TEXTBOOK
PREVENTION IN
MENTAL HEALTH
Prof. Dr. Clemens M.H. Hosman
Dr. Karin van Doesum
Radboud University Nijmegen
Revised Edition 2019
i
In Honour of
“the four pioneers and advocates
of prevention in mental health
who played a crucial role in
shaping my passion, views and expertise
in science-based prevention
through their teaching, writings and
inspiring consultations and contacts”
Clemens Hosman
Prof. Gerald Caplan (1917-2008), child psychiatrist, Harvard
University, Boston. He was one of the founders of American
preventive psychiatry. His books, lectures and workshops on
preventive psychiatry and preventive consultation methods have
had a major impact on the development of prevention in mental
health in The Netherlands.
Prof. George Albee (1921-2007), professor of psychology,
University of Vermont. Chair of the influential series of Vermont
Conferences of Primary Prevention of Psychopathology. In his
many writings and lectures around the world, he made a strong
plea for primary prevention and fighting against the social causes
of psychopathology and mental suffering. He was former
President of the American Psychological Association, and Chair of
the US Task Panel of Prevention under President Carter.
Dr. Beverly Long, public health nurse, has been for many decades
one of world strongest advocates for mental health, prevention and
public mental health. She is former President of the World Federation
of Mental Health and chaired numerous US and international
committees and initiated world conferences on prevention. In 2007,
she received an Honorary Doctorate from Emery University for her
life-long work for prevention and mental health.
Prof. Richard Price, organizational psychologist and community
psychologist, University of Michigan. Director of one of the first
Prevention Research Centers in the US (Ann Arbor) specialised in
work-related prevention. During the 1980s and 1990s, he played an
influential role as consultant for the development of science-based
prevention in the Netherlands. In his research and consultation,
projects are running across many countries, including China, Finland,
Spain and Ireland.
ii
TEXTBOOK
PREVENTION IN
MENTAL HEALTH
iii
Table of contents
In honour of
Curriculum Vitae Lecturers
Course outline and exam instructions
Educational goals of the course
Introduction on the need for prevention
PART I
PREVENTION HISTORY AND CONCEPTS
1.
Naive prevention:
on the preventive nature and culture of man
2.
History of preventive mental health care:
From 1800 to present
3.
Mental Disorder Prevention and Mental Health Promotion
Concepts, strategic framework and current practice
PART II
1
11
31
57
THEORETICAL APPROACHES
4.
Theoretical approaches: Overview
5.
Behavioural approach: A closer look at some models
111
6.
Developmental psychopathology approach
125
7.
Integrated stress-theoretical approach
135
8.
Positive psychology approach
155
9.
Social support and social network approach
165
10.
Community approaches
191
PART III
91
PLANNING AND STRATEGY
11.
Planning models and processes of planned change
217
12.
Setting targets for preventive interventions
239
13.
Intervention analysis, strategies and methods
253
iv
PART IV
EVIDENCE AND EFFECTIVENESS
14.
Evidence of Effectiveness and Improving Effectiveness
in Prevention and Mental Health Promotion
15.
Database of effective youth interventions
The Netherlands Youth Institute/ NJi
PART V
285
305
PREVENTION THEMES
16.
Prevention of emotional problems and psychiatric risks in children of mentally ill
parents in the Netherlands: a comprehensive science-based approach
Clemens M.H. Hosman, Karin T. M. van Doesum, Floor van Santvoort
317
17.
Prevention of emotional problems and psychiatric risks in children of mentally ill
parents in the Netherlands: Interventions
Karin T. M. van Doesum, Clemens M.H. Hosman
335
18.
Prevention of anxiety disorders
351
v
About the course leaders
Dr. Karin van Doesum, Ph.D. is a prevention psychologist working as the
head of the Deventer Prevention Department of Dimence, a mental health
service organisation in the districts of Zwolle, Deventer and Almelo. She
is also a part-time lecturer and researcher at the Prevention Research
Centre of the Radboud University Nijmegen and part-time researcher at
the University of Tromsø in Norway. She studied prevention and clinical
psychology at the Radboud University. For almost 25 years, she is a
leading specialist in The Netherlands and Europe on prevention of
transgenerational transmission of psychopathology. She has developed,
implemented and evaluated prevention programmes for children and
families of parental mental illness (COPMI). Her dissertation was focused
on the development and effect evaluation of a preventive video-feedback
training programme for depressed mothers and their babies. In addition,
she has developed prevention programmes for pregnant women suffering
from mental disorders and stress, support groups for these children and families and educational
programmes for the parents. Karin van Doesum trains mental health and prevention specialists in the
Netherlands and several European countries on coping with children of mentally ill parents. She also
manages and supervises process and effect studies on several new prevention programmes. Over
many years, her prevention team in Deventer has offered an attractive learning environment where
many students have worked as ‘intern’ and written their theses.
E-mail address: k.vandoesum@psych.ru.nl
Room: Spinozagebouw A.07.21, Montessorilaan 3, Nijmegen (on Thursdays)
Or: Impluz, Prevention Department of Dimence groep, Deventer: k.vandoesum@impluz.nl
Clemens M.H. Hosman, Ph.D. (1947), psychologist, is emeritus
Professor of Mental Health Promotion and Prevention of Mental Disorders
at the Maastricht University (Health Sciences) and Radboud University
Nijmegen (Clinical Psychology), and former director of the Prevention
Research Centre, located at both universities. The Research Centre is
oriented at prevention of depression, prevention for children of parents with
mental
illness,
community-intervention
strategies,
programme
development, effectiveness and effect management, and innovation and
future of prevention and mental health programmes. He is visiting
professor at the University of Zagreb, where he is one of the founders of
the Croatian PhD Program on Prevention and Mental Health Promotion.
The late Professors Gerald Caplan and George Albee, founders of
American preventive psychiatry and preventive psychopathology, were among his teachers.
He is involved in prevention since 1969 and played a crucial role in the development of
prevention and promotion in the Netherlands. He wrote many publications on different aspects of
prevention and prevention research, e.g. needs assessment methods, preventive goal analysis,
prevention theories, international classification of preventive interventions, programme evaluation,
effectiveness, effect prediction and effect management, prevention of depression, prevention of
relationship problems, prevention of transgenerational transfer of mental disorders, dissemination of
evidence-based model programmes, long term policies in prevention and mental health promotion and
international collaboration. He is co-author of the PREFFI 2.0, a Dutch effect management instrument
that aims to enhance the implementation of scientific knowledge on effectiveness in policy and practice.
vi
The instrument is also used in several other European countries. His research team has collaborated
with over 30 mental health organisations in the Netherlands.
He has played a leading role in enhancing European and worldwide prevention and mental
health promotion. He was chair of the European WHO Task Force on Mental Health Promotion and
Prevention (1995-1998), chair of the Clifford Beers Foundation on Mental Health Promotion (1996-2000,
2008-2011), and member of several international networks and committees, such as the European
Community Psychology Network, the European Mental Health Promotion Network of the European
Commission, the Prevention Faculty of the World Federation of Mental Health (WFMH), the Prevention
Section Staff of the World Psychiatric Association (WPA), Global Effectiveness Program of the
International Union for Health Promotion and Education (IUHPE), the Board of the international US
Society for Prevention Research (SPR; 1999-2003). From 2004 to 2007 he was the Chair of the World
Consortium for the Advancement of Prevention and Promotion in Mental Health (GCAPP), in which 17
international organisations are involved (e.g. WHO, World Federation of Mental Health, World
Psychiatric Association, Society of Prevention Research, CDC, The Carter Center, VicHealth Australia).
Since 2010, he chairs their International Taskforce for Capacity Building and Workforce Development.
From 1999 – 2003 he was Board member of the US Society for Prevention Research.
He received the 2002 International Collaborative Prevention Research Award of the US Society
of Prevention Research; and the 2001 Friend of the Early Career Preventionist Award for his life-long
work in educating new generations of prevention experts in The Netherlands and other European
countries.
He organised several European and World Conferences on Promotion of Mental Health and
Prevention of Mental and Behavioural Disorders. He is a prevention advisor to the World Health
Organization and several European countries and coordinated the WHO project on Evidence-based
Prevention of Mental Disorders, (Hosman, Jane-Llopis & Saxena, 2004). The final report serves as a
basis for the WHO prevention policy in this field.
To facilitate the use of scientific knowledge on prevention, to enhance the dissemination of
evidence-base prevention programmes, to stimulate international research collaboration of effect
predictors, and to develop international training programmes the Nijmegen Prevention Research Centre
hosted several European projects (IMPHA, DataPrev). These projects have resulted in a European
database of Evidence-based Preventive Trials (DataPrev), a European Training Programme and a
European Mental Health Promotion Policy Report.
Since 2012, Clemens Hosman is emeritus professor and runs a private consultancy company, named
Hosman Prevention Consultancy and Innovation that offers advice, training, lectures and workshops,
nationally and internationally. Email-address: hosman@psych.ru.nl
vii
Introduction to Prevention in Mental Health
Course outline
The main goal of this course is to let you acquire knowledge and insight in prevention of mental disorders
and promotion of mental health. You are taught how effective preventive interventions are developed:
stepwise, systematically, theory-based and practice-based. After a general introduction to the course
and the field, we will first discuss preventive behaviours and preventive mechanisms as we have
encountered them for millions of years in both animal and human biology and still present in our current
daily lives (chapter 1). Although we often do not realise it, every hour of the day we occupy ourselves
with all kinds of preventive practices.
Prevention and health promotion as a scientific and professional discipline deals with situations
in which the existing preventive or protective mechanisms of individuals, populations and communities
work insufficiently, resulting in a poor development of one’s health potential or well-being, the occurrence
of serious mental problems and illnesses, and their huge social and economic impact on our life and
society. As introductory chapter, we will discuss the arguments why professional prevention, prevention
policies and prevention science are needed.
The history of professional prevention and health promotion, which goes back to the mid-19th century,
is discussed in chapter 2. Professional or academic ‘prevention’ and ‘health promotion’ seek to improve
preventive and promoting mechanisms in individuals, groups, organisations, and communities and to
develop innovative preventive practices or measures (chapter 3). The chapter discusses what we mean
by the term ‘prevention’, how prevention is subdivided in multiple sectors, what is done in practice and
how it is organised. The same applies to the term ‘health promotion’, which is narrowly related to
‘prevention’. During the course many examples will be given from concrete programmes and practices
viii
in prevention and promotion. An impression of the activities of prevention teams and health promotion
teams currently active in many health organisations is given.
Basic Planned Change Model
A major goal of this course is to explain different scientific models on which preventive interventions
can be based. These concern theoretical approaches from psychology, psychiatry and sociology, such
as behavioural models, stress and coping models, developmental psychopathology and positive
approaches, and social network and community models. These are discussed in the chapters 4 to 10
(Part II).
Basic to the development of
any prevention and health programme
is the use of so-called planning of
change models. These describe the
different stages needed to plan,
develop, implement and evaluate a
prevention or health promotion
intervention. We present three types of
planning models. First, the Basic
Planned Change Model (Figure 2)
describes the various basic steps that
must be followed in any process of
planned change, so this also applies to
the process of developing an effective
prevention programme. A systematic
planning approach as described in Figure 2 is one of the essential conditions needed to achieve
preventive effects in target populations. The model provides a central framework for this course and is
discussed more extensively in chapter 11.
Developmental Trajectory of Effective Prevention
In the same chapter, also a more extensive planning model is described that integrates this basic
planning model in a so-called public health approach, called the Developmental Trajectory of Effective
Prevention (Figure 3). This means that the model not just describes the steps toward an effective
intervention, but also the steps needed to achieve aimed preventive effects in a target population or
community as a whole (public impact). For instance, how can we reduce the high prevalence of
depression in the population of a whole city, or one neighbourhood? This requires the development,
selection and combined implementation of multiple interventions and measures. Compare this, for
example, with the many measures a city takes to reduce traffic accidents and related traffic injuries and
deaths. This stepwise process reflects, therefore, a community health planning approach. This extended
model also includes several additional stages: the dissemination, adoption, implementation and
institutionalisation of effective prevention programmes. In prevention practice these additional steps are
essential to achieve a wide reach of prevention programmes within the population, a high degree of
impact in ‘at risk’ populations, and ultimately a broad mental health, health and social impact in society
as a whole. In addition, the authors will also discuss the Precede-Proceed model, common in health
promotion, which integrates a planning model with a theoretical model on health behaviour, health and
quality of life.
ix
Fig. 3 Developmental Trajectory Effective Prevention
Communityanalysis
Program-development
Needs
Current
prevention
Practices
Setting priorities
Policy
problem analysis
goal analysis
strategy development
designing materials
multiple try-outs
process evaluation
effect evaluation
Model
programs
Combining
Effective
modules
Integral
multi-component
approaches
cost-effectiveness
improved versions
Preventive effects
Large scale dissemination
in the general population
Adoption and Adaptation
and populations at risk
Institutionalizing and Reach
In chapters 12 and 13, two important stages in both models are discussed in more detail: (1) Defining
targets of preventive and health promotion programmes, and (2) the process of designing a preventive
strategy, based on making reasoned choices on strategic dimensions. The stages of evaluation,
effectiveness, and dissemination of ‘model programmes’ are discussed in chapters 14 and 15.
In this textbook, and during the lectures and exercises, the use of these planning models is
discussed and illustrated through themes and risk groups that get a lot of attention in the current
prevention and mental health promotion practice. Since the number of lectures is limited, not all chapters
and items from this textbook can be discussed during the sessions. Students are required to study some
parts themselves without extensive presentations during the course meetings. This applies, for instance,
to chapter 2 about the history of prevention and how different ideologies and scientific developments
have shaped current prevention in mental health. The educational goals of the course (see later in this
chapter), and the study questions at the end of each chapter should give sufficient support to study the
non-discussed chapters independently.
The reader
Originally, this textbook was written in Dutch. In 2009, it was translated in English to make it accessible
to foreign students as well. In the next years, the book has been stepwise revised and updated, based
on the feedback of last year’s students and on recent developments in science and practice. In 2014,
the book was significantly revised and updated.
Part V of this textbook presents applications to a range of core themes in current prevention and mental
health promotion. Chapters 16 and 17 focus on children of mentally ill parents (COPMI), a topic that for
25 years has been a core issue in our own prevention and research work. For other applications
(depression, anxiety disorders, child abuse and E-health), we will refer to some recent publications in
peer-reviewed journals that can be downloaded through the Electronic Journal website of the Radboud
University Nijmegen.
x
Although in 2015 we have put much effort in improving the used English language, it is still
possible that you as a reader will come across typing and grammatical errors. If you have suggestions
for further improvement, also in terms of the content of this textbook, we welcome any comments. These
can be sent to Dr. Karin van Doesum, k.vandoesum@psych.ru.nl.
Finally, this course builds upon earlier provided information on prevention and health promotion
in the psychology curriculum at the Radboud University, especially during single sessions on this topic
in the B1 year and in the B2 course on Health Psychology. As students from pedagogical sciences have
not followed this first introduction, some earlier discussed concepts will be summarised during the
course presentations and in this textbook.
Instructions for the exam
Exam material
The exam material that must be studied consists of:
1) The textbook Introduction to Prevention in Mental Health, edition 2018 (completely revised)
2) Scientific articles are accessible for students through online databases, accessible through
Brightspace.
3) Subjects discussed during the lectures and in the PowerPoint presentations
PowerPoint presentations will be posted in Brightspace. The PowerPoint presentations of the lectures
are meant to a) explain the text in the textbook, but b) they also give additional information and are
therefore exam material unless otherwise indicated.
Starting point for learning the exam topics are the educational goals of the course and the study
questions at the end of each chapter. These study questions are formulated to support the student in
studying the course material and preparing for the exam.
The exam consists of 40 multiple-choice questions with four response categories. The questions do
not only test knowledge, but are also designed to test understanding and ability to think critically.
Additional questions regarding the content of the lectures will be posted separately in Brightspace.
Additional to the multiple-choice exam one can earn a bonus by participating in a group assignment.
xi
Educational goals of the course
Knowledge and insight
Have knowledge and understanding of:
Naive prevention
Concepts of mental disorder prevention and mental health promotion
Different types of prevention
History and origin of prevention and recent developments
Organisation of professional prevention and health promotion
Theories and models of mental disorder prevention and mental health promotion, e.g.
cognitive-behavioural, developmental, stress-theoretical, social support, community
Preventive strategies and methods
Intervention analysis, strategic dimensions, making strategic choices
Prevention on specific themes and target groups
Problem analysis, risk factors, strategies and programmes, outcomes
Effectiveness of prevention and providing evidence
Effect management: strategies to optimise effects and cost-effectiveness
Relation between preventive and curative care / therapy
Skills
Be able to:
Defend the importance of prevention
Think critically about prevention
Discuss the dangers and bottlenecks of prevention
Apply staged planning models
Design a preventive intervention and provide theoretical and empirical justification
Attitude
Acquire a professional preventive attitude
Have an own opinion regarding prevention viewpoints and prevention practice
Have an opinion regarding the place of prevention in your own professional future or
current professional practice
xii
Introduction to the need for prevention
Introductory historical notes
2
The importance of prevention
3
Psychological and psychiatric morbidity
Increasing mental health care use and treatment gap
Social and economic significance
Conclusions and implications
7
1
Introduction to the need for prevention
Clemens M. H. Hosman
Introductory historical notes
Over the last 150 years, many countries around the world have developed a strong preventive
health sector in addition to a curative health care sector. This prevention sector has evolved
as a typically multidisciplinary field, involving public health scientists, epidemiologists, doctors,
educators, district nurses, psychologists, pedagogical scientists, social workers, and recently
health economists. Prevention started as a professional field in the midst of the 19th century
with public health measures such as safe water supply and sewer systems, and with the
emergence of district nurses at the end of the century as its first professional discipline. Their
family-focused work included preventive education and hygiene support.
In the Netherlands and worldwide, behavioural scientists became first active in disease
prevention and health promotion (HP) around 1970. Currently, many professional institutions,
within and outside the health system have experts and even whole departments specialised in
prevention, health education or health promotion. In addition, many health and prevention
scientists are working in universities, research centres and national institutes to develop new
knowledge and effective interventions to strengthen health and fitness of people and to prevent
common diseases. The current prevention field addresses a wide range of diseases, such as
cancer, cardiovascular diseases, caries, accident-related injuries, AIDS and other sexually
transmitted diseases, but also mental disorders (e.g. depression, anxiety disorders) and
addiction. Frequently, interventions aim to influence risk and health behaviours that are related
to these diseases, such as smoking, alcohol use, drug use, exercise, eating habits and dieting
behaviour, child abuse, and bullying. Prevention experts are also involved in reducing social
problems such as poor parenting practices, school dropout, discrimination, domestic violence,
aggression, delinquency, and poverty. Awareness is growing about the narrow relationships
between physical health problems, mental health problems and social problems, and the need
for more integral preventive approaches that address clusters of multiple related problems.
This book is focused on prevention and health promotion in the field of mental health.
During the last 25 years, mental health problems and mental disorders are worldwide
recognized as one of the most important burdens of disease, a significant threat to human wellbeing and quality of life, and a major cause of the increasing economic health costs. In addition,
the evidence is growing that positive mental health (mental fitness and mental capacities)
represents a significant condition for positive social outcomes such as school achievement,
productivity at work, good citizenship, public safety and social cohesion.
In this introductory book, both science and practice of prevention will be discussed.
Although examples from preventive practice will be presented from all over the world, special
attention will be given to prevention in The Netherlands and other European countries, where
the authors of this book have their professional roots. For practical reasons, we will use the
term ‘prevention’ to refer to both prevention of mental disorders and mental health promotion.
2
The importance of prevention
Societies have become more and more prevention-oriented over the last century and health
care has become increasingly preventive in its approach. Also within mental health care,
prevention has gained a position. The need for prevention became explicit in response to the
growing insight in the high prevalence of mental disorders and poor mental health, the alarming
increase in use of mental health services and related economic impact. Taking the Netherlands
as an example, the Dutch Scenario Committee on Mental Health and Mental Health Care
concluded that the demand for specialised mental health care had increased dramatically over
the period 1970 – 1990 and predicted a further rise in service use until 2010 (Scenario
Commission GVG and MHC, 1990). The facts of the last 20 years have confirmed this
prognosis. As from 2000, specialised mental health care in the Netherlands has even become
the fastest growing sector within the whole health care system. We will discuss this increase
in use later more in detail.
With the increase in treatment use, the involved economic costs have increased
dramatically as well. In the Netherlands, the direct treatment costs of mental health care for
2011 were estimated at € 5.7 billion and all treatment costs for mental illnesses across the
whole health system at €19.6 billion (RIVM, 2011). Due to these rising costs in combination
with the economic recession, governments and health organisations are challenged to find
innovative solutions that maintain high quality of mental health care for many, while reducing
the total costs significantly. More investment in prevention might prove to be an effective cost
reduction strategy, apart from its value for reducing avoidable human suffering.
Psychological and psychiatric morbidity
According to the figures presented in a five countries study (US, Canada, Netherlands,
Germany, Chili), the annual prevalence of DSM-IV mental disorders in the population is
estimated to vary between 17% and 29%, as measured by the CIDI instrument (Bijl et al.,
2003). In the Netherlands, a prevalence of 24.4% was found, including an annual prevalence
of 8.2% for mood disorders, 13.2% for anxiety disorders and 9.9% for substance use disorders.
This means that each year around one in four persons experiences severe psychiatric or
psychosocial problems that meet the international diagnostic criteria of the DSM-IV. In an
extensive review on the current knowledge on psychiatric epidemiology and prevention, a
committee of researchers at the American Institute of Medicine concluded that in both children
and adults, the one-year prevalence of a diagnosable psychiatric disorder is about 20%
(Mrazek & Haggerty, 1994; National Research Council and Institute of Medicine, 2009). There
are several indications that 'psychiatric morbidity' has increased in recent decades, particularly
concerning problems and disorders in which social and cultural factors play a major role. Hard
evidence for this increase does not yet exist because of a lack of reliable epidemiological
comparisons based on longitudinal studies.
An increase can be expected due to the improved life expectancy at birth in braindamaged children, and an increase of dementia because of the growing number of elderly over
80 years of age. It is also expected that a growing proportion of the world population will be
exposed to circumstances that lead to more risk and vulnerability to mental disorders due to,
for instance, disappearing traditional networks, economic recession, globalisation and their
social consequences. Globalisation causes, for example, economic migration with a strong
impact on family life, a clash of cultures and a loss of traditional values and social networks,
3
drugs criminality, poverty and trafficking of women and children. It is expected that growing
environmental problems, shortages of natural resources (e.g. food, water and energy),
conflicting religions and inequity between rich and poor will increase risks of social conflicts,
wars, refugee flows and related losses and traumatic experiences. The call from citizens,
health professionals and organisations is becoming louder to reflect on ‘social answers’ to
these social threats of mental and physical health. This is illustrated by two recent
‘Declarations’ accepted at world conferences on mental health and mental health promotion,
the Melbourne Charter on Promoting Mental Health and Preventing Mental Disorders 2008
and the Lyon Declaration on Globalisation and Mental Health (October 2011).
Increasing mental health care use and treatment gap
In the Netherlands, between 1990 and 2005 the number of clients in outpatient mental health
care increased by 123% and for intensive treatment even by 239% (Trimbos Institute
publications). Converted in absolute numbers, there were “only” 535,000 clients in mental
health care in 2001. This number grew from 638,000 to 757,000 between 2003 and 2005, and
further increased to over 1 million clients in 2010. This could be seen as a success of longterm efforts to make mental health services more available and accessible to those who are in
need. It is, however, questionable if we should consider 1 million inhabitants (from a total of
16.5 million) with serious mental health needs and receiving specialised mental health services
as an acceptable public mental health situation.
Nevertheless, the number of people with
Box 1 Treatment gap in Europe
mental disorders who do not receive professional
Many do not receive professional treatment
help is still large, as data show (Box 1). Comparisons
•
Alcohol dependence 92.4%
from epidemiological studies in the US, Canada,
•
Anxiety disorder
62.3%
Netherlands, Germany and Chili show that even
•
Panic disorder
47.2%
among the severe cases of mental illness one third
•
Major depression
45.4%
to two third did not receive any professional
•
Bipolar disorder
39.9%
•
Psychosis
17.8%
treatment (Bijl et al., 2003). Among the cases with a
mild mental disorder, between 50% and 75% were
Source: Kohn et al. (2004)
found untreated. For the Netherlands, the
percentages of untreated cases were 33.7% for
serious disorders and 57.0% for mild disorders.
These figures illustrate, as George Albee already argued in 1959 and at many
occasions later, that the mental health treatment system will never be able to treat all cases of
mental disorders present in a population. This offers a strong argument for changing national
mental health policies from a dominating focus at curative care and specialised treatment to
more investments in preventing the onset of mental disorders (Albee, 1959; 1996). Professor
Albee was former president of the Clinical Psychology Division of the American Psychological
Association and one of the most famous advocates and pioneers of prevention for almost 50
years. In addition to this ‘treatment gap’ argument, Albee stated that even when treatment
facilities would be expanded, it is not expected that this will result in a substantial reduction of
psychiatric disorders in society: "Public health teaches us that no mass disease or disorder
has ever been controlled or eliminated through individual treatment or by increasing the
number of therapists” (Albee, 2005, p. 37). Here, the Dutch expression “Dweilen met de kraan
4
open” (“Mopping the floor, while leaving the tap
open”) is very appropriate. To stop a serious
water overflow (new mental disorders) one
should close the running tap (prevention);
mobbing the floor with a running tap (treatment)
does not help. Prevention is aimed at averting
new cases of mental disorders by removing or
neutralizing the causes.
Social and economic significance
The importance of prevention is not only inspired
by ethical considerations about preventing
avoidable human suffering and the ever-increasing demand for care. In addition, the social and
economic consequences of psychiatric morbidity argue for an increasing investment in
developing effective forms of prevention. This concerns in particular the large impact of mental
disorders on social security costs, labour productivity, absenteeism, and social benefits.
For the last 20 years, the social and economic value of mental health has been
increasingly understood. For instance, depressive disorders are responsible for a larger loss
of productivity than any other health problem, except for cardiovascular disease (Mrazek &
Haggerty, 1994). In England, the cost of depression, both for direct treatment and indirect costs
such as loss of production are estimated at €14.5 billion per year. Only 4% of these costs are
treatment costs (Thomas & Morris, 2003, Figure 2). The costs of depression in the Netherlands
are about €1.3 billion per year. This amount includes €660 million for medical expenses and a
similar amount of money for absenteeism and loss of productivity (GGZ Nederland, 2007).
Mental disorders and poor mental health lead also to other type of costs such as school
dropout, loss of academic achievement, lower income levels, unemployment, youth and adult
delinquency and related costs for police and justice. Some years ago, the total European total
costs for affective disorders, anxiety disorders, psychotic disorders and addiction were
estimated at €360 billion by a Swedish economic institute (Andlin-Sobocki, Jonssen, Olesen &
Wittchen, 2005). Recently, the World
Economic Forum estimated the total costs of
mental disorders worldwide to be $2.5 trillion
in 2010 and expects that by 2030 these
costs will more than double to an amount of
$6 trillion ($ 6.000.000.000.000) (WEF,
2012).
Insight in these costs and which
stakeholders in society are affected by it is
crucial to develop coalitions of multiple
organisations and social parties who are
willing to invest in prevention of mental
disorders and promotion of mental health. Many different stakeholders are directly or indirectly
affected by the human, social, and economic burden of mental disorders. Stakeholders include
first of all citizens themselves being either patients, family members, neighbours, colleagues
or tax payers, but also health care professionals, schools and teachers, companies, health
insurers, social benefit officials, local governments, justice, and police. In a positive way, good
5
mental health is considered to be a keystone in a wide spectrum of positive human and social
outcomes, such as a higher quality of life and well-being, better physical health, less chronic
diseases and mortality, better academic achievements, higher productivity at work, good
citizenship, social cohesion and social participation, safe communities and less violence, and
finally to significant cost reductions in health, social security and justice.
The more we can convince different stakeholders in our society of the impact mental
health has on their primary interests, the more we may expect them to be willing to invest and
support health promotion and preventive programmes to improve ‘mental capital’ and to reduce
the burden of mental illness. Opportunities for implementing prevention and health promotion
programmes are heavily dependent on their support. The main arguments for the need to
invest in the prevention of mental disorders and promoting mental health are summarised in
Box 2.
Box 2
Ten arguments for investing in prevention of mental disorders
1.
Humans are by nature preventive beings, but the efficacy of their ‘naive prevention’ has
its limits and regularly fails. Professional prevention aims to restore and strengthen the
preventive capacities of citizens, families, organisations and communities.
2.
Serious psychiatric problems are prevalent in society and have reached epidemic
proportions. This number is expected to further increase as well as the demand for
treatment, unless the society invests more in mental health promotion and prevention.
3.
An important number of people with serious psychiatric problems is without help
(untreated morbidity) notwithstanding expanding services: the treatment gap.
4.
In the end, therapeutic help resembles at “mopping up the floor while the water tap keeps
running” (Dutch expression). “Therapy has never eliminated a disease from society”
(George Albee, one of the founders of prevention of psychopathology).
5.
The costs of curative mental health care and many other social and economic costs of
mental disorders are high and expected to increase significantly. Investments in
prevention can reduce these costs.
6.
Psychiatric disorders are a significant risk factor for chronic physical disorders and preterm mortality. Preventing mental disorders is expected to contribute to less physical
illnesses and mortality.
7.
Mental health care often means individualising problems of people, while many problems
are the outcome of social factors (e.g. poverty, domestic violence, discrimination).
Therapy is not addressing such causes and does not have the potential to change them;
prevention and health promotion may also include efforts to influence social risk factors.
8.
Historically, the focus of health care systems has evolved from caring to curative and,
during the last century, more and more to prevention. Society as a whole develops
steadily towards a more preventative orientated society, across multiple social sectors
investments in prevention are increasing.
9. Preventive interventions are found to be effective in controlled studies and show a wide
range of health-, social- and economic effects.
10. A mere treatment-focused health care system should be considered as unethical when
possibilities for effective prevention exist.
6
Conclusions and implications
Why did we start this book with an introduction on the need for prevention and an overview of
the arguments? When a person develops an illness, he mostly feels sick and suffers from
physical pain, emotional stress or other symptoms. When these symptoms subsist, a feeling
of suffering usually urges the person to go to his (her) general practitioner to seek professional
help. When needed the general practitioner involves medical specialists and hospital
departments for further diagnostic support and specialised treatment. As many people in the
population suffer from a physical or mental illness there is a constant and large public demand
for ‘curative care’, i.e. medical and mental treatment. Our health system and related financing
systems (e.g. health insurance) are primarily designed to cover this demand for treatment of
diseases.
Managers of health services (e.g. hospitals and outpatient services) and the medical
professions strongly protect their established budgets for treatment and care. Especially
nowadays, while governments and health insurance companies pressure them to reduce their
budgets. As a result, the part of the national health budget spent on prevention is and stays
marginal (Box 3). This also applies to the field of mental health. The highly skewed distribution
of health investments, mainly financing curative care, is highly debatable from both an ethical
and an economic perspective.
Box 3
Some facts about costs of the Dutch health care and prevention
•
The total costs for health care in The Netherlands were 89.2 billion in 2010
•
Costs of health care as percentage of the gross national income (GNP), spent on
health care have increased from 8% in 1972 to 13% in 2010. A recent study by the
Netherlands Bureau for Economic Policy Analysis predicts these costs will increase
further to between 19% and 31% of the GNP in 2040, i.e. between one fifth and one
third of the national income. Awareness that such increases become unaffordable.
•
In 2007, the national expenses for prevention were about €13 billion. From this budget,
€10 billion were spent outside the health care system on health protection, especially
on improving traffic safety and reducing air pollution. Only €3 billion of these prevention
budgets was spent by the health care system, mostly for screening of patients,
preventive medication, and vaccination (€2.5 billion).
•
Only €0.5 billion, which is less than 1% of the national health budget, was spent on life
style improvement (health promotion) and behaviour-focused preventive interventions.
Sources
Centraal Planbureau (2012). Trends in health care. The Hague: Netherlands Bureau for Economic
Policy Analysis.
RIVM National Institute for Public Health and Environment.
CBS 2011. Uitgaven aan zorg groeien minder snel (Spendings to care show a lower increase). Press
release, 18 mei 2011, Netherlands Bureau for Statistics.
Efforts to improve resources for prevention and health promotion face at least two major
barriers. To begin with, prevention advocates cannot refer to an immediate need for action as
easily as patients who are suffering from an acute illness. Secondly, it is hard to overcome the
7
resistance of established and powerful stakeholders in medical care defending their budgets.
Strong arguments are needed to convince health managers and policy makers that they should
shift part of the health budgets from care to prevention. In addition, for their implementation in
practice, prevention and health promotion programmes depend heavily on collaboration with
and support from local organisations (e.g. schools and companies) for whom preventive work
is not their core business. Asking them to invest in prevention could on first sight, even compete
with their primary concerns (e.g. efficient use of teachers’ hours, or intensifying productivity).
As a result of these circumstances, prevention and health promotion managers and
practitioners spend much of their time convincing policy makers, financing agencies and other
stakeholders of the need for and the benefits of prevention and health promotion. The
perspectives for their work are depending on their expertise in convincing different
stakeholders in society of such benefits. This requires a deep understanding of the core
interests and priorities of these stakeholders and how promotion of mental health could benefit
these interests. This chapter has presented a range of arguments and ways of thinking that
advocates of prevention can use to strengthen their argumentation and position. Such
advocates are not only prevention and health promotion managers, but also individual
practitioners as primary health care psychologists and youth care professionals who want to
increase their preventive work with clients, schools and workplaces.
Literature
Albee, G. W. (2005). Call to revolution in the prevention of emotional disorders. Ethical Human
Psychology and Psychiatry, 7(1), 37-44.
Andlin-Sobocki, P., Jonssen, J., Olesen, H. U., & Wittchen, B. (2005). Cost of disorders of the brain in
Europe. European Journal of Neurology, 12, 1-27.
Bijl, R., de Graaf, R., Hiripi, E., Kessler, R., et al. (2003). The Prevalence of treated and untreated mental
disorders in five countries. Health Affairs, 22, 3, 122-133.
Kohn, R., Saxena, S., Levav, I., and Saraceno, B. (2004) The treatment gap in mental health care.
Geneva: Bulletin of the World Health Organization, 82 (11).
Mrazek, P. J., & Haggerty, R. (Eds.). (1994). Reducing risks of mental disorder: frontiers for preventive
intervention research. Washington: National Academy Press.
Melbourne charter 2008: http://www.vichealth.vic.gov.au/en/Publications/Mental-health-promotion/
Melbourne-Charter.aspx
National Research Council and Institute of Medicine. (2009). Preventing Mental, Emotional, and
Behavioral Disorders among Young People: Progress and Possibilities. Committee on
Prevention of Mental Disorders and Substance Abuse Among Children, Youth and Young
Adults. Washington, DC: The National Academies Press.
Thomas, C. M., & Morris, S. (2003). Cost of depression among adults in England in 2000. The British
Journal of Psychiatry : The Journal of Mental Science, 183, 514–519.
Study question for this chapter
What are the arguments for investing in prevention of mental disorders and promotion of
mental health?
8
PART I
PREVENTION
HISTORY AND CONCEPTS
9
10
1 Naive prevention: on the preventive nature and
culture of man1
1.1
Introduction
12
1.2
Preventive behaviour in animals
13
1.2.1
Natural selection
14
1.3
Naive prevention
15
1.4
Humans as prevention-oriented beings
16
1.4.1
Preventive role of reflexes and learned responses
16
1.4.2
Preventive behavior in daily life
16
1.5
Prevention in primitive cultures
17
1.5.1
Sculptures, masks, fetishes and amulets
17
1.5.2
Taboos
18
1.5.3
Myths and legends
19
1.6
The preventive meaning of rituals
19
1.6.1
Functions of rituals
20
1.6.2
Transition rituals
22
1.6.3
Mourning rituals
23
1.6.4
General decline of rituals
25
1.7
Conclusions
25
1.7.1
Elements of preventive processes and capacities
26
1.7.2
Failing naive prevention
26
1.7.3
Challenges for professional prevention
27
Literature
29
Study questions for this chapter
30
1
This chapter is a revised version (2013) of a text originally written by Clemens Hosman in 1985.
11
1 Naive prevention: on the preventive nature and culture of man
Clemens M. H. Hosman
1.1
Introduction
As an academic, it is tempting to consider the development of preventive practices and
preventive care in a community as mainly initiated by professionals and researchers. It is a
dominating tendency to assume that "prevention" was invented by public health specialists. It
is true that ‘prevention’ as a formal task of health systems in societies was introduced in the
midst of the 19th century when public health services emerged. It is also true that professional
preventive care has been strongly developed during the 20th century with extensive use of
scientific knowledge and intervention theories and social technology, from neurobiology,
psychiatry, epidemiology, psychology, pedagogical science, sociology, social marketing and
health promotion.
This attitude, however, might cause preventive mental health care, like other health
care sectors, to fall into the trap of progressive professionalisation, also called ‘protoprofessionalisation’, and not recognizing the true preventive nature of human beings,
communities and societies. Proto-professionalisation refers to the process of making people
for their health and wellbeing more and more dependent on professionals and academic
knowledge. Although scientific knowledge has proved to contribute significantly to better health
and lower mortality rates, overestimation of their value can also have a detrimental effect on
the survival of natural care systems and natural preventive systems in society. As argued by
the philosopher Iwan Illich, proto-professionalisation leads to "structural iatrogenesis”: the
decline of non-professional or natural health care and self-care in a society, because
professional health care increasingly takes over care functions that previously belonged to
preventive or curative care provided by people themselves, or by their family, friends,
neighbours or other community support systems (Illich, 1974). The term ‘iatrogenesis’ is
derived from Greek and means illness producing. By emphasising more and more professional
health care to address health threatening conditions, the preventive capacities that humans,
communities and cultures have developed over many generations and even millions of years,
might decline and citizens become more and more dependent of professional care. This in turn
might increase their vulnerability to diseases or serious mental and social problems.
On the other hand, since the 1980s there has been a strong plea in favour of further
professionalisation of efforts to prevent mental disorders like it has been done for other disease
categories such as cancer, cardiovascular diseases and AIDS (Hosman, 1989, 1991). If
prevention as a professional sector wants to have a legitimate place in the health care system
and society as a whole, it should offer additional value to ‘natural’ preventive practices and
self-care. To create this additional value, the use of scientific knowledge is crucial and scientific
evidence that such interventions are effective and indeed add value should be provided. This
also requires national policies for prevention and health promotion, more research, a
specialized professional workforce, and professional training. Creating these conditions is
already on international agendas since the 1980s, and they are still relevant to date. At the
start of the 21st century, international organisations such as the World Health Organization
(WHO), the European Union (EU) and the World Federation for Mental Health, have declared
12
science-based and practice-based prevention of mental disorders and the promotion of mental
health to be high public priorities.
At first sight, these stances seem contradictory: a plea for non-professionalisation versus a
plea for professionalisation. Criticism on the proto-professionalisation in health care during the
1970s and 1980s especially found support among health promoters and preventionists, who
advocated for ‘empowerment’ of natural health promoting capacities in citizens and
communities and stimulating self-help approaches. Originally, this resulted in a reserved
position against a scientific approach to prevention. This attitude has significantly changed in
the last 30 years, while our field increasingly became aware that empowerment of citizens and
communities, and scientific approaches can productively go together, and need each other.
Certain risk factors only become visible through long-term scientific research, such as the
impact of stress, anxiety and depression during pregnancy on the developing cognitiveemotional brain systems of the child, or the wide spectrum of long-term detrimental effects of
early child abuse and neglect. In longitudinal studies, popular parenting practices many people
believe to be effective (e.g. harsh punishment) have found to be counterproductive. Also
common views of local practitioners on the effectiveness of some local preventive practices,
have found to be untrue when tested in controlled research. Like medical interventions and
pharmaceuticals, professional prevention and health promotion has to legitimize its existence
by providing evidence for its added value and lack of negative side effects. This requires
scientific research and expertise, in combination with critical reflections by practitioners and
other involved stakeholders. Over the last decades much has been invested in expanding the
science base of prevention and health promotion, resulting in evidence for many effective
prevention programmes (Coie et al., 1993; Mrazek & Haggerty, 1994; Hosman et al., 2004; US
National Research Council and Institute of Medicine, 2009). Nevertheless, prevention experts
and scientists need constantly to be aware of the danger of creating too much dependency on
professional care (proto-professionalisation), and the need to respect, use and reinforce the
capacities already present in people and communities.
This chapter discusses preventive functions and behaviours that show itself in nature and
culture, not elicited by professional interventions. Scientific prevention without the drawbacks
of professionalisation is only possible when it chooses this ‘natural prevention’ or ‘naïve
prevention’ as a starting point and understands its role. The chapter describes examples of
preventive practices we encounter in our current everyday life of animals and human beings,
and can already be found in the life of primitive human cultures.
1.2
Preventive behaviour in animals
Some animals stand out because their looks and behaviour seem to have an obvious
preventive value. For instance, animals such as the chameleon and certain fishes and birds
have a perfect camouflage and can therefore easier escape the attention of an enemy (Fig.
1.1, left). Several animals even have different appearances in summer and winter, which
makes them less visible for predators, for example, brown in the summer and white in the
winter (e.g. hares in the Nordic countries). Other animals, such as the peacock and certain
butterflies (e.g. the moth) have eye-like spot patterns to deter predators (Fig 1.1, middle).
13
An elephant is easy to spot, so he will seek protection in the herd when there is danger.
Baboons use the so-called "two phase shout", a signal to indicate threat to their colony and an
incentive for collective flight behaviour to avoid confrontation with a dangerous intruder.
Animals not only show preventive behaviour when they are in danger, but it may also occur
long before such a threatening situation becomes reality. A squirrel stocks up on food
provisions at the end of the summer. At that moment it seems useless, but later when it is
winter it becomes clear that his behaviour was useful: he will not starve by a lack of food (Fig.
1.1, right). Birds migrating to the south is another example of natural preventive behaviour
when the winter is approaching in the north and food will become scarce. Sometimes, the
period between such animal behaviour and its effects is even bigger. When young lion cubs
regularly fight with each other, they develop strength, speed and dexterity. These skills will
help them later as adults to look for food and self-preservation.
At first sight, these examples suggest that animals have the ability to deliberately aim
for a preventive goal: self-preservation, hazard avoidance, and guard against future threats.
However, as the etiologist van den Assem already stated in 1973, it is obvious that animals do
not have the same sense of purpose as humans do, i.e. a pre-conceived objective, pursued
through rational behaviour. We assume that animals are not aware of what they do or why they
do it. There is no evidence to suggest that on a beautiful summer day the squirrel thinks, “Well
this is a good time to start my winter stock of nuts. If I do not start soon I might starve in the
winter”. In such cases, therefore, it is better to speak of behaviour with a preventive 'function'
or 'survival value', as Darwin states it. Behaviour that appears to have a preventive function is
more likely to persist through the process of natural selection.
1.2.1 Natural selection
Natural selection is mainly based on a simple principle: a statistically unequal chance to
contribute to the next generation. Between individuals of the same species differences
(variation) exist both in structure and in behaviour. These are partly based on differences in
the environment where the animals live or grow up, and partly due to hereditary differences.
Because of these differences some individuals are better adapted than others to threatening
14
environmental conditions. The squirrel that was not able to stock enough food for winter will
be the first to starve and does not produce offspring the next year.
Better-adapted individuals produce more fertile offspring than their less adapted
counterparts. The (preventive) characteristics of better-adapted animals will pass on by
inheritance and may become more represented in the next generation. This process repeats
itself across many generations and, if conditions remain the same for a long time, these
"preventive" capacities of the better-adapted animals will become increasingly common.
Darwin called this favouring of certain genetic patterns over others, ‘natural selection’.
Natural selection is not the only way in which animals develop behaviour with a
preventive effect. It is generally known that individual animals are capable of learning, as it
applies to human beings. A dog can learn through training or by trial and error that he should
not run onto the busy motorway in front of the house. However, learned behaviour is - to our
knowledge- not genetically translated onto a next generation. This makes natural selection, at
least for animals, the main base from which they develop preventive behaviours and
characteristics.
1.3
Naive prevention
In general, preventive behaviour can be seen as behaviour that prevents harm or exposure to
harmful situations. In the context of this chapter on biological roots, the term prevention is less
appropriate, because this word has not been introduced earlier than in the 19th century to refer
to planned actions and measures to reduce diseases in the population (chapter 2: History of
preventive mental health care). To describe preventive behaviours or mechanisms that have
developed through biological and social evolution, other terms might be more suitable, such
as self-preservation, self-defence, avoiding danger, or adaptation.
Present prevention experts and health promoters use educational programmes and
social and environmental measures to promote people showing healthier and more preventive
behaviour (e.g. healthy eating, daily exercise, safe driving, no domestic violence). It is
important that professionals are aware that people are not a blank sheet when it comes to
prevention. Biological evolution, cultural transmission, socialisation, and life experiences have
already pre-programmed people to many preventive behaviours, although not all of them might
be effective. This includes physiological, cognitive, emotional and behavioural types of
programming. When designing preventive interventions, we must take this existing
programming into account, as people will not simply change their behaviour because
professionals advocate for certain new behaviours as being healthier.
Preventive behaviour in the domains of mental and physical health has always been
an integral part of human nature and culture. The science and practice of prevention could
benefit from knowledge of this so-called "naive prevention", the natural preventive behaviour
that can be expressed in biological, psychological and social ways. Prevention and health
promotion experts should therefore constantly ask questions like: What do people already use
in their daily lives to prevent harm in the future or to safeguard their well-being? Do certain
values, norms, habits and rituals have a preventive function? What positive and negative
effects do they have? Are there ‘blind spots’ or incapacities in our natural preventative care,
which might lead to diseases and disorders? Have traditional preventive mechanisms lost their
original value due to the rapid economic and cultural changes?
15
1.4
Humans as prevention-oriented beings
Humans have a wide variety of congenital and acquired capabilities to preserve their species.
The following examples will show how much this preventive orientation is interwoven with
everyday life.
1.4.1 Preventive role of reflexes and learned responses
Reflexes on sensory stimuli form the most basic preventive capacities in human biology. An
obvious example is the blink reflex. Each of us has experienced that our eyes automatically
close when they are overly stimulated by bright light or an impending collision with an object.
The narrowing of the pupil in bright light (pupil reflex) has a similar preventive function; it
prevents tissue damage in the retina. Also pain sensations try to protect the body against
(further) injury. A small child touching a hot stove, will pull back immediately to avoid a serious
burn. Pain is a preventive reaction providing very pervasive signals that “tell" us that something
threatens to go wrong. Apart from the prevention of direct damage, the pain signal is also a
protective response in long-term prevention. Those who have once been badly burned will be
wary that it does not happen again. The experience of pain enables us to learn adequate
responses to avoid similar dangerous situations in the future.
Reflexes are preventive capabilities that humans have acquired through biological
selection processes during their evolution. Furthermore, we learn signals ("cues") of potential
dangers through classical and instrumental conditioning and through tradition and education.
Examples are beginning toothache, "something sharp", and a thermometer with a value below
zero, a red light signal, a siren, a label with a skull, and the smell of smoke. Knowledge of the
meaning of these signals helps us to prepare for risks and future damages and to avoid or
reduce them.
Depending on when a threatening situation is already present or is to be expected in
the near future, we speak of reactive and proactive prevention. The experience of pain or a
direct confrontation with violence indicates that there is already a health-threatening force
("stressor") present. Preventive behaviour in response to this existing stressor is called
"reactive prevention” and aims to reduce its harm. When we respond to signals of future
dangers and show anticipatory behaviour to avoid or prepare for them, or even prevent them
to occur, we speak of "proactive prevention". This is the case when we protect our house
against burglary, brush our teeth, and take driving lessons or when parents or teachers inform
children about the danger of sexual abuse and how you should act when such a situation
should arise.
1.4.2 Preventive behaviour in daily life
Although we are not always aware of it, there are innumerable examples of preventive
behaviours in our daily lives. Parents explain their children what dangers they might encounter
when they will participate in traffic or start using alcohol, in the hope that they are better
prepared for these risks and learn to avoid them. Dangerous drugs and bottles are stored in a
way children cannot poison themselves. They are taught social skills to be capable to build
and maintain good social relationships in their later life (Figure 1.2).
16
Parenting has everything to do
with prevention: teaching and developing
knowledge,
social-emotional
and
cognitive skills and resilience to stress
during childhood, to prepare the later
adolescent and adult to be able to tackle
many problem situations and to make
them able to further develop themselves.
Taking out an insurance policy is another
example of prevention. People insure
themselves against the risk that they will
face unaffordable costs in the future, due
to illness, accidents, fire or damage to others. Preventive behaviour requires a current
investment (cost) to avoid higher costs or receive important benefits (profit) in the future. We
have become used to information about fire, accidents or burglary prevention through TV
programmes, posters, brochures and other warnings. Even many simple tools we use daily
have a preventive value, such as a winter coat, bicycle-bell, toothbrush, door key and an
umbrella. They have become a familiar part of our everyday environment. In short, our
everyday life and social life are intertwined with many preventive behaviours and mechanisms.
1.5
Prevention in primitive cultures
The need to prevent disaster, to avoid all kinds of ‘evil’, and to secure our own survival and
happiness is typical for human nature. Preventive customs are a substantial part of any society
and culture, and are already very visible in so-called primitive cultures.
1.5.1 Sculptures, masks, fetishes and amulets
This preventive attitude is clearly
reflected in the sculptures of
primitive tribes. For the modern
Western world, these sculptures
are mainly aesthetic objects, but
originally they were not purely
created for this purpose. In
primitive societies the artist had
an important functional and
religious role. Primitive men live in
a difficult world, faced with lack of
food, illness, death, danger in the
hunt and attacks from other tribes.
17
To protect themselves
humans in primitive cultures
sought refuge in magic and
religion, and asked for the help of
gods and the spirits of ancestors.
The
artist's
role
was
materialising the contact with this
supernatural world. Sculptures,
masks and amulets are primitive
tools to come into touch with and
visualise the spiritual world
(Figures 1.3 and 1.4). People in
primitive cultures believe that
gods and ancestors are actually
present in these images and when in a good mood - have a protective (preventive) effect on their daily life (Fraser, 1962;
Winizki, 1972; Africa Museum, 1981). These images and sculptures were placed in the house,
at the front of a temple (guards) or sometimes on the borders of the village to protect residents
against diseases and hazards. In a threatening situation, a new nail was beaten in an ancestor
sculpture to activate the protective power of the ancestor. Terrifying masks were used to ward
off impending epidemics or other evil. Amulets are small versions of these statues and masks
that people carried with them to protect themselves. In modern society amulets and charms
are still used for this purpose. Museums on primitive art, such as the Africa Museum near to
the university town Nijmegen, offer collections of such protecting sculptures and masks.
1.5.2 Taboos
The use of taboos, found in all societies, also has a preventive meaning. Taboo is originally a
Polynesian word (tapu) which refers to ‘something that needs to be avoided’. This can be
persons, objects or acts that may possess a threat or dangerous powers. Because of the
demonic conception of life in primitive cultures, ‘madness’ was seen as possession by evil
spirits or as punishment from the gods for the breaking of a taboo. When the behavioural
constraints of taboos were breached, an automatic supernatural punishment was supposed to
follow. For example, food taboos on consuming meat of particular animals exist worldwide.
Although taboos are often related to religious notions (e.g. pure and impure), the origin
of taboos often had mostly a very practical reason. The taboo on eating pork meat in the Jewish
culture can be explained from the time that bacteria were often present in pork meat, and the
food often led to disease or death. We can speak of a rational measure with a clear preventive
function, even though at the time people did not know about bacteria and attributed a religious
meaning to the harmful effects. The modern use of fridges and preservatives made the original
function of this taboo superfluous, but the religious tradition continues. There are probably
many more of these in origin preventive actions and taboos that we now no longer recognise
as such. They have lost their function due to material and cultural changes over time. They still
exist because of their derived purpose, which already in early social psychology is called the
principle of functional autonomy (Allport, 1937).
Another well-known taboo is the taboo on incest (e.g. Freud's 'Totem und Tabu', 1912).
Margaret Mead (1968) describes how the opinions of scientists on the taboo function of incest
18
diverge widely. Some suggest that the purpose of the incest taboo is the prevention of
inbreeding and mental retardation. Others, such as Freud, consider the function of the incest
taboo as protection of the integrity and continuity of the family. Biologists state that the incest
taboo serves to arrange complementary relations with other social groups, because these
relations are necessary for the development of the gene pool and the chances of survival of
our species. Especially in the last 25 years, psychological and psychiatric research has made
evident that incest has a very harmful and long term impact on the social-emotional
development of a child and later functioning of adults. Independent of the type of explanation
all theories attribute a preventive function to the incest taboo.
1.5.3 Myths and legends
Also myths and legends perform a preventive role in ancient cultures and Eastern philosophies.
Referring to Chinese philosophies such as Taoism, Mora (1962) states in his essay on the
history of psychiatry: "The principle of prevention achieved through proper education was also
stressed: the ancient sages did not treat those who were already ill, they instructed those who
were not ill" (p. 18).
Myths and legends, ancient types of story-telling, are used to prepare us for possible
disaster, but also to educate on coping with common life issues such as illness, death, and
parenting problems. Mostly they do not offer a concrete advice how to act, but give courage
and self-confidence to people, and offer a positive outlook on problem situations. They contain
a clear ideological message: to make sure that life does not get you, it is important to develop
your physical and mental strength.
This message strikingly resembles to what in modern mental health promotion is called
the "educational approach" or “positive mental health approach”. This approach has a strong
emphasis on strengthening people’s personal skills (resilience). More confidence, more selfunderstanding and greater self-realisation are partly pursued as an end in itself, and partly
because they offer protection against many life threatening conditions, including mental
disorders. This approach builds on ancient philosophical traditions such as Zen Buddhism, in
which the process of self-realisation is also seen as the main condition for mental well-being.
Educative story-telling through myths and legends is associated with past times and
does not appeal to modern youth, who will disregard them as outdated practices. It would be
incorrect, however, to conclude that educative story-telling has disappeared in modern culture.
Current practices of story-telling with an educative function can easily be found in comic
educational strips, children’s books and modern saga (e.g. Harry Potter, Lord of the Rings),
modern movies and documentaries (e.g. relational problems, parenting) and on the internet
(e.g. websites of NGOs, blogs and Facebook of experts with a lived experience, you-tube films
by fellow-sufferers).
1.6
The preventive meaning of rituals
Rituals exist in all societies, both primitive and modern. Due to numerous scientific studies
much is known about the psychological and social meaning of rituals (e.g. van der Hart, 1978;
d'Aquili et al., 1979; Lukken, 1984; Salemink, 2006). This can help us understand how ‘natural’
preventive mechanisms work, because rituals represent a clear example of these natural
19
mechanisms. Moreover, these studies show that the disappearance of traditional rituals and
the lack of renewing rituals can have a strong impact on the mental health of people.
It is not easy to describe what a ritual is, while multiple characteristics are attributed to
rituals, reflecting different views. Rituals can have religious, psychological and social
meanings. In general, it can be said that rituals have a symbolic character. They are “habits
with something extra: the acts refer to something else” as the clinical psychologist Van der
Hart already stated in 1978 (p.32). He defines rituals as: "prescribed symbolic acts that need
to be performed in a certain way and in a certain order- whether or not accompanied by verbal
formulas” (p.33). For this book on prevention, especially the
functional meaning of rituals for a person, his environment or
Box 1.1 Types of
society as a whole is important and will be discussed in the
rituals relevant to
mental health
next sections.
There is a large variety of rituals, e.g. protest rituals,
Healing rituals
war rituals, healing rituals, liturgical rituals and opening
Birth rituals
rituals. There are also repetitive rituals, for instance greeting
Initiation rites
rituals. Seen from a mental health perspective the most
Marriage rituals
important rituals are the ‘transition’ rituals (rites de passage)
Family rituals
because they help us cope with important changes in our
Mourning rituals
Meeting rituals
lives. As the death of a child, partner, parent or a friend
Religious rituals
places a heavy emotional burden on people and strongly
Conflict-related rituals
challenges their emotional competence and capabilities to
Reconciliation rituals
mourn, mourning rituals are discussed more extensively (Box
1.1).
1.6.1 Functions of rituals
This paragraph will give an overview of the different functions rituals can have, as described
in anthropological (d'Aquili et al., 1979; Lukken, 1984) and psycho-logical theories (van der
Hart, 1978).
The adaptive and economical function
Generally, a distinction is made between psychological and social functions of a ritual, in which
social can refer to functions of rituals within groups, communities and the society as a whole.
Throughout their lives individuals, groups and communities have to deal with many problems,
have to react to threats and challenges, and to adapt to internal and environmental changes.
This was also the case for previous generations, so for most problems we can use the creativity
and solutions that others before use have developed. Adequate solutions will be repeated and
transferred from generation to generation, which is an essential element of ‘culture’. Rituals
are the carrier of important learning experiences from the past that make them available for
the present. In a way, they can be considered as the preventive memory of a society. As long
as they are a useful solution for current problems, rituals will form an important part of our
adaptive systems and preventive capacities. Besides this adaptive function, rituals have an
economic function. Because they serve as ready solutions, they save us a lot of thinking, risky
try-outs and disappointments, and needless loss of energy in difficult periods of our life.
However, there is a drawback. When rituals do not longer offer a good solution to our
problems due to significant changes in our cultural and social environment, and people stick
to those rituals by habit or tradition, they might backfire and hinder more adequate solutions.
20
For example, in the 1950’s there were strict rules regarding sexual behaviour before marriage,
often dictated by the church. Adolescents had to adhere to certain courting rituals in which
talking about sexuality or birth control was taboo. Nowadays, with different opinions about
relations and sexuality before marriage, we are aware that such traditional taboos pave the
way to unwanted teen pregnancies. Especially among teenagers, unwanted pregnancies are
an important risk factor for the development of serious mental problems and problem behaviour
in both the young mother and her child, as many developmental studies have shown. New
adaptive rituals have emerged, such as talking about birth control measures during a first
sexual encounter and parents who inform their children about the use of preservatives during
early adolescence. A Dutch study on sexual health among almost 5000 youngsters between
12 and 25 years showed, however, that in some ethnic cultures or religions, these traditional
rituals are still common (De Graaf, Meijer, Poelman & Vanwesenbeeck, 2005).
Other functions that have been attributed to rituals are mostly specifications of the
adaptive function. They are connected to specific stages of the adaptation process: perception
and interpretation of the situation, emotional response, selection and implementation of an
adequate behavioural response. These stages constitute the core elements of modern stress
and coping theories.
Perceptual function. Rituals may structure perception, offering an interpretational framework
that helps people understand and calculate their situation. Rituals indicate what is and what is
not important in a situation. It secures against disintegration of the perception of our
environment in times of stress. Rituals protect us from a collapse of our cognitive systems,
offer a cognitive matrix and regulate our affective state (McManus, 1979). This applies, for
instance, to conflict resolution rituals in situations that are highly emotional.
Emotional function. Rituals can play an important role in emotional dealing with problems or
transitional situations. This function is expressed in different ways: it gives room to emotional
expression, and they can be confrontational. Regular confrontations with farewells, such as
memorial events, limit the need to suppress our feelings. Rituals can also provide emotional
support.
Behavioural function. Offering behavioural reactions in times of stress is one of the best known
adaptive functions of rituals. Lukken (1984) describes these situations as “need-to-act-butdon’t-know-how” (pag.24). The “don’t know how” refers to situations that are new to the person
involved, and he does not know how to react. It may also be that the problem situation exists
of an overdose of different impressions which makes it difficult for him to choose from the
different behavioural reactions that are available. In the first case the rituals offer an effective
response; in the second case the rituals contribute to a reduction of choices among the many
possible reactions. This is not only useful for individuals, rituals also offer collective behaviour
models to communities in times of traumatic events or ecological stress, and may serve as a
buffer against extreme social changes in the environment. This is the case, for instance, when
schools or communities are confronted with deadly shootings, which unfortunately has
happened in the US and Europe many times over the last decades. In such hard times, rituals
can help a community to collectively deal with rage and grief.
Religious or magical function: some ritual behaviours or thoughts have a magic function, which
means that persons who use such rituals think they can evoke supernatural forces to support
and protect them. This has been discussed earlier when we talked about the protective function
21
of statues and amulets. Also using prayers as a common way of coping behaviour among
religious communities in times of stress and threat, exemplifies this function. Irrespective of
the question whether supernatural forces actually exist, the mere belief in the existence of such
forces can already make a huge difference in dealing with highly stressful situations. This is
similar to the empirical finding that perceived social support is probably more related to stress
reactions then enacted support.
Besides these basic functions, rituals may have other functions such as sense making,
contacting the past, strengthening identities of persons and groups, reinforcing group cohesion
and social control. The discussion above reveals that rituals not only serve multiple adaptive
functions for individuals, but also for social systems such as families, organisations or
communities.
1.6.2 Transition rituals
In many places and times people have used rituals and ceremonies to highlight transitions
from one stage of life to another. These transitions may bring radical changes and can even
become a crisis. Therefore, some authors also speak of "rituals for life crises”. Gerald Caplan,
one of the founders of preventive psychiatry, argued in his crisis theory that it depends on how
a crisis is processed whether a person ends up weaker or stronger, with more self-confidence,
skills and less vulnerable, or with severe mental problems and weakened capacities (Caplan
& Grunebaum, 1967). Major life crises can be a source for both the emergence of mental
disorders and strengthening resilience and social-emotional development. Which of the two
outcomes will occur depends on how the coping process during the crisis proceeds and
whether social support is available.
Transition rituals have an important supporting role in coping with a crisis: by restoring
a lost balance and developing a new identity. They offer a framework that invites those who
are affected to express and process their grief or fear. They indicate what kind of support
neighbours, family, friends or colleagues should give to people who go through a difficult or
challenging transition, such as having a first child, becoming seriously ill or coping with the
death of a partner. Rituals accompany changes in position and status of individuals and
structural changes within groups. They contribute to the creation of new social relationships
between people. Rituals are the scenarios of a culture, on how such transitions can be made.
For these reasons it is important to integrate insights about the role of rituals with insights from
crisis theory about how people deal with crises in their lives.
Well-known transition situations are marriage, pregnancy, birth, a child leaving home,
and the death of a spouse. These are transition situations for which culture offers or prescribes
many rituals. The most sustainable rituals are probably those surrounding marriage and
funerals, although many changes in the form of these rituals have taken place over time.
Other rituals have even completely disappeared from our society and can only be found
in other cultures. Puberty rites or initiation rites are well-known examples. During these rituals
the life as a child is ended by symbolic acts and the boy or girl is initiated in the adult world.
Although some initiation rituals are no longer used, others still exist in our culture, such as the
initiation rites that are practiced by student fraternities.
22
1.6.3 Mourning rituals
Our country, the Netherlands, had an extensive culture of mourning rituals, which remained
most preserved in smaller rural communities, although many of those rituals have disappeared.
Lukken (1984) gives a striking description of these old mourning rituals:
"When someone died, he was laid in state at home. The curtains of the mourning house were
closed and the mirrors covered. The survivors were in mourning: They wore black or dark
clothing; around the sleeve of the overcoat often a black belt was worn. The condolence visit
began and often ended by saying goodbye to and praying for the dead. On the day of the
funeral the body was brought to the church and the cemetery in a mourning coach. The horses
were covered with black sheets. The windows of the accompanying coaches were closed with
black curtains; the survivors sat in the twilight. After the funeral service, people stayed in
mourning for a long time. They did not appear on festive occasions. Especially widows and
widowers continued to be marked as such for a long time." (pag.46)
In the past death and mourning were much more a public event. Also, the fact that people
usually died at home and not in hospital, made a large difference for this visibility. Former
mourning rituals offered ample opportunity to say goodbye to the deceased and prevented that
death was obscured. In the months after the funeral, the survivors were often confronted with
the dead when they made their way through the village; the cemetery was often not far from
the village centre and mostly next to the central church. Moreover, in the year after the death
periodic memorial services were held in church for families and neighbours.
The supportive role of rituals in the mourning process is especially visible in the rules
concerning mourning clothes. In the 19th century and the beginning of the 20th century, there
was a whole cult of mourning clothes. All major cities had well-stocked stores specialising
exclusively in mourning clothes. The black clothes reminded the survivors constantly of the
separation from their beloved. But for the immediate surroundings, such clothing was also a
continuous reminder to inform how it went and to offer help. Both the commemoration services
and rules for mourning clothes
provided for a gradual reduction of
mourning and a transition to
normal life and a new identity (e.g.
a single). In successive periods
mourning clothes were gradually
reduced, as can be seen in Figure
1.5 (Tayler, 1983). In primitive
cultures, mourning rituals were
often much simpler. For instance,
mourning women in West-Iran
often covered themselves with
white ashes and clay in the period
after the funeral. In many oriental
countries like China, the mourning
colour is white.
23
Decline of mourning rituals
The preceding description has made clear that mourning rituals serve many psychological and
social functions. They provide ample opportunity to pay the last respects, to express emotions
and there is little occasion to escape confrontation with death. The mourning rituals provide
clear behaviour rules at a time that most people are overcome with grief. Rituals ensure that
others will be there to offer emotional and practical support. Ritualised mourning has the
psychological benefit that the mourning period has a clearly prescribed end, making a
permanent fixation on mourning less likely. When these types of rituals and their associated
functions suddenly disappear, we become aware of their preventive significance.
Rituals play an important role in the prevention of serious problems with mourning.
When we look today at how death, funeral and mourning take place, the difference with
previous periods becomes apparent. Most of the time people die in hospital. Many people do
no longer have a religious affiliation, which makes the use of rituals like a traditional funeral
and memorial services offered by churches less accessible. City dwellers often do not know
who passed away in their neighbourhoods. Traditional visiting rituals throughout a
neighbourhood after someone died are no longer in place. The funeral often takes place
outside the local community. In our daily lives a social taboo on death exists. Frequently death
is hidden and buried away. There are few rituals left to express sorrow and mourning. They
have been replaced by a social reward for controlling feelings of sadness and getting back to
normal as soon as possible. Given this tendency it is not surprising that unresolved mourning
problems are a common issue in modern psychotherapy. Complicated grief disorder has a
prevalence of 6.7% after major bereavement (Kersting, Brahler, Glaesmer, & Wagner, 2011)
and among grieving older adults even 25.4% (Newson et al., 2011).
Fortunately, in recent
years there has been a renewed
interest in mourning rituals, e.g.
dying at home, erecting shrines
for those who killed in a traffic
accident and silent parades after
violent
accidents
in
the
community (Fig. 1.6). At funerals
new
rituals
have
been
developed over the last two
decades. Also the public
funerals and memorial services
of well-known personalities (e.g.
Princes
Diana,
Michael
Jackson, and Andre Hazes)
helped in the renewed attention
for mourning rituals.
24
1.6.4 General decline of rituals
Traditional rituals fall into disuse when they are no longer effective, that is when they no longer
have a function or become outdated. This can have many reasons: new social ideologies,
secularisation, blurring of the meaning of traditional symbols, commercialisation, and the
increasing pluralism in society. Rituals are bound by place, time and culture.
Given the rapid social changes in the last 50 years, it is not surprising that we do no
longer find recognition in many traditional rituals. This doesn’t need to be a problem. From a
functionalist view, it is clear that behaviour is abandoned when it is no longer effective. New
forms of behaviour are then used to replace it. This is exactly the problem when old rituals
disappear, but new ones are not yet developed. To date, the transition from one life phase to
another is no longer ritually emphasized, or only very little. The increasing pluralism in society
contributes to less room for new rituals becoming generally accepted.
Already in the 1970s, Van der Hart stated that traditional cultural rituals are partially
replaced by different types of rituals that are smaller and family centred: "Rituals have a more
‘worldly’ and less religious nature; they are more intimate and less public, less repressive and
authoritative; they are fewer in number and less extensive. Members of a family copy rituals
from their parental house, but adapt them to their own needs”. (van der Hart, 1978, p. 248).
He describes that psychotherapists frequently have the task to help their clients to develop
their own new rituals in order to improve coping with major losses and changes in life. The
plea to use rituals and the development of new rituals as a therapeutic factor is also useful for
prevention. Educational programmes in schools can indicate the use of functional rituals and
teach youngsters to design or adapt their own rituals. This has happened, for instance, in
school-based programmes to prevent bullying, were new rituals are introduced to enhance
communication between bullies and their victims.
1.7
Conclusions
This chapter started with the proposition that preventive mental health care without the
drawback of professionalisation is only possible when it takes naive prevention (i.e. existing
preventive behaviours of people) as its starting point. Knowledge on naive prevention enables
professional preventionists and health promoters to better attune to the needs and strengths
of the people they serve (Box 1.2). This can avoid that professional prevention has an
alienating or even iatrogenic effect. More attention to naïve prevention makes it easier for
prevention experts to adopt a respectful and democratic attitude towards their target groups
What has naive prevention taught us about prevention and preventive mechanisms? It
became evident that we are daily involved in numerous preventive behaviours. Preventive
behaviour is not something we have learned from professionals in the 20th and 21st century; it
is a basic feature of the nature and culture of both animals and man. Preventive behaviour is
closely related to our daily battle for existence and survival, the evolution of the species and
adaptation to the constant changes around us. This chapter discussed many examples from
the animal world, primitive cultures and modern western culture. The study of animal and
human behaviour showed that it is meaningful to make a difference between functional
preventive behaviours, i.e. inborn behaviours with a preventive effect, and intentional
preventive behaviours, in which people purposefully want to achieve a preventive effect. Many
preventive behaviours features are innate and result from processes of natural selection;
25
others are acquired and the result of learning processes, reflection, parenting and education,
sometimes concerning learning processes across multiple generations.
1.7.1 Elements of preventive processes and capacities
This discussion on preventive behaviours, features and processes has revealed the following:
•
Preventive capacities can be inborn or learned. Sources for the development of
preventive capacities are: biological influences and natural selection (heredity),
socialisation (e.g. parenting, model behaviour, education, myths and legends),
personal learning experiences and self-reflection.
•
Preventive reactions can be reflexes, intuitive or rational in nature, more internal or
external (behavioural).
•
The perception and evaluation of impending danger, understanding its causes and the
execution of preventive behaviours are all basic adaptive capacities of humans, which
can be biological, psychological or social in nature.
•
To protect health and to prevent disease many types of preventive behaviours and
mechanisms can be used. They can refer to behaviour or processes of individuals,
organisations, neighbourhoods or societies.
•
In response to danger or threats humans and animals make use of signals to enable
the perception of danger and to enhance timely preventive behaviours. The time period
between signal, preventive behaviour, and the moment that the preventive effect
becomes visible can vary significantly. Preventive behaviours can focus reactively on
preventing damage in the present (e.g. pain), but also proactively on achieving long
term benefits (e.g. strengthening capacities for adulthood, preservation of health,
preventing future disease).
•
The social environment can have different preventive roles: direct protection against
danger by influencing the danger source or prevent exposure to it, sending signals,
social support, implementing taboos or rituals, setting behavioural norms, and creating
legal barriers to expose people to high risks and obligations to prevent danger.
•
The prevention of serious mental and physical problems can be studied as an individual
phenomenon (e.g. instinctive reactions, attitudes, individual preventive behaviour), but
also as a behaviour that is contingent on our social environment and culture (e.g.
taboos, norms, customs, parenting, education, legislation).
1.7.2 Failing naive prevention
Experience shows that natural prevention has its boundaries and sometimes fails. Especially,
when failing occurs frequently and systematically, professional prevention can play a
significant role, for instance to help preventing diseases, accidents or domestic violence.
Crucial questions are: In what situations does naive prevention fail? Why is this the case and
which groups are especially affected? It is possible to discern some typical situations in which
practices of naive prevention could fail (Figure 1.7)?
26
•
Overdose of threat or damage: The danger is too grave compared to the natural
preventive capacities available to a person and his direct environment, for instance in
extreme circumstances as natural disasters, child abuse, hostage, war violence or
combinations of threatening circumstances.
•
Unforeseen danger or consequences: A danger was not perceived or too late because
(a) there were no alarming signals or they were not recognised as such and (b) lack of
knowledge of the dangers and the harmful consequences of certain circumstances.
•
Only short term anticipation: A selective focus on the ‘here and now’ and the inability
to anticipate long term dangers and benefits. It is more difficult to recognise long term
dangers and benefits than those that we face directly. Eating unhealthy food and harsh
parenting are good examples.
•
Insufficient knowledge of the causes: People might not be familiar with the causes of a
certain danger, or might have incorrect beliefs about the causes. For instance, parents
might not understand what causes aggressive behaviour in their children, or might have
wrong ideas about what causes such behaviour. As a consequence, they are poorly
equipped to prevent such behaviour in their children.
•
Lack of preventive capacities: This lack can be, for example, insufficient knowledge or
skills to deal with a problem, or inability for long term investment. This can be caused
for example by a lack of coping skills or by exposure to inadequate role models.
•
Lack of support and protection from the social environment: This could be caused by a
loss of rituals or by rituals being outdated, growing individualisation in society, decline
of traditional family ties and neighbourhood networks, more single parent families and
the increase of single elderly, designs of new neighbourhoods not attuned to current
needs for communication and support.
1.7.3 Challenges for professional prevention
These six causes of failing naive prevention each offer an important entry point for actions by
prevention or health promotion professionals. For instance, prevention can be aimed at the
elimination of child abuse (overdose of stress), making schools aware of the long term negative
effects of bullying (lack of awareness about consequences), educating about mechanisms
27
through which children of parents with a mental illness develop a high risk for problems
themselves (knowledge) and how parents and children can tackle these causes (skills), and
creating new opportunities for social support for these children at risk. As these examples
show, prevention of health problems can follow different types of strategies:
28
•
Making people aware of our preventive nature, and advocating the importance of
investing in prevention and health promotion. People need to become more aware of
their preventive capacities and strengths, so they can use them more often and more
adequately. This applies not only to individual persons and families, but also to schools,
non-profit organisations, local communities and companies.
•
Stimulate awareness and reflection on the impact of one’s own behaviour and social
risk factors: people, families, schools, and companies need to be stimulated to look
critically at present risk behaviour and social threats to mental health and well-being.
•
Improve preventive capacities and health promotion competence through education: if
necessary support people breaking the habit of ineffective preventive behaviours and
learning new, more effective behaviour through education and training. Health
promoting capacities also refer to the way schools, neighbourhoods and communities
function. The use of rituals with a preventive function and the introduction of new,
effective rituals are an example of such preventive capacities.
•
Health protection: prevent an overdose of threat of important stressors by implementing
social and environmental interventions, e.g. mass education, social policy
implementing local measures, fighting against repressing ideologies, supporting human
and child rights, and implementing preventive legislation.
•
Strengthen social support: promote the possibilities of people to support each other in
solving problems and protecting each other’s health. Examples are parenting
education, strengthening social networks and supportive peer contact, and the creation
of self-help organisations or supportive internet communities.
Literature
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Allport, G. W. (1937). Personality. New York: Holt.
Assem van den, J. (1973). Gedrag als aanpassingsfenomeen, een beschouwing over de functie van
gedrag. In Ethologie, de biologie van gedrag. Wageningen.
Caplan, G., & Grunebaum, H. (1967). Perspectives on primary prevention. A review. Archives of General
Psychiatry, 17(3), 331–346.
Coie, J. D., Watt, N. F., West, S. G., Hawkins, J. D., Asarnow, J. R., Markman, H. J., et al. (1993).
The science of prevention. A conceptual framework and some directions for a national
research program. American Psychologist, 48, 1013-1022.
D' Aquili, E. G., Laughlin, C. D., & McManus, J. (Eds.). (1979). The spectrum of Ritual. A biogenetic
structural approach. New York: Columbia University Press.
Fraser, D. (1962). Primitieve Kunst. Den Haag: Gaade.
Graaf de, H., Meijer, S., Poelman, J., & Vanwesenbeeck, I. (2005). Seks onder je 25e: Seksuele
gezondheid van jongeren in Nederland anno 2005. Delft: Eburon.
Hart van der, O. (1978). Overgang en bestendiging. Over het ontwerpen en voorschrijven van rituelen
in de psychotherapie. Deventer: van Loghum Slaterus.
Hosman, C. M. H. (1989). Toekomst en innovatie van de preventieve geestelijke gezondheidszorg.
Tijdschrift Gezondheidsbevordering, 10, 184-207.
Hosman, C. M. H. (1991). Adaptatie en gezondheid: een integratieve benadering. In C. P. F. van der
Staak & C. A. L. Hoogduin (Eds.), Psychologische aspecten van leefstijl en adaptatie.
Nijmegen: Bureau Bêta.
Illich, I. (1974). Medical nemesis. London: Calder & Boyars.
Kersting, A., Brähler, E.H., & Wagner, B. (2011). Prevalence of complicated grief in a representative
population-based sample. Journal of Affective Disorders, 131, 1–3, 339–343.
Lukken, G. (1984). Geen leven zonder rituelen. Baarn: Ambo.
McManus, J. (1979). Ritual and Ontogenetic development. In E. G. D'Aquili, C. D. Laughlin & J.
McManus (Eds.), The spectrum of ritual: a biogenetic structural analysis. New York: Columbia
Press.
Mead, M. (1968). Incest. In: International Encyclopedia of Social Sciences. London: Collier and
MacMillan Publishers.
Mrazek, P. J., & Haggerty, R. (Eds.). (1994). Reducing risks of mental disorder: frontiers for
preventive intervention research. Washington: National Academy Press.
National Research Council and Institute of Medicine. (2009). Preventing Mental, Emotional, and
Behavioral Disorders among Young People: Progress and Possibilities. Committee on
Prevention of Mental Disorders and Substance Abuse Among Children, Youth and Young
Adults. Washington, DC: The National Academies Press.
Newson, R.S., Boelen, P.A., Hek, K., Hofman, A., & Tiemeier, H. (2011). The prevalence and
characteristics of complicated grief in older adults. Journal of Affective Disorders, 132, 231–
238
Salemink, O. (2006). Nieuwe rituelen en de natie. Inaugurele rede, Vrije Universiteit Amsterdam.
Tayler, L. (1983). Mourning Dress. London: George Allen and Unwin.
Winizki, E. (1972). Gesichter Afrikas. Luzern: Kunstkreis.
29
Study questions for this chapter

