‘Keep strong,remember everything you have learnt’: Constructing support and solidarity through online interaction within a UK cancer support group

Introduction

Learning that you have cancer and learning to live with its uncertainties can be a deeply isolating experience, even when you have the care, love and support of family and friends. It may often seem as if you are cut off from the rest of the world filled with complacent people who take their health and continuing survival for granted. It may feel at times as if your experiences of cancer are a taboo subject, neither welcomed nor understood. In contrast, peer support groups constitute a separate social space in which cancer patients (and their carers) are able to express fears, overwhelming emotions, altered priorities and a renewed sense of urgency to live fully (Yaskowich and Henderikus, 2003). In the United Kingdom alone, 2.5 million people are living with cancer; 356,630 people contract some form of cancer each year and 162,640 people die from the disease, although survival rates are improving (Macmillan Cancer Support, 2017). In response, there are a range of UK charities raising funds to support cancer patients and some of these offer courses for patients and carers, both residential and non-residential. Following these, patients may set up or join cancer support groups, either face-to-face or online. This article analyses the linguistic and multimodal interactions of such a group of cancer patients, who had previously met on a residential course and subsequently set up an online support group.

Specifically, I explore the ways in which this group of two carers and seven cancer patients (including myself), with varying stages and lengths of disease, construct relationships of support and solidarity with each other while interacting online. I consider the concepts of support (i.e. ‘giving help to others’) and solidarity (i.e. ‘feeling a strong, collective empathy with, and trust of one another’) as iterative, interdependent and interwoven rather than as having a directional or causal link. Giving support to individuals helps to strengthen group solidarity, and group solidarity creates a space in which members feel enabled to support each other. I investigate how multimodal uses of language serve as vital resources to enable these individuals to offer support to each other at different stages of their illness. There is considerable research across a range of disciplines using publicly available interview data or social media data to theorise the value of support groups for patients (e.g. Campbell, 2013; Lewallen, 2014; Thompson et al., 2016). There is also work from corpus linguists looking at the role of certain linguistic features, such as key words and metaphor, to express patients’ experiences of coping with cancer (e.g. Charteris-Black and Seale, 2010; Semino et al., 2015). However, there is very little published work based on ethnographic data gathered over a period of time from naturally occurring interactions within privately formed support groups. Using Interactional Sociolinguistics analysis, I intend to show how one such support group, utilising the mobile phone application ‘WhatsApp’, evolved its social relationships to build a robust support group in which certain linguistic and multimodal features became evident. I hope the value of this study will be to elucidate the range of discursive features and styles that index ‘giving and receiving support’ in order to achieve solidarity within a group of cancer patients. It is hoped that this in turn could inform best practice for future online cancer support groups. The study shows how the use of certain linguistic features and styles can offer cancer patients relief, friendship, support and hope from the isolation of being silenced, isolated, misunderstood or left in despair.

Research background

There are various interrelated areas of research that are relevant to an understanding of the context and significance of this study, which I review in this section. First, in terms of my overall theoretical perspective, I utilise a discursive (also known as poststructuralist) perspective towards analysing the language of the cancer support group. This approach considers that language is a key form of social practice (Butler, 1990; Cameron, 2005; Clifton, 2012; Weedon, 1997). That is, language is a principal resource that enables individuals to construct and perform their identities in social contexts and to build relationships with others through naturally occurring interactions both face-to-face and online. Individuals use language to (re)present themselves in different ways and thereby to construct diverse identities for themselves as required by role, subject positioning, relationship and context (Weedon, 1997). The discursive approach views language as constitutive of individual identities in two senses: it offers a set of resources by which people have the agency or authority to perform certain identities or ‘selves’, but it also features within broader institutional practices (Foucault, 1980). Thus, institutional discourses (e.g. of medicine and illness) also intervene variously to position the interactions of support group members in complex and subtle ways. In the interests of space, my focus will be on the first sense; that is, the micro-analytical level of how group members utilise specific discursive resources in order to develop strong relationships of solidarity and support. The discursive approach is also closely associated with a social semiotic understanding of how language works (e.g. Kress and Van Leeuwen, 2001), which regards all modes of expression (visual, aural, sensory, etc.) as conveying particular cultural meanings. As a sociolinguist, I will be primarily analysing verbal modes of interaction, but as a participant, I was fascinated by, and will also examine, group members’ diverse use of supplementary, visual and aural resources.

