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The confluence of two salient events in the early 1960s—efforts to deinstitutionalize the chronically mentally ill and legislation to create community mental health centers across the nation— launched the community mental health movement. With the aid of a prevention framework adapted from the field of public health, this movement has continued to evolve and grow. Initial emphases on tertiary prevention, often in the form of alternative communitybased methods of treatment for the severely mentally ill, were followed by efforts aimed at early detection and intervention (secondary prevention), for example, suicide prevention telephone ‘‘hotlines.’’ In both tertiary and secondary forms of prevention, emotional and behavioral problems, or early antecedents thereof, continued to be identified at the level of the individual. Interventions were implemented within institutions in contrast to within communities. However, to reduce the incidence of disorder in the population, primary prevention programs aimed at communities, population groups, or settings were developed and implemented. The positive concept of promoting well-being was a further evolution from the notion of preventing disorder. This research paper describes, explains, and illustrates with exemplary programs the evolution from tertiary prevention to the promotion of well-being that has characterized the community mental health movement during the second half of the twentieth century.
I. Origins of the Community Mental Health Movement in Twentieth-Century America
II. Principles of Prevention
III. Tertiary Prevention
IV. Secondary Prevention
V. Primary Prevention
VI. Promotion of Well-Being
I. Origins of the Community Mental Health Movement in Twentieth-Century America
Widespread implementation of conceptions of community mental health did not begin in America until the early 1960s, even though these ideas and practices had numerous roots that originated both in previous centuries and in other nations. In fact, several scholars date the origins of interest in prevention as an alternative to treatment back to the twelfth-century Spanish philosopher Maimonides who spoke of ‘‘preventing poverty.’’
Returning to more recent history, in 1961, in response to a Congressional mandate the final report of the Joint Commission on Mental Illness and Health entitled Action for Mental Health was released. Among other things, it called for improved and expanded mental health services including: (a) improved care in small psychiatric hospitals of chronically mentally ill patients; (b) improved and expanded aftercare services, both partial hospitalization and rehabilitation in the community; (c) intensive care for acutely disturbed mental patients in mental health clinics in the community, general hospital psychiatric units, or in small intensive psychiatric centers; and (d) increased efforts at public education about both psychological disorders and the citizenry’s inclination to reject the mentally ill.
President John F. Kennedy was extremely receptive to the Action for Mental Health report. In a message delivered in 1963, he stated:
we must seek out the causes of mental illness . . . and eradicate them . . . For prevention is far more desirable . . . more economical and it is far more likely to be successful. Prevention will require both specific programs directed especially at known causes, and the general strengthening of our fundamental community, social welfare, and educational programs which can do much to eliminate or correct the harsh environmental conditions which are often associated with mental retardation and illness (p. 2).
Comprehensive care available to all people in their local communities was central to his clarion call for a ‘‘bold new approach.’’ These concepts were enacted into legislation as part of the Community Mental Health Centers Act of 1963.
As a result of this legislation, some 1500 catchment areas (currently referred to as mental health service areas) with populations ranging from 75,000 to 200,000 people were created in the United States; each catchment area was eligible for federal construction and staffing funds for a community mental health center. These centers were mandated initially to offer inpatient care, outpatient care, emergency services, partial hospitalization, and consultation and education, and ultimately to include diagnostic services, rehabilitation services, precare and aftercare services, training, and research and evaluation.
Both implicitly and explicitly, the goals of the Joint Commission on Mental Illness and Health, the Kennedy Administration, and the Community Mental Health Centers Act were to provide more humane and effective rehabilitation to those who were severely mentally ill. Patients needed to be integrated into their local communities and smaller treatment settings in contrast to huge, anonymous state hospitals in remote physical locations. Most importantly, they needed continuity of care, as indicated by the array of services to be offered by the local community mental health center.
Several other factors converged with this more humane and progressive approach to the treatment of the chronically mentally ill that were critical to the implementation of this movement toward deinstitutionalization. The use of phenothiazines made it more feasible to return patients to their communities as they were less likely to engage in the extremes of deviant behavior. At the same time, deinstitutionalization was seen as a dramatic cost-saving device by fiscally conservative legislators. As we describe below, ultimately, these fiscal motives undermined the continuity of care and services in the community envisioned by its originators.
