PSYCHOTHERAPY: THEORY, RESEARCH AND PRACTICEVOLUME 8, # 1 , SPRING, 1971

PEER GROUPS AND MEDICATION, THE BEST "THERAPY" FORPROFESSIONALS AND LAYMEN ALIKE*

0. HOBART MOWRERUniversity of Illinois

Urbana, Illinois

The Transition from Individual to GroupTreatment

For many years the emphasis was exclu-sively on individual psychotherapy. This wasunfortunate but understandable. In medicine,the Hippocratic Oath binds the physician toconfidentiality, i.e., to seeing and speakingwith the patient privately; and the penaltyfor priestly violation of the Seal of Confessionis an extremely severe one. Therefore, it wastacitly assumed by psychologists that if theirethics were not to be impugned, they too wouldhave to respect the patient's privacy and workwith him on a one-to-one basis. What we failedto realize was that privacy, in the sense ofguilt-laden secrets, far from being the cure, isvery often the disease itself and that telling asecret of this kind to a professional withwhom it will be "safe" cannot be expected tomove a duplicitous, secretive, withdrawn per-son very far toward a clear conscience, open-ness, and normal social responsiveness. Soclinical psychology searched feverishly fornew methodologies, but such innovations aswere thus developed were practiced in thesame interpersonal setting as had traditionallyprevailed both in medicine and in the churchfor many centuries. The results, as the Boul-der Report indicates, were not conspicuouslybetter than had been previously obtained byphysicians and clergymen.

Now all of this involved two curious over-sights. Beginning in 1935, an organizationknown as Alcoholics Anonymous had come

* An abridged version of a paper prepared for asymposium, "Where Do Therapists Turn for Help?Personal Self-change Techniques of Experienced Psy-chotherapists," held under the sponsorship of Division29 (Psychotherapy), at the annual convention of theAmerican Psychological Association, Miami Beach,Florida, September 4, 1970.

into existence which, by 1949, had alreadyhelped thousands of men and women achievesobriety where all else had failed (Anony-mous, 1955); this organization was (a) char-acterized by the absence of professional ser-vices of any kind and (b) consisted of "a fel-lowship of men and women who share theirexperience, strength, and hope with each otherthat they may solve their common problemand help others to recover from alcoholism"(italics added). Here, manifestly, was grouptherapy—and it was successful! Also, underthe exigencies of the psychiatric manpowershortage during World War II, it had beendiscovered by 1946 that, contrary to all expec-tations, "shell-shocked" or "battle-fatigued"patients were responding more positively to aprofessional therapist when treated in groupsrather than individually.

In 1961,1 published a small book in whichI said:

The trail which AA has blazed is the only onedown which I can at present gaze and see anythingthat looks like the road to the future. How AA prin-ciples can be adapted or modified to meet the needsof other kinds of confused and suffering people is notfully clear to me. But I am as sure as I can be ofanything that no therapy will be radically andbroadly successful which does not take the neurotic'sguilt seriously and does not help him admit his errorsopenly and find ways to work in dead earnest to rec-tify and compensate for them (Mowrer, 1961, pp.109-110, italics added).

1969 may appropriately be referred to asthe "Year of the Group." Virtually everylarge-circulation magazine in this country car-ried at least one feature article on the phe-nomenon of grouping, not to mention moviesand TV programs on the subject. Of numerousarticles and books on this subject by profes-sionals (Mowrer, 1971a), I would place Na-than Hurvitz's (1970) "Peer Self-Help Psy-chotherapy Groups and Their Implications for

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I

PEER GROUPS AND MEDICATION 45

Psychotherapy" at the top of the list.1 Whythis relatively sudden explosion of both popu-lar and professional interest in various formsof group experiences?

A perhaps too synoptic and truncated butessentially valid view of the matter is that,during the last half century, urbanization,geographic and socioeconomic mobility, andassorted technological changes have badly dis-rupted the traditional institutions of home,church, school, and neighborhood, with the re-sult that great masses of people no longer arefinding the sense of personality identity, emo-tional intimacy, and cosmic meaning whichthey once knew and that the small-groupmovement represents an attempt to create, notjust a kind of "therapy," but actually a newprimary social group, or institution, which willcompensate for these basic human losses (cf.Gendlin, 1968, 1970; Gendlin & Beebe, 1968;Mowrer, 1970; 1971a).

In one of his papers Gendlin says:

For a long time we haven't had anything on thegroup level that corresponds even to "friendship" [cf.Schofield, 1964], To be in a group, one had to pleadsick (therapy) or one has to have (or pretend) aninterest in photography, adult education, or politics.Often groups want to continue to meet, though theirreason for being is over (after the election, for exam-ple) and no socially understood pattern exists for con-tinuing a group because there is a human need to be-long to a group. But such a pattern is coming. Al-ready today we have psychotherapy groups, T groups,development groups, sensitivity groups, managementskills groups, brainstorming groups, all quite similar.Soon it will become understood that everyone needsto be in a group.

