“They Understand What You’re Going Through”: Experientially Similar Others,Anticipatory Stress,and Depressive Symptoms

Abstract

Past research demonstrates that experientially similar others—people who have confronted the same stressor or who occupy the same social role—are uniquely equipped to provide empathic understanding and tailored coping strategies to individuals navigating comparable, taxing circumstances. Using the case of premedical education, fixed-effects regression analyses of egocentric network data (N = 286) indicate that premeds whose support networks include a greater proportion of premedical peers over time experience fewer depressive symptoms. However, among premeds who report greater anticipatory stress about failing to achieve medical school admission, the presence of additional peers in support networks strengthens the detrimental effects of anticipatory stress. Qualitative data (n = 39) shed light on this empirical puzzle. Although peers offer a broad spectrum of support functions, they can also accentuate stressors or serve as a basis for negative social comparison. These findings introduce new considerations for theorizing the role of similar other support in the stress process.

Keywords

experientially similar support experiential homophily the stress process egocentric networks depressive symptoms anticipatory stress

The relationship between social support and positive mental health is one of the most extensively documented and widely accepted associations in the social sciences (Berkman et al. 2000; Thoits 2011; Umberson, Crosnoe, and Reczek 2010). Conceptually, social support encapsulates an individual’s belief that she or he is loved, esteemed, and able to count on others during times of need (Turner and Turner 2013). Thoits’ (1986, 2011) theoretical and empirical work usefully delineates between two types of supporters: significant others and similar others. Most research grounded in the stress process focuses on the former; primary group members including family, friends, and romantic partners. By contrast, similar others are secondary group members who are facing, or who have faced, the same taxing circumstances that presently confront a distressed individual. Thoits (2011) contends that the emotional support and coping assistance provided by significant others differs from the support provided by similar others. While significant others offer unconditional love and concern, similar others are uniquely positioned to provide empathic understanding. Whereas significant others supply generalized instrumental aid (e.g., financial assistance), similar others provide advice on potentially effective coping strategies informed by their own experiences combatting the same stressor. To date, research that has taken seriously the distinction between these supporters finds evidence that people who confront traumatic life events and chronic stressors—ranging from bereavement (Suitor and Pillemer 2000) to surgical recovery (Thoits et al. 2000) to caring for an ill family member (Gage 2013)—benefit considerably from the support offered by experientially similar others.

Although the receipt of support from similar others is associated with greater life satisfaction and reduced psychological distress (Lim and Putnam 2010; Thoits et al. 2000), the view that these relationships offer unmitigated benefits for mental health is contravened by recent research that illuminates how similar others can also create difficulties for people (Ellison and Lee 2010; Krause et al. 2000; McConnell 2017) or serve as a basis for negative social comparisons (Gage 2013). In order to contribute to a deeper understanding of the complexities of relationships with experientially similar others, in this study I examine the case of premedical education. The literature on similar other support suggests that premedical students are ideally situated to help their fellow premeds cope with the distinctive stressors they face. However, research also suggests that these students are more inclined to reach out to family, friends, and romantic partners for assistance than their classmates (Klink, Byars-Winston, and Bakken 2008). This reluctance to share with other premedical students makes sense given the uneasy climate found in premedical education—a circumstance fostered by competition among students for one of a limited number of medical school seats during an application cycle (Conrad 1986; Lin et al. 2014). Consequently, while research on similar other support indicates that premeds who invest in friendships with their peers should reap psychological benefits from the empathic understanding and instrumental support they provide, the sometimes-thorny relationships found among premeds hint that these peers might also amplify the threat posed by failure to achieve medical school admission and, in turn, prove detrimental to mental health and well-being.

To provide a window on the interrelationships among experientially similar support, anticipatory stress, and depressive symptoms, in this article I use longitudinal egocentric network data and in-depth interviews conducted with first- and second-year undergraduates as part of a prospective study of premedical students. These data provide analytic leverage to investigate three interrelated questions: (1) Is within-individual change in the proportion of experientially similar others in support networks associated with depressive symptoms? (2) Does the presence of additional similar others in support networks over time buffer or exacerbate the positive associations between anticipatory stress and depressive symptoms? And (3) what mechanisms explain the buffering or exacerbating effects of experientially similar support?

Background

The Complexities of Experientially Similar Support

While studies of social support frequently focus on the caring and assistance provided by primary group members like close friends and family, experientially similar others need not be particularly close to an individual, they are simply those who have navigated, or are currently facing, the same life stressor (Thoits 1986, 2011). Due to their intimate knowledge of a stressor, similar others can validate a person’s feelings about the stressor that significant others are unable to understand, help reframe the threat posed by the stressor, or provide a safe space for ventilating emotional reactions that a person may be too embarrassed or ashamed to share with significant others (Thoits 2011). Similar others can also provide tailored, context-specific advice (as a result of their own trial-and-error learning) or, through role modeling, provide inspiration that a stressor can be successfully parried. A variety of research has shown that when confronted by a stressor, people often reach out to those with the same experience: Individuals with chronic ailments contact others with the same condition (Barker 2008), those grieving the loss of a loved one lean on people who have also been through the bereavement process (Suitor and Pillemer 2000), and those providing care for an ill family member seek aid from other caregivers (Gage 2013; Gage-Bouchard et al. 2015). This coping aid from similar others has been linked to improvements in subjective well-being and reductions in psychological distress (Lim and Putnam 2010; Thoits et al. 2000).

