J o u r n a | of P r i m a r y P r e v e n t i o n 8(3), S p r i n g 1988
Topical Review: Primary Prevention and the Partnership of Clinical, Community, and Health Psychology BERNARD L. BLOOM The past decade has witnessed an explosion of activity in the new field of health psychology, and with it a challenging opportunity for mental health professionals identified with the fields of clinical and community psychology. Health psychology is bound to clinical and community psychology by their common interest in health. Clinical and health psychology are bound together by the surprisingly generic nature of their treatments; community and health psychology are bound together by their shared interest in prevention (Reppucci, 1985). If we start with the commonly accepted definition of psychology as the scientific study of behavior (see, for example, Bourne & Ekstrand, 1985), then we may consider the field of health psychology as the scientific study of health-related behavior. The concept of behavior is a broad one in this definition, and includes thoughts, attitudes, and beliefs as well as observable actions. Thus, the field of health psychology concerns itself with the scientific study of behavior, thoughts, attitudes, and beliefs related to health and illness. This definition is clearly too broad for daily use, since it is all-encompassing. The fields of clinical and community psychology have identified more manageable component parts of this larger enterprise, however, and are productively occupied in extending the knowledge and practice base. Edited volumes directly pertinent to the field of health psychology are being published at a prodigious rate. To illustrate this point, among the particularly noteworthy volumes published since 1979 should be included Ahmed, & Coehlo (1979); Bannerman, Burton, & Wen-Chieh (1983); Baum, & Singer (1982); Baum, Taylor, & Singer (1984); Burish, & Bradley (1983); Coates, Peterson, & Perry (1982); Doleys, Meredith, & Ciminero (1982); Elliott, & Eisdorfer (1982); Felner, Jason, Moritsugu, & Farber (1983); Ferguson, & Taylor (1980a, 1980b, 1981); Gatchel, Baum, & Singer (1982); Gentry (1984); Hamburg, Elliott, & Parron (1982); Haynes, Taylor, & Sackett (1979); 1
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Karoly (1985), Krantz, Baum, & Singer (1983); Levine, & Ursin (1980); Matarazzo, Weiss, Herd, Miller, & Weiss (1984); Mechanic (1982); Millon, Green, & Meagher (1982); Pomerleau, & Brady (1979); Prokop, & Bradley (1981); Rachman (1980, 1984), Rosen, & Solomon (1985); Schneiderman, & Tapp (1985); Stone, Cohen, & Adler (1979); Weiss, Herd, & Fox (1981); and West, & Stein (1982). In the past several years, there has been a gradual shifting in the thinking of many clinical and community psychologists from their interest in clinical and community mental health to the larger field of clinical and community health. This shift is particularly true regarding primary prevention, as it has become increasingly obvious that almost everything that is known about the prevention of mental disorders applies equally well to the prevention of physical disorders. Interest in primary prevention is sweeping the entire health service delivery system, and mental health professionals have important contributions to make to the prevention of all illness--physical as well as mental. In this review, I want to comment briefly on the public health view of the field of prevention, and then deal with five themes--(1) the growing convergence of the paradigms that govern the thinking of general health professionals and mental health professionals; (2) the growing awareness of the interdependence of physical and mental health; (3) the concept of the generic illness that is emerging from contemporary research; (4) the rationale of nonspecific preventive interventions in the fields of both physical and mental health; and (5) the implications of the growing understanding of the role of self-destructive lifestyles in the development of illness. In one way or another, many of the recent volumes identified above deal with these five themes, although not often in terms of their implications for the growing partnership expressed in the title of this review.
The Public Health View of Prevention In the control of any disorder--emotional or physical--two types of interventions exist. The first type seeks to reduce the number of persons suffering from the disorder, that is, to reduce the prevalence of the disorder. The second type seeks to reduce the severity or discomfort or disability associated with the disorder. Programs designed to reduce severity, discomfort, or disability are formally known as tertiao, prevention, but are better known as rehabil-
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itation. With lifelong disorders, rehabilitation programs generally have little effect on prevalence. Indeed, a well-run rehabilitation program m a y actually increase the prevalence of these disorders by increasing life expectancy. Unfortunately, given our current knowledge, many physical and emotional disorders appear to be lifelong or nearly lifelong, and thus cannot be significantly reduced in prevalence through rehabilitation programs. Because the prevalence of any disorder is a function of its duration and the rate at which new cases are produced, two approaches to reducing the prevalence of a disorder are commonly identified. The first seeks to reduce prevalence by reducing the duration of the disorder, usually through the development of some form of early casefinding combined with the prompt application of effective treatment. This approach is formally called secondary prevention. Secondary prevention efforts are preventive only in that systematic early case-finding brings with it the possibility of reducing the duration of the disorder. Should a technique for the early identification of some disorder be developed, without the concomitant development of more effective treatment procedures, such as in the case of the improved early identification of diabetes, a paradoxical increase in the prevalence of that disorder would occur (Gruenberg, 1980). A similar increase in the prevalence of a disorder has occurred in the case of Down's Syndrome, as a consequence of the development of antibiotics, which have significantly reduced the death rate from secondary causes among persons with that syndrome. It is this biomedical advance that has resulted in what Gruenberg has called, the "failures of success" (1977). The alternative approach to prevalence reduction is to reduce the rate at which new cases of a disorder develop. This approach seeks to reduce prevalence by reducing incidence, and is formally designated as primary prevention. The concept of primary prevention most clearly matches the lay use of the term, prevention. Effective primary prevention programs prevent disorders from occurring in the first place (Adam, 1981; Perlmutter, Vayda, & Woodburn, 1976). Gilbert (1982) has perhaps most recently described primary prevention in clear and straightforward language: To "prevent" means to keep from happening and is what primary prevention is about. A social problem, be it mental retardation, drug abuse, illegitimacy, delinquency, poverty, suicide, or some other affliction, is kept from happening either by doing something to the at-risk population that
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strengthens their immunity and resistance to the problem or by doing something to diminish the social conditions that breed the problem. (p. 293)
Convergence of Health and Illness Paradigms Until perhaps twenty years ago, the prevailing models that governed the work of health care providers were essentially disease-specific. Diseases were thought to differ from each other in terms of causative factors and treatment responsivity, so that for each unique disease there might be found a unique means for its prevention and a unique strategy for its treatment. In the case of physical illness, the prevailing disease-specific model was biomedical; in the case of mental illness, the prevailing disease-specific model was psychodynamic. Those of us who are old enough can remember the great stabilizing rudder of psychodynamic theory that governed our lives as students and as practitioners. The past two decades have witnessed an extraordinary biologizing of the field of psychiatry. This turning to the test tube and the microscope is, in part, the result of our increasing awareness of the limited effectiveness of psychotherapy, and it seems possible, although by no means certain, that more success will be found in the laboratory than in the consulting office in treating the mentally ill. While psychiatry is being biologized, general medicine is being psychologized--and perhaps for the same reason. J u s t as the psychodynamic approach is failing to live up to the hopes of its advocates in mental health, the biomedical approach is failing to live up to its hopes in general medicine. Whether we consider physical or mental disorders, the research of the past two decades has made a compelling case that there is a biology of health, a psychology of health, and a sociology of health (Dubos, 1959; Engel, 1977, 1980, 1982) and that whether we are thinking about treatment or about prevention, these three domains must be studied in their natural interactions. We are seeing a dramatic trend toward an ecumenical view of health and i l l n e s s - - a trend that opens new vistas for each of the core mental health disciplines. To be sure, physiological factors are powerfully related to the development and perpetuation of illness. Community psychology is actively providing evidence, however, that experience, on the one hand, and physical and h u m a n ecology, on the other hand, invade physiology and can either
