Social Support and Health

Social support refers to assistance provided by friends, family, and others to an individual who is facing stressful circumstances or problems. This assistance may be aimed at helping the stressed individual solve the problem or at easing the painful emotions caused by the problem. Social support can take many forms, including reassurance, encouragement, a new perspective on the problem, advice, needed resources, or physical assistance with tasks. People who report high levels of social support are less likely to become depressed or ill following stressful life events. There is evidence that their health is better overall and that they are more resistant to infection and recover more quickly from illness than people who report low levels of social support.

This article covers specific types of social support, aspects of interpersonal relationships that are related to social support, measurement of social support, scientific evidence that social support affects health, and theories about how social support exerts its beneficial health effects.

Types of Social Support

Although researchers use somewhat different terms, there is wide agreement on the most important types of social support. Some types of social support are directed at solving the problem or changing the circumstances that are causing the individual distress. These include information support and tangible support. Information support includes advice, guidance, and factual input on the problem situation. Tangible support includes needed resources, such as money or the loan of equipment. It also includes assistance with tasks, such as providing transportation or helping with child care. Support that is directed at problem solution is often termed instrumental support.

People who face difficult situations experience a wide range of emotions, which are often painful and may interfere with effective problem solving. Frequently, these emotions stem from specific beliefs about the self, other people, and the situation. Some types of social support are directed at diminishing the intensity of unpleasant emotions and altering the beliefs that cause them. The first such type is emotional support, which consists of expressions of caring, empathy, and concern. Emotional support reassures the stressed individual that he or she is not alone and that others care about his or her distress. The second is esteem support, which consists of encouragement and expressions of belief in the individual’s skills, competence, and value. Esteem support combats beliefs in personal helplessness and fosters self-efficacy. Appraisal support, input on the nature or severity of the problem situation, also addresses beliefs that affect emotional reactions. When people are under stress, they often exaggerate the severity of their problems. Another person can often help the stressed individual put the problem in perspective and evaluate it as less catastrophic or unsolvable.

Related Aspects of Interpersonal Relationships

Social support is provided in the context of relationships with other people. Thus, a person who is completely socially isolated lacks social support. Most people have relationships with others, although the number and quality of relationships vary widely. A concept that is closely related to social support is that of the social network. A person’s social network consists of the people with whom he or she interacts and who influence his or her life. Many different qualities of social networks have been studied, and some are related to social support. Number of persons in the social network is weakly related to social support. Those with more relationships report somewhat higher social support. However, there is evidence, especially among low-income women, that large networks can be a burden by demanding time, energy, and resources. Frequency of contact with other people is also modestly related to social support. Those who have more frequent contact with others report somewhat higher social support. Those who have networks in which most people know each other report somewhat higher social support, although there is evidence that for some kinds of stressful life events, a network with more diverse people from more diverse settings is most helpful.

Relationships with others are defined by social roles, such as parent, child, sibling, spouse, lover, friend, co-worker, committee member, and acquaintance. Number of roles relates to what is called social integration. There is evidence that people who play multiple social roles have better mental and physical health. It is not clear whether people who play multiple social roles have more social support or whether social integration enhances health in other ways, such as giving structure and predictability to daily life.

People who are experiencing difficult events in their lives are not always treated with warmth and concern. Especially when the person’s problems persist over a long period of time, members of the social network may behave in negative or hurtful ways, such as criticizing the stressed person for failing to recover faster. Although this behavior is sometimes termed negative support, a better way to label criticism, complaints, and expressions of blame is negative behavior. Negative behavior has a strong harmful effect on well-being. Most studies find that negative behavior has a larger impact than supportive behavior on well-being.

Actual attempts at assistance that have an unintended negative impact, such as undermining the stressed person’s self-confidence, should be termed failed support attempts.

There is evidence that failed support attempts cause resentment in close relationships and can have negative effects on mental and physical health. Failed support attempts are not as damaging as negative behaviors.

