Encouraging People With Mood Disorders to Attend a Self-Help Group1

THOMAS J. POW ELL^ School ofSocial Work University of Michigan

ELIZABETH M. HILL University of Detroit Mercy

LYNN WARNER WILLIAM YEATON Institute for Health, Health Care Policy

and Aging Research Rutgers University

Institute for Social Research Universiry of Michigan

KENNETH R. SILK Uniwrsily ofMichigan Health System

Using an intervention based on referent power, self-help sponsors sought to encourage attendance at self-help meeting. They encouraged patients with major depression or bipo- lar disorder to attend self-help meetings following their hospitalizations. The intervention successhlly increased the attendance of the experimental group compared to those in the control group. Implications for practice are discussed.

For persons with serious mental illness, participation in self-help groups has been associated with better outcomes (Edmunson, Bedell, Archer, & Gordon, 1984; Galanter, 1988; Galanter, Talbott, Gallegos, & Rubenstone, 1990; Humphreys & Rappaport, 1994; Raiff, 1982; Young 8z Williams, 1988). In par- ticular, for persons with mood disorders, participation in a diagnosis-related self- help group has been associated with better coping and less rehospitalization (Kurtz, 1988). The processes by which participation in mood disorder self-help groups can lead to better outcomes by helping people learn about the illness, maintain morale, negotiate with professionals, update medication information, and reduce stigma have been described in various qualitative studies (Karp, 1992; LeVeck, 1982; Wetzel, 1991).

'This research was supported by USPHS Grant MH 46399 from the National Institute of Mental Health. The authors are grateful to Jay Callahan, Joanne Janssen, Robert D. Jones, Jr., Angela P. Viv- iano, Julie A. Wheaton, and Charles Windle for their assistance in canying out the study. They are also grateful to Keith Humphreys for comments on the paper.

*Correspondence concerning this article should be addressed to Thomas J. Powell, School of Social Work, University of Michigan, 37% Social Work Building, Ann Arbor, MI 48 109-1 106. e- mail: tpowell@umich.edu.

Journal of Applied Social Psychology, 2000, 30, 1 1. pp. 2270-2288. Copyright 0 2000 by V. H. Winston 8 Son, Inc. All rights reserved.

MOOD DISORDERS AND SELF-HELP GROUPS 2271

People with mood disorders, like others with serious mental illness, tend to underutilize both professional and self-help services (Regier et al., 1993). Underutilization is an even greater problem with self-help groups (Gottlieb & Peters, 1991; Lieberman & Snowden, 1994; Meissen, Gleason, & Embree, 1991). For example, though their local affiliate groups number in the hundreds, the National Depressive and Manic Depressive Association and other self-help and advocacy organizations for people with mood disorders reach only a small frac- tion of their potential membership (Lish, Dime-Meenan, Whybrow, Price, & Hirschfeld, 1994; Wetzel, 1991; White & Madara, 1998).

Social power theory has been used to explain phenomena similar to the underutilization of self-help services. It has been used to explain the choices of consumers, patient cooperation with physicians, compliance with medical regi- mens, and responses to counseling styles (Raven, 1992,1993). Although ongoing theoretical development continues to define new types of power (Raven, Schwarzwald, & Koslowsky, 1998), the new types represent differentiations of the six original types, each with a distinctive basis. Information power is based on the compelling nature of the content of the message; coercivepower is based on the agent’s threat of punishment; rewurdpower is based on the agent’s prom- ise of pleasure or reward; legitimafepower is based on the agent’s entitlement to influence; and expert power is based on the agent’s technical knowledge.

Referentpower, the focus of this study, is based on the perceived similarity between the person open to influence and the agent exercising influence (French & Raven, 1959; Raven et al., 1998). The response to referent power results in the person becoming more like the agent. Notwithstanding problems in measurement and conceptual consistency, the overall social power framework has received considerable validation (Frost & Stahelski, 1988; Hinkin & Schriesheim, 1989,1990; Humphrey, O’Malley, Johnston, & Bachman, 1988; Podsakoff & Schriesheim, 1985; Rahim & Magner, 1996; Raven, 1988). And among the six types of power, referent power has been among the most consistently validated (Podsakoff & Schriesheim, 1985; Rodrigues, 1995).

