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W h o T a l k s ?The Social Psychology of Illness Support Grou ps

Kathryn P. Davison,James W. PennebakerSally S. DickersonT h e H u m a n A s s e tUn ivers i t y o f T exa s a t Au s t i nUn ivers i t y o f Ca l i fo rn ia, L o s An g e l e s

M o r e A m e r i c a n s t r y to c h a n g e t h e ir h e a lt h b e h a v i o r sth ro u g h se l f -h e lp t h a n t h ro u g h a l l o th er f o r m s o f p ro f es -s i o n a l l y d es ig n e d p ro g ra m s . M u tu a l su p p o r t g ro u p s, i n -vo l v in g l i t tl e o r n o co s t t o p a r t i c i p a n t s , h a ve a p o we r fu le f f ec t o n men ta l a n d p h ys i ca l h ea l th , ye t l it t le i s kn o wna b o u t p a t t e rn s o f su p p o r t g ro u p p a r t i c i p a t i o n i n h ea lt hca re . W h a t k i n d s o f il l n es s exp er i en ces p ro m p t p a t i en t s t oseek e a ch o th er ' s co m p a n y ? In a n e f f o r t t o o b serve so c ia lc o m p a r i s o n p r o c e s s e s w i t h r e a l - w o r l d r e l e v a n c e , s u p p o r tg r o u p p a r ti c i p a ti o n w a s m e a s u r e d f o r 2 0 d i s e a s e c a t e g o -r i es in 4 me t ro p o l i t a n a rea s (New Y o rk , C h i ca g o , L o sAn g e l es , a n d Da l la s ) a n d o n 2 o n - l i n e Jb ru ms . S u p p o r ts e e k i n g w a s h i g h e s t f o r d i s e a s e s v i e w e d a s s t i g m a t iz i n g(e.g. , A IDS , a l co h o l i sm, b rea s t a n d p ro s ta t e ca n cer ) a n dwa s l o w es t f o r l e s s emb a r ra ss in g b u t eq u a l l y d eva s ta ti n gd i so rd ers , su ch a s h ea r t d i sea se . T h e a u th o rs d i scu ss im-p l i ca t i o n s f o r so c ia l co m p a r i so n t h eo ry a n d i t s a p p l i ca t i o n sin hea l th care.

T he experience of illness is a profoundly social one.Suffering elicits intense emotions and hence thedesire to talk to others. Through interpersonal ex-changes, patients develop an understanding of their illness:They may talk to friends, relatives, and professionals aboutwhat their diagnosis and treatment may entail. Over thecourse of their particular illness, relationships are strainedor broken, and new ones become valuable, such as thosewith doctors, nurses, or physical therapists. For some, thecondition itself constitutes a dangerous secret that erects abarrier between themselves and their support network.Thus, patients' experiences of illness both influence, andare influenced by, the social fabric that surrounds them.

A recent development in the social milieu of thepatient is the proliferation of mutual support groups forpeople coping with illness. Across the country, in hospitals,churches, empty offices, and even shopping malls, smallgroups of individuals assemble to cope collectively withtheir unique challenges. Such populist approaches often gounnoticed by psychologists because of a bias toward pro-fessionalism on the one hand and a lack of awareness onthe part of group participants that they are part of a largermovement on the other (Jakobs & Goodman, 1989). Thepsychological and physical health importance of this dif-fuse community is striking. Through such groups, millionsof Americans attempt to overcome addiction, discuss inno-

vations in insulin treatments, grieve for the loss of a breast,or share fears about the possible progression of HIV toAIDS. Some conditions are associated with more supportgroups than others. What kinds of illness experiencesprompt the formation and maintenance of support groups?What makes the support group appealing for cancer pa-tients but not for cardiac patients? Why is mutual supportan intrinsic part of AIDS case management but utterlylacking from hypertension treatment'?V e n u e s f o r S o c i a l C o m p a r i s o nFestinger's (1954) social comparison theory postulated thatsocial behaviors could be predicted largely on the basis ofthe assumption that individuals seek to have and maintaina sense of normalcy and accuracy about their world. Intimes of uncertainty, Festinger predicted that affiliativebehaviors would increase as people sought others' opinionsabout how they should be thinking or feeling.Empirical tests of social comparison theory havefound that affiliative behaviors increase under conditions ofhigh anxiety. Participants awaiting a fake medical proce-dure presumed to include an electric shock expressed astrong preference for the presence of another, especiallysomeone facing the same procedure (Schachter, 1959).However, later studies about affiliative motivation raisedfurther doubts about social comparison motives (e.g.,Teichman, 1973). Sarnoff and Zimbardo (1961) examinedpreferences of college students who thought they wereawaiting an electric shock but also were told that theywould be required to suck bottle nipples as part of theexperimental procedure. In this more embarrassing contextof anxiety, participants indicated a marked d e c r e a s e in thedesire to have another present. Sarnoff and Zimbardo con-cluded that the kind of anxiety associated with humiliation

Editor 's no te . Melissa G. Warren served as action editor for this article.

Author's no te . Kathryn P. Davison, The Human Asset, Dallas, Texas;James W. Pennebaker, Department of Psychology, University of Texas atAustin: Sally S. Dickerson, Department of Psychology, University ofCalifornia. Los Angeles.Preparation of this article was aided by Grant MH52391 from theNational Institutes of Health. We are indebted to Laura King, David Buss,and Josh Holahan tbr their comments on an e arlier version of this article.Correspondence concerning this article should be addressed to JamesW. Pennebaker, Department of Psyc hology, University of Texas, Austin,TX 78712. Electronic mail may be sent to [email protected].

February 2000 American PsychologistCopyright 2000 by the AmericanPsychologicalAssociation. nc, 0003-066X/00/$5.00Vol. 55, No. 2. 205-217 DOt: 10.1037//0003-066X.55.2.205205

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or embarrassment actually would decrease affiliative mo-tivation. Anxiety apparently motivated socialization butcould not serve as a singular explanatory variable in thesocial comparison process, because the emotion resultedfrom different concerns.Social comparison is intrinsic to the health care set-ting, where anxiety levels are often high, and information,when available, may not come in a form that patientsunderstand. Diagnosis, treatment, side effects of medica-tion, or other kinds of life disruptions prompt patients totalk with others undergoing a similar challenge.C h a r a c t e r i z i n g t h e S e l f - H e l p C a t e g o r yThe self-help concept stems from the assertion that peoplefacing a similar challenge can help each other simply bycoming together. The power of this approach lies in thebelief that a collective wisdom is born through the sharedexperience of participants rather than through the profes-sional training or style of the leader. The kinds of helprequested and offered in this context are largely free ofprofessional structures or assumptions (Riessman, 1985).Self-help group participation costs its members little ornothing.Overall epidemiological figures on self-help in theUnited States indicate a prevalence rate of approximately3% to 4% of the population over a 1-year period, andlifetime participation rates are estimated at around 25 mil-lion (Kessler, Mickelson, & Zhao, 1997; Lieberman &Snowden, 1993). Lifetime use of self-help is higher formen than for women (3.6% vs. 2.4%). Caucasians are threetimes as likely to participate as African Americans, withHispanic participation levels falling about midway betweenthe two. The mean age of participants is 43.1 years, andmean education level is 12 years (slightly higher than thenational average of 11 years).Due to the grass-roots nature of the self-help phenom-enon, support groups exist in a wide range of styles andstructures. Precise boundaries around self-help categoriza-tion are not only difficult, but impractical. Within theself-help arena, considerable innovation and diversity ofstyle occur as participants tailor group processes over timeto reflect group needs and goals. Lieberman and Snowden(1993) have reported that over 60% of observed groupswere professionally facilitated while simultaneously beingcharacterized as self-help. Such findings point to the diffi-culty of categorical boundaries and the problematic natureof research in real-world social patterns. Nevertheless,groups that define themselves as self-help, whether they areprofessionally led or not, are viewed by members as sell'-help. For example, many hospital-based support programsdescribed as professionally facilitated are in fact hybridprograms developed with guidelines from a national foun-dation and idiosyncratically shaped by the time commit-ments of the patient volunteers and the coordination skillsof a nurse or social worker employed by the hospital.Group counts say little about health outcomes or otherquality-of-treatment measures, just as other reports of so-cial participation, such as church membership or maritalstatus, say little about the quality of those experiences.

Although distinctions between professionally facilitatedand peer-mediated groups may be meaningful in outcomestudies aimed at discerning the active agents in curativeprocesses, it is important to bear in mind that as a measureof basic value to participants, participation is its own indexof success: Groups without value cease to be groups. Mem-bers vote with their feet.The most comprehensive analysis of self-help groupsin general found that the leading reason for participation ingroups of any kind was the experience of physical illness(Lieberman & Snowden, 1993). Even after excluding cop-ing with substance abuse, groups for coping with physicalillness composed approximately 42% of the self-help-group population, dwarfing statistics for bereavement,crime victimization, parenting issues, and personal growth,yet no studies have addressed the epidemio logy of mutualsupport by diagnostic category.E f fe c tiv e n e s s o f M u t u a l S u p p o r t inI m p r o v i n g P h y s i c a l a n dPsycholog ica l H ea l thSupport groups are an important means by which Ameri-cans change their health behaviors. In some cases, mutualsupport constitutes the exclusive "treatment" for a healthproblem, as in the case of Alcoholics Anonymous (AA).Self-help has also been found to be as effective as profes-sional treatment for some forms of mental (e.g., depres-sion) or physical (e.g., headache) illnesses that have tradi-tionally been viewed as the domain of psychotherapy ormedicine (Gould & Clum, 1993). The stories told and heardin this context carry the weight of shared experience, theemotional potency of common suffering, and an avenue forsocial learning. Rappaport (1993) has sugges ted that theseshared stories form a kind of group narrative that consti-tutes a social identity, distinguishing the self-help groupfrom any kind of formal psychotherapy (see also Gergen &Gergen, 1997). In a similar vein, Yalom (1995) has as-serted that self-help groups offer a unique venue forgrowth, social experimentation, and change.Measurement of the efficacy of self-help is problem-atic from the outset because of its inherently self-selectednature. However, investigations of the effects of support-group participation, even under random assignment, haveyielded positive results on the whole. Rheumatoid arthritis,cancer, heart attack, and epilepsy patients in supportgroups, for example, have exhibited more health benefitsthan nonparticipating controls or controls on a waiting list(Bradley et al., 1987; Dracup, 1985; Droge, Arntson, &Norton, 1986; Telch & Telch, 1986). Mutual support in-terventions can be highly cost effective: One study ofrheumatoid arthritis patients participating in peer-facili-tated groups reported mean pain reductions of 20%, in-creases in self-efficacy, and an average four-year cost sav-ings of $648 per person (Lorig, Mazonson, & Holman,1993). Pain reductions were strongly related to increases inself-efficacy, an identified factor in positive health behaviorchange (DiClemente, 1995). If typical self-help participa-tion rates (3%) occurred among the 32 million arthritissufferers, the four-year savings in arthritis care alone could

