Journal of Primary Prevention, 7(4), Summer 1987
Agenda for Action Who is going to do the job of preventing mental-emotional disorders? The work must involve people from many walks of life. Mental health professionals, public officials, physicians, teachers, television network executives and employers are among the key participants.
Leadership There must be strongly exercised leadership if the potential of prevention is to become reality. While the mental health system alone cannot do the job, its members must take the lead. To forge change within the mental health system and the broader health, educational, legal and business milieus requires commitment by top policymakers, convinced professionals and a strong public constituency. Success will depend on public awareness and demand for adequate budgets, appropriate administrative structures and effective management.
Federal Government The Executive Branch and the Congress have reflected, but also provided leadership for, the growing national interest in fitness and health. In 1976, Congress passed the Health Information and Health Promotion Act (PL 94-317), the precursor of what is now the federal Office of Disease Prevention and Health Promotion (ODPHP). This Ofrice provides the structure for a national prevention strategy. Mental health, however, has not yet found a full and equitable status within this framework. The Commmission urges the Congress and the Administration to: • require that health policymakers develop a process and formula so that tax dollars for health services and research are allocated in rational alignment to the amount of disability and lost productivity cause; • appropriate specific and adequate budgets for the prevention research, training and service functions mandated for the Alcohol, Drug Abuse and Mental Health Administration, in particular the provisions of Public Health Service Act 455(d) and the prevention research of the National Institute of Mental Health; 224
© National Mental Health Association 1986
Agenda for Action
225
request that the General Accounting Office study and report on the cost benefits of interventions to prevent medical-emotional disabilities. (A comparable study relative to mental retardation, "Preventing Mental Retardation: More Can Be Done," was issued in 1977); require equitable attention to mental health in prevention policies and programs throughout the Department of Health and Human Services, including the Office of Disease Prevention and Health Promotion and the programs of the Centers for Disease Control. Task forces and advisory groups to these programs should include mental health representatives familiar with prevention principles. N I M H and A D A M H A The National Institute of Mental Health (NIMH) and its parent agency, the Alcohol, Drug Abuse and Mental Health Administration (ADAMHA), are the tax-supported federal agencies responsible for the promotion of mental health in this country. In 1980, the lead role for prevention in the field of mental health was assigned to the NIMH by Congress under Section 455(d) of the Public Health Service Act. The law mandates an administrative unit for prevention and requires the NIMH to develop national goals and priorities, encourage and assist local entities and state agencies to achieve the goals and priorities developed, develop and coordinate federal prevention policies and programs, and assure increased focus on the prevention of mental illnesses and the promotion of mental health. This leadership role complements but is distinct from the responsibilities of NIMH for prevention research (see Research, p. 38). The Commission urges the NIMH to intensify its efforts and move aggressively to meet these leadership requirements. The Commission specifically recommends that NIMH: • proceed to develop national goals and prioties with the active involvement of citizens and professionals in the mental health and prevention community; • convene regular (annual or biannual) conferences of recognized national, state and local leaders in prevention to share information and report progress in the field; • convene specialized workgroups during the year to share information and coordinate efforts in specific topic areas;
226
Journal of Primary Prevention
• disseminate information in a timely manner. The Prevention Publication Series already instituted by NIMH exemplifies the kind of information needed in the field. 2 • establish, either within NIMH or through outside contract, a clearinghouse to provide information on prevention resources and programs throughout the country; • provide information for the public to increase general awareness of the potential of prevention efforts and programs; • actively collaborate with the National Institute of Alcohol Abuse and Alcoholism and the National Institute of Drug Abuse in the development of programs, recognizing t h a t m a n y interventions directed towards reducing mental-emotional problems are also effective in reducing substance abuse, and vice versa; • campaign aggressively for prevention programs throughout federal agencies and at state and local levels. In support of such programs, NIMH must provide technical assistance and funding for demonstration projects; • work with educational institutions and professional organizations to develop appropriate curricula for incorporating mental health and prevention principles into training programs for hum a n service professionals; • work with business and labor groups in support of prevention efforts in work settings, through technical assistance and sharing of information. Mental Health Association
Prevention of mental illnesses has been one of three major goals of the National Mental Health Association since its founding in 1909. At national, state and local levels, the Association has a responsibility to ensure effective efforts in prevention. This advocacy role requires determining prevention needs, identifying who can best address those needs, helping to initiate action and then monitoring the efforts. The report of this Commission is a major step, not only for the Association, but also, we believe, for the prevention field, in assessing current status, determining needs and identifying responsible participants. 2Also highly relevant are the studies and reports initiated by NIMH in collaboration with the Institute of Medicine of the National Academyof Sciences. These includeResearch on Stress and Human Health, 1981;Health and Behavior, Frontiers of Research in the Biobehavioral Sciences, 1982;Bereavement: Reactions, Consequences and Care, 1984.