While these groups have different names, and insome cases deal with very different contents (e.g., reli-gious doubts, politics, a certain vital group processoccurs in all of them: The newcomer finds himselflistened to, responded to, discovers that he makes sense,can articulate feelings and reach out to others, beaccepted, understood, appreciated, responded to closely(italics added).

In the future we will provide people with a quietclosed group in which they can move in depth, tellhow things are, share life so to speak, perhaps saylittle at times, perhaps do major therapeutic workwhen needed, but always having the belonging, theanchoring which such a group offers. Then, in addi-tion, those who want to, can serve a vital function inthe other type of group that is open to newcomers,

1 Perhaps the most eloquent testimony to the ubi-quity of small groups is the cartoon which appearedin the July 18, 1970, issue of Saturday Review withthe legend: "My therapy group can lick your therapygroup."

where a few veterans who know how to relate inti-mately can swiftly bring a whole group of new peopleto the break-through point (Gendlin, 1970, p. 23).

This is only one of many possible sources ofevidence that the Small Group is indeedemerging as a new primary social institution.How it will be related to the more traditionalprimary groups is still an open question, butthere is at least some basis for speculation inthis connection. Small Groups may help stabi-lize the nuclear family by providing a kind ofsubstitute for the Extended Family. James Pe-terson (1960) and other writers on courtshipand marriage have shown that the husband-wife relationship is likely to be or becomeunstable unless anchored in a larger socialcontext. The Small Group often admirablyprovides such a context for engaged or mar-ried couples.

There are indications that the Small Groupmay largely replace the Established Church.Christianity started as a small-group move-ment (McNeill, 1951; Poschmann, 1964;Mowrer, 1967), with great "therapeutic"power; but it has evolved institutionally insuch a way as to become increasingly "irrele-vant" for many modern men and women. In-tegrity Groups, while non-theistic, are highlyreligious in that they are vitally concernedwith human reintegration, reconciliation, orreconnection (which is what religion means—Mowrer, 1969, 1971b).2 There is more thanone reason for thinking that the Small Groupmay be the emerging "church" of the 21st Cen-tury. Already we have in one of our IntegrityGroups an ordained minister, now defectedfrom the conventional church, who says:"This is now my church." Recently I wasspeaking with a liberal rabbi who observedthat Judaism is today fixated on certain formsof worship which consist, mainly, of "conver-sation," on the part of both the congregationand the rabbi, with a deity who is no longervery real to any of them. Yet they do notseem to be able to abandon these ancient andtoday largely meaningless liturgical forms."What we really need," this rabbi said, "is tolearn to talk to each other." This is what theSmall Group provides, better than any other

'Integrity Groups are the particular facet of theSmall Groups movement with which the presentwriter is specifically affiliated. They will be alludedto subsequently in this paper.

46 O. HOBART MOWRER

presently existing institution: the chance forpeople to talk to each other, in depth and witha view to personal change ("salvation").

It used to be that people who lived adjacentto one another constituted a neighborhood orcommunity. Today, in rural areas and smalltowns there is still some sense of community;but in cities, and especially among largeapartment dwellers, anonymity and personalisolation are instead the rule. There is no in-herent reason why the city or even apartmenthouses need be so impersonal, but the fact isthat, in general, they are; and we have peoplein our groups who say that these groups are,to all intents and purposes, also their commu-nities, the people whom they know best andwith whom they interact most. Perhaps smallgroups may prove useful in revitalizing neigh-borhoods and communities in the geographicsense of these terms.

The developing relationship of the SmallGroup movement to the schools is particularlyinteresting. Until a few years ago, counselingin schools and colleges was almost entirely onan individual, one-to-one basis. But schoolsare moving to group counseling methods,(Mahler, 1969, Ohlsen, 1969); such experi-ence in the schools prepares or "conditions"our youth—nationwide—for participation inSmall Groups in later life.

A bright undergraduate psychology studentwho happened to have read an earlier draft ofthis paper—and also a paper by Rollo May(1953) suggested the following: May is say-ing that when the primary institutions of a so-ciety are characterized by "disunity and disin-tegration" and many poorly integrated, anx-ious, "neurotic" individuals, then, as a result,a new profession of "trouble-shooters" comeinto being who first spend their time studyingand trying to "patch-up" such persons. Later,what is learned in this way will be fed backinto the common culture to produce institu-tional reform or the creation of new, previ-ously non-existent institutions.