Referent power theory, of course, does not explain all of the reasons that a per- son might not participate in self-help groups. For some, nonparticipation may be simply a matter of time or transportation; while for others, the overwhelming tur- moil of their everyday lives may be the barrier. Still others may be too anxious or too hopeless to contemplate participation in a self-help group. And then there are those who do not want to compare themselves with others who have mood disor- ders, or even to think of themselves as having a mood disorder (Festinger, 1954).

Among those who accept that they have a mood disorder, however, reference- group theory can explain why referrals to self-help by mental health profesionals have met with only limited success (Kaufmann, Schulberg, & Schooler, 1994; Osher & Kofoed, 1989; Satel, Becker, & Dan, 1993; Woods, 1991). Profes- sionals, even if they are familiar with self-help programs, are not well suited to

2272 POWELL ET AL.

convey the value of self-help programs. Their technical, expert-based communi- cations do not easily convey the experiential, referent-power-based benefits of self-help groups. Conversely, self-helpers are well suited to convey the experien- tial benefits of self-help programs since they manifest the benefits of self-help that can be realized through the mutual exercise of referent power. And when self-helpers reveal a continuing struggle with residual symptoms, they may expe- rience an increase in their referent power, for their struggle causes them to be seen as even more similar to the observer and to have a more credible message. In such circumstances, the quality and magnitude of the referent person’s influ- ence has been compared to that of charismatic leaders (Halpert, 1990).

The identification between the person open to influence and the agent of ref- erent power is based on a feeling of oneness. The identification often motivates the person to seek a relationship with the agent. Analogously, if the agent is rep- resented by a group of individuals, the person will desire to join the group. And such openness to referent power is likely to be heightened in ambiguous situa- tions rife with doubts and uncertainties (Schachter, 1959). In these situations, people tend to seek the advice of a similar other and are ready to try something new. This, we assumed, would be the situation of many of the hospitalized patients in the present study.

When a referent power identification is made, the person will often strive to perceive and act in the manner of the individual or group agent (French & Raven, 1959), especially if there is correspondence between the need of the person and the resources of the agent (Dell, 1973). Thus, the more a person feels the need for understanding (or for a challenge, or for new coping techniques) and the better the need fits the profile of the referent individual or group, the greater the power of the peer referent agent.

Recognizing their limitations in making self-help referrals, professionals in the field of dual diagnosis (severe mental illness and alcoholism) have attempted to invoke referent power in order to move their clients toward self-help participa- tion. Unfortunately, the procedures used often invoke only a limited and there- fore weak version of referent power. Rather commonly, professionals facilitate “pre-A.A. connect” groups to prepare clients to participate in Alcoholics Anony- mous (Caldwell & White, 1991; Daley, Salloum, & Jones-Barlock, 1991). But by presenting themselves as models of recovery, rather than offering models closer to the clients, professionals limit the development of referent power (Woods, 1991). Finally, professionals fbrther limit their referent power by locating meet- ings in professional mental health clinics, which tends to underscore the expert- based rather than the referent-based nature of their influence (Kurtz et al., 1995). Consequently, agency-based dual-recovery (or “double-trouble”) groups typi- cally are able to marshal only a limited form of referent power.

Interventions used in the general alcoholism field have been more successful in using referent power, and they could be adapted to mental healtWillness self-

MOOD DISORDERS AND SELF-HELP GROUPS 2273

help groups. Common to these interventions is the practice of encouraging early involvement with an A.A. sponsor (McCrady & Irvine, 1989; Nowinski & Baker, 1992). Early involvement with a sponsor was key in a small experiment con- ducted by Sisson and Mallams (198 l), which is particularly applicable to the present study. Before the client left the therapist’s office, the therapist arranged telephone contact between members of the experimental group and an A.A. or Al-Anon member. The therapist also arranged for experimental group members to meet the contact person before the first A.A. or Al-Anon meeting and to be taken to the first meeting. All of the experimental group members attended A.A. or Al-Anon again, on their own and within a week. During their next two therapy sessions, they were encouraged to continue attending, and all did so. All 10 mem- bers of the control group failed to attend, even though they were given informa- tion by their therapists about the time, date, and location of the meetings.