The view that social connectivity is wholly beneficial for mental health is contradicted by recent evidence on the “dark side” of social ties (Baller and Richardson 2009; Umberson and Montez 2010). Despite being well-intentioned, supportive ties may offer uninformed advice or call attention to a person’s negative emotional state (Bolger, Zuckerman, and Kessler 2000). Ties may also entail costs, such as an obligation to reciprocate support (Offer and Fischer 2017). It follows that exchanges with similar others are not universally positive. For example, Desmond and Travis (2018) found that among low-income Milwaukee renters, supportive ties to other low-income residents were associated with greater exposure to others’ trauma, which in turn nullified feelings of political efficacy also fostered by these relationships. Other research on experientially similar others embedded in institutions ranging from the mental health treatment system (McConnell 2017) to religious organizations (Ellison and Lee 2010; Krause et al. 2000) indicate that in addition to providing empathy and compassion, similar others can also create problems for people. These individuals might intensify the threat posed by a stressor by discussing it incessantly or exaggerating its negative consequences. In a similar vein, while social comparisons to similar others may inspire hope that one can surmount a given stressor, if a person feels they are incapable of achieving the same level of coping success, it can engender feelings of pessimism or a sense of inadequacy. For example, in her study of parents coping with pediatric cancer, Gage (2013) found that some parents experienced emotional upset when they compared their situation to parents whose children were more responsive to treatment. Thus, while experientially similar others provide a wide array of support that functions to protect mental health, support from similar others may also magnify a stressor.

Vital to the stress process is the notion that social and psychological resources, including perceptions of social support, can be deployed to offset the pernicious effects of stressors (Thoits 2011; Turner and Turner 2013). Support acts on mental health in at least two ways: first, by bolstering an individual’s mental state, and second, by “buffering” one’s mental health against the vicissitudes of life. While multiple studies demonstrate a robust inverse association between perceptions of support and psychological distress (Bolger et al. 2000; Grace and VanHeuvelen 2015; Schnittker 2012), findings regarding the moderating effects of support on the relationship between stressors and mental health have been less consistent (Aneshensel 1982; Donnelly, Robinson, and Umberson 2019; Ducharme and Martin 2000; Schafer and Koltai 2015). Furthermore, although scholars have examined how the buffering effects of different forms of support (e.g., affective, instrumental) are contingent on the type of stressor one confronts (Cohen and McKay 1984; Cohen and Wills 1985), less research has examined how these effects might hinge on who provides it. To this end, the present study takes as its analytic focus a relationship that to date has received little empirical scrutiny: whether and how experientially similar support moderates the detrimental effects of anticipatory stress on mental health.

Fear of Failure as an Anticipatory Stressor

As people contemplate the future, they may consider the possibility of experiencing stressful events or undesirable outcomes. For instance, a person might worry about losing their job, the sudden death of a family member, or being the victim of a violent crime. These concerns, known as anticipatory stressors in the stress process, are the worries that people have about the future that have not occurred—and may never—but which nevertheless loom as potential threats (Pearlin and Bierman 2013). Across the variety of stressors that comprise the “stress universe” (Wheaton 1994; Wheaton et al. 2013), a limited body of research has addressed the associations between anticipatory stressors and mental health. Two notable exceptions, however, can be found in the literature on minority stress and goal-striving stress.

Research on the health and wellbeing of racial/ethnic and sexual minorities finds that members of these groups report higher levels of vigilance and are more likely to anticipate experiences of discrimination and social rejection than majority group members (Hicken et al. 2014; Lu, LeBlanc, and Frost 2019; Thomeer et al. 2018). These circumstances pose deleterious consequences for the mental and physical health of these groups, having been linked to weight gain, elevated rates of hypertension, and greater depressive symptomology (Hicken et al. 2014; Hicken, Lee, and King 2017; Lee and Hicken 2017). But while hyper-vigilance and expectations of social rejection are anticipatory stressors unique to minority group members, anticipatory stress is an animating concept with broad applications beyond this specific case. The literature on goal-striving stress is particularly instructive in this regard.

Deeply embedded in the fabric of American society is a near-compulsion to continuously strive for success (Merton 1968). Yet the notion that one’s aspirations can be realized with sufficient effort conflicts with the reality that a person’s life chances are sharply constrained by structural forces (Weber 1921). In the social science literature, the tension between a person’s present circumstances and future ambitions is referred to as goal-striving stress (Kleiner and Parker 1963; Parker and Kleiner 1966) or aspiration strain (DeAngelis and Ellison 2018; Zhang et al. 2014). As operationalized by Parker and Kleiner (1966), goal-striving stress is the discrepancy between a person’s aspirations and current achievements, weighted by her or his subjective evaluation of her or his likelihood of goal-attainment and the relative salience of that goal to the individual. It is theorized that individuals with excessive goal-striving stress internalize their inability to achieve success, which produces feelings of worthlessness, inferiority, and poor mental health (Kleiner and Parker 1963). Consistent with this theorizing, a sizable literature finds that higher levels of goal-striving stress are connected to elevated depressive symptoms and psychological distress (DeAngelis and Ellison 2018; Neighbors et al. 2011; Sellers and Neighbors 2008; Sellers, Neighbors, and Bonham 2011).

Goal-striving stress and aspiration strain are future-oriented stressors that capture the tension between an individual’s current social standing and her or his future aspirations (Zhang et al. 2014)—a strain often rooted in the experience of “non-events” or unmet expectations (Mossakowski 2011). Yet people who have not yet had the opportunity to even attempt goal-attainment may experience trepidation about failing to fulfill their ambitions in the distant future. Analogous to theorizing on goal-striving stress (Kleiner and Parker 1963; Parker and Kleiner 1966), whether or not a person ultimately experiences failure, persistent rumination on the possibility of not attaining one’s goals may induce feelings of hopelessness and diminished self-concept. Consequently, there is reason to suspect that this circumstance fosters depressive symptoms among individuals who fixate on the possibility of experiencing failure in the future.

The Interplay between Experientially Similar Support and Anticipatory Stress: The Case of Premedical Education

Premedical education provides an informative case for tracing the associations among experientially similar support, anticipatory stress, and mental health. At most colleges in the United States, students who intend to apply to medical school do not declare a “premedical” concentration but rather indicate an interest in attending medical school to their undergraduate institution during the application process. The courses required by medical schools vary slightly across institution, but most mandate the completion of eight to ten core courses in chemistry, biology, physics, and mathematics. Medical school admission hinges on more than the simple completion of this course sequence. It entails securing top grades in coursework, attaining high scores on the MCAT, and cultivating a résumé replete with extracurricular activities and lab experience.