Measuring Social Support

Three different approaches to measuring the quantity and quality of social support in people’s lives have been developed. These approaches are described well in a book edited by Sheldon Cohen, Lynn Underwood, and Benjamin Gottlieb. The first approach measures perceived social support. Measures of perceived social support assess people’s subjective judgments about the extent to which members of their social network provide social support in times of need. Perceived social support measures incorporate judgments of the quality of the support that is available, sometimes through questions about how satisfied the individual is with the support he or she typically receives. A different approach measures received social support. Measures of received social support assess how frequently specific types of social support were provided by members of the social network, usually in the last month. Both perceived and received social support are measured with questionnaires. The third approach to measuring social support does not rely on questionnaires, but on observations of actual conversations. Observational coding systems to quantify observed social support typically yield frequency counts of different types of social support during a 10-to 20-min interaction in which one person is asked to disclose a personal problem or concern to another person. The emotional tone (e.g., warmth or hostility) of each social support behavior may also be evaluated. Observed social support measures were first developed in the early 1990s, so much less research has been published on their association with health than on measures of perceived and received social support, which have been used since the early 1970s.

There are advantages and disadvantages of each approach to measuring social support. Measures of perceived social support tap the recipient’s subjective evaluations of the quality of support he or she believes is available from the social network. These evaluations may reflect subtle differences in the sensitivity and reliability of the person’s support resources that are not captured by other kinds of support measures. Perceived support measures allow the individual to express the extent to which the support provided by the social network reflects his or her specific preferences and needs. However, measures of perceived social support have been criticized because of their subjectivity. People’s personalities affect the way they evaluate others. Thus, it has been argued that measures of perceived social support reflect peoples’ personalities more than the actual social support resources available to them. How much people like another person and feel they have in common with another person also affect judgments about that person’s supportiveness. Perceived support may also be colored by relationship beliefs. Individuals who believe that others are generally responsive to their needs may perceive high levels of support in relationships that are not actually supportive. Some research shows that when an actual crisis occurs in peoples’ lives, they receive less social support than they expected. Thus, estimates of type and quality of support that would be available if needed are biased in ways that decrease their accuracy. Despite these inaccuracies, an important point is that measures of perceived social support show by far the strongest associations with mental and physical health. Although peoples’ perceptions of social support may be somewhat inaccurate, they appear to be very important to well-being.

Measures of received social support involve less subjectivity and are viewed as somewhat more accurate reflections of the support resources available to the individual because they are based on actual experiences in a specified time period. However, the circumstances of the time period when received support is measured may affect the nature of the person’s responses. If received support is assessed during a period of relative calm, the results may not generalize to times of extreme crisis. Thus, actual support resources in times of extreme duress may be greater or less than would be expected based on one measurement of received support. Another issue is that received social support measures do not tap the quality of support received to the same degree as measures of perceived social support. Thus, many instances of support may be reported, but if none of them meet the specific needs or preferences of the stressed person, a high score may not reflect high-quality support. Measures of perceived and received support do not correlate very highly. Research shows that received social support scores are not as strongly associated with mental and physical health as are perceived support scores. In fact, some studies show that people who report higher levels of received support are actually more distressed. This may reflect the fact that when people face more severe stressful events, the people in their social network provide more support. Thus, level of received support may be an index of the severity of the stressor or the distress of the stress victim.

Measures of observed social support are useful for understanding exactly how people communicate support to one another. Not all social support attempts are successful. Observing actual support transactions provides information on verbal and nonverbal components of effective social support. This information is needed to develop interventions that help people become more effective support providers. Observational measures are not biased by the personality or relationship beliefs of the individual. However, like measures of received support, observational methods do not tap the subtle nuances of interactions that enter into people’s subjective evaluations of the support they receive. Observational assessments of social support are also limited because they are based on a single brief interaction between two people. This small sample of behavior may or may not be representative of how the individuals typically interact. A related method for assessing social support that addresses this problem is the daily diary. Individuals are asked to keep daily records on their interactions with other people over a 1- to 2-week period. In a sense, people serve as their own observers. They complete ratings of how supportive interactions were and report on the content of the interactions they have with other people. Although the objectivity of a trained observer is lost, the advantage of the daily diary approach is the longer time frame over which support interactions are recorded. Most studies using observational and daily diary techniques to assess social support have focused on the relation between social support and the quality of specific relationships, such as marital satisfaction. Few studies have tested links between observed support and health. A small literature suggests that support measured in daily diary studies is associated with better mood and lower anxiety.

