Psychological Reports, 1979, 44, 1119-1125. @ Psychological Reports 1979
THE DILEMMA OF MEMBERSHIP IN RECOVERY, INC., A SELF-HELP EX-MENTAL PATIENTS' ORGANIZATION1 RICHARD C. OMARK Central Michigan University Summary.-Organizational beliefs and group processes in meetings of Recovery tend to "trap" members in the organization indefinitely. Although the stated goal of the organization is to reduce "nervousness" and solve emotional problems of members, there is no recognition of successful termination of membership. Many members joined the organization years ago and still attend sporadically. The "power of positive thinking" about the success of the Recovery method discourages contact by members with other kinds of community mental health facilities, so that Recovery groups ate isolated in the community. This further traps members within the organization.
Recovery is a self-help organization for ex-mental patients and "nervous" people. The main problem for members has to do with organizational goals: the explicit goal of Recovery is to "cure" the emotional problems of its members and reduce their "nervousness." But an implicit goal of any organization is to survive and maintain itself (an unstated goal). The research problem in studying Recovery is much like the problem in prisons, mental hospitals, and drug programs-they have the goal of cure or rehabilitation, but the organization also wants to maintain itself whether or not it is effective. Recovery has what can be called a "structural dilemma:" The organization's ideology and group processes keep members in its hold. As new members take on roles in the organization, they are "trapped" in the organization because exit from it is ambiguous. So the structural dilemma is that the organizational goal of "cure" is subverted by the goal of maintaining the organization. An aspect of this is how Recovery meetings fit in with other kinds of mental health care in the metropolitan area. Being "trapped" within the organization is illustrated by answers to certain questions: Does Recovery cooperate with other mental health facilities? Does it refer its disturbed members to Community Mental Health Centers or private psychiatrists in the area? In its printed literature Recovery says that it prefers referrals from Community Mental Health Centers and psychiatrists, but does it get them? Recovery, Inc. is one of many self-help organizations composed completely of one type of deviant. In this respect, it is like Alcoholics Anonymous, Synanon, Gamblers Anonymous, and Mattachine. However, Recovery started independently of these others. Dr. A. A. Low, a psychiatrist and head of a Chicago mental hospital, started experimenting with half-way houses for his hospitalized 'Paper presented at the meetings of the Midwest Sociological Society, Minneapolis, April, 1979. This research was made possible by a faculty research grant from Central Michigan Universiry, 1977. I wish to thank Peter K Manning, Edward Sagarin, Larry Tifft and William Ewens for helpful comments on an earlier draft of the paper.
patients in 1937. By 1950, he was holding public meetings for his ex-mental patients, compiled a book of his ideas about how to solve emotional problems and reduce "nervousness" (Low, 1950), and set down rules on how to run meetings. In 1952, he authorized the establishment of groups in other cities as some of his ex-mental patients moved away from Chicago. H e died in 1954, but the organization has continued to spread. Now it is found in all of the major and moderate-sized cities in the United States and Canada. The headquarters of Recovery, Inc. is still in Chicago, but it primarily publishes pamphlets and other literature for use by local groups in advertising the organization. The metropolitan area of nearly 200,000 in which Recovery groups were observed has five regular groups, each of which meets on a different evening of the week, in churches in widely separated areas of the city. In 1971, several of these groups were observed for a few meetings. In 1977, twenty-seven consecutive meetings of two of the groups were observed: 14 Wednesday group meetings and 1 3 Friday group meetings. Although the district leader and one group leader knew of my research interest in observing the groups, other members of the groups did not know. I simply went to the meetings, which are open co the public, and eventually participated in the two groups as if I were a regular member. This participant-observer role limited the research, especially in the brief time after each meeting when I could informally question members about how they got into the organization and how long they had been members, but some of this information was volunteered by members in the meetings anyway. Notes on each meeting were recorded in private directly after the meeting. The organizational ideology is based on one book (Low, 1950). The book is a compendium of examples taken from meetings and interviews with his patients, each followed by commentary by Dr. Low. His basic ideas are: Inner experience is composed of four interrelated elements: thoughts, impulses, sensations, and feelings. Only thoughts and impulses can be controlled by the "will" (which only accepts or rejects ideas). But control of thoughts and impulses gives the person indirect control over sensations and feelings. For example, he says, "all you have to do to dispose of [an internal] fear is to refuse to believe that there is danger." One can replace insecure or anxious thoughts with secure thoughts. When the patient "spots" the symptom as harmless, he prevents "working himself up" (getting upset) over it, and the symptom will likely disappear eventually. Dr. Low took the position that a "nervous condition" literally results from weakened nerves. This is the "illness model" used in Recovery. Tenseness of the body produces symptoms because nerves are weakened by the tenseness and cannot resist the symptoms. If tenseness is reduced, the nerves are strengthened and the symptoms are reduced in intensity and eventually disappear. Tenseness can be reduced by controlling "temper" of anger or fear, and preventing "working oneself up."
