Introduction

Numerous theories have been used to explain how people can benefit from mental health consumer-run organizations (CROs) and other types of self-help. Prominent perspectives include the helper therapy principle (Riessman 1965), empowerment theory (Maton and Salem 1995; Segal et al. 1993), social networks (Biegel et al. 1994; Goldberg et al. 2003), social support (Cohen et al. 2000), and experiential expertise (Borkman 1999). Although each of these explanations has merit, it is difficult to understand how they relate to one another and operate together in the CRO context. The goal of this article is overcome these shortcomings by providing a more comprehensive conceptualization of how people can benefit from CROs. More specifically, the goal of this study is to develop a quantitatively testable theoretical framework that connects the ideas of existing explanations and accounts for a greater variety of outcomes obtained through CRO participation.

A more comprehensive theoretical understanding of CROs can be useful to a variety of CRO stakeholders including CRO leaders, potential members, mental health professionals, policy makers, and researchers. CRO leaders can use this information to better understand how their organization needs to be structured in order to be beneficial to members. Potential members can use this information to evaluate whether CRO participation would be beneficial to them. Mental health professionals can use an improved understanding of CROs to better assess which of their clients may benefit from a referral. Policy makers who understand how and why CROs are beneficial can make better decisions about how to support CROs. Finally, researchers can use the improved theoretical understanding to design evaluations and measures that are consistent with the theorized processes and outcomes of CRO participation.

To develop a more comprehensive conceptualization of CROs, this study uses the concept of roles to integrate structural and psychological perspectives. The introduction of this article explores the role concept and its relationship to several existing explanations of how CROs are beneficial. The use of roles as a unifying concept also allows for the extension of existing CRO explanations through consideration of role-based theories that have not been previously applied to CROs. Identity theory (Burke 2003; Stryker 1980) is one such theory that explains how the process of identity transformation may be an important benefit of CRO participation. Following an explanation of identity theory is a presentation of the preliminary theoretical conceptualization that integrates existing theoretical explanations with identity theory using the concept of roles. Before the role concept is explored, a more detailed background on CROs is provided.

Consumer-Run Organizations

CROs are first and foremost organizations operated by people with mental illness. The exclusion of non-consumers from organizational decision-making is a central tenet of their operation. Beyond this central tenet, CROs manifest considerable variation. Typically, CROs are grounded in a self-help/mutual-aid philosophy, which values the promotion of inner strengths, empowerment, a reliance on helping each other, a rejection of hierarchy, and self-acceptance (Riessman and Carroll 1995). Many early CROs started as part of the ex-patients liberation movement of the 1970s, which was a reaction against institutionalization and the disempowering dependency roles found in the traditional mental health system (Chamberlin 1990). Instead of being taken care of by mental health professionals, CROs provide an environment where people with mental illness learn to take care of each other in helper roles.

CROs generally maintain more structure than self-help groups (Brown et al. 2008b). Instead of existing as an informal gathering of people, CROs often operate as incorporated nonprofits that can receive grants and have paid staff governed by a board of directors. Although increased structure and external funding can help CROs achieve their goals, it should be pursued with caution because it can also compromise grassroots camaraderie and independence (Brown et al. 2007a). Popular CRO activities include operating a drop-in center, organizing recreational and educational activities, hosting support groups, advocating for consumers, educating the public about mental illness, and volunteering in the community (Brown et al. 2007a; Trainor et al. 1997). In the literature, CROs have also been referred to as self-help agencies (Segal and Silverman 2002), consumer/survivor initiatives (Nelson et al. 2001), and peer-run programs (Clay 2005).

The Concept of Roles

The concept of roles has historical roots in several social science disciplines, including sociology (Mead 1934), psychology (Lewin 1948), and anthropology (Linton 1936). Although much debate about the nature of roles exists (e.g., Turner 1985), most would agree that a role is a set of behavioral expectations describing how one person is supposed to interact with another person in the environment. It is important to note that the precision of behavioral expectations varies from role to role, and all roles require some degree of improvisation. Further, the certainty that behavioral expectations will be fulfilled varies across roles. People are frequently unsure of what to expect in their role because their understanding of the situation is incomplete. Words such as anticipation, prediction, hope, plan, or assumption may more accurately describe the certainty of an individual’s behavioral expectations.

