clinical psychology

1. INTRODUCTION ANDINTRODUCTION AND
HISTORY OF COMMUNITYHISTORY OF COMMUNITY
PSYCHOLOGYPSYCHOLOGY
Lecture 37Lecture 37

2.  Many approaches of therapy basically focus on theMany approaches of therapy basically focus on the
individual who has already developed psychologicalindividual who has already developed psychological
problems.problems.
 At the theoretical level, therapists have long acceptedAt the theoretical level, therapists have long accepted
the idea that all behavior (pathological or otherwise) isthe 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, theYet in their day-to-day therapeutic efforts, the
emphasis of clinicians was generally on one-to-oneemphasis of clinicians was generally on one-to-one
therapy of some sort.therapy of some sort.
 A relatively newer approach, communityA relatively newer approach, community psychology,psychology,
shows great promise for addressing mental healthshows great promise for addressing mental health
problems.problems.

3. PRINCIPLES OF COMMUNITY PSYCHOLOGYPRINCIPLES OF COMMUNITY PSYCHOLOGY
 What "causes" problems?What "causes" problems?
Problems develop due to an interaction over timeProblems 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 particularProblems can be defined at many levels, but particular
emphasis is placed on analysis at the community andemphasis 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.

4.  How are services planned?How are services planned?
The needs and risks in a community areThe needs and risks in a community are
proactively assessed.proactively assessed.
 What is the emphasis in communityWhat is the emphasis in community
psychology interventions?psychology interventions?
Prevention of problems rather than treatment ofPrevention 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.

5. PERSPECTIVES ANDPERSPECTIVES AND
HISTORYHISTORY

6. THE COMMUNITY PSYCHOLOGYTHE COMMUNITY PSYCHOLOGY
PERSPECTIVEPERSPECTIVE
 Community psychology has been described asCommunity psychology has been described as
an approach to mental health that emphasizesan approach to mental health that emphasizes
the role of environmental forces in creating andthe role of environmental forces in creating and
alleviating problems (Zax & Specter, 1974).alleviating problems (Zax & Specter, 1974).
 The major aspects of this perspective areThe major aspects of this perspective are
cultural relativity, diversity, and ecology (the fitcultural relativity, diversity, and ecology (the fit
between persons and the environment).between persons and the environment).

7.  First, community psychologists should not beFirst, community psychologists should not be
concerned exclusively with inadequate environmentsconcerned exclusively with inadequate environments
or persons. Rather, they should direct their attention toor persons. Rather, they should direct their attention to
the fit between environments and persons-a fit thatthe 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 theSecond, the focus is on action directed toward the
competencies of persons and environments rathercompetencies of persons and environments rather
than their deficits.than their deficits.
 Third, the community psychologist is likely to believeThird, the community psychologist is likely to believe
that differences among people and communities arethat differences among people and communities are
desirable.desirable.
 The community psychologist is not identified with aThe community psychologist is not identified with a
single social norm or value, but instead looks to thesingle social norm or value, but instead looks to the
promotion of diversity.promotion of diversity.

8.  In Rappaport's (1977) view, three sets of concernsIn 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,,
andand sciencescience..
In many ways, these are antagonistic elements.In many ways, these are antagonistic elements.
 Political activists are often impatient and ridicule morePolitical activists are often impatient and ridicule more
traditional clinicians as bringing society too little tootraditional clinicians as bringing society too little too
late.late.
 Clinicians, in turn, often criticize activists asClinicians, in turn, often criticize activists as
unprofessional and overly concerned with hawkingunprofessional 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 andThe scientists, in turn are appalled by activists and
clinicians alike; both are seen as shockingly willing toclinicians alike; both are seen as shockingly willing to
act on the basis of invalidated hunches and lack ofact on the basis of invalidated hunches and lack of
data or, worst of all, without a viable theory to guidedata or, worst of all, without a viable theory to guide
them.them.

9.  In fact, true societal changes vis-a-vis mentalIn fact, true societal changes vis-a-vis mental
health will require the cooperation of each ofhealth 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 individualit 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 communityFurther, individuals and community
organizations are encouraged to take controlorganizations are encouraged to take control
of and master their own problems (viaof and master their own problems (via
empowerment) so that traditional professionalempowerment) so that traditional professional
intervention will not be necessary.intervention will not be necessary.