DILEMMA: MEMBERSHIP IN SELF-HELP GROUP
1121
The names of most emotions have been transformed. Dr. Low's reason for this is: If a person talks using words that evoke emotion, then the person again feels those emotions (e.g., "I felt angry at my boss yesterday"), so the new vocabulary is designed to be less emotion-laden. I will return to the vocabulary and ideology of the organization but first need to describe a typical meeting. The group meetings are fairly small, averaging eleven participants per meeting (range: 6 to 1 7 ) . Attendance is quite sporadic; in the 27 observed meetings 59 different people were seen at one time or another. Meetings are of 2 hr. duration, led by that evening's leader. The program of the meetings is fixed and never varies. Members sit around a large table. New people are told not to talk during the meeting. For a half hour they read aloud passages from the book (no comment or discussion of i t ) ; an hour during which members give "examples" and comments on the examples; then a "collection," and a half hour of "mutual aid" (coffee and cookies and informal talking). The main portion of the meeting is giving "examples." The leader asks members to volunteer an example. The leader has a sheet of paper in front of him on how to give an example; it lists four steps: (1) describe a recent event that caused the member some emotional difficulty and the member's reactions (e.g., temper of anger); ( 2 ) the symptoms and discomfort subsequently produced; ( 3 ) the "spotting of temper," the "working up process," and concept of "averageness." In other words, the person giving the example typically indicates how he or she successfully resolved the emotional difficulty using ideas and principles from the book. And finally, ( 4 ) the reactions and symptoms which the member would have experienced before Recovery training. Other members raise their hand to comment on the example, usually by referring to other ideas and principles from the book that could have been used. Perhaps this description will be more concrete by presenting an example actually given at a meeting, with the comments on the example made by other members. ( I will explain some of the concepts used in the example shortly.) Ed volunteered an example and said: "I went into a department store yesterday to buy an x. The salesman told me that they no longer sell it. I had temper of anger at the salesman for not having it, and started telling him everything that had ever gone wrong with me in that store. But then I spotted that it was not the salesman's fault and that it was not good for my mental health to work myself up over it. I apologized for getting angry at him, and asked him what other store might have an x." Ed completed the last step of the example by saying, "Before my Recovery training, I would have stormed on for minutes at the salesman, and it would have wrecked my whole day. I had a nervous breakdown and was hospitalized once for three weeks." The group leader said, "Okay. That was a good example. W h o would like to comment?" Comments included: "There was some sabotage when he expressed his temper of anger, but I liked the way he willed his mouth muscles
1122
R. C. OMARK
to stop expressing the temper." Judy said, "it is an average response to have temper of anger in such a situation, and Dr. Low tells us that we are entitled to our initial response." Mary, "it is an average event these days" (i.e., an x is hard to find in stores). Linda, "I liked the way he took the judgement and blame out of it." Bill, "Ed recognizes that his mental health is his supreme goal" ( a chapter title from the book); "he replaced his insecure thought that the store is bad, with the secure thought that another store might have an x." And finally, "his example is one of high expectations and disappointments" (another chapter title from the book). After the last volunteered comment, the leader asked Ed, "Did you endorse yourself?" and he replied, "yes." An example usually has a positive outcome, and comments by others are rarely critical. Also, the positive example shows that a person can handle emotional problems using the ideas from the book. In other words, an "example" is an example of the s~ccessfulapplication of the ideas of the book to a member's emotional difficulties. A member can