Second, online or digital interaction refers to multi-participant exchanges that are often, but not necessarily, conducted via the Internet and make use of some form of electronic device, such as a computer, tablet or mobile phone. In analysing interactions on the messaging service WhatsApp, there are some differences to be noted between digital and face-to-face interactions. First, participants in such ‘instant messaging’ (IM) exchanges tend not to be in close physical proximity but are engaging ‘remotely’. Second, interactions usually take place through a combination of written and visual media using a range of multimodal methods. Third, there is often a delay of variable length (‘asynchronicity’) between the production and reception of a message, unless a participant happens to catch the message just after it is sent. This can cause problems of coherence, especially in a multi-party chat. Finally, IM is generally perceived to be an informal communication channel (although it is increasingly used in institutions; see Markman (2015). Darics (2016) identifies a number of orthographic features of informal IM, such as abbreviations, emoticons, capitalisation to ‘shout’ a message, and so on. She also found a number of conventionalised linguistic features, such as the use of a range of politeness strategies like greetings. Markman (2015) commented on the ways in which instant messages are structured, for example by the use of ‘utterance chunking’ to break down single utterances into separate parts. However, in much of the research literature focusing on language, digital interaction is conceptualised as far more than simply a medium by which information is transmitted and shared; it is also a space in which communities and (sub)cultures can be developed and nurtured (Benwell and Stokoe, 2006). Hine (2000) defines it as a ‘performative space’ in which users are often hyper-sensitive to the way their behaviour is interpreted by others and may be highly self-reflexive in their responses. Furthermore, Benwell and Stokoe (2006) describe ‘digital communication’ as working within a ‘cyberspace’, that is, at once ‘communal and social … informative and educative … unstable, ephemeral … radical and capable of innovation’ (p. 246). Mackenzie (2016) argues that just as language offers a set of resources by which its users can position themselves in the world, digital communication has ‘particular affordances that individuals can exploit in their interactions with others’ (p. 58). It is these affordances of IM that will inform this study of cancer support group interactions.

Finally, much of the literature on the language of cancer patients in online support groups can be attributed to scholars of health and medicine rather than specialist linguists. Studies by the former tend to use large-scale quantitative methods followed by statistical analysis of publicly available data. Some studies also supplement with qualitative methods, such as close study of particular words and phrases used in their immediate context. There are a range of foci within these studies. For example, health psychologists Thompson et al. (2016) compare face-to-face support groups with online support groups to find out how adolescent cancer patients express their experiences of the illness. While face-to-face groups may facilitate more sense-making of past events through storytelling and positive feedback, online groups appear to be better able to provide space to express negative feelings, engage in information seeking for decision-making and discuss sensitive topics like friendships and sex. The authors suggest that interactions online provide a less face-threatening space in which deeper feelings can be explored. The oncologist Lewallen (2014) examines how language affects peer responsiveness in a specific online cancer support group with implications for design and treatment. She reviews previous research on the ways in which positive group interactions develop in online support groups and finds that message content, self-disclosure and emotional expression are central to this process. Using quantitative methods to identify linguistic markers of emotional expression and pronoun use, she learnt that certain types of expressions, such as self-disclosure, the support group itself, medical experiences and experiences with the website, elicit positive responses. Campbell (2013) investigated the potentially empowering outcomes that online support groups can give cancer patients and found from interview data that these included increased knowledge, the ability to participate in treatment-related decisions, an increased sense of community and enhanced communication with their practitioner. Finally, of the non-specialist articles reviewed, Yaskowich and Henderikus (2003) looked at cancer narratives produced by patients in online support groups. They found that such groups provide a ‘performative’ function for patients whereby they can conduct ongoing ‘biographical work’. By this, the authors (Yaskowich and Henderikus, 2003) suggest that

Because chronic illness upsets the equilibrium between the individual’s previous, current and future sense of life, biographical work is required to understand the illness in the context of one’s life story, based on one’s current view of the self in the social world. (p. 734)

Among specialist linguists, research on the language used by cancer support groups remains sparse and is largely quantitative. For example, Semino et al. (2015) conducted a corpus linguistic study combining quantitative with some qualitative methods to examine the use of ‘violence’ and ‘journey’ metaphors in the language of cancer patients, carers and professionals, within both publicly available interview and online forum genres. They found that there is an extensive use of these metaphors, particularly by patients and carers, and they can often (but not always) have a positive, therapeutic value. They also discovered that the online forum fosters the agency to express views and emotions more freely, including the use of violence metaphors, than in more formal interview contexts. Metaphors enabled members to express personal determination, mutual solidarity and encouragement to one another. Charteris-Black and Seale (2010) also investigated the language of illness using corpus linguistic analysis and interview methods. In their case, the authors looked at the gendered choices made by women and men describing personal experiences of serious illness, including cancer, and concluded there were some linguistic differences. In small, qualitative case studies such as my own, the focus is upon the detailed insights that may emerge from a particular set of discursive relationships, rather than upon generalisations about larger social variables such as gender (Denzil and Lincoln, 2000).

Methodology

This is a semi-ethnographic case study that arose directly from my own experiences as a participant in the support group. Ethnography generally involves the researcher participating overtly in people’s daily lives for an extended period of time watching what happens, listening to what is said, asking questions and collecting whatever data are available to throw light on the issues that are the focus of the research (Atkinson and Hammersley, 2007; Snell et al., 2015). I use the term ‘semi-ethnographic’ here advisedly because in no sense was this study pre-conceived, and therefore I did not apply the range of ethnographic methods that might be expected of a pre-planned approach, such as field notes, diaries or interviews. My interest in the ways in which language was being used to construct trust, support and solidarity within the group grew gradually as I participated, and only emerged as a research pursuit after the group discontinued. However, an emerging interest in a topic of this type is consistent with the ethnographic approach of immersion and ‘being there’. For instance, Miles and Huberman (1994) argue that often, the conceptual framework, important research questions and instruments of study only emerge from the properties of the settings and the participants’ view of them. According to Stake (2000), the function of a case study is to find out what can be learned from the single case. He suggests that an ‘intrinsic’ case study is not one that represents other cases or illustrates a particular trait or problem; rather, it is one with its own ‘particularities and ordinariness, the case itself is of interest’, and one that will capture ‘the stories of those “living the case”’ (Stake, 2000: 437). Yet by so doing, the case may offer insights and understanding that might resonate with participants in similar contexts.