10. HISTORY AND CATALYZING EVENTSHISTORY AND CATALYZING EVENTS
 In 1955, the U.S. Congress passed legislation creatingIn 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 aIts report encouraged the development of a
community mental health concept and urged acommunity 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 andBased on the premise that psychological distress and
the development of mental disorders were influencedthe development of mental disorders were influenced
by adverse environmental conditions, Presidentby adverse environmental conditions, President
Kennedy called for a "bold new approach" toKennedy called for a "bold new approach" to preventprevent
mental disorder.mental disorder.
 Their aims were to promote the early detection ofTheir aims were to promote the early detection of
mental health problems, treat acute disorders, andmental health problems, treat acute disorders, and
establish comprehensive delivery systems of servicesestablish comprehensive delivery systems of services
that would prevent the "warehousing" of chronicthat would prevent the "warehousing" of chronic
patients in mental hospitals .patients in mental hospitals .

11.  The American Psychological Association endorsed theThe American Psychological Association endorsed the
desirability of community residents' participating in alldesirability of community residents' participating in all
these decisions.these decisions.
 A conference held in 1965 is regarded by many as theA 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 ofShortly after this conference, the Division of
Community Psychology was organized within theCommunity Psychology was organized within the
American Psychological Association.American Psychological Association.
 SoonSoon The Community Mental Health JournalThe Community Mental Health Journal andand
thethe American Journal of Community PsychologyAmerican Journal of Community Psychology
began publication.began publication.
 Courses in community psychology and programs ofCourses in community psychology and programs of
graduate training have been established, and theregraduate training have been established, and there
are even books now on the history of communityare even books now on the history of community
mental health.mental health.

12. Issues or concerns that have catalyzed theIssues or concerns that have catalyzed the
emergence of community psychology:emergence of community psychology:
TREATMENT FACILITIESTREATMENT FACILITIES
 Although the mental hospital population in the UnitedAlthough 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 forsocially oriented clinicians continued to press for
alternatives to the costly, inefficient, and often largelyalternatives to the costly, inefficient, and often largely
custodial hospitalization of patients. Three factorscustodial hospitalization of patients. Three factors
combined at about this time to markedly reduce thecombined 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.

13.  A problem with many mental hospitals was their lackA problem with many mental hospitals was their lack
of trained therapists.of trained therapists.
 Regarded by lay-persons as a realistic means forRegarded by lay-persons as a realistic means for
solving difficult emotional problems, hospitalizationsolving difficult emotional problems, hospitalization
itself often created nearly as many problems as ititself often created nearly as many problems as it
alleviated.alleviated.
 Over the years, mental hospitals (particularly thoseOver the years, mental hospitals (particularly those
run by the states) too often became ware-houses orrun by the states) too often became ware-houses or
custodial bins.custodial bins.
 Care was often marginal and sometimes downrightCare was often marginal and sometimes downright
inhumane. Professional staff was severely lacking ininhumane. Professional staff was severely lacking in
numbers and sometimes in quality.numbers and sometimes in quality.
 Indeed, many still argue (and have demonstratedIndeed, many still argue (and have demonstrated
empirically) that hospitalization is not an especiallyempirically) that hospitalization is not an especially
effective treatment strategy.effective treatment strategy.

14. PERSONNEL SHORTAGEPERSONNEL SHORTAGE
 Even as more clinical psychologists and psychiatristsEven as more clinical psychologists and psychiatrists
were trained; demands for their services outstrippedwere trained; demands for their services outstripped
their increase in numbers.their increase in numbers.
 Many of the newcomers were entering privateMany of the newcomers were entering private
practice, and others were being diverted into teachingpractice, and others were being diverted into teaching
or research.or research.
 A number of trends all seemed to coalesce to produceA 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 imperativeTo grapple with these shortages, it became imperative
that new sources of personnel be sought, that morethat new sources of personnel be sought, that more
effective use be made of professional time, and thateffective use be made of professional time, and that
new models of coping with human problems benew models of coping with human problems be
developed.developed.
 Albee (1959, 1968) predicted that it would be literallyAlbee (1959, 1968) predicted that it would be literally
impossible to train enough mental health professionalsimpossible to train enough mental health professionals
to meet existing and future needs, and recommendedto meet existing and future needs, and recommended
that prevention be pursued as a strategy.that prevention be pursued as a strategy.

