“I Had to Make Them Feel at Ease”: Narrative Accounts of How Women With Breast Cancer Navigate Social Support

Abstract

Social scientific studies of social support predominantly focus on the positive associations between social support and emotional well-being. The negative aspects of social support have received much less attention. We conducted semi-structured interviews of women with breast cancer (n = 47) to examine the emotional strain associated with social support and how recipients navigate it in ways that protect themselves and their relationships. Based on our analysis of narratives of women’s lived experiences of breast cancer, we found that social support can be perceived negatively and associated with experiences of emotional strain. Interviewees engaged in strategies of avoidance, information control, and cognitive reframing to minimize emotional strain. We applied the concept of emotion work to understand the complexity of emotional strain in this context. The findings highlight the difficulties of social support from a recipient’s perspective and emphasize the importance of perception and agency in navigating this experience.

Keywords

breast cancer social support cognitive reframing emotion work perception agency strategies of avoidance information control qualitative phenomenology United States

Research on social support often focuses on its associations with emotional well-being and quality of life for those who are physically or mentally ill (Kim et al., 2010; Sammarco, 2001).

Within this literature, various types of social support are theorized to ameliorate the impact of stress caused by illness (Arora et al., 2007; Kornblith et al., 2001). Social support has also been associated with improved physical outcomes that include lower rates of morbidity and mortality as well as quicker recovery from life-threatening illnesses (Uchino et al., 2011; Wills & Shinar, 2000).

Although evidence for the positive effects of social support is compelling, there are also examples in the literature of situations in which social support has negative associations or effects for recipients. The potential for emotional strain associated with social support has been observed (Drageset et al., 2012) but has received much less attention (Gallant, 2003). We argue that those seeking a robust understanding of social support must attend to emotional strain caused by social support and consider how recipients respond to it.

Focusing on recipients’ experiences and perceptions of support, qualitative studies can shed light on multiple emotional or cognitive aspects of support acceptance or avoidance (Faw, 2014; King et al., 2006). In the research reported here, we examined the narratives of women with breast cancer (BC) regarding their experiences of and responses to available and received social support from their social network (predominantly friends and family). In particular, we were interested in understanding more about their interpretations of social support as a source of burden or emotional strain. We attended to how the interviewees avoided stress and maintained a positive sense of identity. In so doing, we sought to contribute and learn more about the emotion work experienced in navigating social support among women with BC.

Social Support

For women diagnosed with and living with BC, emotional stress may derive from concern over the physical aspects of the disease (including body image and sexuality), which may be accompanied by psychological distress, anxiety, or depression (Spiegel, 1997; Vilhauer, 2008). Literature on BC and social support has addressed forms of informational, emotional, and tangible support (Arora et al., 2007; Hirschman & Bourjolly, 2005) that may help to reduce stress (Kim et al., 2010; Thoits, 1995) and are most often positively related to well-being and higher quality of life (Sammarco, 2001).

Social support is complex (Williams et al., 2004), however, and unsuccessful attempts to provide it may have a negative emotional impact (e.g., psychological distress or lower self-esteem) upon the recipient (Uchino et al., 2011). Scholars have been calling attention to the lack of studies of the potentially negative aspects of social support since the 1980s (Shumaker & Brownell, 1984) and in relation to BC and chronic illness the lacuna still exists (Boinon et al., 2014; Gallant, 2003). Research that has addressed the negative effects of social support in relation to BC or chronic illness has focused on how a negative perception of support may develop in relation to unsupportive friends and family (Gallant, 2003), incongruities between the recipient’s and provider’s understanding of support (Arora et al., 2007), and how recipients of support can feel overwhelmed by too much support (Drageset et al., 2012).

Other studies of the negative aspects of social support have similarly focused on the mismatch of providers’ and recipients’ understanding of support. For example, Faw’s (2014) study of young adults managing weight loss notes that support can be perceived as disruptive or unhelpful by the intended recipient. Studies of social support in relation to job hunting and the workplace have looked at the negative psychological reactions and lower self-esteem related to miscommunication between provider and recipient about what qualifies as support (Deelstra, 2003) and unsolicited support (Deelstra et al., 2003; Song and Chen, 2014).

Understandings of what constitutes social support or what support is needed are matters of perception. Uchino et al. (2011) argued that the perception of available support is related to higher levels of well-being than the actual support received. In their review of research on perceived available support, Wills and Shinar (2000) discussed its buffering effects in relation to physical and psychological stress.

Quantitative studies, however, can have thin conceptualizations of “perceived support.” Uchino et al. (2011) defined perceived support merely as potential access to social support.

Gallant’s (2003) study of self-management and chronic illness focused on the perception of “availability” of support in relation to emotional, informational, or tangible support. In a study of perception of support among women with BC, Arora et al. (2007) measured perception using secondary analysis of two survey questions: whether or not support was received in the last 2 months followed by a Likert-type-scale rating of how helpful it was (Arora et al., 2007, p. 476). Arora et al. pointed out that their analysis was responding to the lack of multidimensionality in research on perception, yet their conceptualization of social support neglected the participants’ own accounts of what they perceived as support or an accounting of the contexts in which it occurred.

Operationalized constructs are useful for measuring statistically significant relationships between support and well-being or quality of life, but they are not instructive when researchers want to know more about how women actively perceive and experience support. In contrast, qualitative research on social support allows recipients to discuss it in their own words (Iannarino et al., 2017).

Theoretical Frameworks

In symbolic interactionist theory, which focuses on one-to-one and small-group interactions, shared assumptions and expectations about an interaction taking place are often referred to as the “definition of a situation.” The assumptions that people have about a situation allow for them to coordinate their actions based upon which roles they are playing (Sandstrom et al., 2013). If interactants share assumptions about the situation, then there is a higher likelihood it will go well. In analyzing social support situations, there are two roles or perspectives that are considered: provider and recipient (King et al., 2006). When they share assumptions about the social support situation (e.g., what constitutes social support), the interaction is more likely to be successful. When there is not a mutual consensus, the result can lead to misunderstanding, stress, and conflict, which requires those involved to develop strategies to respond (Åsbring & Närvänen, 2004; Davey et al., 2012; King et al., 2006).

Erving Goffman’s concept of impression management provides a framework for understanding the agency of the individuals involved in an interaction. In his dramaturgical approach to interactionism, Goffman acknowledges that individuals as performers use various techniques or strategies in communicating information to others so that others will come to share the desired impression of the performer (Goffman, 1959).

