Social Support and Health

Author(s): Berton H. Kaplan, John C. Cassel and Susan Gore

Source: Medical Care, Vol. 15, No. 5, Supplement: Issues in Promoting Health Committee Reports
of the Medical Sociology Section of the American Sociological Association (May, 1977), pp. 47-58
Published by: Lippincott Williams & Wilkins
Stable URL: http://www.jstor.org/stable/3763353
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MEDICALCAM
May 1977, Vol. XV, No. 5, Supplement

Social Support and Health

BERTONH. KAPLAN,PH.D.,* JOHNC. CASSEL,M.D.,f

AND SUSANGORE,PH.D.4

IN HUMAN COMMUNICATION SYSTEMS, what the place of the study of social support in
is the function of social support in the biomedical research.
etiology, precipitation, course and recovery There are really four basic questions that
from disease? In what way does social sup- concern us in this paper:
port ameliorate stress? In what ways does 1. What is the place of the social support
social support act to promote health? While hypothesis in understanding biomedical
many researchers30have speculated on the events? What is the evidence concerning
importance of social support and a few the effects of social support on the indi-
have proclaimed it to be significant in myo- vidual's health and well-being? What kinds
cardial infarction8 49 there is little strong of diseases have been attributed to the ab-
empirical evidence to confirm the role it sence (or lessening) of support? This in-
may play in health and illness. This is not volves focusing on social support as an in-
surprising: attempts at conceptualization dependent or conditioning variable.*
and measurement have been inadequate, 2. What does social support alter in the
discipline-bound (or study-bound), and person? What are the mechanisms in the
usually formulated for post-hoc interpreta- social environment (the institutions, social
tion of unexpected, but striking findings.
roles, self-perceptions, relationships, etc.)
that maintain, produce, or remove the sup-
Basic Purposes
ply of supports available to an individual?
The purpose of the present paper is to 3. Experimentally, is there a more useful
unravel some important dimensions of the way of ordering the multidimensional prop-
social support concept and to help clarify erties of social support for further work?
The multidimensionality of social support
This paperis dedicatedto JohnCassel,M.D., a requires a clarification of the relevance of
remarkableepidemiologist,a creative and vital varying types of social support for the indi-
force in modernmedicine,and a greatfriendand
colleague. vidual, and the mechanisms that permit
Presentedat AmericanPublicHealthAssociation
* This
Meetings,November9, 1973, San Francisco,Calif. questionraises the old problemof the
*Professorof Epidemiology(Sociology), De- conceptualization of socialintegrationin the Durk-
partment of Epidemiology, School of Public heimian14 sense. Durkheimwas interestedin social
Health,Universityof NorthCarolina,ChapelHill, supportas an independentvariableand how it
N. C. affectedmentalhealth, namelysuicide. He was,
however,also interestedin supportas a dependent
f Professorof Epidemiologyand Chairman,De- variable,that is: whattypesof conditionsaffector
partment of Epidemiology, School of Public predictthe level of socialintegration?In the first
Health,Universityof NorthCarolina,ChapelHill, case, the emphasisis on the health of the indi-
N. C. vidual. In the latter,the questionfocuseson the
t AssistantProfessorof Sociology,Department health of society. In a classic sociologicalsense,
of Sociology,Universityof Massachusetts,
Boston, what is the link between"socialintegration"and
Mass. support?
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KAPLAN ET AL. MEDICAL CARE

affiliative needs to be met by socially sup- mining susceptibility to a wide variety of