Agenda for Action
227
Ongoing, objective monitoring of prevention efforts by a group representative of citizens, professionals and educators is essential to maintaining m o m e n t u m in the field. The Commission therefore urges that NMHA: • form a coalition with other nongovernmental groups to define mutual goals and priorities and provide visibility to the prevention field. Essential would be regular opportunities to share information and develop consensus for recommendations for policy leaders and agencies; • provide leadership, through its national office and network of state divisions and local chapters, to educate and inform the public and support model prevention programs.
States" Responsibilities State mental health departments are responsible for providing leadership and coordination for prevention efforts in their state. Their role within the state is comparable to that of NIMH for the nation. At present, about a dozen states have active prevention programs. These vary in their areas of focus, addressing infant mental health services, school mental health programs, prevention of family violence or social support and mutual help. Such programs are dependent on political support and must have longterm commitment of resources to be effective. The Commission recommends that each state mental health department have a designated unit responsible for prevention, with adequate budget and administrative structure. The Commission urges legislative mandate for such a unit. Responsibilities should include: • developing a statewide plan for prevention of mental-emotional disabilities with goals, priorities and time lines. This process must be coordinated with overall mental health department planning as well as other health and h u m a n service agencies, and involve citizen participation; • providing technical assistance and incentives to community mental health centers to develop, implement and evaluate prevention programs; • working with relevant state agencies in support of programs such as prenatal care, adolescent pregnancy prevention, school mental health programs, mutual help groups, etc.;
Journal of Primary Prevention
228
• establishing a statewide clearinghouse for prevention information and programs; • informing and educating the public.
Community Programs The actual implementation of preventive interventions will take place primarily in community settings. It will require organized efforts to inform and train mental health professionals about prevention. In general there is a need for prevention expertise at the local level. The Commission has recommended that national and state agencies undertake the responsibility of providing technical assistance. There are, however, interventions that can be implemented now at the community level, programs such as mutual help groups, home visits to at-risk families, and training in coping skills and stress management. Some community mental health centers and other agencies have developed prevention programs. However, the continuation, let alone the expansion, of such programs is seriously threatened by the increased necessity that these groups receive payment for services. Federal and state monies have been cut back, and health insurance generally does not pay for preventive services. The responsibility of mental health services systems in ensuring prevention programs involves formulating and evaluating programs and then providing direct preventive services or handing over programs to other relevant agencies and assuming a consulting role. It also involves supporting programs developed by others through referral, consultation and liaison. Mental health agencies and professionals should encourage the development of mutual help groups. These generally are based on a philosophy different from psychotherapy. Usually the most appropriate role for mental health workers is offering encouragement, recognition and consultation rather than assuming leadership. The Commission recommends that local mental health and human service agencies and the professionals in them: • become informed about effective prevention programs; • ensure programs of support, preventive intervention and education for infants, children and adults at risk for mental-emotional disabilities because of critical life events and circumstances; • provide consultation to institutions that significantly influence mental health, such as public health agencies, schools, corporations, hospitals, the courts, the media and many more.
