Social Workers in Primary Prevention: Action and Ideology in Mental Health Richard Matus, Ph.D.* Elane M. Nuehring, Ph.D.
ABSTRACT: Primary prevention and a public health model have been among the distinguishing innovations of the community mental health movement. Social work practice, however, has historically been involved in community intervention and environmental manipulation to offset social and psychological jeopardy. Given a long tradition of commitment to activity and techniques which are now hailed as mental health"s "'third revolution," this study explores the role of social work in primary prevention. Data are from a survey of three community mental health centers in which professional staff completed the Gottesfeld Critical Issues of Community Mental Health questionnaire, a time-distribution form, and a prevention questionnaire. In addition, all staff working in primary prevention were interviewed in depth. The total sample of this study of mental health professionals was 84. This study points to some interesting contradictions found between social work action and ideology in primary prevention. Also, social workers are compared with other professionals in order to isolate some primary prevention tasks and attitudes that appear unique to each.
Prevention of mental disorder and promotion of mental health are among the distinguishing themes of the community mental health movement and are conventionally grouped under one rubric, "primary prevention" (Kessler & Albee, 1975; Roman & Trice, 1974). Adapted from public health models, primary prevention refers to strengthening the resistance of populations and groups, and the offsetting of harmful influences in advance of their impact (Caplan, 1964). In the promotive vein we see such efforts as mental health education aimed at improving the coping skills of groups such as expectant parents and preretirees, community planning and development to improve the quality of social conditions and resources, and so on. In the preventive area there are programs such as genetic counseling, preschool screening for disabilities and disturbances, many kinds of crisis intervention such as divorce counseling, and the training of other caregivers to sharpen their skills in detection and intervention. The evolution of the community mental health movement, begun in the late 1950s and early 1960s, is perhaps most accurately characterized by John F. Kennedy's call to Congress in 1963 to fund new facilities where prevention as well as treatment is a major activity (Kennedy, 1963). This mandate has been earmarked by an ideological shift in mental health practice from emphasis on *Dr. Matus is Research Associate, Institute for Social Research, Florida State University, Tallahassee, Florida, 32306. Dr. Nuehring is Associate Professor, Barry College School of Social Work, Miami Shores, Florida. The research on which this study is based was supported by NIMH Research Grant No. 1 R01 MH 23646-02MHS. An earlier version of the paper was presented at the meetings of the American Public Health Association, Miami, October, 1976. Community Mental Health Journal Vol. 15(1), 1979
0010-3853/79/1300-0033500.95~ 1979 Human Sciences Press
33
34
Community Mental Health Journal
the inner psychic, to emphasis on the broader social networks that presumably shape human behavior. The movement, however, has not been characterized by the speedy conversion of rhetoric to action in that by 1973, 10 years later, community mental health centers were spending only about 7.7% of their time doing primary prevention but 64.8 % of their time directly treating clients (Miller, 1976). Why is more prevention not being done? There is, stated simply, too much confusion and uncertainty. The general consensus is that the fundamental problem is a lack of understanding as to what prevention is and how it should be done (Simon, 1975). A proper investigation, then, should begin with who is doing the prevention, what are they doing, and what is the ideology or knowledge base they are working from. Under the community mental health rubric, a number of professional subspecialties have emerged. Primarily, these are community psychiatry and community psychology; and a myriad of highly specialized professionals now include music therapists, vocational therapists, recreational therapists, agratherapists, and so on, all ostensibly representing expertise in community mental