PREVENTIVE
MEDICINE
5,
187-198 (1976)
Primary Prevention and Health Promotion in Mental Health’ HAROLD Commission
on Mentrd
illness
L.
MCPHEETERS
und Retardation. Atlanta, Georgiu
Southern 30313
Regional
Education
Board,
Despite frequent pleas for mental health programs to devote more resources to primary prevention, mental health programs remain overwhelmingly oriented to treatment. Prevention is given low priority because many psychiatrists who are leaders in the mental health field are focused on a medical-pathological model of prevention that has limited usefulness in mental health and because the guidelines for a social-behavioral model are not always clear. A model for conceptualizing and programming of primary prevention and promotion in all of the human services is offered with special attention to mental health functioning. Strategies for both primary prevention and promotion may be directed to individuals or to the environment, but, in either case, the targets and the strategies must be clearly identified. Prevention strategies are directed toward persons under some specific stress or risk, while promotion activities are directed to persons in normal situations ofgrowth and development. For either prevention or promotion, the most widely effective strategies are those that require the least personal cost and effort-usually the strategies that are directed toward the environment. Prevention and promotion both depend on clear assessment of the stresses and needs and must be evaluated. Programs are often too global or too diffuse to be effective or credible. Working in closed social systems and sharp evaluation will help correct these problems.
The mental health programs of this country remain strongly oriented to the treatment and restoration of the mentally ill, the emotionally disturbed, the mentally retarded, and alcohol and drug abusers despite the occasional calls for more work in primary prevention. President John F. Kennedy in his historic messageof February 5, 1963, stated that: “First we must seek out the causes of mental illness and of mental retardation and eradicate them. . . . For prevention is far more desirable for all concerned. It is far more economical and it is far more likely to be successful. Prevention will require both selected 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 often are associated with mental retardation and mental illness” (9). Despite this plea in the call for the Community Mental Health Centers Act of 1963 for prevention, to be a major priority of comprehensive community health, prevention is presently given a very low priority in community mental health centers, staff being almost totally involved in treatment services (6). The citizens associations for mental health continue to have a high level of concern for preventive work, but there has been little
I Address correspondence to: Harold L. McPheeters, M.D., Director, Commission on Mental IIIness & Retardation, Southern Regional Education Board, 130 Sixth Street N.W., Atlanta, Ga. 30313. 187 Copyright @ 1976 by Academic Press, Inc. All rights of reproduction in any form reserved.
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sustained effort from the professionals or the operating mental health agencies. Concern for primary prevention is not new. Adolf Meyer wrote a half a century ago that communities would have to turn from “mere mending” to prevention. The early mental hygiene movement led by Clifford Beers was focused on prevention, although much of the concern at that time was for secondary prevention. Today, with several states organizing their health and social services programs into broad human resource agencies, there is greater concern for doing promotional and preventive work rather than continuing to focus mental health efforts only on treatment of the mentally disabled. A few state mental health agencies have employed staff persons to stimulate preventive programs, and several community mental health centers are attempting to do something in primary prevention in order to comply with the federal requirement to do “consultation and education.” However, the guidelines and program directions are unclear. Kessler and Albee (10) in a recent review of the literature of prevention in mental health likened the matter of prevention in mental health to the Okefenokee Swamp-inviting and beautiful from a distance but containing only a few spots of solid ground along with a great deal of water and soft marshland. At this time it is appropriate to examine some of the issues of programming for primary prevention and promotion in mental health in order to make our program efforts somewhat more specific and effective. Concepts of Primary Prevention in Mental Health There has been considerable controversy over primary prevention in mental health. The traditional public health concept of primary prevention is “activities or programs to prevent an illness or disease condition from occurring.” The epidemiological model of prevention is based on the notion of: (a) a causative agent, (b) a susceptible host, and (c) an environment that brings them together. Many psychiatrists continue to think in terms of this epidemiological model and reject primary prevention in mental health because there is no single causative agent in most mental disorders. However, a few of the organic psychoses, such as central nervous system syphilis and lead encephalitis, have responded to this model. However, long ago even the medical profession moved away from this epidemiological model of prevention. In 1954, Iago Gladston (5) suggested that deprivation and stress are important causative factors in health and disease. Many diseases are known to have multiple causes, and preventive programs are often built on this concept. Thus there have been programs to prevent vitamin deficiency dementias, and programs to assure adequate prenatal nutrition to prevent certain forms of mental retardation and childhood behavior disorders. Many psychiatrists remain focused on these concepts of a medical-pathological model of prevention. Since there is often no demonstrable physical stress or deficiency, these psychiatrists reject the idea of devoting resources and efforts to prevention. Much of medicine is much more flexible, however, and recognizes that many physical disorders, such as hypertension and cancer, have many causes and many associated factors that provide a basis for conducting prevention programs. It may
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not be possible to totally eliminate some of these more complex disorders, but it surely is possible to do some prevention to reduce the prevalence of the disorders. Most psychiatrists have been strongly oriented by their medical training to the medical-pathological concept of prevention. There have been some dramatic examples from this approach, and much more work is needed in this area. However, as Eisdorfer (4) has noted, much preventive work can be done on the basis of a social-adaptive model of prevention of mental disorder as well. Little has been said by most psychiatrists about psychological and social approaches to primary prevention. Psychologists, social workers, and educators have given the socialadaptive model much more attention. In the social-adaptive model, the mechanisms become more complex and less sharply defined. The model is especially applicable to the emotional disorders rather than to the mental illnesses. The model postulates a complex “web of causation” of life stresses. Much of it is based on a psychogenic hypothesis that emotional behaviors are learned in early childhood and that they influence later emotional health or disorders. There is ample documentation in the literature that this is true. Nevertheless, there is much less evidence that preventive strategies aimed at changing child rearing practices and early childhood development will have a later effect of reducing emotional or mental disorders in the adult years. Bloom (1) suggests that the mental health enterprise should proceed on the assumption that preventive strategies of this kind will have an effect. He notes that . . . preventive activities have been signihcantly more powerful than treatment in reducing the prevalence of most disease. This is true for both the infectious as well as the nutritional diseases and should be equally true for the vast reservoirs of the chronic conditions among which will be found mental disorders. Long before the advent and acceptance of germ theory with its implications of specific diagnosis and disease-specific treatment, the sanitarians and humanitarians had combined to indict odors and odor-producing filth as the cause of all disease and to propose a massive clean-up campaign and sewage disposal system as a disease preventive. The emphasis on cleanliness and on the eradication of miasmas or noxious odors had enormous consequences for disease incidence. . The current community mental health movement, with its occasional emphasis upon the removal of existing accumulations of psychic sewage and its efforts to prevent its further accumulation is a logical and most appropriate descendant of the sanitary awakening of more than a century ago, and we have much to learn from the miasmatists of old.
