.k. Sci. Med. Vol. 28. No. 12. pp. 1275-1282. 1989 0277-9536189 $3.00 + 0.

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Printed I” Great Britain. All rights reserved Copyright ,p 1989 Pergamon Press plc

SOCIAL SUPPORT: DIVERSE THEORETICAL

PERSPECTIVES
MIRIAM J. STEWART
Faculty of Health Professions, Dalhousie University School of Nursing,
Halifax, Nova Scotia B3H 3J5. Canada

Abstract-The useful predictions and interpretations about social support which can be derived from
attribution, coping, equity, loneliness and social comparison theories have typically not been recognized.
Attribution theory can enable explanation of motives of donors, the phenomena of help-seeking and
helping, and negative effects of support efforts. Coping theory demonstrates how social support and
coping interface in the stress process; adds a cognitive dimension to support; and considers costs of
support. Equity theory explains reactions to support from donor and recipient viewpoints and the
reciprocal nature of social support. Loneliness theory attests to the significance of social relationships and
emphasizes the affective dimension of support. Social comparison theory is helpful in interpreting positive
and debilitating effects of support when the donor is a peer. Further, these five theories enhance theoretical
interpretation of social support through their distinctive explanations of the concepts of ‘appraisal’ and
‘helping’. Relevance to health professional assessment and practice can be delineated.

Key rcsords-Social support, attribution, coping, equity, loneliness, social comparison

INTRODUCTION according to relative weights assigned to internal

The sociological theories of symbolic interactionism,
role and anomie [I] have been identified as precursors
to the development of social-support theory. What
typically have not been recognized, however, are
the conceptual interpretations about social support
which can be derived from attribution, coping, social-
exchange, social-comparison and loneliness theories.
The benefits of bidirectional support can be explained
by invoking social-exchange theory, which is
also referred to as equity theory. Equity, social-
comparison and attribution theories can guide inter-
pretation of the positive and negative features of
support. Attribution, coping and loneliness theories
assist analysis of the perceived availability versus
receipt or enactment of supportive resources and
elucidate the duration of support relationships.
(“Perceived social support,” in Barrera’s [2] words, is
the cognitive appraisal of being reliably connected to
others, while “enacted support” is the action or
assistance rendered.)
Finally, these theories all encompass the notions of
appraisal and helping, so relevant to both social
support and health care. For these reasons, the paper
aims to summarize each of these five theories and to
highlight its potential relevance to health professional
practice and to social-support theory. Accordingly,
practical examples of the application of these supple-
mentary social-support theories in health care are
outlined, and conceptual definitions and propositions
are proposed in a preliminary attempt to consider a
revised theoretical approach to social support.
ATTRIBUTION THEORY
The search for meaning and mastery in threatening
events is attributional [3]. Attribution theory [4, 51
posits that individuals formulate attributions to
understand. predict and control their environment
(client) or to external (environment) factors. Thus,
when individuals assign blame for the origin of a
problem and ascribe control over the problem solu-
tion to either the provider or recipient, this influences
helping relationships. As delineated by Brickman et
al. [6,7] explanations of responsibility for causing
and solving a person’s problems have been used to
construct four discrete helping and coping orienta-
tions: the compensatory, enlightenment, medical and
moral models.
Brickman ef al. [7] summarized the propositions
for theories of fairness in helping as: (1) recipients
deserve help to the extent that they are not responsi-
ble for their deficit in resources and (2) donors will
feel obligated to help to the extent that they are not
responsible for their surplus of resources. The propo-
sitions for theories of helping effectiveness are: (1)
recipients can use help more effectively if they are
seen by providers as responsible for outcomes and (2)
donors can give help more effectively if they are seen
as responsible for outcomes.
People form negative attributions about the
suffering because they believe in a fair world, where
individuals “get what they deserve” [8] and “deserve
what they get”. Causal and solution attributions can
lead to blaming the victim [9], insensitive, uncaring,
unhelpful behavior [3, lo], and an undermined sense
of competence and control [7j.
Commentary on relevance to social support and
health care
The close association of helping and social support
makes Brickman’s typology [6] particularly relevant
to any discussion of social support. According to
these unique helping orientations, responsibility for
causing or solving a problem can be attributed by
potential help-givers to the individual rather than the
environment. Hence victim-blaming [9], avoidance
and nonhelpful behaviors [IO] can be experienced

