More mental health Promotion and primary prevention programs have emanated f rom CMHCs than f rom any other source, but the obstacles are formidable.

Mental Health Promotion and the CMHC: Opportunities and 0 bstacles

Peter 2: Adler

It has been proposed that two classes of factors, stressors emanating from the environment and organic or other factors inherent in the individual, increase vulnerability to disability. Conversely, competence previously developed by the individual and support available from the environment decrease vulner- ability. I n a discussion of variables related to mental illness, Swift (1980) calls attention to the simple but powerful formula proposed by Albee to explain the precipitation of mental and emotional disability:

stress + physical vulnerabilities social supports + coping skills + self-esteem

mental illness =

Early efforts at prevention followed the public health analogue of specific causesfor conditions.As a result,they focused heavily on the top halfof the formula by attempting to identify and control the effects of specific environmental stres- sors and specific individual vulnerabilities. Recently, however, as the field of prevention has focused on stressful events that precipitate a variety of disabili- ties (Bloom, 1979; Dohrenwend and Dohrenwend, 1974) attention has shifted to the bottom half of the formula and the development of a capacity within

F. D. Pcrlrnutier (Ed.). Nim Dmrlionrjor Mmlal H d h Snrzzrc~ Mtnfal Hcolrh Promotion and Pnrnory Prcucnlion, nu. 13. San Francisco: Jnssey-Bass. March 1982. 45

46

individuals to withstand the harmful effects of potential stressors. At this time, the two most compelling strategies of mental health promotion and disability prevention are competence building in those who may be exposed to stress and deve- lopment of social supports that will be available to them in their environment at times of stress (Bloom, 1979; Cowen, 1977; Kelly, Snowden, and Munoz, 1977).

As a characteristic of individuals, competence was first described as the motivation to deal actively with one’s environment; since then, it has come to mean those characteristics that have adaptive payoff in significant environ- ments (Sundberg, Snowden, and Reynolds, 1978) and facilitate effective cop- ing with stressor events. The importance of the availability of external sup- ports in determining how well an individual will be able to navigate stressful circumstances has long been a key element in crisis theory (Caplan, 1964), and the development of community support systems has become a significant area of theory and practice (Biegel and Naparstek, 1981; Caplan, 1974; Cap- Ian and Killilea, 1976; Collins and Pancoast, 1976).

It has also become clear in recent years that prevention cannot be viewed solely from an individual perspective; rather, many levels of social organization are involved (Bronfenbrenner, 1979; Rappaport, 1977). In a recent analysis of the concept of competence, Adler (in press) identified four levels of potential preventive interventions: single individuals; social micro- systems, such as families or small work or friendship groups; social mesosys- tems, such as a single agency or organization; and social macrosystems, such as an entire service network, an entire community, or all society. Any compre- hensive review of mental health promotion and disability prevention effort must take all four levels into consideration.

Since the early sixties (Joint Commission on Mental Health and 111- ness, 1961), mental health services have been viewed as a national priority, and a nationwide network of community mental health centers (CMHCs) was developed to institutionalize that priority. More than 500 federally established centers currently exist, and with federal legislation serving as the catalyst, many states have developed additional centers on a model approximating the federal one. T o the extent that mental health services reach most people and most communities without geographic, economic, or sociocultural limitations, C M H C s have been, currently are, and hopefully will continue to play a critical role. If mental health promotion and disability prevention are to be a mean- ingful aspect of the mental health effort, the C M H C must play a critical role.

This chapter has two objectives: first, to review the opportunities for preventive activity by CMHCs- that is, the opportunities to implement the two major strategies of competence building and social support development at the various levels of social organization - and, second, to examine the obstacles to preventive activities by CMHCs .

47 CMHC Opportunities for Health Promotion

Competence Building. Community mental health centers contribute to the development of competence at all levels of social organization. At the indi- vidual level, the primary strategies of competence development are those of mental health education. In early efforts, C M H C s reached out to a n undiffer- entiated general public with wide-ranging information about human develop- ment and behavior, mental disability and its management, and service avail- ability (Davis, 1965). In recent years, however, many C M H C s virtually abandoned general education in favor of very sharply focused education aimed at a wide variety of specific target populations. Programs have been developed to promote competence in common social roles, such as that of parent, woman, or member of a couple; to promote specific interpersonal skills, such as assertiveness, communication, conflict resolution, and social problem solving; to help individuals to navigate specific developmental stages and transitions, such as starting school, entering adolescence, and experienc- ing parenthood, retirement, and old age; and to help people cope with stressful circumstances, such as divorce and separation, single parenthood or the “blended family,” widowhood, chronic illness, unemployment, and the illness, disability, aging, or death of family members; potentially disabling affects, such as depression, fear, and anger; and habit disorders, such as bedwetting, insomnia, and smoking. The variety is almost infinite.