health and especially in preventive mental health. However, turning to social work, which typically comprises the largest professional group in mental health settings, no new professional area of specialization has been developed in response to the community mental health movement. At the same time, if one considers the traditional knowledge base of social work, the tenets of community practice are readily discernible. Historically, social work has concerned itself with anticipatory intervention and manipulation of the social environment to offset potential social and psychological jeopardy in individuals, groups, and populations. Given, then, that social work is founded upon preventive assumptions and, presumably, has a better developed set of preventive skills than newcomers to the community enterprise, it is of interest to ask to what extent are social workers carrying out the preventive mandate of community mental health. On these dimensions, do they differ from others in community mental health practice? METHODS Data are derived from several instruments employed in NIMH funded studies of the staffs of three community mental health centers. The centers were chosen to represent an urban-rural continuum, a size range (small to large), diverse professional directorships, and were located in three different southern states. In this way three major sources of diversity among centers were taken into account and although the centers were purposively (as opposed to randomly) selected, they are representative of centers at large. Further, because centers comply with a common set of federal regulations for funding, they evidence considerable similarity nationally in terms of staffing patterns, services provided, and organizational policy and design (Glasscote & Gudeman, 1969). Thus findings can be judiciously generalized to other centers. This study was interested in isolating those who were planfully and consciously involved in primary preventive activities; thus only professionals (operationally, those with a master's degree or better) were used for the analysis. In addition, administrators were excluded if they did not work directly with clients or programs in the centers. This procedure yielded 84 professionals, falling into the three major categories of social workers (N = 41), psychologists (N = 27), and other specialized professionals (N = 16). (Psychiatrists were conspicuously absent from the anal-
Richard Matus and Elane M. Nuehring
35
ysis because they were very few in number and were not attached to primary prevention efforts of the community mental health centers that were studied.) This group of 84 professionals accounted for 80% of the preventive activities done by all professionals in the centers that were studied and about 55% of preventive activities done by all of the staff (N = 195). Clearly, this group represents those in the community mental health centers who are doing the bulk of the primary prevention. FINDINGS O u r earlier discussion suggested that the activities labeled as " p r i m a r y p r e v e n t i o n " aim to anticipate life crises, to offset their impact, and to change damaging aspects of the b r o a d e r social n e t w o r k s that shape h u m a n behavior. For the p u r p o s e s of this analysis, six categories of activities were identified which constituted p r i m a r y prevention: 1. 2. 3. 4. 5. 6.
Program consultation Public information (the center's activities) Public information (mental health in general) Training community caregivers Growth and education groups Community planning and development
W h e n the h o u r s spent doing these activities are s u m m e d , t h e y equal the time an individual, group, or center has s p e n t doing p r i m a r y prevention. The c o m b i n e d time s p e n t b y the three c o m m u n i t y mental health centers doing primary p r e v e n t i o n equaled 7.8% of all staff time. This agrees with the national figure of 7.7% cited earlier, indicating that these centers are probably not atypical of centers across the nation. Table 1 shows the distribution of professional categories b y percentage a m o n g cohorts and m e a n hours. As the data indicate, social w o r k e r s as a g r o u p do substantially m o r e p r e v e n t i o n than the other two categories. Social workers not only do more as a g r o u p but individually h a v e a h i g h e r m e a n per w e e k of h o u r s s p e n t doing