1275
1276 MIRIAM J. -STEWART
by cancer patients and others who need support.
Furthermore, it has intuitive appeal for interpreting
‘helping’ professionals’ views of client problems, as
professionals may assign blame for the cause or
responsibility for solution to the client. Assessment of
attributions can explain perceptions of help seekers
and lay and professional helpers regarding help-
seeking and helping. In this context, Ryan [I l]
applied attribution theory to compare and explain the
different helping models preferred by different lay
support groups and professionals.
Assessment of attribution can contribute to the
explanation of the motives/perceptions of help
seekers and lay and professional helpers. Karshmer
ef nl. [13] found that both health professionals and
clients in a psychiatric-care setting tend to inequit-
ably attribute behavior of clients to dispositional
(personal) rather than external/situational (environ-
mental) causes. The probability that this victim-
blaming phenomenon is not peculiar to mental-health
services is yet another reason why attribution
theory should be applied to the analysis of support
rendered by professional and nonprofessional
caregivers.
Cronenwett and Brickman’s [14] query, whether
professional role socialization determines the choice
of helping models, is relevant to health professionals.
(Brickman proposed that congruence between help-
ing models of helper and helpee enhances helping
effectiveness.) Social support researchers who over-
look attributional problems, such as application of
the wrong or incongruent model, do not accurately
reflect the multidimensional nature of social support
and help-seeking [12]. For example, attribution
theory would be a useful adjunct to studies which
demonstrate that the family’s reaction to the breast
cancer patient is crucial to the patient’s adjustment
after mastectomy. Clearly, health status and health
behavior depend on individual and group ability to
interpret, manipulate, and cope with environmental
stressors.
Example relevant to health care
Children with cystic fibrosis or chronic obstructive
pulmonary disease who join a mutual-aid group
would encounter peer informational, appraisal and
emotional social support. The first two forms would
emphasize situational rather than dispositional
attributions, thus avoiding self-blame regarding the
cause of their illness; environmental and hereditary
causative factors would legitimately be assigned
‘blame’. However, children in the group would
quickly become aware that they were responsible for
adhering to dietary and environmental restrictions
and to medication and exercise regimens. (This
exemplifies Brickman’s [6] compensatory model.)
Further, changes in the helping models preferred by
children, which evolve from joining to membership
termination, could be tested.
COPING THEORY
Coping has been defined as “constantly changing
cognitive and behavioral efforts to manage specific
external and/or internal demands that are appraised
as taxing or exceeding the resources of the person”
[l5, p. 1411. Coping is determined by the relationship
between the person and the environment; it is a
transactional process with problem-focussed and
emotion-focussed functions [ 151.
Three types of cognitive appraisal, or evaluative
cognitive processes, intervene between the encounter
and the reaction in the coping process: primary,
secondary, reappraisal [ 151. Speculation about the
stage(s) in the coping process at which social support
operates is continuous and conflicting.
(1) Information provided by others about events
and stressors directly influences primary appraisal;
social comparison indirectly affects primary appraisal
through mental representations of others in relation-
ships and modeled responses to the event [l&19].
(2) Social support plays a major role in secondary
appraisal when the individual assesses coping re-
sources by broadening the number of coping options,
offering resources such as modeled emotional coping
strategies, referrals to professional services, encour-
agement to seek assistance, provision of information
and problem-solving techniques; by providing norms
which prescribe behavior, set constraints on coping
activities and affect self-perceptions; and by enhanc-
ing self-esteem [ 15-191.
(3) Social support may result in reappraisal, inhibi-
tion of maladaptive responses or facilitation of adap-
tive counterresponses [ 161.
(4) Social support can function directly as a coping
strategy by providing the recipient with the resources
required to meet specific needs evoked by the stressor,
redirecting problem-solving strategies, providing
tangible aid, offering emotional sustenance and
changing coping patterns/mechanisms employed to
deal with stressful events [ l6-181.
In an attempt to resolve conceptual difficulties,
Lazarus and Folkman [IS] treat social support under
the rubric of coping as a resource available in the
social environment (social network). People, they
argue, must cultivate and may or may not call
upon this social network, depending on access to
alternative coping strategies. In addition, they view
social support as “a transactional process that
changes with demands of the stressful encounter”,
and as a multidimensional construct, encompassing
emotional, tangible and informational functions.
Two years ago, Thoits [20] usefully reconceptualized
social support as coping assistance in stress manage-
ment. This view is congruent with Dunkel-Schetter,
Lazarus and Folkman’s [9] more recent opinion that
stress and social support are complex interacting
processes.
In summary, from a coping theorist’s perspective,
the perception of social support is one element in the
individual’s appraisal of the significance of a stressor
for personal well-being [21]. Moreover, social support
is one of a variety of potential coping resources [19].
Social support, like other coping resources, regulates
negative effects of stressful conditions [18]. It may
sometimes be the only available coping method; at
other times it may not be the most preferred or
cost-effective method [22]. Whether positive or nega-
tive, social support may be perceived as potentially
available from the social network or may be actually
provided and received. Both forms are important in
the coping process.
 Social support: diverse theoretical perspectives 1277