Although attendance is a proxy for involvement, many researchers testing interventions to increase self-help involvement have used attendance as the out- come variable (Kaufmann et al., 1994; Levy, Derby, & Martinkowski, 1993; Medvene, Mendoza, Lin, Harris, & Miller, 1995; Sisson & Mallams 1981). Attendance has an advantage over other outcome variables (e.g., participation) in that it can be more readily and reliably measured. And, clearly, attendance is a prerequisite to the kind of involvement necessary to obtain the benefits of self- help.

To summarize, social power theory suggests that self-help group representa- tives can become influential referent power agents by fostering the person’s awareness that he or she is not alone but rather “one” with self-help representa- tives who are coping effectively with the illness (Van Der Avort & Van Harber- den, 1985). Such representatives symbolize the hope that the person can learn to cope in a similarly effective manner by identifying with members of the self-help group and attending their meetings.

Thus, it is hypothesized that the experimental group that receives an interven- tion based on referent power will exhibit higher levels of attendance following hospitalization than will the control group. The referent power intervention involves introducing mood-disorder patients to self-help sponsors who later accompany them to a self-help group meeting.

Method

Participants

Study participants were hospitalized patients with mood disorders in a large teaching hospital from 1990 to 1994. The sample was constructed with partici- pants from both a quasi-experimental design and a randomized design. The ran- domized design became possible midway during the study because of a

2274 POWELL ET AL.

reorganization of the hospital’s psychiatric units. It allowed random assignment of participants to conditions within each unit.

Patients 18 years or older, without mobility impairments that would bar their attending self-help meetings, were eligible to participate in the study if they resided in areas served by the Manic-Depressive and Depressive Association (MDDA) of metropolitan Detroit, Michigan. Patients were screened for mood disorders by the admitting psychiatrist using a DSM-IIIR-based symptom check- list (Diagnostic and Statistical Manual IIIR; American Psychiatric Association, 1987). After the participant’s consent had been obtained, the Structured Clinical Interview for the DSM-IIIR (SCID) was administered to confirm the original diagnosis (Spitzer, Williams, Gibbon, & First, 1992). When this confirmation procedure demonstrated substantial agreement between the shorter checklist and the SCID (kappa = .80, N = 155), the SCID was used only to support the continu- ing validity of the checklist. Table 1 indicates that women outnumbered the men, and that more of the participants had unipolar mood disorders than bipolar ones. Overall, the sample was relatively well educated, with approximately 14 years of education. Table 1 also indicates that there were no differences between the experimental and control groups on variables likely to be related to self-help group attendance.

Intervention Procedures

The experimental intervention involved introducing hospitalized, prospective members to a sponsor from the MDDA, who discussed MDDA and then accom- panied the prospective member to a self-help group meeting outside the hospital. Sponsors were recruited by MDDA leaders. Through articles in the group’s news- letter and announcements at meetings, MDDA leaders sought potential sponsors whose illnesses had been stabilized and who were intrigued by the idea of helping people currently experiencing an episode of the illness. A few persons without the requisite stability were advised to inquire again when their situations stabilized.

Potential sponsors were trained by MDDA leaders with support from the Uni- versity of Michigan, Center for Self-Help Research. MDDA leaders played a major role in designing and administering the intervention following recom- mended collaborative practices (Borkman, 1990; Kaufmann, 1994). MDDA leaders conducted full-day workshops for two cohorts of prospective sponsors. The MDDA trainers explained the purpose of the study, discussed the rationale for the intervention, provided information about hospital policies, discussed con- fidentiality provisions, and explained intervention procedures. Prospective spon- sors role-played the intervention so that they would be more confident about what to say after meeting the patient. Sponsors were encouraged to relate in a personally comfortable manner to the prospective member and to refer to their own experiences in carrying out the intervention. The sponsor was further

