CLINICAL QUALITY OF CARE – PRACTICE PARAMETERS 

Office of the Chief Medical Officer 
Clinical Operations 


Referral to Self-Help Groups 

ClinP-9
 
Category: Clinical Programs 
Published Date: November 2008
  1. INTRODUCTION
    1. DMH has many clients who could benefit from self-help groups. Clinicians should understand the nature and value of these groups and make skillful referrals.
    2. Self-help groups, in concert with other services, use identification, fellowship, social interaction, modeling, mentoring, and advocacy to assist clients with learning to take ultimate responsibility for their own recovery, remove barriers to positive behavioral and emotional changes, and enhance clients’ roles in the community.
    3. Self-help groups have been described as “self-governing groups whose members share a common health concern and give each other emotional support and material aid, charge either no fee or only a small fee for membership, and place a high value on experiential knowledge in the belief that it provides a special understanding of a situation.” Surgeon General C. Everett Koop’s Workshop on Self-help and Public Health 1988.
    4. There are many opinions of what constitutes the necessary properties of self-help groups. To some, self-help groups are “totally voluntary, non-coercive” in nature, “autonomous of the mental health system and professionals” and culturally competent. (Reaching Across: Mental Health Clients Helping Each Other), Zinman, Harp, Budd, editors, 1987).
    5. For the purposes of referral to self-help groups by DMH clinicians, any group that is peer-led and dedicated to developing recovery-oriented skills can potentially qualify.
    6. Clinicians should note that there are differing degrees and types of evidence of effectiveness for different groups.
       
  2. DEFINITIONS OF SELF-HELP GROUP FOR PURPOSES OF DMH REFERRAL: A self-help group meets all of the following criteria:
    1. The group’s purpose is to pursue personal and or social growth and change.
    2. Everyone in the group is a peer.
    3. There is sharing and/or interaction among members.
    4. The group is self-governing regarding internal affairs.
    5. Any leadership positions are shared or rotated and are not based upon professional status. Each member of the group can become a leader with minimal training.
    6. The group is not dependent on a particular person for its continued existence.
    7. Dues and fees—if present—are nominal, reflecting only group expenses.
    8. The self-help group may have components of larger programs with established structures and policies, e.g. Recovery Inc., 12-step programs
    9. Self-Help Group Types (Leading Self-Help Groups, Lucretia Mallory, 1984):
      1. Support groups usually define support as a verbal process. The process may include sharing experiences, verbal affirmations of individual members, and acceptance of feelings.
      2. Growth/Self-Improvement groups are focused on changes within the individual as a result of experiences provided in the group. These groups often have a series of group experiences provided in the group.
      3. Educational groups assume that their members will best be helped by information. These groups often have speakers and a lecture-discussion format.
      4. Social/Recreational groups are organized to provide opportunities for members to get together to enjoy a common activity. The help they offer their members is the opportunity to meet people and have fun.
      5. Social Action groups are those in which the energies of the group are focused on making changes in the external environment of group members, by influencing and informing the public or elected officials.
         