The nine participants in this case decided to form a private group online in order to foster the relationships of support that their shared experience on the residential course had initiated. None of the participants had known each other prior to meeting on the residential course. This had already covered a number of substantive areas to promote health and well-being, ranging from practical, physical, emotional and ‘spiritual’ guidance; but above all, we had all benefitted from each other’s company as cancer patients and wanted to continue this connection. Shortly after the residential course finished, a male member of the group, ‘Steve’, one of the two carers, organised the setting up of the group on the mobile phone IM facility WhatsApp, which offers a free, encrypted service to its users. This usually works asynchronically, allowing users to send messages at any time, and enables multimodal forms of communication to be sent alongside verbal comment, such as photographs, online videos, cartoons and emojis (small digital images or icons used to express an idea or emotion). The study comprises 7 months of interactions (November 2016 to May 2017) between members of the group, with the most intensive engagement in the first 2 months or so. After this, interactions became more sporadic, and eventually petered out. Despite this, the group had provided fantastic support for one another during that time and continues to interact periodically. As a linguist, I became fascinated by the diverse use of multimodal resources to construct that support. In terms of seeking ethical consent for this study, I approached all members of the group individually by email several months after the group had closed to ask their permission to utilise the WhatsApp group data. Those who were interested were also sent copies of the draft article to approve.

In composition, the group comprised a range of ages, genders, ethnicities and occupations. In age, the nine members ranged from their early 30s to their late 60s, and the group comprised six women and three men. Ethnically, eight members of the group were White-Caucasian and one member was of British Asian descent. In terms of occupation, everyone who was not retired identified themselves with a profession, which backs up research showing that support groups are more likely to come from professional backgrounds and to be well-educated (Kessler et al., 1997). One man had just received confirmation of cancer, two women and one man were currently being treated for cancer, three women were in remission for breast cancer, and one woman and one man were attending as carers with their partners.

The data were gathered by manually transcribing the entire record of 7 months of interaction straight from the WhatsApp facility, a record of which remains on a smartphone unless it is deleted. The data amounted to some 10,000 words, which, while not a large corpus of linguistic evidence, corresponds to the style and format of IM, tending to comprise short, bite-sized chunks of text rather than long, extensive messages. The data were initially analysed using the manual, inductive methods of qualitative data analysis (Denzin and Lincoln, 2000). The whole transcript was repeatedly read in order to allow linguistic and multimodal patterns in the data to emerge naturally, as well as significant moments within interactions to be noted. These significant moments were points within an exchange that appeared to index support and solidarity within the group’s relationship or possible ‘changes in gear’ (in mood, style, topic and relationship) between the participants. These could only be gleaned by repeated readings and annotations of the data, followed by an emergent, manual coding of patterns.

The data were then analysed according to principles of Interactional Sociolinguistics (IS) (Gumperz, 1982; Holmes, 2006; Ochs, 1992), which focuses on finely grained micro-analysis of what group members actually write at the level of lexical and grammatical choices, turn-taking, visual and orthographic features. My approach is closely aligned with that of Darics (2015), who uses the IS approach to analyse IM data. IS helps to provide rich and detailed information about speakers by means of ‘contextualisation cues’, linguistic, paralinguistic and multimodal, which can ‘index’ aspects of social identities and relationships such as gender, sexuality, class, ethnicity and status. Such cues can also index different social ‘styles’ (longer-term linguistic patterns) within interaction and point to ways in which a relationship may be developing or breaking down. As an inductive method, IS encourages meanings to emerge that may (or may not) index aspects of social relationships. Ochs (1992) posits that ‘linguistic features may index social meanings (e.g. stances, social acts, social activities)’, which in turn help to constitute wider social meanings (p. 341). I have borrowed the occasional term from the rich metalanguage of Conversation Analysis to describe features of turn-taking where appropriate. I also draw upon familiar concepts from politeness theory (e.g. Brown and Levinson, 1987), such as positive and negative politeness, ‘face’, ‘face needs’ and ‘face threats’, where these help to explain how contextualisation cues link to social meanings. I now turn to the analysis of the data themselves.

The analysis

As I note earlier, the process of reading through the data repeatedly allowed me to identify significant moments which either typified or highlighted the ways in which participants construct engagemented and solidarity with each other. I have selected four of these moments, which are taken from different points in the interaction: the start, when the group was setting itself up; two points during the middle period; and one towards the end when interaction was becoming more sporadic. The pseudonyms of the nine members of the group are Dawn, Dee, Eliot, Edie (carer), Kate, Louise, Ravi, Steve (carer) and me.

