The Journal of Primary Prevention, Vol. 15, No. 3, 1995

Advocacy and Services: The National Mental Health Association and Prevention Sandra J. McElhaney 1 and Heather A. Barton 2,3

This article follows the work of the National Mental Health Association in its efforts to advocate for and provide services on behalf of prevention. KEY WORDS: Prevention; advocacy; services; research; mental health; constituency.

Since 1964 when Gerald Caplan wrote his preeminent work, Principles of Preventive Psychiatry, many forces have converged to spur the development of the field of prevention in mental health. The combined efforts of numerous organizations, agencies, researchers, service providers, and several notable advocates have brought this fledgling discipline from its infancy into a rich childhood. Throughout this period, the National Mental Health Association (NMHA) has been a committed force in the prevention movement. The Association has worked toward a national prevention agenda that emphasizes high quality research and broad-based services. At the time of Caplan's writing, the federal infrastructure for prevention was non-existent. Through the ongoing advocacy efforts of NMHA and other organizations, in the years that followed, prevention has emerged as an area of emphasis in mental heath. This is evidenced by the presence of prevention components within the two major federal mental health entities; the Na-

ISandra J. McElhaney, M.A., is the Direct of Prevention, National Mental Health Association. 2Heather A. Barton is Prevention Specialist, National Mental Health Association. 3Correspondence and requests for information about the programs, papers and services described in this article should be addressed to Heather Barton, National Mental Health Association, 1021 Prince Street, Alexandria, VA 22314. 313 9 1995 Human SciencesPress, Inc.


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tional Institute of Mental Health and the Center for Mental Health Services. Furthermore, there is now a budding science base in prevention research and a momentum toward the establishment of a national organizational base for prevention services. As the nation's oldest and largest voluntary charitable organization working to change the way America thinks about mental health and mental illnesses, it is not surprising that NMHA's role in prevention actually predates Caplan's 1964 publication by some 55 years. Since NMHA's founding in 1909 by former mental patient Clifford Beers, the Association has worked on behalf of a broad-based agenda encompassing the whole of the mental health continuum. Prevention, mental health promotion, as well as better care and treatment of persons with mental illnesses have historically been the issues to which NMHA has been dedicated. Together with nearly 500 affiliated Mental Health Association Chapters across the nation, NMHA strives toward the attainment of its mission: Working for America's Mental Health and Victory Over Mental Illness. This article will not elaborate on NMHA's early work in prevention. That information has already been eloquently documented by Long (1989). What it will focus on is the Association's work following Caplan; particularly that initiating in the early 1980's. It is the work beginning in this particular time period that spawned NMHA's current multifaceted efforts of today. These efforts are directed toward advocacy for prevention research and services, and the provision of information and technical assistance to individuals and organizations across the nation. Any discussion of NMHA and prevention would not be complete without paying appropriate homage to a person who is regarded as the igniter of the flame for the prevention advocacy movement. Through more than 20 years of work at the local, state and national levels, Beverly B. Long has been the perpetual voice of prevention within NMHA. Her work as President of the Georgia Mental Health Association led to an appointment on President Carter's Commission on Mental Health. The Report of that Commission (1978) described the federal role in the prevention of mental illness and the promotion of mental health as "unstructured, unfocused, and uncoordinated" (p. 53). To begin to address this problem, the Commission recommended the development of a Center for Prevention within the federal agency charged with providing leadership for mental health issues, the National Institute of Mental Health (NIMH). Through significant advocacy efforts on the part of NMHA and other groups, this recommendation did become a reality and in late 1979 a small prevention office was established at NIMH.

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THE NMHA COMMISSION ON THE PREVENTION OF MENTAL-EMOTIONAL DISABILITIES After the Carter Administration, mental health efforts generally-and prevention efforts specifically-were deemphasized. What available resources there were for mental heath were, by and large, directed into the area of most immediate need - - services, treatment and research on serious mental illness. To refocus national attention on prevention, NMHA convened its Commission on the Prevention of Mental-Emotional Disabilities (hereafter to be identified as "the NMHA Commission") in 1984. Chaired by Beverly Long, the purpose of the NMHA Commission was threefold: 1) To assess current knowledge about the prevention of mental-emotional disabilities; 2) To assess the application of that knowledge; and 3) To make recommendations for the future. Comprised of outstanding scientists, professionals and citizens, the NMHA Prevention Commission convened meetings with experts across the country to discuss specific areas within prevention. These forums covered the life stages, from before conception through old age. Separate forum sessions were also held to consider schizophrenia and major depressive disorders, prevention activity in public and private sectors, as well as education and information efforts related to prevention. The NMHA Prevention Commission's final report (1986) was heralded as "a leap forward whose impact will help rechart the course of the field of mental health" (Albee, 1987, p. 176). The report proposed an agenda for action with specific guidance directed at many interests including the federal government, the National Mental Health Association, states, communities, foundations, schools, the workplace, and the media. Of particular importance are the recommendations that the NMHA Prevention Commission issued to the National Mental Health Association. The NMHA Prevention Commission urged NMHA to accomplish the following: 1.