An exercise to become aware of everyday behaviours that are preventive in nature: Take
in mind a random weekday. Write down all actions you usually perform during the day.
Then note for each behaviour if it helps to prevent a certain (future) damage or negative
outcome from occurring. Differentiate between behaviours with a short and a long term
preventive outcome. In conclusion: How preventive do you consider yourself? What
improvements in your preventive behaviour do you consider as necessary?

A second exercise: Imagine what would happen if warning signs such as in traffic and on
products would disappear overnight? Imagine what would happen (and has happened)
when various rituals disappear in your life that have a meaningful function? On a social
level: What would be the impact on mental health and wellbeing when a number of social
laws would be abolished e.g. Anti-discrimination, Labour and Security Act?

What is meant by naïve prevention? Why is knowledge of naïve prevention important for
prevention professionals? How can they use this knowledge in their work?

Why is man essentially a prevention-oriented human being? What are differences and
similarities between preventive behaviours and functions of animals and human beings?

Explain the concepts "structural iatrogenesis” and “proto-professionalisation” and why
these should be avoided.

What qualifies as "reactive prevention" and what as "proactive prevention"?

What has this reflection on naive prevention revealed as basic features, elements or
mechanisms of preventive processes?

What are the developmental processes through which animals and humans have acquired
preventive capacities?

What role do rituals play in prevention? List some different types of rituals. What functions
can rituals perform? When do rituals start working counterproductive to health and wellbeing? Can you think of new rituals with an evident preventive value?