A fear of failure is highly salient among premedical students. Indeed, the prospect of not achieving medical school admission would thwart an ambition that for many premeds is forged long before college enrollment (Schafer 1973). Throughout their undergraduate careers, premeds continually reevaluate their likelihood of getting into medical school in light of the academic obstacles they face (Lin et al. 2014). This process not only involves one’s current grades but also projections about future performance in coursework and on the MCAT. Given that fewer than half of applicants to American medical schools are accepted—a number that does not include the multitude of students who leave at points preceding application—the looming threat of not achieving medical school admission is a palpable and realistic fear for many premeds.

The literature on similar other support suggests that premedical peers are well-suited to help students cope with the stressors inherent to the premed process. Peers can provide instrumental aid by helping with assignments and lab reports or serve as partners in commiseration—people who thoroughly understand the social life sacrifices and pressures that are part and parcel of premedical studies. Yet, when asked to identify their primary sources of support, premeds frequently name family members, friends, and romantic partners (Klink et al. 2008). That premeds were substantially less likely to nominate their classmates than other relations is unsurprising given the pervasive competition characteristic of the premedical track (Lin et al. 2014). Although the myth of conniving premeds who actively sabotage their peers has been debunked, a combination of the premed track’s structure—characterized by “weeder” courses that rank-order students’ performances—and an oversupply of students vying for a limited number of medical school seats each year nevertheless spurs on competition among premed students (Conrad 1986; Lin et al. 2014).

Connections to peers thus pose two contrasting possibilities for mental health. On the one hand, peers may safeguard mental health by providing tangible coping advice or by validating concerns one has about getting into medical school. On the other hand, in the absence of clear objective criteria to evaluate one’s progress on the premed track, high-achieving peers may come to serve as a basis for upward social comparisons (Festinger 1968; Gage 2013). These contrasts may lead to unfavorable self-appraisals of academic performance and one’s prospects of medical school admission, in turn fostering self-doubt and depressive symptomology (Festinger 1968; Hyman 1968). Peers might also amplify stress by drawing attention to unforeseen medical school requirements or hyperbolically elaborating on the negative consequences of failing to achieve medical school admission. In light of these potentially divergent outcomes, premedical education serves as a useful case to examine the complexities of relationships with experientially similar others and their consequences for mental health.

Methods

Site and Quantitative Sample

Survey data were collected from freshman and sophomore premedical students at Midwest University (MU), a flagship research institution in the Midwestern United States. All first- and second-year undergraduates at MU on the premedical advising department’s e-mail listserv were invited to participate in the online survey. The initial study invitation was sent three weeks into the fall semester of 2015, and students were offered a modest honorarium ($10 Amazon gift card) for their participation. To supplement recruitment, premeds were also recruited from five introductory sociology classes at MU and granted extra credit in these courses in return for their participation (this effort yielded <11 percent of the sample). Three hundred and ninety of 2,853 first- and second-year premedical students at MU participated for a response rate of 13.7 percent. Although this response rate is not unusually low for studies using similar sampling strategies (Galea and Tracy, 2007), it nevertheless limits the generalizability of the findings presented here. I elaborate on this issue further in the Discussion section.

Respondents were invited to participate in a follow-up survey administered three and a half weeks prior to the end of the 2016 spring semester. Two hundred and ninety-two respondents elected to participate in the follow-up survey, for a retention rate of roughly 75 percent. Because the elimination of cases with missing data at either survey wave would have reduced the analytic sample to 272 respondents, multiple imputation procedures were employed to retain respondents with missing values on time-varying measures. Regression equations for missing data were imputed into twenty datasets using all outcome and predictor variables. Following imputation, respondents who initially had missing values on the study’s dependent variable were removed (n = 6), leaving a final sample of 286 (von Hippel 2007).

Table 1 provides descriptive statistics for the analytic sample. The sample is majority female, with women comprising 69 percent of respondents. Although MU does not keep statistics on the demographic composition of each incoming cohort of premed students, the most recent unofficial census conducted by the pre-health advising department in 2010 found that the freshman cohort was 54 percent female, indicating that women are over-represented in this study. Fifty-seven percent of respondents are freshmen, and 43 percent are sophomores. The majority of respondents are non-Hispanic white (70 percent), 8 percent are Black, 11 percent are Asian American, 8 percent are Hispanic, and 3 percent identify as American Indian, Alaska Native, or multiracial (non-Hispanic). The unofficial census conducted by the university in 2010 indicated that the sample is similar to the distribution of premedical students by race/ethnicity. Descriptive statistics for all time-varying measures can also be found in Table 1.

Table 1.

Descriptive Statistics for Survey (N = 286) and In-Depth Interview Samples (n = 39).

