Mutual Aid Group Work: Social Work Leading the Way to Recovery-Focused Mental Health Practice

Abstract

The emphasis on recovery principles in mental health practice in Australia challenges the predominant medical model in mental health service delivery. This article describes a mental health-based, telephone-mediated, mutual aid support group for carers of people with severe mental illnesses. Data was collated from evaluations of these groups over a period of 7 years. Outcomes of the evaluation indicated that participants of these groups highly valued the supportive and collaborative nature of the mutual aid groups. The author emphasizes the potential of this approach and the promise of social group workers leading the way to recovery-focused mental health practice.

Keywords:

• mutual aid
• recovery model
• mental health
• group work
• social work
• recovery principles
• telephone group
• telephone mediated support group
• caregivers of mentally ill
• Australia

INTRODUCTION

Social work tenets of antioppression, self-determination, and empowerment are often challenged in mental health work that is strongly influenced by legislative and medical frameworks. The social work field has been criticized for showing reluctance to challenging the dominant medical construction of psychiatric illness and, thus, inadvertently aligning with oppressive practices (Morley 2003).

The Practice Standards for Mental Health Social Workers (Australian Association of Social Workers, 2008), emphasizes core skills, values, and knowledge for social workers in the mental health field. This includes valuing the lived experience of consumers and family members and affirming the importance of partnership and mutuality. The core skills mirror the recovery model approach to mental health practice that is now being recognized internationally as a best practice in the mental health field (Thornton & Lucas, 2011)

The model is based on consumer narratives and represents a significant shift away from the biomedical model. In mental health, biomedical language is prominent in diagnosis and treatment. The recovery model, on the other hand, focuses on the importance of hope, the individual as expert, and the value of developing partnerships with family members and carers. Although these concepts of the recovery model are being touted as a “new” approach, they are, of course, immensely familiar to social workers. They are concepts that are allied with the mutual aid model of social group work practice.

GROUP WORK AND THE CONCEPT OF MUTUAL AID IN SOCIAL WORK PRACTICE

The mutual aid model of group work epitomizes principles of the recovery model in mental health. Social group work practice has always had a strong self-help focus. Personal narratives are often used to raise consciousness, find common ground, unite group members, and reduce feelings of isolation. Cohen and Graybeal (2007) noted that mutual aid can help people to gain a sense of personal, interpersonal, and environmental control over their lives. They stated that one of the goals of a mutual aid group is to encourage the collective resourcefulness and creativity of the group and minimize the need for professional intervention. This requires the group worker to share power with group members so that the helping process is collaborative.

Power sharing through mutual aid is familiar practice for social workers and is consistent with recovery-oriented practice. In contrast, the psychoeducational model of group work takes an educative stance in which health professionals deliver knowledge. In psychoeducational groups there may be little room set aside for collaborative sharing, mutual support, spontaneity, and purposeful recognition of participants' knowledge and expertise. This contrasts with mutual aid group work where sharing lived experiences and “mutual education” (Ife, 1999) are valued.

Although, psychoeducation is a best practice in working with families in mental health (Cohen & Graybeal, 2007; Glick & Dixon, 2002) it can be patronizing and disempowering if group members are not invited to share their experiences and expertise. Mutual aid adds a recovery-focused dimension to group work practice.

Steinberg (2010) stated that the concept of mutual aid is unique to social group work practice. She said that “no other helping profession places it as its very epicenter” (p. 55). She argued that mutual aid is group work and that mutual aid by itself is evidence of best practice social work. She described mutual aid as “a process through which people

1.	develop collaborative, supportive, and trustworthy relationships;
2.	identify and use existing strengths and/or to develop new ones;
3.	work together toward individual and/or collective psychosocial goals (p. 54).

Steinberg asserted that mutual aid is holistic and strengths driven and has exceptional goodness-of-fit with antioppressive practice. It is a process in which power sharing and the experience, wisdom, and knowledge of participants is central—as opposed to processes that rely exclusively on professional expertise and knowledge.

Pistrang, Barker, and Humphrey (2008) emphasized the benefits of socially supportive interactions between people who have had similar experiences. They also separated people's experiential knowledge from workers' professional knowledge and stated that the sharing of like experiences results in benefits such as reduction in feelings of isolation, increased sense of empowerment, and self-efficacy and the acquisition of effective ways of coping.

