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Friendship in Adolescents and Young Adults With Experience of Cancer

A Dimensional Analysis

Evered, Jane A. BSN, RN

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doi: 10.1097/NCC.0000000000000686
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Abstract

Friendships are social relationships with deep intrapersonal and interpersonal implications. For adolescents and young adults, spending time with friends is a particularly salient influence on physical, social, and emotional development.1,2 Each year in the United States, 70 000 adolescents and young adults receive a diagnosis of cancer.3 The biomedical model of cancer focuses on treatment, cure, and survivorship. However, the experiences of friendship in these adolescents and young adults as they live with and after cancer are largely ignored and thus poorly understood conceptually, scientifically, and clinically.

Background and Significance

Empirical investigations of friendship in adolescents and young adults without cancer have commonly addressed peer culture, social support, and social influence as drivers of psychosocial outcomes, such as prosocial and risky behavior.4 Attempts to understand friendship in the context of illness have focused on quality and quantity of friendships rather than experiences of friendships.5,6 Furthermore, in the context of cancer, clinicians and researchers inclusively characterize social experiences with and social support from “friends and family” or “peers and friends” without delineating between relationship types. Differences between companions, supporters, confidants, close acquaintances, and friends are also not addressed. The potentially unique dimensions of friendships become blurred.

There is fluidity in which group identity, the normative developmental period of adolescence and young adulthood or the identity of being a person with a chronic health condition, is in the forefront (Figure 1). Dependent on the circumstances of a social experience, the relative salience of one group over the other may shift moment to moment. This investigation takes the perspective of an adolescent or young adult with cancer. However, the possibility of normative experiences of adolescence and young adulthood being in the forefront widens the application of this work those without cancer as well. The friendships of youth with cancer may ultimately be as often normative as experienced through the lens of chronic illness.

Figure 1
Figure 1:
Group identities of adolescents and young adults with cancer.

Adolescents and young adults with cancer are often noted to be at risk of poor psychosocial outcomes. Adolescents and young adults who become cancer-free can experience ongoing adverse outcomes in quality of life,7 work and school functioning,8 and future relationships.9 Unmet psychosocial needs may explain why this age group lags behind children and older adults in improvements in cancer survival rates.10 The challenges faced by this age group demand increased focus. Friendships, as distinguished from other close social relationships, may offer a means to improve clinical and psychosocial outcomes.

The concept of friendship lacks definitional clarity particularly in the context of cancer. The primary research question for this investigation was: What is the nature of friendship in adolescents and young adults with experience of cancer? Methodologically, dimensional analysis provides an opportunity to explore the nature of friendship more deeply and completely by breaking down and then rebuilding meaning in this phenomenon.

Methods

Dimensional Analysis

Leonard Schatzman11 proposed dimensional analysis as a structured analytic method to generate grounded theory. Rooted in Symbolic Interactionism, dimensional analysis is a data-expanding process of bringing forth and examining “what all is involved”12 by identifying all the associated components of a concept.13 This method becomes particularly critical when attempting to characterize a socially constructed concept existing in multiple contexts and viewed from multiple perspectives.13 By determining the attributes of a concept with cultural- or societal-laden meaning, the investigator exposes the complexity of the implicit and explicit dimensions of the concept and clarifies their theoretical relationships.13 Dimensionalizing open, axial, and theoretical codes helps drive analytic decisions, bracket the boundaries of the phenomenon, understand patterns, and organize the explanatory matrix.

Data Selection

For this investigation, adolescence and young adulthood span ages 12 to 39 years. This delineation of the age groups aligns with the World Health Organization, National Institutes of Health, and Centers for Disease Control and Prevention's conceptualization of this period within the life span as ages 12 to 24 years.14 It further makes use of the National Cancer Institute's Adolescent and Young Adult Oncology Progress Report's call to broaden the age range up to 39 years.15 The author defined cancer experience as having either active disease or previous experience of cancer in childhood, adolescence, or young adulthood. Search terms based on these population parameters fell into 3 categories: friendships, adolescence and young adulthood, and cancer. Search terms related to friendship included “friends,” “friend,” “social network,” “peer relationship,” and “peer.” The search terms “adolescent,” “adolescence,” “young adult,” and “young adulthood” and the keywords “neoplasms” and “cancer” limited search results to adolescents and young adults with cancer. Database searches of PubMed, CINAHL, Scopus, MEDLINE, EMBASE, PsycINFO, Cochrane, and AnthropologyPlus initially yielded 4554 results.

