comparisons and well-being in medical populations is based on cross-sectional, correlational methodologies. Hence, inferences about causation, confounding, and possible third variable explanations cannot be ruled out. In addition to noting this methodological problem, Tennen and Affleck (1997) argued that reports of relative standing or scores from comparative rating scales do not necessarily represent the result of downward coping efforts, but merely comparison conclusions. These conclusions may be accurate, rather than biased, because some patients will be doing well and will be veridically “better off' than others (Affleck et al., 1988). Although Tennen and Affleck are correct that longititudinal studies are needed to distinguish between comparisons and outcomes, all comparisons need not be effortful or intentional to be helpful. Patients may contemplate that “things could be worse” without intending anything beforehand; nonetheless, once patients have the thought they may seize on it for comfort.
Similarly, constructed norms may bouy a patient's spirits even if they are based on no concrete explicit comparisons. For example, Suls, Marco, and Tobin (1991) interviewed a sample of 100 senior citizens, many of whom were coping with serious chronic illnesses. After rating their health on a 4-point scale (excellent, good, fair, poor), respondents were asked to “report about the kinds of information that 'came to mind' in thinking about their overall level of health, “ such as whether they thought about how their health compared to someone else, to a group, with their health some time in the past, or based on direct feedback information from someone else. Sixty-seven percent of the sample reported that their health was “good” or “excellent, “ a result consistent with larger survey studies of elderly self-assessments of health (Levkoff, Cleary, & Wetle, 1987; B. S. Linn & M. W. Linn, 1980). Interestingly, mention of social comparison was unrelated to health ratings. Temporal comparisons were related to ratings, but in a negative direction (i.e., mentioning temporal comparison was associated with lower self-ratings of health). Because no specific, explicit social or temporal comparisons were related to the positive self-ratings, it was not obvious what factors accounted for the overwhelmingly positive health assessments. Suls et al. proposed that rather than being based on specific comparisons, the health assessments were based on implicit comparisons with a fabricated, generalized other and a stereotypical notion that most of the elderly population is quite frail and ill. Although many of the elderly respondents had serious diseases, they evaluated themselves positively because of their general stereotypes rather than a specific comparison other.
In any case, longitudinal studies are needed that include intensive assessments of the prospective relation between comparison coping efforts and subsequent outcomes (Tennen & Affleck, 1997). In this way, researchers can obtain more direct evidence of the causal relation between comparison efforts and adaptational outcomes. In addition, measures of expectancy, in accord with Wood and Vanderlee's should be included. More attention also needs to be paid to identification of specific evaluative questions served by a given comparison (Suls, 1999). Patients diagnosed with cancer might initially ask “Will I survive this?” Upward contact with a longtime survivor may be useful and inspiring. But other questions are more specific (“Will I become nauseous or lose my hair after radiation therapy?”) and probably are best answered by people who are closer in standing to themselves. Some important concerns are in the form of “Can I do X?” In such instances, individuals might compare themselves with someone who is similar in background attributes (age, gender) who has recently gone through the procedure (Wheeler et al., 1997). Available research has conceptualized upward and downward comparisons in global terms (better vs. worse). Patients, however, probably make finer distinctions among potential comparison others both with regard to background factors and current adaptation to disease.
Although the study of comparison processes among chronically ill patients has identified an important area of coping, health psychologists still do not know what social comparison opportunities should be made available to patients and how they should be implemented. Perhaps Kulik and his associates' efforts with regard to acute medical threats (reviewed earlier) may offer suggestions in this regard. Also, more attention to the specific day-to-day evaluative questions and concerns pressing on patients and members of their support network may facilitate this active line of health psychological research.
This chapter has reviewed four areas of health psychology in which the role of social comparison has been strongly implicated. Classic and contemporary social psychological comparison theories and research shed light on some important medical and public health phenomena, and also provide suggestions for possible interventions. There is good reason to believe that social comparison processes will be implicated in other health psychology domains because comparison is such a fundamental aspect of social behavior. Just as advances in cellular biology and medical technology have contributed significantly to medical science and health care, it is clear that Virchow's 19th, century observation was correct-medical science is grounded in a social field.
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