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significantly increase or decrease vulnerability to illness as well as its severity and duration. With the growing evidence that in the health care delivery system of the near future, mental health and general health services may be far more integrated than they are today, this convergence of the physical illness and mental illness paradigms could not have come at a better time. Interdisciplinary collaboration rarely thrives in the academic setting. In the applied field setting, however, the situation is quite different. The health care delivery system that is being fashioned in the United States out of the key concepts of health maintenance, comprehensive care, and predictable cost will form the field setting where health, clinical, and community psychologists can productively develop those alliances that can result not only in a better understanding of health and illness, but also in significant improvements in life quality that are associated with improved health and vitality. Interdependence of Physical and Mental Health
A second important aspect of the growing convergence of thinking about physical and mental health is the overwhelming evidence linking them together. Insofar as vulnerability is concerned, there is clear evidence that the mentally ill have far more physical illness than those who are thriving psychologically, and that people who are physically ill are at higher risk of developing psychiatric disorders than those who are physically healthy. Insofar as remediation is concerned, there is considerable evidence that attention to physical well-being results in increases in psychological well-being and vice versa (Eastwood, 1975; Hankin, & Oktay, 1979; Kellner, 1966; Regier, Shapiro, Kessler, & Taube, 1984; Taube, Burns, & Kessler, 1984; Ware, Manning, Duan, Wells, & Newhouse, 1984). Preventive mental health services in the physical health context, through such programs as psychiatric liaison (see, for example, Levitan, & Kornfeld, 1981) are remarkably cost effective--an important consideration in this day and age. The cost of medical care is now so high, that virtually any responsible effort at prevention is justified. In the short run, prevention pays, although in the long run, we will be faced with a painful public policy debate, as we witness the inevitable consequences of successful prevention programs. As of 1983, of the total of just over two million deaths in the United States, more than 800,000 (41%) occurred prior to age 70 (National Center for Health
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Statistics, 1985). Preventing all preventable illnesses will reduce the number of these premature deaths, but will ultimately increase the number of medically expensive chronic illnesses and deaths that occur among the subsequently growing elderly population. The Emergence of the Generic Illness
While the majority of research seeking more effective strategies for prevention continues to be disease-specific, a third aspect of the growing convergence in the thinking about physical and mental health is the increasing evidence that there is a very strong generic component to illness (Dumont, 1984; Stein, & Jessop, 1982). An example of this generic phenomenon can be found in the research regarding stressful life events and social support networks. This research yields two dramatically different conclusions, depending on the research design. When persons who are ill are contrasted with persons who are well, the ill group is virtually always found to have undergone significantly more recent stress and to have significantly weaker sources of social support than the well group. On the other hand, when persons who have a particular illness (almost regardless of the nature of the illness--physical or mental) are contrasted with persons who have another type of illness, differences in stress or in the strength of social support networks are rarely found. Thus, the evidence suggests that many illnesses are more a function of characteristics of the host than of the agent. Stress appears to precipitate illness, but in individual cases the illnesses are unspecifiable. Recent research studies have made a very persuasive case that unmanageable stress appears to be associated with excess risk of an astonishing variety of disorders (see, for example, Bloom, Asher, & White, 1978). A strong social support network appears to reduce the risk of many different illnesses. But again, in individual cases these illnesses are unspecifiable. Nonspecific Preventive Interventions
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Close examination of the nature of recent preventive intervention programs in the field of general health reveals a fourth important obs e r v a t i o n - t h e programs focus primarily on strategies that are nonspecific--more careful attention to nutritional practices, increasing physical activity in persons with relatively sedentary jobs, and reducing smoking, alcohol, and other drug abuse.
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The evidence suggests that there are nonspecific mental health components that should be introduced into any preventive intervention program. Included in this list would be reduction of social isolation by the building of a psychological sense of community (Sarason, 1974); reduction of the sense of powerlessness by the increasing of self-efficacy (Bandura, 1977; Rappaport, 1981); and enhancement of interpersonal problem-solving skills by the use of such methods as social competency building, mental health education and community organization (Spivack, & Shure, 1973; Shure, & Spivack, 1982). What is particularly striking about such nonspecific preventive interventions is that they usually result in improved physical health as well as in improved mental health. Many of these nonspecific interventions are educational in nature, and that is entirely appropriate. In this context, we all need to keep in mind the origin of the word, doctor. It comes from the latin word, docere, meaning, to teach. Mental health professionals should be working toward becoming better teachers ourselves, and toward helping our colleagues in primary care medicine to become better teachers. While it is not directly pertinent to primary prevention, it is noteworthy that paralleling the results of studies regarding the nonspecific nature of preventive interventions are the results of studies regarding nonspecific psychological treatments. These findings strongly suggest that regardless of whether the condition that is being treated is essentially psychological or physical in nature, a period of brief psychotherapy is often significantly helpful in reducing the negative consequences of these illnesses (Bloom, 1980, 1981; Jones, & Vischi, 1979; Mumford, Schlesinger, & Glass, 1982). Lifestyle Components of Ill Health
A fifth component of the convergence of thinking about physical and mental disorders has been the attention that has been drawn to the role of lifestyle in the predisposition, precipitation, and perpetuation of illness (Lalonde, 1974). Of the ten leading causes of death in the United States, seven are in large part behaviorally determined (Albee, 1985). Modifying lifestyle implies modifying attitudes and behavior. Changing attitudes and behavior requires a special set of competencies --competencies that are the special domain of the mental health professions and the social sciences. Furthermore, health-compromising lifestyles are not uncorrelated with each other. Rather, they tend to form a syndrome of behaviors
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that covary (Jessor, 1982). Thus, successful reduction of the intensity or prevalence of one risk factor may be accompanied by parallel reduction of other risk factors as w e l l - - a n o t h e r aspect of the generic nature of illness that has already been identified. In a recent bibliography of research studies dealing with smoking cessation programs, for example, (U. S. Dept. of Health and H u m a n Services, 1984) there were perhaps 35 different papers from around the world describing an extraordinarily cost effective strategy and pleading for its increased implementation. The strategy takes ten seconds and costs virtually nothing. The strategy is for physicians to suggest to their patients that they should quit smoking. Recent literature suggests that if all physicians would take a moment to urge their smoking patients to stop smoking, their aggregate efforts would produce more ex-smokers than do all of the intensive smoking cessation clinics combined (Russell, Wilson, Taylor, & Baker, 1979). The interesting question, again one that social scientists may be especially competent to explore, is why so few physicians make that suggestion. Mental health professions have earned a special place in the continuing social policy debate in the United States, and by and large, take that responsibility very seriously. That role needs to continue its ongoing efforts to enhance health-affirming lifestyles--in encouraging better prenatal and postnatal care, for example, and better preparation of adolescents for the role of husband, wife, and parent.