The whole point of the preceding section ofthis paper has been to suggest that whatstarted out, in the latter part of the 19th cen-tury, as "individual psychotherapy" eventu-ally led to therapy in groups, which are nowdropping the term "therapy" and are becom-ing a new, here-to-stay, social institution in

their own right. As yet we don't have any veryspecific name for groups of this kind, but theimportant thing is that we have the groups.Much experimentation, refinement, and ex-pansion are still needed, but the core junction—Gendlin says "a certain vital group processoccurs in all of them"—has been identifiedand more or less effectively implemented. Andthat is what counts!

As yet we have relatively few objectivemeasures of the positive value and effective-ness of groups (cf. Mowrer, 1971c). How reli-able an index to validity their present popu-larity is remains to be seen. In some quarters,bitter criticism as well as high enthusiasm, canbe found. If a new social institution or primarygroup is indeed in the making here, there isgoing to be much trial and error, throughwhich the new institution, in a generally ac-ceptable and effective form, will eventuallyevolve. Because we cannot be absolutely sure,a priori, where we are going in this connectionor what the best way of getting there is, it isprobably dangerous to try to pontificate orlegislate. Miss Lundberg (1970) observes, "Itseems doubtful that anybody will be able toregulate or supervise a practice that anyonecan indulge in" (p. 11). Witness the inabilityof the authorities of the whole Roman Empireto stop another small-groups movement:namely, the "House Church" of Early or so-called Primative Christianity.

II"Diagnostic" and Professional Implications ofthe Small Group Movement

The myriad theories of "neuroses" are nowbeing dwarfed into insignificance by the diag-nostic premise which flows, almost axiomati-cally, from group procedures. If increasedgroup interaction is what most "neurotic" per-sons need (i.e., greater community), then theunderlying problem is personal withdrawal,social isolation, alienation.

One account of this transition is by V. E.Bixenstine (1970):

About 1960, after some eight years of having pliedmy hand as a counselor employing in broad outlinethe traditional analytic model, I was forced to con-front the fact that I was not very successful. This wasin spite of the fact that I believed that I had usefullyadopted needed corrections to analytic (Freudian) as-sumptions. Paradoxically, the more people I saw and

PEER GROUPS AND MEDICATION 47

the more I began to look more closely at that braveminority who, presumably with my help, made signifi-cant and difficult changes in their lives and behavior.How in the world did they succeed? Their successwas more in spite of than because of what I did. Es-sentially, they managed to overcome the barrier ofanalytic distance, impersonality, and aloofness so im-portant to my role and establish, without my willingcooperation, a personal and significant relationshipwith me. I meant something to them. What I said andthought of them was important. Inevitably, they be-gan to mean something to me so that whether or notthey changed did not find me a detached observer (ii-iii).

This author then debated with himself, overa considerable period of time, as to whether hecould, or should, try to change his style of re-acting to clients so as to increase the chancesof such a "relationship" developing.

The cultivation of warm gratitude and affection inorder to "sell a product" seemed odious to me. I havesince learned to be suspicious of my ability to findreasons for avoiding expressions of warmth. However,had I been able to shift and change my ways radicallyand promptly the likelihood is we would not havehad the Saturday Morning Group.

As it was, I concluded that I could not change suffi-ciently to encourage a significant increase in this rela-tionship factor I had unearthed. Having arrived atthis conclusion the logic was straightforward: if therelationship factor could not be increased in one per-son, myself, perhaps it could be increased by integrat-ing across a number of persons, such as a group situa-tion. This certainly condenses my thoughts as therewas a range of rationale which helped to give birth tomy work with Groups. But it captures the essentials.

The Saturday Morning Group started in 1961 andwas made up of the variety of persons I had beenseeing or had seen who were still in the vicinity.Right from the beginning we knew we hadsomething. . . .

The changes which took place led incrementally tothe concept and inception of Community House (v).

A relationship has power, to be sure, in effectingbehavioral change, but community harnesses morethan the power in multiple relations, it taps as well aunity of shared judgment. Consequently, a number ofassociates together in a group will mount a social in-fluence greater in force than will the same separately(vi).

Charles Dederich, after he had accidentallydiscovered a type of residential communitythat has proven remarkably successful in re-habilitating hard-core drug addicts, cannilyconcluded that such a community recreates atribal psychology and sociology (Yablonsky,1965). This is the very antithesis of "individ-ual treatment" or "private therapy."

Sidney Jourard (1964) wrote: "Would it be

too arbitrary an assumption to propose thatpeople become clients because they do not dis-close themselves in some optimal degree to thepeople in their life. I have come to believethat it is not communication per se which isfouled up in the mentally ill. Rather it is afoul-up in the process of knowing others, andof becoming known by others" (p. 329).