After limiting the date range to articles published in the last 5 years, the author scanned titles and abstracts for relevance to the friendship experiences of adolescents or young adults. Given the broad nature of the guiding research question, the author initially comprehensively considered titles and abstracts with any mentions of social experiences, social well-being, peers, or social contexts such as school. In a full-text read of articles selected from the title and abstract review, the author searched more specifically for descriptions of friend or friendships. The author excluded articles with participants outside the chosen age range of 12 to 39 years (Figure 2). The author scanned bibliographies of selected articles to ensure she considered all literature published in the last 5 years that might be relevant to understanding all that is involved in adolescent and young adult friendships. During and following data analysis, the author also conducted theoretical sampling. This helped fill identified gaps in how initially selected literature was informing an emerging understanding of friendship.

Figure 2
Figure 2:
Search strategy.

The final literature base for this dimensional analysis contains 80 multidisciplinary empirical and theoretical articles and abstracts written in English and published from January 2013 to June 2018. Works in this sample include various study designs along with reviews, case studies, conference proceedings in the form of conference abstracts available online, and published dissertations located through database searches. The decision to include abstracts and dissertations aligned with the aim of this dimensional analysis. Comprehensively selecting a literature base supported the goal of determining what all is involved in the friendship concept.

Data Analysis

The author first read each article keeping in mind the guiding question of the nature of friendship in adolescents and young adults with cancer. Next, through dense line-by-line coding of all 80 articles, the author extracted words and phrases related to the nature of friendship into a list of open in vivo codes to inclusively identify all meaning units relating to the phenomenon.11 This fracturing of the data divorced meaningful data units from the authors' original intentions. Condensation of open codes and arrangement into developing patterns by similar concepts and ideas enabled labeling of groups of open codes with axial codes. At this stage, the author gave all axial codes equal weight, reading them together to better understand emerging theoretical codes.13 Proceeding from open to axial to theoretical coding was a nonlinear process involving constant comparison of codes to other evolving themes and the literature sample.12

Upon reaching a critical mass of dimensions and with the emergence of a preliminary explanation of the phenomenon, the author built an explanatory matrix to represent theoretical relationships.12 The perspective, the concept with the most “explanatory power,”12 helped determine which concepts warranted matrix inclusion and focused the organization of theoretical codes into context, conditions, processes, and consequences. The author refined the matrix until each concept included could not be captured by any other concept and until there were no redundant patterns. Theoretical sampling proceeded throughout matrix development to clarify theoretical relationships and fill holes in the resonance of the matrix as an explanation for the phenomenon.

Maintenance of Rigor

A thorough audit trail of analytic memos provided a record of analytic decisions, evolving questions, and emerging themes. Analytic memos are a detailed record of how analytic determinations are made about the meaning, organization, and scope of codes. For example, after dimensionalizing normalcy, the author made the analytic decision that this code warranted separation into a condition, Goal of Normalcy, and a consequence, The Usual. The author wrote memos recording her understanding that the diverse meanings of normalcy are too different to be grouped together. Cocoding, codimensionalizing, and co–matrix development occurred with a fellow investigator undertaking dimensional analysis of a different phenomenon with some overlapping and some conceptually distinct dimensions. This collaboration enabled greater reflexivity, “peer rehearsals” of theoretical relationships, and acknowledgement of assumptions.12

Results

The explanatory matrix takes the point of view of an adolescent or young adult with cancer. Given that young people with cancer are still in adolescence and young adulthood, findings of the matrix may also apply more broadly to those who are not experiencing illness.