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total $650 million. The pressures of managed care andincentive structures such as capitation may increase atten-tion to lower cost approaches to health management.Support group participation has also been associatedwith superior prognosis in breast cancer and heart disease.In one highly publicized study, a sample of 88 metastaticbreast cancer patients received either group ps ychotherapyor informational and nutritional support. Those randomlyassigned to the therapy condition had survival times ap-proximately twice those of controls (1.50 vs. 0.75 years,respectively; Spiegel, Bloom, Kraemer, & Gottheil, 1989).Similar findings have been reported for a sample o f patientswith malignant melanoma (Fawzy et al., 1993). Finally,various programs have been adopted for heart patients thathave relied heavily on regular group support for patientsand, on occasion, their spouses. Across multiple studies,markers of heart disease progression, including measuresof atherosclerosis and resting blood pressure, have demon-strated clinically significant improvement (Ornish et al.,1990).The interventions cited above represent highly refined,professionally developed, programmatic approaches tocoping with serious health threats. Although they bearmarked differences from patient-initiated groups, they mayalso share some fundamental therapeutic qualities worthnoting, such as opportunities for disclosure, empathic con-nection, shared goals, and psychological adjustments to lifechallenges. They underscore the medical value of mean-ingful, group-based programs whose psychological focuselicits psychosocial and physical health benefits. Addi-tional research can help clinicians identify the optimalblend of patient and professional agendas to maximizetreatment success.On the basis of these very limited reports, it is appar-ent that group approaches to health care can play an instru-mental role in health behavior change, treatment adherence,cost control, and disease reversal. Such groups have sig-nificant therapeutic potential, yet it is apparent that theprimary feature of mutual-support participants is their self-selected nature. These considerations prompted a series ofinvestigations about the demand side of the support groupcomm unit y--w ho participates and why.E x a m i n in g _ S u p p o r t iv e B e h a v i o r s a s aF u n c t i o n o f I l l n e s s T y p eIllnesses vary along a number of psychologically meaning-ful dimensions, such as life threat, embarrassment, andbehavioral impact on disease course. Although health con-cerns are the most frequently cited reason for joining asupport group, no studies have examined how support-group participation varies as a function of illness featuresor type. We designed a series of three studies to assess (a)the prevalence of support groups in 20 different patientpopulations, (b) the activity rates of virtual support forumsfor those same patient groups, and (c) the identifiablefactors associated with support seeking across diagnosticcategory.Our choice of methodology merits some discussion.The selection of diseases, rather than individuals, as sub-

jects and the use of groups as our units of analysis, ratherthan counts of individuals, is somewhat unusual. However,the experience of illness does engender, either permanentlyor temporarily, an illness identity (for an excellent treat-ment of these themes, refer to Kleinman, 1995). We wantedto examine the social context of illness at the collectivelevel. To do so, we adapted a design that would allowresearchers to observe something of how groups coalesce.In our first study, the goal was to identify patterns, ifany, of support group participation by illness category. Toaddress this question, four major metropolitan areas --NewYork, Los Angeles, Dallas, and Chicago--were canvassedin an eftort to identify every support group that existed foreach of the 20 studied conditions. Counts were subse-quently adjusted for population and prevalence and testedfor consistency across cities.An extension of the first question centered on thenewest avenue of social interface, the Internet. In oursecond study, the primary goal was to assess identifiablepatterns of mutual support activity among patient popula-tions in this virtual community. A related goal was tounderstand in what ways virtual and actual support patternswould resemble one another. For a period of two weeks,every post made to support forums for the 20 conditions intwo on-line domains (America Online and the larger Inter-net) was collected and counted as a measure of mutualsupport.in our third study, we sought to identify factors asso-ciated with the search for mutual support, both face-to-faceand on-line. Judges' ratings were obtained on 16 dimen-sions: suspected of playing a role in support behaviors.Ratings were then correlated with support measures togenerate a sense of the issues that drive the search formutual support.S t u d y 1 : AssessingS u p p o r t P a t t e r n sin M e t r o p o l i t a n A r e a sFour major metropolitan areas--Chicago, Dallas, Los An-geles, and New York--were the focus of a semistructuredseries o f surveys to identify the number of support groupsin that area for patients suffering from 20 different healthproblems. We contacted the mental health services agencyserving each of the surveyed cities and requested anyhandbook or comprehensive compilation of support groupsfor that area. After receiving the compilations, each agencyor contact listed under every diagnostic category studiedwas called to confirm that the group existed and was not aduplicate or expired listing. Counts resulting fr om thesecalls were assembled into a support profile for each city.D i s e a s e S e l e c t io n C r i t e r iaThe conditions selected for study are listed in Table 1. Theselection process was driven by practical rather than theo-retical reasons, with the goal of capturing a wide range ofproblems that afflict people potentially capable of attendinga support group. Inclusion efforts focused on the mostprewtlent and deadly conditions, as well as those withsignificant psychologi cal and behavioral components, pre-

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T a b l e iAn Overview o f the Prevalence and Death TollAssociated With the Studied DiseasesPrevalence Deaths

Rate RateDisease type (in thousands) Rank (in thousands) RankA I D S 7 8 5 1 6 9 . 8 1 1A l c o h ol is m 1 3 , 7 6 0 5 8 . 0 1 2A n o r e x i a n e rv o s a 5 3 0 1 8 0 . 5 1 5A r th r it is 3 2 , 6 4 2 1 0 . 0 1 8A s t h m a 1 3 , 0 7 4 6 1 . 4 1 4B r ea s t c a n c e r 1 , 7 6 9 1 3 1 2 . 0 9C o l o n c a n c e r 9 1 1 1 5 2 3 . 6 5L un g c a n c e r 3 9 4 1 9 4 0 . 8 3P r os ta te canc e r 58 3 17 13 .5 8C h r o n i c f a t i g u e 1 , 0 0 0 1 4 0 . 0 1 8C h r o n ic p a i n 3 0 , 0 0 0 2 0 . 0 18D e p r e s s io n 9 , 4 0 0 8 1 1 . 0 1 0D i a b e t e s 7 , 8 1 3 9 1 9 . 6 7E m p h y se m a 1 , 9 0 0 1 2 3 6 . 0 4H e a r t d i s e a s e 2 1 , 2 5 5 4 2 8 8 . 0 1H y p e r t e n s io n 2 7 , 5 4 9 3 2 . 0 1 3M i g r a i n e 1 1 , 0 2 3 7 0 . 0 1 8M u l t i p l e s c le r os is 3 5 0 2 0 0 . 0 1 8S t ro k e 3 , 0 0 0 1 1 5 6 . 0 2U l ce r 4 , 5 6 9 1 0 2 2 . 0 6Note . All figures were derived from the 19 92 and 19 93 reports of theNationa l Center or Health Statistics and the 19 96 re port of the Centers orDisease Control and Prevention CDC), exce pt or the follow ing: alcoholism(Taylor, 1995); anorex ianervosa NationalAssociationoF Ano rexiaNervosaand AssociatedDiso ders, http://ww w, anad.org.Factsht97, tm , retrieved une1996); chronic fatigue (CDC, 1 99 4; Kroenke et al., 1988); chronic pain(Taylor, 1995 ); depression Na tionalMentalHealthAssociation, http://v,,",~mhsource com/resource /mh/html, retrievedJune 19 96); d iabetes (NationalInstitutes of Health, 199 5}; emphysema American Lung Association, http://www. lung .usa .o rg .no f rames/ lea rn / lung / lungemphysema.h tml , retrieved une1996); migraine (National H eadache Foundation, h~p://www.headachesorg, retrievedJune 199 6); mu ltiple sclerosis (Multiple Sclerosis Foundation,http://ww w msfacts.org/html, retrieved une 1996); and ulcer U.S. Bureauofthe Census, 199 6). The prevalence ate or hea rtdiseases s the sum of 13,49 0,00 0 myocardialinfarction and coron aryheartdiseasediagnosesand almost8,000,000 anginacases with or without dentifiedheart problems.

s u m a b l y r e s p o n s i v e t o p s y c h o s o c i a l s u p p o r t . C o n d i t i o n sa s s o c ia t e d w i t h e x t r e m e o l d a g e o r c o n t a g i o n w e r e e x -c l u d e d f r o m c o n s i d e r a t i o n .