Explain in what ways naive prevention can fail. Which tasks and strategies for professional
prevention can be extrapolated from this failure?
30
2
History of preventive mental health care:
from 1800 to present
2.1
Introduction
32
2.2
Treatment of mental illness before 1800
33
2.3
The nineteenth century
34
2.3.1
Reform movement in the period 1790-1885 and the moral treatment approach
34
2.3.2
Development of social medicine and the role of the state
36
2.3.3
Darwin and Social Darwinism
38
2.3.4
Psychiatry after 1850
39
2.4
The period around the turn of the century until the 1950s
40
2.4.1
Adolf Meyer and psychobiology
40
2.4.2
Mental Hygiene movement
41
2.4.3
Freud, Adler and the Neo-Freudians
44
2.4.4
Eugenetic movement
46
2.4.5
Influence of First and Second World War
47
2.5
The 20th century until 2010: Prevention Developments in the Netherlands
48
2.5.1
Mental hygiene in the Netherlands
48
2.5.2
The impact of the Community Mental Health Movement
49
2.5.3
Gerald Caplan: consultation method and Dutch prevention
49
2.5.4
Prevention departments in mental health services
50
2.5.5
Developments in the Netherlands after 2000
51
2.5.6
Governmental policies
52
2.5.7
International collaboration and programme exchange
53
2.6
Conclusions
54
Literature
55
Study questions for this chapter
56
31
2
2.1
History of preventive mental health care:
from 1800 to present
Introduction
Compared to psychotherapy, science-based mental disorder prevention as a professional
approach made a much later entrance into the field of mental health care. Nevertheless, its
history goes back to the first half of the nineteenth century.
First, knowledge of the history of prevention in mental health offers insight into its social and
scientific roots and the theoretical paradigms and ideologies that have influenced preventive
thinking over the course of time. The development of ideas about preventing mental disorders
is closely related to the emergence of social medicine, sociology, psychology, educational
sciences and psychiatry in the nineteenth century and the beginning of the twentieth century.
The historical ties with these different scientific disciplines accounts for why prevention and
prevention science constitute a typical multi-disciplinary field.
Secondly, one of the main distinctions in prevention, namely its differentiation into primary,
secondary and tertiary prevention, is strongly grounded in the subsequent historical stages of
this field. The development of a preventive approach first focused on tertiary prevention
(improving the quality of life of psychiatric patients and relapse prevention), then secondary
prevention (timely recognition and treatment of mental illness) and more recently primary
prevention (preventing the emergence of mental illnesses).
Thirdly, studying the history of the emergence of prevention and health promotion offers a
better understanding of the social and political conditions under which prevention and health
promotion practices and the development of this new professional field could flourish. The
presence of ideas and theories on preventing mental disorders are in themselves insufficient
to develop a thriving prevention practice in the society at large. Crucial additional conditions
are, for instance, an active role of governments accepting responsibility for public health and
prevention, nationwide prevention policies and financial investments in preventive
programmes, prevention research and prevention expertise, and the active involvement of
citizens, community leaders and a wide range of non-profit and profit organisations.
Fourthly, historical analyses could also provide insight into the mistakes made earlier in the
development of prevention, which could help us avoid similar mistakes in the future. For
instance, the development of preventive care in the period before 1970 was almost exclusively
based on ideologies and lacked a proper scientific foundation. For this reason, the initial
enthusiasm and support for the idea of preventing mental disorders gradually made room for
scepticism during the 1980s. This only changed after the emergence of a solid scientific
foundation for mental health promotion and prevention, and evidence of the effectiveness of
preventive interventions gradually became available after 1990.
In this chapter, the history of mental health prevention will be divided into four periods (Figure
2.1). First, we will describe the period up to 1800 in which no systematic vision on prevention
of mental illness existed. Next, developments during the 19th century will be discussed; a
period in which the first steps toward a science of public health and prevention of physical
diseases emerged. The third section of this chapter describes the developments in the first
half of the 20th century, characterised by the emergence of a global “mental hygiene
32
movement”, representing the origin of current mental disorder prevention. It was not earlier
than two decades after World War II that a specialised professional prevention and health
promotion sector entered the field of primary health care and mental health care, with social
scientists in a role of prevention and health promotion experts.
2.2
Treatment of mental illness before 1800
According to Hippocrates and other Greek doctors from the pre-Christian era, mental illness
could be regarded as a disease process that is not distinctly different from physical illnesses.
The causes were sought in natural rather than in supernatural or spiritual causes. Therefore,
mental illnesses should be left to the care of doctors and not priests. Despite this relatively
'modern' vision of Hippocrates, a religious or demonic vision on the development of mental
disorders dominated well into the Middle Ages. As we have seen in the previous chapter on
naive prevention, this demonic vision on the origin, treatment and prevention of illness was
present in various primitive cultures. In this vision, the causes of illness are attributed to the
influence of the evil powers of gods, demons, and ancestors.
In medieval feudal society, care for the mentally ill was in the first place a family affair (Beek,
1974). The mentally ill person was seen as a deviant who was at the least tolerated. Only the
acutely dangerous insane were isolated. In those days, there was no form of institutionalised
care for the mentally ill (Fox & Stoop, 1975). Some insane persons were ‘treated’ by doctors,
priests, ‘medicine men’ or ‘saints’. The healing practices often consisted of a mixture of
religious, magical and medical methods, such as pilgrimages, exorcism, flogging, and herbal
and thermal treatments.
During the 15th century, the first large madhouses were created, such as the Reinier van Arkel
Asylum in ‘s-Hertogenbosch, the Netherlands (Figure 2.2). These were designed especially for
the most delirious mad persons. These madhouses can be considered as precursors of the
increasing societal isolation of mentally ill and other ‘poor deviants’ which takes place in the
course of the 16th, 17th and 18th centuries. The ‘lunatics’ who were less seriously ill often
ended in disciplinary institutions and workhouses. These accommodated those who were
unproductive or cast a stain on civil order with their unruly behaviour. These houses saw
33
beggars, vagabonds, the unemployed and the dangerous mentally insane, but also those who
behaved in an unruly and disobedient manner, such as rioters, drunkards, prostitutes and
heretics. The emergence of asylums, correctional institutes and workhouses has been linked
to the rise of a capitalist society in which families had no opportunities or were no longer willing
to look after disturbed relatives (Crossley, 2006). During the Enlightenment and its glorification
of the ‘Reason’, there was little
attention for the mentally ill,
except for a group of humanistic
professionals.
Under
the
influence
of
the
French
Revolution and the huge need for
cheap and unskilled labour by
the end of the 18th and during
the 19th century, a division was
made in these houses between
the ‘insane’ and the ‘criminals’.
Those criminals who were
considered fit to work were urged
to become factory workers. The
French philosopher Foucault
made the comment that in the 18th century this division originally was advocated because
criminals deserved a better fate than to be locked up with the insane (Foucault, 1964). The
result, the isolation of the 'mad', was the basis on which psychiatry and psychiatric science
could develop in the course of the 19th century.
2.3
The nineteenth century
2.3.1 Reform movement in the period 1790-1885 and the moral treatment approach
Towards the end of the 18th century the so-called ‘moral treatment movement’ emerged in
response to the inhuman conditions in the madhouses. The leaders pleaded for a more
humane, psychosocial and personalised approach of the insane. This can be considered as
the earliest example of efforts in the field of what later is called ‘tertiary prevention’. One of the
best-known representatives was Phillipe Pinel, a hospital doctor in revolutionary France, who
made history as the ‘liberator of the mad’ (Figure 2.3). Pinel worked as medical director in two
hospitals in Paris in which both mentally ill and criminal patients were detained. He was
touched by the fate of the ‘poor fools’, who had to live in filthy cells, often chained, abused and
neglected and in general bad hygienic conditions. In 1793, Pinel pleaded to free the insane
from their chains and create decent establishments in which they could live. According to Pinel,
the patients became ‘difficult persons’ by a lack of freedom and fresh air.
Despite the opposition of the Commune de Paris, they managed to open an "asyl"
where the "poor fools” could get a humane treatment without chains. Pinel was also driven by
scientific motives and is considered as the father of the French psychiatry. In his “Traité
medico-philosophique sur aliénation mentale ou la manie" he advocated a new psychiatric
theory based on clinical observations. He was the first doctor who systematically described the
case history of patients (Hodiamont, 1982).
34
The "moral treatment" approach resembles the application of current methods of behaviour
modification. The liberation of the insane was mainly made possible by the liberal ideals of the
French
Revolution:
liberty,
equality, fraternity and human
dignity. During the revolution, the
“Declaration of human and
civilian rights” (1789) was drafted.
It declared that any form of
unlawful detention was illegal,
unless based on official justice.
Based on the Declaration a
commission was formed, which
had to decide on the fate of the
“hospiteaux” in which still
thousands of people were kept
without any form of justice. As we
will see later on in this historical
analysis, far-reaching reforms in the care for the mentally ill always took place in periods during
which there were important changes and reforms for society as a whole (Reimann, 1967). This
period was no exception. Those who in the 19th century were responsible for the reform of
mental institutions were not acting on new scientific visions on the development of mental
illness. The reforms were mainly inspired by humanistic professionals, who detested the
dishonouring way in which the ‘insane’ had been treated so far. They gave more freedom to
the 'patients' despite heavy protest of those still considering the mentally ill as ‘potentially
destructive beasts’ (Gibbs et al, 1980). During the 19th century, similar moral treatment
movements emerged in other countries such as England, Italy, Germany, the Netherlands and
the United States.
Characteristics of the 'moral treatment'
Three aspects can be distinguished in the reforms that the 'moral treatment' movement
pursued. The first goal was to change the inhuman situations in the workhouses and
institutions. A second goal was to plea for state appointed advocates who would monitor the
human situation in the institutions. This way, the moral treatment movement has contributed
to the disappearance of abuse and the instalment of state control over the insane. The 1840
laws on insanity have been adopted everywhere in Europe, as well as procedures for
monitoring and emergency admissions.
A third feature of the 'moral-treatment' was an optimistic view on the possibility of treating
mental illness. Under the influence of rationalism and humanism, treatment of the insane
acquired an educational nature (Bockhoven, 1963). Purpose of the treatment was that the
patient revealed the 'morality' of his personal and social live. The patient had to be activated.
This was done by labour projects, recreation, religious meetings, talks in small groups, and
social contacts with the personnel of these institutions. Recreation was promoted through
fishing, gardening, drawing and music. This humanistic-interactive approach was possible
because the doctors often treated only a limited social group of patients with which they could
identify. The 'moral treatment' actually remained limited to the richer insane in private
establishments (Caplan, 1969). It is not surprising that institutions using moral treatment
35
showed very positive results. About 60 to 90% of the patients were eventually considered to
be fully improved (Bockhoven, 1956). These results showed that under certain conditions it
was considered feasible to treat the mentally ill, something that was hitherto unheard of.
Decline of the 'moral treatment'
One of the factors that facilitated the development of a "moral treatment" approach was the
small number of mentally ill admitted in establishments in the early 19th century. However, the
situation changed dramatically during the course of this century. Social and economic
developments led to a significant increase in the number of recorded mentally ill (Schuurmans
& Stekhoven, 1922). The main reason for this increase was the growing industrial capitalism
and the rapid urbanisation in Western society. Industrialisation drew large groups of people
from the countryside to the cities and major industries. This was accompanied by a large
increase of “disabled" persons who were admitted to institutions for the mentally ill. In the
United States, also the Civil War and the great flow of immigrants from the European continent
had their impact. Mental illness was more prevalent among immigrants. In the middle of the
19th century in the U.S., large numbers of people lived in mental institutions, especially poor
immigrants. These institutions could barely cope with this large influx of patients given their
limited budget and diminishing support from society (Rappaport, 1977). This caused the end
of the moral treatment and the beginning of the “great confinement" or the "asylum era". As a
result, also, the number of discharges fell and the number of chronic patients increased. The
percentage of mentally ill that was declared cured dropped to below 4% (Hodiamont, 1982).
That the 'moral treatment' did not succeed as a new form of treatment was probably also due
to the lack of a scientific foundation. The moral treatment was the product of a 19th century
humanist movement and was not accompanied by a scientific analysis. In summary, we
conclude that the ideas of 'moral treatment' were hardly implemented on a large scale. The
success of the 'moral treatment' lies mainly in the elimination of the worst inhuman conditions
in the institutions. Viewed from the modern division between primary, secondary and tertiary
prevention, the 19th century developments in the care for the mentally ill can be characterised
as an important contribution to tertiary prevention (see next chapter).
2.3.2 Development of social medicine and the role of the state
In the 18th century, many already accepted the idea that protection of health was not merely
an individual responsibility, but one of the governments as well (Thoma, 1975). In the first half
of the 19th century, numerous studies were carried out on the relationship between social and
material living conditions and disease. In that period, research particularly focused on the
relationship between working conditions and illness. Several studies in the late 18th and early
19th century demonstrated a clear link between morbidity, mortality and poverty (Thoma,
1975). The risk of disease and mortality was especially high in the lowest social classes.
Social medicine and the emergence of preventive health care
Against this background, social medicine arose in the middle of the 19 th century. Equivalent
terms are "public health” and “'social hygiene”. In 1838, Rochoux made a distinction between
‘personal hygiene’ that should be left to the care of the individual, and 'social hygiene' or ‘public
hygiene’, which should be promoted through laws and governmental measures (Rochoux, in:
Rosen, 1979). In 1848 in France the surgeon Jules Guérin introduced the term ‘social
médicine’: "La médicine sociale est l'ensemble des rapports entre la médicine et la societé".
36
He pleaded the medical profession to promote actively the living conditions of the population.
He divided social medicine in four areas:
-
Social physiology: the study of the relation between the physical and mental health of the
population, and the role of laws and other social institutions;
-
Social pathology: the study of the influences of social problems on health and disease;
-
Social hygiene: determining and executing measures to promote health and prevent
disease;
-
Social therapy: providing medical and other measures to deal with social disintegration
and other harmful social conditions
The second half of the 19th century shows a further development of social medicine and an
emerging prevention focus in Europe, with a gradually increasing influence of sociology, best
illustrated by the work of the French sociologist Emile Durkheim on social alienation and
suicide (1897). Besides examining the relationship between employment and health, social
medicine doctors in that period also worked on infant deaths, alcoholism, the impact of poor
nutrition, poor housing conditions, social disintegration and school health care.
Prevention strategies of social medicine
Many of the prevention strategies we know today have been developed in the 19th century
(Verdoorn, 1965; Rosen, 1979) (box 2.1). Firstly, legislation can be considered as an influential
preventive instrument. In the Netherlands, for example several laws were implemented to
improve working conditions and to
eliminate child labour. In order to reduce
Box 2.1 Prevention strategies developed
the risk of infectious diseases many
in the 19th century
environmental measures were taken,
Preventive legislation
such as the construction of sewers and
Environmental policies
water refreshment. For the protection of
(e.g. sewerages, municipal cleaning, protection drink water)
public health, special services were
Improvement of labour conditions
established such as the Municipal Health
Inspection of food
Service (in Dutch: GGD). Education
Health education
became a widely used instrument to
Vaccination
promote public health and enhance
Infant care, home nursing services
hygienic behaviour (Verdoorn, 1965).
Community Health Services
Around the middle of the 19th century,
England appointed the first "health
officers” whose role was to implement these educational programmes. In the Netherlands,
these initiatives were installed in the second half of the 19th century. The district nursing
services played a special role here. As of their introduction in the 1880’s they were actively
engaged in educating the population by providing information on hygiene and child care in
people’s home situations and through lectures, groups for mothers, and informative brochures.
They acted as the first prevention professionals.
Successes of social medicine
In the past hundred years, impressive health effects have been achieved by preventive
measures. In our Western societies diseases as diphtheria, plague, cholera and tuberculosis
37
are virtually eliminated, while in the 19th century large groups of people still died due to such
epidemics. In some periods during the Middle Ages, a third of the European population died
because of plague and cholera. Examples of effective preventive measures are the
introduction of the sewerage system, the protection of drinking water, the improvement of
sanitary facilities in houses, education on hygienic lifestyles, and the introduction of vaccination
and screening programmes among the population. Another example is the improvement of
health care, especially pregnancy counselling and infant care. Within a period of 100 years,
neonatal mortality was reduced by 900%. Across 150 years, our average lifespan has been
extended by nearly 40 years, just by improving living conditions and implementing preventive
measures. In relation to the slow evolutionary path along which mankind develops, it is
apparently possible to establish almost revolutionary changes in health through preventive
measures. Many of these measures have become so common in society, that we do not even
recognise them as preventive anymore.
2.3.3 Darwin and Social Darwinism
No one influenced scientific thinking in the second half of the 19th century as strongly as the
biologist Charles Darwin (1808-1882) did. Darwin's evolution theory influenced psychology in
different ways. His concept of heredity offered an explanation for the infirmity of the human
structure, while also being able to explain differences between individuals. With the increased
understanding of the role of heredity the realisation grew, that ‘current’ man can only be
understood from his developmental history. For preventive thinking, Darwin’s concept of
adaptation was of particular importance, namely the idea that
animals and man are involved in a continuous process of
adjustment to their surroundings. From a phylogenetic point of
view, an anatomic structure, a behavioural feature or emotion is
adaptive when it contributes to the survival of the species.
Similarly, but now from an ontogenetic perspective, a behaviour
or personality trait is adaptive when it improves the chance of
survival of an individual member of the species. Darwin also
applied his evolution approach to emotional reactions. He stated
there is not only an evolution of morphological structures but also
of what Darwin called ‘the mental and expressive capacities’
(Klerman, 1979).
Darwin’s influence on thinking about disease and mental illness and the opportunities
and (un)desirability of preventive interventions settled mainly through the so-called Social
Darwinism, which refers to the application of the biological evolutionary theory to social
processes. This social movement won many adherents in-between the American Civil War and
the First World War, especially in the United States and several European countries.
In the 19th century, it was particularly the philosopher Herbert Spencer who was
involved in the significance of evolution theory for psychology and sociology. Spencer saw
human society as a product of the struggle for existence and survival of the fittest. The weak
will perish and the strong will contribute to the further development of society. He thought that
society should be equipped to secure its survival and improve the quality of life. Spencer was
against any form of state intervention and social legislation because this interfered with the
process of natural selection. He opposed to public education and state intervention in private
health care. Social welfare assistance in his view destroys the biological potential and helps
38
the weak to breed. Thus, Social Darwinism can be regarded as a normative theory. Supporters
of Social Darwinism felt that patients with mental disorders, either inherited or caused by their
social position, were unsuited to survive in the new industrial order. Nineteenth century
psychiatrists adopted these views and defended them as scientific by retaining only a biological
explanation for mental illness (Bockhoven, 1963). Mentally ill were regarded as failures and
placed in large psychiatric hospitals, many of which were built in the second half of the
nineteenth century.
Until the 20th century and even into the current 21th century, Social Darwinian ideas
heavily dominated the ideas of intellectuals and the population in the United States and
England (e.g. Roman & Trice, 1974). For a long time they were the basis of the economic
structure and government politics. To this day, the Social Darwinian ideas play a role in
whether governments want to invest much, little or nothing in preventive mental health care,
social welfare and poverty reduction. These ideas are contrary to the notion that preventive
care should particularly provide support to the weak and the groups at risk in society. This
difference in views is still present in contrasting political visions of right-wing and left-wing,
respectively conservative and social-democratic parties and their related governmental health
and social policies. In general, social-democratic governments support the further
development of prevention and public health, while conservative or right-wing governments
usually reduce public investments in these areas.
2.3.4 Psychiatry after 1850
Two main streams, a scientific, medically orientated approach and a more social approach
marked psychiatry in the second half of the 19 th century. The first became the most dominant
in that period. Most psychiatrists then thought mental illness was caused by a somatic illness
or by hereditary transmission. The somatically oriented psychiatrists saw mental illness as a
symptom of an organic disorder, caused by metabolic disease, brain damage or other
neurological defects. Among others, the German psychiatrist Kraepelin, mainly known for his
classification of psychiatric diseases, complete with syndrome descriptions, diagnoses and
prognoses, belonged to this "somatic school". The somatically oriented psychiatrists had a
rather pessimistic view on the chances of recovery, not even mentioning prevention. Because
of this, psychiatry at the end of the 19th was mainly a form of "custodial care”.
Under the influence of Darwin's publications, a large number of psychiatrists agreed at
the turn of the century (1900) that mental disorders should be considered as a hereditary
disease (Caplan & Caplan, 1967). They saw mental illness as nature’s way to eliminate the
poor and weak, as they were unable to adapt to their environment. Psychiatrists advised the
public against marriages with people showing signs of mental illness. Putting the grounded
ethical objections to such an advice aside for a moment, one could nevertheless consider this
advice as a first example of aimed preventive psychiatry.
The dominance of the somatic-biological approach in psychiatry in the second half of the 19th
century did not mean that the humanist and social approach to mental illness (moral treatment)
had completely disappeared during that period (section 2.3.1). It is among the followers of
these more social orientations that we find the first important steps to the prevention of mental
illness. Firstly, there was the influence of social medicine that has set the stage for modern
social psychiatry. Another example of a 19th century impetus to prevention in the field of
psychiatry comes from the United States. In 1880 in Cleveland, a number of reform-oriented
39
social workers, neurologists, psychiatrists and lay people created the National Association for
the Protection of the Insane and the Prevention of Insanity. The association fought for the
rights of patients, improving the conditions in asylums, creation of facilities for early treatment
and education of the public regarding the nature of mental illness. The association attracted,
however, strong hostility from the powerful association of medical directors of mental
institutions (Reimann, 1967).
2.4
The period around the turn of the century until the 1950s
At the beginning of the 20th century, in the field of mental health a reform movement started
which would play a major role in spreading ideas about prevention and mental health promotion
until well into the twentieth century: the mental hygiene movement. This movement was part
of a wider range of social movements and changes that characterises the progressive era
between 1890 and 1910, such as movements to improve poor labour conditions in factories,
actions for abolishment of child labour, and the emergence of a women’s liberation movement
fighting for the right to vote (suffragists).
This section will discuss the origins of this movement and the role of biology, psychiatry,
psychology and the psychoanalytical framework in its development. An assessment is given
of the successes and limitations of the mental hygiene movement. Next, an evaluation will be
given of the eugenics movement, which was strongly influenced by Darwin’s evolution theory
and social Darwinism. In the end, this also included practices such as sterilisation of mentally
ill and mentally retarded. Finally, the influence of both two World Wars on the development of
prevention of mental disorders prevention will be discussed.
2.4.1 Adolf Meyer and psychobiology
The medical-psychiatric model, which was represented among others by Kraepelin (18551926), already received some serious criticism at the beginning of the 20th century. There
were strong voices against the prevailing medical approach of "mental illness". Adolf Meyer, a
Swiss psychiatrist who moved to the United States and became head of the New York
Psychiatric Institute in 1906, led this critical approach. He focused his research on the family,
social network, community and work environment of his patients. Meyer made a clear shift
from the strictly somatic approach to a more psychological and social approach to psychiatric
symptoms. He regarded disorders as a specific response
of the personality on the total of physical, psychological
and social influences from the environment. In his
psychobiological approach, psychiatric disorders are
failed adjustments of a person to different requirements,
restrictions and threats. The influence of Darwin on his
thinking is clearly recognisable, especially his ideas about
adaptive processes. Meyer also referred to "biological" as
to the continuous struggle of a person with his
environment. With this dynamic view on the emergence of
psychiatric disturbances, Meyer turned away from the
static psychiatry of Kraepelin and his classification
system. His psychobiological approach was an explicit
40
opposition to the rigid application of biological determinism in psychiatry, which at that time
was in its heydays. He was strongly inspired by leading functionalist psychologists as William
James, John Dewey, Leon Thorndike and Stanley Hall. He had a close friendship and
collaborative relationship with William James. Both were among the founders of the Mental
Hygiene Movement, which in the end would become the strongest advocate group worldwide
for prevention of mental disorders and promotion of mental health, as an additional approach
to the treatment and care of mental patients.
The basic concept of Meyer's psychobiology is that of integration, also called the holistic
approach. Man can only be understood in his ‘totality’, where he is considered as an indivisible
unit of study. Humans can be studied at different levels, e.g. chemical level, the reflex level
and the psychobiological level. Phenomena at a certain level cannot be understood without
using knowledge of the influence of the other levels as well. Activities at a given level are
affected by changes in other levels. Thus, psychobiology assumes that the study of the
individual inevitably must go along with the study of the actual context in which this individual
develops. For Meyer this multi-system level approach also meant that mental health
interventions could be chemical, psychotherapeutic and social in nature.
Psychobiology also looks at the human developmental perspective: the relationship
between an individual’s past, present and future. Personality is a temporal phenomenon and
is under continuous development through individual experiences and social influences. The
focus on the interaction between an individual and society and the longitudinal development
of a person’s nature, are features that make psychobiology a dynamic approach. At the time,
there was much resistance against Meyer’s ideas, because in the psychiatric establishment
medical thinking dominated.
Meyer was optimistic about the possibilities to prevent mental disorders. He particularly
stressed the possible preventive improvements that could be achieved through parenting and
environmental change. Moreover, he thought that psychiatric patients should be guided in their
return to society. For this service to succeed, the general public needed to be better informed
about mental illness and the conditions in the institutions. Health care should be more
educative instead of accumulating knowledge in the ivory towers of their own profession. These
were revolutionary ideas because academic psychiatry at that time was dominated by a
neurological approach to mental illness.
2.4.2 Mental Hygiene movement
The Mental hygiene movement, (in Dutch: Psychohygiënische Beweging) historically is one of
the most important sources of contemporary preventive mental health. The mental hygiene
movement was the first organised international movement
that had incorporated the prevention of mental disorders in
its goals. The beginning of the mental hygiene movement is
usually linked to the appearance of the book "A mind that
found itself” (1908) by Clifford Beers. He was a former
psychiatric patient who suffered from a serious psychosis
and suicidal behaviour. As a former patient, he protested
strongly against the humiliating and abusive conditions in
mental asylums and fought for the reform of the mental
health institutions. His book about his history as a patient
41
and his recovery was at that time a bestseller in America especially in the academic world, and
had 26 reprints, the latest of which in 1956. In the epilogue of one of these reprints Clifford
Beers later characterised his own book as "the opening gun in a permanent campaign for
improvement in the care and treatment of mental sufferers, and the prevention, whenever
possible, of mental illness itself" (1950, p.255). He advocated successfully for his ideas across
not only the US, but also worldwide including in Europe.
In 1908, the first "Committee for Mental Hygiene” was established in Connecticut,
followed one year later by the establishment of a “National Committee for Mental Hygiene”. As
stated earlier, besides Beers the founders also included William James and Adolf Meyer.
Meyer proposed to call the organisation “Mental Hygiene”. The novelty of the movement was
its multidisciplinary character. Psychiatrists and psychologists but also sociologists, lawyers,
teachers, theologians and historians supported the mental hygiene movement. Both lay people
and scientists were represented in the movement.
The mental hygiene movement had four goals:
1. Improving the health and living conditions of the mentally ill. This process involved
among others the development of outpatient services and other alternatives to
hospitalisation, a community orientation, and elimination of abuse in institutions.
2. Psychiatric prophylaxis, i.e. prevention of psychiatric diseases by (a) preventing the
emergence of mental illness and (b) early recognition and treatment.
3. Dissemination of knowledge of psychosocial health (e.g. on effective parenting) among
the public and among key social figures in order to improve mental health.
4. Cooperation with civil organisations in society that can influence the mental health of
people.
These goals were formulated in 1908 and run more or less parallel with the modern division
into "mental health promotion" (objective 3 and 4), primary prevention (objective 2a and 4),
secondary prevention (objective 2b) and tertiary prevention (objective 1). The fourth objective
refers to a particular strategy to achieve the other goals. We may even conclude that these
goals are virtually identical to the goals of the prevention movement in the 1960’s and 1970’s,
and are even reflected in the "Health for All ' strategy which the WHO implemented in the
1980’s and 1990’s. Current ideas on primary, secondary and tertiary prevention, mental health
promotion and even the plea for a multi-sectoral approach to mental health were in fact already
present in the initial phase of the mental hygiene movement at the beginning of the 20th
century.
Within twenty years after its creation, the movement had spread worldwide. In most
countries, 'Associations for Mental Hygiene’ were established, e.g. in Finland (1917)and in
Germany (1928). Between all these national associations and interest groups, a global network
of mutual contacts arose in the twenties and thirties. In Europe, the mental hygienists
succeeded in organising international meetings where prevention also was a topic of
discussion. The Mental Hygiene Movement constituted the basis for the establishment of the
World Federation for Mental Health in 1947, an organisation associated with the United
Nations. Still to date, the Federation (WFMH), together with the Clifford Beers Foundation, are
the strongest worldwide protagonists for prevention of mental disorders and promotion of
mental health.
42
Child Guidance Movement, and focus on education
As we will discuss in the next section, the mental hygiene movement became more and more
influenced by psychoanalytic thinking, which also received wide international interest in the
first decades of the 20th century. This influence is reflected in the importance the mental
hygienists attached to parenting issues and encouraging a parenting style that was conductive
to healthy social-emotional development of the child. They attributed a strong impact of
childhood experiences on adult mental health. Mental hygienists considered parents and other
educators as a potential entrance to achieve short-term and long-term preventive effects,
especially through parenting education. Besides parents, also teachers were an important
target group for the mental hygienists. In their view, the school was not just the place for
developing academic skills, but also for providing a favourable environment for the
development of the entire person. It was partly a task of teachers to stimulate actively the
development of the personality, including the emotional, intellectual and social development of
the child.
Successes and failures of the mental hygiene movement
Looking back, what can be considered main achievements of the mental hygiene movement?
To begin with, there were the obvious improvements in reducing inhuman conditions in mental
institutions, better quality of care for psychiatric patients, and the development of earlier
ambulatory care through which admissions could be prevented. Also, the development of
psychosocial treatment facilities for children was among the successes of the mental hygiene
movement. Nevertheless, these positive developments could not prevent that until around
1980 mental health care in many European countries was still dominated by psychiatric
hospitals and inpatient care.
The mental hygiene movement also strongly contributed to the fact that for the first time
different scientific views on mental illness, mental health, and parenting reached the large
public. This has undoubtedly led to more social acceptation of psychiatry and to less
stigmatisation of psychiatric patients. However, concerning the development of specific
prevention programmes and practices (especially in primary prevention) and of specific
prevention expertise, the results of the mental hygiene movement have been very small. In
several mental health reports published after the World War II, the concept of prevention
appeared only incidentally and was approached with scepticism by traditional mental health
professionals and policymakers (Breemer ter Stege & Gittelman, 1987; Freeman, Fryers &
Henderson, 1985; May, 1976). The systematic development of professional mental disorder
prevention practices will eventually have a cautious start in the 1970’s.
How can it be explained that the mental hygiene movement was a successful global
movement, but that - despite its preventive goals and ideas about prevention – it has failed to
develop an influential prevention sector during more than 50 years? Although no systematic
research has been done on the causes, it seems likely that the following factors have played
an important role:
-
The scientific basis of mental hygienic activities was relatively weak, the supportive
sciences were still in development and moralistic thinking and humanistic ideologies
dominated the movement. For example, it was recommended by mental hygienists that
young people should not visit the cinema, as this would have a corrupting influence on
their mental health.
43
-
The movement failed to translate its vague preventive goals into specific targets, and
to make a long term planning for the systematic development of intervention
programmes. The science of determinants of mental disorders and the science of
planned interventions were still in their infancy.
-
The preventive ideas of the movement were not translated into governmental policy or
legislation.
-
Many countries only had a very limited budget available for mental health care; mental
health had a low priority in society. Investing in the promoting mental health was seen
as a luxury.
2.4.3 Freud, Adler and the Neo-Freudians
Freud never launched explicit ideas about the prevention of mental disorders (Lemkau, 1956).
However, his psychodynamic theory has had a major influence on the development of
contemporary scientific thinking about prevention. His theories and practices gave many for
the first time the idea that the human mind and behaviour can be influenced. This can be
considered as a prerequisite for preventive thinking. The influence of Freud's psychodynamic
theory is very well recognisable in the mental hygiene movement and especially in the related
child guidance movement. The large influence of Freudian ideas on the development of the
mental disorder prevention after 1960 is mainly due to the work of a number of his followers,
the Neo-Freudians and ego-psychologists.
Neo-Freudians
Although Freud in particular stressed the importance of the somatic origin of passions and
constitutional factors, he also acknowledged the influence of culture on the development and
change of a personality structure (Cofer & Appley, 1962). Yet a number of critics believed that
Freud neglected the influence of social and cultural factors in the development of the
personality in favour of a unilateral biological point of view. Freud often referred to external or
social forces as ‘accidental factors’. Some of these critics, also known as 'Neo-Freudians’,
turned strongly against the - in their eyes - rigid doctrine of Freud concerning the instincts.
These Neo-Freudians had a significant impact on mental hygienic thinking. Therefore, on the
basis of modern preventive mental health care we will devote some attention to their ideas.
The most famous Neo-Freudians were Karen Horney, Harry Stack Sullivan, Erich
Fromm and Erik Erikson. Although they do not deny that each personality development has a
biological basis, in their personality theory they focus primarily on the influence of social and
cultural factors. Because of this strong sociological thinking, the Neo-Freudians are also known
as the "School of Cultural Psychoanalysis”. The Neo-Freudians played an important role in the
spreading of mental hygienic ideas in society.
Adler’s vision on prevention
In the history of psychology and psychiatry, Alfred Adler (1870-1937) is best known for his
work in psychotherapy and his collaboration with Freud and Jung in the Vienna Psychoanalytic
Society. By training, Adler was a doctor of social medicine, and in that function, he was involved
in preventive health care from the beginning of his career. Unlike Freud, he did not base his
work on a medical model, but on a humanistic and educational model of man. In his writings
already at the end of the 19th century, he extensively pays attention to prevention. In his
44
preventive work, Adler was inspired by Rudolf Virchow (1821-1902), an eminent physiologist
and humanist activist, who is considered the founder of social medicine in Germany. Adler's
first publication, "Health Book for the Tailor Trade” appeared in 1898 in a series called 'Guides
to Occupational Hygiene: Advice for the Prevention of Occupational
Diseases and Industrial Accidents’. In his book, he discusses the
relationship between economic circumstances and health and
more specifically the impact of poor work conditions and living
conditions on the health of tailors. He pleaded for improvement of
legislation on labour conditions, better housing conditions, the
introduction of disability insurance and a pension plan. This
publication shows his interest for a social approach of health and
prevention, which is also to be found in his later work.
Adler was also one of the persons to introduce the concept
of ‘life style’, which would later become a leading concept in modern
health promotion. Many of his later publications contain a plea for
prevention; not only in medical sense but also in the field of psychological prevention. In his
view, psychologists should more explicitly take a stand in social and societal conditions that
threaten mental health, such as social inequality between men and women, and domestic
violence; Adler’s views have also contributed significantly to the emergence of humanistic
psychology.
In his article ‘The physician as educator’ (1904) he states: “Not to treat and cure sick
children but to protect healthy children from sickness is the logical and noble challenge of the
science of medicine” (reprint 1973, p. 203). In the same article, he also argued for a focus on
improving the mental health condition of children by enhancing their self-confidence, feelings
of independency and decision skills. In his view, this could contribute to the prevention of
neurotic illnesses. For this reason, both general practitioners and parents should be offered
training on improving mental health and parenting. Through his influence, 28 parent education
centres were established in Vienna. Schools should contribute to the prevention of depression
by educating children in social competence, the ability to collaborate with others, and problem
solving skills. In his view, special preventive attention should be given to the guidance of
physically handicapped and neglected children. In his later years, he also became involved in
prevention of delinquency in children.
Karin Horney
A Neo-Freudian who played a major role in the development of
a new view on mental illness and mental health was Karin
Horney (1885-1952). Although she contributed a lot in
disseminating Freud’s ideas among the general public, she was
also one of his major critics. In her view neuroses are the
product of cultural influences and of disturbed relationships
between parents and children, more than of ‘preformed
instincts’ as Freud stated.
In her article ‘Culture and
neurosis’, Horney discusses the impact of social factors on the
development of neuroses. She points at the dominating
influence of economic competition on human relations, the
economic exploitation of people, the excessive emphasis on
45
success, and the inequity in rights and opportunities between people. Also, contradictions in
‘modern’ culture feed the development of neurotic conflicts in persons. She refers, for instance
to the contrast between the emphasis on ‘success and winning’ and the need for ‘social
companionship’, the stimulation of aggression and the suppression of it, and the continuous
stimulation to need satisfaction that in our daily society which is in conflict with continuous and
structural barriers to satisfy them. Especially, when these contrasts affect children and
adolescents they may create feelings of helplessness, insecurity, low self-esteem and social
isolation.
She rejected Freud’s pessimistic concept of man. Inspired by Adolf Meyer’s
psychobiology, she adheres his optimistic and humanistic view on human beings: a belief in
inner dignity and freedom of people, a human drive to self-actualisation and a constructive
attitude towards life. She considers a positive self-image as a crucial condition for mental
development. Her optimistic view of man can be considered as a forerunner of current positive
psychology that currently strongly influences paradigms of mental health promotion and
prevention (e.g. the work of Martin Seligman).
2.4.4 Eugenetic movement
The supporters of the eugenetic movement advocated a very specific way of preventive
thinking. They were almost completely opposed to the ideas of the mental hygiene movement
and the child guidance movement. The eugenetics supported the idea that the performance of
both individuals and entire populations depended largely, if not solely, on hereditary
predetermination. Education would have little or no effect.
Eugenetic ideas
The eugenics movement developed under the influence of Social Darwinism and the growing
knowledge of genetics in the 19th century. Like the mental hygiene movement, the eugenics
movement had an international character. Social Darwinism applies Darwin's ideas about
survival of the fittest to the development of the human species (section 2.3.3). They assumed
that the nature and quality of the human species is maintained by ensuring that the fittest
survive and the weak do not. Protection and conservation of the weak would be against the
principle of selection. Based on this principle they rejected any social or political support for
the weakest in society. In their view, social legislation withdrew the weak, disabled and
intellectually inferior from the struggle for existence. This would lead to degeneration of the
human species.
The supporters of the eugenics movement advocated the maintenance of high genetic
dispositions and improvement of the race by controlling reproduction. The eugenetics pleaded
for restriction of procreation of criminals, epileptics, mentally impaired, mentally ill and
alcoholics. For this purpose, measures were appointed such as medicinal screening before
marriage, a martial prohibition for the named categories, sterilisation and isolation of the
"mentally inferior”.
Eugenetic practices
During the 1930s, large-scale forced sterilisations took place among mentally disabled and
mentally ill in Germany and Sweden. In 1939, Hitler gave the command to kill all mentally
disabled children. This took place in Hadamar under the guise of euthanasia and 'der
Gnadentod' (operation T4). The forced sterilisation and the murder of the children (estimated
46
200,000 victims) were defended with the argument that mental illness was a major threat for
public health and the purity of the race. Also, references were given to the high cost of care for
the mentally ill. The practice of forced sterilisation was not limited to Europe. Between 1899
and 1907, 465 criminals were sterilised in the U.S. state of Indiana. In 1935, 27 American
States had laws that saw to the sterilisation of the biologically unfit. Based on this argument,
over 20,000 people were involuntary sterilised.
2.4.5 Influence of First and Second World War
The severe economic depression, which was initiated by the stock market crash in 1929, gave
impetus to the decline of Social Darwinism in the US. The idea that personal happiness and
progress depend purely on personal qualities and hard work, proved no longer tenable. The
consequences of the crisis on the threatened welfare of millions of people were so evident that
state intervention in the socio-economic life and the creation of social services for victims had
become inevitable. The crisis made clear that social and economic factors were important
determinants of personal happiness of the people. These changes reduced the influence of
Social Darwinism.
Against this background, in the United States during the period 1930 to mid-sixties
various national, social incentive programmes were designed and implemented, such as the
New Deal, War on Poverty, Head Start and Great Society. Within these programmes, much
experience was gained with systematic interventions aimed at improving economic
development opportunities and health of vulnerable groups in society. These programmes
have provided a major impetus to the development of contemporary prevention strategies in
the field of mental health. For example, the programme "Sesame Street", now transmitted all
over the world, was created in the sixties to stimulate the early cognitive and emotional
development of children, a typical early example of mental health promotion.
The two World Wars have also played an important role in the development of preventive
mental health care. During the Second World War, there was a huge increase in psychiatric
patients. To prevent that the army would lose its forces, two strategies were developed, both
of which had a preventive character. To maintain the armed forces, it was essential to identify
and treat the early stage cases of psychiatric diseases among soldiers at the battlefront.
Psychiatrists in the military developed so-called secondary prevention methods, such as crisis
intervention, and other early intervention and treatment methods. Another prevention strategy
was the development of screening tools in order to identify young people with a high risk for
psychiatric disorder during recruitment, which could be used as a selection procedure or be
followed with preventive guidance of those at risk. The experiences in World War II made a
significant contribution to the development of early screening tests (Sanford, 1974; Gleiss,
Abholz and Seidel, 1973).
Another reason to develop a more preventive approach to mental health problems
occurred after the Second World War and the Korean War. The U.S. were then faced with a
huge increase of the number of patients in psychiatric institutions. Many of them were former
soldiers (veterans) struggling with posttraumatic stress and other mental disorders due to war
experiences. Later we saw the same because of the wars in Vietnam, Iraq and Afghanistan.
In the early 1950s there were hundreds of thousands hospitalised psychiatric patients, often
with chronic diseases. The U.S. government started to realise that mental disorders constituted
a public health problem number 1, creating an enormous economic problem (Gleiss et al,
47
1973). In the first place, the large number of psychiatric patients led to a sharp increase in
direct costs of psychiatric hospitals. However, just as important were the high indirect costs.
The many hospitalised psychiatric patients were a serious loss of economic productivity, a
serious problem in a period of upward economic development with a big demand for labour
force. For both reasons, a need arose in the U.S to reform the mental health care system
significantly, including the need for a more preventive approach.
2.5
The 20th century until 2014: Prevention Developments in the Netherlands
In this last section, we discuss how the professional field or prevention and mental health
promotion developed in our own country, the Netherlands. We also discuss how some
international developments had a special impact on what happened in our country.
2.5.1 Mental hygiene in the Netherlands
From the 1920s, the mental hygiene movement also reached our country and in the next
decades until 1960 gave rise to the establishment of an extensive network of local outpatient
mental health services. These included social psychiatric services (SPDs), youth psychiatric
services (JPDs), child guidance clinics for parenting issues and early child psychiatric
problems (MOBs), adult mental health counselling services (LGVs) and institutes for medical
and multidisciplinary psychotherapy (IMPs). Given the exclusively inpatient mental health care
up until then, these new services represented a revolution in mental health care. At that time,
such services were frequently still affiliated to religious organisations. For instance, in the city
of Nijmegen, until 1980 separate catholic and protestant child guidance clinics and adult
counselling services existed.
The Dutch psychiatrist Querido, one of the great pioneers in the field of mental hygiene,
played an important role in the development of mental health services outside the psychiatric
hospitals. During the 1930s, he became worldwide famous for founding in Amsterdam one the
first Public Health Services, an outpatient facility with a strong mental health focus. Its purpose
was to prevent admissions in mental hospitals by using a community approach and guidance
for mental patients at home.
Querido also introduced the so-called ‘echelon principle’ in Dutch health care: a division
of health care in primary health care (district and community based care by general
practitioners, social services, district nursing, etc.), secondary echelon care (specialised
ambulatory care at district level) and third echelon care (hospitals, clinics, nursing homes).
More simply, it was labelled as ‘first line’, ‘second line’ and ‘third line’ care. This system could
provide care in a much earlier stage of a developing physical or mental disease (secondary
prevention). Because care more frequently started to take place in the client’s own community,
the social conditions under which diseases developed became more visible (e.g. child abuse,
neglect and poor living conditions). Although the term prevention was used regularly, its
practice involved mainly early individual- or family-oriented treatment (secondary prevention)
and rehabilitation and re-socialising of patients discharged from a mental hospital (tertiary
prevention). At that time, prevention was mainly considered as a characteristic of good early
treatment. Especially treatment of early child behavioural and psychiatric problems was
assumed to contribute to preventing psychiatric problems during adolescence and adulthood,
although any evidence for such a long-term effect was lacking.
48
According to their mission statements, the discussed ambulatory treatment facilities
were prevention-oriented. However, efforts to prevent the onset of new psychiatric disorders
were not systematically developed. This would only start after 1980 when the different local
mental health services merged into one comprehensive regional outpatient mental health
centre (RIAGG), influenced by community-based service models from the United States.
2.5.2 The impact of the Community Mental Health Movement
The developments in the US after the First and Second World War (par. 2.4.5), offered ground
for major change in mental health policy and the mental health system during the 1960s. After
Pinel and his liberation of the 'mad' during the French Revolution, and after the emergence of
psychoanalysis, this Community Mental Health Movement is commonly considered as the third
psychiatric revolution.
In 1955, the U.S. government installed a 'Joint Commission on Mental Health and
Illness', with the task to examine thoroughly possibilities for changing the hitherto mainly
inpatient-based mental health care towards a mainly community-based mental health care.
Studies of this committee clearly indicated that a large proportion of people with serious
problems did not receive professional help, and that admittance to a psychiatric hospital could
be prevented by more outpatient facilities. This was especially true for people from lower social
classes and other disadvantaged groups. The final report "Action for Mental Health '(1961)
contained a plea for a drastic reform of the mental health system: more integral communityoriented care, closer to people, more accessible, with more attention to social conditions of
clients and involving community leaders and local key people. This would also make the
prevention of serious problems possible.
Community Mental Health Centres and Dutch RIAGGs
In 1963, President John F. Kennedy issued a memo based on this report, advocating for a
national mental health policy for the first time in American history. This resulted in the adoption
of the ‘Community Mental Health Centres Act’. In this law, financing was arranged for
Community Mental Health Centres (CMHC's). In each health region, a CMHC would have to
offer a wide range of mental health care services to the local community: hospital and
outpatient care, crisis shelter, therapeutic assistance, facilities for day or night care, as well as
specific programmes that assist patients to return to society and find employment. Important
goals were increasing the accessibility of care and improving continuity of care for psychiatric
patients. Each CMHC also got a preventive task, called "Consultation and Education". This
"Community Mental Health Movement" was an important impetus to the systematic
development of prevention programmes, also targeting social risk and protective factors. In
addition, prevention was also practiced through a variety of programmes for disadvantaged
social groups in the context of the so-called "war against poverty".
In the 1970s, this Community Mental Health Movement became a major source of
inspiration for the development of mental health in the Netherlands. The RIAGG’s (in Dutch:
Regionale Instituten voor Ambulante Geestelijke Gezondheidszorg), established in the early
1980s, were modelled after the American Community Mental Health Centres, although
restricted to outpatient care, but with inclusion of special prevention departments.
2.5.3 Gerald Caplan: consultation method and Dutch prevention
During the sixties of the 20th century, the debate on prevention focused on whether prevention
could be given a broader interpretation, i.e. beyond preventive oriented treatment of patients.
49
The first attempts to more explicit preventive actions were linked to the term 'consultation'. In
1964 and 1965 the child psychiatrist Gerald Caplan, founder of American preventive
psychiatry, visited the Netherlands to deliver seminars on mental health consultation.
Consultation was introduced as a specific method by which mental health professionals could
transfer their specialised expertise to primary health care, social workers and other key
persons in the community such as teachers, pastors, police officers and personnel officers
(Caplan, 1963). Transfer of such knowledge and skills to professionals and organisations more
close to people and communities, could contribute to reach more people, to offer appropriate
help with mental health problems in an earlier stage (secondary prevention), to prevention of
new disorders (primary prevention) and to promotion of positive mental health population-wide.
Bringing more mental health expertise to local communities could prevent that people with
mental health problems would be referred to very specialised and costly treatment facilities.
Simply put, moving expertise to local communities, instead of moving patients to specialised
mental health centres.
The consultation methodology still fits in the 21st century and current national policy
perfectly through the concept of strengthening the mental health capacities of primary health
care, social services and local community organisations. This would warrant a revival of again
investing developing the skills of consultation methodology among mental health professionals
and prevention experts.
The influence of Caplan on the Dutch prevention sector has been much larger than the
introduction of the consultation method alone. Both through his writings and through various
seminars and trainings in the 1960s and 1970s, he has transferred the basic ideas of
Community Mental Health and preventive psychiatry to Dutch experts. His main ideas can be
found in his influential book “Principles of preventive psychiatry” (Caplan, 1964). This book,
now almost fifty years old, presents a wide range of preventive strategies of which several are
still innovative to date in the 2010s. These include, for instance, collaboration with city planners
and architects on community planning to design urban neighbourhoods that are supportive to
the development and protection of mental health. A strategy that would perfectly fit, for
instance, to current efforts of urban development and designing new neighbourhoods, such as
recently took place in Nijmegen where on the other side of the river a whole new city quarter
has been built.
2.5.4 Prevention departments in mental health services
The major force that created a professional prevention sector for mental health was the
introduction of specialised prevention experts and prevention departments in the outpatient
mental health services from the 1970s and the RIAGGs from the 1980s. Commonly addressed
prevention themes in these early years were parenting problems, social-emotional
development of children, sexual education, relationship problems, social isolation, coping with
inability to work, and mental health consultation to general practitioners. During the 1980s, the
number of prevention professionals steadily increased and many prevention projects were
initiated, although their effectiveness had to be proven.
After a first decade of try-outs, a critical reaction emerged from both the professionals
themselves and from governmental agencies concerning the quality of these projects and the
lacking evidence of effectiveness. The prevention field was challenged to invest more in
becoming more professional and developing a scientific base and proof of their preventive
50
impact. The first National Conference on
Prevention in Mental Health held at the
University of Nijmegen in 1987 offered a
major turning point to such a more sciencebased prevention approach and a tradition
of programme effect research (Hosman, van
Doorm & Verburg, 1988).
Since the 1990s, all mental health
services, addiction clinics and public health
services have a prevention or health
promotion department, which is unique in
comparison to other countries. The most
common themes they addressed in the
period 1980-2000 are listed in Box 2.2. Their
work is nationally supported by prevention
and health promotion departments of
national institutes (e.g. Trimbos institute for
Mental Health and Addiction) and
prevention and health promotion research
centres at universities.
Box 2.2 Prevalent topics in prevention
programmes of mental health and addiction
services
Parenting education and support
Sexual abuse and child abuse
Children of parents with psychiatric problems
School-based prevention programmes
Bullying and aggressive behaviour
Depression and anxiety
Addiction (alcohol, drugs, gambling)
Work, stress management and mental disability
Early detection of schizophrenia
Chronic psychiatric patients and their carers
Elderly dementia patients and their carers
Mental resilience and fitness
2.5.5 Developments in the Netherlands after 2000
Recently, several major changes are ongoing in the field of mental health promotion,
prevention and care. First, due to new legislation the financing of preventive services has
changed dramatically. Since 1980, all preventive activities by RIAGGs were integrally financed
by one national budgeting system. From 2014, the budgeting of preventive services has been
changed. From 2007 to 2014, the Care Insurance Act (Zorgverzekeringswet) had arranged
that Health Insurance Companies financed part of preventive activities. This applies to
evidence-based indicated prevention, i.e. preventive services for individuals with subclinical
symptoms. Only indicated prevention of depression, anxiety and alcohol dependency was
recognised as such by the insurance companies. In addition, a second law was introduced, it
regulates the financing of preventive programmes and projects: the Law on Personal Support
(WMO, Wet Maatschappelijke Ondersteuning), which is completely an affair of municipalities.
The WMO offers the local government the opportunity to finance prevention initiatives that fit
into their local priorities. Prevention departments have to compete with other local
organisations for getting such local grants. This facility offers the opportunity to support
financially local initiatives for mental health promotion, selective prevention (targeted at
populations at risk) and universal prevention (targeted at whole population segments, e.g.
schoolchildren). Since 2014, most of the selective preventive activities are financed by the
municipalities (WMO) and partly by the GP-practice. Mental health consultants offer indicated
preventive services (groups and e-health) in the GP-practice. This is paid by the insurance.
This development resulted in disappearance of prevention departments in the specialised
mental health care.
A second development is an outcome of the current economic recession; we refer to
cuts of 20% or more in mental health care and prevention budgets. A related trend is replacing
expensive specialised mental health care by ‘basic mental health care’, i.e., short- term early
51
treatment provided by primary mental health care professionals in local communities, such as
psychiatric nurses and health care psychologists. In some parts of the Netherlands, the
prevention teams are part of this new basic mental health care service (www.mindfit.nl or
www.indigo.nl).
A third development is a specific way in which prevention, treatment and care currently
become integrated by the adoption of a stepped-care-model in mental health services. The
model means that for certain mental health problems (e.g. depression) a layered package of
services is offered to the population. It starts with low intensive and low budget services for a
large group of people (e.g. written or internet-provided information, self-help materials and
consulting hours), through stepwise more extensive services (e.g. home visiting, short
preventive courses, short treatment methods) and ending with the opportunity for the intensive
forms of treatment and eventually admission to an inpatient facility only for a limited group of
severe cases. The idea is to have a system that is both preventive and curative in orientation,
is cost-effective by offering services that are sufficiently intensive for the problem addressed,
and to guarantee an easy accessible service system that offers continuity of care to those who
are in need. The introduction of such a stepped-care system for the prevention and treatment
of depression in elderly (>75 yrs.) resulted in a reduction in incidence of depression and anxiety
disorders by 50% (van’t Veer-Tazelaar et al., 2009).
Finally, another major change in both preventive and treatment services is the fast
growing practice to offer internet-based health and mental health services. Generally, such
services are called E-health. Internet treatments for mental disorders are found to be effective
for certain groups of clients. Many specialised mental health services in our country have
planned to turn 20 to 40% of all treatment into internet-treatment within the next years. Also
developing preventive services through E-health is becoming a booming business, for instance
internet-based self-help sites with information and support to improve mental fitness (Dutch
example: www.mentaalvitaal.nl), or to address relationship problems, oncoming depressive
complaints or problems with alcohol (self-help website by Trimbos-instituut:
www.zelfhulpwijzer.nl). Preventive E-mental health also includes participation in online
courses and chatboxes under guidance of a mental health expert. Several studies have shown
that internet interventions are able to reduce the onset of mental disorders. More information
on this topic will be provided in the last two chapters of Part V of this book.
The developments above also mean that under the current economic and political
circumstances funding for primary prevention programmes has become at least more difficult.
It has challenged prevention experts and health promoters to find innovative ways to attract
the support of new stakeholders and investors especially from outside the health sector, for
example from companies or other commercial organisations through ‘social innovation’
initiatives. It stresses the need to explain to them the value of mental capital for their primary
interests and core business. For instance, many companies have fitness rooms for their
employees, as fitness lowers sickness costs and increases quality and productivity of the
employees. For the same reasons, employees could be offered exercise and other
opportunities to increase their mental fitness.
2.5.6 Governmental policies
Since 1983, each new Dutch government has published a long range of national memoranda
and policy papers on mental health, public health, health promotion, prevention, and
specifically mental disorder prevention. The most important ones are listed in Box 2.3.
52
In these papers the importance of
Box 2.3 Dutch governmental memoranda
health promotion and prevention is further
and policy papers on prevention
explained, as well as the need for evidence
and health promotion
and outcome research, effective use of
prevention resources, prioritisation of
mental health issues to be prevented,
Outpatient mental health and its interfaces (1983)
cooperation between local agencies,
Health in limited resources (1983)
creating conditions for prevention practices
New Mental Health Note (1984)
at local level, and the delegation of
Note 2000 on health promotion (1986)
responsibilities
between
professional
Preventing Mental Health Memorandum (1988)
services, citizens, communities and
Discussion paper Suicide Prevention (1989)
government. As illustration, in the paper
Draft Document on Health Policy (1989)
"Choosing for Healthy Living” (2006) the
prevention of obesity, depression and
Prevention for public health (1992)
addiction problems have been assigned as
Mental health in social perspective (1993),
key national priorities. The current Minister
Healthy and Well (1995)
of Health considers preventive actions
Choosing for Healthy Living (VWS, 2006)
primarily as a responsibility of citizens
Health nearby (2011)
themselves and of local communities, with
a limited role of governmental agencies (in
contrast to the view of previous
governments). This view applies especially to the responsibility of adults for their own health.
Prevention and health promotion for children is still considered as also an explicit governmental
task.
2.5.7 International collaboration and programme exchange
The "Health for All” strategy of the World Health Organization (WHO, 1984) has been a strong
driving force for international cooperation in developing health promotion and prevention. The
Netherlands also participated in a range of international WHO projects like "Healthy Cities" and
"Health Promoting Schools”, and EU-based projects such as Dataprev and Depression. WHO
projects have contributed significantly to the improvement of health conditions in communities
and schools around the world (see relevant WHO websites). Most of these programmes
however, were focused on improving the physical health of children, adolescents and adults
(e.g. exercise, food consumption, safety, sex education and HIV/AIDS, cardiovascular
disease). A focus on mental health promotion, especially in schools, has emerged more
recently (e.g. parenting, social competence, problem solving, stress management, bullying).
(Hosman, Llopis & Saxena, 2004)
For prevention of mental disorders and mental health promotion, we see from the early
1990s an international market emerging of international exchange of best practices and
effective programmes. This is supported by several international and national databases and
websites that provide descriptions, outcome data and materials on theory- and evidence-based
programmes. Well-known US-based websites are the database on social-emotional learning
programmes of CASEL (http://www.casel.org) and the prevention database of the
Governmental
Department
of
Mental
Health
and
Addiction
SAMHSA
(https://www.samhsa.gov/ebp-resource-center). In the Netherlands, the National Youth
53
Institute provides such a database (http://www.nji.nl/Databanken) and the National Institute for
Public Health and Environment RIVM (http://www.loketgezondleven.nl/leefstijlinterventies/).
Over the years, several American, English and Australian programmes on violence
prevention, parenting education, social-emotional learning, prevention of depression and
anxiety have been introduced in the Netherlands. Vice-versa, Dutch prevention programmes
are now adopted and implemented in other countries. This applies, for instance to various
Dutch Prevention Programmes for Children of Parents with Psychiatric Problems (COPMI),
such as the Parent-Baby intervention and support groups for children between 8 and 18 years
(Van Doesum, 2007). In addition, EU and WHO launched a European-wide action plan for the
prevention of mental disorders and the promotion of mental health (Mental Health: Facing the
challenges, building solutions). In 2005, this plan was adopted by ministers from 52 countries
in the WHO European Region and has since been further elaborated (EU Green Paper on
Improving the Mental Health of The Population in the European region, downloadable from the
internet).
With support of the European Community, our Prevention Research Centre developed
the two European projects Implementing Mental Health Promotion Action (IMHPA) and
DataPREV. These projects have developed a European collaborative network, a description
of ongoing activities in this field in each of the EU countries, training opportunities, policy
guidelines and an international database, which systematically describes effective
programmes.
2.6
Conclusions
Mental disorder prevention and mental health promotion are no invention of the last decennia,
but have a long history that goes back to the first half of the 19th century. Social medicine in
the 19th century and the mental hygiene movement in the beginning of the 20th century
contributed significantly to the development of modern preventive mental health care. Many
current ideas on prevention and its strategies already developed a long time ago. The need to
develop mental disorder prevention first arose from humanistic and protest movements. Only
much later, after a combination of the following conditions was met, ideas on mental disorder
prevention were tested on their efficacy and became systematically implemented in practice
on a large scale:
•
•
•
•
•
Sufficient social and political support
Social and economic need to develop mental disorder prevention
A government that takes responsibility for the creation of a prevention sector and its
finances
Prevention science that offers prevention a scientific basis and evidence on its
outcomes, to replace mere ideology-based prevention
An organisational structure exists providing preventive interventions on a regular base
from health organisations or other providers
By studying the history of prevention, we learn from mistakes made in the past in order to
create better chances for effective prevention in the future.
In recent years, international collaboration has proved to be essential for the development of
effective prevention. This international point of view is important for three reasons: 1) since the
54
beginning of the 20th century the development of mental disorder prevention in our country has
been closely linked to similar developments in other European countries and especially in the
USA; 2) national developments in prevention and health promotion are influenced by
international agreements and policies of the World Health Organization (WHO) and the
European Union; 3) International collaboration is particularly focused on prevention research
and the development, dissemination and larger scale implementation of effective prevention
programmes. As one of the trendsetters in health promotion and prevention, the Netherlands
have become one of the leading countries in this international collaboration.
Literature
Beek, H.H. (1974) Waanzin in de Middeleeuwen. Beeld van de gestoorde en de bemoeienis met de
zieke, ICOB.
Bockhoven, J.S. (1963). Moral treatment in American Psychiatry. New York: Springer.
Bosma, M. W. M., & Hosman, C. M. H. (1990). Preventie op waarde geschat. Een studie naar de
beïnvloedbaarheid van determinanten van psychische gezondheid. Nijmegen: Beta.
Breemer Ter Stege, C., & Gittelman, M. (1987) The direction of change in Western European mental
health care. International Journal of Mental Health, 16, 6–20.
Bremer, J. B. G. (1964). De zorg voor de kleuter, voordrachten over psychisch hygiënische, sociaal
hygiënische en pastorale kleuterzorg (Vol. nummer 26). Utrecht: Spectrum.
Caplan, G. (1963).Types of mental health consultation. American Journal Orthopsychiatry, 33, 470-48
Caplan, G. (1964). Principles of preventive psychiatry. New York: Basic Books.
Caplan, R. B. (1969). Psychiatry and the community in nineteenth-century America. NY: Basic Books.
Crossley, N. (2006). Contesting Psychiatry: Social Movements in Mental Health. New York: Routledge
Foucault, M. (1964). Madness and Civilization: A History of Insanity in the Age of Reason. New
York: Routledge.
Fox, A., & Stoop, B. (1975). Psychische stoornis en maatschappij. Doctoraalscriptie. Katholieke
Universiteit Nijmegen, Nijmegen.
Freeman HL, Fryers T, Henderson J (1985) Mental health services in Europe 10 years on (Public health
in Europe 25) World Health Organisation, Copenhagen
Gibbs, M., Lachenmeyer, J. R., & Sigal, J. (1980). Community psychology: theoretical and empirical
approaches. New York: Gardner Press.
Hodiamont, P. P. G. (1982). Historische en Theoretische trends in de psychiatrie. Nijmegen: Afdeling
Sociale Psychiatrie, Katholieke Universiteit Nijmegen.
Hosman, C. M. H., van Doorm, I. & Verburg, H. (Eds.) (1988) Preventie in-zicht. Swets & Zeitlinger,
Lisse.
Rappaport, J. (1977). Community psychology: values, research and action. New York: Holt, Rinehart &
Winston.
Roman, P.M., & Trice, H.M. (Eds). (1974). Sociological Perspectives on Community Mental Health. F.A.
Davis, Philadelphia.
Rosen, G. (1979). The evolution of social medicine. In H. E. Freman, S. Levine & L. G. Reeder (Eds.),
Handbook of medical sociology. Englewood Cliffs, N.J.: Prentice-Hall.
Thoma, P. (1975). Die Geschichte der Sozialmedizin als Einführung in der Gegenstand der
Medizinsociologie. In B. Geissler & P. Thoma (Eds.), Medizinsoziologie. Frankfurt: Campus
Verlag.
Van Doesum K. 2007. An early preventive intervention for depressed mothers and their infants, its
efficacy and predictors of maternal sensitivity. Thesis Radboud University Nijmegen.
Van’t Veer-Tazelaar, P. J., van Marwijk, H. W. J., van Oppen, P., van Hout, H. P. J., van der Horst, H.
E., Cuijpers, P., … Beekman, A. T. F. (2009). Stepped-care prevention of anxiety and depression
in late life: a randomized controlled trial. Archives of General Psychiatry, 66(3), 297–304.
Verdoorn, J. A. (1965). Volksgezondheid en sociale ontwikkeling. Utrecht: Spectrum.
55
Study questions for this chapter

What was the "moral treatment" approach and to what type of prevention does it resemble
most?