Prevention of Psychiatric Disorders Health psychology shares with clinical and community psychology a deep commitment to the prevention of illness. Indeed, the history of medicine is a history of triumphs of disease prevention. In the case of the infectious diseases, we need only remember smallpox, typhus, cholera, typhoid fever, plague, malaria, diphtheria, tuberculosis, tetanus, and more recently, m a n y of the sexually transmitted diseases, measles, and polio. In the case of the nutritional diseases, we have but to think of scurvy, beriberi, pellagra, rickets, kwashiorkor, endemic goiter, and dental caries. Most of these diseases were conquered in a simpler time, to be sure, and their sharp drop in incidence has had a by-product, the development of a far more complex group of chi-onic conditions, including m a n y emotional disorders. But these victories should give us courage for the future. To be sure, the search for specific psychiatric diseases should continue.
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But if we start with the premise t h a t the concept of disease assumes t h a t some biological causative agent or agents exist t h a t are specific to each identified disease, we can see why the specific disease prevention paradigm is beginning to fail us. With some notable exceptions, it is becoming increasingly difficult to find new diseases. Thus, we would be wise to accord equal status to primary prevention programs t h a t invoke the more general health promotion paradigm (McPheeters, 1976), even though these programs have an unspecifiable although generally salutary effect on health. In my judgment, the most effective health promotion programs are embedded within stressful life event theory. It is a theory t h a t suggests t h a t reducing counterproductive stresses wherever possible, and helping people cope more successfully with stress where stresses are unavoidable, will make people generally healthier and less vulnerable to illness. If mental health professionals want a model to follow in reacting to the emerging importance of primary prevention, we could well emulate the dental profession. The profession of dentistry showed both enormous support and grace when evidence began to build t h a t fluorides in the drinking water appeared to reduce the risk of dental caries. Clinical activities should not be abandoned, of course, but we should do whatever we can to support those mental health professionals who are devoting their energies in the search for effective primary preventions. I know t h a t there are some mental health professionals who cannot find the beef in primary prevention. These mental health professionals would say, "Show me the flouride, and I'll show you the grace." Analysis of the recent prevention literature leaves absolutely no doubt t h a t preventive intervention programs that are based upon stressful life event theory are remarkably effective. The work of our group at the University of Colorado in implementing and evaluating a preventive intervention program for persons undergoing marital disruption has had such favorable long-term results t h a t it could stand as a prototype of what can be accomplished in working with persons undergoing stressful life events (Bloom, Hodges, Kern, & McFaddin, 1985). In addition, I would mention the work of Felner and his colleagues (1982) dealing with the stress of developmental transitions within the school system, Lynch (1985) dealing with stresses associated with coronary artery disease, and Melamed and Bush (in press) dealing with stresses in children t h a t are precipitated by medical procedures. We have hardly begun to explore the full possibilities of the health promotion paradigm in the prevention of mental disorders.
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In encouraging mental health professionals to consider the health promotion paradigm, you should note that that paradigm has an unusual and provocative solution to the question, "How many different psychiatric disorders are there?" While the DSM suggested that the answer was 60 in 1952, and 145 in 1968, and now suggests that the answer is 230, the health promotion paradigm suggests that the answer to that question is one. To put the health promotion paradigm into the form of a testable hypothesis, would be to suggest that the variance in h u m a n behavior that is accounted for by a simple assessment of degree of misery, or degree of demoralization (Frank, 1973), or degree of nonspecific psychological distress (Dohrenwend, Shrout, Egri, & Mendelsohn, 1980) is significantly greater than the variance accounted for by any specific diagnosis. Testing this hypothesis may, in fact, be one of the most important research agendas for the next decade. There appears to be some uncertainty about how to define mental disorders in the context of primary prevention. One hears, for example, that the inability to cope with stress, or the presence of an existential dilemma, or feelings of distress, or unhappiness, or pathological interpersonal relationships are not real mental disorders, and thus that efforts to prevent those conditions are not credible. Yet it would be the rare mental health professional who would not undertake to treat a prospective patient who complained of the inability to cope with stress, or of a pervasive sense of meaninglessness in life, or with a chronic inability to establish satisfying long-lasting relationships. In considering how to identify a mental disorder worthy of being prevented, I would urge the adoption of a general p r i n c i p l e - - i f it is a condition that a mental health professional would appropriately treat, then it is a condition that we have an equal responsibility to try to prevent.
