Recovery International: A Wellness Model for Self-Help Mental Health
Continuum – The Journal of The American Association for Ambulatory Behavioral Healthcare
Psychiatrists and other practitioners suggest that in an era of managed care, it behooves professionals to familiarize themselves with a wellness model like Recovery International to help their patients regain and maintain better mental health. As a community-based program, Recovery is considered an adjunct to professional care. In this article, the author describes the principles upon which this program is based and examines its characteristics. She describes its basic techniques, including the emphasis placed upon the use of language and its importance in providing a sense of safety and security for the patient.
Recovery International is among the oldest self-help mental health organizations, if not the oldest. Founded in 1937 by Abraham A. Low, M.D., it is perhaps best known for helping persons who suffer from nervous symptoms and fears. The purpose of the organization is to help prevent relapses in former mental patients and forestall chronicity in nervous patients. Like many other long-lived self-help groups, Recovery International is nonprofit, nonsectarian, and has been completely member-managed since 1952. Recovery provides training in systematic techniques for controlling behavior and changing attitudes. At weekly group meetings led by carefully trained group leaders, members learn to practice these techniques in their daily lives and share their successes, setbacks, and insights.
How does Recovery translate into a wellness model? Many factors come into play, but perhaps one of the most significant depends upon the person who is seeking relief. Success in a self-help program is more likely to happen if members admit to having a problem and are willing to do something to help themselves. This identifies individuals who are ready for a program of self-help. In a controlled study conducted by Galanter (1988), he found a decline in both symptoms and concomitant psychiatric treatment after subjects had joined the group. He concluded that peer-led self-help groups have value as an adjunct to [professional] treatment.
Members learn self-leadership techniques in the Recovery program and are urged to take responsibility for their own mental health while cooperating with their mental health professional. As a lay-led program, Recovery does not attempt to offer diagnosis, treatment, advice, or counseling. It is designed to help persons with different diagnoses because its focus is on symptoms rather than diagnosis. No matter what the disorder, persons experience similar problems: low resistance to stress, fatigue, depression, anxiety, nameless fears, racing thoughts, obsessions, compulsions, anger, low self-esteem, and a host of others. Recovery works toward solutions instead of dwelling on problems.
In Recovery, we believe that a wellness model must demonstrate that persons can regain and maintain better mental health. As its executive director, I see this demonstrated in a very pragmatic way, supported by the letters that continually cross my desk from persons who have written to tell me how their lives have been changed. Individuals who were too afraid to leave their homes are now going about their business, participating in family and community life, able to work again, able to enjoy an average life. These are the grateful members who express their thanks that Recovery was available when they needed the program. This surely is evidence of a successful wellness model. We welcome the opportunity to set forth here the essence of a wellness model that has affected so many lives.
Recovery International was founded November 7, 1937, by Abraham A. Low, M.D., who developed the Recovery method after many years of research, study, and treatment of patients. The organization itself was formed by thirty ex-patients under the care of Dr. Low, who was assistant director of the Psychiatric Research Institute of the University of Illinois Medical School at that time. They regained their health after receiving shock treatments and/or other therapies but felt they still needed help because the outside world regarded them as ill ("once a mental patient, always one"). They appealed to Dr. Low to help them find some solution to the stigma that was ruining their lives. While working with these patients, Low was convinced they could be taught specific principles that would prove they could regain and maintain their mental health. Between 1937 and 1940, the organization limited its services to the patients admitted to the wards of the Psychiatric Institute. In the fall of 1940, it expanded its work to include the psychoneurotic patients of the outpatient department. In September 1941, the group left the shelter of the University of Illinois Medical School and established its own headquarters in downtown Chicago. After 1942, the bulk of its membership was recruited from Low's private practice. He had an opportunity to try out techniques with the intramural patient population, with out-patient groups, and with private patients. Today, the thousands of people attending Recovery's weekly meetings come from a wide range of backgrounds. Some have been hospitalized, some are under the care of a professional, and others are seeking better ways to manage stressful lives. There are more than seven hundred groups that meet weekly throughout the United States, Canada, and abroad. The object of Recovery International apart from its tendency to save time for the professional and money for the patient, is to help prevent recurrences in mental diseases and to forestall chronicity in psychoneurotic conditions. The techniques that were developed place emphasis on self-help, the underlying premise of a wellness model.