Within a CRO, two roles that promote recovery are friendship roles and leadership roles (Brown et al. 2007b, 2008a). CRO members can develop friendship roles with others during CRO recreational activities (Brown et al. 2004). If the friendship is close, expectations associated with the role are likely to include a willingness to perform favors or provide emotional support in times of need. CRO members can also develop leadership roles through involvement in organizational operations and decision-making. Expectations associated with a leadership role may include coordinating the completion of specified tasks or more generally contributing where needed. The following subsections will explain how the role concept relates to several prominent explanations of how people can benefit from CROs, including: (1) social networks (2) social support (3) experiential expertise (4) empowerment theory, and (5) the helper-therapy principle.

Social Networks

Conceptually, roles directly relate to social networks because the nature of every relationship in a social network can be described using role expectations. Such a description can flesh out the meaning of different social network connections. For the social networks of people with mental illness, role descriptions can distinguish between dependency relationships with power differentials and interdependent relationships where reciprocity is expected. By providing members with the opportunity to participate in shared activities while exerting control over the organization, CRO participation can lead to egalitarian, mutually beneficial social network connections (Hardiman and Segal 2003).

Social Support

Through the development of friendship roles, CRO participants obtain social support, which is widely recognized to promote physical and mental health (Barrera 1986; Cohen et al. 2000; Thoits 1985). The importance of friendships and social support in the CRO context is further supported by Mowbray and Tan (1993), who found that social support is the dominant reason people come to CROs and gaining more friends is the most frequently cited benefit.

Experiential Expertise

The peer-based social support provided in friendship roles developed at the CRO may be particularly helpful because the support comes from people who have experiential expertise in coping with mental illness. The shared experience of coping with a specific challenge such as mental illness enables the provision of appropriate expertise-based support that can serve as a key bonding point between members (Borkman 1999). The benefits of sharing experiences with others who have faced similar hardships include a sense of validation, normalization of the experience, a reduction in social and emotional isolation, and a sense of belonging (Cowan and Cowan 1986; Helgeson and Gottlieb 2000; Lieberman 1993; Rosenberg 1984; Toseland and Rossiter 1989).

Empowerment Theory

In addition to friendship roles, participants can adopt leadership roles at their CRO, where they contribute to organizational functioning and decision-making. Through these leadership roles, participants can gain a sense of control and ownership with the organization (i.e., develop a sense of organizational empowerment). This organizational empowerment can transfer into a sense of personal and community level empowerment (Peterson and Zimmerman 2004; Schulz et al. 1995). Research on CROs by Segal and Silverman (2002) found that organizational empowerment was the best predictor of personal empowerment and social functioning.

Helper-Therapy Principle

The friendship role and the leadership role are two types of helper roles available at a CRO. Participants who adopt helper roles at their CRO can benefit from the helper-therapy principle (Riessman 1965). The helper-therapy principle states that the act of providing help is therapeutic, often more so than receiving help. Helping others is thought to provide the helper with a sense of interpersonal competence, a sense of equality, personally relevant learning, and social approval (Skovholt 1974).

Identity Theory

Roles are not only useful in drawing conceptual connections between existing explanations of how CROs are beneficial but in considering how established but previously unapplied role based theories can be used to understand CROs. Identity theory (Burke 2003; Stryker 1968, 1980; Stryker and Burke 2000) is one role based theory that explains how the structurally useful concept of roles shapes the psychologically powerful concept of identity and vice versa. In this study, identity theory is used explain how the roles available in a CRO can change the identities of participants. Several researchers have studied the identity transformations that occur within self-help settings (e.g., Kennedy and Humphreys 1994; Rappaport 1993), however no research to this authors knowledge connects these identity transformations to the roles being played within the self-help setting. The stark contrast between the helper roles found in CROs and the dependency roles found in the public mental health system operate as a compelling explanation for why identity transformations may occur.