Other salient factors that drove the community mental health movement included well-publicized, analytic reports that indicated that the mental health needs of the population far outstripped the resources of trained personnel. Moreover, those that needed services the most, for example, urban and rural poor, children, adolescents, and the elderly, received them least often and, generally paid more for these services when they did receive them. If prevention was to fulfill its promise, hard-to-reach, unserved, and underserved populations needed to be reached.
The principles of comprehensive community-based treatment, prevention and the promotion of well-being inherent to the ideology of the community mental health movement have continued to hold sway among practitioners and scholars to the present time. However, presidential support, implementation mechanisms, and financial resources at the national level were seriously undermined during the Nixon and Reagan Administrations.
II. Principles of Prevention
As we have seen, the preceding policy initiatives in the area of community mental health were inextricably intertwined with the idea of prevention. In 1964, Gerald Caplan published his classic book entitled The Principles of Preventive Psychiatry. Using public health concepts, he described three types of prevention—tertiary, secondary, and primary—as they related to mental health and illness.
The overriding goal of prevention is to reduce the prevalence or number of cases of mental disorder(s) at a specified moment in time in the population or community. Prevalence is, however, a function of both the incidence (the number of new cases diagnosed during a specified time period) and duration (the time between the initial diagnoses and recovery) of a disorder. Reducing duration, incidence, or both, reduces prevalence. Tertiary prevention reduces prevalence by decreasing the duration of a disorder. Secondary prevention can reduce prevalence either by short-circuiting the duration of a disorder or by intervening in the developmental course of a disorder before it has become fully manifested (and so labeled) to decrease incidence. Primary prevention reduces prevalence solely by decreasing the incidence of disorder.
In tertiary prevention, the goal is to reduce the duration of an individual’s career as a patient. Here, the patient has already been identified with a problem(s) in living. Thus, tertiary prevention is more appropriately referred to as rehabilitation. In secondary prevention, the goal is to identify early signs or antecedents of psychopathology in an individual so that intervention can be implemented promptly to alter the developmental course, duration, and/or severity of psychopathology. Here, short-circuiting a disorder’s duration is the primary means of diminishing prevalence. Early treatment or crisis intervention represent the most common forms of secondary prevention or intervention.
In both tertiary and secondary prevention, problem identification and change take place at the level of an individual person. This distinguishes them from primary prevention. In primary prevention, the prevalence, and more specifically the incidence of a disorder, in a population or setting is reduced. Thus, primary prevention is mass in contrast to individually oriented. It also differs from tertiary and secondary prevention by occurring ‘‘before-the-fact.’’ With regard to the nature/target of intervention, the distinction between tertiary/secondary and primary prevention is less clear. While most often the target of intervention in tertiary and secondary prevention is an individual, as we will see below, occasionally the target is the creation or alteration of a setting that a group of problem-identified individuals inhabit. However, based on the sharp differences in problem identification and the locus of change, some authors have suggested that referring to tertiary and secondary prevention as preventionmakes the concept of prevention meaningless.
As early as 1964, Caplan offered a compelling definition of primary prevention:
Primary prevention is a community concept. It involves lowering the rate of new cases of mental disorder in a population over a certain period by counteracting harmful circumstances before they have had a chance to produce illness. It does not seek to prevent a specific person from becoming sick. Instead, it seeks to reduce the risk for a whole population, so that, although some may become ill, their number will be reduced. It thus contrasts with individual patient-oriented psychiatry, which focuses on a single person and deals with general influences only insofar as they are combined in his unique experience (p. 26).
In primary prevention (or ‘‘true’’ prevention), the level of assessment or target of intervention is not an individual, but instead the reduction of the prevalence of disorder in an entire population or setting before it occurs. A vaccine can inoculate an entire population from contracting an illness before anyone has been affected, as exemplified by the polio vaccine or fluoride in water. Similarly, effective social policies can reduce the incidence and prevalence of unwanted problems in a society, as in the case of an effective gun control policy that reduces the homicide rate or a policy of availability and accessibility of condoms for sexually active adolescents that reduces unwanted pregnancies. An example specific to mental health is pellagra that is accompanied by psychotic-like symptoms. Pellagra is a disease that stems, in part, from a deficiency of niacin in the diet. Today, the disease is prevented with a dietary intake that includes a sufficient amount of niacin.
