Introduction

STARTING IN 1970, an interdisciplinary collaboration process began that validated both the biomedical, community, and psychological approaches that generated the denominated "new intercultural psychiatry" (Kleinman, ¹⁹⁸⁷). Regarding clinical care processes, other approaches were considered beyond the biomedical perspective. The social environment and community care have become more relevant in the care of people facing mental health problems. This panorama implies some challenges at an ethical, social, administrative, and even epistemological level (Patel et al., ²⁰¹⁸).

Especially since 1990, with the Declaration of Caracas, mental health care aims to move from psychiatric clinics with asylum characteristics, and create psychiatric wards in general hospitals. In addition to integrating mental health into primary health care, it is proposed the individual and the community as the axis of recovery (World Health Organization- who- & Pan American Health Organization - paHo-, ¹⁹⁹⁰). The latter concept is articulated in the expression nothing about us without us. Explained as: those who suffer from mental health problems affirm their empowerment and invite them to defend their participation in the structuring of care services and research in the field.

This recovery approach centers the desires of people with mental health disorders as the main focus of the goals of care. Beyond the observable reduction in the manifestation of the disorder, it aims to restoration of cognitive abilities, as well as community and occupational performance. It emphasizes the efforts of the person to live by their own meaning, consistent with the role that each person wishes to carry out in their various contexts. This ultimately will lead to fulfillment (Davidson et al., ²⁰⁰⁵). Between 75 and 90% of those who need treatment for mental problems do not obtain it in their contexts (WHO, ²⁰¹⁶). Hence, so low- cost interventions, as Mutual Help Groups (MAG) in mental health, could be beneficial (Cohen et al., ²⁰¹²; Nickels et al., ²⁰¹⁶). On the other hand, MAG could be a complementary tool to clinical care itself. This is supported by studies that mention that up to 70% of patients remain depressed after treatment and 50% will not continue with the drugs due to side effects (Connolly & Thase, ²⁰¹²; Rosenblat et al., ²⁰¹⁹; Kelly et al., ²⁰¹⁹). In some cases, it has been proposed as a mechanism to improve the financial pressure associated with psychosocial disability (Russo et al., ²⁰⁰⁷; Kelly et al., ²⁰¹⁹).

Although it has been mentioned that there is a lack of agreement on definitions of MAGS (Chaudhary et al., ²⁰¹³), multiple definitions agree in groups where mutual peer support is provided. These face- to- face or virtual meetings are designed, in response to mental health problems or situations. The control of the group remains with its members rather than with an external agency (Chaudhary et al., ²⁰¹³; Wilson, ¹⁹⁹⁴; Borkman, ¹⁹⁹⁹; Steinke, ²⁰⁰⁰; Baldacchino & Rassool, ²⁰⁰⁶). Self- help groups are described as "groups composed of people who meet regularly to help each other cope with a life problem" by the American Psychological Association (APA, ²⁰¹⁹). MAGS have also been described as mutual aid and mutual support groups, as well as the broader terms self- help groups and mutual aid groups, or peer support groups (Pistrang et al., ²⁰⁰⁸).

On the other hand, core components are denominators in empirically proven treatments that serve as a reference point for the understanding, implementations, and evaluation of an intervention. These may be techniques, contents, or discrete skills (Chorpita et al. ²⁰⁰⁵; Garland et al., ²⁰⁰⁸). Consequently, this core component approach to evidence- based practice improves better decisionmaking when implementing health strategies or plans (Chorpita et al., ²⁰⁰⁷).

Some previous studies as the one by Rettie et al. (²⁰²¹) sought to determine the core components in support groups led by peers, that are very similar to MAGS. It highlighted the following components concerning problematic substance use: linkage to community support, structured environment, healthy lifestyle, expectations of positive and negative consequences, involvement in protective activities, adequate reward system. Also, there were found as components regarding the problematic: management of high-risk situations, trust-building activities, developing assertive communication style, and presence of people who support their recovery. The most important considered core component was the ability of the group members to improve their self-confidence and the less important component was the provision of group rewards. Although self-help groups have some evidence supporting their effectiveness, there is still no clarity on the appropriate way to document their effect. Qualitative and quantitative methodologies have been used to document their positive consequences and the processes that lie beneath.