Commentary on relevance to social support and reciprocal value of social support has been infre-
health care quently studied [32].
Social support should be considered within The costs and benefits associated with giving and
the context of the stress and coping process, as receiving help (support) are relevant to the issue of
socially mediated coping. Social networks and reciprocity. Support provided may be perceived as
social support, however. may be more than resources unhelpful, particularly when it undermines self-
to be called upon at will. In fact, social networks esteem. Further, social networks may be strained and
influence help-seeking from formal and informal conflicted. People may be unwilling to seek or accept
sources and attributions regarding causes and solu- help if they feel unable to return the benefit [33]. For
tions for stressors, thereby influencing the coping example, when aid is involuntary, relationships
process. will be negatively influenced if actual or potential
The social support and coping interface in the reciprocity does not exist. The extent to which recip-
stress-coping process influences health and thus is ients feel indebted depends on their perception of the
relevant to health professionals. Coping is deter- magnitude of rewards and costs incurred by both
mined by the relationship between the client and the participants, the locus of causality of the donor’s
environment. Informal support improves client actions, the donor’s motives, and cues from compari-
coping during life stressors and transitions [23]. son with others [18, 341.
Moreover, “coping strategies practised by individuals
Commentary on relevance to social support and
provide important clues to their associates about
health care
whether or not support is needed and about the types
of support needed” [24]. Coping is, therefore, perti- Social-exchange theoretical concepts (like attribu-
nent to health professionals’ assessment of support. tion theory) can interpret positive and negative reac-
By focussing attention on social support as a resource tions to support from both donor and recipient
to facilitate coping with stressors, coping theory perspectives, and help-seeking from professional and
could enrich research on, for example, perception of nonprofessional (social network) sources. Social sup-
childbirth and impact on adaptation and functioning port, like professional support, may have negative
during this experience. connotations which could be explained from a social-
exchange perspective. The social-exchange model has
Example relevant to health care demonstrated utility for furthering the understanding
Coping theorists frequently overlook self-help of the advantage of support by primary groups
groups as a coping-support resource. Coping theories vis-a-vis that of professionals.
could guide health professional practitioners or Clients in inequitable relationships with profes-
researchers interested in assessing the coping pro- sionals or others will experience distress and attempt
cesses and health outcomes of self-help groups for the to restore equity. Maton 1371confirms that bidirec-
recently unemployed. Peers in these groups would tional supporters experience greater well-being than
share coping strategies regarding job hunting, bud- unidirectional supporters. Lay groups in the environ-
geting, family relationships and socializing. In addi- ment can maximize collective rewards, according to
tion, individual behavioral changes in lifestyle and equity theory. Thus, self-help groups emphasize
leisure-time management; and societalienviron- mutual, reciprocal aid as a primary form of support.
mental/employer changes which encourage hiring of These premises are critical to needs assessment of
handicapped persons, interim short-term job health professionals’ clientele.
prospects, and follow-up support for the employed, Unfortunately, reciprocity is not always feasible:
could be promoted/advocated by self-help group the physically and psychologically ill, for example,
members. The impact on psychological, physiological frequently encounter nonegalitarian and nonrecipro-
and social health could be evaluated. cal relationships. Indeed, most network ties are asym-
metric [36]. Furthermore, equity theory can explain
the imbalanced exchange of resources and resultant
SOCIAL-EXCHANGE (OR EQUITY) THEORY
resentment between the elderly and their caretakers.
New parents, another frequently encountered target
Pioneer social-support theorists [25,26] used population, would presumably have more opportuni-
social-exchange constructs implicitly as formu- ties than the ill or aged to reciprocate in the future
lations in their descriptions of the reciprocal quality because of the time-limited nature of their ‘stressor’.
of support interactions. Similarly, Shumaker and It would seem that bidirectional support over time
Brownell’s [18] definition of social support as can prevent unpleasant feelings of indebtedness and
‘exchange of resources’ reaffirms these pioneering dependence. Surely the ill, disabled or elderly clientele
descriptions. Equity theories [27-291 suggest that would have enhanced self-esteem and security in the
there is a desire to maintain equity of exchanges in relationship if they were permitted to offer certain
relationships. types of support. Support would not necessarily have
Four propositions inherent in equity theory are: to be in kind; the provider or caregiver may need
(1) individuals will try to maximize their out- to be reassured of the value of their contribution
comes. (2) groups can maximize collective reward, (appraisal support) or of the recipient’s continued
(3) individuals in inequitable relationships will caring and love (emotional support). Finally, social-
experience distress, and (4) individuals in inequit- support measures or assessment tools should distin-
able relationships will attempt to restore equity guish between those network members who provide
[30, pp. 114-l 151. Exchange models are particularly only positive forms of social support and those who
relevant to supportive exchanges [31,22], yet the are also sources of negative interaction.
 1278
Example relevant to health care