Bixenstine continues:It became evident that I was at best a member of a

community whose experience, knowledge and percep-tion earned him a not unqualified measure of respectand attention. In this community, however, I couldnever again rest secure behind my diploma and wardoff ungentle inquiry with detached analysis of "trans-ference" and "resistance." The result is that as a psy-chologist I feel, I imagine, a bit like Linus withouthis blanket. There is to be sure a compensatory senseof excitement and enthusiasm, but I canot deny a cer-tain yearning to find, if not another blanket, someclearer modus operandi whereby I might earn mykeep.

Bixenstine's "metamorphosis", disconcert-ing as it was, certainly was not very trau-matic. After all, he had a tenured position as auniversity professor which was not likely to beaffected by the particular form of psychother-apy he engaged in; and this, too, was my ownsituation (see last section) and has been thatof many other clinical psychologists. But whatabout the psychologist or psychiatrist whowas in "private practice," i.e., dependent forhis livelihood upon the fees he collected fromhis clients? In the first place, having to see"your doctor" in the presence of a lot of otherpeople no doubt seemed to a lot of people amuch less valuable experience than having hisexclusive attention—and therefore not worthnearly so much per hour (although, in the ag-gregate, the therapist usually nets substan-tially more). Moreover, the therapist himselffaced an excruciating dilemma: If he contin-ued to do essentially "individual" therapy butwith several other persons present, this wasnot true group therapy; and although theother "members" of the group had the oppor-tunity to see and hear each other in actionthat was supposedly therapeutic, they neversaw the therapist himself model this behavior,i.e., play the "patient" role. And if such atherapist did himself become anxious or other-wise disturbed, what was he to do? If he re-sorted to help from another therapist on an in-dividual basis, he was showing a lack of conn-

48 O. HOBART MOWRER

dence in the "product" which he himself wasselling; and if he turned to one or more of hisown groups for help, the question might thenarise as to who should be paying whom andfor what. Some therapists, caught in this di-lemma, have formed a special type of peergroup, i.e., groups consisting of themselvesand other professionals. Thus they can benefitfrom group therapy without having to "partic-ipate" or "be a patient" in the groups whichthey themselves conduct as experts, leaders, ortherapists. But in the groups conducted bysuch therapists the only way a patient canidentify with him (or her) is qua therapist,and what patients have traditionally wanted isnot how to learn to "be a doctor" but how to"get well."

There are increasing reports of "participa-tion" on the part of therapists in the groupswhich they conduct (Ruitenbeek, 1969; Psy-chotherapy, Fall, 1969). But if the groupleaders are using their groups for their ownbenefit (personal change), there is a questionas to whether they are justified in chargingthe other participants a fee when they them-selves are deriving therapeutic benefit; and ifthey are simulating participation only as aploy, then they are modeling a form of inau-thenticity which they are presumably tryingto eliminate in their patients.

For some years now, my wife (Dr. WillieMae C. Mowrer) and I, in what we call Integ-rity Groups, have avoided these embarrass-ments by (a) not charging anyone a fee forbeing in these groups, (b) participatingtherein as co-equal members rather than asleaders or therapists, and (c) talking onlywhen we felt we were helping others or genu-inely in need of help ourselves. Special respon-sibilities, such as Group Chairman or CouncilRepresentative, revolves and the obligation togive as well as receive help is widely diffused.Every therapist is also a patient (if one wishesto use these terms), every student a teacher.This arrangement has many advantages,prominently including the cultivation of deepand enduring involvement and (much in themanner of AA and Synanon) the developmentof persons who (again to use a convenient butrather odious terminology) are not only"cured" but also trained. This strategy is, webelieve, superior to any plan thus far proposed

for training paid "sub-professionals" (cf.Bower, 1970; Kovacs, 1970) to alleviate themuch discussed mental-health manpowershortage.

As we had helped develop Integrity Groupsand hoped they would remain, no one was go-ing to make any money from them (just as noone, except a few specialists in the New YorkCentral Office, makes any money for their ac-tivities in Alcoholics Anonymous). There is asaying in AA circles, "You can't keep it unlessyou give it away," and anyone who tried tosell AA would soon find himself in trouble, onmany scores. Similarly it has been our feelingthat anyone who charged fees for the kind ofactivities that go on in Integrity Groupswould be prostituting himself in a way whichwould not only damage others but would ulti-mately destroy himself. The various Commu-nity Mental Health Acts—local, state, andfederal, now offer a number of salaried posi-tions which will permit a person to give hisservices to others who need and are willing toparticipate in Integrity Groups or similar mu-tual-help operations. Such salaried personscan serve as catalysts and consultants. It isnot coincidental that the first person to comeout of our graduate clinical training programhere at the University of Illinois who also,with his wife, has had extensive I. G. experi-ence and training is now serving as the firstDirector of Mental Health in a county in Illi-nois which said it wanted a community mentalhealth program but not one which operatedalong traditional lines. This man and his wife(and an assistant who got his beginning expe-rience in the School of Hard Knocks and then"graduated" from Gateway Houses, in Chi-cago) have made Integrity Groups their basictool for personal change and have startedthem by bona fide personal participation. Nowthey have experienced group members whocan not only keep established groups goingand growing but who can also participate inthe "seeding" of new groups.