Within identity theory, roles are thought to provide people with a sense of identity because people use roles as basic conceptual tools in thinking about self. When a role associated with a social network position is played on a regular basis, it becomes internalized as a “role identity” and adopted as a component of the self (McCall and Simmons 1978). In the CRO context, playing the role of friend would lead people to view themselves as friendly or sociable whereas people who take on a leadership role may begin to see themselves as leaders.

According to identity theory, individuals draw on the most appropriate role identities in a given situation to guide their behavior. When a particular role identity is activated, it serves as an “identity standard” or set of expectations that represent who one is and how one should behave. For example, when socializing with familiar others in the CRO context, people may activate their friend identity and expect lighthearted exchange. People compare their identity standard to feedback from the social situation in a self-appraisal process. If feedback is consistent with the identity standard, then the identity is verified and the self-image is reinforced. If an individual is unable to create congruence between the identity standard and the social situation then the individual will experience anxiety (Riley and Burke 1995). The CRO member who is able to maintain lighthearted exchange will gain confidence in their self-view as friendly whereas someone who consistently evokes combative exchanges may begin to doubt their identity as friendly.

Figure 1 provides a more detailed theoretical description of the identity control system. In this system, the “comparator” (a cognitive, self-appraisal process) determines the level of congruence between the social situation and the identity standard. Meaningful behavior then alters the social situation in such a way that it will be more congruent with one’s identity standard. Because of this need for congruence, adequate role performance is critical to well-being, motivating people to develop the skills necessary to meet role expectations. In a CRO, people need social skills to be good friends and leadership skills to be good leaders.

Fig. 1
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The identity control system (Burke 1991)

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Behavior change through skill development is not the only way to achieve congruence, however. People can also change their identity so that it becomes consistent with the social situation. As such, new roles and new feedback from the environment can lead to changes in identity. For example, a CRO member who takes on a leadership role will start to identify as a leader if the social situation continually provides such feedback, even if they fulfill expectations with existing skills.

Preliminary Explanatory Framework

The explanatory framework under investigation in this study uses the role concept to connect several theories that have been used to explain how participation in a CRO can change the people who get involved. The helper therapy principle, experiential expertise, social networks, social support, and empowerment can all be understood in the context of the proposed framework. Expanding upon these existing explanations is identity theory, which has not been applied to CROs in previous research. Figure 2 illustrates this preliminary framework. Each of the following subsections provides further description corresponding to a particular component of the framework.

Fig. 2
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The preliminary framework of how people can benefit from CROs

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Person–Environment Interaction

An individual’s experience interacting with the CRO environment determines how that individual will benefit (or not) from CRO participation. Characteristics of the person and the environment largely determine the course of person–environment interaction. Personal characteristics that are relevant to interaction within a CRO include having a mental illness and maintaining few friendship or leadership roles. Without these existing characteristics, it is unlikely that an individual would engage in or benefit from CROs.

Environmental characteristics that promote the development of friendship and leadership roles are also important to consider. If the organization provides an empowering behavior setting, then new members will have many opportunities to get involved in operating the organization and taking on leadership roles. CROs may also be uniquely adept at helping newcomers develop friendship roles because existing members have experiential expertise in coping with mental illness. Maintaining an atmosphere that is respectful, accepting, free from coercion, and available on a regular basis can also promote positive person–environment interactions (Holter et al. 2004).

Role and Relationship Development

If person–environment interaction persists, participants will extend their social network as they develop new roles and relationships. The nature of each role depends on the nature of each relationship. If the relationship is oriented towards productivity at the organization then it may be an empowering leadership role such as board member or director. If the relationship is oriented towards recreation and social support, then it can be described as a friendship role. In both friendship and leadership roles, there are opportunities to help others and benefit from the helper-therapy principle.