In an effort to reduce the prevalence of a disease, the progression from tertiary to primary prevention points the way toward the promotion of well-being. To the degree that interventions or policies can successfully promote well-being in the population, we will have succeeded in reducing the incidence and prevalence of a wide array of disorders and undesirable outcomes.
In the subsequent sections of this research paper, we will utilize the preceding principles and articulate more specific ones. These principles will be underscored with the use of exemplary programs in each area: tertiary, secondary, and primary prevention, and the promotion of well-being.
III. Tertiary Prevention
Long-term hospitalization of the mentally ill seemed to do little more than guarantee a chronic pattern of institutionalization. Thus, with the ideology and resources behind the community mental health movement in the 1960s, we began to see the development of a variety of innovative, experimental alternatives to institutional treatment. The goals were to remove patients from state psychiatric or Veteran’s hospitals and reintegrate them into local communities with the provision of a comprehensive and critical array of supportive services ranging from housing and employment to cooking, personal grooming, and treatment. These innovative community-based alternatives were not viewed as magical cures, but instead as the best means to provide patients with some semblance of ‘‘normal’’ lives, and at a minimum, a way to halt the well known iatrogenic effects of institutional treatment.
As a result of the Community Mental Health Movement, the number of state hospital beds were dramatically reduced over the years. Unfortunately, many of the patients who were deinstitutionalized did not receive the continuity of community-based services called for by the architects of this movement. Many patients would quickly return to the hospital for services. They would stay for a short period of time and, then again, be released to the community. This pattern would repeat itself; it came to be known as the ‘‘revolving door’’ phenomena.
Closing state hospitals and reducing the number of beds available did save money, but over time, fewer and fewer of these revenues were returned to local communities to provide for the continuum of services that were essential to community-based treatment. To date, this paradoxical pattern has not abated. Thus, an increasing number of people with serious problems in living are found roaming the streets; they lack access to a comprehensive array of essential residential and rehabilitative services.
While many in politics and the media have judged deinstitutionalization to have been a failure, this verdict is misleading. As envisioned by its architects, the policy of deinstitutionalization was never genuinely implemented since a continuum of comprehensive services tailored to the needs of individual patients was never put into place. However, though isolated, exciting and promising innovative experiments were implemented. Unfortunately, the results of these demonstration programs were ignored as fiscally minded politicians seized upon the opportunity to cut mental health budgets on the basis of the savings realized from the reduction in the number of hospital beds.
One such example of a successful demonstration program in the 1960s was developed by Fairweather and his colleagues; they created an innovative setting as an alternative to institutionalization, known as the community lodge program. Here, 8 to 10 long-term mental patients worked and lived in an autonomous unit outside the hospital. The ‘‘lodge’’ was often located on the border between a middle class and a poor neighborhood. In this way, the residents were able to create a small business and, at the same time, they were less likely to be rejected by their neighbors. The lodge residents shared household management and tasks ranging from cooking and cleaning to budgeting. They established a joint business, for example, a janitorial service, that enabled them to earn income and develop a sense of accomplishment. They ran their own ‘‘show’’ with leadership emerging from their ranks. Professional services, ranging from psychotherapy and medications to accounting, were available to them, but on an as needed basis, and after a time, only when the residents requested these services. Thus, unlike institutional treatment and many group homes that appear similar on the surface, patients no longer found themselves in the characteristic ‘‘one-down’’ relationship with the ‘‘doctor who knows best.’’ Results demonstrated that they were able to remain in the community for a longer period than were patients who were assigned to traditional outpatient care upon their release from the hospital.
To prevent the negative effects of institutionalization a number of exemplary innovations were implemented at the point of psychiatric admission. For example, in the 1970s, the Stein, Test, and Marx group in Madison, Wisconsin, developed, implemented, and evaluated an intriguing program that occurred within 1 week of hospitalization. Patients with extensive histories of psychiatric hospitalization who were deemed ‘‘unreleasable’’ by hospital personnel were placed into independent living situations based on their individual resources and needs. The goal was for these patients to make it in the natural environment. In that vein, staff took on the roles of advocate, resource finder, and teacher. Initially available on a 24-hour basis, staff gradually phased themselves out. Staff endeavored to keep patients independent of the usual mental health system and to help them obtain the resources needed for daily living by prodding and supporting job finding, grooming and cooking skills, recreational and social activity, and so forth. Staff also encouraged others to view patients as responsible citizens, even if it meant allowing the patient to spend a day or two in jail for breaking the law. In research evaluating this program, as in the community lodge program, the experimental group of patients was far more successful at maintaining themselves in independent living arrangements than the control group, yet few differences in psychiatric symptomatology were demonstrated between the two groups of patients.