T h e p r e v a l e n c e a n d m o r t a l i t y r a t e s f o r e a c h o f t h es t u d i e d c o n d i t i o n s w e r e c o l l e c t e d to a d j u s t s u p p o r t - g r o u pc o u n t s f o r t h e p o p u l a t i o n f r o m w h i c h t h e y w e r e d r a w n .U n l e s s o t h e r w i s e n o t e d , t h e s o u r c e f o r a ll w a s t h e N a t i o n a lC e n t e r f o r H e a l t h S t a t i s t i c s ( N C H S , 1 9 9 6 ) . S ta t i s ti c s u n -a v a i l a b le f r o m N C H S w e r e o b t a in e d f r o m f o u n d a t i o n ss e r v i n g t h e p a t i e n t g r o u p s ( e .g . , A m e r i c a n C a n c e r S o c i e t y )o r f r o m e p i d e m i o l o g i c a l r e s e a r c h r e p o r t s ( r e f e r t o Notess e c t i o n o f T a b l e 1 ).Survey P rocedureT h e g o a l o f th e r e s e a r c h w a s t o i d e n t i f y a s m a n y g r o u p s a sp o s s i b l e p e r c o n d i ti o n i n a w a y t h a t m i n i m i z e d s a m p l i n g

b i a s a n d r e f l e c t e d t h e a p p r o a c h o f p o t e n t i a l u s e rs , F o r t h i ss t u d y , a g r o u p w a s c o u n t e d a s s e l f - h e l p if t h e c o s t o fp a r t i c i p a t i o n d i d n o t e x c e e d $ 8 p e r s e s s i o n , i f t h e r e s p o n -d e n t d e p i c t e d t h e g r o u p a s s e l f- h e l p , a n d i f t h e m e e t i n g sw e r e h e l d o n a r e g u l a r b a s i s , w h e t h e r t h e g r o u p w a s p r o -f e s s i o n a l l y f a c i l i t a t e d o r n o t .

W e i d e n t i f i e d a n d c o n t a c t e d g r o u p s f o r c o n f i r m a t i o nt h r o u g h t h e l i s ti n g s i n l o c al r e g i s t r ie s o f s e l f - h e l p a n d s o c i a ls e r v i c e f a c i l i t i e s ." T h e s e r e g i s t ri e s f e a t u r e l i s ti n g c a t e g o r i e sa c c o r d i n g t o d ia g n o s i s o r n e ed , s u c h a s " b e r e a v e m e n t " o r" d i a b e t e s . " O n c e t h e g r o u p s w e r e i d e n t i f ie d , w e c o n t a c t e de a c h o n e a n d , i n a s ta n d a r d i z e d p r o t o c o l , d e t e r m i n e d t h en u m b e r o f g r o u p s r u n t h r o u g h t h e p a r t ic u l a r a g e n c y , t h ef r e q u e n c y o f g r o u p m e e t i n g s , a n d t h e a v e r a g e g r o u p s iz e . 2Survey Resul ts and DiscussionT h e s u r v e y p r o c e s s y i e l d e d a t o t al o f 1 2 , 5 9 6 s u p p o r t g r o u p si n th e f o u r c i ti e s. T h e r a w c o u n t s , t h e p o p u l a t i o n - a d j u s t e dc o u n t s , a n d t h e p r e v a l e n c e - a d j u s t e d i n d i c e s o f s u p p o r t o f f e ra v a r i e t y o f i n s i g h t s a b o u t t h e s c o p e a n d f r e q u e n c y o fs u p p o r t s e e k i n g f o r h e a l t h c h a l l e n g e s ( s e e T a b l e 2 ) .

A s i s e v i d e n t a t th e b o t t o m o f T a b l e 2 , th e f o u r c i t i esv a r i e d c o n s i d e r a b l y i n t h e t e n d e n c y t o p a r t ic i p a t e i n s u p -p o r t g r o u p s . P o p u l a t i o n - a d j u s t e d g r o u p t o t a l s i n d i c a t e t h a ts o m e c i t ie s a r e c h a r a c t e r i z e d b y h i g h e r o v e r a l l s u p p o r tl e v e l s t h a n o t h e r s. A c h i - s q u a r e a n a l y s i s o f t h e f o u r c i tyg r o u p t o t al s ( a d j u s t e d ) y i e l d e d a h i g h l y s i g n i f i c a n t d if f e r -e n c e b e t w e e n e x p e c t e d a n d o b s e r v e d t o ta l s f o r th e f o u rc i t ie s , X 2 ( 3 ) = 4 9 1 . 3 1 , p < . 0 0 1 . D a l l a s h a d th e l o w e s tl e v e l o f s u p p o r t , w i t h 1 3 9 . 5 g r o u p s p e r m i l l i o n , w h e r e a sC h i c a g o h a d t h e h i g h e s t m e a n o f 7 5 4 . 9 . A l t h o u g h i t i sb e y o n d t h e s c o p e o f t h is s t u d y t o i d e n t if y t h e r e a s o n s f o rt h e s e v a r i a t i o n s i n s u p p o r t l e v e l s a c r o s s c i t ie s , i t w o u l d b eh e l p f u l to u n d e r s t a n d t h e f a c t o r s a t w o r k - - l o c a l m e n t a lh e a l t h a p p r o p r i a t i o n s l e v e ls , f o u n d a t i o n s u p p o r t , p o p u l a -t i o n d e n s it y , o r h i s t o r i ca l a n d c u l t u r a l o r i e n t a t i o n s - - t h a t

F~r the four surveyed areas , the hand book s used were as fo l lows:Lo s Angeles--Los Angeles Count' Social Service Resource Directory;N ew York-- Soeia l Service Directo O' of Greater New York Cio ' an dDirectoly oj" Se!/-Help Groups in New York City," Chicago---Directot-y ofSel]:Hell) and Mutual Aid Groups; Da l l a s - -u n t i t l e d p r i v a t e c o mp i l a t io nprovided by the Dallas County Mental Health Association. All l ist ingsunder the re levant ca tegories were ca l led un less there were mo re than 20separate l ist ings, in which case only the first 20 were contacted, and theme an results of those first 20 were extrapolated to the rest of the l ist ings.For example , more than 20 agencies and ind iv idu als fac i l i ta te g roups fo rAIDS patients in the New York area. so the first 20 l isted were contacted.The n umb er of g roups in ex is tence was ob ta ined for each l i s ting , and thenthese num bers were averaged: the resu lt ing average was m ul t ip l ied by thetotal number of l ist ings.= W hen a g roup was ca l led bu t there was no answer, there were th reepossib le ou tcomes: (a) If a message m achine p layed a tape of sched uledmeetin,2-s, that intk)rmation was regarded as cur rent con firma tion and w asrecorded as data. (b) If a message machine identified that l ist ing (tele-phone number) as the contac t fo r a support g roup , the researcher wouldrecord the groups as "1" and make an effort to ca ll back and confi rm. (c)If a message m achine answered and no m ent ion was made of a g roup , o rin the case of no an swer a t a l l , the researcher made th ree fu rther a ttemptsto confirm the l ist ing. No groups were counted unless confirmed. Finally,i f in the course of the survey the contac t person vo lun teered the name ofa group or agency that was not featured in the researcher's registry, theresearcher a l so contac ted tha t g roup .

2 0 8 F e b r u a r y 2 0 0 0 A m e r i c a n P s y c h o l o g i s t

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T a b l e 2Sup port Group Totals by. Con di t ion and Ci ty. , M ean Grou ps Across Ci t ies, and Prevalence-Adjusted Sup portIndices Across Ci t ies, Along W ith Their RanksChicago Dallas Los Angeles New York City All cities

No. of No. of No. of No. ofCondition groups Rank grou ps R an k groups Rank groups Rank Mean Rank Index RankA IDS 21 9 35 2 155 2 257 2 18 .96 2 241 .52 2A lcoho li sm 4 ,003 1 128 1 2 ,83 5 1 4 ,0 00 1 402 .78 1 292 .72 1Anorex ia 32 8 2 13 13 7 7 7 2 .19 12 41 .30 4Ar thr i tis 19 11 5 7 18 3 5 10 2 .12 13 0 .6 5 16Asthma 19 11 22 3 6 10 6 9 4 .0 6 9 3 .1 0 14Cancer , breast 57 4 12 4 18 3 97 3 10.48 3 44 .49 3Cancer , co lon 37 5 2 13 4 11 2 12 5 .7 9 5 21 .55 6Cancer , lung 1 16 2 13 1 15 1 15 4 .93 6 9 .33 9Cancer , prosta te 13 13 6 5 16 6 7 7 6 .0 4 4 34 .66 5Chron ic ta t igue syndrome 19 11 1 15 1 15 0 18 0 .9 4 14 9 .3 8 8Chron ic pa in 2 15 0 18 0 19 1 15 0 .12 17 0 .04 18Depress ion 57 3 6 5 17 5 31 4 4 .71 7 5 .01 12Diabetes 80 2 1 15 10 8 23 5 4 .51 8 5 .7 7 11Emphysema 0 18 0 18 1 15 2 12 0 .63 15 3 .2 9 13Hear t d isease 36 6 4 8 4 11 5 10 2 .2 9 11 1 .08 15Hyper tens ion 0 18 0 18 0 19 0 18 0 .0 0 19 0 .0 0 19Mig ra ine 0 18 0 18 0 19 0 18 0 .00 19 0 .00 19Mu l t ip le sc lerosis 3 14 3 10 1 15 1 15 0 .58 16 16.61 7Stroke 34 7 3 10 10 8 10 6 2 .42 10 8 .08 10Ulcer 0 18 0 18 1 15 0 18 0 .03 18 0 .0 6 17Group total 4 ,60 5 265 3 ,201 4 ,53 5Popula t ion ( in mi ll ions) 6 .1 0 1 .90 8 .9 0 7 .0 0Mean g roups pe r m i l li on 754 .92 139 .47 359 .66 647 .86Note. Population igures or citiesare from he U.S. CensusBureauStatistics ht~p://venus.census.gov/cdrom/Iookup, etrievedSeptember20, 1996). Meanswere computed by averaginggroup counts per m illionacrosscity. b Index epresentsprevalence-adjusted upportmeasurederived rom computing meangroups per million across he four cities sampled)divided by prevalence,multipliedby 1,3,000.