also give a "problem example" (where the difficulty was not resolved) but these are rare: Of 103 recorded examples, only ten were problem examples. Problem examples are usually given by new members. A few of the main concepts commonly used in exanlples are: AVERAGE-a member should strive to view his feelings and impulses as average, as opposed to trying to be exceptional (i.e., don't think of your feelings as exceptional). BALANCEis an individual goal of striving toward being average. Dr. Low wrote, "Nervous patients lack balance." CYCLEmeans that an individual feels "up" or "down" emotionally. The concept of cycle is used to maintain the organization, as seen in a statement by a member, "A person may leave the group when he feels up, but sooner or later, the members rerurn when they feel down." If a member doesn't show up for a meeting, or even for several meetings, it does not demoralize the group because it is inevitable that they will feel down again, and return. SELF-ENDORSEMENT means patting oneself on the back for making an effort to get through a difficult situation by using the concepts and methods of the book. SABOTAGEis the attempt of an individual to thwart the purpose of the group he is in; so, it has many forms depending on which group he is in. It is used in the meetings as "sabotage" of Dr. Low's ideas (and the book) and hence, of Recovery itself. A person has to read the book and become familiar with the vocabulary and concepts in order to become a member of Recovery, and in order to give "examples" in the meetings. The leader might call on a new person to give an example after three or four meetings. But once a person is a member, he is likely to return to meetings off-and-on indefinitely-he is trapped in the organ-
DILEMMA: MEMBERSHlP IN SELF-HELP GROUP
1123
ization. Learning the language used in Recovery meetings "locks" the person into the organization and obscures other options for other kinds of mental health treatment. It should be clear how members become "trapped" in Recovery if we compare Recovery meetings to group psychotherapy. Recovery is open to the public-anyone can walk in, and eventually become a member. The Recovery leader is just another member, following the program and asking for examples and comments; he is not paid; contributions go to the organization. In group psychotherapy, the therapist is paid for his skill, training and concern. The therapist is likely to question the meaning of absences, and make interpretations of behavior in the meeting itself. But the most crucial difference is in entry and exit: In group therapy, the therapist makes a diagnosis and determines a set of goals for the patient to work toward. In Recovery, the individual has to decide himself what his problems are and what goals he seeks from participation. This also makes exit highly ambiguous in Recovery groups. In group psychotherapy, termination occurs when the therapist and the patient agree that the planned goals have been attained. But in Recovery, the group leader is not concerned with defining specific and realistic goals for new members. The Recovery group does not recognize successful "termination" and, on the contrary, the leader hopes that members will continue to come to the group meetings, so as to make his group viable. Two sorts of evidence bear on the ineffectiveness of Recovery groups: the sporadic attendance of the members, and the lengths of membership of the members. Table 1 shows that the median attendance of the Wednesday groups observed fourteen consecutive times was five meetings (36% of the meetings). Similarly, of the thirteen Friday groups consecutively observed, the median attendance of members was five meetings (38% of the meetings). This sporadic attendance is a behavioral indication that there is ambiguity for the members about being cured or being a member of the group. There is ambivalence in the degree of attachment to the group, and it is not dear just when a person is in the group. In this situation, the end or goal (cure) can be confused with the means (participation). TABLE 1 MEDIAN ATTENDANCH OF MEMBERS IN m E TWO GROUPS Wednesday Group Meetings Observed 14 Numbers of Members* 27 Median Attendance of Members 5 New People Who Did Not Return 4 'These numbers include five members who attended both groups.
