World Journal of Psychiatry and Mental Health Research
Review Article
Published: 09 Aug, 2022
How Can Psychiatry Catch Up with the Wave of the
Future During the Current Global Mental Health and
Addiction Crises? A Clinician’s Perspective
Sebastian Salicru*
Private Practice, PTS Psychology, Canberra, Australia
Abs tract
We are experiencing global mental health and addiction crises that have created unprecedented
challenges for psychiatrists and other mental health professionals. These crises cannot be dealt with
using traditional delivery models of services alone. They have created the need for interventions using
new ways of delivering mental healthcare services. This conceptual paper explores how psychiatrists
can contribute to alleviating the current crises through the revival of mental health self-help.
Coined as ‘the wave of the future’ over three decades ago, mental health self-help is an umbrella
term that encompasses a multiplicity of participatory and collaborative approaches dating back to
the 1950s. Integrating extant theoretical and empirical findings, and taking a scientist-practitioner
stance, this paper unpacks the therapeutic factors and mechanisms of change embedded in mental
health self-help and self-help groups. Their corresponding outcomes and benefits are also
highlighted by elucidating the linkages between theory and practice. The paper further discusses
how psychiatrists can support the new 2030 Agenda for Sustainable Development in global mental
health, beyond what has been traditionally understood. By examining past and present relevant
research findings to explore the future of mental health, this paper advances understanding of the
need for collaboration between psychiatrists and other mental health professionals, end-users and
the community at large, as a way of moving out of the current crises.
Keywords: Global mental health crisis; Addiction; COVID-19; Mental health self-help; Self-help
groups; Helper therapy principle; Single-session interventions
OPEN ACCESS
*Correspondence:
Sebastian Salicru, Private Practice,
PTS Psychology, Canberra, 45 Farran
Street, Canberra ACT 2912, Australia;
E-mail: s@pts.net.au
Received Date: 04 Jul 2022
Accepted Date: 04 Aug 2022
Published Date: 09 Aug 2022
Citation:
Salicru S. How Can Psychiatry Catch
Up with the Wave of the Future during
the Current Global Mental Health
and Addiction Crisis? A Clinician’s
Perspective. World J Psychiatry Ment
Health Res. 2022; 6(1): 1031.
Copyright © 2022 Sebastian
Salicru. This is an open access
article distributed under the Creative
Commons Attribution License, which
permits unrestricted use, distribution,
and reproduction in any medium,
provided the original work is properly
cited.
Remedy Publications LLC.
In tro d u ctio n
We are in the midst of a global mental health crisis [1-3]. Worldwide, most people needing
Mental Health (MH) care lack access to quality services due to stigma, fragmented service delivery
models, shortages of human resources, and lack of capacity to implement the required policy
changes [4]. MH and addictive disorders in high-income and upper-middle-income countries affect
a significant amount of the global population, and have increased dramatically in the last decade –
mostly due to stigma and lack of treatment [5]. In fact, addiction has been become a global threat
and, being the most common comorbid disorder in individuals with other mental conditions, is the
costliest to treat and the least treated, with catastrophic economic impact, and in desperate need for
solutions [6].
The COVID-19 pandemic has skyrocketed the demand for mental health services. As a result, it
has become increasingly challenging for individuals to access Mental Health Professionals (MHPs:
e.g. psychologists, psychotherapists, psychiatrists) who are available. The negative impacts of these
states of affairs on individuals, families, and communities have been astonishing. Even some of the
most developed nations in the world are in crisis mode. In the US, for example, “the current mental
system is collapsing with a wobbling infrastructure" [7]. In the UK, the Royal College of Psychiatrists
reports the MH crisis in England as terrifying, and psychiatrists warn about overrunning the National
Health Service (NHS), following a record number of adults and children seeking help during the
pandemic [8]. The Australian National Association of Practicing Psychiatrists (NAPP) claims “the
Australian Mental Health Crisis” is a system failure in need of repair [9]. These challenges, in turn,
have also been impacting MHPs. Psychiatrists, especially many who have never experienced the
current working demands and conditions in their lifetime, as a result are experiencing – or are at risk
of experiencing – compassion fatigue, secondary traumatic stress, vicarious traumatization, and even
Post-Traumatic Stress Disorder (PTSD) -related symptoms [10].