Agenda for Action
229
Paying the Bill The cost for care and treatment for people with mental illnesses currently is borne by federal, state and local governments, public and private employers and health insurance. But who pays for prevention of mental-emotional disability? Federal Medicare and Medicaid programs do not pay for preventive services. In a few states, a small percentage of the mental health b u d g e t - - l e s s than 1 % - - i s devoted to demonstration projects and services in prevention or resource development. Generally, across the nation there is no substantive allocation of resources. An increasing number of employers pay for stress management or health promotion programs for workers. There is some evidence that they get a good return on their investment. Equitable Life Assurance Company reports a return of $5.52 for each dollar spent in terms of decreased symptoms and greater productivity following stress management training. Some employers also use funds budgeted for community contributions or public relations to support prevention efforts in the community. But for the most part, government and corporate prevention efforts fall far short of what is needed, possible and cost effective. The current model by which insurers, employers and governmental agencies fund health care fails to recognize the basic interaction of mental and physical health and the long-range value of preventive interventions. This situation must be changed. The Commissions urges that: • Every mental health agency at every level of government allocate a substantial share of its service, education and research budgets to prevention, increasing the allocation to at least 15% by 1995; • Employers and insurers support prevention efforts by including coverage for prevention activities in benefit plans and insurance packages. Research Scientific knowledge determined through research is the bedrock of prevention of mental-emotional disabilities. Prevention research is a distinct area within mental health research. It involves research on risk factors, the acquisition of coping skills and competence building and interventions to prevent the occurrence of symptoms. Prevention research must also address issues of service delivery and knowledge t r a n s f e r - - h o w to go from scientific findings to real-life impact. There as been substantial work in recent years. The establishment
230
Journal of Primary Prevention
in 1982 of the Center for Prevention Research at NIMH formed the basis for a national effort toward a recognized, coherent framework for prevention research. With sufficient policy endorsement to ensure attention and financial support, the Center will be able to develop that framework and coordinate research efforts across institutions, disciplines and interest areas. Besides providing prevention research grants in a number of areas, NIMH has established five Prevention Intervention Research Centers (PIRCs). These multidisciplinary centers, located in different parts of the country, are each directed to different risk populations and areas of prevention programming. Regular communication among the PIRCs provides interchange of theory, methodology and findings. The Commission is encouraged by the establishment of the Center for Prevention Research at NIMH and its accomplishments to date. To continue to expand the knowledge base for prevention efforts, the Commission recommends that NIMH:
• establish a specific process by which a prevention research agenda is determined. Priorities should be developed from consensus of recognized experts in the field after active interchange and deliberation with consideration of different viewpoints and disciplines; • increase funding for prevention research through appropriation by Congress and allocations within NIMH. This Commission reiterates the recommendation of the 1978 President's Commission on Mental Health that no less than 10 percent of NIMH's budget be allocated to support mental health research that is clearly and specifically prevention research; • continue to establish Preventive Intervention Research Centers until the originally planned 12 are realized; • encourage long-term research. Some prevention research requires long-term evaluation. To learn the long-range effects of preventive interventions beyond immediate behavioral and cognitive changes requires a financial commitment to longitudinal research and a professional commitment to follow participants over years. Such a commitment has been the exception rather than the rule; • develop research tools specific to prevention; • give attention to translating relevant basic findings in other mental health, behavioral, biomedical and neurological research into intervention programs;
Agenda for Action
231
• pursue research on how our knowledge about risk factors and developmental needs can be presented to the public with resulting positive changes in behavior.
The Commission strongly urges that private funding sources, including foundations, also support prevention research. Training Providing preventive interventions, either through the mental health system or within other institutions, requires personnel knowledgeable about mental health and prevention. Today's prevention-oriented mental health professions developed their expertise on their own rather than by way of formal training. Training programs must be designed and instituted to: • develop a new mental health professional, the prevention specialist who combines public health principles of prevention with knowledge from mental health disciplines. The Commission urges schools of public health and the mental health disciplines to work together closely to establish relevant training; • incorporate prevention principles into clinical training of mental health professionals. In addition to general clinical training grants, some of which include prevention training, NIMH recently funded two research and development initiative programs for the utilization of prevention research in clinical training. These programs are expected to develop curricula. These initiatives should be continued and expanded; • include prevention principles as an integral part of training for all mental health professionals--psychiatrists, psychologists, psychiatric nurses and social workers. Licensing boards should require demonstrated competence for certification and recertification; • develop competence in basic mental health principles for teachers, physicians and other professionals whose work significantly affects the welfare of others. Professional training programs must begin to incorporate such mental health content not as a separate element, but as an integral part of professional education. Inservice training and continuing education can provide mental health knowledge for those already practicing professions. • The Center for Prevention Research at NIMH should continue and expand its program of New Investigator Research Awards in Prevention.
