THE STATE OF
prevention in mental health by Gerald Landsberg
WITHIN
the past two decades, prevention in mental health has become a key concept; however, its effectiveness has been impaired because of confusion, inconsistency, and, too often, empty promises. According to a report issued by two leading mental health associations, prevention is the least understood of the essential mental health services as to what it is supposed to be and what it is supposed to accomplish. (Glasscote, et al., 1969) Defining mental health prevention is analogous to pinpointing the boundaries of a cloud. Depending on one’s ideology the definition can either be all-encompassing or extremely limited. I suggest the confusion that exists is a result of an inadequate definition of prevention, the tendency of mental health professionals to make undeliverable grandiose claims, and an oversimplification of complex problems. Compounding the difficulty is a deeply entrenched resistance among mental health professionals to new programs that are not within the traditional medical - public health - disease model. Lack of specificity in the term prevention is critical in a field that already has a large element of vagueness. (Bower, 1972) For example, schools are a frequent marketplace for mental health professionals engaged in so-called prevention activities. Specifically, what components within the school consultation programs are preventive? Claims are often made, but as Bower
has stated, “. . . they are seldom defined with a specificity allowing an observer to judge their preventive functions.” Definitions of prevention generally follow the public health model, or medical model, which is disease oriented. The question is, how appropriate is this model to mental illness and health? I would suggest that by using this approach to prevention we harness ourselves in a schematic straitjacket. Broskowski and Baker ( 1974) observe, “The reliance on a medical-disease model is not surprising because the concept of prevention was borrowed from public health practice, which has historically concerned itself with biological diseases. . . . The system is based on a linear cause and effect model; i.e., the germ entering the host leads to illness, medicine attacks germ, and illness terminates.” As a consequence of our adherence to a public-health model, and our tendency toward an over-simplification of complex problems, we speak about “cause” of mental illness as if a cause could be isolated like a germ under a microscope. We casually mention “poverty,” “over-crowding,” “broken homes,” “poor and inappropriate parental upbringing,” and a variety of other factors as if each produced specific quantifiable effects. W e operate as if there exists a simple chemical formula, such as, Hz -t 0 2 = H20, for describing the cause of mental illness. Our use of these oversimplified formulas implies extensive knowledge of causation. To 15
Psychiatric Care
“I describe our knowledge about causation as anything more than rudimentary is an overstatement. (Dohrenwrend, 1975 ) Millions of dollars have been spent on prevention activities in the social environment as if we mental health professionals knew specific causal relationships. Freeman ( 1975 ) , on this subject, notes: Scientifically, a good deal of caution is needed since it is very unlikley indeed that direct cause and effect relationship will be found berween specific features of the urban environment on one hand, and abnormal mental states or forms of psychological malfunctioning, on the other. Reality is much more complex than that. Since our knowledge of causation is limited, one should question, for example, how realistic are the goals of the mental health professionals who are quoted in Chu and Trotter ( 1972) : The mental health specialist offers consultation to legislators and administrators and collaborates with other citizens in influencing governmental agencies to change laws and regulations. Social action includes efforts to modify general attitudes and behavior of community members by communication through the educational system, the mass media, and through interaction between the professional and lay committees. One fact psychiatrists have learned is that in times of social crisis people are susceptible to help. We also know it is at such moments that they are willing to change. If we can reach the mayors and the people concerned about the cities in their crises with assistance in the acute problems they are facing, they will begin to use us and we can help bring about change. I suggest that we begin to take them on as clients. We cannot wait for them to request our services because they are not going to ask us. We must begin right now to fill in and be of assistance to them with issues they are facing. Actually, no less than the entire world is a proper catchment area for present-day psychiatry, and psychiatry need not be appalled by the magnitude of this task. Although such grandiose statements may not be representive thinking of all mental health professionals, they do represent a sizeable and influ16
ential number. The absurdity of such grandiose goals is discussed by Chu and Trotter: For even if mental health professionals had sufficient expertise to change society at large, and sufficient wisdom to create new social structures more conducive to positive mental health, they do not have the necessary power. Put simply, it is highly unlikely that society will alter its priorities because mental health professionals point out that present priorities may not be good for the mental health of millions.
