Abstract
Group-based psychosocial programs provide an effective forum for improving mood and social support for cancer patients. Because some studies show more benefit for patients with initially high psychosocial distress, and little or no benefit for patients with initially low distress, support programs may better address patient needs by only including distressed patients. However, distressed patients may benefit particularly from the presence of nondistressed patients who model effective coping, an idea many researchers and extensions of social comparison theory support. We present a theoretical analysis, based on a social comparison perspective, of how group composition (heterogeneous group of distressed and nondistressed patients versus homogeneous group of distressed patients) may affect the efficacy of cancer support programs. We propose that a heterogeneous group allows distressed patients maximal opportunity for the various social comparison activities they are likely to prefer; a homogeneous group does not. Though the presence of nondistressed patients in a heterogeneous group potentially benefits distressed patients, the benefits for nondistressed patients are unclear. For nondistressed patients, heterogeneous groups may provide limited opportunities for preferred social comparison activity and may create the possibility for no benefit or even negative effects on quality of life. We also discuss ethical issues with enrolling nondistressed patients whose presence may help others, but whose likelihood of personal benefit is questionable
Introduction
The standard psychosocial referral for cancer patients is to a support group, a fact that highlights the importance of providing effective theoretically based programs. In contrast to cancer clinical trials that enroll only patients who require medical intervention, psychosocial support group trials typically include all patients of a particular cancer site or stage, regardless of any demonstrated psychosocial need for an intervention. Research indicates that psychosocial group support programs can increase social support and decrease psychological distress in cancer patients but may be most effective for patients in distress and/or with limited social resources (Goodwin et al., 2001; Helgeson, Cohen, Schulz, & Yasko, 2000; Lepore & Helgeson, 1999). These findings suggest that interventions may best address patient need by including only those most likely to benefit. Nonetheless, researchers have varying opinions about the advisability of providing interventions to a homogeneous group of psychologically distressed patients since nondistressed patients may be needed to model adaptive coping to distressed patients (Helgeson et al., 2000; Helgeson, Cohen, Schulz, & Yasko, 2001; Lepore, 2001). However, group psychological interventions comprising both heterogeneous (Antoni et al., 2001; Helgeson, Cohen, Schulz, & Yasko, 1999; Lepore & Helgeson, 1999; Lepore, Helgeson, Eton, & Schulz, 2003) and homogeneous (Eldredge et al., 1997; Silverman et al., 1999; Telch & Telch, 1986; Telch et al., 1993) compositions with respect to distress levels have resulted in improvements for distressed individuals. Thus, important theoretical and practical questions are whether heterogeneous groups are better than homogeneous groups for distressed patients and whether nondistressed patients are benefited by group support interventions. No single research study to date has considered the foregoing questions.
Here, we instead provide a theoretical evaluation of these issues by examining group composition (heterogeneous versus homogeneous groups) from the perspective of social comparison theory, which was originally proposed by Festinger (1954). For simplicity, we will discuss homogeneous and heterogeneous groups in reference to psychological functioning and assume a homogeneous group with regard to disease factors, as most cancer support group studies include only individuals facing a particular cancer and typically exclude individuals with advanced disease (unless that is the focus of study). To illustrate the potential importance of group composition for the efficacy of cancer support group programs, we briefly describe how our ideas may operate in group cognitive behavioral therapy (CBT) programs. Our goal is to provide a critical theoretical evaluation of how the structure of typical support groups in clinical and research settings may impact its participants. Our evaluation is based on published research emanating from the United States and Western Europe, but our specific hypotheses have not been tested directly to date. Ultimately, we hope this evaluation leads to theory-based research.