232
Journal of Primary Prevention
Roles for Others
The leadership for the prevention of mental-emotional disabilities must come from the mental health community, as will many prevention programs. But there are roles and responsibilities that must be addressed by other systems. The mental health of individuals is affected for better or for worse by the practices and policies of societal institutions. A leadership role entails advocacy. National, state and local leaders in the mental health community, both professionals and concerned citizens, must lobby for those human service programs and policies that significantly affect mental health. The Commission urges their active support for efforts to help ensure wanted, full-term, healthy babies; programs to help adolescents postpone pregnancy; parenting education; nutrition programs for young children and the needy elderly; work opportunities for minority youth; employment policies sensitive to family needs; prosocial television programming; and others. Schoo~
The Commission is especially concerned that the nation's schools have the mental health resources and expertise they need. Mental health professionals bear a special responsibility to help school administrators and teachers develop competent individuals. Competence and mental health are inseparable. Children must learn academic skills to succeed and feel confident; they must learn how to get along with others to succeed in school and later in life. The school's job is enormous and critical. Teaching children interpersonal skills and providing health education, including coping skills and sex education, are as essential as teaching reading, writing, arithmetic and science. The Commission recommends that teachers and administrators receive appropriate training, consultation and resources, and that the public commitment to education includes the funding to pay for it. The Workplace
American businesses are involved in health; they pay approximately one-half of the nation's health care bills. With the continuing escala-
Agenda for Action
233
tion of health care costs, managing for health as well as productivity is good business. The worksite can be an especially appropriate setting for prevention programs. About 100 million people go to work each workday; systems of communication are already established, providing opportunities for training in stress management and feedback from employees about stressful conditions that may be modified. Businesses need and are seeking information about effective programs and how to modify their systems so that both the individual employee and the company benefit. Informed mental health professionals can provide this information. The Washington Business Group on Health, 3 a membership organization of major corporations, is a focal point for exchange of information about the corporate world's prevention and promotion efforts through its quarterly publication, Corporate Commentary: A Worksite Health Evaluation Report. The Commission urges employers to learn about and take account of mental health aspects of work, which affect both productivity and workers' lives. Benefit packages, work schedules, management policies and lay-off procedures should be determined in ways that help employees manage stress, rather than produce additional stress.
Media Television and radio programming reaches almost everyone in our society, including many who are not involved with social service and health care systems. These media have unique opportunities and power for shaping public attitudes, knowledge and behavior. Ensuring that this influence promotes positive mental health will require strong citizen advocacy and consultation to the media from the mental health community. To encourage and provide the necessary expertise for programming that portrays positive ways of dealing with stress and resolving interpersonal problems, a regular forum should be established in which representative members of the mental health community consult with media executives. 32291/2Pennsylvania Avenue, S.E., Washington, D.C. 20003.
Journal of Primary Prevention
234
Conclusion The recommendations we have made are ambitious. They require a basic commitment to prevention, a willingness to commit resources-and an awareness t h a t we are dealing with the quality of people's lives. They will require us, regardless of our professional orientation, to adopt a new attitude, a prevention attitude. We know that certain people are at risk for mental-emotional disabilities--and we cannot be content with that knowledge. We must provide preventive services that will reduce that risk. The Commission has charged a number of agencies and systems with responsibilities for prevention of mental-emotional disabilities. Yet members are aware t h a t even if all the agencies were to make the recommended changes, there would remain an individual responsibility for one's own and one's children's mental health. The changes recommended in this report will help us meet t h a t responsibility.
