Flora, K., Raftopoulos, A., Pontikes, T. (2010) A Look at the Evolution of the Self-Help Movement.

Journal of
Groups in Addiction and Recovery, 5(3), 214-225.

Self-Help Movement: Development, Current Status, Research topics

Authors: Flora, Katerina; Raftopoulos, Antonios; Pontikes, Theodote

Abstract:[ ]

1. Introduction

The notion of self-help is primarily or exclusively related to personal

responsibility/accountability (i.e., the mobilization and use of “personal resources”
vis-à-vis needs, which are related to the management of solitary or personal
problems/conflicts). The term “self-help groups” is interpreted and applied more
widely than the indications for individual psychotherapy. It refers to a group of
individuals with common or similar problems (e.g., diabetes; alcohol dependence
and other addictions; psychosis; affective disorders), whose central purpose is to
mobilize the individual by the rich experience of a “working through” of life events
and problem solving with fellow group members (Bairaktaris, 1994).

Controversy remains among social scientists regarding the meaning of the terms
“self-help” and “mutual help,” so it merits clarification that the essence of a self-
help group is for an individual to offer assistance and, in this way, also receive
benefit (Riessman, 1997).

The material which emerges in each group session is primarily examined through
the therapeutic process, without continuing beyond the allotted timeframe. In
fact, the individual’s subsequent physical separation from the group is
emphasized. Such group therapies (perhaps also for their fiscal
prudence/benefit) have been preferred among psychotherapeutic services over
the past two decades (Bairaktaris, 1994).

Other definitions have also been described with respect to self-help and self-
help groups, which may contribute to a better understanding of the field.
According to the accepted definition of the World Health Organization (WHO),
self-help refers to typical (formal) or atypical (informal) organized groups, within
the structure of the healthcare system (i.e., already formed social groups with a
common – sometimes broader – denominator) aiming towards novel solutions for
problem management, citizen autonomy, and humanism in healthcare delivery.
It includes self-help groups, self-help organizations and complementary
healthcare services, which all comprise entities in the phenomenon characterized
as the self-help movement. The term “self-help” is used more widely than
“mutual help,” but the latter may be preferable since it underscores the notion of
reciprocity vs. self-interest (Kickbusch & Hatch, 1983).

However, the most widely employed definition for self-help groups was
formulated by Katz and Bender (1976) as small, voluntary configurations for the
mutual assistance and realization of a specific goal. They are characteristically
comprised of a homogeneous group of people, who congregate to offer
assistance for the gratification of a common need, the confrontation of a common
difficulty or of problems that threaten their lives, as well as to bring forth a desired
social and/or personal lasting change. The founders and members of such
groups believe that their needs are not or cannot be met (gratified) through
existing means or social structures. Self-help groups emphasize direct
interpersonal communication among members, as well as personal
responsibility/accountability. They often offer substantive advice and emotional
support. Often, members are directed towards the etiology of the problem, while
an ideology or value system is purported to assist them in attaining an increased
awareness of their personal identity (Kickbusch & Hatch, 1983).

A simpler, as well as broader definition of self-help groups is: “groups of people

who feel they possess a common problem and, therefore, unite in action, so as to
do something about it.” In order to differentiate between self-help groups and
other groups of interest, Katz and Bender propose that the impetus for the former
is a sense of powerlessness, which members hope to overcome – within society,
as well as the healthcare system (Kickbusch & Hatch, 1983).

According to Riessman (1997), the ten principles characteristic of self-help

groups are: the homogeneity (i.e., equality) of members; self-determinism; the
therapeutic effect on the individual who offers assistance and the subsequent
restructuring of this assistance; the manner in which each individual handles
his/her “capital” ( i.e., the capacity to offer aid); withholding power with respect to
pathology; non-commercialization; social support; a code of ethics; the
understanding that the modality of self-help can resolve many difficulties; and the
aptitude for inward reflection.

Given that self-help groups are distinguished by respective motives, goals, and
actions, three basic types have been identified. They are: (a) Insider-only, with
homogeneity in problem-type, motives and goals. Historically, these are
considered the first in the field of self-help groups (e.g., AA; NA; diabetics). (b)
Groups which collaborate with interested individuals sensitive to the said cause
and willing to volunteer their services, skills, and knowledge. (c) Mixed groups
(direct insiders – patients/clients/members and professional healthcare providers)
with the participation of paid professionals and the use of their
services/knowledge. In other words, this entails an attempt at a high-functioning
collaborative effort of hetero- and self-help, where the specialist (therapist), more
or less intervenes and remains in control of fine-tuning the entire management
(Bairaktaris, 1994).
The most important/influential self-help groups – AA; NA

AA was established in 1935 by Bill W. and Dr. Bob, two men who suffered from
severe alcohol abuse. The essential treatment program is encapsulated in The
Twelve Steps, which were published in 1939 in a volume known as the “Big
Book” in the circles of AA. The main written text for the organizing principles of
AA consists of The Twelve Traditions, published in 1946 in AA’s journal, “AA
Grapevine.” The fundamental organizing units of AA are the groups and
meetings themselves (Makela et al., 1996).