Impression management is an attempt to “control” others’ understandings and therefore actions in the situation (Goffman, 1959). Qualitative studies examining health interactions can help to elucidate such strategies (even when not explicitly using interactionist theory). Åsbring and Närvänen (2004) demonstrated how patients with chronic illness employed strategies such as persuasion or confrontation to influence their doctors’ understanding of the patient. Davey et al. (2012) examined how African American parents navigated BC and parenting by withholding intense emotional information while communicating information about BC as an illness in interactions with their children. In her study of parents with seriously ill children, Gengler (2015) noted that in anticipation of “precarious emotional circumstances” parents would devise “their own preemptive strategies to maintain steady and hopeful emotional states for themselves and their children” by offering upbeat responses to inquiries about their children’s health, limiting their social interactions, and withholding information about their children’s condition (p. 615).

Such strategies can be employed to avoid subjecting oneself to a stressful emotional experience. This can also be thought of as emotion work, a concept central to emotion management that was developed by Arlie Hochschild (1979, 1989) as an inwardly aware corrective to the outward-focused impression management. Hochschild (1979) described emotion work as involving an exchange of emotional feeling between two people according to culturally defined rules “appropriate to the situation” and one’s social status (p. 552). Emotion work between those with strong personal bonds has been extended to include an intention of promoting a positive emotional state in one’s fellow interactant (Thomeer et al., 2015). The greater burden of emotion work typically falls upon women’s shoulders due to social expectations of care based on gender norms (Hochschild, 1983; Hochschild & Machung, 1989), even when their health is impaired (Thomeer et al., 2015).

Relationships and their histories affect the emotional dimension of support (Sandstrom et al., 2013). Social support is not a static moment, but a process that involves interpersonal relations (King et al., 2006). Women with BC actively engage their social support networks to meet their own needs and those of others (Shenk, 1991). The quality, nature, and history of a relationship are important contextual factors for the support experience (Kroenke et al., 2013). If the relationship is not secure, then the acceptance of support may lead to feelings of guilt or indebtedness in the recipient (Deelstra, 2003). Family and friends of a cancer patient who have exhibited a history of being critical or dismissive or who have an aversion to discussing cancer-related topics may not be effective in facilitating social support interactions (Boinon et al., 2014).

Social support relationships change over the course of the illness experience, along with patients’ knowledge of cancer and their social support needs. Studies of social support that examine contextual factors often consider how personal relationships and time (in relation to the diagnosis and duration of disease) contextualize acts of support (Charmaz, 1993). Arora et al. (2007), for instance, highlighted that BC patients’ coping skills and knowledge about cancer evolve along with the skills and knowledge of their family and friends. As these coping skills develop, the intensity of the need for support may diminish (Arora et al., 2007).

Recipients and providers of support define support situations for others and themselves. In other words, navigating social support involves actively constructing one’s own definition of the situation, understanding one’s role, and one’s emotions in a broader context of emotion management. Research focusing on “reframing,” “cognitive restructuring,” or “cognitive adaptation” in relation to social support experience has been grounded in the social constructionist position (Lakey & Cohen, 2000). In the social constructionist literature, framing or reframing can be understood as “an act of surrounding situations, acts, or objects with mental brackets that basically transform their meaning” (Zerubavel, 1993, p. 11). Discussing reframing in the context of social support in marital relationships, Ducharme (1994) described it as redefining “stressful situations in order to make them more manageable” (p. 175). Shumaker and Brownell (1984) alluded to the “positive” and active aspects of reframing in their definition of cognitive adaptation as including the search for meaning, gaining a sense of control, and enhancing one’s self-esteem in relation to coping with a crisis. In their research on the emotional well-being of women with BC, Kim et al. (2010) discussed the concept of “positive reframing,” which correlated to higher quality of life and reduced stress. They defined positive reframing as an active cognitive strategy for coping with the BC experience, operationalizing it as “looking for something good in what is happening” (Kim et al., 2010, p. 5). Ching et al.’s (2009) interviews of Chinese women with BC also discussed reframing as positive in helping women newly diagnosed with BC to construct new ways of understanding their lives.

In this study, we focus on the recipients of social support and their narrative accounts of social support experiences. We wanted to know more about the individual-level interpretive aspects of perception with an emphasis on emotional stress related to social support and how individuals took actions to create more suitable outcomes for themselves. Specifically, we sought to answer the following questions: How have women with BC experienced and perceived social support? Have they ever experienced social support as burdensome or stressful? Based on their experiences, how have they chosen to navigate social support situations?

Data and Methods

The participants for this study (n = 47) were from a sample of women enrolled in the Pathways Study at Kaiser Permanente Northern California (KPNC). The Pathways Study is a longitudinal study of women living in San Francisco Bay Area with BC that examines how “lifestyle factors such as diet, physical activity, quality of life,” social support, and the use of non-biomedical complementary therapies along with “molecular factors such as genetic polymorphisms involved in the metabolism of chemotherapeutic agents” affect prognosis and survival (Kwan et al., 2008, p. 1066). Its overall aim is to better understand and hopefully improve the life and care experiences and outcomes of women with BC.

The Pathways Study provided access to women with BC who were already participating in a study considering lifestyle and social network factors. It provided access to organizational resources to evaluate the study design and secure servers to store survey and interview data that included personal health information. Sampling a subset of participants allowed us to explore women’s narratives of living with BC in relation to a variety of topics including social support.¹ In this article, we focused on interviewees’ experiences of social support in close relationships (e.g., family, partners, and friends) with a few instances of acquaintances and coworkers.

Prior to selecting the sample and contacting the participants, inclusion/exclusion criteria were applied to the Pathways Study cohort requiring English as a primary language and that women had to have been diagnosed at least a year prior to sample selection (to lower the probability that we would contact women who were still undergoing surgeries and chemotherapy).² After this study was approved by the KPNC institutional review board (IRB), 350 surveys were mailed to participants. There was a 43% response rate (n = 149) for the surveys out of which 47 women opted to participate in a semi-structured interview. Along with the survey, we sent a consent form detailing the study background, purpose, procedures, and confidentiality. We acknowledged the personal nature of the questions and stated participants’ right to withdraw at any time. Due to the risks posed by a loss of privacy that comes with disclosing personal health information, we discussed the secure storage of the survey and interview data.

Interviews were conducted from March to June 2013. The majority took place in participants’ homes and others took place in Kaiser Permanente conference rooms with a few in cafes and public parks. All but one interview was strictly one-on-one, which was due to the anticipation of a possible language barrier by the granddaughter who was present and occasionally contributed her own perspective. Prior to conducting each interview, we reviewed the study and reminded participants that they could opt out of the interview at any time. The interviews typically lasted 90 to 120 minutes. The interviews were recorded with permission and later transcribed verbatim.

