Come together

How social support aids physical health

It was actually pretty funny. Just days before our wedding, my fiancé and I met with the pastor who would perform the marriage ceremony for our required premarital counseling session. He held in his hand the results of a compatibility test we had each completed several months earlier. Frowning a bit, he said, “You know, if the wedding wasn’t this weekend, I think I’d urge you to reconsider.”

The tests showed what we already knew. I was an introvert, preferring thinking more than talking, while my fiancé was an extrovert in every sense of the word, enjoying parties, socializing and leadership positions. On paper, our relationship was doomed.

That was 25 years ago. My husband and I are still together, and while our married life hasn’t been without rocky patches and comical situations brought about in part by our vastly different personalities, we’ve always been there for each other.

Now a growing body of research suggests that healthy relationships with spouses, peers and friends are vital not just for mental, but also for physical health. And this effect extends beyond nagging your husband to go to the doctor or reminding friends to take their medications or check their blood sugar.

It’s increasingly evident that involvement in social networks can directly affect the levels of stress hormones in our blood, the location of critical immune cells in our bodies and even the circadian rhythms that govern our sleep cycles. Depression and anxiety, which correlate with isolation, can worsen health outcomes. Conversely, strong peer support has been associated with greater longevity in some groups of breast cancer patients.

“It’s becoming very clear that positive social relationships may help people live not just better, but also longer,” says David Spiegel, MD. Spiegel, the Jack, Samuel and Lulu Willson Professor, is the medical director of the Center for Integrative Medicine and the director of the Center on Stress and Health at Stanford Medicine.

“These interactions can lower stress, increase happiness and even improve sleep — all of which appear to help people stay healthy and recover from disease and trauma by affecting key biological parameters.”

Surprisingly, this effect also extends to our friends and even the complicated tangle of relationships that make up our social network. In fact, some research suggests that healthy behaviors like regular exercise, as well as more risky practices such as smoking, alcohol use and overeating, can spread through our friends and our friends’ friends, and even our friends’ friends’ friends, with a marvelously shocking facility. In other words, it’s possible you are who you hang out with, regardless of how self-directed you may feel.

“We tend to think of ourselves in this culture as individuals, rather than as being embedded in relationships,” says Cheryl Koopman, PhD, professor emerita of psychiatry and behavioral sciences at Stanford. “But our interactions with others, be they friends, spouses or caregivers, are vitally important.”

Researchers like Spiegel, Koopman and Firdaus Dhabhar, PhD, Stanford associate professor of psychiatry and behavioral sciences and a member of the Stanford Institute for Immunity, Transplantation and Infection, are learning how social relationships and emotional states keep us healthy, or make us sick.

“Reducing depression, which is also often associated with social isolation, for example, predicts longer survival in cancer patients,” says Spiegel, “and cancer patients with abnormal patterns of expression of the stress hormone cortisol die sooner than others. Even sleep and wakefulness are important. If you sleep better at night, with fewer disruptions, you may actually live longer than those patients who don’t. It’s important to understand exactly how social support affects our biology and our health.”

The idea that relationships can affect physical health is not new. But the magnitude of the potential impact was first hinted at in studies Spiegel conducted in the late 1970s in 86 women with metastatic breast cancer. That study, which was published in The Lancet in 1989, found that women who were randomized to participate in a weekly psychotherapy group of women with similar cancer diagnoses lived an average of 18 months longer than those who did not participate in the intervention.

“At first we were warned that bringing women with a similar diagnosis together would demoralize them, as they watched their friends struggle and die,” says Spiegel. “But exactly the opposite occurred. They encouraged one another and grew as they learned to face others’ and their own mortality.”

A number of subsequent studies, however, yielded mixed results as to whether participation in a peer support group increased survival of cancer patients. A study published in 2007 in Cancer by Spiegel of 125 women with various forms of breast cancer failed to show any survival benefit in those randomized to receive group therapy versus others who received educational materials only — except in one subgroup of 25 women with an especially intransigent form of the disease. Members of that subgroup who participated in psychotherapy support groups lived an average of 30 months, which was about 21 months longer than those who received educational literature alone. Moreover, support group participants overall reported a reduction in fear, anxiety and pain.

One possible reason for Spiegel’s conflicting results, he believes, is that breast cancer treatments improved significantly during the decades since the original study was conducted. If women with metastatic breast cancer were living longer in general, an effect of peer group participation may have been masked. Furthermore, the subgroup that benefited had a type of breast cancer that lacked estrogen receptors, so they could not benefit from powerful new treatments that block the effects of hormones on tumors.

All told, nine out of 16 recent studies conducted by researchers worldwide suggest that support groups guided by a psychotherapist can help cancer patients live longer. But regardless of the effect on life span, Spiegel feels the benefit of professionally led peer group therapy focused on building new bonds of social support, improving communication with family members and health-care professionals, and allaying fears and anxiety is unquestionable.

