RecoveryInc.,asanAdjunctto TreatmentinanEraofManagedCare Peter Murray, M.D.

As capitation increasingly limits professional mental health services, self-help pecially in regard to the self-help of organizations may play an expanding role. Recovery, Incorporated, is an in tercare of former mental patients and ternationally active mental health self-help organization developed in the late the chronic problems of “¿nervous―pa 1930s by Abraham A. Low, M.D. The author reviews concepts about mental tients. He later developed the self illness and health developed since Low's time, such as locus of control, help group Recovery, Incorporated. In learned helplessness, defense theory and Antonovsky's salutogenic model. his 1950 book Mental Health Through He describes how these concepts support many of the principles developed Will-Training: A System ofSelf-Help in by Low, in particular the idea that optimal health is achieved when a person Psychotherapy as Practiced by Recoc assumes responsibility for his or her failure or success. In the structured for erij, Incorporated (24) and in other mat that Low designed for Recovery, Inc., meetings, members learn to iden writings (25,26), Dr. Low described tify self-defeating and illness-promoting thoughts and impulses and counter many principles that have since been them with self-endorsing thoughts and wellness-promoting actions. The au supported by more recent conceptual thor suggests that professionals should become familiar with self-help orga frameworks about niental illness and nizations in their communities, promote relevant research, and facilitate re health. This support lemids credibility ferral to these groups. (Psychiatric Services 47:1378—1381,1996) to the tenets of such groups as Recov cry, Inc., and reinforces their value as aftercarc mental health resources. I 11 these days of managed care, apeutic processes that occur in these niental health professionals are groups. For example, Maton's work Control, defense, and ever more burdened with t@ing to (15) suggests that Riessman's “¿helper responsibility find therapeutic resources that are therapy principle― (16), in which an in As noted, many studies have explored cost-effective, quality controlled, wide dividual's acting in a helping role is relationships between perceptions of hyavailable, and attractive to patients. therapeutic for that individual, miiavac control and mental illness, especially Because insurance coverage of inpa count for part ofthe effectiveness of in depression . Control theomy describes tient stays and outpatient therapy is volvement in self-help groups (1). the diffenences between the belief that limited fom'mamiy patients, effective al Another factor that may contribute life outcomes are largely the result of tenmiatives and adjuncts to traditional to the effectiveiiess of these groups is one's own attributes and behavior (in treatment programs are needed. The members' development of a stronger ternal locus of control) and the belief mental health industry continues to internal locus of control. In the last that outcomes are largely determined search for ways to reduce hospitaliza three decades since Rotter's study (17) i)y external forces (external hocus of tions and improve the effectiveness of of loci of control, many studies have control) (17). Hiroto (18) has shown outpatient programs . However, pa explored relationships l)et\veen sense that people with an external locus of tients may resist using the vemy ser of control, problemn solving, and mem3- control are more susceptible to vices that professionals believe might tal illness, especially depression (18— learned helplessness, a conditioned, keep themii well. 22). Antonovskv's salutogenic model negative response to aversive stimuli. Mental health self-help groups (23)suggestsa relationshiipl)ct\veemiStudies ofdepression and control have sometimes referred to, perhaps more health and people's ability to believe generally shown that a greater sense of accurately, as iiiutuial-aid groups—miiay “¿thatlife is comprehensible, manage internal control is associated with a play au expanding role to meet several able, and meaningful.― lower rate of depression (22,27). mieeds. Research on the effectiveness More than 50 years ago, a Chicago Defense theory is another line of in of self-help groups has generally neuropsychiiatnst, Abrahamii A. Low, vestigation. It looks at differences be shown good outcomes (1—14). Some began to formiiulate his own ideas tweeii those who accept res@)0nsibihity studies have begumito explore the ther about control and problem solving, es for good otitcomiies but reject responsi l)ilitV for had outcomes and those whio accept rcspomisil)ihityfor l)ad outcoiiies Dr. Murray is (1psychiatric resident at @Ve.sternPsychiatric Institute 0,1(1Clinic, .3811 l)tmtreject responsibility for good out O'Hara Street, Pittsburgh, Pennsylrania 1.5213. conies. The latter group, who self