make mutual support more the norm in Chicago than inDallas.To assess the relative consistency of s u p p o r t i v e n e s s asa construct by diagnostic category, we computed Spearmanrank correlations (r~) for the tour city counts. The resultingcorrelations were high: A reliability analysis indicated analpha for the four cities of .89. Given this high degree ofintercorrelation, we collapsed across cities to generate apopulation-adjusted mean and rank for each disease, in-cluded in Table 2. Not surprisingly, alcoholism ranked first,with AIDS second. The cancers followed, with breast can-cer showing the highest levels of support and lung cancerthe lowest. Finally, collapsed population-controlled countswere adjusted for prevalence (figures represented in Table1) so that the resulting support indices also reflected thepopulation sizes from which the participants were drawn.The preponderance of support groups in the alcohol-ism category is at once predictable and noteworthy and sodeserves specific mention. Of the 12,596 total groups iden-tified for all of the conditions studied, across all citiessampled, AA groups constituted 10,966, or 87%, of thegroup counts. These numbers, and hence the AA story, area testament to the potential strength and efficacy of mutual

support: The largest number and degree of health behaviorchanges in the country are the product of a network oflargely anonymous, expert-free, cost-free groups whosesole purpose is mutual support. It is also useful to note thatthe AA philosophy asserts that group participation is alifetime commitment: Addiction is an incurable conditionmanaged only by enduring vigilance. Although a detailedaccount of the AA literature is outside the focus of thisarticle, multiple factors have been identified that describeself-help and treatment success in coping with addiction(e.g., Tucker, 1995).What is striking is the degree, or range, in supportseeking in general among illness categories after adjustingfor prevalence. AIDS patients, for instance, are 2 5 0 t i m e smore likely to participate in a support group than hyper-tension patients. Breast cancer patients have formed over40 times as many support groups as heart disease patients,whose conditions undeniably benefit from psychosocialand behavioral changes. Such contrasts raise questionsabout the motivations of participants.Our methodology suffers from a few problems intrin-sic to the self-help culture that make clear quantificationinherently difficult. Comorbidity in both disease and sup-

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port makes c lean counts problematic. For instance , stroke ishighly related to hypertension. It is evident, though, thatthose with high blood pressure will seek support after astroke much more readily than before it. Individuals suf-fering from hypertension, moreover, have a higher proba-bility of also suffering from diabetes or heart disease. It isunclear whether patients carrying more than one diagnosistend to be involved in more than one support group. Insome cases, support groups were not exclu sively composedof individuals in the diagnostic category of interest. Forexample, in the case of support groups for anorexia, some(e.g., Overeaters Anonymous) included participants withbulimia and obesity problems as well.

A second unavo idabl e probl em concerns the processof adjustment for the prevalence rates of the diseases.Given the relatively low participation rates of all patienttypes in mutual support, the observed ranks are heavilydriven by the prevalence rates themselves. Despite theacknowledged problems, the methodology was the mostvalid means of assessing support group patterns withoutintrodu cing significant bias. The observed participa tionpatterns in these face-to-face groups prompted questionsabout how virtual avenues of support might elicit similar ordifferent patterns among the same patient groups.Study 2 : Frequency andCharacter ist ics of O n-Line S uppo rtAs of 1996, approximately 15% of Americans (about 40millio n) already had Internet access, with growth est imatedat 20% per month (Ferguson, 1996). Moreover, interest inon-li ne participation is significantly driven by health issues.A recent Louis Harris poll con ducted to assess the motivesbehind new subscriptions to on-line services found thathealth concerns were ranked first (reported by Ferguson,1996). The social con necti ons enabled by the advent of theInternet constitute a new forum of social support that hasunknown, and largely unstudied, potential. For the patient,the availabil ity of on-line support introduces a new dimen-sion of social connection and access to information. Forresearchers, the observation of on-line support groups of-fers a unique window for unde rstan ding the kinds of expe-riences that patients wrestle with, from reluct ant insurers topatronizing doctors, as well as histories of suffering, con-fusion, and misdiagnosis. A few examples from our Inter-net posts are featured below.Dear Carol, Hi! I understand your concerns. I am 47 and I justsurvived my first and hopefully last heart attack. I too cont inue tothink of one day or the next will be my last day. I weep for thisbecause I have not danced at my daughter's wedding and Iplanned to sit on a porch with my husband and I cling to this lifewith all of the intensity that I can muster. But I know your fearand I know your depression so very well. Whether or not I canmake it past another twelve months without another episode isnow the issue since I have survived the first month. Carol they justdon't know very much about women and heart disease--thismuch I know for sure. (AOL subscriber, heart disease bulletinboard)

Was wondering if any women who have had breast cancer havenoticed a correlation between stress in their life and the onset ofthe bc? Two years ago my husband and I separated and in the lastyear --the year from hel l- -I experienced a car accident, the real-ization that someone I loved was on the verge of schizophrenia, apeeping Tom invading my privacy, my father's death, the loss ofmy job and financial security, and then breast cancer . . . Afterawhile [ s i c ] I wondered if it was worth living. I lost my zest andcouldn't find much joy in life . . . . Psychologically and emotion-ally, as most of you know who've been through similar things, Ifeel wiped out. I pray a lot and have good friends who help me asthey can and also pray for me. (contributor to an Internet supportforum for breast cancer)Let me give you my idea on how to be a good CFS [chronicfatigue syndrome] wife. Tell him to order pizza or something.Have him clean the exotic molds in the refrigerator. Prepareyourself. Stay in bed all day and make sure you are more inter-esting than the vixens he works with all day . . . . Give him agrocery list and tell him to buy whatever he wants to drink. Feelfree to cry about your day. Men love to comfort and protect. Goto sleep the moment he arrives. If he wants a clean house, he canvisit a neighbor. (contributor to the chronic fatigue discussionlist--Intemet)The reason they are calling your mother a Type II is because thefirst hour was 212 and the second 183. Two hours after eating iswhen your sugar levels should peak out. Because her levels wereabove 120 two hours after eating, she is probably a Type II. Sinceher bg [blood glucose] levels were down to 11 three hours later,it probably means that your morn has lazy organs like I do. Shemay be put on reeds, then again she may be able to control it withdiet and exercise. Maybe you should go with your mona to thedoctor and try to get all the informat ion that you both need. Thedoctor probably wo n't mind, and will probably be glad that herfamily has taken such an interest in her well being. (response tothe daughter of a recently diagnosed diabetic on the Internetdiabetes forum)

Each individual account contributes to a larger col-lective narrative that paints a portrait of identity bydiagnosis. With good reason, researchers in the fields ofpsychology, sociology, and anthropology are focusingon the narrative approach to under stand ing identity andculture in various groups. A comparison of virtual andactual support enriches a basic underst andin g of support-seeking patterns on the part of individua ls coping withhealth problems.

The aim in this study was to identify those kinds ofhealth problems that prompt higher levels of on-li ne par-ticipation and to determine what similarities would existbetween virtual and actual avenues of support. Our strat-egy, as in Study l, was not to assess the availabi lity of allsupport resources for patients (e.g., friends, family, healthcare professionals, and coworkers) but to gain a broaderperspective on those types or experiences of illness thatcause patients to seek out others facing the same challenge.Using a method similar to that used for the city surveys, wemeasured support levels for the 20 studied conditions bycounti ng all contribut ions to on-line forums by participants

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o v e r a t w o - w e e k p e r i o d . 3 T w o o n - l i n e d o m a i n s w e r e c h o -s e n fo r m o n i t o r i n g : I n t e r n e t n e w s g r o u p s a n d t h e ir A m e r i c aO n l i n e ( A O L ) c o u n t e r p a rt s , b u l l e t i n b o a r d s. F r o m t h o s et w o v e n u e s , 3 7 v i r t u a l s u p p o r t g r o u p s w e r e i d e n t i f i e d a n dm o n i t o r e d f o r a p e r i o d o f t w o c o n s e c u t i v e w e e k s . 4

T h e I n t e r n e t , a t t h e t i m e o f t h e s tu d y , f e a t u r e d o v e r4 0 , 0 0 0 n e w s g r o u p s , w i t h d o z e n s o f n e w o n e s b e i n g g e n -e r a t e d d a il y . T o d e t e r m i n e w h i c h g r o u p s t o m o n i to r , w ec o m p i l e d a m a s t e r l i s t o f a ll e x i s ti n g E n g l i s h l a n g u a g en e w s g r o u p s ( n a t i o n w i d e a n d / o r i n t e rn a t i o n a l o n l y , no t r e -g i o n a l ) a n d th e n u s e d k e y w o r d s e a r c h e s f o r e a c h d i s e a s ec a t e g o r y . F r o m t h e re s u l t s o f t h o s e s e a r c h e s , w e c o u l di d e n t if y a l l g r o u p s t h at w e r e d e e m e d t o b e m u t u a l s u p p o r tg r o u p s a s o p p o s e d t o g r o u p s t h a t w e r e f o r u m s f o r l o b b y i st s ,r e s e a rc h e r s , o r o t h e r e x p e r t e x c h a n g e . I f m o r e t h a n o n eS u p p o r t g r o u p e x i s t e d , w e s e l e c t e d t h e g r o u p e x h i b i t i n g t h eh i g h e s t v o l u m e o f e x c h a n g e o v e r a t w o - d a y p i l o t p e r io d .

