George W. Albee

Revolutions and counterrevolutions in prevention.

The new prevention science put forward by the National Institute of Mental Health and by the Institute of Medicine advocates strict experimental interventions with controls to reduce risks for psychiatric disorders. Articles by R. F. Muñoz, P. J. Mrazek, and R. J. Haggerty (1996, this issue), K. Heller (1996, this issue), and D. Reiss and R. H. Price (1996, this issue) support, elaborate, and discuss this agenda. Issues that seem controversial include (a) the use of risk reduction of psychiatric disorders as the criteria for acceptable research, (b) rejection of studies of competence promotion as not aimed at specific disorders, and (c) rejection of prevention studies, done before the counterrevolution that occurred in 1980 and thereafter, that advocated social and political change aimed at achieving social equality for disadvantaged groups. Arguments against the restricted new approach are presented.

Suffer the little children

This year, and for many years in the past and many years in the future, some 14 million of the worlds children will die before the age of 5. A very large proportion of these deaths is preventable. Three million children die of dehydration due to diarrhea and another 3 million die of preventable infectious diseases. Others starve or die of malnutrition-related infections. At a very modest cost, oral rehydration therapy could save the lives of the first group, and relatively inexpensive vaccination against the five major diseases of childhood could save many of the rest. Diarrhea could be eliminated or greatly reduced by insuring safe water supplies throughout the world. This would require a modest investment by nations that care. Unfortunately, too few care. A small part of the money the world has budgeted for military weapons could save the majority of these doomed children as well as their brothers and sisters who grow up undernourished with underdeveloped bodies and minds. But there is money to be made in manufacturing weapons—enormous sums of money. Contractor corporations—sometimes called Merchants of Death—make huge profits as do their stockholders and managers. So millions of little children suffer and die, and other millions of little children suffer and live.This year, and for many years in the past and many years in the future, some 14 million of the worlds children will die before the age of 5. A very large proportion of these deaths is preventable. Three million children die of dehydration due to diarrhea and another 3 million die of preventable infectious diseases. Others starve or die of malnutrition-related infections. At a very modest cost, oral rehydration therapy could save the lives of the first group, and relatively inexpensive vaccination against the five major diseases of childhood could save many of the rest. Diarrhea could be eliminated or greatly reduced by insuring safe water supplies throughout the world. This would require a modest investment by nations that care. Unfortunately, too few care. A small part of the money the world has budgeted for military weapons could save the majority of these doomed children as well as their brothers and sisters who grow up undernourished with underdeveloped bodies and minds. But there is money to be made in manufacturing weapons—enormous sums of money. Contractor corporations—sometimes called Merchants of Death—make huge profits as do their stockholders and managers. So millions of little children suffer and die, and other millions of little children suffer and live.

Fifty years of clinical psychology: Selling our soul to the devil

An account of the post-World War II development of clinical psychology based on the personal experiences and observations of the author is presented. Acceptance of the medical-organic explanation of mental disorder and devotion to one-on-one psychotherapy paid for by health insurance has led clinical psychology to its present state of desperation, grasping at drug-prescription privileges as a way of surviving by further embracing the invalid medical would. Alternatively, only acceptance of the public health strategy of primary prevention, striving for social justice, and thorough grounding in social learning theory will guarantee survival of the field.

Psychopathology, Prevention, and the Just Society

The problem of defining mental disorders is examined and models to explain emotional disturbances are considered. Arguments against a sickness explanation are advanced, and definitions of mental health are reviewed. All of these concerns lead into a discussion of primary prevention. Sources of opposition to prevention efforts include those persons committed to organic models, to one-to-one intervention, and those who oppose social change efforts as inappropriate for mental health workers. An agenda for community change is proposed.