Based on my own experience and a survey of the limited material on the subject, I suggest that ventures in mental health prevention often have negative consequences that are not anticipated. Four negative consequences that come to mind are the folIowing:
1. Existing informal community and social mechanisms for helping may be seriously undermined. Communities, as sociological evidence indicates, almost always have substantial mechanisms for providing informal assistance to members in need. Community resources that are available include clergy, friends, relatives, neighbors, and self-help groups. As Gottlieb (1974) notes: “The availability of such resources reduces the population’s risk for disease and its need for subsequent artificial intervention.” In examining the impact of consultation and education services offered to natural self-help systems, he concludes, . . . the imposition of professional elements of helping the consultive process risks damage to the natural helping process in the community. The mental health professional might better serve a preventive function in mental health by “leaving well enough alone.”
In other words, if one short-term consequence of weakening community support systems is to strengthen the professional group, is the longrange consequence a shift from prevention-promoting to professional-promoting? It is not without some validity that Graziano ( 1972) in his article, “In the Mental Health Industry Illness
Number 1
I5 is our Most Important Product,” suggests that our activities rather than being preventive are “geared at increasing our clientele and our treatment business.”
2. Community education may change commf,nity tolerance for deviant behavior. There are indications that, contrary to professional belief, the public is indeed more tolerant of deviant behavior than are professionals. (Cumming and Cumming, 1957 j Given this trend, may we not, in effect, be educating communities to reduce their tolerance of deviant behavior (Gottlieb, 1974), and “mobilizing our social power to convince more and more persons that they are mentally ill”? (Graziano, 1972 j Ironically, a lack of prevention activity may result in fewer people in a community being labeled mentally ill; therefore, fewer people will suffer the stigma of the label.
3. Prevention programs may cause undue competition between community groups. In poor communities or in times of economic stress, the introduction of employment opportunities, especially offers of jobs that require limited skills (e.g., the mental-health paraprofessional j , can, as we have seen in the anti-poverty programs, cause community turmoil and stress on the social system. Therefore, though there may be mental health benefits in creating special jobs in prevention programs, their very creation may cause rather than prevent stress in certain segments of the community. 4. Consultation.and education sewices may provide community agencies a way to neglect and reassign their responsibilities. How often, for example, does the consultation and education service to a school result in the development of needed specialized and appropriate programs for disturbed children in a school? Isn’t the outcome more often a referral by the school of a child to a mental health facility? In other words, consultation and education services may provide agencies an excuse for what they are doing or not
doing - a way to circumvent making changes in their own systems, thereby avoiding the necessity to deal with the problem first hand. These are but a few of the more obvious negative consequences of the mental health professions’ prevention program. I would suggest that there are substantially more negative than positive consequences which we mental health professionals have, for the most part, chosen to ignore. Is this not reminiscent of the many years we chose to ignore that certain forms of psychiatric treatment and institutionalization had deleterious effects on patients? References Bolman, William M., “Towards Realizing the Prevention of Mental Illness” (Bellak, L. and Barten, H., Eds.) Progress in Community Mental Health, New York: Grune and Stratton, 1969. Bower, Eli, “Primary Prevention of Mental and Emotional Disorders: A Conceptual Framework and Action Possibilities” (Bindman, A. and Spiegel, A,, Eds. ) , Perspectives in Community Mental Health, Chicago, Ill.: Aldine Publishing, 1972. Broskowski, Anthony and Frank Baker, “Professional Organizational and Social Barriers to Primary Prevention,” American Journal of Orthopsychiatry, October, 1974. Chu, Franklin D. and Sharland Trotter, T h e Mental
Health Complex, Part I-Community Mental Health Centers, Washington, D.C.: Center for the Study of Responsive Law, 1972. Cumming, J. and E. Cumming, Closed Ranks, Cambridge, Mass.: Howard University Press, 1957. Dohrenwrend, Bruce, “Sociocultural and Social-Psychological Factors in the Genesis of Mental Disorders,” Journal of Health and Social Behavior, December, 1975. Freeman, Hugh, “The Environment and Human Satisfaction,” International Journal of Mental Health, Volume 4, No. 3, 1775. Glasscote, Raymond, et al, (Eds.) , T h e Community Mental Health Center: An Interim Appraisal, Washington, D.C.: The Joint Information Service of the American Psychiatric Association and the National Association for Mental Health, 1969. Gottlieb, Benjamin H., “Reexamining the Preventive Potential of Mental Health Consultation,” Canuda’s Mental Health, Vol. 22, No. 4, 1974. 17
prevention in mental health by Gerald Landsberg
WITHIN