Form a coalition with other nongovernmental groups to define mutual goals and priorities and provide visibility to the prevention field. Essential would be regular opportunities to share information and develop consensus for recommendations for policy leaders and agencies. Provide leadership, through its national office and network of state divisions and local chapters, to educate and inform the public and support model prevention programs. (p. 36)

From these recommendations, NMHA has built a comprehensive, national prevention advocacy and services program.


McEIhaney and Barton ADVOCACY FOR PREVENTION RESEARCH AND SERVICES Working at the National Level

At the core of NMHA's prevention advocacy effort is the National Prevention Coalition (NPC). Immediately following the release of the NMHA Prevention Commission report, in early 1987, NMHA invited representatives from numerous mental health and related organizations to a meeting to discuss the prevention of mental-emotional disability and the enhancement of mental health. The meeting was presided by Beverly Long, who would eventually assume the role of NPC chair. Participants from 12 national organizations shared information on the prevention activities of their respective organizations and began identifying common interests. Participants recognized the interrelationship of mental-emotional disabilities, substance abuse, adolescent pregnancy, delinquency, unemployment and other social problems. Participants further agreed on the need to increase the attention given to mental health within health policy and practice. One need identified was the process and support for transferring research knowledge into practice. Following the meeting, a preliminary "mission statement" for the new NPC was drafted and ultimately approved stating the purpose of the NPC to: 9 Share information about current prevention efforts; 9 Provide a forum for discussing issues relevant to prevention; 9 Foster prevention research and seek consensus on priority needs for such research; 9 Foster transfer of knowledge from research to service; 9 Gain acceptance of and use of prevention services as a part of the continuum of mental health services; 9 Share information about current policies affecting prevention; 9 And to influence those policies. The NPC operates under the following ten premises: 1. Health as defined by the World Health Organization is "a state of complete physical, mental and social well-being and not merely the absence of disease." Mental health and physical health are interrelated. 2. Mental-emotional disabilities comprise an extensive list of conditions. They range from severe illness such as schizophrenia to less severe, less chronic but often acutely disabling disorders.

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3. Mental-emotional disabilities can rarely be attributed to a specific cause such as a virus, bacterium or gene, but instead develop from complex interaction of biological, physiological, psychosocial, interpersonal and environmental factors. This complexity is not unique to mental-emotional disabilities and does not make prevention impossible. Rather than an exclusive focus on a specific disease or disability, the prevention focus is more on a vulnerability-healthiness continuum. 4. Prevention means literally to keep something from happening. Within the field of mental health, it means intervening in a deliberate and positive way to counteract harmful circumstances before they cause disorder or disability. 5. The potential of preventing mental-emotional disabilities is based on public health approaches of eliminating or modifying antecedent factors and of enhancing the individual's ability to tolerate those factors. Prevention within the mental health field thus involves modifying risk factors or stressors, developing competence and ensuring support. 6. A substantial and rapidly expanding knowledge base exists to direct efforts in the prevention of mental-emotional disabilities. 7. Knowledge of risk factors provides impetus to prevention work by suggesting avenues of intervention. It is recognized that the "at risk" label is a statistical concept, to be used with caution and sensitivity. The competencies, support and modification of stressors that are involved in the prevention of mental-emotional disorders are positive, relevant and important for every individual. 8. No prevention specialist claims that the current state of knowledge is sufficient to prevent schizophrenia. On the other hand, leads derived from prevention-oriented research may contribute to unraveling the complex and inter-related causes of these most severe, as well as some of the more limited, disabilities. Further progress will come with intensified and coordinated research to identify causes and risk factors and with the development of effective interventions. 9. The scope of prevention efforts is across the life span, from prenatal care and recognition of attachment needs of infants to fostering social networks and personal control for the elderly. 10. Investing in prevention will in the long run be cost-effective. There is evidence of long term effects of prevention interventions in reduced social costs. The intangible benefits of preventing rather than treating disabilities are obvious.


