INTRODUCTION AND INTRODUCTION AND HISTORY OF COMMUNITY HISTORY OF COMMUNITY

PSYCHOLOGYPSYCHOLOGY

Lecture 37Lecture 37

Many approaches of therapy basically focus on the Many approaches of therapy basically focus on the individual who has already developed psychological individual who has already developed psychological problems.problems.

At the theoretical level, therapists have long accepted At the theoretical level, therapists have long accepted the idea that all behavior (pathological or otherwise) is the idea that all behavior (pathological or otherwise) is a joint product of situational and personal factors. a joint product of situational and personal factors.

Yet in their day-to-day therapeutic efforts, the Yet in their day-to-day therapeutic efforts, the emphasis of clinicians was generally on one-to-one emphasis of clinicians was generally on one-to-one therapy of some sort.therapy of some sort.

A relatively newer approach, community A relatively newer approach, community psychology, psychology, shows great promise for addressing mental health shows great promise for addressing mental health problems.problems.

PRINCIPLES OF COMMUNITY PSYCHOLOGYPRINCIPLES OF COMMUNITY PSYCHOLOGY

What "causes" problems? What "causes" problems?

Problems develop due to an interaction over time Problems develop due to an interaction over time between the individual, social setting, and systems.between the individual, social setting, and systems.

How are problems defined?How are problems defined?

Problems can be defined at many levels, but particular Problems can be defined at many levels, but particular emphasis is placed on analysis at the community and emphasis is placed on analysis at the community and organization level. organization level.

Where is community psychology practiced?Where is community psychology practiced?

In the field or in the social context of interest.In the field or in the social context of interest.

How are services planned?How are services planned?The needs and risks in a community are The needs and risks in a community are proactively assessed.proactively assessed.

What is the emphasis in community What is the emphasis in community psychology interventions?psychology interventions?Prevention of problems rather than treatment of Prevention of problems rather than treatment of existing problems.existing problems.

Who is qualified to intervene?Who is qualified to intervene? Interventions are often carried out through self-Interventions are often carried out through self-help programs.help programs.

PERSPECTIVES AND PERSPECTIVES AND HISTORYHISTORY

THE COMMUNITY PSYCHOLOGY THE COMMUNITY PSYCHOLOGY PERSPECTIVEPERSPECTIVE

Community psychology has been described as Community psychology has been described as an approach to mental health that emphasizes an approach to mental health that emphasizes the role of environmental forces in creating and the role of environmental forces in creating and alleviating problems (Zax & Specter, 1974). alleviating problems (Zax & Specter, 1974).

The major aspects of this perspective are The major aspects of this perspective are cultural relativity, diversity, and ecology (the fit cultural relativity, diversity, and ecology (the fit between persons and the environment).between persons and the environment).

First, community psychologists should not be First, community psychologists should not be concerned exclusively with inadequate environments concerned exclusively with inadequate environments or persons. Rather, they should direct their attention to or persons. Rather, they should direct their attention to the fit between environments and persons-a fit that the fit between environments and persons-a fit that may or may not be good.may or may not be good.

Second, the focus is on action directed toward the Second, the focus is on action directed toward the competencies of persons and environments rather competencies of persons and environments rather than their deficits. than their deficits.

Third, the community psychologist is likely to believe Third, the community psychologist is likely to believe that differences among people and communities are that differences among people and communities are desirable.desirable.

The community psychologist is not identified with a The community psychologist is not identified with a single social norm or value, but instead looks to the single social norm or value, but instead looks to the promotion of diversity.promotion of diversity.

In Rappaport's (1977) view, three sets of concerns In Rappaport's (1977) view, three sets of concerns define the community psychology perspective: define the community psychology perspective:

Human resource developmentHuman resource development, , political activitypolitical activity, , and and sciencescience..

In many ways, these are antagonistic elements. In many ways, these are antagonistic elements. Political activists are often impatient and ridicule more Political activists are often impatient and ridicule more

traditional clinicians as bringing society too little too traditional clinicians as bringing society too little too late. late.

Clinicians, in turn, often criticize activists as Clinicians, in turn, often criticize activists as unprofessional and overly concerned with hawking unprofessional and overly concerned with hawking their own visions of the world. their own visions of the world.