Concluding Comments The health care system in the United States is undergoing changes of revolutionary proportions that are long overdue, and mental health professionals will be inexorably carried along with these general changes. Replacing the current largely unorganized, fee-for-service system that varies wildly in its quality, accessibility, and cost, will be an entitlement system that will be increasingly accessible, cost- and quality-conscious. One aspect of this change will be significantly increased activities in preventive intervention. The transformation of the American medical care delivery system
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will surely not take place without difficulties, but health psychologists along with their colleagues in clinical and community psychology, can help minimize these complications and the disruptions that will result in health service delivery. With the exception of the administration of immunizations against infectious diseases, interest in preventive intervention has rarely been reinforced in the training or practice of primary care physicians. In the case of the psychosocial preventive interventions that are the focus of this review, primary care physicians generally have neither interest nor competence, and the responsibility for their implementation will fall primarily on clinical, community, and health psychologists along with medical social workers. A second aspect of the transformation in the American medical care delivery system will be an almost single-minded preoccupation with cost containment. This concern has two immediate implications for psychology--one scientific and the other related to public policy. The scientific implication concerns itself with the evaluation of preventive intervention services. For reasons that are undoubtedly embedded in the societal mandate to the healing professions, demands for positive outcomes are far more stringent in the case of prevention than in the case of treatment. Sound evaluation of cost effectiveness will be demanded of preventive interventions, and psychologists will likely have considerable responsibility in carrying out these evaluations. The public policy implication lies in the area of constituency building. In this era of high competition for limited resources, preventive activities do not have a large constituency. That statement is particularly true in the case of psychosocial interventions, that is, interventions that seek to reduce illness by improving life quality. Psychologists working in the health setting will have to exercise continued vigilance in order to ensure that the interest in cost containment will not result in a dehumanization of medical practice. Psychologists will have to help in the process of constituency building, particularly among policy makers. If resources for health services continue to shrink, allocating money for preventive intervention will have increasingly serious competition from those who believe that funds ought to go primarily, if not exclusively, to the treatment of the already ill. J u s t as most illnesses have their constituency groups, so will prevention have to develop an effective constituency. A third implication for health psychologists is the need to defend the environmental change strategy as a way of enhancing health. Prior to the era of germ theory, when illnesses was thought to be brought about by environmental miasmas, there was little choice other than to make
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ecological i m p r o v e m e n t s in order to b r i n g a b o u t a r e d u c t i o n in t h e incidence of infectious diseases. Indeed, t h e e a r l y p r e v e n t i o n i s t s w e r e act i v e social r e f o r m e r s (see Bloom, 1965). One of t h e l i t t l e - a p p r e c i a t e d c o n s e q u e n c e s of g e r m t h e o r y as t h e f u n d a m e n t a l e x p l a n a t o r y principle for illness w a s t h e e l i m i n a t i o n of t h e n e e d to i m p r o v e life q u a l i t y in order to r e d u c e t h e p r e v a l e n c e of disease. A f o u r t h i m p l i c a t i o n of t h e c h a n g i n g c h a r a c t e r of m e d i c a l practice c o n c e r n s i t s e l f w i t h i n c r e a s i n g t h e t o l e r a n c e for n o n t r a d i t i o n a l f o r m s of h e a l t h e n h a n c e m e n t on the p a r t of p r i m a r y care p h y s i c i a n s . T h e s e n o n t r a d i t i o n a l practices, such as t r a n s c e n d e n t a l m e d i t a t i o n , for e x a m ple, m a y be at s o m e r i s k i f b i o m e d i c a l l y t r a i n e d p r a c t i t i o n e r s a s s u m e p r i m a r y control of t h e m e d i c a l care system. N o n t r a d i t i o n a l f o r m s of m e d i c a l p r a c t i c e a r e n e a r l y a l w a y s psychosocial in n a t u r e r a t h e r t h a n biomedical. H e a l t h psychologists, a l o n g w i t h t h e i r colleagues in clinical a n d c o m m u n i t y p s y c h o l o g y will b e a r special r e s p o n s i b i l i t y for d e m o n s t r a t i n g t h e effectiveness a n d efficiency of t h e s e m o r e psychosocial f o r m s of t r e a t m e n t .
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cal review of the literature. DHEW Publication No. (ADM) 78-661. Washington, DC: U. S. Government Printing Office. Haynes, R. B., Taylor, D. W., & Sackett, D. L. (Eds.) (1979). Compliance in health care. Baltimore, MD: Johns Hopkins University Press. Jessor, R. (1982). Critical issues in research on adolescent health promotion. In T. J. Coates, A. C. Petersen, & C. L. Perry (Eds.), Promoting adolescent health: A dialog on research and practice. New York: Academic Press. Jones, K. R., & Vischi, T. R. (1979). Impact of alcohol, drug abuse and mental health treatment on medical care utilization: A review of the research literature. Medical Care, 17 (Suppl.), 1-82. Karoly, P. (Ed.) (1985). Measurement strategies in health psychology. New York: Wiley & Sons. Kellner, R. (1966). Psychiatric ill health following physical illness. British Journal of Psychiatry, 112, 71-73. Krantz, D. S., Baum, A., & Singer, J. E. (1983). Handbook of psychology and health: Vol. 3. Cardiovascular disorders and behavior. Hillsdale, NJ: Lawrence Erlbaum Associates. Lalonde, M. (1974). A new perspective on the health of Canadians. Ottawa: Canadian Government Printing Office. Levine, S., & Ursin, H. (Eds.) (1980). Coping and health. New York: Plenum. Levitan, S. J., & Kornfeld, D. S. (1981). Clinical and cost benefits of liaison psychiatry. American Journal of Psychiatry, 138, 790-793. Lynch, J. J. (1985). The language of the heart: The body's response to human dialogue. New York: Basic Books. Matarazzo, J. D., Weiss, S. M., Herd, J. A., Miller, N. E., & Weiss, S. M. (Eds.). (1984). Behavioral health: A handbook of health enhancement and disease prevention. New York: Wiley. McPheeters, H. L. (1976). Primary prevention and health promotion in mental health. Preventive Medicine, 5, 187-198. Mechanic, D. (Ed.) (1982). Symptoms, illness behavior, and help-seeking. New York: Prodist. Melamed, B. G., & Bush, J. P. (in press). Maternal-child influences during medical procedures. In S. M. Auerbach & A. L. Stolberg (Eds.), Issues in clinical and community psychology: Crisis intervention with children and families. New York: Hemisphere. Millon, T., Green, C. J., & Meagher, R. B. (1982). A new psychodiagnostic tool for clients in rehabilitation settings: The MBHI. Rehabilitation Psychology, 27, 23-35. Mumford, E., Schlesinger, H. J , & Glass, G. V. (1982). The effects of psychological intervention on recovery from surgery and heart attacks: An analysis of the literature. American Journal of Public Health, 72, 141-151. National Center for Health Statistics (1985). Advance report of final mortality statistics, 1983. Monthly Vital Statistics Report, 34, No. 6, Supplement (2). Sept. 26, 1985. DHHS Pub. No. (PHS) 85-1120. Hyattsville, MD: U. S. Public Health Service. Perlmutter, F. D., Vayda, A. M., & Woodburn, P. K. (1976). An instrument for differentiating programs in prevention--primary, secondary, and tertiary. American Journal of Orthopsychiatry, 46, 533-541. Pamerleau, O. F., & Brady, J. P. (Eds.) (1979). Behavioral medicine: Theory and practice. Baltimore, MD: Prokop, C. K., & Bradley, L. A. (Eds.) (1981) Medical psychology." Contributions to behavioral medicine. New York: Academic Press. Rachman, S. (Ed.). (1980). Contributions to medical psychology: Vol. 2. New York: Pergamon Press. Rachman, S. (Ed.) (1984). Contributions to medical psychology: Vol. 3. New York: Pergamon Press.