Friday Group
13 25
5 8
1124
R. C. OMARK
Table 2 showing the lengths of membership in Recovery gives some evidence on how well members get trapped in the organization as members. Although these data are limited by the sporadic attendance of the members, it shows that many members have been in the organization (sporadically) for years. It also shows that the organization is effective in its advertising and has a fairly high number of visitors ( 1 2 ) who were observed to attend one meeting, and were not seen again during the period of observation. TABLE 2 LENGTHSOF MEMBERSHIP OF MEMBERS OF BOTHRECOVERY GROUPS Length of Membership
N
Less than one year One year or more Don't know? Members New people who did not return Total participants 'This group averaged 8 yr. as members and ranged up to 18 yr. -/-People in chis group indicated membership by their familiarity with the vocabulary of the group, but the length of membership could not be determined because of cheir sporadic attendance.
Members become "locked into" the organization because there are several sorts of attachment to the group, and options are unavailable for other kinds of care: members share certain characteristics in common, including how members got t o the organization in the first place; and there are no referrals out of the organization to other mental health facilities (that is, there is a lack of organizational linkage). Recovery appeals to certain sorts of people. The members observed are predominantly married; two-thirds are women; the estimated average age is forty-nine years; and they appear to be of lower-middle and working socioeconomic class. In addition, many members have a history of short-term psychiatric hospitalization. Also, Recovery appeals to people who view emotional problems as grounded in the body and who accept the emphasis from the book on "nerves" and on muscles. Such people are not sophisticated about different psychological theories of emotional problems. Most members were not referred to the organization by a doctor or psychiatrist. Some were brought to a meeting by a member; some were told about it by a friend or relative; some read about Recovery in the newspaper. This suggests that membership is largely self-selected; many hear about the organization and attend a meeting, but only some continue and become members. Recovery is not an adjunctive service for psychiatry and the Community Mental Health Centers in the sense of referring its most disturbed members to a
DILEMMA : MEMBERSHIP IN SELF-HELP GROUP
1125
psychiatrist or Community Mental Health Center. Beginning in 1971, Recovery has a policy of not discussing doctors or therapists at meetings. But also, advice for a disturbed member is to attend more Recovery meetings (this could be dangerous, e.g., for the suicidal). It should be clear by now why a member would not be recommended to a professional: Examples given in meetings are designed to show the successful application of Recovery principles to the members' emotional difficulties. To recommend that a member seek an alternative source and method of help for emotional difficulties would be to admit that the Recovery method does not work. In this sense, other options are closed off. This "power of positive thinking" about the success of the Recovery method is reinforced by the participants themselves-if a member decided it didn't work, he would stop attending meetings, so other members would not hear his doubts. In conclusion, the dilemma of membership in Recovery is that the organizational beliefs and group processes tend to trap members in the organization indefinitely. The group does not recognize anything like successful therapeutic termination; on the contrary, with the idea of an emotional cycle of ups and downs, some members believe that an absent member will inevitably return when feeling down again. Some evidence was presented showing that many members joined the organization years ago and still attend meetings. At the same time, it is also empirically clear that attendance in the groups is quite sporadic. Group meetings include some who are strangers to each other (both old members and new visitors) so that the groups are not very cohesive. As presented in the meetings the successful examples of the resolution of emotional difficulties using ideas from the founder's book serve to reinforce the belief that the Recovery method "works" and chat "we are all getting better." However, it obscures questioning why the member joined the group in the first place, so that participation in the group comes to replace recognition of a cure. The "positive thinking" about the success of the Recovery method discourages the contact with and use of alternative mental health facilities and techniques. Recovery groups are isolated from other mental health facilities, rarely receiving and never making referrals. This also serves to trap members within the organization indefinitely. REFERENCE Low, A. A. Mental health through will-training. Boston: Christopher, 1950. Accepted May 24, 1979.
