Prevention Activities in Professional Psychology

Prevention Activities in Professional Psychology
A Reaction to the Prevention Guidelines
Evelyn Rivera-Mosquera
Department of Mental Health, Columbus, Ohio
E. Thomas Dowd
Kent State University
Marsha Mitchell-Blanks
Cleveland State University
In this reaction article, the authors provide a historical context for prevention activities and their place in psychological practice. They then discuss the prevention guidelines in the Major Contribution authored by S. M. Hage et al. (2007 [this issue]) and
provide their critique. Finally, the authors offer ideas for the future specific applications of these general guidelines and illustrate with a case example.
Hage et al. (2007 [this issue]) are to be commended for their comprehensive, thorough, and thoughtful contribution. They have managed to pull
together the relevant literature regarding prevention efforts and its supporting research, as well as organize this work into a set of aspirational guidelines. The scope of their efforts is truly impressive—a scope that has its
own problems as well as its obvious successes. This response will first provide a brief historical context for prevention activities, and then provide a
general response to these guidelines. We will conclude with ideas of our
own for future applications of these guidelines and prevention in general.
HISTORICAL OVERVIEW OF PREVENTION
Hage et al. (2007) correctly state that prevention activities have historically been an important aspect of the practice of counseling psychology
(p. 497). This is consonant with counseling psychology’s developmental
approach to mental health as compared with the more remedial approach of
clinical psychology and the more case management approach of social work.
Community psychology as a professiponal psychological specialty was
Correspondence concerning this article should be addressed to Evelyn Rivera-Mosquera,
Minority Behavioral Health Group, 1293 Copley Road, Akron, OH 44320; e-mail: rivera-mosquera
@sbcglobal.net.
THE COUNSELING PSYCHOLOGIST, Vol. 35, No. 4, July 2007 586-593
DOI: 10.1177/0011000006296160
© 2007 by the Division of Counseling Psychology
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originally intended to focus more on prevention (and ironically consists primarily of clinical psychologists), but it has never had the impact its
founders envisioned. Although prevention has been an important part of
counseling psychology since its early years, the authors note the paradoxical finding that despite a growing interest in prevention, counseling psychologists’ actual prevention activities are quite limited (Hage et al., 2007,
p. 498). The reasons, we suspect, are largely economic. The field of mental
health, like that of physical health to which status it has consistently aspired,
is now and always has been remedial in orientation. There is little money to
be made in prevention, and during the 1970s and 1980s counseling psychology attempted to play “catch-up” to clinical psychology in obtaining
third-party reimbursements for its services to individuals. Third-party payers in both medicine and psychotherapy typically do not pay for prevention,
although in the long run it is cheaper than remediation. Therefore, advocating for preventive mental/physical health activities is likely to be a hard
sell indeed, especially given the comprehensive, multiple causal factors,
contexts, and domains to which Hage et al. argue we should devote our
efforts (p. 529).
REACTION TO THE GUIDELINES
Overall, the guidelines appear to be well grounded in research, and the
authors do a superb job of building their case for prevention. They demonstrate how the development of these guidelines evolved over time and were
based in sound research as well as systemically discussed by key stakeholders before they were promulgated. This process gives the guidelines
much more credence and potential for acceptance by the entire psychological community. The authors have taken a complex and convoluted area of
practice/research and narrowed it down to guidelines that can help psychologists conceptually organize how they might best begin to engage in
prevention work. While the guidelines are phrased in very cautious language that may make them more politically acceptable in some quarters,
they may also fail to provide forceful guidance for significant change in the
practice of psychology.
The authors’ categorization of the guidelines into four conceptual areas
(practice, research and evaluation, education and training, and social and
political advocacy) is critical because it sets up the conceptual framework
for the areas in which psychologists should be engaging in order to do
prevention (Hage et al., 2007, p. 501). These domains will be discussed in
more detail in the following sections.