The opening question of each interview was focused on BC experience, but broad enough to allow the interviewee to respond with what seemed most comfortable: “Did you want to start by telling me about where you are right now in the cancer experience?” This strategy was used to help build rapport, which is considered as part of the criteria for rigor within the phenomenological approach to collecting data (Usher & Jackson, 2014). After the opening question, the interviewer asked about the following topics: use of complementary medicine, attitudes toward conventional medicine, understandings of health and illness, social support, conceptions of BC and identity, cancer culture (e.g., books on cancer, cancer events, or “pink-ribbon culture”), and coping. The interviewee’s response to the opening question provided direction for the order in which questions were asked. This flexibility and the avoidance of a “directive style” or the imposition of “too much structure” is characteristic of the phenomenological method (Houston & Mullan-Jensen, 2012, p. 269).

We prefaced our question about reliance upon social support by saying, “During times of illness, people sometimes rely on others to help them through difficult times.” We then asked, “How have you relied on others (e.g., husband or partner, close friends, children, persons at work, people from your religious congregation or spiritual community, others) since your diagnosis, and how has this affected you?” We followed up by asking, “Did you ever feel burdened at all by some people’s attempts at support through your cancer experience?” If the interviewees answered “yes,” we probed further.³ In these semi-structured interviews, when matters of support arose in relation to other topics, the interviewer probed further by asking about experiences of support.

The women who opted into the interviews (n = 47) shared many of the same attributes of those who took the survey (n = 149) and did not opt in. Given that all women contacted were part of the Pathways Study, which recruited from Kaiser Permanente, they all had health insurance through Kaiser Permanente at the time of diagnosis. Of the 47 women interviewed, 53% (n = 25) had Stage 1 cancer, 40% (n = 19) had Stage 2 cancer, and 6% (n = 3) had Stage 3 cancer.⁴ The average age of interviewees was 59 years, and the median age was 61. Their ages ranged from 33 to 82 years. Sixty-two percent were married and the other 38% were a combination of “single, never married” (4%), separated or divorced (21%), and widowed (13%). Over 50% of the women were non-Latina White (NLW) (n = 24), 23% were Hispanic/Latina (n = 11), 17% were Asian (n = 8), and 9% were African American (n = 4). However, interviewees had higher rates of postgraduate degrees (38% of interviewees had postgraduate degrees, compared with 22% of those who opted out) and lower rates of some college or less (38% vs. 44%).

While the sample study (n = 149) employed multiple methods (e.g., surveys and secondary data analysis) and allowed for interviewees to opt in after being selected in a random stratified sample, we took a phenomenological approach to designing the semi-structured interview questions and the process of interviewing for this article. The phenomenological approach is used to understand people’s lived experiences (Usher & Jackson, 2014). As a research method, this approach utilizes semi-structured, in-depth interviews to collect experiential data in the form of “lived-through moments” and “remembered stories of particular experiences” (Adams & van Manen, 2008). Integral to this approach is the researcher–subject relationship wherein the former helps to co-construct knowledge about lived experiences (Osborne, 1994) through a researcher’s questions about experiences and the subsequent interpretive and methodological consideration of narrative as text (Adams & van Manen, 2008).

We utilized a phenomenological approach to the thematic analysis of data in which we sought to understand the complexity of social support and how it is navigated by women with BC. This approach is inductive and is used to find common themes within verbatim interview transcriptions (Fereday & Muir-Cochrane, 2006). This is an iterative and reflexive process wherein “data collection and analysis stages” are “undertaken concurrently” (Fereday & Muir-Cochrane, 2006, p. 83). Transcripts were reviewed for patterns and emergent themes while interviews were ongoing. Particular experiences of social support had to occur in multiple interviews to be considered consistent themes that could be used to re-examine the data. These emergent themes took the form of similarities in emotional experiences of social support and the strategies used to navigate it. Research notes that included emergent themes, considerations of similarities in social support literature, and personal reflections were kept during the transcript review and analysis process; these can serve as a “trail of evidence,” which can be scrutinized to demonstrate dependability (Fereday & Muir-Cochrane, 2006).

After the first 10 interviews were transcribed and emerging themes had been identified, two co-researchers met to discuss the themes in relation to excerpts from the transcribed interviews, which contributed to the validity of the themes and helped to ensure credibility in the study (Usher & Jackson, 2014). QSR International’s NVivo 11 was used as the data management program for the interview transcripts and research memos. Codes of social support from the interviews were entered into NVivo, which was used to check for “cross-transcript themes” (Houston & Mullan-Jensen, 2012, p. 269).

We also incorporated some broad constructionist themes from qualitative research on health into our approach to research design and analysis that extended our attention including the meaning of cancer (or health and illness) and perceptions of the way it altered or changed their relationships with others as well as themselves (Conrad, 1990; Kleinman, 1989).

Results

Women discussed their experiences of social support throughout the interviews. In total, 70% (n = 33) of the interviewees discussed burden, emotional strain, and/or strategies to avoid emotional strain in relation to social support. This includes the 47% of women who discussed feeling burdened by social support when asked directly. Conversely, 30% (n = 14) answered “no” when asked if they ever felt burdened by social support and also did not discuss emotional strain or strategies to avoid emotional strain in the interview.⁵

Women’s narratives about perceiving and navigating social support are complex. Even when help was needed, women in this study found that accepting support could be difficult. In addition, the participants described a desire to avoid being a burden on others and feeling stressed about potential and received social support.

BC Interactions, Emotional Strain, and Emotion Work

Women with BC who discussed emotional strain when interacting with others talked about difficulties in maintaining relationships, not wanting to appear to need support, accepting support, and not wanting others to feel burdened. They also described pressure to reassure family and friends that they would be “okay” (i.e., that they were getting well, or at least not dying).

One participant, an NLW woman in her early 50s, continued her regular duties at her job despite having BC. She described her biggest challenge in doing so as “maintain[ing] that façade” because she did not feel she could be “as on top of things” as she normally was. She did not have the physical energy to be as present and persistent as the person she wanted others to see.

A 71-year-old NLW woman talked about friends and family who came to help her during difficult times in her BC experience. Although she did not always want their help, she thought that showing her true feelings “would be very ungrateful.” Hence, she engaged in emotion work to maintain the appearance of gratitude. Similarly, a 59-year-old NLW participant elaborated on the emotional work she engaged in when a few close friends came to provide emotional support to her during her chemotherapy:

Some friends came to visit me while I was actually getting the chemo. And I would have rather not have had them there. . . . I was in a room where there were other people also getting the chemo [and] I liked talking to those people . . . Then my friends came, so I had to kind of leave the conversation.

Perceiving that her visiting friends felt frightened and uncomfortable, she said “they were really good friends, so I felt like I had to make them feel at ease and join in the conversation so all of us could feel at ease [emphasis added].” Likewise, a 53-year-old Asian participant recalled reassuring her mother that she was not going to die:

. . . she’d want to just start crying and I [would say], “Mom, I’m fine. I’m doing okay.” I understand that from my mother’s point of view, you never want to see your child sick.