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Rappaport, J. (1981). In praise of paradox: A social policy of empowerment over prevention. American Journal of Community Psychology, 9, 1-21. Regier, D. A., Shapiro, S., Kessler, L. G., & Taube, C. A. (1984). Epidemiology and health service resource allocation policy for alcohol, drug abuse, and mental disorders. Public Health Reports, 99, 483-492. Reppueci, N. D. (1985). President's column. The Community Psychologist, 19, 1-2. Rosen, J. C., & Solomon, L. J. (Eds.) (1985). Prevention in health psychology. Hanover, NH: University Press of New England. Russell, M. A. H., Wilson, C., Taylor, C., & Baker, C. D. (1979). Effect of general practitioners' advice against smoking. British Medical Journal, 2(6184), 231-235. Sarason, S. B. (1974). The psychological sense of community: Prospects for a community psychology. San Francisco, CA: Jossey-Bass. Schneiderman, N. S., & Tapp, J. T. (Eds.) (1985). Behavioral medicine: The biopsychosocial approach. Hillsdale, NJ: Lawrence Erlbaum Associates. Shure, M. B., & Spivack, G. (1982). Interpersonal problem-solving in young children: A cognitive approach to prevention. American Journal of Community Psychology, 10, 341-356. Spivack, G., & Shure, M. B. (1973). Social adjustment of young children: A cognitive approach to solving real-life problems. San Francisco, CA: Jossey-Bass. Stein, R. E. K., & Jessop, D. J. (1982). A noncategorical approach to chronic childhood illness. Public Health Reports, 97, 354-362. Stone, G. C., Cohen, F., & Adler, N. E. (Eds.) (1979). Health psychology: A handbook. San Francisco: Jossey-Bass. Taube, C. A., Burns, B. J., & Kessler, L. (1984). Patients of psychiatrists and psychologists in office-based practice: 1980. American Psychologist, 39, 1435-1447. U. S. Dept. of Health and Human Services. (1984). Bibliography on smoking and health: 1983. DHHS (PHS) 84-50196. Washington, D. C.: U. S. Government Printing Office. Ware, J. E., Manning, W. G., Duan, N., Wells, K. B., & Newhouse, J. P. (1984). Health status and the use of outpatient mental health services. American Psychologist, 39, 1090-1100. Weiss, S. M., Herd, J. A., & Fox, B. H. (Eds.) (1981). Perspectives on behavioral medicine: Proceedings of the Academy of Behavioral Medicine Research Conference, Snowbird, Utah, June 3-6, 1979. New York: Academic Press. West, L. J., & Stein, M. (Eds.) (1982). Critical issues in behavioral medicine. Philadelphia: J. B. Lippencott.
Topical Review: Primary Prevention and the Partnership of Clinical, Community, and Health Psychology BERNARD L. BLOOM The past decade has witnessed an explosion of activity in the new field of health psychology, and with it a challenging opportunity for mental health professionals identified with the fields of clinical and community psychology. Health psychology is bound to clinical and community psychology by their common interest in health. Clinical and health psychology are bound together by the surprisingly generic nature of their treatments; community and health psychology are bound together by their shared interest in prevention (Reppucci, 1985). If we start with the commonly accepted definition of psychology as the scientific study of behavior (see, for example, Bourne & Ekstrand, 1985), then we may consider the field of health psychology as the scientific study of health-related behavior. The concept of behavior is a broad one in this definition, and includes thoughts, attitudes, and beliefs as well as observable actions. Thus, the field of health psychology concerns itself with the scientific study of behavior, thoughts, attitudes, and beliefs related to health and illness. This definition is clearly too broad for daily use, since it is all-encompassing. The fields of clinical and community psychology have identified more manageable component parts of this larger enterprise, however, and are productively occupied in extending the knowledge and practice base. Edited volumes directly pertinent to the field of health psychology are being published at a prodigious rate. To illustrate this point, among the particularly noteworthy volumes published since 1979 should be included Ahmed, & Coehlo (1979); Bannerman, Burton, & Wen-Chieh (1983); Baum, & Singer (1982); Baum, Taylor, & Singer (1984); Burish, & Bradley (1983); Coates, Peterson, & Perry (1982); Doleys, Meredith, & Ciminero (1982); Elliott, & Eisdorfer (1982); Felner, Jason, Moritsugu, & Farber (1983); Ferguson, & Taylor (1980a, 1980b, 1981); Gatchel, Baum, & Singer (1982); Gentry (1984); Hamburg, Elliott, & Parron (1982); Haynes, Taylor, & Sackett (1979); 1
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Karoly (1985), Krantz, Baum, & Singer (1983); Levine, & Ursin (1980); Matarazzo, Weiss, Herd, Miller, & Weiss (1984); Mechanic (1982); Millon, Green, & Meagher (1982); Pomerleau, & Brady (1979); Prokop, & Bradley (1981); Rachman (1980, 1984), Rosen, & Solomon (1985); Schneiderman, & Tapp (1985); Stone, Cohen, & Adler (1979); Weiss, Herd, & Fox (1981); and West, & Stein (1982). In the past several years, there has been a gradual shifting in the thinking of many clinical and community psychologists from their interest in clinical and community mental health to the larger field of clinical and community health. This shift is particularly true regarding primary prevention, as it has become increasingly obvious that almost everything that is known about the prevention of mental disorders applies equally well to the prevention of physical disorders. Interest in primary prevention is sweeping the entire health service delivery system, and mental health professionals have important contributions to make to the prevention of all illness--physical as well as mental. In this review, I want to comment briefly on the public health view of the field of prevention, and then deal with five themes--(1) the growing convergence of the paradigms that govern the thinking of general health professionals and mental health professionals; (2) the growing awareness of the interdependence of physical and mental health; (3) the concept of the generic illness that is emerging from contemporary research; (4) the rationale of nonspecific preventive interventions in the fields of both physical and mental health; and (5) the implications of the growing understanding of the role of self-destructive lifestyles in the development of illness. In one way or another, many of the recent volumes identified above deal with these five themes, although not often in terms of their implications for the growing partnership expressed in the title of this review.
