JSPR

Article

Journal of Social and

Personal Relationships
Supporting the supporter: 1–22
ª The Author(s) 2016
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physiological stress among DOI: 10.1177/0265407516680500

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caregivers of children
with severe disabilities

Meara H. Faw
Rutgers University, USA

Abstract
The social, economic, and physical costs associated with providing long-term care for a
child with disabilities can be overwhelming, and it is not uncommon for caregivers to
experience burnout, emotional distress, and significant health ailments as a result of their
commitment to their child. Social support can be a key resource to combat these
negative effects, as ample research has shown that social support can act as a buffer to
the negative effects of stress. The current study explored whether short-term sup-
portive interactions between parents of children with disabilities and members of
their supportive network (n ¼ 40 dyads) influenced the physiological stress responses
(as measured by salivary cortisol) of both interactants. Results indicated that receiving
support in a short interaction resulted in parents experiencing decreases to their phy-
siological stress, though the quality of the support played a key role in determining how
beneficial the interaction was in this context. These results suggest the importance of
considering support quality when examining the influence of social support on physical
outcomes for support recipients.

Keywords
Caregiving, children with disabilities, salivary cortisol, social support, stress, verbal
person-centeredness

Corresponding author:
Meara H. Faw, Department of Communication, Rutgers University, 4 Huntington Street, New Brunswick, NJ
08901, USA.
Email: meara.faw@rutgers.edu

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2 Journal of Social and Personal Relationships

Mental and physical disabilities affect millions of people in the U.S., and managing
disabilities is associated with significant costs for family caregivers. It is not uncommon
for caregivers to experience negative outcomes stemming from their responsibilities
(Centers for Disease Control and Prevention [CDC], 2010). Social support, however,
may help caregivers better manage their demands, as previous research suggests that
social support can protect individuals from the deleterious effects of stress (Cohen &
Willis, 1985). There is still much to learn, however, about when support works best and
how the quality of support might influence individuals’ stress.
This study has two primary goals. First, it explores how engagement in a supportive
interaction affects the physiological stress of both parents caring for a child with dis-
abilities (PCDs) as well as the support provider. Understanding the implications of social
support for PCDs is an important step in promoting caregiver health. Exploring the
experiences of relationship partners supporting PCDs is also important, as provider
experiences have received less empirical attention and carry implications for the health
of the provider and the relationship they have with PCDs. Second, this study seeks to
advance the literature outlining the associations between social support and health by
exploring how support quality influences short-term experiences of physiological stress.
Additionally, this study examines more natural conversations between relationship
partners when considering support quality, contributing to the growing list of methods
for exploring the connections between social support and health.

The community costs of disabilities in the U.S.

According to CDC (2012), the disability prevalence in the U.S. has grown 17.1% in the past
decade. Having a child with disabilities is linked to numerous significant challenges, such as
an increased risk for falling below the poverty level (Emerson, 2003), experiencing
depression, a higher incidence of health complaints, and an increased risk for all-cause
mortality (Schulz & Beach, 1999). A 2006 study by the National Alliance for Caregiving
found that all of the 528 caregivers surveyed reported declines in their health and increases in
their stress as a result of caregiving activities (National Alliance for Caregiving, 2006).
Caregiving parents face some unique challenges that can exacerbate these outcomes
(Faw & Leustek, 2015). Disabled children can engage in problematic behavior that can
disrupt family life and strain relationships (De Andrés-Garcı́a, Moya-Albiol, &
González-Bono, 2012). Similarly, PCDs must navigate stigma associated with dis-
abilities and the grief that comes with realizing a child will never achieve certain
milestones (Ha, Hong, Mailick Seltzer, & Greenberg, 2008). In addition to care provi-
ders, the costs of caregiving can influence the health of the person receiving care (CDC,
2010). Declining caregiver health is associated with premature institutionalization of
disabled individuals (Carretero, Garcés, Ródenas, & Sanjosé, 2009), underscoring the
importance of caregiver health in families of children with disabilities.

Social support and its role in caregiving

Because caregiving carries serious health implications, practitioners have pinpointed
social support as a resource key to reducing caregiver strain (Lovell, Moss, & Wetherell,

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Faw 3

2012). Social support is ‘‘verbal and nonverbal communication between recipients and
providers that reduces uncertainty about the situation [ . . . ] and functions to enhance a
perception of personal control in one’s life experience’’ (Albrecht & Adelman, 1987, p.
19). Many types of support exist, though emotional support, which includes acts of
caring and expressions of love, has received the most empirical attention (Cutrona &
Russell, 1990), as it is most strongly associated with enhanced well-being. This is true
for PCDs, as previous research has shown strong associations between emotional support
and parents’ subjective well-being and psychological adjustment (White & Hastings,
2004). Indeed, PCDs often cite challenges centered on feelings of social isolation and
desiring emotional connection as key difficulties they face (Faw & Leustek, 2015).

Social support, stress, and health

The associations between support and health are well established, with research indi-
cating that higher levels of perceived support positively influence health outcomes
(MacGeorge, Feng, & Burleson, 2011). Because of these findings, scholars have
investigated specific mechanisms to explain this relationship. One theory, the stress
buffering hypothesis, argues that support serves a protective function by helping dis-
tressed individuals cope with their problems (Cohen & Willis, 1985). According to this
hypothesis, support is most essential when people experience difficulties, as this is when
stress is most likely to increase.
Studies based on the stress buffering hypothesis have shown that heightened levels of
support result in many positive outcomes, including lower levels of psychological dis-
tress and fewer health complaints (Cohen & Willis, 1985). While the stress buffering
hypothesis originally measured social support as a perception, research has since
demonstrated the associations between communicated support and positive outcomes
(e.g., Afifi, Granger, Denes, Joseph, & Aldeis, 2011). Additionally, research has high-
lighted the importance of considering how specific types of support, and especially
emotional support, influence health (Cohen, 2004). Along with calls for considering the
effects of communicated support, researchers have also challenged an assumption
underlying much of the stress buffing hypothesis research: that more support is always
better, as this assumption minimizes the fact that support varies in its effectiveness
(MacGeorge et al., 2011). Finally, researchers continue to explore the biological
mechanisms that explain the connections between social support, stress, and health
(Uchino, Bowen, Carlisle, & Birmingham, 2012).
This study investigates how emotional support of differing quality might buffer a
person’s physiological stress as manifested by salivary cortisol. Scholars have increas-
ingly focused on cortisol to elucidate the connections between social phenomena and
stress (Floyd et al., 2007; Priem & Solomon, 2015). Cortisol is a glucocorticoid hormone
with many functions including stress response. When a person experiences stress, cor-
tisol is secreted by the adrenal glands through a series of chain reactions in the hypo-
thalamic–pituitary–adrenal axis. After stressor exposure, cortisol is secreted into the
blood stream and passively diffuses into saliva (Hellhammer, Wust, & Kudielka, 2009).
When exposed to a stressor, increases in serum cortisol happen quickly, whereas

