Responsive social support serves important functions in clinical communication: Translating perspectives from relationship science to improve cancer clinical interactions

Abstract

Patient-clinician interactions are critical to patient-centered care, including in cancer care contexts which are often defined by multiple patient-clinician interactions over an extended period. Research on these dyadic interactions has been guided by perspectives in clinical communication science, but the study of clinical communication has not been fully integrated with perspectives on interpersonal interactions from relationship science research. An overlapping concept in both fields is the concept of responsive social support. In this article, we discuss responsiveness as concept that offers opportunities for connections between these two disciplines. Next, we focus on how relationship science research can be applied to research in clinical settings. We discuss how three areas of relationship science define responsiveness and have potential for extension to clinical communication: (1) (in)visibility of social support, (2) attachment orientations, and (3) shared meaning systems. We also discuss how social biases can impede responsiveness and suggest research avenues to develop ideas and understand potential challenges in connecting these two fields. Many opportunities exist for interdisciplinary theory development that can generate momentum in understanding interpersonal processes in cancer care.

Introduction

Interactions between patients and medical professionals are a critical component of patient-centered care that respects an individual’s needs, social environment, and uniqueness (Epstein and Street, 2011a). Although these interactions have been examined extensively from a clinical communication perspective, similar contributions are missing from the psychology of relationships. Opportunities exist for advances in relationship science to improve a theoretical understanding of patient-clinician interactions, as well as provide insights into improving those interactions and the cancer-related outcomes that follow. In this article, we integrate perspectives in clinical communication science (Epstein and Street, 2007; Street and Epstein, 2008) with concepts from research on responsive social support within close relationships (Feeney and Collins, 2015; Lemay et al., 2007) by highlighting example areas of close relationship research that could theoretically be extended into the study of clinical communication. These example domains are among several opportunities for interdisciplinary theory development (Dunkel Schetter, 2017) which can build a stronger basis for innovative research in health-related interpersonal dynamics both within and outside of clinical contexts.

Interpersonal responsiveness is a linking concept that is central to both relationship science and clinical communication science. For this reason, our article focuses on the concept of responsive support – defined as support that matches and respects the needs and perspectives of the recipient (Collins et al., 2010; Feeney, 2004; Rafaeli and Gleason, 2009). For example, people may have preferences about receiving emotional support (e.g., expressions of empathy), instrumental support (tangible help), informational support (sharing information or recommendations), or appraisal support (providing feedback or support for a decision) (Heaney and Israel, 2008), and these preferences could depend on their current needs, the support context, and the support provider. Responsive social support is also delivered sensitively, rather than, for example, in a way that makes the recipient feel like a burden or feel frightened (Feeney and Collins, 2015; Zee and Bolger, 2019). Social support is most effective when it is responsive (Feeney and Collins, 2015; Lemay et al., 2007; Collins et al., 2010; Newcomb, 1990). Accordingly, responsiveness is a key principle underlying relationship science in integrative theoretical reviews of the field (Finkel et al., 2017; Reis, 2007).

Aspects of responsive support are also evident in frameworks related to health care delivery. The World Health Organization defines the responsiveness of health systems as responsiveness to “universally legitimate expectations of individuals” (De Silva, 2000). More closely tied to research on close relationships are concepts aligned with responsiveness to patient needs within clinical interactions (i.e., interactions within the health care setting, such as an exam room or telehealth encounter). Patient-clinician interactions can be impactful for health outcomes, and within these interactions are several functions of communication including those described in Table 1: fostering healing relationships, exchanging information, responding to emotions, managing uncertainty, making decisions, and enabling patient self-management (Epstein and Street, 2007). Aspects of responsiveness are reflected in this set of communication functions. Importantly, these communication functions are not necessarily distinct. In fact, they are interdependent and overlapping during patient-clinician conversations and over the course of the patient-clinician relationship. Different functions can be used individually or in combination to be responsive to the patient and achieve the same goal of patient-centered communication (Street, Mazor, and Arora, 2016). Furthermore, this set of dynamic communication functions intersects with other factors, including clinical contexts and findings, values, and past experiences (Stacey, 1995; Wilson et al., 2001) and other salient relationships, including clinical teams, family members, caregivers, and social networks (Epstein and Street, 2007; Wilson et al., 2001). This article focuses on aspects of responsiveness within the patient-clinician dyad. We use the term “clinician” broadly to reference any clinician within a healthcare team that interacts with the patient, while acknowledging that there are many patient-clinician dyads (i.e., the patient interacts with many clinicians and clinicians have many patients) (Epstein and Street, 2007). However, we highlight as a future direction research that integrates dyadic, triadic, and social network perspectives on responsive support.

