Printable Version 

Gathering Information: Learning More about Patients’ Social Support

Illness may prohibit individuals from having access to their support system or being able to socialize in their usual way. When people are in pain, they often withdraw from others in order to conserve inner resources and physical energy, and they may not ask for the help that they need. Clinicians can inquire about each person’s current social support resources and help them to pinpoint where there is a need for additional support and to identify how it might be met.

After a clinician has reviewed answers to questions about family, friends, and co-workers from the PHI, other questions can take the conversation about relationships and social supports deeper. As noted earlier, social support has three dimensions, and all of them are important. Consider asking about all three:

1. Who provides you with support?
2. How satisfied are you with the support? A negative relationship may be worse than no relationship at all.
3. What types of support do you receive? Social support can be emotional or instrumental (i.e., involves receiving labor, time, or funding from others). It may also involve receiving mentoring (feedback) or information.

The Social Support Questionnaire, developed in 1983, contains 27 questions that can be used to gather more information about social support – who provides it, the type of support a person receives, and how satisfied a person is with that support.¹ If individuals are not “very satisfied” or “fairly satisfied,” it is worth exploring their answers in more depth, if possible. The following questions are from the six-item short version of that questionnaire.²

1. Whom can you really count on to be dependable when you need help?
2. Whom can you really count on to help you feel more relaxed when you are under pressure or tense?
3. Who accepts you totally, including both your worst and your best points?
4. Whom can you really count on to care about you, regardless of what is happening to you?
5. Whom can you really count on to help you feel better when you are feeling generally down-in-the-dumps?
6. Whom can you count on to console you when you are very upset?

And here are some other key questions you can consider:

• Which relationships fulfill and/or strengthen you?
• Do you have a significant other?
• If single: Are you satisfied with being single, and do you have the support you need in your life?
• Are you sexually active? Are you satisfied with this aspect of your health, and why or why not?
• Do you feel supported by your partner?
• Do you have any children? What ages?
• What activities do you and your partner do together?
• Is anyone hurting you? (Never forget to ask about safety at home, as noted in Surroundings.) Have you been hit, kicked, punched, choked, or otherwise hurt by an intimate partner?
• Do you get the support you need from your loved ones?
• Are you lonely?
• How often do you share your feelings and thoughts with others?
• Who or what drains your energy? Can you change this?
• Do you have friends or family members you can talk to about your health?
• What do your partner and family think are the causes of your health issues?
• Has an illness of a loved one ever affected you? Are you taking care of anyone with chronic illness?
• Is there someone you would like to have come with you to your health care appointments?
• Are you close to your blood relatives (parents, siblings, extended family, children)?
• Who do you consider to be your “family of choice?” Is it your blood relatives? Who else is important to you in your life?
• How deeply are your family members involved in each other’s lives?
• Tell me about your closest friend. What do friendships mean to you?

What Clinicians Can Offer: The Therapeutic Relationship

The ideal practitioner-patient relationship is a partnership, which encourages patient autonomy and values the needs and insights of both parties. The quality of this relationship is an essential contributor to the healing process.³

There are many ways that clinicians can enhance the therapeutic relationship. Recall the study mentioned earlier where veterans who had attempted suicide noted that one of the most important things that the health system could have done to decrease their suicide risk was to help them to have stronger therapeutic relationships.⁴ We know that healing relationships with clinicians improve patient quality of life, because they instill in patients a sense of hope and trust. Better relationships are also linked to decreased morbidity and mortality and better clinical outcomes.^5,6

Acts of kindness such as deep listening, empathy from care team members, generous acts of effort that go beyond what the patient expects, timely care, gentle honesty, and support for caregivers are all important pieces of health care that decrease the emotional turmoil of cancer for patients, caregivers, and clinicians.⁷ When therapists’ empathic abilities are lacking, rates of therapeutic dropout increase; when present, it beneficially influences the patients’ lives and behaviors.⁸ Finally, strong therapeutic relationships enhance clinician resilience and allow them to avoid burnout, not to mention reduce the risk of malpractice lawsuits.⁹