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4 Journal of Social and Personal Relationships

increases in salivary cortisol appear after about 10 min and return to their basal level
after about 30 min (Afifi et al., 2011; Floyd et al., 2007).
Cortisol has been used previously to explore general associations between social sup-
port and stress. For example, a 2008 study by Floyd and Riforgiate found that spouses who
received more supportive affection from their partner experienced diurnal cortisol profiles
indicative of lower stress levels. This finding is echoed among PCDs in a 2012 study by
Lovell and colleagues, which found that PCDs who reported higher levels of perceived
support experienced a cortisol awakening response indicative of enhanced well-being.
These particular studies focused on the physiological responses of participants over
several hours or even a full day. Studies like these, while valuable, are limited in that
they present aggregate information and cannot speak to specific interactions or to the
immediate effects of a single interaction (Priem & Solomon, 2015). Investigating
responses to a single supportive encounter provides an opportunity for uncovering what
might make support more effective. Additionally, understanding a short-term interac-
tion’s influence on physiological stress is valuable, as interactions can take place any-
time and with anyone. Thus, knowledge about these short-term effects provides one
potential avenue for offering care to PCDs.
In an effort to answer some of the lingering questions about the short-term effects of
social support on stress, recent studies have examined how salivary cortisol levels
change when receiving support immediately following a stressful task (Priem & Solo-
mon, 2009, 2011, 2015). In these studies, the researchers found that receiving support
after a stressful task resulted in salivary cortisol decreases. In their 2011 study, parti-
cipants who received hurtful messages, rather than supportive ones, did not experience
these same decreases, suggesting that receiving support does influence short-term
physiological stress. These studies provide a foundation for understanding the rela-
tionship between support and stress, but they are limited in their ability to address
questions of support quality. This study contributes to the ongoing research exploring the
role of support quality on salivary cortisol using a hierarchy of support message quality:
message verbal person-centeredness (VPC).

Communicated social support and support quality

Message VPC (Burleson, 2003) is defined as ‘‘the extent to which messages explicitly
acknowledge, legitimize, and contextualize the feelings and perspectives of a distressed
other’’ (Bodie et al., 2011, p. 231). Many studies have explored message VPC with
results from a meta-analysis indicating a strong, positive relationship (r ¼ .61) between
message VPC and support effectiveness (High & Dillard, 2012). In its original con-
ception, coding for message VPC consisted of nine levels with each increasing level
indicating a step up in support quality (Burlseon & Samter, 1985). However, most
research exploring message VPC simplifies the scheme by coding support based on three
broader categories, and research does not find evidence to support that the nine levels are
truly distinct from one another (High & Dillard, 2012).
According to the simplified coding scheme (High & Dillard, 2012), the first level of
support features messages labeled as low person-centered (LPC) support. These mes-
sages ignore or deny the distressed individual’s feelings and criticize their emotions. The

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Faw 5

next level in the hierarchy, moderate person-centered (MPC) support, recognizes the
other person’s feelings but does not fully legitimize them. These messages often include
sympathy or attempts at distraction. The final level includes messages high in person-
centeredness (HPC). HPC messages fully acknowledge the other’s feelings and legit-
imize their emotions. Evidence suggests that HPC support helps distressed people gain
insight into their circumstances, allowing them to engage in cognitive reappraisals
(Jones & Wirtz, 2006). Many studies have explored the effects of message VPC, con-
sistently finding HPC messages to be the most sensitive and the most likely to encourage
reappraisals (High & Dillard, 2012; Jones & Wirtz, 2006).
Although ample evidence supports the associations between positive outcomes and
HPC support, researchers have only recently begun to examine the physiological out-
comes associated with receiving support of differing quality. In one study, participants
with high levels of communication apprehension were offered comforting messages
before they had to give a speech. The researchers found that distracting messages
(messages likely classified as MPC) produced significant reductions in salivary cortisol.
The same was not true, however, for messages designed to be more sensitive (Priem &
Solomon, 2009). This is interesting, as research would generally suggest that HPC
support should produce the most positive outcomes (High & Dillard, 2012). Other
studies have manipulated support quality by coaching some study participants to provide
supportive messages while others are instructed to provide hurtful (Priem & Solomon,
2011) or impartial (Priem & Solomon, 2015) messages. Results from both of these
studies indicated positive outcomes for individuals who received support.
When interpreting these results, it is important to note that all of these participants
were exposed to an acute stressor and then received comfort from either someone with
whom they were not close or a close individual who had received specific instructions
about how to act. These conditions are very different from people’s day-to-day inter-
actions and do not fully explore the influence of support quality on physiological stress.
The large amount of evidence demonstrating the effectiveness of HPC messages, taken
with evidence from research that found that PCDs’ ratings of friends’ and family’s
support were the most consistent predictor of parent well-being (White & Hastings,
2004), suggests that better-quality support should produce positive, short-term outcomes
for PCDs. As such, I hypothesize that PCDs who receive HPC support in a short-term
interaction will experience greater reductions in physiological stress compared to their
baseline stress levels than PCDs receiving MPC or LPC support (Hypothesis 1).
Similarly, I predict that PCDs who receive MPC support in a short-term interaction will
experience greater stress reductions compared to their baseline levels than PCDs
receiving LPC support (Hypothesis 2).