Qualitative approaches have shown beneficial outcomes in MAGS, while quantitative studies that, for the most part, examine outcomes in psychiatric symptoms, show mixed effects, especially on symptoms and social functioning (Pistrang et al., ²⁰¹⁰). However, some authors as Humphreys & Rappaport (¹⁹⁹⁴), propose that quantitative methods may not be the most suitable to evaluate MAGS in their entirety. This due to the aspects mentioned in its definition (characteristics difficult to control and randomize). Some meta-analyses that have included randomized studies mention the little impact on clinical manifestations (Lloyd-Evans et al., ²⁰¹⁴). But it is mentioned that these studies are largely randomized and the causal mechanisms remain unspecified (Markowitz, ²⁰¹⁵).

Qualitative studies focus on variables as empowerment, social cohesion, and life skills. While quantitative studies focus on psychiatric symptoms' outcomes, most often without integrating both aspects into a single model. Making the ability to specify the core components by which these MAGS achieve certain benefits, particularly challenging (Markowitz, ²⁰¹⁵). Specifying these components could be very useful in the implementation of the groups, especially in countries facing difficulties accessing mental health care and recovery strategies.

Although these strategies for the recovery of mental health are widely recommended by scientific studies and public policy documents, some methodological elements have not been described or explored. This impacts their correct application and the achievement of the objectives that are proposed. Based on the above, this article aims to identify the components associated with mutual aid benefits.

Materials and Methods

This scoping review is based on the methodological framework introduced by Arksey and O'Malley (Tricco et al., ²⁰¹⁸) and the methodology manual published by the Joanna Briggs Institute for scoping reviews (Peters et al., ²⁰¹⁵).

Results

Of the 62 articles included from databases and 12 from gray literature, 37 associated some form of benefit of mutual aid groups with core components (Figure 1). Among the chosen research studies, eight related to chronic diseases were found, as cancer, hypertension, diabetes mellitus, stroke. Of bipolar disorder and psychosis, two articles were found, one of them qualitative. On depression and anxiety, nine articles were selected, from quantitative methodologies, including an implementation protocol. On the consumption of psychoactive substances, six studies were found. Six studies discussed core components in mental health problems without a specific diagnosis.

Figure 1 Flowchart of search results 

Two more mentioned the components in the framework of behavioral problems in adolescents, also two, one qualitative and the other quantitative, addressed caregivers in their theme (Table 1). Subsequently, the grouping proposed by experts considers the following key elements. To summarize the data, we performed a content analysis of the different articles selected and the information recorded in the Excel table. This procedure was done with the aim of detecting the key categories in each of the elements of interest (core component, and benefit) in each of the included articles.

Table 1 Description of the findings 

Note: Own elaboration.

Once the relevant data for each study was identified, the elements of interest found in the articles were consolidated under the consensus of experts into a new category. This category was established as a core component: Coping strategies understood as techniques learned or enhanced in the group that facilitate the individual approach to adverse personal situations. Emotional recognition and management as the identification of aspects on the group dynamics that have not been considered before and that are important for the emotion's identification. Problem solving: understood as the perception of some psychological abilities, including specific techniques or individual strategies that do not belong to a proper technique, that allow facing daily difficulties. Supportive interaction: it can be understood as the active exploration of group actions for mental health by the same people. This with the intention of relating to others who can be helped or from whom help can be received. Trust: group's value that allows group doings in which a person can tell freely what has happened to them without expecting a value judgment that makes them feel wrong. Identity Building: conceptualized as the identification and appropriation in the group of individual aspects that are part of the personality and that are necessary to consider in each recovery process. Social networks: it is perceived as the recognition of the group as a tool that provides the person with constant availability for their difficulties. Active agency: can be understood as the increase of abilities or moving these skills to functions, which has been obtained through the participation in the group (Table 2).

Table 2 Procedure for consolidating the elements of interest found in the articles, into a new category that was established as a core component based on expert judgment 

Note: Own elaboration.

From the proposed categories, it can be observed that the most detected core component in the different studies was that of supportive interaction (16 times). Followed by social networks (11 times), and problem solving and active agency (eight times). Emotion recognition and management was the least identified. The authors who most identify components are Rossi and Tognetti Bordogna (²⁰¹⁴), Nieto Zermeño (²⁰⁰⁸), Wijekoon et al. (²⁰²⁰), and Sample et al. (²⁰¹⁸).