1378 PSYCFIIATRICSERVICES•¿December 1996 Vol.47 No. 12 blame, have been generally viewed as which he described as expressing “¿thehe knows that he has ‘¿miotyet' learned more susceptible to depression than extent to which an individual has a to avoid resisting the physician. The the former group (28—30). pervasive, enduring though dynamic, ‘¿notyet' is reassuring. It suggests that In 1990 Minowsky and Ross (22) feeling of confidence that life is com in time he will learn.― published the results of a study that prehensible, manageable, and mean Rejecting the common psychoana rated depression among four groups: ingful.―Initial studies in 20 countries lytic doctrine of his day, Low (24) said instrumentalists, who believe they are of the Sense of Coherence Scale that that he chose to side with Kraepelin responsible for both good and bad out Antonovsky (32) constructed indicate and Wundt I)y “¿emphasizingthe prior comes; fatalists, who accept responsi its cross-cultural reliability and validi ity ofWill over Drives.―He noted that bility for neither good nor bad out ty; future studies using the scale may it is inconceival)le that adult human conies; self-defenders, who accept re reveal clearer correlations between a life can be ordered without a Will sponsibihity for good outcomes but not person's attitudes, behavior, and place holding down impulses.―Low empha for bad; and self-blamers, who accept on the continuuni of mental and phys sized that while feelings and sensa responsibility for bad outcomes but ical health and illness. lions are “¿eitherexperienced or not cx not for good. The results of the study A better understanding of “¿stressperienced,― the will is capable of con supported the view ofcontrol theorists buffers―has obvious implications for a trolling thoughts and impulses. that “¿fatalistsare more depressed than variety of fields. For example, Sullivan Fundamental to Low's process of instrumentalists― (22). (33,34) described the relatedness of will training is group members' prac However, the results did not support models ofcontroh theory, will to mean lice ofrecovery principles in their dai the views ofdefense theorists that self ing, learned helplessness, hardiness, hy life. This process, much as in the defenders are less depressed than self and sense of coherence and provided cognitive psychotherapy later devel blamers. In fact, the depression scores an analysis of these concepts, especial oped by Beck (29), involves learning to of the fatalists, self-blamers, and self ly in regard to their usefulness in nuns identify self-defeatimig and illness-pro defenders in the study were not signif ing education, practice, and research. moting thoughts and inipulses and icantly different. This finding supports Other recent investigations into the countering them with self-endorsing the view that it is important, at least utility of Antonovskv's work inchimde thoughts and wehlness-promoting ac with respect to depression, to believe studies exploring applications in coun tions. Mental Health Through Will that one is responsible not only for seling psychology and medicine Training is filled with examples of how one's successes in life but also for one's (35,36). this process can be brought to bear in failures. As the authors pointed out, “¿A daily life. The book serves as a re sense of control oven and responsibili Similarities with other models source for training in Low's Recovery ty for past problems implies the possi Although much of the work in control method. bility of avoiding them in the ftmture.― theory has focused on its relationship As noted, the sense of coherence al This is not to suggest that one might to the development of depressive lows a person to cope with stress and benefit from assuming responsibility symptoms, Antonovsky's niodel is chaos, in Antonovsky's words (23), for the existence ofone's mental disor more global. Low's system of self-help, through a “¿pervasive,enduring though den; however, it niay be health promot the Recovery method, which is de dynamic, feeling ofconfidence that life ing to believe that the nature of one's scribed in Mental Health Through is comprehensible, manageable, and responses to illness can lead either to Will-Training (24), focuses on how meaningful.― Low's methods, incorpo good or to bad outcomes. training the will can help mental pa rated in Recovery, Inc., address these tients prevent relapse and chronic suf three beliefs. The first, that life is corn Salutogenesis fering. Rather than restrict his princi prehensible, is fostered by Recovery Not unrelated to one's sense of control pies to particular diagnoses, Low ad members' analysis of their own and are beliefs that one's life can be under dressed common elements expeni other members' life problems. At Re stood, has meaning, and can be man enced l)y people who have mental ill covery meetings, members relate cx aged. In theoretical work, Aaron ness and described principles that aniples of the difficulties they experi Antonovsky (31) has espoused that people can use to improve their out ence in their everyday lives. A struc these beliefs optimize health and psy comes. tuned furmat of presentation is fol chological well-being. His salutogenic Inherent in Low's approach is the lowed. First, the disturbing event itself model of health and illness focuses on message of control theory—that opti is described. The symptoms and dis “¿whypeople remain healthy despite mal health is achieved when a person comfort that the event produced arc stress― and proposes that the internal assumes a sense of responsibility for then detailed. Next, the presenter de resources enabling people to stay his or her failure or success. When dis scribes his or her dysfunctional re healthy have a common facton—―they cussing a patient's “¿sabotage―of the sponses and the Recovery principles help make sense out of the stressons therapeutic process, for example, Low that enabled more effective coping. Fi with which individuals are constantly (24) described the benefit oftaking re nally, the presenter reflects on the bombarded― (23). sponsibihity for bad outcomes as well symptoms and reactiomis he or she At the core of this model of stress as good: “¿Contraryto expectation, it is would most likely have experienced and resistance is the comistructAnton comforting to the patient to be called a before training in the Recovery ovsky called the sense of coherence, sah)oteur. Considering himself as such methiod.