Table 1.

Communication functions within patient-clinician dyads

Communication function	Description (From Epstein & Street, 2007)
Fostering healing relationships	Establishing trust, rapport, guidance, and emotional support in the patient-clinician relationship.
Exchanging information	Delivering information while considering patients’ illness representations, the information they bring to the interaction from other sources, and their information needs and preferences.
Responding to emotions	Responding to patients’ and caregivers’ emotions.
Managing uncertainty	Communicating information about uncertain outcomes or treatments and helping patients to interpret this information (see also Politi & Street, 2011)
Making decisions	Engaging in medical decision-making through a process of information exchange, deliberation, and making the final decision
Enabling patient self-management	Helping patients take care of themselves engage in health-promoting behaviors

Table 1, from Epstein and Street (2007), makes clear that clinical communication functions are best achieved when responsive support is involved (i.e., providing the type and amount of support needed for a given situation and in a sensitive way). For example, providing responsive informational support involves identifying the recipient’s current need for information, recognizing the amount of information the recipient prefers, and understanding the perspectives and preferences of the recipient in deciding how to communicate the information (Epstein and Street, 2007). Clinicians’ responsiveness is also implicitly reflected through active listening in communication with patients to foster healing relationships and mutual trust, validating patients’ emotions and sharing empathy, supporting patients’ autonomy while helping them navigate the complexities of their treatment plan, and understanding patients’ perspectives as part of the collaborative decision-making process (Epstein and Street, 2007).

Objective

Although there are overlapping themes of responsiveness in both clinical communication and relationship science, the literatures are fairly distinct. The purpose of this article is to highlight insights from relationship science that can be applied to research in clinical settings and included when thinking about factors that can determine whether support and communication between clinician and patient are considered responsive. Although relationship science often studies close relationships, responsiveness to the other’s needs is theoretically critical in all forms of relationships in which support is provided – because responsiveness focuses on feeling understood and valued by the other person (Reis, 2003) and is not specific to relationship type. The specific areas that we highlight include how sensitively support is provided (i.e., whether or not it is perceived by the patient or clinician as visible or is invisible), relevant characteristics of the clinician and patient who are engaged in communication (attachment orientations), and relationship factors that affect whether responsiveness is achieved (such as the patient and clinician having shared meaning systems). We also discuss how social biases and gaps in empathy due to intergroup dynamics can impede responsiveness. Finally, throughout this article, we discuss: implications of responsiveness within each domain (social support, attachment orientations, and shared meaning systems), insights regarding the importance of responsiveness for social and health outcomes, and potential linkages to patient-clinician communication and trust in clinical encounters.

This article highlights the importance of responsive support and opportunities for future research on close interpersonal relationships and clinician-patient communication within a cancer care context. There are several reasons why strengthening responsiveness in cancer care interactions is important. Cancer care involves multiple healthcare professionals and follow up with them over the course of cancer survivorship (Ose et al., 2017), such that there are many challenges and opportunities for managing and strengthening responsiveness within interpersonal relationships among patients, clinicians, and family or other caregivers. Cancer, cancer care, and cancer survivorship are also complex in several other ways, including involvement of multiple care settings, treatments, and side effects; emotional experiences of patients and caregivers; and the impact of cancer on one’s life and relationships (Gilligan et al., 2017; Ose et al., 2017). Given these complexities, research on relationship building and communication between patients and their clinicians – in addition to their informal caregivers and social networks - is a priority (Gilligan et al., 2017; 2018).