Social support and the support provider

Because support is dyadic by nature, it is important to consider the support provider
when assessing the potential outcomes of a supportive interaction. Evidence on support
provision’s effects is mixed. In some cases, those sought for support might feel their
autonomy is threatened or resent the distressed person (Lu, 1997). Providing support has
also been linked with emotional strain, as is the case with PCDs (Carretero et al., 2009).

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6 Journal of Social and Personal Relationships

There are also benefits to providing support, including increased positive affect and
feelings of satisfaction (Lu & Argyle, 1992). Studies have found that support provision is
associated with enhanced feelings of trust, a greater sense of purpose, and a reduced risk
of mortality (Brown, Nesse, Vinokur, & Smith, 2003).
Research exploring the benefits of expressing affection highlights the potential
benefits of support provision. This research has consistently found positive outcomes,
such as lower physiological stress, associated with expressing affection (Floyd et al.,
2007). While providing support is not the same as communicating affection, the two
behaviors are associated (Floyd & Riforgiate, 2008). This is especially true for the
communication of emotional support (Cutrona & Russell, 1990). In one study, partici-
pants who reported higher levels of affectionate expression experienced lower salivary
cortisol levels even when controlling for the affection they received (Floyd, 2006). This
implies that the communication of affection is salubrious, and it is likely that the same
effect exists for communicating support.
In these interactions, it is possible that the quality of the support offered influences the
outcomes experienced by the support provider. Researchers have posited that matching
support to meet support seekers’ needs is essential to creating a successful interaction
(Cutrona & Russell, 1990), and it is possible that individuals providing high-quality
support (e.g., HPC messages) derive satisfaction from offering support that is thought-
ful and engaged. On the other hand, providing HPC messages requires higher levels of
cognitive complexity, and it is possible that producing HPC messages requires signifi-
cant effort and emotional resources that might leave a provider feeling drained (Burle-
son, 2010). Presently, little research has investigated what the effects of offering support,
let alone of offering different quality support, might have on providers. As such, I pose
the following research question: Does the quality of the support provided affect the
physiological stress response of the support provider (Research Question 1)?

Method
Participants
Participants (n ¼ 40 dyads) were recruited through snowball sampling. Each dyad
consisted of at least one PCD and one conversation partner. Conversation partners were
identified by parents as people they had previously approached for support. Parents were
almost exclusively mothers (97.5%) and ranged from 25 to 77 years old (M ¼ 48.65,
SD ¼ 10.62). Conversation partners (female: 40%) ranged from 27 to 80 years old (M ¼
49.30, SD ¼ 10.04). Participants were predominately white (93.8%). Conversation
partners consisted of spouses or romantic partners (60%), friends (17.5%), parents
(12.5%), or adult children of the parent (10%). These dyads had usually known one
another for more than 7 years (90% of dyads).

Exclusion criteria
Interested individuals completed a screening questionnaire. Because of the nature of
cortisol, all participants could not currently use any steroids, prescription hormones

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Faw 7

(excluding contraceptives), thyroid medication, or tobacco products. Pregnant or

breastfeeding women were also excluded from participation (Floyd et al., 2007).

Appointment procedures
Appointments lasted about 2 hr. All participants refrained from eating anything, drinking
anything but water, exercising vigorously, brushing their teeth, or chewing gum for at
least 2 hr prior to their appointment as these activities are known to affect salivary
cortisol (Gordis, Granger, Susman, & Trickett, 2006). At the onset of the appointment,
participants provided baseline saliva specimens using a passive drool method (Granger
et al., 2007). Under this method, participants rinsed their mouths out with water. They
then provided approximately 2 mL of saliva in a polypropylene centrifuge tube by
drooling or spitting into the tube.
Next, participants completed the study’s conversation portion. Conversations lasted
10 min and were recorded. In the conversation, the PCD was instructed to share chal-
lenges they experienced when caring for their child. In response, partners were asked to
respond in helpful, appropriate ways. This direction was intended to prime the partner to
respond in generally supportive ways. Both participants were told that the goal was for
the conversation to feel natural. After the interaction, participants engaged in a 10-min
rest period before providing another saliva specimen. They then completed a 20-min rest
period followed by a third specimen. During these rest periods, participants were under
supervision of the researcher. They were not allowed to talk with one another or engage
in any activity other than reading a magazine from a preapproved selection. After pro-
viding the third saliva sample, they were given access to a survey with several scales.
Twenty minutes after their third specimen, participants provided a final specimen. At the
study’s end, each participant received US$25.

Measurements
Salivary cortisol assay. Saliva samples were kept on ice when transported from the
appointment and then frozen at 5 C until they were transferred to a 20 C freezer in
the laboratory. Specimens remained frozen until analysis, when they were thawed and
centrifuged at 2,800 r/min for 20 min. The aqueous layer of the saliva was separated into
aliquots and stored at 20 C. Specimens were assayed using a competitive microtiter
plate enzyme immunoassay. All specimens were run in duplicate and at a variety of
dilutions (from 1:1 to 1:10). Specimens that fell outside the assay limits of detection or
had unacceptable coefficients of variation (CVs) were re-assayed. Acceptable mea-
surements for all samples were achieved resulting in no missing data. The specimen
intra-assay CVs (n ¼ 14 plates) ranged from 9% to 15%, and inter-assay CVs ranged
from 8% to 14% across the three controls.