“The power of group support makes tremendous sense to me,” Spiegel says. “We are social creatures. Throughout evolution, we’ve relied on the ability of our relatively large brains to form connections with others and build networks of support that help us deal with threats, nurture our young and help us stay alive.”

‘I came into the group absolutely gobsmacked. I was literally speechless. ... but as I watched and listened to the other women in the group, I began to think, “I can do this.”’

Many of the women in Spiegel’s support group studies have since died from their disease. Those who are still alive say their participation instilled lessons and skills that helped them live more fully while also supporting one another.

“I came into the group absolutely gobsmacked,” recalls Jennifer MacLeod, who was diagnosed with metastatic breast cancer in 1993 and was a participant in the study published in 2007. “I was literally speechless. I had never dealt with a serious illness of my own before. I was very reluctant to speak at first. But as I watched and listened to the other women in the group, I began to think ‘I can do this. I can take this journey.’ And I began to realize who I was in this new life.

“One thing I remember so clearly that David said to the group was, ‘I want you all to turn around and look at the black raven that is sitting on your shoulder. Look at it. It’s death. It’s time to think about making changes in your life to eliminate toxic relationships,’ ” says MacLeod. “That statement echoed deeply with me.”

But how might this work on a biological level? Dhabhar’s research addresses how emotional states directly impact the body, and his findings are telling. Reducing the amount of stress, pain and anxiety experienced by the patient directly affects key physiological parameters, he’s learned.

“We’ve found that levels of stress can impact recovery from surgery and how well our bodies mount an immune response after vaccination,” says Dhabhar, who is also a member of the Stanford Cancer Institute, Bio-X and the Neurosciences Institute.

It’s well-known that chronic inflammation can cause long-term damage to the cardiovascular system and other organs. Dhabhar has shown that long-term stress and disorders such as depression and PTSD can increase the levels of inflammatory markers in a person’s blood. And he’s shown that naturally anxious mice — those that choose to remain in an enclosed area rather than explore new terrain — not only develop more numerous skin cancers when exposed to ultraviolet light than their more laid-back peers, but may also be more likely to experience the metastasis of these tumors over time. These stressed-out mice also had higher levels of cortisol and of immune-suppressing cells, which could tamp down a successful immune attack on a newly formed tumor.

Dhabhar’s research on mice and humans shows that not all stress is harmful, however. Short-term stress in the face of a sudden challenge or an unpleasant event can actually be adaptive — providing a boost of stress hormones and marshaling immune cells resting in the spleen into the skin and blood to help with wound healing, for example.

“People who are able to mobilize these immune cells quickly and correctly recovered faster, and better, after knee surgery than those whose immune cells responded poorly,” says Dhabhar, who published the findings in the Journal of Bone and Joint Surgery in 2009. “But the amount of long-term stress an individual is experiencing seems to determine whether or not they can mount the correct protective response. If you increase chronic stress over time, two things happen. One is the baseline number of immune cells that you have to defend yourself decreases. The other is that you are less able to mobilize the cells you do have.

“What we’ve proposed is the concept of a stress spectrum,” says Dhabhar. “On one end, there’s the ‘good’ stress that can be protective; on the other is the chronic ‘bad’ stress and disorders such as depression. Ideally we would all find ways to optimize our stress spectrum and avoid the bad stress that is associated with poor immune function and inflammation. One way to do that could be through maintaining adequate social support.”

Can we really connect the dots between the biological effects of stress, depression and anxiety with the role played by our personal relationships and our larger social network? Increasingly, scientists are saying yes.

A 2013 study by researchers at University College London published in the Proceedings of the National Academy of Sciences indicated that the risk of death among elderly people was increased in those who were socially isolated, even when other mental and physical factors were taken into account, and multiple previous studies have shown that simple loneliness increases our risk for many types of illnesses, including heart disease and high blood pressure. One analysis of 229 50- to 68-year-old people conducted in 2010 as part of the Chicago Health, Aging and Social Relations Study showed that a higher degree of loneliness at the study’s onset was associated with greater increases in systolic blood pressure measurements during the subsequent four-year follow-up period.

Loneliness and social isolation can be hard to define, however. Researchers at the University of North Carolina-Chapel Hill published a study in 2016 in the Proceedings of the National Academy of Sciences showing a direct correlation between the size of a person’s social network in adolescence and early adulthood and four telling health statistics: body mass index, waist circumference, blood pressure and the amount of C-reactive protein (a marker of inflammation) in the blood. The researchers found that in adolescents social isolation was as great a contributor to inflammation as physical inactivity; in the elderly it was an even greater risk for high blood pressure than previously known risk factors such as diabetes.