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Since 1987, the NPC has met bi-annually. These public forums highlight the viability of prevention in mental health as well as provide an arena for discussion of the latest issues confronting the prevention field. Under the leadership of N M H A and with 25 national organization members, the NPC has worked on behalf of numerous prevention research advocacy initiatives (Long, 1992). Successful efforts have included the establishment of a Steering Committee on prevention research within the NIMH and an annual N I M H National Conference on Prevention Research. The N I M H national conferences have already produced a 64 page national research agenda on the prevention of mental disorders (NIMH, 1993). A prevention services-research demonstration program has also been established within NIMH. At present, this program is providing funding support for six comprehensive multi-site programs; three for the prevention of chronic conduct problems and three for the prevention of youth suicide. The NPC has also advocated for a Institute of Medicine Study on the Prevention of Mental Disorders. This congressionally mandated project, which is currently underway, will provide recommendations on federal policies and programs of research support leading to a comprehensive prevention research agenda as well as on opportunities for maximization of involvement and improvement of coordination among federal agencies. In early 1991, former N M H A President, L. Patt Franciosi succeeded Beverly Long as NPC Chair. Under Franciosi's leadership, current priorities on the NPC advocacy agenda include efforts to integrate preventive mental health services into health care reform (McElhaney, 1993). Coalition members maintain that the following five preventive mental health interventions should be included in a reformed health care system: 1. 2.



Screening for developmental delays and mental health problems for children and adolescents as part of regular check-ups. Screening for mental health problems in adults, as part of routine preventive exams, to screen, for example, depression, anxiety, or potentiality of suicide. Counseling for individuals and families in situations that place them at high risk for developing mental or emotional disorders, i.e., children whose parents have mental illness, children whose parents have a history of substance abuse, children who have been abused, victims of violence, the recently unemployed, disaster victims, and bereaved individuals. Home visits and other intensive interventions in high risk situations involving stress and lack of social support for pregnant women and parents and infants, such as premature infants, low income households and teenage parents.

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Self-help groups to assist persons confronting health problems, mental health problems, or life situations of stress or change.

These recommendations have been forwarded to members of the Clinton Administration and U.S. Congress. The establishment of the federal Center for Mental Health Services (CMHS) in fiscal year 1993 has provided the NPC with an Administrative locus to which advocacy for prevention services can be addressed. While federally funded prevention research is now advancing, the same cannot be said for prevention services. Thus, the NPC is now working to encourage Congressional appropriation for a CMHS prevention services program that would provide leadership and support for practitioners across the nation. Working at the Grass-Roots Level

While the National Prevention Coalition provides a forum for convening national organizations on behalf of pressing prevention issues, N M H A recognizes that the role of the individual--researcher, service provider, educator, policy maker, advocate, and s t u d e n t - - i s critical to the ongoing development of the field. Thus, in 1993, N M H A recently launched a grass-roots focused Prevention Constituency membership program. The N M H A Prevention constituency provides a forum for sharing, networking and concentrating needed attention to the mental health benefits offered by primary prevention. Members stay informed of the latest information on studies, programs and issues through a quarterly newsletter, NMHA Prevention Update. Members also receive periodic information on legislative issues. To data, the Prevention Constituency's advocacy thrust has focused on maintaining support for prevention research, while trying to advance the lagging arena of prevention services. Working for Prevention Leadership in the States

Although the Association's prevention advocacy efforts have traditionally focused on federal activities, in August 1993 N M H A released recommendations to N I M H on the development of primary prevention activities in the fifty states (Barton, McElhaney, Franciosi & Pritchard, 1993). A lack of comprehensive primary prevention activities at the state level led NMHA, in conjunction with NIMH, to convene two focus groups of prevention leaders from across the nation to discuss the opportunities and challenges to increasing state prevention services. This effort was in-


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itiated in response to a study by Goldston (1991) which found only seven states with significant involvement in prevention through their mental health departments. All focus group participants agreed on the need for a full continuum of mental health services in every state from primary prevention through early intervention, treatment, and rehabilitation. Based on the discussion at the focus group meetings, participants offered recommendations to facilitate the development of primary prevention activities within states. These recommendations focused on four areas, the need for a widely adopted definition of prevention; the need to market prevention to multiple audiences; the need for the exchange of knowledge between the research and service communities; and the need to develop comprehensive prevention services programs to create an infrastructure for prevention within the states.