TABLE 1
Primary Preventive Activity by Professional Category MEAN HOURS
% OF ALL
PER WEEK
PREVENTION
% OF TOTAL STAFF
SOCIAL WORKERS (41)
1.80
29.69%
21.03t
PSYCHOLOGISTS (27)
1.54
16.67%
13.85~
1.33
8.56%
8.21%
54.92%
43.09%
SPECIALIZED
PROFESSIONALS
TOTAL
(16)
(84)
36
Community Mental Health Journal
prevention; that is, not only are they as a profession contributing more to the mandate of prevention, but individually as well. Of particular importance is the fact social workers constitute 21% of the total staff, yet contribute nearly 30% of the prevention being done. It was noted that social workers did not differ significantly from other professions by years of experience in the field of mental health. The next closest group are the psychologists who account for 13.85% of the total staff and contribute 16.67% of the prevention effort, while the group of other specialized professionals, constituting 8.21% of the total staff, can account for only 8.56% of the prevention mandate. This implies that w h e n a profession does more prevention, it is done in a rather exponential fashion; that is, it is not simply an additive function of there being more social workers, but rather the more social workers, the more prevention plus a factor that is being done. An additional question concerns the quality of activity. For example, are social workers merely performing heavily in one program area, or are they broad based in their approach to primary prevention? The "generic" tradition of social work suggests that they would be quite broad in their approach and adept at m a n y program activities considered preventive in nature. A list of 14 exemplary preventive programs from the mental health literature (DeWild, 1975) was presented to the sample group asking them to (a) identify whether they had ever worked with such programs, and (b) which of the programs they thought were preventive. The respondents were not aware that all 14 of the programs were, in fact, considered in the literature to be primary preventive; they were simply asked to state their experience in such programs and identify whether or not they thought these programs were examples of primary prevention. (An elaboration of the programs presented to respondents is available from the senior author.) Table 2 details the percentage of each professional category that indicated experience working with each program. Again, larger percentages of social workers were experienced in most of the program exemplars (10 out of 14) indicating a rather broad-based arena of practice. Other specialized professionals dominated 3 of the 14 programs, and psychologists dominated only 1 of the 14 (the reader is cautioned in this instance, in that the numbers for some of the programs become quite small; for example, genetic counseling had only 5 of the 84 respondents claiming they had experience in this area). The list of programs is by no means exhaustive; however, it is useful to look at dominant programs within and between professional categories. Though this does not appear to differentiate between categories, it gives the reader some feel for the more popular preventive activities among professionals. Ranking the programs within categories of professionals, the highest rates of experience appeared in the same five programs; training other caregivers, speaking to civic groups, programs for court referrals, expanding crisis networks, and two-way consultation with other agencies. Programs in which the professional groups had lower rates of experience still matched well on the ranking. Although relatively more social workers had experience in almost
Richard Matus and Elane M. Nuehring
37
TABLE 2
Experience with Primary Preventive Programs Specialized
Social
I.
2.
Phone calls to the elderly
Childhood Screening
Workers
Psychologists
Professionals
39%
41%
44%
(16)
(11)
(7)
46%
33%
44%
(19) 3.
Ghetto Organizing
59%
(24) 4.
Model Cities Planning
42%
(17) 5.
6.
7.
8.
9.
Training Other Caregivers
Speaking to Civic Groups
Growth Groups
Train Teachers for screening
Genetic Counseling
Non-Client Rec. Groups
Required Psych. Screening
13.
Program for Court Referrals
(5)
31% (S)
(33)
(17)
(11)
85%
63%
81%
(35)
(17)
(13)
56%
52%
(23)
(14)
59%
44%
(24)
(12)
5%
7%
46%
5%
(2) 19% (5) 7% (2)
76%
63%
(31)
(17)
50% (8) 44~ (7) 6% (1) 56% (9) 19% (3) 63% (1o)
Expand Crisis Center Networks
14.
19%
(5)
65%
(2) 12.
(8)
31%
63%
(19) 11.