MOOD DISORDERS AND SELF-HELP GROUPS 2275

Table 1

Baseline Characteristics of Experimental and Control Groups

Experimental Control

Characteristics M(SD) or% N M(SD) or% N p

Age Education Gender (%)

Male Female

No Yes

Bipolar Unipolar

Age at onset Hospitalizations Employed >15hr/wk or

student (%) Prior MDDAattendance

Income (%) <$5,000 $5,000-9,999 $10,000- 19,999 - >$20,000

Marital status (%)

Minority (%)

Diagnosis (%)

Mamed SeparatecVdivorcecV

Single widowed

38.0 (13.4) 122 14.2 (2.3) 122

24 76 12 1

84 16 121

28 72 121 25.6 (12.8) 93

1.9 (2.0) 99

54 117

10 116

27 18 22 34 119

33

28 39 122

~ 39.0 (13.6) 13.8 (2.6)

34 66

88 12

27 73 27.5 (13.6)

1.9 (2.1)

52

10

36 18 14 32

36

31 34

104 .61 104 .31

104 . I 1

104 .37

104 .84 104 .29 104 .94

102 .78

102 .90

97 .38

104 .67

encouraged, as appropriate, to discuss how MDDA had helped them to feel less alone and more effective in coping with the illness. Plans for the first and second meeting with patients were also discussed.

At the first meeting, the sponsor was instructed to provide the prospective member with literature about MDDA. In addition, the prospective member was

2276 POWELL ET AL.

offered a free l-year subscription to the newsletter along with a copy of the cur- rent issue, which included a schedule of the support groups for the metropolitan area. Meetings with patients were designed to last about 1 hour. The plan also included the expectation that, if the patient agreed, the sponsor would return to the hospital a second time to transport the prospective member to an MDDA meeting outside of the hospital. Throughout the training, it was made clear that self-help group participation was intended to complement, not to replace, professional care.

Of 49 eligible sponsors, 47 received the workshop training, while 2 were later individually trained. Of the 49 individuals, 36 actually sponsored a prospective member. A typical sponsor carried out two or three interventions, although a small number of sponsors carried out eight or more. The sponsors received a $25 payment plus mileage expenses for each completed intervention.

Sponsors were matched with prospective members by a research coordinator, taking into account the prospective member’s preferences regarding the sponsor’s age, education, and race. Matches were made with a sponsor of the same gender, whose mood-disorder symptoms would be compatible with those of the prospec- tive member. Thus, sponsors with bipolar illnesses were matched with prospec- tive members who had either a bipolar or unipolar illness, while sponsors with unipolar illnesses were matched only with those who had a unipolar disorder.

Because of increasingly shorter hospital stays (dropping from a mean of 26 days to 12 days) during the course of the study, the intervention was modified for 68% of the prospective members. The modification involved either holding one of the sponsor meetings after discharge or combining two meetings into one. In either case, the minimum requirement for an intervention was for the prospective member to be accompanied to a meeting by an MDDA sponsor. Control-group members completed baseline data forms, but did not meet a sponsor and were not transported to an MDDA meeting. No effort was made to withhold ordinarily available information about MDDA from the control group. Though members of the control group may have heard about MDDA, they were not offered a system- atic introduction to it.

Measures

Attendance was the dependent variable in this study. Attendance was an objective measure of presence at MDDA meetings, which was derived from an attendance database maintained for all MDDA meetings in the study catchment area. All persons attending all MDDA meetings during this period were asked to f i l l out a simple evaluation form at the meeting they were attending. The form asked for the last seven digits of their Social Security numbers, which iden- tified the attender while preserving his or her anonymity (Yeaton, 1994). This procedure made it possible to search the database for meetings attended by exper- imental and control-group participants.

MOOD DISORDERS AND SELF-HELP GROUPS 2277

The database contained a record of 7,250 attendances from 841 meetings held by the 18 to 25 groups operating in the metropolitan Detroit area over the 4- year study period. The database contained records for 75% of the actual atten- dances based on information about meetings for which no forms were returned and others for which the returns were incomplete. However, there is no reason to believe that the measurement procedure biased counts of attendance for either the experimental group or the control group. Thus, it is assumed that the measure- ment procedure provided a conservative but unbiased estimate of actual atten- dance.