Perspective

“Time Marking” emerged as the dimension with the greatest inclusivity of what “all is involved” in the nature of friendship for adolescents and young adults with cancer.12 While time can be marked chronologically or narratively, Time Marking is a fluid way of measuring and characterizing the passage and future of narrative time. A series of events in narrative time occur nonlinearly; flashbacks to the past, freezing time in the present, or foreshadowing to the future disrupt a linear chronology. This narrative Time Marking contrasts with a forwardly moving developmental trajectory of chronological time where normative expectations determine points in time that represent phases and levels. Adolescents and young adults with cancer mark time narratively. With cancer, there is a before, a beginning, a middle, and an after. Time is segmented into before the cancer, a “person they were before diagnosis” and after composed of treatments, survivorship, and uncertain future health.16 As they live their cancer experiences, these individuals may also be forced to mark time in a new way, with an end. Adolescents and young adults with cancer faced with their own and their friends' potential mortality come to understand that time is finite. When time is a limited resource, Time Marking assumes greater urgency.

Similar time markers characterize experiences with friends. Friendships begin with an initial meeting, pursuit, or exposure followed by a process of forging a relationship. Friendships clearly include a middle where the relationship is enjoyed and valued. The end of friendships is not often described. Adolescents and young adults with cancer long for friendships that never end. Wishing to “never be forgotten,” they make plans for ways their friends can remember them after their deaths.17 For example, one adolescent asked friends to “embroider her name in their prom and wedding dresses.”17 Through this request, this adolescent aimed to give permanence to the legacy of her life and her friendships.

Time Marking involves processes of “looking back” and “getting back.” Adolescents and young adults with cancer look back to preexisting friendships, previous concepts of normalcy, and previous understandings of the self. In addition to simply looking back, the adolescent or young adult with cancer also attempts to get back, that is, to reintegrate, reestablish, or reenter a previous familiar time. As time keeps moving and continuing on for peers, cancer pauses the lives of adolescents and young adults.

While looking back to and getting back to a previous time, adolescents and young adults also keep looking forward. Sometimes looking forward involves continuity. They predict experiences that exist in the present or past such as cancer sequelae or connections with friends will be ongoing into the future. Other times, looking forward involves changes from the current, such as making plans with friends for after hospital discharge or setting new goals for peer relationships. Indeed, the changes experienced in the body, in friendships, and in routines as a result of cancer are driven by time. Experiencing or hoping for change is the outcome of contrasting the present with the past and looking forward to an uncertain future. The inherent motion of Time Marking captures the dynamic necessary to organize and understand the relationships among other concepts (Figure 3).

Figure 3
Figure 3:
An explanatory matrix of adolescent and young adult friendships.

Context

Within Time Marking, Places and Spaces, Timing and Mistiming, I Am Me, and Tools became the context or the environment in which friendship acts and exists.12 Places and Spaces are where friendship interactions happen. In this investigation, data reveal Places and Spaces including summer camps, social clubs, swimming pools, the hospital, school, or home. Online platforms also emerge as a location of friendship, evident in the admission, “most of my friends live online in my computer.”18 These settings provide labels and thus boundaries for friend types: other hospitalized young people, school friends, home friends, and Facebook friends. Places and Spaces can represent a place of socializing or sometimes a place away from socializing. For example, a parent's appraisal that an adolescent's lack of socializing with friends “outside of the school” meant not really having friends contrasts with school being the primary arena in which friendships are formed and maintained.19 In these ways, Places and Spaces are where conditions, processes, and consequences of friendship exist.

Timing and Mistiming refers to when friendship interactions happen. Each friendship interaction has inherent timing or mistiming. In some instances, adolescents and young adults deliberately control the timing of a friendship exchange. For example, they must carefully decide when to disclose their cancer to friends.20 Sometimes potential friendship exchanges are mistimed. In an illustrative case, a young adult analyzes an interaction with a radiation technician his/her same age and contrasts the inappropriate timing of the technician's “good joke” during a medical encounter with what might have been a friendship in another context and time.21 Timing and Mistiming circumscribe contextual boundaries for friendship.