portive networks need to be better under- disease outcomes. The specific manifesta-
stood. tions of those disease outcomes we are sug-
4. What are the medical care policy im- gesting will be a function of the genetic con-
plications of existing data on social support? stitution of the individuals and the nature of
the physicochemical insults they encounter.
Clearly, this paper cannot do full justice If such a formulation is correct, it would
to each of these areas, but it is profoundly
indicate that actions designed to prevent
important-indeed, of critical creative im- disease should be focused on attempts to
portance-to be much more specific about
change these psychosocial factors, rather
the kinds of questions that must be an-
than on efforts at early case findings and
swered in this area. To fully answer these
detection of disease. Modification of these
four questions requires a book, and not a
factors should lead to the prevention of a
paper. Accordingly, we only provide selec- wide variety of manifestations of ill health.
tive documentation.
Of the two sets of postulated factors it
would appear further that strengthening
Psychosocial Factors in social supports is more immediately prac-
Disease Etiology
tical than attempting to reduce the occur-
In previous papers,11 41 we have indi- rence of the stressor situations. Therefore,
cated that there may be two types of psy- this paper is concerned with attempts at
chosocial processes of importance in disease further definition and clarification of the na-
etiology. The first are those deleterious or ture of social supports. It is hoped that im-
stressor factors which enhance disease sus- proved conceptualization will lead to the
ceptibility; the second would be protective development of more adequate instruments
factors which buffer or cushion the organism for their measurements and direction for
from the effects of noxious stimuli (includ- attempts at modification. Before presenting
ing psychosocial stressor factors). these ideas we will briefly summarize some
We have suggested further that a char- of the evidence for the notion that the ab-
acteristic common to most stressor situations sence of adequate social supports increases
is the inability of the individual to obtain the susceptibility of the organism to various
meaningful information that his actions are forms of disease. We also present some of
leading to desired consequences. For ex- the theories to explain the possible bio-
ample, such circumstances would pertain in logical and psychological processes which
most situations of role conflict, role am- might operate.
biguity, blocked aspirations and cultural Both animal and human studies have
discontinuity. The protective factors we be- provided evidence of the protective effect
lieve are largely a function of the nature, that the presence of important other mem-
strength and availability of social supports. bers of the same species confers on the in-
It is our contention that the joint effects of dividual under some form of stress. Conger
these two sets of factors determine to a con- et al.,12 for example, have shown that the
siderable extent the susceptibility of the efficacy with which an unanticipated series
organism to physicochemical disease agents of electric shocks (given to animals previ-
(including microorganisms, toxins, chem- ously conditioned to avoid them) can pro-
icals, nutritional deficiencies, et cetera). In duce peptic ulcers is determined, to a large
this instance, we do not conceptualize those extent, by whether the animals are shocked
psychosocial factors as being directly patho- in isolation (high ulcer rates) or in the
genic, but as conditioning variables deter- presence of litter mates (low ulcer rates).
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Vol. XV, No. 5, Supplement SOCIAL SUPPORT AND HEALTH