  3. SELF-HELP FORMATS (See appendix for lists by category)
    1. Twelve-step groups for individuals with mental illnesses: The best-known form of self-help groups are those patterned after Alcoholics Anonymous, which is a spiritual program using the Twelve Steps and Twelve Traditions. Those designed for individuals diagnosed with mental illness include those for individuals with co-occurring substance abuse, with depression, with anxiety, with eating disorders, with anxiety disorders, with various addictions and compulsions, and with a variety of other emotional problems. These 12-Step groups usually have “Anonymous” in their titles and have a particular structure of which clinicians should be aware.
    2. Recovery, Inc.: A self-help mental health program based on the work of a neuropsychiatrist, Abraham A. Low, M.D. Recovery, Inc offers its members a free method to regain and maintain their mental health by learning techniques for handling everyday situations.
    3. PR: TNS Programs: Project Return: The Next Step offers a variety of self-help groups throughout Los Angeles County, including socialization clubs, groups called Ups and Downs, which address unipolar and bipolar disorders, and Schizophrenics Anonymous, which is a six-step program that addresses issues related to schizophrenia and schizoaffective disorder. PR: TNS also runs a warm line and two Discovery Centers.
    4. Other self-help groups for individuals with mental illnesses: These groups are for individuals who are diagnosed with mental illnesses, but are not based on the 12-Steps of Alcoholics Anonymous.
    5. Survivors groups: These groups are for individuals recovering from emotional trauma. Examples include groups for survivors of physical and/or sexual abuse.
    6. Twelve-step groups not primarily focused on recovery from mental illness: These groups comprise a majority of self-help groups, the major group being Alcoholics Anonymous. While they are not specifically created for individuals with mental illness, they often welcome such individuals and may be extremely useful for dealing with life problems. Examples include groups for co-dependency, gambling, tobacco use, divorce, and other personal problems.
    7. Los Angeles County Client Coalition ("Client Coalition") and other Client Advocacy Groups: The Client Coalition holds monthly meetings, trainings, and workgroups in a variety of mental health centers and other sites in Los Angeles County for the purposes of developing advocacy skills which are then used to improve the delivery of mental health and related services in Los Angeles County, combat stigma and discrimination, and assure rights’ protection as well as enhance the quality of life of mental health clients through mutual support. The statewide advocacy group with similar purposes is the California Network of Mental Health Clients
    8. Other self-help groups not primarily focused on recovery from mental illness: A wide variety of self-help groups that are not based upon the 12-step model are available for many life problems, including alcohol and substance abuse. There are support groups for bereavement, parenting, anger management, dealing with physical illness, and caregivers. Other possibilities include peer counseling groups, drop-in centers, performing groups, rights advocacy groups, holistic healing groups, warm lines, and hotlines, client-run businesses, client-run residences, and detoxification centers, creative arts groups, and exercise groups. “In other words, a self-help group can take many different forms; its parameters are limited only by the desires, energy, and possibilities of its members.”(Zinman, et al.)
    9. Self-help groups that address the needs of family members of mental health clients: The National Alliance for the Mentally Ill (NAMI) has groups throughout Los Angeles County. Other support groups for families include Family to Family and Survivors after suicide.
       
  4. INDICATIONS FOR REFERRAL (any of the following):
    1. Social needs: New friends, role models, a mentor, or peer support to decrease feelings of being overwhelmed, helpless or hopeless.
    2. Low self-esteem: Experience of shame or stigma about self, diagnosis, or other life circumstances.
    3. Problems with illness management: Difficulty with adapting to necessary lifestyle changes, undue reluctance to follow sound clinical advice, unwarranted demands for clinician time, denial of the need for treatment as presently constituted or functional limitations, using mental illness or other life circumstances as an excuse for not taking action to better one’s situation.
    4. Co-occurring substance use or abuse.
    5. Alternative intervention: Individuals with emotional problems who do not meet DMH criteria for provision of services; individuals who fail to respond or have a suboptimal response to treatment, individuals with problems interacting with clinician and/or mental health systems.
    6. Support of unique status: Individuals with emotional problems and unique ethnic, linguistic, or cultural status.
    7. Unresolved Life Crises: Individuals with a range of life crises, including bereavement, family problems, domestic violence, sexual assault, job loss, homelessness, and child abuse.
    8. Support for individuals and families with specific diagnoses: Individuals with specific disorders, including anxiety disorders, mood disorders, ADHD, and PTSD.
       
  5. SELECTION CRITERIA
    1. Individuals must be able to be with a group of people for at least 20 minutes without being disruptive.
       
  6. CONTRAINDICATIONS TO REFERRAL
    1. Violence with lack of impulse control.
    2. Expressed disinterest in self-help options after adequate explanation.
    3. For clients who are taking appropriately prescribed psychiatric medication, referrals should not be made to self-help groups where members encourage clients to stop taking their psychiatric medications against physician advice, or where mental health consumers are not treated as full members of the group because of their prescribed 
       
  7. STAFF ROLE IN REFERRAL PROCESS
    1. Information about self-help options should be routinely available to all clients.
    2. All clinicians, case managers, and other screening personnel should have a working knowledge of the benefits of self-help groups and how to make an effective referral.
    3. Clinicians should be knowledgeable about specific groups, contact information, availability, and group etiquette.
    4. Clinicians should have access to a current annotated referral list that is readily available at the clinical site or via a website.
    5. Clients should be encouraged but not required to follow up with the self-help referral.
       
