ or a feeling of ‘I am not the only victim’. This realisation promotes mutual disclosure among all the affected individuals, a behaviour found to buffer stress as well as ameliorate negative feelings and concerns (Pennebaker & Haber, 1993). In their study on how the process of communal coping unfolds after social support resources have diminished, Richardson and Maninger (2016) discovered that a sense of mutuality and shared problem increased.

Taken together, there is enough evidence that communal coping has a significant impact on relationships. These impacts are evident in the development and maintenance of relationships; the desire or obligation to cater to the wellbeing of others and the collective good (Lyon et al., 1998). Perhaps, in well-established relationships, communal coping is likely to strengthen relationship characteristics such as trust. For instance, the confidence that people within a connected network will exchange support during or after a distressing situation promotes a sense of dependence which may improve the quality of a relationship.

Lyons and colleagues argued the actualization of relationship development and maintenance regarding relational trust or improving relationship quality emerge from a sense of compassion (empathy-driven) or obligation (responsibility – driven) towards the wellbeing of others in the relationship. Although empathy-driven and obligation – driven motives are distinct based on the type of relational tie, in most cases the end goal is for the collective good.

The benefits of communal coping described to this point focus on the intention to meet the emotional need of others during a stressful life event. However, the self can also benefit from participating in the process. There is a likelihood for the person offering empathy-driven or obligation – driven support to experience a sense of fulfilment. Lyons et al. (1998) used social integration and excitement to explain self-benefits of communal coping. In their explanation of social integration as a benefit of communal coping, Lyons et al. noted people who consider themselves resourceful in the coping process of others consider themselves competent, valued, loved and indispensable. In the same vein, communal coping fosters a sense of togetherness and cooperation. Excitement usually results from a sense of togetherness and cooperation that yield positive results.

Given that people and resources such as money, time and goods are exchanged in the process of communal coping during certain stressful events, there is a likelihood for some of the individuals involved to experience discomfort. Lyons et al. (1998) alluded to this discomfort as costs of communal coping.

Costs of Communal Coping

A significant characteristic of communal coping is ‘dependency’. Cultural (collectivism versus individualism) and social factors play into how we expect others to depend on us and how much we are willing to depend on others. Communal coping will perhaps be perceived as a cost in situations where there is a lack of mutual understanding and expectation within a social unit consisting of members experiencing a common or personal stressful event. In such instances, Lyon et al. noted individuals in the social unit will need to deal with issues such as equity and individual-adaptation.

The equity problem arises from a lack of agreement or existing social norms on the expectation of individual efforts channelled towards communal coping. In a comparison of gender roles after a distressing event, women specifically wives and mothers were expected to hold higher responsibility for helping others manage and recover from a stressor. More so, given that communal coping requires significant reliance on other people, individuals who are used to this style of coping during or after a stressful event may experience trouble adapting to a situation or circumstance in the absence of someone to rely on. There is evidence for this in studies about how people embedded in a strong community experience difficulty after a change of location for the pursuit of life goals.

One drastic consequence of communal coping is the possibility of stress contagion to occur. In this case, rather than working towards alleviating the stressor, connected individuals wallow in negative emotions and feelings. This behaviour escalates old and fosters new stressors for all the people involved. These factor provide evidence that the communal coping process follows a complicated pattern likely to yield contradictory results. Even more, some complex factors influence how people use communal coping. The complex nature of these factors is evident in how they are not universal or consistent.

Concept Application

The communal coping framework is relatively new and there has not been much variation in the context to which the concept has been applied. Mickelson, Lyons, Sullivan and Coyne (2001) argue for the need to apply the communal coping conceptual framework to less collective stressors such as recovery from natural disaster (e.g. Richardson & Maninger, 2018) to more individualistic stressors such as job loss and illness (e.g. Vleet, Hegelson, Seltman, Korytwoski, Hausmann, 2018). Scholars who have attempted to apply the communal coping framework to context outside of illness and natural disaster have looked at the concept in relation to relational transgression (Pederson & Faw, 2019); the experience of athletes and members of their family (Nelly, McHugh, Dun & Holt, 2017) and ; the experience of refugees ( Afifi, Afifi, Merill & Nimah, 2016).