30%
(7)
81%
(2) IO,
(9)
68%
63%
63%
(28)
(17)
(Io)
Two-way Consultation with Agencies
81% (33)
67% (18)
63% (lO1
38
Community Mental Health Journal
every case, it is notable that for all disciplines, primary prevention experience takes on a strikingly similar character. That is, no matter what profession, more people gain experience in the same preventive activities. Respondents were also asked to identify which of the 14 programs they thought were examples of primary prevention; that is, having discussed the activities in terms of hours and experience, what about prevention ideologies? Table 3 presents the percentage of "correct" responses (percentage of programs identified as preventive in nature) by profession. The reader is reminded that the respondents were not told that, in fact, all of the 14 programs were justified in the professional literature as being preventive in nature. Obviously, none of the three professional groups indicated that even half of the programs represented primary prevention; yet each has a rational base in the literature. This attests to the confusion and uncertainty that exists with respect to what prevention is and how it should be done. Even with the broad experiential base of social workers, they faired no better than the other professionals in identifying preventive programs. This raises the question: If activities described as primary prevention in the literature do not tally with practitioners' perceptions, what then do practitioners construe as primary prevention? What about their attitudes and beliefs toward primary prevention? Do experience and activity either develop or result from favorable dispositions toward primary prevention? In order to assess this aspect of ideology among professionals, the Gottesfeld Community Mental Health Critical Issues Test (Gottesfeld, 1972) was also administered to the professionals surveyed. The Gottesfeld Test consists of six scales of questionnaire items which correspond to the major issues found in an exhaustive review of mental health literature. One of the scales deals with issues surrounding reducing the incidence of mental illness and is appropriately entitled the "Prevention Scale." Table 4 presents the mean scores by profession on the Gottesfeld Prevention Scale. Higher scores are associated with a greater acceptance of primary prevention in principle and, as we see, psychologists lead the way. Here again a cautious interpretation might attribute this to the professional training and TABLE 3 Correct Responses to Primary Prevention Exemplars Percent
Mean Number
Corrent
Correct
Social Workers
32.5%
4.55
Psychologists
32.1%
4.49
37,8~
5.29
Specialized Professionals
Richard Matus and Elane M. Nuehring
39
TABLE 4 Mean Gottesfeld "'Prevention Scale" Scores Mean Score
Social Workers
(41)
2.69
Psychologists
(27)
2.90*
(16)
2.64
Specialized Professionals
*Significant
beyond the . I 0 level on a t w o - t a i l e d T - t e s t against the other
two professional groups.
exposure to the rhetoric of prevention within the "community psychology" framework. By now, however, the distinct lack of ideology and conceptual awareness, in contrast with actual involvement and breadth of activity on the part of social workers, becomes apparent. DISCUSSION What seems to exist is that social workers do more primary prevention and are more experienced in the broad range of preventive activities than their professional colleagues in other disciplines. They do not, however, conceptualize these activities as preventive and, moreover, do not particularly embrace a preventive ideology. This may be a manifestation of social work's notoriously atheoretical and concrete orientation which largely involves doing, without reference to abstract principles or philosophical postures. (Note that both psychiatry and psychology have evolved subspecialties with theories and conceptual frameworks in which to place the practice of community mental health, but social work has not.) Equally important, these observations raise a question regarding the indications that relatively little primary prevention is done in community mental health. If one of the largest, if not the largest, professional groups doing primary prevention does not perceive its efforts in these terms, is it possible that considerably more primary prevention is actually implemented but not identified? REFERENCES Caplan, G. Principles of preventive psychiatry. New York: Basic Books, 1964. DeWild, D. The influence of civil libertarian values on programs for the prevention of mental illness. Unpublished doctoral dissertation, Florida State University, 1975. Glasscote, R. M., & Gudeman, J. E. The staffof the mental health center: Afield study. Washington, D.C.: Joint Information Service of the American Psychiatric Association and the National Institute of Mental Health, 1969. Gottesfeld, H. The critical issues of community mental health. New York: Behavioral Publications, 1972.
40
Community Mental Health Journal
Kennedy, J. F. The role of the federal government in the prevention and treatment of mental disorders. In S. K. Weinberg (Ed.), The sociology of mental disorders: Analyses and readings in psychiatric sociology. Chicago: Aldine, 1967. Kessler, M., & Albee, G. W. Primary prevention. Annual Review of Psychology, 1975. Miller, K. S., Correlates of preventive activities in community mental health centers. Final Report of NIMH Grant I RO1 MH 23646-02MHS. Tallahassee, Fla: Institute for Social Research, Florida State University, 1976. Roman, P. M., & Trice, H. M. Strategies of preventive psychiatry and social reality: The case of alcoholism. In P. M. Roman & H. M. Trice (Eds.), Sociological perspectives on community mental health. Philadelphia: Davis, 1974. Simon, G. C. Is there progress in community mental health? In L. Bellak & H. H. Barten (Eds.), Progress in community mental health (Vol. 3). New York: Brunner/Mazel, 1975.