Encompassing personality, knowledge, maturity, and life perspective, I Am Me is the context in which an individual experiences a friendship with another person. I Am Me refers to a sense of self as a unique being with internal thoughts, preferences, and characteristics distinct from those of other people. I Am Me is also inclusive of internal emotional experiences, basic human needs of relating to others, value placed on relationships, and previous attachment experiences that an individual brings to a relationship with a friend. As a contextual element, I Am Me contributes to the foundation on which friendships are initiated and maintained.

Tools, the means through which social interactions happen, is the final contextual dimension. Tools describe how friendship conditions, processes, and consequences occur. Available conduits of friendship include in-person exchanges, calling, sending cards, emailing, texting, and video chatting. In addition to social media representing a place where friendships occur, it also becomes a common tool with which adolescents and young adults connect with their friends. From the perspective of Time Marking, tools that enable friendship to exist provide contextual boundaries for conditions, processes, and consequences.

Conditions

Within the perspective of Time Marking, the conditions of friendship are Marked With Cancer, Goal of Normalcy, Able to, Want to, and Kept From. These conditions promote or block the process of friendship and inform its consequences.12 Marked With Cancer describes the intrapersonal and interpersonal ways adolescents and young adults experience cancer. Healthy peers are distinctly apart from the “separate medical world” of cancer peers and survivor peers who are marked with cancer.22 With the cancer mark, the before is defined by a “noncancer self.”23 The after encompasses a new “social role of cancer patient” with the future, as cancer becomes a part of life and a part of self, awaiting the adolescent or young adult.24 In this conceptualization, cancer is not merely a disease, but a mark assigned by society, by medicine, by family or friends, or by the adolescent or young adult.

The treatments, sequelae, changes in appearance, exposures, and risks of cancer collectively mark and re-mark an adolescent or young adult. Marking with cancer by others happens through questioning, special attention, assumptions about how cancer patients should act or feel, expressions of pity or sympathy, or perceptions of cancer patients as “breakable invalids” or “brave superheroes.”18 In addition to these “cancer survivor archetypes,” the mark of cancer also encapsulates others' assumptions that cancer is a “death sentence,” and the afflicted person, a victim.21 Regardless of when and how the mark is made, it facilitates or impedes friendship processes. For example, the mark of cancer can be associated with an obligation to be nice to or help an adolescent or young adult with cancer.16 This drives friendship processes.

The Goal of Normalcy is a quest for and pursuit of what is normal, typical, regular, or mainstream. Normalcy can refer to a person, an environment, a feeling, an activity, or a conversation. The Goal of Normalcy entails striving toward meeting expectations of what is normative and appropriate for adolescents and young adults belonging to a certain age group. Normalcy in this context becomes something actionable that can be promoted, maintained, or achieved. Normalcy also refers to the goal of a “new normal” or an act of “just be(ing) normal,” which influences processes such as interactions with other peers who have cancer.18

Able to, including physical, cognitive, and emotional capacities; functioning; deficits; skills; and impairments, is a barrier or facilitator of the processes of friendships. Able to may refer to being able to play sports, to speak, or to process what friends verbally or nonverbally communicate. Knowledge about the timing and tools of friendship is also considered a part of Able to. Finally, having agency is captured by Able to since having choices and the capacity to decide can block or facilitate engagement in the processes of friendship. Able to exists in a conditional relationship with the processes of friendship and in turn drives its consequences.

Want to surfaced as an additional friendship condition. Want to is a desire, willingness, or interest in engaging in the processes of friendship evidenced by expressions such as “don't really want to go”25 and “want to be my friend.”19 Want to varies in degree from simply a “willingness to become socially involved”19 to a stronger “desire to connect.”26 Want to also includes preferences for whom, when, and where adolescents and young adults want to engage. As a condition of friendship processes, a young person wants to interact with friends.

