|Volume 1||Fall 1999|
"Focus on the Growing Efficacy of Prevention Programs"
George Albee, Ph.D., Professor Emeritus, University of Vermont, and Courtesy Professor Florida Mental Health Institute and the University of South Florida, has had a distinguished career within the field of psychology He has served both the Eisenhower and Garter Presidential Coin-missions on Mental Health and is a past-president of the American Psychological Association (1969-1970). He has significantly influenced legislation with regard to public health policy and has held numerous teaching positions at universities worldwide. He has written dozens of books and hundreds of articles on the merits of prevention and received the Gold Medal A ward for Public Service from the American Psychological Association in 1993. In 1997 he was given the Lifetime Achievement Award in Applied Preventive Psychology. Albee remains very active in his work and lives with his wife in Longboat Key Florida.
Q: Tell us a little about prevention and what it means for us.
A: Prevention is the act of stopping or hindering something from happening. True primary prevention deals with people who show no overt signs of having a disorder. You look for people who are high risk, and you do things in advance in order to reduce the probability tat they will develop a particular disorder. It is very similar to immunizations. I am ordered because of my age to get a flu shot every fall. It is not because I have any symptoms of the flu, but because I am in a high risk group. People who are in high risk groups are the targets. Secondary prevention is when you see some of the beginning signs, you rush in and try to keep it from getting worse. The third area of prevention is tertiary and that really means doing something to reduce the handicap after it has been established.
Q: It sounds as though our focus then, is really to target high risk populations...those at the poverty level?
A: Those who live at poverty levels are the highest risk group.
Q: What would be the second highest risk group?
A: Any group that is exploited. For example, the group with the highest rate of alcoholism, drug abuse, mental disorders, is the 5,000,000 migrant farm workers. They live in poverty, they move all the time, their children cannot get adequate schooling, their kids work in the fields with them, they never earn enough money to pay their bills from the company that supplies them with food, drink and cigarettes, so they are an exploited group. Any exploited group is high risk. Including women.
Q: Would it also be true that in Europe because of the wars, there is a higher rate of illness?
A: People in the northern countries, Scandinavia, Finland, and Iceland have better health and lower rates of mental disorder. England is somewhere in the middle. There is a marvelous book called Unhealthy Societies written by Richard Wilkinson. He takes a look at different societies, and most important is the size of the gap between the rich and the poor. As a general rule, a society that has a narrower gap between the rich and the poor, has better health, significantly longer life expectancy, better mental health, fewer people in prison. There are a whole series of positive things tat go along with a narrower gap. In those countries with the widest gaps, you have the worst health and the shortest life expectancy. Poverty is one of the major causes of mental and emotional problems.
Q: Do you see a big difference between the U.S. and Europe in this regard?
A.: Yes, the United States is way down on the list. Interestingly, the top two countries in terms of narrow disparity between rich and poor, the best two countries in that respect are Sweden and Japan. It is also interesting that in Japan very few people go to jail. Instead they are in rehabilitation of some kind. The police are seen as kind of counselors, and their prisons are almost a last resort. What is happening now in the United States is that the prisons are becoming a repository for those with serious mental disorders. There was an article in the New York limes a couple of weeks ago that gave all the figures on how many people are in prison. People with a chronic mental disorder need long-term treatment. What has happened is that these people are often put in jail. They are found sleeping in parks, or shoplifting for example, because they are hungry and they get put into prison. When they get out, they do something quickly to get put back in, because at least you get fed and are able to sleep. So the repository for those with chronic mental disorders is often the prison system.
Q: What do you see as the biggest need for children today?
A: If every child born was a wanted child we would significantly reduce the rate of mental and emotional disorders in the next generation. Additionally, if the expectant mother had an adequate diet, enough protein, if she was not on drugs, if the father was not on drugs or alcohol, if they had a decent standard of living, if the baby were full-term and breastfed... all this would help.
Q: Why hasn't this happened? What do you think have been our main barriers to making this happen?