T h e c o m m e r c i a l n a t u re o f A O L ' s o r g a n i z a t i o n d i s ti n -g u i s h e s i t t o a l a r g e d e g r e e f r o m t h e g r o u p s f o u n d o n t h eI n te r n e t. G r o u p s p r e s e n t o n A O L ' s " H e a l t h C h a n n e l " r e -f l ec t t h e c o m m e r c i a l o r p u b l i c s e r v i c e g o a l s o f l a rg e g r o u p st h a t w o u l d l i k e t o h a v e a p r e s e n c e o n t h a t s e r v e r ( e . g . ,A r t h r it i s F o u n d a t i o n , A m e r i c a n L u n g A s s o c i a t i o n , v a r io u sp h a r m a c e u t i c a l c o m p a n i e s ) . T h e p a tt e rn o f e m e r g e n c e o fn e w s g r o u p s ( o r b u l l e ti n b o a r d s a s t h e y a re k n o w n o n A O L )i s j u s t t h e o p p o s i t e o f t h a t o f t h e l a r g e r I n t e r n e t. I n t e r n e tg r o u p s a r e o r g a n i z e d b y i n t e r e s t e d i n d i v i d u a l s , s o n o sy s -t e m a t i c c o m m e r c i a l m o t i v e s a r e p ar t o f t h a t a g e n d a . T h i sm a k e s f o r a so u r c e o f u n i q u e p a t t e r n i n g i n t h e g r o u p s o nA O L a n d t h e I n t e r n e t , w h i c h i s d i s c u s s e d m o r e f u l l y l a te r .

T h e r a w t o t a l s a n d a d j u s t e d i n d i c e s o f su p p o r t , a l o n gw i t h t h e i r r a n k s , a r e f e a t u r e d i n T a b l e 3 . I n t h o s e c a s e s i nw h i c h a c o n d i ti o n l a c k e d a f o r u m , t h e n u m b e r o f p o s ts w a sr e c o r d e d a s z e ro . P o s ts o n A O L o v e r t he t w o - w e e k p e r i o d ,f o r a ll g r o u p s s t u d i e d , t o t a l e d 2 , 0 4 3 , w h e r e a s p o s t s o n t h el a r g e r I n t e r n e t t o t a l e d 5 , 4 4 0 . T h e h i g h e s t r a t e s o f a c t i v i t yo b s e r v e d o n A O L w e r e f o r m u l t i p l e s c l er o s is , f o l l o w e d b yd i a b e t e s , a n d t h e n b y d e p r e s s i o n . T h e h i g h e s t ra t e s o fa c t i v it y o n t h e I n t e r n e t w e r e f o r c h r o n i c f a t i g u e s y n d r o m e ,f o l l o w e d b y d i a b e t es , a n d t h e n b y b r e a s t c a n c e r. T h e l o w e s tr a t e s o f a c t i v i t y o n b o t h d o m a i n s w e r e o b s e r v e d f o r c h r o n i cp a i n , e m p h y s e m a , a n d m i g r a i n e . C h r o n i c f a t i g u e s y n d r o m es u f f e r e r s e x h i b i t e d e x t r e m e l y h i g h a c t i v i t y l e v e l s o n t h eI n t e r n e t , w h e r e a s n o l i st w a s a v a i l a b l e f o r t h o s e s u f f e r e r so n A O L . T h i s c o n t ra s t m a y r e f l e c t t h e im p e r f e c t m e e t i n gg r o u n d b e t w e e n c o n s u m e r - d r i v e n o r g a n i z a t i o n a l p a t t e r n so n t h e I n te r n e t a n d t h e p r o v i d e r - d r i v e n e v o l u t i o n o f A O L .R a n k c o r r e l a t i o n s b e t w e e n t h e t w o f o r u m s a p p r o a c h e d b u td i d n o t r e a c h s i g n i f i c a n c e , r~ ( 1 8 ) = . 3 5 , p = . 1 3 . T h i sf i n d i n g m a k e s s e n s e i n l i g h t o f t h e f a c t th a t I n t e r n e t a n dA O L s u p p o r t g r o u p s r e f l e c t d i f f e re n t u s e r b a se s . U s i n g am e t h o d s i m i l a r t o t h a t u s e d f o r t h e c i ty g r o u p s , w e c o l -l a p s e d t h e t w o o n - l i n e m e a s u r e s w i t h i n e a c h d i a g n o s t i cc a t e g o r y a n d a d j u s t e d f o r p r e v a l e n c e i n o r d e r to y i e l d am o r e a c c u r a t e r e f l e c t i o n o f t h e r e la t i v e p r e v a l e n c e o f o n -l i n e s u p p o r t b e h a v i o r s . T h e s e f i g u r e s a r e o u t l i n e d i n T a b l e3 . R a n k c o r r e l a t io n s o f p r e v a l e n c e - a d j u s t e d o n - l i n e a n df a c e - t o - f a c e c i t y i n d i c e s w e r e q u i t e h i g h , r~ ( 18 ) = . 70 ,p < . 01 .

S e v e r a l p a t te r n s e m e r g e d i n th e o n - l i n e f o r u m s t h a td i s t in g u i s h e d t h e m f r o m t h e m e t r o p o l i t a n g r o u p s . F i rs t ,a l c o h o l i s m , w h i c h d o m i n a t e d t h e f a c e - t o - f a c e s a m p l e s, e x -h i b i te d a m u c h l o w e r a c t i v i ty l e v e l o n - l in e , r a n k i n g n i n t ha n d s e v e n t h o n A O L a n d t h e I n te r n e t, r e s p e c t i v e l y . T h i s i su n d e r s t a n d a b l e g i v e n t h e l o n g t r a d i t io n o f a c t u a l s u p p o r te n j o y e d b y A A m e m b e r s , w h o m a y f i n d v i r tu a l s u p p o rt ap o o r ' s u b s t i t u te f o r th e g r o u p e x p e r i e n c e . S e c o n d , c h r o n i cf a t ig u e s y n d r o m e , w h i c h d i d n o t e m e r g e a s a d i a g n o s t i cc a t e g o r y u n t i l 1 9 8 8 , h a d t h e h i g h e s t a c t i v i t y l e v e l o f a l l o ft h e l n t e r n e t g r o u p s . I n v i e w o f th e h i g h r a t e o f u s e b ym u l t i p l e s c l e r o s i s s u f f e r e r s a s w e l l , th e o n - l i n e d o m a i n m a yb e p a r t i c u l a r l y u s e f u l in b r i n g i n g t o g e t h e r t h o s e w h o s u f f e rf r o m r a r e a n d d e b i l i t a t i n g c o n d i t i o n s , i n w h i c h g e t t i n gt o g e t h e r p h y s i c a l ly w o u l d p r e s e n t a n u m b e r o f p ra c t i c a lb a r r ie r s . V i r t u a l s u p p o r t c a n b e v e r y a t t r a c t i v e t o t h o s ew h o s e d i s a b i l i t y i m p a i r s m o b i l i t y , a n d , m o r e s t r i k i n g , t h eo n - l i n e c o m m u n i t y a l l o w s f o r a n o n y m i t y . P o t e n t s o c ia lf a c t o r s l i k e p h y s i c a l a t t r a c t i v e n e s s , v o c a l c h a r a c t e r i s ti c s ,e t h n i c i t y , a n d s o c i a l s k i l l s a r e n e u t r a l i z e d .

D e s p i t e t h e s e d i f fe r e n c e s , r a w c o u n t s f o r t h e t w oo n - l i n e m e a s u r e s w e r e p o s i t i v e l y c o r re l a t e d w i t h t h e c o l -l a p s e d m e a s u r e o f t h e c i t y g r o u p s - - r ~ ( 1 8 ) = . 4 5, p < . 05 ,f o r A O L ; r ~ (l 8 ) = . 3 7 , p = . 1 1 , f o r t h e I n t e r n e t ( t w o - t a i l e di n a lll c a s e s ) - - s u g g e s t i n g t h a t an u n d e r l y i n g c o n s t r u c t o fs u p p o r t s e e k i n g d o e s e x i s t b y d i a g n o s i s , w i t h t h e d i f f e r e n t

:~ From a m ethodological standpoint, it w as unclear whether theappropriate comparison in this domain would be the number of uniquecontributors or the numb er of contributions in total. The resulting decisionto count contributions was a judgm ent call based on the goal of having anindex of active participation rather th an participants. The virtual arena isalso populated with a large number of "lurkers," or individuals who readothers ' posts but do not contribute. It was felt that the overall amount ofconversation was a more accurate reflection of social exchange than thenumber of members. In any case, post hoc analyses of the number ofunique users per forum revealed that ranks o f users per category and ranksof contribution totals per category exhibited a correlation of .95, suggest-ing that the different measures were comparable.To determine which groups to monitor, we compiled a master listof all existing newsgroups (nationwide and/or international only, notregional) and performed keyword searches for each disease category.From the results of those searches, all groups that were deemed to bemutual support groups, as opposed to forums for lobbyists, doctors,researchers, or other expert exchange, were identified. In cases in whichmore than one support group was identified, the group that exhibited thehighest w~lume of exchange ove r a two-day pilot period was selected.Most support groups for both physical and mental illness begin with theprefix al:.support. For example, the arthritis support group isalt.support.arthritis . The most notable exception to this trend was themost active support group for breast cancer, which is [email protected]. The only difficult aspect in identifying theappropriate support forum em erged w ith respect to AIDS. In some senses,although new cases reflect a change in the demographics of AIDS, it hastraditionally been strongly tied to the homosexual community. The news-group alt.~upport.homosexual was monitored and found to have a sub-stantial focus on the AIDS epidemic; however, to select the list as thefbrum for support would have misrepresented a significant portion of thediscussion. The point to bear in mind is that AIDS, unlike any o f the otherdiseases, encompasses lifestyle and sexual issues that make its discussionhard to contain, at least by diagnostic boundaries. Many groups wereforums in which AIDS was discussed. Sci.med.aids was chosen because ofits focus on A 1DS and its lack of homosexual bias (w hich cannot really beconsidered any advan tage, merely notewo rthy). A complete list of theselected newsgroups is available from the authors.