Kept From captures self-imposed or environmentally imposed restrictions on openness, access, and availability. Sometimes visitation policies, rules around mitigating neutropenia risks, or constraining medical routines restrict access. The drivers of Kept From can also be internal, a feeling of not being able to be open with friends, a desire to keep cancer “encapsulated and away,” or a fear of burdening others.27 “Intentionally prohibit[ing]”28 friends from visiting the hospital potentially because of a desire to “never let them see you hurting” is a strong example.29 On the contrary, opportunities for interaction are an example of not being kept from friendship.

Processes

The processes of friendship, as interactions of a phenomenon driven by conditions that create consequences, include 4 interrelated categories. The processes are Reciprocal Being, Unidirectional Being, Reciprocal Doing, and Unidirectional Doing. Each group of processes is distinct but connected to the other forms of doing and being in friendship. Being and Doing are processes derived of the perspective, context, and conditions. Being, incorporating themes such as being a friend, being there, hanging out, and companionship, links with having time together either in person or online. Simply being there and having a presence that is either literally or virtually felt as physical is a friendship interaction. Doing, aligning with the experience of an “act of friendship,”30 surfaces in interpretation of the axial codes participation, attendance, and communication. Often driven by the Goal of Normalcy in the face of the mark of cancer, participation and attendance are ways of keeping up and catching up in the perspective of Time Marking. The process of Doing also refers to not doing, such as carefully filtering one's words so as not to offend an adolescent or young adult with experience of cancer.

Doing and Being can be unidirectional processes. Friends being there as a “peer shield” that shelters adolescents and young adults from others' negatives reactions to their cancer is an example of Unidirectional Being.28 Another example is observing and comparing a friend's maturity, life experience, physical appearance, or ability to one's own. Unidirectional Being can also refer to a feeling of dislocation, that is, being absent or ignored or having distance from being there literally or emotionally. For example, spending time with a friend but failing to perceive his/her nonverbal cues is an instance of Unidirectional Being. Doing can also be unidirectional, with communication directed to an individual in instances of venting, helping, checking on, questioning, giving advice, informing, or making unappreciated jokes. Unidirectional Doing further includes being judged, pressured, rejected, or mistreated. Social comparison processes involved in stigmatizing someone with cancer is another example of Unidirectional Doing.

Some Doing and Being processes are reciprocal. For example, a friend coming to sit with an adolescent during chemotherapy demonstrates the interaction of Reciprocal Being with its emphasis on nonverbal cues.31 Doing can also be reciprocal, such as engaging with peers in school or in team or club activities. Reciprocal Doing may further be experienced in communication processes, as in mutual sharing or laughing together.

Revealing the cancer mark illuminates the lived experience of Doing and Being processes in friendship in the context of cancer. As an illustration of all 4 interaction processes, this ongoing process of “com[ing] out” to another about one's cancer warrants specific discussion.32 Revealing the cancer mark is sometimes reciprocal doing, either matched by a friend's self-disclosure or responded to with expressions of validation or acceptance. Sometimes revelations of the cancer mark involve Unidirectional Doing on the part of the adolescent or young adult with cancer, as seen in the experienced need to “teach people about what I am like.”19 It can also be Unidirectional Doing in cases where an attempt at revealing the cancer mark is made, but friends do not want to discuss it.32 Some revelations proceed automatically through the Unidirectional Doing of community fundraisers for a cancer patient or a teacher's disclosure by proxy before an adolescent's reentry into school. Other times, the revelation is a process of Unidirectional Being such as a friend noticing cancer-related changes in physical appearance.

Revealing the cancer mark might not occur if an adolescent or young adult lacks the condition of Able to, is Kept From access to friends, or Want(s) to keep the cancer mark hidden. In the perspective of Time Marking, revealing the cancer mark in some cases is a way of putting the cancer mark in the past and seeing the self independently, as the process “cuts their story short… they can get on with being themselves.”33 Existing in all 4 Doing and Being processes of friendship, the process of revealing the cancer mark underscores how both the unidirectional and reciprocity of friendship interactions create consequences.

