Kamis, 02 Januari 2014

Ecology, Prevention and Promotion

Nelson, G., & Prilleltensky, I. (2005). Community psychology: In pursuit of liberation and well-being. Palgrave Macmillan
Ecology, Prevention and Promotion

Warm-up Exercise
1. Reflecting on your childhood, think of some risk factors or stressful situations that threatened your sense of wellbeing.
2. What were some of the resources or protective factors (personal qualities, relationships, situations) that helped you deal with those stressful situations?
In this chapter, you will learn the definition, rationale, value-base, action implications and limitations of two of the key principles on which community psychology (CP) has been built:
■ the ecological metaphor
■ prevention and promotion.
We elaborate on each of these concepts that we briefly introduced in Chapter 2.
Macro-system (for example social norms, policies)
Figure 4.1  Nested ecological levels of analysis
Source: Prilleltensky, Nelson & Peirson (2001a) 

The Ecological Metaphor
What Is the Ecological Metaphor?
The ecological metaphor can be defined as the interaction between individuals and the multiple social systems in which they are embedded. Community psychologist Jim Kelly introduced four principles of the ecological perspective: interdependence, cycling of resources, adaptation and succession (Kelly,1966; Trickett, Kelly & Todd, 1972). To illustrate the usefulness of these principles, we consider the example of the deinstitutionalization of people with serious mental health problems (a problem that Bret Kloos treats in more depth in Chapter 21). From the 1850s to the 1950s, people with serious mental health problems in western nations were institutionalized in large mental hospitals. Beginning in the 1950s, governments began a policy of deinstitutionalization. The inpatient populations of mental hospitals shrank dramatically, with hospitals in some locales being dosed, and people with mental health problems were discharged into the community (Rochefort, 1993). How do the principles of the ecological metaphor help us to understand this change and its impacts on people and communities?


The principle of interdependence asserts that the different parts of an ecosystem are interconnected and that changes in any one part of the system will have ripple effects that impact on other parts of the system. As we noted in Chapter 2, the ecological metaphor draws attention to three interdependent levels of analysis: personal (micro), relational (meso) and collective (macro). All of these levels are interconnected with each smaller level nested within the larger levels (see Figure 4.1). Deinstitutionalization provides a clear example of this interdependence. The closing or downsizing of mental hospitals led to former patients being discharged to poor living conditions in the community, including substandard housing (and, increasingly, homelessness for many) and inadequate support services. The ripple effects of deinstitutionalization also included uninformed and unprepared communities, with community members often displaying prejudice and rejection rather than welcoming acceptance of people with mental health problems. Families were also stressed and burdened by their having to assume the role of primary care providers, with little or no support. Attending to the unintentional side effects of a systems change is an important implication of the principle of interdependence.

Cycling of Resources
This principle focuses on the identification, development and allocation of resources within systems. One clear finding from the experience of deinstitutionalization is that, with a few notable exceptions, resources were not reallocated from mental hospitals into community support and housing programs, as was needed (Kiesler, 1992). Psychiatric wards in general hospitals were created, but these are short-stay facilities.  Without adequate support following discharge, people with mental health problems experience a 'revolving door' of readmission to, and discharge from, these programs. The cycling of resources principle also draws attention to potential untapped resources in a system. Traditionally, society has regarded the formal mental health service system as  the  resource. However, with deinstitutionalization, nontraditional sources of support have been identified, organized and used to address the problems faced by people with serious mental illness. These include a person's social network, non-professional community helpers or volunteers and self-help organizations (both for mental health consumers and family members). The cycling of resources principle suggests that the community can be a valuable resource to people with serious mental illness and their families.

The principle of adaptation suggests that individuals and systems must cope with and adapt to changing conditions in an ecosystem. In the wake of deinstitutionalization, communities have had to adapt to the integration into their ranks of people with ongoing mental health problems; community support workers and programs have had to cope with inadequate funding and waiting lists for limited community services; families have often had to become primary care providers; and people with mental health problems have had to contend with stigma, poor housing, poverty and inadequate support services (Capponi, 2003). When housing, community support and self-help are available to help support individuals, the potential for recovery, community integration and quality of life is enhanced (Aubry & Myner, 1996; Nelson, Lord & Ochocka, 2001a).

Succession involves a long-term perspective and draws attention to the historical context of a problem and the need for planning for a preferred future. There are many explanations for why deinstitutionalization occurred. It is often argued that the advent of psychotropic medications helped to reduce psychiatric symptoms in this population and hastened their release from hospital. But this is only a partial explanation. Scull (1977) found that hospital downsizing began before these drugs were developed. Scull argued that the rising costs of the institutional care and the development of public welfare systems were the major reasons for deinstitutionalization. It was becoming less expensive for governments to maintain people with mental health problems in the community than in institutions. However, deinstitutionalization created a whole new set of problems, but in a different context. In looking at deinstitutionalization in hindsight, most observers and critics agree that there was very little planning or anticipation of problems. As a result, some 50 years later, communities continue to struggle with the question of how they can adequately house and support people with serious mental health problems so that they can enjoy a desirable quality of life.

Why Is the Ecological Metaphor Important?
Community psychologists use an ecological metaphor in their emphasis on people in the context of social systems, because they believe that mainstream psychology has focused too much on individual psychological processes and neglected the important role that social systems play in human development. Community psychologists need to understand the pathogenic or oppressive qualities of human environments — those that block personal growth and create problems in living — and the positive qualities of environments that promote health, well-being and competence (Cowen, 1994).
We need to know the characteristics of competent communities, communities that promote liberation and well-being (Iscoe, 1974).
It is also important to recognize that environments sometimes affect different individuals in distinct ways. This has been called a person—environment interaction.
One case of a person—environment interaction of particular interest to community psychologists is that of 'person—environment fit'. In this case, a certain quality of the environment provides a good fit (or has a positive impact) for only some individuals.
An example of this is provided by Canadian community psychologist Pat O'Neill (1976) in a study of fourth grade girls in conventional and open-space classrooms.
Open-space classrooms are organized into large open areas with few partitions and teachers are flexible in their teaching approach. He found that students who were high in divergent thinking (creativity) had higher self-esteem in open classrooms than in conventional classrooms. Thus, open space classrooms had a positive impact on self-esteem, but only for those children high in divergent thinking. O'Neill (2000) introduced the idea of cognitive CP as a way of highlighting the importance of both individual and environmental qualities and the interrelationship between the person and the environment. Think of what type of environment is a good fit for you. If you are a private person, a noisy university residence with several roommates is not likely to be a setting in which you would be comfortable.
Since mainstream applied psychology has focused on individuals, there are many ways of thinking about individuals (psychoanalysis, behaviourism, humanism) and assessing their characteristics (for example personality, IQ and other tests of individual differences). In contrast, the study of social environments is in its infant stages of development. Community and environmental psychologists have been instrumental in developing ways of conceptualizing and assessing human environments (Linney, 2000; Moos, 2003; Shinn & Toohey, 2003). The study of cross-level relationships is a complex undertaking (Shinn & Rapkin, 2000; Shinn & Toohey,2003).
Community psychologist Jean Ann Linney (2000) has recently reviewed three ways of thinking about and assessing environments: (a) participants' perceptions of the environment, (b) setting characteristics that are independent of the behaviour of participants, and (c) transactional analyses of the dynamic relationship between behaviour and context. We briefly consider each of these three approaches, which can be applied to both neighbourhoods/communities and settings (for example schools, community organizations, workplaces).