Narcotics Anonymous (NA) is today’s second most well-known self-help group

in existence for the management of substance addictions. It is organized at a
regional level by self-governing, self-managed groups, who believe in a unified
system of principles and functions, modeled after The Twelve Steps and The
Twelve Traditions of Alcoholics Anonymous. The first NA meeting took place in
Lexington, Kentucky in 1947; whereas in 1953, the first independent communal
group was established in Los Angeles, California; thus, marking the starting point
for today’s NA movement (Zapheirides, 2001).

Although the functional programming of NA and AA is based on similar

principles, certain distinctions exist between the two groups. NA members
characteristically use illicit substances, in contrast to most AA members who until
recently could be simply described as typical alcoholics. Furthermore, instead of
using the term “alcoholism,” NA members refer to the problem as “addiction” and
include the abuse of the entire spectrum of psychotropic agents. Nevertheless,
there is a clear overlap in the approach and the membership of the two groups,
despite the complete independence of one from the other. By following the steps
of AA, the development and spread of NA groups was rapid (Galanter et al.,
1997).

The great proliferation of these self-help groups is the subject of much scientific
research. Until recently, professionals did not play a significant role in this
process. However, in the past several years, various therapeutic systems based
on the structural programming of AA have proven to be important in the
proliferation of such groups, especially in Spain, Sweden, Switzerland
(Eisenbach – Stangl, 1992a; Makela in press; Rehm et al., 1992) and Greece
(Self-Help Promotion Program, Thessalonica).

In 1998, over 97,000 AA groups were operating on a weekly basis in more than
120 countries (Membership Survey, 1998). In 2005, over 21,500 registered NA
groups held more than 33,500 weekly meetings in 116 countries (Facts about
NA, 2005).
2. Self help and Research

Until the early 1970s, the interest of American social scientists in examining the
theory of self-help was lacking. With the exception of a study by Bales (1944)
about the therapeutic role of AA group, there were not any empirical studies in
the literature until 1957 when Alfred Katz published his dissertation thesis,
entitled “Parents of Disadvantaged People – Recovery Inc.” Despite the
substantial rise in self-help groups in the 1960s, only descriptive case studies,
studies of specific organizations or more generalized studies by authors from
clinical fields including social work and psychology were published (Katz, 1981).

Social scientists and mental health professionals did not immediately recognize
the existence and importance of self-help groups. Systematic research of this
phenomenon is an even more recent development. Today, we can more easily
tally the number of studies encompassing a broad range of self-help groups
which address a variety of concerning problems and dilemmas. Although
empirical research has made great strides in the past two decades, basic
demographic information, such as “who and how many” participate in self-help
groups in the U.S. remains virtually unknown. Such data is especially important
in light of discussions for imminent changes in the provision of healthcare
benefits and services (Lieberman & Snowden, 1994).

In 1976, Tracy & Gussow completed the first research assessment using an
analysis of the increasing membership of self-help groups. The study examined
the degree of growth in six self-help organizations during a period of thirty years
(1942 – 1972) and showed a stable annual increase in 1950 and thereafter.
Between 1972 and 1978, the study revealed a 50% increase in their proliferation
(Lieberman & Snowden, 1994).

The U.S.’s National Institute of Mental Health (NIMH) refers to the use of self-
help groups as a part of the efforts to understand the function of the mental
healthcare system. Summarizing the results of studies in 1993, 7% of the
sample reported attending self-help groups. Among the participants, 7.9% had
substance abuse problems; 9.7% had a dual diagnosis of a substance use
disorder and another psychiatric illness; and 5.1% suffered from other unrelated
disturbances. 12.6% of overall healthcare services is represented by self-help
groups, whereas 20.6% benefit those with substance abuse disorders.
Individuals who participate in self-help groups have higher treatment adherence
(i.e., attend more meetings) than those who use any other healthcare service
(Lieberman & Snowden, 1994).