From the competency-building point of view, the common element all these programs is that they provide a cognitive perspective on the target issue to show that it has common analyzable elements, including predictable problems and challenges, which can be met by specific understandings and skills. The programs commonly offer the opportunity to learn and practice these skills under supervised and supportive conditions. Individuals exposed to such mental health education are thus given a sense of growing mastery over circumstances that may have seemed overwhelming and unmanageable.

This writer does not wish to imply that C M H C s alone have developed this variety of focused individual competence-building programs. Growth cen- ters, universities, private providers, and popularizing professional writers have been very active in these areas. CMHCs have, however, played a signifi- cant part in the widespread diffusion of these opportunities, particularly to individuals who for geographic, economic, or sociocultural reasons might not otherwise have had them.

At the microsystem level, building competence in families through mental health education has been another major concern of CMHCs . Family issues are commonly targeted for mental health education efforts like those described. Much work has been done both with specific dyads, such as parent- child or husband-wife, and with whole-family units to teach relationship skills

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and to help individual members to cope with each other’s development. Pro- grams have also been developed to teach poor families and others who may not naturally develop such skills how to locate and utilize resources available in their community and how to establish satisfactory relationships with lay care- taker institutions in their community.

At the organizational level, CMHCs have been eager to promote men- tal health-related competence in organizations devoted to education, health, welfare, criminal justice, religion, and other human services. Beginning with client-centered activities, such as case consultation, facilitation of appropriate referrals, and coordination around mutual clients, CMHCs branched out to a much wider array of increasingly organization-centered activities. CMHCs have long been active in providing staff of such agencies with training and consultation to improve their role performance competence. They also have offered program consultation to organizations to help them deal with their own programmatic concerns. Finally, some CMHCs have provided other human service organizations with organization development techniques and processes to improve communications, decision making, and organizational morale; handle personnel problems; and generate crucial information about organizational effectiveness. Traditionally, organizational consultation has not been available to human service agencies, and CMHCs have capitalized on relationships built through narrowly defined client-centered mental health consultation and training to introduce them.

Recently, some CMHCs have taken part in employee assistance pro- grams that help industry to deal constructively with employees who have men- tal health and alcohol abuse problems. Such programs serve a secondary pre- vention function by bringing clinical services into the workplace at a n earlier time and for more acceptable reasons than might otherwise be the case. Indi- rectly, they can serve to sensitize key industrial personnel to a wide range of mental health-related issues, and they can become the medium for introducing such primary prevention programs as stress management. In geographical areas where traditional management consultation resources are not available, CMHC personnel have become a major human relations resource for local business organizations.

At the community level, CMHCs have been active in coordination. That is, they bring agencies with common interests together in order to coor- dinate their activities. Where interagency councils or special task forces do not exist, CMHCs have been instrumental in creating them. While these linkages typically begin with an agenda of individual case-related coordination prob- lems, they often progress through identification of gaps in community service to plans for joint program development and effective utilization of the total community pool of human service resources. For example, councils of com- munity children and youth agencies have been formed to develop a library of prevention and parent training materials and resources for all to draw on, and

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such councils have jointly promoted pareht education workshops. C M H C personnel have often worked closely with citizen groups to identify areas of unmet needs and to develop programs or generate resources that deal with these gaps in community service capacities.

Developing Social Support Networks. Community mental health cen- ters have also helped to develop support systems for both individuals and orga- nizations faced with stress or crisis.

At the individual level, the many self-help and mutual support organi- zations that have proliferated in recent years (Silverman, 1978), such as Alco- holics Anonymous, Parents Without Partners, families of chronic mental patients, and so forth, have been a significant source of support in specific types of stressful circumstances. Many C M H C s have initiated, assisted, or collaborated with chapters of such organizations. C M H C s have also contrib- uted to the crisis-oriented hot lines that now exist in almost every community. Although these hot lines were developed to deal primarily with suicide or drug-related crises, they are used by individuals who do not have or who can- not use the support of family, friends, or formal caretaker organizations for a variety of concerns. While such hot lines are not always a formal part of C M H C services, C M H C s have helped to start them, selected and trained vol- unteers to staff them, provided consultation and professional back-up, and served as a referral resource.