Build Role Skills

If people do not already have the skills necessary to meet role expectations, they will have to develop role specific skills. In order to be successful in friendship roles, social skills will be required. Similarly, leadership skills will be needed for leadership roles.

Identity Transformation

Identity transformations refer to changing identity standards or expectations for self. They can also be thought of as changes in self-perception, self-view, or sense of self. The adoption of new roles can lead to identity transformations that reflect the expectations associated with enacted roles, as described the identity control system (Burke 1991). For example, people who start regularly playing the role of friend may begin to see themselves as good at striking up conversation, listening, and cheering people up. Similarly, CRO participants who take on leadership roles may begin to see themselves as leaders. Once these identity transformations take place, CRO participants may become more likely to develop friendship or leadership roles outside the CRO.

Although far from all encompassing, the proposed framework for understanding how participants can benefit from CROs is more comprehensive than other theoretically driven explanations in the literature on CROs. The framework lacks its own empirical support, but it is transparently grounded in a large theoretical knowledge base that maintains considerable empirical support. The current study explores how this preliminary framework fits with the CRO participant’s understanding of how involvement leads to personal changes. The empirical data gathered will be compared to this preliminary framework in search of confirming and disconfirming evidence. Because the goal of this study is to develop rather than test theory, the preliminary framework is considered a theoretical starting point in understanding data, rather than an ending point. As such, attempts to adjust the theoretical framework in light of disconfirming evidence are made.

Method

In order to understand the participant’s perspective on how CROs are beneficial, 250 CRO members from 20 CROs were surveyed about their CRO participation experiences. Although a number of close-ended questions were asked of participants, two open-ended short answer questions are of importance to this study: (1) What personal changes have occurred as a result of your involvement here? and (2) What experiences did you have here that enabled personal change?

Study Setting

At the time of data collection, there were 20 CROs receiving grant funding from the Kansas Department of Social and Rehabilitation Services, Division of Mental Health and this study collected data from all of them. Researchers at Wichita State University’s Center for Community Support and Research collected all data. This center also receives funding from the Kansas Department of Social and Rehabilitation Services to provide all CROs with technical assistance. CRO membership consisted solely of persons with a severe and persistent mental illness, as is required by the Kansas Department of Social and Rehabilitation Services. The average CRO existed in a community of 49,000 people, maintained a membership list of 56 people, and operated on a yearly budget of $31,000. All CROs in this study operated a drop-in center. Other activities varied from CRO to CRO but included increasing public awareness about mental illness, hosting support groups, conducting volunteer community services, fundraising activities, and educational activities.

Data Collection Procedure

Site visits were used to collect survey data during December 2003 and January 2004. Researchers attempted to schedule site visits at times when the CROs would be heavily attended and CRO leaders encouraged attendance on the day of the site visit. The method of survey administration depended on the needs of individual participants. Participants who felt comfortable independently completing the survey were allowed to do so. Participants who preferred an interview format were provided that option. In a few cases, researchers read each question to a group who then marked their answer on the survey form. Participants received $5 for completing the survey.

Study Sample

Of the 254 people eligible to complete the survey, only two people (1%) declined. Two surveys (1%) were omitted from the final data set due to obvious respondent error (i.e., marking all answers on the far right side of each page). Of the 250 survey respondents, 39 left both the personal change and experiences leading personal change questions blank. An additional 17 wrote N/A, none, or unsure on both questions. The answers of the 194 (78%) remaining respondents were subject to coding analysis. There are several potential explanations as to why the questions were left blank. Some respondents may not have attributed personal changes to their CRO participation experience. Others may not fully understand how they have changed or know how to describe the changes that have occurred. Problems with reading comprehension and writing ability may also have inhibited individual ability to answer questions. Of the 250 respondents, 14% did not have a high school diploma or GED. Finally, survey fatigue may have prevented a response to questions. There were 73 closed ended questions preceding the two open-ended questions.