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T a b l e 3Totals of O n-Line Sup port Co ntributions for AOL and the Internet by Disease, Along W ith The ir Ranks, as W ellas Prevalence-Adjusted Indices of Ov erall On-Line Su ppo rt Activity a nd The ir RanksAOL In te rne t AO L and In te rne t

N o . o f N o . o fDisease contr ibut ions Rank contr ibut ions Rank Adju sted RankA ID S 1 2 7 8 1 3 8 9 1 6 8 . 7 9 7A l c o h o li s m 7 1 9 2 7 0 7 1 2 . 3 9 1 1A n o r e x i a 6 1 1 0 2 5 1 8 2 9 4 . 3 4 4A r th r it is 156 6 77 12 3 .5 7 15A s th m a 3 9 1 2 1 0 3 1 0 5 . 4 3 1 2C a n c e r , b r e a s t 2 2 1 4 9 4 6 3 3 2 9 . 8 5 3C a n c e r , c o l o n 9 1 4 3 3 7 5 1 8 9 . 9 0 6Can ce r , l ung 173 5 no l is t 18 21 9 .5 4 5C a n c e r , p r o s ta t e 4 0 1 1 1 4 1 5 4 6 . 3 1 1 0C h r o n i c t a t ig u e s y n d r o m e n o l is t 1 8 1 , 0 3 5 1 5 1 7 . 5 0 2Ch r on i c pa in no l is t 18 56 13 0 .93 17D e p re s si on 2 4 8 3 7 7 9 4 5 4 . 6 3 9D i a b e te s 2 9 1 2 9 8 9 2 8 1 . 9 1 8Emphysema no l is t 18 no l is t 18 00 .0 20H e a r t d i s ea s e 1 4 4 7 7 1 6 3 . 5 5 1 6Hype r t ens ion 10 13 no l is t 18 . 18 19M i g r a i n e n o li st 1 8 9 0 1 1 4 . 0 8 1 4M u l t i p le s c le ro s is 4 5 1 1 3 1 7 6 1 , 0 9 7 . 1 4 1S t roke 0 18 31 14 5 .1 7 13U lce r 2 15 no l is t 18 0 .2 2 18T o ta l pos ts 2 ,0 43 5 , 44 0Note. Ranks ass igned ind ica te a rank ing o f 1 fo r h ighes t observed va lues . AOL - Am er i ca On l ine . On- l i ne ad jus ted index was der i ved by comput ing mean to ta l pos ts per cond i t i on (AOL + In te rne t /2 ) , d i v ided by preva lence, mu l ti p li ed by 1 ,000 .

a v e n u e s o f s u p p o r t c o n s t i tu t i n g a k i n d o f m e t h o d v a r i an c e .B o t h t y p e s o f s u p p o r t ar e m e a n s b y w h i c h s o c i a l c o m p a >i son i s enab l ed : S im i l a r su f f e r e r s can t e l l t he i r s t o r i e s t os y m p a t h e t i c a u d i e n c e s a n d c a n e x c h a n g e t i p s a b o u t t h em a n a g e m e n t o f th e i r c o n d it i o n s . M e a n s o f th e t w o o n - l i n em e a s u r e s c o m p u t e d f o r e a ch c o n d i t i o n e x h i b i te d a s t ro n gre l a t i on t o t he c i t y pa t t e rns , r~(18 ) = . 47 , p < . 05 . I n as i m i l a r v e i n t o t h e p a t t e r n s o b s e r v e d i n t h e m e t r o p o l i t a ng r o u p s , b r e a s t c a n c e r , d e p r e s s i o n , a n d d i a b e t e s w e r e c o n -d i t i o n s i n w h i c h t a l k ( in t h e f o r m o f p o s t s ) o c c u r r e d a tr e l a t i v e l y h i g h r a t e s , w h e r e a s t a l k b y m i g r a i n e , u l c e r , a n dc h r o n i c p a i n s u f f e r e r s w a s c o n s p i c u o u s l y a b s e n t f r o m t h eb u l l e t i n b o a r d s .

B e c a u s e c i t y g r o u p p a r t i c i p a t i o n a n d o n - l i n e p a r t i c i -p a t i o n r a t e s w e r e s i g n i f i c a n t l y c o n ' e l a t e d , w e f e l t i t w o u l db e u s e f u l t o g e n e r a t e o n e c o m p r e h e n s i v e s u p p o r t i n d e x ,a c r o s s b o t h o n - l i n e a n d a c t u a l g r o u p s , l e a v i n g o u t t h ep r e v a l e n c e a d j u s t m e n t t h a t s o s t r o n g l y s h a p e d r a n k i n g so b s e r v e d i n T a b l e s 2 a n d 3 . B e c a u s e o f i ts e x t r e m e v a l u e ,a l c o h o l i s m w a s e x c l u d e d . T o c o n v e y a s i m p l e r p i c t u r e ,f i g u r e s f o r a l l c a n c e r s w e r e c o m b i n e d , a n d a n o v e r a l lc a r d i o v a s c u l a r d i s ea s e c a t e g o r y w a s g e n e r a t e d b y c o m b i n -i n g h y p e r t e n s i o n , c o r o n a r y h e a r t d i s e a s e , a n d s t r o k e . B o t h

t h e p o p u l a t i o n - a d j u s t e d c i t y in d e x ( r e f e r t o T a b l e 2 ) a n d th em e a n o n - l i n e i n d i c e s ( T a b l e 3 ) w e r e c o n v e r t e d i n t o zs c o r es , M e a n s o f th o s e z s c o r e s a c r o s s th e t w o s u p p o r tt y p e s w e r e c o m p u t e d a n d a r e d e p i c t e d i n F i g u r e 1 .

A s i s e v i d e n t i n F i g u r e 1 , o t h e r t h a n a l c o h o l i c s , c a n c e rp a t i e n t s e x h i b i t t h e h i g h e s t o v e r a l l t e n d e n c y t o s e e k a n do f f e r su p p o r t . A l s o n o t a b l e w e r e s u p p o r t l e v e l s fo r A I D S ,d i a b e t e s , d e p r e s s i o n , a n d c h r o n i c f a t i g u e . B y c o n t r a s t , e x -t r e m e l y l o w l e v e ls o f s u p p o r t w e r e o b s e r v e d i n t h e c a se s o fu l c e r , e m p h y s e m a , c h r o n i c p a i n , a n d m i g r a i n e . S u p p o r tl e v e l s i n t h e c a r d i o v a s c u l a r d i s o r d e r s , e v e n a s c o m b i n e d ,a r e o n l y s l i g h t l y h i g h e r t h a n t h o s e f o r a n o r e x i a , a c o n d i t i o nw h o s e p r e v a l e n c e i s a l m o s t 1 , 0 0 0 t i m e s l e s s p r e v a l e n t .S o m e c o n d i t i o n s, t h e n , a re n o t e w o r t h y f o r t h e a m o u n t o ft a l k t h e y g e n e r a t e a m o n g s u f f e r e r s , w h e r e a s o t h e r s a r e n ol e s s n o t e w o r t h y i n t h e i r r e l a t i v e s i l e n c e .I f m i g r a i n e s a r e a s r e s p o n s i v e t o s e l f - h e l p a s t o m e d -i c at io n , w h y d o n ' t m i g r a i n e s u f fe r e r s g e t to g e t h e r ? W h a tk i n d s o f s u f f e r i n g d o n o t g e n e r a t e s o c i a l c o m p a r i s o n b e -h a v i o r s ? B e a r i n g i n m i n d t h e s h a r e d a n d d i s t i n c t i v e f e a -t u re s o f t h e t w o s u p p o r t v e n u e s a n d t h e m a r k e d l y h i g hc o n s i s t e n c y i n t e n d e n c i e s t o p a r t i c i p a t e i n s u p p o r t , o u r g o a lw a s t o u n c o v e r t h e m o t i v e s b e h i n d s u c h p a t t e r n s .


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F igure 1Summary Indices of Supportiveness Combining Cityan d On-Line Measures

Note. Indices represent mea ns of z sco res associated with population-adjusted city groups an d m ean (America Onlin e and Internet) on-line totals. ThealI-CVD categ ory was derive d by combining coran ary heart disease, hyperten-sion, and stroke conditions. Alcoholism, although unquestionably the conditioncharacterized by the highest support levels, was exclude d because its extremevalue would have suppressed all standard scores . CFS = chronic fatiguesyndrome; MS = multiple sclerosis; CVD = cardiov ascula r disease.

Study 3: Identifying Co rrelates ofSupp ort SeekmgSocial comparison theory asserts that affiliative behaviorsincrease in times of uncertainty or anxiety. The difficulty inpredicting behaviors on the basis of such considerations is thatthe experience of anxiety issues from myriad cau ses-- emb ar-rassment, threat to life, pain, anticipated pain, financial bur-den, and so on. Our goal in this study was to identify sourcesof anxiety relevant to patients ' exp eriences of illness in orderto understand which, if any, of these sources would b e relatedto support seeking. Three broad areas of investigation servedas the conceptual foundation of our inquiries: patient charac-teristics, (b oth psych olog ical and dem ogra phic ), health careburden (aspects of illness that increase medical care usage),and social burden (the interpersonal dimensions o f the illnessexperience). The goal was to clarify whether support seekingwas primarily motivated by personal, social, or health-care-induced anxiety,A number of personal factors are involved in care-seeking behaviors . For ins tance, some segments of thepopulat ion exhibi t higher levels of concern about theirheal th s tatus . The elderly and women, for example, useheal th care services more extens ively than do young adul tsand men (Aday & Andersen, 1974). AA part ic ipants withunsupport ive social networks exhibi t higher adherence lev-els to the self-help program (Tucker, 1995). Individual

differences , such as sociabi l i ty or com mitm ent to work, arealso related to support seeking. Prior s tudies of self-helppart ic ipants found that they have higher levels of socialski l ls than do their nonpart ic ipat ing counterparts (Taylor,Falke, Shoptaw, & Lichtman, 1986). One question, then,was the degree to which some pat ient groups would beperceived as general ly fr iendl ier than others .

