Community Interventions in Mental Health Research Paper

In the United States, the impetus to move toward community interventions in delivering mental health services was linked to both political issues and conceptual developments in mental health and public health during the last 40 years of the twentieth century. Political support was provided by the 1963 Mental Retardation and Community Mental Health Centers Act (Public Law 88-164) signed by John Kennedy. Fueled in part by the report of the federally-sponsored Joint Commission on Mental Health and Mental Illness, this act was designed to localize mental health services in communities and expand the range of professional activities to include consultation and education as well as direct service.

Conceptually, the theoretical writings of Gerald Caplan (1964) provided an approach to the provision of services which was both community-based and focused on prevention as well as remediation. Caplan’s vision included a variety of assumptions about human behavior and the role of the mental health professional which would be increasingly realized over time. First, the community of concern was the entire community at risk from psychological problems, not only those already identified as having difficulty. Service integration based on a knowledge of the community was highlighted, with services tailored to the specific populations of concern. Second, individual behavior was to be assessed in terms of its adaptive significance in its local context, arguing against the universalist assumption about signs and symptoms of disorder. Third, the role between professional and citizen was redefined from one of expert–client to one of collaboration.

Finally, Caplan over time (1989) elaborated on four specific components of his population-oriented approach which have become significant areas of community intervention in mental health: (a) Prevention (discussed below); (b) Crisis Theory, in which intervention is provided during times of acute stress due to either natural disasters such as floods or incidents such as schoolyard shootings; (c) Mental Health Consultation, where scarce professional resources are used in community settings such as schools to increase indigenous capabilities of high impact individuals such as teachers; and (d) Support Systems, where social support to deal with difficult life circumstance is either provided through professional intervention or through working with the ongoing support systems of individuals.

Caplan’s overarching goal of promoting mental health and reducing the rates of disorder in a community has been articulated in public health as well. Altman (1995) suggests that a fundamental rationale for the importance of community-level intervention involves the understanding that shared determinant risks such as social class and social isolation themselves affect a broad variety of health outcomes. He outlines a five phase framework for conducting communitylevel interventions designed to benefit the public health, including mental health: (a) research, (b) transfer, (c) transition, (d) regeneration, and (e) empowerment. The focus of these phases is to move from a databased understanding of the problem to a collaborative community-level intervention which creates community empowerment over time. Feedback of data to local citizens is critical to this process.

1. Population-oriented Community Interventions

Most population-oriented community interventions have focused public health concerns. Thus, the Stanford Five-City Project involved a comprehensive, multilevel intervention to decrease the risk of cardiovascular disease in two intervention and three control cities. Multimedia campaigns were complemented by educational interventions in public schools and workplaces and health-related messages in restaurants and food stores. Results showed not only a greater decrease in cardiovascular risk scores in the experimental communities but increased reductions in overall smoking level, cholesterol level, and blood pressure (Farquar et al. 1990). While the specific implications of the intervention with respect to mental health outcomes were not assessed, the project serves as a model for approaching mental health using a community-wide, multilevel, collaborative intervention paradigm.

Similar projects focusing on community mobilization and multilevel intervention around health issues have been reported in many other countries. Higgenbotham, Heading, McElduff, Dobson, and Heller (1999) evaluated the effects of a 10-year community intervention in the Australian coalfields to reduce coronary heart disease. In this project lack of overall community mobilization resulted in a focus on specifically affected subgroups in the community such as families of heart disease patients, school children, retired persons, and women responsible for family nutrition. The process aspect of conducting community-level intervention is outlined by Pena, Thorn, and Aragon (1994) in their description of a community intervention project in the El Limon, an isolated goldmining community in Nicaragua. Focus was on the health and living conditions for the population of the town in general and the working environment of miners in particular. Local citizens—in particular miners—served as data collectors. Prevalence rates of various physical and mental health conditions, such as acute respiratory disease and nervous disorders, were calculated and now serve as the basis for developing community intervention programs.