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Clearly, the current crises pose unique challenges for the general
population and MHPs, cannot be dealt with using traditional delivery
of services alone, and require a large-scale response [11]. Psychiatrists
need to face their short- and long‐term consequences [3,12]. This
new response requires collaboration among MHPs, and entails
psychiatry shifting from a social and biological paradigm towards a
recovery model of mental illness [13]. The historical tension
between social and biological psychiatry and the recovery movement
[14] can reconcile by considering this as a progressive shift rather
than a radical move. This transition can be viewed as a repositioning
of perspectives within a dimensional plane of epistemologies, which
locates homothetic knowledge (a tendency to generalize; used by the
professional-centered model) and idiographic knowledge (a tendency
to be specific and focus on subjective phenomena) [15], at each end
of the continuum. It thus proposes that psychiatry adopt a more
recovery-oriented approach [16]. The essence of the recovery model
is the belief that individuals can recover from mental illness, and lead
fulfilling and satisfying lives. This approach to MH is holistic and
person-centered. Research evidence indicates that self-management
strategies are more valuable than models based on physical health
[17]. From a stakeholder perspective, the recovery model identifies
the following six themes: (1) identity and meaning; (2) the service
provision agenda; (3) the social domain– connection and supportive
relationships; (4) power and control; (5) hope and optimism; and (6)
risk and responsibility [18].
years and today outnumber traditional MH organizations [24].
SHGs are voluntary, small configurations for the mutual assistance
and achievement of specific goals, which enable individuals with
a range of concerns to develop a tailored response to their specific
needs [25]. SHGs have also been defined as “self-organizing groups
where people come together to address a shared health or social issue
through mutual support. They are associated with a range of health
and social benefits, but remain poorly understood” [26]. The most
widely researched type of SHG is Alcoholics Anonymous (AA). This
is due to the fact that AA germinated and pioneered a message of
recovery for those struggling with alcohol addiction [27]. In 1987 in
the US, for example, the Surgeon General C. Everett Koop stated that
SHGs such as AA had become a significant alternative to the formal
healthcare system. By the 1980s, SHGs were viewed by psychologists
as “a major and legitimate format for delivering mental health care”
[28]. At its core, the notion of self-help is primarily related to the
taking of personal responsibility and accountability by mobilizing
and using inner personal resources and the management of solitude.
Albeit that the importance of SHGs was neglected by social scientists
for many years – mostly due to methodological research challenges
and limitations – to date many quantitative and qualitative studies
have been conducted in this field and offer meaningful contributions
to treatment outcomes and directions for future research [29].
This includes the fact that SHGs are able to promote emotional
recovery [29] and assist individuals with severe and long-standing
mental illnesses [30], including complicated conditions such as
chronic fatigue syndrome [31] and schizophrenia [32]. International
examples of these types of SHGs include Recovery Inc., Emotions
Anonymous, GROW International [33], Narcotics Anonymous,
Cocaine Anonymous (CA), Gamblers Anonymous (GA), SMART
Recovery, Overeaters Anonymous (OA), and many other so called
12-Step Programs (12SP) [34].
The good news is that this paradigm shift is already in motion. A
good recent practical example is the ‘Reinventing mental health care’
forum, initiated by the Harvard T.H. Chan School of Public Health
[19]. In brief, this initiative aims at transforming mental healthcare,
and adopts the recovery model, which integrates the above-mentioned
themes in three principles, represented by the three Ps: People (social
support – family, friends, peers); Place (physical environment); and
Purpose (finding purpose from lived experience).
Why Should Psychiatrists be Confident in
Makin g Re fe rrals to Se lf-H e lp Gro u p s ?
This article explores how psychiatrists can further contribute
to the management of the current MH crisis, while simultaneously
relieving their own workloads, by supporting the recovery model via
the revival of Mental Health Self-Help (MHSH), as evidence-based
strategies that are in line with the new 2030 Agenda of Global Mental
Health (GMH) – an emerging discipline “that seeks to address one of
the most neglected global health issues of our time” [20]. Drawing on
the extant literature, and taking a scientist-practitioner stance, this
qualitative paper examines past and present relevant theoretical and
empirical findings to explore the future of MH.
Me n tal H e alth Se lf-h e lp an d
Gro u p s – Th e W ave o f th e Fu tu re
Previous research suggests that MHPs (e.g. medical practitioners,
psychologists, psychiatrists, social workers) may hold certain attitudes
that could interfere with their collaboration with SHGs, due to the
perceived ‘dangers’ of SHGs [35]. This includes dangers to patients
and their families, and to professionals resulting from the differences
in the systems of meaning that professionals construct regarding
SHGs [36]. However, other research investigating the nature of the
relationship between SHGs and MHPs indicates that MHPs: have a
certain degree of familiarity with SHGs; believe they could be
helpful; hold favorable attitudes toward them; and are prepared to
inform about and to make referrals to such groups [37]. The extent to
which psychiatrists oppose, or refrain from, making referrals to SHGs
precludes collaboration and the formation of valuable alliances; thus,
diminishing efforts in the struggle to improve MH care services that
are so urgently needed.
