Social comparison and coping with cancer treatment

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Abstract

In the present study scales were developed as indicators of four social comparison processes of respectively identification with others who are either doing better or worse and contrasting one's situation against the situation of either upward or downward comparison others. In a sample of 112 cancer patients, support was obtained for the validity of these scales. First, the internal consistency and stability of the scales were high. Interestingly, higher order factor analyses showed two basic factors labeled `positive interpretation' (encompassing upward identification and downward contrast) versus `negative interpretation' (encompassing upward contrast and downward identification). In addition, it was shown that the tendency to identify oneselves with others who are doing better and to contrast oneselves against others who are doing worse were moderately but significantly associated with a basic tendency to engage in confrontive coping styles, such as reinterpretation/growth, social support and active coping. The theoretical significance as well as the therapeutic implications of the findings are discussed.

Introduction

One out of every three individuals develops cancer at some point in life. Imagine that you go to your physician because you feel tired all the time, assuming that he or she will tell you that you work too hard and that you end up knowing that you suffer from incurable leukaemia. No one will deny that such an experience is threatening and asks for a complete reevaluation of who you are and what you strive for in life. Remarkably, most individuals seem to adapt to such threatful events rather effectively. For example, several studies among patients suffering from serious diseases such as cancer Morris, Greer, & White, 1977, Cassileth et al., 1984, Penman et al., 1986, Vinokur, Threatt, Caplan, & Zimmerman, 1989, Van Knippenberg et al., 1992 or spinal cord injuries (Schulz, & Decker, 1985) have shown that these patients seem to be able to maintain a sense of well-being that is comparable to that of individuals who are not confronted with serious health threats. Although, of course, not everyone readjusts completely (Silver, & Wortman, 1980), most people manage to readjust rather effectively to problems with their health. Individuals seem to be able to cope with serious health problems by making use of the support from individuals in their social networks, that is their beloved, their friends and family members, and by using their individual coping resources Gurin, Veroff, & Feld, 1960, Wills, 1982, Taylor, 1983. Lazarus and Folkman (1984) define coping as “constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person”.

In the present research the interest was in one particular strategy that may play an important role in coping with health problems. Research has shown that when confronted with serious health problems, people seem to relate their own situation to the situation of others. This process might be helpful when adapting to the threatful situation they have to face (e.g. Wood, Taylor, & Lichtman, 1985; Molleman, Pruyn, & Van Knippenberg, 1986; Taylor, Buunk, & Aspinwall, 1990; Affleck, & Tennen, 1991, Suls, Marco, & Tobin, 1991, Taylor, Buunk, Collins, & Reed, 1992a, Buunk, 1994). Earlier studies have provided evidence for the use of social comparison in a range of life contexts, including health problems (Gibbons, & Gerrard, 1991). It has for example been shown that by selectively using information from the social environment patients with serious diseases may obtain a relatively favourable comparison with one or more target others (e.g. Gerrard, Gibbons, & Sharp, 1985; Wood et al., 1985, DeVellis et al., 1990) and that favorable comparison situation then produces an increase in subjective well-being for the comparer (Affleck, Tennen, Pfeiffer, Fifield, & Rowe, 1987; Van der Zee, Buunk, & Sanderman, 1995, Van der Zee et al., 1996a; see also Wills, 1987, Wills, 1997). In the present study an instrument for measuring identification and contrast processes in social comparison was developed and evaluated. First, the reliability and internal structure of the scales were examined. Second, in order to examine the validity of the instrument, its relationship with general coping styles was examined among patients who were receiving cancer treatment.