Quantitative Sample (N = 286)
	Wave	Mean (%)	SD	Range
Sex
Male		(31)		0, 1
Female		(69)		0, 1
Class year
Sophomore		(43)		0, 1
Freshman		(57)		0, 1
Race/Ethnicity
White		(70)		0, 1
Black		(8)		0, 1
Asian American		(11)		0, 1
Hispanic		(8)		0, 1
American Indian / Alaska Native / Non-Hispanic multiracial		(3)		0, 1
Socioeconomic status
Median neighborhood income		66,764	25,435	27,618-201,354
First-generation college student		(20)		0, 1
Attended private high school		(11)		0, 1
Mental health
Depressive symptoms	W1	6.86	4.33	0-21
	W2	8.39	4.72	0-21
Support network^a
% Premed	W1	4.93	15.07	0-100
	W2	4.57	15.04	0-100
% Family	W1	32.89	31.85	0-100
	W2	34.08	33.01	0-100
% Friends – home	W1	29.43	29.73	0-100
	W2	25.28	28.49	0-100
% Friends - Midwest University	W1	18.00	25.91	0-100
	W2	24.13	30.03	0-100
% Faculty/staff – Midwest University	W1	5.45	18.80	0-100
	W2	3.51	13.73	0-100
% Co-workers	W1	0.14	1.50	0-20
	W2	0.23	2.10	0-25
Size	W1	5.15	4.77	0-25
	W2	4.60	4.04	0-25
% Same sex	W1	60.39	31.46	0-100
	W2	61.44	32.83	0-100
% Same race	W1	71.25	37.89	0-100
	W2	72.00	36.28	0-100
Mean contact (1 = daily/every few days)	W1	0.63	0.48	0, 1
	W2	0.70	0.46	0, 1
Anticipatory stress
Fear of medical school admission failure	W1	5.95	1.57	2-8
	W2	5.99	1.55	2-8
Qualitative Sample (n = 39)
	%	N
Sex
Male	28	11
Female	72	28
Class year
Freshman	51	20
Sophomore	49	19
Race/ethnicity
White	59	23
Asian American	15	6
Black	15	6
Hispanic	8	3
American Indian/Alaska Native	3	1

Relationship composition measures do not sum to 100% due to the number of respondents who reported support networks with zero alters (n = 25 at Wave 1; n = 23 at Wave 2). W1 = Wave 1 (Fall 2015); W2 = Wave 2 (Spring 2016).

Depressive Symptoms

Depressive symptomology was measured using the Center for Epidemiologic Studies of Depression Scale (CES-D) seven-item short form (Levine 2013; Radloff 1977). These items ask respondents to identify how frequently during the past month they experienced a lack of appetite, trouble paying attention, feelings of depression, the feeling that everything was an effort, sadness, restless sleep, and an inability to ‘get going’. Potential responses range from (0) rarely or none of the time to (3) most or all the time. Responses were summed across the items that comprise the scale (α = .82 for Wave 1, α = .84 for Wave 2).

Experientially Similar Support

To assess the presence of experientially similar others in respondents’ support networks, a name generator was used, which asked “If you were having personal problems at school, with whom would you feel comfortable talking about these issues?” Respondents could nominate up to 25 network alters. This item gauges respondents’perceptions of social support, or belief that they could seek assistance from these individuals in the face of adversity (Krause 1997). Following ascertainment of a respondent’s support network roster, a series of follow-up questions were used to elicit greater detail about network members. The first item asked, “What is your relationship to each person you named?” This question was used to determine the percentage of respondents’ support networks comprised of premedical peers, family members, friends from home, friends from MU, faculty/staff members at MU, and co-workers (created by dividing the number of members belonging to each group by the respondents’ total network size and multiplying by 100). The percentage of premeds in respondents’ networks represents the proportion of similar others in their support system.

Respondents were also asked to report demographic information for each network alter and how frequently they were in contact with each person. A series of support network measures were derived from responses to these items. To account for network homophily (McPherson, Smith-Lovin, and Cook 2001; Smith, McPherson, and Smith-Lovin 2014), adjustments were made for the proportion of respondents’ support systems comprised of same-sex and same-race alters. Frequency of contact, ranging from (1) less than once a month to (5) daily, was averaged across alters and subsequently binarized to capture those who spoke to members of their support network, on average, every few days or more (1 = daily/every few days). A log-transformed version of network size is also included in regression models.

Anticipatory Stress

Respondents’ fear of failing to achieve medical school admission is measured by a two-item additive index (α = .79 for Wave 1, α = .79 for Wave 2). These items asked respondents the extent to which they agreed with the following statements: “I often worry that I will not do well enough on the MCAT to gain admission to medical school” and “I often worry that my grades in premed classes will prevent me from gaining admission to medical school.” Possible responses to these items range from (1) strongly disagree to (4) strongly agree.

Analytic Plan: Quantitative Analyses

Regression analyses utilize a fixed-effects framework. Relative to other methods, fixed-effects models provide greater insight into causal processes by removing the confounding effects of all stable respondent characteristics whether or not they are observed (Halaby 2004). Substantively, in these models each respondent serves as her or his own control to identify how within-individual change in similar other support associates with changes in depressive symptoms. The use of fixed-effects models was further substantiated by Hausman test results (p <. 05) comparing coefficients from random- and fixed-effects models where depressive symptoms were regressed on support network characteristics. These test results indicated a plausible correlation between the error term and explanatory variables, representing a violation of the strict exogeneity assumption. The general form of the fixed-effects model used in regression analyses is as follows:

\begin{matrix} y_{it} - {\bar{y}}_{i} = β ({X^{ı}}_{it} - {\bar{X}}^{ı}_{it}) + (c_{i} - {\bar{c}}_{i}) \\ + (u_{it} - {\bar{u}}_{i}), t = 2015, 2016, \end{matrix}

where y_it is depressive symptoms for individual i at time t, x_it is a vector of explanatory variables, c_i is an unobserved effect present across periods but constant over time, and u_it is an idiosyncratic error term. It must be emphasized that despite their many advantages, fixed-effects models are not a panacea for addressing issues of causality or endogeneity. The implications of these methodological limitations for study findings are addressed further in the discussion section.

Two additional statistical adjustments require comment. Recall that women are overrepresented in the sample relative to the 2010 census of incoming premeds at MU. To account for this discrepancy, post-stratification weights are used in all regression analyses so that the gender composition of the sample more closely mirrors that of a typical premedical cohort. Second, inverse probability weighting is used to adjust for bias stemming from the loss of respondents to follow-up (Wooldridge 2010). This process assigns greater weight to the information provided by respondents who were probabilistically the least likely to participate in the follow-up survey (the logit model used to create these weights can be found in Appendix A).