Another significant mechanism has resulted from mental health educa- tion groups described earlier. Besides building competence, these groups have allowed people who are facing similar stressful circumstances to develop mutual support systems on their own. Thus, C M H C s have been instrumental in the creation of peer support groups for individuals facing stress, and they ,

have started support groups. By attending to people’s need for focused support at certain times of life and under certain circumstances and by avoiding the stigma of psychopathology, C M H C s have vastly increased the availability and accceptability of such support.

At the microsystem level, C M H C programs have been established to develop supportive relationships with families who are unconnected to other social supports; for example, with families involved in child abuse and neglect. The goal of such programs is to attach these families to program staff and then to transfer this attachment to other available supports, such as neighbors and service provider agencies .

Some C M H C programs have attempted to develop neighborhood mutual support systems, especially for specific populations, such as young mothers without extended families or established peer groups, and newcomers intransient neighborhoods and rapidly changing communities. The encourage- ment of “natural helping systems” has also been used by C M H C s to enhance the supportive capacity of neighborhoods (Vallance and DAugelli, 1981).

At the organizational level, C M C H s have worked to expand the sup-

portive capacity of existing service provider agencies. By sensitizing and train- ing clergy, teachers, medical and welfare personnel, and other service pro- vider staff to recognize individuals under stress and to manage stress-related behavior and feelings, they have helped these caretaker personnel to become an ever-available support resource for the many individuals whom they encounter.

CMHCs have also worked to increase the support available to service provider organizations. By being available as consultants and by providing back-up or supplementary service as needed, CMHCs have enabled such organizations to tackle problems that might otherwise prove overwhelming. For example, housing projects and nursing homes can serve ex-mental hos- pital patients if they receive consultation and reliable back-up from a CMHC. Thanks to their CMHC supports, many service provider organizations have been able to deal with a vastly expanded range of problem situations. Individ- uals who otherwise would have overtaxed the resources of the caretaker orga- nization and been exiled to more restrictive settings have been retained in the caretaker network. Such strengthening of the mental health-related capacity of non-mental health service providers must be viewed as a significant primary prevention achievement.

Obstacles to CMHC Health Promotion Activity

From the preceding discussion, it is clear that the opportunities for CMHC involvement in activities that promote mental health and prevent mental disability are many and varied. Yet, it is abundantly clear from annual reports published by the National Institute of Mental Health that the actual record of the CMHCs is not impressive. While many centers have developed a rich array of preventive services, many others have not. Why is the gap between opportunity and accomplishment so great?

There are three types of obstacles to the implementation of preventive services in CMHCs: conceptual and philosophic obstacles, structural obsta- cles, and financial obstacles.

Conceptual and Philosophic Obstacles. Significant conceptual and phil- osophic obstacles are inherent in CMHCs from their origin. One precipitating factor was disenchantment with the practice of treating major mental illnesses in large and isolated institutional settings. CMHCs were to allow such treat- ment to take place in smaller, community-based settings. Another precipitant was distress that services for the mentally and emotionally disturbed were not available in many parts of the country, particularly in areas where such distur- bance was highest. CMHCs were to be a mechanism for overcoming geo- graphic, economic, and sociocultural barriers and making treatment available to all in need.

However, certain other factors were favorable to prevention. There was concern that much of the distress and dysfunction in the general popula- tion was due not to major mental illness but to the stresses of normal living;

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there was concern about other social systems that were deeply involved in detection and management of emotional problems; and finally, the concern that C M H C s were to relate to prevention and health promotion as well as treat- ment was an articulated position but a minority one.

Nevertheless, from their origins, C M H C s have been governed by con- ceptual and philosophic principles that are inimical to preventive work. The first is the belief that their target is the mentally ill. I n another context, Adler (1972) discussed two types of caretaker systems: common caretaker systems, such as schools, general physicians and hospitals, and churches, which are designed to meet needs so universal that almost all individuals will come into significant contact with them, and special caretaker systems, such as the crim- inal justice, welfare, and special education systems, which are designed to meet the needs of a limited but socially significant population. The ideology of mental health promotion and disability prevention requires that C M H C s be viewed as common caretakers, but the prevailing ideology of C M H C s holds that they are special caretakers, who cater to the mentally ill.