In 2005, Kaiser Permanente identified key aspects of the approaches they took to enhance clinician communication and relationship skills.¹⁰ They outlined a “Four Habits Model,” which included the following:

• Invest in the beginning.
  • Create rapport quickly. Introduce yourself to everyone in the room, acknowledge the wait time, and put the patient at ease.
  • Elicit the patient’s concerns using open-ended questions.
  • Plan the visit with a patient. Let her/him know what to expect and prioritize as needed.
• Elicit the Patient’s Perspective.
  • Ask for the patient’s ideas about what is going on and what is concerning her/him most, as well as what she/he has already done to address the concerns.
  • Elicit specific goals in seeking care.
  • Determine how the illness has influenced the patient’s life.
• Demonstrate empathy.
• • Be open to the patient’s emotions.
  • Make empathic statements, e.g. “You seem frightened.”
  • Use nonverbal communication to convey empathy.
• Invest in the end.
• • Deliver diagnostic information.
  • Educate the patient, e.g. explain why tests or treatments are being done, discuss potential side effects, course of recovery, and resources that can be used.
  • Involve the patient in decision-making.
  • Complete the visit by summarizing the visit and next steps, asking if the patient has other questions, and verifying that she/he has received what is needed.

Sympathy

Sympathy involves feeling concern and understanding for the suffering of others, whereas empathy goes beyond that. Empathy is the ability to mutually experience emotions, direct experiences, and thoughts of others¹¹, while recognizing appropriate boundaries; one reaches into another’s experience without getting caught up in it.¹²

In 1968, Wilmer shared his perspectives on empathy:

If there is empathy there is real understanding of the other as another person. Here we understand his suffering in relationship to his personal and social world. We share, we feel for him and with him; psychologically, we get inside him for the purpose of understanding how he feels. In empathy it is as if “I were him.” To achieve an empathic relationship, we use ourselves as the instrument for understanding, but by the same token we keep our own identity clearly separate. In this situation the observer guards against his biases and misperceptions, and must thereby understand himself.¹³

Empathy occurs in a clinical encounter when a clinician clearly demonstrates he or she relates to a patient’s experience. The clinician may have an awareness of feelings, emotions, sensations, conceptions, convictions, hopes, and fears that the patient is experiencing regarding the disease or illness and options for recovery. A healthy approach for clinicians is to continue to engage in their own self-care practices and to be aware of personal and professional biases that interfere with authentic connection with the patient. When a clinician experiences increased symptoms of burnout or compassion fatigue, depersonalization increases and empathy decreases. It is vital to be aware of this if it is beginning to occur.¹⁴

Compassion

---

It’s not how much you do but how much love you put into the doing that matters.

—Mother Theresa

---

Once we are able to recognize the importance of empathy, we can begin to generate a sense of compassion for one another. Gelhaus holds that empathic compassion involves an appreciation for the common worth and dignity of all beings, noting that it can be taught.¹² He states that the following characteristics need to be present for a compassionate response:

1. There is recognition of the situation and the suffering related to it.
2. There is benevolence or kindness.
3. It is directed toward a person.
4. There is a desire to relieve suffering.

Most training programs for health care professionals give little emphasis to the cultivation of compassion in trainees. In fact, by selecting students based on certain academic criteria, personality traits, or educational institutions, they may screen out people with high levels of compassion in favor of less compassionate people who display high levels of ambition, strong test taking skills, or other traits.

Many mindful awareness training programs include what is commonly referred to as a Compassion Practice, or Loving-Kindness Meditation. The “Compassion Practice” handout offers a sample of this sort of meditation.

Mindful Awareness Moment: Feeling Compassion

Think of a patient (or other person in your life) who is struggling in some way. Send that person an affirmation:

• May you be safe.
• May you be happy.
• May you be healthy.
• May you be peaceful.

As you focus on these intentions for them, what do you notice? Do you feel a particular sensation in your body? What emotions come up? We often speak of our compassion for others being “heartfelt.” What do you notice in your heart as you think of this person? There is no right or wrong answer; the key is simply to take notice.