Interview Data

To more fully grasp how social relationships influence students’ premedical track experiences, I conducted semi-structured, in-depth interviews during the summer of 2016 with respondents who participated in both survey waves. A quota sampling approach was used to interview respondents who represented the different combinations of class year, sex, and racial/ethnic background in the study. One hundred and two respondents were contacted to generate the final interview sample of 39. The characteristics of the interview sample can be found in Table 1. The interview focused broadly on the premedical experience, the different stressors students encountered during the year, and the extent to which social relationships contributed to respondents’ ability to cope with stress. All interviews were conducted over the phone and lasted an average of 41 minutes.

Analytic Plan: Qualitative Analyses

An abductive approach was used to analyze interview transcripts (Timmermans and Tavory 2012). An initial family of codes was created based on Thoits’ (2011) typology of support functions provided by experientially similar others. When anomalous trends were identified in these data, abductive reasoning was employed to develop and refine concepts capable of explaining unanticipated patterns. Subsequent readings were undertaken to ensure that the final coding scheme was adequately nuanced and captured the multi-dimensionality of relationships with premedical peers. All coding was conducted using Dedoose™ (SocioCultural Research Consultants 2019), an online platform for qualitative analysis.

Results

Quantitative Findings

Model 1 in Table 2 examines the association between experientially similar support and depressive symptoms. Net of other support network components, higher levels of similar other support are associated with a significant reduction in depressive symptoms over the study period (ß = -.052, p < .01). Turning to the relationship between anticipatory stress about medical school admission and depressive symptoms, results from Model 2 indicate that respondents who report greater fear of failing to achieve medical school admission experience greater depressive symptomology (ß = .704, p < .001) over time.

Table 2.

Fixed-Effects OLS Regressions of Depressive Symptoms on Experientially Similar Support, Anticipatory Stress, and Experientially Similar Support × Anticipatory Stress (N = 286).

	Model 1	Model 2	Model 3
Support network
% Premed	−.052** (.019)		−.149*** (.046)
% Family	−.008(.014)		−.013(.031)
% Friends – home	−.004(.014)		−.005(.031)
% Friends – Midwest University	−.000(.014)		−.022(.035)
% Faculty/staff – Midwest University	.001(.016)		−.050(.055)
% Co-worker	.003(.094)		−.230(.238)
Size (log)	−.047(.327)		−.245(.320)
% Same sex	−.015(.008)		−.012(.008)
% Same race	.013(.011)		.015(.010)
Mean contact	.257(.459)		.116(.451)
Anticipatory stress
Fear of medical school admission failure		.704*** (.166)	.414(.426)
Anticipatory stress × support network interactions
Fear of medical school admission failure × % premed			.019* (.008)
Fear of medical school admission failure × % family			.001(.005)
Fear of medical school admission failure × % friends – home			−.000(.005)
Fear of medical school admission failure × % friends – Midwest University			.003(.005)
Fear of medical school admission failure × % faculty/staff – Midwest University			.009(.010)
Fear of medical school admission failure × % co-worker			.068(.053)
Semester^a	1.842*** (.321)	1.740*** (.308)	1.626*** (.314)

Note. Unstandardized beta coefficients are presented with standard errors. Models are based on 20 multiple-imputation datasets. Models include post-stratification weights for gender and inverse probability weights for selection into the sample.

Semester is coded as 0 = fall 2015, 1 = spring 2016.

p < .05. **p < .01. ***p < .001 (two-tailed tests).

Model 3 examines whether similar other support moderates the relationship between anticipatory stress and depressive symptoms. Results show a positive, significant interaction between experientially similar support and anticipatory stress about medical school admission (ß = .019, p < .05). These results indicate that among premeds who are more concerned about failing to achieve medical school admission, the presence of additional premedical peers in their support networks exacerbates, rather than buffers, the positive association between anticipatory stress and mental health. This association is further illustrated in Figure 1, which plots predicted values for depressive symptoms across the range of anticipatory stress about failing to achieve medical school admission for respondents with support networks comprised of different percentages of premedical peers (specifically, at -1 SD from the mean, at the mean, at +1 SD above the mean, and at +2 SD above the mean). The steeper slopes for support networks that include a greater proportion of premedical peers demonstrate that the association between anticipatory stress about medical school admission and depressive symptoms is strengthened among respondents whose support networks are more densely populated by experientially similar others.

Figure 1.

Predicted values of depressive symptoms for networks with different proportions of premedical peers across the range of anticipatory stress about medical school admission.

Qualitative Findings

Qualitative analyses provide a more textured understanding of the associations among similar other support, anticipatory stress, and depressive symptoms. Table 3 depicts the prevalence of themes found in the qualitative data, measured as the percentage of cases where a code occurred at least once. This metric provides an indication of how widespread the positive and negative aspects of relationships with premedical peers were across the interview sample. Many of the beneficial aspects of relationships with experientially similar others identified in this study correspond with those documented in past research. These support functions fall under the umbrella of either emotional sustenance, active coping assistance, or positive social influence. Although negative aspects of relationships with premedical peers were mentioned in a relatively small number of cases, peers nevertheless fostered distress among respondents in at least two ways. One interactional process, which I refer to as stress accentuation, occurs when similar others re-affirm or amplify the threat posed by a stressor. A second way that peers induced anxiety was through negative social comparisons. Contrasts with high-achieving peers had the effect of making respondents feel they were not doing enough to achieve entry into medical school or that they lacked the innate disposition to do so. These processes provide two possible mechanisms to help explain the finding that greater representation of similar others in respondents’ support networks exacerbates the harmful effects of anticipatory stress on mental health.

Table 3.

Premedical Peer Evaluation Coding Scheme (n = 39).