The Public Health View of Prevention In the control of any disorder--emotional or physical--two types of interventions exist. The first type seeks to reduce the number of persons suffering from the disorder, that is, to reduce the prevalence of the disorder. The second type seeks to reduce the severity or discomfort or disability associated with the disorder. Programs designed to reduce severity, discomfort, or disability are formally known as tertiao, prevention, but are better known as rehabil-
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itation. With lifelong disorders, rehabilitation programs generally have little effect on prevalence. Indeed, a well-run rehabilitation program m a y actually increase the prevalence of these disorders by increasing life expectancy. Unfortunately, given our current knowledge, many physical and emotional disorders appear to be lifelong or nearly lifelong, and thus cannot be significantly reduced in prevalence through rehabilitation programs. Because the prevalence of any disorder is a function of its duration and the rate at which new cases are produced, two approaches to reducing the prevalence of a disorder are commonly identified. The first seeks to reduce prevalence by reducing the duration of the disorder, usually through the development of some form of early casefinding combined with the prompt application of effective treatment. This approach is formally called secondary prevention. Secondary prevention efforts are preventive only in that systematic early case-finding brings with it the possibility of reducing the duration of the disorder. Should a technique for the early identification of some disorder be developed, without the concomitant development of more effective treatment procedures, such as in the case of the improved early identification of diabetes, a paradoxical increase in the prevalence of that disorder would occur (Gruenberg, 1980). A similar increase in the prevalence of a disorder has occurred in the case of Down's Syndrome, as a consequence of the development of antibiotics, which have significantly reduced the death rate from secondary causes among persons with that syndrome. It is this biomedical advance that has resulted in what Gruenberg has called, the "failures of success" (1977). The alternative approach to prevalence reduction is to reduce the rate at which new cases of a disorder develop. This approach seeks to reduce prevalence by reducing incidence, and is formally designated as primary prevention. The concept of primary prevention most clearly matches the lay use of the term, prevention. Effective primary prevention programs prevent disorders from occurring in the first place (Adam, 1981; Perlmutter, Vayda, & Woodburn, 1976). Gilbert (1982) has perhaps most recently described primary prevention in clear and straightforward language: To "prevent" means to keep from happening and is what primary prevention is about. A social problem, be it mental retardation, drug abuse, illegitimacy, delinquency, poverty, suicide, or some other affliction, is kept from happening either by doing something to the at-risk population that
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strengthens their immunity and resistance to the problem or by doing something to diminish the social conditions that breed the problem. (p. 293)
Convergence of Health and Illness Paradigms Until perhaps twenty years ago, the prevailing models that governed the work of health care providers were essentially disease-specific. Diseases were thought to differ from each other in terms of causative factors and treatment responsivity, so that for each unique disease there might be found a unique means for its prevention and a unique strategy for its treatment. In the case of physical illness, the prevailing disease-specific model was biomedical; in the case of mental illness, the prevailing disease-specific model was psychodynamic. Those of us who are old enough can remember the great stabilizing rudder of psychodynamic theory that governed our lives as students and as practitioners. The past two decades have witnessed an extraordinary biologizing of the field of psychiatry. This turning to the test tube and the microscope is, in part, the result of our increasing awareness of the limited effectiveness of psychotherapy, and it seems possible, although by no means certain, that more success will be found in the laboratory than in the consulting office in treating the mentally ill. While psychiatry is being biologized, general medicine is being psychologized--and perhaps for the same reason. J u s t as the psychodynamic approach is failing to live up to the hopes of its advocates in mental health, the biomedical approach is failing to live up to its hopes in general medicine. Whether we consider physical or mental disorders, the research of the past two decades has made a compelling case that there is a biology of health, a psychology of health, and a sociology of health (Dubos, 1959; Engel, 1977, 1980, 1982) and that whether we are thinking about treatment or about prevention, these three domains must be studied in their natural interactions. We are seeing a dramatic trend toward an ecumenical view of health and i l l n e s s - - a trend that opens new vistas for each of the core mental health disciplines. To be sure, physiological factors are powerfully related to the development and perpetuation of illness. Community psychology is actively providing evidence, however, that experience, on the one hand, and physical and h u m a n ecology, on the other hand, invade physiology and can either
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significantly increase or decrease vulnerability to illness as well as its severity and duration. With the growing evidence that in the health care delivery system of the near future, mental health and general health services may be far more integrated than they are today, this convergence of the physical illness and mental illness paradigms could not have come at a better time. Interdisciplinary collaboration rarely thrives in the academic setting. In the applied field setting, however, the situation is quite different. The health care delivery system that is being fashioned in the United States out of the key concepts of health maintenance, comprehensive care, and predictable cost will form the field setting where health, clinical, and community psychologists can productively develop those alliances that can result not only in a better understanding of health and illness, but also in significant improvements in life quality that are associated with improved health and vitality. Interdependence of Physical and Mental Health
A second important aspect of the growing convergence of thinking about physical and mental health is the overwhelming evidence linking them together. Insofar as vulnerability is concerned, there is clear evidence that the mentally ill have far more physical illness than those who are thriving psychologically, and that people who are physically ill are at higher risk of developing psychiatric disorders than those who are physically healthy. Insofar as remediation is concerned, there is considerable evidence that attention to physical well-being results in increases in psychological well-being and vice versa (Eastwood, 1975; Hankin, & Oktay, 1979; Kellner, 1966; Regier, Shapiro, Kessler, & Taube, 1984; Taube, Burns, & Kessler, 1984; Ware, Manning, Duan, Wells, & Newhouse, 1984). Preventive mental health services in the physical health context, through such programs as psychiatric liaison (see, for example, Levitan, & Kornfeld, 1981) are remarkably cost effective--an important consideration in this day and age. The cost of medical care is now so high, that virtually any responsible effort at prevention is justified. In the short run, prevention pays, although in the long run, we will be faced with a painful public policy debate, as we witness the inevitable consequences of successful prevention programs. As of 1983, of the total of just over two million deaths in the United States, more than 800,000 (41%) occurred prior to age 70 (National Center for Health
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Statistics, 1985). Preventing all preventable illnesses will reduce the number of these premature deaths, but will ultimately increase the number of medically expensive chronic illnesses and deaths that occur among the subsequently growing elderly population. The Emergence of the Generic Illness
While the majority of research seeking more effective strategies for prevention continues to be disease-specific, a third aspect of the growing convergence in the thinking about physical and mental health is the increasing evidence that there is a very strong generic component to illness (Dumont, 1984; Stein, & Jessop, 1982). An example of this generic phenomenon can be found in the research regarding stressful life events and social support networks. This research yields two dramatically different conclusions, depending on the research design. When persons who are ill are contrasted with persons who are well, the ill group is virtually always found to have undergone significantly more recent stress and to have significantly weaker sources of social support than the well group. On the other hand, when persons who have a particular illness (almost regardless of the nature of the illness--physical or mental) are contrasted with persons who have another type of illness, differences in stress or in the strength of social support networks are rarely found. Thus, the evidence suggests that many illnesses are more a function of characteristics of the host than of the agent. Stress appears to precipitate illness, but in individual cases the illnesses are unspecifiable. Recent research studies have made a very persuasive case that unmanageable stress appears to be associated with excess risk of an astonishing variety of disorders (see, for example, Bloom, Asher, & White, 1978). A strong social support network appears to reduce the risk of many different illnesses. But again, in individual cases these illnesses are unspecifiable. Nonspecific Preventive Interventions
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Close examination of the nature of recent preventive intervention programs in the field of general health reveals a fourth important obs e r v a t i o n - t h e programs focus primarily on strategies that are nonspecific--more careful attention to nutritional practices, increasing physical activity in persons with relatively sedentary jobs, and reducing smoking, alcohol, and other drug abuse.