As noted in the “Mindful Awareness Overview,” research has found that regular meditation practice leads to lasting changes in brain activity.¹⁵ A 2014 systematic review, while noting that further research is needed, found that “kindness-based meditation” led to decreases in depression, increased mindful awareness, greater compassion toward others and toward oneself, and more positive emotions.¹⁶

What Clinicians Can Offer: Recommendations for Personal Health Plans

In addition to doing all they can to create a healing therapeutic relationship predicated on empathy, compassion, and the various components of the “Four Habits Model,” there are other ways clinicians can help people have positive relationships with family members, friends, and co-workers. Examples include the following:

• Encourage patients to try Compassion Meditation (as described in the “Compassion Practice” handout).
• Explore with patients their positive—and negative—social supports, discussing how they might increase their exposure to the former and decrease it for the latter. Clinicians should consistently screen for domestic violence. Elder abuse must always be considered as a possibility for older individuals.
• Involve social workers on the health care team. Social workers can prove invaluable allies in many ways. For a description of what social workers do, refer to “Why Choose the Social Work Profession?” from the National Association of Social Workers. Social workers and case managers can match people up with the programs that can prove most helpful to them.
• Learn about support groups in your facility and in your patients’ communities. There are many online support groups available.

A 2016 review focused on peer facilitator and support group outcomes found only 1 of 9,757 studies met inclusion criteria, noting that more research is needed.¹⁷ One study of patients with malignant melanoma found that those who participated in a six-week support group after the removal of malignant melanoma had half the rate of recurrences and a third of the mortality rate when compared to the control group at five years follow-up.¹⁸ Internet support groups are very popular, and also show some evidence of benefit on social support and self-efficacy.¹⁹

• Encourage people to become involved in volunteer work. We know that volunteer work enhances well-being in a number of ways.²⁰ A research report “The Health Benefits of Volunteering: A Review of Recent Research” is available from the Corporation for National and Community Service.²¹ Older adults who give love and support to others have significantly fewer health issues.²² Refer to the section on volunteer work in the “Personal Development Overview” for more information.
• Encourage people to find ways to become more active in their local communities. Examples include the following:
• • Attending community events, such as civic celebrations, theater performances, or fundraisers
  • Helping to direct or organize community events (e.g. joint a steering committee or board)
  • Participating in the arts in the community
  • Attending local sporting events
  • Joining a religious or spiritual community
  • Taking a course of some kind

Back to Michelle

During a session with Michelle, her physical therapist commented on how much she seems to care about her current family and former coworkers. Michelle mentioned this to a nurse on her primary care team. After some discussion, and with Michelle’s buy-in, the team helped her create a health plan that focused on Family, Friends & Coworkers.

Michelle continued to work through the cardiac rehabilitation program. In addition to learning more about exercise and nutrition, she also learned more about emotions, communication skills, and mindful awareness during a self-care course he signed up for. She began trying to open up more to her daughter and friends. She started working with Mental Health more regularly and was introduced to meditation.

A few months later, Michelle took an eight-week class on mindful awareness and compassion that was offered at her local senior center with minimal charge to her. It made her feel uncomfortable at first, but she enjoyed it over time and made new friends as she got to know her classmates. She found himself sharing more about her emotions and thoughts, both in the course, and with her loved ones. She also began volunteering in a foster care program. She has been able to take advantage of being retired and, for the first time is “going out with friends.” She makes a point of calling her daughter and her family at least once a week, and she is saving up for a trip to go see them.

Integrative Health Tools

• Animal-Assisted Therapies

Resources

Online Resources

• Verywell Mind. How Can I Find Support Groups Near Me? Guidance for finding support groups for people with various mental health problems.
• The Center for Nonviolent Communication

Additional Resources

• Compassion: Bridging Practice and Science, Stanford University, e-book
• Center for Healthy Minds, Richard Davidson, University of Wisconsin-Madison

What we know about integrative health care has come to us thanks to the efforts, experiences, and collective wisdom of people from many cultures and backgrounds. We wish to acknowledge all the healers, researchers, patients, and peoples who have informed the content of this tool.

Author(s)

This overview was adapted for the Osher Center for Integrative Health at the University of Wisconsin-Madison from the original written by Christine Milovani, LCSW, and J. Adam Rindfleisch, MPhil, MD, and updated by Greta Kuphal, MD.