Self-help groups for parent caretakers of chroni-
cally ill children could meet initially either in a special
room in the hospital or in places like a McDonald
House, and later could convene on a rotational basis
in the houses of parents whose children have been
discharged. Benefits would accrue through social
comparison (appraisal support); decreased feelings of
indebtedness through reciprocal support; enhanced
coping through reciprocal provision of information
on resources (informational support); and lessened
feelings of isolation and loneliness, through emo-
tional support provided by peers who can communi-
cate empathetically with each other. Pairs of parents
could look after each others’ children (instrumental
support) in extra-group contacts and maintain phone
communication (emotional support). Lastly, parent
members can reinforce each other, in dealing with the
formal system to advocate changes in hospital and
school environments which would expand and
enhance opportunities for social interaction for their
disabled children. Thus, throughout the self-help
group experience, bidirectional reciprocal exchange
would be evident.
SOCIAL-COMPARISON THEORY
Social-exchange theory represents a merging of
facets of cognitive dissonance, distributive justice and
social-comparison theories. Social comparison can
be defined as the tendency of people to evaluate
themselves and to elicit information about their
characteristics, behavior, opinions and abilities
through comparison with similar others [36]. Clearly,
this evaluation process influences self-concept
[33,39,40]. The basic tenet of Festinger’s [38] theory
is that individuals evaluate themselves through
social comparison with others to validate and define
reality.
People will make upward comparisons with
those coping better than they are (who serve as role
models) and downward comparisons to enhance
self-esteem and protection [3]. The process of both
upward and downward comparison occurs in mutual-
aid groups and, depending on the direction and
dimension of comparison, will influence emotions,
coping effectiveness and prevention [17,41]. There
are two types of equity comparisons: reference-group
or referential comparisons and person-other com-
parisons [34]. Both are relevant to lay helpers. The
social-support functions of appraisal support, reas-
surance of worth, affirmation, esteem support, valida-
tion and feedback are akin to the concept of social
comparison.
Commentary on relevance to social support
health care
The relevance of both social comparison and
social exchange to social support is intuitively appeal-
ing because comparison by partners and exchange
of resources occur in supportive relationships. Fur-
thermore, these theories can be used to interpret
positive and negative reactions to help received from
a. peer. Social comparison theory reinforces earlier
views of social support’s feedback functions. Social
MIRIAMJ. STEWART
comparison influences self-esteem and attitudes (331.
Thus it is relevant to lay support groups and health
professional’s clientele.
Social comparison can exert influence at five
stages of health and illness: behaviors that prevent
or induce illness; decisions about the meaning of
symptoms; decisions about the treatment of symp-
toms; responses to professional care; and recovery
from illness [39]. Hence, the theory is germane to
health professional practice.
Social comparison is a logical theoretical basis for
determining whether people are similar in terms of
health status, illness severity, stressor mastery or
coping stage [23]. Health professionals, wishing to
explain and evaluate positive and debilitating effects
of peer helpers and mutual-aid groups on clients,
should recall that upward comparison facilitates cop-
ing through modeling, and downward comparison
facilitates emotional adjustment in support dyads and
groups.
Certainly social comparison theory is relevant to
the social support associated with target groups of
health professional studies, namely the bereaved, the
ill, new parents, and the elderly. It is safe to assume
that these people, like the cancer victims studied by
Taylor [3], would make upward comparisons with
those coping better than they are for modeling pur-
poses and downward comparisons to enhance self-
esteem.
Example relevant to health care
Arthritis victims might join a self-help group with
the primary intent of affiliating with those suffering
from the same affliction, and with the associated hope
that this would decrease their anxiety concerning this
disease. However, the new members would begin to
compare the stage or progress of their regimen with
that of other members. They would find that others
experience more or less pain and are more or less
visibly disabled in terms of mobility and contortion
of limbs. Further, these recent joiners would compare
their own ability to cope with the activity and dietary
restrictions of their disease, with that of others.
If others at a similar stage of the disease appear to be
having more difficulty coping, their self-esteem might
be enhanced. On the other hand, they would learn
new coping strategies from other members who are
coping better with the frustrations and fears accom-
panying this disability.
LONELINESS THEORY
Loneliness has most typically been defined as a
subjective, unpleasant experience resulting from a
perceived deficiency in social relationships or rela-
tional provisions [42]. Rook [43, p. 1391 claims that
and loneliness is “an enduring condition of emotional
distress that arises when a person feels estranged
from, misunderstood, or rejected by others and/or
lacks appropriate social partners for desired activi-
ties, particularly activities that provide a sense of
social integration and opportunities for emotional
intimacy”. Weiss [44] appropriately distinguishes be-
tween the loneliness of emotional isolation (absence
of a close emotional-attachment figure) and that
of social isolation (absence of an accessible social
 Social support: diverse theoretical
network and socially-integrative relationships or
sense of community).
Various definitions of loneliness embody diverse
theoretical perspectives. Perlman and Peplau [45]