This past year, for the first time, my wifeand I, with the help of some of our "ThursdayNight" I. G. members, have given a graduateseminar, with an associated practicum, whichhas been received by graduate students (andsome young faculty members) in a number ofdepartments far more enthusiastically than we

PEER GROUPS AND MEDICATION 49

ever dared anticipate. In short, it now seemslikely that there will be numerous employmentopportunities for persons who are profession-als in starting non-professional, mutual-helpgroups (instead of "doing therapy" them-selves) and that universities can train andsupply persons competent to perform this typeof function.3

A word may be in order at this point con-cerning terminology. What is in essence individ-ual therapy merely conducted in a group set-ting is not group therapy but might, for exam-ple, be called "demonstration therapy." Andeven if the leader encourages group interac-tion but does not himself participate, as a per-son with both solutions and problems, this is,by our standards, at best a low level group.Only in situations in which beginners maylook forward to eventually possessing thesame knowledge and skills as those now pos-sessed by the more experienced memberswould we speak of a genuine, democratic, or"peer" group.

But this is not to imply these groups are thesame as so-called "leaderless" groups. Everysession of what we would regard as a peergroup has a chairman, who is determined onsome sort of revolving or random basis andwhose responsibilities are nominal. The realwork of the group is done between personswith problems and other group members whoare able to bring the greatest skill to bearupon the constructive resolution of these prob-lems.

This, in essence, is what is meant by a peergroup; but a further distinction must be madehere, between (1) a group of peers in thesense of persons having, for example, compa-rable professions, socio-economic, sex or agestatus, or the "same problem" and (2) agroup of persons who are highly diverse inthese and other characteristics but who arepeers in the sense of being equals, without sta-tus or rank, except as special functions may betemporarily assigned to them—or in terms ofinformally recognized group experience and

"For information concerning two operations withvery similar objectives, write to Professor John W.Drakeford, Southwestern Baptist Theological Semi-nary, Fort Worth, Texas 76122, and Professor V.Edwin Bixenstine, Department of Psychology, KentState University, Kent, Ohio 44240.

competence (cf. Dreikurs, 1961). Thus, whenusing the term "peer group," it should bemade clear whether meaning (1) or (2) is in-tended. Meaning (2) is the one intended inthe title of the present paper, but this is not tosay that type-1 peer groups (of which Alco-holics Anonymous is an example) are not le-gitimate and, for some purposes, especiallyuseful.

The other source of possible ambiguity hasto do with the expression "self-help." A muchmore appropriate term is "mutual-helpgroups," which implies give and take. Yetthere is a sense in which no one can be helpedby others unless he also helps himself. I havesometimes tried to capture this paradox withthe statement: "You can't do it alone, but youalone can do it."

Recently I heard someone quoteHeidegger's definition of man as "that crea-ture who is a problem to himself." A rabbit'srabbitness is as given, whereas a man's manli-ness or a woman's womanliness has constantlyto be worked at. As many writers have ob-served (cf. Childe, 1951, and White, 1949),man makes himself. And no one can do thejob for him, but neither can he do it by him-self because being a proper man, a properwoman, a proper person implies "character,"i.e., special competences, skills, wisdoms, val-ues, in relation to other people such that theywill be in community rather than "marginal"human beings or "outcasts." A properly con-stituted Small Group seems to offer human be-ings the optimal circumstances for increasingtheir humanness.

Not "Sin" Alone but "Sin" AND Sickness

For many years I belonged among thosewho hit psychiatry (the disease model) andtouted psychology (the behavior model) ashard as I could.

To date, seven studies have been carried outwhich compare the degree of concordance(coincidence) of cyclothymia (mood disorders)in monozygotic (genetically identical) twinsand dizygotic or "fraternal" twins (who are nomore alike genetically than ordinary siblings).When the findings for all seven of these in-vestigations are combined, the Chi-square forthe difference in concordance for this type ofdisorder between the two types of twins turns

50 O. HOBART MOWRER

out to be 82. Here a X2 of 10 is statisticallysignificant at the .001 level of confidence. TheP-value for a X2 of 82 is thus fantastically high(cf. Price, 1968).