Concept Critique

The communal coping framework is very dynamic in the sense that it can be applied to distinct research contexts yet facilitate empirical and general knowledge that aligns with the tenets of its models. This strength also lies in the weakness of the framework. Some scholars within the distinct field to which the concept has been applied propose models for communal coping with little to significant variations. For instance, Lyons and colleagues (1998) from the field of psychology proposed the first model. Their model served as a backdrop for the emergence of other models from experts in communication (Afifi, Hegelson & Krouse, 2006); sociology and anthropology (Hegelson, Jakubiak, Vleet, & Zajdel, 2018). Keefe, LeFevbre, Egert, et al. (2000) also advocated for a communal coping model of pain catastrophising. With the growth in the application of the conceptual framework, it might be beneficial to consider developing a model for studying the phenomenon that can be used across all fields or areas of research. A probable benefit of this suggestion is the promotion of jointly agreed conceptualisation of the communal coping phenomenon.

References

  • Lyons, Renee F.; Mickelson, Kristin D.; Sullivan, Michael J.L.; Coyne, James C. (October 1998). “Coping as a Communal Process”. Journal of Social and Personal Relationships. 15(5), pp.579-605. doi:10.1177/0265407598155001. hdl:2027.42/68813. ISSN 0265-4075. S2CID 145788518.
  • Fiske, Veronica; Coyne, James C.; Smith, David A. (1991). “Couples coping with myocardial infarction: An empirical reconsideration of the role of overprotectiveness”. Journal of Family Psychology. 5(1), pp.4-20. doi:10.1037/0893-3200.5.1.4. ISSN 0893-3200.
  • Wellman, Robert J. (1988). “Editor’s esoterica”. doi:10.1037/e410022005-004.
  • “The relationship of self-concept and social support to emotional distress among women during the wall”. Journal of Social and Clinical Psychology.

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What is Masking (Personality)?

Introduction

Masking is a process by which an individual changes or “masks” their natural personality to conform to social pressures, abuse or harassment.

Masking can be strongly influenced by environmental factors such as authoritarian parents, rejection, and emotional, physical, or sexual abuse. An individual may not even know they are masking because it is a behaviour that can take many forms.

Masking should not be confused with masking behaviour, which is to mentally block feelings of suffering as a survival mechanism (refer to Defence Mechanism).

Brief History

The term masking was first used to describe the act of concealing disgust by Ekman (1972) and Friesen (1969). It was also thought of as a learned behaviour. Developmental studies have shown that this ability begins as early as preschool and improves with age. In recent developmental studies, masking has evolved and is now defined as concealing one’s emotion by portraying another emotion. It is mostly used to conceal a negative emotion (usually sadness, frustration, and anger) with a positive emotion.

Causes

Contextual factors including relationships with one’s conversation partner, status differences, location, and social setting are all reasons as to why an individual would express, suppress, or mask an emotion. Masking is a façade to behave in certain ways that would help one hide their emotions and represses emotions that are not approved by those around them. Because a person wants to receive acceptance from the public, masking helps disguise characteristics like anger, jealousy or rage – emotions that would not be considered socially acceptable.

Situations

  • Personal space: Varies with individuals could be masking emotions to those close to them or strangers.
  • Setting.

Gender Differences

Masking negative emotions differ for each gender. Females tend to have an advanced ability when hiding their negative emotions towards something they dislike as compared to males. One of the possible reasons as to why females are able to mask their negative emotions better is society’s pressure that a girl must act nice.

Ethnicity

Masking also differs between cultures. Some studies state that certain cultures tend to moderate their expressions of emotion while others show a greater amount of positive emotions and expressions.

Autistic Masking

Some autistic people have been described as being able to “mask” or “camouflage” their signs of autism in order to meet social expectations. This may involve behaviour such as suppressing self-calming repetitive movements, faking a smile in an environment that they find uncomfortable or distressing, consciously evaluating their own behaviour and mirroring others, or choosing not to talk about their interests. As masking is often a conscious effort, it can be exhausting for autistic people to do this for an extended period of time (socially, but also in work contexts). In addition to making the person appear non-autistic or neurotypical, masking may conceal the person’s need for support. Such autistic people have cited social acceptance, the need to get a job, avoiding ostracism, or avoiding verbal or physical abuse as reasons for masking.

Research has found that autistic masking is correlated with depression and suicide. Many autistic adults in one survey described profound exhaustion from trying to pretend to be non-autistic. Therapies that teach autistic people to mask, such as some forms of applied behaviour analysis, are controversial.

Signs and Symptoms

Each person masks their emotions differently. During one’s childhood, an individual learns to behave a certain way when they receive approval from those around them and thus develops a mask. The individual is “not conscious of the role they’ve adopted and is projecting outwards to people they meet”. In some cases where the individual is highly conscious, they may not know that they are wearing a mask. Wearing a mask takes away energy from a person’s consciousness and, in the long run, wears out their energy.

Masking tendencies can be more obvious when a person is sick or weak, since they may no longer have the energy to maintain the mask.