A second considerat ion centered on i l lness factors thatdetermine pat ients ' perceived self-care needs and t reat-ment-adherence pat terns . The most widely ci ted model ofpat ients ' schemas about i l lness suggests that such con-structs fall into five dimensions: illness identity, timecourse, consequences , causal models , and l ikel ihood ofcure (Leventhal , Meyer, & Nerenz, 1980). Some i temscharacterized under headings of h ea l t h ca re sa l i en ce andp a t i en t b u rd en were generated to capture the anxiety-relevant aspects of i l lness and t reatment consis tent withLeventhal e t a l . ' s model of i l lness schemata. Examplesinclude degree of l i fe threat , ideas about cause, burden onpat ient to manage, and social s t igma.Final ly, some i tems were included to assess the inter-personal impact of a given i l lness category. Examplesinclude embarrassment , s t igmatizat ion, and disf igurement .We hypothes ized that social anxiety might be assuagedthrough support group part ic ipat ion.Judges ' ra t ings were obtained from four heal th careexperts indicat ing, on a scale of 1 to 7, to what degree eachdescript ion accurately depicted each of the 20 diseases orthe pat ients that suffered from them. All judges had at leas ta ma ster s degree level of t raining in nurs ing, publ ic heal th,or medicine. One rater was an MD; the three other raters(one Phi) in nurs ing, one MS in nurs ing, and one MS inpubl ic heal th) were nurses on facul ty at a large teachinghospi tal . Overal l , agreement among the judges was ade-quately high, yielding a mean alpha of .72 across the 16i tems. We averaged each rat ing across judge s and com -puted subsequent correlat ions with support levels to iden-t i fy which factors , i f any, were associated with supportseeking.As shown in Table 4, having an i l lness that is embar-rass ing, social ly s t igmatizing, or dis f iguring leads people toseek the: support of o thers with s imilar condi t ions . Themost s t r iking associat ions , then, between support seekingand i l lness features centered around the i n t erp erso n a l con-sequences of i l lness : Condi t ions described as emb arrass ing,social ly s t igmatizing, and disf iguring were associated withhigher levels of support of both kinds . In fact , embarrass-men t around discuss ion o f the i l lness eme rged as the s t ron-ges t associat ion with supp ort of both kinds . This pat tern ofresul ts , on the surface, confl ic ts markedly with prior workin social comparison theory. Embarrassment has beenwidely presumed to weigh agains t aff i l ia t ive behavior(Sarnoff & Zimbardo, 1961; Teichm an, 1973), yet a l ien-at ion from one 's usual support network may be preciselythe kind of social anxiety that in turn increases the value ofthe mutual support context .Aspects of i l lness associated with cos t of t reatmentand loss of l i fe were posi t ively associated with supportseeking in the ci ty groups but not in the on-l ine forums.

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T a b l e 4Corre la tes o f M u tua l Sup por t : P a t ien t, Il lness, andSoc ia l AspectsA m o u n t o f o n - l in e A m o u n t o f m u t ua lRa t ing i t em supp or t ac t i v i t y ( r anked) supp or t ( r anked)

Hea l t h ca r e sa l i enceC a u s e k n o w n - . 3 7P a t ien t mus t ma nage - . 13H o w d i s a b l in g . 0 4Cost l iness oft r ea tmen t . 22A t t it ude impo r t ance . 40 *A te rmina l i llness .18Pat ien t ch aracter is t icRe lated t o ag ing - . 3 2W om an ' s i ll ness . 29F r i e n d l y p a t i e n t s - . 3 1S oc ia l bu r denD is f i gu r i ng . 34Embar rass ing .43"Symptomsn o t ic e a b l e - . 1 7Const i tutes a st igma .30

- . 1 4- . 0 1.0 1. 5 2 *.3 4. 3 8 * *.1 0

- . 0 4- . 1 3.51 *. 6 7 *

- . 1 4. 4 3 * *Note. R a n k s o f s u p p o r t b e h a v i o r s a n d p u b l i c a t i o n s r e f l e c t t h a t a r a n k o f 1 i sa s s i g n e c t t o t h e l o w e s t v a l u e , a n d h i g h e r r a n k v a l u e s a r e a s s i g n e d t o h i g h e rv a r i a b l e v a l u e s . F o r a l l f i g u r e s , n = 2 0 .* p < . 0 5 . * * p < . 1 0 ( t w o - t a i le d , a l l c o r r e l a t io n s a r e b a s e d o n t h e S p e a r -m a n r a n k c o r r e l a t i o n c o e f f i c i e n t ).

The threat of death and the experience of costly medicaltreatment are the two factors most highly correlated withparticipation in face-to-face support groups. The personalfeatures grouped as patient characterist ics showed no sig-nificant relations to support behaviors of any kind. None ofthe personal characteristics we considered--friendliness ofpatients, illnesses directly related to aging, or illnesses thatstrike women--were associated with support seeking. Thisresult stands in contrast to earlier findings by Taylor et al.(1986) reporting higher participation rates by women. On-line support was unique in its correlation with importanceof patient's attitude to outcome. This pattern of findingssuggests that virtual support occurs at higher rates amongpatients whose conditions, although not necessarily lifethreatening, are debilitating in ways less responsive topurely medical care.Discuss ionThe aim of these studies was to identify patterns of patientsupport, both in face-to-face encounters and through theuse of on-line options. The tendency to participate in sup-port groups was highly consistent by category across cities.The highest levels of support were found in the cases ofalcoholism, AIDS, breast cancer, and anorexia, and thelowest levels of support were found in the cases of hyper-tension, migraine, ulcer, and chronic pain. Wide disparitieswere observed in (a) the overall tendency to participate in

support groups between cities and (b) the tendencies otpatients with certain conditions to seek or not to seeksupport, particularly after adjusting for prevalence.

Comparable patterns emerged in the on-line domain.In that case, a modest relationship was found between thetwo venues of virtual social exchange. The highest levels ofsupport activity were exhibited by sufferers of multiplesclerosis, chronic fatigue syndrome, breast cancer, andanorexia. The lowest activity levels were observed forsufferers of chronic pain, ulcer, hypertension, and emphy-sema. On-line and face-to-face support patterns were sig-nificantly correlated, suggesting that broad tendencies toseek support do vary by diagnostic category. Standardizedmeasures of face-to-face and on-line support, when col-lapsed, revealed a broad picture of variations in supportseeking by diagnosis. Alcoholism, cancer, AIDS, depres-sion, and diabetes are conditions that have given rise to theformation and maintenance of mutual support forums.These tendencies, according to correlations withjudges' ratings, may be spurred by the interpersonal con-sequences of illness, specifically, embarrassment , stigma,and disfigurement. Actual groups were unique in theirassociation with conditions rated as terminal and costly totreat. This kind of seriousness index was not evident inmotivating on-line support. On-line forums appear to beslightly more oriented around conditions poorly understoodand somewhat overlooked by the medical community.Those confronted with grave concerns may feel moreacutely the need to experience the physical presence, thevalidation, and the sense of belonging that come withactual encounters. Virtual support may have its limits.

According to social comparison theory, in conditionsof uncertainty or anxiety, affiliative motivation should beincreased, except under conditions of embarrassment. Inparticular, individuals would prefer the company of otherswho are in a similar situation when experts are absent.These postulations are fitting in the case of the on-lineforums, in which a relative amount of anonymity is present,and thus confiding can occur without immediate socialrepercussions. In the case of the city support groups, how-ever, hypotheses about lowered support seeking in condi-tions associated with embarrassment were pointedly dis-confirmed. These groups are populated by individualswhose illnesses, either by their very nature or as a result oftreatment (e.g., mastectomy), have forced them to experi-ence embarrassment and social stigmatization. The serious-ness of their conditions, the weight of their illness impact,and the degree of readjustment required under the circum-stances suggest motives only partially captured by termslike ambi gu i t y and anxiety. In these cases, the patients'experiences set them apart from their immediate socialsetting and propel them toward others who have beensimilarly marked.The findings surrounding support-group participationsuggest that laboratory investigations of social motives lacksome ecological validity: It is not a great challenge for astudent to anticipate the experience of emban'assment anddecline the opportunity to share this with another in ahighly controlled lab study. The experience of embarrass-

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r a i s i n g o u t l e t s ( C h e s l e r & C h e s n e y , 1 9 9 5 ). W h e n a s u p p o r tg r o u p c o n v e r t s f r o m o n e o f e m o t i o n a l a n d i n f o r m a t i o n a ls u p p o r t i n t o o n e o f s o c i a l a c t i v i s m , w h a t d o e s i t d o f o rm e m b e r s ? T h e l if e li n e o f m e m b e r p a r t i c ip a t i o n a n d g r o u pl i f e i n g e n e r a l i s h i g h l y v a r i a b l e . A s n o t e d e a r l i e r , A Am e m b e r s h i p i s a l i f e l o n g o n e. O t h e r g r o u p s a r e m o r e t e m -p o r a r y i n o r i e n ta t i o n . A s w i t h i l ln e s s e s , p e o p l e h a v es c h e m a a b o u t t h e d u r a t io n o f s u p p o r t n e e d s . F o r p s y c h o l -o g i s t s , t h e d y n a m i c s o f t h e s e g r o u p s o v e r t i m e o f f e r i n -s i g h ts a b o u t s o c i a l th e o r y a n d a b o u t p a t i e n t n e e d s .