Se lf-h e lp
Mental Health Self-Help (MHSH) is an umbrella term that
encompasses a multiplicity of approaches and interventions that date
back to the 1950s, and were coined as “the wave of the future” over three
decades ago [21]. The MHSH movement emphasizes the importance
of responsibility and self-actualization in the healthcare sector [22],
and focuses on how people with mental illness, and their families,
organize multiple self-directed, mutual support-oriented initiatives,
including Self-Help Groups (SHGs), and non-profit organizations
[23]. MHSH embodies self-directed organizations of people that create
social change and facilitate personal transformation. Such strategies
constitute evidence-based, low-cost interventions with processes that
benefit their users and interface with the MH system. In the US, for
example, such initiatives have become increasingly common over the
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With a view to dispel any doubts among the psychiatric
community in relation to the potential benefits of SHGs, I next outline
the main research findings in relation to their therapeutic outcomes
and factors, mechanisms of change, and other related benefits –
including financial and economic benefits. In doing so, in the main,
I draw on 12SP in the treatment of addiction, as this represents their
genesis and historical development and the fact that they have been
the most researched types of SHGs.
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World Journal of Psychiatry and Mental Health Research
has found statistically significant greater levels of spirituality among
individuals maintaining recovery than those continuing to relapse
[45].
Th e rap e u tic Ou tco m e s
Multiple studies consider AA and other 12SP as one of the
few approaches to derive positive outcomes, including motivation
to refrain from drinking, increased active coping strategies, and
sustained self-efficacy. Thus, they claim that 12SP produce equivalent
outcomes to some evidence-based treatments such as Cognitive
Behavioral Therapy (CBT) [38]. Further, various meta-analytic
studies report that AA attendance: predicts complete abstinence and
reduction of alcohol consumption; enhances self-efficacy; quenches
the urge to drink; increases interest in others; increases abstinence;
and enhances social functioning and purpose in life and psychosocial
behavior [39].
Therapeutic group factors
The therapeutic group factors that underlie 12SP, and act as
mechanisms of change, relate to the processes or curative factors
emerging from group therapy research [46]. Such factors are known
to be powerful therapeutic agents in helping individuals with a range
of mental health problems, and are namely: instillation of hope;
universality; information giving; altruism; corrective recapitulation
of the primary family; improved social skills; imitative behavior;
interpersonal learning; group cohesiveness; catharsis, and existential
factors. These therapeutic factors are particularly relevant for
individuals experiencing Alcohol Use Disorder (AUD), or Substance
Use Disorder (SUD), given that the prevalence of comorbidities
(e.g. anxiety, depression, bipolar disorder, personality disorders) in
such populations is the norm rather than the exception, and they
require integrated treatment [47]. In essence, 12SP offer therapeutic
strategies that address treatment for populations with co-existing
mental disorders along with addiction, and extend to disenfranchised
and vulnerable groups.
Me ch an is m s o f Ch an ge
Extensive studies provide empirical support for the mechanisms
of change of 12SP. The positive relationship between participation
in 12SP and abstinence has been reported to be partially mediated
by inter-related factors such as enhanced motivation for abstinence,
positive social networks with less pro-drinking influences, more
friendships supportive of abstinence, and psychological and spiritual
mechanisms – including finding meaning in life. The mechanisms
of action for behavior change in AA and related 12SP fall into three
categories: (1) common processes; (2) AA-specific practices; and
(3) social and spiritual processes. Their main strength, however,
lies in the fact that they offer long-term, free, and easy access
exposure to recovery-related common therapeutic factors that can
be accessed according to users’ recognized needs [39]. Reported
mechanisms of change linked to NA participation, for example,
include: reconstruction of social support and network; sponsorship
or personal mentoring; increased motivation for abstinence;
transformations of identity and worldview; increased confidence in
one’s recovery; enhanced self-esteem and self-efficacy; improved
coping strategies; therapeutic effects of helping others; spiritual
renewal (life meaning and purpose); and decreased stress, anxiety,
depression, and shame [40].