  8. REFERRAL PROCEDURE
    1. Clients should be counseled as to the benefits of their attending a self-help group.
    2. With client input and approval, the clinician should collect the following information in preparation for referral: Client goal(s) in group attendance, most convenient location for group attendance, and any specific cultural or linguistic needs.
    3. Clinician may directly refer a client to a specific self-help group, based upon his/her personal knowledge or clinic referral lists. When possible, the client should be introduced on the clinician’s telephone to another consumer attending that group. Anonymity during referral should be maintained (e.g., introduce the individuals by first name only).
    4. When another client already attending the self-help group is not available, the client may be referred to SHARE! the Self-Help And Recovery Exchange [toll-free 1-877-SHARE49] and also given the phone number and evening hours for the Friendship Line [(888) 448-9777, 6:00 p.m.-10:00 p.m.] to speak with a consumer involved in self-help groups/activities.
    5. Clinicians should also give clients the contact information for the Client Coalition (DMH Office of Consumer Affairs: (213) 637-2370
    6. Clinicians should discuss general and specific self-help group etiquette with the client. For example, the clinician might describe the appropriate focus of group sharing in 12- step programs.
    7. Clients should be encouraged to attend six scheduled self-help meetings in a row and regularly thereafter.
    8. Whenever possible, peer advocates should accompany the clients to the first three sessions.
    9. Clients should be encouraged to report on their experience of self-help groups or programs during their regular clinical appointments.
    10. At regular intervals, clinicians should actively encourage clients to attend the self-help groups through reminders about goals and benefits.
    11. Clinicians should ask suitable clients if they would like to be a contact person for the group they attend.
       
  9. DOCUMENTATION
    1. Self-help attendance should be documented in the clinical record.
    2. When the client is willing to give feedback on the group or program, the relevant feedback should also be documented, including groups attended, frequency of attendance, and clients’ observations or concerns about groups.
       