PSYCHIATRICSERVICES. December 1996 Vol. 47 No. 12 1379 The presentations are reinforced at The fellow sufferer who explains how controls can be established (37); such meetings I)\' rneml)ers reading aloud he ‘¿licked'his frightful palpitations of groups are widely availalhe and have exaniples fromii Lows 1)00k. Moreover, ter years of invalidism cannot possibly l)een shown to he effective (3,4). Be Iilemiil)ersare encouraged to adopt the be suspected of trying to sell some cause the method ofRecover@ Imic.,in use of “¿Recoverylanguage―developed thimig. He convinces the miovice that tentiomially avoids distimictions based l)\' Low, whiich serves to exorcize self ‘¿chronic'conditiomis are not hiopeless.― on diagnosis and proniotes effective defeatimig, temperaniental, and overly The effectiveness (3,4) and longevity coping with the fears, stigmria, and clinical speechi from their discussions. of Recovemy, Inc. , may owe much to eve@day stressors common to niost Tliroughi repeated exposure to this this factor—that a supportive, peer people with mental illiiess, it can help process, miiemnl)ers gaimi insight imito structured therapy group has a unique people with a broad range of dysfunc amid umiderstamiding about themselves potential for gently guiding a person tions—ifthey choose to “¿walkthrough and life in general. This process of with mental illness toward the critical the door.― sharing successful expeniemices, in task of accepting respomisibility for his A task facing self-help groups is to conibimiatiomi with the technique of en Or her well-being. In this light, such consider if and how they might re dorsememit in which members affirm groups may l)egin to l)e appreciated spond to newly identified issues and thseir own and others' health-promot not as second-rate replacements for needs ofthie miiental health commnunity, ing thinking and behavior, affirms professiomial care but rather as poten especially as the availability of profes nie,nI)ers belief that by their own ef tially critical adjuncts to professional sional services changes. No single re fort, life can indeed be manageable care that may in fact increase its effec source cami1)eexpected to meet all of a the second criterion of Antonovsk@ tiveness. cornmiiunity's needs. Questions arise U)\\r5 strict design of the Recovery If it is true that participation in self about the al)ihty of Recovemy, Inc., Al niecting irocess also includes a social help or mutual-aid groups can greatly cohohics Anomiynious, and other groups aspect. The “¿mutual-aid―segment of optimize mental wellness, then key to address issues such as poverty miieetimigsfollows the structured seg tasks facing mental health profession among 1ers@ns with mental illness, so niemit amid is a time when members can als include faniihiarizing themselves cial stigma, and the availability of ne sit together over a cup of coffee and with such organizations, promoting sources to people of different races, share their experiences more extemii relevant research, and facilitating re genders, socioecononiic classes, and poraneously. Durimig this time, mern ferral to these groups. Alcoholics types and severity levels of mental ill bers get to know one another in an ac Anonymous, Recovery, Inc., and other ness. cepting atmiiosphere iii which they can organizations have been invited by For example, the policies and prac practice social skills. Relationships de some hospitals to operate groups for tice of Recovery, Inc., are set by a velop, and a social context for life is inpatients on a volunteer basis. Al board of directors made up of miiem fostered. In this way the last of though this practice may blur lines be bens; a guiding principle of the board Antonovsky's criteria is advanced tween professional and lay therapy has been that the organization's effec life can be seen as meaningful. and create conflicts of interest, it ap tiveness depends on fairly strict adher pears to be a logical and viable tool for ence to Low's tenets in the operation Discussion and conclusions introducing patients to such resources of the organization. Such adherence Exacerbation of mental illness often as long as the introduction is thought has brought certain challenges, such as challenges a person's sense of control. fully carried out and quality control dependence on psychological terms Experiemicing symptoms that necessi measures are instituted. from Low's books that have become tate acute care or hospitalization pre Questionsalwaysariseaboutwhat somewhat arcane. In practice, some sents an individual with evidence that type of person with what type of men groups are choosing to dc-emphasize he or she cannot fumiction indepen tal disorder would benefit from a given