Consequences

The consequences of the friendship processes include The Usual, Version of Me, I See Me in You, Navigating Friendships, and Closeness. Consequences are the results or outcomes created by processes and conditions.12 The theoretical code The Usual is a personalized way of understanding and living normalcy, distinct to the person. The Usual often includes being at school, participating in regular or “before” activities, and being treated “normally” as in keeping with the “before” of Time Marking. The Usual is what was experienced in the past, could be experienced in the present if not for or despite the mark of cancer, and what is hoped to be experienced in the future. For its emphasis on that which is not cancer, it subsumes results of friendship that encompass providing an escape, distraction, or outlet. In a telling vignette, one adolescent describes friends who would unfearfully hop into the hospital bed and “ask [me] if I had cute doctors.”34 This vignette illuminates how The Usual permeates a new cancer environment, the hospital, and allows an adolescent or young adult to get back to an interaction that could as easily have happened at school. In returning to or looking forward to “usual social worlds,”35 young people come to understand normalcy more colloquially than developmentally.

Version of Me denotes the effects of friendship's contexts, conditions, and processes on adolescents and young adults' conceptions of the world, identity, appreciation of relationships, and emotions. These emotional experiences have positive and negative valence, possibly including fear, frustration, comfort, worry, belonging, trust, loneliness, acceptance, encouragement, connectedness, shame, guilt, pride, safety, and love. Acceptance, comfort, esteem, compassion, worth, autonomy, confidence, awareness, and maturity are further examples of consequences related to Version of Me. Finally, Version of Me may relate to consequences of friendship on an adolescent or young adult's cancer experience, encompassing themes of resilience, coping, control, processing experiences, growth, and adaptation. For example, the processes of friendship may help an adolescent or young adult cope with feelings about their cancer, face treatment, or make it through a hospitalization. Overall, friendship processes drive a sense of being the same or a different version of oneself.

Understanding or having shared experience describes I See You in Me. Seeing oneself in another can simply result from being the same age or may entail similar medical or social experiences in the past, present, or future. It can also refer to a lack of understanding of others not being able to “get it.”18 Sometimes not being able to see oneself in another is the result of not having the same mark of cancer. At the same time, there can be shared cancer experience because of the processes of friendship rather than a shared mark of cancer. As one adolescent comments, “friends are survivors of a sort too.”18 Sometimes friends have experienced the cancer alongside the adolescent or young adult through friendship processes of Being and Doing. When seeing oneself in another did not occur, feelings of difference even progressing to a “chasm of experience” can make peer group reintegration difficult.22 The existence and exacerbation of difference may catalyze the loss of friendships during and after cancer.

Navigating Friendships provides an understanding of how friendships might begin, be maintained, and end. In some cases, the processes of friendship might lead to the emergence of new friendships. For example, after communicating with fellow patients at cancer camps or online, adolescents and young adults may identify “cancer peers turned friends.”21 In navigating existing friendships, adolescents or young adults engage in certain friendship processes to manage how others see or understand them. Challenges with peers, including loss of contact with friends or “changes in the amount of peers they considered friends,” might occur as a consequence of friendship processes not taking place.30 Through the processes of friendships, youth with cancer may come to “find out who [their] friends are”.32 In these ways, Navigating Friendships is a consequence of the context, conditions, and processes of friendship.

Closeness is the final consequence of friendship contexts, conditions, and processes and describes the degree or quality of friendships. Closeness refers to how friends measure bonds with others on continuums of closeness, truth, intimacy, and depth. This often occurs through the identification of a best friend, a true friend, a distant friend, or a lifelong friend. Demonstrating the interconnected nature of processes and consequences, Closeness may feedback to Doing and Being processes and lead to increases or decreases in engagement with friends.

Discussion

Friendship in adolescents and young adults with cancer, as a concept, is better understood through the explanatory matrix denoted by the perspective of Time Marking, with looking back, getting back, keeping up, and looking forward occurring in nonlinear narrative time. In the context of Places and Spaces, Timing and Mistiming, I Am Me, and Tools, the conditions Marked With Cancer, Goal of Normalcy, Able to, Want to, and Kept From create the processes of Being and Doing interactions. The Usual, Version of Me, I See Me in You, Navigating Friendships, and Closeness became consequences of the conditions and processes. This exposition of friendship in the context of cancer provides a novel and innovative concept for use in research, practice development, and outcomes for adolescents and young adults living with and after cancer.