Consequences

Little is known about the effects of masking one’s negative emotions. In the workplace, masking leads to feelings of dissonance, insincerity, job dissatisfaction, emotional and physical exhaustion, and self-reported health problems. Some have also reported experiencing somatic symptoms and harmful physiological and cognitive effects as a consequence

Masked Emotions

  • Emotions that are usually concealed:
    • Anger.
    • Anxiety.
    • Disgust.
    • Disinterest.
    • Embarrassment.
    • Fear.
    • Frustration.
    • Sadness.
  • Emotions that are expressed in place of the concealed emotions:
    • Amusement.
    • Boredom.
    • Contempt.
    • Frustration.
    • Happiness.
    • Interest.
    • Sadness.

An Overview of Mental Health in China

Introduction

Mental health in China is a growing issue. Experts have estimated that about 173 million people living in China are suffering from a mental disorder.

The desire to seek treatment is largely hindered by China’s strict social norms (and subsequent stigmas), as well as religious and cultural beliefs regarding personal reputation and social harmony. While the Chinese government is committed to expanding mental health care services and legislation, the country struggles with a lack of mental health professionals and access to specialists in rural areas.

Brief History

China’s first mental institutions were introduced before 1849 by Western missionaries. Missionary and doctor John G. Kerr opened the first psychiatric hospital in 1898, with the goal of providing care to people with mental health issues, and treating them in a more humane way.

In 1949, the country began developing its mental health resources by building psychiatric hospitals and facilities for training mental health professionals. However, many community programs were discontinued during the Cultural Revolution.

In a meeting jointly held by Chinese ministries and the World Health Organisation (WHO) in 1999, the Chinese government committed to creating a mental health action plan and a national mental health law, among other measures to expand and improve care. The action plan, adopted in 2002, outlined China’s priorities of enacting legislation, educating its people on mental illness and mental health resources, and developing a stable and comprehensive system of care.

In 2000, the Minority Health Disparities Research and Education Act was enacted. This act helped in raising national awareness on health issues through research, health education, and data collection.

Since 2006, the government’s 686 Program has worked to redevelop community mental health programs and make these the primary resource, instead of psychiatric hospitals, for people with mental illnesses. These community programs make it possible for mental health care to reach rural areas, and for people in these areas to become mental health professionals. However, despite the improvement in access to professional treatment, mental health specialists are still relatively inaccessible to rural populations. The program also emphasizes rehabilitation, rather than the management of symptoms.

In 2011, the legal institution of China’s State Council published a draft for a new mental health law, which includes new regulations concerning the rights of patients to not to be hospitalised against their will. The draft law also promotes the transparency of patient treatment management, as many hospitals were driven by financial motives and disregarded patients’ rights. The law, adopted in 2012, stipulates that a qualified psychiatrist must make the determination of mental illness; that patients can choose whether to receive treatment in most cases; and that only those at risk of harming themselves or others are eligible for compulsory inpatient treatment. However, Human Rights Watch has criticised the law. For example, although it creates some rights for detained patients to request a second opinion from another state psychiatrists and then an independent psychiatrist, there is no right to a legal hearing such as a mental health tribunal and no guarantee of legal representation.

Since 1993, WHO has been collaborating with China in the development of a national mental health information system.

Current Situation

Though China continues to develop its mental health services, it still has a large number of untreated and undiagnosed people with mental illnesses. The aforementioned intense stigma associated with mental illness, a lack of mental health professionals and specialists, and culturally-specific expressions of mental illness may play a role in the disparity.

Prevalence of Mental Disorders

Researchers estimate that roughly 173 million people in China have a mental disorder. Over 90 percent of people with a mental disorder have never been treated.

A lack of government data on mental disorders makes it difficult to estimate the prevalence of specific mental disorders, as China has not conducted a national psychiatric survey since 1993.

Conducted between 2001 and 2005, a non-governmental survey of 63,000 Chinese adults found that 16 percent of the population had a mood disorder, including 6% of people with major depressive disorder. Thirteen percent of the population had an anxiety disorder and 9 percent had an alcohol use disorder. Women were more likely to have a mood or anxiety disorder compared to men, but men were significantly more likely to have an alcohol use disorder. People living in rural areas were more likely to have major depressive disorder or alcohol dependence.

In 2007, the Chief of China’s National Centre for Mental Health, Liu Jin, estimated that approximately 50% of outpatient admissions were due to depression.

There is a disproportionate impact on the quality of life for people with bipolar disorder in China and other East Asian countries.