15. QUESTIONS ABOUT PSYCHOTHERAPYQUESTIONS ABOUT PSYCHOTHERAPY
 In the 1950s, people began to question not just theIn 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 psychicSome began to wonder if it was not just intra psychic
factors that created problems, but the interactionfactors that created problems, but the interaction
between person and society.between person and society.
 At the same time, economic factors were pushingAt the same time, economic factors were pushing
therapy beyond the reach of the poor andtherapy beyond the reach of the poor and
disadvantaged.disadvantaged.
 The relationship between mental illness and socialThe 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 betweenNow, it seemed, there was also a relationship between
social class and the availability of psychotherapy.social class and the availability of psychotherapy.

16. MEDICAL MODELS AND ROLESMEDICAL MODELS AND ROLES
 We know the widespread role of the medicalWe 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 whichThe 1960s ushered in a climate in which
institutional prerogatives and traditionalistinstitutional prerogatives and traditionalist
beliefs came under attack.beliefs came under attack.
 That climate produced listeners who were moreThat climate produced listeners who were more
willing to accept attacks on traditional viewswilling to accept attacks on traditional views
about mental illness.about mental illness.
 All of this contributed to an increased tendencyAll of this contributed to an increased tendency
to look for the social-community antecedents ofto look for the social-community antecedents of
problems in lining, rather than internalproblems in lining, rather than internal
biological or psychological etiological agents.biological or psychological etiological agents.

17.  The general activism of the 1960s also catalyzed theThe general activism of the 1960s also catalyzed the
long-standing discontent of many clinicians with a rolelong-standing discontent of many clinicians with a role
that relegated them to waiting passively for society'sthat 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 healthWould not an activist role that took mental health
services to the people be more consonant with aservices to the people be more consonant with a
social-community model? If so, such a role would alsosocial-community model? If so, such a role would also
provide a measure of autonomy from the dominanceprovide 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 psychologyAfter 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 medicalSuch behavior is hardly a rejection of the medical
model or an acceptance of the social-communitymodel or an acceptance of the social-community
approach.approach.

18. THE ENVIRONMENTTHE ENVIRONMENT
 Another force that helped shape the communityAnother force that helped shape the community
psychology movement was a greater awareness of thepsychology movement was a greater awareness of the
importance of social and environmental factors inimportance of social and environmental factors in
determining people's behavior and problems.determining people's behavior and problems.
 Poverty, discrimination, pollution, and crowding werePoverty, 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 thesebeing required that psychologists pay attention to these
factors that they go beyond a reflexive consideration offactors that they go beyond a reflexive consideration of
the early childhood determinants of people'sthe early childhood determinants of people's
personalities.personalities.
 The emotional problems of large numbers of peopleThe emotional problems of large numbers of people
may be influenced by poverty, unemployment, jobmay be influenced by poverty, unemployment, job
discrimination, racism, diminished educationaldiscrimination, racism, diminished educational
opportunities, sexism, and other social factors.opportunities, sexism, and other social factors.
 Such influences are hardly proposed by therapies thatSuch influences are hardly proposed by therapies that
seek answers in internal dynamics.seek answers in internal dynamics.

19. THE CONCEPT OF COMMUNITYTHE CONCEPT OF COMMUNITY
MENTAL HEALTHMENTAL HEALTH
 The 1955 Joint Commission on Mental HealthThe 1955 Joint Commission on Mental Health
and Illness made several basicand Illness made several basic
recommendations that set the tone for therecommendations that set the tone for the
subsequent development of communitysubsequent development of community
psychology-a tone that still resonates in accordpsychology-a tone that still resonates in accord
with political and financial pressures across thewith political and financial pressures across the
nation.nation.
 These recommendations wereThese 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 healthmental health

20. (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 ostracismillness can stem from social factors (such as ostracism
and isolation); andand 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 theIn 1963, federal funds were provided to help in the
construction and staffing of comprehensive mentalconstruction and staffing of comprehensive mental
health centers.health centers.
To qualify for these funds,To qualify for these funds, aa community mental healthcommunity 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);

21. (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 serviceprofessional, educational, and service
personnel in the community.personnel in the community.
Beyond these required services, it was hopedBeyond these required services, it was hoped
that the mental health centers would alsothat the mental health centers would also
provideprovide
(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.