Referent power had two components: the power of the individual sponsor, and the power of the sponsored group meeting. Both the individual sponsor and the sponsored group components were assessed by telephone interview 1 month after hospitalization. The nine-item (a = .7 1) measure of the sponsor component asked whether the sponsor (a) discussed his or her illness, (b) discussed his or her experience with the illness, (c) understood the problems that the participant faced, (d) discussed what MDDA members were like, (e) discussed the location of the meeting, ( f ) described what the meeting would be like, and (g) encouraged attendance. Prospective members were also asked (h) if they felt comfortable, and (i) if they trusted the sponsor.

The measure of the sponsored group meeting component contained 12 items (a = .78). This instrument asked prospective members how they participated in the meeting with regard to whether they (a) shared personal information, (b) per- ceived similarities, (c) asked questions, (d) felt comfortable, (e) gave support, ( f ) were conhsed (reverse scored), and (g) left more hopeful and were enthusias- tic about hture meetings. It also asked whether (h) anyone introduced themselves, (i) anyone shared information about themselves, (i) the prospective member met someone he or she would like to get to know better, (k) the prospective member found people with things in common, and (1) the prospective member found others who faced the same medical or social and psychological difficulties. (A complete copy of these instruments is available fiom the first author.)

Data Analysis

A regression model was constructed to test the hypothesis that the intervention encouraged after-hospital MDDA attendance. To maximize statistical power, the subsamples fiom the quasi-experimental and randomized designs were combined. However, to control for any confounding variables, comparisons were made between: (a) the experimental subsamples, (b) the control subsamples, (c) the combined experimental and control samples, and (d) the intervention completers and the dropouts. Comparisons were also made for the variables of age, educa- tion, gender, minority status, diagnosis, age at onset, number of hospitalizations, employment status, prior knowledge of MDDA, and prior attendance at MDDA.

2278 POWELL ET AL.

Where differences were detected using a conservative (p < .15) criterion and the variable was correlated with attendance (p < .05), the variable was entered into the hierarchical regression equation. This technique resulted in the entry of four variables before the experimentakontrol group analysis. These variables were education, diagnosis, prior attendance, and prior knowledge of MDDA. This procedure controlled for any variance as a result of differences between the subsamples or between the f u l l experimental and control groups, and made it possible to obtain a more precise estimate of the variance attributable to the experimental condition (Rossi & Freeman, 1993).

Logistic regression was used to model the effect of the intervention (i.e., group assignment: experimental or control) on attendance. The magnitude of the effect was reflected by the odds ratio.3 The odds ratios reported here represent the independent effect of the predictor variables on attendance after controlling for the variables noted previously.

Results

Two versions of the hypothesis that the experimental group would exhibit more attendance were tested. The more stringent hypothesis, based on the inten- tion-to-treat principle (Pocock, 1983), was evaluated with the full experimental group, including those who did not complete the intervention (i.e., they did not attend a sponsored meeting after their introduction to a sponsor). The less strin- gent hypothesis was evaluated restricting the experimental group to those persons who completed the intervention (i.e., went to a meeting with a sponsor). Both models used the covariates described earlier (education, diagnosis, prior MDDA knowledge, and attendance/experience) to control for potential bias as a result of differences measured between the groups. However, when prior MDDA howl- edge and attendance/experience were entered simultaneously, only experience was independently significant (p < .05). Therefore, prior knowledge was omitted from the final regression models presented in this section.

Model 1 (N= 226), presented in Table 2, is the more stringent test of the hypothesis, which includes intervention dropouts. The experimental sample size was 122 (50 from the quasi-experimental design and 72 from the randomized design). The control sample size was 104 (57 from the quasi-experimental design and 47 from the randomized design). In Model 1, the group (experimental vs. control) variable was significant after controlling for education, diagnosis, and prior MDDA attendance.

Model 2 is the test of the hypothesis that includes only those in the experi- mental group who completed the intervention (N = 167). Model 2 results show a

3This is a common measure for comparing groups on a dichotomous measure. It is the ratio of the odds that one group has attended, compared to the odds for the other group (Hillis & Woolson, 1995).