Themes	Codes	% (Total cases)
Emotional sustenance		49 (19)
	Empathic understanding	41 (16)
	Acceptance of ventilation	26 (10)
	Validation of feelings/concerns	10 (4)
Active coping assistance		62 (24)
	Information/advice	62 (24)
	Coping encouragement	13 (5)
	Threat re-appraisal	10 (4)
	Stress reduction activities	10 (4)
Positive social influence		33 (13)
	Role modeling	23 (9)
	Inspiring hope	15 (6)
Emotional upset
Emotional upset	Stress accentuation	10 (4)
Negative social influence
	Negative social comparison	15 (6)

Emotional Sustenance

As a result of their fluency with a stressor, experientially similar others are able to provide empathic understanding and affirmation that help to alleviate stress. A notable portion (41 percent, Table 3) of respondents mentioned the value of shared experiences with their premedical peers. This common bond allowed peers to knowingly acknowledge what one was going through in ways that family and friends could not. This sentiment was relayed by a sophomore as he described those upon whom he relied for support in dealing with anxiety from coursework:

I relied mostly on my friends who are also premed, because you know not only do they know kind of how to calm you down because they’re going through the same thing, but they understand what you’re going through. (ID#20051—male, white)

Due to their acute awareness of the challenges presented by the premed track, peers also served as willing partners in the ventilation of negative emotions arising from premedical studies (26 percent, Table 3). As one sophomore detailed, “we study together, or vent about you know, it is hard, and it’s kind of nice to have someone going through that can relate to what you’re going through” (ID#20125—female, white). The emotional catharsis achieved through this mutual commiseration—what Thoits and colleagues (2000:271) term “shared misery”—represents a form of emotional support uniquely available from experientially similar others who understand the gravity of the stressor facing an individual. Several respondents also noted the importance of knowing someone who shared their anxieties about the premedical track and consequently could validate their emotional reactions as an appropriate response to stressful circumstances (10 percent, Table 3). Cumulatively, these support functions were perceived by respondents as having restorative properties for mental health and well-being.

Active Coping Assistance

While coping advice offered by family and friends may be viewed as unrealistic or unhelpful, similar others are able to provide coping strategies specifically tailored to the exigencies of a situation. The most common form of coping aid ascribed to premedical peers was the provision of academic support (62 percent, Table 3). These instances largely involved assistance with learning key course concepts. As one freshman elaborated:

My friends that I have in other classes that are premedical, we just, we help each other out. And if one person doesn’t understand a certain subject, somebody understands it better, we’re sort of there to help each other out and we all want each other to succeed. (ID#10160—male, black)

Beyond assistance with assignments and studying, premedical peers also shared advice regarding coursework. Specifically, peers who had previously taken a course drew upon their knowledge of an instructor’s effectiveness to offer informal academic advising.

Premedical peers also acted as boosters who delivered well-timed coping encouragement (13 percent, Table 3). These peers cheered on respondents in the face of stressors and provided reassurance that they had the wherewithal to overcome the obstacles presented by the premedical track. Such unconditional support and encouragement are evident in a sophomore’s description of his friendship with a fellow premed:

We just try to always be really supportive of each other any time one of us is having a hard time coping with the amount of time we were spending studying, or the lack of sleep we may have had for a task, or leading up to quizzes and exams, whatever they may be. We just always try to be very supportive and remind each other that we were capable. (ID#20007—male, white)

Premedical peers also played a pivotal role in respondents’ support systems by helping them reassess the threat posed by stressors—particularly those viewed as a death knell for one’s medical school aspirations (10 percent, Table 3). An example of the threat re-appraisal performed by peers is captured by a freshman’s recollection of receiving her first low grade in coursework:

I got a C+ in calculus and to me it was almost the end of the world because I thought that I would never get into med school with a C+, which, I talked to people and you know, realized that was a little doomsday-ish. (ID#10163—female, white)

This form of coping assistance prompted respondents to more reasonably evaluate their response to stressors and gauge whether their reactions were appropriate for the situation or overly pessimistic. By re-framing events viewed as catastrophic to one’s medical school prospects as minor setbacks, similar others not only diminished the initial despair felt by respondents but also were perceived as helping them to react to adversity with greater equanimity.

A type of coping provided by similar others in this study not explicitly addressed elsewhere involved engagement in stress reduction activities (10 percent, Table 3). This form of coping support does not directly engage a stressor but rather provides brief respite from it. Several respondents mentioned the importance of peers who invited them to participate in social activities (e.g., shared meals, intramural sports) that momentarily alleviated the grind of the premedical track. As one freshman explained, “We would get bagels, or we’d bake together, or we’d do something to just take the pressure off” (ID#10219—female, white). These activities provided a healthier outlet for stress release than other alternatives (e.g., binge drinking).

Positive Social Influence

Individuals who have successfully coped with a stressor may serve as role models to be emulated by those grappling with the same issue. In the case of premeds, the peers whom respondents often cited as role models were typically more advanced students (i.e., juniors and seniors). Aside from serving as a standard worthy of imitation, advanced premedical peers could also be queried for advice on coursework or how to develop relationships with faculty (23 percent, Table 3). As one sophomore explained:

They [upperclassmen] told me a lot about how they like, the research that they did, how they talked to professors, and just when they started thinking about the MCAT. What they needed to study, stuff like that, so it was very helpful. (ID#20037—female, Asian American)

Similar others who have effectively coped with a stressor can also inspire hope. Several respondents (15 percent, Table 3) specifically cited their premedical peers as motivating them to continue with their studies despite the personal hardships they faced: “I have really good friends who are premed, and they’re the ones that kind of inspire me to go premed” (ID#20131—sophomore, female, white). These similar others were perceived by respondents as a beacon of hope that one might also succeed on the path to medical school.