THE DILEMMA OF MEMBERSHIP IN RECOVERY, INC., A SELF-HELP EX-MENTAL PATIENTS' ORGANIZATION1 RICHARD C. OMARK Central Michigan University Summary.-Organizational beliefs and group processes in meetings of Recovery tend to "trap" members in the organization indefinitely. Although the stated goal of the organization is to reduce "nervousness" and solve emotional problems of members, there is no recognition of successful termination of membership. Many members joined the organization years ago and still attend sporadically. The "power of positive thinking" about the success of the Recovery method discourages contact by members with other kinds of community mental health facilities, so that Recovery groups ate isolated in the community. This further traps members within the organization.
Recovery is a self-help organization for ex-mental patients and "nervous" people. The main problem for members has to do with organizational goals: the explicit goal of Recovery is to "cure" the emotional problems of its members and reduce their "nervousness." But an implicit goal of any organization is to survive and maintain itself (an unstated goal). The research problem in studying Recovery is much like the problem in prisons, mental hospitals, and drug programs-they have the goal of cure or rehabilitation, but the organization also wants to maintain itself whether or not it is effective. Recovery has what can be called a "structural dilemma:" The organization's ideology and group processes keep members in its hold. As new members take on roles in the organization, they are "trapped" in the organization because exit from it is ambiguous. So the structural dilemma is that the organizational goal of "cure" is subverted by the goal of maintaining the organization. An aspect of this is how Recovery meetings fit in with other kinds of mental health care in the metropolitan area. Being "trapped" within the organization is illustrated by answers to certain questions: Does Recovery cooperate with other mental health facilities? Does it refer its disturbed members to Community Mental Health Centers or private psychiatrists in the area? In its printed literature Recovery says that it prefers referrals from Community Mental Health Centers and psychiatrists, but does it get them? Recovery, Inc. is one of many self-help organizations composed completely of one type of deviant. In this respect, it is like Alcoholics Anonymous, Synanon, Gamblers Anonymous, and Mattachine. However, Recovery started independently of these others. Dr. A. A. Low, a psychiatrist and head of a Chicago mental hospital, started experimenting with half-way houses for his hospitalized 'Paper presented at the meetings of the Midwest Sociological Society, Minneapolis, April, 1979. This research was made possible by a faculty research grant from Central Michigan Universiry, 1977. I wish to thank Peter K Manning, Edward Sagarin, Larry Tifft and William Ewens for helpful comments on an earlier draft of the paper.
patients in 1937. By 1950, he was holding public meetings for his ex-mental patients, compiled a book of his ideas about how to solve emotional problems and reduce "nervousness" (Low, 1950), and set down rules on how to run meetings. In 1952, he authorized the establishment of groups in other cities as some of his ex-mental patients moved away from Chicago. H e died in 1954, but the organization has continued to spread. Now it is found in all of the major and moderate-sized cities in the United States and Canada. The headquarters of Recovery, Inc. is still in Chicago, but it primarily publishes pamphlets and other literature for use by local groups in advertising the organization. The metropolitan area of nearly 200,000 in which Recovery groups were observed has five regular groups, each of which meets on a different evening of the week, in churches in widely separated areas of the city. In 1971, several of these groups were observed for a few meetings. In 1977, twenty-seven consecutive meetings of two of the groups were observed: 14 Wednesday group meetings and 1 3 Friday group meetings. Although the district leader and one group leader knew of my research interest in observing the groups, other members of the groups did not know. I simply went to the meetings, which are open co the public, and eventually participated in the two groups as if I were a regular member. This participant-observer role limited the research, especially in the brief time after each meeting when I could informally question members about how they got into the organization and how long they had been members, but some of this information was volunteered by members in the meetings anyway. Notes on each meeting were recorded in private directly after the meeting. The organizational ideology is based on one book (Low, 1950). The book is a compendium of examples taken from meetings and interviews with his patients, each followed by commentary by Dr. Low. His basic ideas are: Inner experience is composed of four interrelated elements: thoughts, impulses, sensations, and feelings. Only thoughts and impulses can be controlled by the "will" (which only accepts or rejects ideas). But control of thoughts and impulses gives the person indirect control over sensations and feelings. For example, he says, "all you have to do to dispose of [an internal] fear is to refuse to believe that there is danger." One can replace insecure or anxious thoughts with secure thoughts. When the patient "spots" the symptom as harmless, he prevents "working himself up" (getting upset) over it, and the symptom will likely disappear eventually. Dr. Low took the position that a "nervous condition" literally results from weakened nerves. This is the "illness model" used in Recovery. Tenseness of the body produces symptoms because nerves are weakened by the tenseness and cannot resist the symptoms. If tenseness is reduced, the nerves are strengthened and the symptoms are reduced in intensity and eventually disappear. Tenseness can be reduced by controlling "temper" of anger or fear, and preventing "working oneself up."