The number of survey respondents from each CRO ranged from 2 to 32 and largely corresponded with the membership size of CRO. Frequency of participation was relatively high, with 21% participating every day, 59% participating several times a week, 13% participating once a week, 5% participating a couple of times per month, and 2% participating a few times a year. Length of participation was also relatively long, with 75% participating 1 year or more, 13% participating for about 6 months, 7% participating for a couple of months and 5% participating for a couple of weeks. Of those who have been participating for 1 year or more, the average length of participation was 5.2 years.

Respondents ranged in age from 19 to 69 (with a mean of 44) and 54% were female. Racially, 79% described themselves as White, 8% as Black, 8% as mixed, 3% as Hispanic, 2% as Native American, and 0.5% as Asian. In terms of highest education level, 9% graduated from college, 40% received some post-secondary education, 37% graduated from high school, and 14% had not graduated from high school.

While it is impossible to know exactly how the group sampled differs from the population of CRO members, it is thought that this sample over represents those members most active in CROs (the regular attendees). CROs typically have a core group of members who participate on a regular basis. In addition to the core group is a larger group of people who sporadically attend. The convenience sampling method used is thought to have captured most of the core group of CRO members and a small proportion of the sporadic attendees. This bias was intended, as it facilitated a more representative sample of active CRO members. Studying these active members is advantageous because identity transformation is thought to be a relatively slow process that requires intensive involvement.

Data Analysis

QSR N6 (2002) qualitative data analysis software was used to facilitate data organization and analysis. The software allowed for open coding and text searching of all responses for keywords. Coding analysis of the answers of 194 respondents led to the creation of 15 categories describing personal changes, four categories describing the experiences that led to personal change, and three dual categories that were both personal changes and experiences leading to personal change. The author conducted all coding. Although the previously discussed theoretical framework inevitably influenced the coders understanding of the respondent’s words, all categories were created in an attempt to describe themes that emerged from the words of informants. A constant comparative method of data analysis was used, where categories constantly evolved as new data was taken into consideration in coding. Individual responses to questions were frequently coded into multiple change or experience categories, as informants often expressed multiple distinct concepts in one sentence. For example, the response, “I have more friends now and higher self-esteem” would be coded into both a social network category and a self-esteem category.

Results

Responses to the two questions were overwhelmingly positive. Four respondents listed negative interactions, but they did not form a coherent category. As such, they are not included in the results. There were also six responses left uncategorized because they were idiosyncratic and 18 responses left uncategorized because they did not make sense in the context of the question.

In coding analysis, the answers to the separate questions frequently overlapped, making it difficult to distinguish between the personal changes and the participation experiences that led to those changes. For instance, one respondent described the experiences that led to personal changes by writing, “I made friends and became involved. It made me more confident in myself.” In the second sentence, the respondent listed a personal change, rather than an experience that led to change, as the question had asked. Even though it came from the experiences question, it was coded as a personal change because this change was not mentioned in the question about personal changes. Any time a causal statement was made, the cause was coded in the experiences that led to change categories and the effect was coded in the personal change categories. As the analysis progressed, it became clear that some of personal changes were also being listed by respondents as experiences that led to personal change. Social support, social networks, and helping others emerged as dual categories of personal change and experiences that led to change.

Table 1 presents a list of all categories generated, along with the definition of each category, an example response, the number of respondents who mentioned each category, and the percentage of respondents who mentioned each category. The percentages are relatively small because respondents were not prompted to consider any particular category.

Table 1 Categories of personal change, causes of personal change, and dual categories (N = 194)
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Integrating Categories into the Theoretical Framework

If a comprehensive theoretical conceptualization is the goal, then the explanatory framework should be able to account for all empirical categories. The section explores how the theoretical framework can account for the empirical categories generated by this study. Although data analysis proved useful in generating the categories a comprehensive framework needs to consider, data analysis could not provide insight into the relationship between personal changes and the CRO participation experiences that led to change. Relationships and causal connections made between categories by respondents were too scattered for themes to emerge. In the words of CRO participants, all of the personal changes are related to all of the participation experiences that led to change. While this reflects the interrelated nature of the different CRO participation experiences and personal changes occurring, it does not provide a coherent theoretical explanation of how people can benefit from CROs.