The strengths-based focus and evidence-based process inherent in a mutual aid model of group work and the goodness-of-fit with antioppressive practice suggest that its use in the mental health field is not only valuable, but also necessary. There is a need to be particularly mindful of antioppressive practice within mental health service delivery in Australia, given the disempowering nature of the legislative framework and dominant medical model in which it operates.

FAMILIES AND MENTAL ILLNESS

Family members who provide care for relatives who are suffering from any major illness face challenges that affect all aspects of their lives. For example, poor physical and emotional well-being, financial burdens, restrictions on recreational, occupational and social opportunities, and feelings of isolation, loss, and grief. In addition, carers of people with a mental illness or disorder may be confronted with antisocial and dangerous behaviors, the strain associated with stigma and feelings of shame, the uncertainties of an illness that is episodic and unpredictable, and experiences of discrimination and complex loss (Jones, 2004; Pagnini, 2005; Parker, Leggat, & Crowe, 2010; Zausniewski, Bekhet, & Suresky, 2009). Carers of mentally ill family members may experience hidden, continuous, and unrecognized disenfranchised (Doka, as cited in Bland, Renouf, & Tullgren, 2009) and nonfinite grief (Bruce & Schultz, 2002).

Parker et al. (2010) stated that carers of people with a mental illness may also be called on to confront their loved ones' drug use and abuse and are “inevitably and continuously emotionally involved and often deeply traumatized by their relative's illness” (p. 164). The stigma with which mental illness is viewed in society results in considerable reluctance on the part of the family members to seek help.

FAMILIES AND MENTAL HEALTH SERVICES

Families of people with a mental illness or disorder have historically had troubled relationships with mental health service providers. Glick and Dixon (2002) and Jones (2004) noted that the predominant model of family therapy that emerged in the 1960s was psychoanalytically based. Families were viewed as a major factor in the etiology of mental illness. The blame approach was mitigated, in part, by lowering high expressed emotion in the family through psychoeducation that aimed to prevent relapse and improve family and patient well-being (Campbell, 2004; Glick & Dixon, 2002). More recently, the concept of expressed emotion has been criticized for promoting a culture of blame and misinterpreting family members' of mental ill persons' feelings of grief, guilt, and shame (Bland et al., 2009; Jones, 2004).

Bland et al. (2009) stated that the move to involve carers and family members in the treatment and management of mental illness originated from the family self-help movement and empowerment model, which endorses the right of carers to participate in all aspects of service development and delivery, including the training of mental health practitioners.

In Australia the increasing recognition of the special impact of mental illness on carers and family members has resulted in changes in national policy and legislation that now mandates carer involvement in the treatment and management of mental illness, alongside mental health professionals. The changes are embodied Australia-wide in documents such as the National Practice Standards for the Mental Health Workforce (National Mental Health Education and Training Advisory Group, 2002), The National Standards for Mental Health Services (Mental Health Standing Committee, 2010), and The Fourth National Mental Health Plan 2009–2014 (Australian Health Ministers, 2009)

Nevertheless, as Parker et al. (2010) noted, the elevation of this issue to a matter of public health in Australia and its incorporation into national policy and legislation has not always resulted in its implementation. There is a significant gap between the legal and policy initiatives and the reality of practice in Australian mental health services. Family members and carers remain “inadequately served by the existing system” (p. 163).

Although there has been strong advocacy for family involvement in mental health service delivery, Campbell (2004) stated that the implementation of family interventions into clinical practice is difficult. Zauszniewski et al. (2009) called for encouraging families to participate in self-help support groups to build resilience. Jones (2004) called for families to participate in support groups to allow complex feelings of bereavement to be expressed. Parker et al. (2010) stated that families of people with a mental illness need information about mental illness, illness management skills, and communication and problem-solving skills.

Research on psychoeducation indicates reduced relapse rates and improvements in family and patient well-being (Cohen & Graybeal, 2007; Glick & Dixon, 2002). Campbell (2004) reported that the use of behavioral family therapy, essentially a psychoeducation approach that involves information and skill acquisition, has resulted in reductions in stress levels and subjective burden, as experienced by participating family members, and in improving their comfort level with mental health service providers.