With time, the target populations of C M H C s extended so far beyond the indisputably mentally ill that C M H C s have been accused of neglecting the severely and chronically mentally ill (President’s Commission on Mental Health, 1978; Rothman, 1980). However, this extension has resulted from expansion of the scope of psychiatric diagnosis to cover most distresses and dysfunctions of normal living. Thus, rather than acknowledging that their tar- get should be both the “normally” problematic as well as the pathological, C M C H s have maintained their conceptual self-image. Their target is mental illness and anything that does not utilize a mental illness frame of reference is suspect. Since much preventive work is incompatible with that framework, there is a strong tendency in C M H C s to reject prevention.

The second governing principle that is inimical to preventive work is the belief that if the target is mental illness, the method of prevention of the C M H C is “treatment,” and the intervening agent is a “therapist.” Any method that is not one of the relatively few acceptable therapies tends to be suspect. Suspect methods include the well-developed range of interventions described as mental health education (National Committee for Mental Health Educa- tion, 1977), the activities Gf self-help and mutual support groups (Silverman, 1978), interventions that encourage social and political activism as a way of promoting external change (Rappaport, 198l), and methods that stress social and vocational skills development through supervised practice. All these meth- ods, which are central in the mental health promotion and disability preven- tion repertory, are acceptable and rather widely used in C M H C s under the guise of “therapy” provided by “therapists,” but when the guise of therapy is removed, they are viewed as inappropriate or ancillary.

T h e third governing principle that is inimical to preventive work is the belief that C M H C interventions occur at the individual and family levels. When the C M H C deals with other systems, it is primarily for the purpose of

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case consultation or referral facilitation for individuals who are current, for- mer, or potential clients. When prevention practitioners express interest in the working of the systems themselves, this interest, i f supported or tolerated, is not granted equal importance with individual-level intervention.

Thus, when fiscal constraints require service cutbacks, reduction of consultation and training services to organizations that cannot pay a fee is acceptable even in centers where there is a long-standing commitment to pre- vention and systems-level intervention. By contrast, potential reductions in treatment services for individuals, even for individuals who are not in severe crisis, meet with far greater resistance from staff, who are oriented to individ- ual-level concerns.

CMHCs have accepted these three governing principles without ques- tion, because they are the conceptual and philosophical principles with which the leadership of CMHCs was professionally socialized. The first CMHCs were directed by psychiatrists, who had been trained to focus on mental illness and active individual treatment of the severely disturbed. While the leadership of CMHCs has shifted to nonmedical professionals, many of them, too, have been trained and socialized in the model of individual psychopathology and its treatment (Sarason, 198 1).

If CMHCs are to stand in the fore of mental health promotion and dis- ability prevention efforts, they must accept a conceptual and philosophic base that goes beyond the traditional clinical intervention model and recognizes promotion of competence and development of social support networks as legit- imate goals, and that values systematic intervention at the organizational and community levels.

Structural Obstacles. While the legislatively mandated structure of the CMHCs already provides support for mental health promotion and disability prevention, it also creates some structural obstacles to prevention efforts. Of the five services mandated in the original act, only one, consultation and edu- cation (C&E), is not specifically a treatment service. Thus, only C&E has not limited its focus to psychiatrically diagnosable populations or its target to the individual and family levels of intervention. It is worth noting that these limi- tations are not inherent in the CMHC structure: Emergency units could work to develop community support networks for emergency care and to enhance the crisis intervention capacity of other community systems, and outpatient and partial hospitalization units could develop extensive programs of mental health education and living skills development for populations that are not generally viewed as pathologically impaired, but they rarely do. Where such activities have occurred, they have almost always been triggered by the C&E unit.

Not all C&E activities have been oriented toward prevention. In the early days, the most common C&E activities were providing information on CMHC services to the public, offering client-centered case consultation with very little spread effect, facilitating referrals from caretakers, and developing

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in-service training for clinical staff. With maturity, however, many C&E units have abandoned their original role as handmaidens of clinical services and moved to develop independent prevention-oriented services (Adler, 1972, 1977). In fact, C M H C consultation and education units have been the most prominent mechanism for development and dissemination of mental health promotion and disability prevention programs in the mental health move- ment. To the extent that C M H C s have explored the opportunities for preven- tion described earlier, it has largely been a function of their C&E units.