You want to be able to take that pain away. So, I understood . . . what she was feeling, but I also felt like . . . I need to let her know, I’m okay.

Participants engaged in emotion work because they did not want to cause their families unnecessary stress or worry. “I never got upset or cried . . . it was just ‘Okay, I need to figure out what to do,’” recalled a 50-year-old Latina woman who explained that she “just acted happy and like everything was great the whole time.” She ended by humorously understating that doing so had been “a little difficult.”

Participants struggled emotionally with accepting help from others, even when they understood that they needed it. This was especially true for those who talked about being independent. Accepting help “was hard” for one 60-year-old NLW participant because she considered herself a person who “gets things done.” She recalled her adult daughter taking her to a positron emission tomography (PET) scan appointment even though she could have taken herself:

I told my daughter, “You don’t need to come with me.” And [my daughter] said, “You can’t go . . . by yourself. You can’t go to your doctor’s appointments without emotional support from us. We feel like you need that.” And [pause] to be honest, I do. I do, you know. I feel up for it a day or two before that . . . But when push comes to shove, I really do want them there during those difficult times.

An NLW woman in her early 50s explained that although it was “hard to accept” assistance from others in her close network, once she “turned [herself] over to that . . . It felt good.” She talked about how she felt supported and appreciated because she had others who just “took charge.” She described a fear of feeling useless but stated that she ultimately understood that it was okay to acknowledge that she might need help.

Others discussed not wanting to be a burden on their families. In the one instance where the participant’s family members were present and active in the conversation about the BC experience, a 62-year-old Fijian participant said, “I want . . . them not to feel too bad for me, you know.” Her granddaughter quickly followed up with

Yeah, she just kept feeling like she was a burden to us. She’s always like that . . . she was always the one taking care of us, cleaning our diapers, cleaning us up. Then it was backward, it was us caring for her, wiping her scar, you know, [doing] this [and] that.

Interviewees acknowledged and had to accommodate the feelings of others in their interactions after a BC diagnosis. Their motivations in doing so appeared to vary. Nevertheless, they found themselves in multiple situations in which they were faced with additional emotional strain to which they responded. The next section focuses on the various strategies they adopted to avoid emotional strain or additional emotion work. These strategies are not mutually exclusive.

Preventive Work

In anticipation of situations that may cause emotional strain, people may employ “preemptive strategies” to avoid those situations altogether or use strategies that create more positive emotional states in their interactions (Gengler, 2015). Interviewees used various strategies to prevent additional emotional strain and emotion work. Preventive work serves to protect women with BC from having to do engage in additional emotion work during a time already disrupted by illness (Bury, 1991) and provides a sense of control.

For example, one 55-year-old NLW woman used upbeat responses. She recalled that when she had BC years earlier, she had felt miserable and “emotionally spent.” Being honest with others, she said, would often make matters worse. Their grief combining with hers acted like a feedback loop, amplifying emotions. In her current experience of BC, she adopted a new strategy. Now, when people would ask her how she was doing, she would reply in a cheerful voice, “I’m fine, how are you?” Even when she did not feel well, she noted that her response “just kind of set the tone” for the conversation.

Interviewees sought to prevent emotional strain by determining whether and how they would interact with family and friends (Charmaz, 1993). Interacting with others sometimes added pressure to already strained physical and emotional states, particularly when they were going through chemotherapy, during which they experienced physical illness and extreme exhaustion. Interviewees described avoiding or limiting interactions, using go-betweens and virtual interactions (e.g., emails and blogs), and controlling information.

A semiretired 56-year-old NLW woman who struggled with the side effects of chemotherapy talked about her friends wanting to do things for her such as cook and clean. Privately, she said to herself, “Oh, please, just go away. Go away.” She discussed her friends’ offers of tangible support as overwhelming because they were upset, and she had to reassure them that she was okay as well as coordinate with them. Although they had the best intentions, she discussed how she eventually had to avoid them altogether because of the additional emotion work.

Another participant, a 65-year-old NLW woman, refused to take phone calls from friends inquiring about her condition after a certain point in the day. She was often asked to update others on her condition multiple times daily; with each retelling, she had to continue living the reality of sickness. In explaining her decision to stop taking calls, she jokingly remarked, “that’s why God invented the answering machine.”

Interviewees also used loved ones as go-betweens. In such situations, husbands, siblings, or close friends acted as gatekeepers who provided health information and updates for others while also controlling who could visit. For instance, a 46-year-old Latina participant recalled that when she had finished her chemotherapy treatments, she did not want others to see her yet, so she instructed her husband to limit her visitors. “I didn’t want people to feel sympathy for me,” she explained, “because when you see somebody and they’re sick you’re like ‘Oh, no’ [in a sympathetic voice] . . . I didn’t want that.” Similarly, another participant, finding that telling others about her cancer was “emotionally exhausting,” asked her husband to update others and schedule phone calls for her when she was feeling up to having a conversation. She said that this had worked well for her and had given her more control.

Go-betweens used personal conversations, email, and phone calls to keep others in the participant’s larger social network informed. A few interviewees used online tools such as email and blogs for this purpose themselves, updating their social networks and coordinating with those who wanted to provide tangible support.

Interviewees also controlled information to avoid additional emotional strain and emotion work. Some kept their BC diagnosis a secret. A 74-year-old Latina woman recalled an interaction at work in which she and another woman discussed experiencing nausea and extreme fatigue after chemotherapy. When the coworker asked how she dealt with family who became sad because of the symptoms she experienced after her treatments, she admitted that she had not told her family, remarking, “I mean, why would I tell them? . . . They can’t change it. . . . It’s not going to make me feel better and it’s going to make them feel worse.”

A 46-year-old Latina woman explained that she did not want anyone to know about her BC. Those from whom she sought to withhold the diagnosis included most of her friends and family, including her adolescent children. She underwent chemotherapy during the summer while her kids were at summer camp or staying with family. When she returned to work in the fall, she wore a wig and did not discuss the experience with anyone. She was reticent because she wanted to avoid altering her relationships. She did not want others, as she put it, “fawning all over me.”

While such comments suggest a stoic attitude in some participants who withheld information, other women described a more emotionally intense experience. As one participant described how much she told others, her eyes began filling with tears:

[I]t’s just when your body, every moment of the day is in pain [pause], that’s what you have to deal with. And so my family doesn’t know this. I wouldn’t tell them because what are they going to do, you know? [. . .] They don’t know about the constancy of the pain, but what are they going to do anyway? So, it seems silly to even tell them.

Not wanting to evoke feelings of sadness or feelings of discomfort in others, these participants withheld information to maintain control of the situation and avoid more intensive emotion work. Maintaining a sense of control is one of the basic elements of “coping” with disease (Kralik et al., 2004; Seeman & Seeman, 1983).