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The evidence suggests that there are nonspecific mental health components that should be introduced into any preventive intervention program. Included in this list would be reduction of social isolation by the building of a psychological sense of community (Sarason, 1974); reduction of the sense of powerlessness by the increasing of self-efficacy (Bandura, 1977; Rappaport, 1981); and enhancement of interpersonal problem-solving skills by the use of such methods as social competency building, mental health education and community organization (Spivack, & Shure, 1973; Shure, & Spivack, 1982). What is particularly striking about such nonspecific preventive interventions is that they usually result in improved physical health as well as in improved mental health. Many of these nonspecific interventions are educational in nature, and that is entirely appropriate. In this context, we all need to keep in mind the origin of the word, doctor. It comes from the latin word, docere, meaning, to teach. Mental health professionals should be working toward becoming better teachers ourselves, and toward helping our colleagues in primary care medicine to become better teachers. While it is not directly pertinent to primary prevention, it is noteworthy that paralleling the results of studies regarding the nonspecific nature of preventive interventions are the results of studies regarding nonspecific psychological treatments. These findings strongly suggest that regardless of whether the condition that is being treated is essentially psychological or physical in nature, a period of brief psychotherapy is often significantly helpful in reducing the negative consequences of these illnesses (Bloom, 1980, 1981; Jones, & Vischi, 1979; Mumford, Schlesinger, & Glass, 1982). Lifestyle Components of Ill Health
A fifth component of the convergence of thinking about physical and mental disorders has been the attention that has been drawn to the role of lifestyle in the predisposition, precipitation, and perpetuation of illness (Lalonde, 1974). Of the ten leading causes of death in the United States, seven are in large part behaviorally determined (Albee, 1985). Modifying lifestyle implies modifying attitudes and behavior. Changing attitudes and behavior requires a special set of competencies --competencies that are the special domain of the mental health professions and the social sciences. Furthermore, health-compromising lifestyles are not uncorrelated with each other. Rather, they tend to form a syndrome of behaviors
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that covary (Jessor, 1982). Thus, successful reduction of the intensity or prevalence of one risk factor may be accompanied by parallel reduction of other risk factors as w e l l - - a n o t h e r aspect of the generic nature of illness that has already been identified. In a recent bibliography of research studies dealing with smoking cessation programs, for example, (U. S. Dept. of Health and H u m a n Services, 1984) there were perhaps 35 different papers from around the world describing an extraordinarily cost effective strategy and pleading for its increased implementation. The strategy takes ten seconds and costs virtually nothing. The strategy is for physicians to suggest to their patients that they should quit smoking. Recent literature suggests that if all physicians would take a moment to urge their smoking patients to stop smoking, their aggregate efforts would produce more ex-smokers than do all of the intensive smoking cessation clinics combined (Russell, Wilson, Taylor, & Baker, 1979). The interesting question, again one that social scientists may be especially competent to explore, is why so few physicians make that suggestion. Mental health professions have earned a special place in the continuing social policy debate in the United States, and by and large, take that responsibility very seriously. That role needs to continue its ongoing efforts to enhance health-affirming lifestyles--in encouraging better prenatal and postnatal care, for example, and better preparation of adolescents for the role of husband, wife, and parent.
Prevention of Psychiatric Disorders Health psychology shares with clinical and community psychology a deep commitment to the prevention of illness. Indeed, the history of medicine is a history of triumphs of disease prevention. In the case of the infectious diseases, we need only remember smallpox, typhus, cholera, typhoid fever, plague, malaria, diphtheria, tuberculosis, tetanus, and more recently, m a n y of the sexually transmitted diseases, measles, and polio. In the case of the nutritional diseases, we have but to think of scurvy, beriberi, pellagra, rickets, kwashiorkor, endemic goiter, and dental caries. Most of these diseases were conquered in a simpler time, to be sure, and their sharp drop in incidence has had a by-product, the development of a far more complex group of chi-onic conditions, including m a n y emotional disorders. But these victories should give us courage for the future. To be sure, the search for specific psychiatric diseases should continue.
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But if we start with the premise t h a t the concept of disease assumes t h a t some biological causative agent or agents exist t h a t are specific to each identified disease, we can see why the specific disease prevention paradigm is beginning to fail us. With some notable exceptions, it is becoming increasingly difficult to find new diseases. Thus, we would be wise to accord equal status to primary prevention programs t h a t invoke the more general health promotion paradigm (McPheeters, 1976), even though these programs have an unspecifiable although generally salutary effect on health. In my judgment, the most effective health promotion programs are embedded within stressful life event theory. It is a theory t h a t suggests t h a t reducing counterproductive stresses wherever possible, and helping people cope more successfully with stress where stresses are unavoidable, will make people generally healthier and less vulnerable to illness. If mental health professionals want a model to follow in reacting to the emerging importance of primary prevention, we could well emulate the dental profession. The profession of dentistry showed both enormous support and grace when evidence began to build t h a t fluorides in the drinking water appeared to reduce the risk of dental caries. Clinical activities should not be abandoned, of course, but we should do whatever we can to support those mental health professionals who are devoting their energies in the search for effective primary preventions. I know t h a t there are some mental health professionals who cannot find the beef in primary prevention. These mental health professionals would say, "Show me the flouride, and I'll show you the grace." Analysis of the recent prevention literature leaves absolutely no doubt t h a t preventive intervention programs that are based upon stressful life event theory are remarkably effective. The work of our group at the University of Colorado in implementing and evaluating a preventive intervention program for persons undergoing marital disruption has had such favorable long-term results t h a t it could stand as a prototype of what can be accomplished in working with persons undergoing stressful life events (Bloom, Hodges, Kern, & McFaddin, 1985). In addition, I would mention the work of Felner and his colleagues (1982) dealing with the stress of developmental transitions within the school system, Lynch (1985) dealing with stresses associated with coronary artery disease, and Melamed and Bush (in press) dealing with stresses in children t h a t are precipitated by medical procedures. We have hardly begun to explore the full possibilities of the health promotion paradigm in the prevention of mental disorders.