Invisible and Visible Social Support

One domain related to responsiveness is the visibility of social support. Social support can be delivered in different ways by the support provider. Invisible support occurs when support is provided (e.g., reported by a provider or by an observer) but the recipient does not report receiving it, because they do not interpret the action as unidirectional support to them (Bolger et al., 2000; Bolger and Amarel, 2007; Zee and Bolger, 2019). Examples include: preventing a stressful event from occurring, providing support before the recipient requests it or would interpret it as such, or providing support in a subtle way, such as by using a conversational tone and examples from other people (rather than emphasizing the salience of the recipient’s stressor or defining the recipient as someone who needs help) (Bolger et al., 2007; Howland and Simpson, 2010; Zee and Bolger, 2019). In contrast, visible support is provided in such a way that it is acknowledged as support that has been received. Importantly, both invisible and visible support occur across all types of support (i.e., emotional support, instrumental support, informational support), and invisible support is not a form of withholding support from the participant. Rather, support visibility defines how a type of provided support is delivered.

In many contexts, invisible support is considered most responsive to the recipients’ needs, in that it can more effectively reduce recipients’ distress in the face of a stressful experience (Bolger et al., 2000). Studies show that individuals experience less negative affect and greater personal well-being after receiving invisible than visible support, particularly in stressful contexts (Howland and Simpson, 2010; Jakubiak et al., 2020; Lüscher et al., 2015). Beneficial effects of invisible support, when they occur, are at least partially due to maintaining recipients’ self-efficacy and preferences for autonomy (Bolger et al, 2000; Bolger and Amarel, 2007) and not prompting feelings of obligation to reciprocate support to the provider (Zee and Bolger, 2019).

However, whether invisible or visible support is more responsive may depend on a number of factors (e.g., Zee et al., 2018). For example, goal-related support may be most beneficial to personal and relational well-being when visible, but stress-related support may be most beneficial when invisible (Jakubiak et al., 2020). Effects of support visibility may also be moderated by the recipient’s current emotions, with visible support (i.e., overt reassurance) responsive when the recipient is highly distressed but less responsive when they are not distressed (Girme, Overall, and Simpson, 2013). Further, effects may depend on the outcome of interest. For example, smokers had less negative affect, but smoked more cigarettes after receiving emotional support (such as listening to one’s partner) and instrumental support (such as helping the other person with a task) that was delivered in an invisible way by their romantic partner (Lüscher et al., 2015). These moderators are relevant to consider in cancer clinical contexts – for example, when a goal involves both reducing patient distress and also increasing supports for specific behaviors, such as healthy eating behaviors or physical activity among cancer survivors (Campbell et al., 2019). Thus, it is possible that individual and cultural differences in support preferences may play a role in what is most responsive.

Research on support visibility is relevant to several areas of communication among clinician-patient dyads. One area of overlap is the overarching concept of autonomy – a psychological need “to self-regulate one’s experiences and actions” (Ryan and Deci, 2018, p. 10). Maintaining support recipients’ need for autonomy is one reason why invisible support is often effective. This is aligned with enabling patient self-management - a health communication function that includes supporting patients through autonomy-supportive, rather than controlling or directive, behaviors (Epstein and Street, 2007). For example, invisible support may be advisable when the objective of a clinical interaction is to help patients achieve health goals (e.g., commit to regular physical activity or quit smoking) (Girme et al., 2013). Future research in this arena could be very fruitful to determine whether support delivery in clinical contexts might be tailored to individual- and context-dependent needs for invisible versus visible support as a way of helping patients manage their care.