The scientists, in turn are appalled by activists and The scientists, in turn are appalled by activists and clinicians alike; both are seen as shockingly willing to clinicians alike; both are seen as shockingly willing to act on the basis of invalidated hunches and lack of act on the basis of invalidated hunches and lack of data or, worst of all, without a viable theory to guide data or, worst of all, without a viable theory to guide them.them.

In fact, true societal changes vis-a-vis mental In fact, true societal changes vis-a-vis mental health will require the cooperation of each of health will require the cooperation of each of these "camps." these "camps."

Whatever else community psychology may be, Whatever else community psychology may be, it is not a field that emphasizes an individual it is not a field that emphasizes an individual disease or individual treatment model . disease or individual treatment model .

The focus is preventive rather than curative.The focus is preventive rather than curative.

Further, individuals and community Further, individuals and community organizations are encouraged to take control organizations are encouraged to take control of and master their own problems (via of and master their own problems (via empowerment) so that traditional professional empowerment) so that traditional professional intervention will not be necessary.intervention will not be necessary.

HISTORY AND CATALYZING EVENTSHISTORY AND CATALYZING EVENTS

In 1955, the U.S. Congress passed legislation creating In 1955, the U.S. Congress passed legislation creating the joint Commission on Mental Health and Illness. the joint Commission on Mental Health and Illness.

Its report encouraged the development of a Its report encouraged the development of a community mental health concept and urged a community mental health concept and urged a reduction in the population of mental hospitals.reduction in the population of mental hospitals.

Based on the premise that psychological distress and Based on the premise that psychological distress and the development of mental disorders were influenced the development of mental disorders were influenced by adverse environmental conditions, President by adverse environmental conditions, President Kennedy called for a "bold new approach" to Kennedy called for a "bold new approach" to prevent prevent mental disorder. mental disorder.

Their aims were to promote the early detection of Their aims were to promote the early detection of mental health problems, treat acute disorders, and mental health problems, treat acute disorders, and establish comprehensive delivery systems of services establish comprehensive delivery systems of services that would prevent the "warehousing" of chronic that would prevent the "warehousing" of chronic patients in mental hospitals . patients in mental hospitals .

The American Psychological Association endorsed the The American Psychological Association endorsed the desirability of community residents' participating in all desirability of community residents' participating in all these decisions.these decisions.

A conference held in 1965 is regarded by many as the A conference held in 1965 is regarded by many as the "official" birth of community psychology."official" birth of community psychology.

Shortly after this conference, the Division of Shortly after this conference, the Division of Community Psychology was organized within the Community Psychology was organized within the American Psychological Association. American Psychological Association.

Soon Soon The Community Mental Health JournalThe Community Mental Health Journal and and the the American Journal of Community PsychologyAmerican Journal of Community Psychology began publication. began publication.

Courses in community psychology and programs of Courses in community psychology and programs of graduate training have been established, and there graduate training have been established, and there are even books now on the history of community are even books now on the history of community mental health.mental health.

Issues or concerns that have catalyzed the Issues or concerns that have catalyzed the emergence of community psychology:emergence of community psychology:

TREATMENT FACILITIESTREATMENT FACILITIES Although the mental hospital population in the United Although the mental hospital population in the United

States peaked at about 500,000 in the mid-1950s, States peaked at about 500,000 in the mid-1950s, socially oriented clinicians continued to press for socially oriented clinicians continued to press for alternatives to the costly, inefficient, and often largely alternatives to the costly, inefficient, and often largely custodial hospitalization of patients. Three factors custodial hospitalization of patients. Three factors combined at about this time to markedly reduce the combined at about this time to markedly reduce the population of mental hospitals:population of mental hospitals:

The advent of psychotropic medications, The advent of psychotropic medications, A more liberal discharge philosophy, A more liberal discharge philosophy, And better treatment in mental hospitals. And better treatment in mental hospitals.

A problem with many mental hospitals was their lack A problem with many mental hospitals was their lack of trained therapists. of trained therapists.

Regarded by lay persons as a realistic means for Regarded by lay persons as a realistic means for solving difficult emotional problems, hospitalization solving difficult emotional problems, hospitalization itself often created nearly as many problems as it itself often created nearly as many problems as it alleviated. alleviated.