Traditionally, it has been supposed that under stressful circumstances, such as confrontation with a life-threatening disease, individuals tend to compare their situation primarily with the situation of others who are doing worse Hakmiller, 1966, Wills, 1981, Wood et al., 1985, Taylor et al., 1990 and that such downward evaluations may contribute to well-being (Affleck et al., 1987; for an overview, see also Taylor, & Brown, 1988, Van der Zee et al., 1996a). This supposition is built upon the assumption that individuals contrast their situation with the situation of the comparison other. In such a case, seeing that other patients are doing worse may lead to the comforting conclusion that one is at least doing better than some others. However, not all studies support the notion that social comparisons are evaluated positively by patients suffering from serious illnesses such as cancer. Even more so, a number of studies among cancer patients suggests that victims of cancer avoid potential downward comparison targets Dunkel-Schetter, & Wortman, 1982, Dakof, 1986, Molleman et al., 1986. Taylor and Lobel (1989) argue that whereas explicit evaluation of one's situation vis-à-vis less fortunate others may be comforting, affiliation with and information seeking about fellow sufferers who are doing worse may be rather depressing and may therefore be avoided by cancer patients. Face-to-face confrontations with someone else whose illness has progressed further, for example in the physician's waiting room are not likely to be encouraging (e.g. Collins, Dakof, & Taylor, 1988, Gibbons, & Gerrard, 1991).

Indeed, Taylor and Lobel (1989) proposed that although cancer patients will predominantly evaluate their situation against the situation of fellow patients who are doing worse, they will prefer actual contact with others who are doing better. Fellow patients faced with comparable health problems who are better off may provide information that may assist one's problem solving efforts. Think for example about a woman with breast cancer who may regard the optimism and fighting spirit she observes in a fellow breast cancer patient as a real example for herself. She probably may have learned something about effective coping from this example. Empirical evidence supports the idea that individuals under stress prefer actual contacts with others who are better off and that such upward contacts are evaluated more positively among cancer patients (e.g. Molleman et al., 1986, Taylor, Aspinwall, Guiliano, Dakof, & Reardon, 1993; Van der Zee, Buunk, & Sanderman, 1998a).

Although Taylor and Lobel (1989) argued that actual contacts with patients who are physically deteriorating are threatening for cancer patients, they do not explain why these downward contacts may be threatening. Moreover, the assumption that the direction of comparison is linked to the mode of comparison (explicit evaluation versus actual contact) has been challenged by studies of for example Gerrard et al. (1985) and by DeVellis et al. (1990). In a study among self-help groups for bulimic patients, Gerrard et al. (1985), showed that all participants preferred comparison with someone having a fairly severe case of bulimia. DeVellis et al. (1990) provided arthritis patients with an opportunity to choose a folder describing an arthritis patient who was doing worse or doing better than the subject and found that 64.2% chose downward information. These studies showed a clear preference for actual information about fellow patients who were doing worse. Moreover, in an earlier diary study we showed that the daily comparisons of cancer patients evoked much more positive affect and much less negative affect when they were downwardly directed than when they were laterally or upwardly directed, despite the fact that the majority of those comparisons reflected actual interactions (having talked with someone, or seen someone) (Van der Zee, Wheeler, Buunk, Sanderman, R., Van den Berg, & De Jong, submitted for publication).

Buunk and Ybema (1997) have suggested that upward and downward comparison may be interpreted both in a positive and in a negative way (see also Buunk, Collins, Taylor, VanYperen, & Dakof, 1990). They argue that interpretation of social comparison information is dependent upon whether individuals contrast themselves or identify themselves with comparison targets. The traditional idea was that in socially comparing themselves, individuals contrast their situation against the situation of the comparison other. In the case of downward comparison this leads to the comforting conclusion that one is better off, whereas in the case of upward comparison this leads to the threatening conclusion that one is doing worse. In contrast, when individuals identify with the comparison target they may feel worse when they compare with downward comparison targets (e.g. Ybema, & Buunk, 1995; Buunk, & Ybema, 1997; see also Collins, 1996). Identification has been defined in terms of closeness to the target (Tesser, 1988), forming a unit or a bond with the target Heider, 1958, Miller, Turnbull, & McFarland, 1988 and being similar in personality (Wills, 1991). Because in identification one assumes similarity to the comparison target (Collins, 1996), the target's position on the comparison dimension may influence the expectations of one's own future standing on the dimension. Interestingly, in the sociological literature, common fate has been regarded an even stronger determinant of identification with social groups than similarity (Campbell, 1958). Because we believe that in the context of serious illness, perceiving that you share a common fate with someone else, rather than perceiving that you are similar (which is seldom the case), is the most central aspect of identification, identification was operationalized as future similarity. Wills (1991) suggested that downward comparison may be threatening only when these comparisons invoke negative future similarity, that is when individuals perceive that it is likely or possible that they will become like the comparison target in the future.