Researchers characteristically follow three types of studies related to self-help

groups involving: the participants’ effectiveness; a group factor analysis via
qualitative-ethnographic methodology; and action studies that measure group
participation (Kurtz, 1997). With respect to methodology, the majority of the
above studies are qualitative and make use of the interview and the survey
questionnaire as principal methodological instruments. Exceptions include
quantitative studies, which examine epidemiologic and demographic
characteristics. The use of scales is also common and includes: the Twelve
Steps Persuasion Scale; the Twelve Steps Commitment Scale; the
Categorization Scale [which assesses where one categorizes him/herself in a
specific group of people (e.g., the addicted)]; and the Self-Stigmatization Scale
[which assesses how one stigmatizes him/herself due to a specific situation (e.g.,
addiction)] (Powel, 1994).

Furthermore, in the past two decades, the importance of recounting personal

narrative among self-help group members has increased (Rappaport, 1994), and
an effort has been made to also focus on the more social and communal group
aspects, in addition to the individual, personal characteristics which are at the
epicenter of research interest. Ethnographic and naturalistic methods seem to
facilitate progress in this direction (Maton, 1994; Kennedy et al., 1994). Interest
has also been expressed in determining a potential role for consumers of mental
healthcare services in research. For example, this role could be one of a typical
research subject; or an individual who is fully informed about the nature of
research; or someone who is a key informant about the group. The most
recently studied roles of individuals who make use of any healthcare service are
those by research collaborators, where the research protocol is designed by the
principal investigators (Kaufman, 1994).

The repertoire of studies that have been conducted on Twelve Step groups
reveal that, research activity in this area has: not proven the reliability and validity
of self-reported disclosures; has not found sufficient evidence regarding the
nature of addiction; and has not adequately described the demographic
characteristics of group members (although samples are often not
representative, particularly with respect to socioeconomic status and gender).
With respect to the nature of research concerning Twelve Step groups, varied
formulations have been published by researchers and scholars in the field. After
confirming the effectiveness of such groups, J. Wallace reported (among other
things) that rigorous scientific research on Twelve Step groups is not feasible and
that all existing studies are deficient to some degree. An improvement in
methodological instruments will subsequently enhance the quality of scientific
inquiry, and so, it behooves the younger generation of researchers to work
towards this goal (Emrick et al, 1992). A brief review of the most recent studies
from expert researchers on the groups of NA and AA confirms the conclusions of
Emrick et al. (1992) that serious omissions and lack of clarity with respect to
methodology exist, mainly with respect to the recruitment of the studied group
samples.

In an effort to determine the latest research activity in the domain of self-help

and, particularly, regarding NA and AA groups, two types of studies can be
distinguished: (a) those involving quantitative characteristics, such as the profile
of individuals who approach such groups and (b) those focusing on qualitative
factors, which are concerned with the essential process itself which occurs within
the groups, as well as with the intrapersonal and interpersonal psychological
processes; abstinence from substances; change and spiritual growth; and the
micro-collective processes (Miller & McCrady, 1992).

A general conclusion drawn from a preliminary literature search highlights that

the most substantive research abroad has focused on AA groups, not NA groups.
This may be due to the extensive proliferation of the former, which premiered as
Twelve Step self-help groups for those struggling with a substance addiction.

According to the official webpage of the GSO (General Service Office, AA), AA
conducted its own first demographic survey in 1977 and, ever since, similar data
are gathered at frequent intervals (approximately every three or four years).

Central and regional organizations of AA and NA groups have studied

characteristics related to group participation. In 2004, a study of AA members by
the GSO regarding individual participant mobilization showed: 31% were referred
by another member; 31% participated through a treatment facility; 30% were self-
referred; 23% were urged to participate by their families; 8% were referred by a
counseling service; and 8% were referred by a social worker. In the same study,
78% of the participants reported having a sponsor, and 70% of those had a
sponsor in the first ninety days of their participation. 36% had a period of
sobriety beyond ten years; 14% for five to ten years; 24% for one to five years;
and 26% for less than one year. The average period of sobriety was eight years.
The average frequency of group meetings was twice weekly.

Comparable studies have been conducted by NA organizations (Victoria, 2003;

New Zealand, 2005). In the most recent New Zealand study (2005), 37% of
participants reported that a therapeutic center was the primary influence
responsible for their engagement in the group; 34% credited their contact with
NA members; 18% were either self-referred or referred by friends; and 8% were
mandated by judicial or police authority. 74% had a sponsor and 31% were
sponsors themselves, with 59% of the latter having one to two sponsors and 7%
having more than seven. 10% were sober for more than fifteen years; 10% for
ten to fifteen years; 15% for five to ten years; 19% for two to five years; 11% for
one to two years; 9% for six months to one year; and 27% for less than six
months. With respect to the frequency of participation, 7% participated less than
once weekly; 23% attended one meeting weekly; 25% attended twice weekly;
24% attended three meetings weekly; 10% attended four meetings weekly; and
10% attended more than five meetings weekly. The study in Victoria (2003),
reported that members in the sample participated in the groups between eleven
years (30%) and one year (11%). In addition, 81% of individuals voluntarily
participated in many of the group services.
 Quartini et al. (2001) provide characteristics for NA group participation in Italy.
22.4% reported engaging in the group by self-referral; 26.5% via the urging of
friends/family; 20% by the institution Ser. T; 14.3% were referred by another
organization; 14.3% were referred by AA; and 2% by a therapeutic community.
76.5% reported sobriety – 17.95% of this group for less than one year; 15.4% for
one to two years; 17.95% for two to three years; and 48.7% for more than three
years. 50% of the sample reported a minimum period of sobriety of three years
and came to appreciate the relationship between their abstinence from
substances with an improvement in their quality of life.

