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In my hour of need, I truly am indeed alone again, naturally -Gilbert O'Sullivan (1972)
The hit song by Gilbert O'Sullivan tells the story of a person who, like all of us, encounters life's tribulations. He recalls such events as being left by a lover and his father's death. His conclusion is always the same: alone again, naturally. This is indeed a tragedy, as the science of relationships suggests the importance of close ties for our happiness and to help in our deepest hour of need. In fact, when people are asked what is most important to them, the most common response is not their jobs or material possessions but their personal relationships (Berscheid, 1985). In a Gallup poll (13 October 2000), the presence of a spouse was reported as having one of the strongest influences on happiness. As a test, think about how you would want to spend your time if you had only six months to live. How about two weeks? Many of us would want to share that time with the individuals who have given us the most joy in our lives. If placed in that situation, I would not be sitting here alone writing this book! When it comes down to it, our close relationships matter the most.
Individuals with satisfying and supportive relationships find it difficult to imagine not having such people in their lives. Much research shows that socially supportive relationships protect individuals from a multitude of mental health problems, ranging from mild depression to suicidal tendencies (Cohen, Underwood, and Gottlieb, 2000). This book focuses on the less-obvious possibility that a lack of supportive relationships places an individual at risk for mortality from various diseases, ranging from cardiovascular disease and cancer to infectious diseases.
What overall evidence exists to show that a lack of supportive relationships can contribute to mortality from serious physical health conditions, such as coronary artery disease? Every few months the popular media report on a research study that finds that our social environment influences our health. For every one popular news report, probably five other well-conducted research studies are published that the public does not hear about. The next section examines the contributions of several researchers whose work provides the basis for this research and continues to influence how researchers think about the association between social relationships and physical health outcomes.
The study of social factors and physical health has a long research tradition. Renowned French sociologist Emile Durkheim is credited for jump-starting an examination of social relationships and mortality. In his classic analysis, he argued persuasively for the scientific study of suicide (Durkheim, 1951). His analyses of suicide rates across social classes, cultures, religious affiliation, and gender led him to conclude that there were three basic forms of suicide. Although suicide would seem like an intensely personal event, Durkheim concluded that each form of suicide was so closely intertwined with the larger society that it could not be understood without reference to the larger social structures in which an individual was situated.
The most well-known form of suicide was what he termed egoistic suicide. Egoistic suicide results from a lack of integration of the individual to society or family life. As a result, individuals are left to face the challenges of life on their own. A second form of suicide he termed anomic. Anomic suicide can result from a sudden or more gradual change in societal regulation (for example, spousal death or economic changes). These changes may result in dramatic changes in standards (for example, role confusion) with subsequent suffering that can lead to suicide. Durkheim also argued that too much social integration might be harmful for the individual. He called the third form of suicide altruistic, and it occurs when the social situation is governed by rigid rules that result, for instance, in an individual taking his or her life at the command of a leader.
Durkheim's analysis was impressive in scope and careful in conclusion. Several points are particularly important for the social relationships and mortality studies that I later review. He clearly demonstrated that the social environment could influence significant outcomes, such as mortality rates. He also realized that the social environment could have both health-promoting and health-damaging effects on individuals, although this last point has been less emphasized in contemporary research. Durkheim's analysis had an influential role on subsequent researchers' interest on whether relationships influence mortality patterns.
Durkheim's analysis made it easy to see how the absence or presence of relationships might influence mortality from suicide. This link between relationships and mortality was much less obvious when applied to the medical domain, in which researchers have historically focused on the biology of disease. The more traditional medical model drew a separation between body and mind, a distinction that left little room for the incorporation of psychosocial factors in health and disease. However, medical researchers whose orientation questioned the mind-body separation provided a paradigm for examining the link between psychosocial factors and disease processes (Levenson, 1994). In 1939, the journal Psychosomatic Medicine was launched, and the American Psychosomatic Society was founded in 1942. The goals of the society were to formally study the links between the environment, mind, and disease. It thereby set the groundwork for asking questions about social support and disease processes.
One of the founders of the American Psychosomatic Society, George Engel, published an important article in 1977 on that general approach in the journal Science. His paper formally criticized the reductionist medical model on the grounds that it ignored the different levels of analysis that may influence health. He proposed the now-classic "biopsychosocial model" of health and disease that has since served as the cornerstone for the interdisciplinary fields of psychosomatic medicine, behavioral medicine, and health psychology. The biopsychosocial model made evident that human health could be influenced by diverse factors that ranged from the sociocultural milieu (for example, socioeconomic status) to the biological (for example, atherosclerosis). Further, these factors or levels of influence were not independent of each other but instead represented embedded and interacting processes.
The general approach endorsed by psychosomatic medicine and the biopsychosocial model was evident in two seminal papers on social support and health published in 1976 by Sidney Cobb and John Cassell. Cobb carefully defined social support as information from others that one is cared for, loved, esteemed, and part of a mutually supportive network. Social support was ultimately based, according to this perspective, in the meaning behind the supportive messages from others. He then reviewed evidence suggesting that these social support resources were important in dealing with a range of stressful life events such as pregnancy, hospitalization, and bereavement. The range of outcomes examined by Cobb made it difficult to argue that social support was not an important predictor of health outcomes.
While Cobb focused more on the nature and meaning of supportive interactions that might in turn influence disease, Cassell approached his review from a biological perspective. He argued that social support might best be seen as a protective factor provided by important network members that modifies an individual's biological resistance to disease. He reviewed studies suggesting that such relationship factors may modify bodily processes (for example, blood pressure, endocrine activity) that might then influence disease states depending on the disease agent, genetics, and prior experience.