The instances from the literature of a clear preference for upward comparisons Dunkel-Schetter, & Wortman, 1982, Dakof, 1986, Molleman et al., 1986 are presumably examples of identification with the target. When an individual identifies with an upward comparison target, he or she will probably perceive that it is likely to become like the comparison target in the future. In that case upward comparisons may be inspiring (Helgeson, & Taylor, 1993) and may meet motives of self-improvement (Wood, 1989). Van der Zee et al. (1998a) for example showed that breast cancer patients displayed more positive reactions to concrete information about a fellow patient who was doing better than to information about a fellow patient who was doing worse. Moreover, they showed that the more individuals identified themselves with upward comparison targets, the more positive feelings they experienced following the comparison. In a second experimental study it was shown that when given the opportunity to select interviews with fellow patients on their experiences, patients clearly preferred to read interviews with patients who were better off and also showed more positive reactions to such interviews (Van der Zee, Oldersma, Buunk, & Bosch, 1998b).

To summarize, in comparing themselves with others, patients may either contrast themselves or identify with the comparison target. When it concerns downward comparison targets, contrast is associated with the comforting conclusion that one is better off, whereas identification leads to the threatening realization that it is possible to decline. On the other hand, contrasting oneself with an upward target results in a threatening perception that one is worse off, whereas identification leads to the comforting realization that it is possible to improve. The aim of the present study was to develop scales aimed at measuring these four comparison processes of upward and downward identification and upward and downward contrast and to examine the psychometric qualities of the developed scales. More specifically, first the internal consistency, scale-intercorrelations and stability over the course of treatment were considered. Earlier studies have revealed that there are stable individual differences in social comparison processes Van der Zee, Buunk, & Sanderman, 1996b, Gibbons et al., 1999. In general, coping styles are often regarded as dispositional tendencies (e.g. Watson, & Hubbard, 1996) and the same seems to hold for social comparison. Gibbons and Buunk (1999) for example found a test–retest reliability of 0.72 over eight-months for a scale aimed at measuring social comparison orientation (INCOM). Although the use of identification-contrast processes may to some extent be affected by point of treatment, it was expected that such processes do reflect stable individual differences and will therefore show reasonable stability over time. Secondly, the validity of the instrument was examined by considering its relationship with general coping styles.

As was stated earlier, in the present study social comparison was regarded as a strategy that may play an important role in coping with health problems. Coping may be defined as cognitive and behavioral efforts to master, reduce or tolerate the internal and/or external demands that are created by the stressful transaction Lazarus, & Launier, 1978, Folkman, & Lazarus, 1980. Essential to this definition is that coping is defined regardless of its outcomes, that is whether the efforts result in enhanced well-being or not. The coping literature usually distinguishes between three main (protective) functions of coping: instrumental coping, i.e. management of the problem causing the distress through elimination or modification of the conditions giving rise to it, appraisal-focused coping, i.e. changing the perception of the meaning of the experience so as to neutralize its problematic character, and, finally, emotion-focused or palliative coping, involving the regulation of emotional distress produced by the problem Pearlin, & Schooler, 1978, Folkman, & Lazarus, 1980, Moos, & Schaefer, 1984. Thereby, instrumental coping and appraisal-focused coping may be regarded as active coping strategies, because they represent active attempts to reduce threat either by eliminating the problem or by changing its meaning. Although the disease itself is regarded uncontrollable, cancer patients may use behavioral strategies to deal with practical problems they are confronted with as a result of their illness, for example by exercising or keeping up a healthy diet in order to keep in good shape. The appraisal-focused strategies encompass mechanisms such as cognitive reinterpretation or attribution and are also referred to as defensive reappraisal or cognitive coping Lazarus, 1966, Lazarus, & Launier, 1978. Emotion-focused coping strategies are referred to as passive strategies because nothing is done to reduce the threat itself (Wills, 1997). Examples of passive strategies are responding with anger, seeking distraction, wishful thinking or helplessness.