ABSTRACT: Primary prevention and a public health model have been among the distinguishing innovations of the community mental health movement. Social work practice, however, has historically been involved in community intervention and environmental manipulation to offset social and psychological jeopardy. Given a long tradition of commitment to activity and techniques which are now hailed as mental health"s "'third revolution," this study explores the role of social work in primary prevention. Data are from a survey of three community mental health centers in which professional staff completed the Gottesfeld Critical Issues of Community Mental Health questionnaire, a time-distribution form, and a prevention questionnaire. In addition, all staff working in primary prevention were interviewed in depth. The total sample of this study of mental health professionals was 84. This study points to some interesting contradictions found between social work action and ideology in primary prevention. Also, social workers are compared with other professionals in order to isolate some primary prevention tasks and attitudes that appear unique to each.
Prevention of mental disorder and promotion of mental health are among the distinguishing themes of the community mental health movement and are conventionally grouped under one rubric, "primary prevention" (Kessler & Albee, 1975; Roman & Trice, 1974). Adapted from public health models, primary prevention refers to strengthening the resistance of populations and groups, and the offsetting of harmful influences in advance of their impact (Caplan, 1964). In the promotive vein we see such efforts as mental health education aimed at improving the coping skills of groups such as expectant parents and preretirees, community planning and development to improve the quality of social conditions and resources, and so on. In the preventive area there are programs such as genetic counseling, preschool screening for disabilities and disturbances, many kinds of crisis intervention such as divorce counseling, and the training of other caregivers to sharpen their skills in detection and intervention. The evolution of the community mental health movement, begun in the late 1950s and early 1960s, is perhaps most accurately characterized by John F. Kennedy's call to Congress in 1963 to fund new facilities where prevention as well as treatment is a major activity (Kennedy, 1963). This mandate has been earmarked by an ideological shift in mental health practice from emphasis on *Dr. Matus is Research Associate, Institute for Social Research, Florida State University, Tallahassee, Florida, 32306. Dr. Nuehring is Associate Professor, Barry College School of Social Work, Miami Shores, Florida. The research on which this study is based was supported by NIMH Research Grant No. 1 R01 MH 23646-02MHS. An earlier version of the paper was presented at the meetings of the American Public Health Association, Miami, October, 1976. Community Mental Health Journal Vol. 15(1), 1979
0010-3853/79/1300-0033500.95~ 1979 Human Sciences Press
33
34
Community Mental Health Journal
the inner psychic, to emphasis on the broader social networks that presumably shape human behavior. The movement, however, has not been characterized by the speedy conversion of rhetoric to action in that by 1973, 10 years later, community mental health centers were spending only about 7.7% of their time doing primary prevention but 64.8 % of their time directly treating clients (Miller, 1976). Why is more prevention not being done? There is, stated simply, too much confusion and uncertainty. The general consensus is that the fundamental problem is a lack of understanding as to what prevention is and how it should be done (Simon, 1975). A proper investigation, then, should begin with who is doing the prevention, what are they doing, and what is the ideology or knowledge base they are working from. Under the community mental health rubric, a number of professional subspecialties have emerged. Primarily, these are community psychiatry and community psychology; and a myriad of highly specialized professionals now include music therapists, vocational therapists, recreational therapists, agratherapists, and so on, all ostensibly representing expertise in community mental health and especially in preventive mental health. However, turning to social