Measurement of Social Network Variables and Social Integration

Social network variables, such as number in the network and frequency of contact with network members, are typically assessed by asking individuals to generate a list of the people with whom they interact on a regular basis. Frequency of contact with each person is assessed, as well as other characteristics of the relationship with that person. Social integration is assessed by a series of questions about participation in social roles, such as marital status, contact with friends and relatives, church membership, and participation in organized and informal groups.

Associations Between Social Relationships and Health

The relation between social support and health is not simple, and many questions remain about the aspects of social relationships that are most important to health. Some associations between social relationships and health are supported by strong and consistent evidence, but others are found less consistently. Research on ties between social integration and health began in the 1960s. In the mid-1970s, researchers began to investigate links between social support and health. The best known study of social integration and health was conducted in the 1960s and 1970s in Alameda County, California. Lisa Berkman and S. Leonard Syme studied the health and social integration of approximately 5,000 men and women over a 9-year period. They discovered that people were significantly less likely to die during that 9-year period if they were actively involved with family, friends, church, and civic organizations. This association between social integration and mortality was significant regardless of gender, income, or physical health at the beginning of the study. In fact, the researchers found that social isolation posed about the same degree of risk to health as cigarette smoking, high blood pressure, and obesity. The relation between social integration and mortality has been replicated in several studies. In addition, social integration has been associated with lower rates of mental and physical illness, better adjustment to chronic illness, and recovery following heart attack, stroke, and cancer. Sheldon Cohen and his colleagues conducted an experiment in which people were intentionally exposed to a cold virus. They found that people who were high on social integration were less likely to develop an upper respiratory illness than those who were low on social integration. In sum, there is abundant evidence that active involvement with other people is associated with better health. One question that remains concerning the effects of social integration on health is whether relationships are actually beneficial or whether social isolation is harmful.

Relatively few studies have examined links between perceived or received social support and mortality. However, in Sweden, Bertil Hanson found that elderly men with high social support were less likely to die over a 5-year period than men with low support, and Kristina Orth-Gomer found that middle-aged men with high levels of emotional social support were less likely to develop coronary artery disease than those with low levels. In the United States, Lisa Berkman and colleagues found that men with high levels of emotional support were more likely to survive a heart attack than men with low emotional support, and Alan Christensen and colleagues found that hemodialysis patients survived longer if they had high rather than low levels of support from their families. There is evidence from two additional studies that social support prevents stressful life events from increasing one’s risk for mortality.

The most consistent health-related finding is that people who have high levels of perceived social support are less likely to become depressed following negative life events. Sheldon Cohen and Thomas Wills reviewed a large number of studies and concluded that perceived availability of social support protects or buffers people from emotional distress following a wide range of stressful life events, such as job loss, death of a loved one, and criminal victimization. A second consistent finding is that people with high perceived social support report that they are in better physical health than people who have low perceived support. This association must be interpreted with caution because psychological factors strongly influence self-assessments of health. People who are demoralized or depressed evaluate their physical health more negatively than people who are in good spirits. There is considerable evidence that people who have higher perceived support engage in healthful behaviors more than people who perceive little social support from their network. For example, people with high perceived support tend to exercise, take their medication, and eat healthy foods more than people with low perceived social support. They are also less likely to abuse alcohol. People who perceive their spouse to be supportive are more successful when they try to lose weight or stop smoking.