After this, the outcomes of the MAGS were synthesized in five categories: Quality of Life, Improvement, Mental Health Learning, Social Functioning, Life Skills, Hope, and the relationship of the components with these outcomes was investigated in the selected studies. The frequency was established for the core component and the benefits, according to the studies that cite it considering the new consolidation. The work of Petrini et al. (²⁰²⁰) is the one that reports the most benefits, being social functioning and health learning the ones that it recognizes. Yip (²⁰⁰²) identifies four benefits where skills for life is the most frequent. Ngai et al. (^2021b), Moos (²⁰⁰⁸), Landstad et al. (²⁰²⁰), and Ahmad et al. (²⁰²¹) report four benefits in their studies, the most frequently reported being life skills, social functioning, and improvement in quality of life (Table 3).

Table 3 Benefits identified in each of the included studies 

Note: A: Quality of Life Improvement; B: Mental Health Learning; C: Social Functioning; D: Life Skills; E: Hope.

Finally, the relationship between the core component and the detected benefit was determined on a heat map (Table 4). It is found that the components that were most related to benefits were active agency, supportive interactions, and problem solving. Those that were moderately related were trust, identity construction, and social networks. Those that were related to improvement in few studies were emotional management and coping skills.

Table 4 Frequency of relationship between central component and perceived benefit 

Note: A: Quality of Life Improvement; B: Mental Health Learning; C: Social Functioning; D: Life Skills; E: Hope.

Present Moderately present Absent

As Figure 2 indicates, there are components that are more relevant to achieve the benefits of MAGS described by the research reviewed. Other components more related to techniques of health services were not so decisive in the outcomes found, especially Emotional Recognition and Management.

Figure 2 Core components and outcomes 

Discussion

The objective of this scoping review was to determine the core components associated with positive results in the Mutual Aid Groups (MAGS). The above, seeking to overcome the barriers for the implementation of proposed strategies for mental health (Agudelo-Hernández & Rojas-Andrade, ²⁰²¹). The results identified a total of 37 documents that allowed their detection. Although there a few studies with similar scopes to the current one, the findings are discussed in the light of different theoretical postulates and scientific literature on the subject.

In this review, the following core components were identified: active agency, coping strategies, emotion recognition and management, problem solving, supportive interaction, trust, identity building, and social networks. Some previous studies as the one by Rettie et al. (²⁰²¹) sought to determine the components in peer-led support groups, which are very similar to MAGS. And showed the following components in relation to the improvement of problematic substance consumption: structuring a life project, healthy life habits, real expectations, involvement in protective activities. As well as the following components: appropriate rewards, detection of risk of relapse, and self-confidence. The most important component considered was the group's ability to improve self-confidence and the least important component was the provision of group rewards.

The results found in this scoping review differ and agree with some central elements identified in the mentioned studies. However, the different methodologies used to reach their description must be considered. This work generated a new categorization and definition of the central components based on the expert consensus in which the different elements identified in the different studies were consolidated.

For Ngai et al. (^2021a), the benefits of the group also have to do with the active role of the facilitators, with their knowledge and skills. The presence of external facilitators has also been analyzed through communicative rationality in the public sphere. This has been considered, in the case of Chaudhary et al. (²⁰¹³), as fundamental to maintain the independence of powerful structures as the state. Since without this separation, associations would not try to develop according to their own logic or by creating their own definition of needs (Eley, ¹⁹⁹²). The mentioned would imply for MAGS the loss of their role as places where people reconceptualize health and social problems with their direct experience (Munn- Giddings, ²⁰⁰³; Chaudhary et al., ²⁰¹³; Avis et al., ²⁰⁰⁸).

MAGS have been specified as spaces where the discomfort that supervision can generate is absent (Akin et al., ²⁰²¹). Seebohm et al. (²⁰¹³) argue that many groups acted against stigma in their families, friends, and other stages that attracted considerable interest. This also improved the ability to function socially in terms of learning and development.

Likewise, in MAGS, medical problems are both individual and shared by all, and that also helps to de- stigmatize them, something that Magura et al. (²⁰⁰⁷), specify as a spiritual component. This refers "to the potentially healing power inherent in interpersonal relationships based on reciprocity and equality". Markowitz (²⁰¹⁵) points out that MAGS reduce stigma indirectly. This by contradicting the idea that people with mental health disorders cannot participate in the construction of their own lives, and even of programs. This agrees with Stewart (¹⁹⁹⁰) and Katz (¹⁹⁷⁰). In Yip (²⁰⁰²), among the support strategies provided by other members, those that allowed sharing guidelines for the management of the disease (for example, drug intake) were fundamental. Therefore, supportive interaction, through the communication of feelings and knowledge based on real situations among the members of the group, is related to an understanding of the need for support. Achieving this through the learning of useful strategies for coping with chronic conditions, especially in young people (Ngai et al., ^2021b; Magura et al., ²⁰⁰⁷).