Extract 1: ‘I am missing the free herbal tea’

This extract, almost the first words written after each participant has been added to the WhatsApp group, is difficult to understand without some prior context. Steve and his partner, Kate, had initiated the idea of the group and then set it up, sending invitations to each of the group. The first message below is highly deictic of a humorous conversation held during the residential course about a photograph of Ravi’s kitchen showing an untidy table:

1. Steve |08.44 |distinct lack of clear table pictures☺ methinks its cluttered again ☺

2. Ravi | 09.06 | [Photograph of untidy kitchen table with poinsettia plant] Oh yea of little faith! ☺

3. Steve | 09.07 | OK – one is impressed ☺

4. Steve | 09.07 | and a poinsettia ☺ Mr Christmas!

5. Ravi | 09.07 | ☺ [wearing halo]

6. Louise |10.56 | Thanks Kate for setting up the group. Ravi the table is looking beautiful, Steve I am missing the free herbal tea as well (☺ winking). Have a great Sunday x

7. Me |17.10 | [Video of dog looking at camera] I’m trying to teach my dog mindfulness … not sure he’s quite got it! Missing our sessions. x

8. Ravi |17.12 | I think he’s saying WTF mum! ☺

9. Steve |18.03 | Very cute though! And very mindful! ☺

10. Ravi |18.20 | A friend sent me this. In case it’s relevant to anyone else here or other friends you know, I’m sharing it. ‘The illness hasn’t come for a reason – to give you a lesson or as karma’ … [Here follows a lengthy commentary offering words of wisdom about how to live with cancer.]

In this extract, Steve’s message in line 1 would make no sense to a newly formed group that had not previously met each other. The line refers to the humorous conversation off-line mentioned earlier, and Steve’s comment about a ‘lack of clear table pictures’ acts as a provocation to Ravi to respond with an online photograph, and mocking use of the biblical expression ‘Oh yea of little faith!’. There is then a sequence of synchronous, quick-fire banter between Steve and Ravi, ending with the latter’s use of a smiley, acting as a punctuation mark to close the sequence off. A couple of hours later, Louise enters the conversation with a non-sequential series of comments aimed at different members of the group. There is nothing in her comment in line 6 to suggest that she is continuing the humorous style. Rather, her comments use features of ‘positive politeness’ (Brown and Levinson, 1987) towards different members of the group: gratitude to Kate, an apparently sincere compliment to Ravi, and a deictic reference to Steve about the prevalence of herbal tea (thought to combat cancer) on the residential course. In making this comment, she is tending to the ‘positive face needs’ (Brown and Levinson, 1987) of three members of the group, while making deictic reference to the tea-drinking experience shared by all. Her sign off (‘Have a great Sunday ’) implies that no reply is expected. Several hours later, I send a photograph of my dog to the application, making a humorous reference to another course experience – sessions on ‘mindfulness’ (a form of meditation aiming to bring people into the ‘here and now’). I then make the deictic reference explicit with the positive, evaluative comment, ‘Missing our sessions!’. This is immediately picked up by Ravi, who responds in a similarly light-hearted style, indexed by the idiomatic abbreviation ‘WTF’, used informally across online communities to mean ‘what the fuck’. Steve uses light sarcasm to build on this mocking style (‘very mindful’), while paying attention to my positive face needs as the dog’s owner (‘very cute though!’). Just 20 minutes later, in line 10, this topic is completely changed by Ravi, who introduces some words of wisdom that he quotes from ‘a friend’. This is a substantial homily for an instant message, amounting to some 250 words.

In this early moment from the group’s interaction, the members are seen to be harnessing the energy and goodwill that was originally created on the residential course. There are early signs that members are (re)constructing in-group solidarity by references to their previous shared experiences – drinking herbal tea, mindfulness – that provided the initial bonding. Every comment is taken up by a respondent, and a topic is only dropped if the contributor does not expect a response. Even within a few lines, the style and tone of the extract varies from banter to serious, quasi-religious comment about the meaning of life with cancer. At this early stage, it appears that different levels of comment are being ‘tried for size’ by various members of the group. As yet, however, only four members of the group have contributed.

Extract 2: ‘I was at oncology the other day . . .’

The following extract is not directly triggered by a previous topic of conversation. Prior to this, the group had been discussing a lengthy, comic allegory that Steve had reported describing cancer as a ‘mountain lion’ that is trying to attack people. This had led to a discussion about setting up face-to-face support groups in our own localities:

1. Dawn |18.09| I was at oncology yesterday, I can’t have chemotherapy because my kidney function isn’t good enough. There’s talk about radiotherapy but the side effects are a concern. Also told bladder cancer can lead to lung, liver or bone cancer. Having a diagnostic CT scan then another chat with oncologist. Luv to all, Dawn. X

2. Me|18.12| I really hope the news is good for you, Dawn, fingers crossed! Xxx

3. Dee|18.12| Dawn, keep strong, remember everything you have learned. Love to you, Dee xx

4. Ravi|18.20| Dawn, I’m sending my love R x

5. Dee|18.23|Thinking of you all. Keep lines of communication open, we need each other. Dee xx

6. Kate|18.24|Keeping everything crossed for you. Take care of yourself xx. Judy, the group sounds great! Well done! ☺

7. Me|21.08|Thank you! Though it won’t ever match our group! ☺

8. Dawn |21.09|We were special! X

9. Ravi |21.32|(Photo of himself in the dark with fist raised, smiling)

  On the beach in Bournemouth.