Henry et al.,23 have been able to produce quently in "marginal"people who, for one
persistent hypertension in mice by placing of various reasons, had no friends, family or
the animals in intercommunicating boxes intimate social group to which they could
all linked to a common feeding place, thus relate. Similar findings have been reported
developing a state of constant territorial for schizophrenia,3' 36 multiple accidents,47
conflict. Hypertension occurred, however, suicide,25 and respiratory diseases other
only when the mice were "strangers." Popu- than tuberculosis.25 Separation from the
lating the system with litter mates did not family and evacuation from London during
produce these effects. Liddel32 found that World War II appeared more deleterious
a young goat isolated in an experimental for London children than enduring the
chamber and subjected to a monotonous blitz with their families.48 Combat studies
conditioning stimulus will develop trau- have suggested the effectiveness of the
matic signs of experimental neurosis, while small group (platoon, bomber crew) in
its twin in an adjoining chamber, and sub- sustaining members under severe battle
jected to the same stimulus, but with the stress.34 As will be recognized, these latter
mother goat present, will not. studies have indeed examined the effect of
The evidence from human studies is social supports under some form of pre-
somewhat more conflicting. To a large ex- sumed stressful situation, the blitz in one
tent we believe this to be due to lack of instance and combat in the other. The
recognition by many investigators that so- degree to which the subjects were in fact
cial supports are likely to be protective only exposed to such stressors was, however, not
in the presence of stressful circumstances. measured; the existence of stressors being
Thus, the majority of studies have con- implicit rather than explicit. In one recent
tented themselves with attempts at relating study, however, both the stressors and the
the absence of some form of social support supports were more directly measured.
to disease or with the effect of some postu- Nuckolls et al.,41 studied the joint effects
lated stressful situation to disease, but have of these two processes on the outcome of
rarely examined the joint properties of the pregnancy. The data were obtained on 170
stressful situation together with the avail- primipara between the ages of 18 and 29
ability and nature of the social supports as of similar social class, all being delivered
they related to disease. Despite this, a num- by the same obstetrical services. The stres-
ber of studies have produced reasonably sors were measured by a life change score
convincing, if somewhat indirect, evidence calculated from the schedule of recent ex-
implicating the absence of social supports perience as developed by Holmes and
in disease genesis. Holmes,24 for example, Rahe26which was administered at 32 weeks
has shown that the highest rates of tubercu- of pregnancy. Social supports (or as they
losis in Seattle occurred in those people were termed "psycho-social assets") were
who, because of their ethnic group, were measured by an instrument designed to
distinct unaccepted minorities in the neigh- assess the subject's feelings toward herself
borhoods in which they lived (even when and her pregnancy and her relationship
they lived in affluent upper socioeconomic with her husband, her parents and his par-
class neighborhoods); and in those people ents, and friends and neighbors in the com-
of whatever ethnic group who were living munity. This instrument was administered
alone in one room, who had had multiple prior to the 24th week of pregnancy. Fol-
occupational and residential moves and who lowing delivery, all medical records were
were more often single or divorced. In reviewed "blind" and any complications of
short, the disease was occurring more fre- pregnancy or delivery (using the criteria
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KAPLAN ET AL. MEDICAL CARE

developed by the Collaborative Study on deed afford a plausible explanation for

Cerebral Palsy, Mental Retardation and many of the findingsreportedabove, there
Other Neurological and Sensory Disorders is as yet no unanimitythat such processes
of Infancy and Childhood) were recorded. function in this manner in humans. How-
Using these criteria, the Collaborative Study ever, there is a diverseliteratureon the role
found some 50 per cent of primapara had of social support and health.t
one or more complications. The rate for
the present sample was 47 per cent. Taken Some Assessmentof the Mechanisms
alone, neither the life-change score nor the of Social Support
psychosocial asset score were significantly Most of the studies which we have all
related to complications. However, when
seen and which utilize the concept of social
considered jointly it was found that 91 per
cent of the women with a high life-change supporteither implicitly or explicitly tend
to define (or assume) supportas one of the
score but low asset score had one or more
following:
complications, whereas only 33 per cent of
women with an equally high life-change 1. Supportis the "metness"or gratification
score but with a high asset score had any of a person'sbasic social needs (approval,
complications. esteem, succorance,etc.) through environ-
Taken together, these studies would sug- mentalsuppliesof social support. (The best
gest that at both the human and animal attempt at classificationand discussion of
levels the presence of another animal of the metness is found in Henry Murray'sEx-
same species may, under certain circum- ploration in Personality.39 Basically, all
stances, protect the individual from a humans and all primates have needs which
can be satisfied only through social inter-
variety of stressful stimuli. The mechanisms
or processes through which such interper- action with others).t
sonal relationships may function had so far 2. Support is defined by the relative pres-
been largely a matter of speculation. ence or absence of psychosocial support
Theories have been advanced, however, at
both the biological and the psychosocial f It is importantto point out that there are a
level. Perhaps one of the more attractive numberof traditionsin the literaturewhich lend
importantjustificationto examiningthe functionof
theories at the biological level is that pro- social supportas a preventorof disease,or as an
pounded by Bovard.5 6 He suggests that ameliorating factor. The majortraditionsarethose
stressful psychological stimuli are mediated stemmingfromthe classicalsociologicaltraditionof
Durkheim,Tonnies,Simmel,and othersas well as
through the posterior and medial hypo- the presentinterestin socialparticipationand the
thalamus leading via the release of a chemo- like; the social psychologicaltradition,for ex-
transmitter to the anterior pituitary to a ample, the Lewiniantraditionand its contempo-
rary;the religiousand philosophicaltraditionsas
general protein catabolic effect. He further exemplifiedin the work of Schracter,Brewster
suggests that a second center located in the Smith and others;the psychoanalytical tradition,
anterior and lateral hypothalamus when with referenceto problemsof intimacyas found
in Freud,Erickson,Lowenthal,Weiss and others;
stimulated by an appropriate social stimu- the comparative biologicaltraditionas exemplified
lus (namely the availability of a supportive in the workof HarryHarlowand in the popular
workof DesmondMorris;and in somewhatover-
relationship) calls forth in the organism a lapping fashion, the social psychiatrictradition
"competing response" which inhibits, masks which has its continuitiesespeciallyin Durkheim
or screens the stress stimulus such that the and is expressedin the work of AlexanderH.
latter has a minimal effect. While these Leighton,Tom Langner,MorleyBeisner,Jerome
Myers and others.3' 4, 13-15, 21, 22, 31, 38, 40
mechanisms have been reasonably well
t See AppendixA compiledfromworkby Gore18
documented in animal research and do in- and Pinneau.43
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Vol. XV, No. 5, Supplement SOCIAL SUPPORT AND HEALTH