A: Well, people are having children when they are not ready to have children, the lack of family planning information, and strong opposition to groups that counsel teenagers, such as Planned Pare hood. We also ought to have an agenda for looking the children of the world. If all humankind is related to each other, there are about 14,000,000 who die each year from tainted drinking water and infant diarrhea, both of which we know how to cure with formula. The death of a child or a parent is a stressful time. There are so many things we could do to make childhood better.
Q: We see adolescents who are depressed. We see the symptoms but we want to get to them before there are any symptoms. Who is most at risk? What do we need to think about here?
A: It is very interesting that as a group, girls a women are 2 to 3 times more likely to experience depression than men. But successful professional women have very low rates of depression. Poverty stricken mothers with pre-school children have high rates of depression. Depressed mothers cause depression in their children. Those adolescents with low self-esteem are at a higher risk level. People under stress are at high risk. One major source of stress is involuntary unemployment
Q: Prevention means providing jobs for people?
A: Yes, corporations that move their operations to Mexico or Indonesia and throw 10,000 people out of work, this is a major cause of depression.
Q: For a long time, we thought of mental illnesses as being biologically based only, with treatment and medication as our primary objective. We have been reactive and treating rather than proactive and preventing in this area.
A: Treatment can sometimes be long. Unfortunately, we can't spend money on prevention because we have people lined up outside thee door needing treatment. But we can try to prevent situations that are unhealthy for children. There are a number of noxious organic situations (agents) to try to avoid. Stress, abuse, violence, sexism, exploitation, poverty are all noxious agents. I think if children sense in their bones that they are wanted, loved and appreciated, they develop a great internal self-confidence that resists all kinds of stress. Many children who grow up in the worst environments, family-wise, community-wise, have succeeded; they are called resilient children because of the care and concern of someone. This person could be an aunt, scoutmaster, coach or a teacher. Many kids are saved by a teacher who believes in them. For many children, support must come from outside the dysfunctional family. The more we can strengthen the resistance of the child (the host), by developing high levels of self-confidence early, at home or at school, have the child feel loved and well perceived, and have people round them providing support, the stronger the child will be to resist adverse outcomes. Every child in a family is also unique and needs different ways of being nurtured.
Q: Why do we tend to go to crisis intervention rather than prevention?
A: There is a great deal of social pressure to do crisis intervention. However, there are never enough people to be effective in crisis intervention. That requires treating one person at a time. We can't do crisis intervention for thousands of people in Turkey who have lost everything. Better if we had enforced the laws there that insist on the structural integrity of their buildings. This way we can prevent the next tragedy.
Q: What questions should we be asking our legislators, doctors, educators, and parents?
A: Is it possible that we could spend as much on children as we do on the elderly? The elderly have a very effective lobbying organization, the AARP. There are many considerations given to older people whether it's medicare, early bird lunches or discounted movie tickets. We spend so little money on children because they don't vote.
Q: Who do you follow these days? Who do you think we should be watching for because their work is good and on target? Whose work would you recommend we read?
A: The person who has contributed the most is Emory Cowen (University of Rochester Psychology Department A.B. Brooklyn College, 1944; MA. Syracuse, 1948; Ph.D. 1950) who developed a whole series of programs tat are now in place in hundreds of schools around the country. He learned that in the first grade if you want to identify the high risk child who will be in trouble, you ask the other children. The other kids can pick out the endangered child. Then he worked out a system of getting volunteer people, mostly women, to tutor the child in the first grade. They came regularly and became a source of support and developed a relationship. The positive effects of getting a support system in place in the early years.
Q: Is there something that I have not asked you or that you feel is important to share?
A: There are two explanations for mental and emotional problems. The one currently in favor by the mental health establishment is a disease model. It's all a medical illness; it's all brain disease. That satisfies the establishment because you don't have to spend any money on poverty. You don't have to spend any money on unequal expenses, poor housing and the homeless. There is politically compelling support for the brain disease model. The alternative model (social stress) had been in place until 1980, when it was decided that no more research on the social causes of mental disorder would be done. There would be support only for organic, chemical, and bio-chemical research. Another thing about treatment: if someone has a serious mental disorder, gets two years of weekly psychotherapy and recovers, as they are no longer fearful, and they now can get out and relate and work; this means that mental disorders are reversible. This happens all the time. If they are reversible, they cannot be brain diseases!