Many of the above models of family work focus on families as a target of intervention by mental health professionals, thus reinforcing the dominant power base of the mental health system; as opposed to a mutual aid model of group support where power is shared with participants. Bland et al. (2009) noted that effective family practice in mental health should be geared more toward an emphasis on learning rather than therapy, and on respect, collaboration, and empowerment.

TELEPHONE-MEDIATED GROUP WORK: THE TELEGROUP COUNSELLING PROGRAM (TGC)

Telephone-mediated groups have been utilized for many decades. Tropp (1987) described teleconferencing as a group work method utilized by the Social Work Section of the Department of Veteran's Affairs in Australia since 1977 to support isolated aging beneficiaries. Kaslyn (1999) and Regan (1997/1998) referred to the historical development of teleconferencing from the mid-1970s in Australia and the United States to reduce isolation, offer support, and deliver educational and therapeutic programs. Ritchie et al. (2000) described the advantages of telephone support intervention and noted its limitations due to expense. Presently, advanced technology has minimized this barrier to the provision of telephone-mediated groups with teleconferencing services being provided at minimal costs.

Telephone groups have been used to provide emotional support, deliver information, assist with problem solving, share experiences, and reduce isolation among a number of different targeted clientele in the health and welfare fields and especially for those who are geographically dispersed or distant from mainstream services. These client groups include women with spinal cord injury (Jalovcic & Pentland, 2009), older stroke caregivers (Hartke & King, 2003), caregivers of people with brain injury (Brown et al., 1999), carers of people with dementia and dependent elderly adults (Rosswurm, Larrabee, & Zhang, 2002; Shanley, 2008; Shanley, Roddy, Cruysmans, & Eisenberg, 2004; Smith & Toseland, 2006), HIV-positive persons (Meier, Galinsky, & Rounds, 1995; Nokes, Chew, & Altman, 2003), Alzheimer's disease caregivers (Martindale-Adams, Nichols, Burns, & Malone, 2002), parents of children with chronic conditions (Ritchie et al., 2000), women with breast cancer (Heiney et al., 2003), and homebound elderly (Kaslyn, 1999).

There are few examples in the literature of the use of telephone support groups in the mental health field. Pagnini (2005) reported on an evaluation of a carers' mental health project run by a nongovernment organization in Australia that delivered multiple carer support programs including a telephone support group. However, the sample group is small and evaluated only two groups and a total of nine participants.

Comparison studies involving face-to-face groups and telephone-mediated groups consistently demonstrate that none of the therapeutic factors of group participation is lost in the transition from traditional support groups to telephone groups (Hartke & King, 2003; Martindale-Adams et al., 2002; Rosswurm et al., 2002). According to Martindale-Adams et al. (2002) the benefits of telephone support groups include anonymity, low technological demands on participants, flexible meeting schedules, increased accessibility, and increased safety as a result of remaining in the home. Shanley (2008) noted further advantages as cost-effectiveness, effective utilization of time through strict time limits, removal of geographical distance as a barrier to accessing support services, and ability of participants to remain involved even when they need to be in different locations from week to week, for example, when they are on vacation.

Despite not compromising therapeutic outcomes, telephone support groups do present some challenges. Toseland and Larkin (2011) outlined the suitability of telephone groups for a variety of clientele and noted the clinical adaptations required when leading such groups. Facilitators must be skilled to manage the lack of visual cues, keep careful track of participants' contributions, and be keenly attuned to the verbal cues of the participants as well as to the silences. Facilitators must be able to manage participants' expressions of emotions within tight time frames and to effectively manage abrupt beginnings and endings. Participants on the other hand may become distracted by environmental factors such as lack of privacy as in a work situation or background noises such as a ringing doorbell or a barking dog.

Technological problems inevitably arise and must be managed without too much interruption to the therapeutic flow. Shanley (2008) believes that social workers possess the skills to be ideal group facilitators and initiators of telephone support groups.

Program Background and Description

This article presents mutual aid telephone support groups for family members of people diagnosed with long-standing and chronic mental illnesses. The service, provided since 2004, has been delivered by social workers in a rural psychiatric inpatient facility. Each program has been evaluated separately, and the results used to improve the program. Up until now a collective evaluation of the total program, over the years, had not been formally undertaken. It was hoped that such an evaluation would assist in identifying themes and trends about the impact of the program as well as contribute to the literature about social work with groups.