Developmental theories of friendship in adolescence and young adulthood mark friendship in chronological time and stress friends' roles in satisfying developmental tasks such as needs for intimacy36 and attachment.37 From this developmental perspective, distress in adolescents and young adults with cancer stems from the inability to continue achieving developmental tasks.38 Helping youth with cancer stay on track is thus thought to improve distress.39 However, such a viewpoint neglects the significance of the retrospection inherent in Time Marking. Time Marking refines the relationship between adolescents or young adults' friendships and time. In contrast with the end of treatment representing a point at which adolescents and young adults can “return to normality”40 and begin reconstructing their lives, this investigation reveals marking time in friendships to be more dynamic and less linear.

Friendship theorists commonly subscribe to the similarity attraction theory that people seek friendships with those who are similar to themselves.41 The draw of adolescents and young adults toward friendships with peers with whom they share a mark of cancer corroborates this view. However, at the same time, the processes of friendship also create similarity, represented in I See Me in You. This socialization process through which friends become more similar over time confirms previous understandings of normative friendship focusing on behavioral similarities.42,43 However, in the context of cancer, similarity becomes focused on understanding rather than substance use, sexual behaviors, or other behaviors typically termed delinquent.

Extant theoretical literature holds that social support influences health and well-being, in the presence of life-limiting illness.35,44 Critically, this literature fails to clearly elucidate friendship as distinct from social support. Some authors conceptualize friendships as merely “highly useful”45 relationships. This conceptual investigation reveals friendship to be much more than a way of fulfilling needs. The diverse and dyadic consequences of friendship and the reciprocal nature of some of the processes of friendship necessitate a new conceptualization of friendship in the context of illness. While friendship incorporates some dimensions of support, it must also be investigated, assessed, and facilitated as conceptually distinct from social support.

From the perspective of Time Marking, the findings of this dimensional analysis also provide a new understanding of normalcy by distinguishing between the Goal of Normalcy as a condition and The Usual as a consequence. Contrasting with the Goal of Normalcy, which drives forward along developmental time, The Usual is tied to the perspective of looking back, getting back, and looking forward. The Usual is experienced either in the absence of cancer or because a process of revealing the cancer mark or comparing to others resulted in the cancer mark ceasing to exist, conceptually. Normalcy, specifically the process and experience of realizing a new normal, has received recent attention as a key concept in understanding quality of life in young people with cancer.46 The Usual is an achievement of a new normal in the personalized way it can exist despite cancer. The Usual as a consequence with Doing as a process also corroborates the conception of health-related quality of life for youth with cancer including participation in “usual activities” and “interact(ing) with others”.47

While quality of life is a frequently studied outcome in the context of youth cancer, the relationship between quality of life and friendship has not been clearly elucidated. Given that clinicians, patients, and families may base clinical decisions on perceptions of impact on quality of life, a greater understanding of the placement of friends within this global assessment of health and well-being is clinically necessary.46 Most existing definitions of quality of life reference interacting with “others,”47 “having relationships,”48 and “social functioning”49 as important domains. Auditioning friendship as a potentially separate component of the social experience inherent in quality of life will require further theoretical understanding of the friendship concept. Greater conceptual clarity of the distinctions between relationships that make up the social domain may bolster the overall conceptual underpinnings of quality of life.