10. Dee|21.33|Go skinny dipping.

In line 1, Dawn delivers a very direct account of her state of health, her future prognosis and the treatments she can or cannot receive with her type of cancer. Using categorical assertions and common medical terminology, she is unsparing in the details she gives and expresses no emotions or judgements about her condition. In line 2, I am the first to respond to her topic by expressing the emotion of hope that Dawn perhaps feels herself, but does not articulate. Her report also provokes a series of responses (comments 2–5) from other members of the group, a couple of which may have been composed simultaneously, given the timings. Each respondent ‘hails’ Dawn by using her name, but this also increases the emotional intensity of the exchange. Indeed, each response echoes each other in phraseology (e.g. line 2: ‘fingers crossed’; line 6: ‘everything is crossed for you’) and in expressing feelings of love, hope and empathy with Dawn. Certain responses are almost exhortatory, instructing Dawn how to feel and behave (e.g. ‘remember everything you have learnt’; ‘take care of yourself’). Dee finishes the sequence by drawing a generalisation from the individual messages when she says ‘Keep lines of communication open, we need each other’. This shows an awareness of what the support expressed for Dawn means for the whole group – that anyone could be ‘in Dawn’s shoes’ and may need to be similarly supported in the future. Dee’s extrapolation to the whole group context signifies that a topic change is permissible, and Kate achieves this by moving effortlessly from Dawn’s case to mine, when she refers to a previous exchange with me about setting up local support groups. I respond to this new topic with politeness, showing appreciation that my initiative has been acknowledged. Then I try to downplay the ‘face threat’ of a rival group by directly invoking in-group solidarity: ‘Though it won’t ever match our group!’. This is picked up by Dawn, who states ‘We were special!’. The sequence of emotive expressions is then broken by Ravi, who sends a photograph of himself making a cheering gesture accompanying his comment ‘on the beach in Bournemouth’. Dee’s humorous, idiomatic comment ‘Go skinny dipping’ potentially lightens the mood and shifts the direction of the exchange.

In this early period of the group’s interactions, members are prepared to describe their experiences of illness directly and unemotionally as it is happening. The honesty and fearlessness of Dawn’s account elicits commensurate expressions of strong empathy, positivity and support from other members, which work to strengthen the sense of trust and solidarity within the whole group. The extract shows that the first expression of support (line 2) elicits a ‘ripple effect’ of empathetic comments among other members of the group. Yet once again, no single mood or style of interaction prevails for long, and after a 20-minute pause within the interaction, Ravi’s change of topic helps to distance members from the ‘brute reality’ of living with cancer.

Extract 3. ‘Scary rapper?’

This extract, just before the New Year, followed an intensive exchange of messages across the group about Christmas festivities during which photographs of people enjoying themselves with families were shared. Despite the festive season, members continued to have cancer treatment, and occasional references were made to this:

1. Ravi |13.39|My new 2017 look (selfie of Ravi without hair following chemo)

2. Steve |13.50|Rocking the look my friend ☺ x

3. Dee |14.25| Hot hot hot xx

4. Ravi | (☺ winking and holding a heart)

5. Me |15.15| Suits you sir!

6. Dee |17.35|(sends web link to site on how to make homemade sauerkraut in a mason jar – Cooking lessons from the Kitchen: when life gives you cabbage, you make sauerkraut ….)

7. Dee |17.37|If anyone is interested, there has been a lot of research on fermented foods. Good for gut bacteria, detoxing.

8. Steve: |18.34|Is it too much for our summer-themed New Year’s Eve Party?

9. (Selfie in a boater and fake moustache)

10. Dee |18.37|That’s fine just need to grow a beard ☹

11. Ravi |21.22|:Very sophisticated

12. Ravi |21.23|(Selfie of Ravi wearing woolly hat, fake beard and making a monstrous face)

13. Dee |21.24| Scary rapper?

In this exchange across around 8 hours, Ravi opens with a photograph of himself without hair – previously he had a head of thick, black hair. His comment ‘my new look’ is self-denigrating, but clearly ironic as it would normally refer to a person’s fashion choice, but on this occasion, it is an unwished-for side effect of treatment. The ironic tone is picked up by Steve in message 2, who mirrors the fashionable, ironic style associated with ‘youth speak’ (Kerswill, 2013). To emphasise that his use of irony is mocking yet friendly, he adds the endearment ‘my friend’ and a clowning smiley. The style now established, Dee in line 3 repeats the youth speak term ‘hot’ three times, signifying approval. The phrase actually refers back to a previous message by Ravi, who had sent a video clip of a song with the title ‘Feeling hot, hot, hot’ by the pop group, The Merry Men. The song itself is an upbeat, jaunty number indexing a party mood in a hot country. Dee’s use of the phrase helps to build solidarity in the group because it weaves together references to past and present conversations, thus constructing a sense of collective group history and story-making. It supports Ravi’s desire to be positive about his loss of hair, while reminding others of his previous messages that the group has enjoyed. Ravi signals his appreciation of the light-hearted support by his use of a smiley winking. Rather belatedly, I add my own comment in the same mocking spirit, and the topic closes.