There are variable mechanisms for implementing programs of primary prevention according to this model. The major strategies have been: (a) intervention at crisis times in individuals’ lives to give them consultation assistance, (b) providing individuals with anticipatory guidance for handling the stresses of their lives, and (c) consultation to agencies and programs to alter the balance of social-psychological pressures and problems on people. Others have suggested that simply altering the quality of life for individuals would be an effective strategy for primary prevention-especially if it were based on some of the documented impacts of family breakdowns, poor housing, poor nutrition, poverty, etc. on the mental health of children and adults. The Concept of Promotion of Positive Mental Health The concept of promoting positive mental health or attempting to enhance per-
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sonal and interpersonal functioning without regard to whether the activity is targeted to preventing some disorder or disability has received little attention by psychiatrists. Meanwhile other mental health professionals, such as Marie Jahoda (8), have explored the concepts of positive mental health and identified such components as attitudes toward one’s self, self-actualization, perceptions of reality, autonomy, mastery of one’s environment, and integration of personality. Others add relatedness to people, curiosity, creativity, and coping strength in crisis. Ringness (12) describes it: “Mental Health consists of being able to function successfully in terms of one’s own goals, abilities and opportunities within the context of one’s social and physical environment.” Nevitt Sanford (14) goes so far as to ask whether the concept of prevention is necessary or useful. He suggests that the mental health establishment should use its resources in building-up activities rather than in preventing particular problems. He acknowledges that the notion of promotion of positive mental health is fraught with value judgements that may be time- and culture-bound and that may become controversial, but he believes that certain concepts, such as competence and wholeness, are likely to be acceptable objectives in almost everyone’s value system. At any rate, the concept of positive mental health is not the cult of happiness, nor the cult of adjustment. It is comparable to those programs of physical fitness and nutrition that are targeted to improved physiological performance for large groups of the population rather than those programs of prescribed physical activity or special nutrition programs that are directed to preventing specific clinical disorders such as coronary artery disease. The concept of positive mental health has been one of the major goals of many of the youth programs such as Scouting, 4H and the Y’s. However, there has been little systematic thought given to how these components of positive mental health might be developed in individuals or what kinds of programs might be devised to develop them. Ojemann (1 1), Bower (2), and others have established school based programs directed to school children, teachers, and parents, but these programs have won only limited acceptance. A Conceptual Model for Prevention and Promotion in Mental Health The field of mental health lies partly in the area of health and partly in the area of social welfare. Psychological and social factors have major infhtences on emotional and mental well-being, as well as biological factors. Thus many of the strategies for intervention for either treatment or prevention are psychological or social, as well as biological. From earlier work in manpower studies for mental health and social welfare at the Southern Regional Education Board (15), there has been formulated a model for conceptualizing mental health services which provides a basis for viewing prevention and promotion in mental health as part of a larger human service system. It is illustrated by the Human Service Cube which is shown in Fig. 1. The Human Service Cube represents all of the areas of human need-not just health and mental health. It shows how interventions in one part of the system may be expected to benefit mental health as well as the entire system. Along the right side of the cube are shown the domains of living in which each
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SCIENCES
person functions and has needs. These include housing, employment, health, education, economic security, a safe and secure environment, mental health, spiritual life, etc. If all went well, everyone would function normally in all of these domains of living, but this is not the case. While many people function normally, many others are in crisis or disability. The front side of the cube shows that people operate at different levels offunctioning. Many persons function in the normal range; a few seem to perform at ideal levels. Others function normally at any particular time, but they are functioning under stress or at risk of some difficulty in one or more domains of living. Still other persons are in crises of one kind or another and require help. Still other persons function at a level of temporary or permanent disability and require supportive services of various kinds. The left side of the cube represents obstacles tofunctioning. One of these is deficiencies in individuals (i.e., physical or mental illness, mental retardation, ignorance) which prevent the person from functioning normally. Another is lack of resources (i.e., no jobs available, no housing, no schools). Still another is restrictive rules, regulations, policies or laws (i.e., ineligibility because of age, geographic area of residence, or income). A fourth obstacle is catastrophies and noxious agents. These are relatively rare in the case of mental health. The objective of all of the human services is to move as many people as possible to functioning in the normal column-or into the “ideal” column in the case of
t;
Education
b
Family Integrity
2 3 B
Housing Leisure
I Comuni Integrity
ty I
FIG. 1.
Human services cube.