Delivering invisible support within patient-clinician relationships may serve other communication functions. For example, related to decision-making within patient-clinician dyads, invisible support in a decision-making context might involve engaging the patient in conversations about their priorities and preferences (Steenbergen et al., 2022) early in an interaction as a way of facilitating interpersonal connection and integration of those preferences into the further discussions that guide treatment decisions. When patient preferences and priorities are discussed in a conversational tone at a time separate from a time-sensitive treatment decision or when the patient is upset, this could be a form of invisible support that deflects attention away from the recipient’s stressors or challenges (Howland & Simpson, 2010). Related, the complexities in needing to coordinate and maintain follow-up treatments or appointments could be introduced in clinical interactions that are less stressful (allowing patients time to develop plans for their self-management that fit within their personal motivations) and could include examples of others who have achieved a variety of personal goals while managing their cancer treatment (indirectly reassuring patients) (Howland & Simpson, 2010).

In these examples, support is provided in an unobtrusive way that makes such procedures seem standard, rather than seeming like a form of explicit social support. This approach has the potential to affect appraisal of the relevant medical procedures (i.e., reduce a patients’ focus on a stressor as compared to visible support; Bolger et al., 2000; Bolger and Amarel, 2007) but needs to be studied in clinician-patient dyads. Research opportunities include, for example, coding of support visibility in spontaneous interactions in clinical settings to identify whether there are differences in support visiblity’s effects that are not seen in the literature on close relationships (such as due to the more formal nature of the dyad, the salience of emotion, or clinical context). Research would also be valuable in identifying potential barriers for clinicians in modifying support visibility. This process might be easier in close informal relationships which are not defined by professional responsibilities and are characterized by greater interdependence between dyad members.

Attachment Orientation

Responsiveness is also evident in the study of how individual differences in attachment orientation affect the exchange and interpretation of support within close relationships. Attachment orientation reflects the extent to which one’s bonds with close others tend to be secure (characterized by both low anxiety about close interpersonal relationships and low avoidance of closeness in interpersonal relationships) versus insecure, including attachment styles characterized by anxiety about whether one will be loved and supported or avoidance of closeness in one’s relationships. Secure attachment bonds are based in warmth and responsiveness, and secure attachment early in life is associated with reduced health problems and lower physiological reactivity during conflicts in adulthood (Puig et al., 2013; Raby et al., 2015). Attachment processes also continue throughout the life course, particularly when adults seek support from attachment figures (e.g., caregivers or other family members) during times of stress (Collins et al., 2010).

Attachment orientation can affect how an individual provides and experiences social support (Collins and Feeney, 2000). Secure individuals tend to seek support from others, expect responsive support from others, and provide responsive support to others (Collins et al., 2010; Pietromonaco and Collins, 2017). In contrast, insecure individuals have difficulty receiving responsive support and may provide less responsive support to others (Collins and Feeney, 2000; Feeney and Collins, 2001). The partners of those with insecure attachment are also more likely to perceive the support they receive from them as negative such that it causes feelings of inadequacy or burden or is insensitive to their needs (Collins and Feeney, 2004; Kane et al., 2007). This suggests that invisible support may have specific benefits involving people with insecure attachment orientations. However, the relative benefits of visible and invisible support across attachment orientations are likely nuanced. For example, although individuals with high attachment avoidance may benefit from invisible support that maintains their feelings of autonomy (Girme et al., 2019), it is possible that visible support could attenuate concerns about relationship security for those with high attachment anxiety.

Insecure attachment can also affect how people perceive relationships and express themselves, which has implications for whether they receive responsive support. People with insecure-avoidant attachment styles are less likely to seek support from others (Collins et al., 2010; Collins and Feeney, 2010), which can result in challenges for supportive others in perceiving their needs. Compared to secure individuals, insecure individuals tend to express secondary defensive emotions (e.g., anger rather than disappointment, in response to a disappointing event), which can cause challenges in providing support that is responsive to the recipients’ emotions (Cutrona and Russell, 2017). In addition, insecure attachment predicts being less bolstered by positive social interactions (Pietromonaco and Collins, 2017). Compared to secure individuals, avoidant individuals may require more substantial practical support to achieve support-related benefits compared to those with secure attachment orientations, while experiencing negative outcomes at low levels of tangible support (Girme et al., 2015).