A dramatically different alternative to psychiatric hospitalization became more ascendant in the1980s—self-help groups and mutual support organizations. Although self or mutual help groups often are viewed as adjuncts to traditional treatment, as illustrated in the next paragraph, mutual help organizations have greater potential as a true alternative, in that, beyond the weekly group meetings, there are many other ways that members engage themselves in each others’ lives as prodders and supporters. Moreover, some of these organizations view themselves as an international community health movement.
GROW, a mutual help organization, came to the United States in the late 1970s. The organization was created in Australia in the late 1950s by a group of former mental patients seeking more appropriate ways to deal with their problems in living than what they were receiving within the state institutions. In part, they modeled their mutual help group meetings along the lines of Alcoholics Anonymous meetings, which some of them had attended. Over time they developed a far more elaborate structure and set of principles, both for the group meetings, per se, and for the larger and more encompassing ‘‘sharing and caring community’’ that they established for their members. The organization’s most fundamental principle is not to do ‘‘to’’ or ‘‘for’’ people, but ‘‘with’’ people. Roles and niches are created, at whatever level of functioning people are at, where individuals can attain a sense of accomplishment and pride. In this way, their members can feel empowered and begin to grow. Members create friendship networks that provide support and assistance beyond the weekly group meetings. Local groups are organized into a regional network and they create other social functions; the regional network often establishes a small residential setting where they can tend to members at crisis times. Mutual help organizations clearly provide people with serious problems in living a social and psychological community in which to grow in contrast to institutional treatment and living.
Grassroots mutual help organizations such as GROW have a complete philosophy of treatment, offer a continuum of services, and operate relatively inexpensively. Because they are less dependent on outlays of financial resources from the government and, at the same time, are free of many bureaucratic constraints, they are more likely to be sustained and disseminated in contrast to many innovative demonstration programs that, most often, erode and disappear after the initial funds have been exhausted, no matter how effective they had been. The ‘‘catch 22’’ is that while mutual help organizations offer considerable therapeutic promise, their ascendance runs the risk of allowing governmental bodies to continue to rationalize their decreasing financial commitment to a continuum of mental health services.
As we have seen, several innovative treatment methods have been developed as alternatives to institutional treatment. They reduce the duration, and thus, the prevalence of serious problems in living. These alternatives are community-based and provide a continuum of supportive and residential services that keep people out of hospitals. Most often, these programs are characterized by a philosophy that dictates that they work with individual patients, in contrast to doing things to or for them. In essence, the traditional pattern of ‘‘one-up, one-down’’ role relationships between patients and service providers is restructured in these innovative and successful tertiary prevention programs. Nevertheless, these innovative methods provide rehabilitation to individuals constituting forms of tertiary prevention. They do not short-circuit problems, nor do they prevent groups/populations from developing mental health problems in the first place.
IV. Secondary Prevention
In secondary prevention, problem identification and intervention occur much earlier in the process than in tertiary prevention. The duration or magnitude of a mental health problem can be short-circuited by identifying and intervening early in the problem’s developmental course, thus, reducing its prevalence. On the other hand, if a problem is identified early enough in its course that it is not even considered a mental health problem, its incidence and, in turn, its prevalence can be reduced. Here, the potential problem can be thought of as being ‘‘cut off at the pass.’’ In both forms of secondary prevention, intervention occurs at the level of the individual; intervention is not mass-oriented as it is in primary prevention. However, in the latter form of secondary prevention, problem identification can occur at the level of a population or setting.
Once individuals enter the mental health system, they seem to become entrapped within it. From a secondary prevention perspective, we might want to examine gateways to the mental health system—how individuals enter the system. In some communities this gateway is the State’s Attorney’s Office, who must file a petition in order to legally involuntarily commit someone who appears disturbed. The State’s Attorney is often asked to file petitions for involuntary commitment on persons who would profit more from other services, for example, short-term housing, a friendship network, help in finding employment, or intensive outpatient counseling regarding a recent family crisis. Unfortunately, given limited resources and options, involuntary commitment is too often the easiest and most expedient action for the legal system.