Agenda for Action Who is going to do the job of preventing mental-emotional disorders? The work must involve people from many walks of life. Mental health professionals, public officials, physicians, teachers, television network executives and employers are among the key participants.
Leadership There must be strongly exercised leadership if the potential of prevention is to become reality. While the mental health system alone cannot do the job, its members must take the lead. To forge change within the mental health system and the broader health, educational, legal and business milieus requires commitment by top policymakers, convinced professionals and a strong public constituency. Success will depend on public awareness and demand for adequate budgets, appropriate administrative structures and effective management.
Federal Government The Executive Branch and the Congress have reflected, but also provided leadership for, the growing national interest in fitness and health. In 1976, Congress passed the Health Information and Health Promotion Act (PL 94-317), the precursor of what is now the federal Office of Disease Prevention and Health Promotion (ODPHP). This Ofrice provides the structure for a national prevention strategy. Mental health, however, has not yet found a full and equitable status within this framework. The Commmission urges the Congress and the Administration to: • require that health policymakers develop a process and formula so that tax dollars for health services and research are allocated in rational alignment to the amount of disability and lost productivity cause; • appropriate specific and adequate budgets for the prevention research, training and service functions mandated for the Alcohol, Drug Abuse and Mental Health Administration, in particular the provisions of Public Health Service Act 455(d) and the prevention research of the National Institute of Mental Health; 224
© National Mental Health Association 1986
Agenda for Action
225
request that the General Accounting Office study and report on the cost benefits of interventions to prevent medical-emotional disabilities. (A comparable study relative to mental retardation, "Preventing Mental Retardation: More Can Be Done," was issued in 1977); require equitable attention to mental health in prevention policies and programs throughout the Department of Health and Human Services, including the Office of Disease Prevention and Health Promotion and the programs of the Centers for Disease Control. Task forces and advisory groups to these programs should include mental health representatives familiar with prevention principles. N I M H and A D A M H A The National Institute of Mental Health (NIMH) and its parent agency, the Alcohol, Drug Abuse and Mental Health Administration (ADAMHA), are the tax-supported federal agencies responsible for the promotion of mental health in this country. In 1980, the lead role for prevention in the field of mental health was assigned to the NIMH by Congress under Section 455(d) of the Public Health Service Act. The law mandates an administrative unit for prevention and requires the NIMH to develop national goals and priorities, encourage and assist local entities and state agencies to achieve the goals and priorities developed, develop and coordinate federal prevention policies and programs, and assure increased focus on the prevention of mental illnesses and the promotion of mental health. This leadership role complements but is distinct from the responsibilities of NIMH for prevention research (see Research, p. 38). The Commission urges the NIMH to intensify its efforts and move aggressively to meet these leadership requirements. The Commission specifically recommends that NIMH: • proceed to develop national goals and prioties with the active involvement of citizens and professionals in the mental health and prevention community; • convene regular (annual or biannual) conferences of recognized national, state and local leaders in prevention to share information and report progress in the field; • convene specialized workgroups during the year to share information and coordinate efforts in specific topic areas;
226
Journal of Primary Prevention
• disseminate information in a timely manner. The Prevention Publication Series already instituted by NIMH exemplifies the kind of information needed in the field. 2 • establish, either within NIMH or through outside contract, a clearinghouse to provide information on prevention resources and programs throughout the country; • provide information for the public to increase general awareness of the potential of prevention efforts and programs; • actively collaborate with the National Institute of Alcohol Abuse and Alcoholism and the National Institute of Drug Abuse in the development of programs, recognizing t h a t m a n y interventions directed towards reducing mental-emotional problems are also effective in reducing substance abuse, and vice versa; • campaign aggressively for prevention programs throughout federal agencies and at state and local levels. In support of such programs, NIMH must provide technical assistance and funding for demonstration projects; • work with educational institutions and professional organizations to develop appropriate curricula for incorporating mental health and prevention principles into training programs for hum a n service professionals; • work with business and labor groups in support of prevention efforts in work settings, through technical assistance and sharing of information. Mental Health Association
Prevention of mental illnesses has been one of three major goals of the National Mental Health Association since its founding in 1909. At national, state and local levels, the Association has a responsibility to ensure effective efforts in prevention. This advocacy role requires determining prevention needs, identifying who can best address those needs, helping to initiate action and then monitoring the efforts. The report of this Commission is a major step, not only for the Association, but also, we believe, for the prevention field, in assessing current status, determining needs and identifying responsible participants. 2Also highly relevant are the studies and reports initiated by NIMH in collaboration with the Institute of Medicine of the National Academyof Sciences. These includeResearch on Stress and Human Health, 1981;Health and Behavior, Frontiers of Research in the Biobehavioral Sciences, 1982;Bereavement: Reactions, Consequences and Care, 1984.