What was the mental hygiene movement and what were its goals? Explain why the mental
hygiene movement partially failed.

Explain how the stages in the history of mental health can be associated with current
prevention divisions.

What is meant by Social Darwinism? How do Social Darwinists think about prevention?

What were the core ideas of the psychobiology of Adolf Meyer? How are his ideas related
to modern theories in prevention, as discussed in part II of this text book?

How would you summarise the view of Alfred Adler on prevention?

Name some prevention strategies that social medicine already developed in the 19th
century. What were the major successes of social medicine in the field of prevention? What
influence did social medicine have on the position of prevention in society?

Explain both the positive and negative impact several ideologies discussed in this chapter
have had on the development of prevention.

What does this historical analysis show about the conditions that need to be present in
society for an effective prevention sector to develop?

What role does international collaboration have in the development of prevention and what
role do WHO and the European Community have in it?

Describe the meaning of the ‘consultation method’ as introduced by Gerald Caplan. What
are the aims of this method and why could this method be characterised as a prevention
method? Why is this method currently highly relevant again?

What major trends have occurred between 1920 and 2000 and more recently in the field
of prevention? What is the meaning of ‘stepped care’ and ‘Basic mental health care’?
56
3 Mental Disorder Prevention and Mental Health Promotion
Concepts, practice, providers and partners
3.1
Introduction
58
3.2
Concepts of mental illness and mental health
58
3.2.1
Mental illness
58
3.2.2
Mental health
59
3.2.3
Views about the relation between mental illness and mental health
60
3.3
Classifications of prevention
62
3.3.1
Primary, secondary and tertiary prevention
62
3.3.2
Universal, selective and indicated prevention
65
3.3.3
Disease specific and "broad spectrum" prevention
67
3.3.4
Mental health promotion
68
3.4
Profile of practice
69
3.4.1
Professional roles and specialisations in prevention
69
3.4.2
Professional tasks
70
3.4.3
Intervention methods
72
3.4.4
Organisations providing prevention and health promotion
72
3.4.5
Stakeholders and coalition development
74
3.4.6
Professionalisation and quality management
80
3.4.7
Availability of effective programmes
80
3.5
Limitations, risks and and bottlenecks of professional prevention
81
3.6
Conclusions
83
Literature
85
Study questions for this chapter
87
57
3
Mental Disorder Prevention and Mental Health Promotion
Concepts, practice, providers and partners
Clemens M.H. Hosman
3.1
Introduction
Before we discuss the theoretical base and strategies of effective prevention of mental
disorders and promotion of mental health, we first need to address a range of conceptual
issues. Mental disorders, mental health, and the term ‘prevention’ are no clear-cut concepts.
Prevention, for instance, could refer to a broad spectrum of possible goals and actions. Its
definition varies among professionals, organisations and sectors. Furthermore, prevention and
health promotion are partly overlapping concepts. Many interventions that aim to prevent
mental disorders are actually focused on promoting mental health. Likewise, mental health
promotion programmes may also, in the end, result in a lower incidence of mental disorders.
This chapter first examines a range of key prevention and promotion concepts. Next, a profile
of practice is presented to offer insight into different roles and tasks of professionals that work
in the practice of mental health promotion and prevention. It offers a first introduction to
policies, strategies and intervention methods used in this field. The work includes collaboration
with many stakeholders and sectors outside the health system. To achieve significant
improvements of the mental health condition of target populations multisectoral coalitions and
partnerships are needed. Finally, some criticisms and bottlenecks of professional prevention
are discussed and ways to cope with them.
3.2
Concepts of mental illness and mental health
3.2.1 Mental illness
Over the last decades, mental illness is internationally recognised as a major public health
problem, comparable with physical diseases already given priority, such as cardiovascular
diseases, cancer and HIV/Aids. As explained in the introduction chapter, populations across
the world show a high prevalence of mental disorders and this has resulted in an enormous
human, social and economic burden for societies. Due to the high level of relapse and
recurrence, mental disorders are considered as one of the modern chronic diseases. While
most epidemics are currently under control, to date health policies are mainly targeted at
controlling and preventing prevalent chronic disorders.
Definitions of 'mental health' and 'mental disorder' changed over time. The search for
international consensus on defining psychiatric illnesses took many decades. Current
classification systems like ICD-10 and DSM-V provide an internationally shared framework of
concepts, classifications and diagnostic criteria. These have facilitated the development of
population-based monitoring tools to assess psychiatric morbidity in populations, to identify
populations at risk, study social risk factors, and compare psychiatric morbidity between
countries. They also made it possible to estimate the social and economic costs of mental
disorders. This significantly contributed to the raise of awareness on mental disorders and poor
mental health as a major public health problem. Classification systems have also contributed
to the development of science-based prevention strategies and programmes.
58
In spite of these achievements, these psychiatric classification systems have been
criticised for several reasons. Firstly, they do not cover the whole spectrum of serious mental
health problems in the population. For instance, burnout problems, pathological grief, severe
parenting problems, and serious partner-relation problems are not covered by the ICD-10.
Secondly, the arbitrary nature of chosen boundaries between disorders and normality is much
debated (Widiger & Coker, 2003). Here we are facing a serious dilemma. When a person has
mental or behavioural symptoms that fail to meet criteria for a psychiatric diagnosis, it does not
mean that professional support would be needless. For instance, subclinical levels of
depressive symptoms could cause substantial dysfunction comparable to or worse than that
of patients with major chronic medical conditions such as hypertension, diabetes and arthritis
(Wells et al., 1989). In addition, subclinical depression is found to be a risk factor for later mild
and serious depressive disorders which deserves preventive action. Among clinicians, such
findings have yielded a tendency to include ‘subclinical and minor disorders’ and labels like
‘not otherwise specified (NOS)’ in psychiatric classification systems (Brown & Barlow, 2005;
Widiger & Samuel, 2005). On the one hand, it means that these less severe problems are also
taken seriously. The danger of such inclusions is, however, that we extend psychiatric labelling
of human problems. By accepting this, we support the process of ongoing medicalisation of
our society. In the end, it contributes to a further increase of the costs of health care and making
people more dependent on professionals and psychotropic drugs to solve their problems
(structural iatrogenesis).
Another issue of criticism is that clinical classification systems reduce ‘problematic
behaviour’ to individual processes that must be treated individually. The high prevalence of
depression and excessive alcohol consumption in some groups, however, also reflects serious
social problems (e.g. discrimination of minority groups, poverty, domestic violence, poor social
cohesion in neighbourhoods, trafficking) that primarily need a social and political response.
Such social policy measures become less likely when psychiatric labelling has defined the
human consequences of such social problems as individual pathology.
3.2.2 Mental health
Over many decades, efforts have been made to find a positive, measurable and science-based
definition of mental health. An important historical example is the landmark book "Current
concepts of mental health" by Marie Jahoda (1958). Based on a survey of scientific opinions
at that time, she defined six clusters of criteria for "mental health": (1) the attitude of a person
in relation to himself (esteem), (2) the presence of growth, development and self-actualisation,
(3) the extent to which a person is internally integrated, (4) the autonomy of a person, (5)
having a sensible perception of reality, and (6) having a reasonable control over the own
environment (environmental mastery). Over the past decades, many authors tried to define
such positive features of mental health, see for instance “Mental health promotion” by Keith
Tudor (1996), the series of volumes on "Promotion of Mental Health, (Trent & Reed, 19931997) and the work of Corey Keyes (2002, 2007).
As important features of mental health several authors have suggested human qualities
such as happiness, ability to love, self-confidence, identity, autonomy, assertiveness, positive
attitude toward life, happiness, the capacity to develop and change oneself, being physically
healthy, access to social support and ability to live productively (e.g. Tudor, 1996; Health
Education Board of Scotland, 1998). According to advocates of the positive mental health
concept, these qualities need to be promoted because they represent fundamental positive
human values, and not just because they might protect against mental disorders. These
qualities as indicators of mental health have long been criticised because of the lack of theory59
based inclusion and exclusion criteria and their unverifiable character. Also, some definitions
mix basic features, antecedents and outcomes of mental health (Hosman, 1997a; 1997b). For
instance, should we consider physical health a determinant, a feature or a consequence of
mental health? When mental health has diverse meanings, it will be difficult to develop
research-based knowledge on determinants of mental health that could become widely
accepted targets of mental health promotion activities. Recent developments in the science of
positive psychology have countered this criticism by better assessment tools, theoretical
embedding and a cumulating body of evidence showing the importance of positive features for
a wide range of aspects of human life (Seligman, 2000; Carr, 2004; Keyes, 2007, chapter 8).
3.2.3 Views about the relation between mental illness and mental health
It has long been debated how 'mental health' and 'mental disorder' exactly relate to each other.
Are they qualitatively different concepts or do they form ends of the same continuum? In
general, four distinct views on mental health can be differentiated, described here as models
of mental health (Hosman, 1997; Figure 3.1):
1. Categorical medical model: A
person is mentally healthy when no
mental disorder is present. Health
and illness are treated as a
dichotomy; you are either sick or
healthy. This corresponds to the
categorical
view
on
which
classification systems like ICD-10
and DSM-V are based.
2. Dimensional medical model. In a
more recent view, psychiatric
diseases and mental health are
considered as two sides of a
continuum that is defined by the
number of psychiatric symptoms.
There is no clear-cut separation
assumed between the two. The presence of many psychiatric symptoms represents psychiatric
illness, while few or no symptoms point at mental health. The more symptoms the more
seriously ill, the less symptoms the healthier a person is functioning.
According to both the categorical and dimensional model, logically there would be no
difference between promoting health and preventing disease, as the promotion of health is
defined by the prevention of illness or symptoms. In both cases, health is defined negatively
as the absence of a disorder or symptoms. That is not the case it in the following two views.
3. Positive model of mental health: Many scientists, health promoters and mental health
practitioners consider the two models above as unsatisfactory. According to them, the
categorical disease-model and the more recent dimensional view on psychiatric illness are too
dominated by traditional medical thinking, i.e. viewing health only from a negative perspective
as the absence of disease, deficits and symptoms. They advocate for a different and more
positive definition of mental health, independently from the term mental disorder. For instance,
Keyes (2002) defined mental health as a syndrome of symptoms of hedonia and positive
functioning, operationalised by measures of subjective well-being, such as individuals’
perceptions and evaluations of their lives and the quality of their functioning in life. Positive
60
mental health is becoming increasingly conceptualised as a multi-dimensional concept. In his
empirical study of basic features of mental health, Keyes (2005) differentiates between three
factors, i.e. emotional well-being, psychological well-being and social well-being. Recently,
Vaillant (2012) even distinguished seven models of positive mental health. These include (1)
positive functioning as measured by the DSM-GAF-score, (2) presence of multiple strengths
over weaknesses, (3) maturity, (4) positive emotions, (5) high social-emotional intelligence, (6)
subjective well-being, and (7) resilience. In several positive definitions also functional aspects
are underscored, which we will discuss separately as the next model that links mental health
and mental illness in a functional way.
4. Functional model of mental health. In this model (Figure 3.2) mental health is considered a
cluster of psychological resources and abilities, that people need for well-being, to develop
themselves mentally and physically across the life span, to have a satisfying and productive
life in domains as health, relationships, love, school, parenting and work, to be able to cope
with life stressors and challenges, and to reduce the risk of negative life outcomes such as
mental
disorders,
physical
diseases and serious social
problems (Hosman, 1997a, 1997b;
Lavikainen, Lahtinen, & Lehtinen,
2001). This functional model is in
agreement with current definitions
of mental health that differentiate
between an internal dimension of
mental health (subjective wellbeing) and an external one
(capacity to relate positively and
productively
with
one’s
environment). It conceives mental
health as cluster of adaptive
features.
The functional model considers mental health and mental disorders as different
concepts but assumes a functional relationship between the two (Hosman, 1997a, 1997b). As
is illustrated in Figure 3.3, the functional model makes a distinction between (1) characteristics,
(2) determinants and (3) outcomes of mental health. Mental health can be considered as
'functional' as it contributes to a wide range of important individual, social and even societal
outcomes, including the possible development of a mental disorder.
This broad spectrum of different outcomes is important for practice, because they
provide a basis for getting public support for mental health promotion programmes, such as
from schools, private companies and the justice sector. Even if such ‘stakeholders’ are not
primarily interested in investing in mental health (e.g. less depression, conduct disorders),
secondary effects of such programmes (e.g. public safety, less school absenteeism, better
academic achievements, more productivity at work, more social cohesion in communities)
could motivate their readiness for political or financial support.
61
This functional view is reflected in two recent authoritative definitions of health and mental
health. Recently an international group of health scientists has proposed a new definition of
health to replace traditional WHO definitions of health. They suggest considering:
Health as an ability to adapt and to self-manage, when life is facing people with
physical, emotional and social challenges (Huber et al., 2011)
In addition, WHO adopted a new definition of mental health that stresses human capacities
and their functional value:
Mental health is a state of well-being in which an individual realises his or her
own abilities, can cope with the normal stresses of life, can work productively
and is able to make a contribution to his or her community. In this positive sense,
mental health is the foundation for individual well-being and the effective
functioning of a community“ (WHO, Factsheet 220, 2010).
In this book on mental health promotion and prevention, we will use these capacity-based and
functional definitions of health and mental health as our base.
3.3
Classifications of prevention
Over the last five decades, prevention has been defined and subdivided in different ways.
Below we discuss the most important classifications.
3.3.1 Primary, secondary and tertiary prevention
Best known is the original public health classification of disease prevention (Commission of
Chronic Illness, 1957) which differentiates between primary, secondary and tertiary prevention
(Figure 3.4). This classification distinguishes interventions according to the developmental
stage of a disease and corresponding preventive goals.
Primary prevention refers to interventions aimed at preventing the onset of new cases
of diseases or disorders, thus reducing ‘incidence’. Primary prevention is not the same as
preventing "problems" in general. Psychological problems are actually a part of a healthy life.
62
Learning to cope with problems of life can even be seen as a prerequisite for healthy
psychosocial development. Primary prevention aims to prevent healthy people developing
serious mental problems that are no longer manageable for them, resulting in serious mental
suffering or serious harm to their environment. Such problems require professional treatment
to be solved. These kinds of problems are classified as diagnosable psychiatric disorders and
described in the DSM-V and ICD-10. Primary prevention is often focused on groups at high
risk or sometimes at an entire population, but can also be individually-oriented. Three
examples:
(1) Preventing child abuse by parent education can contribute to lower risk of subsequent
depression, anxiety disorders, behavioural disorders, substance abuse and chronic diseases
(2) Preventing anorexia nervosa through educating and counselling of catwalk models in the
fashion industry who are a risk group for this disorder, or by legal measures on minimal body mass
index to be allowed as model.
(3) Prevention of bullying in schools, through classroom education, social skill training, peer
counselling and measures affecting the school culture and norms (Box 3.1).
Secondary prevention aims to detect disorders in an early stage, enhance their early treatment
and prevent them staying untreated. This prevents beginning or moderate disorders from
developing into severe disorders, and helps to avoid chronicity and long-term mental suffering.
By reducing the duration of a disorder, its prevalence will also be reduced, which is the number
of existing cases of a disease in the population during a defined period. Prevalence mostly
refers to the percentage of cases during the period of a year (12-months prevalence), but may
also be measured as the percentage of cases in the population at a certain date (point
prevalence), or during the past life time (lifetime prevalence).
A prerequisite for secondary prevention is knowledge of the early course of a disease,
and the availability of reliable methods for its early detection. It is still unclear which impact
secondary prevention can have on the ever-increasing use of mental health facilities and the
associated costs. On the one hand, it is hoped that early detection and treatment can prevent
severe disorders and chronicity, shorten the duration of necessary treatment and reduce health
care costs. Generally, untreated mental disorders result in a poorer prognosis of the progress
63
Box 3.1 Prevention of bullying: a "textbook example" of
a multi-component primary prevention programme
A classic example of successful prevention is a Norwegian bullying prevention
programme, originally developed in Norway by Olweus (1991, 1993).
Problem: Epidemiological data have shown that about 15% of primary school
pupils are involved in bullying, either in the role of victim or perpetrator. Both
groups have a high risk of developing serious psychological problems. For
victims that can be social anxiety, depression or even suicidal behaviour. The
perpetrators are at increased risk for behavioural disorders, delinquency and
alcohol addiction.
Programme: The programme is based on a multi-component approach. First it
is considered important to encourage a school environment that is characterised
by warmth and positive interest in students and their emotional well-being,
commitment and social support from adults, and that set limits and non-physical
sanctions for unacceptable aggressive behaviour. To create these conditions,
teachers and parents are first made aware of the problem of bullying and receive
knowledge about its consequences. Second important element is to create a
monitoring system in schools for detecting bullying.
A variety of interventions is used to prevent and reduce bullying. For
instance, at the level of the school system this is done by creating a more
attractive playground, setting up workgroups for parents and teachers, and by
organising consultation meetings between the two groups. Teachers receive an
instruction manual, parents a brochure and to both groups a video is presented
about bullying. At the level of the class, clear rules are made to combat bullying.
Students learn new behaviours through role playing, classroom work on
solutions and written information. Direct consultations are given between
parents, children and teachers to address bullying problems. Individual
interventions were also part of the overall strategy, such as individual guidance
of children and parents of bullies and victims, support by a neutral fellow student
(peer counsellor), or transferring a child to another class.
Effects: In a period of 20 months after the start of the programme the incidence
of bullying decreased by at least 50%. The incidence of new bullying victims
decreased from 2.6% to 0.6% for boys and from 1.7% to 0.5% for girls. In this
period, other forms of antisocial behaviour such as vandalism, truancy and
stealing reduced as well (Olweus, 1991).
Broad implementation: Based on this success, the Norwegian Government
decided to run this programme in all primary schools. Partly inspired by its
success many Dutch schools and schools in other countries around the world
have adopted the programme as an essential part of their prevention of bullying
strategy. Where needed, the programme has been adapted to local context and
culture.
64
of a disorder and more risk of chronicity. On the other hand, secondary prevention may
contribute to more cases of mental disorders entering the care system and therefore increasing
health care costs. Early recognition is a major task for primary health care. Examples are early
recognition and treatment of depression or alcohol abuse by nurses and general practitioners,
and of developmental problems in child health centres.
Tertiary prevention seeks to decrease the disability associated with an existing disorder or
illness. Successful tertiary prevention aims to reduce problems in social functioning of people
with a severe disorder and to improve their quality of life. Simply put: preventing that new
problems arise from severe psychiatric problems. Some examples are: the prevention of
hospitalisation, combating stigma and social isolation and promoting the reintegration of
psychiatric patients into society.
In addition to these categories, the term relapse prevention is used. This type refers to
interventions that aim to prevent a previously existing disorder from occurring again or to
prevent new acute episodes of a chronic disorder. Relapse prevention is often considered as
a component of tertiary prevention. Well-known are activities to prevent relapse in people who
earlier successfully overcame their addiction to alcohol, drugs or smoking. Relapse prevention
is also important in depression and other Axis-I disorders. Several studies have shown that a
person who had a first depressive episode during adolescence or early adulthood has a high
risk of getting subsequent depressive episodes (Lewinsohn et al, 1999; Mueller et al. 1999). A
large part of current depression prevalence consists of relapsed cases. Effective relapse
prevention is an important tool to reduce the prevalence and incidence of mental disorders in
society. People, who already have experienced a period of severe psychological suffering,
might be more motivated to engage in preventive activities than those without such a history.
Although the division into primary, secondary and tertiary prevention is a classical one, there
are many who consider only primary prevention as ‘true’ prevention. Secondary and tertiary
prevention can also be seen as forms of adequate treatment and care (high quality care).
3.3.2 Universal, selective and indicated prevention
A second and widely used classification is the distinction between universal, selective and
indicated prevention (Gordon, 1983; Mrazek & Haggerty, 1994, Figure 3.5). They can be
regarded as a subdivision of primary prevention. This classification is primarily based on
differences in risk level between populations and in the size of targeted populations. These
two aspects are related, populations with a defined high-risk are mostly much smaller that lowrisk populations. For groups at high risk more expensive prevention programmes are
considered as defendable. The higher the risk in a population the more people could benefit
from an intervention and the higher the economic benefits could be. Still, if a low-risk population
is very large, many cases could be prevented if a low-cost large-scale intervention would prove
to be effective.
Universal prevention is defined as interventions targeted at the general public or at a large
population segment with no increased risk level, such as all schoolchildren, all pregnant
women or all elderly. For these audiences, the introduction of preventive interventions is only
feasible and justifiable when they concern low labour-intensive interventions that target each
person at relatively low costs. An example in the field of mental health is introducing a
programme to increase social resilience of all children in primary schools through socialemotional education. Of course, such a general group will include certain children at high risk,
for instance children who have a parent with a mental disorder.
65
Selective prevention targets individuals or subgroups of populations whose risk of developing
a mental disorder is significantly higher than average, as evidenced by the presence of
biological, psychological or social risk factors. The higher the risk, the more people in such a
group are in need of preventive support and the higher the potential benefits of effective
preventive interventions could be. Even a prevention programme with relatively high costs,
could be an economically sound investment for this reason. Groups at high risk for mental
disorders include, for instance, children of parents with psychiatric problems or drugdependent parents, victims of child abuse or partner violence, professionals with high work
stress (e.g. teachers) or at high risk of traumatic experiences (e.g. emergency workers),
survivors of suicide, and those living in poverty .
Indicated prevention targets high-risk persons having minimal but detectable signs or
symptoms forewarning a likely developing mental disorder, or who have biological markers
indicating a predisposition for a mental disorder, but who do not yet meet the diagnostic criteria
for that disorder. In such cases, clinicians also speak of the presence of subclinical symptoms.
Examples are adolescents with an
increased level of depressive
symptoms but no diagnosed
depressive
disorder,
an
adolescent female with deviant
dieting behaviour but no anorexia,
or someone with excessive
alcohol consumption that could
eventually lead to a serious
alcohol addiction and related
physical disorders. The risk of
developing a mental disorder in
these groups is demonstrably
higher than in the population at
large.
As Figure 3.6 shows, the two
classifications can be combined. Universal, selective and indicated prevention can be
66
considered as subdivisions of primary prevention, while all their definitions refer to situations
wherein no diagnosable disorder is present yet.
3.3.3 Disease-specific and ‘broad spectrum’ prevention
A third classification can be made between disease-specific prevention and "broad spectrum"
or generic disease prevention (Figure 3.7). This distinction refers to differences in the width of
the targeted preventive outcomes.
In disease-specific prevention, the goal is to prevent one particular disease or disorder (e.g.
depression, anorexia nervosa or alcohol addiction). Risk factors or determinants of that
disease are investigated and preventive interventions are designed to influence as many of
these factors as possible. Interventions aimed at preventing a specific disease are generally
based on the assumption that risk factors for that disease are predominantly disease-specific
in nature, for instance, that they mainly predict depression and no other disorder. If that is the
case, disease-specific prevention programmes are most appropriate. However, the emergence
of many diseases and disorders, including depression, depends not only on disease-specific
risk factors, they also share risk factors with other diseases.
Generic prevention, also called broad-spectrum prevention, is based on the assumption that
multiple diseases and disorders have major risk or protective factors in common, and that only
a limited part of the incidence can be explained by disease-specific determinants. Examples
of common factors are poverty, child abuse, social and problem-solving skills, self-esteem and
social support. A lack of social skills can contribute to an increased risk of depression, eating
disorders, excessive alcohol use and juvenile delinquency. Child abuse appears to increase
the risk of a wide range of mental and physical disorders. Interventions aimed at influencing
common risk or protective factors may result in a broad-spectrum of preventive effects, which
means a reduction of multiple diseases and problems.
A distinction can also be made according to the differences in the type of primary benefits that
are aimed with preventive interventions. Most common goal of prevention in the health sector
is disease prevention, which differs for instance from the primary aim of mental health
promotion (3.3.4). It might also be the case that different stakeholders in a prevention
67
programme might have different views about the targeted primary benefits. For some, it could
be less cases of a disorder, for others a reduction of care consumption or health care costs,
while for other stakeholders a resulting social benefit might be the primary reason of support
for this programme. These distinctions have strong implications for how we should define the
effectiveness of interventions, for stakeholders might use different criteria of success.
3.3.4 Mental health promotion
The primary aim of mental health promotion is to empower people and to enhance their positive
mental health and well-being, not primarily to prevent illness. To achieve this, mental health
promotion aims to support individuals, families, groups, organisations, communities and
governments to create the individual capacities and social conditions that are needed for
people to develop and protect their mental health and well-being. Individual capacities might
include the type of capacities we defined earlier as features of mental health, such as selfesteem, emotional resilience, social competence, problem solving skills and feelings of
mastery. Enhancing social conditions for mental health means on the one hand to empower
people to create supportive and stimulating environments and positive experiences that
enhance and protect their mental health and well-being, but also to eliminate, reduce or avoid
social conditions that represent a threat to mental health, such as poverty, discrimination,
abuse, violence, and unemployment (Joubert & Raeburn, 1998; Hodgson, Abasi, & Clarkson,
1996; WHO, 2008). Typical for health promotion is also to use a participative approach with
citizens and to avoid a top down approach in which only professionals define goals. Citizens
are stimulated to play an active role in shaping needed actions and policies that could improve
the health and mental health conditions of their life. Health promotion stresses not only
governmental agencies and professionals have a responsibility, but that it is in the first place
a responsibility of citizens and communities themselves.
Although there is no overall consensus on a definition of mental health promotion, the
following definition summarises its main principles: Mental health promotion aims to protect
and improve mental health, and related health and social outcomes by enabling individuals,
families, groups, organisations and communities to enhance mental health promoting factors
and to reduce harmful factors through intersectoral public policy, and educational and
environmental actions at micro, meso and macro level with use of participatory methods.
Mental health promotion is usually targeted at whole population segments, not
specifically at those at high individual risk to develop mental illness. For instance, mental health
promotion can be targeted at all schoolchildren, or specifically at all schoolchildren living in
poverty areas. While large population groups also include some people who are at high risk
for developing, for instance depression, mental health promotion activities can strengthen
protective factors and can contribute to preventing the onset of mental disorders. For this
reason, mental health promotion and primary prevention partly overlap in practice. Originally,
mental health promotion and primary prevention were even considered as more or less
interchangeable concepts (Perlmutter, 1982).
Figure 3.8 schematically shows the various classifications of prevention according to the main
criterion on which each classification is based.
68
3.4
Profile of practice
This section presents a profile of the practice of mental health promotion and prevention, and
the type of professionals and organisations operating in this field, which differs between
countries. It illustrates that mental health promotion and prevention concerns a multidisciplinary field and that its work includes many challenging tasks. Successful prevention and
health promotion in our society requires the input from a wide range of expert domains.
3.4.1 Professional roles and specialisations in prevention
Within the field of prevention and health promotion there is a variety of professional roles and
academic specialisations. The most important are:

Senior prevention and health promotion experts: Their work consists of developing new
science-based intervention programmes, testing and evaluating them, policy
development, team and project management, quality control, advocacy and training of
professionals and organisations. Some experts are generalists and able to address a
wide range of themes and target populations, others are specialised in working with
specific age groups (e.g. children or elderly) or on specific themes such as depression
and anxiety, substance abuse, domestic violence or work. Usually such experts have
an academic degree in health promotion or in social sciences with a specialisation in
prevention and health promotion, or more specifically in mental health promotion. Such
experts are appointed, for instance, by national institutes or by local public health
organisations, mental health centres or addiction clinics.
69

Prevention and health promotion practitioners, whose primary task is implementing
health promotion and preventive interventions on a daily basis, for example providing
courses, training, educational activities, offering preventive consultation and
developing preventive collaboration between different local professionals and
organisations. Mostly, on top of the basic training in their discipline (e.g. social work,
youth work, psychology), they have received a special graduate or postgraduate
training in providing health promotion and preventive interventions. Their work covers
a wide variety of activities as we will illustrate in the next sections and chapters.

Health and mental health care professionals, with a part-time prevention task, as part
of their curative work and through their participation in prevention programmes. These
include, for instance, public health nurses, psychiatric nurses, psychotherapists,
gerontologists, primary care psychologists, school psychologists, organisational
psychologists, hospital psychologists and school-based social workers.

Professionals working in social services and educational institutes, who consider health
and mental health promotion as a part of their work. This group includes for instance
teachers and school counsellors, fitness professionals and stress management
counsellors in companies, personnel working in homes for elderly.

Staff and policy officers in governmental institutions, professional organisations, and in
organisations of interest groups. Part of their task is to develop health promotion and
prevention policies for countries, districts, cities, or companies.

Prevention and health promotion researchers, at universities, research institutes or
working in large service organisations. They usually collaborate closely with practice.

Teachers in prevention and health promotion at universities and professional schools
with the task to educate new generations of prevention and health promotion
professionals, and to increase the prevention capacity in a wide variety of disciplines.
All these different professionals are needed to move our society into a healthier and mentally
healthy one.
3.4.2 Professional tasks
What kind of work is performed by these professionals? In order to achieve preventive effects
in a population, community or target group, involved professionals need to fulfil a range of
tasks. We summarise the main ones:
70

Needs and risk assessment at the level of individuals, groups and communities: This
involves identifying needs and opportunities for prevention and health promotion
through various assessment methods, the identification of target groups (at risk), and
detection of risk and protective factors. This requires the use of various research
methods such as case studies, surveys, epidemiological research, group interviews,
community observation methods, social indicator studies and network analysis.

Running problem analyses. Prevention experts have a task in analysing how risk and
problems have developed over time and which major causes could be influenced by
health promotion and prevention policies and interventions. For generalists, the
problems and themes they study can vary over time and between the communities they
serve. Other experts are specialised in a specific domain, for instance, depression,
substance abuse, child maltreatment or elderly. This requires scientific knowledge of
developmental psychopathology, mental health development and theories or in-depth
knowledge about a specific issue.

Programme Development: systematic development and testing of new prevention and
health promotion programmes, based on problem analysis, goal analysis, target group
analysis, feasibility analysis. Designing an effective programme requires the use of
science-based and practice-based knowledge about programme planning, processes
of change, intervention strategies and moderators of effectiveness and public impact. .

Development of educational and advocacy materials, such as leaflets, brochures,
workbooks, lesson plans, games, videos, press releases, social media messages,
websites and Internet-based interventions (E-health). The development of attractive
and effective educational materials, for example making a video film, requires much
preliminary work, such as literature analysis, interviews with people from the audience,
and pre-testing new materials on comprehension, attractiveness and usefulness.

Implementing interventions: this means providing prevention and health promotion
programmes to target groups and applying a wide variety of intervention methods
(chapter 13). In this work, professionals can play different roles such as being an
advocate, educator, trainer, consultant, facilitator, mediator or coalition builder. A
distinction is made between interventions aimed directly at the final target population
(e.g. children, pregnant women, depressed adolescents, employees) or at intermediate
target groups (e.g. teachers, nurses, doctors, police, community leaders, business
managers, civil officers). Intervention methods may target individuals, groups,
organisations or entire populations. Professionals may choose from a wide range of
standardised, evidence-based programmes described in national and international
databases.

Safeguarding sustainable implementation: Activities to ensure that organisations (e.g.
schools, companies, local non-profit organisations) will adopt and implement new
prevention and health promotion policies and programmes on a structural and
sustainable basis. This requires a professional to perform tasks such as advocacy,
negotiating, instructing and coaching organisations, staff training and making
interventions a steady part of their long term agenda.

Programme-evaluative research: conducting process evaluations, effect studies and
economic evaluations (e.g. cost-benefit and cost-effectiveness analysis). From such
studies conclusions should be drawn for the improvement of prevention policies, and
programmes, and for a more efficient use of available resources. Positive outcomes
can be used for advocacy purposes.

Prevention policy and management: This includes setting of priorities and goals for
preventive actions by governmental, non-profit and for-profit organisations, or writing a
policy plan for how prevention is implemented. It can also include making agreements
on how prevention tasks are distributed across organisations, setting quality standards,
implementing quality control, and acquisition of economic resources and manpower.
Furthermore, prevention work requires many managerial tasks, such as managing a
department or team, developing a local coalition and project management.

Professional education and training: providing education and training in prevention and
health promotion to professional groups who are involved in such activities, often
alongside other tasks. Examples of professional groups are general practitioners, baby
71
clinic personnel, school nurses and doctors, school counsellors, therapists, police,
company social workers and staff officers. For instance, to increase the preventive
capacity of nurses, they could be offered training in early detection and treatment of
depression among pregnant women.
This multitude of tasks requires professionals to have broad expertise and have knowledge
and skills in different domains. This is what makes health promotion and prevention work so
interesting and varied. Another common strategy to ensure the availability of all these types of
expertise is working with multidisciplinary teams and collaborating with other organisations at
local or national level to bring in additional strengths. In the next part of this book the required
expertise and professional skills for these tasks is discussed further.
3.4.3 Intervention methods
Although professionals in this field have many different tasks, the practice or mental health
promotion and prevention derives its identity especially through the type of intervention
methods they use. These partly overlap with those used in treatment of mental disorders, such
as preventive medication, cognitive-behavioural intervention methods and psychoeducation
but then applied for preventive purposes in groups at high risk. Cognitive-behavioural methods
are used, for instance, in face-to-face courses, self-help manuals and E-mental health
programmes for people with increased levels of depressive symptoms, who are at risk for
developing a clinical depression (indicated prevention). Prevention professionals also use a
wide range of other intervention methods, such as skills training, organising support groups for
people facing similar problems, involving former clients as trained volunteers or mentors, home
visits and use of social media.
To increase mental health promotion and preventive capacity in communities, schools,
health care, workplaces and other organisations, they use advocacy methods, mass media
and internet, staff training, workshops, symposia, protocol development, organisational
consultation, task forces, and network development. At national level, it can include advocacy
and consultancy to promote preventive measures, policies and legislation. Such methods may
be used to reduce social risk factors, to enhance health-promoting environments or to increase
the resources for prevention. Professionals working in this field will each not use all these
methods, but may specialise themselves in a selection of them. Chapter 13 offers an extensive
discussion of intervention methods and strategies.
3.4.4 Organisations providing prevention and health promotion
Health promotion and preventive interventions are provided by a wide range of health and nonhealth organisations. These could be governmental organisations, nongovernmental
organisations and for-profit organisations. The situation differs largely between countries,
especially in the case of preventive services in the field of mental health. For instance, in the
Netherlands for many decades the outpatient mental health services were the major initiators
and providers of preventive interventions in this domain. In England, public health services
played a major role in implementing mental health prevention programmes in districts and
communities. In Sweden, the provision of preventive services has always been strongly
decentralised across local health and social service organisations. Also, national organisations
play an active role in implementing mental health promotion and prevention programmes such
as Mentality, The Samaritans, Mental Health Media and the Royal College of Psychiatrists in
England. In The Netherlands, the Trimbos institute, the National Institute for Mental Health and
Addiction, plays a significant role in countrywide provision of E-mental health services. The
72
organisational structure of prevention in European countries is described in a study supported
by the EU (Jané-Llopis & Anderson, 2006). WHO has strongly pleaded for integrating
prevention efforts in primary health care centres worldwide (WHO, 2008).
In general, we may conclude that services for mental health promotion and prevention
are provided by a wide range of national and local organisations. Which service or programme
is provided by which organisation depends on the type of mental or social problem that is
addressed (e.g. child and parenting problems, depression, substance use, aggressive
behaviour, domestic violence, dementia), and on the type of prevention. For instance, schools
and public health organisations mostly provide mental health promotion and universal
prevention programmes, while primary health care services, hospitals and mental health care
centres mainly focus on indicated prevention, relapse prevention and suicide prevention.
Which organisation provides which kind of preventive services and in what volume also
depends on the health and social legislation in a country and the financing systems for
preventive and health promotion services. For instance, through the Law on Collective
Prevention, Dutch Public Health
Services
became
explicitly
involved
in
mental
health
promotion and prevention, e.g.
through school-based prevention
programmes, bullying prevention
programmes, programmes for
disadvantaged youth and the
elderly. Recently, through a
change of Dutch health laws the
long
existing
budgets
for
prevention by district mental
health services was strongly
reduced and many of their
preventive tasks were transferred
to primary health care and
community care services.
To illustrate the wide range of
organisations that can be involved
in implementing mental health
promotion
and
preventive
services in the domain of mental
health, Figure 3.9 lists the
organisations involved in the
Netherlands. We stress here the
importance of involving a wide
range of national and local
organisations in the provision of
mental health promotive and
preventive interventions. This seems to us an essential condition for making this a field that is
deeply integrated in the societies of the future. Up until now, international models for the
organisation and provision of prevention programmes in the field of mental health do not exist.
Multiple organisational models should become available to support countries and communities
73
in selecting the model that fits best into their social and professional culture, health system and
available resources.
3.4.5 Stakeholders and coalition development
Which programmes are provided by whom and for whom, and in which frequency and size, is
not just up to a providing organisation. Actually, there are many stakeholder organisations
directly or indirectly involved in such policies and decisions. Some stakeholders may influence
the availability of budgets for prevention and mental health promotion or who is providing what
type of preventive service. Other stakeholders may be crucial to acquire needed knowledge
and expertise, to create access to settings for implementation or as partner in providing
prevention programmes to target populations. Finally, stakeholder organisations might become
involved because of their influence on specific social conditions for mental health that lie
outside the health system, or because they are mainly interested in social and economic
benefits of improved mental health. In this field we frequently have to deal with complex
problems, this means clusters of related problems of which mental health problems are just a
part.
The context in which prevention and mental health promotion is developing and
implemented, could best be considered as a social arena. This label stresses the practice of
mental health promotion and prevention being influenced by many parties that might have
different but related interests, and sometimes competing interests. For preventionists and
mental health promoters it means that they should understand who the major stakeholders
are, what their interests and strengths are, how these are related, and which windows of
opportunities they could provide. Improving the mental health of populations or reducing
targeted problems requires partnership and the development of coalitions of stakeholders and
combinations of multiple actions to generate ‘collective impact’. Figure 3.10 gives a schematic
overview of the most important sectors and actors in this social arena of mental health. Their
role and interests are discussed below.
74
Government
Health policy is a concern of all national governments around the world. In each country, the
Ministry of Health has the primary responsibility to safeguard the health condition of its citizens,
including mental health. Governments develop health legislation, public health policies, provide
health budgets and collaborate on this with all other countries within the World Health
Organization (WHO). A classic example of this is the WHO Health for All Strategy that was
initiated in 1984, and advocated investments in the promotion of the health of populations and
collaboration across multiple public sectors to achieve this (WHO, 1985). This need for
intersectoral collaboration and policies is based on the idea that health problems (e.g. heart
diseases, ebola, cancer, mental disorders, and suicide) and premature death affect many
sectors of society, not just the health sector. In addition, many causes of poor well-being and
diseases are rooted in environmental, social and economic conditions that are outside the
control of the health sector. For mental health, such conditions include, for instance, road
safety, crime, emancipation, poverty, school policies, stress at work, social security, and
refugee policy. Efforts to improve mental health also require measures in other sectors, and
successful mental health promotion programmes are found to generate benefits outside the
mental health domain, such as better school achievements, more safety and increase in
productivity. Public health and mental health problems can only be effectively addressed
through cooperation between multiple sectors, such as education, health, justice and public
safety, work and industry, social benefits, sport, recreation and urban development. This not
only stresses the need for health promotion to stimulate collaboration between governmental
agencies, NGO’s, the private sector and citizen organisations, but also at national and local
level between different ministries or municipal departments. Because of current
decentralisation trends in many countries, local governments (municipalities) increasingly
become major players in the field of health and mental health. This is supported by new
legislations that increase the responsibility of local governments for health care, health
promotion and populations at risk.
During efforts to develop intersectoral collaboration, also conflicting interests may
become visible. For instance, in efforts to reduce alcohol problems the economic interests of
the distillers and the Ministry of Economic Affairs are diametrically opposite to the interests of
the Ministry of Health. Economic measures to reduce the national deficit by lowering social
benefits might increase poverty and lower social cohesion, which may contribute to more
health problems and related costs.
Education and schools
An increasing appeal is made on schools to take up a ‘health educational’ role to help
preventing health, mental health and social problems. Primary and secondary education can
contribute to healthier life styles in children and adolescents, but also teach them skills that will
increase their emotional resilience, social competence and coping with stress. They can
achieve this by adopting special educational programmes or a health-promoting school policy.
It is also recognised that the school system and the school environment itself may produce risk
factors by a lack of rules for social interactions, high levels of bullying and aggression, or by
teachers who lack sensitivity to social-emotional problems of children and adolescents.
Today, in many countries, schools have implemented such programmes and policies,
and research has provided strong evidence for their effectiveness (Durlak et al., 2011). Schools
might have problems with this appeal in a period with steady lowering budgets. In this respect,
it is important that outcome studies have shown that investments in school-based mental
75
health promotion programmes also result in better school achievements and less school
dropout.
Industry and business sector
Working conditions are a major source of mental health problems owing to stressful work
conditions, work overload and burnout, child labour or very low wages. At the same time, work
contributes to mental health through meaningful daytime activities, social contacts, social
appreciation and income. This means that companies have some control on conditions that
influence the mental health of employees. Many companies do not see, however, promotion
of mental health as one of their responsibilities. Investing in such activities might only become
relevant when companies recognise that some common interest exists. This may be the case
when they become aware of evidence showing that ‘mental capital’ significantly contributes to
their primary concerns, such as high labour productivity, product quality and low costs due to
reduced sickness leaves by their employees. This stresses the need to understand better the
economic value of mental health.
Health insurance companies
For health insurance companies it is important that costs of care are under control and kept as
low as possible. Increases in health care costs are their major concern. In the Netherlands, for
instance, the costs of mental health care were rising faster during the last decade than the
costs in any other health domain. To counter rising costs, they use several strategies, such as
increasing revenues by raising the insurance premiums, lowering or maximising the level of
reimbursement of costs of health care services, and excluding certain services from their
insurance policy. This raised questions such as: Should the criteria for psychiatric disorders
be redefined in a more restrictive way? Can the length of insurable psychiatric treatments be
reduced? Can early detection and treatment by primary health care reduce the need for longterm care and costly treatments? Will covering also costs of prevention boom expenses?
Health insurance companies are interested in prevention as is evident from their
covering of costs of vaccinations, early detection of diseases and relapse prevention. However,
their interest is mainly restricted to indicated prevention and secondary prevention, which
means to evidence-based preventive services only for patients with subclinical or beginning
diseases. Among these groups, they expect the best return of investment. For instance, in our
country the costs of participating in interventions aimed to prevent the onset of depression
among those with subclinical symptoms are included in all insurance policies. Health insurance
companies are, however, very reluctant to reimburse the costs of general preventive services
because they expect that this might increase their expenditures exponentially. In addition, they
consider the field of health promotion, universal prevention and selective prevention as
primarily a responsibility of local and national governments. On a local level, municipalities
increasingly negotiate with health insurance companies on dividing responsibilities concerning
prevention or on financing prevention projects together.
Health insurers are also entrepreneurial and competitive, which triggers questions such
as: Which new "markets" can we tap? How do we attract customers? The creation of
prevention centres by health insurers, with emphasis on fitness and stress reduction, can be
understood as an interest in primary prevention, but also as services that are initiated for
marketing reasons, thus to attract new customers. On the other hand, it offers a good example
of how private companies can be persuaded to support prevention initiatives to increase their
market position or and to serve as co-financers for shared benefits.
76
Employers / managers in mental health care
The growth of prevention is among others dependent on the degree mental health services
adopt prevention policies and practices. Usually the primary loyalty of managers in these
services is to curative care, which they consider as the core business of mental health services.
They mostly consider prevention as a minor issue, which from our point of view is a debatable
stand. Mental health services should present themselves as centres of mental health expertise
offering citizens the best and most up-to-date support to maintain, increase or restore their
mental health. This reflects a broader and flexible view on mental health services. Moreover,
due to the dominating clinical culture of current mental health services, managers will not easily
approach the issue of prevention from an epidemiological and public health perspective, which
would be essential for understanding the need for primary prevention and mental health
promotion. If they support preventive services, their major criterion is whether such preventive
services fit in the existing treatment and care system, and not the mental health needs of the
population.
Recently, the interest in a public mental health approach is noticeable in response to
increasing mental health care costs and the economic recession. There is strong political
pressure to reduce the client inflow to highly specialised and expensive treatment, to
strengthen early and short-term mental health services in primary health care, and to stimulate
self-care and community care in the case of mental health problems or people at risk.
In conclusion, mental health care managers are faced with dilemmas. Some skip
prevention tasks as a way to deal with shrinking budgets, others consider the development of
community-based and treatment-based preventive interventions as a challenge to innovate
mental health services and to find new sources to finance mental health services in the future.
Over the next decade, we consider it as very likely that the dominance of the traditional oneto-one and face-to-face psychiatry and psychotherapy will make room for a much more
community based response to the mental health needs and risk of the population.
Mental health, health promotion and public health professionals
Psychiatrists, social workers, psychiatric nurses, educationalists and psychologists
traditionally play an important role in mental health services as diagnostic experts, therapists
and professional care providers for those who suffer from mental disorders. In a period of
shrinking mental health budgets, they may become more protective of treatments budgets at
the cost of their involvement in prevention. Over the last decades it has been debated in many
countries whether the development of preventing mental disorders should be a primary
responsibility and task of mental health professionals, or should be assigned to specially
trained prevention and health promotion experts. In the Netherlands, for instance, prevention
experts and prevention teams are since the 1970s appointed by mental health services to be
leading professionals in prevention. They can involve other health and mental health
professionals in preventive work. Appointing prevention experts requires the availability of
institutional budgets for such positions; there are only a limited number of countries in the world
who can afford such appointments within mental health care. Mostly, preventive services are
provided by mental health professionals who feel some affiliation with prevention.
This affiliation is likely to vary between mental health disciplines. For instance,
psychiatrists are more interested in relapse prevention, while psychiatric nurses have by
training a more public health orientation, and are more open to community-oriented work,
home-visiting, early detection and collaboration with primary health care. Pedagogues are
inclined to value parent education and early child interventions as their main focus of
prevention, while clinical psychologists are especially interested in cognitive-behavioural
77
training of those who are at high risk and showing subclinical symptoms of disorders such as
depression, eating disorders or substance abuse problems. In our experience, children of
parents with psychiatric problems represent a population at high risk in which mental health
professionals have a special interest because they are already treating the parents or while
their young or adult clients in treatment are frequently themselves a child a parent with a mental
illness or substance abuse.
In several countries, the development and implementation of mental health promotion
and prevention programmes is initiated from public health agencies by health promotion and
public health experts. Through their professional background and institutional embedding, they
might be more inclined to focus at universal prevention and population-oriented efforts to
promote mental health. This could include, for instance, supporting schools with implementing
programmes to enhance emotional resilience, problem-solving skills and social competence in
children and adolescents.
In sum, professional disciplines and the positioning of professionals in certain health
organisations will influence their interests in preventive and health promoting services and the
chances they get to be involved in them. Their affiliation with prevention will also depend highly
on the policies and financing systems of health insurance companies, local governments and
ministries of health.
Client organisations and social interest groups outside health care
Over the last decades, client and consumer organisations are increasingly recognised as
important partners in the health and mental health sector. The number of such organisations
has expanded tremendously over the years. Just as illustration, the Dutch National Mental
Health Fund identified already during the 1990s no less than 76 clients, patient and family
organisations in the field of mental health (Dercksen & van ’t Hof, 1996). Their activities are
focused on a wide range of targets, such as stimulating mutual aid between clients, sharing
life stories and learning experiences, disseminating information about mental diseases,
advocacy for mental health to influence public opinions and policy makers, and participation in
boards of services. They also provide school-based education to increase the literacy about
mental health and reduce stigma to mental diseases. Client organisations are particularly
interested in improving the quality of life of chronic patients and innovations of outpatient
mental health care to make them more accessible and sensitive to their needs.
Also social interest organisations are interested in health promotion and disease
prevention activities, such as organisations against alcoholism, organisations fighting child
abuse and domestic violence, and national NGO’s on child protection, sexual education,
mourning support or on the quality of life and rights of elderly. The interest of these client and
social interest organisations is primarily the improvement of the mental health and well-being
of patients and their families, not the reduction of health budgets. Nevertheless, governments
and health insurers strongly appeal to such organisations to stimulate self-care, social
networks and community care to prevent the need for costly specialised treatments and long
term stay in mental hospitals.
Coalition development
As discussed, multiple sectors and stakeholders are involved in this social arena of mental
health with different but related agendas and strengths. Single organisations independently
usually do not have the capacity to create significant changes in the mental health condition of
target populations and communities. This stresses the need to develop temporary or more
permanent partnerships and coalitions of organisations with complementary strengths. For
78
instance, reducing domestic violence in a city - a major risk factor for mental health and many
other problems - requires effective collaboration between primary health care, child and youth
care services, child protection services, mental health services, women’s services, police and
justice, local governments and mass media. In addition, multisectoral coalitions offer the
opportunity for a dialogue with non-health organisations about the meaning and value of
mental health in our society. This prevents that mental health is only associated with psychiatric
hospitals and treatment of severe disorders.
Health promoters and prevention professionals have a significant role in developing
partnerships and coalitions, which requires specific attitudes and skills. Experience with
coalition building and maintenance in the past has learned that they largely vary in success.
Some coalitions offer poor outcomes, end prematurely or don’t even reach their initiation
phase. Common pitfalls are lack of clarity about shared goals, lack of shared views and trust,
poor communication, lack of time and resources for collaboration, less benefits then costs, and
an unbalanced division of benefits between coalition partners. Based on shared experiences
from coalition building in different countries we have listed in figure 3.11 a range of features
that characterise successful coalitions and can be considered as guidelines for coalition
builders at local or national level. As an example, coalitions are only feasible when the partners
have common or complementary interests. It might be possible that some parties participate
in a coalition to achieve mental health goals, while others have other reasons, such as public
safety (justice) or better education productivity (schools). Such different benefits are highly
related and mutually dependent. When coalition partners experience mutual benefits, it offers
a more workable basis for intersectoral collaboration than just asking other parties to contribute
just because mental health is an important charitable issue.
79
3.4.6 Professionalisation and quality management
The past 30 years, significant steps have been made to ensure professionalisation of mental
disorder prevention and mental health promotion and to increase quality and effectiveness of
programmes (Hosman, van Doorm & Verburg, 1988; Hosman, Jane-Llopis & Saxena, 2004;
Molleman et al. 2006). Initiatives for quality enhancement, improving effectiveness and
capacity building have been started in many countries (e.g. US, Canada, Norway, UK,
Netherlands, Finland, Sweden, Croatia, and South Africa). These initiatives have resulted in:
National research programmes on programme development, effectiveness and cost-effectiveness
that have resulted in thousands of controlled outcome studies and a rich knowledge base on
effectiveness, benefits and effect moderators.
National and international databases of evidence-based programmes, to stimulate exchange and
large-scale implementation of the best programmes.
Bachelor and master courses, master programmes and postgraduate training programmes in
(mental) health promotion and prevention at universities and professional schools.
Trained mental health promotion, prevention and public health experts in different organisations.
Quality standards and quality assessment instruments to evaluate ongoing practices and
programmes and to select programmes for implementation grants.
National institutes and university research centres, with research and development programmes on
mental health promotion and prevention, and supporting policy and practice.
National and international professional associations (e.g. Society for Prevention Research,
European SPR, International Union for health Promotion).
National and international policies on mental health promotion and prevention, among others by the
European Union, UNICEF and World Health Organization (e.g. the EU green paper on Mental
Health Promotion).
Regular international conferences and symposia on mental health promotion and prevention.
Through all these initiatives, a professional infrastructure has emerged to safeguard high
quality research and practice. In developing such an infrastructure, international collaboration
plays a significant role. This collaboration is supported by governmental organisations as WHO
and EU, and by professional organisations as, for instance, Society for Prevention Research,
International Union for Health Promotion and Education, and World Psychiatric Organization.
The DataPrev project on identification and dissemination of effective programmes across
Europe offers an example (Anderson, Llopis & Hosman, 2011). Some international networks
are initiated by prevention researchers themselves, such as the International Network of
Children and Families of Parents with Mental Illness (COPMI). Still large differences in
progress exist between countries, which offers a further challenge to strengthen international
collaboration and especially to support middle- and low-income countries in closing this gap.
3.4.7 Availability of effective programmes
To improve mental health in a target population, a first requirement is that preventive
interventions and health promotion programmes are ‘evidence-based’. There should be valid
proof that programmes work and valid information on what effects they are able to produce.
To date, governmental agencies, health insurance companies and other funding agencies
require such proof of effectiveness as condition for financing large-scale implementation of an
intervention. When such proof is not present, such as in the case of programmes that are
80
developed bottom-up in a specific community with involvement of local stakeholders, it is
recommended to apply evidence-based principles and guidelines for effective interventions.
As we will explain in subsequent chapters, especially in part VI and V of this textbook,
evaluation has provided convincing evidence that preventive interventions can indeed be very
successful. In recent years multiple review studies and meta-analyses of controlled studies
have been published (e.g. IOM Report, 2009; Cuijpers et al., 2008; Hosman, Llopis & Saxena,
2004; Durlak et al., 2011; Anderson, Jane-Llopis & Hosman, 2011). For instance, significant
reductions of new depressive episodes in adolescents and adults, eating disorders, conduct
disorders in children and juvenile delinquency have been demonstrated as outcomes of
prevention programmes. Numerous risk factors and protective factors can be successfully
influenced, such as premature births and low birth weight, parent-child interaction and
parenting competence, child abuse, problem-solving skills, negative cognitive styles, bullying,
stress management, socio-emotional support, and self-esteem. Furthermore, it appears
programmes also have numerous social benefits, such as better academic outcomes, fewer
school dropouts, more safety, higher labour productivity, lower youth unemployment and
reductions in social benefits. As discussed in chapter 14 and 15, national and international
databases are currently available on evidence-based mental health promotion and prevention
programmes. Countries like for instance US, Norway, Netherlands and Germany have national
databases.
However, we should be modest in our expectations while prevention successes when
measured at the level of whole populations are currently still very small or even non-existent.
Programmes need further improvement to become highly effective. In addition, major
investment is needed in large-scale implementation of effective prevention programmes and
policies to generate a large-scale reach and public mental health impact. Public impact is the
outcome of a combination of programme effectiveness and programme reach in a target
population.
3.5
Limitations, risks and bottlenecks
Although the need to prevent mental disorders is evident and recent developments in
knowledge about the outcomes of preventive interventions are promising, the practice of
prevention in this domain is also criticised.
Criticisms addressed at prevention fundamentals and practices
We have listed a range of common criticisms from different stakeholders that we have
encountered in our preventive work over the last decades, irrespective of our view on their
validity:

Knowledge about determinants of mental disorders is still too limited to invest on a large
scale in the development and implementation of prevention programmes already. The
idea of preventing mental disorders in populations at risk or in the total population is
premature and too pretentious.

Mental disorder prevention focuses too much on promoting positive qualities of people
but is criticised by traditional psychiatrists as having little to do with preventing severe
psychiatric disorders.

Some insight exists into the effectiveness of prevention programmes but knowledge
about effective interventions that actually reduce the incidence of mental disorders is
81
still too limited to justify diverting mental health budgets from curative care to
prevention.

A sound long-term vision on how to develop science-based prevention that will have a
proven impact on the mental health of whole populations is still lacking.

Prevention practice still offers prevention programmes to the public for which the
preventive effects have not been demonstrated.

Mental disorder prevention programmes currently provided reach only a marginal part
of the population, so their impact on the mental health of the population is marginal.
Interventions are needed with potential to reach large segments of the population (at
risk). In addition, interventions and measures are lacking that aim to reduce social risk
factors that have impact on the mental health of large groups of citizens.
Existing beliefs about potential risks and adverse effects in prevention

Money for prevention is taken from the funds needed for curative care: treatment. Care
of psychiatric patients and urgent problems should always have priority even if this
would mean a lack of funding for prevention.

Prevention is tutelage: it means too much interference in the privacy of people.
Prevention is therefore no task of the government.

The danger exists that by increased preventive care, the care for health becomes even
more professionalised (proto-professionalism, structural iatrogenesis) and people
become even more dependent on professionals for their well-being.

Successful prevention programmes reduce the stigma on mental problems and
improve access to mental health services, which will result in increasing numbers of
clients. So prevention really does not lead to cuts, but to an increase of health care
costs.

Risk of stigma through identification of groups at risk while attributing the causes to the
individuals themselves (‘blaming the victim'), and by more distress due to the
awareness of being at risk of a serious disease.

Person-focused prevention (e.g. coping with stress) may be used by the government,
employers and other social parties as a tool to let people adapt to adverse
circumstances, such as work overload, poverty and social inequality. It lowers the social
pressure for political measures and social actions to reduce social risk factors.
These criticisms are a selection of the issues that are discussed between prevention advocates
and critical stakeholders in response to the calls for more investment in prevention of mental
disorders and mental health promotion. They come from different public parties (e.g.
psychiatrists, health insurance companies, mental health service managers, governmental
agencies, critical consumers) and some from prevention experts themselves.
Are presented criticisms justified?
We will not take a defensive stand here, as good criticism is essential for the further
development of effective prevention with an accepted role in society. We invite you as a reader
to develop your own reactions using your own experiences and views, but also the body of
knowledge that is presented in this textbook on prevention science, prevention practice and
preventive programmes. In the Introduction chapter of this textbook, we have already
82
summarised a range of arguments in favour of prevention that could be used to counter several
criticisms.
In our view, some criticisms are very justified (e.g., the still moderate public reach and impact
of current prevention). Other critical statements are not supported by us, but are more an issue
of views and values (e.g. no investment in prevention, while all resources are needed to
respond to already existing mental illnesses). Several of the mentioned statements are not
defendable anymore if we take into account the huge progress that has been made over the
last three decades in scientific knowledge about the risk and protective factors for mental
health, and about prevention programmes with significant mental health and social effects.
3.6
Conclusions
Mental health is a far from clear concept and diverse meanings have been attached to it. These
are described in this chapter as ‘models of mental health’. Most recent views, also defended
in this chapter, support a positive functional definition of mental health, in which mental health
is seen as the capacity of people to realise their own abilities, to cope with the challenges and
stresses of life, and to function effectively in their communities. Such capacities are also
essential in preventing onset of mental disorders. This view on mental health also makes it
possible to understand how efforts to promote mental health and efforts to prevent mental
disorders are linked to each other.
Next, we have presented several subdivisions of prevention, showing that prevention
encompasses a wide range of targets and approaches. These subdivisions play an important
role in defining the objectives of prevention. They are also used in dividing different types of
preventive work between organisations and funding agencies.
The major part of this chapter was devoted to presenting a profile of the practice of
mental health promotion and prevention, first by describing the professional roles and tasks
that characterise the work in this field. In later chapters, more concrete examples of
programmes are described. The profile describes this field as a typical multidisciplinary one
and as one that requires the performance of a wide variety of roles and tasks. For
professionals, it makes working in this field a fascinating challenge, not only because of the
variety of professional activities, but it also challenges professionals to explore innovative ways
to further develop the field bringing in new ideas, knowledge and fields of expertise.
By offering a profile of the professional work, one could be inclined to consider this
further development and implementation mainly a task of health promotion and prevention
professionals. As we have explained, a more appropriate model describing this field is to
consider it as a social arena in which different stakeholder organisations are involved, each
with different interests, strengths and agendas. For the successful development and anchoring
of mental health promotion and prevention in society, it is essential to understand which
stakeholders should be involved, what their interests are, how they are related to mental health,
and what their role and contributions could be. Developing a better mental health condition of
populations requires that we are able to create a critical mass of investors and synergy
between them. Therefore, professionals should be able to advocate for mental health in
different sectors, to link mental health with other health and social interests, and to develop
effective coalitions of stakeholders that can generate significant collective impact in
communities. This is not a challenge unique to the domain of mental health, but similar to what
happens in other public domains, such as in the protection of our environment, the creation of
83
safer communities and workplaces, and the war on poverty and in community approaches to
reduce sex and racial discrimination.
Finally, we have discussed a range of critical statements that different parties in society
have expressed toward our prevention field. We invite the reader to study them critically and
to find arguments to counter or endorse them. This textbook and the related course meetings
offer a rich source to find counterarguments that show that some criticisms are not justified. In
the end, we expect that you will be able to formulate your own grounded stand on these issues.
In the next two parts of this book we will discuss the theoretical and scientific base for
the practice of mental health promotion and prevention, the planning process that rules
programme development and implementation, dealing effectively with defining goals and
objectives, designing effective strategies and interventions, and evaluating their outcomes.
84
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Study questions for this chapter

What different views exist concerning the meaning of ‘mental health’? What is the
'functional model' of mental health and how is mental health defined within the functional
model? How does the functional model differ from other models? Why does the functional
model offer insight in how mental health promotion and prevention are linked?

What criticisms exist on classification systems for psychiatric disorders, such as DSM-IV,
DSM-V and ICD-10?

What classifications exist in prevention? How can the different classifications be
distinguished from each other? How can they be combined? What is the meaning of each
of the terms for specific subdivisions of prevention (e.g. tertiary prevention, selective
prevention, indicated prevention, and general or non-specific prevention)?

Can you describe in your own words what mental health promotion means and how this is
related to prevention?

Why does the author state that mental health should be understood as a ‘social arena’?
What does this mean? What are the implications for prevention practice?

What is meant by ‘intersectoral policy’ in health promotion? What is the background of this
term? Why is it so important for effective mental health promotion?

What types of professionals are involved in mental health promotion or prevention? What
kind of tasks and roles do they perform to prevent mental disorders and to promote mental
health?

What type of organisations can be involved in prevention of mental disorders and mental
health promotion? Who are major stakeholders and what could be their role? How could
we deal with the different interests between these stakeholders when we try to develop a
coalition and synergy for promoting mental health?

Argue why a significant impact on the mental health condition of target populations is only
possible through partnerships and coalitions.

What are pitfalls in running coalitions for prevention and mental health promotion? What
are important guidelines for successful developing, running and maintaining such
coalitions? Give some examples.

What criticisms and bottlenecks exist for professional prevention? How can you counter or
support these criticisms based on the discussed arguments in favour of prevention
(Introduction Chapter) and on knowledge and visions presented in other chapters of this
textbook? Define your own grounded stand on the criticisms presented in section 3.5.
87
88
PART II
THEORETICAL APPROACHES
89
90
4
Theoretical approaches: Overview
4.1
Introduction
92
4.2
Type of determinants and their interrelations
93
4.2.1
Risk factors and protective factors
93
4.2.2
Attributable risk
94
4.2.3
Relationships between factors
94
4.3
Theories on determinants in development and course of mental health and
mental disorders
96
4.3.1
Ordering of theories on development of mental health and mental disorders
96
4.3.2
Biological models
98
4.3.3
Cognitive behavioural models
99
4.3.4
Developmental Psychopathology
99
4.3.5
The stress theoretical approach and integrative stress model
100
4.3.6
Competence models and positive psychology
100
4.3.7
Social support and social network models
101
4.3.8
Community prevention and macrosocial models
101
4.3.9
Choosing between theoretical approaches
101
4.4
Strategy and programme development
104
4.4.1
Stage models
106
4.4.2
Strategy development and intervention analysis
107
4.4.3
Effect management
108
4.5
Conclusions
108
Literature
109
Study questions for this chapter
110
91
4.
4.1
Theoretical approaches: Overview
Introduction
To develop effective preventive interventions, to implement them effectively and to achieve
evidence based mental health effects in a target population, scientific theories are
indispensable. The kind of theories we need for effective mental health promotion and
preventive interventions can be divided into five clusters (Figure 4.1):
Five clusters of theory development
Fig 4.1
Mental health
Mental disorder
1
Facilities
and care
consumption
3
Determinants and Development
4
Preventive interventions
5
Individual, social
economic
consequences
2
Planning phases & Management of effective prevention
Development, evaluation, implementation, dissemination, adoption, adaptation, institutionalization
1. Theories about the meaning of the terms 'mental health’ and ‘mental disorder’, which is the
core target of prevention and health promotion in this book. Already discussed in chapter 3.
2. Theories about the health, social and economic impact of mental health and mental
disorders on persons, families, social networks, schools, community, work, society, health
care use. This impact is reviewed in the introductory chapter on the need for prevention.
3. Theories about determinants (i.e. risk, protective and positive factors), development and
course of mental health and mental disorders.
4. Theories of change: theories about influencing human behaviour, risk and protective
factors, populations and social conditions and systems. Theories of effect management:
knowledge about what moderates effects and principles of effective preventive and health
promoting interventions.
5. Planning Theories: Theoretical models on the process of development, implementation,
dissemination, adoption and institutionalisation, and evaluation of mental health promotion
and prevention programmes, and about combining multiple programmes into a
comprehensive community approach. This also includes theories about generating the
conditions to make the development and implementation of intervention programmes
possible, e.g. policy making, capacity building, coalition development, financing and
resource development.
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In this and the following chapters, the theoretical approaches that play a major role in
modern prevention, health promotion and mental health will be discussed. Attention will be
paid to biological models (section 4.3.2), cognitive behavioural models (section 4.3.3 and
chapter 5), the developmental psychopathology approach (section 4.3.4 and chapter 6), the
stress theoretical approach (section 4.3.5 and chapter 7), competence and the positive
psychology approach (section 4.3.6 and chapter 8), the role of social support systems
(section 4.3.7 and chapter 9), and community models (section 4.3.8 and chapter 10). These
theoretical approaches belong particularly to the clusters 3 and 4 in figure 4.1. Some of them
are also relevant for other clusters. For instance, positive psychology is also about research
on meaning and outcomes of positive mental health (cluster 1 and 2). Theories about
community functioning can also be used to understand the impact of mental capital and
illness on communities (cluster 2) and the opportunities for capacity building, coalition
development and creating political support for investments in mental health promotion.
A specific mental health problem, for instance depression, can be approached from
a wide variety of theoretical angles. Which theoretical approach or combination of
approaches a scientist or professional uses to ground preventive interventions, is a matter of
choice. This might be a personal choice based on your own visions and values, it could also
be related to your discipline or the type of organisation from which a professional is working.
Anyway, academics are required to make a reasoned choice for a specific theoretical
approach and to be able to defend this choice to other stakeholders. Such explicit choices
are important for they will have far-reaching consequences for which studies we run, which
mental health problems and determinants we select for intervention, what preventive
strategies or interventions we choose, and what kind of effect we can expect from it. We
challenge the reader to use this chapter to practise making such choices.
4.2 Types of determinants and their interrelations
To understand how to use a theoretical model for designing a preventive intervention, it is
essential first to have knowledge about types of relationships that can exist between causal
factors (determinants) and the different roles such factors can play in the development of
mental health and mental disorders.
4.2.1 Risk and protective factors
A distinction is made between risk factors and protective factors. Preventive interventions
are focused on reducing risk factors and enhancing protective factors which both are
assumed to have a causal influence on the development of mental disorders, their severity
or duration. Risk and protective factors can be found at each system level, so within a
person, a family, a neighbourhood, a school and in the society at large.
Risk factors are factors that are likely to increase the development of poor mental
health and mental disorders. Examples of such factors are genetic vulnerability, traumatic
events, child abuse, poor parental skills, insecure attachment, growing up with addicted
parents, bullying, poverty, and social isolation of older people. Factors that increase the risk
for one disease are called disease-specific risk factors (e.g. role model behaviour of an
anxious parent), and factors that contribute to the development of multiple diseases and
problems are called generic or nonspecific risk factors (e.g. child abuse and neglect).
93
Factors that can reduce the risk of mental disorders in the presence of risk factors are called
protective factors. They protect humans against the harmful influence that risk factors may
have. The effects of individual protective factors are consistent with the medical concept of
'immunity'. The more protective factors a person has available the better his immune system
and level of resilience. Examples of protective factors are: positive affectivity, problem
solving skills, positive self-image, stress resistance, parental warmth and care, social
support from family and friends, or a social-emotional supportive school environment. They
strengthen the resiliency of a person and offer social protection and support in threatening
circumstances.
Non-specific risk factors can cause a "broad-spectrum effect", meaning that they can
influence the development of a wide range of mental problems or other negative outcomes.
Protective factors are usually non-specific in nature and can have two functions: a buffering
function against the impact of risk factors, or a main effect function, i.e. a direct independent
positive impact on mental health (e.g. the effect of parental warmth on the emotional
development of a child). In the case of mental health promotion, it is more common to speak
of positive factors or health promoting factors instead of protecting factors, which is a term
more linked to prevention.
4.2.2 Attributable risk
In epidemiology, the strength of the impact of a risk factor (X) on the development of a
disease is called ‘attributive risk (AR)’, which is defined as that causal part of the onset of a
disease that can be explained by exposure to risk factor X. The level of attributive risk linked
to a risk factor also tells us what the maximum preventive effect (incidence reduction) is that
can be achieved in a given population by preventive interventions when they are 100%
effective in removing that risk factor. The attributive risk of a risk factor can be calculated by
subtracting the incidence of a disease (new cases within a specified period) among persons
who were not exposed to the risk factor from the incidence of the disease in the total
population. Another usual name for attributive risk is ‘etiological fraction’. Likewise, the
proportion of disease cases that could be prevented by the presence of a protective factor is
called the ‘prevented fraction’.
4.2.3 Relationships between factors
While mental disorders and also mental health are always caused by multiple determinants,
a next important question is how risk factors are related to each other. As we will discuss,
the type of relationship has major implications for how we select and use risk factors in
prevention strategies. We differentiate between four possible types of relationships: additive,
exponential, interactive and sequential, as is illustrated in figure 4.2.
Additive model: when risk factors have an additive relation to each other, each of the factors
independently contributes to the development of a disorder. Their independent effects can
be added up in estimating what their total impact is on the development of a mental disorder.
For instance, the death of a partner, a negative style of thinking, and a history of child abuse
can each independently contribute to the onset of depression in women during mid-life.
When a preventive intervention is aimed at influencing only one of these determinants, the
maximum achievable preventive effect on depression will never be larger than the part that
this factor explains in the onset of the disorder (attributive risk). If we want to achieve a
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considerable preventive effect, it
would be wise to target a preventive
intervention or the factor with the
highest attributive risk or preferably
a combination of independent
determinants which together explain
a substantial part in the emergence
of the disorder. For this reason, a
successful preventive approach
based on an additive model of risk
factors, is preferably composed of
multiple preventive interventions (),
each targeting a different risk factor
().
Fig 4.2
Types of relations between
determinants of depression
A
B
Moderators
Competencefactors
Depression
Stressors
Depression
Social support
Interaction model
Additive model/exponential model
depression
mother
sensitve brain development
response
child
ego-resiliency
child
Mental health
Depression
Behavioural problems
Sequential causal model
C
Exponential model: Multiple risk factors can also have an exponential effect on the onset of a
mental disorder. Michael Rutter (1984) and other researchers have shown that it is often the
accumulation of multiple risk factors that is responsible for the emergence of
psychopathology. For instance, it is known that as the number of risk factors (e.g. number of
traumatic events) in children cumulates, the probability of the emergence of depression
could increase exponentially. After one or two stressful events, the risk is still relatively low,
but with three or more events, the risk increases exponentially. What does this mean for
prevention? Interventions could be aimed at reducing the number of risk factors by
addressing the most malleable risk factors, while leaving ‘the hard to change’ untouched,
and still produce a significant preventive effect.
We give an example: for children a divorce can cause a chain of traumatic stress
experiences (e.g. witnessing domestic violence, moving out of town, loss of friends or
contact with father, parental depression, lack of emotional warmth and support, low family
income). Preventive interventions aimed at guiding divorcing parents in coping with the
stress of their children can reduce the chance of an accumulation of risk factors for their
children. Wolchik et al (2002) demonstrated in a randomised experiment that such a
preventive programme for divorcing parents and their children resulted in a significant lower
risk of developing mental disorders in children during a period of six years after participating
in this intervention (i.e., 23.5% in the control group vs. 11% in the prevention condition).
In the case of an additive effect, the number of risk factors have a linear relationship with the
incidence rate of a disorder, while an exponential effect will result in a curvilinear relationship
and might make it possible to identify a threshold effect, which refers to the critical number of
risk factors above which the risk of onset of a mental disorder quickly increases.
Interaction model. The impact of a risk factor on the onset of a disorder can be dependent on
the presence of a second factor. In that case, both determinants interact. A classic example
is the impact gender has on how children react to family conflicts. Most studies show that
girls are more likely to develop internalising problems (e.g. depressive symptoms), while
boys are more inclined to react with externalising problem behaviour (e.g. aggressive
behaviour). Such interactions are also at stake in the relation between risk and protective
factors. As stated earlier, the presence of a protective factor (e.g. problem-solving skills or
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social support) can provide a "buffer" against the influence of a risk factor, such as parental
conflict, unemployment or the loss of a loved one. From a preventive point of view,
interactive models offer the choice between reducing or eliminating the risk factor, or
strengthening a protective factor. In the case of an interaction, successful manipulation of
one of the two factors might be sufficient to cause a preventive effect.
Sequential model. Multiple risk factors, but also multiple protective factors can have a
sequential causal relationship over time, which means they could form a causal chain. For
instance, early childhood risk factors can be the beginning of a series of consecutive risk
factors wherein each risk factor evokes a next one, resulting in trajectory of subsequent risk
factors over time. Developmental psychopathologists study such sequential causal
processes during childhood, adolescence and early adulthood (chapter 7). For example:
depression in young mothers often leads to insensitive and non-responsive contact with the
baby. This can cause insecure attachment in the child, which is likely to result in poor social
competence. This in turn can contribute to an increased risk of behavioural problems or
depression in adolescence. Next, such problem behaviour might contribute to greater social
isolation and negative peer reactions and an escalation of problem behaviour and
depression, which in their turn increase the risk of alcohol dependence. Note that these are
not 'necessary' sequences, but that each subsequent development in such a long-term risk
trajectory is defined by increased risk.
4.3 Theories on determinants in development and course of mental health
and mental disorders
4.3.1 Ordering of theories on development of mental health and disorders
To understand better how
various theories about the
onset and course of mental
disorders differ, in figure 4.3
their differences are described
as
positions
on
three
dimensions:
scientific
discipline, system level and a
developmental dimension.
Scientific discipline: refers to
the scientific perspective from
which
mental
health
is
examined: such as genetics,
neurobiology, psychiatry, psychology, educational sciences,
sociology or economics. Each of these disciplines offers its own explanation for the development of mental disorders, that each can be seen as a starting-point for designing
preventive interventions. Progress in knowledge can be expected especially from research
into the relationship between factors that are studied by different disciplines. For instance, it
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appears that social and cognitive stimulation in early childhood leads to a more differentiated
neural development and contributes to prevention of mental retardation in children of
retarded mothers (Ramey & Ramey, 1998). In turn, this stimulation seems to depend on the
social and economic circumstances of the family.
System level. Determinants that influence the development of mental health and mental
disorders are anchored in different system levels: micro-level (individual, family, and group),
meso level (e.g. neighbourhood, school, work, community) or macro-level (e.g. social
ideologies, mass media, economic conditions, legislation, health policy). Health determinants
influence each other across different system levels. As an example, national education
policy (macro) influences whether primary schools and their teachers in the classroom
(meso) have time and expertise to invest in socio-emotional learning of children (micro).
Social-emotional competence could serve as a powerful protective factor in the life of
children and as an important condition for their further flourishing during adolescence and
adulthood. Improving emotional competence and mental fitness in children requires
concerted actions at multiple levels: national policies, school, teachers and classrooms,
children, peers and families.
The developmental dimension. Some theories focus on the present or the very recent past
(e.g. stress and coping theories, cognitive behavioural theories, social support theories),
thus on behaviours and risk factors directly preceding the onset of a health problem or
disorder. This approach has long dominated in prevention and health promotion, but
currently their limitations become more evident. During the last 25 years, scientific
knowledge from developmental research has stressed the importance of early risk factors
and early enhancement of resilience for the development of mental health and mental
disorders during the different stages of the life span up to adulthood and even old age.
Leading research fields in this life course approach are developmental psychopathology,
epigenetics, neuropsychological development, developmental psychology, attachment
theory, and studies on transgenerational transmission of risk factors and strengths in the
case of parental mental illness or addiction.
For the study of mental disorders and their prevention, we need theoretical approaches
along all these three dimensions. For instance, to understand the onset of depression
knowledge is needed about biochemical processes in the brain, transgenerational risk
transmission through genetic risk factors and child-parent interaction, long term impact of
early traumas (e.g. child abuse), cognitive-behavioural processes (e.g. negative thinking),
coping and social support in stress situations, and the impact of economic recession and
poverty on these micro-level processes.
The multidimensional framework in figure 4.3 shows how the described theories are
positioned to each other. The developmental and system-level dimensions of this framework
are also part of the integrative stress theoretical model (chapter 7) and included in the
system of dimensions that are used in defining intervention strategies (chapter 13).
Based on the above-discussed three dimensions, we can distinguish eight types of theories
and theoretical approaches on the emergence of mental health and mental disorders (figure
4.4): biological explanatory models, vulnerability-stress theories, cognitive behavioural
models, competence development models, social network and support models, communityoriented models and macro social models. The field of developmental psychopathology and
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developmental epidemiology represents a multidisciplinary approach that seeks to integrate
different scientific approaches and is for that reason placed in the centre. To date,
developmental psychopathology represents the most comprehensive theoretical approach
for designing mental health promotion and prevention programmes.
Fig 4.4
Theoretical paradigms
in prevention and health promotion
Stress & vulnerability
models
Cognitive behavioural
models
Biological
models
Competence
models
Developmental epidemiology
Developmental psychopathology
Macro social models
Social factors
Community prevention
models
Social support
models
Below, we offer a short profile of each of them. In the following chapters of Part II, several of
them are discussed more extensively.
4.3.2 Biological models
Although much criticism has been expressed on the individualising medical model of mental
disorders, medical and biological sciences have generated a wide area of knowledge that is
not only relevant for the development of new types of treatment for mental patients, but also
for prevention. This applies, for instance, to the study of genetic, prenatal and perinatal
processes in the development of psychosis. This knowledge might offer perspectives for
early interventions during pregnancy and prophylactic medication to prevent the onset of a
full-blown psychosis in adolescents and young adults. Further, each episode of psychosis
has been found to reduce the ‘grey matter’ of the brain, as brain-imaging studies have
revealed. This knowledge stresses the importance of preventing first psychotic episodes in
ultra-risk adolescents and preventing relapses after the first episode. Highly interesting are
recent research outcomes on early gene-environment interactions, showing how
environment can act on gene-expression and gene-development. Another area relevant for
prevention is the studies on the impact of social stress, depression and anxiety during
pregnancy on the developing neuropsychological systems in the unborn child that could
result in long-term psychiatric vulnerability. In this period the main ‘hardware’ of the
neurological and emotional systems of children and adolescents is developed. This
biological approach of psychopathology and mental health draws on contributions from
neuroscience, neuropsychology, psychopharmacology, biochemistry, genetics and
physiology. A main challenge for further research is to understand how social factors
influence these neurobiological processes.
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4.3.3 Cognitive behavioural models (chapter 5)
In these models, health and illness are considered as outcomes of the health and risk
behaviours of people. Many diseases are regarded as so-called "behavioural diseases", i.e.
they are considered as the result of unhealthy and risk behaviour. These could be
behaviours of the people at risk themselves, but also risk behaviours of others. This applies,
for instance to overweight, hypertension, cancer, cardiovascular diseases, sexually
transmitted diseases, caries, traffic accidents, eating disorders, psychotraumas, phobias and
depression. In such cases, prevention aims to prevent or reduce unhealthy or damaging
behaviours, such as smoking, excessive drinking, drunk driving, unhealthy eating habits,
domestic violence, bullying or discriminative behaviours.
Prevention and health promotion make extensive use of scientific behavioural
models. Core determinants in these models are knowledge, expectations about behavioural
outcomes, attitudes (affective), subjective skills (self-efficacy) and social norms. By
influencing these behavioural determinants through prevention programmes, we expect that
citizens at risk will show more preventive and less harmful behaviour. Chapter 5 describes
three of the most common cognitive behavioural models: ‘Health Belief Model’, the ‘Theory
of Planned Behaviour’ and the ‘ASE Model’. All approaches are closely related. The Model
of Planned Behaviour can be regarded as a model that integrates several other cognitive
behavioural models. The trans-theoretical model of behaviour, also called 'Stages of Change
Model’, is a different type of cognitive behavioural model. It describes behaviour as a
cognitive and motivational process in which different stages can be distinguished, each
requiring specific attention of professionals who want to encourage people to change their
behaviour. This model is applied, for example, to smoking cessation, promotion of moderate
alcohol use and bullying prevention.
4.3.4 Developmental Psychopathology (chapter 6)
Developmental epidemiology and developmental psychopathology have a more recent
history (Rolf et al, 1990, Cicchetti et al, 1995). Developmental psychopathology studies have
shown that mental disorders and mental health are the result of lengthy and complex
interaction processes between the person and his environment that already start during
pregnancy and infancy. An important feature of developmental psychopathology is its
interdisciplinary and integrated nature, in which scientific knowledge from various scientific
approaches are combined. Furthermore, it is characterised by a life-cycle approach in
studying the development of psychopathology. Developmental psychopathology traces
etiological lines from early development to psychiatric problems during adolescence and
adult life. This makes it possible to apply preventive interventions in a much earlier stage. It
is widely assumed that preventive interventions are more effective when they are applied
early in life, when risk factors have not yet been ingrained in the person. For instance, the
Nurse-Family Partnership programme offers pregnant women at risk parent education,
stimulation of health behaviours and support through home visits during pregnancy and the
first two years. Several controlled studies have found a wide range of long-term preventive
effects in these children up to 15 years after the intervention (Olds, 2006). These include for
instance, large reductions in child abuse, onset of drug use, alcohol problems, promiscuous
sexual behaviour and delinquent behaviour.
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4.3.5 The stress theoretical approach and integrative stress model (chapter 7)
Stress theoretical models often focus on the interaction between three clusters of variables:
type and number of stressors, personal capacities to cope with them, and social support.
Social support can help a person with the cognitive and emotional processing of a stressful
experience and with avoiding, reducing or eliminating the stressors. These models are also
labelled ‘strain-capacity models’ (Dutch: draaglast-draagkracht modellen). Strain refers to
the degree of stress that a person is exposed to, while capacity refers to the degree of own
competence (emotional resilience) and the degree of social support which is available.
Stress models will be discussed in chapter 7, with special attention to the cognitive stress
and coping model of Richard Lazarus. This model offers insight in the cognitive and
emotional processes that are linked with the interaction between stressors, competence and
support and their impact on the development of pathological behaviour.
Secondly, the ‘integrative stress model’ is discussed that offers a framework for
grounding various kinds of prevention strategies. These include for instance: reduction of
external or internal stressors, stress inoculation, modification of subjective needs, enhancing
psychosocial resilience (e.g. general problem-solving and social skills), influencing
personality variables such as internal control and self-esteem, increasing problem-specific
knowledge, strengthening the size or quality of social support, and improving feedback on
the outcomes of coping behaviour. The model also includes a life-span and multilevel
dimension, that can be used to design interventions for different life stages and social
interventions at micro, meso and macro level.
4.3.6 Competence models and positive psychology (chapter 8)
Prevention of mental disorders is criticised for its negative approach of people, by primarily
targeting illnesses and problems, and by aiming to repair weaknesses, defects and risk
behaviours. Although many prevention programmes in fact also target competencies and
strengths of people at risk, the ultimate intention is to counter risk factors and to prevent
disease and problems. This criticism goes back to the longstanding debate about the
objections against the ‘medical model’ of psychiatry versus a ‘positive model’ of mental
health (section 3.2.3). George Albee, one of the founders of modern primary prevention of
psychopathology advocated his whole life against the dominating illness approach and in
favour of a focus at people’s competences and strengths. “A Competence Model Must
Replace the Defect Model’ was the title of his address at the start of the Fourth Vermont
Conference on Primary Prevention of Psychopathology in 1980 (Albee, 1980). Albee stated
that the incidence of emotional problems and ‘pathological’ behaviour is not just the outcome
of a combination of stress and organic causes, but the imbalance between these risk factors
and people’s competence, coping skills, self-esteem and support systems. He strongly
pleaded for a shift towards building human competence and promoting social environments
early in life and in schools where children and adolescents can fully develop their cognitive
and emotional strengths and their potential to cope with the hazards of life.
In the work of Albee, Garmezy and the developmental psychopathologists,
competence is primarily valued as a protective factor, human strengths protecting children
and adults against the negative impact of risk factors. Ten years later, Martin Seligman, one
of the most influential psychologists to date, started to advocate a fundamental change in the
focus of psychology, including prevention, and initiated the concepts of positive psychology
and positive prevention (Seligman & Csikszentmihalyi, 2000; Seligman, 2002). Positive
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psychology aims to study and promote human happiness, well-being, human strengths, the
flourishing of people and building competence. They are not only relevant because they
provide a buffer against mental illness, but they represent core human values in itself and
they contribute to a wide range of positive outcomes, such as school success, intimate
relationships, and productivity. It also aims to understand and foster the factors that allow
individuals, communities, and societies to thrive. The views, values and theoretical model of
positive psychology have been translated in positive interventions that are nowadays
implemented in many schools around the world.
4.3.7 Social support and social network models (chapter 9)
The social support and social network approach is not directly centred on the behaviour of
the person at risk, but on the behaviour of individuals and social systems in his
surroundings, such as parents, friends, teachers, work colleagues and peers. Many studies
have convincingly demonstrated that social support has a strong health and mental health
protecting impact, for instance on the onset of depression and anxiety disorders, but also on
mortality. This approach studies the social network of a person, and multiple functions of
social support for people dealing with stress and mental health problems are mapped.
Network analysis identifies the different partners in a social network, their interrelations, and
the type and quality of their supporting roles. Multiple support-focused preventive strategies
are outlined, that use this model. Improving the quality and presence of social support
contributes to preventive effects as many studies have shown. The lack of support or an
environment that obstructs healthy behaviour, contributes to the emergence of serious
health and mental health problems.
4.3.8 Community prevention and macro-social models (chapter 10)
Some models describe the impact of social factors and 'community' processes on the
development of mental health and well-being of people. Humans are not isolated entities but
a part of a larger environment or community. A community usually refers to a group of
people who share the same norms, values, neighbourhood and institutions, such as schools
and a municipality. Theories of health education and health promotion recognise that the
(health) behaviour of people and their mental health status is highly determined by their local
environment. Community factors that were found to affect mental health and well-being of
citizens include social cohesion and isolation, community violence, poverty, unemployment,
quality of housing, but also the local availability of health and social services.
On macro-social level, social risk factors for mental health include the impact of
economic crisis, migration, globalisation, discrimination against minorities, wars and
exposure to cruelties, large-scale parental death through AIDS, child pornography and
trafficking of women. At the Sixth World Conference on Mental Health Promotion and
Prevention of Mental Disorders in Washington (November 2010) several speakers discussed
the expected huge impact that climate change, pollution and environmental conditions might
have on the mental health of populations in the next decades. For instance, the expected
shortage in drinking water, usable agricultural area and food caused by pollution and
increasing temperature, in combination with a growing world population may raise the
likelihood of war, large-scale migration and refugees. Such conditions affect the well-being,
health and mental health of millions of people (e.g. impact of war traumas, rape, malnutrition,
orphan children, repression, and violence against women.
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4.3.9 Choosing between theoretical approaches
Which theoretical approach would you choose to understand what causes the development
of depression, alcohol problems, borderline disorders, or emotional resilience in adults? A
first requirement for the academic quality of your work is that you make an explicit and
reasoned choice, not just relying on what the usual approaches are. All the discussed
theoretical approaches are applicable in illuminating causal processes. This is illustrated in
box 4.2 where different theoretical approaches are applied to ground strategies to reduce
alcohol problems. The box shows that different theoretical approaches will ultimately lead to
very different prevention strategies. Which approach would you choose and why?
Box 4.2
Prevention of alcohol problems from different theoretical perspectives
The choice of a particular theory on the development of mental disorders can have a
significant impact on the choice of subsequent prevention strategies. Below we give an
example of the relationship between various theoretical models on the emergence of alcohol
problems and corresponding preventive strategies.
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Theoretical approach
Stress and Coping
Prevention strategy (examples)
Reduction of stress in risk groups
Increase stress-management skills (other than ‘drinking’)
Expanding social and problem solving skills
Cognitive behavioural
models
Increase knowledge about harmful effects of alcohol
Change attitudes towards alcohol
Strengthen resistance against social pressures to drink
alcohol through skills training in dealing with social pressures
Urgent behaviour advice to pregnant women to avoid alcohol
Social support
Strengthening support from environment for moderate
drinking and a sensible approach to alcohol
Encouraging Self-help groups (e.g. Alcoholics Anonymous)
Macro-social models
(environment and public
focused)
Reduce availability of alcohol, e.g. through increased alcohol
tax, age restrictions, reducing sales points, and monitoring
compliance with these measures;
Banning alcohol on the streets, in stadiums, in canteens
Ban on alcohol advertising
Preventive mass media campaigns to influence behaviour
Preventive billboards along the road
Developmental
psychopathology
Prevent traumatic experiences in children (e.g. child abuse)
Prevent occurrence of insecure attachment in children
Preventative support to children of addicted parents
Early treatment of alcoholic parent
Foster identity development in children
Enhance individual skills, positive self-image, self confidence
and mastery in youth
Academics are required to make an argued choice and should be able to defend that
choice. Some choose cognitive behavioural theories and social learning theories to
understand how depression emerges and to ground the design of a preventive intervention.
Others prefer to study the causes of the high prevalence of depression from a societal
perspective, as an outcome of living in poverty, being the victim of domestic violence, or
having poor perspectives on getting a job due to their migrant status. Empirical evidence
exists for both choices. Some others prefer to combine multiple theoretical approaches. So
the next question is what arguments are used and what arguments do we consider as
acceptable? What arguments would you use to defend your choice?
Based on our own experiences of over 40 years of prevention work, it is evident that
different researchers and professionals make different choices when targeting the same
mental health problem. We came across a wide range of arguments used to defend a choice
for a specific theoretical approach:

best supported by empirical evidence

fits best to the type of problem

offers the best perspective for action

fits best to my professional role, e.g. therapist or prevention expert

fits best to my discipline: e.g. clinical psychologist, psychiatrist, pedagogue,
sociologist, community nurse, public health expert.