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mental health promotion. Mental health treatment services have been directed to people in crisis or disability at the right side of the cube. Furthermore, they have focused almost exclusively on correcting the deficiencies in individuals through drugs, psychotherapy, etc.-one or two little cells of this entire cube. Community mental health strategies suggest that much can be done for persons in mental crises or in disability by strategies directed to other parts of the cube (i.e., improving their finances, getting them jobs, improving their environment). This is the essence of most of the social and rehabilitation programs of community mental health. Ideally, the clinical program for any particular individual is made up of some blend of both intrapersonal and environmental strategies. In the case of primary prevention and promotion of positive mental health, the focus of strategies lies in the first two columns of the cube: (a) those persons who are presently functioning satisfactorily but are at risk (column 2) for preventive activities, and (b) those who are functioning satisfactorily to help them function even better (column 1) for promotion of mental health. In both prevention and promotion there are two major strategies: 1) to work with individuals to help them avoid stresses or better cope with them, and 2) to change the resources, policies, or agents of the environment so that they no longer put people in stress but rather enhance their functioning. The main differences between programs of primary prevention and promotion of positive mental health lie in the persons at whom they are targeted. In the case of primary prevention, the target persons are those in stress or at risk, while in promotion of mental health the target is persons in situations of normal growth and development. In either case the targets and strategies must be sharply identified and directed. There will undoubtedly be many situations in which the same program strategy will have both preventive and promotional benefits. As an example, a program of Parent Effectiveness Training (7) may have the effect of improving family communications and interpersonal competence of many family members (promotion), while it also may prevent some runaways and juvenile rebellion. Programs
of Primary
Prevention
in Mental
Health
In primary prevention, the strategies are directed toward persons in stress or at risk in one or more of the domains of living. The stress on the emotional health of individuals should be clearly identified. Too often preventive programs have been undertaken with only the vaguest notion of how a risk or stress element related to mental health. This connection may be difficult to establish because there are often multiple factors that impinge on any particular emotional disorder and the impacts are often remote, as in the case of early childhood stresses that show up in neuroses in adulthood. Programs of primary prevention do not require total elimination of the risks, nor do they depend on knowing the entire etiology of a condition. It is quite possible to simply reduce the risks substantially and to do this through strategies that are strongly and clearly related to the risks. In prevention it is not necessary to know specific causes, but only to know that strong relationships exist between certain risks and the conditions. It is generally easier to identify risks and persons at risk in a relatively small or
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closed social system than it is in the society at large. For example, it may be easier to identify the specific stresses and risks in a single nursing home, or in a school or in a business than in the community as a whole. Much of the problem of credibility regarding prevention in mental health is the result of attempts to become global in the choice of targets. However, whether one is working with a relatively closed social system or with the community at large, the persons at risk and the related strategies must be clearly identified. In the case of mental health, the concern should be with the prevention of all kinds of emotional and mental disorders and emotional maladjustment as well as with the major mental illnesses. While the natural history and causes of many of the major psychoses are not clear, the processes are clear whereby certain stresses lead to anxiety and emotional maladjustments of various kinds, and these can provide the basis for preventive work. To some persons this may seem like meddling in the normal problems of living, but if these distresses have clearly antecedent causes and relationships, they are valid targets for preventive work in mental health. Some persons argue that it is not the business of mental health professionals to be concerned with the other parts of the human service system, but when stresses in economic security, employment, housing, etc. lead to emotional crises, it is clear that all of the domains of living are related to mental health. It may not be the obligation of mental health to actually carry out the preventive program in other human service fields, but mental health had better be concerned about them and offer some leadership and consultation to the other fields within the human services. The strategies may then be planned in one of two categories: 1. Strategies directed toward helping the individuals at risk to either avoid the risk or to better cope with it: a. These may be educational strategies (sometimes called anticipatory guidance) offered through pamphlets, films, meetings, television, etc. for persons at risk. These strategies are directed at the population at risk-not to the general population. b. They may be developmental strategies to improve the individual’s ability to resist or cope with the stresses. These may include such strategies as self-help groups of parents, (i.e., of children with Sudden Infant Death Syndrome) or groups of parents of children with specific disabilities such as mental retardation, to learn more about the disability and to develop their own resources to cope with their children’s problems or the development of neighborhood and community action groups. c. These may be consultation and supportive interventions at the times ofcrises in individuals’ lives (i.e., at times of physical illness, retirement or layoffs from employment, deaths of family members, etc.) This approach is especially documented by Caplan (3). 2. Strategies directed to the environment: a. Reduce the restrictions in rules, regulations, policies, and practices. Some examples of restrictions that are known to lead to anx-
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iety and depression are compulsory retirement at age 65, company policies against hiring new employees over age 40, and restrictions against hiring the handicapped. b. Increase the resources so that people can better meet their needs. Examples are: development of new jobs for the unemployed, developing an activity program for a nursing home, and creating homemaker services in order to keep families together when one parent is hospitalized. c. Remove noxious agents that put people at risk. Examples are: reducing noise levels in factories, removing lead based paint from home use, and reducing traffic congestion and hazards. In any of these environmentally oriented strategies, the specific program activities such as consultation, community organization, advocacy, or community action will depend on what is determined to be the risk and the agency or mechanism through which the changes can best be made. In general, those preventive strategies that require the least personal expense and inconvenience are likely to be the most successful for the largest number of people. Thus, putting fluorides in the drinking water of a community is likely to be more effective for preventing dental caries for all of the children of the community than requiring all children to come to a dentist for a yearly application of fluorides to their teeth. This is also true in mental health. The simple strategies directed to the environment are more likely to be widely effective than those directed to individuals which require considerable commitment of their time and effort. For example, a strategy of making the streets one-way to reduce traffic congestion will be more successful than one that requires all motorists to take a course in defensive driving. Programs for Promotion
of Positive Mental
Health
In promotion of positive mental health, the strategies are directed to persons in situations of normal growth and development (normal families, schools, churches, industry) rather than to those persons known to be at risk. However, here, too, the target persons and the strategies should be clearly identified and planned. They are not directed indiscriminately at the population in general, although the targets may be larger and more diffuse than in prevention. In promotion, as in prevention, the strategies may call for programs in any domain of living in order to improve the functioning of people. Better physical health, improved housing, more jobs, better schools, and increased economic security may have far greater impact on the mental functioning of the people than specific psycho-educational strategies directed to individuals. It may not be the responsibility of the mental health program to conduct programs in these areas, but the mental health program will do well to provide the leadership and assistance to other programs in the human services when they are clearly related to mental health functioning. A common difficulty experienced by many mental health promotion programs, as well as some prevention programs, is that the strategies have been too loosely related to mental health. It is not sufficient to conclude, for example, that merely putting a swimming pool in a ghetto area will be sufficient to improve the mental