What Constitutes a Wellness Model
As a program that was developed by a neuropsychiatrist, subject to research, trial, and testing over a period of nearly fifteen years before it became a self-help association, it can be said that the foundation of the Recovery model is solidly based upon medical principles. We believe this is one of the primary reasons why it is considered a wellness model. Because of its structure, the Recovery model is also one that can be easily understood. Once participants become familiar with the spotting techniques, these systematic tools are used to help reduce or eliminate the nervous symptoms and fears that are common to an assortment of different diagnoses. The Recovery method is effective in dealing with a host of different mental or emotional problems, including depression, panic and anxiety attacks, obsessive compulsive disorder, bizarre thoughts, anger, and sleeplessness, as well as helping to prevent relapses in the former mental patient. Persons who become familiar with the Recovery method learn that the trivial problems of daily life stem from either angry or fearful temper. Angry temper comes when people believe that someone else has done them wrong, and it often results in resentment, impatience, indignation, disgust, or even hatred. On the other hand, fearful temper is when people believe that they themselves are wrong. This usually expresses itself in feelings of inadequacy, discouragement, preoccupation, embarrassment, worry, shame, hopelessness, despair, and withdrawal. Fearful temper often leads a person to have feelings of inferiority and low self-esteem.
In Recovery, members learn that we all experience feelings and sensations, thoughts and impulses. We cannot change feelings and sensations, but we do have the ability to control our thoughts and impulses. The Recovery method teaches us how to differentiate between thoughts and impulses, feelings and sensations, and then demonstrates the techniques for controlling thoughts and impulses. Being shown how to train ourselves to control our thoughts and impulses to dispel angry or fearful temper and thus relieve symptoms is another important tenet that contributes to a wellness model.
A practical example of how this works was told to me by a young man who was suffering from depression and feelings of insecurity. Although he had been attending a support group for more than six years to be with others who shared the same diagnosis, he was drawn to Recovery because he almost never went away from his support group meeting feeling better about his problems. After eight months of attending Recovery, he had learned enough systematic techniques to help him change his thoughts and control his impulses in order to minimize or eliminate his symptoms. In the most basic terms he said, "At Recovery I am learning what to do to help myself. Before Recovery, I was relying on others to make me feel better. Now I know I can do something to help myself." A program such as Recovery, that provides effective tools to exercise control over thoughts and impulses and enables persons to manage their psychiatric problems themselves, can be characterized as a wellness model.
Many self-help and support groups that are unstructured and informal encourage persons who share a common problem to come together to talk about their difficulties in the hopes that jointly they will find some answers. They want relief but often don't understand what to do to help themselves. Low believed that his patients could learn to exercise control over their thoughts and impulses and that this control would give them the ability to manage their psychiatric problems.
Some Characteristics of an Effective Wellness Model
- It concentrates on wellness rather than illness.
- It is structured and systematic rather than informal (this supports the research conducted by Yalom (1985), which demonstrates that systematic instructions are effective in achieving a desired goal of behavior shaping).
- It is informative and instructive.
- Use of examples helps integrate information and demonstrates how to use the principles as tools.
- It instills hope (helpless but not hopeless) so that persons can feel that their thoughts/symptoms are not unique.
- It provides a safe, welcoming environment and offer comfort and acceptance.
- It offers the opportunity to help others; this makes one feel good about one's own self.
- It helps develop a sense of personal responsibility and minimize fostering co-dependent behavior.
- It should be recognized by mental health practitioners as effective so that they can make referrals. This is more easily done if it follows a medical model based on research and practical application.
- It recognizes the patient's right to self-determination, thereby demonstrating adherence to social work principles.
- It should be affordable (free, if possible).
How Does Recovery International Work?
According to Lieberman and Borman (1979), Recovery International can be described as having four basic points:
- Authority of the doctor. Most patients attending Recovery (ed. Note: anyone attending a Recovery group meeting is considered a 'member' of the organization) are also seeing a physician or psychiatrist at the same time. In the early years, this figure was Dr. Low himself. Since Low's death in 1954, members have seen private doctors, and no professionals have played a role in the organization. It remains a crucial tenet of Recovery teaching, however, that the doctor is always right. To question the doctor's diagnosis is to take the first step in undermining health. There is an important hidden assumption here--that the member's psychiatrist, whatever his or her views, is offering a brand of supportive therapy that emphasizes the client's basic soundness. Thus, to accept the doctor's "diagnosis" is to believe oneself essentially well, or at least getting better.