Over the years, mental hospitals (particularly those Over the years, mental hospitals (particularly those run by the states) too often became ware houses or run by the states) too often became ware houses or custodial bins. custodial bins.

Care was often marginal and sometimes downright Care was often marginal and sometimes downright inhumane. Professional staff was severely lacking in inhumane. Professional staff was severely lacking in numbers and sometimes in quality. numbers and sometimes in quality.

Indeed, many still argue (and have demonstrated Indeed, many still argue (and have demonstrated empirically) that hospitalization is not an especially empirically) that hospitalization is not an especially effective treatment strategy.effective treatment strategy.

PERSONNEL SHORTAGEPERSONNEL SHORTAGE Even as more clinical psychologists and psychiatrists Even as more clinical psychologists and psychiatrists

were trained; demands for their services outstripped were trained; demands for their services outstripped their increase in numbers. their increase in numbers.

Many of the newcomers were entering private Many of the newcomers were entering private practice, and others were being diverted into teaching practice, and others were being diverted into teaching or research. or research.

A number of trends all seemed to coalesce to produce A number of trends all seemed to coalesce to produce critical shortages of hospital and clinic personnel. critical shortages of hospital and clinic personnel.

To grapple with these shortages, it became imperative To grapple with these shortages, it became imperative that new sources of personnel be sought, that more that new sources of personnel be sought, that more effective use be made of professional time, and that effective use be made of professional time, and that new models of coping with human problems be new models of coping with human problems be developed. developed.

Albee (1959, 1968) predicted that it would be literally Albee (1959, 1968) predicted that it would be literally impossible to train enough mental health professionals impossible to train enough mental health professionals to meet existing and future needs, and recommended to meet existing and future needs, and recommended that prevention be pursued as a strategy.that prevention be pursued as a strategy.

QUESTIONS ABOUT PSYCHOTHERAPYQUESTIONS ABOUT PSYCHOTHERAPY In the 1950s, people began to question not just the In the 1950s, people began to question not just the

efficiency of psychotherapy but also its effectiveness.efficiency of psychotherapy but also its effectiveness. Some began to wonder if it was not just intra psychic Some began to wonder if it was not just intra psychic

factors that created problems, but the interaction factors that created problems, but the interaction between person and society. between person and society.

At the same time, economic factors were pushing At the same time, economic factors were pushing therapy beyond the reach of the poor and therapy beyond the reach of the poor and disadvantaged. disadvantaged.

The relationship between mental illness and social The relationship between mental illness and social class had been documented by researchers.class had been documented by researchers.

Now, it seemed, there was also a relationship between Now, it seemed, there was also a relationship between social class and the availability of psychotherapy.social class and the availability of psychotherapy.

MEDICAL MODELS AND ROLESMEDICAL MODELS AND ROLES We know the widespread role of the medical We know the widespread role of the medical

model and some of the dissatisfaction with it. model and some of the dissatisfaction with it. The 1960s ushered in a climate in which The 1960s ushered in a climate in which

institutional prerogatives and traditionalist institutional prerogatives and traditionalist beliefs came under attack. beliefs came under attack.

That climate produced listeners who were more That climate produced listeners who were more willing to accept attacks on traditional views willing to accept attacks on traditional views about mental illness. about mental illness.

All of this contributed to an increased tendency All of this contributed to an increased tendency to look for the social-community antecedents of to look for the social-community antecedents of problems in lining, rather than internal biological problems in lining, rather than internal biological or psychological etiological agents.or psychological etiological agents.

The general activism of the 1960s also catalyzed the The general activism of the 1960s also catalyzed the long-standing discontent of many clinicians with a role long-standing discontent of many clinicians with a role that relegated them to waiting passively for society's that relegated them to waiting passively for society's casualties to walk in the door. casualties to walk in the door.

Would not an activist role that took mental health Would not an activist role that took mental health services to the people be more consonant with a services to the people be more consonant with a social-community model? If so, such a role would also social-community model? If so, such a role would also provide a measure of autonomy from the dominance provide a measure of autonomy from the dominance of the medical profession. of the medical profession.

We must not overstate these developments, however. We must not overstate these developments, however. After all a major current trend in clinical psychology After all a major current trend in clinical psychology has been a headlong rush into private practice. has been a headlong rush into private practice.