In terms of well- being, Seebohm et al. (²⁰¹³) found that most groups promoted a healthy lifestyle, exercise, and diet inside of their meetings, including access to complementary therapies, walking groups, and sex education. Thus, generating a perception of MAGS as safe places where members felt cared for. Moos (²⁰⁰⁸) considers participation in satisfying and rewarding activities as strategies that are present in this core component. In the same way, Corrigan et al. (²⁰⁰⁵) conceptualizes that participation in MAGS can have some direct and indirect benefits on the quality of life and the symptom reduction. This through strategies to strengthen the self- concept and to improve social networks that provide social support. In addition to the change of role, from someone who receives help, to someone who gives it in a space to share and take care of oneself and others (Markowitz, ²⁰¹⁵; Weaver & Salem, ²⁰⁰⁵; Repper & Carter, ²⁰¹¹). Other MAGS members specified enthusiasm for being with another, courage and desire to explore as core components of their group (Magura et al., ²⁰⁰⁷).

On the other hand, income- generating activities allowed the groups to grow. Providing learning opportunities for asset and money management as a precursor to income- generating projects was a critical component of capacity development (Gona et al. ²⁰²⁰). Similarly, for Yip (²⁰⁰²) it is essential in MAGS to carry out processes related to the guidelines to achieve adequate employment. According to empowerment theory, this could correspond to greater control and awareness of the sociopolitical context in which groups operate (Gona et al., ²⁰²⁰; Kieffer, ¹⁹⁸⁴; Zimmerman, ²⁰⁰⁰; Zimmerman & Rappaport, ¹⁹⁸⁸). Compared to the identity component, Markowitz (²⁰¹⁵) mentions that when people with mental illness integrate into significant groups and engage in productive activities. Their self- awareness increases, MAGS assume there is enough power within the group to manage themselves, instead of looking elsewhere for solutions (Carlén & Kylberg, ²⁰²¹; Southall et al., ²⁰¹⁹). So, it can also increase self- confidence (Carlén & Kylberg, ²⁰²¹).

Along the same lines, other authors (Ngai et al., ^2021b; James et al., ²⁰²⁰) have mentioned that as people join in MAGS, they understand their own and others' difficulties. And because of that, they can improve their abilities and turn them into functions. Similarly, the meetings contribute to the development of norms framed in trust and reciprocity, as requirements for strengthening social capital (Putnam & Nanetti, ¹⁹⁹³). This could propose the empowerment variable as a mediator in solid behavioral changes (Gugerty et al., ²⁰¹⁹; Stewart, ¹⁹⁹⁰; Katz, ¹⁹⁷⁰).

In this sense, cohesion is essential for the sustainability of a MAG (Cheung & Ngai, ²⁰¹⁶). For Yip (²⁰⁰²) those elements that made up group cohesion were sharing data, strengthening dialectical spaces, entering taboo areas. What the authors called a feeling of being "all in the same boat". Within this cohesion, it was mentioned as fundamental to generate conditions in the groups to show "an authentic identity". Considering honesty as a core component of the correct functioning of a MAG (Chambers et al., ²⁰¹⁷), and the promotion of communication mechanisms as a group operating strategy (Moos, ²⁰⁰⁸). The above was reinforced by the concept of sense of community, knowledge and respect of the other, as a step towards self-knowledge. This occurred through mutual learning strategies, that resulted in, apart from increasing that sense of belonging, a decrease in hospitalizations and an ease of access to health services (Matusow et al., ²⁰¹³).

The provision of affective support has a facilitating role between group relationships and the perception of well-being. In addition, the reception and provision of emotional support sequentially mediated the relationships between group interaction with the purpose in life, being satisfied with life and individual growth. These are part, in turn, of other components (Ngai et al., ^2021a). In Yip (²⁰⁰²), among the strategies of support given by other members, those that allowed sharing guidelines for the management of the disease (for example, drug intake) were fundamental. Martin et al. (²⁰⁰⁹), mentions the control of symptoms as a result, especially in chronic diseases. In these processes of self-knowledge of the disease itself and of the body itself were mediated.