Perceived Environments
Rudolf Moos (1994) and colleagues have emphasized the importance of the social climate or atmosphere of a setting. The key notion with this conceptualization of environments is the emphasis on people's  perceptions  of the environment. Most people can think of settings that they have experienced as oppressive and settings that were experienced as empowering. Moos have argued that there are three broad dimensions of different social environments: relationships, personal development, and systems maintenance and change. We can apply each dimension to a familiar setting — a school. The relationship dimension is concerned with how supportive or cohesive the setting appears to be. Are the teachers caring and compassionate? The personal development dimension addresses the individual's need for self-determination. Does the school provide opportunities for autonomy, independence and personal growth? The systems maintenance and change dimension is concerned with the balance between predictability and flexibility. Does the school provide clear expectations, yet at the same time demonstrate openness to change and innovation? Too much predictability in a school can produce boredom and resentment, because it may reflect rigid authoritarianism and resistance to change. Too much flexibility, on the other hand, can produce confusion due to continuous uncertainty and flux. Moos and colleagues have developed self-report questionnaires tapping these three broad dimensions and specific sub-dimensions to assess classrooms, families, community programs, groups and work settings (Moos, 1994).

Objective Characteristics of Environments
A second approach to the assessment of environments is to examine characteristics of settings that are more objective and independent of the behaviour of individuals who participate in those settings. Different types of measures (for example obseryational methods, demographic and social indicator data) are used to assess qualities of environments, such as the physical and architectural dimensions, policies and procedures, and environmental resources. One example of an observational method cited by Linney (2000) is the PASSING approach designed by Wolfensberger (1972) to assess the extent to which facilities for people with disabilities reflect the construct of normalization. Wolfensberger (1972) defined normalization as the 'utilization of means which are as culturally normative as possible in order to establish and/or maintain behaviours and characteristics which are as culturally normative as possible' (p. 28). External observers spend several days observing these settings to come up with ratings on a number of different dimensions, including physical integration of the setting with the community, the promotion of resident autonomy, social integration within the neighbourhood, and many more (Flynn & Lemay, 1999).
Another way of assessing environments is to examine demographic and social indicator information about the community or setting. Such information provides an aggregate description of the characteristics of the individuals residing in the community (age, socioeconomic status, ethnic background) and characteristics of the community (types of housing, crime rates, rates of people under treatment for different psychosocial problems). An example of how one can use an objective approach to the assessment of environments is provided in Box 4.1. 

Box  4.1  Objective Assessment of School Atmosphere
Rutter et al. (1979) used both observational and social indicator/demographic information In a study of 12 inner-city secondary schools in London, England. The major goal of the research was to identify characteristics of school atmosphere and to see if those characteristics related to students' rates of delinquency, behavioural problems, academic achievement and attendance over the three years they were enrolled in these schools. Some of the measures of school atmosphere were gathered through observational methods.
Students had better outcomes in schools that showed a strong academic emphasis, as indicated by the total amount of teaching time, starting the class on time, assigning homework, planning departmental curriculum, displaying students' work and frequently using teacher praise for students. Other qualities of the school that were related to positive outcomes were good care and condition of the school, encouragement of student responsibility and participation, low teacher turnover rates and the number of experienced teachers in the school. While the researchers demonstrated an association between school atmosphere and student outcomes, these relationships could be due to other factors, such as the characteristics of the students. To control for this selection factor, the researchers used the method of social indicator and demographic assessment to describe the qualities of the students at the ti me they entered the school, Students with higher verbal aptitude and who came from higher socioeconomic status backgrounds had better outcomes three years later than those who were lower on these dimensions.  But the important finding of the study was that the school atmosphere measures predicted outcomes over and above the characteristics of the students at the time they entered these schools, School atmosphere does make a difference for students. ,
Transactional Approaches
Linney (2000) describes transactional approaches as those that include both the behaviour of individuals and characteristics of the environment. One transactional approach is the concept of 'behaviour settings' developed by Barker (1968). The two main components of a behaviour setting are a standing or routine pattern of behaviour and the physical and temporal aspects of the environment. There are implicit guidelines on how to behave in behaviour settings. For example, a classroom science lesson and gym period is different behaviour settings, and the behaviour of people in these settings can be better predicted on the basis of the setting than on the characteristics of the people in the setting.
One interesting extension of the behaviour settings concept is Barker and Gump's (1964) theory of understaffing. They asserted that as the size of an organization increases, the number of people available to staff the different behaviour settings also increases. Furthermore, they hypothesized that, in small organizations, individuals would experience more invitations and pressure to take responsibility for staffing the different settings than they would in large organizations. In a study of high schools, they found support for this theory of understaffing. Students in smaller schools, including students with academic and social difficulties, were involved in a wider range of activities than students in larger schools. This approach to the understanding of environments has important implications for the CP value of participation and collaboration. Small, more intimate environments are apt to pull for more participation than larger, more impersonal environments. One downside to small settings, such as high schools, is that the number of activities in which students can participate is often restricted.