Such behavior is hardly a rejection of the medical Such behavior is hardly a rejection of the medical model or an acceptance of the social-community model or an acceptance of the social-community approach.approach.

THE ENVIRONMENTTHE ENVIRONMENT Another force that helped shape the community Another force that helped shape the community

psychology movement was a greater awareness of the psychology movement was a greater awareness of the importance of social and environmental factors in importance of social and environmental factors in determining people's behavior and problems. determining people's behavior and problems.

Poverty, discrimination, pollution, and crowding were Poverty, discrimination, pollution, and crowding were being recognized as potent factors. being recognized as potent factors.

Providing people with choices and enhancing their well-Providing people with choices and enhancing their well-being required that psychologists pay attention to these being required that psychologists pay attention to these factors that they go beyond a reflexive consideration of factors that they go beyond a reflexive consideration of the early childhood determinants of people's the early childhood determinants of people's personalities. personalities.

The emotional problems of large numbers of people The emotional problems of large numbers of people may be influenced by poverty, unemployment, job may be influenced by poverty, unemployment, job discrimination, racism, diminished educational discrimination, racism, diminished educational opportunities, sexism, and other social factors. opportunities, sexism, and other social factors.

Such influences are hardly proposed by therapies that Such influences are hardly proposed by therapies that seek answers in internal dynamics.seek answers in internal dynamics.

THE CONCEPT OF COMMUNITY THE CONCEPT OF COMMUNITY MENTAL HEALTHMENTAL HEALTH

The 1955 Joint Commission on Mental Health The 1955 Joint Commission on Mental Health and Illness made several basic and Illness made several basic recommendations that set the tone for the recommendations that set the tone for the subsequent development of community subsequent development of community psychology-a tone that still resonates in accord psychology-a tone that still resonates in accord with political and financial pressures across the with political and financial pressures across the nation. nation.

These recommendations were These recommendations were (1) More and better research into mental health (1) More and better research into mental health

phenomena; phenomena; (2) A broadened definition of who may provide (2) A broadened definition of who may provide

mental health mental health

(3) That mental health services should be made (3) That mental health services should be made available in the community; available in the community;

(4) That an awareness should be fostered that mental (4) That an awareness should be fostered that mental illness can stem from social factors (such as ostracism illness can stem from social factors (such as ostracism and isolation); and and isolation); and

(5) That the federal government should support these (5) That the federal government should support these recommendations financially.recommendations financially.

In 1963, federal funds were provided to help in the In 1963, federal funds were provided to help in the construction and staffing of comprehensive mental construction and staffing of comprehensive mental health centers. health centers.

To qualify for these funds, To qualify for these funds, a a community mental health community mental health centercenter had to provide five essential services: had to provide five essential services:

(1) Inpatient care; (1) Inpatient care; (2) Outpatient care; (2) Outpatient care; (3) Partial hospitalization (for example, the patient works (3) Partial hospitalization (for example, the patient works

during the day but returns to the hospital at night); during the day but returns to the hospital at night);

(4) Round-the-clock emergency service; and (4) Round-the-clock emergency service; and (5) Consultation services to a variety of (5) Consultation services to a variety of

professional, educational, and service professional, educational, and service personnel in the community. personnel in the community.

Beyond these required services, it was hoped Beyond these required services, it was hoped that the mental health centers would also that the mental health centers would also provide provide

(1) Diagnostic services, (1) Diagnostic services, (2) Rehabilitation services, (2) Rehabilitation services, (3) Research, (3) Research, (4) Training, and (4) Training, and (5) Evaluation. (5) Evaluation.

THE CONCEPT OF PREVENTIONTHE CONCEPT OF PREVENTION The idea of The idea of prevention prevention is the guiding principle that has is the guiding principle that has

long been at the heart of public health programs in the long been at the heart of public health programs in the U.S.U.S.

Basically, the principle asserts that, in the long run, Basically, the principle asserts that, in the long run, preventive activities will be more efficient and effective preventive activities will be more efficient and effective than individual treatment administered after the onset than individual treatment administered after the onset of diseases or problems . of diseases or problems .