DILEMMA: MEMBERSHIP IN SELF-HELP GROUP
1121
The names of most emotions have been transformed. Dr. Low's reason for this is: If a person talks using words that evoke emotion, then the person again feels those emotions (e.g., "I felt angry at my boss yesterday"), so the new vocabulary is designed to be less emotion-laden. I will return to the vocabulary and ideology of the organization but first need to describe a typical meeting. The group meetings are fairly small, averaging eleven participants per meeting (range: 6 to 1 7 ) . Attendance is quite sporadic; in the 27 observed meetings 59 different people were seen at one time or another. Meetings are of 2 hr. duration, led by that evening's leader. The program of the meetings is fixed and never varies. Members sit around a large table. New people are told not to talk during the meeting. For a half hour they read aloud passages from the book (no comment or discussion of i t ) ; an hour during which members give "examples" and comments on the examples; then a "collection," and a half hour of "mutual aid" (coffee and cookies and informal talking). The main portion of the meeting is giving "examples." The leader asks members to volunteer an example. The leader has a sheet of paper in front of him on how to give an example; it lists four steps: (1) describe a recent event that caused the member some emotional difficulty and the member's reactions (e.g., temper of anger); ( 2 ) the symptoms and discomfort subsequently produced; ( 3 ) the "spotting of temper," the "working up process," and concept of "averageness." In other words, the person giving the example typically indicates how he or she successfully resolved the emotional difficulty using ideas and principles from the book. And finally, ( 4 ) the reactions and symptoms which the member would have experienced before Recovery training. Other members raise their hand to comment on the example, usually by referring to other ideas and principles from the book that could have been used. Perhaps this description will be more concrete by presenting an example actually given at a meeting, with the comments on the example made by other members. ( I will explain some of the concepts used in the example shortly.) Ed volunteered an example and said: "I went into a department store yesterday to buy an x. The salesman told me that they no longer sell it. I had temper of anger at the salesman for not having it, and started telling him everything that had ever gone wrong with me in that store. But then I spotted that it was not the salesman's fault and that it was not good for my mental health to work myself up over it. I apologized for getting angry at him, and asked him what other store might have an x." Ed completed the last step of the example by saying, "Before my Recovery training, I would have stormed on for minutes at the salesman, and it would have wrecked my whole day. I had a nervous breakdown and was hospitalized once for three weeks." The group leader said, "Okay. That was a good example. W h o would like to comment?" Comments included: "There was some sabotage when he expressed his temper of anger, but I liked the way he willed his mouth muscles
1122
R. C. OMARK
to stop expressing the temper." Judy said, "it is an average response to have temper of anger in such a situation, and Dr. Low tells us that we are entitled to our initial response." Mary, "it is an average event these days" (i.e., an x is hard to find in stores). Linda, "I liked the way he took the judgement and blame out of it." Bill, "Ed recognizes that his mental health is his supreme goal" ( a chapter title from the book); "he replaced his insecure thought that the store is bad, with the secure thought that another store might have an x." And finally, "his example is one of high expectations and disappointments" (another chapter title from the book). After the last volunteered comment, the leader asked Ed, "Did you endorse yourself?" and he replied, "yes." An example usually has a positive outcome, and comments by others are rarely critical. Also, the positive example shows that a person can handle emotional problems using the ideas from the book. In other words, an "example" is an example of the s~ccessfulapplication of the ideas of the book to a member's emotional difficulties. A member can