Practice
The practice guidelines set the broad overarching guidelines for the
practice of prevention. Guidelines 1–5 describe the basic elements necessary for the practice of prevention. Hage et al. (2007) use this section to call
for psychologists to actively engage in the practice by (a) developing proactive programs that prevent human suffering; (b) basing prevention programs in empirical research; (c) using culturally relevant prevention
practices as well as engaging key stakeholders in all levels of the planning
and implementation process; (d) addressing both individual and social contextual factors; and (e) focusing on both reducing risks and promoting the
strengths of the targeted groups (pp. 501-519). These best practices build upon
the general principle of justice and respect for people’s rights and dignity
(Hage et al., 2007, p. 495). We agree that these should be the core components in the practice of prevention, and are especially pleased that culturally relevant prevention was included as one of the top three guidelines. It
is critical that programs targeting marginalized groups such as ethnic
minorities, the hearing impaired, Appalachian, lesbian/gay/bisexual/transgender, and other cultural groups adapt their programs to meet the cultural
and linguistic needs of the population as well as involve the stakeholders
from these communities at all levels of the planning and implementation
process (Reese & Vera, 2007).
Research and Evaluation
This domain (Guidelines 6–9) was the most difficult for us to “wrap our
heads around” conceptually; in part, this may be because of the sheer complexity of prevention literature. Although the term prevention science was
coined at a National Institute of Mental Health prevention conference in 1991,
it does not appear to have infiltrated the field of psychology to its fullest extent.
Thus, psychologists may not be as familiar with the field as other disciplines
such as public health and social work (Hage et al., 2007, pp. 519-533).
Undoubtedly, the field of psychology needs to actively engage in prevention
efforts that are accurately targeted, efficiently executed, rigorously evaluated
and that focus on the systemic empirical study of risk and protective factors
impacting health and psychological dysfunction (Bloom, 1996).
We liked the authors’ use of the National Institute of Mental Health’s categorization of prevention research that classifies prevention research into three
functions (preintervention epidemiology, preventive intervention [primary,
secondary, and terciary], and prevention service delivery system) and three
levels (biological, psychological, and sociocultural; Hage et al., 2007, p. 520).
This classification matrix can guide prevention researchers toward literature
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they need to examine prior to conducting their studies, as well as help them
identify future directions for research based on their findings (Waldo &
Schwartz, 2003).
We agree wholeheartedly with Guideline 7 that calls for psychologists to
be competent in a variety of cross-disciplinary research methods, both qualitative and quantitative. We want to point out that the potential number of contextual variables and the possible interaction effects that Guideline 8 alludes
to, which may occur in prevention research, are truly mind-boggling.
Guideline 9 (ethical issues) is very important and perhaps deserves a domain
of its own because prevention research can be fraught with ethical dilemmas.
Education and Training
This domain (Guidelines 11 and 12), in our estimation, is one of the
most important sections because psychologists must be educated early in
their training on the how and why to engage in prevention and social justice issues, if they are to do so later in their careers. The guidelines appear
to be geared toward psychologists who have completed their PhD training
rather than current PhD students. We would like to see prevention theory,
research, and practice worked into the curriculum of every psychology student at all levels (BA, MA, PhD, and PsyD) in order to prepare future psychologists in the prevention field, much like social work has done in the
National Association of Social Workers’ policy statement on mental health
(National Association of Social Workers, 2003–2006). This prevention
training should seek to expand psychologists’ repertoire of skills to include
cross-disciplinary training in advocacy, grant writing, program development, and grassroots community involvement needed by psychologists
to perform prevention work (Bluestein, Goodyear, Perry, & Cypers, 2005).
It could also include training on the ecological prevention approach
espoused by the field of social work (Kriste-Ashman, 2000).