the past two decades, prevention in mental health has become a key concept; however, its effectiveness has been impaired because of confusion, inconsistency, and, too often, empty promises. According to a report issued by two leading mental health associations, prevention is the least understood of the essential mental health services as to what it is supposed to be and what it is supposed to accomplish. (Glasscote, et al., 1969) Defining mental health prevention is analogous to pinpointing the boundaries of a cloud. Depending on one’s ideology the definition can either be all-encompassing or extremely limited. I suggest the confusion that exists is a result of an inadequate definition of prevention, the tendency of mental health professionals to make undeliverable grandiose claims, and an oversimplification of complex problems. Compounding the difficulty is a deeply entrenched resistance among mental health professionals to new programs that are not within the traditional medical - public health - disease model. Lack of specificity in the term prevention is critical in a field that already has a large element of vagueness. (Bower, 1972) For example, schools are a frequent marketplace for mental health professionals engaged in so-called prevention activities. Specifically, what components within the school consultation programs are preventive? Claims are often made, but as Bower
has stated, “. . . they are seldom defined with a specificity allowing an observer to judge their preventive functions.” Definitions of prevention generally follow the public health model, or medical model, which is disease oriented. The question is, how appropriate is this model to mental illness and health? I would suggest that by using this approach to prevention we harness ourselves in a schematic straitjacket. Broskowski and Baker ( 1974) observe, “The reliance on a medical-disease model is not surprising because the concept of prevention was borrowed from public health practice, which has historically concerned itself with biological diseases. . . . The system is based on a linear cause and effect model; i.e., the germ entering the host leads to illness, medicine attacks germ, and illness terminates.” As a consequence of our adherence to a public-health model, and our tendency toward an over-simplification of complex problems, we speak about “cause” of mental illness as if a cause could be isolated like a germ under a microscope. We casually mention “poverty,” “over-crowding,” “broken homes,” “poor and inappropriate parental upbringing,” and a variety of other factors as if each produced specific quantifiable effects. W e operate as if there exists a simple chemical formula, such as, Hz -t 0 2 = H20, for describing the cause of mental illness. Our use of these oversimplified formulas implies extensive knowledge of causation. To 15
Psychiatric Care
“I describe our knowledge about causation as anything more than rudimentary is an overstatement. (Dohrenwrend, 1975 ) Millions of dollars have been spent on prevention activities in the social environment as if we mental health professionals knew specific causal relationships. Freeman ( 1975 ) , on this subject, notes: Scientifically, a good deal of caution is needed since it is very unlikley indeed that direct cause and effect relationship will be found berween specific features of the urban environment on one hand, and abnormal mental states or forms of psychological malfunctioning, on the other. Reality is much more complex than that. Since our knowledge of causation is limited, one should question, for example, how realistic are the goals of the mental health professionals who are quoted in Chu and Trotter ( 1972) : The mental health specialist offers consultation to legislators and administrators and collaborates with other citizens in influencing governmental agencies to change laws and regulations. Social action includes efforts to modify general attitudes and behavior of community members by communication through the educational system, the mass media, and through interaction between the professional and lay committees. One fact psychiatrists have learned is that in times of social crisis people are susceptible to help. We also know it is at such moments that they are willing to change. If we can reach the mayors and the people concerned about the cities in their crises with assistance in the acute problems they are facing, they will begin to use us and we can help bring about change. I suggest that we begin to take them on as clients. We cannot wait for them to request our services because they are not going to ask us. We must begin right now to fill in and be of assistance to them with issues they are facing. Actually, no less than the entire world is a proper catchment area for present-day psychiatry, and psychiatry need not be appalled by the magnitude of this task. Although such grandiose statements may not be representive thinking of all mental health professionals, they do represent a sizeable and influ16
ential number. The absurdity of such grandiose goals is discussed by Chu and Trotter: For even if mental health professionals had sufficient expertise to change society at large, and sufficient wisdom to create new social structures more conducive to positive mental health, they do not have the necessary power. Put simply, it is highly unlikely that society will alter its priorities because mental health professionals point out that present priorities may not be good for the mental health of millions.