- The Will. Dr. Low maintained that, no matter what stress he or she faces, every human being retains a certain autonomous power of choice. The seal of this choosing faculty is the Will, which lies within a kind of impregnable bastion at the center of each person. Despite appearances, Low maintained, no emotional body can capitulate to stress without secretly choosing to do so. The reason is that no stressful experience is ever wholly real; properly tutored, we can learn to ignore it and go on acting.
- Illusions of illness. Recovery International offers two explanations for the appearance of illness that continues to beset group members. The first points to some mixture of habit and defeatist language. In many cases, the member is someone who has been ill (hospitalized); as a result, he is still prone to using "sick" language about himself, to speak of "relapses," and "unbearable pains." Recovery teaches him a different language that curtails unhealthy thoughts. Thus, "depression" becomes "lowered feelings," "relapses" becomes "setbacks," and "unbearable pain" becomes "bearable distress." In addition, Low maintains that if anyone practices Recovery methods for two months and still finds that his troubles persist, the reason is that he secretly indulges them. Without realizing it, he is probably engaging in "self-diagnosis," and thus "sabotaging the physician's efforts."
- Will-Training.This is the way Recovery defines its main therapeutic activity. The "training" seems to be a matter both of alerting the Will against its possible complicity with symptoms and of giving it ways to "stay in charge" in the face of any crisis. There are two prongs to this strategy.
The first is the devaluation of feeling. In Dr. Low's view, the Will is assailed constantly by a welter of conflicting thoughts and impulses, feelings and sensations, most of them highly untrustworthy. One of its basic tasks is to choose among these, rejecting some and accepting others. In Low's book, Mental Health Through Will-Training (written in 1950, the principal text used by members attending Recovery groups), he puts the crucial feature of this task very forcefully: "Get it into your heads that a human being has the power to choose what to believe and what not to believe. This power to choose is called the Will. The main beliefs between which the Will must choose are that in a given condition you are either secure or insecure. If you accept the thought that your head pressure is the result of a brain tumor, you have formed the belief of insecurity. If instead you choose to think of it as a mere nervous headache, you have rejected the belief of insecurity and put in its place that of security."
The mark of a well-trained Will, then is an ability to "accept the secure thought and reject the insecure one." In actual practice, however, Recovery seems much more concerned with ways of rejecting perceptions and feelings than with ways of accepting them. The essential technique is termed "spotting," the art of identifying and curtailing insecure thoughts before they get out of hand. Most of the group's sayings and formulas are directed to this end. Some of these ("I can bear the discomfort"; "There is no right and wrong in the trivialities of everyday life") negate the importance of events in the outer environment of social life and personal relations. Others ("Feelings are not facts"; "That's just fearful temper"; "It's distressing but not dangerous") are meant to combat threats from the inner environment, the realm of emotions and somatic symptoms. The actual use of these formulas is varied. However, all of them seem to be ways of softening disturbing perceptions by treating them either as meaningless or as able to affect the self.
The second prong of Will-Training is the promotion of action. Just as the Will is free to reject threatening perceptions, it is also free to initiate actions that benefit the patient, even in the face of great anxiety or depression. The secret of this freedom is a technique that Dr. Low labeled "muscle-control." It is based on the simple fact that anyone, even a person who has "lost the desire to do anything," retains the power to move the muscles of the skeletal frame. If he moves them in the right order, he can go through the motions of being a normal human being. And this is precisely what Recovery tells him to do. The assumption is that "the muscles can reeducate the brain." If the member acts normal for a long enough period, he will begin to feel normal too. Much the same strategy applies to the daily trials of social life. Here members counsel one another, when beset by strange impulses and unpleasant thoughts, to practice "wearing the mask" and "controlling the speech muscles" in other words, to keep up a solid pretense of normalcy. The guiding principle under such conditions is "group-mindedness," which means behaving in accord with social obligations in spite of anything they may feel. The key assumption is that being normal is fundamentally a matter of acting that way.