Agenda for Action
227
Ongoing, objective monitoring of prevention efforts by a group representative of citizens, professionals and educators is essential to maintaining m o m e n t u m in the field. The Commission therefore urges that NMHA: • form a coalition with other nongovernmental groups to define mutual goals and priorities and provide visibility to the prevention field. Essential would be regular opportunities to share information and develop consensus for recommendations for policy leaders and agencies; • provide leadership, through its national office and network of state divisions and local chapters, to educate and inform the public and support model prevention programs.
States" Responsibilities State mental health departments are responsible for providing leadership and coordination for prevention efforts in their state. Their role within the state is comparable to that of NIMH for the nation. At present, about a dozen states have active prevention programs. These vary in their areas of focus, addressing infant mental health services, school mental health programs, prevention of family violence or social support and mutual help. Such programs are dependent on political support and must have longterm commitment of resources to be effective. The Commission recommends that each state mental health department have a designated unit responsible for prevention, with adequate budget and administrative structure. The Commission urges legislative mandate for such a unit. Responsibilities should include: • developing a statewide plan for prevention of mental-emotional disabilities with goals, priorities and time lines. This process must be coordinated with overall mental health department planning as well as other health and h u m a n service agencies, and involve citizen participation; • providing technical assistance and incentives to community mental health centers to develop, implement and evaluate prevention programs; • working with relevant state agencies in support of programs such as prenatal care, adolescent pregnancy prevention, school mental health programs, mutual help groups, etc.;
Journal of Primary Prevention
228
• establishing a statewide clearinghouse for prevention information and programs; • informing and educating the public.
Community Programs The actual implementation of preventive interventions will take place primarily in community settings. It will require organized efforts to inform and train mental health professionals about prevention. In general there is a need for prevention expertise at the local level. The Commission has recommended that national and state agencies undertake the responsibility of providing technical assistance. There are, however, interventions that can be implemented now at the community level, programs such as mutual help groups, home visits to at-risk families, and training in coping skills and stress management. Some community mental health centers and other agencies have developed prevention programs. However, the continuation, let alone the expansion, of such programs is seriously threatened by the increased necessity that these groups receive payment for services. Federal and state monies have been cut back, and health insurance generally does not pay for preventive services. The responsibility of mental health services systems in ensuring prevention programs involves formulating and evaluating programs and then providing direct preventive services or handing over programs to other relevant agencies and assuming a consulting role. It also involves supporting programs developed by others through referral, consultation and liaison. Mental health agencies and professionals should encourage the development of mutual help groups. These generally are based on a philosophy different from psychotherapy. Usually the most appropriate role for mental health workers is offering encouragement, recognition and consultation rather than assuming leadership. The Commission recommends that local mental health and human service agencies and the professionals in them: • become informed about effective prevention programs; • ensure programs of support, preventive intervention and education for infants, children and adults at risk for mental-emotional disabilities because of critical life events and circumstances; • provide consultation to institutions that significantly influence mental health, such as public health agencies, schools, corporations, hospitals, the courts, the media and many more.