Considering the large number of categories, it appears as though there are innumerable ways in which CROs can be conceptualized. While this is true, it is also true that many of the categories are interrelated and maintain strong ties to the experiences that led to change. By taking a step back from the data, a larger process integrating the disparate categories can be seen.

The preliminary theoretical framework is useful in conceptualizing this larger process, however, some categories could not be easily incorporated into the original framework. These include self-esteem, optimism, social support, paid employment, and information. In order to incorporate these categories, the conceptual framework was expanded. The conceptual addition of a resource exchange component and a self-appraisal component allows for their integration without compromising the cohesion of the framework. Further justification for the inclusion of these components, along with a more detailed explanation of their meaning, is provided in the following resource exchange and self-appraisal subsections, which are part of the larger explanation of the revised framework.

Figure 3 illustrates the expanded framework and shows how the categories generated by short answer questions fit into the framework. The process of fitting categories into framework components was primarily driven by logic rather than data and a different perspective may have led to the placement of categories into different components. Each component of the revised explanatory framework is described further in its own subsection below, which provides a narrative explanation of how the categories fit into and flesh out each component. In the narrative explanation, categories are italicized.

Fig. 3
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The revised theoretical conceptualization of how people can benefit from CROs

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Person–Environment Interaction

People interact with CROs through recreational involvement and work involvement. Recreational involvement varies from organization to organization but includes unstructured socialization, playing cards, pool, board games, puzzles, smoking cigarettes, ping-pong, crafts, cooking, gardening, cookouts, camping, shopping, and parties. Work involvement takes a variety of forms, including writing grants, cleaning, building maintenance, planning activities, setting up activities, conducting volunteer work in the community, creating newsletters, making public presentations, recruiting members, organizing parties, recognizing volunteers with awards, completing quarterly reports, operating a warm line, providing transportation, purchasing supplies, and going to board meetings.

Through participation in these work and recreation activities people experience a wide variety of interpersonal interactions. Many respondents cited a positive atmosphere as an important environmental characteristic that promoted interpersonal interaction, work involvement, and recreational involvement. Respondents described the CRO atmosphere using terms such as friendly, open, understanding, safe, and non-judgmental.

Role and Relationship Development

If people continue to interact in the CRO, new roles and relationships will develop and an individual’s social network will expand. As long as the new roles and relationships continue, they will consume individual energy and people will experience increased activity. Keeping busy and engaged in these role relationships can add healthy levels of stress to a person’s life, providing focus and purpose, while preventing aimless wandering and boredom (Thoits 1985).

Both friendship and leadership roles can change the way CRO participants interact with others because they involve helping others. Several respondents mentioned the act of being a help provider as both an experience that led to personal changes and as a personal change in and of itself. This stands in stark contrast to the many dependency roles people with mental illness typically play. In the professional mental health system, consumers receive a variety of government-funded services from therapists, case managers, attendant care workers, and doctors. Frequently, people with mental illness live in a world where they do nothing for anyone else and little for themselves.

Resource Exchange

Embodied but not emphasized in identity theory is the fact that a resource exchange takes place when people engage in role-oriented behavior. Roles are defined and described by the reciprocal rights and obligations within a relationship (Thoits 1985). In other words, roles consist of patterned interactions where people give what is expected of them (their obligations) and in turn receive what they expect (their rights). Drawing from the ideas of resource theory (Foa and Foa 1974), these rights and obligations can be thought of as an exchange of resources. For example, in the role of paid employee people give their time and energy to the CRO in exchange for financial compensation. This role establishes an interdependent resource exchange, where the CRO benefits from the employee’s services and the employee benefits from both the paychecks and the intrinsic rewards of being in a helper role.