resources from significant others. Work in these needs as "striving sentiments" and
social psychiatry has focused on the del- argues that changes in the physical and
eterious effects of support loss through social environment which interfere with pat-
death, separation or any change in the en- terns of social interaction will result in poor
vironment which disrupts existing social re- health.
lationships. Presumably, loss of social sup- e. Finally, in a study of psychiatric uti-
port leads to unmet needs of the individual, lization among affiliated and unaffiliated
which are suggested by the following: college students, Segal et al.46 found that
a. Studies which establish the high death for adjusted and maladjusted (according to
rate for spouses (particularly husbands) fol- MMPI criteria) psychiatric utilization was
lowing bereavement for their partner.42 significantly higher for the non-affiliated.
b. In-depth psychological interviews with He interpreted these findings to suggest
families moved from Boston's West End that affiliated students more easily met
through urban renewal efforts. These find- needs for esteem in their daily interactions,
ings suggest these individuals, especially the while the unaffiliated experience more in-
women, experience a grief syndrome similar security about self worth. This interpreta-
to that evidenced in bereavement. Both tion seems quite plausible if we view
depression and physical symptoms are mani- therapy visits as a kind of secondary (i.e.,
fest up to and beyond a two-year period professional) social support.
after the move. Fried and Gleicher argue These studies (with the exception of
that these outcomes are explained more by Segal's) establish a loss or alteration in the
lost gratifications from the old neighbor- presence of supportive others, which is
hood than deficits in the new. Residents, assumed to result in unmet needs and ulti-
especially non-working mothers, benefited mately psychiatric and physical disability.
from the structural crowding through in- This interpretation is in line with French's16
creased communication, sharing and ex- elaboration of P-E Fit (person-environment
changes of tangible support, i.e., what is fit) theory. Persons who do not receive
often called "mutual aid." Relocation in a enough support from their social environ-
new neighborhood meant that these needs ments to meet their needs will, with time,
were met only with difficulty.17 experience psychologic and physiologic
c. In explaining the similarities in dis- strain. This P-E fit framework will be uti-
ruptive and inappropriate social behavior lized through the remainder of the paper.
among institutionalized population, Gruen- Other research has focused on the pres-
berg19 has argued that the "Social Break- ence or absence of environmental supplies
down Syndrome" evolves from the initial or resources or the fit between the person
withdrawal of support by friends, family
and his social environment. This approach
and community from the individual who is
focuses on social integration and embraces
having difficulty meeting social obligations. such dimensions as: 1) The negative end
Their lack of support further discourages
of the support supply continuum: social
the individual in his faith that he can per-
form, resulting in his inability to take care isolation;' 2) The use of "objectively"
of himself or in his institutionalization. measured behaviors such as amount of
d. The work of Alexander Leighton30 and social affiliation;45 and 3) Those socially
colleagues gives support to the hypothesis faciliative or inhibitive aspects of the
that changes in social relationships result in environment (i.e., the social structure, in-
psychiatric disability if basic human needs stitutions, relationship, norms) that set
can no longer be met. Leighton refers to constraints on supportive behavior.9
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KAPLAN ET AL. MEDICAL CARE

