Gerald Caplan

Four studies of crisis in parents of prematures

The responses of 86 families to the birth of a premature baby have been investigated in four linked studies in order to refine the concept and understanding of crisis. Patterns of the grappling behavior during the crisis were identified which enabled accurate predictions of the short-term mental health outcome. Psychological tasks presented by the stress of premature delivery were also identified. The adequacy with which these tasks were accomplished was predictive of the patterns of early maternal care and mother-child relationships. Results indicate that this type of study is relevant to studies of the causation of mental health and mental illness and to preventive intervention.Certain methodologic and research implications are derived from these studies and point to further research effort which is now practical and desirable.

Loss, stress, and mental health.

Erich Lindemann in 1944 reported on a study of the adjustment process of a group of normal people who had just been involved in a fire in a Boston night club. In the fire and the panic that followed, many people were killed or injured by burning, asphyxiation or trampling. Most of the survivors were treated at the Massachusetts General Hospital of Harvard Medical School, where Lindemann and his psychiatric colleagues joined the surgeons in caring for them and for members of their families. Lindemann identified a dominant syndrome of normal grieving tha t seemed characteristic of those survivors whose loved ones had been killed, and that was minimally moulded by idiosyncratic personality factors. He also identified a subgroup of cases where this orderly pattern of grieving was not seen. He felt tha t in this latter group there was a defensive refusal to suffer the pain of grieving; and this appeared to be linked with the emergence of psychopathology or psychosomatic disease. Characteristic of his approach was his immediate application of his findings to work out ways of encouraging what he theorized to be heal thy patterns of grieving, thereby interrupting the possible development of mental ill health resulting from the bereavement. Lindemann spent the rest of his life studying the significance of maladaptive responses to bereavement in the etiology of mental disorder, and ways of organizing services to help people adjust to the death of those they loved in such a way that there would be no deterioration in

Principles of Community Psychiatry

Our primary goal in community psychiatry is to satisfy the service needs of a bounded population for whose mental health we have accepted responsibility and accountability. We base our programs on public health practice models: These direct us to focus on segments of our population which are currently exposed to harmful bio-psycho-social factors that increase their risk of becoming mentally ill. We focus on preventing psychosocial problems or their consequences by reducing their population rates: either the incidence of new cases (primary prevention), the prevalence of all existing cases (secondary prevention), and the rates of residual disability (tertiary prevention). We increase our efficiency and effectiveness by organizing our program on the basis of crisis theory which demands that we reach out to people in crisis and provide them with immediate guidance and help to master their current difficulties during the short period when they are open to influence and amenable to change in ways that have long term mental health consequences. We spread our own influence by organizing support groups and we multiply many-fold our impact on the huge problems involved in covering the needs of our population by recruiting the collaboration of other professional caregivers and non-professional helpers. We enhance the mental health component in the daily work of all caregiving agencies and institutions and individual professionals in the community through education and mental health consultation and collaboration. We also reach out to assist non-professional caregiving individuals and organizations, especially those who provide mutual help to fellow sufferers. In our latest work we are currently identifying harmful practices in our caregiving systems that actually harm those people whom we are trying to help. We are in the process of developing methods for reducing this system-generated damage.

An approach to preventive intervention in child psychiatry.

A conceptual model for primary prevention is proposed. Its five elements are (1) Risk Factors that increase the likelihood of (2) eventual Mental Disorder contingent upon (3) intervening psychological stresses that promote Crises, which the individual may master more or less effectively dependent on (4) his current psychological Competence and (5) the powerful influence of Social Supports. The paper summarizes recent preventive intervention efforts and evaluative studies that focus on these elements in seeking to reduce psychiatric disorders in child populations: reduction of risk factors through mental health consultation and collaboration by mental health clinicians with child care workers and administrators; improvement of competence in children t risk by special educational programs with children and their parents that seek to enhance their cognitive and emotional programs with children and their parents that seek to enhance their cognitive and emotional problem-solving and coping skills; crisis intervention for children and their families by anticipatory guidance and preventive intervention; and fostering protective social supports by convening supportive groups for persons in need, and organizing mutual help groups, both of which seek to provide individuals under stress with help with emotional reequilibrium and cognitive guidance to compensate for capacities that are usually temporalily eroded by the upheaval of crisis.

The Future of Primary Prevention

Over the past 40 years, we have published a series of studies of issues involved in preventing psycho-social disorders (Caplan, G., 1955, 1961, 1963, 1964, 1965, 1968, 1970, 1975, 1980, 1986, 1989; Caplan, G. and Caplan, R. B., 1980, 1993, 1994; Caplan, R. B., 1972, 1982), and we have developed key concepts that lead to a model program of primary prevention of certain mental disorders. We predict that over the coming decades our theoretical model will be explored in various countries by investigators who will modify it to conform to local conditions. The following key concepts are likely to be generally acceptable as the basis for organizing programs of primary prevention of psycho-social disorders: Definition of Primary Prevention:We accept the public health definition of primary prevention, namely organized programs for reducing the incidence (rate of new cases) of a disorder in a defined population. We are especially interested in mental disorders that occur in reaction to particular circumstances of adversity. We base ourselves on empirical studies that have identified the hazardous circumstances by demonstrating the populations of individuals and their families exposed to these bio-psycho-social circumstances have higher rates of disorders than are found in similar populations that are not exposed to these hazards. Crisis Theory:We believe that these mental disorders occur as a result of the operation of factors of adversity over a prolonged period. However, the course of pathological development is not smooth but occurs in a series of steps, each of which is preceded by a short period of upset to which we have given the term “crisis.” It appears that these crisis periods are way stations when the trajectory of the mental health of the individuals may change and lead them in the direction of improved mental health or of mental disorder. We have studied the short term developments that characterize such crisis periods, which are not

Organization of preventive psychiatry programs.

Primary prevention seeks to lower the rate of new cases of psychosocial disorder in a high risk population by reducing the impact of pathogenic life stressors, and by increasing psychosocial supports that enable people to master their adversity in healthy ways. The organization of such a program in Jerusalem is described. It seeks to prevent psychosocial disorders in children of divorced parents. The entire population at risk is contacted in order to reach out to the subpopulation who are unable to cope on their own, but who can be helped to master their difficulties by the coordinated efforts of community caregivers.

Mental Health Consultation: Retrospect and Prospect

During my quarter of a century of consultation work, a number of issues have become apparent that have helped clarify what is useful or effective in consultation and what is not. Although it is difficult to evaluate scientifically the effectiveness of various techniques or approaches to mental health consultation, personal contact with thousands of consultants over the years in the United States and other countries has produced a perspective at the Laboratory of Community Psychiatry about those techniques in consultation that have stood the test of time and those that have not. It is useful to review some of these ideas in order to bring them up to date.

Some Comments on “Community Psychiatry and Social Power”

that based upon information about harmful consequences of the ideas and services of community psychiatry. The article by Dr. Leifer does not fall into this category, but is apparently founded on ethical and political misgivings, and upon expectations of doom linked to a fear of governmental encroachment on the rights of individuals. Nevertheless, its arguments must be soberly considered because, even though not based upon fact, they may be useful in helping us clarify and guard against possible difficulties. Dr. Leifers first fear is that com-