The Telegroup Counselling (TGC) program offers a mutual aid model of group work for a maximum of six carers over a period of 8 weeks via telephone contact. The aims of the program are

1.	To facilitate mutual support between carers through the sharing of experiences
2.	To reduce carers' isolation
3.	To acknowledge the carers' lived experience and knowledge
4.	To provide information and resources
5.	To provide opportunities for inclusion in the care of the family member in hospital.

The participants for the TGC are drawn from family members and carers of residents of two medium- to long-term rehabilitation units in a large rural psychiatric inpatient facility within the Bloomfield Campus of the Orange Health Service. Orange is a provincial city situated approximately 250 kilometers west of Sydney. The two units comprise Manara Clinic and Turon House that are 16-bed psychiatric rehabilitation units for males and females, respectively. They have been in operation since 2003. The TGC was introduced in 2004 by a social worker. At the time the program was scheduled to operate two times per year to support family members and carers. Over this time 10 programs have been completed. Participants are recruited through the distribution of a flyer and letter of invitation to the family members and carers of the residents. This is followed by a phone call from the facilitator who is the principal rehabilitation social worker.

Residents of these facilities are referred for inpatient psychiatric rehabilitation from a vast geographical area across the state of New South Wales. Distance creates an obstacle for engaging carers and offering them supportive services, particularly when they live beyond the state borders. The provision of the TGC has been one way in which this challenge has been addressed.

Structure of the Program

Two group work facilitators conduct the groups, and each session lasts 1 hour. The content is discussed and decided on, together with the participants, during the first session. The group workers share their knowledge of the interests of past groups to advance the discussion and decision making. There is a component of psychoeducation in the groups (information about mental illness and services available); however, the most significant component is mutual support and the provision of a narrative forum. A newsletter is written at the conclusion of each session as a summary of the content and sent to each participant along with any relevant and requested resources. Group guidelines are discussed in the first session and reinforced in subsequent sessions to ensure an understanding of confidentiality and to ease the participants into the use of the telephone to engage in group discussion.

The participants interact with one another from their homes and sometimes from their places of work. The group workers are in separate offices at the hospital facility. Through a teleconference service provided by the national telecommunications company they are able to phone each participant at an agreed-upon time and place them on hold until all have been connected. There is a warning provided by the telecommunication company 5 minutes before the end of the session to allow for preparation of the session's close and to avoid a sudden disconnection. To date, the 10 programs have been delivered to a total of 56 family members.

METHOD

A registration form serves as a preprogram survey with a postprogram evaluation conducted at the conclusion of the 8 weeks. The registration form is sent to each participant. The completed form being mailed back to the facilitators. The postprogram evaluation is conducted over the telephone in the weeks after the program's completion by a worker in the service who has not been involved with the running of the groups. The evaluation consists of a combination of demographic and qualitative data. The majority of the questions rely on subjective self-reporting of the participants that is similar to measures such as the group evaluation (GE) form suggested by Meier et al. (1995) and measures of caregiver burden used in numerous studies including Hartke and King (2003), Brown et al. (1999), Zauszneiwski et al. (2009), Rosswurm et al. (2002), and Wong (2000).

Participants, at pre- and postprogram are asked to rate a list of measures covering quality of life, well-being, and relationships and to rate a list of reasons for participating in the TGC. In addition to these measures participants are asked open questions about what they liked most and least about their participation in the program and whether the program met their needs and their expectations. The numerical data from the 10 completed programs were collated and are presented as percentages of the total number of participants. Themes were identified from the qualitative open questions and are discussed in the following sections.

FINDINGS

Among the total of 56 participants 51 registration forms were analyzed retrospectively representing a completion rate of 91%. There were 49 postprogram evaluations representing a completion rate of 88%. The majority of participants identified as the parents of the residents (47% daughters and 42% sons) with other relationships including siblings (5%), niece, stepmother, and granddaughter (2% each). The average age of the family member providing the care was 54 with 95% being female and only 5% male. Significantly, all the male participants (n = 3) were part of three couples who participated in three separate telephone support groups. The group participants were drawn evenly from metropolitan areas (42.3%) and rural areas (52%) across New South Wales with the remainder living interstate (5.7%).

The majority of participants felt that the TGC had met their needs (74% yes, 9.3% mostly) with similar results in regard to whether the TGC met their expectations (67.4% yes, 16.3% mostly). Three participants did not circle any of the responses but noted that they did not have expectations prior to commencing the program.