classified the conceptual and theoretical approaches
to this construct as psychodynamic, phenomenologi-
cal, existential-humanist. sociological, interactionist,
cognitive, privacy and systems. Three are particularly
pertinent to social support: sociological explanations
see loneliness as common, normative and a product
of societal problems external to the individual [45];
interactionists, including Weiss [44], view loneliness
as a normal reaction resulting from an interaction
of personality and situational factors; cognition is
the mediating factor between social deficits and
this unpleasant experience, according to Peplau and
Perlman [42]. who are concerned with the process of
loneliness among normal populations.
Loneliness theorists, like others theorizing about
social support. implicitly draw on other relevant
theories. Interpersonal competence, viewed as being
a coping resource, is purported to be lacking in some
lonely individuals [45] and coping strategies for deal-
ing with loneliness include altering social relation-
ships and/or persona1 desires for relationships [47].
Loneliness can also be conceptualized as a deficit in
social exchange of provisions or rewards.
Commentary on relevance to social support and
health care
Conceptual and theoretical approaches to the con-
struct of loneliness are particularly relevant to social
support. Yet, there have been few attempts to bridge
these conceptually related lines of work [48]. The
most common conjectured cause of loneliness is
limited opportunity for social contact. Thus, social
support can presumably prevent and redress certain
forms of loneliness, which can indirectly influence
health.
Loneliness influences physical well-being as well as
psychological health. Life situations characterized by
loneliness and social isolation have been associated
with autoimmune and infectious diseases [49]. When
assessing or intervening, health professionals should
remember that dyadic support can mitigate or pre-
vent emotional loneliness, while the companionship
from aggregate-level created and natural social net-
works can alleviate or avoid social loneliness.
Loneliness theory can be invoked by health profes-
sionals in their practice and research. It is clearly
applicable to the types of losses experienced by
widows and single parents. This theory has obvious
relevance to many elderly .persons living alone; it
could be incorporated in examinations of this target
population. Often the physically disabled also live
alone and have limited contact outside the home. The
chronically ill may suffer from social loneliness due
to the restrictions of their illness and associated
rejection or misunderstanding by others. Frequently
caretakers of the chronically ill and those who are
visibly disabled can be socially isolated and can suffer
from a mismatch between the individual and the
environment. Therefore. size of network and satisfac-
tion with support received. measured by social sup-
port instruments, could be interpreted in the context
of loneliness theory.
perspectives 1279
Example relevant to health care
A widower-to-widower program, similar to
Vachon et al.‘s [50] widow-to-widow program, could
be established. This could sequence dyad and group-
level support from other widowers. Initially, ‘recov-
ered’ widowers would offer one-to-one support as
needed, such as practical help in locating community
resources, supportive telephone calls and face-to-face
discussions. These peer helpers would then invite the
widower to attend a self-help group, which would
provide social companionship, practical advice and
role models. All activities within the group would
indirectly address the social isolation experienced by
the widower who no longer has a companion to
accompany him on social outings (social loneliness),
and the emotional loneliness engendered by loss of an
intimate. Generally, the self-help group would redress
the former type of loneliness in the group context.
However, close friendships may spring up within the
group, which could partially mitigate emotional lone-
liness. Long-term follow-up and evaluation inter-
views could focus on physical and psychological
well-being outcomes including loneliness.
SUMMARY AND CRITIQUE
In summary, these five models can delineate a
definite approach to social support. Attribution the-
ory can enable explanation of the motives of donors,
the phenomena of help-seeking and helping, and the
possible negative effects of support efforts. Coping
theory demonstrates how social support and coping
interface in the stress process by acknowledging
individual and environmental perspectives, adds a
cognitive dimension to support, and considers costs
of support efforts. Equity theory explains reactions to
support from donor and recipient viewpoints, the
reciprocal nature of social support, its impact on
help-seeking, and its beneficial and detrimental fea-
tures. Loneliness theory attests to the significance of
social relationships, takes into account the individ-
ual’s contributions to the network and vice versa, and
emphasizes the affective dimension of support.
Social-comparison theory is helpful in interpreting
and evaluating positive and debilitating effects of
support when the donor is a peer.
To reiterate, these five theories enhance theoreticaf
interpretation of social support and health care
through their distinctive explanations of the shared
concepts of appraisal and helping. Further, these
interlocking theories could augment the social-
support construct. However, a conceptual framework
that selectively merges the relevant features of these
supplementary theoretical stances may promote a
more informed and realistic view of social support. A
preliminary attempt to propose pertinent conceptual
definitions and relationship statements appears in
Table 1.
In this context, these five theories can guide assess-
ment, planning and intervention strategies in the
practice domain. Evaluation of health professional
social-support interventions could focus on outcomes
such as enhanced coping, decreased loneliness, situa-
tional versus dispositional attributions regarding
causes of problems, impact on help-seeking from the
1280 MIRIAM J. STEWART