also give a "problem example" (where the difficulty was not resolved) but these are rare: Of 103 recorded examples, only ten were problem examples. Problem examples are usually given by new members. A few of the main concepts commonly used in exanlples are: AVERAGE-a member should strive to view his feelings and impulses as average, as opposed to trying to be exceptional (i.e., don't think of your feelings as exceptional). BALANCEis an individual goal of striving toward being average. Dr. Low wrote, "Nervous patients lack balance." CYCLEmeans that an individual feels "up" or "down" emotionally. The concept of cycle is used to maintain the organization, as seen in a statement by a member, "A person may leave the group when he feels up, but sooner or later, the members rerurn when they feel down." If a member doesn't show up for a meeting, or even for several meetings, it does not demoralize the group because it is inevitable that they will feel down again, and return. SELF-ENDORSEMENT means patting oneself on the back for making an effort to get through a difficult situation by using the concepts and methods of the book. SABOTAGEis the attempt of an individual to thwart the purpose of the group he is in; so, it has many forms depending on which group he is in. It is used in the meetings as "sabotage" of Dr. Low's ideas (and the book) and hence, of Recovery itself. A person has to read the book and become familiar with the vocabulary and concepts in order to become a member of Recovery, and in order to give "examples" in the meetings. The leader might call on a new person to give an example after three or four meetings. But once a person is a member, he is likely to return to meetings off-and-on indefinitely-he is trapped in the organ-
DILEMMA: MEMBERSHlP IN SELF-HELP GROUP
1123
ization. Learning the language used in Recovery meetings "locks" the person into the organization and obscures other options for other kinds of mental health treatment. It should be clear how members become "trapped" in Recovery if we compare Recovery meetings to group psychotherapy. Recovery is open to the public-anyone can walk in, and eventually become a member. The Recovery leader is just another member, following the program and asking for examples and comments; he is not paid; contributions go to the organization. In group psychotherapy, the therapist is paid for his skill, training and concern. The therapist is likely to question the meaning of absences, and make interpretations of behavior in the meeting itself. But the most crucial difference is in entry and exit: In group therapy, the therapist makes a diagnosis and determines a set of goals for the patient to work toward. In Recovery, the individual has to decide himself what his problems are and what goals he seeks from participation. This also makes exit highly ambiguous in Recovery groups. In group psychotherapy, termination occurs when the therapist and the patient agree that the planned goals have been attained. But in Recovery, the group leader is not concerned with defining specific and realistic goals for new members. The Recovery group does not recognize successful "termination" and, on the contrary, the leader hopes that members will continue to come to the group meetings, so as to make his group viable. Two sorts of evidence bear on the ineffectiveness of Recovery groups: the sporadic attendance of the members, and the lengths of membership of the members. Table 1 shows that the median attendance of the Wednesday groups observed fourteen consecutive times was five meetings (36% of the meetings). Similarly, of the thirteen Friday groups consecutively observed, the median attendance of members was five meetings (38% of the meetings). This sporadic attendance is a behavioral indication that there is ambiguity for the members about being cured or being a member of the group. There is ambivalence in the degree of attachment to the group, and it is not dear just when a person is in the group. In this situation, the end or goal (cure) can be confused with the means (participation). TABLE 1 MEDIAN ATTENDANCH OF MEMBERS IN m E TWO GROUPS Wednesday Group Meetings Observed 14 Numbers of Members* 27 Median Attendance of Members 5 New People Who Did Not Return 4 'These numbers include five members who attended both groups.