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health functioning of the people. The rationale must be more clearly drawn so that the directness of effects is more apparent. Promotion efforts have also suffered from trying to be too global. Here, also, it is easier to work with closed social systems than with entire communities or society at large. In closed systems, such as a single school, business, or agency, it is easier to know the values, policies, and personalities and to bring about changes that will have more specific impacts. As in primary prevention, the strategies may be directed to individuals or to the environment: 1. Strategies directed to improving the ability of people to deal more effectively with everyday life-to be more productive, more tolerant, more flexible, etc. a. These may be educational strategies (anticipatory guidance) in the form of pamphlets such as Pierre, the Pelican (13) which is a series of pamphlets directed to the parents of all firstborn babies offering guidance on the emotional aspects of infant care, or other efforts through the media, meetings, etc. b. They may be developmental strategies to help people improve themselves by actually experiencing greater self-actualization, creativity, mastery, etc. Many of the youth programs (Boy Scouts, Girl Scouts, the YMCA and YWCA) have these objectives. Community action groups and senior citizen clubs also have these objectives. 2. Strategies directed to the environment. These may be program strategies: a. Increase resources (i.e., better housing, a more esthetic environment, a new local industry with better job opportunities). b. Change rules, regulations, policies, so that programs (i.e., recreation centers, playgrounds, etc. open for longer hours) serve more people, and improve their functioning. As in the case of prevention, those strategies that involve the least personal expense or inconvenience are the ones that will be most effective for the largest number of people. However, programs directed to a few individuals may be quite effective and appropriate for those few individuals who are motivated to participate. An example is Parent Effectiveness Training which may be very helpful for those parents who are committed to participating in such programs, but P.E.T. programs can hardly expect to reach large numbers of the total population of parents. These issues must be carefully thought out when setting priorities for mental health promotional activities. Assessing Needs and Evaluating Prevention and Promotion Programs One of the serious problems that has faced prevention and promotion efforts in mental health is that programs have been undertaken on a largely intuitive basis with no hard data on which to establish a program and no record system or plan for evaluating whether there has been any impact. 1. Assessing needsfor programs. The first step in planning preventive or
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promotional programs is to have a reasonably clear idea of the extent of the need and the natural history of how events influence emotional distress or mental health. There are several possible approaches: a. Statistical data from the clinical records of the specific community, group or agency under consideration is the best source of needs assessment data. This requires the maintenance of a statistical system, as well as individual clinical records, and scanning the data for trends that might lend themselves to preventive work. Such a record system will lend itself to analysis of the natural course of stresses and suggest intervention strategies. As an example, statistical records might reveal a high incidence of truancy referrals from a single junior high school. Analysis of the records of several boys might show that all are related to an aggressive gym coach who is contemptuous of boys who do not have high athletic ability. This suggests, as a prevention strategy, that someone might consult with the principal to try to modify the coach’s cruel behavior toward boys of poor athletic ability. b. Social indicator data is another source of needs assessment data. These include public records of such events as divorces, arrests for drunkeness, .delinquency, single room occupancy rates, etc. Such data must be used carefully since they are often too crude and nonspecific to be useful in program planning. c. Special surveys or studies may be done. These may be highly sophisticated social research studies or they may be quite simple studies by students or volunteers, especially if the trends are found to be strong. 2. Setting objectives and criteria. In any case, a program of primary prevention or of mental health promotion should state the objectives it plans to accomplish in measurable terms, so that the program can be evaluated by clearly defined criteria. In the assessment of needs, a definite data base for the incidence or prevalence of the condition should have been established. It makes sense to set the program objectives and criteria measures in much the same data terms so that the program can be evaluated on the basis of the data that are already available. While this is not always possible, some kind of measure is always possible. 3. Evaluating programs. Finally there should be reasonably sophisticated gathering and analysis of data regarding results being accomplished, problems encountered, and any side effects (good and bad) that are not anticipated. This will tell whether the program is accomplishing what was intended and whether it should be continued or modified. Evaluation o;’ programs of prevention and mental health promotion is especially desirable for three reasons: a. Past efforts have often been so soft and intuitive that the whole matter of primary prevention in mental health has fallen under a cloud. Hard thinking with sharp evaluation will remedy this.
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b. Costs for preventive and promotional programs are not reimbursa-
ble under third party payment plans. If they are to be supported by state or local tax monies, they will need sharp documentation. c. Preventive and promotional programs may yield a high return of benefits for the effort expended. It is important to document this in order to shift more of mental health program resources to these activities. Who Will Do Prevention and Promotion in Mental Health? There has been little thought given to who will do mental health prevention and promotion. At this time, none of the mental health professions provides any amount of systematic training for prevention and promotion. In addition, there is the problem that most of the mental health professionals are naturally rather conservative about trying new things and reticent about moving out of areas that they have considered to be their turf. Many mental health professionals do not feel comfortable in relating to persons from other fields, such as education, corrections, politics, public administration, etc., where much of the preventive and promotional work will be done. There is a tendency in some mental health agencies to employ an educator (a health educator or an adult educator) on the assumption that prevention and promotion are educational endeavors (anticipatory guidance). However, it is clear that only some of the strategies of mental health prevention and promotion are educational, and that these tend to be the least effective strategies for widespread results. It is apparent that whoever will be responsible for prevention and promotion programs in state or local mental health agencies will need some continuing education about the whole matter-assessing needs, setting objectives, developing and implementing programs, and evaluating them. It seems reasonable to assign the primary responsibility for prevention and promotional programs to a single person or a small group of staff persons who can then develop expertise in these concepts and can serve as consultants and leaders for other staff member who wish to become involved. They may also serve as consultants to other human service agencies. REFERENCES 1. Bloom, B. L. Strategies for the prevention of mental disorder in “Issues in Community Psychology and Preventive Mental Health.” Behavioral Publications, New York, 1971. 2. Bower, E. M. Primary prevention in a school setting, in “Prevention of Mental Disorders in Children” (G. Caplan, Ed.). Basic Books, New York, 1961. 3. Caplan, G, (Ed.). “Prevention of Mental Disorders in Children.” Basic Books, New York, 1961. 4. Eisdorfer, C. “Handbook of Community Mental Health” (S. Golann and C. Eisdorfer, Eds.). Appleton-Century-Crofts, New York, 1972. 5. Gladston, I. (Ed.). “Beyond the Germ Theory: The Roles of Deprivation and Stress in Health and Disease.” Health Education Council, New York, 1954. 6. Goldston, S. E., Ojemann, R. H., and Nelson, R. H. Primary prevention and health promotion, in “Mental Health: the Public Health Challenge” (E. J. Lieberman, Ed.). American Public Health Association, Washington, D.C., 1975. 7. Gordon, T. “Parent Effectiveness Training.” P. H. Wyden, New York, 1970. 8. Jahoda, M. “Current Concepts of Positive Mental Health.” Basic Books, New York, 1958.
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9. Kennedy, J. F. “Message from the President of the United States Relative to Mental Health and Mental Illness.” House Document No. 58, 88th Congress, 1st Session, Washington, Government Printing Office, 1975. 10. Kessler, M., and Albee, G. Primary prevention, in “Annual Review of Psychology.” Annual Reviews, Palo Alto, California, 1975. 11. Ojemann, R. H. Investigations on the effects of teaching an understanding and appreciation of behavior dynamics, in “Prevention of Mental Disorders in Children” (G. &plan, Ed.). BasicBo&, New York, 1%1. 12. Ringness, T. A. “Mental Health in the Schools.” Random House, New York, 1968. 13. Rowland, L. W. “Pierre, the Pelican; A Program of Parent Education in Principles of Mental Health for Parents of First-born Children.” Louisiana Association for Mental Health, New Orleans, Louisiana, 1957. 14. Sanford, N. Is the concept of prevention necessary or useful?, in “Handbook of Community Mental Health” (S. Golann, and C. Eisdorfer, Eds.). Appleton-Century-Crofts, New York, 1972. 15. Teare, R. L., and McPheeters, H. L. “Manpower Utilization in Social Welfare.” Southern Regional Education Board, Atlanta, Georgia, 1970.