What Is the Value-base of the Ecological Metaphor?
The ecological perspective addresses the value of holism. Western science and ways of thinking about the world have emphasized linear, reductionistic and fragmented ways of understanding. In psychology, people are broken down into component parts (learning, perception, cognition) and are examined as isolated entities. Moreover, the researcher is a detached, objective scientist who is viewed as independent of the people he or she is studying, and the professional is an 'expert' helper. The ecological perspective revives the emphasis on holistic thinking, feeling and acting that was evident in Gestalt psychology.
The holistic emphasis of the ecological perspective is also quite similar to the world view of aboriginal people. Connors and Maidman (2001) assert that the roots of tribal culture lie in holistic thought, which involves 'interdependence between the environment, people and the spirit' (p. 350). In the traditional world view of aboriginal people, there is a strong emphasis on the interconnection of people with their spiritual roots and the natural environments and on balance and harmony. Aboriginal holistic thinking also incorporates values (for example bravery, respect, cooperation) in the form of teachings which guide community members, unlike western science which claims to be value-neutral. The medicine wheel is a symbol of holism:
This form of thought is often symbolized by the sacred circle or medicine wheel, which contains the teaching about the interconnection among all of Creation. The circle is a symbol that represents the knowledge offered by holistic world-views shared by aboriginal people. From this perspective, elements that affect change in a person are simultaneously seen as impacting on the person's family, community, nation and surrounding environment. (Connors & Maidman, 2001,p. 350)

Flow Can the Ecological Metaphor Be Implemented?
Jim Kelly and Ed Trickett have expanded on the four principles of the ecological perspective and have outlined their implications for preventive intervention (Kelly, 1986) and the conduct of research (Trickett, Kelly & Vincent, 1985). The major implication of the ecological metaphor for research is that research needs to be conducted in a much more collaborative, participatory manner than mainstream psychological research (Trickett, 1984; Trickett et al., 1985). Since CP research is carried out in the community with community partners, it stands in contrast to the mechanistic approach of experimental psychology and other basic sciences that are conducted in laboratories in which the variables under study are tightly controlled. Community members and settings are stakeholders in the research, who want to ensure that their needs are met. In community research, people are active participants in the research process, not passive subjects.
Moreover, community researchers are not exclusively detached, objective scientists. They are human beings with interests, agendas, values and feelings. Community psychologists are passionately concerned about disadvantaged people and social issues; they want to change the world, to make communities more caring and just. We believe that it is important for community psychologists to write more about their experiences and describe their standpoints in their research reports and writings. In Part IV, we elaborate more on the implications of the ecological perspective for community research.
Trickett (1986) has identified several implications of the ecological metaphor for intervention. First and foremost, the spirit of the ecological approach to intervention is distinctive. Not only are problems framed in terms of a systemic analysis, but the process of the intervention is one that is participatory and collaborative. Trickett (1986) captures this spirit in the following passage:
The spirit of ecologically-based consultation is to contribute to the resourcefulness of the host environment by building on locally identified concerns to create processes which aid in empowering the environment to solve its own problems and plan its own development. This spirit is concretized in the kinds of activities engaged in by the consultants, which further highlight the distinctiveness of the ecological metaphor. (p. 190)
The spirit of ecological intervention is one of working with rather than on people.
A second implication for community intervention is that attempts to change one part of the system will have side effects on other systems, and that these side effects will often not be anticipated. The ecological metaphor suggests that social change is not linear. Attempts to solve a problem may lead to new problems in another context (Sarason, 1978). The case of deinstitutionalization of people with serious mental health problems cited earlier is an example of this. A third implication of the ecological perspective is that the intervention should not focus exclusively on the attainment of outcome goals for participants in a specific program. While it is important to see how individuals benefit from programs, the ecological perspective draws attention to goals at multiple levels of analysis. A successful ecological intervention builds the capacity of the setting to mobilize for future action and create other programs. The extents to which setting members participate in and take ownership for the intervention are also important.
Fourth, there are implications of the ecological metaphor for the role and qualities of the interventionist. Since ecological intervention is flexible and improvisational in nature, consultants must be able to form constructive working relationships with different partners from the host setting. They must problem-solve, think on their feet, be patient and take time to get to know the setting and the people within it. They must not jump into offering solutions, but must tolerate the ambiguities and frustrations that inevitably occur in any intervention, and help the setting to mobilize resources from within or to identify external resources. They must also be creative and attend to issues of entry and exit from the setting (Kelly, 1971).
A fifth implication of the ecological metaphor for community intervention is that the dimension of time is highlighted. The changing nature of ecosystems and human adaptation requires a long-term time perspective. Contemporary social problems have both historical roots and future consequences. When community psychologists examine social issues and problems from an ecological perspective, they consider these issues and problems at multiple levels of analysis and over a longterm time perspective.
Finally, it is important to consider both individual and setting characteristics in community intervention. For example, research by O'Neill (2000) and colleagues has shown that social change tends to occur when there are recent improvements in social conditions (an environmental characteristic) and when people have a sense of injustice and a belief in their personal power to effect change (individual characteristics).

What Are the Limitations of the Ecological Metaphor?
The ecological metaphor has value in providing a systemic and holistic perspective for the understanding of human experience and behaviour and it has led to the development of different ways of understanding and assessing human environments.
To date, however, CP has tended to focus on micro and meso levels, to the neglect of macro-level structures and interventions. In the 1980s, Janet Cahill (1983) pointed out how different dimensions of the macroeconomy have an impact on mental health. Moreover, the macroeconomic trends that Cahill described have worsened since the publication of her article (for example larger gaps in income between the rich and poor, greater capital mobility). Inattention to the macro level of analysis is not a limitation of the ecological perspective, but rather a gap in the extent to which community psychologists have focused on larger social structures.
One limitation of ecological and systems perspectives is that in their emphasis on circular causality (the idea that everything is causally related to everything else), they do not take into account or highlight power differences within ecosystems. For example, the phenomena of child maltreatment and violence against women can be understood in terms of an ecological perspective, with multiple layers of influence.
But it is also important to recognize that some players have more power than others in any ecosystem and that those individuals who abuse power must be accountable for their actions. Abused women and children are not architects of their abuse. This is why the ecological metaphor needs to complemented with the concept of power (Trickett, 1994), which we consider in the next chapter.