Based on my own experience and a survey of the limited material on the subject, I suggest that ventures in mental health prevention often have negative consequences that are not anticipated. Four negative consequences that come to mind are the folIowing:
1. Existing informal community and social mechanisms for helping may be seriously undermined. Communities, as sociological evidence indicates, almost always have substantial mechanisms for providing informal assistance to members in need. Community resources that are available include clergy, friends, relatives, neighbors, and self-help groups. As Gottlieb (1974) notes: “The availability of such resources reduces the population’s risk for disease and its need for subsequent artificial intervention.” In examining the impact of consultation and education services offered to natural self-help systems, he concludes, . . . the imposition of professional elements of helping the consultive process risks damage to the natural helping process in the community. The mental health professional might better serve a preventive function in mental health by “leaving well enough alone.”
In other words, if one short-term consequence of weakening community support systems is to strengthen the professional group, is the longrange consequence a shift from prevention-promoting to professional-promoting? It is not without some validity that Graziano ( 1972) in his article, “In the Mental Health Industry Illness
Number 1
I5 is our Most Important Product,” suggests that our activities rather than being preventive are “geared at increasing our clientele and our treatment business.”
2. Community education may change commf,nity tolerance for deviant behavior. There are indications that, contrary to professional belief, the public is indeed more tolerant of deviant behavior than are professionals. (Cumming and Cumming, 1957 j Given this trend, may we not, in effect, be educating communities to reduce their tolerance of deviant behavior (Gottlieb, 1974), and “mobilizing our social power to convince more and more persons that they are mentally ill”? (Graziano, 1972 j Ironically, a lack of prevention activity may result in fewer people in a community being labeled mentally ill; therefore, fewer people will suffer the stigma of the label.
3. Prevention programs may cause undue competition between community groups. In poor communities or in times of economic stress, the introduction of employment opportunities, especially offers of jobs that require limited skills (e.g., the mental-health paraprofessional j , can, as we have seen in the anti-poverty programs, cause community turmoil and stress on the social system. Therefore, though there may be mental health benefits in creating special jobs in prevention programs, their very creation may cause rather than prevent stress in certain segments of the community. 4. Consultation.and education sewices may provide community agencies a way to neglect and reassign their responsibilities. How often, for example, does the consultation and education service to a school result in the development of needed specialized and appropriate programs for disturbed children in a school? Isn’t the outcome more often a referral by the school of a child to a mental health facility? In other words, consultation and education services may provide agencies an excuse for what they are doing or not
doing - a way to circumvent making changes in their own systems, thereby avoiding the necessity to deal with the problem first hand. These are but a few of the more obvious negative consequences of the mental health professions’ prevention program. I would suggest that there are substantially more negative than positive consequences which we mental health professionals have, for the most part, chosen to ignore. Is this not reminiscent of the many years we chose to ignore that certain forms of psychiatric treatment and institutionalization had deleterious effects on patients? References Bolman, William M., “Towards Realizing the Prevention of Mental Illness” (Bellak, L. and Barten, H., Eds.) Progress in Community Mental Health, New York: Grune and Stratton, 1969. Bower, Eli, “Primary Prevention of Mental and Emotional Disorders: A Conceptual Framework and Action Possibilities” (Bindman, A. and Spiegel, A,, Eds. ) , Perspectives in Community Mental Health, Chicago, Ill.: Aldine Publishing, 1972. Broskowski, Anthony and Frank Baker, “Professional Organizational and Social Barriers to Primary Prevention,” American Journal of Orthopsychiatry, October, 1974. Chu, Franklin D. and Sharland Trotter, T h e Mental
Health Complex, Part I-Community Mental Health Centers, Washington, D.C.: Center for the Study of Responsive Law, 1972. Cumming, J. and E. Cumming, Closed Ranks, Cambridge, Mass.: Howard University Press, 1957. Dohrenwrend, Bruce, “Sociocultural and Social-Psychological Factors in the Genesis of Mental Disorders,” Journal of Health and Social Behavior, December, 1975. Freeman, Hugh, “The Environment and Human Satisfaction,” International Journal of Mental Health, Volume 4, No. 3, 1775. Glasscote, Raymond, et al, (Eds.) , T h e Community Mental Health Center: An Interim Appraisal, Washington, D.C.: The Joint Information Service of the American Psychiatric Association and the National Association for Mental Health, 1969. Gottlieb, Benjamin H., “Reexamining the Preventive Potential of Mental Health Consultation,” Canuda’s Mental Health, Vol. 22, No. 4, 1974. 17