SOCIAL AND POLITICAL ADVOCACY
This domain is made up of Guidelines 13–15, which are equally as critical because they call for psychologists to step out of their traditional roles
and engage in political processes in order to improve the world in which
they live. Many decisions affecting physical/mental health care are made on
the basis of political considerations, rather than on scientific or educational
merit. Whether because of insecurity, disinterest, or disdain, it is tempting
for psychologists to leave this work to others, not recognizing that psychologists are the experts in behavior change. The skills psychologists possess
Rivera-Mosquera et al. / PREVENTION GUIDELINES 589
could be applied to any arena in which behavior change is warranted,
including but not limited to the political process as well as the more traditional
areas of schools, health care, violence prevention, and so forth. Psychologists
need to become part of solving these serious social problems facing our
country and world (Albee, 1986). Unfortunately, these are exactly the areas
in which our efforts may be most controversial and, thus, uncomfortable for
our profession.
WHERE DO WE GO FROM HERE?
Although these guidelines provide an overarching set of best practices,
they fall short in that they do not provide the necessary information for
“how to” do this work. These guidelines are broadly stated and therefore
may not provide the direction or structure a psychologist may need in order
to become competent in prevention work. Nevertheless, the guidelines
serve as the springboard for further investigation into how the field of psychology will actually train, cultivate, and develop psychologists who will
engage in proactive, socially just prevention work.
The choice to have a clinical and a counseling psychologist as well as a
social worker respond to this article was purposeful. Clearly, each of us
brings a unique experience and set of skills that are needed to begin to address
the serious societal problems facing our country and our world. We must
work together as professional disciplines, sharing our skill sets, lessons
learned, and methodology to bring about real social change. As eloquently
argued by Hage et al. (2007), prevention work needs to be at the forefront
of a comprehensive mental health agenda (p. 494). We would argue, however,
that the term prevention may need to be expanded in order for this to occur.
Prevention is often juxtaposed with remediation, as if they were dichotomous
constructs. It is our premise that prevention and remediation lie on a continuum,
with group-based interventions occupying a space somewhere in between.
We would argue that prevention should be viewed as one of the tools on
the continuum of therapeutic/treatment services and that the paradigm shift
should consist of the acknowledgement that some of what we are labeling
as prevention could actually be considered therapeutic interventions that
are empirically based, well grounded in theory, and developed from a thorough assessment of need (Nation et al., 2003). For example, the first author
(a clinical psychologist), along with her training director and fellow counseling psychology interns, while on their American Psychological Association
internship at the University of Akron’s Testing and Career Center, developed
a grassroots career and college preparation program called Latinos on the
Path to Higher Education (Rivera-Mosquera, Phillips, Castelano, Martin, &
590 THE COUNSELING PSYCHOLOGIST / July 2007
Mowry, 2007). The goals of the program were to reduce the dropout rate
and improve the college entrance of Latino youths—both serious societal
problems facing the United States. The interns, utilized the first author’s
strong clinical assessment and treatment skills, in addition to the counseling psychology interns strong career development and educational prevention skills, to design and implement the program in a local Hispanic church.
Most of the students recruited for this program could have been treated
individually by any number of disciplines within psychology in an office
environment, and the therapist could have secured third-party payment
based on issues of learning/academic difficulties. The difference was that
insurance covered interventions provided under the individual remedial
model and not under the prevention model. It is our premise that prevention
programs that are grounded on clinical and counseling theories of psychological behavioral change are actually psychotherapeutic in nature and,
thus, should be called psychotherapeutic prevention programs that could be
reimbursed as treatment interventions by third-party payers.
The question then becomes: How do psychotherapeutic prevention programs differ from group therapy? The goal of group therapy is, of course,
for the group process to facilitate behavior change in the individuals in that
group. This is also true for psychotherapeutic prevention. Perhaps the primary difference is the targeted audience. Psychotherapeutic prevention programs are generally larger in scope, may address more issues simultaneously,
and usually reach a larger audience. We propose that well-researched and
well-designed psychotherapeutic prevention programs be viewed as a form of
group therapy and, thus, be considered as psychological treatment interventions. Viewing prevention as a treatment tool opens the doors for innovative
programs to be developed and funded that may not only prevent symptoms
from developing in targeted populations but could also provide a group therapeutic process to change behavior on a larger scale.