Prevention and Promotion
What Are Prevention and Promotion?
Prevention is a concept that has been around for some time. In the 18th century people believed that disease resulted from noxious odours, ‘miasmas’ that emanated from swamps or polluted soil. Improving sanitation resulted in a decline in the rates of many diseases (for example typhoid fever, yellow fever). George Albee (1991) has recounted one of the important stories in the history of prevention, that of John Snow and the Broad Street pump. In the year 1854 in London, John Snow determined that an outbreak of illness was traceable to one source of drinking water. People, who drank from the well at Broad Street, but not other wells, were the ones who became sick. Removing the handle on the Broad Street pump and providing an alternative water source prevented the disease of cholera.
An important lesson from this story is that prevention is possible even without knowledge of the causes of a problem. No one knew exactly what caused cholera, but this did not stop Snow and others from engaging in community action that led to successful prevention outcomes.
Prevention has its roots in the field of public health. The thrust of the public health approach to prevention is to reduce environmental stressors and to enhance host resistances to those stressors. In the case of smoking, public policy could attempt to restrict advertising and sales to young people (an environmental change) and programs could teach ways of resisting peer pressure and commercial exploitation (enhancing host resistances). The public health approach to prevention has been very successful in reducing the incidence (the number of new cases in a time period) of many diseases, yet this approach is effective only with diseases that have a single identified cause, be it a vitamin deficiency or a germ. The problem with this approach when applied to mental health and psychosocial problems in living is that very few of these problems have a single cause (Albee,1982). This is how the ecological perspective is related to prevention. Most psychosocial problems are multiply determined, with micro, meso and macro factors all playing a role in causation.
Community psychologists have taken the lead in translating the idea of prevention into concepts, research and programs that are applicable to psychosocial and mental health problems. For example, George Albee (1986, 1996a) has drawn attention to the issue of politics and power in prevention, arguing that prevention should be a basic feature of a just society. Another community psychologist, the late Emory Cowen, played a pioneering role in prevention theory, research, practice and training.
As we noted in Chapter 2, primary prevention strives to reduce the incidence or onset of a disorder in a population, whereas secondary prevention is not really prevention, but rather early detection and intervention. There are three defining features of prevention (Nelson, Prilleltensky & Peters, 2003). First, with successful prevention, new cases of a problem do not occur. Second, prevention is not aimed at individuals but at populations; the goal is a decline in incidence (the rates of disorder). Third, preventive interventions intentionally focus on preventing mental health problems ( Cowen, 1980).
A typology of prevention has been promoted by the Institute of Medicine (I0M, 1994). Universal preventive interventions are targeted to the general public or a whole population group that has not been identified on the basis of individual risk. An example of a universal preventive intervention for physical health is childhood immunization. Selective preventive interventions are targeted to individuals or subgroups of the population whose risk of developing problems is significantly higher than average. A Head Start or other early childhood programs for all children living in a socioeconomically depressed neighbourhood is an example of a selective prevention intervention.  Indicated preventive interventions are targeted to high-risk individuals who are identified as already having minimal, but detectable signs or symptoms or biological markers, indicating predisposition for the mental disorder, but who do not meet diagnostic criteria. An intervention to prevent depression in children with one or both clinically depressed parents is an example of an indicated preventive intervention. (NIMH Committee on Prevention Research, 1995, pp. 6-7) (original emphasis)
Prilleltensky, Peirson and Nelson (2001) have noted that universal, selective and indicated approaches to prevention differ in two  ways (see Figure 4.2). First, they differ with respect to the timing of an intervention. Universal and selective approaches take place before a problem has occurred, but indicated approaches are used during the early stages of the problem. Second, they differ with respect to the population served. Everyone is served in a universal intervention; only those who are `at risk' are served in a selective intervention; and only those who are already showing signs of a problem are served in an indicated intervention. In this book, we use the term prevention to mean primary prevention, which includes both universal and selective (or high-risk) approaches.

Figure 4.2 illustrates how these different types of prevention can be applied to the prevention of child maltreatment. The line that bisects the oval represents the timing of the intervention. The right-hand side of the line is the reactive end of the continuum (working with families in which a child has already been abused), while the lefthand side of the line represents the proactive end of the continuum (working with families in which child abuse has not occurred). The ovals represent the populations served by the prevention approach. The large oval indicates that the universal approach serves everyone; the next largest oval (with broken lines) represents a sub-set of the population (families that are at risk of abuse); while the smallest oval (again with broken lines) represents an even smaller sub-set of the population (families in which a child has already been abused). Whereas clinical intervention focuses on a small sub-set of the population after problems have developed (reactive approach), prevention works with larger segments of the population before problems have developed (proactive approach).

Health Promotion
Complementary to prevention is the concept of health promotion. Where prevention, by definition, focuses on reducing problems, promotion can be defined as the enhancement of health and well-being in populations. In practice, health promotion and prevention are closely related. For example, universal interventions that promote healthy eating, physical activity and fitness, and abstinence from smoking have also been shown to prevent cardiovascular disease (Pancer & Nelson, 1990).
Cowen (1996) identified four key characteristics of mental health promotion or well-being: (a) it is proactive, seeking to promote mental health; ( b) it focuses on populations, not individuals; (c) it is multidimensional, focusing on 'integrated sets of operations involving individuals, families, settings, community contexts and macro level societal structures and policies' (p. 246); and (d) it is ongoing, not a one-shot, time-limited intervention. See Box 4.2 for some of the ways that wellness can be promoted.

Routes to Psychological Health and Well-Being  Box 4.2
Cowen (1994) argues that there are several key pathways towards mental health promotion.
1. Attachment.  Infants and preschool children who form secure attachments to their parents and Caregivers early in life fare well in later life. Home visits-lion programs that work with parents and their infants are one example of a strategy to promote attachments,
2. Competencies.  The development of age-appropriate and culturally relevant competencies is another health promotion strategy. School-based social competence (for example social problem-solving skills, assertiveness, interpersonal skills) enhancement programs are one promising approach.
3. Social environments.  Another pathway to the enhancement of health and well-being is to identify the characteristics of environments that are associated with health and then direct social environments towards those characteristics that have been shown to be  important for well-being. Changing family, school, community and larger social environments can be used to promote health.
4. Empowerment. Empowerment refers to perceived and actual control over one's life and empowering interventions are those that enhance participants' control over their lives, An empowerment approach stresses the importance of providing opportunities for people to exercise their self-determination and strengths, so that they are in control of the intervention.
5. Resilience and resources to cope with stress.  The ability to cope effectively with stressful life events and conditions is another key pathway to health and well-being. Life stressors are often seen as presenting an opportunity for growth, if the person has the resources to manage the stressors.

Why Are Prevention and Promotion Important?
`An ounce of prevention is worth a pound of cure.' A stitch in time saves nine.' These proverbs get to the heart of why prevention is important. Once problems occur, they are very difficult to treat. Often one problem cascades into another.
Treatment methods can be helpful, but many people experience relapse or reoccurrence of problems. Moreover, even if treatments were 100% effective, there are not nearly enough trained mental-health professionals to treat all those afflicted with mental health and psychosocial problems in living. As we noted in Chapter 1, the prevalence rates of psychosocial and mental health problems far outstrip available human resources. Albee (1990) has stated that 'the history of public methods (that emphasize social change) has clearly established, no mass disease or disorder afflicting humankind has ever been eliminated by attempts at treating affected individuals' (p. 370).
Another argument for primary prevention and health promotion is that they can save money in the long run. Both institutional and community treatment services provided by professionals for health, mental health and social problems are very costly. The costs of hospitalizing a person for one day is several hundred US dollars in most western countries and it is not uncommon for therapists to charge $100 US for an hour of therapy. Some research has documented the cost-effectiveness of prevention programs. For example, a longitudinal evaluation of the High/Scope Perry Preschool, a preschool educational program for economically disadvantaged children living in a community in Michigan in the US, found the following:
Compared to the no-preschool group, the preschool group had higher rates of employment and self-support, a lower welfare rate, fewer acts of serious misconduct and a lower arrest rate. For every dollar invested, the 30-week program returned six dollars to taxpayers and the 60-week program returned three dollars. (Schweinhart & Weikart, 1989, p. 109)