A survey of some recent study findings follows. They were selected to

convey a representative view of contemporary research in the field. Research
activity on NA and AA groups abroad by experts mainly concerns itself with an
investigation of demographic characteristics (e.g., gender; age). However, in the
majority of cases, there is a correlation between one or two of these variables
with group participation, as well as with the outcome of the therapeutic process.

According to Bischof et al. (2000), AA members manifested a greater social

commitment to preserving their abstinence from alcohol compared to others who
did not seek AA services for their affliction. Nevertheless, the evidence suggests
that among those successfully recovering, there are more similarities than
differences, irrespective of the treatment source.

Participation in AA and NA groups appears to have several positive outcomes.

Specifically, abstinence from substances as a consequence of participation in AA
groups is correlated with an increase in the sense of well-being (Kairouz et al.,
2000). Similarly, participation in NA via the use of services; regular meeting
attendance; and ongoing “work” on the Twelve Steps is positively correlated with
a reduction in dangerous substance use and with an improvement in social
network support (Toumbourou et al., 2002).

Furthermore, participation in AA appears to play a determining role – beyond the

reduction of alcohol use – in the progression of possible psychiatric comorbidities
(Humphreys, 2003), while self-help groups appear to be concerned with the
social and psychological equilibrium of their members subsequent to continued
sobriety (Fredersdorf et al., 2003).

A significant portion of recent work involves research activity concerning relapse

prevention. In general, contact with Twelve Steps appears to be positively
correlated with relapse prevention (Kelly & Moos, 2003). In particular, findings
concerning AA showed that ongoing group participation was positively correlated
with relapse prevention and with sobriety maintenance (McCrady et al, 2004;
Bottlender et al., 2005). The existence of many therapeutic choices has also
been highlighted as a determining factor in relapse prevention for AA members
(Heinz et al., 2003). It appears that group participation steadily leads to relapse
prevention in alcoholics who have a stronger motive for therapy (Staines et al.,
2003).

The attributes of the sponsor are very important in the recovery process for NA
and AA groups, and so has also been a subject of investigation. For NA
members, sponsors serve as mentors who provide guidance and support to their
mentees, which was found to facilitate and contribute to sobriety (Crape et al.,
2002). Similarly, in AA groups, the collaborative nature of providing assistance
among group members appears to contribute to their own ongoing abstinence
from alcohol (Pagano et al., 2004).

Factors such as gender, age and racial origin have been examined with respect
to their impact on participation in self-help groups. Gender serves as an often
researched variable regarding its role in the recovery of individuals referred to
self-help groups and, especially, to AA. It appears that older women may have
better recovery outcomes compared to men of the same age (Satre et al., 2004).
Moreover, men and women of advanced age have similar outcomes in the
reduction of alcohol consumption and its sequelae (Moos et al., 2004).
According to the same study, the social climate and life circumstances are risk
factors for relapse in advanced age for both genders. In a study on adolescents,
it was found that following the completion of one recovery program, adolescent
girls participate in self-help groups at a higher percentage and have better
therapeutic outcomes than their male counterparts (Hsieh & Hollister, 2004).

Apart from gender, age – perhaps in correlation – appeared to significantly

influence the course of the recovery process. Alcoholics of advanced age who
reported late-onset initial substance use and who participate in AA will likely
reach remission with less difficulty than their younger counterparts. In addition,
advanced age is positively correlated with better long-term therapeutic outcomes
in alcoholics compared to younger ages (Nespor et al., 2005; Satre et al., 2004).

Certain studies have examined racial origins (e.g., African- American; Hispanic)
as factors which play a role in seeking help for treatment from psychotropic
substances. Specifically, individuals of Hispanic descent were found to have a
higher likelihood of seeking help and participating in a self-help group. It appears
that the social factor of racial origins has been identified as a predictor of group
participation (Kammer, 2002; Kaskutas et al., 1997).

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