And yet, the C&E service has not been strongly accepted. Of the man- dated services, i t is generally the smallest, most peripheral, and least ade- quately staffed in a center. The total national C&E effort has been a pitifully tiny percentage of the total C M H C effort. Indeed, its existence has been due almost exclusively to federal presence. If federal legislation had not mandated C&E, few centers would have developed it, and if federal funds had not sup- ported C&E, few centers would have sustained it. State mental health pro- grams have often been indifferent and sometimes overtly hostile to the C&E and prevention aspects of comprehensive community mental health, a prob- lem noted by the author in Pennsylvania and Massachusetts and shared by other C M H C executives across the nation. In recent years, even the federal support for C&E has diminished. T h e Mental Health Systems Act of 1980 contained no support specifically for C&E, which was included with adminis- tration, outreach, and other “non-revenue-generating services.” Faced with this competition, it would not have survived except in centers where it was already firmly established. Under a state-administered and funded structure, the chances for survival of a nationwide network of C&E units are few in- deed. Without the federal mandate for C&E, we can predict that the already limited preventive thrust of C M H C s will diminish even more.

For preventive and promotive opportunities to be grasped by CMHCs , a structure with that specific mandate is necessary. I t has been demonstrated repeatedly that, without a separate structure, preventive activities will suffer from the pressure to do individual clinical work, even in centers that are philo- sophically hospitable to prevention ideology.

Financial Obstacles. As C M H C s become increasingly concerned about fiscal survival, there are overwhelming financial disincentives to the develop- ment and maintenance of preventive programs. Few mental health services are paid for directly by those who use them. Treatment services are primarily supported by broadly based, employer-financed health insurance programs that guarantee reimbursement to the provider when the subscriber has a legiti- mate need for services. With only minor exceptions, preventive service is not covered by such health insurance, and there is no equivalent form of guaran- teed reimbursement. Except for the federal monies for C&E, prevention has not been funded.

While preventive service has not always been a total drain on C M H C finances (Adler, 1976), practitioners have had to muster considerable ingenu-

i ty to maintain a semblance of solvency. C&E units of C M H C s have devel- oped significant fee-for-service capacity. They have developed contracts for training, consultation, and preventively oriented service with a variety of community agencies and organizations; they have marketed a variety of men- tal health education services to individuals; and they have mounted a few major preventive programs through grants from various non-mental health funding sources. However, the conflict between the original C&E drive to pro- vide service according to community nee,d and the pressure to maintain sol- vency is mounting. Increasingly, service follows dollars of the organizations and individuals that are most accepting of preventive service and most able to pay for it.

Since individuals and organizations are more willing to pay to meet short-term needs, such as relief from pain and dysfunction or promotion of specific competencies, programs aiming at more generalized system effects receive lower priority. Kelly, Snowden, and Munoz (1977) affirm that pri- mary prevention requires a commitment to long-term intervention in the environment. For fiscal reasons, such long-term intervention is becoming increasingly difficult to sustain. At the individual level, the needs of the “chronic” client have been recognized (President’s Commission on Mental Health, 1978), and both federal and state governments have provided mechanisms for financing such care through Medicaid and program monies specifically for that population. No similar mechanism exists for providing ser- vice to organizations and communities that have a chronic or long-lasting need. Thus, for fiscal reasons, services at the organizational and community level are threatened for those most in need, least likely to seek aid, and least able to pay for it.

Influenced by the pressure to perform reimbursable services, C M H C prevention units are tending to focus on individual-level interventions and on organization- and community-level interventions that have a direct and immediate impact on individuals. Interventions meant to have an impact on the system itself, particularly those aiming at long-term effect, are not as read- ily reimbursable and hence more likely to be neglected. If C M H C s are to real- ize their potential for preventive service, a mechanism for funding prevention that does not rely on the affluence and commitment of service recipients is essential.

Summary

This chapter has reviewed the rich and various contributions of C M H C s to the promotion of mental health and the prevention of disability by competence building and social support development. Thanks to their num- ber, nationwide spread, and frequent communication, C M H C s have proved to be the medium for widespread diffusion of preventive programming. Nevertheless, compared with the opportunities, the actual programming has

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been relatively limited. T h i s chapter has reviewed the barriers to preventive programming by CMHCs, including obstacles inherent in the conceptual a n d philosophic backgrounds of CMHC leaders, obstacles inherent in the organi- zational structure of the CMHC, and obstacles related to the funding of men- tal health services. Whether preventive programming flourishes or a t least sur- vives in CMHCs will depend largely on whether these obstacles can be over- come.

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Peter 7: Adler, who has a Ph. D. in psychology, is director o f the Herbert Lipton Community Mental Health Center in Fitchburg, Massachusetts, where preventive programming is alive and well. Previousb, he served as director of consultation and education o f the South Hills Health System Community Mental Health Center in Pittsburgh, Pennsylvania, where much o f the information

f o r this chapter was gathered.