What Is the Value-base of Prevention and Promotion?
Prevention and health promotion focus on the values of health and well-being. Many people think of health or mental health in negative terms, as the absence of disorder. But a broader view of health can be framed in positive terms, as the presence of optimal social, emotional and cognitive functioning within a health promoting and sustaining context. According to the Epp (1988) report Mental Health for Canadians: Striking a Balance:
Mental health is the capacity of the individual, the group and the environment to interact with one another in ways that promote subjective well-being, the optimal development and use of mental abilities (cognitive, affective and relational), the achievement of individual and collective goals consistent with justice and the attainment and preservation of conditions of fundamental equality. (p. 7)
According to this definition, mental health is defined ecologically in terms of transactions between the individual and his or her environment, not just in terms of qualities of the individual. The value of health, which underlies the concepts of prevention and promotion, holds that health is a basic human right. Article 24 of the United Nations Convention on the Rights of the Child (United Nations, 1991), for instance, asserts 'the right of the child to the enjoyment of highest attainable standard of health', while Article 19 asserts that children should be protected from harmful influences on their health: 'State parties shall take appropriate legislative, administrative, social and educational measures to protect the child from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse.'

How Can Prevention and Promotion Be Implemented?
As we noted earlier, there are two interrelated approaches to prevention and promotion: one focuses on risk reduction for mental health problems and the other on community-wide approaches to health promotion (Cowen, 1996, 2000).

Risk Factors, Protective Factors and High - Risk
Approaches to Prevention Since the early 1970s, a substantial amount of research has confirmed that most psychosocial problems are associated with many different risk factors. A risk factor is any factor that is related to the occurrence of a problem (Rae-Grant, 1994). Moreover, the effects of risk factors may be exponential. That is, most people can withstand one risk factor without being adversely affected, but when there is a `pile-up' of risk factors, the impacts may be particularly devastating. For example, Rutter (1979) found a fourfold increase in subsequent rates of psychiatric problems when two risk factors were present in childhood and a 24-fold increase when four risk factors were present in childhood.
Some individuals, however, demonstrate resilience in that they are able to withstand exposure to many risk factors (Cowen, 2000). These individuals have protective factors, which are resources (for example coping skills, self-esteem, support systems) that help to offset or buffer risk factors. Albee (1982) views the incidence of mental health problems as an equation: 

Incidence =     Risk factors  Organic causes + Stress + Exploitation -
Protective factors Coping skills + Self-esteem + Support systems

This formulation is ecological and transactional in nature (Felner, Feiner & Silverman, 2000). As Rae-Grant (1994) has shown, risk and protective factors can occur at multiple levels of analysis. For example, risk factors can occur at the individual (low self-esteem), family (marital discord or separation) and community (living in a violent community) levels of analysis. Similarly, protective factors can be individual (good coping skills), family (a warm and loving relationship with one parent) or community (opportunities for socialization, recreation or skill development) in nature. An example of a selective intervention program is the Prenatal/Early Infancy Project described in Box 4.3.
The Prenatal/Early Infancy Project  Box 4.3
This project was developed by David Olds and colleagues in 1977 In Elmira, a semi-rural community in upstate New York. This community was extremely economically depressed and had the highest rates of child maltreatment in the state. Nurse home visitors worked with first-time mothers during the prenatal period, continuing until the children reached two years of age. This was a selective Of 'high risk’ approach to prevention of child maltreatment, because the women who were selected were low-Income, unmarried or teenaged. The mothers were randomly assigned to the home visit program or to a control group that received transportation for health care and screening for health problems but no visits. The home visits focused on promoting parent education, enhancing informal support and linkage with formal services. The nurses completed an average of 32 visits from the prenatal period through to the second year of the child's life. The results of the evaluation showed that during the first two years after delivery, 14 per cent of the poor, unmarried teenage mothers in the control group abused or neglected their children, as compared with 4 per cent of the poor, unmarried teens visited by a nurse (Olds et al., 1986). Many other positive outcomes were found for the mothers and their children in the short term, including the fact that the program resulted In a cost saving.
However, it is the long-term findings that are the most striking. In their analysis of the poor, unmarried women, Olds et al. (1997) found that nurse-visited women had higher rates of employment than the women in thecontrol group, as well as lower rates of Impairments due to alcohol or substance abuse (41% vs 73%), verified child abuse or neglect (29% vs 54%), arrests (16% vs 90% according to state records), convIctionS, days in jail, use of welfare and subsequent pregnancies by the ti me the children were 15 years of age. Also, compared with those whose mothers were in the control group, the children whose mothers participated in the home visitation program had sigrifficantly fewer incidents of running away (24% vs 60%), arrests (20% vs 45%) and convictions and violations of probation (9% vs 47%) at age 15 (Olds et al, 1998).
The risk and protective factor formulation is based on the broader approach of social stress theory.  As we noted in Chapter 1, community psychologist Barbara Dohrenwend (1978) introduced social stress theory to CP as a framework for understanding both how social environments can have negative impacts on individuals and how social interventions can be designed to prevent social stressors or reduce the negative consequences of social stressors. A central thesis of social stress theory is that stressful life events and changes, particularly negative life events, create stress reactions in individuals and that the long-term consequences of these stress reactions can be negative, neutral or positive. That is, stress presents an opportunity for growth, as well as the potential for negative outcomes. Moreover, Dohrenwend (1978) asserted that there are a variety of psychological and situational factors that can moderate the impacts of stressful life events. For example, a person with a good social support network or good coping skills may adjust well to a stressful life event such as marital separation, whereas a person without such resources may fare worse. Such moderating factors are also referred to as 'protective factors' or 'stress-meeting resources'.
Since Dohrenwend's (1978) initial formulation, there has been a great deal of research and further theorizing about social stress in CP (Sandler, 2001). One of the advances of this research is that there is now a greater understanding of the role of particular life events, such as job loss (Dooley & Catalano, 1980, 2003) and divorce (Sandler, 2001), in contributing to psychosocial problems. In particular, research has helped to clarify the mechanisms by which stressful life events can have negative impacts on individuals. Sometimes stressful life events set in motion a variety of additional problems or ongoing life strains to which people must adapt. For example, unemployment leads to ongoing financial strains that impact on one's marital, family and social network relations. Thus, it is not just the stressful life event that is the problem, but all that ensues in the aftermath of that event. Irwin Sandler (2001) has found that the adversity of divorce can negatively impact on children's academic competence, self-worth and coping skills, which, in turn, can have a negative impact on children's behaviour. Thus, research has clarified the role of mediating factors (for example academic competence, self-worth, and coping skills) that link stressful life events with negative outcomes for individuals. Community psychologists have used knowledge gained about mediating and moderating factors to design preventive interventions to reduce the negative impacts of stressful life events such as job loss (Price, Van Kyn & Vinokur, 1992) and parental divorce (Sandler, 2001). For example, mentoring programs have been successfully used to enhance the support and offset stressors faced by children or young people who are lacking social support (DuBois et al., 2002; Rhodes & Bogat, 2002).
Universal Approaches to the Promotion of Health and Well - being Over the past few years, there has been an increasing focus on health and the promotion of well-being (Cicchetti et al., 2000; Cowen, 1994, 2000; Prilleltensky & Nelson, 2000; Prilleltensky et al., 2001a). Health promotion approaches are often provided on a universal basis to all individuals in a particular geographical area (for example neighbourhood, city, province) or particular setting (for example school, workplace, public housing complex). Moreover, health promotion is more likely to focus on multiple ecological levels than on risk reduction, which is more often aimed at individuals.
While many of the original prevention programs in mental health used the risk reduction or selective approach, focusing on at-risk individuals, more recently there has been a greater emphasis on setting-wide and community-wide approaches to prevention. These more environmental approaches to prevention focus not only on specific prevention programs, but more broadly on building the capacities of organizations and communities. A major focus of these interventions is developing partnerships or coalitions of various community stakeholders to plan, implement and evaluate the intervention (Foster-Fishman, Berkowitz et al., 2001; Wolff, 2001).
Community-wide approaches have been used to address a variety of issues, including substance abuse, HIV/AIDS, heart disease, immunization, teenage pregnancy and child development (Roussos & Fawcett, 2000).