Covariates and control variables. Because salivary cortisol serves multiple functions and is
sensitive to changes, certain covariates were included in analysis. Cortisol operates on a
diurnal pattern, with levels peaking approximately 30–45 min after waking and
slowly declining throughout the day (Edwards, Evans, Hucklebridge, & Clow,

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8 Journal of Social and Personal Relationships

2001). As such, the appointment start time and participants’ time of waking were
included as covariates. Cortisol levels are also known to fluctuate based on sleep
quality (Lasikiewicz, Hendrickx, Talbot, & Dye, 2008). Participants rated the quality
of their sleep the night before their appointment on a scale of 0 ¼ not well at all to
4 ¼ very well (M ¼ 2.56, SD ¼ 0.90). Finally, participants indicated their experi-
ences of stress leading up to the appointment on a scale of 0 ¼ not stressful at all to
4 ¼ extremely stressful (M ¼ 0.85, SD ¼ 0.93).
In addition, data was also collected in the survey administered toward the end of the
appointment (during the rest period between the Time 3 and Time 4 saliva sample
collection). Parents were asked to evaluate the appropriateness of their partner’s beha-
vior (Bodie et al., 2011), using a 1 ¼ strongly disagree to 5 ¼ strongly agree scale.
Sample statements included ‘‘my conversation partner behaved correctly’’ and ‘‘my
feelings toward my conversation partner became more positive a result of this con-
versation.’’ Items indicating negative perceptions were reverse coded so that high scores
represented more appropriate conversations (M ¼ 4.25, SD ¼ 0.56). Parents also
responded to 5 items assessing the normalcy of their partner’s behavior (e.g., ‘‘my
partner behaved as he/she normally would’’; M ¼ 4.40, SD ¼ 0.67). Partners also
responded to these items, though they were adjusted to reflect partners’ perceptions of
their own behavior, with higher scores indicating the belief that they had behaved
appropriately (M ¼ 4.08, SD ¼ 0.79) and normally (M ¼ 4.14, SD ¼ 0.59).
Finally, parent participants also completed the Global Perceived Stress Scale
(GPSS; Cohen, Karmarck, & Mermelstein, 1983). This 14-item scale asked parents to
indicate how often they perceived events in their life to be overwhelming on a scale of
0 ¼ never/almost never to 4 ¼ more than once per week. Six scale items were reverse
coded so that higher scores represented higher levels of perceived stress (M ¼ 1.95, SD
¼ 0.63).

Coding interactions
All conversations between dyads were coded to examine the quality of support provided.
First, all conversations were transcribed. Second, two coders analyzed the conversation
using the transcripts. Coders received training on the definition of emotional support as
well as common message features that constitute emotional support. Coders rated the
interaction’s overall quality of support using Burleson’s original (1982) coding scheme
for message VPC, which classified messages on a 1–9 scale (for a description of this
coding scheme, see High & Dillard, 2012). These scores were then used to classify the
support provided in the interaction as LPC, MPC, or HPC support. Conversations coded
with a score of 1–3 were coded as LPC messages; conversations with scores of 4–6 were
labeled as MPC messages; and conversations with scores from 7–9 as HPC messages.
Before coding began, the coders engaged in 3 hr of training to familiarize themselves
with the definition of emotional support, the coding scheme, and the codebook
instructions. The coders carefully studied Burleson’s (1982) coding scheme as well as
the coding scheme outlined in High and Dillard’s (2012) meta-analysis on message VPC.
Additionally, the researcher provided examples of messages varying in VPC based on
the literature. The coders discussed at length what could be considered emotional support

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Faw 9

and how to evaluate emotional support using the coding scheme. To complete the
coding, coders were instructed to first read through the transcript. Then, during a second
reading of the transcript, coders were asked to assess the quality of support provided
during the interaction by considering all expressions of emotional support. Coders then
identified which level of message VPC was most prevalent in the exchanges. Although
message VPC has traditionally been studied at a message level (rather than a con-
versation level), recent research has expanded examinations of message VPC by
examining entire conversations (Bodie, Jones, Vickery, Hatcher, & Cannava, 2014; High
& Solomon, 2014). As such, coders rated each conversation as a whole rather than
breaking them down into smaller units.
Intercoder reliability was tested at several points. Both coders first independently
coded five random transcripts using the 1–9 VPC scale. From this information, each
conversation was coded as LPC, MPC, or HPC support. Both the 1–9 coding score and
the LPC/MPC/HPC coding scores were then compared, and intercoder reliability was
assessed using Scott’s p. The coders then came together, reconciled their differences,
and clarified the coding scheme. They then coded an additional five cases, assessed the
reliability, and reconciled their differences. At this point, coders had engaged approxi-
mately 12 hr of training, coding, and discussion. The coders had also established
acceptable intercoder reliability (reliability on the 1–9 message VPC coding scheme:
Scott’s p ¼ .74; 84.6% agreement; reliability on the 1– 3 message VPC coding scheme:
Scott’s p ¼ 1.0; 100% agreement). The remaining cases were then randomly divided
among the coders and coded for message VPC. Among study participants, there were 11
cases of LPC support, 14 cases of MPC support, and 15 cases of HPC support.

Results
The first step of analysis was to examine the cortisol specimens for deviations from
normality. Because the cortisol data were not normally distributed, a natural log trans-
formation was used to address the skew of the data (average skew: 1.04, SE ¼ .37; post-
transformation skew: .17, SE ¼ .37; Keene, 1995). The cortisol data was also assessed
for outliers, and none were found. Next, a correlation matrix was used to assess rela-
tionships between the variables of interest for each group of participants (for PCDs, see
Table 1; for partners, see Table 2).

Support quality and physiological stress among parent caregivers

The first set of hypotheses explored the relationship between the support provided during
the study conversation and parents’ physiological outcomes. Before analysis, steps were
taken to assess whether parents who received LPC, MPC, or HPC support significantly
differed in potentially confounding ways. Using one-way analyses of variance (ANO-
VAs), groups were evaluated for differences in their caregiver burden and the func-
tioning of their disabled child (as measured using survey data). Neither of these variables
significantly differed between groups, caregiver burden: F(2, 37) ¼ 2.52, ns; child
functioning: F(2, 37) ¼ .50, ns. Groups also did not differ in their reports of stress
leading up to the appointment, F(2, 37) ¼ .11, ns. Similarly, the groups were assessed for

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 10
Table 1. Descriptive statistics for the primary variables of analysis for parents of children with disabilities.