fits to the identity and mission of my organisation

fits to the type of prevention for which financing is available

fits in to my personal values, views on human functioning and world views

fits best to my personal capacities: I am good in ……

fits best to the way of thinking of my clients or the stakeholders I work with

offers the best perspective on reaching many people and achieving a largescale preventive effect in the population.
These arguments may result in very different choices. Reflect on the following examples of
argumentation by two professionals.
First case. A professional states: given my personal views about life and the world and
supported by available epidemiological knowledge, I would like to analyse and reduce social
risk factors of depression, and I have problems with the individualising interpretation of the
causes of depression by traditional mental health care and psychiatry. However, I am aware
that in practice only for person-centred interventions a budget is available from health
insurance companies. In addition, the culture of my mental health service does not allow a
preventive strategy that addresses social risk factors (e.g. poverty issues, social cohesion of a
community, domestic violence). Therefore, in the end my choice is to ground my preventive
work in depression on social-cognitive theories of depression.
Second case. A social psychologist working in a district public health service is asked to draft
a community prevention policy and suggests to prioritise interventions to reduce aggressive
behaviour among young adolescents in an at risk community. He is educated as a behavioural
psychologist and is familiar with studies showing evidence for the role of biased perception
processes and lack of social skills in the onset of aggressive behaviour. He has identified a
range of school-based behavioural intervention programmes for adolescents and found
evidence for their effectiveness. He recommends their large-scale implementation at
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secondary schools. A local consultative meeting is held where he presents this proposal and
asks for feedback from colleagues and local stakeholders.
A colleague developmental psychologist, with an academic training in developmental
psychopathology and working at the community child health department, argues that many
longitudinal studies have shown that aggressive behaviour is found to be a rather stable type
of behaviour. The core group of aggressive adolescents starts to show this type of behaviour
already in an early stage, at kindergarten and primary schools. She, therefore, states that the
available prevention budget could better be invested in programmes for young children, at an
age where this type of behaviour is not yet deeply rooted and easier to change. She also
reports that evidence-based primary school programmes have been found not only to reduce
the aggressive behaviour but also to show a wider spectrum of positive outcomes in children
over time, such as more emotional resilience and better school achievements.
At the same meeting, a municipal official reports that she has recently visited a
meeting of colleagues from other cities to discuss common public safety issues. At that
meeting she heard a presentation about the Communities-that-Care Program (CtC) that is
currently implemented in several Dutch cities to reduce violent behaviour, alcohol abuse,
school drop-outs, delinquency and teen pregnancy (chapter 10, box 10.6). In other countries,
the programme had already proved to be successful. She was impressed by the CtC
approach, for it actively involves citizens - supported by professionals - in running a
community self-diagnosis and managing the programme. Based on their community diagnosis
a local committee develops an integral community programme that is composed of a selection
of evidence-based interventions meeting the risk profile of their community. Her positive
attitude towards CtC was especially based on the programme’s underlying philosophy: to be
successful, prevention programmes need to be based on active community involvement and
citizens taking responsibility for the quality of life in their own communities.
During the meeting, the pros and cons of each of these approaches were discussed.
Based on this discussion and the argumentations a small Task Group was installed by the City
Government to formulate a final proposal for the next city council meeting.
These examples illustrate that a theoretical approach to a specific problem is not a given, but
is based on a choice between alternative approaches. Such choices can make a huge
difference in how a health or social problem in a local community will be addressed.
4.4 Strategy and programme development: Theoretical models of
development, dissemination, adoption and implementation of prevention
programmes
This textbook aims to provide students and professionals with knowledge and tools for
improving health, mental health and well-being in the population through science-based
development and implementation of ‘prevention programmes’ and ‘health promotion
programmes’. During several decades, we have witnessed a range of major public efforts to
create healthier populations. We have seen successful approaches that have reduced major
risk factors in society, such as smoking, high fat levels in food, unsafe sex, fatal traffic
accidents and more safe cars and roads. Governments, public health services and private
sectors for years have made huge investments to stimulate people to exercise more,
consume healthy food, moderate their alcohol use and drive safely. Such efforts aim, for
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instance, to reduce the incidence of cancer, cardiovascular diseases, coronary heart
diseases, diabetes, physical handicaps and premature death.
To date, mental health, mental fitness, mental capital and well-being have become
major issues on national and international public agendas. Could we reduce the high
prevalence of depression in the next 15 years with 20%? Is it possible to significantly lower
violence, school dropout and youth delinquency by improving social-emotional competence
in children and youngsters in high-risk communities? Could we reduce the ever-ongoing
transgenerational transmission of psychiatric problems from parents to children by 2040 with
at least 30%? Is it possible to prevent in a city as Rotterdam or Berlin one of every three
cases of child abuse and domestic violence, especially in high-risk neighbourhoods? What
can we do to achieve such targets, and how much time does such intervention processes
take to reach such reductions?
Achieving significant preventive effects in individuals or individual families is currently
part of daily practice in health and social care. To achieve the same in whole populations or
segments of them is a lengthy and complex process. Experiences with complex change
processes in other fields, such as in industry, reducing criminality and protecting the
environment, have taught us that such challenges can best be approached through wellmanaged, staged planning processes. These processes were first described in the Planning
of Change literature of the 1960s and 1970s (Lippit, Watson & Westly, 1958; van Beugen,
1969; Bennis, Benne and Chin, 1970; D’Zurilla and Goldfried, 1971; Zaltman, Kotler &
Kaufman, 1972). These classic publications were required literature in the university training
programme on social change, in which the first author of this textbook participated at the
beginning of the 1970s. Core principles described in this early literature still hold at the
beginning of the 21th century. They are further elaborated for prevention and health
promotion in more recent leading textbooks such as Health Promotion Planning (Green &
Krauter, 1999, 2005) and Planning Health Promotion Programs (Bartolomew, Parcel, Kok &
Gotlieb, 2006).
Reducing alcohol use and addiction is in our field a well-known example of a lengthy
and complex process in which multiple stages can be distinguished. These include, for
instance, performing epidemiological research on the prevalence, causes and development
of alcohol use and alcohol-related problems; designing-testing-evaluating new prevention
programmes; disseminating and anchoring these programmes in the community, and
ensuring that they become adopted, implemented and institutionalised by local organisations
(e.g. schools, companies, justice, mental health and public health institutions). Only when all
such steps are taken, prevention could lead to a reduction of alcohol problems in a
population. Furthermore, to reduce of a major health problem in the population we cannot
merely rely on the implementation of just one single intervention. Such an ambition requires
the implementation of a combination of multiple, well chosen programmes and measures
that together have the power to generate significant collective health impact in populations.
In the next section, we have limited ourselves to a brief sketch of three theoretical
frameworks that play an important role in planned change and programme development:
stage models, strategy development and effect management. In Part III and IV we will
consider in more detail the use of stage models in programme development (chapter 11),
running a goal analysis (chapter 12) and how to design a prevention strategy (chapter 13).
The current progress in effectiveness and effect management will be discussed in chapter
14.
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4.4.1 Stage models
Stage models describe the various stages in planned change and problem solving
processes, and provide guidelines for effective action. The realisation of preventive goals in
our society can best be understood as a challenge to solve a complex problem. This could
concern questions such as how to reduce countrywide the amount of electricity used by
citizens or the rate of crimes, but also the question of how to reduce the number of
depressive disorders or cases of child abuse in a city. To solve complex problems
successfully, they first need to be divided in a series of smaller manageable sub-problems
and tasks that can be addressed partly separately and simultaneously, partly in subsequent
steps. Solving the main problem successfully will depend on our ability to solve interrelated
sub-problems in the right sequence. Solving one sub-problem in this functional sequence is
called a stage. Outcomes of each preceding stage serve as building stones for solving the
next sub-problem in the next stage. All professions dealing with targeted change use stage
models. Planning of change models exists in a wide variation. The core stages are mostly
the same, but they might be adapted or extended to make them more suitable for specific
situations, tasks and aims.
We illustrate these stages in the case of reducing depression. We need to start with
analysing the prevalence and incidence of depression in a community, where it
concentrates, what the causes are why so many people develop a depressive disorder, and
if these causes are sensitive to change. Based on such an analysis we can define goals for
a depression prevention programmes and select target groups. Having insight into the
problem, its causes and the aimed preventive goals and target groups, we can start
designing a prevention programme or strategy that could in the end lead to achieving stated
preventive objectives. After the implementation of such a programme, we are in need of
getting feedback. Did we reach our target population? Was the implementation process
successful? Did the programme produce the targeted effects? Were risk factors reduced?
How many depressions were prevented in the population? What are the costs of preventing
one depression? Did the financial investment (costs) balance the total of benefits of the
programme? Did we use the right combination of measures and interventions?
As we stated at the start of this textbook, the availability of an effective prevention
programme (model programme) does not mean that we will be directly successful in
reducing a health or mental health problem in a whole population or target group. This will
also depend on how successful we are in disseminating the programme nationally or locally
(distribution), and seeing it adopted and implemented by many organisations and in multiple
settings, in order to reach many citizens. How could we achieve large-scale implementation?
Only through widespread dissemination and coverage, prevention programmes can be
expected to affect public health. These issues follow the stages that were discussed in the
basic Planned Change Model that we presented at the start of this textbook.
We can learn here from successful dissemination strategies that are used by private
companies to get their innovations and new products sold all over the world (Apple,
Microsoft, and Toshiba). In his famous book "Diffusion of Innovations" (1995), the late
Everett Rogers describes his experiences with dissemination of innovations all over the
world. The theoretical models on dissemination he developed based on his experiences
have been used worldwide to enhance the dissemination of prevention and health promotion
programmes. In chapter 11, we discuss our extended stage model that also includes the
stages of dissemination, adoption and large-scale implementation.
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4.4.2 Strategy development and intervention analysis
The design of an intervention programme always begins with making an argued choice
about what the programme should achieve and for whose benefit, thus about its goals and
target groups. The next question is: What can we do to achieve these goals? Chapter 13
describes how prevention strategies are designed and what alternative strategies are
possible in prevention. A strategy is described as a series of choices that one should make
about how to go successfully from A to B, for instance from annually 10.000 new cases of
depression in a region of 400.000 inhabitants to 7.000 new cases (30% less). In chapter 13,
we will discuss eight strategy dimensions for making such choices that together build up the
unique profile of each intervention or programme.
Examples of such choices are: How do we define – as precisely as possible - the
target population of our planned intervention? Do we need to segment the target population
in several subpopulations to make a better reach possible and to tailor interventions to their
specific needs and culture? From an ecological perspective, do we primarily want to focus
our interventions at individual citizens at risk, or also at their social network, school or work
setting, local community or municipal policies? What type of intervention methods will we
use to change behaviours of citizens, community leaders, health personnel, school boards,
private companies or municipal councils? Do we also want to change regulations,
professional quality standards, policies or even laws? Whom do we choose as the
messenger, advocate or trainer? Ourselves as prevention experts, or local key persons,
trained volunteers or peers? Do we want to achieve our goal by using one intervention tool
(e.g. a course or a website) or by a combination of multiple interventions at different
ecological levels and in different settings?
Together, these and many other choices make up in the end the unique ‘profile’ of a
chosen intervention strategy and programme. Throughout this textbook, numerous examples
will be given of such choices and the resulting prevention strategies. The effectiveness of
preventive interventions depends on the extent to which involved professionals and
stakeholders are able to make explicit and informed choices on such strategic dimensions,
based on the best available scientific knowledge and practice-based knowledge.
In designing prevention strategies and programmes, we need not only theories about
determinants of health and mental health problems, but also theories and principles of
effectively influencing people and their environment. Most prevention and health promotion
programmes use theories and principles of change from behavioural sciences, such as
theories about social learning, classical and instrumental conditioning, modelling, feedback,
attitude and behaviour change, communication, motivation processes, goal setting,
socialisation, parenting, stress inoculation and social support. For designing successful
interventions that aim to change social, organisational and environmental conditions for
better mental health and well-being, we can make use of a diversity of theories from social,
organisational and cultural sciences. These include, for instance, theories about social
ecology, social marketing, advocacy, diffusion and dissemination, institutionalisation, social
networks, organisation change, learning organisations, community development, social
innovation, social movements, and about the role of mass media, internet and other social
media.
In sum, to design and ground interventions we can make use of a rich scale of
theoretical approaches and their related empirical research. This requires from professionals
openness for alternative theories and bodies of knowledge and to be able to select the
107
approach that fits best to the targeted problem and context. It also underlines the importance
of multidisciplinary teams and collaboration between experts and stakeholders with diverse
training backgrounds. Finally, it challenges us as scientists and professionals to learn to
cope with complexity, as human beings and the environment in which they life and develop
are complex. We have no other choice then learn to deal with that as effectively as we can.
4.4.3 Effect management (chapter 14)
Prevention programmes can result in impressive effects. Throughout this textbook, multiple
examples are presented of effective programmes. Research has also shown that many
prevention and health programmes in practice have only small or short-term effects, no
effects or even negative effects. Besides being effective in improving mental health in
individuals and families, we need to understand how to create mental health impact in
communities and whole populations. For this reason, it is important to understand what
conditions and ingredients enhance effectiveness (success factors), and what conditions bar
the road to success (failure factors).
The last two decades many prevention and health promotion experiments have been
evaluated by professionals and stakeholders and by researchers, resulting in a rich body of
knowledge about the pitfalls and strengths of the used approaches. Recently, meta-analytic
studies have started to identify participant, programme, implementation and context
characteristics that are related with higher effect sizes (e.g. Jane-Llopis, Hosman, Jenkins &
Anderson, 2003; Stice, 2008; Fisak, Richard & Mann, 2011). Some 15 years ago, our
research centre and some colleagues around the world have started to develop a theoretical
framework on ‘effect moderators and effect predictors’. In chapter 14 on “Evidence of
effectiveness and improving effectiveness in prevention and mental health promotion”, we
offer an introduction to this framework. These science-based and practice-based insights in
effect moderators have been translated in guidelines of effect management for practitioners,
policy-makers and scientists who are involved in designing and implementing prevention and
health promotion programmes. Based on these insights and learning systems we expect
future programmes and policies to become more effective in improving mental health and
well-being of programme participants, groups at high risk and in the end of populations at
large.
4.5
Conclusions
Earlier in this textbook, we described the many preventive behaviours that we as human
beings, as organisations, and as society put into practice on a daily basis, based on our
biological nature, cultural traditions, and learning experiences. We differentiated them from
the preventive activities and programmes by professionals. The main difference is that
prevention and health promotion professionals design their preventive work on a systematic
analysis of determinants of health and disease, and on scientific and professional knowledge
of processes of change. Theories and theoretical models are the main tools we use to
integrate and validate this knowledge, and to convert knowledge into policies and
professional practice. This chapter gave an introductory overview of the type of theoretical
frameworks that professionals need in order to act effectively in prevention and health
promotion.
108
We have also seen that different scientific approaches are used to analyse the
determinants and processes of how mental health and mental disorders develop across the
lifespan. These differences are related to scientific disciplines, but also reflect personal
values of professionals and the cultures and policies of their organisations. We have
stressed that the choice of theoretical approach has a significant impact on what strategies
professionals and scientists will use to prevent mental illness and promote mental health.
Professional quality requires they are aware of the possible theoretical approaches that can
be applied and their implications. In such choices, not only scientific arguments but also
ethical dilemmas play a role. For instance, how do we deal with known social causes of
mental illness in a mental health care system dominated by person-centred approaches?
Finally, the wide spectrum of possible theoretical and scientific approaches in this field also
stresses the need to combine multiple approaches in an integral preventive strategy or
policy, as each approach might reflect a different part of the same reality. For this reason,
the field of mental health promotion and prevention is a typical interdisciplinary field that
requires interdisciplinary and interorganisational collaboration.
Literature
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(Eds.) Competence and coping during adulthood. Vermont Conferences on Primary
Prevention of Psychopathology. Hanover: University Press of New England.
Bartholomew, L. K., Parcel, G. S., Kok, G., & Gottlieb, N. H. (2006). Planning health promotion
programs: an Intervention Mapping approach (2nd ed.). San Francisco, CA: Jossey-Bass
Bennis, W.G., Benne, K.D., & Chin, R. (1970). Planning of change. London: Holt, Rinehart & Winston.
Cicchetti, D., & L., T. S. (1995). Developmental psychopathology perspective on child abuse and
neglect. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 541-565.
D’Zurilla, T.J., & Goldfield, M.. (1971). Problem solving and behaviour modification. Journal of
Abnormal Psychology, 78, 1, 107-126.
Fisak, B.J., Richard, D., & Mann, A. (2011). The prevention of child and adolescent anxiety: a metaanalytic review. Prevention Science, 12, 255–268.
Green, L.W., & Krauter, M.W. (1999). Health promotion planning: An educational and environmental
view. Mountain View: Mayfield.
Lippitt, R., Watson, J. and Westley, B. (1958). The Dynamics of Planned Change. New York:
Harcourt, Brace and World.
Jane-Llopis, E., Hosman, C. Jenkins, R., & Anderson, P. (2003). A meta-analysis of depression
prevention programmes: What predicts effect? British Journal of Psychiatry, 183, 384-397.
Olds, D. (2006). The nurse–family partnership: an evidence-based Preventive intervention. Infant
Mental Health Journal, 27, 1, 5–25.
Ramey, C. T., & Ramey, S. L. (1998). Early intervention and early experience. American
Psychologist, 53(2), 109-120.
Rogers, E. (1995). Diffusion of innovations. New York: The Free Press.
Rolf, J., Masten, A., Cicchetti, D., Nuechterlein, K., & Weintraub, S. (Eds.). (1990). Risk and protective
factors in the development of psychopathology. New York: Cambridge University Press.
Rutter, M., & Quinton, D. (1984). Parental psychiatric disorder: effects on children. Psychological
Medicine, 14(4), 853-880.
Seligman, M. (2002). Positive psychology, positive prevention, and positive therapy. In C. R. Snyder
and S. J. Lopez (Eds.), Handbook of Positive Psychology (pp. 3-9). London: Oxford University
Press.
Seligman, M., & Csikszentmihalyi, M. (2000). Positive psychology. American Psychologist, 55, 1, 514.
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Stice, E., Marti, N., Shaw, H., & O’Neil, K. (2008). General and program-specific moderators of two
eating disorder prevention programs. International Journal of Eating Disorders, 41, 611–617.
Van Beugen, M. (1969). Sociale technologie. Assen: van Gorcum.
Wolchik, S. A., Sandler, I. N., Millsap, R. E., Plummer, B. A., Greene, S. M., Anderson, E. R., et al.
(2002). Six-Year Follow-up of Preventive Interventions for Children of Divorce: A Randomized
Controlled Trial. JAMA, 288, 1874-1881.
Zaltman, G., Kotler, Ph., & Kaufman, I. (1972). Creating social change. New York: Holt, Rinehart &
Winnston
Psychologist
Study questions for this chapter

Prevention uses very different types of theories. What types of theories do we need
in prevention? For which purposes?

What is the difference between risk and protective factors? Illustrate the difference by
some specific factors that play a role in e.g. depression.

What kind of relations can causal factors have with each other during the process of
the development of mental health or a mental disorder? What are the implications of
these different kind of interrelations for designing a prevention programme?

What is the meaning of: etiological fraction, prevented fraction, attributive risk, broad
spectrum effect?

What types of theoretical models on determinants of (mental) health are used in
prevention? What are the main differences between these types of models and what
consequences can these differences have for the choice and outcome of prevention
strategies?

Select one of the following problems: alcohol problems or aggression problems in
youngsters, or depression or anxiety disorders among elderly. Or select another
problem that you are familiar with.
Do you prefer a specific theoretical approach to analyse this problem? Explain why
you favour this theoretical approach. Can you imagine that a colleague or a different
stakeholder might prefer a different theoretical approach to the same problem? How
would you explain that you both have different views on this?

Anticipate on what your choice of theory implies for the type of interventions that you
will design or select to prevent the problem? What might it imply for how successful
you will be in preventing the problem? Now looking back, are you satisfied about the
choice of your theoretical approach?

Why do we need stage models in prevention and health promotion? (See also
chapter 11)
110
5
Behavioural approach in prevention and health promotion
A closer look at some models
5.1
Introduction
112
5.2
Health Belief Model
112
5.3
Theory of Planned Behavior
114
5.4
ASE-model
117
5.5
Transtheoretical model (Stages of Change Model)
119
5.6
Conclusions
120
Literature
122
Study questions for this chapter
123
Preface
The aim of this chapter is to learn to apply different cognitive-behavioural models to problem
behaviours and health behaviours that are targeted in preventive interventions and health
promotion programmes. These applications include, for instance, reducing bullying
behaviour, stopping smoking, decreasing alcohol consumption, asking for help from social
networks, changing unresponsive or harsh parenting behaviour.
111
5
Behavioural approach in prevention and health promotion
A closer look at some models
Clemens M.H. Hosman
5.1
Introduction
In prevention and health promotion, all behavioural models are based on the assumption
that health and disease are largely determined by how people behave. For health
behaviours, it is possible to differentiate between ‘health-promoting’ or 'preventive’
behaviours (e.g. diet, exercise, assertiveness) and ‘health-risk’ or 'illness' behaviours (e.g.
smoking, systematically ignoring problems, rumination). In the terminology of this reader, the
first behaviours are similar to protective factors, and the second ones resemble behavioural
risk factors. The promotion of healthy and preventive behaviour and the reduction of risky
behaviour can both contribute to improving health and preventing disease.
To achieve preventive effects with a behavioural approach, it is important to influence
determinants of health behaviour and risk behaviour effectively. In recent decades, many
behavioural models that describe which determinants affect health behaviour and show how
this behaviour can be influenced, have been developed and scientifically tested. In this
chapter, four frequently used behavioural models will be discussed, each of which can be
used to derive strategies to motivate people to show preventive behaviour: the Health Belief
Model, the Theory of Planned Behaviour, the ASE-model and the Transtheoretical model
(Stages of Change Model). At the end of this chapter, an overview is given of different types
of prevention strategies, which can be used to influence the different behavioural
determinants.
5.2
Health Belief Model
The Health Belief Model (HBM, figure 5.1) is a psychological model developed by
Rosenstock (1974) and Becker (1974) that attempts to explain and predict health
behaviours. Originally, the model was designed to predict behavioural responses to
treatment received by acutely or chronically ill patients, but in more recent years the model
has been used to predict the likelihood that an individual undertakes recommended actions
to improve or protect his health.
The HBM is based on the understanding that a person will take preventive action if
he or she: 1) feels that a negative health condition can be avoided, 2) has a positive
expectation that by taking a recommended action this negative health condition can be
avoided, and 3) believes that he or she can successfully perform the recommended action.
The HBM assumes that people will not show preventive behaviour, unless they feel a
‘readiness to act’ based on the following considerations:
112

Perceived susceptibility: refers to a person’s perception that a health problem is personally
relevant and that he might be at risk, or that a diagnosis of an already present illness is accurate.
Example: I might become seriously depressed if I don’t do something about my increasing
depressive feelings.

Perceived severity: even when one recognises personal susceptibility, it is not likely that a person
will take action unless he considers the condition or disease and its consequences as serious
(e.g. poor prognosis, negative impact on quality of life, high costs). Example: Getting heavily
depressed would seriously interfere with my relation and my study.

Perceived threat of disease: based on the combination of perceiving susceptibility and
perceptions about the severity of the disease. It refers to the experienced negative
consequences, if the person would not take preventive action.

Perceived benefits: an individual's assessment of the positive consequences of performing a
preventive behaviour (belief that the action will prevent the illness or its severity). Example:
visiting the website on depression, study about what I could do to better cope with my depressive
feelings and use the advices in my daily life to prevent that I become seriously depressed. It is a
website of the Trimbos institute so I trust the quality.

Perceived barriers: an individual's assessment of the factors that facilitate or hinder the
performance of the promoted health behaviour (e.g. the complexity, duration, accessibility, costs).
Example: Using internet does not cost any money, nobody will know about it, and I can do it at
any time during the day that I like.
Comparing perceived benefits and barriers will determine the likelihood that a person takes
preventive action in response to the perceived threat. Three clusters of external or
background variables were added to the model as factors that might moderate the health
and behavioural perceptions of a person.

Demographic variables: such as age, gender, ethnicity, occupation.

Socio-psychological variables: such as socioeconomic status, personality, coping styles,
knowledge, and peer behaviours.
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
Cues to action: external influences promoting the desired behaviour. This may include information
provided or sought, reminders by powerful others, persuasive communications, and personal
experiences. These can all activate the readiness to adopt the preventive behaviour.
Motivational strategies
Based on this model there are different strategies possible to motivate someone to exhibit a
desired preventive behaviour. For health educators and health promotes, each of the
variables in the HBM provides an opportunity to stimulate people to a targeted preventive
behaviour:

Make people aware of their perceived susceptibility. Education can teach people the risk of a
particular disease or hazard, and through tailored education personalise risk perception
based on a person's features or behaviour (Am I really at risk? How large is the risk?).

Increase the perceived severity in the target person or population: give insight into the
personal consequences of the risk and condition (How bad will it be if I would get this
disease? Are the negative consequences only temporary or long term?).

Educate people about the perceived benefits of the preventive behaviour: convince the
audience that behaviour X is effective in substantially reducing the risk of a particular disease
or problem, and in achieving significant health or other individual or social benefits (Does it
help if I show this behaviour? How will this be beneficial to me? When?).

Identify and reduce perceived barriers for the behaviour: through reassurance (e.g. show that
the behaviour has little disadvantages or requires low investment), incentives (e.g. lower the
price of more healthy products or services), and assistance (e.g. provide training and
guidance in performing the preventive action).
In later versions of the HBM, the factor self-efficacy was added to the model, as was the case in the
Theory of Planned Behaviour Model and the ASE-model, as will be discussed below.
5.3
Theory of Planned Behaviour
Like the HBM, the Theory of Planned Behaviour (TPB, figure 5.2)) was developed to explain
and stimulate behaviour change at individual level. It was proposed by Ajzen as an
extension of his original Theory of Reasoned Action (Fishbein & Ajzen, 1975). The model
has been applied in many fields such as advertising, public relations, media campaigns,
safety, health care, and in prevention and health promotion.
The Theory of Planned Behaviour specifies the nature of relationships between beliefs,
attitudes and behaviour. According to this model, people’s evaluations of, or attitudes toward
behaviour are determined by their beliefs about the behaviour and their own and other’s use
of that behaviour (Ajzen & Fishbein, 2005). It is restricted to those behaviours of which
people are conscious and that they may choose to perform as a result of a reasoning
process. This is a restriction while many behaviours, also health-relevant behaviours, are not
the result of reasoning about the pros and cons, but are ruled by nonconscious brain
processes and habits. The theory of Planned Behaviour has three components:
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
Attitudes towards behaviour: the degree to which behaviour is valued positively or
negatively by the person. In this model these attitudes are determined by the belief that a
desired outcome will occur if that behaviour is performed (behavioural beliefs) and that
the outcome will be beneficial to the person or to others that are important for him
(evaluation of behavioural outcomes). For example, people will be more likely to have a
positive attitude towards reporting suspected child abuse if they believe it is an effective
means of stopping child abuse and prevent further hard to a child.

Subjective norm: relates to a person’s beliefs about what others think he or she should
do (normative beliefs), and by an individual’s motivation to comply with their norms. For
example, if a smoker estimates that most people do not smoke and that most of his
friends want him to quit, it is more likely that he will develop a positive subjective norm
towards quitting.

Perceived behavioural control: recognises that a person’s intentions will become
significantly more likely to perform a specific behaviour if he feels personal control over
that behaviour. The term ‘perceived behavioural control is’ similar to Bandura’s concept
of self-efficacy. According to Bandura, self-efficacy is the belief in one's ability to succeed
in specific situations (Bandura, 1986). One's sense of self-efficacy can play a major role
in how one approaches specific goals, tasks, and challenges. People with high selfefficacy - that is, those who believe they can perform well - are more likely to view
difficult tasks as something to be mastered rather than something to be avoided.
Perceived behavioural control is influenced by control beliefs: an individual's beliefs
about the presence of factors that may facilitate or impede performance of a specific
behaviour (Ajzen, 2001). For example, a school kid who is bullied is more likely to show
a social assertive response when the child has some confidence that he or she is able to
perform such behaviour adequately.
The three components lead to a behavioural intention that indicates an individual's readiness
to perform a specific behaviour. The intention to act is the key determinant of behaviour, and
all other factors affecting behaviour are mediated through behavioural intention. As a general
rule; the more favourable the attitude toward behaviour and subjective norm and the greater
115
the perceived behavioural control, the stronger the person’s intention to perform the
behaviour in question. Finally, given a sufficient degree of actual control over the behaviour,
people are expected to carry out their intentions when the opportunity arises (Ajzen, 2002b).
For an example, see Box 5.1.
Box 5.1 TPB applied to bullying and multiple actors
The first question is: whose behaviour influences the bullying? These persons are for
instance the bully, the bullied child, peers, teachers, school management and parents.
The TPB assumes that bullying is primarily based on an implicit or explicit choice of the
bully: will I do it or not? This choice (“I'm going to bully Theo” or “I'm going to force
Astrid to give me money”) depends on his attitude towards bullying, the benefits the
bully expects compared to the disadvantages; second, it depends on the expected
reactions of other students ("They think I am cool"), teachers (“They do not dare to
interfere”) and parents ("They won’t find out”). Finally, it is about experienced
behavioural control. For the bully: Am I able to control my tendency to bully, am I able
to show prosocial behaviour? For the bully victim: Am I able to respond assertive?
The behaviour of the bully may be influenced by the behaviour of others. This might be
the supervision of teachers or intervention by peers. For these bystanders it is
important that they feel able to effectively intervene in these situations without harming
themselves. Preventive interventions may influence each of these elements and actors
supported by TPB.
Motivational strategies
The TPB is useful in first understanding what beliefs drive current behaviour of people who
are at risk (e.g. bully victims) or the behaviour of those who put someone else at risk (e.g.
bullies, drivers with alcohol). Based on this knowledge tailored educative intervention can be
designed to stimulate people to more preventive behaviour. The TPM model offers several
options to motivate target persons to change their behaviour:

Provide information about the benefits of healthy behaviour and reduce the expected
disadvantages of that behaviour.

Provide information about the disadvantages of risky behaviour and how the expected
benefits of that behaviour can be overestimated or misperceived.

Promote social norms in the environment that support preventive behaviour and reject
harmful behaviour, make target persons aware of these norms, and encourage them to
conform to these behavioural norms through rewards and penalties.

Fight social norms and rewards in the environment that encourage risky or harmful behaviour,
and encourage people to act independently against such an environment (stimulate less
conformity, put such harmful norms under pressure through public policies or school policies,
local media and social media).

Remove barriers that may hinder or demotivate your target persons to perform the preferred
behaviour, (e.g. increase skills to deal with social pressure for alcohol or drug use; create
facilities in the environment to change risky behaviour in healthy behaviour, such as healthy
snacks in a vending machine instead of chocolate bars and chips).
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5.4
ASE-model
The previous models received a number of criticisms. Repeatedly mentioned major
deficiencies are:

The lack of attention to the influence of ‘skills' and 'social support';

The absence of a distinction between behaviour and behaviour maintenance;

Absence of feedback processes.
To deal with these criticisms, the ASE-model was developed at the Maastricht University (De
Vries et al, 1998). This model (figure 5.3) is based on the TPB and Bandura’s view on the
explanation of behaviour. The model states that behaviour can be explained from the
behaviour intention and that intention in turn can be explained by the three main
determinants:
1) Attitude (A): like in the TPB, attitudes refer to the expected consequences of the
behaviour, both affective and cognitive. How positive is someone about the behaviour
(pro’s and con’s)?
2) Social influence (S): refers to social norms, but includes social support and the perceived
behaviour from others as well. How positive is the environment concerning the
behaviour?
3) Self-Efficacy (E): is the degree to which a person expects that he/she is able to perform
the specific behaviour successfully. Can you perform the behaviour (possibilities, skills)?
The fewer skills a person attributes to himself and the more expected barriers to perform
the behaviour, the lower the self-efficacy.
In addition, two other factors are included in the ASE model: actual skills and barriers. Both
factors could moderate the impact of attitudes, social influence and self-efficacy on
behaviour. Even if each of these variables support the intention to perform the preferred
behaviour, the actual performance of that behaviour may be impeded while a person lacks
the behavioural skills to enact the intended behaviour, or while unforeseen external barriers
block the behaviour (e.g. through interventions by others, lack of situational opportunities,
unforeseen costs).
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The model also indicates how the person perceives his own health behaviour and its
consequences. This generates feedback: the perception of success will motivate the
maintenance of the behaviour and perception of failure and insufficient performance or only
moderate outcomes might lead to behaviour change or de-motivation. This feedback
mechanism is an important element of the ASE model, which facilitates the model to be a
dynamic one.
The more specific we define the targeted behaviour, its determinants and context, the
better we are able to predict future behaviour in similar or renewed conditions. For example:
“going to a local sport accommodation twice a week” is more specific than just “exercise
more”. The model assumes that other external variables do not directly influence the
behaviour, but only through the discussed direct determinants. For example, gender does
not directly influence exercise behaviour, but indirectly it might be the case. Imagine, for
instance, differences in attitude, in which boys want to exercise to be fit, and girls to lose
weight. Or think of social influence in choosing typical male or female sports, such as
respectively rugby and ballet.
Recently, the ASE model has been extended with ideas from the TPB, Bandura’s Social
Cognitive Theory, Prochaska’s Transtheoretical Model, the HBM, and goal setting
theories. The Integrated Model for explaining motivational and behavioural change is called
the I-CHANGE Model (De Vries et al., 2008). The I-Change Model is a staged model and
distinguishes three stages in the behavioural change process: 1) Awareness; 2) Motivation;
3) Action. For each phase, particular determinants are more relevant. The I-Change Model
assumes that motivational processes are determined by various predisposing factors such
as behavioural factors (e.g. life styles), psychological factors (e.g. personality), biological
factors (e.g. gender, genetic predisposition), social and cultural factors (e.g. the price of
liquor, policies), and informational factors (quality of messages, channels or sources used).
Motivational strategies
In addition to motivational strategies mentioned earlier, the ASE model indicates the
following possibilities to motivate and facilitate preventive behaviour:

Strengthen self-efficacy to perform the specific behaviour, but also offer opportunities for the
person to increase the cognitive and behavioural skills he needs to convert his intentions into
actual and effective behaviour.

Promote a supportive environment that encourages the person to show the preventive
behaviour.

Create an environment where others show the preventive behaviour.

Not only motivate the person to show new preventive behaviours, but also to maintain the
new behaviour.

Promote behaviour that leads to motivating attributions on preventive behaviour in future
situations (internal attributions for success).

Prevent demotivating attributions ("the situation cannot be changed” or “I do not have the
capacity to change”).
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5.5
Transtheoretical model (Stages of Change Model)
The Transtheoretical model is also known by the acronym ’TTM’ and by the term ’Stages of
Change model’. This theory was developed by Prochaska and DiClemente to explain the
different stages of change, which appear to be most common for the majority of behaviour
change processes (figure 5.4).
The Transtheoretical model is based on the assumption that behaviour change is a process,
not an event, and that individuals have varying levels of motivation or readiness to change
(Prochaska & DiClemente, 1983; Prochaska et al., 1992; 1997). The model has been
developed based on research about the prevention and early treatment (therapy) of various
forms of addictive behaviour (smoking, excessive drinking, overeating). The authors note
that change always shows the same sequence of stages, which applies equally to
individuals who ‘self-initiate’ a change and to those responding to advice and
encouragement to change. The model is currently widely used in different domains of
prevention.
The TTM has two major sets of constructs: stages of change and processes of
change. During five stages of change, people move from a state of ‘no motivation to change’
to actual action and, finally, to internalisation of the new behaviour:
1) Precontemplation: a person is not intending to take action in the future, usually measured as the
next 6 months. Usually in this phase people do not experience a problem and do not consider
changing their behaviours. If people decide to seek advice, it is usually done because other
people put them under pressure to do so.
2) Contemplation: a person considers making a change to a specific behaviour. People are aware
that there is a problem and consider changing it, but they do not yet have a concrete intention to
do so. In this phase, they consider the pros and cons of their current situation and of the possible
solutions.
3) Preparation: a person makes a serious commitment to change in the immediate future, (usually
measured as the next month) and begins to make the necessary preparations to do so.
119
4) Action: In order to solve the problem a person initiates to change his own behaviour, experiences
or environment. People have successfully made specific overt modifications in their life styles
within the past 6 months.
5) Maintenance: a person sustains the change over time. This also means to keep working on it to
prevent relapse. This stage is estimated to last from 6 months to about 5 years.
In addition, the researchers conceptualised ‘relapse’, which is not a stage in itself but rather
the ’return from action or maintenance to an earlier stage’. People appear to move through
these stages in a predictable way, although some move more quickly than others do. The
theory is circular rather than linear, as people can enter or exit at any point.
The basic idea is that preventive interventions need to use motivational strategies in
each of the stages in the change process, unless sufficient motivation is already present in a
specific stage. Neglecting one or more steps in this process can have a negative influence
on the effectiveness of an intervention. The model provides a useful way of thinking about
the types of persuasion, information, and support people need to move through the stages of
change. Progress requires firstly to monitor precisely in which stage a person or a group of
persons is in this stepwise change process and to attune interventions on to that stage.
Secondly, apply specific change processes for each stage, such as raising awareness
(education and feedback) at the precontemplation stage, re-evaluation of outcome
expectations (information on the benefits of change) to make the change from
precontemplation to contemplation; reinforcement and social support during the action stage,
and guided practice for skills improvement can help with the change from action to
maintenance.
The experience in using this model in practice is that people pass the first three stages a
couple of times before actual behaviour change occurs. Similarly, people sometimes go
through the first four stages several times, before they are ready to maintain the new
behaviour. For instance, it is necessary to practice smoking cessation several times before
one is able to sustain this behaviour. The same may apply to stopping dieting behaviour
among female adolescents at risk for developing an eating disorder, such as anorexia.
5.6
Conclusions
Box 5.2 summarises the prevention and education strategies that can be derived from the
models discussed in this chapter. We do not pretend to offer a complete overview of useful
behavioural models. There are other models as well, such as the Protection Motivation
Theory (Rogers), Social learning Theory (Bandura), the MODE Model (Fasio) and the
Composite Model of Attitude-Behaviour Relations (Eagly & Schaiken). Several of these
models are variants or improvements of the Health Belief Model and the Planned Behaviour
Model. For a discussion about these additional models, we refer to Predicting Health
Behaviour (Conner & Norman, 2005) and The Psychology of Attitudes and Attitude Change
(Maio & Haddock, 2009).
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Box 5.2
Prevention strategies based on a behavioural
approach
Influence attitude and beliefs
 Provide information about the chances of getting a disease or disorder and the
severity of the consequences (perceived risk).
 Provide information about the positive impact of preventive behaviour and the
negative consequences of risk-increasing behaviour
 Other interventions to strengthen a positive attitude towards preventive
behaviour and negative attitude towards risk-increasing behaviour, e.g.
behavioural exercises, statements by "idols".
Influence Self-Efficacy
Increase self-confidence to carry out preventive behaviour and avoid risk-increasing
behaviour, e.g. gain positive experiences with the behaviour through role-play and
homework exercises, receiving positive feedback, expressing confidence in a person.
Increase or reduce Social influence
 Reduce negative social norms in the environment on the preventive behaviour,
and reinforce positive norms (e.g. from friends, parents, teachers, idols,
neighbourhood, public opinion).
 Reduce positive social norms in the environment for risk-increasing behaviour,
and reinforce negative norms.
 Empower people against social pressure to exhibit risk-increasing behaviours
(e.g. binge drinking).
 Increase social support for showing healthy behaviour, e.g. support groups,
provide individual emotional support, and show model behaviour.
Promote intentions for healthy behaviour
Encourage overt statements about behavioural intentions.
Increase skills and reduce barriers
 Increase behavioural skills in preventive behaviour through behavioural advice,
modelling, behavioural training, and rewards.
 Remove material, financial or other situational barriers for preventive behaviour.
Create physical, financial or other barriers to risk-increasing behaviours (alcohol
sales ban, fines, and controls).
Influence feedback
 Give positive feedback on the impact of the changed behaviour to improve
maintenance.
 Influence attributions of failure in behaviour change.
121
Literature
Ajzen, I. (2001). Nature and operation of attitudes. Annual Review of Psychology, 52, 27–58.
Ajzen, I. (2002). Perceived behavioral control, self-efficacy, locus of control, and the theory of planned
behavior. Journal of Applied Social Psychology, 32, 665-683.
Ajzen, I., & Fishbein, M. (2005). The influence of attitudes on behaviour. In Albarracin, D., Johnson,
BT., Zanna MP. (Eds.). The handbook of attitudes, Lawrence Erlbaum Associates.
Bandura, A. (1986). Social foundations of though and action: A social-cognitive theory. Englewood
Cliffs: Erlbaum.
Becker, M.H. (1974). The Health Belief Model and personal health behaviour. Health Education
Monographs, 2 (entire issue).
Bridle, C., Riemsma, R.P., Pattenden, J., Sowden, A.J., Mather, L., Watt, I.S., & Walker, A. (2005).
Systematic review of the effectiveness of health behaviour interventions based on the
transtheoretical model. Psychology and Health, 20, 283–301.
Brug, J., van Assema, P., & Lechner, L. (Red.) (2007). Gezondheidsvoorlichting en gedragsverandering: Een planmatige aanpak. Assen: Van Gorcum.
Conner, M., and Norman, P. (Eds.) (2005). Predicting Health Behaviour: Research and Practice with
Social Cognition Models. Maidenhead: Open University Press.
De Vries, H. & Mudde, A. (1998). Predicting stage transitions for smoking cessation applying the
Attitude - Social influence - Efficacy Model. Psychology & Health, 13, 369-385.
De Vries, H., Kremers, S., Smeets, T., Brug, J., & Eijmael, K. (2008). The effectiveness of tailored
feedback and action plans in an intervention addressing multiple health behaviours. American
Journal of Health Promotion, 22(6), 417-425.
Fishbein, M., & Ajzen, I. (1975). Belief, Attitude, Intention, and Behavior: An Introduction to Theory
and Research. Reading, MA: Addison-Wesley.
Maio, G. & Haddock, G. (2009). The Psychology of Attitudes and Attitude Change. SAGE
Publications.
Prochaska, J.O., & DiClemente, C.C. (1983). Stages and processes of self-change of smoking:
toward an integrative model of change. Journal of Consulting and Clinical Psychology,51(3),
390-395.
Prochaska, J.O., & DiClemente, C.C. (1992). Stages of change in the modification of problem
behaviours. Progress in Behaviour Modification, 28, 183-218.
Prochaska, J.O., & Velicer, W.F. (1997). The transtheoretical model of health behaviour change.
American Journal of Health Promotion,12(1), 38-48.
Prochaska, J.O., DiClemente, C.C., & Norcross, J.C. (1992). In search of how people change.
Applications to addictive behaviours. American Psychologist, 47(9), 1102-14.
Rosenstock, I.M. (1974). Historical origins of the Health Belief Model. Health Education Monographs,
2, 1-8.
122
Study questions for this chapter

Apply the cognitive-behavioural models described in this chapter to your own health
behaviour, such as your alcohol use, physical exercise, smoking, assertive
behaviour, handling conflicts, or asking for emotional support of friends. Which
preventive interventions for your own health can you derive from this? Who could
influence your health behaviour? Which behaviour changes are needed from these
persons to achieve change in your health behaviour?

Give arguments why motivation is important for preventive interventions.

Why is it necessary to look at multiple actors when designing a prevention
programme? Give some examples based on prevention of bullying.

What are the core concepts of the Health Belief Model, ASE-model, and
Transtheoretical model? What are the main differences between the HBM model and
the ASE model?

Which prevention and educational strategies can be derived from each of the
discussed behavioural models? Do differences in models have consequences for
differences in intervention strategies? Could you give an example?

What are the disadvantages of the presented behavioural models?

How could you combine these behavioural models with for instance the stress model,
social support model and developmental psychopathology approach (chapters 7-9)?