That such approaches can work is graphically That such approaches can work is graphically illustrated by Price, Cowen, Lorion, and Ramos-illustrated by Price, Cowen, Lorion, and Ramos-McKay (1988). McKay (1988).

Their book, Their book, Fourteen Fourteen Ounces Ounces of Preventionof Prevention, , describes 14 model prevention programs for children, describes 14 model prevention programs for children, adolescents, or adults. adolescents, or adults.

Prevention programs for adults have been developed Prevention programs for adults have been developed and implemented as well.and implemented as well.

PRIMARY PREVENTIONPRIMARY PREVENTION This type of prevention represents the most radical departure This type of prevention represents the most radical departure

from the traditional from the traditional ways ways of coping with mental health problems.of coping with mental health problems.

The essence of the notion-of The essence of the notion-of primary prevention can be primary prevention can be seen in seen in Caplan's (1964) emphasis on "counteracting harmful Caplan's (1964) emphasis on "counteracting harmful circumstances before they have had a chance to produce circumstances before they have had a chance to produce illness". illness".

Albee (1986) points out, however, that the complexity of human Albee (1986) points out, however, that the complexity of human problems often requires preventive strategies that depend on problems often requires preventive strategies that depend on social change and redistribution of power. social change and redistribution of power.

For many in society, this is not a highly palatable prospect. For many in society, this is not a highly palatable prospect. Some examples of primary prevention include programs to Some examples of primary prevention include programs to reduce job discrimination, enhance school curricula, improve reduce job discrimination, enhance school curricula, improve housing, teach parenting skills, and provide help to children housing, teach parenting skills, and provide help to children from single-parent homes. from single-parent homes.

Also grouped under this heading are genetic counseling, Head Also grouped under this heading are genetic counseling, Head Start, prenatal care for disadvantaged women, Meals on Start, prenatal care for disadvantaged women, Meals on Wheels, and school lunch programs.Wheels, and school lunch programs.

SECONDARY PREVENTIONSECONDARY PREVENTION This involves programs that promote the early This involves programs that promote the early

identification of mental health problems and prompt identification of mental health problems and prompt treatment of problems at an early stage so that mental treatment of problems at an early stage so that mental disorders do not develop. disorders do not develop.

The basic idea of The basic idea of secondary prevention secondary prevention is to attack is to attack problems while they are still manageable, before they problems while they are still manageable, before they become resistant to intervention.become resistant to intervention.

Often this approach suggests the screening of large Often this approach suggests the screening of large numbers of people. Such screening may be carried out by numbers of people. Such screening may be carried out by a variety of community service personnel.a variety of community service personnel.

Early assessment is followed, of course, by appropriate Early assessment is followed, of course, by appropriate referrals.referrals.

An example of secondary prevention is the early detection An example of secondary prevention is the early detection and treatment of those individuals with potentially and treatment of those individuals with potentially damaging drinking problems damaging drinking problems

A further example is the Rochester Primary Mental Health A further example is the Rochester Primary Mental Health Project pioneered by Emory Cowen.Project pioneered by Emory Cowen.

TERTIARY PREVENTIONTERTIARY PREVENTION The goal of The goal of tertiary prevention is tertiary prevention is to reduce the duration to reduce the duration

and the negative effects of mental disorders after their and the negative effects of mental disorders after their occurrence. occurrence.

Its aim is not to reduce the rate of new cases of mental Its aim is not to reduce the rate of new cases of mental disorder, but to lessen the effects of mental disorder once disorder, but to lessen the effects of mental disorder once diagnosed.diagnosed.

A major focus of many tertiary programs is rehabilitation. A major focus of many tertiary programs is rehabilitation. The methods used may be counseling, job training, and The methods used may be counseling, job training, and

the like. the like. Although their language is a bit different, tertiary Although their language is a bit different, tertiary

preventive programs are not very different from person preventive programs are not very different from person oriented programs based on a deficit philosophy. oriented programs based on a deficit philosophy.

However, it is important to remember that all forms of However, it is important to remember that all forms of prevention are distinguished by their attempts to reduce prevention are distinguished by their attempts to reduce the rates of, or problems associated with, mental disorder the rates of, or problems associated with, mental disorder on a community-wide (or population-wide) basis.on a community-wide (or population-wide) basis.