In the Midwest during the 1970s, Delaney, Seidman, and Willis developed and evaluated an innovative and successful crisis intervention program for individuals in jeopardy of being involuntarily committed to a psychiatric hospital. They negotiated an arrangement in which they would immediately be notified by the State’s Attorney that they were considering filing a petition for involuntary commitment. Within 24 hours, the crisis intervention team would see the person in their natural environment, fully assess the problem, and develop a comprehensive plan of intervention, and set the plan into motion. State hospitalization was often deemed inappropriate or was used only as a last resort for a seriously disturbed individual. This program reduced the number of state hospitalizations in the area, provided persons with more appropriate services, thereby reducing many of the iatrogenic effects of hospitalization.(Were the focus of the program tertiary prevention, researchers would have aided the patients only after they had been involuntarily committed.)
Many secondary programs intervene with children since it is believed that the seeds of many problems are sown in childhood. Early detection and intervention is viewed as optimal. Since most children go to school, early identification programs often take place within schools, where populations of individuals can be screened.
One of the earliest exemplars of early detection and intervention programs was known as the Primary Mental Health Project developed by Cowen and his associates. Mass screening allowed early identification of children thought likely to manifest future adjustment problems. (This differs from a tertiary prevention program, which would focus on children that have already been identified as exhibiting problem behaviors.) The identified children were then assigned to minimally paid volunteer child aides (housewives or college students) to work one-on-one with them after school. These aides were trained and closely supervised by university personnel. By using paraprofessionals, the program extended the limited numbers and reach of mental health professionals.
Secondary prevention reduces incidence and prevalence by short-circuiting problems before they are fully realized. In this way it is clearly preferable to the rehabilitation strategies of tertiary prevention. However, intervention remains at the level of the individual and, thus, still runs the danger of stigmatizing and ‘‘blaming the victim.’’
V. Primary Prevention
Primary prevention programs endeavor to reduce the incidence of disorder, or unwanted outcomes, in a population or setting, such as the school, the workplace, or the community. Problem identification occurs at the level of a population or setting, not at the level of an individual. In contrast to tertiary and secondary prevention, the population or setting’s constituents have not been screened to determine if they have symptoms or problems.
Primary preventive interventions are mass-oriented; some programs are aimed at entire populations or communities, while others are aimed at population groups at high risk for negative outcomes. For example, poverty places some demographic groups at greater risk for maladaptive mental health outcomes. A variant of the high-risk approach is that a setting or transition can be considered ‘‘risky,’’ where residing in a particular setting or making the particular transition is associated with a higher likelihood or negative outcomes. For example, the work environment of air traffic controllers is considered a risky setting because of the high rates of physical and psychological stress reactions controllers experience. Similarly, the movement from elementary to junior high school is often deemed a risky transition because of the concomitant and precipitous drops in self-esteem and academic performance. In these examples, the social and environmental organization and structure of these risky settings and transitions need to become the focus of primary preventive interventions.
Regardless of the scope of the preventive intervention, malleable risk and protective factors take on increased importance. Stressful life events, for example, the death of a parent or divorce, and daily hassles are common risk factors, while positive social support is a common protective factor. The immediate goal of many recent primary prevention programs has become the reduction of risk factors and/or the enhancement of existing protective factors with regard to a specific risk–disorder linkage. However, the relationship between a particular risk and disorder, by no means, manifests a one-to-one correspondence. The same risk may be linked to several outcomes. For example, the risk of parental discord is related to both conduct disorder and depression. Consequently, the reduction of a single risk (or enhancement of a specific protective) factor may lead to reductions in the prevalence of several disorders. Thus, primary preventive interventions may be most powerful when they target a broad range of disorders with a set of salient risk and protective factors.
When the focus of intervention is a population or subpopulation, ‘‘inoculation’’ methods are the most common type of preventive intervention. Such programs endeavor to provide individuals directly with the skills, resources, and know-how to cope with future stresses, strains, and interpersonal encounters that might lead to problems—that is, inoculate them beforehand. Such a repertoire is intended to make the individual stronger and better prepared to deal with whatever may occur in the future. Inoculation programs are often administered to entire classrooms as part of the educational curriculum. In this type of primary prevention program, individuals remain the agents of change, although they are less likely to feel ‘‘blamed’’ than in tertiary and secondary prevention programs since they have not been singled out; everyone is receiving the inoculation.