Agenda for Action
229
Paying the Bill The cost for care and treatment for people with mental illnesses currently is borne by federal, state and local governments, public and private employers and health insurance. But who pays for prevention of mental-emotional disability? Federal Medicare and Medicaid programs do not pay for preventive services. In a few states, a small percentage of the mental health b u d g e t - - l e s s than 1 % - - i s devoted to demonstration projects and services in prevention or resource development. Generally, across the nation there is no substantive allocation of resources. An increasing number of employers pay for stress management or health promotion programs for workers. There is some evidence that they get a good return on their investment. Equitable Life Assurance Company reports a return of $5.52 for each dollar spent in terms of decreased symptoms and greater productivity following stress management training. Some employers also use funds budgeted for community contributions or public relations to support prevention efforts in the community. But for the most part, government and corporate prevention efforts fall far short of what is needed, possible and cost effective. The current model by which insurers, employers and governmental agencies fund health care fails to recognize the basic interaction of mental and physical health and the long-range value of preventive interventions. This situation must be changed. The Commissions urges that: • Every mental health agency at every level of government allocate a substantial share of its service, education and research budgets to prevention, increasing the allocation to at least 15% by 1995; • Employers and insurers support prevention efforts by including coverage for prevention activities in benefit plans and insurance packages. Research Scientific knowledge determined through research is the bedrock of prevention of mental-emotional disabilities. Prevention research is a distinct area within mental health research. It involves research on risk factors, the acquisition of coping skills and competence building and interventions to prevent the occurrence of symptoms. Prevention research must also address issues of service delivery and knowledge t r a n s f e r - - h o w to go from scientific findings to real-life impact. There as been substantial work in recent years. The establishment
230
Journal of Primary Prevention
in 1982 of the Center for Prevention Research at NIMH formed the basis for a national effort toward a recognized, coherent framework for prevention research. With sufficient policy endorsement to ensure attention and financial support, the Center will be able to develop that framework and coordinate research efforts across institutions, disciplines and interest areas. Besides providing prevention research grants in a number of areas, NIMH has established five Prevention Intervention Research Centers (PIRCs). These multidisciplinary centers, located in different parts of the country, are each directed to different risk populations and areas of prevention programming. Regular communication among the PIRCs provides interchange of theory, methodology and findings. The Commission is encouraged by the establishment of the Center for Prevention Research at NIMH and its accomplishments to date. To continue to expand the knowledge base for prevention efforts, the Commission recommends that NIMH:
• establish a specific process by which a prevention research agenda is determined. Priorities should be developed from consensus of recognized experts in the field after active interchange and deliberation with consideration of different viewpoints and disciplines; • increase funding for prevention research through appropriation by Congress and allocations within NIMH. This Commission reiterates the recommendation of the 1978 President's Commission on Mental Health that no less than 10 percent of NIMH's budget be allocated to support mental health research that is clearly and specifically prevention research; • continue to establish Preventive Intervention Research Centers until the originally planned 12 are realized; • encourage long-term research. Some prevention research requires long-term evaluation. To learn the long-range effects of preventive interventions beyond immediate behavioral and cognitive changes requires a financial commitment to longitudinal research and a professional commitment to follow participants over years. Such a commitment has been the exception rather than the rule; • develop research tools specific to prevention; • give attention to translating relevant basic findings in other mental health, behavioral, biomedical and neurological research into intervention programs;
Agenda for Action
231
• pursue research on how our knowledge about risk factors and developmental needs can be presented to the public with resulting positive changes in behavior.
The Commission strongly urges that private funding sources, including foundations, also support prevention research. Training Providing preventive interventions, either through the mental health system or within other institutions, requires personnel knowledgeable about mental health and prevention. Today's prevention-oriented mental health professions developed their expertise on their own rather than by way of formal training. Training programs must be designed and instituted to: • develop a new mental health professional, the prevention specialist who combines public health principles of prevention with knowledge from mental health disciplines. The Commission urges schools of public health and the mental health disciplines to work together closely to establish relevant training; • incorporate prevention principles into clinical training of mental health professionals. In addition to general clinical training grants, some of which include prevention training, NIMH recently funded two research and development initiative programs for the utilization of prevention research in clinical training. These programs are expected to develop curricula. These initiatives should be continued and expanded; • include prevention principles as an integral part of training for all mental health professionals--psychiatrists, psychologists, psychiatric nurses and social workers. Licensing boards should require demonstrated competence for certification and recertification; • develop competence in basic mental health principles for teachers, physicians and other professionals whose work significantly affects the welfare of others. Professional training programs must begin to incorporate such mental health content not as a separate element, but as an integral part of professional education. Inservice training and continuing education can provide mental health knowledge for those already practicing professions. • The Center for Prevention Research at NIMH should continue and expand its program of New Investigator Research Awards in Prevention.