Durkheim14 was interested in the phe- sequences of environmental change which

nomenon of social support, and how its ab- reduces support, or on the state of social
sence affects mental health, namely suicide. isolation which results in unmet needs.
He was perhaps most concerned with sup- Much less attention, however, has been de-
port as a dependent variable, i.e., in the voted to the healthful consequences of ade-
types of social structures needed for the quate support and the processes by which
adequate integration of the individual. support becomes effective.
The work of Langner and Michael29 on Earlier in this paper we referred to the
mental health risk again deals with the lack conditioning effect of social support on the
of support supplies, i.e., isolation. Their relationship between environmental stress
work does not demonstrate whether isola- and disease. Findings from some studies
tion leads to mental illness, or mental ill- indicate social support serves to ameliorate
ness to isolation. However, their work does or buffer the effects of stress for the indi-
establish that the crucial distinction is that vidual.43
between having no friends and having one In his study of NASA administrators,
or more. scientists and engineers, Caplan10 found
Focusing on the positive dimensions of that stress arises from ambiguities within
mental health, Bradburn, Caplovitz7 and work-related roles and that it can be
and colleagues have established that high ameliorated by supportive interpersonal re-
affiliators have greater avowed happiness lations on the job, particularly those with
than low affiliators. This, they argue, can be one's subordinates. Since peers and super-
explained by the voluntary nature of affilia- visors may be perceived as the sources of
tion. Since people are free to terminate the inconsistencies, they are not likely
unsatisfying relationships, continued inter- candidates to be called upon for support.
action contributes to positive satisfactions, Caplan suggests that relations with subor-
which balanced against dissatisfactions, dinates are erective because the person ex-
affects mental health. pects that they will help him to remedy the
Caplovitz indirectly takes up the issues situation. This might involve either tangible
of metness of needs in considering satisfac- support (help to get the job done), or
tion with social relationships. He found appraisal support (help in redefining the
high affiliators who are dissatisfied with the role expectations). In either case, the fit
extent of their affiliation have higher between the individual and his work en-
avowed happiness than satisfied low affili- vironment is improved.
ators. This finding might be interpreted to With regard to this appraisal function of
suggest that need-meeting through affilia- social support, the laboratory work of
tion further increased the need for affilia- Schacter45 provides a useful point of de-
tion. High affiliators who are less satisfied parture. He studied the effects of experi-
want more interactions and therefore have mentally induced states of anxiety on the
strong needs for affiliation. Questions of this desire to be with people, i.e., "the affiliative
kind suggest that a comprehensive model tendency." His results seem to suggest that
of social support mechanisms should include affiliative tendencies are the manifestations
the dimension of personal need and a de- of "needs for anxiety reduction and needs
termination of the level at which the need for self-evaluation." Ambiguous situations
is satisfied. or feelings lead to a desire to be with others
The above findings and interpretations as a means of socially evaluating and de-
represent a sample of the relevant work termining the "appropriate and proper
which tends to focus on the pathologic con- reaction."
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Vol. XV, No. 5, Supplement SOCIALSUPPORTAND HEALTH