When the focus of an intervention is a setting, inoculation methods are not employed. Instead, the prevention strategy is more often to restructure the social regularities of the setting. The goal is to modify the setting to become more facilitative of positive mental health outcomes. Thus, strategies to restructure settings characterize efforts more aptly depicted as the promotion of well-being than primary prevention. Indirectly these strategies reduce the incidence of an array of disorders for members of the setting. A more detailed example is presented in the next section.
When one thinks of primary prevention, one generally envisions programs for children. However, there are many adult problems that cry out for preventive interventions. For example, unemployed workers often suffer from depression and diminished self-efficacy after a futile search for new employment. In true cyclic form, depression and diminished self-efficacy can make finding a job more difficult and thus lead to greater depression.
At the University of Michigan, the Jobs Project was designed by Price, Caplan, and Vinokur to inoculate a high-risk population of recently unemployed individuals from the sequelae of depression and to evaluate the program’s success. Participants were recruited from the lines of the recently unemployed at the Michigan Employment Security Commission and randomly assigned to either an experimental or control group. The experimental group received an eight-session curriculum, while the control group received a brief booklet in the mail with general information about job seeking. The curriculum included topics such as dealing with obstacles to reemployment, handling emotions related to unemployment and job seeking, thinking like an employer, identifying sources of job leads, contacting potential employers, completing job applications, preparing a resume, conducting the information interview, rehearsing interviews, and evaluating a job offer. A second part of the intervention was participation in discussion and analysis of the unemployment situation; the researchers felt that when individuals felt empowered to solve their problems they would experience greater self-efficacy and be more committed to follow through and implement the strategies for seeking reemployment.
Participants in the program were assessed at 1 month and 4 months after the intervention program. At both times, program participants had a higher reemployment rate and reported a better quality of working life than the control group. Among those who were re-employed, program participants were more likely to report finding jobs in their main occupation and reported higher earnings. Participants who remained unemployed reported higher levels of job-search self-efficacy than the unemployed control group members. Even more importantly, long-term effects for the intervention were found in a follow-up approximately 3 years later. Program participants continued to report higher earnings and more stable employment than the control group. In addition, a cost-benefit analysis confirmed the utility of this program. Finally, central to our primary prevention focus, among participants deemed high risk for a depressive episode (based on their initial scores on depression, financial strain, and low social assertiveness), this intervention reduced both the incidence and prevalence of depressive symptoms. Had the researchers taken a secondary prevention perspective, they would have selected only individuals who manifested early signs of depression.
A different approach to primary prevention begins at the earliest point in human life—the unborn fetus. When carried by a poor, teenage mother, a baby is more likely to be delivered preterm and/or low in birth weight. As a result, these infants and children are at greater risk for physical and mental health problems. These poor, teenage mothers often do not get the necessary prenatal care to ensure a healthy and safe delivery. For many of these mothers, the lack of resources and social support often result in their dropping out of school and/or having difficulty maintaining stable employment; in turn, these negative outcomes further compound the negative effects and risk of disorder for their children.
To address these issues, David Olds and his colleagues developed the Prenatal/Early Infancy Project. It was designed as a population-level prevention program in which nurses went into the homes of teenagers in the early stages of their first pregnancy as well as during the first 2 years of the infant’s life. Initially, the nurses educated the mothers about fetal and infant development and helped the women improve their diet and try to eliminate the use of cigarettes, alcohol and drugs, they identified signs of pregnancy complications, they encouraged rest and exercise, they prepared parents for labor and delivery and early care of the newborn, and they encouraged use of the health care system and future family planning. Once the infant was born, the nurses would visit the families weekly for the first 6 weeks, gradually reducing the frequency of their visits from every other week to every 6 weeks until the infant was 2 years of age. During these visits the nurses would improve parents’ understanding of infant temperament, and they would promote socioemotional and cognitive development and the physical health of the child.
