Stanford University psychiatrist David Spiegel attributes the effectiveness of his breast cancer support groups to a focus on emotional expression. But many experts think the question is open, since attending a support group could change the life of a cancer patient in many ways. It could make them more assertive about getting medical information, leading to better medical decisions. It could help them follow their doc's instructions more closely. It could improve sleep or nutrition.
"There were a multitude of variables that were affected, and you don't know what might account for the greater longevity," says Jill Littrell, an assistant professor of social work at Georgia State University who studies psychosocial factors in AIDS. "It could even change the perception of stresses, giving a more positive view of what's going on."
Focusing on trouble?
The scientific literature on emotional expression is mixed, she says, and some scientists think that "focusing on trouble can actually make depression worse, that you are better off focusing on positives." If emotional expression "leads to a more optimistic view of things, or a way of looking at things that doesn't get you upset, that's very beneficial," she adds. "If it keeps you going over the negatives, it might be harmful."
Some of that ambiguity is evident in work by James Pennebaker, a social psychologist at Southern Methodist University. Pennebaker asked some students ("undergraduate lab rats") to write about a trauma they had experienced. He asked others to write non-emotional paragraphs. Afterwards, the trauma-writers used less medical care than the control group members. This indicated that feeling the experience had somehow improved their health, seeming to buttress Spiegel's thesis about the benefits of expressing emotion.
But when Pennebaker asked another group of lab rats to write about someone else's trauma, he got the same result. That would seem to attribute the health benefits to another factor -- perhaps a feeling of inspiration or a positive reframing of the experience.
Then, in 1995, Pennebaker and colleagues reported that writing about personal trauma increased antibody production after hepatitis B vaccination, offering, he wrote, "further support for a link between emotional disclosure and health."
Support groups can also provide pure information. (For a study of the value of information versus emotional support for cancer patients, see "Comparison of Brief Group Therapies... " in the bibliography.)
Still, as with the cold-susceptibility studies, there's a missing link in this research. Namely, what is the
Mechanism?
As we've indicated, many factors could explain a correlation between increased longevity and social support: changes in diet, health practices, even better access to medical care. But researchers think that at root there must be a measurable biological change.
"You have all of these mechanisms that could play a role," Littrell points out. Much of the attention has focused on three so-called "stress hormones:" cortisol, epinephrine, and norephinephrine. Stress hormones help the body prepare for a fight or a flight, and suppress parts of the immune system. Since the immune system helps fight cancer, that could explain why lowering emotional stress is associated with longer survival.
The support group's effect could also be due to changes in beta-endorphins, brain chemicals released during exercise that boost natural killer cell activity. Or it could be caused by a direct nerve connection between the brain and the spleen, a storage unit for white blood cells.
And although the details about the best forms of support, and details on the biological mechanism will be a long time coming, Spiegel says support groups -- preferably ones that allow emotional expression -- should be "part of the standard care for cancer."
For her part, Littrell says, "A safe position right now is that better social support is good. If you can surround yourself with people who like you, it will be very positive. Positive beliefs about the future and about yourself are good."
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