Parallels Between Recovery International and Cognitive Behavioral Principles
Low was a pioneer in cognitive behavioral therapy, although he did not give his method this name. This affords a unique value in that the Recovery method is compatible with cognitive behavioral concepts, although Low's terms are different. To recap the close parallel between cognitive behavioral therapy and Recovery International they both: (1) educate patients about stressful reactions, (2) break problems into small units or trivialities, (3) reframe and re-label the problem, (4) teach patients to use self-monitoring methods, (5) coach and rehearse patients on methods and concepts, (6) instruct patients as to how to use the method in daily life situations, (7) teach that patients must always reward or "self-endorse" themselves, (8) demonstrate how the method works by telling how they were before and after treatment, and (9) provide opportunities to teach new members. Recovery International expands this last opportunity to include roles of assistant leader, group leader, and area leader for a larger geographical unit.
The following was prepared by Donald T. Lee, M.S.W., A.C.S.W., comparing the Recovery method taken from Low (1950) and "How to Give A Recovery Example" by Low, as well as Lee's personal observations using the schema by Cormier and Cormier (1985).
Schema for Cognitive Recovery Method Behavioral Therapy
1. Therapist educates patient about stressful reactions.
1. Members are educated about the stressful reactions. Recovery method by the group and in reading Low's book, Mental Health Through Will-Training. There are six parts to this initial education:
a. Patients must be prepared for the "inevitable set-back."
b. Patients will practice self-sabotage until they learn how to overcome sabotaging themselves.
c. Treatment starts by convincing the patient that "sensations can be endured, the impulse controlled, the obsession checked."
d. Will permeates all significant phases of daily life and can be utilized to overcome the many difficulties experienced.
e. No "common everyday" inner experiences are "irresistible"; they are just not resisted.
f. Patients must "endorse themselves" every time they make a "will to effort" to apply the method.
2. Therapist breaks problems into small units.
2. Patients learn to do things in parts and are taught they do not deal with complex issues, only the "trivialities of everyday life."
3. Therapist reframes and relabels the problem. This restructuring presents a different view for the patient.
3. Patients learn that "symptoms are distressing, but not dangerous." "Angry and fearful tempers" bring on symptoms. A "vicious cycle is induced" when the patient's fear of the "permanent handicap" brings about more symptoms.
4. Therapist teaches patient how to use selfmonitoring methods
4. Patients learn how to "spot" for themselves and on others when examples are given in meetings.
5. Therapist coaches patient in use of relabeled concepts and monitoring methods.
5. The meetings help Recovery members rehearse the method by following the four steps for presenting examples.
Step One describes the event that is to be reported as an example, mentioning the various things that were said or done, the persons involved, the time, and then the temperamental reaction.
Step Two describes the symptoms and discomfort the member experienced.
Step Three describes the Recovery spotting and practice.
Step Four describes what would have happened before Recovery training.
6. Therapist instructs patient in applying these concepts in daily life situations.
6. The patient is taught to practice the method in daily life and give examples in meetings. When difficulties occur, the member calls an experienced member and presents an example in a five-minute phone call. The experienced member then spots on this example.
7. Therapist instructs patient in how to give self a reward for using the concepts.
7. Any use of practice of the Recovery is known as a "will to effort." Patients must reward themselves immediately by saying, "I endorse myself." They learn to endorse for "effort and not necessarily success."
8. Therapist encourages and supports a patient in telling how he was before treatment and how he is now reacting to real life situations.
8. Each time the patient gives an example, the last step calls for describing how Recovery training has made improvement over how he or she would have reacted before Recovery training.
9. The patient takes on the role of teacher to others.
9. After a period of progress, the leader may ask experienced members to give some of their medical history of hospitalizations or other difficulties. The newcomers then can appreciate that those Recovery members who seem so functional in giving an example went through many serious problems too.
Each time patients give an example in the meeting they become a role model for others in the group.
At some point, members of the group are asked to become assistant leaders and later leaders of a group. All leaders are given extensive training in the method and in how to handle the responsibilities of leadership.
The Importance of Language in the Recovery Method
In his daily rounds in state hospitals, Dr. Low came across all kinds and degrees of illness. He quickly discovered that with the less disturbed patients the right choice of words had the power to mobilize their will to health. He, who had spent so much time in the study of language, now used every interview to make a search for the most effective words.