MEDICINE
5,
187-198 (1976)
Primary Prevention and Health Promotion in Mental Health’ HAROLD Commission
on Mentrd
illness
L.
MCPHEETERS
und Retardation. Atlanta, Georgiu
Southern 30313
Regional
Education
Board,
Despite frequent pleas for mental health programs to devote more resources to primary prevention, mental health programs remain overwhelmingly oriented to treatment. Prevention is given low priority because many psychiatrists who are leaders in the mental health field are focused on a medical-pathological model of prevention that has limited usefulness in mental health and because the guidelines for a social-behavioral model are not always clear. A model for conceptualizing and programming of primary prevention and promotion in all of the human services is offered with special attention to mental health functioning. Strategies for both primary prevention and promotion may be directed to individuals or to the environment, but, in either case, the targets and the strategies must be clearly identified. Prevention strategies are directed toward persons under some specific stress or risk, while promotion activities are directed to persons in normal situations ofgrowth and development. For either prevention or promotion, the most widely effective strategies are those that require the least personal cost and effort-usually the strategies that are directed toward the environment. Prevention and promotion both depend on clear assessment of the stresses and needs and must be evaluated. Programs are often too global or too diffuse to be effective or credible. Working in closed social systems and sharp evaluation will help correct these problems.
The mental health programs of this country remain strongly oriented to the treatment and restoration of the mentally ill, the emotionally disturbed, the mentally retarded, and alcohol and drug abusers despite the occasional calls for more work in primary prevention. President John F. Kennedy in his historic messageof February 5, 1963, stated that: “First we must seek out the causes of mental illness and of mental retardation and eradicate them. . . . For prevention is far more desirable for all concerned. It is far more economical and it is far more likely to be successful. Prevention will require both selected 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 often are associated with mental retardation and mental illness” (9). Despite this plea in the call for the Community Mental Health Centers Act of 1963 for prevention, to be a major priority of comprehensive community health, prevention is presently given a very low priority in community mental health centers, staff being almost totally involved in treatment services (6). The citizens associations for mental health continue to have a high level of concern for preventive work, but there has been little
I Address correspondence to: Harold L. McPheeters, M.D., Director, Commission on Mental IIIness & Retardation, Southern Regional Education Board, 130 Sixth Street N.W., Atlanta, Ga. 30313. 187 Copyright @ 1976 by Academic Press, Inc. All rights of reproduction in any form reserved.
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sustained effort from the professionals or the operating mental health agencies. Concern for primary prevention is not new. Adolf Meyer wrote a half a century ago that communities would have to turn from “mere mending” to prevention. The early mental hygiene movement led by Clifford Beers was focused on prevention, although much of the concern at that time was for secondary prevention. Today, with several states organizing their health and social services programs into broad human resource agencies, there is greater concern for doing promotional and preventive work rather than continuing to focus mental health efforts only on treatment of the mentally disabled. A few state mental health agencies have employed staff persons to stimulate preventive programs, and several community mental health centers are attempting to do something in primary prevention in order to comply with the federal requirement to do “consultation and education.” However, the guidelines and program directions are unclear. Kessler and Albee (10) in a recent review of the literature of prevention in mental health likened the matter of prevention in mental health to the Okefenokee Swamp-inviting and beautiful from a distance but containing only a few spots of solid ground along with a great deal of water and soft marshland. At this time it is appropriate to examine some of the issues of programming for primary prevention and promotion in mental health in order to make our program efforts somewhat more specific and effective. Concepts of Primary Prevention in Mental Health There has been considerable controversy over primary prevention in mental health. The traditional public health concept of primary prevention is “activities or programs to prevent an illness or disease condition from occurring.” The epidemiological model of prevention is based on the notion of: (a) a causative agent, (b) a susceptible host, and (c) an environment that brings them together. Many psychiatrists continue to think in terms of this epidemiological model and reject primary prevention in mental health because there is no single causative agent in most mental disorders. However, a few of the organic psychoses, such as central nervous system syphilis and lead encephalitis, have responded to this model. However, long ago even the medical profession moved away from this epidemiological model of prevention. In 1954, Iago Gladston (5) suggested that deprivation and stress are important causative factors in health and disease. Many diseases are known to have multiple causes, and preventive programs are often built on this concept. Thus there have been programs to prevent vitamin deficiency dementias, and programs to assure adequate prenatal nutrition to prevent certain forms of mental retardation and childhood behavior disorders. Many psychiatrists remain focused on these concepts of a medical-pathological model of prevention. Since there is often no demonstrable physical stress or deficiency, these psychiatrists reject the idea of devoting resources and efforts to prevention. Much of medicine is much more flexible, however, and recognizes that many physical disorders, such as hypertension and cancer, have many causes and many associated factors that provide a basis for conducting prevention programs. It may
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not be possible to totally eliminate some of these more complex disorders, but it surely is possible to do some prevention to reduce the prevalence of the disorders. Most psychiatrists have been strongly oriented by their medical training to the medical-pathological concept of prevention. There have been some dramatic examples from this approach, and much more work is needed in this area. However, as Eisdorfer (4) has noted, much preventive work can be done on the basis of a social-adaptive model of prevention of mental disorder as well. Little has been said by most psychiatrists about psychological and social approaches to primary prevention. Psychologists, social workers, and educators have given the socialadaptive model much more attention. In the social-adaptive model, the mechanisms become more complex and less sharply defined. The model is especially applicable to the emotional disorders rather than to the mental illnesses. The model postulates a complex “web of causation” of life stresses. Much of it is based on a psychogenic hypothesis that emotional behaviors are learned in early childhood and that they influence later emotional health or disorders. There is ample documentation in the literature that this is true. Nevertheless, there is much less evidence that preventive strategies aimed at changing child rearing practices and early childhood development will have a later effect of reducing emotional or mental disorders in the adult years. Bloom (1) suggests that the mental health enterprise should proceed on the assumption that preventive strategies of this kind will have an effect. He notes that . . . preventive activities have been signihcantly more powerful than treatment in reducing the prevalence of most disease. This is true for both the infectious as well as the nutritional diseases and should be equally true for the vast reservoirs of the chronic conditions among which will be found mental disorders. Long before the advent and acceptance of germ theory with its implications of specific diagnosis and disease-specific treatment, the sanitarians and humanitarians had combined to indict odors and odor-producing filth as the cause of all disease and to propose a massive clean-up campaign and sewage disposal system as a disease preventive. The emphasis on cleanliness and on the eradication of miasmas or noxious odors had enormous consequences for disease incidence. . The current community mental health movement, with its occasional emphasis upon the removal of existing accumulations of psychic sewage and its efforts to prevent its further accumulation is a logical and most appropriate descendant of the sanitary awakening of more than a century ago, and we have much to learn from the miasmatists of old.