Originally Created: 2014, Updated: 2019

Modified for UW Integrative Health: 2020

References

1. Sarason IG, Levine HM, Basham RB, Sarason BR. Assessing social support: the social support questionnaire. J Pers Soc Psychol. 1983;44(1):127.
2. Sarason IG, Sarason BR, Shearin EN, Pierce GR. A brief measure of social support: practical and theoretical implications. J Soc Pers Relat. 1987;4(4):497-510.
3. Principles of Holistic Medicine. American Board of Integrative Holistic Medicine website. Available at: http://www.abihm.org/about-us/principles. Accessed September 30, 2014.
4. Montross Thomas LP, Palinkas LA, Meier EA, Iglewicz A, Kirkland T, Zisook S. Yearning to be heard. Crisis. 2014;35(3):161-167.
5. Kelley JM, Kraft-Todd G, Schapira L, Kossowsky J, Riess H. The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials. PLoS One. 2014;9(4):e94207.
6. Teutsch C. Patient-doctor communication. Med Clin North Am. 2003;87(5):1115-1145.
7. Berry LL, Danaher TS, Chapman RA, Awdish RLA. Role of kindness in cancer care. J Oncol Pract. 2017;13(11):744-750.
8. Coutinho JF, Silva PO, Decety J. Neurosciences, empathy, and healthy interpersonal relationships: recent findings and implications for counseling psychology. J Couns Psychol. 2014;61(4):541-548.
9. Virshup BB, Oppenberg AA, Coleman MM. Strategic risk management: reducing malpractice claims through more effective patient-doctor communication. Am J Med Qual. 1999;14(4):153-159.
10. Stein T, Frankel RM, Krupat E. Enhancing clinician communication skills in a large healthcare organization: a longitudinal case study. Patient Educ Couns. 2005;58(1):4-12.
11. Olinick S. A Critique of Empathy and Sympathy. In: Lichtenberg JD, Bornstein M, Silver D, eds. Empathy. Hillsdale, N.J.: Analytic Press : Distributed by L. Erlbaum Associates; 1984.
12. Gelhaus P. The desired moral attitude of the physician: (I) empathy. Med Health Care Philos. 2012;15(2):103-113.
13. Wilmer HA. The doctor-patient relationship and the issues of pity, sympathy and empathy. Br J Med Psychol. 1968;41(3):243-248.
14. Sotile WM, Sotile MO. The Resilient Physician: Effective Emotional Management for Doctors and Their Medical Organizations. Chicago, IL: American Medical Association; 2002.
15. Davidson R. Meditation/Compassion Training. Center for Investigating Health Minds, University of Wisconsin-Madison website. Available at: http://www.investigatinghealthyminds.org/cihmProjMeditation.html. Accessed September 30, 2014.
16. Galante J, Galante I, Bekkers MJ, Gallacher J. Effect of kindness-based meditation on health and well-being: a systematic review and meta-analysis. J Consult Clin Psychol. 2014.
17. Delisle VC, Gumuchian ST, Kloda LA, et al. Effect of support group peer facilitator training programmes on peer facilitator and support group member outcomes: a systematic review. BMJ open. 2016;6(11):e013325.
18. Fawzy FI, Fawzy NW, Hyun CS, et al. Malignant melanoma. Effects of an early structured psychiatric intervention, coping, and affective state on recurrence and survival 6 years later. Arch Gen Psychiatry. 1993;50(9):681-689.
19. Parker Oliver D, Patil S, Benson JJ, et al. The effect of internet group support for caregivers on social support, self-efficacy, and caregiver burden: a meta-analysis. Telemed J E Health. 2017;23(8):621-629.
20. Thoits PA, Hewitt LN. Volunteer work and well-being. J Health Soc Behav. 2001;42(2):115-131.
21. Grimm R, Spring K, Dietz N. The health benefits of volunteering: a review of recent research. Corporation for National and Community Service, Office of Research and Policy, Washington, DC,. 2007.
22. Depner CE, Ingersoll-Dayton B. Supportive relationships in later life. Psychol Aging. 1988;3(4):348-357.