Chapters 16 and 17 discusse the problems of children of mentally ill parents
(COPMI), the consequences of living with a mentally ill parent, the risk and protective
factors, and what preventive interventions are available. These chapters are written
from a developmental psychopathology background. Could you think of some
examples of how you could apply cognitive behavioural models to understand the
problems of these children and their parents, and to design preventive interventions
for them?
123
124
6
The developmental psychopathology approach
6.1
Introduction
126
6.2
Core concepts and dimensions
125
6.2.1
Multidisciplinary and integral approach
127
6.2.2
Equifinality and multifinality
127
6.2.3
Developmental pathways
126
6.2.4
Psychopathology and mental health
127
6.2.5
Sensitive periods
127
6.2.6
Multiple system levels
127
6.3
Summary of features and principles
128
6.4
Conclusions
129
Literature
131
Study questions for this chapter
132
125
6
The developmental psychopathology approach
Clemens M.H. Hosman
6.1
Introduction
The most recent development in prevention theories is represented by the field of
developmental epidemiology and developmental psychopathology (Achenbach, 1982;
Cicchetti et al., 1995, Hankin & Abela, 2005; Kellam et al., 1999; Luthar, Burack, Cicchetti &
Weisz, 1997; Wenar & Kerig, 2005). Developmental psychopathology studies have shown
that mental disorders and mental health are the result of long term and complex interaction
processes between a person and his environment, and between risk and protective factors.
These interactions start already during pregnancy and the first years of life. Developmental
psychopathology is characterised by an interdisciplinary and integrated character, and by a
life course approach. It traces early developmental factors and long term developmental
trajectories of mental disorders that might encompass multiple life stages into adulthood.
This makes it possible to offer preventive interventions in a much earlier stage than is
common in prevention and health promotion based on behavioural models. In general, we
assume that preventive interventions are more effective when they are offered early in life, at
the time risk factors first emerge and still are not rooted in the person or its social
environment. Figure 6.1 outlines the multidisciplinary and life span framework of
developmental psychopathology.
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6.2
Core concepts and dimensions
6.2.1 Multidisciplinary and integral approach
Developmental psychopathology is a field of interdisciplinary science that links and
integrates knowledge on psychopathology and mental health from several disciplines, such
as psychiatry, clinical and developmental psychology, pedagogical sciences, developmental
epidemiology, neurobiology and neuropsychology, genetics, experimental psychopathology,
sociology and educational sciences. It is the combination and cross-fertilisation of knowledge
from different sciences from which we expect the most innovative contributions to the
understanding of how mental disorders develop and how mental health can flourish.
Developmental psychopathology has become one of the core scientific pillars for designing
prevention programmes and policies in the field of mental health.
6.2.2 Equifinality and multifinality
Scientific research has revealed numerous biological, psychological and social factors that
influence the development of psychopathology and mental health of people. The DSM
classification differentiates both within childhood and adolescence and within adulthood
many disorders. Researchers mostly study each disorder, its development and its
determinants separately. This has created a complex and scattered body of knowledge that
is hard to translate into a comprehensive prevention policy. Developmental psychopathology
aims to disentangle this complexity by introducing concepts such as common risk factors,
etiological pathways, equifinality and multifinality, and by studying how multiple disorders are
related.
Equifinality refers to the phenomenon that a mental disorder can have multiple
etiological pathways. Literally, equifinality means multiple roads leading to the same end.
Developmental psychopathologists study these different developmental pathways and their
related risk factors to reveal likewise multiple strategic entries to prevent such a disorder. By
combining such strategies in one comprehensive prevention policy, in the end we will be
better able to reduce that disorder in the population. It also may reveal different populations
at risk for the same disorder, each requiring a preventive approach tailored to a specific
developmental trajectory. Researchers have found different causal trajectories for the onset
of depression. One trajectory starts with a history of child abuse that could cause long-term
emotional and neurological vulnerabilities. Other factors that can contribute to the onset of
depression are living with a depressed parent, lack of parental care, the death of your only
child through an accident, sexual abuse, and exposure to violence, long-term unemployment
or loneliness among single elderly in disintegrated communities. Each of such backgrounds
can trigger a pathway to depression, especially when they are combined with poor coping
skills and a lack of emotional support.
Multifinality refers more or less to the opposite: the finding that one specific risk factor
or lack a specific protective factor can result in multiple negative outcomes. For instance, a
history of child abuse and neglect has been found to increase the risk of a wide spectrum of
psychological and pathological outcomes. These include insecure attachment, low selfesteem, less social competence, anxiety disorders, conduct disorders, depression, alcohol
abuse, injuries, mortality and suicidal ideation, but also an increased risk of chronic diseases
later in life. For this reason, we frequently speak of a ‘common risk factor’ or ‘broad spectrum
risk factor’. For prevention, common factors represent an important target, for preventive
127
interventions that successfully eliminate or reduce such a common factor might, likewise,
produce a broad spectrum of preventive outcomes. For this reason, we have introduced in
chapter 3 the concept of ‘broad-spectrum prevention’. The same reasoning applies to
protective factors yielding a broad-spectrum of positive effects.
6.2.3 Developmental pathways
Knowledge on developmental pathways can also be used to understand the high prevalence
of comorbidity between mental disorders, and between mental and physical diseases. We
differentiate between two types of comorbidity: combinations of multiple disorders in one
person simultaneously (concurrent comorbidity) and combinations of disorders that appear
subsequently (sequential comorbidity). Over time, risk factors can trigger each other to form
long-term risk trajectories. Likewise, the outcomes of earlier mental disorders can trigger
secondary disorders and diseases. For instance, anxiety disorders in childhood are a risk
indicator for depression in adolescence, and depression in adolescent girls increases risk of
bulimic pathology and overweight in adult females (Stice et al., 2004). Earlier substance
abuse symptoms are found to be a predictor for the onset of depression in adolescent
females (Stice, et al., 2004). When risk factors and mental disorders trigger each other over
time, preventing early risk factors and early disorders might prevent the emergence of longterm high-risk trajectories.
In the case of simultaneous comorbidity, common risk factors might play a causal
role as we discussed in the previous section on multifinality. Addressing a common cause
could produce a broad-spectrum preventive effect. Developmental psychopathology
scientists are longitudinally studying long-term pathways of multiple causal chains of risk and
protective factors, and subsequent problem behaviours through so-called ‘Cascade models”.
We refer to a special edition of the journal Development and Psychopathology on
developmental cascade studies (Masten & Cicchetti, 2010). The concept of cascades refers
to waterfalls starting as a normal river but splitting up step by step in multiple falls and
streams, reflecting multifinality (Figure 6.2, left picture). The other way around, is also
common, i.e. multiple independent falls and streams ultimately feeding the same river,
reflecting equifinality (Figure 6.2, right picture).
Fig. 6.2
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Symbolic representation of cascades. Left resembles the process of
multifinality, right the process of equifinality
6.2.4 Psychopathology and mental health
In spite of its name, developmental psychopathology studies both the pathological pathways
to mental disorders (vulnerability) and the pathways that strengthen competence and
resilience in children over time, thus mental health. Both pathological and normal
developmental trajectories can be better understood, when they are studied in relation to
each other, which is frequently the case in developmental psychopathology studies. In
addition, risk factors and protective factors can be considered as two sides of the same coin.
Child neglect is studied as a major risk factor in the development of a range of later risk
factors such as insecure attachment and poor social competence. Reducing child abuse
implies enhancing the opposite, i.e. parental care, responsiveness and warmth, which in turn
are conditions found to enhance the positive social-emotional development and resilience in
children sustainably.
6.2.5 Sensitive periods
Since developmental psychopathology studies when specific risk and protective factors
emerge at different stages and transitional periods in life, it offers scientific information that
could guide decisions on the best timing of preventive interventions. Preventive interventions
are considered more effective when they are offered during sensitive periods. This idea goes
back to the work of Erick Erikson on developmental stages and related developmental tasks.
He considered the transition from one developmental period to the next as a time of
developmental crisis, in which children and adolescents run an increased risk of developing
emotional and behavioural problems. Knowledge on the subsequent ‘developmental tasks’
of a child during early childhood, late childhood and adolescence could inform us on
sensitive periods in which specific protective factors start to develop such as secure
attachment, social competence, cognitive problem solving skills or self-esteem. Children
starting to go to school, or moving from primary to secondary school, are also examples of
sensitive periods. During these periods, children encounter large changes in their lives.
When children cope well with such phases of crisis, they increase their competence and selfesteem. At the same time, these developmental crises are considered as periods in which
children are more unbalanced and sensitive to external influences. Caplan, the founder of
the crisis theory and preventive psychiatry, identified these sensitive periods already fifty
years ago as great opportunities for effective emotional support and preventive education
(Caplan, 1964).
Finally, sensitive periods also refer to periods in which the onset of risk behaviours
and specific disorders is more prevalent than during other periods. For instance,
epidemiological studies have identified mid-adolescence as the period most sensitive to the
onset of first depressive episodes, psychotic episodes, and the beginning of pathological
dieting. Developmental psychopathology research informs us about the pre-clinical episodes
for such disorders with beginning symptom behaviour. During these periods, children can be
targeted by indicated prevention programmes. This requires systems for early detection of
such pre-clinical symptoms in early or mid-adolescence.
6.2.6 Multiple system levels
Due to its multidisciplinary nature, developmental psychopathology studies risk and
protective factors across multiple systems levels. In this respect, the developmental
psychopathology framework is strongly influenced by social ecology theories (e.g.
129
Bronfenbrenner). It includes studies on biological, behavioural and family risk factors, as well
as on the impact that social risk factors in schools, communities and societies exert on the
development of emotional vulnerability and resilience. Examples of evidence-based social
risk factors are poverty, economic crisis, domestic violence, poor housing conditions,
aggressive school climates, living in disadvantaged neighbourhoods, lack of social cohesion,
and exposure to war violence. This can be illustrated by studies that show evidence for
causal relations between poverty and domestic violence, stress, depression and smoking
during pregnancy and their impact on the developing emotional systems in the brain of the
unborn child (Braveman et al., 2010; Lundquist et al, 2012; Lovisi et al., 2005; van den
Bergh et al., 2005). Insight in these multi-level interactions is of great importance to feed
future prevention programmes and policies.
Of special interest are studies about the interaction between risk and protective
factors that are operating at similar or different system levels. At different levels applies, for
instance, to the study of the interaction between genetic risk factors and environmental
influences. Such studies have revealed that the likelihood that genetic vulnerability results in
the onset of mental disorders (genetic expression) depends on its interaction with
environmental conditions (Caspi & Moffitt, 2006; Jaffee & Price, 2007). For instance,
Kaufman et al. (2007) showed that the impact of child maltreatment on later early alcohol
use (e.g. getting drunk) was around 30% higher among children with specific genetic
features (resp. 5-HTTLPR allele) in comparison to maltreated children without these genetic
characteristics. Exposure to environmental stressors increases the likelihood of genetic
expression, while environmental protective factors reduce the risk that genetic factors will
lead to mental disorders.
6.3
Summary of features and principles
Developmental psychopathology is not a specific theory, but a scientific approach. It offers
an organisational and conceptual framework that combines and integrates different
theoretical perspectives. Although individual studies are focused on specific factors and
mechanisms, the field as a whole aims to provide a holistic approach towards
psychopathology and mental health. Furthermore, it is important to be aware that
developmental psychopathology is not identical to the mere study of child and adolescent
psychopathology. Developmental psychopathology represents a specific scientific approach
of the study of psychopathology across the life span. Summarising, this approach is
characterised by a combination of the following principles and features:

Studying the different stages of the development of mental disorders (onset, course,
maintenance, recovery, recurrence) as well as normal development (mental health);

A lifespan approach, including the development of long term pathways of related causal factors,
and trajectories of subsequent and related disorders (sequential comorbidity); outcomes of earlier
developmental stages have an impact on later stages;

Studying both risk and protective factors and the impact of their interactions, as well as their role
as mediators or moderators in the developmental process;

Study of multiple developmental pathways in the onset and course of a single disorder (e.g.
behavioural problems, depression, eating disorders), known as equifinality, as well the multiple
130
outcomes of a common risk or protective factor (e.g. adverse early experiences such as child
abuse), known as multifinality;

A multilevel analysis, i.e. the study of interactions between causal factors at different system
levels (e.g. person, family, school, work, community, society);

A transactional approach, i.e. person and environment mutually influence each other over time.

Given the many factors that are involved in normal development and the development of mental
disorders, developmental psychopathology represents a probalistic and not a deterministic
approach;

The short term and long term outcomes of mental disorders in terms of subsequent vulnerabilities
(‘scars’);

Identification of sensitive periods in which certain risk or protective factors are more open to
change as a result of interventions.
The research on risk and protective factors in the lives of children of mentally ill parents
(COPMI) described in chapter 16, is a typical example of developmental psychopathology
research (Hosman, van Doesum & van Santvoort, 2009). Studies on the long-term pathways
in the development of conduct disorders represent another well-known example. Aggressive
and antisocial behaviour in children emerges frequently already very early in life (from the
third year) and early aggressive behaviour has found to be fairly stable during later childhood
and adolescence. Prevention of the early signs of conduct disorder through interventions in
childhood is probably in the end far more effective than interventions during adolescence.
During this later period, aggressive and antisocial behaviours are much more difficult to
change because by that time they are usually strongly anchored in habits and in
relationships with aggressive peers. For instance, ADHD in combination with family stressors
increases the risk of early oppositional behaviour disorder during childhood, which then
increases the risk of severe behavioural disorders and alcohol and drug problems in
adolescence.
Since it emergence during the 1980s, developmental psychopathology research has
developed a rich body of knowledge on determinants and developmental trajectories of
mental health, especially through numerous fundamental longitudinal studies and through
interventions studies. For more information on such studies, we refer to Development and
Psychopathology, which is the leading scientific journal in this field.
6.4
Conclusions
Developmental psychopathology plays an important role in prevention science and practice.
The major dimensions and features of this approach parallel major strategic dimensions and
options in preventive strategies. This applies to choices, such as (a) focusing on reducing
risk factors or on increasing protective factors; (b) choosing the system level of intervention:
targeting preventive interventions at biological, emotional, behavioural, social or communitybased risk and protective factors, or combinations of them; (c) the timing of interventions
across the stages of the life span; and (d) aiming primarily at preventing mental disorders or
enhancing mental health, or both.
131
Another major strength of the developmental psychopathology framework is its
potential to integrate a wide diversity of pieces of scientific knowledge into a coherent view
on multiple causal factors at different life stages and different ecological levels. For the same
reason, a developmental psychopathology approach provides not only a useful basis to
develop specific preventive interventions, but also to design a comprehensive strategy to
reduce psychiatric problems and enhance mental health in communities with use of a smart
combination of multiple interventions. Such a science-based comprehensive approach could
include interventions directed at multiple risk and protective factors, timed at crucial sensitive
stages along the life span, targeted at the most important populations at risk, and combining
person-based and system-based preventive actions.
Finally, the longitudinal perspective of developmental psychopathology also offers a
crucial framework for outcome research. The concept of multifinality and developmental
pathways informs evaluation researchers about the spectrum of potential effect indicators of
preventive interventions. One common problem with outcome studies in prevention is that
they mostly test a too small spectrum of potential effects (many times only one or two core
indicators), while the intervention might actually produce a broad spectrum of positive
outcomes. Secondly, prevention researchers for understandable reasons restrict their
evaluation period mostly to pre- post studies or to studies with only short-term follow-up
tests. As a result, such studies might only be able to test immediate and short-term effect
and changes in risk and protective factors. Many potential positive effects may stay invisible.
Developmental psychopathology stresses the need for longitudinal outcome studies of
interventions. Such studies might point at additional potential effects later in the life span.
The study of David Olds on the Nurse-Family Partnership programme for pregnant women at
risk offers an excellent example by showing a wide range of very significant effects
becoming visible when the unborn babies become adolescents. Therefore, the approach
could make more benefits possible (Olds, 2006). Developmental psychopathology
knowledge might inform prevention researchers and practitioners where and when
prevention outcomes can be expected. This facilitates them to select research designs and a
set of outcome indicators that are better able to show the potential value of preventive
programmes. Showing the full range of benefits to all relevant stakeholders is crucial for
strengthening the perspectives for investments in prevention in the future.
132
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basis to a comprehensive approach. Australian e-Journal for the Advancement of Mental
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Gelernter, J. (2007), Genetic and environmental predictors of early alcohol use. Biological
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pregnancy: A survey of mothers attending a public hospital in Brazil. Psychological Medicine.
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Lundquist, R.S., Seward, G., Byatt, N., Tonelli, M.E., & Kolodziej, M.E. (2012). Using a
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133
Study questions for this chapter

What are the main features of the developmental psychopathology approach?

What could be the benefits of designing preventive interventions from a developmental
psychopathology perspective? How can developmental knowledge inform researchers
and practitioners about strategy development and evaluation in prevention?

What is meant by the statement: “Developmental psychopathology is a scientific
approach”?

What do the terms equifinality and multifinality mean? How are these two terms related
to making choices in designing a prevention strategy or prevention policy?

What could be the implications of the existence of concurrent comorbidity and sequential
comorbidity for designing prevention programmes?

To what other theoretical model discussed in this textbook is developmental
psychopathology most related?

What is a sensitive period and what is its meaning for prevention?

What are the implications of developmental psychopathology for designing evaluation
studies in prevention and mental health promotion?
134
7
Integrated stress-theoretical approach
7.1
Introduction
136
7.2
Concept of adaptation
137
7.3
Stress and mental health problems
139
7.3.1
Concept differentiation
139
7.3.2
Transactional perspective
140
7.3.3
Life course perspective
141
7.3.4
Intergenerational transfer
142
7.3.5
Multifactorial approach
142
7.3.6
Multisystem and multilevel approach
143
7.4
Transactional Model of Stress and Coping
144
7.4.1
Limitations
144
7.5
Integrated Stress Theoretical Model
145
7.6
Conclusions
151
Literature
152
Study questions for this chapter
154
135
7
Integrated stress-theoretical approach
Clemens M.H. Hosman
7.1
Introduction
The integrated stress model, presented in this chapter, emerged in the beginning of the
1980s during a range of lectures on epidemiology, stress and mental disorders that were
part of our courses on epidemiology and prevention. Over the years, the model has been
used by many prevention practices in the Netherlands as their core theoretical base for the
development of prevention programmes and policies. Practitioners reported that the model
helped them to understand better the major strategic options for preventive interventions and
used it as a framework to relate the many single pieces of scientific knowledge that they
learned during their academic training. Although the model was not inspired by the field of
developmental psychopathology that emerged later, the integrated stress model is very
much in line with the basic principles of the developmental psychopathology approach. The
difference is that developmental psychopathology offers a specific ‘approach’ to study the
development of mental disorders and mental health, while the integrated stress model has a
specific psychological theory as its centre.
The history of this model started during 1978, when I was participating
in a seminar given by the late Gerald Caplan, when he was visiting
The Netherlands as prevention consultant. As stated earlier he was
one of the founders of Preventive Psychiatry. His basic ideas are
described in his book Principles of Preventive Psychiatry (1964). In
this classic book and his later book Theory and Practice of Mental
Health Consultation (1970), he presented a coherent theoretical and
methodological framework for prevention that was grounded in both
scientific knowledge and his rich experience from the practice of
preventive child psychiatry. Caplan is also the father of the crisis
theory. Even for current standards, his books offer principles and frameworks that are still
relevant to date. His views on primary prevention strategies, social support systems,
community dynamics and on mental health consultation methods to local professionals,
organisations, communities and policy makers are highly topical these days, as we will
discuss in chapter 10. The need for community interventions and the current changes in
mental health service systems (“back to the community”) call for new approaches, for which
Caplan’s views and methods are highly inspiring.
During that seminar in 1978 and the guest lecture he gave to my students, he
presented a theoretical model (crisis theory) that founds his primary prevention approach.
This model, in his own handwriting, is imaged in figure 7.1. He wrote this model on the back
of a Holiday Inn letter sitting in the canteen of our Psychological Institute in Nijmegen on
Wednesday, the 31st of May 1978. He asked me to write the model with chalk on the
blackboard of the lecture room, as PowerPoint did not exist yet at that time. The model
considers the development of (mental) diseases as well as (mental) health as an outcome of
136
the interaction between life stresses, personal competences and social support.
Competence and its counterpart ‘vulnerability’ are considered as the outcome of two clusters
of forces: biological and social risk factors (e.g. birth trauma, pregnancy complications,
family discord,
Figure 7.1 Caplan’s crisis theory as basis of primary prevention (May 31st, 1978)
parental mental illness, cultural deprivation) and competence promoting forces in the social
environment (e.g. parental care, school education). Social support is influenced by the
quality of the social network system (Caplan, 1974). Caplan differentiated explicitly between
risk factors, mental health promoting and protecting factors (intervening variables). Implicit in
the model are a lifespan and an ecological dimension. Caplan’s model became the centre of
my own thinking about mental health and mental disorders. Combined with Richard Lazarus’
cognitive theory of stress and coping, the model evolved to the integrated stress model that I
will introduce in section 7.5.
As a background to this model, I first discuss the concept of adaptation, which is
narrowly related with coping with stress and human development (7.2), summarise
developments in thinking about stress and its impact on mental health (7.3), and describe
the cognitive stress model of Lazarus (7.4).
7.2
Concept of adaptation
Hans Selye, one of the founders of the stress theory, begins his book on stress (1956) with
the phrase: "Adaptation is perhaps the most characteristic feature of life”. Without
adaptation, there is no life, no survival, and no human development. In life sciences, such as
biology and psychology, adaptation is one of the most central concepts. In a theoretical base
to efforts for promoting the development of mental health and preventing the development of
mental disorders, adaptation should be a core concept. Adaptation refers to the ability of
living organisms, including humans, to adapt to the environment. The purpose of adaptation
137
is to increase chances of needs satisfaction, self-protection and survival, and the adaptive
interaction with one’s environment offers opportunities for further biological, cognitive and
emotional development. People with a strong adaptive capacity are better able to survive
and maintain their health. When individual adaptive capabilities (such as problem solving
skills) are not sufficiently developed or damaged by early traumatic experiences, clinical and
developmental psychologists try to restore them through therapeutic interventions.
Preventive interventions aim to strengthen the adaptive skills of individuals and the social
systems in which they live. One strategy is to prevent conditions that damage adaptive
capabilities and to strengthen social conditions that protect and promote them. This includes
for example, programmes that stimulate pregnant mothers to abandon smoking and alcohol
use, offer support to reduce stress, depression and anxiety during pregnancy. In addition,
the prevention of child abuse and neglect through parenting education serves as a good
example, given the evidence of the impact of early traumas on the developing neuroemotional system in the brain.
Individual adaptation cannot be seen separately from social adaptation processes at other
system levels, such as adaptive processes at the level of social networks, organisations,
schools and government. Individual adaptation depends on the adaptive capacities of these
social systems to protect individuals against extreme levels of stress and traumatic
experiences, to provide support when needed and to safeguard conditions in which people
can develop their skills to survive and adapt. Some examples:

After a serious shooting incident at a school, emotional coping of students and prevention of
trauma-related disorders depend on the capabilities of the school and community to support
students and their parents.

The social policy of a company and the way it cares for work-stress prevention and how this is
defined in protective laws or national or international standards for the quality of the work
environment.
Preventive interventions focused on threatening factors and adaptation capacities at higher
social system levels are necessary when we aim to reduce serious mental health problems
in people at risk and in whole populations. Such interventions aim to increase health
promoting and preventive capacities of schools, communities or companies. In turn, such a
“healthy’ environment can contribute to the preventive capacities of individuals.
In most cases, people are able to adapt to difficult circumstances. Stressful
circumstances and the challenge to cope with them are prerequisites for a healthy mental
development. On the other hand, traumatic stress or an accumulation of stressors together
with a lack of social support can lead to serious and lasting psychological problems. This
chapter presents the ‘integrated stress theoretical model’. This model adds a developmental
psychopathology view to the usual stress and coping models and can be seen as a broad
framework in which several theories can be integrated, such as behavioural theories, social
support theories and the positive psychology approach.
138
7.3
Stress and mental health problems
The last 30 years, in both epidemiological and stress research, an avalanche of studies has
appeared on the relationship between adaptation and psychopathology, and especially on
the role of stress, personality characteristics, competence factors, coping, and social support
(Cohen, 1988; Paykel & Dowlatshahi, 1988; Kessler, Price & Wortman, 1985; Neufeld, 1989;
Coyne & Downey, 1991; Martins et al. 2011; Ditzen & Heinrichs, 2014). This research
involved, for instance, the prediction of depression (Paykel, 2003; Stroud, Davila & Moyer,
2008), schizophrenia (Beards et al., 2013), panic disorder (Klauke et al., 2010) and alcohol
use (Veenstra et al., 2006), but also the mental health impact of specific stressors as sexual
abuse (Spaccarelli, 1994), work stress (Ganster & Rosen, 2013) and unemployment
(Strandh et al., 2014; Ziersch et al., 2014). These studies clearly show evidence that a
relationship exists between the experiences of severe or enduring stress and the onset of
mental disorders.
Originally, epidemiological research studied the direct relationship between the
occurrence of stressful life events and the emergence of psychiatric symptoms and
disorders, and found weak relationships. Clearly, there exists no one-to-one relationship
between stress and psychopathology. Many people who experience stressful life events
(e.g. the death of a partner, becoming unemployed) do not develop serious psychiatric
symptoms. For that reason, some psychiatrists even concluded that social stress apparently
has little to do with the development of psychopathology (Lamb, 1985). However, models
that are more complex have replaced the old, simplistic models on this relationship. These
appear to provide a better prediction and offer favourable prospects for preventive
intervention. Current stress-theoretical approaches to psychopathology have the following
characteristics:






use of a more differentiated conceptual framework;
transactional perspective;
life course perspective;
intergenerational transfer;
multifactorial approach (accumulation of multiple risk factors; moderating factors);
multisystem approach.
Overall, there exists a trend towards a more inclusive and multidimensional approach.
7.3.1 Concept differentiation
The low correlations between stress and mental disorders as found in earlier research could
be partly attributed to the sloppy and indiscriminate use of terms such as stressors,
psychological disorders, social competence and support. Today these concepts are more
differentiated and better operationalised, which has improved their predictive value. For
instance, the amount of stress someone experienced was originally measured by simply
adding the number of recent stressful life events. Currently, a distinction is made between
different types of life events. Events with certain features are more likely to increase risk of
mental disorders, or more precisely certain mental disorders. For example, take the following
life events and early stressors:
139
Experiencing a serious loss (e.g. death of parent, spouse or child, a serious
disease),
Confrontation with a serious and unexpected threat or shocking event (e.g. a
life-threatening accident or becoming a victim of violence),
Physical abuse, emotional abuse, physical neglect in early life.
Loss situations are particularly predictive for depression, traumatic experiences for both
anxiety disorders and depression, and early emotional abuse and physical neglect for adult
personality disorders, such as borderline disorder (Carr et al., 2013).
Generally speaking, a stressful event leads to a higher psychiatric risk when it:

is perceived as negative or threatening;

trigger other life events or enduring stressful situations

requires a prolonged or permanent adjustment;

has an ambiguous character, is unknown and leads to uncertainty about its impact or the right
way to react;

is unpredictable (no preparation);

evokes feelings of loss of control (powerlessness).
Risks for psychopathology are particularly high when there is an accumulation of stressors
(Appleyard et al, 2005; Rutter, 1984). That may be the case, for instance, when a stressful
event is the start of a chain of negative events (e.g. someone had a serious car accident 
becomes a disabled person  looses job  substantial decline in income  has to move for
lower rent etc.). Divorce, a serious illness, becoming unemployed and losing income are
other examples of events that may trigger an accumulation of subsequent stressors. Now
current stress research is not restricted to the study of stressful life events as was common
in the past. Modern stress research also studies the impact of chronic stress and how this
increases risk (e.g. poor working conditions, poverty, chronic conflicts in a relationship, a
parent with a chronic mental illness).
7.3.2 Transactional perspective
A second development in psychological stress research has been the transition to a
transactional approach. Typical for the transactional approach to stress is first the
importance of how stressors are perceived: How do people experience potentially stressful
situations? The interpretation of - objectively - the same stressor can vary largely depending
on differences in needs, knowledge, experience, coping skills, and perceived control.
Presenting a lecture for a large audience can be a fun challenge for some and a nightmare
for others.
Secondly, the transactional approach emphasises the dynamic relationship that
develops over time between a person and his environment. A person does not only
experience a stressor (being the passive victim) but also reacts to it, mostly with a series of
successive attempts to reduce the stress experience (coping responses). An individual or
group of persons can try to shape their environment, for instance by creating a more safe,
supportive or rewarding environment; or one that offers better opportunities for emotional
development or to get a job as a member of a minority group. The environment will respond
again to these reactions, triggering subsequent reactions of the person.
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7.3.3 Life course perspective
Well-known scientists as Arnold Sameroff, developmental psychologist, and Michael Rutter,
child psychiatrist, have taken the transactional perspective a step further by describing it
over a longer period of life. Sameroff, for instance, describes how mother and child react to
each other through a long series of problem situations and inadequate coping behaviours.
Over time, such a sequence of disturbed interactions may ultimately lead to serious cognitive
and behavioural disturbance in children (Sameroff & Fiese, 1989). On the other hand, when
problem situations between parents and children are adequately resolved and children
receive warmth and support, children will develop more resilience and hardiness. This life
course-oriented approach to adaptation has received much attention in the epidemiology
and prevention, as evidenced by the rapidly growing interest in developmental
psychopathology. (e.g. Cummings et al, 2000; Hankin & Abela, 2005; Rutter, Izard & Read,
1986; Kerig & Wener, 2005;
chapter 6). Since the 1980s, this
development and life course view
has become indispensable for
gaining insight in the aetiology of
mental
health
and
psychopathology.
We
have
included
a
developmental
dimension in our Integrated
Stress Theoretical Model (figure
7.2, and figure 7.7 in section 7.5).
Developmental epidemiology, an
integration of epidemiology and
life course research, aims to
reveal in population samples the developmental pathways that lead to psychopathology
(Kellam & Werth Amer-Larsson, 1986).
A classic example of such a long-term developmental process ending in a high risk of
psychopathology is provided by the renowned British epidemio-logist George Brown in his
studies about the impact of social risk factors on the onset of depression among low-income
women in London. Based on a range of studies, Brown and his colleagues describe a similar
trajectory of depression development in women who lost their mother early in their life
(Harris et al, 1987; Brown, 1988). The death of their mothers during childhood led to a
prolonged period of lack of care, which contributed to a negative self-image. The lack of care
increased the likelihood that girls leave home at a very young age, having a higher risk of
teenage pregnancy and marrying a person unable to develop an intimate relationship. These
marriages were not only unsatisfactory for both partners, but also increased the risk of a
sequence of new stressful events, serious relationship problems and ultimately depression.
It is especially the long-term accumulation of risk factors during the course of life and
the lack of opportunity to develop resilience that is considered responsible for the
development of mental disorders, recurrent episodes and chronicity. Knowledge on these
longitudinal processes offers insight in multiple opportunities for early professional and
network support to reduce the risk of depression onset during adolescence and adulthood.
The life course perspective is also important because it provides insight in the stages of life
141
in which risk and protective factors are beginning to develop. This information is essential for
proper timing of preventive interventions, i.e. the choice of age at which exposure to a
preventive intervention would be most effective and probably requires the lowest investment
to be successful.
7.3.4 Intergenerational transfer
The combination of a developmental and transactional perspective provides an excellent
conceptual framework to describe also the intergenerational transmission of psychological
problems and disorders. Research has found evidence for such transmission of physical and
sexual abuse (Finkelhor, 1986; Ruf-Leuschner, Roth & Schauer, 2014), serious relationship
problems and divorce (Schaap, Widenfelt & Hosman, 1991; de Graaf, 1991), and for children
of parents with psychiatric problems (van Doesum, Hosman & Riksen-Walraven, 2005;
Hosman, van Doesum & van Santfoort, 2009; chapter 16). Transgenerational transmission
might be mediated by different mechanisms. For instance, Ruf-Leuschner, Roth and
Schauer (2014) found that traumatised mothers with PTSD transmitted such symptoms to
their children, but not directly but mediated by increased violence in the family. Other studies
suggest that epigenetic processes could mediate this. Experience of early abuse and neglect
has been found to cause altered BDNF gene expression in the adult prefrontal cortex (Roth
et al, 2009). In children of depressed mothers, increased psychiatric risk in offspring is likely
mediated by poor mother-child interaction (chapter 16).
7.3.5 Multifactorial approach
Numerous studies on the relationship between stressors and psychopathology have focused
on the influence of personality traits and social support on coping with stress. A multifactorial
approach appears to explain better why some people show pathological reactions to stress
and others do not. Stressful conditions lead in particular to an increased risk of
psychopathology when there is more psychological vulnerability and low social support.
Social support turns out to perform a protecting function against the impact of stressful
experiences (buffer effect), as well as a direct positive influence on mental health (main
effect), even when stressful events are absent. A main effect indicates that social support
can directly fulfil needs, e.g. need for love, appreciation and membership of a social group.
Veltman et al. (1991) and Coyne and Downey (1991) studied the interaction between
these variables for depression. Regarding the influence of individual adaptation and social
support, the risk of depression appears to be greater in subjects with:









A low level of fun activities;
Low self-esteem and low self-confidence;
Depressive attributions and cognitive thinking errors (irrational thoughts);
A strong tendency to dogmatic thinking;
Less cognitive problem-solving skills;
Strong feelings of helplessness (external control) and a tendency to passive responses and
ineffective avoidance behaviour;
Little ability for self-reward;
Low social skills;
Low perceived social support, in particular from an intimate partner.
The studies by Brown (1988) among women with low SES to which we referred above
illustrate this. In his prospective studies, he examined the effect of a combination of some of
142
these factors. In the group of women with severe life events, low social skills and low social
support, 63% developed a depression within one year, opposed to only 2% of the women in
the control group of women not exposed to these risk factors (Brown, 1988).
7.3.6 Multisystem and multi-level approach
In different ways, individuals are for their health highly dependent on social systems in their
environment. These systems are present at micro, meso and macro level, as is elaborated in
the social systems theories and the social-ecological theory of Bronfenbrenner (section 9.1.2
in chapter 9). We have illustrated this in the figures 7.3 and 7.4. From our own daily
experiences, this is evident for the impact of the family, school, neighbourhood, health
services, work places and the local government of a city or village. At a higher system level,
this applies to, for instance, media, commercial food chains, labour unions, social benefit
systems, justice system, national governments and even to multinational organisations (e.g.
Apple or Samsung, Shell, European
Union, United Nations, WHO). For
efforts to promote mental health
and prevent mental disorders, we
need also to understand what role
they play in the onset, maintenance
or prevention of risk factors, or in
the opportunities to develop
emotional resilience and protective
factors in our social environment
and ourselves.
From social system theory,
we can learn two relevant principles
on how systems function. The first
is that in systems at different levels
similar internal dynamic processes
exist. At each system level, we can
define factors such as stressors,
competence and support. This
applies not only to ourselves as
individuals (psychological stress
theories), but also to families,
schools, companies and communities. Secondly, social systems
theory also is about how different
systems relate to each other. This
can be at a same systems level
(e.g. between individuals, between social networks, between organisations), but also
between system levels (e.g. relations between student, family, and school system). Systems
can have different functions and impacts on other systems. They can function as sources of
stress, restriction or even suppression, but also as systems that protect against harmful
social or environmental conditions, that facilitate opportunities for emotional and competence
development, or that offer social, emotional, informational or technical support to other
143
systems who have to deal with stress or other challenges. Therefore, such higher-level
systems should also be targets of health promotion and prevention actions. A common
mistake in prevention is to define risk and protective factors for mental health only on
individual or micro level, and not recognising that powerful risk and protective factors are
anchored in meso and macro systems and also should be targeted at those levels.
7.4
Transactional Model of Stress and Coping
Richard Lazarus introduced his appraisal model of stress and coping as an approach to
understand human adaptation and as a transactional theory (Lazarus, 1966, 1991; Lazarus
& Cohen, 1977; Lazarus & Folkman, 1986; Cohen 1984). He explicitly has included in his
model: coping with stressful events is seen as a process of person-environment transactions
that are firstly mediated by a person’s appraisal of the stressor. When faced with a stressor,
a person evaluates the potential threat (primary appraisal). He makes a judgment about the
significance of that event as stressful, positive, controllable, challenging or irrelevant in
relation to his needs. Next, a secondary appraisal follows, which is an assessment of
possible coping resources and options (Cohen, 1984). In other words, what can one do
about the situation? Moreover, an assessment is made of the expected effectiveness of the
various coping options in order to make the best choice. Primary and secondary appraisals
influence each other and jointly determine the degree of stress, the emotional response and
finally the coping response. According to Lazarus, both appraisal processes and the coping
responses have an impact on the person’s physical, psychological and social wellbeing.
Appraisals and coping responses are assumed to be moderated by perceived personal,
social and cultural resources. Lazarus defines coping as: "Constantly changing cognitive and
behavioural efforts to manage specific external and/or internal demands that are appraised
as taxing or exceeding the resources of the person" (Lazarus et al., 1984, p. 141).
Depending on the level of difficulty of the stress situation and the strength of the
available resources, coping can be a simple or a complex process. Multiple parallel coping
responses might be needed, and coping responses can change over time when previous
coping trials appear to be unsuccessful. Dealing with a problematic situation means in many
cases that not just one but many coping responses are needed to solve the problem. For
instance, solving the problem of being regularly bullied or adapting to the loss of a partner
requires not just one coping act but a combination of coping responses. Such coping
responses can be aimed either at regulating negative emotions, or on trying to solve the
stressful situation (active coping).
7.4.1 Limitations
The transactional model of stress and coping also has several limitations. The model does
not pay attention to a specification of ’goals and needs’ that are assumed to provide a
reference criterion against which a situation is appraised as stressful or not. One way to
cope with a stressful situation is to adapt one’s goals and acquired needs. For example, a
patient with severe arthritis can try to accept that previous activities (e.g. sports, walking,
being pain free) are no longer possible. This acceptance and adaptation of goals could result
in less stress. In addition, we should recognise that stressors might be balanced by
compensating positive circumstances. When stressors are present, the emotional balance
144
can persist if a person experiences compensating positive circumstances. A coping strategy
could be to actively create such compensating experiences in the case a stressor cannot be
avoided or reduced.
The theory of Lazarus also lacks an intergenerational and life course perspective that
explains the relationship between current coping techniques, previous coping and even
coping histories. As we have discussed, in developmental psychopathology this dimension
plays a major role in the development of competence and resilience of a person, or of his
psychological vulnerability in severe stress situations. In this context, it is also important that
a theoretical model is able to describe the long-term process of subsequent coping
responses that a person applies to end his problem, and the feedback processes on the
effects of past successful or unsuccessful coping attempts (feedback loops).
Finally, Lazarus' theory is a psychological theory, and pays little attention to factors at
the meso- and macro level that are often responsible for stressors and coping resources as
well (figures 7.3 and 7.4). As these higher-level factors could also provide a target for health
promotion and prevention interventions, we consider it as essential to include also a systems
level dimension in a stress-theoretical model.
7.5
Integrated Stress Theoretical Model
Based on the limitations described above, Hosman designed a multidimensional stress
theoretical model (Hosman, 1988; Bosma & Hosman, 1990) which has been used as a
theoretical basis in many Dutch prevention programmes. This model aims to combine
several theoretical approaches, such as:








Caplan and Lindemann’s crisis theory
Cognitive coping and stress theory (Lazarus)
Behavioural approach (e.g. Health Belief Model, Theory of Planned Behaviour)
Theories about the role of social support and social networks
Developmental psychopathology approach
Social-ecological and social systems theories (e.g. Bronfenbrenner)
Public health models
A social critical approach
As it aims to combine and integrate different theoretical approaches, it is called the
integrated stress theoretical model, abbreviated as ISTM (figure 7.5).
The core of this IS-model is a staged appraisal process of stress and coping, based on
Lazarus’ cognitive theory (Lazarus & Launier, 1978) and Caplan’s crisis theory. Inspired on
the transactional model several stages are distinguished between the onset of a stressor
and the final coping reaction. The process of primary and secondary appraisal has been
extended to six stages:
1) The appearance of a stressor
This can be caused by the environment (e.g. unemployment, illness, relationship problems),
but also by the person himself (e.g. because of risk behaviour like alcohol abuse).
2) Observation, interpretation and evaluation of the stressor
145
The person perceives the stressor or at least its threat. This perception can be accurate or
biased. The person interprets to what extent this stressor is a barrier for the realisation of
important goals or needs, and whether coping with this stressor will be easy or not given the
competences and social support the person has. This includes an evaluation of the causes
of the presence of the stressor (causal attribution).
3) Problem awareness and crisis
When the contrast between stressor and needs or goals is perceived as low to moderate
and solvable, a person feels triggered to select a suitable response and to act likewise. This
could be the case, for instance, in responding to daily hassles. When the contrast is seen as
large and important (serious obstacle or threat), and solving it as possibly transcending
one’s resources, the person becomes aware that there exists a serious problem. According
to Caplan, this state is labelled as a ’crisis situation’. It leads to an emotional and
physiological alarm that might challenge the person to make extra effort in solving the
problem or protect oneself somehow by another strategy (e.g. via denial). When the
emotional alarm is extreme, it might even lead to a freeze of his cognitive functioning or a
feeling of complete helplessness.
4) Preparation of a coping reaction
This refers to the conscious and rational process or an unconscious process of selecting a
coping (problem-solving) response. Coping theories identify many types of coping
responses. Overall, these can be divided into:



active problem solving,
palliative reactions: coping aimed at reducing the stress feelings
(e.g. repression by medication, alcohol, drugs, relaxation),
do nothing and wait.
To this stage, we could apply cognitive behavioural models and models of preventive
behaviours (e.g. Health Belief Model, Theory of Planned Behaviour, chapter 5). Depending
146
on the nature and seriousness of the perceived problem, a coping response is selected from
one’s reservoir of available problem-solving abilities and strategies (competence) or from the
perceived options for social support in solving the problem or crisis. In terms of the ISTM,
coping reactions may target at reducing or avoiding the stressor, changing one’s problem
appraisal, adapting one’s needs, investing in increasing competence or appealing for
support from one’s network. In Chapter 13 on interventions, an overview is presented of
optional preventive strategies that are grounded in the Integrated Stress Theoretical Model
(Box 13.3). For an insight in the different options for social support, see chapter 9.
5) Implementation of the coping response
Actually executing the response may apply to active or passive coping reactions, asking
support, negotiating, preventive behaviour, illness behaviour, acting out, excessive alcohol
use, anxiety reactions, delinquent behaviour, suicidal behaviour etc.
6) Consequences of coping reaction and feedback
The consequences of coping behaviour will be determined by the extent to which it
contributes to a reduction of the experienced problem or its emotional burden. In the ISTM,
the effects of the coping reaction can also be assessed to the extent in which they contribute
to the improvement of competence, adaptation of goals, satisfaction of needs, reduction of
stressors or improvement of social support. In the model, this is indicated by the effect and
feedback lines. Problem reactions can also be ineffective or even aggravate the problem,
e.g. through excessive alcohol use or acting out behaviour.
Coping effects and perceived feedback are not only determined by the nature and
power of the coping efforts, but also by the environment. For instance, people in your
network might disapprove new coping reactions. Out of self-interest, they might even give
distorted feedback to the enacted problem solving behaviour and its impact.
Each of these six stages could be selected as target for preventive intervention. This could
start with measures to reduce the onset or exposure to stressors (e.g. child abuse, bullying,
war traumas), but could also consist in supporting people to analyse a problem situation, to
lower a paralysing feeling of crisis, to offer help in finding the best coping response, or get a
selected coping response effectively implemented.
Moderating factors
The ISTM differentiates between four clusters of variables that can moderate what happens
in the six stages of the stress and coping process, and influence the outcomes of this
process: (1) Compensating circumstances or alternatives for need satisfaction, (2) Goals,
values and needs, (3) Competencies, or problem solving capacities, (4) Social support and
social networks.
Compensating circumstances. Stressors, especially when they are difficult or impossible to change
(e.g. chronic illness, death of a partner, losses caused by being a refugee), could be compensated
by positive experiences. This could prevent a feeling of crisis, may make a loss more acceptable,
or could generate new energy to solve problems and focus at other goals in life. In some cases, it
could be as simple as having a nice evening with a friend, concentrating on a hobby or taking a
vacation. Several aid organisations such as War Child, Red Cross and UNICEF use this strategy
to help severe chronically ill, refugees and war children to create positive experiences that could
147
balance the sequelae of traumatic experiences or severe restrictions caused by an illness or
handicap.
Goals, values and needs. The appraisal of potentially stressful situations is influenced by the
degree of threat a person experiences from this situation for the satisfaction of important needs, or
for meeting central values or goals in one’s life. An objectively identical situation could be stressful
or not depending on your needs or standards. Maslow’s hierarchy of needs could be used to
estimate the kind of needs that are at stake and their relative importance. This cluster also
includes central belief systems that could help to interpret a stressful situation. For instance, many
people take comfort in religious beliefs when they face the death of a loved one, or those who
have a Buddhist view of life might consider losses or situational constraints as part of life and less
frightening. Reflecting on your values, needs and goals as a person in stress or reflecting on those
of a target group might help to better appraise the situation, might offer opportunities to adapt
values of goals to make the situation more stressful, or to find other ways to reach them
surpassing the existence the identified stressor.
Competencies. These refer to the biological, cognitive, emotional and social capacities that a
person has available in himself or herself to use for understanding problem situations and for
dealing effectively with stressors or important challenges. They could be innate or acquired
through experiences and learning. We could consider them as the ‘strengths’ of a person and they
constitute the core features of mental health, as we have discussed in Chapter 3. Evaluated as
strengths they represent protective factors in the presence of stressors. In mental health
promotion, they refer to the concept of personal empowerment. One of the reasons people could
fail in coping with life stressors are some weaknesses or even defects in their capacities, besides
existing strengths. This is often the case in psychiatric patients, but also in children or adults at risk
due to the exposure to early stress and neglect during pregnancy, infancy or early childhood. We
have defined such weaknesses in chapter 3 as internal risk factors.
Biological capacities and features refer to genetic factors or to neurobiological features that
are acquired through environmental and maternal influences during pregnancy and the early years
of life and childhood when the brain is still developing. These could include, for instance,
temperamental features such as positive affectivity, optimism, activity level, stress reactivity,
neuroticism, self-control and impulsiveness. It is likely that such personality features could be
influenced by mental health promotion and prevention programmes that target pregnancy
conditions, parenting competence and domestic violence.
Cognitive capacities could include analytic skills, creativity, information processing,
perspective taking, cognitive problem solving skills, critical thinking and the availability of
knowledge about relevant problems and solutions. For instance, for children of mentally ill parents
it is considered crucial for their emotional development that they have some understanding of their
parent’s illness. This prevents that they start to blame themselves for the problems of their parents,
and develop feelings of guilt and negative self-esteem. Emotional capacities refer, for instance, to
self- esteem and self-confidence, emotion regulation and stress management skills, and the ability
to delay gratifications. Social skills include assertiveness, showing empathy, negotiation skills,
successfully asking for social support and the ability to accept offers for social support. Increasing
these capacities in children and adolescents is the aim of social-emotional learning programmes
(SEL). Many evidence-based SEL-programmes can be found in international and national
databases of effective intervention programmes, such as the one of the Collaborative for
Academic, Social and Emotional Learning (CASEL, www.casel.org) or national databases for
youth intervention programmes (e.g. http://www.nji.nl/nl/ Databanken/ Databank-EffectieveJeugdinterventies).
148
Social support and social network. We will be short here on this cluster as chapter 9 is completely
devoted to this issue. In that chapter we will discuss different types of social networks at microlevel but also at higher system-levels that could be involved in the process of solving problems,
preventing stressors or increasing a person’s competence. Different types and functions of social
support are discussed, and a differentiation is made between social support and social networks,
as they are actually present in the environment of the person, and what is perceived and valued by
a person as support. It might be that a person is unaware of and/or has no access to available
support systems, or he might consider an offered support as not effective or not sufficiently
sensitive to the culture of his or her social group. In chapter 9, we also discuss the different types
of preventive strategies that could be used to strengthen social networks and social support.
Multiple system dimension
In its core, the ISTM is a micro model, which means a social psychological model about
individual factors and micro-social factors in the direct environment of a person. However,
the model assumes that these factors are also the result of the interaction with the mesolevel (e.g. school, company, and neighbourhood) and forces at the macro level (e.g.
ideologies, cultural norms and values, legislation, economy). For this reason, we have added
a system-level dimension to the ISTM (figure 7.6). Influencing factors at the micro level can
also be achieved through interventions aimed at risk and protective factors and support
systems at meso and macro level. At meso- and macro, we could identify different settings
and networks that can be addressed in mental health promotion and prevention programmes
and policies. For more information on this dimension, we refer back to section 7.3.6.
Developmental dimension
The ISTM is designed as a transactional and dynamic model, which means that is has a
developmental dimension and includes a feedback system (figures 7.7 and 7.5). The model
has actually two developmental dimensions, namely to the development of a person and his
competencies across the life span, and the stages of the development of a problem.
149
The developmental dimension applies in the first place to the developmental process of a
person along his lifespan, starting from pregnancy and infancy, until adulthood and old age.
Secondly, at micro-level it could also be applied to the developmental process of a problem,
which includes subsequently a situation or phase of no risk, increased or high risk, beginning
problems and symptoms, onset of serious problems and disorders, recurrent episodes and
chronicity, and the phase of recovery or return to a healthy situation. Preventive
interventions can be targeted at each of these phases, as we will discuss in section 13.9 on
‘making choices of the strategic dimension ‘Time and Timing’ (chapter 13).
The developmental dimension of the ISTM does not only apply to micro-level but also to
higher systems levels. To promote mental health effectively, we should not only be informed
about the developmental processes of a person and how risk and protective factors and
trajectories influence this process along the life span. We also need to understand how risk
and protective factors and support systems at higher system levels develop over time and
how we could influence them timely in order to empower them and to create mental health
promoting life conditions. For instance, this is the issue in the community approach of mental
health promotion and prevention (chapter 10). Currently, many developments and changes
are ongoing in communities and health systems because of new health and social policies
that aim to reduce the role of expensive, specialised health services and to enhance the role
of community self-care and local social support systems. Health promoters and prevention
professionals are challenged to play a proactive role in these developments and to increase
the mental health promoting capacities of such local systems. Likewise, do the fast
developments in social media, internet and local mass media offer opportunities timely
strengthen their role in supporting the development of mental and social capital in local
populations.
150
7.6
Conclusions
The ISTM offers a broad frame of reference for mental health promotion and prevention in
which different types of theories can be integrated. In the stress model, cognitive behavioural
theories can be used in the process of preparation of coping behaviour. Social support and
social network theories can be used as an elaboration of the social support factor. Theories
on risk perception, attributional theories and social comparison theories can be used to
define the interactions between stressors, their perception and interpretation, and
subsequent emotional reactions. Theories on social determinants (e.g. the influence of the
media, poverty, unemployment, prejudice) relate to the model by explaining how a person
experiences stress because of these social factors, but also how social determinants might
influence the exposure to stressors, shape values and goals in life through prevailing
ideologies, and how they could facilitate or block the development of individual competence
and resilience, and opportunities for social support. The recent appeals by WHO to also
address social determinants of mental health and not just individual or micro-social
determinants, challenge us to include also social criticism to the way our society deals with
mental capital, just as we do this in the domain of environmental protection and health
(WHO, 2008, 2010, 2013). This is not an issue of advocating just for mental health, but also
of learning to understand how mental capital is a cornerstone for good citizenship, social
development, public safety and economic development. Further research, reflection and
critical debate is needed to extend our knowledge about the interplay of genetic,
neurobiological, cognitive-emotional, social and macro-structural factors in shaping mental
health.
As we will discuss in the next chapters, for health promoters, prevention
professionals, health professionals, policymakers, community organisations, companies and
other stakeholders there exist many strategic opportunities in this dynamic system to
contribute to better conditions for mental health and well-being in individual citizens, groups
at risk and whole populations.
151
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Study questions for this chapter

What are the main features of the modern stress-theoretical approaches to
psychopathology?

