Two very different approaches can be employed to promote recovery from psychiatric disorders. One approach is grounded in an understanding of individual psychopathology, and it is clearly central to contemporary care. The second approach to recovery, which is based on group psychology and the support derived from participation in a group, can also be valuable in promoting recovery.
In examining this second approach, I consider Alcoholics Anonymous (AA) and other movements that operate through social and ideologically grounded support. The term "spiritual recovery movement" (1) can be applied to them. On the basis of studies that I and my colleagues have conducted, I describe a psychological model to clarify the operation of such groups.
Social and spiritual recovery can be considered from the perspective of naturally occurring, highly cohesive, and religiously oriented cultic groups, two of which I have studied. One was the Divine Light Mission, headed by a guru who began preaching at the age of six in his native India. Members' responses to a research questionnaire indicated a reduction in their symptoms of psychological distress after they joined the group, and the extent of the reduction was significantly correlated with the intensity of the social cohesiveness a member felt toward the group (2).
Further clarification of the psychology of cultic groups emerged from our studies of the Unification Church, the "Moonies." Using two scales I found that the stronger an individual's affiliative feelings toward the group, the greater his or her psychological well-being (3). A study of long-term members who were matched to their future spouses by the Reverend Moon illustrated that distress associated with compliance with group behavioral demands was counteracted by a greater sense of well-being in direct relation to the intensity of a member's cohesiveness and ideological commitment to the group (4).
These and other findings suggest that a social phenomenon, which I called a charismatic group, may emerge in different settings. Established members attract people who have undergone social dislocation or emotional distress. Inductees experience strong affiliative feelings toward the group's members and an acceptance of its ideology. This response yields diminished emotional distress and a relief effect. The relief effect among recruits reinforces the transformation of their attitudes and behavior, and they soon espouse a philosophy of life quite different from that which they had before joining.
However, the attendant improvement in their mood depends on their maintaining continued ties to the group and adhering to its behavioral expectations. In a seemingly paradoxical way, it is only by maintaining dependent ties to the group that the secondary distress caused by such dependence can be relieved. Major changes then take place in many aspects of a member's life—for example, in social, occupational, or residential status.
How does this intense phenomenon relate to healing through social and spiritual support? When I was conducting these studies, I was struck by a similarity in the way in which attitudes were transformed in charismatic groups, and by the way in which participation in AA led to a reversal in denial of illness and self-defeating behaviors. Changes noted among members of AA were apparently produced by the intense ideological and socially cohesive character of these groups.
A muted form of the psychological forces operating in a charismatic group can be observed in certain social movements that provide relief from dispiriting attitudes and behaviors that are experienced by people who are chronically ill. As in the case of AA, which is typical of the spiritual recovery movements (1), characteristic changes that occur among members of the more intense cultlike charismatic groups can be seen. However, compared with the attitudes and behavioral norms of charismatic groups, the attitudes and norms that characterize social movements are typically much more in conformity with the values of the larger culture. Adherence to a social movement's health-related philosophy does not involve all areas of the follower's life.
However, a spiritual recovery movement does engage its followers in behavioral expectations associated with the health issues it addresses. In this regard, such movements provide a less intense but nonetheless meaningful relief effect such as that described for charismatic groups. People who are experiencing distress over the consequences of their addiction are therefore likely to respond to the strong affiliative and ideological orientation of AA. Their response is operantly reinforced by the relief produced from affiliation with the group's ideology and behavioral norms, which are all related to abstinence and a spiritually oriented lifestyle. It is important to note that AA generates conflict by pressuring members to give up their addictive behaviors and that the distress associated with this conflict is relieved if members cleave to the group.
This pattern was evident in a study we conducted on addicted physicians who had been inducted into AA an average of two years before, while living in a highly cohesive, ideologically oriented treatment setting based on acceptance of the AA philosophy (5). Their responses on a scale designed to measure ideological and cohesive ties to AA members reflected an intensity of affiliative feelings comparable to that found toward members in the cultic groups we had studied.
The openness of sick people to respond to a spiritually or ideologically oriented option is often underestimated by treatment professionals, much to the disadvantage of their patients. For example, we found that the responses of severely compromised, psychiatrically ill, hospitalized substance abusers reflected surprisingly more openness to this orientation for promoting recovery than was anticipated by hospital staff (6,7). Furthermore, adolescents treated in a drug-free therapeutic community, an environment that is not spiritual in orientation, indicated a strong interest in spiritual aspects of recovery (8). The general culture and the subculture of addicted people themselves provide a substrate for such attitudes, and these attitudes can be employed to bolster a constructive orientation among patients.
Zealous, cohesive, peer-led programs exert much of their influence by means of the same psychological forces evident in spiritual recovery movements. Like these movements, peer-led programs typically emerge because of a perceived inadequacy in the conventional medical care system. Their agendas are not necessarily spiritual, nor are they necessarily divorced from established systems of health care. They emerge when people band together to address a common mission to overcome a psychiatric disorder or a health problem.
One group we studied illustrates the similarities between the spiritual recovery movements and peer-led programs. Recovery, Inc., is a national organization with some 10,000 members who support each other with regular meetings and brief phone calls. Small group meetings have a structured format to which members adhere very closely—one that addresses cognitive precipitants of anxiety or depression. The cognitive approach of the program is augmented by a deep commitment to the movement and to the psychiatrist who founded it in 1935.
At each meeting, ritualized readings from the founder's work are read in a manner not unlike that of a religious ceremony. We found that members' responses to a structured questionnaire reflected an intense cohesiveness and commitment to the group's ideology (9). Their responses also reflected a considerable reduction in the intensity of psychiatric symptoms associated with membership. However, Recovery, Inc., has no formal religious or spiritual orientation, and none of the references to God that are characteristic of AA (9).