Although attachment and related relationship dynamics are generally studied within close friends and family, it is relevant for patient-clinician relationships in cancer care, as patients have increasing need to rely on their clinician during active treatment, palliative care, and end-of-life (Salmon and Young, 2009; Tan et al., 2005). Indeed, responsiveness to a patient’s attachment style involves availability to provide a safe haven (for comfort, security, and reassurance) and secure base (for autonomous exploration) (Collins and Feeney, 2000; 2010). This can be extended to the patient-clinician relationship, as clinicians can both give reassurance and address stressful health conditions while also functioning as a secure base from which the patient can take control of their own self-care and feel confident in managing their illness autonomously. Accumulating evidence shows that attachment orientations affect patient-clinician relationships. For example, cancer patients with insecure attachment orientations may feel less satisfied with their clinicians and experience patient-clinician relationships that are less collaborative and involve a lesser exchange of empathy (Hillen et al., 2014; Holwerda et al., 2013; Calvo et al., 2014; Palmer Kelly et al., 2019). Clinicians may experience relationships with patients who have less secure attachment orientations as more difficult (Maunder et al., 2006; Hooper et al., 2012). Insecure attachment may also reduce patients’ treatment adherence (Hooper et al., 2016). Clinicians’ attachment orientations and relational needs and expectations also affect the patient-clinician relationship, with clinicians who have secure attachment orientations potentially better able to help patients express their emotions and more aware of their patients’ emotional distress (Cherry et al., 2013). However, few researchers are studying topics related to both patient and clinician attachment (Cherry et al., 2013).

Support provided by people with insecure attachment styles is more likely to be perceived by the recipient as not meeting their needs. Related, emotional expression differs by attachment orientation. These dynamics are relevant for communication functions that focus on meeting patients’ informational needs, emotional needs, and decision-making preferences. Attachment research can inform potential approaches for improving these communication functions. For example, expressing one’s emotions accurately, and responding to a partner’s emotions in a responsive and affirming way, are both potentially malleable, at least among couples (Cutrona and Russell, 2017). However, research has yet to establish interventions to promote these factors in patient-clinician dyads.

A practical implication from attachment literature is to increase clinicians’ awareness that one’s own attachment orientation and that of their patients can contribute to responsive interpersonal communication and that this information can be useful in identifying skills to develop for exchanging responsive support (Fletcher, McCallum, & Peters, 2016;. Cherry et al., 2018). Assessing patient attachment orientation through measures that have been used with cancer survivors (Nissen et al., 2016; Lo et al., 2009) could also promote an understanding of how to be responsive to patients’ needs (e.g., fostering a need for independence among patients with an avoidant attachment orientation or providing empathy to patients with anxious attachment orientations during times of stress; Hooper et al., 2012). Other examples of how knowledge of attachment orientation can help improve the responsiveness of these communication functions are outlined by Tan and colleagues (2005). For example, understanding that a patient has an anxious attachment style may encourage clinicians to use strategies such as conveying an interest in the patient and reaffirming that the clinician can be considered a reliable source of support.

Related, sharing clear information about when staff are and are not accessible can help foster a healing relationship, particularly for patients who have insecure attachment and greater needs for reassurance (Tan et al., 2005). Other work in relationship science also offers some suggestions that may be relevant for fostering a healing relationship when one of the individuals has an insecure attachment orientation. A model by Simpson and Overall (2014) proposes that dyadic romantic partners can be helpful in stressful contexts if they engage in behaviors that are responsive to their partner’s specific attachment concerns likely to arise under conditions of stress – such as offering reassurance and support (in the context of anxious attachment) and influencing the partner in a non-coercive/directive way (in the context of avoidant attachment) to bolster their partner’s feelings of security. Over time, these responsive reactions to a partner’s attachment concerns can ultimately strengthen the relationship (Simpson and Overall, 2014). These types of interaction patterns, and whether they bolster clinician-patient healing relationships, are worthy of study in clinical contexts which include stressful scenarios and discussions. This may be particularly important in relationships where there is distrust or discomfort, such as clinicians working with patients who experience chronic pain (O’Rorke et al., 2007) or not trusting patients’ reports of their symptom experiences or behavioral regimens; or patients distrusting the health care system (Dean et al., 2017).