Reframing Strategies: Situations, Roles, and Self

Participants engaged in reframing strategies to manage emotional stress (Copp, 1998). Interviewees redefined their roles, the roles of others, situations, and themselves to cope with difficulty in accepting support. These strategies allowed them to accept help from others while maintaining a positive self-reflection. They noted how these experiences changed how they viewed themselves.

Redefining situations

One way to control one’s interactions with others is to redefine the situation. Independent of the interaction, the understanding or framing of a situation can afford a person necessary emotional distance, or the ability to create a positive emotional experience, rather than a feeling of helplessness or sadness. Some interviewees engaged in redefining the situation.

A 42-year-old Latina woman found it emotionally difficult to watch her mother come to her house and “clean the kitchen, do dishes . . . sweep the floor” when she was too fatigued to complete the work herself:

I think . . . that I felt bad . . . I don’t want to say “low self-esteem” because I don’t believe that’s what it was, but . . . when it first started happening, it hit me really hard . . . then I started thinking, I’m just going to have to take it like a vacation. I’m just going to have to give up the reins right now, but then when I get better I can slowly but surely pull ’em back in.

To accept her new reality, she redefined the situation as a type of vacation, a temporary situation in which she could choose to let others help her while not feeling less independent.

Another participant echoed this experience, stating that “it was really hard” to let her children help her clean house or cook meals. She recognized, however, that she simply did not have the strength for these tasks:

I couldn’t do it, and so I had to let go and allow others to help me, and in doing so . . . it was helping them cope with the disease because they wanted to do something for me, but they didn’t know how they could help. . . . so, by allowing them to bring meals, it helped them also cope with the diagnosis.

By allowing her children to help, she exercised control by redefining the situation and averting feelings of shame or guilt. This allowed her to maintain her self-concept about her role as nurturer by redefining the situation from one in which she is receiving help to one in which she is providing it.

Redefining roles and self

Interviewees who were married tended to rely on their spouses for various types of support. This reliance altered marital roles. A 61-year-old NLW woman recounted how helpful her husband was during her experience with BC, especially after her surgeries. “He was great . . . very supportive . . . So, I think having . . . a husband or . . . a sister or a friend who’s really there for you is important.” She continued, “In many ways, my cancer diagnosis was good for our marriage because I have always been so goddamn self-sufficient, and reliable . . . the stable center.” She stated that it was good to have “him be the stable center and me be cared for”; she felt grateful for this “role reversal.” As her experience demonstrates, living with BC can alter long-established relationships, introducing new dynamics that have the potential to change a woman’s idea of the marital roles that she and her partner play.

Examples of relying on others extended to friends and family as well. The following example in redefining role relates to the stage of the disease. A 56-year-old African American woman said she had to “release the people who really cared” about her “because they’re caring about you as a really sick person” (emphasis added). While she had appreciated the help of a close friend and her sister, she discussed having to “wean” them off from offering emotional and tangible support. She struck a biblical tone noting that she did not want to “hold them in bondage” any longer. While she did not contextualize this within the context of emotional strain in relation to their offers, her experience reflects an attempt to redefine her role.

A retired 55-year-old NLW woman suggested she had learned the importance of projecting a positive front in her past work as a nurse, which had helped her to put patients at ease. Accordingly, during her BC experience, she tried hard to “keep up . . . [a] positive attitude, particularly for her kids, because she did not want them to see her ‘feeling down.’” However, one of the medications that she was taking caused neuropathy. One night, she was experiencing a “really bad pain” in her feet and could not sleep. She recalled feeling discouraged and uncharacteristically starting to cry. Her daughter arrived home late that night and saw her mother still up and crying. She was surprised, sprang into action, and asked her mom how she could help or comfort her. The participant noted that although she had always played the role of comforter for her children, her daughter “really rose to the occasion! . . . She came over and was like . . . . ‘Mom, do you want me to do something? I’ll get you some tea. What do you want me to do? I’ll sit up here with you until you feel better.’” She realized that they had switched roles.

Another participant discussed how interactions changed with her two teenage boys. Before her surgeries, she had gotten up “every morning at 6:30” to take care of daily chores and get everyone in the house going with coffee and food. On the first morning following her return from the hospital, both of her teenage sons began getting up early to do morning chores. They also started doing all the house cleaning and shopping. She said that they “just took charge” without asking. She figured that, had they asked if she needed help, she would have just said “no.” She joked that it was an exercise in lowering her standards of cleanliness, but that overall, she appreciated their support so that she could rest and heal. Others echoed these stories, along with their struggles to let others help. Letting others alter their roles was not emotionally easy for participants. However, there was a reward for doing so, which could be both emotional and physical (i.e., more time to rest).

It was through this process of learning to navigate support that some of the interviewees noted a change in their identity. They recognized aspects of themselves that they had found anew or come to accept and feel positively toward. One participant reflected on how “hard” it was for her to rely on others but described how she came to see herself differently, understanding that “we can’t always be in control.” This new self-understanding also altered her attitude in relation to helping others, in that she no longer saw recipients of help as “being weaker or inferior,” recognizing instead that “sometimes people just need support and that’s just it.”

Discussion

Women with BC in this study experienced emotional strain in relation to social support. Their narratives of social support demonstrated that it can be difficult to admit to others that social support can be stressful, unwanted, or burdensome. In stressful social support situations, women in this study used a set of strategies that included avoiding interactions, controlling information, and using cognitive reframing strategies (e.g., redefining the roles of others, themselves, or the situation). These strategies helped them to avoid increased emotional strain and allowed them to maintain a sense of dignity and self-esteem and, for some, a positive transformation.

Our direct question about experiencing burden in relation to social support provided additional insight into the difficulty of discussing emotional strain and burden in relation to social support. Only 30% answered “yes” directly in response to the burden question and 57% directly answered “no.” Yet, when we took into account those who answered indirectly as well as when burden, emotional strain, or a strategy were discussed at some point in the interview, we found that 70% acknowledged burden or difficulty. The difficulty in discussing it is evidenced in women’s narratives to develop strategies of avoidance, controlling information, using go-betweens, and not wanting to appear ungrateful as well as their reluctance to directly answer the burden question. Future research should attend to cultural norms and ways of talking about social support that may contribute to this difficulty, especially in so-called pink-ribbon culture.