In another study, we found that Rational Recovery, a cognitively oriented addiction self-help program, also adheres strongly to the use of the founder's written testament in his text The Small Book (10). The title represents an attempt to distance the movement from the "Big Book" of AA and AA's religiously oriented approach. The program relies heavily on peer support and a cognitively grounded format for fending off "the Beast" of addictive craving. Results of this study showed that members reduced their substance use and that the reduction was associated with a high level of social cohesiveness and acceptance of the program's philosophy. Interestingly, however, members of this program also frequented AA meetings, perhaps to draw on AA's support and spiritual orientation.
We were able to study the integration of the 12-step format into the operation of a methadone maintenance clinic (11), a setting in which the spiritual orientation of addicted individuals is usually neglected. Methadone Anonymous (MA) is an emerging 12-step program designed to address the problems of secondary drug use and disillusionment experienced by many patients on methadone maintenance. It provides them with mutual support, social cohesiveness, and the spirituality inherent in 12-step approaches. We found that affiliative feelings toward MA members and the program's philosophy were associated with a marked improvement in the use of secondary drugs.
In another study, we modified the drug-free therapeutic community approach and combined it with AA meetings to treat highly compromised patients with dual diagnoses at Bellevue Hospital in New York City (12). The study found considerable benefit from integrating the two models in a setting in which conventional pharmacotherapy was also provided. Evaluations of this apporach have shown its effectiveness in retaining patients in treatment and achieving reductions in drug abuse in this highly compromised population (12).
The zealous peer-led approach to psychiatric problems can also be observed in movements in which members address the problems of others whom they wish to help. One interesting example is the psychiatry section of the Christian Medical and Dental Association, in which the psychiatrist members, almost all of whom are self-described as "born again," adhere to a religiously grounded orientation in their professional practice and endorse strong feelings of social cohesiveness toward fellow members. In our study of this movement, members indicated that they often observed a significant clinical benefit when they applied a fundamentalist Christian orientation in treating psychiatric problems, particularly grief reactions, depression, and alcoholism, among patients with a religious orientation similar to their own (13).
Another example of zealous peer leadership among those who wish to help others is of the Federation of Parents for Drug-Free Youth, a national network that consisted of local groups that provided mutual support to address the vulnerability to drug abuse in their children. We asked members to respond to a survey instrument (14). The responses illustrated a strong adherence to an abstinence ideology for members' children, even though these parents endorsed items reflecting the value of their children's independent thinking and development in other areas. Thus parents' commitment to their children's abstinence was highly consistent but discrete from other attitudes toward child-rearing. Our findings illustrate the possibility of a delimited ideology in such peer-led movements, which focus only on a specific health-related issue. This delimited ideology clearly distinguishes these movements from the charismatic groups, whose pervasive influence is imposed on all areas of members' lives.
When these findings are viewed together, it is evident that peer-led ideologically oriented self-help programs illustrate the value of combining intense mutual support with the psychology of commitment to a health-related ideology. Although peer-led self-help programs are not among the approaches employed by traditional psychiatrically grounded providers of care, their success underlines their potential value to mental health professionals who can make use of these programs to complement conventional treatment.
If training programs are to take advantage of the benefits of mutual support programs and peer-led programs, then they must include certain elements in their curricula, such as an understanding of the psychology underlying these programs, an openness to the contribution of such programs to recovery from illness, and competency in referral to—and even collaboration with—these programs. The current practice of professional psychiatric and general medical caregivers does not reflect acceptance of these programs. For example, members of Alcoholics Anonymous, Rational Recovery, and Recovery, Inc., are typically referred to these programs by members rather than by physicians. Physicians who are unaware of the existence of AA and similar peer-led programs, those who do not value the approach of such programs, and those who are not sensitive to the experiences of addicted patients cannot make effective referrals to these programs. In our study of severely compromised inpatients with dual diagnoses, we found that hospital staff and medical students on a general psychiatric service underestimated the openness of patients to a spiritual orientation to recovery (6,7).
Training in the effectiveness of peer-led programs can be integrated into professional curricula. For example, basic seminars that include an introduction to the psychology of zealous social movements and related recovery-oriented programs can be added to curricula designed for new psychiatric residents. As part of their standard curriculum, residents should attend AA meetings and visit a drug-free therapeutic community program. Clinical supervisors should ask them about the phenomena they observe, because trainees, schooled in the individual patient's mental function, do not usually understand such phenomena. Being a co-leader of a peer-led therapy group on an ambulatory service can help residents develop the ability to relate to nonprofessional peer leaders in a collaborative manner rather than from a distant and stilted perspective. All mental health professionals can gain a great deal from understanding cohesive and ideologically oriented recovery movements and acquiring an openness to their use.
Support for this work was provided by the Scaife Family Foundation, the Macy Foundation, the JM Foundation, the Achelis Foundation, the National Institute on Drug Abuse, and the National Institute on Alcohol Abuse and Alcoholism.
Dr. Galanter is professor of psychiatry and director of the Division of Alcoholism and Drug Abuse at New York University School of Medicine, 550 First Avenue, New York, New York 10024. This paper was presented as the Seymour Vestermark Award lecture at the annual meeting of the American Psychiatric Association held May 18-23, 2002, in Philadelphia. This is the final contribution solicited under the editorship of Richard J. Frances, M.D., who has been the editor of Alcohol & Drug Abuse since 1990. Sally L. Satel, M.D., is the new column editor.