For the above, core components were emphasized as understanding, emotional support, increased confidence, adequate care in quality, continuity and time in health services. Also, good relationship with primary care physician; clinical competence knowledge of the disease and knowledge of medications. In this sense, MAGS have been described as an ideal place to accumulate knowledge about accessibility to local resources and to express opinions on experiences with health professionals (Southall et al. ²⁰¹⁹; Carlén & Kylberg, ²⁰²¹). In the study carried out by Giarelli & Spina (²⁰¹⁴), this was described as ways to provide tools for practical life, beyond medical recommendations that cannot necessarily be applied.

Coping strategies have been defined as ones perceived ability to manage "stressful or threatening environmental demands" (Benight et al., ¹⁹⁹⁹), and has emerged as a MAGS strategy for a variety of physical and mental health problems, including stress, anxiety, and depression (Haslam et al., ²⁰¹⁴; O'Dwyer et al., ²⁰²¹). In this sense, for Moos (²⁰⁰⁸), the reinforcement of the self-efficacy and coping skills of the members, was considered as a fundamental active ingredient of the improvement mechanisms in the MAGS. The exchange of information and individual experiences in the group spaces make up learning through modeling and communication skills, and also this is made by the presence of leaders to follow and the individual guidance provided to the participants in a time even outside the meetings. This is also reported as a mediator of the impact on the increase in quality of life given by the MAGS (Magura et al., ²⁰⁰⁷).

The inclusion of articles in Spanish, Portuguese, and English represents a limitation of this review. So, it is recommended for future work to consider other languages that may account for the generation of new knowledge about MAGS. Another limitation includes their scientific rigor because of the type of review in the scoping. Although the conclusions generated must be taken with caution, it must also be recognized that the study of mutual aid and its effectiveness in the recovery processes of mental health. It requires new research methodologies that allow the generation of new elements of evidence to overcome implementation problem.

Conclusions

Despite being recommended in the legislative, scientific, and technical elements of many countries (Patel et al., ²⁰¹⁸), community interventions for mental health have had difficulties in their implementation. At this point, the need for methodologies that contribute to biomedical sciences with therapeutic approaches is reaffirmed. This overcome the passive and unilateral role that human beings with mental problems have had in their recovery, to be assumed in an interactive, lateral, and horizontal way (Dell et al., ²⁰²¹).

In mental health, it is a priority to move from research to practice (Mehta et al., ²⁰²¹). And to develop methods to ensure that evidence- based strategies and programs are effectively translated and used in the real world (Curran et al., ²⁰¹²). These practices, methods, and transfers, require specifying nuclear components, in the first place, subsequently, go through an appropriation, to consolidate an effective strategy that achieves positive changes in people's lives.

In this case, it has been found in this review, as core components of mutual aid groups Coping strategies, Recognition and management of emotions, Problem solving, Supportive interaction. As well as, Construction of identity, Social networks, and Active agency. The application of these components has been associated with greater benefits, that should be considered in the implementation of mental health plans, programs, strategies, or policies.

The components of this type of interaction assume that people who have similar experiences can relate better and, consequently, can offer more authentic empathy and validation. Where reciprocity appears as an integral part of this process, unlike the support of expert workers. These differences mean that socioemotional support is frequently accompanied by instrumental support to achieve a desired social or personal change (Repper & Carter, ²⁰¹¹). MAGS offer much potential benefits, but their ability to execute will depend on local realities, including a differentiated approach, displacement to groups, and skills in handling technological tools (Edwards & Imrie, ²⁰⁰⁸; Gugerty at al. ²⁰¹⁹; Powell & Perron, ²⁰¹⁰).

These findings represent a contribution to the methodology in the development of the MAG and perhaps other group strategies for mental health. Likewise, it is better oriented towards minimum expected or desirable results, although many of these components may not be differentiated as part of the process or the result. Loreto & Silva (²⁰⁰⁴) mention:

The question remains: Where do the processes end and the results begin? We think that this happens due to a difficulty in defining what a process and a result are. Because both are not intrinsically or essentially different, but rather constitute part of a future in which the definition of each one is relative. (p.31)

Similarly, this review also reaffirms that implementation in mental health is more successful when the necessary infrastructure to implement, train, monitor, and evaluation of results are provided. The community is involved in the selection and evaluation of programs and practices. There is a political context that facilitates resources, to let the learning and make necessary adjustments in the implementation process (Fixsen et al., ²⁰¹⁸).