Even when women’s health is impaired, there are still pressures on them to care for others (Thomeer et al., 2015). Hochschild noted that women experience the greater burden of the emotional labor in relationships due to social expectations based on gender norms (1983, 1989). These nurturant roles have been found to impair a woman’s ability to fully adopt the “sick role,” which allows one to step away from one’s obligations like nurturing others (Gove, 1984). This may be one explanation of why it is difficult to deny unsolicited social support as there is pressure on women to help others feel positive about their efforts. Among close relationships, marriage has been noted as a primary stressor during illness in mid- to later life (Taylor & Aspinwall, 1996). This may provide some insight into why women who discussed burden, emotional strain, and strategies to navigate social support as a group were more likely to be married (67%) than those who never discussed burden or emotional strain (50%), especially when there might be a lack of support from that partner. Future qualitative studies should explore women’s experiences of pressure to accept support and seek to understand why burden was experienced in a specific relationship or situation. Doing so could shed light on experiences of obligation within the history and nature of the relationship.

Interviewees in our study managed emotions in the context of social support through cognitive reframing. Past studies have demonstrated the value of cognitive reframing and other active coping strategies for BC patients (Kim et al., 2010). We used open-ended questions in a semi-structured format to allow women with BC to articulate their own strategies of reframing. We were able to categorize these as redefining the roles of others (or role reversal), situations, and self. Qualitative studies such as ours add to the literature by bringing attention to different types of cognitive reframing among specific demographics of women with BC that may be further investigated (Ching et al., 2009). In addition, our study complements studies that examine “how social support is managed within a network” (Faw, 2014, p. 267). In contrast to Faw’s (2014) study focusing on how people “activate support,” our interviewees discussed how it can be “deactivated” (or avoided).

There were also disease- or illness-specific factors in these situations (Charmaz, 1993; Kroenke et al., 2013). One of the illness-specific factors was the time since diagnosis, which was approximately 5.5 years between the diagnosis date and the interview. It is also possible that factors such as age or life stage influenced interviewees’ perspectives. Lewis et al.’s study of women with metastatic BC pointed to age and life stage as a factor that influenced the type of strategy chosen to achieve greater well-being (2016).

The narratives of women in this study led us to question some of the conventional wisdom in BC culture about sharing one’s experience. Cordova et al. (2001) and Boinon et al. (2014) focused on the mental health benefits of sharing information about one’s illness with others. Their studies demonstrate that lack of sharing can lead to psychological distress. In our study, participants chose not to share information to avoid emotional strain or additional emotion work. There is a rich history of research that examines the benefits of withholding information to influence others’ impressions (Goffman, 1986) and is reflected in more recent studies of women with BC (Lewis et al., 2016) and chronic illness (Åsbring & Närvänen, 2004). We did not look specifically at the effects of this behavior over time or its correlation to measures of well-being; however, some of our participants’ narratives cast doubt on the notion that not sharing is necessarily harmful.

Women who used cognitive reframing strategies often recalled their experiences as positive. One explanation of this tendency may be related to their educational level. Women who opted into the interview portion of this study had a higher frequency of postgraduate degrees (38% vs. 22%) and lower frequency of some college or less (38% vs. 44%) than those who did not opt in. Higher levels of education correlate with higher levels of well-being and health (Barr, 2014). Drageset and Lindstrøm (2005) found a positive correlation between higher education and social support in women with BC in Norway given that increased education lead to broader and more long-lasting social networks.

Unsolicited social support often relates to negative psychological effects in the recipient (Deelstra et al., 2003; Song & Chen, 2014). However, we found that in some cases, participants embraced and appreciated unsolicited social support. The social support offered in these situations was instrumental but involved a positive emotional bond among friends and family. Situations and relationships wherein unsolicited social support occurs merits further investigation and so do cultural norms of social support that may be evident within BC culture.

Perceptions and experience of BC within specific racial and ethnic groups deserves more attention in future studies of social support. Only one out of the four African American women who opted to be interviewed discussed emotional strain or burden in relation to social support. This is suggestive and worth examining further because it may point to racial differences in discussing social support. Some African American women perceive BC as a White woman’s disease, which contributes to the awkwardness of discussing it (Moore, 2001). Moore (2001) pointed out that there is little understanding of African American women’s unique lived experiences of BC including that some believe that even asking for help is a sign of weakness to be avoided. If that is the case, it is possible that they may be less likely to discuss stress around receiving social support.

Our qualitative study, while not representative of all women with BC, supplements existing social support literature by focusing on women’s experiences of illness, the meanings it holds for them, the ways it alters or changes their relationships with others, and how it affects their lives and perceptions of themselves. Our study is a snapshot and did not follow the interviewees over time. Follow-up interviews would have provided opportunities to ask more questions about their experiences of emotional strain, emotion work, and strategies.

Considering our phenomenological approach to interviewing, we recognize how the burden question is leading and closed and believe that it should have been phrased differently. However, this mistake also provided an interesting insight into the avoidance of addressing burden in relation to social support directly. Understanding more about this reluctance could have practical application for those offering social support. Knowing that other women have felt such a burden could be useful to women with BC.

Another limitation of this study was that there were no “member checks,” which involve checking back with participants to confirm that the researcher’s representation of their experience is valid (Usher & Jackson, 2014). This would have provided an additional check on the quality and rigor of the study.

We believe that this study provides practical information for patients and providers. Importantly, it demonstrates to women with BC that it is not unusual to have difficulty in accepting social support. The strategies discussed by interviewees may also serve as practical tools. For instance, other women with BC may benefit from leveraging go-betweens and electronic media to communicate health information and function as gatekeepers of social interactions, thereby alleviating emotional strain.

Supplemental Material

sj-docx-1-qhr-10.1177_1049732321989999 – Supplemental material for “I Had to Make Them Feel at Ease”: Narrative Accounts of How Women With Breast Cancer Navigate Social Support

Supplemental material, sj-docx-1-qhr-10.1177_1049732321989999 for “I Had to Make Them Feel at Ease”: Narrative Accounts of How Women With Breast Cancer Navigate Social Support by Jaime D. Wright, Candyce H. Kroenke, Marilyn L. Kwan and Lawrence H. Kushi in Qualitative Health Research

Footnotes

Acknowledgements

We thank all Pathways Study participants for their numerous contributions to this study. The authors thank office and field staff for assistance in data collection, processing, and preparation. We offer a special thanks to Janise M. Roh and Isaac J. Ergas for their roles as Pathways project manager and programmer, respectively.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Pathways Study is supported by the National Cancer Institute at the National Institutes of Health (R01 CA105274, PI: Kushi LH; U01 CA195565, PIs: Kushi LH, Ambrosone CB). Candyce H. Kroenke’s time was supported by the American Cancer Society (PI: Kroenke, RSG-16-167-01-CPPB) and by the National Cancer Institute at the National Institutes of Health (PI: Kroenke, K07CA187403).

ORCID iD

Jaime D. Wright

Supplemental Material

Supplemental Material for this article is available online at .