From his years of study, Low evolved the concept of the duality operating in nature. Everything that had life and movement was made up of a pair of opposites. Even language was so constructed that the meaning of one of the pair could not be understood without its counterpart. How could "above" be understood without its counterpart "below"; "right" without "wrong"; "comfort" contrasted to "effort"? Once the patient realized that for every negative force there was a positive tool with which to combat it, the patient could overcome abnormality with sanity. That is why the techniques of the method consist of such tools as: "Excuse don't accuse;" "Move your muscles" to overcome inertia; "Control your muscles" to control impulses; "Take the secure thought in place of the insecure;" "Do the things you fear to do." This is fully described in Low's biography by Rau and Rau (1971).
Although Low, according to his biographers, found himself at odds with the psychiatric establishment in the 1930s and '40s, which was dominated by the then-popular model of Freudian psychoanalysis, his focus on the role of language was very much in the mainstream of intellectual currents of his time. Low's noteworthy contribution came in evolving this mainstream approach to language into a practical system of self-help techniques. He was certain that if people "created their reality" through the language they used, then the language used by his patients had to be an integral part of both the problems they faced and their solutions.
His two most important concepts are "the symptomatic idiom" and "temper." The symptomatic idiom, he says, boils down to one word - danger! The patient's every symptom, every reaction, every behavior becomes labeled and symbolized as a threatening sign. Temper refers to the mental and linguistic habit of interpreting life in terms of judgments of right and wrong - angry temper, if these judgments are directed towards others; fearful temper, if they are directed towards oneself. If language is an essential part of the problem patient's face, then it follows that language must be a part of the solution. From this insight, Low developed the approach that is central to the Recovery method - the "Recovery language." Over a considerable period of time, Low, with the help of his patients, developed ways to undercut unhealthy linguistic practices by substituting for them a language which has built into it an emphasis upon safety and security. As examples: "Helplessness is not hopelessness," "symptoms are distressing but not dangerous," "every act of self-control builds a measure of self-respect." All of these phrases which are woven into the method are directed at the reduction of temper and the removal of the symptomatic idiom (Collier, 1995).
Following are some of the phrases that are part of the Recovery method:
- You do things while you are getting better rather than waiting until you get better to do things.
- Command your muscles to do the things you may fear to do.
- Change your thoughts by using your free will.
- Set realistic expectations (don't expect to be perfect because no one is).
- Anticipate setbacks, but do not look at them as permanent disabilities.
- Do not stigmatize yourself, and do not allow others to stigmatize you because you have an illness.
- Continue consulting with your professional therapist if necessary.
- Learn the Recovery method and practice using it so that it becomes part of your normal way of life (it is simple but not easy!).
- Focus more on the positive things you accomplish and less on the negative things that do not go as you might have planned.
- Do not expect overnight results.
- Learn to be a patient patient.
- Do not expect to discuss your medications or diagnosis.
- Control your reaction to the outer environment rather than trying to control the outer environment, which is beyond your control.
Because such phrases are simple, their very simplicity makes them easy to learn, to remember, and most important, to apply in times of stress. As a model of wellness, Low has helped patients to live in a reality of hope rather than a reality of fear and despair.
What Are the Benefits of Recovery, Inc.?
- In addition to being an effective program (as attested to by countless mental health professionals who refer their patients/clients to Recovery groups), the program is very cost-effective. There is no required fee to attend a Recovery meeting, although those attending are asked to make a voluntary contribution. The average donation is $2 or $3. For those unable to put anything into the "hat" when it is passed, that's okay too. No one will say anything, nor is anyone pressured to contribute.
- There are more than seven hundred groups throughout the United States, Canada, and overseas. The fact that each Recovery group is structured exactly the same way provides a uniformity that makes it possible for Recovery members to attend group meetings wherever they find themselves without having to learn a new format or use unfamiliar material.
- Recovery International has carefully trained volunteer group leaders who are required to undergo a thorough training process. Even after authorization, group leader training continues on a monthly basis and reauthorization takes place annually by an area leader who oversees group leaders.
- Recovery International has been recognized by the professional community for its effectiveness. The American Psychiatric Association honored five outstanding mental health programs at the opening session of its 43rd Institute on Hospital & Community Psychiatry (now known as Psychiatric Services). Recovery International was chosen as one of the five to receive a Significant Achievement Award from among sixty-four applicants.
- The materials used in conjunction with the program are available in English, Spanish, and French.