Friday Group
13 25
5 8
1124
R. C. OMARK
Table 2 showing the lengths of membership in Recovery gives some evidence on how well members get trapped in the organization as members. Although these data are limited by the sporadic attendance of the members, it shows that many members have been in the organization (sporadically) for years. It also shows that the organization is effective in its advertising and has a fairly high number of visitors ( 1 2 ) who were observed to attend one meeting, and were not seen again during the period of observation. TABLE 2 LENGTHSOF MEMBERSHIP OF MEMBERS OF BOTHRECOVERY GROUPS Length of Membership
N
Less than one year One year or more Don't know? Members New people who did not return Total participants 'This group averaged 8 yr. as members and ranged up to 18 yr. -/-People in chis group indicated membership by their familiarity with the vocabulary of the group, but the length of membership could not be determined because of cheir sporadic attendance.
Members become "locked into" the organization because there are several sorts of attachment to the group, and options are unavailable for other kinds of care: members share certain characteristics in common, including how members got t o the organization in the first place; and there are no referrals out of the organization to other mental health facilities (that is, there is a lack of organizational linkage). Recovery appeals to certain sorts of people. The members observed are predominantly married; two-thirds are women; the estimated average age is forty-nine years; and they appear to be of lower-middle and working socioeconomic class. In addition, many members have a history of short-term psychiatric hospitalization. Also, Recovery appeals to people who view emotional problems as grounded in the body and who accept the emphasis from the book on "nerves" and on muscles. Such people are not sophisticated about different psychological theories of emotional problems. Most members were not referred to the organization by a doctor or psychiatrist. Some were brought to a meeting by a member; some were told about it by a friend or relative; some read about Recovery in the newspaper. This suggests that membership is largely self-selected; many hear about the organization and attend a meeting, but only some continue and become members. Recovery is not an adjunctive service for psychiatry and the Community Mental Health Centers in the sense of referring its most disturbed members to a
DILEMMA : MEMBERSHIP IN SELF-HELP GROUP
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psychiatrist or Community Mental Health Center. Beginning in 1971, Recovery has a policy of not discussing doctors or therapists at meetings. But also, advice for a disturbed member is to attend more Recovery meetings (this could be dangerous, e.g., for the suicidal). It should be clear by now why a member would not be recommended to a professional: Examples given in meetings are designed to show the successful application of Recovery principles to the members' emotional difficulties. To recommend that a member seek an alternative source and method of help for emotional difficulties would be to admit that the Recovery method does not work. In this sense, other options are closed off. This "power of positive thinking" about the success of the Recovery method is reinforced by the participants themselves-if a member decided it didn't work, he would stop attending meetings, so other members would not hear his doubts. In conclusion, the dilemma of membership in Recovery is that the organizational beliefs and group processes tend to trap members in the organization indefinitely. The group does not recognize anything like successful therapeutic termination; on the contrary, with the idea of an emotional cycle of ups and downs, some members believe that an absent member will inevitably return when feeling down again. Some evidence was presented showing that many members joined the organization years ago and still attend meetings. At the same time, it is also empirically clear that attendance in the groups is quite sporadic. Group meetings include some who are strangers to each other (both old members and new visitors) so that the groups are not very cohesive. As presented in the meetings the successful examples of the resolution of emotional difficulties using ideas from the founder's book serve to reinforce the belief that the Recovery method "works" and chat "we are all getting better." However, it obscures questioning why the member joined the group in the first place, so that participation in the group comes to replace recognition of a cure. The "positive thinking" about the success of the Recovery method discourages the contact with and use of alternative mental health facilities and techniques. Recovery groups are isolated from other mental health facilities, rarely receiving and never making referrals. This also serves to trap members within the organization indefinitely. REFERENCE Low, A. A. Mental health through will-training. Boston: Christopher, 1950. Accepted May 24, 1979.