T h e s e l f - h e l p m o v e m e n t , b o t h i n f a c e - to - f a c e a n d v i r-t u a l a r e n a s , h a s t r e m e n d o u s t h e r a p e u t i c p o t e n t i a l . A p p a r -e n t l y , r e l a t iv e i n c r e a s e s i n s o c i a l m a r g i n a l i z a t i o n r e s u l t i n ad e s i r e to c o m p a r e n o t e s w i t h s i m i l a r o th e r s , d e s p i t e th ee x p e r i e n c e o f e m b a r r a s s m e n t . A s s u c h , i t m a y b e p o s s i b l et o d r a w o n t h e c o h e s i v e p o w e r t h a t st i g m a a p p a r e n t l yg e n e r a t e s . R e c r u i t m e n t e f f o r t s fo r r e h a b i l i t a t i o n p r o g r a m so r h e a l th b e h a v i o r c h a n g e m a y b e m o r e s u c c e s s f u l i f r e f -e r e n c e t o o n e o r m o r e o f th e s t i g m a t i z i n g a s p e c t s o f ac o n d i t io n i s m a d e . A d h e r e n c e o v e r t im e m a y b e i n c r ea s e di f m e d i c a l p r o g r a m s i n t e g r a t e m o r e o p p o r t u n i t y f o r e x -c h a n g e a r o u n d t h e h u m a n s i d e o f h e a l th a n d i l l n e s s. O u t -s i d e h e a lt h c a r e , o th e r m a r g i n a l i z e d g r o u p s , s u c h a s i m m i -g r a n t s, m a y b e m o r e e f f e c t i v e l y i n t e g r a t e d w i t h a m o d e s tp u s h t o w a r d g r o u p i n v o l v e m e n t .

A l t h o u g h s e l f - h e l p a n d p r o f e s s i o n a l h e l p a re o f t e np e r c e i v e d a s m u t u a l l y e x c l u s i v e , t h e d a t a i n d i c a t e th a t s u c hp e r c e p t i o n s a r e m i s l e a d i n g : O v e r 6 0 % o f g r o u p s d e s c r i b i n gt h e m s e l v e s a s s e l f - h e l p a r e p r o f e s s i o n a l l y f a c i l it a t e d . T h i sa p p a r e n t c o n t r a d i c t i o n s h o u l d b e m o r e f u l l y e x p l o r e d .G r o u p p a r t i c i p a n t s m a y n o t b e r e s i s t a n t t o p r o f e s s i o n a li n p u t ; ra t h e r, t h e y m a y n e e d t o s p e a k a n d b e h e a r d a b o u ti s s u e s n o t a d d r e s s e d w i t h i n t h e h e a l t h c a r e s e t ti n g . S e v e r a li m p o r t a n t q u e s t i o n s e m e r g e f r o m t h e l a y a n d p r o f e s s i o n a lp e r s p e c t i v e s o n m u t u a l s u p p o r t . W h a t f a c t o r s a r e i m p o r t a n tt o p a t i e n t s h e l p i n g p a t i e n t s , a s o p p o s e d t o p r o f e s s i o n a l sh e l p i n g p a t i e n t s ? W h a t f e a t u r e s o f p r o f e s s i o n a l i n p u t c o n -t r i b u t e t o o p t i m a l o u t c o m e s ? W h a t c o m b i n a t i o n s a r e o p t i -m a l f o r v a r io u s p a t i e n t g r o u p s ? W h a t a r e th e c o s t b e n e f i tsa s s o c i a t e d w i t h g r o u p a p p r o a c h e s t o h e a l t h c a re ? P h y s i c i a ne n l i s t m e n t c o u l d d o u b l e o r t r i p l e s u p p o r t g r o u p p a r t i c i p a -t i o n r a t e s, a n d p s y c h o l o g i c a l e x p e r t i s e c o u l d h e i g h t e n e f -f e c t i v e n e s s i n e m o t i o n a l s u p p o r t , h e a l t h b e h a v i o r c h a n g e ,a n d p a t i e n t p r o g n o s i s . T h e c l i n i c a l p o t e n t i a l o f g r o u p s u p -p o r t i n c o m b i n a t i o n w i t h p r o f e s s i o n a l g u i d a n c e i s la r g e l yu n k n o w n .

W i t h i n c o n t e m p o r a r y h e a l t h c a r e , s u p p o r t g r o u p p a r -t i c i p a t io n p a t t e r n s a r e p a r t i c u l a r l y r e l e v a n t a t t h i s j u n c t u r ei n h i s t o r y g i v e n t h e d i s p a r i t y b e t w e e n t h e c o s t s o f h e a l thc a r e a n d t h e u n m e t n e e d s o f m a n y p a t i e n t s. T h e c u l t u r e o fi n s t i tu t i o n a l h e a l t h c a r e i s s t il l f a r f r o m e m b r a c i n g p s y c h o -l o g i c a l s u p p o r t i n t o h e a l t h c a r e d e l i v e r y , d e s p i t e o v e r -w h e l m i n g e m p i r i c a l j u s t i f ic a t i o n (f o r a n e x c e l l e n t c o m m e n -t a r y o n t h e s e i s s u e s , s e e M o r g e s o n , S e l i g m a n , S t e r n b e r g ,T a y l o r , & M a n n i n g , 1 9 9 9 ). O n t h e o t h e r h a n d , t h e c u l t u r eo f p s y c h o l o g y h a s b e e n f o c u s e d a r o u n d t r e a tm e n t o f m e n -t a l, n o t p h y s i c a l , a i l m e n t s . S u p p o r t g r o u p s r e p r e s e n t o n e o ft h e m o s t a d a p t i v e p e r m u t a t i o n s o f t h e h e a l t h c a re d i l e m m a ,a l l o w i n g s u f f e r er s t o g a t h e r t h e i n f o r m a t i o n m o s t v a l u a b l e

t o t h e m - - s t o r i e s o f s i m i l a r e x p e r i e n c e a n d e n d u r a n c e .T h e s e i n v e s t i g a t i o n s i n d i c a t e t h a t s u p p o r t g r o u p s a r e p a r-t i c u l a r l y v a l u e d b y i n d i v i d u a l s w h o s e l i v e s a n d s o c i a l id e n -t i t i e s h a v e b e e n p u t a t r i s k . A f u l l e r a p p r e c i a t i o n o f t h es o c i a l c o n t e x t o f i l l n e s s e n r i c h e s o u r t h e o r e t i c a l u n d e r -s t a n d i n g s o f s o c i a l s u p p o r t a n d s o c i a l c o m p a r i s o n , w h i l eo f f e r i n g p r a c t ic a l i n si g h t s a b o u t a m o r e a p p r o p r i a t e m a t c hb e t w e e n h e a l t h c a r e d e l i v e r y a n d t h e h e a l t h c a r e s o u g h t b yp a t i e n t s a n d t h e i r f a m i l i e s .

B o t h t h e m e t h o d s a n d r e s u l t s o f t h e s e s t u d i es h a v er e l e v a n c e f o r a n u m b e r o f c o n c e r n s c o m m o n t o al l p s y -c h o l o g i s t s : s o c i a l c o m p a r i s o n , g r o u p f o r m a t i o n , h e a l t hc a r e , e ff e c t s o f s ti g m a , a n d d i s c l o s u r e p r o c e s s e s . T h e m o s ti n t e r e st i n g a s p e c t o f t h e s t u d y i s a l so t h e m o s t p r o b l e m a t i c :A c o n s t a n t c o n c e r n f o r r e s e a r c h e r s is t h a t b a l a n c i n g a c t o fc o n d u c t i n g r e s e a r c h t h a t d r a w s o n p r i o r t h e o r e t i c a l a n de m p i r i c a l f o u n d a t i o n s w h i l e a s k i n g q u e s t i o n s i n t e re s t i n ge n o u g h t o h a v e r e a l - w o r l d r e l e v a n c e . S u p p o r t g r o u p s c o n -s t i t u t e a c a t e g o r y w i t h f u z z y b o u n d a r i e s , a n d a s s u c h t h e ym a k e s c i e n t is t s u n e a s y . I n t h e i n t e r es t o f e l e g a n c e a n de x p e r i n a e n ta l co n t r o l , w e o f t e n p r e f e r m u t u a l l y e x c l u s i v ec a t e g o r i e s a n d s i n g u l a r c a u s a l m o d e l s . T h e g o a l i s u s u a l lyt o i s o l a t e t h e h y p o t h e s i z e d a c t i v e a g e n t i n a p a r t i c u l a rp h e n o m e n o n . A t b r o a d e r l e v e l s o f a n a l y s i s, t h o u g h , s u c ha p p r o a c h e s l a c k v a l i d i t y , i g n o r i n g t h e r e a l i ti e s o f a s o c i e t yi n w h i c h r i c h l y o v e r l a p p i n g c a t e g o r i e s a r e e v e r y w h e r e . I nt h is c a se , t h e m o s t r i g o r o u s m e t h o d o l o g y w a s a l s o a l e s sc o n t r o l l e d o n e . S u p p o r t g r o u p s c a n n o t b e r e p l i c a t e d i n th el a b , b u t t h e t e n d e n c y o f s o m e t y p e s o f p a t i e n t s t o s e e k e a c ho t h e r ' s c o m p a n y m o r e t h a n o t h e r t y p e s o f p a t i e n t s, d e s p i t et h e n o i s e i n t h e i m p e r f e c t c a t e g o r i z a t i o n s , e m e r g e s s t a ti s -t i c a l l y a s a c l e a r p a t t e r n r e p l i c a t e d a c r o s s c i t i e s . W e b e l i e v et h a t p s y c h o l o g i s t s s h o u l d b e e n c o u r a g e d t o e r r m o r e o f t e no n t h e s i d e o f r e a l - w o r l d c o m p l e x i t y i n o r d e r t o s e r v e m o r ee f f e c t iv e l y t h e s o c i e t y t h e y a t t e m p t t o o b s e r v e .REFERENCESAday, L A., & A ndersen, R. (197 4). A framew ork ~br the study of accessto m edical care. H e a l t h S e r v i c e s R e s e a r c h , 9 , 208-220.Bolger, N., Foster, M., V inokur, A. D., & Ng, R. (1996). Close relation-ships and adjustm ents to a life crisis: The case of breast cancer. J o u r n a l

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