The Effectiveness of Prevention and Promotion
While the rationale for prevention is compelling, prevention and promotion need solid research evidence on which to base practice. One of the frequent criticisms of prevention is that practitioners implement programs that have not been proved to be effective and that are uninformed by research. Fortunately, the research base supporting the effectiveness of prevention and promotion programs has grown substantially since the early 1970s. In 1977 Cowen characterized prevention as progressing by 'baby steps,' but by 1996 he spoke of 'lengthy strides' in prevention. In a 1988 publication, a task force of the American Psychological Association (APA) on prevention identified only 14 prevention programs with a research base (Price et al., 1988), whereas the publication of a more recent APA task force on  Prevention: Promoting Strength, Resilience and Health in Young People is filled with information on a variety of effective prevention programs for children and young people (Weissberg & Kumpfer, 2003). By the early 1990s, Durlak and Wells (1997) had located 177 controlled studies of prevention programs for children and young people and found that overall these programs were quite successful in preventing problems and promoting well-being.
In addition to the growth in the amount of research on prevention, there has also been growth in the application of prevention to a variety of different populations and issues. For preschool children, preschool education programs (for example Head Start in the US, Zigler & Valentine, 1997), family support programs (for example home visitation for parents, Olds et a1.,1986), multi-component programs (for example the Perry Preschool, Schweinhart & Weikart, 1989) and programs with a skill-building emphasis (for example the interpersonal cognitive problemsolving program [ICPSP], Shure, 1997) have been found to improve cognitive and/or social—emotional outcomes in children and to prevent child maltreatment and other negative outcomes for children, both in the short term and through adolescence and early adulthood (MacLeod & Nelson, 2000; Nelson, Laurendeau et al., 2001; Nelson, Westhues & MacLeod, 2003; Weissberg & Greenberg, 1998). School-based prevention programs have been found to be successful in promoting school-aged children's social—emotional learning and preventing both externalizing (that is, conduct) and internalizing (that is, shyness, anxiety) problems (Durlak, 1995; Lorion, 1989; Greenberg et al., 2001; Weissberg & Greenberg, 1998). School-based and family support programs have also been successful in preventing a variety of negative outcomes for adolescents, including smoking, substance abuse, risky sexual behaviour, school failure/dropout, delinquency/violence and violence against women in dating relationships (Lavoie et al., 1995; Nation, Crusto et al., 2003). While much of the research in prevention focuses on children and young people, there have been successful applications with adults, including serious and widespread problems, such as depression (Price et a1.,1992) and HIV/AIDS (Peterson,1998). See Box 4.4 for a list of principles of effective prevention programs.
What Are the Principles of Effective Prevention Programs?
What are the Ingredients of effective prevention programs? Based on a review-of-reviews of prevention research, community psychologist Maury Nation and colleagues (Nation of al., 2003) uncovered nine key principles.
1. Comprehensiveness:  Multi-component programs that strive to address several different ecological levels and contexts are more important than singlefocus programs.
2. Varied teaching methods:  Programs need to teach - skills through interaction, 'hands on methods, as well as increasing knowledge and awareness:
3. Sufficient 'dosage':  Programs need to he sufficiently . long and intensive to have positive preventive impacts (Nelson, Westhues, & MacLeod, 2003).
4. Theory driven:  Programs need to be based on a sound theoretical framework that is supported by research, such as the risk arid protective factors formulation,
5. Positive relationships:  Programs for children need to promote positive relationships with parents, teachers, peers, mentors and others.
6. Appropriately timed:  Programs need to be wellti med to address specific developmental issues for children, young people and adults.
7. Sociocultural relevance:  ProgramS must he tailored to the norms of the population served and include them. in planning and implementation.-
8. Outcome evaluation:  Programs should have clearly specified outcome goals that make them amenable to research on the effectiveness of the'program.
9. Well- trained slat.  Programs must provide training for staff to properly implement the program.