MOOD DISORDERS AND SELF-HELP GROUPS 2279

Table 2

Hierarchical Logistic Regression Models Predicting Attendance

Predictor variables Parameter est. (SE) Odds ratio p

Model 1 incomplete and complete interventions (N= 226) Education 0.212 (0.080) 1.2 .008 Diagnosis unipolarhipolar 0.954 (0.370) 2.6 .001 Prior MDDA exp. 1.871 (0.525) 6.5 .001 Group (exp./ctrl.) 1.023 (0.37 1) 2.8 .006

Diagnosis unipolarhipolar 0.908 (0.420) 2.5 .030 Prior MDDA exp. 1.504 (0.55 1 ) 4.5 .006

Model 1 complete interventions only (N= 167)

Group (exp./ctrl.) 1.917 (0.371) 6.8 .oo 1

Note. MDDA = Manic-Depressive and Depressive Association; exp. = experimental; ctrl. = control.

significant effect for diagnosis, prior MDDA attendance, and group membership (experimental vs. control). The odds ratios indicate that participants with a bipo- lar diagnosis (2.48) and those with prior MDDA attendance (4.50) were more likely to attend. The highest odds ratio (6.80) resulted, however, from the com- parison of the experimental group to the control group.

The proportion of persons attending one or more times on their own after the sponsor-accompanied meeting was 56% (35 of the 63 participants) from the experimental group and 15% (16 of the 104 participants) from the control group. The number of meetings attended was not normally distributed. Most of those who attended meetings went only a few times, while a small number went many times. The median number of meetings attended was I; the interquartile range (IQR) was 0 to 5 meetings. The median time to the first meeting after the spon- sored meeting was 28 days, while the IQR was 1 1 to 49 days.

To check whether modifications of the intervention affected attendance, two additional models were tested. One tested for differences between single- or double-session interventions after controlling for diagnosis and prior MDDA attendance with the result that no differences were detected (p = .70). The other tested for differences in the timing of the intervention (in-hospital or after- hospital), controlling for the same variables, with the result, again, that no differ- ences were detected @ = .63).

To evaluate specific components of referent power, additional analyses were performed on the sample completing the intervention (those who went to a sponsored MDDA meeting). Separate examinations were made of the two

2280 POWELL ET AL.

components of referent power: individual sponsor, and group meeting power. The scores on the nine-item sponsor measure did not distinguish attenders from nonattenders since both the attenders and the nonattenders responded positively to the sponsors. Examining individual items, more than 90% indicated that they felt “comfortable” and “trusted” the sponsor.

However, the 12-item sponsored group meeting measure did distinguish attenders from nonattenders, t (55) = 2.70, p = .01. Examining individual items, attenders were significantly more likely to report finding someone they would like to get to know better @ < . O l ) , and to feel enthusiastic about attending future meetings (p < .01). Attenders also showed a trend to report feeling more comfort- able @ = .08) and to be more hopeful about the hture (p = .09).

Discussion

This study is noteworthy in several respects. It is the first carefidly managed intervention that aimed to encourage self-help attendance among persons with mental illness that also used a theoretically based experimental intervention. Fur- ther, we believe that it is the first to track attendance in natural community sup- port groups using an objective, reliable measure (Yeaton, 1994). Together, these features render other, nonintervention causes less plausible. For example, it is unlikely that severity-of-illness differences between the experimental and control groups account for the results because the two groups were equivalent at baseline in two important severity indicators: age of onset, and number of hospitaliza- tions. Exaggerated attendance claims that might have accompanied self-reports were eliminated by the Social Security number method of tracking attendance. Thus, it seems reasonable to conclude that the intervention was responsible for increased attendance among the experimental group members.

The interpretation as to why the intervention worked is more complex, how- ever. In addition to the referent power hypothesis, several alternate hypotheses can be considered: Experimental participants had more information than did con- trol participants (knowledge hypothesis); experimental participants were involved in supportive relationships with hospital staff who encouraged their attendance (social-support hypothesis); and experimental participants experi- enced less anxiety about attending a meeting on their own because of their previ- ous exposure to the sponsored meeting (anxiety-reduction hypothesis).