The evidence that perceived and received social support influence objective measures of physical health is somewhat mixed. Bert Uchino and colleagues summarized the results of numerous studies and concluded that social support has a small but consistent association with blood pressure and a somewhat stronger association with healthy functioning of the immune system. They found that cardiovascular reactivity (increased heart rate) in response to a laboratory-induced stressor was significantly lower among people with high social support than among those with low social support. Mixed results have been found regarding the effect of social support on recovery from illnesses. Perceived support was significantly related to greater mobility, lower pain, less use of pain medication, and shorter hospital stay in some studies, but it was not related to pain, functional status, or health status in other studies.

Some studies have shown that negative behaviors have a greater influence on mental and physical health than supportive behaviors. In addition, not all support attempts are successful. For example, James Coyne and colleagues found that among heart attack survivors, spouse overprotectiveness undermined self-efficacy. Overly protective spouse behavior is associated with poorer functional status among patients with chronic back pain as well.

How Do Social Relationships Influence Health?

There are two major theories regarding the influence of social relationships on health. The first is the direct effects model and the second is the buffering model. An excellent discussion of these theories is contained in a book edited by Sheldon Cohen, Lynn Underwood, and Benjamin Gottlieb.

The direct effects model states that relationships with other people can confer health benefits in good times and bad times through their influence on emotions, thoughts, and behaviors. It is most useful as an explanation for the link between social integration and health. The direct effects approach is rooted in ideas expressed over 100 years ago by Emile Durkheim. He believed that modern industrial society was harmful to people s well-being because it disrupted traditional social ties. People suffer in the absence of clear social roles and strong ties to family and community. Integration into a social network provides resources that are needed for healthy functioning. These include predictability, stability, clear role expectations, and a sense of belonging and purpose. All of these resources contribute to emotional well-being. Emotional well-being is known to influence physical health. People who are embedded in a social network also benefit from the resources they may obtain from members of their social network, such as advice on how to deal with health problems. Because they serve needed functions within their network, people may feel obligated to guard their health by engaging in healthful behaviors, such as exercise and regular physical examinations. It is also possible that social isolation is inherently damaging to peoples health. Social integration may simply prevent the deleterious effects of isolation.

The buffering model states that relationships with other people primarily confer health benefits in times of duress by protecting or buffering the individual from the harmful effects of stressful life events on health. It is most useful as an explanation for the links between social support and health. John Cassel and Sidney Cobb were early and influential proponents of the buffering model of social support. In the 1980s, Sheldon Cohen and Thomas Wills wrote an influential scientific article about this model.

Both perceived and received social support play a role in the buffering model of social support. In the early stages of confronting a problem, the perception that support is available may allow people to appraise the problem as less severe because they believe that others are available to help them deal with the problem. Potentially harmful emotions of fear and despair may be averted. Actual support received may facilitate effective problem solving. Network members may provide input that helps the individual put the problem in perspective, further dampening dysfunctional emotional reactions. They may offer emotional and esteem support, which prevent feelings of isolation and helplessness. They may provide advice about how to solve the problem, and even offer to take direct action that will contribute to problem solution. Thus, the stressed individual may benefit from perceptions that others care about his or her dilemma and the belief that others are available to provide assistance and encouragement, and from input that allows him or her to appraise the problem realistically and take appropriate actions to remove or cope with the cause of his or her distress.

Both the direct effects model and the buffering model provide good explanations for how social support prevents negative attitudes, emotions, and behaviors. Researchers are striving to better understand how these factors influence the physiological processes involved in physical health and illness. There is evidence that psychological states influence neuroendocrine responses (the brains regulatory activities), the immune system, and the cardiovascular system. When the physiology of stress and well-being is better understood, we will have a more complete picture of the mechanisms through which social integration and social support influence health.

In conclusion, multiple components of interpersonal relationships appear to have consequences for health. There is evidence that both social integration and social support decrease risk for mortality and predict better health outcomes; however, some studies have not found a significant link between these variables and health. Both social integration and social support appear to improve psychological well-being, but it is not clear under what circumstances or through what mechanisms psychological well-being translates into physical health. Research is progressing rapidly in this area and will shed light on the precise links among interpersonal relationships, social support, and health.


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