Gottsman & Schields (1966) have reportedthe findings for 11 twin studies of a similarnature for schizophrenics; and here a compositeX2 of 928 was obtained. Sometimes an attempthas been made to dismiss this line of researchon the grounds of poor methodology or otherartifacts. But research designed to check onthese criticisms has rather uniformly resultedin negative findings (cf. Kety, et al., 1968).

The reality of genetic influences in person-ality disorder compels us to speak of diseaseor illness. Moreover, the rapidly developingliterature on psychopharmacology, whichshows the possibility of successful chemother-apeutic intervention in many of the most sev-ere and debilitating forms of personality dis-turbance further supports the view that we arehere dealing with problems not exclusively de-termined by environmental factors or learn-ing. Thanks to the psychotropic drugs, todayhundreds of thousands of persons are leadingessentially normal lives who would otherwisebe seriously incapacitated or institutionalized(Clark & del Giudice 1970).

Now here are two manifestly valid yetseemingly incompatible points of view concern-ing psychopathology: the psycho-social and thebio-chemical.4 How, if at all, can they be re-conciled?

In 1960 I published a paper entitled " 'Sin/the Lesser of Two Evils," and here I defined"sin," not in any metaphysical or theologicalsense, but as any behavior which tends to alien-ate a person from his reference group or com-munity, i.e., dehumanize him. And I furthertook the position that the alternative concept ofmental "sickness" was unsubstantiated and mis-leading. But in the intervening decade, both the

4 Terminological reform in this field is long over-due.Personality disturbance with a manifest or presumedbio-chemical (organic) basis is usually called a "psy-chosis," whereas a disturbance with a psycho-socialbasis is called a "neurosis." If there were a shred ofrationality in all of this, a disturbance with a bio-chemical basis would be called a neurosis (since itinvolves a disorder or "osis" of the neuro-humoralsystem); and a disturbance with a psycho-social basiswould be called a psychosis or—as Van den Berg(1964) has not unreasonably suggested—a sociosis.

genetic and the pharmacological evidence hasaccumulated to such an extent that one can nolonger, in good conscience, take an either-orposition in respect to this problem. Even themost adamant advocates of the so-called "dis-ease model" of psychopathology do not em-phasize genetic and biochemical factors to theexclusion of psycho-social considerations. Infact, the most generally accepted positionamong psychiatrists today is what is known asthe diathesis-stress hypothesis. "Stress" in-cludes, among other sources, the behavioral"maladjustment" psychologists emphasize andalso the anguish of social alienation.

Now "diathesis" is simply an unusual wordfor the familiar concept of constitutional (ge-netic) predisposition or variability. Thus thediathesis-stress hypothesis says that the mani-festation of a particular "mental disease" orsymptom syndrome is multiply determined,interactive. A degree of stress which will pro-duce psychic decompensation in one personwill not do so in another because of congenitaldifferences in stress tolerance; and what thepsychotropic drugs seem to do, in essence, isto increase stress tolerance. Similarly, of twopersons with the same natural stress tolerance,one may become psychically disabled becauseof difference in experienced stress, whereas theother will not. Here is where the question ofwhether a person is a social isolate or "in com-munity" is often of crucial importance; for so-cial isolation is unquestionably more stress-in-ducing than is life in community, which pro-vides many otherwise unattainable satisfac-tions and supports (Mowrer, 1971b).

In other words, the diathesis-stress hypoth-esis says that mental illness is not absolutelydetermined—as, for example, eye-color and sexare—by heredity but is also contingent, for itsovert manifestation, upon environmental andexperiential factors. An apparent exceptionto this general point of view is, however,found in so-called endogenous depression. Inthis connection, Clark & del Giudice (1970)say: "In this illness, episodes occur withoutany immediate life stress. These individualsoften experience recurrence, a small percent-age of them alternating depression with epi-sodes of euphoria and manic excitement" (pp.628-629). The mechanism of such "spontane-ous" mood fluctuations is at present a com-

PEER GROUPS AND MEDICATION 51

plete mystery, except that it has a genetic ba-sis of some sort. Fortunately, it is in preciselythis variety of depression that the psycho-tropic drugs work best. "Somatic therapies, in-cluding the anti-depressant drugs and electro-convulsive therapy (ECT), are the most use-ful with these patients" (Clark & del Giudice,1970, p. 629). It seems also to be true that, nomatter how robust a person is genetically (con-stitutionally), there are forms of moral stresswhich may be of sufficient intensity to pro-duce severe psychic decompensation or inca-pacity. But in between these two extremes, de-compensations or breakdowns do seem to be afunction of two factors rather than only one.