Notes

Author Biographies

Jaime D. Wright, PhD, is an adjunct lecturer in the Religious Studies Department at Santa Clara University. His research focuses on lived experiences of religion and medicine, and spatial based learning.

Candyce H. Kroenke, MPH, ScD, is a research scientist at the Division of Research, Kaiser Permanente Northern California.

Marilyn L. Kwan, PhD, is a senior research scientist at the Division of Research, Kaiser Permanente Northern California.

Lawrence H. Kushi, ScD, is Director of Scientific Policy at the Division of Research, Kaiser Permanente Northern California.

References

Adams

van Manen

(2008). Phenomenology. In Given

(Ed.), The SAGE encyclopedia of qualitative research methods (pp. 615–619). SAGE. http://doi.org/10.4135/9781412963909

Arora

N. K.

Rutten

L. J. F.

Gustafson

D. H.

Moser

Hawkins

R. P.

(2007). Perceived helpfulness and impact of social support provided by family, friends, and health care providers to women newly diagnosed with breast cancer. Psycho-Oncology, 16(5), 474–486. https://doi.org/10.1002/pon.1084

Åsbring

Närvänen

A.-L.

(2004). Patient power and control: A study of women with uncertain illness trajectories. Qualitative Health Research, 14(2), 226–240. https://doi.org/10.1177/1049732303260682

Barr

D. A.

(2014). Health disparities in the United States. Johns Hopkins University Press.

Boinon

Sultan

Charles

Stulz

Guillemeau

Delaloge

Dauchy

(2014). Changes in psychological adjustment over course of treatment for breast cancer: The predictive role of social sharing and social support. Psycho-Oncology, 23(3), 291–298. https://doi.org/10.1002/pon.3420

Bury

(1991). The sociology of chronic illness: A review of research and prospects. Sociology of Health & Illness, 13, 451–468. https://doi.org/10.1111/j.1467-9566.1991.tb00522.x

Charmaz

K. C.

(1993). Good days, bad days: The self and chronic illness in time. Rutgers University Press.

Ching

S. S. Y.

Martinson

I. M.

Wong

T. K. S.

(2009). Reframing: Psychological adjustment of Chinese women at the beginning of the breast cancer experience. Qualitative Health Research, 19(3), 339–351. https://doi.org/10.1177/1049732309331867

Conrad

(1990). Qualitative research on chronic illness: A commentary on method and conceptual development. Social Science & Medicine, 30(11), 1257–1263. https://doi.org/10.1016/0277-9536(90)90266-U

10.

Copp

(1998). When emotion work is doomed to fail: Ideological and structural constraints on emotion management. Symbolic Interaction, 21(3), 299–328. https://doi.org/10.1525/si.1998.21.3.299

11.

Cordova

M. J.

Cunningham

L. L. C.

Carlson

C. R.

Andrykowski

M. A.

(2001). Social constraints, cognitive processing, and adjustment to breast cancer. Journal of Consulting and Clinical Psychology, 69(4), 706–711. https://doi.org/10.1037/0022-006X.69.4.706

12.

Davey

M. P.

Niño

Kissil

Ingram

(2012). African American Parents’ Experiences Navigating Breast Cancer While Caring for Their Children. Qualitative Health Research, 22(9), 1260–1270. https://doi.org/10.1177/1049732312449211

13.

Deelstra

J. T.

(2003). The downside of social support: About negative effects of receiving social support at work [Unpublished doctoral dissertation]. Utrecht University.

14.

Deelstra

J. T.

Peeters

M. C. W.

Schaufeli

W. B.

Stroebe

Zijlstra

F. R. H.

Van Doornen

L. P.

(2003). Receiving instrumental support at work: When help is not welcome. Journal of Applied Psychology, 88(2), 324–331. https://doi.org/10.1037/0021-9010.88.2.324

15.

Drageset

Lindstrøm

T. C.

(2005). Coping with a possible breast cancer diagnosis: Demographic factors and social support. Journal of Advanced Nursing, 51(3), 217–226. https://doi.org/10.1111/j.1365-2648.2005.03495.x

16.

Drageset

Lindstrøm

T. C.

Giske

Underlid

(2012). “The support I need”: Women’s experiences of social support after having received breast cancer diagnosis and awaiting surgery. Cancer Nursing, 35(6), E39–E47. https://doi.org/10.1097/NCC.0b013e31823634aa

17.

Ducharme

(1994). Conjugal support, coping behaviors, and psychological well-being of the elderly spouse: An empirical model. Research on Aging, 16(2), 167–190.

18.

Faw

M. H.

(2014). Young adults’ strategies for managing social support during weight-loss attempts. Qualitative Health Research, 24(2), 267–268. https://doi.org/10.1177/1049732313520079

19.

Fereday

Muir-Cochrane

(2006). Demonstrating rigor using thematic analysis: A hybrid approach of inductive and deductive coding and theme development. International Journal of Qualitative Methods, 5(1), 80–92. https://doi.org/10.1177/160940690600500107

20.

Gallant

M. P.

(2003). The influence of social support on chronic illness self-management: A review and directions for research. Health Education & Behavior, 30(2), 170–195. https://doi.org/10.1177/1090198102251030

21.

Gengler

A. M.

(2015). “He’s doing fine”: Hope work and emotional threat management among families of seriously ill children. Symbolic Interaction, 38(4), 611–630. https://doi.org/10.1002/symb.195

22.

Goffman

(1959). The presentation of self in everyday life. Anchor.

23.

Goffman

(1986). Stigma: Notes on the management of spoiled identity (Reissue ed.). Touchstone.

24.

Gove

W. R.

(1984). Gender differences in mental and physical illness: The effects of fixed roles and nurturant roles. Social Science & Medicine, 19(2), 77–91.

25.

Hirschman

K. B.

Bourjolly

J. N.

(2005). How do tangible supports impact the breast cancer experience? Social Work in Health Care, 41(1), 17–32. https://doi.org/10.1300/J010v41n01_02

26.

Hochschild

A. R.

(1979). Emotion work, feeling rules, and social structure. American Journal of Sociology, 85(3), 551–575.

27.

Hochschild

A. R.

(1983). The managed heart: Commercialization of human feeling. University of California Press.

28.

Hochschild

A. R.

Machung

(1989). The second shift: Working families and the revolution at home. Penguin Books.

29.

Houston

Mullan-Jensen

(2012). Towards depth and width in qualitative social work: Aligning interpretative phenomenological analysis with the theory of social domains. Qualitative Social Work: Research and Practice, 11(3), 266–281. https://doi.org/10.1177/1473325011400484

30.

Iannarino

N. T.

Scott

A. M.

Shaunfield

S. L.

(2017). Normative social support in young adult cancer survivors. Qualitative Health Research, 27(2), 271–284. https://doi.org/10.1177/1049732315627645

31.