work, which typically comprises the largest professional group in mental health settings, no new professional area of specialization has been developed in response to the community mental health movement. At the same time, if one considers the traditional knowledge base of social work, the tenets of community practice are readily discernible. Historically, social work has concerned itself with anticipatory intervention and manipulation of the social environment to offset potential social and psychological jeopardy in individuals, groups, and populations. Given, then, that social work is founded upon preventive assumptions and, presumably, has a better developed set of preventive skills than newcomers to the community enterprise, it is of interest to ask to what extent are social workers carrying out the preventive mandate of community mental health. On these dimensions, do they differ from others in community mental health practice? METHODS Data are derived from several instruments employed in NIMH funded studies of the staffs of three community mental health centers. The centers were chosen to represent an urban-rural continuum, a size range (small to large), diverse professional directorships, and were located in three different southern states. In this way three major sources of diversity among centers were taken into account and although the centers were purposively (as opposed to randomly) selected, they are representative of centers at large. Further, because centers comply with a common set of federal regulations for funding, they evidence considerable similarity nationally in terms of staffing patterns, services provided, and organizational policy and design (Glasscote & Gudeman, 1969). Thus findings can be judiciously generalized to other centers. This study was interested in isolating those who were planfully and consciously involved in primary preventive activities; thus only professionals (operationally, those with a master's degree or better) were used for the analysis. In addition, administrators were excluded if they did not work directly with clients or programs in the centers. This procedure yielded 84 professionals, falling into the three major categories of social workers (N = 41), psychologists (N = 27), and other specialized professionals (N = 16). (Psychiatrists were conspicuously absent from the anal-
Richard Matus and Elane M. Nuehring
35
ysis because they were very few in number and were not attached to primary prevention efforts of the community mental health centers that were studied.) This group of 84 professionals accounted for 80% of the preventive activities done by all professionals in the centers that were studied and about 55% of preventive activities done by all of the staff (N = 195). Clearly, this group represents those in the community mental health centers who are doing the bulk of the primary prevention. FINDINGS O u r earlier discussion suggested that the activities labeled as " p r i m a r y p r e v e n t i o n " aim to anticipate life crises, to offset their impact, and to change damaging aspects of the b r o a d e r social n e t w o r k s that shape h u m a n behavior. For the p u r p o s e s of this analysis, six categories of activities were identified which constituted p r i m a r y prevention: 1. 2. 3. 4. 5. 6.
Program consultation Public information (the center's activities) Public information (mental health in general) Training community caregivers Growth and education groups Community planning and development
W h e n the h o u r s spent doing these activities are s u m m e d , t h e y equal the time an individual, group, or center has s p e n t doing p r i m a r y prevention. The c o m b i n e d time s p e n t b y the three c o m m u n i t y mental health centers doing primary p r e v e n t i o n equaled 7.8% of all staff time. This agrees with the national figure of 7.7% cited earlier, indicating that these centers are probably not atypical of centers across the nation. Table 1 shows the distribution of professional categories b y percentage a m o n g cohorts and m e a n hours. As the data indicate, social w o r k e r s as a g r o u p do substantially m o r e p r e v e n t i o n than the other two categories. Social workers not only do more as a g r o u p but individually h a v e a h i g h e r m e a n per w e e k of h o u r s s p e n t doing
TABLE 1