The suicide rate in China was approximately 23 per 100,000 people between 1995 and 1999. Since then, the rate is thought to have fallen to roughly 7 per 100,000 people, according to government data. WHO states that the rate of suicide is thought to be three to four times higher in rural areas than in urban areas. The most common method, poisoning by pesticides, accounts for 62% of incidences.

It is estimated that 18% of the Chinese population, about 244 million people believe in Buddhism. Another 22% of the population, roughly 294 million people believe in folk religions which are a group of beliefs that share characteristics with Confucianism, Buddhism, Taoism, and shamanism. Common between all of these philosophical and religious beliefs is an emphasis on acting harmoniously with nature, with strong morals, and with a duty to family. Followers of these religions perceive behaviour as being tightly connected with health; illnesses are often thought to be a result of moral failure or insufficiently honouring one’s family in current or past life. Furthermore, an emphasis on social harmony may discourage people with mental illness from bringing attention to themselves and seeking help. They may also refuse to speak about their mental illness because of the shame it would bring upon themselves and their family members, who could also be held responsible and experience social isolation.

Also, reputation might be a factor that prevents individuals from seeking professional help. Good reputations are highly valued. In a Chinese household, every individual shares the responsibility of maintaining and raising the family’s reputation. It is believed that mental health will hinder individuals from achieving the standards and goals- whether academic, social, career-based, or other- expected from parents. Without reaching the expectations, individuals are anticipated to bring shame to the family, which will affect the family’s overall reputation. Therefore, mental health issues are seen as an unacceptable weakness. This perception of mental health disorders causes individuals to internalise their mental health problems, possibly worsening them, and making it difficult to seek treatment. Eventually, it becomes ignored and overlooked by families.

In addition, many of these philosophies teach followers to accept one’s fate. Consequently, people with mental disorders may be less inclined to seek medical treatment because they believe they should not actively try to prevent any symptoms that may manifest. They may also be less likely to question the stereotypes associated with people with mental illness, and instead agreeing with others that they deserve to be ostracised.

Lack of Qualified Staff

China has 17,000 certified psychiatrists, which is 10% of that of other developed countries per capita. China averages one psychologist for every 83,000 people, and some of these psychologists are not board-licensed or certified to diagnose illnesses. Individuals without any academic background in mental health can obtain a license to counsel, following several months of training through the National Exam for Psychological Counsellors. Many psychiatrists or psychologists study psychology for personal use and do not intend to pursue a career in counselling. Patients are likely to leave clinics with false diagnoses, and often do not return for follow-up treatments, which is detrimental to the degenerative nature of many psychiatric disorders.

The disparity between psychiatric services available between rural and urban areas partially contributes to this statistic, as rural areas have traditionally relied on barefoot doctors since the 1970s for medical advice. These doctors are one of the few modes of healthcare able to reach isolated parts of rural China, and are unable to obtain modern medical equipment, and therefore, unable to reliably diagnose psychiatric illnesses. Furthermore, the nearest psychiatric clinic may be hundreds of kilometres away, and families may be unable to afford professional psychiatric treatment for the afflicted.

Physical Symptoms

Multiple studies have found that Chinese patients with mental illness report more physical symptoms compared to Western patients, who tend to report more psychological symptoms. For example, Chinese patients with depression are more likely to report feelings of fatigue and muscle aches instead of feelings of depression. However, it is unclear whether this occurs because they feel more comfortable reporting physical symptoms or if depression manifests in a more physical way among Chinese people.

Misuse

According to various scholars, China’s psychiatric facilities have been manipulated by government officials in order to silence political dissidents. In addition to misuse by the state psychiatric facilities in China are also misused by powerful private individuals who use the system to advance their personal or business ends. China’s legal system lacks an effective means of challenging involuntary detentions in psychiatric facilities.

Chinese Military Mental Health

Overview

Military mental health has recently become an area of focus and improvement, particularly in Western countries. For example, in the United States, it is estimated that about twenty-five percent (25%) of active military members suffer from a mental health problem, such as PTSD, Traumatic Brain Injury, and depression. Currently, there are no clear initiatives from the government about mental health treatment towards military personnel in China. Specifically, China has been investing in resources towards researching and understanding how the mental health needs of military members and producing policies to reinforce the research results.

Background

Research on the mental health status of active Chinese military men began in the 1980s where psychologists investigated soldiers’ experiences in the plateaus. The change of emphasis from physical to mental health can be seen in China’s four dominant military academic journals: First Military Journal, Second Military Journal, Third Military Journal, and Fourth Military Journal. In the 1980s, researchers mostly focused on the physical health of soldiers; as the troops’ ability to perform their services declined, the government began looking at their mental health to provide an explanation for this trend. In the 1990s, research on it increased with the hope that by improving the mental health of soldiers, combat effectiveness improves.