M SD n 1 2 3 4 5 6 7 8 9

1. Baseline cortisol 3.12 0.27 40 –

2. Cortisol T2 3.10 0.26 40 .84** –
3. Cortisol T3 3.04 0.26 40 .79** .85** –
4. Cortisol T4 3.02 0.24 40 .74** .80** .85** –
5. Prestudy stress 0.85 0.53 40 .29 .23 .22 .31 –
6. Waking 6:37 1:11 40 .12 .05 .13 .28 .01 –
7. Sleep quality 2.56 0.90 40 .02 .11 .01 .10 .18 .02* –
8. Appointment time 14:07 3:50 40 .53** .49** .57** .51 ** .42** .01 .00 –
9. Coded support 5.45 2.38 40 .52** .31* .29 .17 .11 .03 .13 .23 –

Note. Analysis represents values for parents of children with disabilities only. T2 ¼ Time 2; T3 ¼ Time 3; T4 ¼ Time 4.
*p < .05; **p < .01.

Table 2. Descriptive statistics for the primary variables of analysis for conversation partners.

M SD n 1 2 3 4 5 6 7 8 9

1. Baseline cortisol 3.20 0.27 40 –

2. Cortisol T2 3.16 0.24 40 .82** –
3. Cortisol T3 3.14 0.24 40 .76** .83** –
4. Cortisol T4 3.11 0.24 40 .87** .85** .88** –

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5. Prestudy stress 0.80 0.82 40 .03 .08 .04 .13 –
6. Waking 6:23 1:15 39 .42** .44** .25 .37* .10 –
7. Sleep quality 2.63 0.81 40 .04 .01 .03 .02 .27 .06 –
8. Appointment time 14:07 3:50 40 .46** .35* .32* .42** .19 .38* .13 –
9. Coded support 5.45 2.38 40 .11 .07 .18 .10 .02 .02 .32* .23 –

Note. Analysis represents values for conversation partners only. T2 ¼ Time 2; T3 ¼ Time 3; T4 ¼ Time 4.
*p < .05; **p < .01.
Faw 11

Table 3. Repeated measures ANCOVA summary table for changes in cortisol by quality of
support provided.

Source SS df MS F p Z2

Cortisol .11 3 .037 3.64 .02 .10

Cortisol  Appointment Time .05 3 .02 1.56 ns .05
Cortisol  Stress .05 3 .02 1.64 ns .05
Cortisol  Wake .07 3 .02 2.43 .07 .07
Cortisol  Sleep .06 3 .02 2.07 ns .06
Cortisol  Support Quality .34 6 .06 5.59 .001 .25
Error .996 99 .01
Note. n ¼ 40. ANCOVA ¼ analysis of covariance; SS ¼ sum of squared; df ¼ degree of freedom; MS ¼ mean
squared.

differences in the perceived conversational appropriateness, F(2, 37) ¼ 1.97, ns, and
normalcy, F(2, 37) ¼ .35, ns. Finally, groups were assessed for differences in their
waking time and appointment time. Results indicated no differences for time of waking,
F(2, 37) ¼ .10, ns, or appointment time, F(2, 37) ¼ 1.24, ns.
H1 and H2 predicted that parents who received HPC support would experience
greater cortisol reductions when compared with parents who received LPC or MPC
support (H1), and that MPC support recipients would experience greater cortisol
reductions when compared with LPC support recipients (H2). To test these hypotheses, a
one-way repeated measures analysis of covariance (ANCOVA) was used. The four
transformed cortisol values (baseline and samples taken at 10, 30, and 50 min post-
interaction) were entered as the within-subject (dependent) variables, and support quality
(LPC, MPC, or HPC) was entered as the between-subject (independent) variable. Time
of waking, quality of sleep, the day’s stress, and the appointment start time were included
as control variables. Results indicated that cortisol levels significantly changed during
the appointment regardless of the quality of support received, F(3, 99) ¼ 3.64, p < .05,
partial Z2 ¼ .10. Analysis also revealed a significant effect of the quality of support on
cortisol, F(6, 99) ¼ 5.59, p < .01, partial Z2 ¼ .25 (see Table 3 and Figure 1).
To further explore these differences, change scores were computed by subtracting
each of the postinteraction cortisol levels from the baseline cortisol measure, resulting in
three scores representing the change in cortisol from baseline to Time 2, baseline to Time
3, and baseline to Time 4. One-way ANCOVAs were used to test for differences between
each level of support at each time point. Each subsequent ANCOVA included time of
waking, quality of sleep, the day’s stress, and appointment start time as covariates. The
first one-way ANCOVA (with level of support as the independent variable and the
change in cortisol from baseline to Time 2 as the dependent variable) revealed statis-
tically significant differences in participants’ cortisol levels, F(2, 37) ¼ 4.38, p < .05,
partial Z2 ¼ .19. Pairwise comparisons using Bonferroni’s correction revealed that
participants who received HPC support experienced cortisol reductions (average
reduction ¼ .10, SE ¼ .03) that were significantly greater than those by MPC support
recipients (M ¼ 0.05, SE ¼ .04, p < .05). The difference in cortisol reductions between
HPC support recipients and LPC support recipients (M ¼ 0.03, SE ¼ .04) approached

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12 Journal of Social and Personal Relationships

Figure 1. Changes on cortisol by support quality. Note. LPC (n ¼ 11); MPC (n ¼ 14); HPC (n ¼ 15).
Error bars represent standard error. LPC ¼ low person centered; MPC ¼ moderate person
centered; HPC ¼ high person centered.