An illustration of what might be consid- structural characteristics which may

ered the conditioning effect of emotional inhibit or facilitate supportive be-
support comes from a study of the mental haviors and relationships.
and physical health consequences of unem- 4. The interaction of the above three
ployment due to factory shutdown.18 It was classes of variables. How does Per-
found that those men who had the emo- son-Environment Fit occur?
tional support of their wives while unem-
The following section of this paper will
ployed for several weeks had few illness
be devoted to the second and third classes
symptoms, low cholesterol levels, and did
not blame themselves for the loss of the job. of variables. We will attempt to interpret
Those who were both unemployed and un- them as social support supplies in the
supported had the most disturbing health language of social networks theory.
outcomes. In this study, the support of wife
and friends did not result in finding new Social Networks as Support Availability
employment sooner, but the men who had The work of Leighton on integration and
support fared better in other respects during mental health,30 studies of group ethnic
the period of unemployment and made a cohesiveness among the Rosetans,9 and Mat-
more rapid return to normal, as indicated sumoto's35 observations on the Japanese
by measures taken at later visits. Thus, society show how important the support
while support did not alter the objective of dependency needs is to health. All this
stress, i.e., time unemployed, it evidently leads us to the Arsenian and Arsenian2
buffered the men's perception of its severity, concern with "tough" and "easy" culture
and enabled them better to cope with the and Leighton's facilitating or integrating30
experience. social systems as supportive of needs. The
The available literature provides us with
previous section of this paper has detailed
evidence of the importance of social sup- and documented this point. (See the Ap-
port, but with few clues about the dynamics pendix for a tentative summary list of
of support processes. Given both the weak-
mechanisms.)
ness in conceptualization and the inade- As indicated in the previous section, while
quacy of measurement, it seems crucial that there are various approaches to social sup-
systematic theoretical and empirical atten- port, much of the past work is scattered
tion be addressed to exploring the following and nonaccumulative. What are the prop-
types of variables: erties of social support? How are they
1. Psycho-emotional needs of the per- measured? What are the characteristics of
son, i.e., needs which can be met communities that facilitate support? What
socially and have a social basis. kind of social conditions are necessary to
2. Relationships as sources of support; maximize the fit between personal needs
both types of relationships and char- and the objective social environment?
acteristics of these relationships The social network theory of Mitchell37
such as complementarity, obliga- appears to be most pertinent and useful,
tion, i.e., the normative structure since it cuts through much of the literature
within which interaction takes and integrates the various mechanisms into
place. a measurable framework. We suggest that
3. Characteristics of the environment, this framework helps to clarify the interplay
including types of stresses or del- of variables that constitute the opportunity
eterious social processes and the for social support. We are exclusively con-
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KAPLAN ET AL. MEDICALCARE

cerned with the dimensions of social contacts may or may not share common
support. values. For example, the sameness of social
A social network includes the people one background of the members in each net-
communicates with, and the links within work yields an ease of supportive facilita-
these relationships. The properties of social tion, but the emphasis is on directness or
networks are first morphologic and refer to how immediate are the range of contacts.
the links in the network. The dimensions The above refers to the shape of the
of morphology are anchorage, density, individual's network28and presents the nec-
reachability and range.37 The second prop- essary conditions for creating an opportu-
erty is interactional or communicated cri- nity structure for meeting whatever sup-
teria. These properties refer to the nature portive needs exist.
of the links, that is their content, directed-
ness, durability, intensity, and frequency. Interactional Properties of Support
All these dimensions are defined as follows: Content (Support). Concerns the mean-
ings that persons in the network give their
Morphology (Necessary Conditions) or relationships. Support provides nourish-
Accessibility Criteria ment to self-esteem, normative affirmation,
Anchorage. The person or group net- dependency relatedness, clarification of ex-
works. Anchorage has two properties- pectations if needed, and the discharge of
length and complexity: a) What is the disturbing affects, etc.
shortest path(s) to others from a specific It seems that if supportive tasks and
individual or group? b) Is it simple or mul- strategies are to be better conceptualized
tiplex (this refers to the number of alterna- and measured, we need a better and new
tives or substitutes available)?37 The more classification approach, which we cannot
the better; the shorter, the better. comment on in this paper. What does need
Reachability. The extent the person can to be done is to examine the question of
use and contact people important to him. supportive tasks and strategies around at
Reachability involves importance in a range least ten categories:
with any number of steps from any starting
1. Rituals, such as religious and other
point. The larger the number of contacts social rituals, which are supportive.
you can reach in the fewest number of steps
is considered compact versus the opposite 2. Values and beliefs of a religious
continuum of small numbers who can be and ethical sort, particularly by
reached in a greater number of steps. The which individuals are supported.
optimum conditions allow a large number 3. Normative consensus, the suppor-
of valent, meaningful contacts within a tive function of shared norms.
short period of time. 4. Interpersonal exchanges, the way in
Density. This implies connectedness. which social networks supply sup-
These are the lines of communications of portive needs.
those in the network who know one 5. The fit between role(s) and de-
another and the extent to which links do
exist between members of your "set." The pendency needs.
focus is on denseness, the proportion of 6. The intimacy-nurturant mechanisms
of support. The opportunities for
people in the set who know one another.
Range. Number of direct contacts-few to actual closeness.
many. These may be homogeneous to 7. The way support is given to the self
heterogeneous types of contacts, that is, the in interaction with others.
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Vol. XV, No. 5, Supplement SOCIAL SUPPORT AND HEALTH