Mental health issue can impact active military members’ effectiveness in the army, and can create lasting effects on them after they leave the military. Plateaus were an area of interest in this sense because of harsh environmental conditions and the necessity of the work done with low atmospheric pressure and intense UV radiation. It was critical to place the military there to stabilize the outskirts and protect the Chinese citizens who live nearby; this made it one of the most important jobs in the army, then increasing the pressure on those who worked in the plateaus. It not only affected the body physically, like in the arteries, lungs, and back, but caused high levels of depression in soldiers because of being away from family members and with limited communication methods. Scientists found that this may impact their lives as they saw that this population had higher rates of divorce and unemployment.

Comparatively, assessing the mental health status of the People’s Liberation Army (PLA) is difficult, because military members work a diverse array of duties over a large landscape. Military members also play an active part in disaster relief, peacekeeping in foreign lands, protecting borders, and domestic riot control. In a study of 11,000 soldiers, researchers found that those who work as peacekeepers have higher levels of depression compared to those in the engineering and medical departments. With such diverse military roles over an area of 8.4 million square kilometres (3.25 million square miles), it is difficult to gauge its impacts on soldiers’ psyche and provide a single method to address mental health problems.

Researches have increased over the last two decades, but the studies still lack a sense of comprehensiveness and reliability. In over 73 studies that together included 53,424 military members, some research shows that there is gradual improvement in mental health at high altitudes, such as mountain tops; other researchers found that depressive symptoms can worsen. These research studies demonstrate how difficult it is to assess and treat the mental illness that occurs in the army and how there are inconsistent results. Studies of the military population focus on the men of the military and exclude women, even though the number of women that are joining the military has increased in the last two decades.

Chinese researchers try to provide solutions that are preventative and reactive, such as implementing early mental health training, or mental health assessments to help service members understand their mental health state, and how to combat these feelings themselves. Researchers also suggest to improve the mental health of the military members, programmes should include psychoeducation, psychological training, and attention to physical health to employ timely intervention.

Implementation

In 2006, the People’s Republic Minister for National Defence began mental health vetting at the beginning of the military recruitment process. A Chinese military study consisting of 2500 male military personnel found that some members are more predisposed to mental illness. The study measured levels of anxious behaviours, symptoms of depression, sensitivity to traumatic events, resilience and emotional intelligence of existing personnel to aid the screening of new recruits. Similar research has been conducted into the external factors that impact a person’s mental fortitude, including single-child status, urban or rural environment, and education level. Subsequently, the government has incorporated mental illness coping techniques into their training manual. In 2013 leak by the Tibetan Centre for Human Rights of a small portion of the People’s Liberation Army training manual from 2008, specifically concerned how military personnel could combat PTSD and depression while on peacekeeping missions in Tibet. The manual suggested that soldiers should:

“…close [their] eyes and imagine zooming in on the scene like a camera [when experiencing PTSD]. It may feel uncomfortable. Then zoom all the way out until you cannot see anything. Then tell yourself the flashback is gone.”

In 2012, the government specifically addressed military mental health in a legal document for the first time. In article 84 of the Mental Health Law of the People’s Republic of China, it stated, “The State Council and the Central Military Committee will formulate regulations based on this law to manage mental health work in the military.”

Besides screening, assessments and an excerpt of the manual, not much is known about the services that are provided to active military members and veterans. Analysis of more than 45 different studies, moreover, has deemed that the level of anxiety in current and ex-military personnel has increased despite efforts of the People’s Republic due to economic conditions, lack of social connects and the feeling of a threat to military livelihood. This growing anxiety manifested in both 2016 and 2018, as Chinese veterans demonstrated their satisfaction with the system via protests across China. In both instances, veterans advocated for an increased focus on post-service benefits, resources to aid in post-service jobs, and justice for those who were treated poorly by the government. As a way to combat the dissatisfaction of veterans and alleviate growing tension, the government established the Ministry of Veteran Affairs in 2018. At the same time, Xi Jinping, General Secretary of the Communist Party of China, promised to enact laws that protect the welfare of veterans.

Loneliness Awareness Week (14-18 June)

This year, Loneliness Awareness Week will take place from 14 to 18 June.

Hosted by the Marmalade Trust, it is a campaign that raises awareness of loneliness and gets people talking about it.

Find out more here and how you can get involved.

In 2020 the campaign reached around 271.5 million people – all without leaving our homes. The campaign saw almost 20,000 charities, organisations, companies and individuals get involved online.