While each of these interpretations has merit, they do not offer, even when taken together, a complete explanation. Various information, social-support, and anxiety-reduction strategies have been studied to encourage attendance at self- help groups. Like this study, they used a one-meeting attendance as the criterion. However, this study’s 56% rate of attendance exceeds the rates found in studies of Alliance for the Mentally Ill (44%; Medvene, Mendoza, Lin, Harris, & Miller, 1995), mental health consumers (17%; Kaufmann et al., 1994), and bereaved

MOOD DISORDERS AND SELF-HELP GROUPS 2281

persons (29%; Levy 8z Derby, 1992). And while the one-meeting standard of attendance is a modest one, it is a standard that has been associated with benefi- cial outcomes in follow-up studies (Medvene et al., 1995). Similar follow-up studies are planned with the present sample.

Referent-power-based interventions may also be more effective than other efforts reported in the literature. The earlier-mentioned pre-A.A. connect groups used various elements of information, support, and gradual exposure to self-help experiences in an effort to promote attendance (Caldwell & White, 1991; Daley et al., 1991). Yet, they do not appear to be as successful as the referent-powered intervention reported here. Indeed, the most applicable study found that referent- powered A.A. sponsors were much more influential than were information- powered therapists in encouraging A.A. and Al-Anon attendance (Sisson & Mallams, 198 1).

Apart from the intervention, other variables had an effect, albeit not as strong, on attendance. In Model 1, education had a modest, positive effect on attendance. Perhaps better-educated people are more resourcefid in seeking out potentially beneficial experiences. In Model 2, for which those completing the intervention were included in the experimental group, education was no longer significant, but diagnosis and prior MDDA experience were again significant.

It was also noted that individuals with bipolar conditions were more likely to become attenders, a finding that is consistent with the impressions of veteran MDDA members. Various conjectures have been offered to explain this differ- ence. Perhaps the ideology of the group fits people with bipolar disorders better than unipolar ones (McPherson, Herbison, & Romans, 1993). Perhaps also vet- eran MDDA members unwittingly offer more encouragement to people with bipolar conditions (Wetzel, 1991). Finally, the higher exploratory energy of per- sons with bipolar conditions may play a role in higher attendance.

In considering the community and clinical implications of these findings, it is important to consider that referent power did not operate entirely consistently with predictions. Individual referent power was not sufficient to encourage atten- dance, even though prospective members felt comfortable with and trusted their sponsors. Rather, it was the referent power of the group that proved critical. This was surprising, as it was expected that the relationship between the patient and a carefully matched individual would be a powerful motivator of attendance. Instead, the sponsor seemed to function as a means of bringing the prospective member into the influence of the specifically relevant reference group. Thus, it seems that the referent-powered intervention may need to address the anxiety associated with the desired outcome-attendance at a group meeting. But to bet- ter understand how referent power operates, the measure itself needs to be refined. For example, the item “wanting to get to know someone better” is a more specific indicator of referent power than “feeling comfortable at a meeting,” which might also indicate support and anxiety management. It would also be

2282 POWELL ET AL.

desirable to have a record of the actual intervention in order to understand how various aspects of the intervention are linked to referent power.

The timing of the intervention needs to be considered. In the planning phase, we assumed that hospitalized patients would be searching for paths to recovery and therefore would be more open to the idea of participating in a self-help group (French & Raven, 1959). In reality, the situation was more complicated. Increas- ingly shorter hospital stays, especially when they included electroconvulsive therapy, meant that patients were asked to decide about self-help at a time when they were still quite i l l and unable to consider when they might get well, much less how participation in a self-help group might contribute to their recovery. Some of these patients might have proved more receptive later in their home environment when they felt more hopeful and better able to make sound deci- sions. Consideration should also be given to a number of other variables, includ- ing cognitive and affective stability, support in home and work environments, and location of the intervention (hospital, clinic, or home). Finally, receptivity needs to be considered within a framework of the fit between the person and the group according to such variables as age, gender, socioeconomic status, and severity of illness (Luke, Roberts, & Rappaport, 1993).