There are variable mechanisms for implementing programs of primary prevention according to this model. The major strategies have been: (a) intervention at crisis times in individuals’ lives to give them consultation assistance, (b) providing individuals with anticipatory guidance for handling the stresses of their lives, and (c) consultation to agencies and programs to alter the balance of social-psychological pressures and problems on people. Others have suggested that simply altering the quality of life for individuals would be an effective strategy for primary prevention-especially if it were based on some of the documented impacts of family breakdowns, poor housing, poor nutrition, poverty, etc. on the mental health of children and adults. The Concept of Promotion of Positive Mental Health The concept of promoting positive mental health or attempting to enhance per-
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sonal and interpersonal functioning without regard to whether the activity is targeted to preventing some disorder or disability has received little attention by psychiatrists. Meanwhile other mental health professionals, such as Marie Jahoda (8), have explored the concepts of positive mental health and identified such components as attitudes toward one’s self, self-actualization, perceptions of reality, autonomy, mastery of one’s environment, and integration of personality. Others add relatedness to people, curiosity, creativity, and coping strength in crisis. Ringness (12) describes it: “Mental Health consists of being able to function successfully in terms of one’s own goals, abilities and opportunities within the context of one’s social and physical environment.” Nevitt Sanford (14) goes so far as to ask whether the concept of prevention is necessary or useful. He suggests that the mental health establishment should use its resources in building-up activities rather than in preventing particular problems. He acknowledges that the notion of promotion of positive mental health is fraught with value judgements that may be time- and culture-bound and that may become controversial, but he believes that certain concepts, such as competence and wholeness, are likely to be acceptable objectives in almost everyone’s value system. At any rate, the concept of positive mental health is not the cult of happiness, nor the cult of adjustment. It is comparable to those programs of physical fitness and nutrition that are targeted to improved physiological performance for large groups of the population rather than those programs of prescribed physical activity or special nutrition programs that are directed to preventing specific clinical disorders such as coronary artery disease. The concept of positive mental health has been one of the major goals of many of the youth programs such as Scouting, 4H and the Y’s. However, there has been little systematic thought given to how these components of positive mental health might be developed in individuals or what kinds of programs might be devised to develop them. Ojemann (1 1), Bower (2), and others have established school based programs directed to school children, teachers, and parents, but these programs have won only limited acceptance. A Conceptual Model for Prevention and Promotion in Mental Health The field of mental health lies partly in the area of health and partly in the area of social welfare. Psychological and social factors have major infhtences on emotional and mental well-being, as well as biological factors. Thus many of the strategies for intervention for either treatment or prevention are psychological or social, as well as biological. From earlier work in manpower studies for mental health and social welfare at the Southern Regional Education Board (15), there has been formulated a model for conceptualizing mental health services which provides a basis for viewing prevention and promotion in mental health as part of a larger human service system. It is illustrated by the Human Service Cube which is shown in Fig. 1. The Human Service Cube represents all of the areas of human need-not just health and mental health. It shows how interventions in one part of the system may be expected to benefit mental health as well as the entire system. Along the right side of the cube are shown the domains of living in which each
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person functions and has needs. These include housing, employment, health, education, economic security, a safe and secure environment, mental health, spiritual life, etc. If all went well, everyone would function normally in all of these domains of living, but this is not the case. While many people function normally, many others are in crisis or disability. The front side of the cube shows that people operate at different levels offunctioning. Many persons function in the normal range; a few seem to perform at ideal levels. Others function normally at any particular time, but they are functioning under stress or at risk of some difficulty in one or more domains of living. Still other persons are in crises of one kind or another and require help. Still other persons function at a level of temporary or permanent disability and require supportive services of various kinds. The left side of the cube represents obstacles tofunctioning. One of these is deficiencies in individuals (i.e., physical or mental illness, mental retardation, ignorance) which prevent the person from functioning normally. Another is lack of resources (i.e., no jobs available, no housing, no schools). Still another is restrictive rules, regulations, policies or laws (i.e., ineligibility because of age, geographic area of residence, or income). A fourth obstacle is catastrophies and noxious agents. These are relatively rare in the case of mental health. The objective of all of the human services is to move as many people as possible to functioning in the normal column-or into the “ideal” column in the case of
t;
Education
b
Family Integrity
2 3 B
Housing Leisure
I Comuni Integrity
ty I
FIG. 1.
Human services cube.