Table I. Prelimmarv comoonents of a conceptual framework
Theory Conceptual definition
Attribution Attribution is the cognitive explanation (appraisal)
by clients, health professionals and lay helpers in
the social environment. of the causes of physical.
emotional, soctal and sptritual health problems
which beset clients and their assignment of
responsibility for solving or helping with these
problems to any or all of these three parties.
Coping Coping is the changing cogmtive behavioral effort
to manage specific external environmental and/or
internal demands that are appraised as taxing or
exceeding the resources of the client. Coping is a
transactional process with health problem-focussed
functions during life stressors and transitions and
is influenced by the relationship between the client
and the social environment. [Lazarus and Folkman
definition adapted.]
Loneliness Loneliness is a subjective, unpleasant, emotional
experience of clients, resulting from a perceived or
actual deficit in social relationships or relational
provisions which would provide a sense of social
integration and/or emotional intimacy.
Social comparison Social comparison is the tendency of clients to
evaluate themselves and to elicit information about
their characteristics, behaviors, opinions, and
abilities through contrasting them with similar
others in natural or created networks of their
social environment. [Festinger’s, Fisher and
Nadler’s, Suls’ definitions modified.]
Social exchange Social exchange refers to the desire by both clients
and members of their social environment to
maintain or restore equity of (support) resource
exchanges in a reciprocal relationship.
on social stmoort for health orofesslonals
Proposiuons relationship statements
(I) If there is external attribution of the cause of
the client’s health problems concerns and internal
attribution of the relevant problem solution(s) by the
support network and the health professional, then
help sought from and rendered by the soctal network
or the health professional will be effective.
(2) If the attribution of cause(s) and solutlon(s) of
the client’s health concerns by clients.
support-network members and health professionals
are congruent. then help available/enacted by the
support network and,or the health professional will
be effective.
Social support from natural or created networks can
facilitate the client’s coping with stress and prevent
health problems.
(I) If the client has lost embedded network support
through bereavement. divorce or other loss. then
loneliness may occur and may increase susceptibility
to health problems through decreased
immunocompetence. Conversely, health problems
may instigate network losses (particularly in cases
where internal/external attributions by clients and
network members are Incongruent).
(2) The health professional may mitigate/prevent
health problems associated with loneliness from
depleted or deficient social-network support by
mobilizing created networks, by enhancing natural
networks. or by temporarily supplementing with
professional support.
The health professional can, through consultation,
encourage upward social comparison in dyadic or
group-level support networks, which may enhance
client coping and health maintenance.
Health professionals can, through consultation,
promote reciprocal exchange of support between
their clients and the social network. and thereby
increase their clients’ self-esteem and the effectiveness
of helping.