8. The self-supports in terms of the the developing of a more adequate theory

self's interaction with itself as an of affiliate need meeting and level of
aspect of identity. This context adaptation.
would be the classification of self An illustration of the above support op-
mechanisms of support-the "I'm portunities and strategies is drawn from
OK strategies." Kaplan's28 observations of Re-Evaluation
9. Social support as the discharge of Counselling. Briefly, Re-Evaluation Coun-
negative effects and the strategies selling is a peer group system of self-help
for emotional discharges in social to manage and reduce personal distress
context. through a series of supportive efforts. Kap-
10. Social support from a sociodemo- lan's observations are that these supportive
efforts involve at least the following social
graphic view with regard to one's
mechanisms: 1) an immediate community
status, such as married, divorced
and the like. network of others on whom to call to ex-
press distress in time of crises; 2) an ongo-
Directedness. Refers to amount of re- ing co-counselling system to express chronic
ciprocity; the direction of the interaction, distress (each member takes the role of
e.g., subordinate or superordinate; the di- counselor and/or counselee); 3) an ideol-
rection of the flow; the ability to mobilize ogy and set of practices that enhance self-
others. esteem through self-validating comments
Intensity. Degree individuals are pre- and games; 4) a group in which high morale
pared to honor obligations and exercise and getting better is encouraged; 5) a series
rights of support, the strength of commit- of meetings and relating styles which en-
ment. courage love of self and others; 6) a theory
Frequency. The number of times inter- that by discharging (talking, shaking, hit-
action is actually counted. ting pillows, role playing, crying, etc.), a
In summary, Mitchell's categories refer
person can overcome rigid ways of behavior
to 1) morphology-the available structure and hurts which create current distress; 7)
for support and indicated dimensions, and a set of practices that loosen repression,
2) actual interactional dimensions. These e.g., safety in allowing self disclosure, allow-
are thus properties of structure and proper-
ties of function, together the opportunity ing rage to be felt and expressed; and 8) a
structure for support. The hypothesized modeling opportunity in which to learn how
to disclose real feelings, solicit love from
relationships are: 1) The greater the struc-
tural availability, the greater the health pro- others, and develop a more correct and posi-
tive self-image.
tectiveness; and 2) The greater the support
functions, the more health protective the
network. Policy Implications for Medical Care
Just how these network properties actu- What are the policy implications of the
ally work will also be affected by the pre- point of view that asserts that social sup-
existing level of stress, personality factors,
and habitual modes of social network skills. ports ameliorate stress? Those holding this
perspective would argue that:
Kaplan27 has suggested an Intimacy Scale
be developed out of these categories, build- 1. Early childhood education (before and
ings on the work of Lowenthal33 and Erick- in school) should pay close attention to
son.15 It is also apparent that links to the encourage need-affiliation tasks and strate-
literature on coping behavior20 is crucial in gies. How do you socialize to avoid anomie?
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KAPLAN ET AL. MEDICAL CARE