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mental health promotion. Mental health treatment services have been directed to people in crisis or disability at the right side of the cube. Furthermore, they have focused almost exclusively on correcting the deficiencies in individuals through drugs, psychotherapy, etc.-one or two little cells of this entire cube. Community mental health strategies suggest that much can be done for persons in mental crises or in disability by strategies directed to other parts of the cube (i.e., improving their finances, getting them jobs, improving their environment). This is the essence of most of the social and rehabilitation programs of community mental health. Ideally, the clinical program for any particular individual is made up of some blend of both intrapersonal and environmental strategies. In the case of primary prevention and promotion of positive mental health, the focus of strategies lies in the first two columns of the cube: (a) those persons who are presently functioning satisfactorily but are at risk (column 2) for preventive activities, and (b) those who are functioning satisfactorily to help them function even better (column 1) for promotion of mental health. In both prevention and promotion there are two major strategies: 1) to work with individuals to help them avoid stresses or better cope with them, and 2) to change the resources, policies, or agents of the environment so that they no longer put people in stress but rather enhance their functioning. The main differences between programs of primary prevention and promotion of positive mental health lie in the persons at whom they are targeted. In the case of primary prevention, the target persons are those in stress or at risk, while in promotion of mental health the target is persons in situations of normal growth and development. In either case the targets and strategies must be sharply identified and directed. There will undoubtedly be many situations in which the same program strategy will have both preventive and promotional benefits. As an example, a program of Parent Effectiveness Training (7) may have the effect of improving family communications and interpersonal competence of many family members (promotion), while it also may prevent some runaways and juvenile rebellion. Programs
of Primary
Prevention
in Mental
Health
In primary prevention, the strategies are directed toward persons in stress or at risk in one or more of the domains of living. The stress on the emotional health of individuals should be clearly identified. Too often preventive programs have been undertaken with only the vaguest notion of how a risk or stress element related to mental health. This connection may be difficult to establish because there are often multiple factors that impinge on any particular emotional disorder and the impacts are often remote, as in the case of early childhood stresses that show up in neuroses in adulthood. Programs of primary prevention do not require total elimination of the risks, nor do they depend on knowing the entire etiology of a condition. It is quite possible to simply reduce the risks substantially and to do this through strategies that are strongly and clearly related to the risks. In prevention it is not necessary to know specific causes, but only to know that strong relationships exist between certain risks and the conditions. It is generally easier to identify risks and persons at risk in a relatively small or
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closed social system than it is in the society at large. For example, it may be easier to identify the specific stresses and risks in a single nursing home, or in a school or in a business than in the community as a whole. Much of the problem of credibility regarding prevention in mental health is the result of attempts to become global in the choice of targets. However, whether one is working with a relatively closed social system or with the community at large, the persons at risk and the related strategies must be clearly identified. In the case of mental health, the concern should be with the prevention of all kinds of emotional and mental disorders and emotional maladjustment as well as with the major mental illnesses. While the natural history and causes of many of the major psychoses are not clear, the processes are clear whereby certain stresses lead to anxiety and emotional maladjustments of various kinds, and these can provide the basis for preventive work. To some persons this may seem like meddling in the normal problems of living, but if these distresses have clearly antecedent causes and relationships, they are valid targets for preventive work in mental health. Some persons argue that it is not the business of mental health professionals to be concerned with the other parts of the human service system, but when stresses in economic security, employment, housing, etc. lead to emotional crises, it is clear that all of the domains of living are related to mental health. It may not be the obligation of mental health to actually carry out the preventive program in other human service fields, but mental health had better be concerned about them and offer some leadership and consultation to the other fields within the human services. The strategies may then be planned in one of two categories: 1. Strategies directed toward helping the individuals at risk to either avoid the risk or to better cope with it: a. These may be educational strategies (sometimes called anticipatory guidance) offered through pamphlets, films, meetings, television, etc. for persons at risk. These strategies are directed at the population at risk-not to the general population. b. They may be developmental strategies to improve the individual’s ability to resist or cope with the stresses. These may include such strategies as self-help groups of parents, (i.e., of children with Sudden Infant Death Syndrome) or groups of parents of children with specific disabilities such as mental retardation, to learn more about the disability and to develop their own resources to cope with their children’s problems or the development of neighborhood and community action groups. c. These may be consultation and supportive interventions at the times ofcrises in individuals’ lives (i.e., at times of physical illness, retirement or layoffs from employment, deaths of family members, etc.) This approach is especially documented by Caplan (3). 2. Strategies directed to the environment: a. Reduce the restrictions in rules, regulations, policies, and practices. Some examples of restrictions that are known to lead to anx-
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iety and depression are compulsory retirement at age 65, company policies against hiring new employees over age 40, and restrictions against hiring the handicapped. b. Increase the resources so that people can better meet their needs. Examples are: development of new jobs for the unemployed, developing an activity program for a nursing home, and creating homemaker services in order to keep families together when one parent is hospitalized. c. Remove noxious agents that put people at risk. Examples are: reducing noise levels in factories, removing lead based paint from home use, and reducing traffic congestion and hazards. In any of these environmentally oriented strategies, the specific program activities such as consultation, community organization, advocacy, or community action will depend on what is determined to be the risk and the agency or mechanism through which the changes can best be made. In general, those preventive strategies that require the least personal expense and inconvenience are likely to be the most successful for the largest number of people. Thus, putting fluorides in the drinking water of a community is likely to be more effective for preventing dental caries for all of the children of the community than requiring all children to come to a dentist for a yearly application of fluorides to their teeth. This is also true in mental health. The simple strategies directed to the environment are more likely to be widely effective than those directed to individuals which require considerable commitment of their time and effort. For example, a strategy of making the streets one-way to reduce traffic congestion will be more successful than one that requires all motorists to take a course in defensive driving. Programs for Promotion
of Positive Mental
Health
In promotion of positive mental health, the strategies are directed to persons in situations of normal growth and development (normal families, schools, churches, industry) rather than to those persons known to be at risk. However, here, too, the target persons and the strategies should be clearly identified and planned. They are not directed indiscriminately at the population in general, although the targets may be larger and more diffuse than in prevention. In promotion, as in prevention, the strategies may call for programs in any domain of living in order to improve the functioning of people. Better physical health, improved housing, more jobs, better schools, and increased economic security may have far greater impact on the mental functioning of the people than specific psycho-educational strategies directed to individuals. It may not be the responsibility of the mental health program to conduct programs in these areas, but the mental health program will do well to provide the leadership and assistance to other programs in the human services when they are clearly related to mental health functioning. A common difficulty experienced by many mental health promotion programs, as well as some prevention programs, is that the strategies have been too loosely related to mental health. It is not sufficient to conclude, for example, that merely putting a swimming pool in a ghetto area will be sufficient to improve the mental