Taylor and Lobel (1989) were the first authors who explicitly linked social comparison to coping with serious illness and argued that social comparison processes are aimed at regulation of emotional states and problem solving in response to highly stressful events. In the present study we were interested in the relation between upward and downward contrast and identification processes and general coping styles. Both downward contrast and upward identification seem to represent active attempts to reduce the threatening meaning of cancer diagnosis. Both mechanisms reflect an optimistic tendency to focus on the positive side of things and earlier studies have suggested that such optimistic tendencies are associated with the use of active coping strategies (Scheier, Weintraub, & Carver, 1986). More specifically, Taylor and Lobel (1989) argued that downward evaluations seem to be clear efforts to regulate emotions by making the person feel better in comparison with worse off others, whereas upward contacts may also serve as a method for meeting emotional needs, by providing hope, motivation and inspiration. The emotion regulating processes as referred to by Taylor and Lobel in relation to upward and downward social comparison in fact represent active attempts to change the negative or maintain a positive perception of the situation (appraisal-focused coping) rather than passive emotional responding. Consistently, Wills (1997) regards downward comparison as an active appraisal-focused strategy. Assuming that downward evaluation usually involves contrasting oneself against someone who is doing worse whereas upward contacts involve identification with a more fortunate comparison target, in the present study it was expected that upward identification and downward contrast are both related to active, appraisal-focused mechanisms. Taylor and Lobel (1989) assumed that upward contacts may be viewed simultaneously as emotion-focused efforts, but also as problem-solving efforts, by providing a person with information valuable for potential survival and successful coping. For example, by observing how fellow patients treat their wound or fight their nausea a patient can learn how to treat his or her own wound or nausea. It was therefore expected that upward identification is also related to active, instrumental mechanisms. No relationship between downward contrast and active, instrumental coping was expected. Contrasting one's situation against the situation of someone else who is doing worse seems not to be very helpful in active attempts to change the situation itself because it does not provide any information that is useful for effective coping (e.g. Wood et al., 1985, Wills, 1987).

Further, in the case of downward identification and upward contrast, nothing is done to reduce the problem or to change its threatening meaning. Both mechanisms reflect a pessimistic tendency to focus on the negative interpretation of incoming social information, and earlier studies have revealed that such pessimism is associated with passive coping strategies such as denial and distancing (Scheier et al., 1986). Consistently, Wills (1997) regards downward identification as a passive strategy, arguing that if people focus on the fact that they will become like the worse off other their behavior may be defined as passive avoidance or helplessness. In the present study, it was therefore expected that both strategies would be associated with passive coping strategies.

Section snippets

Sample and procedure

Patients who were treated for various forms of cancer with chemotherapy and/or radiotherapy in three hospitals in the Northern part of the Netherlands were approached for participation in the study by their physicians (see also Van der Zee, Buunk, Sanderman, Botke, & Van den Bergh, in press). Before entering the study patients signed an informed consent and were told that the information they would provide would be treated confidentially and that participation or refusal to participate would

Internal structure of the measures

First, the internal structure of the measures at T0 was examined. A factor analysis was performed on the twelve social comparison items. Imposing a four factor solution on the data, after an oblique rotation, a pattern of factor loadings was found that corresponded to our a priori scales (Table 1). All items for upward identification loaded highly on the first factor. High loadings on the second factor were found of the items for upward contrast. On the third factor all items for downward

Discussion

Traditionally, it has been supposed that patients prefer social comparison with others worse off (downward comparison) and that such comparisons with less fortunate others are evaluated positively Hakmiller, 1966, Wills, 1981, Wood et al., 1985, Taylor et al., 1990, whereas comparison with others better off (upward comparison) may lead to negative feelings Morse, & Gergen, 1970, Salovey, & Rodin, 1984. This supposition is built upon the assumption that individuals contrast their situation with

Acknowledgements

The collection of data for this study was made possible by a research grant by the Dutch Cancer Society (RUG 95-1136). The authors wish to thank Ab Schoneveld for his assistance in collecting the data for this study.

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