Two hours later, Dee sends a link to a website on ‘how to make homemade sauerkraut’, which is anchored by her added comment about the value of ‘fermented foods … for gut bacteria’. The message has a double significance, referring forwards to the New Year’s Eve festivities and the possibility of hang-overs, but also backwards to the residential course sessions on building a strong immune system. This does not receive an immediate response, but an hour later Steve replies with a tangential message in which he links the ideas of the sauerkraut recipe and heat to his forthcoming New Year’s Eve party. He follows this by sending a photograph of himself in a boater with fake moustache and sideburns – indexing an Italian gondolier or similar. Ravi responds with an ironic compliment, then, perhaps competitively, adds a photograph of himself wearing a bobble hat and pulling a monstrous face, as if to debunk Steve’s sophisticated image. Dee finishes that sequence of messages by supplying the description of himself that Ravi does not supply – ‘a scary rapper?’.

Overall, the sequence of messages is light-hearted and entertaining in style, perhaps indexing the immediate context – that most people will be attending New Year festivities. Underlying this is the serious message that cancer causes severe side-effects, but members of the group are keen to support each other in appreciating that even difficult experiences can have light-hearted if not positive aspects. By this stage in the group’s 7-month conversation, it is clear that certain members are more likely to utilise humour to construct goodwill and support together than others: Dee, Steve, Ravi, Kate, and occasionally, me.

Extract 4: ‘Hey friends long time’

A month had passed before Ravi initiated this exchange. Conversations had become increasingly sporadic, although they continued after this interaction for another month:

1. Ravi | 16.19|Hey friends long time. I often wonder how we are doing.

2. Ravi |16.20|I’ve had 2 doses of iphosphamide and am coping OK. The ‘inner Trump’ is not growing and my belly is softer!

3. Ravi |16.20| And am doing lots with friends and decided to get a little dog!

4. Ravi |16.22|Has anyone looked into high dose vit C? My medics say be careful cause it could protect the cancer but this seems more theoretical. Views/networking/help most welcome.

5. Ravi |16.22|Big ☺ from me for Easter!

6. Kate|16.22| That sounds like very positive news Ravi. A little dog sounds perfect. I’m trying to convince Steve we should get another dog after ours passed away in September. Roman is looking for a new home

7. Kate |16.23|(Mobile tel no) ‘Please visit the kennels if you can offer me my forever home’(three pictures of a dog)

8. Ravi |16.23|Who’s Roman?

9. Kate |16.23|The dog in the photo!

10. Ravi |16.24|Sorry to hear about yours

11. Kate |16.24|Still miss my little dog

12. Ravi |16.24| Steve, any reason for your delay? (Smiley winking)

  I bet they are loving things.

13. Eliot |20.14|Sounds good Ravi …. think the best way to get vit C is juicing daily. I usually drink about three glasses of mainly carrot and apple but mix some green veg and citrus fruits as well …. def think you should get another dog they are very therapeutic, happy Easter to you all.

In this extract, Ravi makes five consecutive attempts to initiate conversation in the group after a month’s hiatus. Of all the members of the group, Ravi was most likely to start the conversation, followed by Steve. Indeed, the bantering between the two of them often formed a considerable part of many of the group conversations online, as indicated in the previous analyses. Here, Steve’s voice is conspicuous by its absence. In his five opening ‘utterance chunks’ (Markman, 2015), Ravi first begins with a phatic greeting, hailing other members indirectly to contribute. Second, he reports on the progress of his treatment using topical humour about the current president of the United States (‘the “inner Trump”’) to describe his condition in more entertaining terms. Third, he describes other aspects of his life (a social life, getting a dog), perhaps to index his positive and forward-looking approach to the illness: cancer is not going to defeat him. Fourth, he introduces new, outside information about the supplement Vitamin C to the longer-term discussion about which resources can help to fight the disease. Finally, he signs off with a valedictory greeting. Markman (2015) argues that ‘utterance chunking’ of this type can serve a variety of purposes, such as breaking down complex information into ‘bite-sized pieces’, as a strategy to hold the floor or as an attempt to make the conversation more informal (p. 75). In the context of this online cancer group, Ravi’s strategy seems to be to convey diverse types of information or to offer various inviting ‘leads’, each of which might appeal to different members of the group. Such a strategy might give his contribution the greatest chance of initiating a response. This reading is endorsed by Kate’s response: she picks up just one of Ravi’s ‘leads’ about the benefits to cancer patients of getting a dog, which she associates quickly with her own experience by explaining that she has lost her own dog and wants to replace him. The benefits of having a dog constituted one of the notable stories weaving through the group’s interactions. The way Kate juxtaposes her message with the advertisement for ‘a dog called Roman’ might index that Ravi’s second utterance chunk has ‘struck a chord’. However, the interaction between them at this point is so synchronous that Ravi has failed to distinguish Kate’s message from the advert, which accounts for his misunderstanding when he responds ‘Who’s Roman?’.