A significant majority stated that they felt comfortable talking in a group over the phone (96%). Supporting comments included factors such as the convenience, the privacy, the ease of talking when not face-to-face, the nonjudgmental factor, and the anonymity. Only two participants recorded an answer of no to the question of whether they felt comfortable talking over the phone. One of these noted that by the third session she felt more at ease.

The preprogram registration and the postprogram evaluation each provided the same set of items for family members to choose from when answering the questions about the reasons for participating (preprogram) and the perceived benefits (postprogram) to allow for comparison. A 5-point Likert-type rating scale was used with 0 (not at all) and 5 (mostly). The categories provided for rating are listed below:

•	Reduce my sense of isolation
•	Allow me to share with others my feelings about myself in the caring role
•	Increase my understanding of myself within the caring role
•	Allow me to share with others my experiences in the caring role
•	Feel supported by others and acknowledged in my caring role
•	Feel understood by others in the program
•	Allow me to explore other ways of coping in the caring role
•	Change my stress levels.

The most popular reasons for participating in the TGC as indicated by carers in the preprogram registration form were to explore other ways of coping, to change stress levels, and to share experiences. The first two of these reasons indicated that people's interests in participating were motivated by a psychoeducational need to gain information and change current behaviors. In the postprogram evaluation there appears to have been a shift away from the practical component toward those factors that characterize mutual aid.

The most popular perceived benefits were feeling supported, feeling understood, and sharing experiences. Sharing feelings and increasing understanding of self were very close behind. The need to explore other ways of coping and reducing stress levels were acknowledged as important outcomes but had diminished in significance from the preprogram statements. These differences are represented in Figure 1 that also shows an increase in the perceived benefit of reducing isolation that had the lowest rating of all the categories in the preprogram registration form. Reducing isolation, feeling understood, feeling supported, and sharing feelings and experiences are the essential components of a mutual aid group.

FIGURE 1 Comparison – reasons for participation and perceived benefits (pre- and post-comments as % total responses.

Participants were asked to rate their own perception of their health and well-being at registration (preprogram) and at evaluation (post-program) using the ratings of excellent, very good, good, fair and poor. Over the 7 years of the program's existence, carers consistently rated a significant improvement in their health and well-being from preprogram ratings to postprogram ratings (Table 1) with a general trend indicating a positive progression from fair to good and very good.

TABLE 1 Carer Statement of Own Health and Well-Being Pre- and Post-program

	Excellent	Very Good	Good	Fair	Poor
Pre-program (% of completed registrations N = 51)	9.8%	7.8%	29.6%	47%	5.8%
Post-program (% of completed evaluations N = 45)	13.3%	20%	40%	20%	6.7%

In response to the open question “What did you like most about the program?” predominant themes included being able to talk to and listen to others who were “sailing in the same boat” with high value placed on feeling comforted and being able to trust. Also included were the opportunity to listen to what has worked for others in managing difficult situations and gaining knowledge and information from one another about resources.

In response to the question “What did you like least about the program?” the most predominant theme was that the program was too short overall. A number of comments stated that each individual session was not long enough. Others commented on the abrupt session endings and the sense of loss at the completion of the program. There were some comments that pointed to the sessions as being too structured and not allotting sufficient time for free discussion. For a few participants the content raised painful feelings. Some reported that it was difficult to hear about the length of time that some family members had been caring for their mentally ill relative.

DISCUSSION

As indicated in the findings 95% of the carers that participated in this program over the 7 years were women. This is consistent with the literature on carer roles. Dow and McDonald (2003) noted that care-giving is a feminist issue. It is interesting to note that the men who participated in the program did so as part of a couple, perhaps conceding to a belief that their role was an ancillary one in the caring task. This could be an area for further investigation.

A significant number of the carers indicated that they felt comfortable using the medium of the telephone, confirming that the therapeutic factors of group participation were not lost in the transition from face-to-face groups. Toseland and Larkin (2011) reported on the issue of confidentiality and stated that it did not present any problems for the participants most of whom valued the anonymity.

The benefits of mutual aid groups were consistently present in these telephone-mediated groups. This included reduced feelings of isolation, feeling understood, feeling supported, and sharing feelings. This was reflected in the responses to the question regarding what the participants liked most about the program: feeling comforted, being able to trust and the ability to learn from others and share information and knowledge. The telephone-mediated groups provided a way of overcoming the barrier of access due to geographic distance.