  10. APPENDIX
    1. Twelve-Step Groups for Mental Health Consumers: These self-help groups are patterned after Alcoholics Anonymous, which is a spiritual program using the Twelve Steps and Twelve Traditions. Having “Anonymous” in their title often denotes them.
      1. Depression Anonymous (310) 305-8878
      2. Double Trudgers (Portals House) (213) 639 2670 - Chris Jones (323) 850-5797- Bob Day This is also the number for Recovery International
      3. Dual Recovery Anonymous http://www.draonline.org Los Angeles (310) 305-8878, (800) 792-2345, (323) 777- 0130 Ext. 223 Long Beach (562) 436-8585 Ext. 291, (562) 437-6717 Ext. 277
      4. Dual Diagnosis Anonymous http://www.ddaworlwide.org Los Angeles (310) 394-6889 Long Beach (562) 437-6717
      5. Emotional Health Anonymous San Gabriel Valley (626) 287-6260
      6. Emotions Anonymous http://www.emotionsanonymous.org/ Inland Empire/San Bernardino (323) 589-3768 San Fernando Valley/Santa Clarita/West LA (818) 377-4341 Long Beach/Orange County (323) 589-3768, (562) 928-0646, (714) 739-5449
      7. Neuroticos Anonimos (Spanish language) (213) 385-5990
      8. Obsessive Compulsives Anonymous (310) 305-8878
    2. Non-Twelve Step Groups for Mental Health Consumers: Other self-help groups that are not based on the 12-Steps of Alcoholics Anonymous but are directed toward, but not necessarily limited to, individuals diagnosed with severe and persistent mental illnesses include:
      1. Depression and Bipolar Support Alliance (formerly known as the ManicDepressive/Depressive Association -MDDA). Their groups may be called Ups & Downs, Affective Disorders http://www.dbsalliance.org/ (800) 826-3632
      2. Los Angeles County Client Coalition (advocacy) or DMH Office of Consumer Affairs: (213) 738-4740
      3. Procovery Circles (310) 668-5288 http://www.procovery.com/ or kcrowley@procovery.com
      4. Project Return: The Next Step Friendship Line Toll-free: (888) 448-9777 L A County (323) 346-0960 (888) 242-2522
      5. Recovery International (310) 322-6411
      6. Schizophrenics Anonymous http://www.sanonymous.com/ (562) 285-0149 o For group locations e-mail: sareferrals@nsfoundation.org
      7. Secular Organizations for Sobriety-Sanity and Sobriety http://www.cfiwest.org/sos/index.htm (323) 666-4295 
    3. Other Self-Help Programs that address a range of issues but welcome everyone including individuals with severe and persistent mental illnesses, for example:
      1. Adult Children of Alcoholics http://www.adultchildren.org/ (310) 534-1815 San Gabriel Valley email: meetinginfo@adultchildren.org Long Beach/South Bay 310-534-1815
      2. Al-Anon/Alateen http://www.al-anon.alateen.org/ (888) 684-6444
      3. Alcoholics Anonymous http://www.alcoholics-anonymous.org/ (800) 923-8722
      4. Artists Recovering Through the 12 Steps (ARTS Anonymous) http://www.artsanonymous.org/(310) 281-8420
      5. Clutterers Anonymous http://www.clutterersanonymous.net (310) 479-4119 Co-Dependents Anonymous http://www.codependents.org/ Los Angeles (323) 969-4995 o San Fernando Valley/San Gabriel Valley (818) 379-3300
      6. Compassionate Friends http://www.compassionatefriends.org/ (310) 474-3407
      7. Compulsive Eaters Anonymous (H.O.W.) http://www.ceahow.org/ (310) 822-7250
      8. Debtors Anonymous http://www.debtorsanonymous.org/ or http://http://www.socalda.org/ (626) 794-0001
      9. Divorce Anonymous http://www.divorceanonymous.com (626) 794-0001 Gamblers Anonymous http://www.gamblersanonymous.org/ (310) 305-8878
      10. Marijuana Anonymous http://www.marijuana-anonymous.org/ (800) 766-6779 Narcotics Anonymous http://www.na.org/ (310) 390-0279 Nicotine Anonymous http://www.nicotine-anonymous.org/ (800) 642-0666
      11. Overeaters Anonymous http://www.oa.org/ or http://www.oalaintergroup.org/ Los Angeles (323) 653-7499 Long Beach (562) 342-9344 Beach Cities (323) 653-7652 San Fernando Valley (818) 881-4776, (818) 342-2222, http://www.oasfvalley.org/
      12. Rape Survivors Anonymous E-mail info@rsaws.org for meetings in your area
      13. Recovering Couples Anonymous http://www.recovering-couples.org/ Toll-free (877) 742-7349 Ext.1234 Culver City: (310) 322-7857 (Jerry or Stephanie)
      14. Sex Addicts Anonymous http://www.sexaa.org/ (213) 896-2964
      15. Sex and Love Addicts Anonymous http://www.slaafws.org/ (323) 957-4881
      16. Sexaholics Anonymous http://www.sa.org/ or http://www.saa-recovery.org/ (213) 480-1096
      17. Sexual Compulsives Anonymous http://www.sca-recovery.org/ (310) 859-5585
      18. S.M.A.R.T. Recovery (addiction issues) http://www.smartrecovery.org/ (310) 275-5433
      19. Survivors of Childhood Abuse (310) 305-8878
      20. Survivors of Incest Anonymous http://www.siawso.org/ (562) 630-6844
      21. Women for Sobriety http://www.womenforsobriety.org/ (626) 355-6048
    4. Other Types of Self-Help Groups that welcome everyone including individuals with severe and persistent mental illnesses, for example:
      1. Anger Management support groups
      2. Bereavement Support Groups
      3. Caregiver support groups
      4. Parent Support Groups
      5. Physical disease support groups
    5. Self-help groups that address the needs of family members of mental health clients:
      1. Family-to-Family – A project of NAMI (310) 478-8761
      2. Keeping Kids Connected (800) 899-2866
      3. Kids Can Cope (323) 564-7911
      4. National Alliance for the Mentally Ill (NAMI) http://www.nami.org/ (213) 632-0782
      5. Procovery Circles (310) 668-5288 or kcrowley@procovery.com
      6. Survivors after Suicide http://www.mkbmemorial.com/sas Encino: (818) 906-8832 o Los Angeles: (213) 934-7958 or (310) 391-1253
      7. Toughlove http://www.toughlove.org (310) 325-8136 Current contact information for self-help groups is available through SHARE! The Self-Help And Recovery Exchange toll-free 1-877-SHARE-49 or 1-877-742-7349.