significance (p < .10). There were no significant differences between MPC and LPC
message recipients.
The second ANCOVA, testing if participants in each level of support (the indepen-
dent variable) experienced differences in the changes to their cortisol levels from
baseline to Time 3 (the dependent variable), was also significant, F(2, 37) ¼ 7.69, p <
.01, partial Z2 ¼ .29. Again, pairwise comparisons using Bonferroni’s correction indi-
cated that HPC support recipients (M ¼ 0.17, SE ¼ .04) experienced greater cortisol
reductions than MPC support recipients only (M ¼ 0.05, SE ¼ .04, p < .01). Differ-
ences between HPC support recipients and LPC support recipients (M ¼ 0.06, SE ¼ .05)
were not significant, and differences between LPC support recipients and MPC support
recipients were also nonsignificant. A third and final ANCOVA tested for differences in
cortisol changes between baseline and Time 4. Results revealed a statistically significant
effect for level of support on cortisol changes between baseline and Time 4, F(2, 37) ¼
11.14, p < .01, partial Z2 ¼ .38. Pairwise comparisons using Bonferroni’s correction
demonstrated that HPC support recipients (M ¼ 0.24, SE ¼ .04) experienced signifi-
cantly larger cortisol reductions when compared with MPC support recipients (M ¼
0.01, SE ¼ .04, p < .01) and LPC support recipients (M ¼ 0.03, SE ¼ .05, p < .01).
Again, no significant differences emerged between LPC support recipients and MPC
support recipients.
These results demonstrated that HPC support recipients experienced cortisol reduc-
tions at all three post-baseline time points, and that these differences were significantly
greater than those experienced by MPC support recipients at all time points and those
experienced by LPC support recipients at Time 4 (with differences that approached
significance at Time 2). Thus, H1, which stated that HPC support recipients would
experience the greatest cortisol reductions, was supported. However, H2, which stated
that MPC support recipients would experience sharper declines in salivary cortisol when

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Faw 13

compared with LPC support recipients, was not supported, as the changes in MPC
support recipients’ cortisol levels did not differ from the changes of LPC support reci-
pients’ cortisol levels at any time point.
Post hoc analyses examined whether the level of support was associated with parti-
cipants’ perceived stress. A one-way ANOVA with participants’ scores on the GPSS
(Cohen et al., 1983) as the dependent variable and participant’s support level (HPC,
MPC, or LPC) as the independent variable was conducted. Results were significant, F(2,
37) ¼ 3.42, p < .05, partial Z2 ¼ .16. Pairwise comparison using Bonferroni’s correction
indicated that HPC support recipients had significantly lower perceived stress (M ¼ 1.69,
SE ¼ .15) than MPC support recipients (M ¼ 2.27, SE ¼ .16, p < .05). However, similar
to the cortisol results, LPC support recipients’ perceived stress levels (M ¼ 1.91,
SE ¼ .18) were not significantly different than MPC or HPC recipients.

Providing support and physiological stress for conversation partners

This study also explored how support provision might affect the provider by examining
whether the quality of support provided influences providers’ physiological stress during
the interaction (RQ1). A repeated measures ANCOVA was used with the four trans-
formed cortisol values as the within-subjects (dependent) variables and the quality of
support provided (LPC, MPC, or HPC) as the between-subjects (independent) variable.
Time of waking, the day’s stress, quality of sleep, and the appointment time were
included as covariates. Results indicated no significant effect of support quality on
partners’ cortisol levels, F(2, 37) ¼ .61, ns.

Discussion
Much evidence demonstrates the strong associations between social support and positive
health outcomes, leading scholars to pinpoint support as a key resource for long-term
caregivers (Lovell et al., 2012). This study explored whether short-term supportive
interactions between PCDs and members of their supportive network influenced the
physiological stress responses of both interactants. Results indicated that communicated
support significantly influenced PCDs’ physiological stress levels. Specifically,
receiving support in an interaction resulted in recipients experiencing decreases to their
physiological stress, though the quality of the support played a key role in determining
how beneficial the interaction was in this context.

Support and support recipients

Results from H1 demonstrated that PCDs experienced significant reductions to their sali-
vary cortisol levels as a result of engaging in a short-term supportive interaction with a
supportive partner. Other research examining communication and cortisol has argued that
short-term cortisol reductions indicate a health benefit (Afifi et al., 2011; Floyd et al., 2007).
Thus, these findings provide some empirical support for the stress buffering hypothesis
(Cohen & Willis, 1985), which states that support positively influences health by protecting
recipients from heightened stress that is known to cause physical deterioration.

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14 Journal of Social and Personal Relationships

This study also sought to expand the stress buffering hypothesis by exploring the role
of support quality in influencing physiological stress. Analyses revealed that participants
receiving high-quality support in the interaction (messages coded as HPC support)
experienced the most pronounced reductions in their salivary cortisol. Results indicated
that HPC message recipients experienced cortisol reductions at all time points relative to
their baseline levels. As HPC messages are commonly identified as the most helpful,
effective form of emotional support (High & Dillard, 2012), this finding aligns with and
expands previous research, suggesting that HPC support can be effective at helping
individuals manage their physiological stress.
While the results demonstrated significant reductions in cortisol levels among HPC
message recipients, it is interesting to note that HPC message recipients experienced
higher salivary cortisol levels at the onset of the appointment when compared with
MPC or LPC message recipients. While preliminary analysis revealed that HPC
message recipients did not significantly differ in their overall caregiver burden, the
functioning of their child, their self-reported stress on the day of the appointment, their
time of waking, or appointment time, it is possible that something about how HPC
support recipients behaved during the interaction as a result of their higher baseline
cortisol levels incited the partner to respond with better support. For example, if the
partner was aware that the parent usually experiences high levels of stress (even when
the parent herself is less aware of this), the partner might approach the interaction
differently with the parent’s needs in mind. That is, in situations where providers
perceive higher emotional stakes, they might seek to respond with their best, most
helpful support.
Research examining the interplay between interactants has found evidence for this
notion, demonstrating that, when support providers perceive recipients to experience
heightened distress, they are more likely to provide solace support behaviors (Barbee,
Rowatt, & Cunningham, 1998). Research suggests that highly distressed people may feel
ambivalent or uncomfortable seeking support (Barbee & Cunningham, 1995). In these
situations, highly stressed participants might benefit from indirectly signaling their need
for support without having to solicit it. Thus, it is possible that HPC message recipients,
as a result of their higher cortisol levels, signaled a need that caused their partner to
respond with better support. Future research should further explore the behaviors that
might signal to providers that they should up their game as well as how providers
interpret and respond to these signals.
Unlike the results for HPC messages, the results for recipients of both MPC and LPC
messages contradict previous research. LPC message recipients in this study experienced
positive changes in their salivary cortisol (i.e., they experienced a reduction in salivary
cortisol from baseline to the end of the appointment). These changes, however, were not
always significantly different from those experienced by HPC message recipients, and
they were never significantly different from MPC message recipients. This would
suggest that participants receiving LPC support experienced physiological outcomes that
were, in some instances, no different from those who received HPC or MPC messages.
As with LPC support recipients, MPC support recipients did not experience the
hypothesized changes to their cortisol levels. In fact, MPC support recipients experi-
enced increases in their salivary cortisol from baseline to Time 2 and Time 3. MPC