232
Journal of Primary Prevention
Roles for Others
The leadership for the prevention of mental-emotional disabilities must come from the mental health community, as will many prevention programs. But there are roles and responsibilities that must be addressed by other systems. The mental health of individuals is affected for better or for worse by the practices and policies of societal institutions. A leadership role entails advocacy. National, state and local leaders in the mental health community, both professionals and concerned citizens, must lobby for those human service programs and policies that significantly affect mental health. The Commission urges their active support for efforts to help ensure wanted, full-term, healthy babies; programs to help adolescents postpone pregnancy; parenting education; nutrition programs for young children and the needy elderly; work opportunities for minority youth; employment policies sensitive to family needs; prosocial television programming; and others. Schoo~
The Commission is especially concerned that the nation's schools have the mental health resources and expertise they need. Mental health professionals bear a special responsibility to help school administrators and teachers develop competent individuals. Competence and mental health are inseparable. Children must learn academic skills to succeed and feel confident; they must learn how to get along with others to succeed in school and later in life. The school's job is enormous and critical. Teaching children interpersonal skills and providing health education, including coping skills and sex education, are as essential as teaching reading, writing, arithmetic and science. The Commission recommends that teachers and administrators receive appropriate training, consultation and resources, and that the public commitment to education includes the funding to pay for it. The Workplace
American businesses are involved in health; they pay approximately one-half of the nation's health care bills. With the continuing escala-
Agenda for Action
233
tion of health care costs, managing for health as well as productivity is good business. The worksite can be an especially appropriate setting for prevention programs. About 100 million people go to work each workday; systems of communication are already established, providing opportunities for training in stress management and feedback from employees about stressful conditions that may be modified. Businesses need and are seeking information about effective programs and how to modify their systems so that both the individual employee and the company benefit. Informed mental health professionals can provide this information. The Washington Business Group on Health, 3 a membership organization of major corporations, is a focal point for exchange of information about the corporate world's prevention and promotion efforts through its quarterly publication, Corporate Commentary: A Worksite Health Evaluation Report. The Commission urges employers to learn about and take account of mental health aspects of work, which affect both productivity and workers' lives. Benefit packages, work schedules, management policies and lay-off procedures should be determined in ways that help employees manage stress, rather than produce additional stress.
Media Television and radio programming reaches almost everyone in our society, including many who are not involved with social service and health care systems. These media have unique opportunities and power for shaping public attitudes, knowledge and behavior. Ensuring that this influence promotes positive mental health will require strong citizen advocacy and consultation to the media from the mental health community. To encourage and provide the necessary expertise for programming that portrays positive ways of dealing with stress and resolving interpersonal problems, a regular forum should be established in which representative members of the mental health community consult with media executives. 32291/2Pennsylvania Avenue, S.E., Washington, D.C. 20003.
Journal of Primary Prevention
234
Conclusion The recommendations we have made are ambitious. They require a basic commitment to prevention, a willingness to commit resources-and an awareness t h a t we are dealing with the quality of people's lives. They will require us, regardless of our professional orientation, to adopt a new attitude, a prevention attitude. We know that certain people are at risk for mental-emotional disabilities--and we cannot be content with that knowledge. We must provide preventive services that will reduce that risk. The Commission has charged a number of agencies and systems with responsibilities for prevention of mental-emotional disabilities. Yet members are aware t h a t even if all the agencies were to make the recommended changes, there would remain an individual responsibility for one's own and one's children's mental health. The changes recommended in this report will help us meet t h a t responsibility.