Book: Mental Health in a Multi-Ethnic Society

Book Title:

Mental Health in a Multi-Ethnic Society: A Multidisciplinary Handbook.

Author(s): Suman Fernando and Frank Keating (Editors).

Year: 2008.

Edition: Second (2nd).

Publisher: Routledge.

Type(s): Hardcover, Paperback, and Kindle.

Synopsis:

This new edition of Mental Health in a Multi-Ethnic Society is an authoritative, comprehensive guide on issues around race, culture and mental health service provision. It has been updated to reflect the changes in the UK over the last ten years and features entirely new chapters by over twenty authors, expanding the range of topics by including issues of particular concern for women, family therapy, and mental health of refugees and asylum seekers.

Divided into four sections the book covers:

  • Issues around mental health service provision for black and minority ethnic (BME) communities including refugees and asylum seekers.
  • Critical accounts of how these issues may be confronted, with examples of projects that attempt to do just that.
  • Programmes and innovative services that appear to meet some of the needs of BME communities.
  • A critical but constructive account of lessons to be drawn from earlier sections and discussion of the way ahead.

With chapters on training, service user involvement, policy development and service provision Mental Health in a Multi-Ethnic Society will appeal to academics, professionals, trainers and managers, as well as providing up-to-date information for a general readership.

What is Helper Theory?

Introduction

Helper theory or the helper therapy principle was first described by Frank Riessman (1965) in an article published in the journal Social Work. The principle suggests that when an individual (the “helper”) provides assistance to another person, the helper may benefit.

Riessman’s model has inspired subsequent research and practice by scholars, clinicians, and indigenous populations to address a variety of social and health-related issues plaguing individuals and communities around the world.

Refer to Peer Support and Skills and Abilities Required for Peer Support.

Riessman’s Formulation

Riessman’s seminal article explored how non-professionals supported one another in self-help/mutual-aid support groups based on Riessman’s observations of a sample of these groups, as well as his summary of the findings of research in the areas of social work, education, and leadership. This article suggested that although the “use of people with a problem to help other people who have the same problem in [a] more severe form” is “an age-old therapeutic approach,” the traditional focus on outcomes for those receiving help to the exclusion of considering outcomes for those providing help is too narrow; instead, Riessman (1965, p.27) advocated for increased consideration of the experience of “the individual that needs the help less, that is, the person who is providing the assistance” because “frequently it is he who improves!”

Although Riessman expressed doubt that individuals receiving help always benefit from the assistance provided to them, he felt more sure that individuals providing help are likely experiencing important gains; thus, according to Riessman, the helping interaction at least has the potential to be mutually beneficial for both parties involved (i.e. for both the individual giving and for the individual receiving aid), but it is not absolutely necessary for the “helpee” to benefit in order for the “helper” to enjoy the benefits of helping. In instances where true mutual benefit occurs, the helper and helpee benefit in different ways, such that the person receiving help benefits by way of receiving whatever specific form of assistance is offered to them (e.g. emotional support, information, etc.) while the person providing help benefits by the very act of providing help, regardless of the type of aid they provide.

Riessman posited several different mechanisms which may facilitate the benefits experienced by an individual engaged in a helping role:

  • Gaining an improved self-image;
  • Becoming more committed to a position through the process of advocating it (i.e. “self-persuasion through persuading others”);
  • Experiencing meaningful development of abilities after having been given a stake in a system and learning through teaching others;
  • Gaining access to a socially-valued role and the resultant sense of social status and importance;
  • Enjoying opportunities to affirm one’s own wellness following placement in a system as a role model; and
  • Shifting one’s focus from self-concerns and problems to assisting others (and thus distracting oneself from ongoing difficulties).

Health Care

Lepore, Buzaglo, Liberman, Golant, Greener, and Davey (2014) investigated the helper-therapy principle in a randomised control trial of a “prosocial”, other-focused Internet Support Group (P-ISG) designed to elicit peer-instigated, supportive interactions online among female breast cancer survivors. When compared to female breast cancer survivors who participated in a standard, self-focused Internet Support Group (S-ISG), which was not designed to explicitly provide opportunities for helping interactions to take place, analyses found that individuals in the P-ISG condition did provide more support to others yet P-ISG participants experienced a higher level of depression and anxiety following the intervention than those in S-ISG. These results fail to provide support for the helper-therapy principle which posits that “helping others is effective at promoting mental health” (Lepore et al., 2014, p.4085). In accounting for these results, Lepore et al. (2014) suggest that it is possible that women in the P-ISG condition felt hesitant to express their negative feelings out of fear that doing so might impact others adversely, whereas women in the S-ISG felt more able to unburden themselves of emotional pain and thus enjoyed better mental health outcomes.