Once this misunderstanding is resolved, Ravi then hails Steve, Kate’s partner and carer, to ask why they might not get a dog. Arguably, this might also be a tactic to encourage Steve to contribute as he has been silent within recent group interactions. Interestingly, Steve does not reply and does not contribute to the online group any time thereafter. The penultimate message in this sequence is 2 hours later, possibly from Eliot. (Eliot and Edie shared a mobile phone number and it was not always possible to gauge who was ‘speaking’.) Eliot responds first to Ravi’s fourth utterance chunk about Vitamin C, giving advice based on his own experience (‘the best way to get Vitamin C …’), and then to Ravi’s second utterance endorsing Kate’s view about the benefits of having a dog.

In this final extract, Ravi recalls strategies previously used during the interaction to construct and maintain group relationships and a sense of solidarity. He attends to the face needs of other members, imparts information, describes his cancer experiences and offers a sense of optimism and forward-thinking to inspire the group. His attempts are partially taken up by Kate and Eliot, but there are contextualisation cues to indicate that the conversation is struggling. Steve does not take up his offer to join the conversation, and the topic of Vitamin C does not elicit further views and networking. Over 7 months the group has offered its members exceptional support, but at this stage its star is possibly waning.

Discussion and final thoughts

Cancer support groups provide a space where the illness carries no obvious stigma and is not looked upon with alarm. Online support groups set up informally may encourage a greater range of expression than more formally organised, face-to face groups. They enable patients to explore concerns about cancer, as well as issues other than the basic problem of cancer itself (Yaskowich and Henderikus, 2003). From my case study, there are a number of insights I can add to this understanding of online support groups, which explain exactly how an online cancer group harnesses multimodal uses of language to construct relationships of support and solidarity through longer-term interactions. These are as follows: diverse ways in which support is constructed, the use of humour, a ‘special’ sense of in-group togetherness, and doing ‘biographical work’ (recasting one’s life history and subsequent identity).

First, the case study found that the multimodal facility of WhatsApp provides diverse and diverging modes by which support with others is constructed and sustained. In the extracts analysed here, members used website links to information sites, photographs of themselves (‘selfies’), their families and home settings, videos of their pets, video clips from the website ‘YouTube’, emoticons and advertisements found online, alongside conventional written messages. The extracts are just partially representative of the rich plurality of modes used to convey messages, which also included the mutual sending and sharing of ‘bitmojis’ (a mobile phone application that allows the user to design their own expressive cartoon likeness or ‘avatar’ of themselves). The latter created much humour, entertainment and certain pathos in the group’s realisation of how they had physically changed as a result of cancer treatment.

Members also used multiple and often surprising types of expression. In line with Lewallen (2014), the articulation of emotions played a strong part in denoting support for others. This was less about conveying a member’s feelings about their own condition, and more about expressing feelings of empathy, hope, encouragement and affection with others who were enduring difficult treatments. There was little evidence of Semino et al.’s (2015) finding that cancer patients use violence and journey metaphors when writing online, perhaps because interactivity was a stronger feature of this particular group than deeper reflection. Members paid careful attention to the ‘face needs’ of other members, especially those who were experiencing ongoing treatment. Conventional forms of politeness (e.g. greeting people, giving thanks, complimenting people and signing off) were closely woven with emotional expressions (e.g. ‘Dawn, I’m sending you my love’). Often, emotional expressions were mediated through exhortations (‘Keep strong, remember everything you have learnt’.) In the extracts earlier, every initiating message was responded to positively, often by several members within a short time span. Also in line with Lewallen (2014), the disclosure of upsetting details about one’s illness, prognosis and treatment was a feature throughout the data (see Extract 2). However, unlike Thompson et al. (2016), disclosure did not extend to the group’s private lives, which were definitely viewed as ‘off-limits’. My results may differ from Thompson’s study of adolescent support groups because adults of widely ranging ages may share fewer assumptions about their private lives. Furthermore, a number of members offered practical information, either in the form of personal anecdotes or by providing links to websites that featured cancer-related advice about food or food supplements (see Extracts 3 and 4). These were often ‘alternative’ methods to conventional cancer treatments, often dismissed by medical institutions. This focus of interaction perhaps indexed the sense of helplessness cancer patients feel towards their destructive illness, the limits of conventional treatments, the need to find ways of gaining control over their condition and to find ways of treating themselves. Finally, members also proffered non-cancer-related news along the lines of ‘what’s happening in our worlds?’. This was not a significant topic of conversation, but came alive during the Christmas period when festivities were occupying people’s time. This diversity of modes and types of expression is made possible by the online facilities that an IM service provides.