The generalizability of the study also needs to be considered in light of the university hospital sample serving a largely White population. Consumers in public programs, who typically contend with more chaotic environments and with fewer personal resources, probably face more barriers to completing the intervention and taking the next step to become an attender. Indeed, this was our experience in a short-lived study at a state hospital that was terminated as a result of the closure of the hospital. In such circumstances, more intensive interventions may be required.

It is also important to consider how the intervention might work in a more multicultural environment. Given the predominance of Whites in MDDA, special efforts were made to intervene in an ethnically sensitive manner. Inquiries were made with people of color about their interest in culturally specific contacts, and where interest was expressed, the coordinator described available options. In par- ticular, efforts were made to match African American prospective members with African American sponsors. This appears to have been effective, as 3 of the 5 African Americans in the experimental group attended beyond the sponsored meeting (this ratio is comparable to that for non-African Americans). Given the small numbers, however, the similar ratio must be viewed cautiously, though it is consistent with the results of other studies. For example, referrals of African Americans to 12-step groups have been remarkably successfbl when the referrals are to groups in communities with a significant African American presence (Den- Hartog, Homer, & Wilson, 1986; Humphreys & Woods, 1993). Perhaps this is to be expected, given the rich, informal tradition of self-help in African American communities (Neighbors, Elliott, & Gant, 1990).

MOOD DISORDERS AND SELF-HELP GROUPS 2283

The generalizability of the intervention may also depend on the focus of the self-help group itself. Diagnosis may be a particularly salient focus, and thus the intervention may work especially well with diagnosis-related organizations. For example, it might work well with prospective members of Agoraphobics in Motion (AIM) or with Schizophrenics Anonymous, but less well with Recovery Inc. or Emotions Anonymous, where the focus is on their distinctive problem- solving method rather than on shared personal characteristics such as a common diagnosis (Galanter, 1988). Consequently, it may be harder for Recovery Inc. or Emotions Anonymous to evoke the feelings of oneness essential to the activation of referent power.

A parallel situation exists with consumer-run agencies where the emphasis is on the importance of empowerment and advocacy rather than on shared personal characteristics, even though members may refer to their shared experiences as consumer/survivors (Mowbray & Tan, 1992; Segal, Silverman, & Temkin, 1993). In any event, the findings suggest that peer or consumer case managers could become more effective referral agents by giving prospective members a tour of groups in which they personally participate. And, similarly, self-help rep- resentatives might increase membership by offering opportunities to visit actual meetings (Kelly, Sautter, Tugml, & Weaver, 1990).

With increasing awareness of the importance of self-help services (Galanter et al., 1990; Heller, Roccoforte, Hsieh, Cook, & Pickett, 1997; Kessler, Mickelson, & Zhao, 1997; Kessler et al., 1999; Kurtz & Chambon, 1987), professionals can facilitate participation in self-help by mng ing for prospective self-help members to meet with veteran members of self-help groups, thereby creating an opportunity for the development of a referent-power-based relationship. But if professionals are to see value in these meetings, they will need to reconceptualize the formally organized, specialized self-help system as a component of the community support system (Powell, 1990; Salzer, McFadden, & Rappaport, 1994; Turner & TenHoor, 1978). The self-help system should be seen as having its own distinctive set of fimctions, separate from the informal, nonspecialized helping system made up of family, friends, coworkers, neighbors, and fellow religionists (Borkman, 1990).

To the extent that professionals can arrange more adequate utilization of the experientially based self-help mutual aid system, they will move toward imple- menting the goals of the Surgeon General’s Workshop on Self-Help and Public Health (Department of Health and Human Services, 1988) and the President’s Commission on Mental Health (1978). The recommendations of these public- policy initiatives deserve to be reexamined, as they envisioned extensive coordi- nation between professional and self-help sectors (Powell, 1994; Powell, Kurtz, Garvin, & Hill, 1996). In the world they envisioned, people with mood disorders would be able to use self-help groups as part of their ongoing efforts to keep up with the latest information about their illness, reduce stigma, and develop coping techniques specific to their disorders.

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