Shared Meaning Systems

Responsiveness can also be achieved in interpersonal interactions through developing and maintaining shared motivations, goals, mental models, and feelings (Reis, 2007). Often, shared meaning systems occur in close, personally meaningful relationships (Aron et al., 2013) and are impactful in these dyadic interactions. For example, greater reports of shared reality among romantic couples predict efforts by the couple to maintain or expand their shared reality in the future (Rossignac-Milon et al., 2021).

Although shared meaning systems are often examined in the context of friendships, family, and romantic relationships, experimental evidence suggests these systems can also be fostered in new interpersonal connections. Shared goals can be achieved among people who do not have a close existing relationship if individuals are presented with cues suggesting that the other person is socially connected to or similar to the self in some way (Walton et al., 2012). Furthermore, among newly acquainted dyads in a lab or online setting, those that exhibited certain behaviors, such as verbalizing similarity or agreement with the other person, self-reported greater shared reality (e.g., rapport and interest in interacting again, and understanding a lab-based task together; Rossignac-Milon et al., 2021). That the beginning of shared beliefs and goals can be seen even in very new interactions suggests that these concepts are relevant to and can be studied among patient-clinician dyads even in the early stages of their relationship. For example, expressing shared feelings (sharing a similar emotional reaction to a diagnosis or treatment outcome – related to responding to emotions) during early interactions can both increase satisfaction with the relationship and set the stage for a more extensive shared reality involving self-disclosure, creation of coordinated goals, and ultimately full inclusion of the partner’s perspectives into one’s own perspectives (Rossignac-Milon & Higgins, 2018). This process may help facilitate a number of communication functions in clinical encounters, including the development of a trusting, healing relationship and facilitation of more natural information exchange and decision making.

The literature on shared meaning systems in interpersonal relationships is closely related to a concept in clinical communication science of shared mind. This is a process whereby patients and clinicians develop a shared frame of reference, thoughts, and feelings; also known as collaborative cognition – that emerges through the social interaction (Epstein, 2013; Epstein and Street, 2011). It prioritizes integration of patients’ priorities and values within medical guidance (Epstein et al., 2022). Clinicians and patients can promote this process in ways related to responsiveness. For example, clinicians can convey connection, empathy, and relational autonomy and get to know the patients’ perspectives and values (Epstein and Street, 2011b). In turn, patients can facilitate this process by expressing their values and preferences to their clinicians (Politi and Street, 2011), which can enable responsive communication. Importantly, shared mind processes do not always work as a result of certain factors, including assumptions about others’ preferences being similar to one’s own (Epstein, 2013; Epstein and Street, 2011b). There are many opportunities for cross-connect between this research and the shared meaning in relationship science to enhance understanding of how these types of collaborative perspectives can be achieved. The idea of shared meaning systems is also conceptually related to communal coping, which is important for couples facing chronic illness or pain (Rohrbaugh, 2021); as such, shared meaning systems may play an important role in helping clinicians to facilitate communal coping with their patients within the clinical encounter.

These suggestions for facilitating shared meaning are also relevant to other relationship science literature discussed earlier in this article. Mutual understanding of values and informational/emotional preferences, which can help foster healing relationships and support in other areas of communication, including information exchange and emotional support, can be more challenging when patients’ attachment styles hinder communication or feelings of security in their interactions with clinicians. Overall, in clinical interactions, shared meaning systems concerning values and preferences are likely to facilitate clinician responsiveness to the patient, and shared meaning systems regarding mental models of disease, illness, and treatment are likely to facilitate the responsiveness of the patient to the clinician. This mutual understanding and responsiveness has the potential to improve healthcare communication and subsequent health outcomes.