2. Moder family medical practice should improve affiliative and coping skills to man-
include a work-up of one's "personal net- age or modify life stresses, to be called
works" and life stresses (e.g., life changes, Affiliative/Coping Assertiveness Training.
work, family) and consider the possibility (See forthcoming paper on this by the first
of providing or helping provide more func- author.)
tional social networks as an integral respon-
Summary
sibility of the health care system. The use
of lay counselors as developed by Pless44 We have thus emphasized the importance
and the development of outreach personnel of social support as protective of health.
represent a beginning in this direction. We have also begun to ascertain the key
3. Modem work settings (a large part of questions that should be addressed; initi-
one's life and locus of self-esteem) should ated a new synthesis of the great variety of
take special note of the need to facilitate types of support; suggested some synthesiz-
the building of high-morale work relation- ing criteria of social support, and finally,
have commented on the policy implications
ships as being protective.
of the social support hypothesis.
4. Special attention should be given to a
medical-religion dialogue that builds per-
sonal networks that are the locus of per- Acknowledgment
sonal and community support. There is a Ellen Friedmanprovidedexcellentresearchas-
sistance.
medical-epidemiological basis for Buber's
"I-Thou" philosophy! References
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Vol. XV, No. 5, Supplement SOCIAL SUPPORT AND HEALTH

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KAPLAN ET AL. MEDICAL CARE

* includes Leighton's work

Appendix A
* socioculturalchange
Some Social Support Mechanisms * forced relocation due to urban renewal and
(A Tentative Formulation) resulting grief reactions
Types of social structures
It is clear that the concept of social support is * Arsenian and Arsenian'spaths-tough-easy
in need of clarificationabout the types of personal
paths to meeting needs
support needs, the characteristicsof the objective * Matsumoto's study of Japan-dependency
social support supplies, and the types of actual
support mechanisms. The following appendix is serving and valued
offered so that others may wish to examine our * Roseto Pennsylvania
efforts in this direction. (Both of these focus on the primarinessof
the social organization)
List 1. Characteristics of the person: psycho-
emotional needs which must be socially gratified: List 3. A tentative summaryof support mecha-
nisms:
security
affection * Appraisal opportunities-the chance to eval-
trust uate "what'sgoing on," reality reassurances.
intimacy * Persuasion-the chance to tell the "other"that
nurturance-succorance his dissonant cognitions can be made con-
sistent and rewarding.
belongingness
affiliation * Normative fit-the comfort, the consensus,
approval the complementarityone feels in shared sup-
portive norms, e.g., your reference group
List 2. Characteristics of or changes in the versus "others."
objective environmentthat alter the state or quan- * Group solidarity-the feeling of "we-ness,"
tity of social support supplies: oneness, that comes out of social binding
Studies of loss of loved ones and the effect encounters; familiarity needs.
on survivors: * Intimacy opportunities-the opportunity to
* work on bereavement and the subsequent share the most personal thoughts.
death of widowers (the quicker readjust- * Role-self rewards/approval-the self-esteem
ment of the spouse if children are present). that comes from approvedfeedback for roles
* children separatedfrom families during war- well performed, e.g., as friend.
time * Dependable social networks-the set of de-
* JeromeMyers'life change inventoryclassifies pendable others, for social support, crises,
events as "loss events" versus "gain events," community, reliable norms.
removing versus providing social support * Tangible support-concrete events that help,
Changes in the physical environment: the e.g., a raise, a praise.
effects of poverty, disasters, crises, urbanza- * Love of significant others-especially spouse
tion, physical and social mobility and friends, God, etc.

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