What Are the Limitations of Prevention and Promotion?
While in the past prevention in mental health has been ignored or dismissed by psychiatry and the medical profession (for example Lamb & Zusman, 1979), more recently the medical profession has become more enamoured of prevention.
Recently, psychiatry has broadened the definition of prevention to include `comorbidity prevention' (preventing the development of a second disorder when a person already has one disorder) and 'relapse prevention' (preventing a person who has been successfully treated from having a relapse) (NIMH Committee on Prevention Research, 1995). Stretching the definition of prevention in this way takes the field back towards 'tertiary prevention' and away from true prevention and promotion, as we have defined them. Moreover, the Institute of Medicine's (1994) emphasis on `prevention science', focuses rather narrowly on the prevention of psychiatric disorders, as defined in the latest version of the  Diagnostic and Statistical Manual, through risk reduction approaches. As Albee (1996a, 1998) and Cowen (2000) have noted, this focus diverts attention from non-medical model approaches, such as health promotion, competence enhancement, empowerment and social change approaches to prevention and promotion.
The 'prevention science' approach tends to `medicaliz,e' and 'depoliticize' prevention. We are critical of this approach, not because we are against science, but because the particular form of science being promoted by the medical profession is very narrow in emphasis. Selective approaches to prevention, which predominate, are often carried out with low-income people because poverty, low social class and unemployment are one set of major risk factors for many different mental health problems (Perry,1996). Moreover, selective approaches typically address the bottom half of Albee's (1982) equation (that is, promoting protective factors), rather than the top half of the equation (that is, reducing stress or exploitation). Also, programs which promote protective factors tend to be person-centred or family-centred, ignoring the larger social environment (Febbraro, 1994). One final criticism of prevention as it is currently practised, is that prevention is something that is done  by professional 'experts'  to 'at risk' people. Professionally driven approaches may not address what these so-called 'at risk' people need or want, they may be disempowering and create dependencies on service systems, and they tend to focus on deficits rather than the strengths of community members.
More recently, some prevention programs have become more communitydriven, with residents in low-income communities actively participating in the planning and implementation of prevention programs in their communities. These programs are not only driven by community members, but they are designed to change or create meso-level settings in the community to foster the well-being of families and children. Moreover, Nelson, Amio et al. (2000) have proposed concrete steps for value-based partnerships in prevention programs, that include processes for inclusion, participation and control by disadvantaged people in the design of prevention programs.
There are some promising examples of partnerships for prevention between schools, parents and communities. One is the Yale—New Haven School Development Program (Cotner, 1985), which began in two schools in a low-income African-American community in Connecticut and has now been implemented in more than 550 schools in the US (Weissberg & Greenberg, 1998). This program is based on: `(a) a representative governance and management group, (b) a parent participation program and group, (c) a mental health program and team, and (d)‘ an academic (curriculum and staff development) program' (Corner,1985, p. 155). There is a strong emphasis on parent participation in school programs and school governance in this program. A three-year longitudinal evaluation of this project found significant improvement on measures of school achievement and social competence for children participating in the intervention compared with children in similar schools (Cauce et al., 1987). A more radical approach to school-based prevention has been implemented in another Connecticut community, using emancipatory and African-centred education as the core philosophy (Potts,2003). At the Benjamin E. Mays Institute, which serves 100 African-American male students in middle school, the focus is on the development of African identity and students as agents of social change. According to community psychologist Randolph Potts (2003):
African history and wisdom teachings provide more than just additional content for primary prevention programs. The Akan symbol  sankofa  represents the African teaching that reclaiming and understanding history are essential for understanding present circumstances and moving forward into the future. For children of African descent, understanding both the African cultural legacy of intellectual achievement and the contemporary structures of domination are essential in preparing them to confront conditions that are destroying their communities. (p. 178)

An evaluation of this program has shown that students in the Benjamin E. Mays Institute score significantly higher on grade point average in tests of maths and writing skills and on a measure of African identity, than children from other middle schools in the same community.
While the direction towards more community-driven approaches is a positive one, prevention needs to move even further towards macro-level analyses' and interventions. Albee (1986, 1996a,1998) has argued that prevention should be linked to social justice rather than the medical model. A social justice approach to prevention strives to address the causes of the causes through social change efforts. Thus, prevention should not just be focused on changing individuals, families or communities, but on larger social structures in which people and settings are embedded. To translate this rhetoric into action, we believe that prevention should encompass not just programs, but also social policies. Since economic inequality is a major structural cause of psychosocial problems (Cahill, 1983; Hertzman, 1999; Wilkinson, 1996), policies that strive to reduce this, such as those practised in western and northern European countries, show the forms prevention can take at the macro-level (Peters et al., 2001). Not only have countries like Sweden been successful in reducing the level of economic inequality in their society, but as a result the literacy and numeracy skills of children in the bottom economic quintile in Sweden are vastly better than those of children in the bottom economic quintiles in the US and Canada ( Hertzman,1999). These findings suggest that there needs to be more emphasis on advocating change in social and economic policies to promote social justice and well-being.

We conclude this chapter by noting that the principles of ecology and prevention tend to focus on personal and relational values, to the neglect of collective values, on ameliorative rather than transformative change, to surface manifestations of larger social problems rather than unequal power relations and to a focus on well-being rather than liberation. Ecology and prevention help to define and differentiate CP from clinical psychology, but they can inadvertently lend support to the existing societal status quo. Nevertheless, ecology and prevention are useful and important principles for CP, and community psychologists can push the boundaries of these concepts more towards the macro level of analysis. Examination of structural causes of human suffering and macro-level policy change to reduce economic inequality are ways that these principles can move towards a more transformative agenda.

