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.