Second, the use of humour formed a major part of the group’s interactions throughout the 7-month period. It may seem surprising that humorous interactions should contribute so substantially to cancer support group’s interactions, given that certain members of the group were experiencing an uncertain future, and almost all of the seven patients had faced the prospect of death. There is little research literature to be found on the value of humour to cancer patients (see e.g. Melton, 2016). Yet humour was a vital constituent of the group’s online interaction, and, as shown in the extracts earlier, was rarely, if ever, of a ‘dark’ or depressive nature. Schnurr (2009) drew up a ‘brief taxonomy of humour’ that includes such types as anecdotal humour, fantasy humour, wordplay, self-denigrating humour, teasing, sarcasm and irony (p. 7). She proposes that actually identifying instances of humour upon which a wider audience might agree needs close study of the local context. My combination of ethnographic methods with IS analysis show that much of the interactive humour in the data is intentional ‘positive humour’ (Morreall, 1997: 230). This aims to foster good relationships among interlocutors by creating an open-minded atmosphere and a necessary space for entertaining each other, perhaps to divert members from more serious issues. Almost all instances of humour are responded to and taken up as comic by other group members. Indeed, these often lead to extended bantering and comic routines that are rich in deictic references to previous exchanges. There are no examples in the extracts of the opposing ‘negative humour’ (Schnurr, 2009: 7), which typically aims to attack people personally. Most of the examples of humour analysed in the four extracts use a combination of self-denigrating humour, gentle teasing, sarcasm, irony (e.g. Extract 1 and 3) and wordplay (Extracts 3). There is also the use of visual slapstick (not mentioned by Schnurr, 2009), exemplified by Steve and Ravi’s use of clowning selfies in Extract 3. All instances of humour serve to create in-group solidarity, which in turn provides a strong basis for trust when more serious topics about individuals’ health are discussed.

Third, a strong sense of togetherness greatly enables the discursive construction of relations of trust and support within an online community. In my case study, the group had the advantage of having met each other face-to-face prior to setting up the online group. This meant that we could visualise each other, attach recognisable identities to each other and could depend on a group back-story – our shared experiences and conversations on the residential course. The first extract illustrates how initial interactions were highly deictic, referring back to previous experiences as a warrant for our immediate intimacy towards each other at the start of the online group’s interactions. This use of deictic expression thus obviated the need to establish tentative first steps about who we were, what we wanted from the group and how we intended to relate to each other.

As the four extracts show, the sense of togetherness was constructed and distributed somewhat unevenly across the group, depending on the relationships and identities performed. Not all members contributed equally, as could be seen by the greater agency of certain members (Steve, Ravi, Kate, Dawn, Dee and me) and the more passive presence of others (Louise, Eliot and Edie). The more ‘audible’ members of the group were more likely to initiate and sustain an interaction than others, and more likely to respond quickly to an opening message. Certain relationships between members developed, gradually transforming into significant group narratives. These included the affectionate relationship between Steve (carer and partner of Kate) and Ravi, expressed by humorous and flippant routines that eventually became embedded into the group’s stories about itself. The experiences of certain members (Ravi and Dawn) were more likely to be the object of the attention of the rest of the group, perhaps because their treatments were new and/or ongoing. Members were increasingly positioned as givers of support to others or receivers of others’ support. Despite this inevitable unevenness within interactions, the group’s drive to establish its own in-group identity, to view itself as ‘special’ and exclusive (see Extract 2), and to be able to draw upon its own store of references, stories, in-jokes and experiences, helped to strengthen group solidarity. It is likely to be a key feature of any really effective online cancer support group.

Finally, my study found that biographical work, that is, recasting one’s own life story, seems to be a priority for those patients facing gruelling treatments, difficult changes to the body, disrupted lives and changing relationships. Yaskowich and Henderikus’ (2003) found that biographical work was a crucial part of patients’ interactions with each other, not least because it helped them to overcome their sense of isolation as they struggled to negotiate a new identity. In any support group, it could be argued that members are exploring the performance of their identities with each other and, to a certain extent, assuming relatively stable subject positions: the humorous one, the helpful one, the kind one, and so on. Yet in my study, only certain members performed evolving biographical work – usually those who were the objects of other members’ attention and support. In the four extracts, Ravi was the one who most clearly explored his changing sense of identity, perhaps because he was still in a state of shock and still coming to terms with his new status as a cancer patient. Through the use of photos, jokes and wise sayings, he moves from a reflective attempt to make sense of his illness in Extract 1, to showing a fighting resistance in Extract 2, to a determination to entertain others and have fun at his own expense with his changing looks in Extract 3 and to an investment in his own longer-term future in Extract 4.

In conclusion, an online support group can play a very special role in helping to counteract the devastating physical, psychological and social effects of cancer. This case study found that the diverse discursive practices deployed by its nine members, ranging from quasi-spiritual messages of wisdom to bawdy humour, were not only specifically helpful in constructing mutual trust and support, but also combined to produce a strong sense of in-group solidarity. For some patients, a support group provides an invaluable opportunity to conduct biographical work, enabling them to come to terms with their chronic illness. Other support groups, particularly online, might learn from this study that few forms of communication are ‘off-limits’ as long as these are ‘positive’, and that multimodal diversity, humour and wordplay, enabled by the IM facility, are vital for the sustenance of a group that wishes to focus on their shared experience of illness, yet be distracted from cancer’s cruelties and entertained by its absurdities. It seems that IM technology has helped to enhance the range of modes by which an online cancer support group can express its relationships of support, particularly in facilitating the agency to find pleasure in life despite the rigours of the illness and its debilitating treatments.