- Recovery does not supplant the mental health professional. Group leaders do not counsel, advise, discuss medication, or try to diagnose anyone's illness. Group leaders encourage participants to consult their own doctor for diagnosis, treatment, and medication.
- Professionals are prohibited from leading Recovery groups. All group leaders are persons who initially came into Recovery needing the program offered. This makes it easier for the average group member to identify with the leader as a model of wellness that can emulated.
- In an era of managed care when many individuals find themselves with caps on their insurance coverage, Recovery International proves to be a community-based program that offers an effective method of self-help for dealing with symptoms common to many disorders collectively referred to as "mental illnesses."
A Professional View of Recovery as a Wellness Model
Basically, Recovery is a support and training process (wellness model), useful in reinforcing the therapist's objectives in treatment, helping the patient sustain himself between visits and avoid acting out. With the enrichment from this support, therapy is accelerated, its overall cost is reduced and the duration of morbidity is decreased.
It is a concept that has been ahead of its time but remains ready for practicable applications if professionals examine and appreciate its potential. For some of my patients, it has been the difference between their being able to function in society or being chronically disabled by illness. At its worst, when a patient fails to use it, the consequences of exposure to it are always benign. Therapy itself seems to be the major benefit of Recovery, Inc. I see my patients in Recovery doing much better clinically than those with comparable problems not in a Recovery group.
Recovery is complementary to therapy and not competitive with it. It will be to our enrichment as professionals to be aware of it as an asset to our patients' health (Solon, 1993).
A Patient's View of Recovery as a Wellness Model
Celinda (her real name) was hospitalized more than 25 years ago. She didn't want to live because she couldn't imagine ever enjoying life again. Today, her life is full and meaningful. The following is a description of how she regained her mental health:
It has been many years since I experienced the dreadful nervous fatigue that debilitated me in my mid-20s. The depression I remember from my early childhood is now a stranger. When I was 28, I was diagnosed as schizophrenic and committed to Camarillo State Hospital. This followed several hospitalizations, each one after a suicide attempt. I had numerous shock treatments and medications, and it was there that I was introduced to Recovery, Inc. At last I had found a program to help me right when I was having symptoms. I gradually changed my beliefs from ""there is no hope for me" to "who knows, I could be one of those who can get well." From there it was a long, slow climb--steps forward and back, but after leaving the hospital, I never returned. Strong symptoms of despair and gloomy thoughts still came frequently, but I learned to recognize them. Usually they were a reflection of my own feelings of inadequacy. As the years went by, these symptoms occurred less and less often, partly because I no longer feared them.
Recovery has given me my life, and it has given me a philosophy that has helped me cope with everyday living. Today, I continue to attend Recovery meetings because I find them to be good insurance against setbacks (Jungheim, 1994).
Comments, Challenges, and Conclusions
If it is true that participation in self-help or mutual aid groups can greatly optimize mental wellness, then key tasks facing mental health professionals include familiarizing themselves with such organizations, promoting relevant research, and facilitating referral to these groups. Recovery International and other organizations have been invited by some hospitals to operate groups for inpatients on a volunteer basis. Although this practice may blur the lines between professional and lay therapy and create conflicts of interest, it appears to be a logical and viable tool for introducing patients to such resources.
Questions always arise about what type of person with what type of mental disorder would benefit from a given therapy. Obviously, the nature of an individual's symptoms, especially cognitive impairment or thought disorder, can limit his or her ability to engage in therapeutic self-help. However, for many people using mental health services, engagement in a self-help organization such as Recovery International may be of real benefit. Low's principles are compatible with current mental health theory and practice.
Moreover, use of Recovery International is extremely inexpensive and intentionally avoids distinctions based on diagnosis. It promotes effective coping with fears, stigma, and everyday stressors common to most people with mental illness. It can help people with a broad range of dysfunctions--if they choose to "walk through the door."
As capitation increasingly limits availability of professional services, new and existing resources within the lay therapeutic community may become increasingly important in the care of people with mental illness. It is both timely and important for mental health professionals to familiarize themselves with all resources in their communities and to make critical assessments about their potential benefits and harms.
Perhaps with judicious, appropriate and even integrated use of such resources, mental health professional will find that providing care for patients and their families in the era of managed care is indeed manageable (Murray, 1996).
Posted with permission of Continuum, The Journal of The American Association for Ambulatory Behavioral Healthcare, and Shirley Sachs.
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