natural network, reciprocity of supportive inter- issues regarding costs, benefits, disposition and
actions, and effects of downward and upward social direction of support (see Table 2) could be embodied
comparison. to facilitate interpretation of social support and
Many social scientists [I, 17, IS] legitimately argue could be used to develop a revised approach to social
that a unifying theory is needed to integrate research support.
findings on social support. Researchers and theor- Acknowledgements-The author gratefully acknowledges
eticians in the health-care field could benefit from the astute advice and encouraging feedback of Dr Benjamin
and contribute to the development of an overarch- Gottlieb, esteemed contributor to the social support litera-
ing theoretical framework. These relevant social- ture and of Dr Alfred Katz. World Health Organization
psychological theories, which clarify conceptual consultant on self-help mutual aid.

Table 2. Social support (SS) issues and concepts explained by theories

Issues interpreted Concepts explained by theories*
Positive, Appraisal Appraisal
Theory Direcuon Disposition negatrve SS Durauon SS needs SS resources Helping Help-seeking
Attnbution Received Enacted + * l * l I
Provided Available -
Coping Received Perceived f l . l * *
Available
Equity Received Enacted + * L l

Provided Avadabie _
Loneliness Received Available + * I * *
Social comparison Received Enacted + * t l

Provided Avatlable
 Social support: diverse theoretical perspectives
REFERENCES
I. Thoits P. A. Conceptual. methodological and theor-
etical problems in social support as a buffer against life
stress. J. Hlrh sot. Behor. 23, 145-159. 1982.
2. Barrera M. Distinctions between social support con-
cepts, measures and models. Am. J. Commun. Psychol.
9, 435-447. 1986.
3. Taylor S. E. Adjustment to threatening events: a theory
of cognitive adaptation. Am. PsychoI. 11, 1161-l 173.
1983.
4. Heider F. The Psvcholog! q( Interpersonal Relorions.
Wiley, New York, 1958.
5 Kelley H. H. Attribution theory in social psychology.
In Nebraska Svmposium on Motillorion (Edited by
Levine D.) University of Nebraska Press, Lincoln,
Neb., 1967.
6 Brickman P.. Rabinowitz V.. Karuza J. er al. Models of
helping and coping. Am. Psychol. 37, 368-384. 1982.
7 Brickman P.. Kidder L. H.. Coates D. et al. The
dilemmas of helping: making aid fair and effective.
In Neu, Directions in Helping: Vol. I. Recipient Reoc-
lions IO Aid (Edited by Fisher J. D., Nadler D. and
Depaulo B. M.). pp. 18-51. Academic Press, New York,
1983.
8. Karuza J.. Zevon M. S.. Rabinowitz V. A. er al.
Attributions of responsibility by helpers and recipients.
In Basic Processes in Helping Relationships (Edited by
Wills T. A.), pp. 107-130. Academic Press, New York,
1982.
9. Dunkel-Schetter C. and Wortman C. B. The interper-
sonal dynamics of cancer: problems in social relation-
ships and their impact on the patient. In Interpersonal
Issues in Heolrh Core (Edited by Friedman H. S. and
Matte0 D.), pp. 69-100. Academic Press, New York,
1982.
IO. Wortman C. B. and Conway T. L. The role of social
support in adaptation and recovery from physical ill-
ness. In Social Support and Health (Edited by Cohen S.
and Syme S. 1.). pp. 281-302. Academic Press, Orlando,
Fla, 1985.
II. Ryan J. M. Models of help preferred by nurses and
mutual aid organizations. Doctoral dissertation, Boston
University, Boston. Mass., 1985.
12. Eckenrode J. The mobilization of social supports: some
individual constraints. Am. J. Commun. Psychol. 11,
509-528. 1983.
13. Karshmer J. F.. Kornfield J. and Carr A. Causal
attribution: bias in the nurse-patient relationship. J.
Psw-hial. Nurs. Menr. Hlrh Sew. 5, 25-30, 1980.
14. Cronenwett 1. R. and Brickman P. Models of helping
and coping in childbirth. Nurs. Res. 32, 84-88, 1985.
15. Lazarus R. S. and Folkman S. Srress. Appraisal and
Coping. Springer. New York. 1984.
16. Cohen S. and Wills T. A. Stress, social support and the
buffering hypothesis. Pswhol. Bull. 98. 310-357. 1985.
17. Gottlieb B. H. Social support and the study of personal
relationships. J. Sot. Pers. Relorionships 2, 351-375.
1985.
18. Shumaker S. A. and Brownell A. Toward a theory of
social support: closing conceptual gaps. J. Sot. Issues
40, 11-36. 1984.
19. Gore S. Social support and styles of coping with stress.
In Social Support and Health (Edited by Cohen S. and
Syme S. 1.). pp. 263-278. Academic Press, Orlando.
Fla. 1985.
20. Thoits P. A. Social support as coping assistance.
J. consulr. clin. PsychoI. 54, 416-423. 1986.
21. Procidano M. E. and Heller K. Measures of perceived
social support from friends and from families: three.
validation studies. Am. J. Commun. PsJchol. 11, l-24,
1983.
22. Kasl S. V. and Wells J. A. Social support and health in