The Prenatal/Early Infancy Project focused on reducing the risk factors associated with being a teenage mother and provided the mothers-to-be with positive social support, a well-documented protective factor. The program promoted the involvement of family members in and around the mother’s home in the development of the infant. The nurses also provided connections to other formal health and human services. Moreover, the nurses paid special attention to the culture and the norms of the family, and they were respectful if they differed from that of the nurse and the program. Once again, this program illustrates an inoculation design because it prevents maladaptive outcomes by preparing and educating the mothers.
Research on this intervention revealed that participants in the home visit program manifested many positive outcomes when compared with a control group who only received free transportation for regular prenatal and well-child visits. During pregnancy, program mothers made better use of formal services, reported greater informal social support, improved their diets, and reduced smoking more than the control group. As a result, among the very young teenagers in the program, the birth weight of their babies was higher, and they were less likely to have preterm deliveries. Among the program mothers at higher risk—poor, unmarried adolescents—their children were less likely to have verified cases of child abuse and neglect and they had fewer emergency room visits. In a 15-year follow-up, program families had fewer subsequent pregnancies, approximately half the number of child abuse cases, and spent approximately half as long on welfare as the control group. Clearly, this primary prevention program was beneficial to the teenage mothers and their offspring. In a secondary prevention program, mothers would not have been targeted until after they had delivered a low birth weight baby or had been accused of neglect.
In sum, primary prevention programs are generally targeted to populations or subpopulations before problems or even signs of problems are manifested. Individuals, per se, are not identified, but instead a population or group placed at increased risk for one or more disorders or unwanted outcomes, often on the basis of a developmental transition that members of the group experience. Inoculation programs are administered to these populations in order to reduce the incidence of one or more disorders. By providing skills and resources, individuals are able to cope more effectively with future stressful and problematic situations that they may encounter. On the other hand, because individuals are not singled out at the stage of problem identification, individuals are much less likely to be (or feel) blamed.
VI. Promotion of Well-Being
There has been a recent movement to go beyond a prevention mindset to focus on promotion of well-being. Focusing on promotion of well-being leads us away from simply thinking in terms of defining problems, their negative outcomes, and ways to prevent them; instead we focus on methods for improving the lives of individuals, and making them healthier and more positive. Promotion of well-being interventions generally move beyond the population level and focus on the setting level, although they may target both or solely a population. To the degree that well-being is promoted, problems are inevitably, although indirectly, prevented.
In New Haven, Weissberg and his associates from Yale University joined together with the superintendent of schools, the Board of Education, parents, community leaders and school staff to develop an organized approach to the promotion of socio-emotional development in the public school system. A Department of Social Development was created with the central element being a comprehensive inoculation program. For every public school in the city, the Social Development Program was incorporated from kindergarten through twelfth grade. This program had from 25 to 50 hours of classroom instruction at each grade level, which focused on problem solving, self-monitoring, conflict resolution, communication skills, respect, responsibility, health, substance abuse, culture, and citizenship. Realizing that there was a need to provide children with activities and outlets outside of the school, and in order to reinforce lessons taught in the classroom, the program moved beyond mere classroom curricula and developed school and community activities. Students participated in mentoring, afterschool clubs, an outdoor adventure class, peer mediation, and leadership groups. Finally, the new department took advantage of previously existing mental health teams in the schools (made up of mental health workers, school staff, and parents). These teams effectively restructured the nature and quality of communication patterns and relationships among the three groups in order to focus on the climate of the schools, needs of the community and the issues that pertained to the growth and development of the students. They ensured that additions to the program were implemented and supported by the school and community.
The majority of school personnel supported the comprehensive and integrative strategy. Lessons taught to the students about problem solving were not only implemented by the students, but actively used by teachers and other school staff. Rather than detaining children for fighting, children received peer mediation or discussed the issues in a life skills class. School hallways were filled with the Traffic Light diagrams illustrating the six problem-solving steps taught in the life skills component. This was not your typical primary prevention program because it did not focus on one problem or even a few problems; rather, it focused on promoting positive social and emotional development and it embraced the entire school day and system.
This comprehensive strategy had many positive outcomes, including reduced problem behaviors. Evaluation research with sixth graders indicated that the curriculum improved students’ problem-solving skills, social relations with peers, and behavioral adjustment. Follow-up evaluations illustrated that students who received 2 versus 1 or no years of training had more durable improvements in problem-solving skills.