Community-level interventions have also been targeted at social norms which support risk behaviors. Framing much of this work is diffusion of innovation theory which historically focused on how agricultural innovations were disseminated over time. Winett, Anderson, Desiderato, Solomon, Perry, Kelly, Sikkema, Roffman, Norman, Lombard, and Lombard (1995) outline this perspective and report on a series of papers by Kelly which employ diffusion of innovation theory in an effort to alter norms related to AIDS risk behavior. These studies focus on gay men living in small cities who frequent gay bars. With the help of bar owners, Kelly identified popular and influential persons who attended the bars and trained them to seek out others and deliver up-to-date information on AIDS transmission and prevention. Greater reductions in risk behavior among gay men frequenting gay bars were reported in the participating cities than in control cities.

Additional reports of efforts to alter community attitudes and responses have come from countries other than the United States. Fawcett, Heise, IsitaEspeje, and Pick (1999) report on a research and demonstration project in Izlacalco, Mexico to modify the response of friends, family, and the community at large to women suffering abuse from their husbands. This project began with focus groups and in-depth interviews which identified community attitudes and beliefs related to violence against women. A two-part intervention consisting of a 12-session consciousness-raising and skill-development workshop and a community-wide media campaign designed to reduce victim-blaming and increase community ownership of violence against women as a community-wide issue.

2. Preventive Community Inter entions in Community Settings

Most community interventions geared toward changing aspects of the community have focused on public health issues social problems or issues such as AIDS, substance abuse, and violence. During the latter years of the twentieth century, however, an increasing number of community interventions in mental health focused on the prevention of varying disorders and the promotion of well being. These efforts were originally grounded in Caplan’s designation of three levels of prevention: primary, secondary, and tertiary. Primary focuses on intervention before the appearance of disorder, while secondary involves intervention based on early identification of behaviors which are risk factors for later disorder. Tertiary prevention, in contrast, seeks to prevent the worsening of an already existing condition. Each of these levels of prevention has been implemented in community settings, and in each the concept of risk-reduction is central to the rationale for the intervention.

The prevention area has made considerable conceptual and empirical progress, and summaries of this progress are found in Felner, DuBois, and Adan (1991), Mrazek and Haggerty (1994), and Durlak and Wells (1997). The following community interventions only begin to outline the range of topics, populations involved, and process issues which are particularly salient in community interventions in mental health.

With respect to the area of tertiary prevention, perhaps the most well-known and discussed is the deinstitutionalization movement which began in the 1960s. As ‘deinstitutionalization’ implies, this movement was intended to mitigate the potentially negative effects of being in total institutions removed from family and friends by returning state hospital clients to the community. The intent was to provide sufficient supportive services in the local community to allow previously hospitalized individuals to rejoin their social networks and families and reduce the incidence of relapse. However, the development and integration of such community-based services was never adequately accomplished. Some deinstitutionalized individuals significantly improved as a result of this policy. However, in the absence of adequate community-based services, others were not able to handle community living. For them, the conditions necessary for effective tertiary prevention were not provided.

The potential of tertiary prevention for this group, however, is well documented in the work of Fairweather (Fairweather and Davidson 1987). In these projects, individuals released from state facilities were placed in a ‘lodge’ located in the community. Here, as a group, they developed job skills and interpersonal skills honed by living in the same environment. Evaluations of this program showed positive effects in terms of gainful employment and lower return rates to state hospitals than control groups. This model has been built on in more recent times through the development of mutual help organizations for chronically mentally ill individuals which provide an ongoing setting, leadership roles, and social support.

Efforts at secondary prevention focus on proactively seeking out potential risk factors or precursors of later mental health-related problems. Many secondary prevention projects have been carried out in such community settings as hospitals and schools, including screening programs for toddlers, parent education, and school involvement programs for immigrant adults, and programs for parents of premature infants. In each instance an at-risk group is identified and educational or consultative services developed.