The Amplifying Effects of Experientially Similar Others on the Anticipatory Stress-Depressive Symptoms Link: Stress Accentuation and Negative Social Comparison

Despite the beneficial main effects of similar other support, greater representation of premedical peers in respondents’ support networks strengthened the positive association between anticipatory stress regarding medical school admission and depressive symptoms in the quantitative analyses. Interview data indicate that some premedical peers inadvertently heightened respondents’ distress through a process of stress accentuation (10 percent, Table 3). Stress accentuation occurs when similar others either actively prime a person to mull over the stressor they face or amplify the threat posed by a stressor. This process can unfold in seemingly benign ways, like when a similar other innocuously mentions a stressor during the course of conversation. In the present case, this included instances where peers would remind respondents of yet another obstacle to medical school admission:

There are moments when someone will bring up something the rest of us hadn’t thought about before and we’ll go, “Oh nooo, that’s something else to worry about,” or “Oh my gosh, I haven’t done that yet.” (ID#20073—sophomore, female, American Indian)

These prompts caused respondents to feel overwhelmed in some cases and to doubt their ability to successfully cope with the demands of the premedical track in others.

Stress accentuation can also occur when a similar other exaggerates the threat posed by a stressor, for instance by catastrophizing the prospect of not gaining admission to medical school. As a sophomore conveyed in her recollection of an interaction with a peer who voiced these concerns,

“Oh my gosh if I don’t get an A on this test I’m going to fail the class and I’m not gonna’ get into medical school, and then I’m just gonna’ die and live in a box in the street.” It’s all just very life-or-death situations for everything. (ID#20055—sophomore, female, white)

These instances aggravated respondents’ stress levels and heightened the perceived severity of failing to achieve medical school admission.

While stress accentuation is the direct result of interpersonal interactions with similar others, the mere presence of similar others can also magnify stress when these individuals are used as a reference for social comparison (15 percent, Table 3). Several respondents mentioned anxiety induced by comparisons to peers perceived as more successful than themselves. As one sophomore explained,

It can also be stressful, especially when you see that someone else is doing something that’s like super great and you feel happy for them, but at the same time it makes you—well it makes me very stressed out. “Why am I not doing something similar to that?” or “I should be more focused on sciences and studying for med school” (ID#20037—female, Asian American)

As this excerpt suggests, contrasts with high-achieving peers often produced a sense that one was “not doing enough” to be successful. Serving as a counterpoint to the optimism similar others can inspire via role modeling, if one feels they are incapable of achieving the same level of success as a similar other, it can create feelings of inferiority or helplessness.

Stress not only emerged from comparison to successful peers but also from contrasts with peers viewed as maniacally driven in their academic pursuits. As one sophomore remarked, “I’ve noticed that the other premedical students are very uptight, and competitive, and it makes me feel like I should be that way when I don’t always want to” (ID#20131—female, white). These comparisons were discomfiting insofar as they led respondents to feel they needed to possess a certain disposition to thrive as a premed that they either could not envision, or did not desire, for themselves. Taken together, these interactional (stress accentuation) and social psychological (negative social comparison) processes help to illuminate why the damaging effects of anticipatory stress on mental health are strengthened when more premedical peers are included in respondents’ support networks.

Discussion

Due to their intimate familiarity with a stressor, experientially similar others can provide empathic understanding and tailored coping advice to individuals navigating comparable, challenging circumstances (Thoits 2011). Accordingly, the concept of similar other support is essential for understanding the full breadth of an individual’s social support system. Employing a multi-method approach, the present study sought to unpack how changes in similar other support associate with mental health over time, and whether this form of support safeguards individuals against the anticipatory stressors that bond them to experientially similar others.

Quantitative results indicate that after adjusting for other sources of support and time-stable respondent characteristics, premedical students who included a greater proportion of premedical peers in their core support networks over time experienced fewer depressive symptoms. Had analyses been limited to a straightforward evaluation of the relationship between similar other support and depressive symptomology, however, the contingent effects of similar other support on mental health would have been overlooked. Among premeds who grew increasingly pessimistic about their prospects for medical school admission, greater representation of premedical peers in support networks exacerbated the positive association between anticipatory stress and depressive symptoms over time.

Quantitative results present an empirical quandary. If similar other support is generally beneficial for mental health, then why would the growing presence of experientially similar others in support networks strengthen rather than attenuate the association between anticipatory stress and depressive symptoms? Qualitative data provide some insight into this dynamic. Stress can reverberate across networks through a variety of social processes. One mechanism detailed in recent research is “stress contagion” (Frost et al. 2017). In stress contagion, an individual experiences distress as a result of empathizing with a significant other—usually a romantic partner—who is in the midst of grappling with an acute stressor. In the present study, I find that premedical peers can sensitize respondents to anticipatory stressors through a distinctive process I call stress accentuation. Stress accentuation occurs when a similar other exaggerates the threat posed by a stressor by excessively harping on it or embellishing its detrimental effects. In the present case, this involved some premedical peers’ reminders about arduous medical school requirements as well as their sensationalized accounts of the consequences of failing to achieve medical school admission. As a result of these interactions, similar others inadvertently created an echo chamber that magnified respondents’ existing anxieties about future medical school admission.

Another way that premedical peers contribute to respondents’ distress is through a more implicit social comparison process. Several respondents made comparisons to peers perceived as more successful or competitive than themselves, a practice which led to negative self-appraisals regarding their ability to cope with the obstacles presented by the premed track. Increasing connectivity to other premeds entails greater possibilities for such upward social comparisons, a dynamic that could intensify the burgeoning doubts one has about whether or not she or he will be a viable candidate for medical school. The harmful effects of social comparisons to similar others found here are not novel. Gage (2013) documented a strikingly similar pattern in her study of pediatric cancer patients, finding that some parents experienced negative emotional reactions when they compared their situation to families whose children progressed more effortlessly through treatment. The correspondence of this phenomenon across cases suggests that upward social comparisons to similar others might be a generalizable phenomenon across contexts.