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Faw 15

support recipients’ cortisol levels did not recover below the baseline, suggesting a trend
that MPC support recipients experienced higher cortisol at the end of the appointment.
This contradicts what past research would suggest (High & Dillard, 2012; Priem &
Solomon, 2009). It is possible that MPC recipients in this study experience a variety of
supportive messages in their day-to-day interactions. If these participants have received
HPC support in the past, then receiving MPC support might fail to meet their expecta-
tions, resulting in the awareness that their needs are not being met. Previous research has
shown that, when support fails to meet expectations, the potential benefits recipients
experience are minimized (Priem & Solomon, 2015).
Another possible explanation for why the results for LPC and MPC message reci-
pients deviated from expectations could be explained by considering participants’
message processing. Recent research using a dual-process framework suggests that
support recipients process messages in two ways, either dedicating significant effort to
fully scrutinize the messages they receive or instead focusing on environmental cues and
heuristics to evaluate the messages (Bodie et al., 2011; Burleson, 2010). According to
this research, in situations where people rely on simple cues or heuristics, they are less
likely to critically evaluate the messages they receive. On the other hand, individuals
who exert the effort to fully scrutinize messages are likely to weigh the message content
and quality, with evidence suggesting that they should respond most positively to HPC
messages (Bodie et al., 2011). Whether individuals exert the effort to process the
message or simply rely on heuristics is determined by their motivation and capability to
process the message (Bodie & Burleson, 2008).
In this study, it is possible that message processing played a role in how PCDs
responded to the supportive interaction. If MPC message recipients were motivated and
capable of processing the support they received, then the dual-process model purports
that they would critically scrutinize the support messages they received. If they engaged
in full and effortful processing, they could conclude that the MPC support they received
was inferior or unhelpful (Bodie & Burleson, 2008; Bodie et al., 2011), potentially
resulting in the physiological stress reactions documented. On the other hand, if LPC
message recipients lacked either motivation or capability to process the support, the
dual-process framework suggests that they would instead rely on heuristic cues,
potentially focusing on the relationship they have with their supportive partner to
understand the interaction. In this sense, they would essential offer their partner the
benefit of the doubt regarding their supportive efforts (Burleson, 2010). If this occurred,
LPC recipients could be satisfied with the support they received and experience some
benefit even though previous research and independent coding would label this support
as ineffective (High & Dillard, 2012). Because no measures of motivation or capability
were included in this study, this possible explanation remains speculation. Future
research should continue to explore the role motivation and capability in supportive
interactions, linking these observations with physiological measures to obtain greater
understanding of the role supportive message processing plays in influencing physio-
logical stress outcomes.
The findings in this study emphasize the need for continued research on support
quality and its effects on physiological stress and health. Although research has con-
sistently found HPC support to be most effective at reducing reports of distress, the

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16 Journal of Social and Personal Relationships

majority of these studies have used contrived interactions relying on trained con-
federates, asked participants to respond to hypothetical scenarios, or required partici-
pants to rate researcher-created messages (High & Dillard, 2012). A limited number of
studies have sought to apply message VPC and VPC coding schemes to more natural
interactions between preexisting relationship partners or examined VPC at the con-
versation level (for exceptions, see Bodie et al., 2014; High & Solomon, 2014).
In more natural interactions (such as those in the current study), the outcomes of
supportive communication are contingent upon factors aside from message VPC. In this
study, parents participated with a key source of support, and it is reasonable to assume
that participants had expectations for the interaction. These expectations probably look
quite different from those experienced by people entering a contrived interaction or even
those held by a person without the same stressors as those experienced by PCDs. It is also
important to note that when receiving contrived support, participants are aware that the
support and its implications end with the research. In more natural interactions, any
conversational antecedents, consequences, and evaluations can carry relational infor-
mation that does not cease with the study. Thus, in some ways, the relational stakes
might be higher in interactions occurring between existing partners, as this support could
filter into future interactions. Awareness of the larger relational and supportive trajectory
could result in partners evaluating messages in more complex ways than contrived
research designs can accurately measure.
With this in mind, future research should explore how expectations, anticipation of
future interactions, and message processing influence perceptions of support. In doing
so, researchers can tease apart when MPC support can be more effective (as in Priem &
Solomon, 2009) versus the situations where it is least effective (as in the results of this
study). Research should also seek to identify when LPC support might be most effective,
as it is possible that these situations exist (Burleson, 2010). Future research should also
explore the mechanisms underlying what makes certain support more effective than
others. Researchers have suggested that HPC messages are more effective because they
encourage cognitive reappraisals (Jones & Wirtz, 2006), and future work should con-
tinue to explore the role that cognitive reappraisals and other potential mechanisms play
in determining the effectiveness of social support.