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In encouraging mental health professionals to consider the health promotion paradigm, you should note that that paradigm has an unusual and provocative solution to the question, "How many different psychiatric disorders are there?" While the DSM suggested that the answer was 60 in 1952, and 145 in 1968, and now suggests that the answer is 230, the health promotion paradigm suggests that the answer to that question is one. To put the health promotion paradigm into the form of a testable hypothesis, would be to suggest that the variance in h u m a n behavior that is accounted for by a simple assessment of degree of misery, or degree of demoralization (Frank, 1973), or degree of nonspecific psychological distress (Dohrenwend, Shrout, Egri, & Mendelsohn, 1980) is significantly greater than the variance accounted for by any specific diagnosis. Testing this hypothesis may, in fact, be one of the most important research agendas for the next decade. There appears to be some uncertainty about how to define mental disorders in the context of primary prevention. One hears, for example, that the inability to cope with stress, or the presence of an existential dilemma, or feelings of distress, or unhappiness, or pathological interpersonal relationships are not real mental disorders, and thus that efforts to prevent those conditions are not credible. Yet it would be the rare mental health professional who would not undertake to treat a prospective patient who complained of the inability to cope with stress, or of a pervasive sense of meaninglessness in life, or with a chronic inability to establish satisfying long-lasting relationships. In considering how to identify a mental disorder worthy of being prevented, I would urge the adoption of a general p r i n c i p l e - - i f it is a condition that a mental health professional would appropriately treat, then it is a condition that we have an equal responsibility to try to prevent.
Concluding Comments The health care system in the United States is undergoing changes of revolutionary proportions that are long overdue, and mental health professionals will be inexorably carried along with these general changes. Replacing the current largely unorganized, fee-for-service system that varies wildly in its quality, accessibility, and cost, will be an entitlement system that will be increasingly accessible, cost- and quality-conscious. One aspect of this change will be significantly increased activities in preventive intervention. The transformation of the American medical care delivery system
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will surely not take place without difficulties, but health psychologists along with their colleagues in clinical and community psychology, can help minimize these complications and the disruptions that will result in health service delivery. With the exception of the administration of immunizations against infectious diseases, interest in preventive intervention has rarely been reinforced in the training or practice of primary care physicians. In the case of the psychosocial preventive interventions that are the focus of this review, primary care physicians generally have neither interest nor competence, and the responsibility for their implementation will fall primarily on clinical, community, and health psychologists along with medical social workers. A second aspect of the transformation in the American medical care delivery system will be an almost single-minded preoccupation with cost containment. This concern has two immediate implications for psychology--one scientific and the other related to public policy. The scientific implication concerns itself with the evaluation of preventive intervention services. For reasons that are undoubtedly embedded in the societal mandate to the healing professions, demands for positive outcomes are far more stringent in the case of prevention than in the case of treatment. Sound evaluation of cost effectiveness will be demanded of preventive interventions, and psychologists will likely have considerable responsibility in carrying out these evaluations. The public policy implication lies in the area of constituency building. In this era of high competition for limited resources, preventive activities do not have a large constituency. That statement is particularly true in the case of psychosocial interventions, that is, interventions that seek to reduce illness by improving life quality. Psychologists working in the health setting will have to exercise continued vigilance in order to ensure that the interest in cost containment will not result in a dehumanization of medical practice. Psychologists will have to help in the process of constituency building, particularly among policy makers. If resources for health services continue to shrink, allocating money for preventive intervention will have increasingly serious competition from those who believe that funds ought to go primarily, if not exclusively, to the treatment of the already ill. J u s t as most illnesses have their constituency groups, so will prevention have to develop an effective constituency. A third implication for health psychologists is the need to defend the environmental change strategy as a way of enhancing health. Prior to the era of germ theory, when illnesses was thought to be brought about by environmental miasmas, there was little choice other than to make
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ecological i m p r o v e m e n t s in order to b r i n g a b o u t a r e d u c t i o n in t h e incidence of infectious diseases. Indeed, t h e e a r l y p r e v e n t i o n i s t s w e r e act i v e social r e f o r m e r s (see Bloom, 1965). One of t h e l i t t l e - a p p r e c i a t e d c o n s e q u e n c e s of g e r m t h e o r y as t h e f u n d a m e n t a l e x p l a n a t o r y principle for illness w a s t h e e l i m i n a t i o n of t h e n e e d to i m p r o v e life q u a l i t y in order to r e d u c e t h e p r e v a l e n c e of disease. A f o u r t h i m p l i c a t i o n of t h e c h a n g i n g c h a r a c t e r of m e d i c a l practice c o n c e r n s i t s e l f w i t h i n c r e a s i n g t h e t o l e r a n c e for n o n t r a d i t i o n a l f o r m s of h e a l t h e n h a n c e m e n t on the p a r t of p r i m a r y care p h y s i c i a n s . T h e s e n o n t r a d i t i o n a l practices, such as t r a n s c e n d e n t a l m e d i t a t i o n , for e x a m ple, m a y be at s o m e r i s k i f b i o m e d i c a l l y t r a i n e d p r a c t i t i o n e r s a s s u m e p r i m a r y control of t h e m e d i c a l care system. N o n t r a d i t i o n a l f o r m s of m e d i c a l p r a c t i c e a r e n e a r l y a l w a y s psychosocial in n a t u r e r a t h e r t h a n biomedical. H e a l t h psychologists, a l o n g w i t h t h e i r colleagues in clinical a n d c o m m u n i t y p s y c h o l o g y will b e a r special r e s p o n s i b i l i t y for d e m o n s t r a t i n g t h e effectiveness a n d efficiency of t h e s e m o r e psychosocial f o r m s of t r e a t m e n t .
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