One of the best documented and successful secondary prevention programs is the Primary Mental Health Project (Cowen et al. 1996). This project has historically focused on children in the elementary grades who are screened for level of behavior problems in the early school years. Careful longitudinal research was done to develop screening procedures which included input from teachers and parents, and to ascertain whether or not those identified as having behavior problems manifested in the classroom were indeed more likely to develop academic and mentalhealth related problems later on. Interventions were then designed and carried out primarily by nonprofessionals in the direct child-aide role. Extensive evaluation data collected both at the end of the intervention program showed that intervention group children were rated as having better mental health outcomes such as less depression, anxiety, and learning difficulty than control group children. Further, followup data several years later showed that these gains were maintained. In addition, the program has been widely disseminated in school districts in the United States.

The area of primary prevention has taken hold in many different settings and across the life cycle. The blueprint from much of this work is found in the five step preventive intervention research cycle (Mrazek and Haggerty 1994). First a problem is identified and information relevant to its extent is gathered. A review of risk and protective factors related to the problem is then undertaken. Next, pilot studies based on a theoretical framework generated from a review of information of risk and protective factors are undertaken to gain preliminary information on the efficacy of the intervention and issues which need further investigation. Only after these steps have been undertaken is a full-fledged large-scale trial of the preventive intervention carried out. The final step is to develop materials and community relationships which promote the implementation and evaluation of the preventive intervention in the community. Information from community implementation becomes part of a feedback loop which informs community interventionists about how to improve the intervention or issues in transporting it to other communities.

The Mrazek and Haggerty (1994) report outlines some of the many areas where community interventions have been aimed at the prevention of disorder across the life cycle. With respect to programs designed to enhance social competence, for example, they describe multicomponent projects such as the Montreal Longitudinal-Experimental Study for disruptive seven year-old boys (Trembley et al. 1991). This project provided both home-based training for parents and in-school social skills training for their children rated by teachers as highly disruptive. Three years after the intervention, children who were rated as being less aggressive were placed in special classes, schools, or institutions less often, and initiated fewer acts of delinquency by age 12.

Programs aimed at adolescents, adults, and the elderly are also abundant. With respect to adolescents, programs designed to provide social influence, resistance training, and promoting norms which counter drug use are described, as are family and school-based programs to prevent conduct disorder. Successful programs have also been reported which redesign the structure and social organization of schools to promote both academic achievement and reduce dropping out. Here the promotion of parent involvement, school-based mental health services, and mechanisms to provide consistent and supportive adult–adolescent relationships, have been found to serve preventive functions.

With respect to adults, programs aimed at altering the marital relationship have been found to affect the level of adult depression and divorce rates. Occupational stress and job loss have also been identified as risk factors for depression. Here, interventions with unemployed workers designed to promote self-efficacy and job-seeking skills have shown success in terms of both mental health and economic outcomes. Household burden and limited English skills have been found to be risk factors for depression in low income, migrant Mexican American women, and interventions using indigenous helpers (Ser idoras) in the local community.

Community interventions with the elderly have focused on the developmentally related risks of relationship loss, chronic illness, social isolation, and caregiver burden. The provision of social support is often central here, as is the involvement of nonprofessionals as intervention agents. For example, programs where widows provide a support and coping strategy-oriented intervention with other recently widowed women has been shown to affect wellbeing.

3. Concluding Comments

Overall, community interventions in mental health have been reported across a range of contexts and populations. Most are person-based, focusing on developing skills and competencies in individuals which will serve as protective factors in dealing with life circumstances. These circumstances may either involve ongoing issues such as promoting positive peer relations or may focus on dealing with particularly stressful situations such as parental divorce or the transition into a new school. However, other interventions target the social conditions and contexts within which individuals function. Together, the intent is to reduce risk factors and promote the development of positive coping of individuals in community contexts of importance to them.

Community intervention in mental health have also raised a new set of issues relating to methods, the research relationship between scholars and citizens, how to assess outcomes at the community level, and ethics. In addition, while many positive findings have been reported, questions remain about the conditions under which community interventions in mental health can fulfill the hopes on which they are built. The future of community interventions will involve an increasing focus on the contributions of factors at differing levels of the ecological environment to individual well-being; the ways in which multiple methods may complement each other in understanding the development and evaluation of community interventions, and models of collaboration in dealing with mental health issues in community contexts.