Arnold, Calhoun, Tedeschi, and Cann (2005) explored both the positive and negative sequelae of providing psychotherapy to clients who had experienced trauma and subsequent posttraumatic growth by conducting naturalistic interviews with a small sample of clinicians (N = 21). Although all interviewees indicated experiencing some degree of negative experience as a result of engaging in trauma-focused psychotherapy (such as intrusive thoughts, negative emotional responses, negative physical responses, and doubts about clinical competence), all participants also indicated some sort of positive personal outcome occurred as a result of assisting psychotherapy clients with these types of experiences. The positive reactions experienced by clinicians engaged in trauma work included: enjoying the gratification that comes through watching others grow and triumph following difficult times; increasing recognition of one’s own personal growth and development; expanding ability to connect emotionally with others; impacting one’s own sense of spirituality; increased awareness of one’s own good fortune in life; and increasing appreciation for the strength and resiliency of human beings. This finding suggests that the helper-therapy principle may operate in a clinical context whereby therapists (i.e. the helpers) benefit from engaging in the process of providing treatment to psychotherapy clients who have survived traumatic experiences.

Pagano, Post, and Johnson (2011) reviewed recent evidence examining “helper health benefits” among populations experiencing problematic involvement with alcohol, other mental health conditions, and/or general medical problems. In brief, their review suggests that when individuals with chronic health conditions (e.g. alcohol use disorder, body dysmorphic disorder with comorbid alcohol dependence, multiple sclerosis, chronic pain) help others living with the same chronic condition, the individual helper benefits (e.g. longer time-to-relapse, remission, reduced depression and other problematic symptoms, and increased self-confidence, self-esteem, and role functioning).

Additionally, Post’s (2005, p.73) review of the literature on altruism, happiness, and health indicates that “a strong correlation exists between the well-being, happiness, health, and longevity of people who are emotionally kind and compassionate in their charitable helping activities”. However, Post also notes that individual helpers may become overwhelmed by over-involvement in the lives of others, and that giving assistance beyond a certain variable threshold may lead to deleterious rather than beneficial outcomes for helpers.

Social Work

Melkman, Mor-Salwo, Mangold, Zeller, & Benbenishty (2015) used a grounded theory approach to understand:

  1. The motivations and experiences which led young adult “careleavers” (N = 28, aged 18-26) in Israel and Germany to assume a helper role; and
  2. The benefits they report enjoying as a result of helping others through volunteerism and/or human-service focused careers.

Participants reported that observing role models involved in helping roles, being exposed to prosocial values, and having opportunities to volunteer within the system in which they were simultaneously receiving care all contributed to later assumption of more stable and regular helping roles. These participants felt obliged to provide assistance to others, desired to provide this assistance to others, and felt sufficiently competent to carry out the tasks required of them in their helping role. These participants reported that helping others provided them with a sense of purpose in their lives, and also increased self-efficacy, social connectedness, and ability to cope with personal issues. Additionally, participants reported that assuming a helping role provided a sense of normalcy to their lives, as well as providing a sense of perspective on their own journey and outcomes. As one participant (a volunteer with a police department who was assigned to work with at-risk youth) shared with the researchers:

“The fact that I could bring a runaway girl back to her home and I made her trust me, the fact that I located a missing girl, the fact that I escorted a rape victim to hospital and I managed to give her strength and support her, these are the things that give me meaning, tell me that I’m in a much better situation than others” (Melkman et al., 2015, p.45).

Self-Help/Mutual-Help

Roberts, Salem, Rappaport, Toro, Luke, and Seidman (1999, p.859) found support for the helper-therapy principle among participants of GROW, a mutual-help group for individuals with serious mental illness, whereby “participants who offered help to others evidenced improvement over time in psychosocial adjustment”.

Maton (1988) reports that occupying both “helper” and “helpee” roles in a self-help/mutual-aid group (i.e. bidirectional support) was positively correlated with psychological well-being and positive perceptions regarding the benefits of group membership, and that these members with dual-roles had a greater sense of well-being and a more favourable opinion of the group than members who were helpees (i.e. recipients of assistance) only.