One of the most significant outcomes in the evaluation concerned carer perception of health and well-being pre- and postgroup. A consistent improvement in health and well-being was reported by carers from pre- to postprogram evaluations over the 7 years of data collection. Considering the previously mentioned impacts on family members who care for a relative with a mental illness, this finding strongly suggests that group support programs based on a mutual aid model such as the TGC can significantly contribute to lessening the degree of carer burden.

Participants were not homogenous in the length of time they had been caring for their loved ones. Consequently, carers who were dealing with their relatives' recent diagnosis of mental illness were exposed to the often-harrowing experiences of other carers who had managed the care of their chronically ill loved one over a significant number of years. Mental illness is episodic, and carers are unable to predict its course as they cycle with their unwell relative through stages of wellness and significant unwellness. The sharing of stories among carers does not by itself guarantee a supportive encounter or constitute a mutual aid experience. It requires skilled facilitation to ensure that hope and optimism are not destroyed in those family members for whom caring for a loved one with a mental illness is a relatively new undertaking. Social workers are well suited with the knowledge- and skill base to encourage hope in these circumstances.

Limitations and Suggestions for Further Study

In their review of studies researching the benefits of mutual aid groups Pistrang et al. (2008) commented on the difficulties inherent in deciding what kinds of changes to focus on and what kind of evidence is relevant. They noted that evaluations using rigorous, standardized controls have been criticized for distorting the informal, peer-driven processes that characterize mutual aid groups. They pointed to the large amount of surveys, qualitative studies, and first-person accounts of the subjective benefits of mutual aid groups. The program evaluation which is the subject of this article fits with the latter group of studies, providing a collation of retrospective descriptive data identifying trends in participant experiences over an extended period of time. By not utilizing control designs and measures the study has limitations regarding validity and generalizability.

Studies using control groups and standardized measures have been conducted on the effectiveness of telephone support groups that used a predominantly psychoeducational approach (Hartke & King, 2003; Heiney et al., 2003; Smith & Toseland, 2006). Two of these studies showed similar results to the themes emerging from the 7 years of collective data in the current study around the lessening of depressive symptoms and strain (Smith & Toseland, 2006) and an increase in competence (Hartke & King, 2003) for caregivers in the treatment groups compared to caregivers in the control groups.

Further study using this methodology and more rigorous qualitative methodologies could explore the links between mutual support factors and the reduction of carer burden as well as further investigate the link between mutual support and perceived improvements in carer health and well-being. In addition, further study is called for to investigate the sustainability of these improvements beyond the conclusion of the program—a topic of research suggested by Chien and Norman (2009). Although the evaluation of this program provides carer-focused data only, further research could explore the use of mutual aid groups for people living with a diagnosis of mental illness as proposed by Pistrang et al. (2008).

CONCLUSION

The evaluation of a telephone support group program for family members of people with a severe mental illness has been implemented over a period of 7 years and offers an example of a form of mutual aid in the mental health field. Outcomes of the evaluation indicated that participants of these groups highly valued the supportive and collaborative nature of the groups. They consistently reported a reduction in isolation as well as positive benefits to their health and well-being. The groups tapped in to the members' collective resourcefulness, extending their impact beyond self-help and advancing the shared power of facilitators and participants working together, as coinvestigators and collaborators.

Although the inclusion of family members and carers in the care of a person with a mental illness has now been mandated in policy and legislation for mental health workers in Australia, the task of translating policy into practice is difficult; especially since mutual aid-driven concepts like the “sharing of power” and “acknowledging lived experience” are adversarial to the traditional medical model thinking and practice.

The recovery model in mental health, with its emphasis on hope and consumer narrative, is challenging the medical model. However, the recovery model will remain in word only until there are good illustrations and examples of practice forthcoming. The values and principles of the recovery model are closely aligned with social work practice, mutual aid group work, and antioppressive and empowerment practice.

Social workers have a leading role to play in the delivery of recovery-focused mental health services that represent collaboration and power sharing between practitioners and consumers of mental health services, as opposed to exclusive adherence to top-down traditional medical model services. Group workers with knowledge and experience in building mutual aid groups can lead the way.