Identity theory focuses on the intrinsic rewards, such as positive self-appraisals, a sense of mastery or environmental control, and a sense of purpose in life (Thoits 1985). While these benefits are certainly important, data from this study suggest that the resource exchanges themselves are important outcomes derived from CRO participation. Respondents discussed paid employment as an important personal change, rather than as an experience that led to change. Because CRO members often live on disability income alone, they live in relative poverty. Small amounts of income can help to solve problems, reduce stress, and provide everyday comforts.

Another resource exchanged during CRO participation is social support. CRO participants discussed the exchange of social support as both an important personal change and as an experience leading to other personal changes. Social support can be conceptualized as consisting of three categories—tangible (i.e., money, transportation), emotional (i.e., love, empathy), and informational (i.e., directions, service system knowledge) (Thoits 1985). Social support at a CRO can take all of these different forms. When a CRO friend volunteers to baby-sit, tangible social support is being provided. Similar to the tangible support of paid employment, these exchanges can solve problems, reduce stress, and provide everyday comforts. The importance of informational support is reflected in the category receive information. Respondents frequently discussed the utility of the information obtained during their social interactions at the CRO. The advice and feedback obtained can help people solve problems and understand different perspectives.

Self-Appraisal

Revisiting Burke’s (1991) model of the identity control system (Fig. 1), an exchange relationship between the person and the environment is evident. People give to the environment meaningful behavior in hopes of meeting the perceived expectations of the environment. If individuals perceive their behavior to be successful in meeting role expectations, then they will obtain positive self-appraisals and verify their identity standard. At times, the environment actually reflects positive appraisals but other times actors must infer appraisals (Thoits 1985).

For example, if a CRO member provides thanks after receiving a ride from a fellow CRO member, s/he is reflecting a positive appraisal to the person who provided a ride. As long as the ride provider interprets this reflected appraisal positively, s/he will receive positive self-regard for a job well done. If the ride recipient says only goodbye and not thank you, then appraisal must be inferred. If the ride provider perceives the ride recipient as dissatisfied with the ride, then positive self-appraisal will not occur. Perhaps the car is too dirty and the ride recipient was uncomfortable. In this case, a negative self-appraisal occurs as the ride provider has failed to fulfill role expectations. Sense of self-esteem is damaged if driver concludes s/he is not good at the role of ride provider, or more broadly, helpful friend.

This process of self-appraisal through social interaction is thought to be the primary mechanism by which people establish self-esteem (Thoits 1985). Positive self-appraisal is synonymous with positive evaluations of one’s overall worth, lovability, and importance. While positive self-appraisal contributes to psychological well-being, negative self-appraisal contributes to anxiety and depression (Kaplan 1980).

Any social interaction provides opportunities for people to develop roles that contribute to self-esteem but CRO participation may be unique in that it promotes the development of helper roles. Numerous positive reflective appraisals are attained in helper roles, thereby encouraging positive self-appraisal and increasing self-esteem. Further, by consistently obtaining positive appraisals in a role, people can become optimistic about their ability to meet role expectations in the future and maintain the rewarding role relationships established at the CRO.

Build Role Skills

Over time, as CRO participants gain experience playing different roles, they develop the skills necessary to fulfill expectations in each of these roles. When helping others and learning how to fend for oneself outside of a dependency role, people learn coping and problem solving skills. With the practice of working through both your own problems and helping others solve their problems, coping and problem solving skills improve. In other roles, people build different skills. For example, in the role of friend people learn social skills by practicing communication, listening and conflict resolution on a regular basis. In leadership roles, such as employee or volunteer people learn job skills.

Identity Transformation

The development of an identity as an independent person may also result from the helper role because people give at least as much as they receive in a relationship. No longer are people eliciting pity and receiving help without giving back. Through the formation of reciprocal relationships, CRO participants become needed. As such, they develop a sense of increased independence because they earn what they receive.