the middle years: work and the family. In Social Supporr
1281
and Health (Edited by Cohen S. and Syme S. L.),
pp. 175-198. Academic Press. Orlando, Fla, 1985.
23. Gottlieb B. H. Using social support to protect and
promote health. J. Prim. Preuenf. In press.
24. Dunkel-Schetter C.. Folkman S. and Lazarus R. S.
Social support received in stressful situations. J. Person.
sot. Psychol. In press.
25. Caplan G. Support Systems and Community Menrol
Heolrh. Behavioural Publications. New York, 1974.
26. Cobb S. Social support as a moderator of life stress.
Psychosom. Med. 38, 30&3 14. 1976.
27. Adams J. S. Toward an understanding of inequity.
J. Abnorm. Sot. Ps_vchol. 67, 422436. 1963.
28. Blau P. M. Exchange and Power in Social Life. Wiley,
New York, 1964.
29. Gouldner S. W. The norm of reciprocity: a preliminary
statement. Am. Social. Rev. 25, 161-178, 1960.
30. Hatfield E. and Sprecher S. Equity theory and recipient
reactions to aid. In New Directions in Helping: Vol. I
Recipient Reactions to Aid (Edited by Fisher J. D.,
Nadler D. and DePaulo B. M.). pp. 113-143. Academic
Press, New York, 1983.
31. Pearlin L. I. Social structure and processes of social
support. In Social Support and Health (Edited by
Cohen S. and Syme S. L.), pp. 43-60. Academic Press,
Orlando, Fla, 1985.
32. Heller K. and Mansbach W. E. The multifaceted nature
of social support in a community sample of elderly
women. J. Sot. Issues 40, 99-112. 1984.
33. Fisher J. D., Nadler A. and Whitcher-Alagna S. Four
theoretical approaches for conceptualizing reactions
to aid. In New Direcrions in Helping: Vol. 1 Recipient
Reoclions fo Aid (Edited by Fisher J. D., Nadler D.
and DePaulo B. M.), pp. 52-86. Academic Press, New
York, 1983.
34. Greenberg M. S. and Westcott D. R. Indebtedness as
a mediator of reactions to aid. In New Direcrions
in Helping: Vol. I Recipiem Reactions IO Aid (Edited
by Fisher J. D., Nadler D. and DePaulo B. M.),
pp. 86133. Academic Press, New York, 1983.
35. DePaulo B. M. Social-psychological processes in
informal help seeking. In Basic Processes in Helping
Relorionships (Edited by Wills T. A.), pp. 255-280.
Academic Press, New York, 1982.
36. Biegel D. E. and Naparstek A. J. (Eds) Community
Supporr Systems and Mental Health. Springer, New
York, 1982.
37. Maton K. 1. Patterns and psychological correlates of
material support within a religious setting: the bidirec-
tional support hypothesis. Am. J. Commun. Psychol.
15, 185-207, 1987.
38. Festinger L.. A theory of social comparison. Humon
Relor. 1, 117-140. 1954.
39. Sanders G. S. Social comparison and perceptions of
health and illness. In Social Psychology of Health and
Illness (Edited by Sanders G. S. and Suls J.), pp.
129-157. Lawrence Erlbaum, New Jersey, 1982.
40. Suls J. M. Social comparison theory and research. In
Social Comparison Processes: Theoretical and Empirical
Perspectives (Edited by Suls J. M. and Miller R. E.),
pp. I-19. Hemisphere, New York, 1977.
41. Shinn M., Lehmann S. and Wong N. W. Social interac-
tion and social support. J. Sot. Issues 40, I l-36, 1984.
42. Peplau L. A. and Perlman D. (Eds) Perspectives on
loneliness. In Loneliness: A Sourcebook of Currenl
Theory. Research and Therapy. pp. l-18. Wiley, New
York, 1982.
43. Rook K. S. Promoting social bonding strategies for
helping the lonely and socially isolated. Am. Psychol. 39,
1389-1407, 1984.
44. Weiss R. S. Loneliness: The Experience of Emorionol
and Social Isolorion. MIT Press. Cambridge, Mass.,
1973.
1282 MIRIAM J. STEWART
45. Perlman D. and Peplau L. A. (Eds) Theoretical
approaches to loneliness. In Loneliness: A Sourcebook
of Current Theory, Research and Therapy, pp. 123-l 34.
Wiley, New York, 1982.
46. Jones W. H. The psychology of loneliness: some person-
ality issues in the study of social support. In Social
Support: Theory, Research and Applicarions (Edited
by Sarason I. G. and Sarason B. R.), pp. 225-242.
Martinus Nijhoff, Dordrecht, 1985.
47. Peplau L. A. Loneliness research: basic concepts and
findings. In Social Supporr: Theory, Research and Appli-
cations (Edited by Sarason I. G. and Sarason B. R.),
pp. 269-286. Martinus Nijhoff, Dordrecht, 1985.
48. Rook K. S. The functions of social bonds: perspectives
from research on social support. loneliness. and social
isolation. In Social Supporr: Theor!, Research and
Appiicarions (Edited by Sarason I. G. and Sarason
B. R.), pp. 243-286. Martinus Nijhoff , Dordrecht.
1985.
49. Cunningham A. J. Mind. body and immune response.
In Psychoneuroimmunology (Edited by Ader R.), pp.
609-617. Academic Press, New York. 1981.
50. Vachon M. L.. Lyall M. A., Rodgers J., Freedman-
Letofsky K. and Freeman S. J. A controlled study
of self-help intervention for widows, Am. J. Psychiar.
137, 1380-1384, 1980.