Community Prevention Services Program To address the N M H A Prevention Commission's recommendations relative to services, the Association has developed an innovative program, which seeks to fill significant gaps in the prevention field. With generous support from The Pew Charitable Trusts, N M H A has been able to develop an extensive Community Prevention Services Program to assist communities in implementing model prevention efforts. This program is unique in that it is the first systematic attempt to provide national support for state and community programming of high quality, researched and evaluated preventive interventions. Through the Community Prevention Services Program, N M H A is providing extensive technical assistance to ten communities in implementing model prevention programs. Working with Mental Health Association (MHA) affiliate chapters, researched and evaluated programs for the prevention of mental and emotional disabilities are being established in communities across the country. At present, all 10 of the MHAs have selected model programs for local implementation. The focus areas of the programs selected by the MHAs fall into three areas considered most effective by NMHA's Commission on the Prevention of Mental-Emotional Disabilities. There areas are: social competency building, parenting education; and programs for individuals in situations of extreme stress (i.e., children facing parental divorce or workers recently unemployed). A second major component of the Community Prevention Services Program is the National Prevention Clearinghouse. The clearinghouse pro-

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vides a number of services including access to three computerized databases: a programs database, a contacts database, and a resource database. The programs database houses information on evaluated primary prevention programs designed for implementation in a variety of settings. The contacts database operates as a network designed to connect experts with those who need their assistance, and to facilitate communication among persons involved in primary prevention. The resource database can conduct customized searches on a variety of prevention-related topics for relevant references, journals, books, resource guides, events/conferences, etc.

Lela Rowland Prevention Award

In concert with NMHA's programmatic support of model prevention programs, the Association has also created an annual award to recognize the most outstanding efforts in this realm. The NMHA Lela Rowland Prevention Award was established to focus attention on the prevention of mental-emotional disabilities by increasing the understanding of primary prevention in the mental health field, stimulating interest in prevention possibilities, demonstrating the existence of credible programs and rewarding those who develop effective programs in this area of concern. The fourteen programs which have received this honor represent the best services the prevention field has to offer.

CONCLUSION Although it can be said that prevention has come a long way since Clifford Beers, Caplan, the President's Commission on Mental Health, and the NMHA Prevention Commission, the road ahead is largely uncharted. In reviewing the major developments and initiatives cited in this paper, it is evident that the progress which has been made to date would not have occurred were it carried out by one organization acting alone. The history of NMHA's involvement in prevention has shown that real advancements in the field come only through collaboration with each and every member of the prevention constituency. As we look toward the future, NMHA encourages the readers of this journal to become a part of the Association's efforts to advance this vital field. Working together, we can ensure that prevention in mental health will grow to be an even stronger force in the decades ahead.


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REFERENCES Albee, G. (1987). Preface. The Journal of Primary Prevention. 7(4), 175-176. Barton, H. A., MeElhaney, S. J., Franciosi, L. P. & Pritehard, K. (1993). Prevention and mental health promotion in the states: opportunities and challenges. (Available from National Mental Health Association, 1021 Prince Street, Alexandria, VA 22314). Caplan, G. (1964). Principles ofpreventh~e psychiatry. New York: Basic Books. Goldston, S. E. (1991). A survey of prevention activities in state mental health authorities. Professional Psychology: Research and Practice, 22, 315-321. Long, B. B. (1989). The mental health association and prevention. In R. E. Hess & J. DeLeon (Eds.), the national mental health association: eighty years of involvement in the field of prevention (pp. 5-52). Binghamton, NY: The Haworth Press. Long, B. B. (1992). Developing a constituency for prevention. In M. Kessler, S. E. Goidston & J. M. Joffee (Eds.), The present and future of prevention (pp. 69-77). Newbury Park, CA: Sage Publications. McElhaney, S. (1993). Recommendations for preventive mental health services in health care reform. (Available from National Mental Health Association, 1021 Prince Street, Alexandria, VA 22314). National Institute of Mental Health (1993). The prevention of mental disorders: a national research agenda. Rockville, MD: National Institute of Mental Health. National Mental Health Association (1986). The prevention of mental-emotional disabilities: report of the National Mental Health Association commission on the prevention of mental-emotional disabilities. Alexandria, VA: Author. President's Commission on Mental Health (1978). Report to the President (Stock No. 040-000-00390-8). Washington, DC: U.S. Government Printing Office. Pritchard, K. (1992). Background paper: prevention and mental health promotion in the states: opportunities and challenges. (Available from National Mental Health Association, 1021 Prince Street, Alexandria, VA 22314).

Advocacy and services: The National Mental Health Association and Prevention.

This article follows the work of the National Mental Health Association in its efforts to advocate for and provide services on behalf of prevention...
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