Kim

Han

J. Y.

Shaw

McTavish

Gustafson

(2010). The roles of social support and coping strategies in predicting breast cancer patients’ emotional well-being. Journal of Health Psychology, 15(4), 543–552. https://doi.org/10.1177/1359105309355338

32.

King

Willoughby

Specht

J. A.

Brown

(2006). Social support processes and the adaptation of individuals with chronic disabilities. Qualitative Health Research, 16(7), 902–925. https://doi.org/10.1177/1049732306289920

33.

Kleinman

(1989). The illness narratives: Suffering, healing, and the human condition. Basic Books.

34.

Kornblith

A. B.

Herndon

J. E.

Zuckerman

Viscoli

C. M.

Horwitz

R. I.

Cooper

M. R.

Harris

Tkaczuk

K. H.

Perry

M. C.

Budman

Norton

L. C.

Holland

J. C.

(2001). Social support as a buffer to the psychological impact of stressful life events in women with breast cancer. Cancer, 91(2), 443–454.

35.

Kralik

Koch

Price

Howard

(2004). Chronic illness self-management: Taking action to create order. Journal of Clinical Nursing, 13(2), 259–267. https://doi.org/10.1046/j.1365-2702.2003.00826.x

36.

Kroenke

C. H.

Quesenberry

Kwan

M. L.

Sweeney

Castillo

Caan

B. J.

(2013). Social networks, social support, and burden in relationships, and mortality after breast cancer diagnosis in the Life After Breast Cancer Epidemiology (LACE) Study. Breast Cancer Research and Treatment, 137(1), 261–271. https://10.1007/s10549-012-2253-8

37.

Kwan

M. L.

Ambrosone

C. B.

Lee

M. M.

Barlow

Krathwohl

S. E.

Ergas

I. J.

Ashley

C. H.

Bittner

J. R.

Darbinian

Stronach

Caan

B. J.

Davis

Kutner

S. E.

Quesenberry

C. P.

Somkin

C. P.

Sternfeld

Wiencke

J. K.

Zheng

Kushi

L. H.

(2008). The pathways study: A prospective study of breast cancer survivorship within Kaiser Permanente Northern California. Cancer Causes & Control, 19(10), 1065–1076. https://10.1007/s10552-008-9170-5

38.

Lakey

Cohen

(2000). Social support theory and measurement. In Cohen

Underwood

L. G.

Gottlieb

B. H.

(Eds.), Social support measurement and intervention (pp. 29–52). Oxford University Press. https://doi.org/10.1093/med:psych/9780195126709.003.0002

39.

Lewis

Willis

Yee

Kilbreath

(2016). Living well? Strategies used by women living with metastatic breast cancer. Qualitative Health Research, 26(9), 1167–1179. https://doi.org/10.1177/1049732315591787

40.

Moore

R. J.

(2001). African American women and breast cancer: Notes from a study of narrative. Cancer Nursing, 24(1), 35–42. https://doi.org/10.1097/00002820-200102000-00006

41.

Osborne

J. W.

(1994). Some similarities and differences among phenomenological and other methods of psychological qualitative research. Canadian Psychology/Psychologie Canadienne, 35(2), 167–189.

42.

Sammarco

(2001). Perceived social support, uncertainty, and quality of life of younger breast cancer survivors. Cancer Nursing, 24(3), 212–219. https://doi.org/10.1097/00002820-200106000-00007

43.

Sandstrom

K. L.

Lively

K. J.

Martin

D. D.

Fine

G. A.

(2013). Symbols, selves, and social reality: A symbolic interactionist approach to social psychology and sociology. Oxford University Press.

44.

Seeman

T. E.

(1983). Health behavior and personal autonomy: A longitudinal study of the sense of control in illness. Journal of Health and Social Behavior, 24(2), 144–160.

45.

Shenk

(1991). Older rural women as recipients and providers of social support. Journal of Aging Studies, 5(4), 347–358. https://doi.org/10.1016/0890-4065(91)90015-k

46.

Shumaker

S. A.

Brownell

(1984). Toward a theory of social support: Closing conceptual gaps. Journal of Social Issues, 40(4), 11–36. https://doi.org/10.1111/j.1540-4560.1984.tb01105.x

47.

Song

Chen

(2014). Does receiving unsolicited support help or hurt? Receipt of unsolicited job leads and depression. Journal of Health and Social Behavior, 55(2), 144–160. https://doi.org/10.1177/0022146514532816

48.

Spiegel

(1997). Psychosocial aspects of breast cancer treatment. Seminars in Oncology, 24(Suppl. 1), S1-36–S1-47.

49.

Taylor

S. E.

Aspinwall

L. G.

(1996). Psychosocial aspects of chronic illness. In Costa

P. T.

VandenBos

G. R.

(Eds.), Psychosocial aspects of serious illness: Chronic conditions, fatal diseases, and clinical care (pp. 7–60). American Psychological Association.

50.

Thoits

P. A.

(1995). Stress, coping, and social support processes: Where are we? What next? Journal of Health and Social Behavior, 35, 53–79. https://doi.org/10.2307/2626957

51.

Thomeer

M. B.

Reczek

Umberson

(2015). Gendered emotion work around physical health problems in mid- and later-life marriages. Journal of Aging Studies, 32, 12–22. https://doi.org/10.1016/j.jaging.2014.12.001

52.

Uchino

B. N.

Carlisle

Birmingham

Vaughn

A. A.

(2011). Social support and the reactivity hypothesis: Conceptual issues in examining the efficacy of received support during acute psychological stress. Biological Psychology, 86(2), 137–142. https://doi.org/10.1016/j.biopsycho.2010.04.003

53.

Usher

Jackson

(2014). Phenomenology. In Mills

Birks

(Eds.), Qualitative methodology: A practical guide (pp. 181–198). SAGE. https://doi.org/10.4135/9781473920163

54.

Vilhauer

R. P.

(2008). A qualitative study of the experiences of women with metastatic breast cancer. Palliative & Supportive Care, 6, 249–258. https://doi.org/10.4135/9781473920163

55.

Williams

Barclay

Schmied

(2004). Defining social support in context: A necessary step in improving research, intervention, and practice. Qualitative Health Research, 14(7), 942–960. https://doi.org/10.1177/1049732304266997

56.

Wills

T. A.

Shinar

(2000). Measuring perceived and received social support. In Cohen

Underwood

L. G.

Gottlieb

B. H.

(Eds.), Social support measurement and intervention: A guide for health and social scientists (pp. 86–135). Oxford University Press. https://doi.org/10.1093/med:psych/9780195126709.003.0004

57.

Zerubavel

(1993). The fine line: Making distinctions in everyday life. University of Chicago Press.

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