Those two papers are important not only in the early nature of their conclusions that social relationships matter for health, but also in their complementary approaches. Cobb called attention to a more precise definition of social support and how it fostered adjustment to life events. Cassell pointed to a more precise biological and medical analysis of the protective effects of social support. These two approaches continue to dominate contemporary research on social support and health outcomes.
A few years after these groundbreaking reviews, one of the first well-controlled longitudinal research studies was published that linked social relationships to mortality. Lisa Berkman and Leonard Syme surveyed thousands of participants from Alameda County, California (Berkman and Syme, 1979). They linked questions about the extent of peoples' social connections to overall mortality and found that people who had fewer social ties had higher mortality rates. This classic paper was also able to rule out possible alternative explanations (for example, results due to poorer initial health status) and hence provided the most compelling empirical links at the time between social relationships and mortality.
In 1985, an important paper was published by Sheldon Cohen and Thomas Wills. In their review of the burgeoning literature on social support and health outcomes, they drew attention to the different ways of measuring social support and how these measures might be related to health. They noted that researchers measured support in at least two ways: structural measures and functional measures of support. Structural measures examined the existence or interconnection among various social ties, for example, the number of close friends or amount of contact with family members. Functional measures of support assessed the actual functions served by social network members, for example, examining expressions of caring or useful advice from close relationships. (A more careful distinction between the measures is discussed in depth in chapter 2).
Cohen and Wills found that structural measures of support were more likely to have general health-promoting effects because they provided an overall sense of stability and self-worth. However, we are sometimes exposed to events (for example, stressors) that challenge our sense of stability and esteem. Under such circumstances, actions provided by supportive networks that help us cope may lessen the impact of stressors on our health and well-being. Consistent with this reasoning, Cohen and Wills found that functional measures of support were more likely to "buffer" the potentially harmful effects of exposure to stress. Their work thus served to link several broad perspectives on social support (for example, social support as a stress buffer) with specific measurement approaches.
In 1988, a review entitled "Social Relationships and Health" was published in Science by James House and colleagues (House, Landis, and Umberson, 1988). The authors examined evidence from available prospective studies indicating that being socially integrated had an independent protective effect on mortality. They argued that these effects were of similar magnitude to standard medical variables such as blood pressure, smoking, and physical activity. They concluded that medical practice might be improved by the future examination and implementation of this impressive body of literature. Their careful analysis of well-designed prospective studies has served as the most recent basis for many researchers interested in the links between relationships and physical health outcomes.
Many other important papers have been published on this topic (for example, Broadhead et al., 1983; Cohen, 1988; Umberson, 1987). An underlying theme of those papers and this book is an emphasis on interdisciplinary research that integrates across different levels of analysis (Cacioppo and Berntson, 1992; Engel, 1977). These levels of analysis range from the macro or sociocultural level to the more micro or biological level of analysis. Interdisciplinary research is critical because of the complexity of the links between social support and physical health that undoubtedly influences just about every level of analysis. Each discipline can bring a unique set of perspectives, skills, and methodologies to each level of analysis and facilitate a more complete understanding of this important phenomenon.
Combining social and biomedical approaches has historically been difficult. Tension existed between the medical community and social scientists because both sides have had reason to be critical of the other's research. Social scientists may not have been sensitive to the rigorous biological approaches of biomedical research, and biomedical researchers may not have been sensitive to the appropriate measurement and theory of the psychosocial phenomenon. There is now much more acceptance of the mending of social science and biomedical research that is, in part, due to the progress and impressive findings made by various interdisciplinary research teams around the world.
In this book I discuss the current research and theory in the area of social support and physical health outcomes that have been informed by interdisciplinary perspectives. An important point of such research is that social support is an extremely complex process. The supportive statement "I know you will be fine in due time" to a person dealing with the loss of a loved one might be interpreted differently depending on who is saying it. If said by a loved one, it might comfort by underscoring the fact that you are not alone. However, if said by a person with whom you have a lukewarm relationship, it could be seen as minimizing your loss. Likewise, the disease outcomes to be considered in this literature are similarly complex. The natural progression of cardiovascular disease differs from the natural progression of cancer, and these issues need to be taken into account in order to understand how and when social support may influence these disease outcomes.
This book is divided into eight chapters. In chapter 2, I review the often difficult question of how one measures and conceptualizes social support. Although the term social support is used by many, its meaning and measurement differ dramatically depending on the background of the researcher. Recent thinking on this question is reviewed, especially in regard to potential links with health outcomes. A broad measurement model is proposed that can serve as a guide for researchers. In chapter 3 I review the main theoretical models linking social support to health outcomes. That chapter helps form a bridge between social and biomedical approaches. It also sets the stage for interpreting the actual evidence for an association between social support and mortality that is discussed in the next chapters.
Excerpted from Social Support and Physical Health by Bert N. Uchino Copyright © 2004 by Yale University. Excerpted by permission.
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|Ch. 1||Introduction and Historical Perspectives||1|
|Ch. 2||The Meaning and Measurement of Social Support||9|
|Ch. 3||Theoretical Perspectives Linking Social Support to Health Outcomes||33|
|Ch. 4||Social Support and All-Cause Mortality||54|
|Ch. 5||Social Support and Mortality From Specific Diseases||83|
|Ch. 6||Pathways Linking Social Support to Health Outcomes||109|
|Ch. 7||Intervention Implications||145|
|Ch. 8||Future Directions and Conclusions||170|