Sponsorship – The therapeutic alliance and the helper
therapy principle
Two additional unique interwoven factors embedded in 12SP,
which have been found to predict program participation and abstinence,
are sponsor contact – a concept equivalent to the therapeutic alliance
[48] – and the Helper Therapy Principle (HTP) [49]. Within the 12SP
recovery context, sponsorship relates to the tradition of sober and
more experienced members of the program (sponsors) supporting
or mentoring newcomers to the program (sponsees). This entails
forming a strong personal and intimate ongoing relationship through
which sponsors share their experience, strength, and hope with
their sponsees. This factor was supported by the findings of Project
MATCH, which revealed that recovering alcoholics who help other
alcoholics maintain sobriety were significantly less likely to relapse
themselves [50]. Research using a rigorous methodological design,
which isolated the specific effects of AA sponsorship, found an overall
reduction in use of alcohol, marijuana, and cocaine over 12 months,
and lagged analyses indicated that AA attendance significantly
predicted increased abstinence [51]. The same study also found that
having an AA sponsor predicted increased alcohol abstinence, and
abstinence from marijuana and cocaine, after controlling for a host of
AA-related treatment and motivational measures associated with AA
exposure or that are generally prognostic of outcome. The sponsorsponsee relationship is comparable to the concept of a therapeutic
or Working Alliance (WA) between client and psychotherapist. The
WA comprises an agreement on goals, assignment of tasks, and the
development of bond, and has long been recognized as the major
factor in achieving change through psychotherapy [52].
Th e rap e u tic Facto rs
The three chief therapeutic factors of 12SP include spirituality,
therapeutic group factors, and sponsorship.
Spirituality
In the context of 12SP, spirituality relates to members’ search
for meaning and belief in a higher power that is apart from and
greater than themselves. Hence, albeit spirituality may include
religion, within the 12SP context, it is different than religion and
is expressed uniquely through each individual [41]. While religion
relates to an organized entity and involves practices and rituals about
a specifically defined God, spirituality is a subjective, intangible,
and multidimensional construct, which relates to an individual’s
search for meaning in life [39]. Spirituality has also been defined as
an expression of the transcendent ways in which to fulfill human
potential, and as a synonym of constructs such as hope, meaning,
wholeness, harmony, and transcendence [42]. Spirituality has been
identified as the most central and unique change mechanism in
12SP [43]. This is not surprising when considering that spirituality
has been identified as a universal quality of human experience [41],
an important feature of the therapeutic process, and a contributor
to improving life satisfaction, well-being, and reduced antisocial
behavior, substance abuse, and suicide rates [44]. Addiction research
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The above findings can also be linked to the HTP, which suggests
that those who help others help themselves [49]. The HTP postulates
that helpers’ MH benefits are derived from helping others with a
shared condition. The HTP, therefore, is embodied by a 12SP, such as
AA, NA, CA, and others. This principle also extends to populations
with chronic conditions beyond addiction [53]. As an example, a
study of GROW – a mutual-help group for individuals with mental
illness that promotes hope, mutual help, and recovery for good
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MH – found that giving help to others predicted improvements in
psychosocial adjustment [54].
knowledgeable of, and had made referrals to, SHGs. Nonetheless, less
than half of the sample had SHG literature available or discussed such
options with their patients. Not surprisingly, an effort to improve
the curricula related to SHGs offered at universities has already been
suggested [64], as a compelling evidence-based perspective for the
efficacy of 12SP interventions has been provided [65].
Benefits Derived from the Ubiquitousness
o f SH Gs
The ubiquitousness of SHGs relates to the fact that such groups
are everywhere and easy to access, as they operate around the globe,
and offer flexible daily schedules. Currently, for example, AA operates
in 180 nations, has an estimated worldwide membership of over
two million, runs approximately 1,23,000 groups around the world,
and the AA literature has been translated into over 100 languages
[55]. Similarly, in 2018 there were more than 70,000 NA meetings
in 144 countries [56]. This means that users can access support 24/7
and several times per day. This unparalleled global presence and
accessibility offer unique direct benefits to end-users themselves and
by default to MHPs – including psychiatrists, who can use SHGs as
adjunct or integrated treatment by referring their clients/patients to
such groups.
At a macro-level, MHSH and SHGs support GMH, which seeks
to address one of the most contemporary neglected global health
issues. Informed by multiple disciplines, such as neuroscience,
epidemiology, health services research, social sciences, and psychology
in particular, GMH is an evolving area of research and practice that
aims to alleviate the mental suffering of individuals and communities
around the globe through prevention, care, and treatment [66]. More
specifically, MHSH supports the four pillars of the new 2030 Agenda
for Sustainable Development [67]: first, the recognition that as a
global public good, MH requires actions beyond the health sector;
second, adoption of a multidimensional approach that conceptualizes
MH as a continuum from wellness to illness, thus enabling equal
emphasis on prevention and treatment of mental disorders along
with the promotion and maintenance of MH; third, emphasis on the
convergence effects of the environmental context and socio-cultural
experience, neurodevelopment, and psychology on brain biology to
create subjective experiences of MH; fourth, the premise that GMH
action is linked to human rights by emphasizing the essential role
played by people with lived experiences of MH conditions in shaping
research, prevention, and care. From this perspective, MHSH and
SHGs improve access to MH care services and reduce inequalities in
MH outcomes.