the use of “¿Recoverylanguage,―a con dently. Receiving outpatient aftencare therapy. Obviously, the nature ofan in troversial topic in the organization and from mental health professionals may dividual's symptoms, especially cogni one that reflects the organization@s dif perpetuate this idea, which may partly tive impairment or thought disorder, ficulties in striving to be flexible while explain many patients' resistance to can limit his or her ability to engage in retaining its sense of therapeutic in “¿compliance―with aftercare. therapeutic self-help. However, for tegrity. Comitrol theory suggests that a key many people using mental health ser Another challenge to Recovery, Inc., task for persons with mental illness is vices, engagement in a self-help onga has been the limitations that its stnmc to accept responsil)ihity for outcomes. nization such as Recovers Inc., may tural organization placed on involve However, promoting patients' “¿owner be of real benefit. Low's principles, in ment of patients' families and friends ship―of their mental health and illness particular, are compatible with current in the therapeutic process. These limi max' not be a task well suited for a sys mental health theory and practice, and tations are ironic considering Low's temii of care that is itself hierarchical Recovery, Inc., has operationalized views ofthe importance ofpatients' fa and often experienced by patients as them in a way that supports rather milial and social contexts. As Low (26) patenialistic. As Low (24) noted, “¿Un than obviates the need for concurrent eloquently described in a lecture, fortunately, the physician is fan froni psychiatric follow-up. which has been published in Peace convincing . . . [but] resistance is easi Moreover, use of Recovery, Inc., is Versus Power in the Family, environ ly overcome in the group interview. extremely inexpensive, and quality mental forces are particularly signifi

1380 PSYCHIATRICSERVICES. December 1996 Vol.47 No. 12 cant for those whose sense ofcontrol is groups. American Journal of Community 19. Sehigman ME: Depression and learned Psychology 10:643—8()5,1991 helplessness, iii The Psychology of Depres challenged by mental illness. sion: ContemiipcmrarvTheory anti Research. Because ofLow's beliefthat the sup 3. RaiffNR: Self-help participatiomi and quality Edited b@Friedman RJ, Katz MI'sh.New of life: a study of the staff of Recovery, Inc. York,Wiles: 1975 pom@tof family and friends can be cniti Prevemition iii Human Services 1(3):79—89, cally important in patients' success in 1982 20. Lefcourt HM: Locus of Control: Cuirremit the community, the Abrahaiii A. Low 4. Raiff NR: Somimehealth-related outcomnesof Trends in Theory and Research. New York, \Viley, 1976 Institute, an organization separate self-help participation: Recovery, mc, as a from Recovery, Inc., created a new case example of a self-help organization in 21. Mirowskv J, Ross CE: Social patterns of dhs niental health, in The Self—Hell)Revolution. tress. Annual Review of Sociology 12:23—45, self-help group patterned on Low's Edited i@yGartner A, Riessnian F New York, 1986 principles called the Relatives Project. Human Sciences Press, 1984 22. Mirowsky J, Ross CE: Comitrol or defense? In Relatives Project groups, family 5. Videka LNI (ccl): Psychosocial adaptation in a Depression and the sense of control over miieml)ers and friemids not only learn medical self—help group, iii Self-Help gou@cland had outcomes. Journal of 1-health Groups for Coping With Crisis: Origins, and Social Behavior 31:71—86,1990 al)out ho@v domestic emivironmental Processes, Menihers, amidImpact. Edited l)y factors can I)e shaped to optimize the Liehernian LD, Borman LD, et al San Fran 23. AntonovskvA:The salutogenic perspectis'e: mental healthi of their loved ones but cisco, Josse@-Bass, 1979 toward a new view ofhealthi and illness. Ad vamices (Institute for Adlvancement of also learn how to manage their own 6. Hinrichsen GA, Revenson TA, Shimin M: Health) 4(1):47—55,1987 stresses by using the Recovery meth Does self-help help? An empirical investiga tion ofscoliosis peer support groups. Journal 24. Low AA: Mental Health Through Will od. In this way, responsibility and con of Social Issues 41:65—87,1985 Training: A System of Self-Help in Ps) trol for wellness are actively sought chotherapy as Practiced by Reca'm; Incur 7. HumghsJM: Adolescent chiklremi of alcoholic porated. Glencoe, Ill, \Villett, 1950 goals shared by patients and their rela parents and the relationship of Alateen to tives and friends. In creating the Rela these children. Journal of Comisulting and 25. L()@VAA: Selections from Dr. Lows \Vorks tives Project, the Low Institute has Clinical Psychology 45:946—947,1977 (1950—1953). Chicago, Recover@ Inc. 1967 met a newly identified need while al 8. Lieberman MA, Vicleka-Sherman L: The irn 26. U@' AA: Peace Versus Power in the Family: pact ofself—helpgroups omithe mental health lowing Recovery, Inc., to continue on Domestic Discord md Emotional l)istress. of widows and widowers. American Journal Glencoe, Ill, Willett, 1984 its traditional path. Flexibility in pro ofOrthopsychiatry 53:435—449,1986 graniming was achieved while sti-uc 27. Benassi VA, Sweeney PD, Dufiur CL: Is 9. Edmundson ED, Bedell JR. Gordon RE: there a relatiomiship between locus of control tural and therapeutic integrity were The commiiunitynetwork development pro orientation and depression? Journal of Ab maintained. ject: bridging the gap between professional flOfli@alPsychology 97:3.57—366,1988 aflercare and self-help, in The Self-Help As capitation imicreasingly limits Revolution. Edited b@Gartner A, Riessnian 28. Beck AT: Depression: Causes amid Treat availability of professional services, F New York, HumamiSciences Press, 1984 memit.Philadelphia, University of Pennsvlva nia Press, 1970 new and existing resources within the 10.Jensen PS: Risk,protective factors,and sup lay therapeutic community may be P@@@Veinterventiomis iii chronic airway ob 29. Beck AT: The developmnent of depressiomi: a come increasingly important in the stnmction. Archives of General Psychiatrv cogiutive na@del, in l'hie Psychology of I)e— 40:1203—1207,1983 pression: Contemporary Thcory and Re cane ofpeople with mental illness. It is 11. Mmdc K, Shosenberg N, Marton f@et al: search. Edited by Friedniami RJ, Katz MM. New York,Wiley,1974 @ l@othtinicly and important for mental Self-help @rotip@ a premature miursery: a health professiomials to familiarize controlled evakmation.Journal of Pediatrics 30. Rizlev R: Depression ami@iDistortion in the themselves with all resources in their 96:933—940,1980 Attribution ofCausalitv Journal of Abnornial communities and to make critical as 12. Peterson C, AbramiisDB, ElderJ@ et al: Pro Psychology 87:32—48, 1978 sessments about their potential bene fessional versus self-help weight loss at the 31. Antonovskv A: The life cycle, mental health, work site: the challenge of making a public fits and harms. This discussion has fo ann the sense ofcoherence. Israel Joumnialof health impact. Behavioral Therapy 16:213- Psychiatry and Related Sciences 22:273— cused on one such resource, and there 222, 1985 280, 1985 are many others. Perhaps with judi 13. Spiegel D, Bloom JR, Yalorn I: Group sup 32. Amitonovsk'sA: The stnicture and propertieS cious, appropriate, and even integrat port for patients with nietastatic cancer: a of the Sense of Coherence Scale. Social Sci ed use of such resources, mental randomized prospective outcome stud)@ ence andl Medicine 36:72.5—733,1993 Archives of General Psychiatry 38:527@33, health professionals will find that pro 1981 33. Sullivan CC: Evaluating Antonovskv's salum viding care for patients and their fami 14. VachonML, Lvall\VA,RogersJ, etal: Acon togenic model for its adaptability to nursing. lies in the era of managed cane is in trolled stud@of a self-help intervention for Journal of Advanced Nursing 14:336—342, 1989 deed manageable. •¿ widows. American Journal of Psychiatry 137:1380—1384,1980 34. Sullivan GC: Towards clarification ofconver Acknowledgments 15. Maton KI: Social support, organizational gent comicepts: sense of coherence, will to characteristics, psychological well-being, meaning, locus of control, learned helpless This work was partly supported by a re and group appraisal in three self-help popu ness, and hardimiess. Journal of Advancedl search fellowship award from the Abraham lations. Americami Journal of Community Nursing 19:1772—1778,1993 A. LoW Institute. The author thanks Ken Psychology 16:53—77,1988 35. \VillGH: Acommunity health role for cotmn ncth Thompson, M.D., for comments and seling psychologists. Australian Psychologist suggestions. 16. Reissman F:The ‘¿helper-therapy―principle. Social Work 10:27—32,1965 27:96—98,1992

References 17. Rotter JB: Generalized expectancies for in 36. Hernian J: The common denominator. Fain ternal vs external control of reinforcement. ily Systems Medicine 9:275—277,1991 1. Levine NI:Social and comniunitv interven Psychological Monographs 80:1—28,1966 tions. Annual Review of Psychology 44:525— 37. Raiff NR: Recover@çInc. and (Jualitv assur 558. 1993 18. Hiroto DS: Locus of control and learned ances in organized self-help. Journal of In helplessness. Joumrnalof Experimental Psy ternational and Comparative Social \Vi'lfare 2. Borkman TJ (ed): Special issu': self-help chology 102:187—193,1974 1:77—89,1984

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