The adoption of leadership roles may lead CRO participants to identify as conscientious. This is because the responsibilities associated with leadership roles may require increased conscientiousness. In roles such as board member, shift manager, or peer counseling coordinator, CRO members need to act conscientiously in order to meet the behavioral expectations associated with these roles.

Viewing oneself as more outgoing may result from playing the role of friend. By spending more time socializing and developing social skills, individuals can begin to identify as outgoing people. Once people identity as outgoing, they may activate this expectation in multiple settings. The friendship and leadership roles may also contribute to a sense of belonging. Identifying oneself as a part of the CRO enhances commitment to the CRO and provides people with a comfortable safe haven when they have nowhere else to go.

Discussion

Based on the responses of 194 participants, the categories generated by this study provide a rich description of the types of CRO participation experiences that are beneficial and conveys a clear sense of how CRO participants felt they benefitted from involvement. Furthermore, the categories serve as a relatively comprehensive list of CRO participation benefits and participation experiences that lead to benefits. This is a useful contribution to the literature on CROs, as these questions have not been addressed in existing research known to the author.

Although the categories stand alone as useful information, they also facilitated the development of a comprehensive explanation of how people can benefit from CRO participation.

In this revised theoretical conceptualization, the individual characteristics of CRO participants interact with the organizational context to determine the course of role and relationship development. Interpersonal interactions during the work and recreational activities of the CRO frequently lead to the development of friendship and leadership roles. Both are helper roles, which have distinctly different expectations from the dependency roles that people with mental illness often occupy in the professional mental health system. CRO participants can obtain a variety of benefits when such helper roles are established. First, resource exchanges occur as a part of the regularized social interactions of role involvement. People give and receive tangible, emotional, and informational resources, which can help in coping with everyday challenges. These resource exchanges are guided by role expectations, which people attempt to fulfill in order to verify identity standards. If successful, people obtain positive self-appraisals, thereby enhancing self-esteem and emotional well-being. Through practice, CRO participants become more adept at meeting their friendship and leadership role expectations. Coping skills, social skills, and job skills develop, thereby enabling a mastery of role expectations. With new roles and accompanying skills established, people experience identity transformations and alter their self-descriptions. They may begin to see themselves as more independent, outgoing, and conscientious. Such skill developments and identity transformations may generalize outside the CRO as people begin to seek enactment of these new role identities in other contexts.

Limitations and Future Research

The primary limitation of the proposed explanatory framework is its lack of empirical support. Although the planned data analysis intended to provide an understanding of how CRO participation experiences led to personal changes, consistent patterns connecting the participation experiences to the personal changes did not emerge. As such, only theory and logic were used to connect the personal change categories to the experiences that led to change. Future research needs to explore whether the proposed connections between personal changes and the experiences that led to change are consistent with the perspective of CRO participants. A second major limitation of this study is that only one person coded the data, preventing the calculation of inter–rater reliability and thus leaving unanswered questions about how reliably distinguishable the categories are. A third limitation of the study is that cross-sectional data was used to study a longitudinal phenomenon. Future research needs to study the benefits of CRO participation prospectively, thereby enabling a more reliable understanding of how the change processes unfold over time. Finally, quantitative studies that can rigorously test whether the proposed processes unfold as hypothesized need to be conducted before the proposed explanatory framework can be considered anything but tentative.

Conclusions

This study provides a tentative but promising explanation of the processes by which people can benefit from CRO participation. The final conceptualization incorporates the ideas of several prominent explanations of how CRO participation is beneficial while maintaining a strong relationship with the CRO participant’s perspective. This more comprehensive conceptualization of CROs can be used to help policy makers, mental health professionals, consumers, and researchers understand why and how CRO participation can be beneficial to people with mental illness. Although future research is needed to establish the utility of the framework, it currently stands as a promising step towards the development of a comprehensive understanding of how CROs are beneficial.