This, then, is the logic on which the title ofthis section is predicated. Therapists who takea rigidly monistic position are likely to findthemselves ineffective in practice and inwardlyconfused and distressed because of their re-fusal to acknowledge the complexity thatcharacterizes this area of human suffering andincapacity.

Thus, in contrast to the position we took afew years ago in our Integrity Groups, we nowhave a consulting psychiatrist who under-stands and is thoroughly sympathetic with ouremphasis upon community but who also fre-quently provides effective bio-chemical inter-vention in neurophysiological states whichmay arise in persons whose community in-volvement and activities are quite satisfactory—but which will soon begin to deteriorate ifthe bio-chemical condition is not corrected. Torefuse to take advantage of the benefits ofmodern psychopharmacology and to insistthat all personality problems reflect what Bix-enstine calls social "dislocation" is, in ouropinion, as unfortunate as the practice ofsome psychiatrists and physicians who pre-scribe psychotropic drugs without any seriousexploration of whether the patient is or is notsuffering from social dislocation and aliena-tion.

Toward the end of section I reference hasbeen made to the fact that small groups or"grouping" is not axiomatically or inevitablya good thing. Groups, if predicated on thewrong principles or exploited by unprincipled"leaders," can be demonic rather than salu-tory. But since the evidence is not yet all in,and because it would, in any case, be legally

difficult in a Democracy to prevent peoplefrom voluntarily assembling and talking toeach other in small groups, we shall have to relyon Natural Selection in this sociological sphere.

The reverse danger has been excellently de-lineated by Lennard, et al. (1970) in an arti-cle in Science entitled "Hazards Implicit inPrescribing Psychoactive Drugs." Theircharge is that the pharmaceutical industry, inorder to extend the use and increase the saleof "psychoactive drugs," is:

It is apparent that the pharmaceutical industry isredefining and relabeling as medical problems callingfor drug intervention a wide range of human behav-iors which, in the past, have been viewed as fallingwithin the bounds of the normal trials and tribula-tions of human existence (p. 438).

Thus, when a physician prescribes a drug for thecontrol or solution (or both) of personal problems ofliving, he does more than merely relieve the discom-fort caused by the problem. He simultaneously com-municates a model for an acceptable and useful wayof dealing with personal and interpersonal problems,(p. 439).

These writers are concerned that both themanufacturers and harried physicians will notonly recommend these drugs for the legitimaterelief of suffering and incapacity which have agenetic or biochemical basis but will also—infact, already pervasively have—encouragetheir use for the relief of psycho-social dis-comforts which are essential, normal signalsthat the person experiencing them ought tochange his style of life (along lines commonlypursued in small groups).

Both peer groups and medication offer thetwo major sources of "therapy" for human be-ings (including professionals as well as lay-men) and both approaches can be misappliedand over-extended. In other words, there canbe and are bad groups, and medication can beand often is prescribed for problems that arefar more appropriately and effectively handledon a psycho-social basis, i.e., in groups.

Someone has observed that the history ofpsychiatry shows that whenever the specificbio-chemical basis of any form of personal dis-order has been definitely identified, the man-agement of this problem soon passes from thefield of psychiatry over into general medicine(consider, for example, pellagra psychosis,paresis, etc.). Today the new psychotropic

52 0. HOB ART MOWRER

drugs are being increasingly administered bygeneral practitioners; and it may soon comeabout that the main role of psychiatrists andclinical psychologists alike will be that of al-ienists, i.e., persons skilled and concerned inhelping isolated, "sinful" persons return to orperhaps for the first time find community. InIntegrity Groups our assumption is that hu-man beings become alienated (lose commu-nity) because of the practice of dishonesty, ir-responsibility, and uninvolvement. Conse-quently, our "relocating" or "reconnecting"(re-educational) thrust is upon the develop-ment of the three opposite positive character-istics. But we first make sure that the individ-ual is not also suffering from bio-chemicalmalfunctions which no amount of grouping orcommunity experience will correct.

It should also be recognized that personal-ity disturbances with a strictly biochemicalbasis may cause a person to withdraw, losecommunity because he recognizes that he isnot functioning adequately as a person, is re-garded as odd or "crazy," and thus tries toavoid being so judged or rejected. Such per-sons, after the biochemical basis of their diffi-culties has been corrected by means of chemo-therapy, often need group experience in re-so-cialization and normal personal interaction.

I l l

My Personal Experience

Among physicians in general, the suiciderate of 36 per 100,000 population contrastswith an over-all U. S. rate of 11 per 100,000.The suicide rate among psychiatrists is 70 per100,000.