Intergroup Biases, Culture, and Communication

In the literatures on relationships and intergroup dynamics, another element of responsiveness is the ability to respond to people empathetically and without bias. However, people often have expectations – either implicitly or explicitly held – that affect their interpersonal communication. Biases toward racial or ethnic minorities, those who are overweight/obese, those who smoke, or lesbian, gay, bisexual, transsexual, and queer (LGBTQ), or individuals with lower socioeconomic status may contribute to health disparities (Banerjee et al., 2021; Zestcott et al., 2016; Blair et al., 2013a; 2013b), via problems in patient-clinician communication (Zestcott et al., 2016; Penner et al., 2014). Related, anxiety about experiencing or expressing prejudice in cross-racial or cross-ethnic interactions can also have negative effects on communication dynamics, including avoidance or rejection (Richeson and Sommers, 2016; Trawalter et al., 2009). These experiences are important to include in developing a full understanding of how responsive support is or is not successfully provided within clinical contexts. This is particularly important at the beginning stages of a relationship (e.g., at the start of treatment) when building and fostering interest and trust in continued interactions are important (Stern and West, 2014).

Moreover, intergroup empathy gaps (Gutsell and Inzlicht, 2012; Cikara et al., 2014) – or an inability to effectively understand the perspectives, feelings, or preferences of an individual from a different racial, gender, or other group – may make it difficult for a person to evaluate the support needs of others, or may render them less motivated to change their provision of support in ways that match those needs. For example, the amount of social support expected and received can be greater when interacting with same-race versus other-race friends in the context of an identity threat (Davis and High, 2017), and people may feel less understood in cross-race than same-race interactions (Mallett et al., 2016; Shelton et al., 2014).

Beyond bias and intergroup empathy gaps, there are cultural and sociodemographic factors that influence perspectives, experiences, and goals that people bring to their social interactions. Cultural differences exist in the tendency for emotional expression that can facilitate understanding of an individual’s needs and perspectives, thereby increasing the likelihood of receiving responsive support. For example, East Asians and East Asian Americans may avoid expressing emotions that convey a need for social support, while Latinos may express positive emotions but avoid expressing negative emotions (Campos and Kim, 2017). In addition, socioeconomic differences can affect perceptions of relationships, with evidence suggesting that strong social relationships are a resource that may be even more beneficial for people experiencing low socioeconomic status (Campos and Kim, 2017; John-Henderson et al., 2015; Woodward et al., 2018).

Improvements in communication across racial, ethnic, and socioeconomic differences can enhance the experience of responsive support, particularly in areas such as responding to emotions, and understanding patients’ and clinicians’ preferences for decision-making. Gaps in empathy, perceptions of social support, and understanding present challenges for responding to emotions and fostering healing relationships in a responsive way matched to individuals’ preferences, and make it difficult for emotions and perspectives to be adequately acknowledged. Bias reduction and multiple common ingroup identity strategies, such as awareness, control, perspective-taking, and finding a common identity between patients and clinicians have been shown to enhance clinical communication (Penner et al.,2014; Zestcott et al., 2016). Other possibilities include encouraging emotional expression (Ellis et al., 2019) or encouraging people to focus on a goal of relationship development rather than being selffocused when approaching an interaction (Stern and West, 2014). These strategies may facilitate responsive support in patient-clinician dyads where the clinician is a member of a group that does not match the patient’s identity. Overall, as we consider future directions when merging fields of interpersonal relationships and patient-clinician communication dynamics, we must also consider how biases and communication across race, ethnicity, socioeconomic status, and culture are incorporated to better understand the factors that affect exchange of responsive support.

Conclusions and Future Directions

Several domains of research focused on responsiveness in relationships outside of the patient-clinician dyad yield insights that are related to responsiveness in frameworks for understanding clinical communication. Ample opportunity exists for research integration of the two fields. The domains of invisible/visible social support, attachment, and shared meaning systems are examples among other researched areas in relationships that define and demonstrate the impact of responsiveness on social, physical, and mental health outcomes. There are also many opportunities to examine how concepts aligned with responsiveness in research on patient-clinician communication can extend to and inform research and theory in the psychology of close relationships. For example, responsiveness is featured in the domains of healing relationships, shared decision making, and patient-centered care. The overlapping concept of responsiveness presents opportunities for building stronger linkages between these two fields, developing more expansive multidisciplinary frameworks to understand dyadic communication, and ultimately enhancing effective communication in cancer care between clinicians and patients.