Primary Preventive Activity by Professional Category MEAN HOURS
% OF ALL
PER WEEK
PREVENTION
% OF TOTAL STAFF
SOCIAL WORKERS (41)
1.80
29.69%
21.03t
PSYCHOLOGISTS (27)
1.54
16.67%
13.85~
1.33
8.56%
8.21%
54.92%
43.09%
SPECIALIZED
PROFESSIONALS
TOTAL
(16)
(84)
36
Community Mental Health Journal
prevention; that is, not only are they as a profession contributing more to the mandate of prevention, but individually as well. Of particular importance is the fact social workers constitute 21% of the total staff, yet contribute nearly 30% of the prevention being done. It was noted that social workers did not differ significantly from other professions by years of experience in the field of mental health. The next closest group are the psychologists who account for 13.85% of the total staff and contribute 16.67% of the prevention effort, while the group of other specialized professionals, constituting 8.21% of the total staff, can account for only 8.56% of the prevention mandate. This implies that w h e n a profession does more prevention, it is done in a rather exponential fashion; that is, it is not simply an additive function of there being more social workers, but rather the more social workers, the more prevention plus a factor that is being done. An additional question concerns the quality of activity. For example, are social workers merely performing heavily in one program area, or are they broad based in their approach to primary prevention? The "generic" tradition of social work suggests that they would be quite broad in their approach and adept at m a n y program activities considered preventive in nature. A list of 14 exemplary preventive programs from the mental health literature (DeWild, 1975) was presented to the sample group asking them to (a) identify whether they had ever worked with such programs, and (b) which of the programs they thought were preventive. The respondents were not aware that all 14 of the programs were, in fact, considered in the literature to be primary preventive; they were simply asked to state their experience in such programs and identify whether or not they thought these programs were examples of primary prevention. (An elaboration of the programs presented to respondents is available from the senior author.) Table 2 details the percentage of each professional category that indicated experience working with each program. Again, larger percentages of social workers were experienced in most of the program exemplars (10 out of 14) indicating a rather broad-based arena of practice. Other specialized professionals dominated 3 of the 14 programs, and psychologists dominated only 1 of the 14 (the reader is cautioned in this instance, in that the numbers for some of the programs become quite small; for example, genetic counseling had only 5 of the 84 respondents claiming they had experience in this area). The list of programs is by no means exhaustive; however, it is useful to look at dominant programs within and between professional categories. Though this does not appear to differentiate between categories, it gives the reader some feel for the more popular preventive activities among professionals. Ranking the programs within categories of professionals, the highest rates of experience appeared in the same five programs; training other caregivers, speaking to civic groups, programs for court referrals, expanding crisis networks, and two-way consultation with other agencies. Programs in which the professional groups had lower rates of experience still matched well on the ranking. Although relatively more social workers had experience in almost
Richard Matus and Elane M. Nuehring
37
TABLE 2
Experience with Primary Preventive Programs Specialized
Social
I.
2.
Phone calls to the elderly
Childhood Screening
Workers
Psychologists
Professionals
39%
41%
44%
(16)
(11)
(7)
46%
33%
44%
(19) 3.
Ghetto Organizing
59%
(24) 4.
Model Cities Planning
42%
(17) 5.
6.
7.
8.
9.
Training Other Caregivers
Speaking to Civic Groups
Growth Groups
Train Teachers for screening
Genetic Counseling
Non-Client Rec. Groups
Required Psych. Screening
13.
Program for Court Referrals
(5)
31% (S)
(33)
(17)
(11)
85%
63%
81%
(35)
(17)
(13)
56%
52%
(23)
(14)
59%
44%
(24)
(12)
5%
7%
46%
5%
(2) 19% (5) 7% (2)
76%
63%
(31)
(17)
50% (8) 44~ (7) 6% (1) 56% (9) 19% (3) 63% (1o)
Expand Crisis Center Networks
14.
19%
(5)
65%
(2) 12.
(8)
31%
63%
(19) 11.