COMMENTARY: Social Class, Power, Ecology and Prevention  Gcoolc  w Albec
The ecological metaphor dearly has much to offer in our efforts to understand that an action has effects in many areas, some unforeseen. As is pointed out in this chapter, CP has tended to focus on micro and meso levels, to the neglect of macrolevel structures and interventions. The example chosen - deinstitutionalization of mental cases in the US - also needs to be considered at macro levels. I would include social class and political power among important macro forces.
From 1850 to 1925 there were a vast number of immigrants from Europe who landed in America. The Irish, Scandinavians, Eastern European Slays and Jews, Southern Italians - mostly peasant and impoverished people - arrived in the hope of a better life for themselves and their families. Living in overcrowded cities they worked hard, were exploited and their children were educated. But because of the excessive stresses, their rate of mental disorders quickly overwhelmed the small retreats and mental wards. Mental disorders were declared to be brain diseases common to people who were seen by the ruling class as biologically inferior. Huge mental hospitals (asylums) were built and (inadequately) funded by the state governments to house the insane. Theses places quickly became the overcrowded hell-holes described as The Shame of the States (Deutsch, 1948). The chronic mental cases were/are mostly from the lowest social classes where few family resources were/are available for their care. Chronic mental cases require long-term care and there is no alternative to tax-supported programs.
In the 1950s a Joint Commission on Mental Illness and Health was appointed by Eisenhower and the US Congress to find an alternative to the huge state hospitals. The Commission's final Report, Action for Mental Health (1961), recommended establishing 4000 Comprehensive Community Mental Health Centers where, through a single door, all persons with mental disorders could find help. Day care, in-patient beds, community support programs, individual treatment, consultation education and research would be available in these centres. This promising program was brought to a halt by the powerful opposition of US medicine. It was socialized health care! Psychiatrists and other staff were to be paid federal salaries and this violated the conservative political opposition to using federal tax dollars to solve social problems and to provide health care.
But the states, delighted at the prospect of saving the enormous costs of running the state hospitals, went on closing them down as planned.
The hapless inmates were mostly dumped into the streets. (They could apply for welfare only if they had a permanent address - but without welfare they could not pay for a permanent address.) So hundreds of thousands were doomed to live under bridges and in bus stations and packing crates.
What is the macro message?
1. One's social class determines the availability of medical care and social support. Today, the group with the highest rate of mental disorders, drug use, mental retardation, alcoholism, sickness and early death is the migrant farm workers.
2. The ruling ideas of a society are those that support the ruling class. Serious poverty affects millions. It is hardest on children and women, on the elderly, on the physically and mentally handicapped. Proposals to raise the minimum wage, to provide health care for the uninsured, to build low-cost housing, all contradict the view of the ruling class that we must rely on hard work, prayer, individual initiative and volunteers to correct social injustice. Spending federal tax money to support the poor and passing federal regulations to protect the handicapped is socialism and must be opposed.
An understanding of the importance of primary prevention is essential for CP. There is a mistaken focus on one-to-one treatment in present-day clinical psychology. Few realize (or will admit) the truth of the public health dictum:  No disease or disorder has ever been treated out of existence.  No matter how successful our individual treatments, curing one person at a time do not reduce the incidence (new cases) of a disease or disorder. Only successful primary prevention reduces incidence.
Some examples:
1. Reducing lead in the environment reduces the number of cases of brain damage. (Strategy: eliminate lead paint, lead toys, lead in gasoli ne.)
2. Reducing the stresses of poverty (low wages, overcrowded and unsanitary housing) reduces the rate of child abuse and neglect associated with childhood emotional and learning problems. (Strategy: raise the minimum wage.)
3. Provide support groups. Isolated persons are at high risk. A wide range of support groups -Scouts, clubs, home visitors and so on, has been shown to reduce psychopathology.
Primary prevention and promotion are aimed at developing interventions that affect groups. The members of these groups may be at risk, but they are not yet affected. For example, there are many effective programs for ensuring that infants are born full-term and of normal birth weight. Such infants are at lower risk later for many negative conditions. Low-birth-weight infants are at high ri sk. The goal of primary prevention is to increase the number at low risk and decrease the number at high risk. Working with premature infants is admirable, but it is not primary prevention.
In recent years the National Institute of Mental Health has stretched the concept of prevention to include interventions at early stages of the development of a mental condition in individuals. While this may be good medicine, it is not primary prevention. It is a strategy to allow allocation of tax dollars to treatment that can count as efforts at prevention. Treatment is profitable. Primary preven-tion is often costly (of tax dollars) and is opposed by political conservatives.
One of the ruling ideas of the conservative society argues that each mental disorder is a separate disease with a separate cause and therefore requires a separate strategy for prevention.
This so-called 'scientific prevention' opposes the position that many different mental disorders may have the same cause - the stresses of poverty, for example. The 'scientific prevention' model argues that there is a specific biochemical cause for most mental disorders and that research funds must go into the search for each specific biological cause of each specific disorder listed in the American Psychiatric Association's (1988)  Diagnostic and Statistical Manual IV  This Manual is unreliable and invalid (Kutchins & Kirk, 1997) but this is not a concem as 'scientific prevention' is far less costly (of tax dollars) than alternative models that require efforts at social changes to achieve social justice, Social class is a major variable for CP (Perry, 1996). It is a macro variable to which more attention should be paid. Poverty causes pathology (Mirowsky & Ross, 1989). If mental disorders are learned in a pathological social environment, like poverty, (with homelessness, exploitation, family disruption, child neglect and so on), then there is hope for primary prevention. Truly meaningful prevention means building a just society. ft means reducing poverty, the stresses of injustice, the loneliness in a society based on consumerism. Of dozens of examples, space will permit only one.
Recent research has come to the clear conclusion that the wider the income differences between rich and poor in a country, the worse the health, the lower the life expectancy, the higher and the rate of violent crime, the more people in prisons and the worse the mental health of the population.
In those societies where the income gap between rich and poor is small there is more social cohesiveness - people are more sensitive to the needs of others, violent crime is far less common, there is less emotional distress and fewer people die young as a result of stresses and selfish preoccupations. This set of observations has been confirmed repeatedly and is generally accepted in social medicine and public health.
The US is far down the ranking on all these pathologies - not because of the structure of our health care, the number and training of our physicians, the quality of our hospitals, the brilliance of research by our pharmaceutical firms - but because of the wide (and growing) gap between rich and poor. Dozens of studies demonstrating the crucial importance of social cohesion for mental health and its relation to the income gap, are summarized in Wilkinson (1996) Unhealthy Societies: The Afflictions of Inequality He cites a wide range of research studies showing that when the income gap widens in a community, a region (state) or a country there is an increase in crime, child abuse, depression and death rates.
The variables are clear and measurable: data on income by social class are gathered routinely for other purposes; rates of death are objectively countable, as are rates of objective diseases and crime rates. The relations are clear. Inevitably the question arises: If the research evidence contradicts the ruling ideas of a society what should be the position of the community psychologist? It is an important question for each of us.

Domestic Violence: An All Too
Familiar Story
A young couple emigrated from Portugal to Canada. In Portugal the man was an auto mechanic and the woman worked at home doing sewing and embroidery. They came to Canada seeking a better life. The man found it difficult to find a job equal to his training and eventually accepted a job cleaning offices. He initially forbade his wife to work, but as their family grew (3 children), she eventually took a job in a garment factory. A retired Portuguese woman helped by providing child care. In spite of both partners working, the two combined were able to bring in only a very low income. The man started to blame the woman for encouraging him to move to Canada, for having three children and for the problems that they were experiencing.
Communication between the two became quite strained and the man began to withdraw from his family and spend more time with male friends.
The woman assumed responsibility for running the household and for all child care and child rearing. The man became physically abusive to the woman when she started to work outside the home. The woman did not know there was a shelter for abused women in the community. The man left for a week and when he returned he was unapologetic and remained verbally abusive.

The couple began to sleep in separate beds and communicated very little. The woman was too ashamed to tell any family members about the violence.
1.  Use the principles of ecology to help you understand what is happening with this couple and their family in the context of the larger community and society.
2. How could the principles of prevention and promotion be applied to prevent domestic violence and promote family well-being?

 Prevention Journals and Websites
Applied and Preventive Psychology,  http://www.nd.edu/ —japp/.
Journal of Prevention and Intervention in the Community,
Journal of Primary Prevention,  http://www.kluweronline.com/issn/0278-095X/contents.
Ontario Prevention Clearinghouse, http://wmv.opc.on.ca .
Prevention Science,  http://www.kluweronline.com/issn/1389-4986/contents.
Prevention and Treatment,  http://journals.apa.org/prevention/.
Prevention Connection: Promoting Strength, Resilience and Health in Children, Adults and Families,
Prevention Yellow Pages, http://www.tyc.state.btus/prevention/.


Nelson, G., & Prilleltensky, I. (2005). Community psychology: In pursuit of liberation and well-being. Palgrave Macmillan, p. 330-347.

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