There are several skills that psychologists will need to develop in order to
conduct prevention work, particularly when working with difficult-to-reach
communities such as ethnic minorities. First and foremost, psychologists
need to develop a strong personal relationship with the targeted community.
The success of the Latinos on the Path to Higher Education program was
based primarily on the quality of the relationship between the first author and
the community. We recommend that psychologists and other mental health
providers go out into the community and cultivate these essential relationships of trust early on in their training so that the stage will be set for program
development later. Professors and students must venture out of the “ivory
towers” and into the community (churches, mental health clinics, and social
service agencies) to explore and experience the social environment and issues
surrounding them. Ethically, psychologists should not develop prevention
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programs if they have not ever ventured into or experienced firsthand the
community in which they plan to research or work.
In addition to developing a trusting relationship, psychologists will also
need to cultivate a number of other skills such as advocacy, program development, grant writing, cultural competence/cultural humility, social justice, and
qualitative and quantitative evaluation skills—just to name a few (Romano &
Hage, 2000). Unfortunately, these skills are not necessarily taught in traditional psychology programs, not even at the doctoral level. Psychology programs should embrace a cross-disciplinary model and allow students to take
courses in other fields that focus on systemic change and/or advocacy such as
social work, public health, nursing, anthropology, and forth. Training models
such as the one used in the Latinos on the Path to Higher Education program
could be readily taught and integrated into doctoral training programs. The
program benefited all of those involved because the youths and their parents
obtained a set of self-efficacy skills, and the interns had an enriched training
experience that enhanced their skills in the area of community engagement,
outreach, advocacy, and cultural competence. In addition, models of training
such as the two pedagogical strategies (service learning and problem-based
learning), which Hage et al. (2007) discuss in their article, could be quite
effective in teaching psychotherapeutic prevention models in psychology
courses (p. 539). The authors even include a mock syllabus for one of the
strategies, making it easier for instructors to develop a prevention course.
Throughout their article, Hage et al. offer practical advice and exposure to
practical prevention research, which can be quite useful to psychologists
seeking to engage in prevention work.
CONCLUSION
Hage et al. (2007) have provided a valuable service to the field of psychology by providing a set of guidelines that can be used as a springboard for further research and development in the field of prevention. Undoubtedly, an
increased emphasis on prevention will require that the field cultivate psychologists who are community-oriented and committed to social justice as well as
to political advocacy so that psychotherapeutic prevention programs may
flourish. Students of psychology must be exposed to important issues faced by
American society early in their training. Practical experiences with marginalized individuals such as ethnic and cultural minorities, the hearing impaired,
lesbian/gay/bisexual/transgender groups, and others are needed so that students can begin their training on psychotherapeutic prevention development
and programming. Psychology students should first understand and acquiesce
to the social justice model as well as develop an empathic connection with the
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movement of marginalized groups or affected societal segments before they
can effectively develop, plan for, and engage in psychotherapeutic prevention
work. Psychology students also need to volunteer and become active in the targeted group in order to develop a strong relationship of trust with that community. This relationship is the cornerstone for the effective delivery of
prevention work. Psychology departments, as well as placement and internship sites, must make a concerted effort to not only integrate prevention into
their curriculums but also to help students connect to and engage in experiential learning in the targeted communities. In addition, psychologists need to
become active and lobby for the funding of psychotherapeutic prevention programs as treatment interventions. Fortunately, the President’s New Freedom
Commission, which President George W. Bush established in 2002, seems to
be leading the charge for establishing prevention as a viable treatment tool in
the arena of mental health. This prevention-focused paradigm shift may have
finally begun to take root.
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