Limitations inherent in this investigation are essential in understanding its import and outlining future empirical and theoretical work. With the guiding research question, what is the nature of friendship in adolescents and young adults with experience of cancer, this investigation was not initially intended to only explore friendships with same-aged peers. However, the articles located for the literature sample focused exclusively on peer friendships. This was an unexpected finding. Although some of the search terms included “peer” as this is often how friends are labeled in the psychosocial literature, the author conducted other database searches for “friend” without age-related modifiers. After initial database searches, the author used theoretical sampling to search for additional articles that might elucidate experiences of nonpeer friendships. This sampling strategy did not yield sufficient data to understand the dimensions of age-discordant friendships, or friendships with parents, siblings, cousins, or health and social care professionals. Friendships with these individuals may not be labeled as friendships or may be less socially sanctioned than peer friendships. While anecdotally adolescents and young adults with cancer may identify parents or siblings as their closest friends, whether these relationships are similar to, diverge from, or even replace peer friendships is unknown. Indeed, the experience of nonpeer friendship may differ significantly from peer friendship and thereby potentially change the perspective, context, conditions, processes, and consequences of the explanatory matrix. The etiology of nonpeer friendships also requires further elucidation to determine whether the emergence of nonpeer friendships is a consequence of the absence of peer friendships.

In a future empirical investigation, collecting qualitative data to uncover nonpeer friendship narratives can help determine the existence and salience of these friendships. Future theoretical clarification is needed to characterize who is a friend and why. Peer may turn out to be a modifier of friendship, in the same way the word friend might be joined with other relational labels such as in camp counselor friend, roommate friend, or coworker friend.50 This work is necessary to help define whether friendship is an independent relationship or rather a “sincerely lived dimension” of relationships with peers, parents, or healthcare providers.50

The present work provides limited commentary on Facebook friends and other friends with strong online presences. In the literature sampled, the authors discussed these friend types mostly in the context of online support groups and structured programs to fulfill social support needs. These data did not correspond to the focus on friendship as arising from encounters not intended to have therapeutic benefit. The author excluded these data from the analysis. As a result, further conceptual work is required to clarify friendship in the context of social media. Currently, Tools is characterized as context for the boundaries of friendship these tools prescribe. The placement of social media tools in the matrix may require reconsideration based on future inquiry, as the evolution of friend from noun to verb on social media may change the conditions of friendships.50 The author also excluded literature on social networks or groups, as they are composed of many friendships but are conceptually distinct from dyadic friendships. A future dimensional analysis of the experience of group membership in a social circle or social network is warranted. Understanding whether and how the dimensions of these experiences differ from friendships may help further refine the friendship concept.

Even though future descriptive and theoretical work is needed to refine and build toward a full theory of friendship in the context of adolescent and young adult cancer, this explanatory matrix of Time Marking suggests preliminary clinical implications. Acknowledged to be a sensitive area, potentially similar to topics such as sexual behavior, fertility, or missed school, assessing friendships has the potential to be glossed over or buried in a clinical encounter. While these other historically taboo topics have become mainstream in oncology treatment and survivorship care, addressing disruptions in education and friendships remains uncommon. The data-driven definition of friendship resulting from this dimensional analysis may inspire greater clinician awareness of and sensitivity to the ways friendship is and can be experienced in the context of cancer. For example, healthcare providers may deliberately honor and protect friendship interactions by acknowledging both Doing and Being as processes involved in friendship.

Psychosocial interventions in healthcare often focus on peer support through camps or support groups. The results of this dimensional analysis reveal that certain conditions and processes outside of support define friendship, thus implying alternative interventions may hold utility. By conceptualizing the past, the present, and the future on the narrative rather than normative chronological timeline, health and social care professionals along with family and friends may be better positioned to support these young people. For example, helping youth acknowledge and process ways they are marked with cancer may facilitate friendship processes.

Adolescents and young adults with cancer are a population with significant risks for unmet emotional and social needs. This dimensional analysis improves the focus on friendship, providing a preliminary understanding of its true complexity. Future theoretical and empirical work building toward better assessing and facilitating friendships for youth with cancer may help reduce psychosocial distress and health disparities across this population.

ACKNOWLEDGMENTS

The author thanks Sarah Kagan, PhD, RN, FAAN; Janet Deatrick, PhD, RN, FAAN; Pamela Hinds, PhD, RN, FAAN; and Clare Whitney, BSN RN

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Keywords:

Adolescence; Cancer; Friendship; Peers; Social relationships; Young adulthood

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