Often, enduring effects are also hindered by the unwritten social and organizational rules and procedures, or social regularities, that govern a setting. The best exemplars of programs that promote well-being challenge the social regularities of a setting and alter them so that they foster positive development and mental health. An excellent example of a promotion of well-being program is one that altered the social regularities involved in the transition from junior to senior high school.
Normative school transitions may be disruptive and negatively impact adolescents’ self-esteem and academic achievement. Often, adolescents make a transition into a more chaotic, more impersonal, less nurturing, and larger school where they have to contend with new routines and demands, numerous different teachers for short periods of time, and a completely different set of peers in each class. In these situations, the social regularities of the new school setting are critical to student well-being.
In the School Transitional Environment Program (STEP), Felner and his colleagues sought to reduce the chaos and flux upon entry into an inner-city high school. STEP students from each homeroom class took all their primary subjects together as a group. The homeroom teachers also taught the students one of their primary classes so they saw their homeroom students at least twice a day. In addition, the five STEP classrooms were in close proximity to each other in order to reduce the distance students traveled, and to keep them close to each other and in less contact with older, perhaps more intimidating students. STEP students experienced a very different environment than their peers, despite being in the same school.
The program was designed to provide adolescents with greater social support from school staff. Homeroom teachers served as the primary liaisons between the students and their parents and the school. Students received a counseling session with their homeroom teachers once every 4 to 5 weeks to discuss any school or personal problems. The homeroom teachers contacted parents of students during the summer before the transition to explain the purpose of the program and that they wanted to be accessible to the parents. Whenever a student was absent, the homeroom teacher would contact the family and follow-up on excuses. The teachers had regular meetings to discuss the students and the program. If a particular student was having a problem, all the STEP teachers were aware of it and tried to work together to help the student.
Research findings revealed that by the end of the first marking period, a comparison group of students declined in academic achievement and increased in absenteeism, whereas STEP students remained stable. By the end of the first year, 19% of comparison students dropped out compared to 4% of STEP students. In terms of academic achievement and absenteeism, the STEP students had significantly higher grades and lower absenteeism than the comparison group in both the first and second years of high school. Moreover, STEP students perceived the school environment to be more stable, well-organized, and supportive than the comparison group.
Although the STEP program was only in place for the incoming freshmen, the researchers felt that this program should have a long-term effect on the students because the transitional year is often the most vulnerable year for students. The researchers followed up their study of the original cohort by examining their school records after they should have graduated from high school. The most impressive finding was the difference in drop-out rates between the STEP students and the comparison students. The drop-out rate was 43% for the comparison group, which was similar to the drop-out rate of other students from the school in previous years. However, the drop-out rate was only 21% for the STEP students. The STEP program has been replicated in many sites, both at the senior high school level and the junior high (and middle) school level. The results are generally consistent across sites. This program illustrates an ideal promotion of well-being program that targets the school environment and makes it less chaotic, rather than a prevention program, which would most likely try to prevent school drop-out by targeting all students and providing them with extra help or supportive services to deal with the school transition.
The evolution of the Community Mental Health Movement from tertiary prevention to the promotion of well-being demonstrates the field’s growth, development and increased knowledge of mental health and the factors necessary to promote positive mental health. Although tertiary (rehabilitative) and secondary (early intervention) programs are still necessary and very much in practice today, it is clear that to incorporate prevention in their names is a misnomer. True prevention can only be through primary prevention and promotion of well-being programs. These types of programs, especially promotion of well-being are the present and future of the development and maintenance of positive mental health. Healthy, positive behavior in the individual cannot be maintained in a negative or chaotic environment. We must move away from solely targeting individuals to targeting the environments in which people live, work and learn.
- Albee, G. W., & Gullotta, T. P. (Eds.). (1996). Primary prevention works. Thousand Oaks, CA: Sage.
- Bloom, B. L. (1984). Community mental health: A general introduction. (2nd ed.). Monterey, CA: Brooks/Cole.
- Caplan, G. (1964). Principles of preventive psychiatry. New York: Basic Books.
- Price, R. H., Cowen, E. L., Lorion, R. P., & Ramos-McKay, J. (1988). 14 ounces of prevention: A casebook for practitioners. Washington, DC: American Psychological Association.
- Salem, D. A., Seidman, E., & Rappaport, J. (1988). Community treatment of the mentally ill: The promise of mutual help organizations. Social Work, 33, 403– 408.