Olson, Jason, Ferrari, and Hutcheson (2005) reviewed the existent literature on four mutual-help organisations (Alcoholics Anonymous, Oxford House, GROW, and Schizophrenics Anonymous). They suggest that the processes of change framework found within the transtheoretical model of intentional behaviour change (Prochaska, Diclemente, and Norcross, 1992) is a useful model to conceptualise the activities of mutual-help organization members throughout their journey of mental health recovery. They explicitly link social liberation, the last of the ten processes of change articulated by the model (the others being: consciousness raising, self-re-evaluation, helping relationships, self-liberation, environmental re-evaluation, dramatic relief/emotional arousal, stimulus control, reinforcement management, and counterconditioning) to the helper-therapy principle, along with a related concept known as bidirectional support (Maton, 1988). Per Olson et al. (2005), social liberation “involves the person in recovery focusing attention away from oneself and developing a broader recognition of social issues that contributed to the targeted problem” which encourages “recovering individuals to take more helping-related attitudes toward others who face similar problems” (Olson et al., 2005, p.174). In reviewing the research conducted among members of these four self-help/mutual-help organisations, they identify three different mechanisms which might underlie the therapeutic effect of mutual-help:

  1. When an individual helps another, the helper’s social functioning improves because the act of providing help to another allows the helper to work through their own difficulties;
  2. When an individual helps another, the helper’s social functioning improves because the act of providing help to another allows the helper to reinforce their own personal learning about recovery; and/or
  3. When an individual helps another, the helper experiences an increase in their own sense of competence and usefulness to others and enables the helper to adopt a “strength-based roles that have not been fully exercised in other areas of life” (Olson et al., 2005, p.175).

In reviewing the research on GROW, specifically, 67% of members of this organisation sampled by Young and Williams (1987) who were asked how they most benefited from participation reported that involvement in GROW “taught [them they] could help others” (the most endorsed answer among all listed categories). As suggested by a study by Maton and Salem (1995), this idea is most succinctly expressed by way of an axiom of GROW which is often recited at meetings: “If you need help, help others.”

A review of empirical studies investigating the effect of mutual help group participation for individuals with mental health problems by Pistrang, Barker, and Humphreys (2008, p.110) provides “limited but promising evidence that mutual help groups benefit people with three types of problems: chronic mental illness, depression/anxiety, and bereavement”.

References

Arnold, D., Calhoun, L. G., Tedeschi, R. & Cann, A. (2005). Vicarious posttraumatic growth in psychotherapy. Journal of Humanistic Psychology. 45(2), pp.239-263.

Lepore, S.J., Buzaglo, J.S., Liberman, M.A., Golant, M., Greener, J.R. & Davey A. (2014) Comparing standard versus prosocial internet support groups for patients with breast cancer: A randomized controlled trial of the helper therapy principle. Journal of Clinical Oncology. 32(36), pp.4081-4086.

Maton, K.I. (1988). Social support, organization characteristics, psychological wellbeing and group appraisal in three self-help populations. American Journal of Community Psychology. 16(1), pp.53-77.

Maton, K.I. & Salem, D.A. (1995). Organizational characteristics of empowering community settings: A multiple case study approach. American Journal of Community Psychology. 23(5), pp631-656.

Melkman, E., Mor-Salwo, Y., Mangold, K., Zeller, M. & Benbenishty, R. (July 2015). Care leavers as helpers: Motivations for and benefits of helping others. Children and Youth Services Review. 54, pp.41-48.

Olson, B.D., Jason, L.A., Ferrari, J.R. & Hutcheson, T.D. (2005). Bridging professional and mutual-help: An application of the transtheoretical model to the mutual-help organization. Applied and Preventive Psychology. 11(3), pp.167-178.

Pagano, M.E., Post, S.G. & Johnson, S.M. (2011). Alcoholics Anonymous-Related Helping and the Helper Therapy Principle. Alcoholism Treatment Quarterly. 29(1), pp.23-34.

Pistrang, N., Barker, C. & Humphreys, K. (2008). Mutual Help Groups for Mental Health Problems: A Review of Effectiveness Studies. American Journal of Community Psychology. 42(1-2), pp.110-121.

Post, S.G. (2005). Altruism, happiness, and health: it’s good to be good. International Journal of Behavioral Medicine. 12(2), pp.66-77.

Prochaska, J.O., DiClemente, C.C. & Norcross, J.C. (1992). In search of how people change: Applications to the addictive behaviors. American Psychologist. 47(9), pp.1102-1114.

Riessman, F. (1965) The ‘Helper’ Therapy Principle. Social Work. 10(2), pp.27-32.

Roberts, L., Salem, D., Rappaport, J., Toro, P.A., Luke, D.A. & Seidman, E. (1999). Giving and receiving help: Interpersonal transactions in mutual-help meetings and psychosocial adjustment of members. American Journal of Community Psychology. 27(6), pp.841-868.

Young, J. & Williams, C.L. (1987). An Evaluation of Grow, a Mutual-Help Community Mental Health Organisation. Community Health Studies. 11(1), pp.38-42.