Financial and Economic Benefits
Finally, SHGs also offer financial and economic benefits. Both
perspectives attempt to estimate the net-benefits of treatment
investment based on the difference between use in SHGs and use
of more traditional approaches. However, while financial analyses
compare the costs or savings to users, enterprises or the community;
economic analyses compare costs or savings to the entire economy.
Due to methodological and practical challenges involved in
calculating such estimates, research in this area is scarce. Nonetheless,
the low‐cost strategy of SHGs has been found to foster post‐treatment
remission maintenance [57], and is a good strategy to extend
treatment benefits, by promoting post-treatment outcomes while
reducing the costs of continuing care, thus generating substantial
long-term savings [58]. The strongest research findings in this area
derive from randomized trials demonstrating that the outcomes of
mutual-help groups are equivalent to those of significantly more
costly professional interventions [59].
At a micro-level, SHGs are peer-based practices that facilitate
a grass-roots process, and their programs are run as participatory
democracies where members make significant organizational
decisions. The benefits of using SHGs are twofold. First, they
empower individuals by enhancing their self-efficacy, self-concept,
and reducing the stigma associated with mental illness. Second, they
relieve psychiatrists and other MHPs from the pressure of excessive
workloads, the impact on poor work-life balance and emotional
exhaustion, which in turn are putting their patients’ care at risk.
Discussion
Based on the foregoing review, the collaboration between
psychiatrists and SHGs seems plausible, and a highly desirable,
integrated, cost-effective, and sustainable delivery model to deal with
the current MH crisis. Hence, more psychiatrists should seriously
consider the benefits of referring patients to SHGs, as a way to
broaden their repertoire of clinical strategies and unburden their own
workloads. This approach is in line with the view that integration
maintenance therapy and psychosocial interventions are likely to be
the most effective to treat SUD and underlying psychological issues
[60]. It is also consistent with state-of-the-art clinical psychiatry,
which aims to provide successful treatment using a comprehensive
approach that integrates biological, psychological, social, and
spiritual perspectives [61]. The results of rigorous research involving
a controlled study of Recovery Inc. – a self-help program for people
with psychiatric problems [62] – area good example of this. This
study reported that subjects with psychiatric problems reduced both
their symptoms and complementary psychiatric treatment following
attendance to SHGs. It concluded that SHG attendance is a valuable
adjunct strategy to psychiatric treatment. Another example is a study
that examined psychiatrists’ referrals to, and support for, participation
in SHGs for patients with mood disorders [63]. In this study, about
75 percent of psychiatrists reported that they believed they were
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Moreover, MHSH and SHGs support Single-Session Interventions
(SSIs) [68-70]. Such interventions promote little treatment with
promising effects, and were developed to address the fact that up to 75
percent of youths with MH conditions never receive care services. SSIs
can be conceptualized as psychological first aid. Hence, an SSI
provides assistance to people who need it, when they need it. SSIs aim
at assisting individuals to manage everyday stress and MH (e.g.
anxiety and depression) by using psychological principles and
components of evidence-based therapy within a single session. Using
this approach, psychiatrists can provide patients what they need by
squeezing the most useful strategies into one optimized session. The
assumption behind SSIs is that they provide individuals with what
they need to help themselves develop and grow, without assuming
they’ll come back for more. Clearly, SSIs are in line with the MHSH
philosophy, and for psychiatrists could entail providing information
related to, and/or referrals to, SHGs.
Lim itatio n s an d Re co m m e n d atio n s
This paper is not free of limitations. The main limitation is that,
being a conceptual paper, this qualitative study is a perspective-based
method of research, which is interpretative in nature. Like most
qualitative studies, it did not involve the collection and analysis of
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World Journal of Psychiatry and Mental Health Research
empirical data or the use of control groups. Hence, the future viability
of the proposed ideas waits to be seen. To this end, future testing of
the propositions outlined in this paper is recommended.
Notwithstanding its limitations, this paper offers relevant and
pragmatic opportunities for psychiatrists, and other MHPs, to
consider ubiquitously in their practice and as a contribution to the
current global mental health and addiction crises.
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collaborative approaches and interventions, to address the current
mental health and addiction crises. This has included discussing the
contextual factors and conditions that have exacerbated these crises,
as well as the main challenges currently faced by psychiatrists. The
paper has further explored how it is in the psychiatrists’ best interest
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moving from the traditional professional-centered model towards
a more holistic, person-centered, and collaborative approach with
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