Several limitations of the study require discussion. Foremost, there are potential issues stemming from non-response bias, selection bias, and the study’s focus on a single research site. The study’s low response rate may be a function of the onerous academic burdens countenanced by premedical students. Although the honorarium offered to participants was increased to encourage participation (from $5 to $10), the response rate was still lower than expected. The monetary incentive may have been insufficient for students whose academic and extracurricular commitments often leave them overextended. Because study invitations were sent via e-mail during relatively busy periods of the semester, it is also possible that they were viewed as an “easy delete” and never actually opened by their intended recipients. In terms of selection into the sample, it is plausible that students from certain social groups were less likely than others to participate in the study. Unfortunately, sociodemographic information for premedical students who elected not to participate in the study was not made available by MU, and therefore, it is not possible to examine whether there were qualitative differences between premeds who chose to participate in the study and those who did not. The study’s focus on a single university also tempers the generalizability of findings to other institutions. While MU is similar in size and composition to other state universities in the region, the requisite coursework in which premedical students enroll is taught in lecture halls containing several hundred students. In this way, and many others, the academic experiences of premeds at MU differs from those at liberal arts colleges and mid-sized schools.

Findings must also be contextualized in view of the unique features of the case. In contrast to relationships among cancer survivors or combat veterans where there are no clear, conceivable costs to providing emotional support or instrumental aid, premedical students are—at least hypothetically—in competition with each other for one of a limited number of medical school seats. As a consequence, these relationships are marked by an implicit tension absent in other scenarios involving similar other supporters. This dimension of the case may be responsible for the finding that greater similar other support exacerbates the damaging effects of anticipatory stressors on mental health. Indeed, it is possible that in other cases—for example, among patients who have had open heart surgery and fear a future heart attack—that support from similar others may not have comparable, aggravating effects. Nevertheless, it is worth noting that recent studies using cases where there is less reason to suspect friction with similar others have also documented negative aspects to these relationships. For example, in his analysis of the support networks of patients with serious mental illness, McConnell (2017) found that network members with mental health issues were more likely to cause problems than other types of supporters. Future research could extend the findings of this study by exploring whether the interactions between similar other support and anticipatory stressors found here occur in cases where relationships with similar others are less fraught.

Although the use of a fixed-effects framework provides greater insight into the causal relationships among similar other support, anticipatory stress, and depressive symptoms, caution should nevertheless be exercised in interpreting results. While fixed-effects models theoretically adjust for all unobserved, stable respondent characteristics, they cannot control for biases stemming from the omission of time-varying measures (Hill et al. 2019). Moreover, while theory suggests that social support directly influences mental health, the possibility of reverse causality cannot be ruled out. That is, it may be the case that greater depressive symptomology causes respondents to withdraw from relationships with premedical peers, leading to a lower percentage of similar other supporters in their networks over time.

Future research on similar other support would also profit from more comprehensive egocentric network items. The name generator in this study lacked details that would have been helpful for disentangling the circumstances under which experientially similar support is most optimal. In their study of men recovering from coronary artery bypass graft surgery, Thoits and colleagues (2000) found that while visits from former patients had no effect on respondents’ depressive symptoms, patients who interacted with ward mates concurrently navigating surgical recovery experienced better mental health outcomes up to one year after surgery. Because the network items in this study did not ask respondents to distinguish the class year of their peers, there is a missed opportunity to discern whether the effects of support from premeds might differ when provided by same-year or more advanced students. Another limitation of the name generator stems from its wording. The name generator used in this study asked respondents whom they would hypothetically contact when experiencing “personal problems at school.”Small’s (2017) recent work suggests that these individuals are not necessarily the same people an individual will actually contact when facing a serious dilemma. In part, this is because the close family members and friends who comprise “important matters” support networks are precisely those whom we do not want to cause concern or disappoint. It is also possible that this phrasing was differentially interpreted by respondents. For some it may have signified challenges in coursework, while for others it may have conjured issues with friends or economic woes. Because surveys were administered electronically, additional information was unavailable to clarify the type of support targeted by the name generator. Future research should more thoughtfully consider the potential biases introduced by the name generator that is implemented.

The results of this study further complicate the narrative that support from experientially similar others inexorably leads to superior mental health. A primary contribution of this study is its provision of preliminary evidence that the effect of similar other support on mental health is contingent on the type of stressor one confronts. In the face of anticipatory stress, additional similar other support exacerbates the effects of stressors on depressive symptoms. This result corroborates the findings of other recent studies that reveal a “dark side” to relationships with experientially similar others (Desmond and Travis 2018; Ellison and Lee 2010; Gage 2013; McConnell 2017). A second contribution of this research is the identification of two intervening mechanisms—stress accentuation and negative social comparisons—that help to explain why relationships with similar others can produce injurious consequences for mental health. Both stress accentuation and social comparison may cause premeds to perseverate on the threat posed by failure to gain admission to medical school, to the detriment of their psychological wellbeing. Future theorizing and empirical inquiry into the association between social support and mental health must recalibrate expectations to consider the full array of outcomes that flow from relationships with experientially similar others, including the potentially countervailing effects of these ties on mental health and wellbeing.

Supplemental Material

ncm-appA-logit-2018-10-14 – Supplemental material for “They Understand What You’re Going Through”: Experientially Similar Others, Anticipatory Stress, and Depressive Symptoms

Supplemental material, ncm-appA-logit-2018-10-14 for “They Understand What You’re Going Through”: Experientially Similar Others, Anticipatory Stress, and Depressive Symptoms by Matthew K. Grace in Society and Mental Health

Footnotes

Acknowledgements

I am thankful to Bernice Pescosolido, Brea Perry, Eliza Pavalko, and Andy Halpern-Manners for their feedback on previous versions of this work. This article also benefited from the extensive comments provided by the editor and three anonymous reviewers. I alone am responsible for any errors or omissions. Generous support for this project was provided by the National Science Foundation through a Dissertation Improvement Grant (#1519056). This study was approved by the Institutional Review Board at Indiana University-Bloomington: Protocol #1411744719.

ORCID iD

Matthew K. Grace

Supplemental Material

Supplemental material for this article is available online.

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