Commentary on Prevention and Counseling Psychology

I am delighted to be asked to comment on these articles because I believe that counseling psychologists have special qualifications and unique advantages as potentially major players in the area of primary prevention. In earlier articles in the United States and in the United Kingdom, I have urged counseling professionals to add prevention to their intervention armamentarium (Albee, 1990a, 1995, 1999; Albee & Perry, 1996; Albee & Ryan, 1998; Albee & Ryan-Finn, 1993). Let me spell out these special qualifications at the outset. The ongoing experience of counseling psychologists repeatedly confirms the reversibility of most patterns of individual distress that are corrected by the therapeutic relationship. If people can grow and achieve better interpersonal (and intrapersonal) relationships in a counseling (psychotherapeutic) relationship—whether psychodynamic, behavioral, or cognitive—then it is clear that most emotional (or behavioral) problems are learned in a social context and that they can be unlearned. Knowing this, from repeated experience, it is just one further step to realizing that the early distortions in social learning leading to distress might be prevented in the first place for those at risk: behold, primary prevention! Let me give an example of an early pathological social environment leading to later adult pathology and of an early positive social-educational experience leading to a richer, more, positive adult life. Rutter (1984) has shown that English children who grew up in a family environment that included multiple forms of social pathology were at great risk for later emotional problems. The unique finding was that there is an interactive and cumulative effect of single stresses. The stresses in combination potentiated each other so that the combination was much worse than a simple summation. The damaging family variables included the following: (a) severe marital discord, (b) low social status, (c) overcrowding or large family size, (d) paternal criminality, (e) maternal mental disorder, and (f) care of the local authority (poverty). Rutter found that “good schools” and high scholastic achievement had a beneficial effect on the high-risk children, and later, jobs that gave a sense of achievement and good self-esteem were a major positive factor leading to improved adjustment. Better social controls, good bonding, and coping skills all helped.

Facts and fallacies about primary prevention.

This paper clarifies eight common misconceptions about primary prevention.

Mental Illness Is NOT “an Illness Like Any Other”

The claim that “mental illness is an illness like any other” has become so wide- spread that its meaning, validity, and implications are seldom analyzed. By examining what its advocates say, we interpret the phrase to mean that mental illnesses share certain characteristics of physical illnesses, particularly in there being identifiable biological defects in people with such diagnoses, in the way diagnoses are made and what they tell us, and in the extent to which diagnoses are independent of cultural influences. We find major differences in all these areas between physical illnesses and mental disorders, and argue that accepting the claim that they are alike diminishes the likelihood of effective prevention by distracting attention from important social causes of a wide range of mental disorders.

The Politics of Primary Prevention

Primary prevention is the only effective strategy for reducing the future incidence of mental/emotional problems. But arguments about methods of reducing the rate of future problems have begun to raise questions that are more political, ideological and ethical than they are methodological. Prevention efforts may focus on safe strategies like individual behavioral change programs or alternatively on stronger non-voluntary group-mandated programs. Another dimension currently under debate is whether programs should be aimed at reducing risks for specific “mental diseases” or at efforts at fostering social competence to resist susceptibility to stress generally. Still another more general issue is the relevance of early childhood trauma like abuse and neglect in producing later emotional problems. Political conservatives favor the organic (biological, genetic) approaches to prevention that do not require social change while radicals argue for reducing social class inequalities and reducing poverty, exploitation and injustice.

Historical Overview of Primary Prevention of Psychopathology: Address to The 3rd World Conference on the Promotion of Mental Health and Prevention of Mental and Behavioral Disorders September 15–17, 2004, Auckland, New Zealand

I wrote my first paper emphasizing the necessity of prevention of mental disorders nearly 50 years ago (Albee, 1959), and prevention has been my preoccupation ever since. In order to be sure that I say everything that I think is important in a talk on prevention around the world, I will make a few statements I believe are true based on scientific research—and, on a personal, political position that favors equal social justice. I am prepared to revise these statements, in the tradition of scientific respect for evidence, at any time. But I believe each of us must make conscious and public our personal beliefs about social justice. A major question here: Do you believe that each person in the world has the same value as each other person? Or are some people more valuable than others? (There is no one right answer to this latter question, but it has profound consequences for our actions.) Here are my statements:

Economic and Social Causes of Sexism and of the Exploitation of Women

Psychologists have neglected the role of the social, economic and political systems in determining behaviour. Rather, our field, consciously or unconsciously, has been instrumental in upholding the status quo. We have accepted societys ruling ideas that perpetuate exploitation, especially of women in the world of work. Women are often the last to be hired and the first to be fired. They are employed part-time and fired early to avoid the cost of fringe benefits and retirement costs. Ideas about womens roles, generated by capitalism and patriarchal religions, are responsible for widespread sexism and the exploitation of many powerless groups, but especially girls and women. This paper reviews several examples of sexist exploitation that have an economic base.