The authors suggest that being aware of and trying to minimize deficits in social relations could be one way to keep people healthy later in life.

Of course, being more connected can also increase the likelihood of unpleasant, stressful interactions. “We’ve found that when women undergo a psychological stress test, which can incite anger, anxiety or fear, their heart rate goes up, their hormone levels change and the amount of interleukin-6, which is associated with inflammatory activity, increases,” says Dhabhar. “The rise in interleukin-6 is proportional in particular to the degree of anger experienced in response to the test. However, this rise is mitigated by the amount of social support the woman expressed having during the preceding week.”

In other words, a good network of support helped the women withstand a flood of anger and anxiety without experiencing a potentially unhealthy increase in interleukin-6 levels.

“A chronic elevation in interleukin-6 levels could contribute to cardiovascular disease and other pro-inflammatory disorders. Therefore, dampening stress-induced increases in interleukin-6 may be one mechanism by which social support buffers against such diseases,” says Dhabhar.

Letting go of anger toward others also appears to be healthy. A small study of 25 people authored by Frederic Luskin, PhD, director of the Stanford Forgiveness Project, published in 2006, showed that those who entered the study with elevated scores on a scale designed to measure anger experienced a significant drop in blood pressure after participating in an eight-week forgiveness-training program when compared with peers who did not receive the training.

Even brain scans have shown the effects of friendship. James Coan, PhD, a professor of psychology at the University of Virginia, showed in a series of experiments that the brains of women told to expect an unpleasant electric shock activated regions known to be involved in response to a threat. Holding hands with a friend (but not a stranger), however, dampened this response. Even more interesting, the friend’s brain activity pattern began to mirror that of the person expecting the shock.

During Jennifer MacLeod’s decade in Spiegel’s peer support group, she became familiar with the power of friendship and the difficulty of watching friends suffer. “It’s such a balance,” she says, “between observing, listening and taking to heart what you need for your life, while also being appalled and terrified by what is happening to your friends. The biggest gift you can give someone who is dying, I think, is just to be there. Just walking with them. It’s incredibly important.”

So maybe we, and our physicians, should be tending to our social relationships with the same care that we devote to exercising, eating right and avoiding unhealthy behaviors. Heck, maybe everyone should run out and get married.

After all, a 2013 study in the Journal of Clinical Oncology of over 700,000 people with cancer showed that married people are diagnosed earlier and are about 20 percent less likely to die of their disease than are unmarried people. A study published in Cancer in April 2016, conducted by Scarlett Lin Gomez, PhD, a consulting associate professor in health research and policy at Stanford and a researcher at the Cancer Prevention Institute of California, concurred. Gomez and her colleagues found in a study of nearly 800,000 cancer patients in California diagnosed between 2000 and 2009 that those who were married were significantly more likely to survive than those who were unmarried, regardless of whether they had health insurance or of the socioeconomic status of the neighborhoods in which they lived.

Of course, marriage isn’t a panacea. But it’s becoming increasingly clear that relationships with peers, spouses, physicians and caregivers contribute in a meaningful way to health and to our ability to recover from disease and trauma. And health-care providers are taking note. Cheryl Koopman has studied the effect of using videoconferencing technology to conduct peer support groups among women with breast cancer in rural California.

These women bonded through shared experience to help each other through tough times. “Women in small communities can start to feel like they are living in a fishbowl, where everyone knows about their cancer but few people can truly share their experiences,” says Koopman. “We’ve found that breast cancer survivors readily adapt to giving and receiving support through video. This was clear when one woman ‘hugged’ another visually through the monitor. They really were supporting one another.”

MacLeod recalls the vital role the in-person peer support group played in her life and that of her friends.

“One day, after about 10 years, David came in to tell us that the study was ending and the group would not continue. By that time, we’d had a lot of turnover as previous participants died and were replaced with new people, who had also come to rely on the group. We were horrified. I really think we could have attacked him, we were that angry. ‘You can’t do this. You just can’t,’ we said.”

Together the women agreed that they would each pay out of pocket, if necessary, to keep the group going.

“We’ve worked the bottom-up medical model as hard as we can, learning how to treat acute medical problems like diabetes or a broken leg,” says Spiegel. “But the better we get at that, the more people are left with chronic illnesses like managed cancer or heart disease. Increasingly we’re seeing people having a lot of trouble handling stress and pain and who want nonpharmacological ways of dealing with these issues.

“Social connection, especially in the face of illness, I think is a very powerful ally. It helps us manage our stress responses, it helps our bodies do better and helps us to help one another get through life-threatening situations. It makes complete sense.”

Krista Conger is a science writer for the medical school's Office of Communication & Public Affairs. Email her at kristac@stanford.edu.

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