22. THE CONCEPT OF PREVENTIONTHE CONCEPT OF PREVENTION
 The idea ofThe idea of preventionprevention is the guiding principle that hasis the guiding principle that has
long been at the heart of public health programs in thelong 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 effectivepreventive activities will be more efficient and effective
than individual treatment administered after the onsetthan individual treatment administered after the onset
of diseases or problems .of diseases or problems .
 That such approaches can work is graphicallyThat 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, FourteenFourteen OuncesOunces 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 developedPrevention programs for adults have been developed
and implemented as well.and implemented as well.

23. PRIMARY PREVENTIONPRIMARY PREVENTION
 This type of prevention represents the most radical departureThis type of prevention represents the most radical departure
from the traditionalfrom the traditional waysways of coping with mental health problems.of coping with mental health problems.
The essence of the notion-ofThe essence of the notion-of primary prevention can beprimary prevention can be seen inseen in
Caplan's (1964) emphasis on "counteracting harmfulCaplan's (1964) emphasis on "counteracting harmful
circumstances before they have had a chance to producecircumstances before they have had a chance to produce
illness".illness".
 Albee (1986) points out, however, that the complexity of humanAlbee (1986) points out, however, that the complexity of human
problems often requires preventive strategies that depend onproblems 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 toSome examples of primary prevention include programs to
reduce job discrimination, enhance school curricula, improvereduce job discrimination, enhance school curricula, improve
housing, teach parenting skills, and provide help to childrenhousing, teach parenting skills, and provide help to children
from single-parent homes.from single-parent homes.
 Also grouped under this heading are genetic counseling, HeadAlso grouped under this heading are genetic counseling, Head
Start, prenatal care for disadvantaged women, Meals onStart, prenatal care for disadvantaged women, Meals on
Wheels, and school lunch programs.Wheels, and school lunch programs.

24. SECONDARY PREVENTIONSECONDARY PREVENTION
 This involves programs that promote the earlyThis involves programs that promote the early
identification of mental health problems and promptidentification of mental health problems and prompt
treatment of problems at an early stage so that mentaltreatment of problems at an early stage so that mental
disorders do not develop.disorders do not develop.
 The basic idea ofThe basic idea of secondary preventionsecondary prevention is to attackis to attack
problems while they are still manageable, before theyproblems while they are still manageable, before they
become resistant to intervention.become resistant to intervention.
 Often this approach suggests the screening of largeOften this approach suggests the screening of large
numbers of people. Such screening may be carried out bynumbers 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 appropriateEarly assessment is followed, of course, by appropriate
referrals.referrals.
 An example of secondary prevention is the early detectionAn example of secondary prevention is the early detection
and treatment of those individuals with potentiallyand treatment of those individuals with potentially
damaging drinking problemsdamaging drinking problems
 A further example is the Rochester Primary Mental HealthA further example is the Rochester Primary Mental Health
Project pioneered by Emory Cowen.Project pioneered by Emory Cowen.

25. TERTIARY PREVENTIONTERTIARY PREVENTION
 The goal ofThe goal of tertiary prevention istertiary prevention is to reduce the durationto reduce the duration
and the negative effects of mental disorders after theirand the negative effects of mental disorders after their
occurrence.occurrence.
 Its aim is not to reduce the rate of new cases of mentalIts aim is not to reduce the rate of new cases of mental
disorder, but to lessen the effects of mental disorder oncedisorder, 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, andThe methods used may be counseling, job training, and
the like.the like.
 Although their language is a bit different, tertiaryAlthough their language is a bit different, tertiary
preventive programs are not very different from personpreventive 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 ofHowever, it is important to remember that all forms of
prevention are distinguished by their attempts to reduceprevention are distinguished by their attempts to reduce
the rates of, or problems associated with, mental disorderthe rates of, or problems associated with, mental disorder
on a community-wide (or population-wide) basis.on a community-wide (or population-wide) basis.