Support and support providers

This study also explored how offering support might influence the physiological stress of
support providers. Results did not illuminate any significant associations between
expressed support and support quality on providers’ physiological stress. It is possible
that participant characteristics may have limited the ability to detect differences. More
than half of the partners (n ¼ 23) were the parent’s spouse or romantic partner. As such,
it is possible that the challenges discussed by these dyads featured problems that directly
affected the partner as well. Thus, partners may have been forced to respond to chal-
lenges present in their own lives, potentially limiting the positive effects of providing
support. This could also lead to corumination, which negatively influences stress (Byrd-
Craven, Granger, & Auer, 2010). If these differences exist, they could be diluted when
combined with data from nonromantic conversation partners.

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Faw 17

It is also possible that other partner characteristics might have made it difficult to
detect differences in their physiological responses. In this study’s sample, all but one
support recipient were female, whereas approximately 60% of partners were male.
Research has previously established that men are less likely to provide highly sensitive
support than women and tend to feel less comfortable doing so (Burleson et al., 2005;
MacGeorge, Graves, Feng, Gillihan, & Burleson, 2004). Research has also shown that
men and women experience different physiological changes in response to their emo-
tional environment, with men less susceptible to both positive and negative interactions
with their partner (Crockett & Neff, 2012). It is possible that any physiological reactions
among partners became muddled by the study’s mixed-gender sample of providers.
Another possible explanation for the lack of findings is the length of the supportive
interaction. It is likely that providers are not experiencing the same levels of distress as
recipients and thus might be less susceptible to short-term physiological changes. This
could be especially true for providers responding to the needs of PCDs, as the chal-
lenges they express might ongoing and familiar. Most research exploring the outcomes
of support provision takes a long-term perspective (see Brown et al., 2003). Scholars
should examine the long- and short-term physiological outcomes associated with
providing support to better illuminate the relationship between offering support and
overall well-being.

Study limitations
Although this study points to interesting conclusions, it is not without limitations. First,
the study includes a small sample size. Previous research using physiological markers
has demonstrated that small sample sizes can be sufficient in identifying meaningful
difference (see Floyd et al., 2007). It is possible, however, that the sample was
insufficient to detect small but meaningful differences. Additionally, this sample is not
representative. The majority of parents were married (82.5%) and white (97.5%), and
approximately 50% reported annual household incomes greater than US$60,000.
Parents also had comparatively low levels of perceived stress (M ¼ 1.95 of 4). It is
possible that single parents, those experiencing lower socioeconomic standing, those
with higher perceived stress, or a combination of the three, could benefit from support
differently than the present sample. Future research should attempt to feature a more
diverse sample so that results may more closely resemble the general population.
Seeking out these groups also serves to benefit those PCDs likely experiencing more
severe needs.
Additionally, nearly all of the parents were mothers. While these women identified as
the primary caregiver, it is possible that fathers experience different responses to the
stressors associated with having a disabled child. Future research should seek to evaluate
the experiences of fathers as support recipients in supportive interactions. It is also
important to note that 60% of participants were romantic couples, including co-parents
of the child with disabilities. It is possible that experiences of these parent-partners
differed from partners who were not a part of the family unit. Research should seek
explore what differences in support provision exist in such dyads when compared with
non-co-parenting dyads.

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18 Journal of Social and Personal Relationships

Another limitation of this study was the limited control exerted over participants’
conversations. This openness was designed to induce conversations mirroring natural
interactions as much as possible. It became clear in analysis, however, that not pro-
viding more structure resulted in topics ranging greatly in their severity. Although all
conversations involved the discussion of a problem and the provision of emotional
support, the wide range of interactions might account for some of the differences seen
among recipients as well as the support provided. In the future, allowing partners to
interact naturally while also utilizing a more structured prompt could better balance the
need for study control with the desire to analyze more natural interactions. Finally, this
study focused solely on verbal aspects of support. Ample evidence highlights that
nonverbal aspects of support are important considerations when assessing support
quality (Bodie & Jones, 2012). Future research should continue to investigate both
verbal and nonverbal conversational elements and how the two create more sensitive,
effective messages.

Conclusion
This study takes an initial step in exploring the effects of short-term supportive inter-
actions on the physiological stress of both support recipients and providers. For scholars,
the findings of this study carry important implications. First, it reinforces the long-held
belief that social support is an important communication process associated with well-
being. Second, it provides evidence that variations in support quality can result in dif-
ferent outcomes for recipients. This expands the stress buffering hypothesis in demon-
strating that support quality is an important factor to consider when examining the
relationship between support and stress. Third, it raises questions about support quality
and where existing assessment tools might fall short. The results of this study did not
cleanly map onto the suggested support hierarchy as proposed by message VPC scho-
larship. This is significant, as much of the current literature surrounding questions of
support quality rests on this model. If this way of evaluating support does not function as
expected, scholars should pause to consider what else might account for differences in
outcomes and how future research could explore these ideas.
The results of this study also carry implications for caregivers as it found that a short,
10-min conversation can affect cortisol levels. PCDs might be encouraged to engage in
supportive interactions more frequently knowing that brief conversations can influence
their physiological stress. Organizations promoting parents’ well-being might use this
information to encourage engagement in support groups or other interactions, empha-
sizing that even short conversations can achieve some benefit. Similarly, practitioners
could use the knowledge that HPC support influenced physiological stress positively to
train others to provide better support, resulting in the greatest chance for enhanced well-
being among caregivers and their families.

Author’s note
Portions of this article were presented at the National Communication Association convention in
Las Vegas, Nevada.

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Faw 19

Acknowledgements
I thank Dr. Malcolm R. Parks, Dr. Kathleen O’Connor, Dr. Valerie Manusov, Dr. Hendrika
Meischke, Dr. Jacquelyn Harvey, Elizabeth Parks, and the anonymous reviewers for their helpful
feedback and encouragement.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/
or publication of this article: This research was funded by the Peter Clarke Graduate Research
Fund at the University of Washington.

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