Although I can hardly believe that suchstudies do not exist, I do not personally knowof any which empirically evaluate the "mentalhealth" of "Experienced Psychotherapists"(including psychologists).5

On two other occasions (Mowrer, 1966,1971e), I have written at some length aboutmy own struggle for "mental health" and sowill be highly synoptic here. During thecourse of my lifetime I have had eight more orless severely incapacitating depressions. Six of

"But there is a somewhat related report edited byWayne E. Oates (1961), entitled The Minister's OwnMental Health.

these occurred between 1921 and 1944 (a pe-riod of 23 years) and only two during the en-suing 26 years: one in 1953 and one in 1966.It is a common expectation that as one getsolder, depressions will become both more fre-quent and more severe, but the data from myown life runs counter to this dictum. Is this acoincidence or is the reversal of the commontrend in some way significant. During the firstperiod of 23 years to which I have alluded, Iconsulted a number of physicians (most ofwhom honestly said they could not help me),but one (in the early 1920's, when "focal in-fections" were held responsible for a wide va-riety of ailments) took out my tonsils, and an-other found a trace of albumin in my urineand prescribed bed rest and a special diet.Later, I also had some 700 hours of psycho-analysis, with three different analysts.

It now seems likely that five variables (allmentioned in the psychiatric literature) haveplayed a role in my experiences of depression:(1) an hereditary tendency toward depressionon my mother's side of the family; (2) thedeath of a parent (my father) when I was 13years old; (3) "upward mobility" expecta-tions on the part of my lower-middle classfamily, which I "introjected"; (4) a rather in-dulgent ("spoiled" in the words of Adler) up-bringing, except for any display of anger ordefiance; and (5) adolescent sex conflictswhich caused me a great deal of guilt, shyness,and withdrawal.

So far as I can see, everything I did prior to1945 in the way of therapeutic endeavor wasineffectual, on all counts. In that year, how-ever, largely as a result of some contact withHarry Stack Sullivan, I began what I havecalled in the title of a paper (Mowrer, 1962),"The Quest for Community." Between 1945and 1953, this involved full self-disclosure toonly one Significant Other, my wife; and thedepression I had in 1953, after eight "goodyears," suggested that although this opennesshad helped, it needed to be further extended;and apparently as a result of gradually be-coming involved in and helping develop whatwe now call Integrity Groups, I subsequentlyhad 13 depression-free years. This protractedgroup experience was probably salutary withrespect to factors (2) through (5), listedabove. But then, in the Fall of 1966, a depres-

PEER GROUPS AND MEDICATION 53

sion of gradual, insidious onset occurred,which seemed to be strictly endogenous, spon-taneous. In the beginning my family, associ-ates, and I tried desperately to find some "rea-son" for the depression but nothing very sub-stantial emerged. We all had a strong bias atthat time against the psychotropic drugs, buteventually, early in 1967, I resorted to one ofthe tricyclic antidepressants (Elavil), withmoderately good results; and later I used an-other one (Pertofrane), with dramaticallypositive effects. Since these are the drugswhich work best with endogenous depressions,the presumption is that the depression whichstarted in the Fall of 1966 was of this nature.

It has been argued by some that all de-pressions, including the so-called endogenousones, "have a purpose" (or cause) which be-comes apparent only after the depression isover and has achieved its objective. It cannotbe denied that the depression which started in1966 changed my attitude toward the wholefield of psychopharmacology, and as a result Inow feel more honest, realistic, "cleaner," abetter scientist than I did before. Paradoxi-cally and somewhat ironically, these facts arethus congruent with what, for example, Da-browski (1964, 1967) calls "positive disinte-gration," which implies a type of psychody-namics. But the results of the twin studiespreviously cited stand and cannot be inter-preted "dynamically," i.e., they unequivocallydemonstrate a genetic or constitutional predis-posing factor in at least some types of depres-sion.

On the basis of my personal experiences andthe observation of others, I am today inclinedto believe that probably everyone ought to bein a mutual-help or peer group (for the bear-ing and sharing of "one another's burdens"),not as "therapy," but as a way of life (cf. theearlier references to Bixenstine and to Gend-lin), and that if symptoms emerge which areintractible in this context, one should seek thebest advice obtainable regarding the use of ap-propriate medication. This is the counsel Iwould give to others and which I accept as theguideline for my own life. Hobbies, diversions,personal generosity, friendship, and concernwith causes which transcend one's own exis-tence are undoubtedly of some, but I wouldsay secondary, importance here. Inveterate

commitment to life in deep community (peo-ple who, in the words of Gendlin, provide "aquiet closed group in which they can move indepth, tell how things are, share life") and,when indicated, the use of the best availablenew psychotropic drugs are, however, the twobasic desiderata.

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