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health functioning of the people. The rationale must be more clearly drawn so that the directness of effects is more apparent. Promotion efforts have also suffered from trying to be too global. Here, also, it is easier to work with closed social systems than with entire communities or society at large. In closed systems, such as a single school, business, or agency, it is easier to know the values, policies, and personalities and to bring about changes that will have more specific impacts. As in primary prevention, the strategies may be directed to individuals or to the environment: 1. Strategies directed to improving the ability of people to deal more effectively with everyday life-to be more productive, more tolerant, more flexible, etc. a. These may be educational strategies (anticipatory guidance) in the form of pamphlets such as Pierre, the Pelican (13) which is a series of pamphlets directed to the parents of all firstborn babies offering guidance on the emotional aspects of infant care, or other efforts through the media, meetings, etc. b. They may be developmental strategies to help people improve themselves by actually experiencing greater self-actualization, creativity, mastery, etc. Many of the youth programs (Boy Scouts, Girl Scouts, the YMCA and YWCA) have these objectives. Community action groups and senior citizen clubs also have these objectives. 2. Strategies directed to the environment. These may be program strategies: a. Increase resources (i.e., better housing, a more esthetic environment, a new local industry with better job opportunities). b. Change rules, regulations, policies, so that programs (i.e., recreation centers, playgrounds, etc. open for longer hours) serve more people, and improve their functioning. As in the case of prevention, those strategies that involve the least personal expense or inconvenience are the ones that will be most effective for the largest number of people. However, programs directed to a few individuals may be quite effective and appropriate for those few individuals who are motivated to participate. An example is Parent Effectiveness Training which may be very helpful for those parents who are committed to participating in such programs, but P.E.T. programs can hardly expect to reach large numbers of the total population of parents. These issues must be carefully thought out when setting priorities for mental health promotional activities. Assessing Needs and Evaluating Prevention and Promotion Programs One of the serious problems that has faced prevention and promotion efforts in mental health is that programs have been undertaken on a largely intuitive basis with no hard data on which to establish a program and no record system or plan for evaluating whether there has been any impact. 1. Assessing needsfor programs. The first step in planning preventive or
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promotional programs is to have a reasonably clear idea of the extent of the need and the natural history of how events influence emotional distress or mental health. There are several possible approaches: a. Statistical data from the clinical records of the specific community, group or agency under consideration is the best source of needs assessment data. This requires the maintenance of a statistical system, as well as individual clinical records, and scanning the data for trends that might lend themselves to preventive work. Such a record system will lend itself to analysis of the natural course of stresses and suggest intervention strategies. As an example, statistical records might reveal a high incidence of truancy referrals from a single junior high school. Analysis of the records of several boys might show that all are related to an aggressive gym coach who is contemptuous of boys who do not have high athletic ability. This suggests, as a prevention strategy, that someone might consult with the principal to try to modify the coach’s cruel behavior toward boys of poor athletic ability. b. Social indicator data is another source of needs assessment data. These include public records of such events as divorces, arrests for drunkeness, .delinquency, single room occupancy rates, etc. Such data must be used carefully since they are often too crude and nonspecific to be useful in program planning. c. Special surveys or studies may be done. These may be highly sophisticated social research studies or they may be quite simple studies by students or volunteers, especially if the trends are found to be strong. 2. Setting objectives and criteria. In any case, a program of primary prevention or of mental health promotion should state the objectives it plans to accomplish in measurable terms, so that the program can be evaluated by clearly defined criteria. In the assessment of needs, a definite data base for the incidence or prevalence of the condition should have been established. It makes sense to set the program objectives and criteria measures in much the same data terms so that the program can be evaluated on the basis of the data that are already available. While this is not always possible, some kind of measure is always possible. 3. Evaluating programs. Finally there should be reasonably sophisticated gathering and analysis of data regarding results being accomplished, problems encountered, and any side effects (good and bad) that are not anticipated. This will tell whether the program is accomplishing what was intended and whether it should be continued or modified. Evaluation o;’ programs of prevention and mental health promotion is especially desirable for three reasons: a. Past efforts have often been so soft and intuitive that the whole matter of primary prevention in mental health has fallen under a cloud. Hard thinking with sharp evaluation will remedy this.
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b. Costs for preventive and promotional programs are not reimbursa-
ble under third party payment plans. If they are to be supported by state or local tax monies, they will need sharp documentation. c. Preventive and promotional programs may yield a high return of benefits for the effort expended. It is important to document this in order to shift more of mental health program resources to these activities. Who Will Do Prevention and Promotion in Mental Health? There has been little thought given to who will do mental health prevention and promotion. At this time, none of the mental health professions provides any amount of systematic training for prevention and promotion. In addition, there is the problem that most of the mental health professionals are naturally rather conservative about trying new things and reticent about moving out of areas that they have considered to be their turf. Many mental health professionals do not feel comfortable in relating to persons from other fields, such as education, corrections, politics, public administration, etc., where much of the preventive and promotional work will be done. There is a tendency in some mental health agencies to employ an educator (a health educator or an adult educator) on the assumption that prevention and promotion are educational endeavors (anticipatory guidance). However, it is clear that only some of the strategies of mental health prevention and promotion are educational, and that these tend to be the least effective strategies for widespread results. It is apparent that whoever will be responsible for prevention and promotion programs in state or local mental health agencies will need some continuing education about the whole matter-assessing needs, setting objectives, developing and implementing programs, and evaluating them. It seems reasonable to assign the primary responsibility for prevention and promotional programs to a single person or a small group of staff persons who can then develop expertise in these concepts and can serve as consultants and leaders for other staff member who wish to become involved. They may also serve as consultants to other human service agencies. REFERENCES 1. Bloom, B. L. Strategies for the prevention of mental disorder in “Issues in Community Psychology and Preventive Mental Health.” Behavioral Publications, New York, 1971. 2. Bower, E. M. Primary prevention in a school setting, in “Prevention of Mental Disorders in Children” (G. Caplan, Ed.). Basic Books, New York, 1961. 3. Caplan, G, (Ed.). “Prevention of Mental Disorders in Children.” Basic Books, New York, 1961. 4. Eisdorfer, C. “Handbook of Community Mental Health” (S. Golann and C. Eisdorfer, Eds.). Appleton-Century-Crofts, New York, 1972. 5. Gladston, I. (Ed.). “Beyond the Germ Theory: The Roles of Deprivation and Stress in Health and Disease.” Health Education Council, New York, 1954. 6. Goldston, S. E., Ojemann, R. H., and Nelson, R. H. Primary prevention and health promotion, in “Mental Health: the Public Health Challenge” (E. J. Lieberman, Ed.). American Public Health Association, Washington, D.C., 1975. 7. Gordon, T. “Parent Effectiveness Training.” P. H. Wyden, New York, 1970. 8. Jahoda, M. “Current Concepts of Positive Mental Health.” Basic Books, New York, 1958.
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9. Kennedy, J. F. “Message from the President of the United States Relative to Mental Health and Mental Illness.” House Document No. 58, 88th Congress, 1st Session, Washington, Government Printing Office, 1975. 10. Kessler, M., and Albee, G. Primary prevention, in “Annual Review of Psychology.” Annual Reviews, Palo Alto, California, 1975. 11. Ojemann, R. H. Investigations on the effects of teaching an understanding and appreciation of behavior dynamics, in “Prevention of Mental Disorders in Children” (G. &plan, Ed.). BasicBo&, New York, 1%1. 12. Ringness, T. A. “Mental Health in the Schools.” Random House, New York, 1968. 13. Rowland, L. W. “Pierre, the Pelican; A Program of Parent Education in Principles of Mental Health for Parents of First-born Children.” Louisiana Association for Mental Health, New Orleans, Louisiana, 1957. 14. Sanford, N. Is the concept of prevention necessary or useful?, in “Handbook of Community Mental Health” (S. Golann, and C. Eisdorfer, Eds.). Appleton-Century-Crofts, New York, 1972. 15. Teare, R. L., and McPheeters, H. L. “Manpower Utilization in Social Welfare.” Southern Regional Education Board, Atlanta, Georgia, 1970.