30%
(7)
81%
(2) IO,
(9)
68%
63%
63%
(28)
(17)
(Io)
Two-way Consultation with Agencies
81% (33)
67% (18)
63% (lO1
38
Community Mental Health Journal
every case, it is notable that for all disciplines, primary prevention experience takes on a strikingly similar character. That is, no matter what profession, more people gain experience in the same preventive activities. Respondents were also asked to identify which of the 14 programs they thought were examples of primary prevention; that is, having discussed the activities in terms of hours and experience, what about prevention ideologies? Table 3 presents the percentage of "correct" responses (percentage of programs identified as preventive in nature) by profession. The reader is reminded that the respondents were not told that, in fact, all of the 14 programs were justified in the professional literature as being preventive in nature. Obviously, none of the three professional groups indicated that even half of the programs represented primary prevention; yet each has a rational base in the literature. This attests to the confusion and uncertainty that exists with respect to what prevention is and how it should be done. Even with the broad experiential base of social workers, they faired no better than the other professionals in identifying preventive programs. This raises the question: If activities described as primary prevention in the literature do not tally with practitioners' perceptions, what then do practitioners construe as primary prevention? What about their attitudes and beliefs toward primary prevention? Do experience and activity either develop or result from favorable dispositions toward primary prevention? In order to assess this aspect of ideology among professionals, the Gottesfeld Community Mental Health Critical Issues Test (Gottesfeld, 1972) was also administered to the professionals surveyed. The Gottesfeld Test consists of six scales of questionnaire items which correspond to the major issues found in an exhaustive review of mental health literature. One of the scales deals with issues surrounding reducing the incidence of mental illness and is appropriately entitled the "Prevention Scale." Table 4 presents the mean scores by profession on the Gottesfeld Prevention Scale. Higher scores are associated with a greater acceptance of primary prevention in principle and, as we see, psychologists lead the way. Here again a cautious interpretation might attribute this to the professional training and TABLE 3 Correct Responses to Primary Prevention Exemplars Percent
Mean Number
Corrent
Correct
Social Workers
32.5%
4.55
Psychologists
32.1%
4.49
37,8~
5.29
Specialized Professionals
Richard Matus and Elane M. Nuehring
39
TABLE 4 Mean Gottesfeld "'Prevention Scale" Scores Mean Score
Social Workers
(41)
2.69
Psychologists
(27)
2.90*
(16)
2.64
Specialized Professionals
*Significant
beyond the . I 0 level on a t w o - t a i l e d T - t e s t against the other
two professional groups.
exposure to the rhetoric of prevention within the "community psychology" framework. By now, however, the distinct lack of ideology and conceptual awareness, in contrast with actual involvement and breadth of activity on the part of social workers, becomes apparent. DISCUSSION What seems to exist is that social workers do more primary prevention and are more experienced in the broad range of preventive activities than their professional colleagues in other disciplines. They do not, however, conceptualize these activities as preventive and, moreover, do not particularly embrace a preventive ideology. This may be a manifestation of social work's notoriously atheoretical and concrete orientation which largely involves doing, without reference to abstract principles or philosophical postures. (Note that both psychiatry and psychology have evolved subspecialties with theories and conceptual frameworks in which to place the practice of community mental health, but social work has not.) Equally important, these observations raise a question regarding the indications that relatively little primary prevention is done in community mental health. If one of the largest, if not the largest, professional groups doing primary prevention does not perceive its efforts in these terms, is it possible that considerably more primary prevention is actually implemented but not identified? REFERENCES Caplan, G. Principles of preventive psychiatry. New York: Basic Books, 1964. DeWild, D. The influence of civil libertarian values on programs for the prevention of mental illness. Unpublished doctoral dissertation, Florida State University, 1975. Glasscote, R. M., & Gudeman, J. E. The staffof the mental health center: Afield study. Washington, D.C.: Joint Information Service of the American Psychiatric Association and the National Institute of Mental Health, 1969. Gottesfeld, H. The critical issues of community mental health. New York: Behavioral Publications, 1972.
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Kennedy, J. F. The role of the federal government in the prevention and treatment of mental disorders. In S. K. Weinberg (Ed.), The sociology of mental disorders: Analyses and readings in psychiatric sociology. Chicago: Aldine, 1967. Kessler, M., & Albee, G. W. Primary prevention. Annual Review of Psychology, 1975. Miller, K. S., Correlates of preventive activities in community mental health centers. Final Report of NIMH Grant I RO1 MH 23646-02MHS. Tallahassee, Fla: Institute for Social Research, Florida State University, 1976. Roman, P. M., & Trice, H. M. Strategies of preventive psychiatry and social reality: The case of alcoholism. In P. M. Roman & H. M. Trice (Eds.), Sociological perspectives on community mental health. Philadelphia: Davis, 1974. Simon, G. C. Is there progress in community mental health? In L. Bellak & H. H. Barten (Eds.), Progress in community mental health (Vol. 3). New York: Brunner/Mazel, 1975.