Moving forward, research on clinical communication will also benefit from examining how responsiveness can be applied in research and encouraged across clinical contexts, diagnoses, treatment outcomes, patient/clinician populations, and varying durations of patient-clinician relationships, both within cancer care specifically and extending to other conditions. One limitation that will need exploration in future research is that much remains unstudied in identifying potential challenges in translating findings from close relationships to patient-clinician relationships. Social support theories do not suggest a limit on the type of dyads to whom the dynamics discussed in this article apply, and attachment literature already suggests relevance of attachment orientation for interpersonal communication between clinicians and patients (Cherry et al., 2013, 2018; Fletcher et al., 2016; Maunder et al., 2006; Tan et al., 2005). However, important differences between close (or informal) relationships and formal (e.g., patient-clinician) relationships should be acknowledged. First, clinicians have a professional responsibility to provide support to patients, and a similar responsibility does not exist in informal relationships. However, some close relationships involve a socially normative responsibility for unidirectional support provision in dyads (for example, parenting a young child or supporting a partner through a stressor that is unique to them; Patrick, McSpadden, Hennessy, & Oh, 2013; Bolger et al., 2000). Nonetheless, additional work is needed, with input from researchers and clinicians, to evaluate potential differences when support responsibility is defined by profession.

Second, patient-clinician relationships have notably less interdependence (e.g., in shared time, space, experiences, and outcomes) than in close informal relationships such as romantic partnerships - and therefore a less continuous view into the other person’s expressions, preferences, and behaviors. This may present unique challenges for knowing when and how to provide responsive support. Third, emotional experiences of the cancer care context specifically may play a role. For example, recent research suggests that support visibility’s effects are moderated by emotional experiences (Girme et al., 2013) or whether emotional support is given (Jakubiak et al., 2020) but it is unknown whether this might vary in clinical interactions. For example, a patient might prefer visible support from their clinician regardless of their emotions because of their clinicians’ expertise and any personal feelings of uncertainty.

Existing methods and perspectives for understanding close relationships and health can also be expanded beyond their focus on dyads. Research in both clinical communication and close relationships have noted the role that other people and broader social networks have for dyadic interactions. For example, responsiveness to the patient may be enhanced if a clinical team (rather than one clinician) is collectively generating understanding of patients’ preferences (Epstein et al., 2010; Haidet et al., 2009). Involvement of caregivers and families is also common and presents benefits and challenges for patient-clinician communication (Epstein and Street, 2007; Laidsaar-Powell et al., 2013; 2017; Mazer et al., 2014). In addition, individuals within the patient-caregiver-clinician triad each have broader social networks which yield a variety of interacting social influences that can affect the social support experiences of patients, clinicians, and caregivers (Jones and Storksdieck, 2019; Ketcher and Reblin, 2019; Yousefi Nooraie et al., 2021). As such, the patterns of support provided by other people can influence the trajectory of the clinical interaction. Research in close relationships also acknowledges that dyads are impacted by broader social networks, friendships, and other interactions (Burk et al., 2007; Felmlee, 2001; Sprecher, 2011). These more complex social dynamics, and the specific methodologies and analyses to study them (e.g., Bond et al., 1997; Burk et al., 2007; Jones and Storksdieck, 2019; Yousefi Nooraie et al., 2021) should be attended to as theoretical application of relationship science to clinical communication is expanded. Ideally, these two fields can enrich each other and yield the development of comprehensive frameworks for understanding reciprocal responsiveness in clinical care contexts.

Highlights.

• Research in clinical communication and close relationships have been distinct.

• Responsiveness is an overlapping theme in both fields.

• Areas from relationship science can potentially inform clinical communication.

• Research needs include studying avenues for connecting these two fields.