Which theories were used as basis for the integrated stress theoretical model?

What is the authors view about the relation between individual and social adaptation?

What dimensions are distinguished in the Integrated Stress Model?

Which clusters of factors are distinguished in the model?

What is the significance of these clusters and dimensions for the design of preventive
interventions?

What is meant with a transactional approach?

What kind of theories described in other chapters could easily be integrated into the
transactional model of stress and coping? Explain where and how?

How do the stress-theoretical models in this chapter differ from the behavioural
models that have been discussed in chapter 5?

What characteristics of stressful life events lead to a higher risk for mental disorders?

Which stages of stress development and coping do the ISTM and the transactional
stress model use?

How is the ISTM related to the idea of developmental psychopathology?

What stand does the author take in relation to social determinants of mental health?

What kind of prevention strategies could be derived from the ISTM?
154
8
Positive psychology approach
8.1 Introduction
156
8.2 Principles and concepts of positive psychology
157
8.3 Measuring positive mental health
159
8.4 Interventions enhancing positive mental health
160
8.5 Conclusions
161
Literature
162
Study questions for this chapter
164
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8
8.1
Positive psychology approach
Introduction
Prevention of mental disorders is criticised for its negative approach of people, by primarily
targeting illnesses and problems, and by aiming to repair weaknesses, defects and risk
behaviours. Although many prevention programmes in practice also target competencies
and strengths of people at risk, the ultimate intention is to counter risk factors and to prevent
disease and problems. This criticism goes back to the longstanding debate on the ‘medical
model’ versus the ‘positive model’ of mental health (chapter 3).
George Albee, one of the founders of modern primary prevention in the domain of
mental health advocated his whole life against the dominating illness approach and in favour
of a focus at people’s competences and strengths. “A Competence Model Must Replace the
Defect Model’ was the title of his address at the start of the Fourth Vermont Conference on
Primary Prevention of Psychopathology in 1980 (Albee, 1980). Albee stated that the
incidence of emotional problems and ‘pathological’ behaviour is not just the outcome of a
combination of stress and organic causes, but the imbalance between these risk factors and
people’s competence, coping skills, self-esteem and support systems. He strongly pleads for
a shift to a competence model: building human competence and promoting social
environments early in life and in schools were children and adolescents can fully develop
their cognitive and emotional strengths and their potential to cope with the hazards of life.
This competence model is reflected in both the positive model and the functional model of
mental health we have discussed in chapter 3.
The competence model got support from the work of leading developmental
psychologists such as Norman Garmezy, a pioneer in the study of emotional resilience. A
core question was: How could we explain that many children do not develop psychiatric
disturbances while exposed to serious stressors and traumas? What could we learn about
their strengths and how can we in general encourage children to develop such strengths? It
is interesting is that Cicchetti, Rolf and Masten, founders of developmental psychopathology,
were all students of Garmezy. The competence approach became an integral part of the
developmental psychopathology framework that emerged during the 1980s (chapter 6; and
Development and Psychopathology journal). In the work of Albee, Garmezy and the
developmental psychopathologists, competence and resilience are primarily valued as a
protective factor, human strengths that protect children and adults against the negative
impact of risk factors. Resilience refers to positive adaptation in the context of adversity and
risk. With the same functional meaning, a competence factor is also integrated in stress
theories where individual competence serves as a buffer against the impact of stressors and
as a container of capacities that can be utilised to cope with stressful situations or to achieve
important goals in life (chapter 7). In his crisis and stress theory, Gerald Caplan (1964)
emphasised that competence is not just a protective factor that could prevent mental
disorders when people are faced with significant risk factors, but that using one’s
competence and being able to cope successfully with stressors and challenges of life also
contribute to the strengthening of mental health. Likewise, modern developmental
156
psychopathology is not restricted to the study of developmental trajectories of mental
disorders, but includes also studies on the development of positive mental health capacities,
as is evidenced by the type of articles published in the peer-reviewed journal Development
and Psychopathology.
During the 1990s and short after 2000 several psychologists, such as Diener, Ryff,
Seligman and Keyes, started to advocate for an orientation of psychology on happiness,
well-being, meaningful life and human flourishing. Martin Seligman (photo), known for his
earlier work on learned helplessness and depression, became internationally the strongest
advocate for this fundamental change in psychology, and extended his criticism to the field
of prevention of psychopathology. He initiated the
concepts of positive psychology, positive
education, positive prevention and positive
therapy (Seligman & Csikszentmihalyi, 2000;
Seligman, 2002; Seligman, Ernst, Gilham et al.,
2012). For most of its existence, psychology,
especially clinical psychology, was targeted at
human suffering, stress, understanding the causes
of pathology, and treating mental illnesses. Positive
psychology does not deny the need to support
people who suffer from mental disorders and serious
mental problems. A psychology, however, that is
mainly driven by a negative approach to mental health is considered by positive
psychologists as science that has lost contact with the positive emotions, motivations and
psychological strengths of people that constitute their daily well-being and happiness. These
strengths empower them to develop themselves, to relate with others, to shape their
environment and to achieve important goals in life. Positive psychology aims to supplement
what is known about human suffering, weakness, and disorder with knowledge about
positive development (Seligman, Steen, Park, & Peterson, 2005).
Increase in well-being is found to produce better learning. Positive emotions broaden
the array of attention, thoughts and behaviour, stimulate more flexible, creative and holistic
thinking, and contribute to social compassion, and the building of sustainable psychological
resources and social support (Seligman et al., 2012; Fredrickson, 2001). These processes
are explicitly described in the ‘Broaden-and-Build’ theory of Barbara Fredrickson and
supported by a long range of experimental studies (Fredrickson, 2013). In conclusion, she
states “when people learn to self-generate more frequent positive emotions—either through
meditation or through more elemental shifts in their attention—they launch themselves onto
positive trajectories of growth”. (p. 32).
8.2.
Principles and concepts of positive psychology
Positive psychology aims to study and promote human happiness, well-being, human
strengths, the flourishing of people and building competence. These features are not only
important because they buffer against mental illness, but also because they represent core
human values in itself and contribute to a wide range of positive outcomes in life, such as
school success, intimate relationships, productivity and good citizenship. The mission of
157
positive psychology is to understand and foster the factors that allow individuals,
communities, and societies to thrive (Kobau et al., 2011). For this reason, theories and
research of positive psychology offer a crucial scientific base for efforts to promote mental
health and well-being.
Well-being and flourishing are core concepts of positive psychology. Well-being can be
subdivided into three components: emotional well-being, psychological well-being and social
wellbeing (Keyes, 2005; Bohlmeijer, Westerhof, Bolier et al, 2013). Emotional well-being
refers to the presence of positive feelings, the absence of negative feelings and satisfaction
about life. A meta-analysis by Lamers, Bolier, et al. (2012) showed that emotional well-being
has a positive effect on recovery and survival of people who suffer from physical diseases.
Psychological well-being concerns the ability for self-realisation and personal growth, and
related positive self-images. Social well-being refers to the evaluation of positive functioning
in social life and one’s society, feeling connected and valued by others.
The term ‘flourishing’ refers to optimal well-being and positive psychology scholars
mostly define the term by summarising its main dimensions. In his book Flourishing (2011),
Seligman described the meaning of flourishing through his PERMA model, in which he
differentiates five essential elements that should be in place for people to experience lasting
well-being:
1.
2.
3.
4.
5.
Positive emotions (P): happiness, joy, love, hope, inspiration, gratitude, curiosity etc.
Engagement (E): using your strengths to meet challenges, getting in a state of flow
Positive relationships (R): connecting with others, intimate relationships,
Meaning (M): meaning in life, finding your purpose
Accomplishment (A): pursue and accomplish goals
These features are grounded in positive individual traits (e.g. optimism, creativity,
attachment, resilience, kindness, perseverance). As experimental and longitudinal studies
have shown, resilient people experience more positive emotions, and positive emotions
broaden people’s attention and curiosity, and enhance successful outcomes in work, social
relationships and health (Kobau et al., 2011).
Positive emotions, positive traits and subjective well-being are considered partly as
heritable, but also as acquired through learning experiences in family life and through
supportive and stimulating environments in schools and workplaces. Outcomes of many
controlled evaluation studies have shown that subjective well-being and positive functioning
can be learned and effectively taught in schools (Seligman et al., 2012; see also 8.4).
The dimensionality of well-being and positive mental health is much under debate.
The number of identified dimensions in research varies from 2 to 7 (Kafka & Kozma, 2001).
For instance, Ryff (1989) distinguished six dimensions of psychological well-being: Selfacceptance, Positive relations, Autonomy, Environmental mastery, Purpose in life, and
Personal growth. Forty years earlier, based on her study Marie Jahoda also defined six
dimensions of positive mental health (chapter 3), but only four of them overlap with those of
Ryff. The PERMA model of Seligman includes ‘positive emotions’ and ‘engagement’ that
are not covered by Jahoda or Ryff. In addition, outcomes of factor analytic studies have
raised questions about the independence of factors that are differentiated on theoretical
grounds. They show that factors share common underlying dimensions (e.g. van
Dierendonck et al. 2008). More research and scientific debate is needed to understand
better the differences, overlap and relationships between the many dimensions that are
158
differentiated in the literature. More unity would be welcome in this labyrinth of concepts
and dimensions.
8.3
Measuring positive mental health
Those who advocated for positive mental health and positive psychology were criticised for
using vague and poorly defined concepts. This would make it difficult to study such concepts
scientifically, measure them and to test the effectiveness of interventions aimed to promote
positive mental health. In response, positive psychologists have invested in developing valid
instruments to measure positive mental health and well-being, and their building stones. We
give some examples:
Scales of Psychological Well-being (SPWB), developed by Ryff (1989) to measure the six
dimensions of well-being that were mentioned in the preceding section.
Social Well-being Scales (Keyes, 1998) differentiates between 5 dimensions of social-wellbeing: social integration, social contribution, social coherence, social actualisation and
social acceptance. Keyes’ study supports the construct validity of these dimensions.
Values in Action Inventory of Strengths (VIA-IS), developed by Peterson and Seligman
(2004) measures character strengths as the core of positive mental health. This self-report
questionnaire is completed by over one million individuals in more than 200 nations, and
was found to have an acceptable validity and reliability. It is currently available for public
use. The VIA-IS has also been adapted and validated for use among adolescents (VIAYouth; Park & Peterson, 2006).
Oxford Happiness Questionnaire (OHQ, 29 items; Argyle, Martin, & Crossland, 1989; Hills
& Argyle, 2002), found to be a one-dimensional scale with good validity and high reliability.
Of this scale, a short version is made of 8 Likert items that predict with 90% accuracy the
scores on the full scale.
Satisfaction With Life Scale (SWLS; Diener, Emmons, Larsen, & Griffin, 1985) is a onedimensional instrument of 5 items, measuring global life satisfaction, the cognitive
component of psychological well-being. The instrument is translated and validated in many
languages.
Mental Health Continuum-Short Form (MHC-SF); a 14-item self-report questionnaire for
measuring emotional, social, and psychological well-being. The MHC-SF is found to be a
reliable and valid instrument to measure positive aspects of mental health (Lamers, Glas,
Westerhof & Bohlmeijer, 2012).
The Warwick- Edinburgh Mental Well-Being Scale (WEMWBS), a one-dimensional scale
composed of 14 positively formulated Likert items, was developed in the United Kingdom
showing good face validity and reliability (Tennant, Hiller, Fishwick et al., 2007). Both
hedonic and eudaimonic dimensions of mental well-being focused on the positive aspects
of mental health including affective–emotional aspects, cognitive–evaluative dimensions,
and psychological functioning. The scale is also translated and used in several other
languages (e.g. Spanish, Chinese). A randomised waiting-list controlled study showed that
participants in an internet-based mental health promotion programme (1529 participants;
1561 controls) showed after 6 and 12 weeks significant better results on the WEMWBS.
159
The intervention (MoodGYM) consisted of 5 interactive modules that teach participants
cognitive-behavioural principles (Powel, Hamborg, Stallard et al., 2013).
Besides well-being questionnaires for use in the general population, there are also tests
specifically designed to measure well-being and quality-of-life in specific groups such as
pregnant women (see review by Morrell, Cantrell, Evans et al., 2013). In addition, more
traditional measuring instruments of psychological features could be used to measure
aspects of positive mental health, such as measurements of self-esteem, social
competence, problem solving skills, creativity, self-efficacy, feelings of mastery and
emotional intelligence. For public access to available instruments that measure positive
mental health or aspects of it, we refer to the website of the Questionnaire Center of Penn
State University (www.authentichappiness.sas.upenn.edu/testcenter).
8.4
Interventions enhancing positive mental health
The views, values, and theoretical model of positive psychology have been translated to
different types of positive interventions that are implemented in home and preschool
settings, schools, health services, and in sport and work settings all over the world. These
include, for instance, parenting programmes and school-based social-emotional learning
(SEL) programmes. Of the parenting programmes, Triple P (Positive Parenting Program) is a
well-known example and is implemented in 25 countries around the world. The programme
got worldwide recognition by the United Nations. Although some doubts exist about the rigor
of some outcome studies, systematic reviews and a meta-analysis across several dozens of
controlled studies show that the Triple P programme has generated a wide spectrum of
positive effects, such as more effective parenting, better well-being and marital relationships
in parents, less parental depression and child abuse, and fewer child behavioural and
physical problems (Prinz, Sanders, Shapiro, Whitaker, & Lutzker, 2009; de Graaf, Speetjens,
Smit, de Wolff, & Tavecchio, 2008).
Positive school programmes are also known under the term Social-Emotional
Learning (SEL). Access to evidence-based SEL-programmes and the advocacy for their
evaluation, dissemination and implementation is provided by the Collaborative for Academic,
Social, and Emotional Learning (CASEL; www. Casel.org). This website offers numerous
descriptions of school-based programmes that meet the principles of positive psychology. It
also contains many reviews of the scientific knowledge on which these programmes are
based and on the evidence of their effectiveness. For instance, the Penn Resilience
Program (PRP) is one of the most known SEL programmes for children between 7 and 15
years and is offered as an after-school programme to enhance learned optimism. Several
controlled studies have shown that this programme increases optimism in youngsters, and
reduces depression, anxiety and behavioural problems (Gillham et al., 2012; Brunwasser &
Gilham, 2008; Seligman et al., 2009). PRP aims to enhance more optimistic explanatory
styles in children and youngsters by stimulating positive thinking, detecting inaccurate
thoughts and learning to challenge negative beliefs. The programme has been adopted and
implemented in many countries around the world, such as United States, United Kingdom,
The Netherlands, Portugal, China and Australia. Internet is used to offer such exercises and
training to large groups of children, adolescents and adults.
160
In Australia, the positive psychology principles were also successfully translated to a
whole school positive education programme (Seligman et al., 2009). To reach the population
at large with positive psychology, the challenge is to make this mental health promotion
approach an integral part of national and local public health policies (Kobau, Seligman &
Peterson et al., 2011). Positive interventions cannot only be offered in settings such as
schools, but also in health care settings, workplaces and through the internet. This requires
staff training and guidance to institutions to help them to provide a mental health-promoting
environment to children, adolescents and adults. Other effective positive psychology
interventions include mindfulness training (Regehr, Glancy & Pitts, 2013; Zoogman,
Goldberg, Hoyt & Miller, 2014), gratitude exercises, daily monitoring good things in life, and
identifying character strength and practice using them in a new and different way (Seligman,
Steen, Park & Peterson, 2005).
Also for positive psychology interventions in organisations, there exists growing
evidence for their efficacy in improving well-being and performance among employees, and
a tendency to less burnout and depression, as was found in a systematic review of 14
controlled intervention studies (Meyers, van Woerkom & Bakker, 2013).
8.5
Conclusions and Discussion
Positive psychology represents a valuable and useful theoretical framework to ground
interventions aiming to improve mental health across the lifespan. The outcome research
that we reviewed supports the assumption that mental well-being of people can be improved
by positive psychology interventions in diverse settings such as for instance preschool
settings, schools and workplaces. According to the functional model of mental health that we
described in chapter 3, these studies suggest that such interventions increase competence
and well-being, and have the potential to prevent mental suffering and disorders, such as
severe stress, depression, anxiety and burnout.
Although the available evidence is promising, it needs further expansion in different
ways. First, more controlled outcomes studies in different countries are needed to be able to
draw strong conclusions about the robustness of the effects and to prove that positive
psychology interventions can work in different populations and cultures. The evidence-base
for positive psychology programmes and for “what works and why?” is still limited. Secondly,
the range of psychological, health, social and economic outcome indicators in such studies
need to be expanded, in order to provide more insight in the full range of possible benefits
that these interventions could provide for different stakeholders in society. Thirdly, the
available knowledge on their effects is still mainly restricted to short term outcomes. As
positive psychology interventions might be successful in improving sustainable features (e.g.
positive thinking, problem solving skills, self-efficacy, social competence), it is likely that they
might generate long-term effects. Due to the recency of this field, such longitudinal positive
psychology studies hardly exist yet. We may use examples from some long-term outcome
studies of competence-enhancing programmes for young children that have been executed
from the 1980s on. Finally, studies on positive psychology interventions have mainly
addressed the research question “Effective or not?” and “Are effects sustainable across 3 to
6 months after the intervention?” To our knowledge, the insight in programme features,
participant characteristics or external conditions that have influence on the level of
161
effectiveness, is still very marginal. Such knowledge is important as so far available main
effect sizes of these programmes show only small to moderate effects. In addition,
programmes vary in efficacy; some did not show aimed effects. Knowledge on effect
moderators is needed to improve programmes, the quality of implementation and
implementation conditions.
The current positive psychology programmes are mainly person-oriented, which
means that they provide educational interventions that directly address target persons in
whom they want to strengthen positive mental health. To broaden the opportunities for
improving mental well-being in large segments of the population, the positive psychology
approach should be expanded in two ways. The first is to develop more knowledge on how
positive psychology principles and interventions can be deeply anchored in communities,
non-profit organisations, companies, public and private policies, justice and international
educational programmes. The second way is to also address social risk factors that raise
barriers for the normal development of positive mental health. This especially concerns the
conditions that impede the development of positive psychological capacities early in life and
during childhood, such as enduring stress in pregnant mothers, prenatal alcohol use, child
abuse and neglect, domestic violence, lack of emotional learning in schools, bullying,
poverty, traumatic war events, refugee status, and childhood experiences of being
discriminated or bullied.
Creating mental health impact in a population requires not only effective interventions
but also large-scale implementation and public reach. Promising in this respect is that
positive psychology is not just a new academic branch of science. It represents a way of
thinking that seems to appeal to many citizens, organisations, private companies and
governments around the world. Its positive philosophy has the potential to generate a social
movement or trend with a large public reach, which was never the case with efforts to
prevent mental disorders.
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Videos/Youtube: Students are invited to look at Youtube films with presentations by Martin Seligman:
http://www.youtube.com/watch?v=zKqVy1OUI8E
Lecture of Martin Seligman about well-being and public policy (2011)
http://www.youtube.com/watch?v=weVPtrXMMx8&feature=related
Lecture of Martin Seligman about positive psychology, well-being and flourishing (2011)
http://www.youtube.com/watch?v=oSx_RxJjjMk&feature=related
Interview with Martin Seligman (2010)
Study questions for this chapter

In what way are positive psychology, developmental psychology and the integrated
stress model related with each other?

What are the main goals and targets of positive psychology? Are these goals
measurable?

What kinds of components are differentiated within the overarching concept of
psychological well-being? Does consensus on the dimensions of well-being and the
components of mental health exist?

What kind of interventions fit into the positive psychology approach? Are such evidencebased interventions available?

What are major limitations of current positive psychology and challenges for the future?

What is your own view on the value of positive psychology? Would it be an approach that
you would like to support and practice, or maybe not? Offer an argumentation for your
stand.
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9
Social support and social network approach
9.1
Introduction
166
9.1.1
The history of social support research
166
9.1.2
Ecological Systems Theory
168
9.1.3
Social networks, Social resources, and Social capital
169
9.1.4
The empowerment approach
170
9.1.5
Social support in prevention practice
171
9.2
A theoretical framework for social support
172
9.2.1
Basic elements of social support
172
9.2.2
Bidirectionality and empowerment
174
9.2.3
Diagnostic tool to assess the quality of social support
176
9.2.4
Mapping social networks
177
9.2.5
Functional analysis of social support
178
9.2.6
Goals and targets of social support
179
9.2.7
Types of social support: What could support systems offer?
181
9.2.8
Timing of social support
181
9.3
Strategic options for professional action
183
9.4
Effectiveness of social support
185
9.4.1
Evidence of effectiveness
185
9.4.2
Effect moderators and effective ingredients
186
9.5
Toolkit for quality assessment and programme development
186
Literature
188
Study questions for this chapter
190
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9
Social support and social network approach
Clemens M.H. Hosman
9.1
Introduction
This chapter discusses the role of social support and social networks in the development of
both mental disorders and mental health. Over the past 30 years, much research has been
done on the role of social networks in our societies and on the effects of social support on
health. Strengthening social support and social networks represents one of the major
strategies for preventing mental health problems and promoting well-being.
In this chapter, we first introduce the concept of social support by a short summary of
its long history in social sciences. In this section, some research data on the effects of social
support on health are also discussed. We link the social network approach to related
concepts and theories such as the social ecology theory, the social resource and social
exchange theory and to concepts such as supply networks and social capital. Next, we
present a theoretical framework on social support and social networks and describe its basic
elements, the types of social support and their psychological and social functions. We pay
special attention to how professionals and scientists can map the relations within a social
network and assess the quality of social support and social support systems. Next, we
explain how they can use the presented theoretical framework to design social support and
network interventions. Section 9.4 discusses what is known about proven effects of supportenhancing interventions. Throughout the chapter, you will find multiple schemes, figures and
boxes that together form a toolkit that professionals and researchers can use in their work
for improving the social support capacity in communities, populations at risk.
How is this chapter related to other chapters in this textbook? First of all, social support is
also an element in other theoretical models that we have discussed earlier. The term ‘social
support’ is part of the ‘social influence’ factor in the ASE model (chapter 5) and one of the
core factors of the integrated stress model (chapter 7). In the developmental
psychopathology framework, social networks are assumed to play a major role in the
interactions between system levels that shape the development of mental health and mental
disorders across the life span (chapter 6). Next, social networks and social support represent
an essential dimension of prevention strategies and programmes. Making a network analysis
is defined as an integral part of each problem analysis a prevention professional or health
promoter has to perform before designing an intervention programme (see chapter 11 on
programme planning). How professionals can include a social network approach in
prevention programmes is discussed in chapter 13 on strategy development.
9.1.1 The history of social support research
Although the concept of social support was introduced in the scientific public health and
prevention literature during the seventies of the last century (Caplan, 1974; Cassel, 1973),
the study of the influence of social networks on mental health is rooted in a long research
tradition. The sociologist Emile Durkheim was one of the first who studied the influence of
social cohesion and solidarity on humans, as he describes in his ‘La division du travail social’
166
(1893). His investigations showed that the number of
suicides was highest in the group of people with the
lowest number of social contacts (La Suicide, 1897).
According to Durkheim, reduced social contacts and the
associated reduction of social roles and norms lead to a
higher number of suicides.
Since the 1980s, several large epidemiological
studies tried to predict mortality through the size of
one’s social support network (Sarason, Sarason &
Pierce, 1990). In prospective studies, Berkman &
Breslow (1983) and Lyyra & Heikinnen (2007) found
that people with weak social ties and a lack of emotional
and practical support have almost 2.5 times higher risk
of death than those with a strong social network that
provides emotional and other types of support. This
impact remained after the researchers controlled for
other risk factors such as weight, alcohol consumption
and cigarette smoking. Poorer levels of social support
are found to be related with a wide range of health
conditions (Berkman, Glass, Brissette, et al., 2000;
Hogan, Linden, & Najarian, 2002), such as a poorer
functioning immune system (Uchino, 2006), more risk of
cardiovascular disease (Uchino, 2009), depression
(Pelkonen, Harttunen & Aro, 2003; Brugha et al., 2004),
and more complications during pregnancy (Elsenbruch
et al., 2007). Social support is also found to have a
beneficial effect on recovery and long-term survival
among patients with acute myeloid leukemia (Pinquart,
Hoffken, Silbereisen, & Wedding, 2007), bone marrow
transplantations (Foster et al., 2012), dialysis patients
(Plantinga et al., 2011), arthritis patients (Fitzpatrick et
al., 1991), and breast cancer (Nausheen et al., 2009).
Overall, epidemiological and clinical studies show that
social support and social cohesion can improve health
and the quality and duration of life.
Although size of a social network plays a role
(Brugha et al., 2004), it is not merely the size of social
networks that ensures beneficial effects. For instance,
some studies show that having only one supporter,
such as a spouse, can also lead to positive outcomes
for the recipient (see review by Hupcey, 1998). Much
research attention has been given to the emotional,
cognitive and social functions that a social network can
provide, and the impact of the quality of supportive
relations on the social-emotional development of
Social Support systems
Social support in the family
Action for Happiness Network
Local social support group
Linked to Online network
Local interest organisation
COPMI International Prev Network
167
children, adolescents and adults, especially when they are exposed to risk factors.
Psychologists and psychotherapists have long underestimated the power of social and
community processes in the development of mental health and well-being, by exclusively
concentrating on the inner cognitive and emotional processes related to pathological
behaviour. These inner processes, however, are shaped by a continuous stream of
interactions with the physical and social environment. The work of Bowlby and other
developmentalists on the long-term impact of early attachment between parent and child,
represent a classic example of this type of research. There is substantial evidence that
children with secure attachments in childhood develop more positive social–emotional
competence, cognitive functioning, physical health and mental health, whereas children with
insecure attachments are more at risk for negative outcomes in these domains (Ranson &
Urichuk, 2008). Recent studies also suggest that attachment style affects the immune
system (Picardi et al., 2013). Numerous other developmental psychopathology studies have
provided convincing evidence of the impact of early caring and supportive environments on
the social-emotional development, resilience and vulnerability of children and adolescents
(See Journal of Development and Psychopathology).
9.1.2 Ecological Systems Theory
The social ecological theory of Urie Bronfenbrenner is one of the leading international
frameworks on the interrelations of risk and protective factors at different system levels.
Bronfenbrenner studied how factors at each of these levels impact the social-emotional
development of the child (Bronfenbrenner, 1975). In his view, child development is not only
an outcome of the genetic impact of the parent and the interactions between the child,
parent, other caregivers and peers at micro-level. Also social forces at higher social system
levels have directly or indirectly a
powerful impact on the development of
the child over time. Children are nurtured
in multi-level nested environments.
Bronfenbrenner delineates four types of
nested systems:

The micro-system, such as the
family, classroom, peer group, family
doctor, teacher;

The meso-system, which is two
microsystems in interaction;

The exo-system: external
environments which indirectly influence
development, (e.g., parental workplace,
health system);

The macro-system: the larger
socio-cultural context, which includes
ideologies and cultural values, public
policies, laws.
The model shows that entries for interventions to prevent child mental disorders and to
promote social-emotional development can be found at multiple systems levels. The higher
168
the chosen entry in the hierarchical system, the more distance to the child, but also the
larger the number of children it might affect in the end. The model invites to study how the
interrelations between system levels work, and what kind of causal pathways are linking the
impact from one level to the other. It is evident that social networks represent one of the
most important pathways of intersystem interaction. Social influences on mental health could
form a multilevel cascade. Protective factors could start at macro level and affect the
microenvironment of children through mediating processes at meso level: national policies
regulate school curricula and school budgets, curricula and budgets influence the room for
social-emotional education in schools, adopted curricula on social-emotional learning guide
the behaviour of teachers, teacher behaviour affects the social-emotional development of
children.
Later, Bronfenbrenner added a fifth system, called the Chrono-system, that refers to
the patterning of environmental events and transitions over the course of life, but also to the
evolution of the external systems over time. Each system contains roles, norms and rules
that can powerfully shape development, but such social norms and rules may change over
time. In times of large societal changes due to economic crisis, economic migration,
globalisation, and worldwide access to the Internet, we see macro-systems and exo-systems
quickly changing. At micro level, this may result in confusion about cultural values and
norms, exposure to conflicting messages and views, and loss of social networks. The longterm economic crisis has a deep impact on the lives of populations all over the world through
increasing poverty, loss of one’s house, and sharply reducing local budgets to support
communities, local organisations and day care facilities for children. It has also resulted in
huge cuts on budgets for prevention and mental health promotion in neighbourhoods and
schools. By adding the chrono-system to his model, his theoretical framework mirrors closely
that of developmental psychopathology and the integrated stress model that we discussed in
the chapters 6 and 7. All these theoretical approaches have a multilevel dimension in
combination with a developmental dimension in common.
A final last remark concerns the value that can be attributed to the influences that the
higher system levels have on the micro system, and in the end on individual children,
adolescents and adults. These influences can be at the one hand supportive and facilitate
social-emotional development across the life span (social protecting and promoting factors);
they also may exert restraining or even harmful effects (social risk factors), as we have
illustrated above.
9.1.3 Social networks, Social resources, and Social capital
Caplan’s introduction of a support systems approach as strategy for preventive psychiatry
and health promotion was based on a nutritional model and resource model (Caplan, 1974;
Caplan & Grunebaum, 1967). In these models, the development of a person’s health,
competencies and emotional development depends on the availability of physical,
psychosocial and socio-cultural resources. Food, shelter, adequate living space, sensory
stimulation, opportunities for exercise and sleeping are resources that are necessary for
physical growth. Likewise, for a healthy cognitive and emotional development in addition to
these physical resources, also psychosocial resources (e.g. love, care, control, protection,
esteem, feedback, opportunities for social participation, family ties) and sociocultural
resources (e.g. stimulating school climate, work, safe and cohesive community, social
benefits, and protective legislations) are needed. Social networks and social support
systems are the vehicles through which children, adolescents and adults get access to these
essential resources. Supportive relationship is the pathways through which resources flow
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through networks. This stresses the crucial role of social networks as catalyst in the
development of emotional health and human strengths. For mental health professionals and
health promoters, providing mental health consultation to informal caregivers, local health
professionals, community leaders, local organisations and policy makers represents a
powerful strategy to enhance availability and accessibility of necessary psychosocial and
socio-cultural resources (Caplan & Grunebaum, 1967; Caplan, 1970).
9.1.4 The empowerment approach
Social networks have multiple outcomes, positive and negative ones. In this chapter, we
focus primarily on the actual and potential positive functions networks could exert for
individual citizens, families, local groups and organisations. From our perspective, functions
are ‘positive’ when they directly or indirectly contribute to more mental capital and human
well-being, and less emotional and behavioural disorders. To achieve this, social networks
and social support systems exert protective functions against hazards of life, and provide
citizens and local organisations the resources they need to create a healthy, productive and
fulfilling life. In turn, professional health promoters and prevention professionals aim to
empower the social networks and support systems in order to increase their preventive and
health promoting roles in society. The philosophy of empowerment was introduced by the
pioneers of community organisation, population education and community psychology, such
as Saul Alinsky, Paulo Freiri and Julian Rappaport in the period between 1950 and 1980.
The WHO’s strategy for health promotion, as defined in the Ottawa Charter on Health
Promotion (WHO, 1986), has adopted these views to launch a worldwide innovative
approach to public health. The Ottawa Charter describes five major strategies to improve
physical health, mental health and social well-being: (1) build healthy public policy, (2) create
supportive environments, (3) strengthening community actions, (4) develop personal skills,
and (5) reorient health services increasingly in a health promotion direction, beyond its
responsibility for providing clinical and curative services. Empowering people and
communities as major strategy to health, is the
common idea behind this visionary policy. The
framework, presented in the Charter, links the
concepts of supportive communities, social resources,
individual strengths and empowerment with mental
health and well-being. Over the last decades, the
Ottawa Charter has guided public health and health
promotion policies and actions in communities and
countries all over the world.
The multi-level concept of Empowerment refers
to the process by which people individually and
collectively in organisations and communities gain
control over the factors and decisions that shape their
life and influence their health. It is the process, by
which they increase their assets and attributes, and
build capacities to gain access to resources, develop
partnerships and networks, and a voice, in order to
gain control. Developing personal skills is a strategy for individual empowerment.
Community empowerment refers to the process of enabling communities to increase control
over their lives. Community empowerment seeks to build partnerships across sectors and
local organisations in finding solutions for health threatening conditions and to make the best
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use of opportunities in the community to promote health and well-being. It can also concern
the development of networks of citizens such as local support groups for caregivers of family
members with dementia, and citizen action groups for more social safety or the preservation
of a community centre. Since the 1980s, internationally ‘Healthy Cities’ and ‘Healthy school’
networks are developed to exchange best practices and to support these local projects.
9.1.5 Social support in prevention practice
In prevention and health promotion practices, interventions to strengthen social support and
social cohesion in social networks are widely used (Röhrle, Sommer & Nestmann, 1998;
Hogan et al., 2002). Box 9.1 lists a range of common examples found in several countries.
From our own Dutch practice in working with children at risk, below we describe one
example more extensively, targeted at children of mentally ill parents (COPMI) in the age of
8 to 12 years.
The
most
common
prevention
programme for these children is support groups
where they can meet other children who live in
similar situations (see also chapter 16). Such
support groups are offered all over the country
by district mental health services. They aim to
provide emotional and cognitive support to
these children who usually feel isolated due to
the stigma attached to the parental mental
illness. Often the children blame themselves for
the problems of their mother or father due to a
lack of knowledge about the parental illness.
They have a hard time in dealing with the
difficult situation at home. In the meetings, the
children receive information about parental
mental illness, and how to cope with it. The
group leader explains in simple terms, how
such illnesses develop, and that their mother’s
or father’s illness is not caused by them. The
children give each other emotional support,
and discuss how they deal with the situation at
home and how they could make their life
enjoyable. The group meetings also offer
pleasant
activities
as
a
temporary
compensation for the stress at home. For many
years, these local preventive practices are
supported by national and international organisations and networks, such as the National
Platform of COPMI professionals, patient organisations, universities, the National Institute for
Mental Health and Addiction, and by the International COPMI Network of researchers,
programme directors and advocates. The national and international networks exchange
innovative approaches, new interventions, educational materials, and the latest scientific
knowledge. The participants use this innovative input to improve the quality of the COPMI
programmes in their countries and in the local communities where they meet the children
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and families. This illustrates how supportive influences go up and down through the
multilevel ecological system.
Although the use of a social support approach is common in health promotion and
prevention since the 1970s, practitioners have often rather simple ideas about what social
support is, how it works and how you can improve its quality. Many professionals lack a
science-based framework to diagnose the support problems of their clients, to identify
opportunities for improvement, and to design an effective preventive intervention based on a
social network strategy. In both the prevention and treatment sector, professionals are
insufficiently aware of the opportunities they have to prevent serious problems in their clients
by helping them to improve social support and strengthen social networks. This makes their
preventive work less effective.
The presented social support approach offers a diagnostic framework for assessing
the quality of existing social support, support systems and networks, and to design or select
the best actions for improvement. Accordingly, this remaining part of this chapter is centred
on two types of questions. The first category concerns diagnostic questions: Who provides
which type of social support, to whom, for what purpose, using which methods, is it delivered
with sufficient quality, and does the support work, so what is the actual effect? The second
type concerns design questions: How can we improve the availability of social support for
the client, make the support fit better to what is needed and improve the quality of the
enacted support? How could social support and social network theory guide professionals in
selecting or designing an effective intervention? What standards should a support
programme meet to effectively reduce the risk of emotional disorders, and increase mental
fitness and well-being?
9.2
A theoretical framework for social support
In this section, we describe a theoretical framework on the interrelations between social
networks, support systems and supportive behaviours, and their impact on mental health
and well-being. Although this chapter is about the relevance of social support theory for
prevention of mental problems and promoting mental health, the framework can also be
used for prevention in other areas where social support strategies are used, such as
physical illnesses (e.g. cardiovascular diseases) and social problems (e.g. unemployment,
violence, discrimination). Social support principles are also utilised by clinicians, who try to
enhance social support for their patients as part of their treatment strategy, for instance for
those who suffer from a chronic mental illness, a depression or a serious limiting physical
disease.
9.2.1 Basic elements of social support
The social support model that we present here is made up of the following elements:

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Support systems, the providers of support, exist at micro, meso and macro level. A
support system could be a person in a dyadic relationship (e.g. child-parent, friendfriend), a group (e.g. family, group of friends, local support group), or an organisation
(e.g. school, patient organisation, labour organisation, professional association).
Support systems at each of these levels are part of social networks of individuals,
groups or organisations (e.g. a family network, a network of organisations fighting for
the social acceptance and safety of homosexuals, a local network of schools). For
reasons of simplicity, we have combined the meso-system and exo-system of
Bronfenbrenner into one label, ‘meso level’.

Recipients of social support, including their needs, risk factors and strengths. The
focal recipients in health promotion are citizens, and in prevention especially citizens
at risk. They represent the ultimate target population. In this multilevel model, in turn,
support systems are not only ‘providers’ but also ‘recipients’, as the quality of their
functioning as providers of support depends of the support they themselves receive
from other support systems at the same or higher system levels. For instance, the
quality of the support teachers give to children to stimulate their social-emotional
learning (SEL), is enhanced by training and programmes in SEL, offered to them by
public health services or national institutes. Normally, a support system is embedded
in a multilevel network of support systems.

Perceived support: the receiver’s awareness and perception of the provided
support. Perceived support is assumed to have a stronger reducing impact on stress,
than the objectively measurable presence of social support. It might occur that a
person is not aware of the available or even enacted support from his social network,
or he might perceive this support not as support but, for instance, as interference in
his privacy or as an act reflecting primarily the interest of a caregiver. In this case, not
receiving support might be a perception or interpretation problem in the first place.

Offered or enacted social support. This is about the actual support given by the
provider. Its nature and quality can be defined by the following five features: (1) the
content of the offered support, so ‘what’ is offered; (2) the intended aim or target of
the provided support, so what does the support is aimed to achieve in the eyes of the
provider; (3) the method used to offer the support and the quality of its
implementation; (4) the timing of the support; and (5) the fit between the offered
support and the needs and culture of the receiver.

Quality of a support system. These include, for instance, the level of knowledge
and skills of a support system has available, his attitudes, cultural sensitivity, ethical
standards, and the openness towards the needs and opinions of those they aim to
support. These support system features are assumed to influence the quality of the
actual supportive behaviours and their impact on the receiver.

Networks of support systems. A support system is usually part of a wider social
network of relations with other actors or systems. These can be relations at the same
ecological level (horizontal networks) or with systems at higher levels (vertical
networks). Horizontal relations exist within micro level networks (e.g., the whole of
family members, friends and neighbours of person), the meso level (e.g.,
collaborative health promotion network of local health and social organisations), or
the macro level (e.g. collaboration between multiple national institutes for health and
well-being, government, and professional organisations). Networks also exist across
system levels (multilevel or vertical networks), such as patient and consumer
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organisations who operate both at local and national level, and have at each of these
levels collaborative relations with other stakeholders.

Quality of social networks can be described along structural dimensions and with
use of process indicators. Structural features of micro, meso and macro networks
might be studied, such as size, density, homogeneity, openness and accessibility.
These structural features may influence the intensity and quality of the flow of social
support activities within a network. The quality of the processes in a network may be
indicated, for instance, by the presence of a common mission and common targets,
frequency of contacts, level of information exchange, internal democracy, leadership,
reciprocity of support, and level of output.
Figure 9.3 outlines how these different elements build up to a multilevel social support
model. It describes support systems and networks at micro, meso and macro level, the
relations between them, and differentiated between offered or enacted support and
perceived support.
9.2.2 Bi-directionality and empowerment
The model, as reflected in Figure 9.3, primarily outlines the supportive actions from support
systems to receivers, represented by upward arrows. However, system theory and current
health promotion approaches stress that influences are going both ways: upstream and
downstream. To date, we consider people not only as passive receivers of support or
treatment, but also as active citizens who to take action and responsibility for their own
health, and seek to improve the social and community conditions for their well-being. The
vertical lines of influences between system levels are bidirectional in nature, and work
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through information exchange and learning, supportive and empowering actions, and
exerting power (Figure 9.4). These cascades of influence go ‘top down’ from macro to meso
level and from meso to micro level (e.g. government and national NGOs  schools 
teachers  parents and children), but could also stream ‘bottom-up’, for instance, through
parent committees, student actions, teacher organisations and school networks. Support
systems are not only used to get emotional relief in times of stress or to improve individual
capacities to cope with a problem, they can also be used to build social influence and
collective power that is strong enough to change social risk or health promoting factors. This
reflects the empowerment philosophy that we have discussed earlier.
What does this view mean for the work of health promoters and prevention
professionals? First of all, they are challenged to focus preventive interventions not only on
improving coping skills and health behaviours of citizens at risk, but also on empowering
citizens, groups and organisations to become themselves health promoters and prevention
experts in their communities. This stresses the need to reorient professional work from
mainly health education to also building prevention and health promotion capacities in
communities. Secondly, it means that we as professionals should consider citizens and local
organisations not only as potential consumers of capacity building for mental health
promotion. We should also support citizen groups and local organisations in their role as
capacity builders of organisations and policymakers at higher levels. Their practice-based
expertise is essential as a bottom-up input for decision making by local and national
governments, national organisations or private companies that affect the conditions for the
health and well-being of citizens. Over the last decades, we have witnessed inspiring
examples of bottom-up influence and capacity building by the environmental movement.
In sum, to be effective mental health promoters and empowerment agents, professionals
need to understand the multiple ways in which people may use their support systems and
social networks to cope with the social stressors, challenges and opportunities in their life.
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Box 9.2
Diagnostic checklist to evaluate the quality of social support,
and of support systems and networks of support systems
Assessment of the availability and quality of social support for a person or a group at risk
could reveal one or more of the following weaknesses that could be repaired by
preventive actions aimed at people at risk, a support system or support network.
1. A relevant social support system or network is lacking, not activated, or
poorly accessible
2. A target person or group (client system) lacks the knowledge, motivation or
skills to get access to available social support and networks
3. Poor quality of support offered by a support system:
 Poor fit of offered support to needs (content and goal)
 Right kind of support, but of insufficient quality, poorly presented,
too late, and not effective enough
 Offered social support is counterproductive
4. Low quality of an existing support system:
 Lacks necessary skills, knowledge, attitudes or other capacities
 Lacks support from others at the same system level (horizontal)
 Lacks support from organisations at meso or macro level (vertical)
5. Low quality of the network of social support systems:
 Support from multiple support systems or persons in a network is poorly
coordinated
 Support from different parties in a network is conflicting
Reflect on how you would act as prevention professional in each of these cases.
9.2.3 Diagnostic tool to assess the quality of social support
Before choosing a network-oriented intervention strategy, it needs to be estimated whether
improving the availability and quality of social support systems could contribute to the
targeted preventive effect. For this reason, we made network analysis an essential part of a
problem analysis at the start of each programme planning process (chapter 11).
The diagnostic checklist presented in Box 9.2 offers a tool to assess bottlenecks in existing
social networks and supportive relationships. It includes a range of possible barriers to
effective social support, and opportunities to strengthen support systems or networks.
Preferably, professionals and members of a targeted population or network make together
an assessment of the current support situation and options for improvement. In addition,
researchers could use the tool as a framework for a social network studies.
There may be multiple reasons why someone has a small or no social network
(Davison et al., 2000, in: Hogan et al., 2002). Some people have poor social skills and have
difficulty building relationships and making friends. Others, for instance single elderly, might
have lost their spouse and have in their neighbourhood poor opportunities to develop new
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social contacts. Their problem might be solved by ‘Befriending’ programmes that nowadays
are offered at many places in the world. People with social contacts might also have difficulty
asking for support when they are struggling with an emotional problem. They might be shy,
introvert or even distrusting because of a negative or traumatic experience with opening up
themselves to others in the past. Also having an emotional disorder, such as a depression,
anxiety disorder or borderline disorder, may result in cognitive or emotional barriers to
develop social supportive relationships (Henderson et al., 1978; Miller, Ingham, & Davidson,
1976; Silberfeld, 1978; Winograd, Cohen, & Chen, 2008). For each of these situations a
tailored response is needed to break through these barriers.
Another quality indicator of social support is the fit between what is offered and what
is needed (Cohen & McKay, 1984). Someone who has recently lost his spouse has a need
to share his grief with a trusted person or to get practical support like assistance in the
funeral preparations. Someone who just lost his job may benefit more from contacts that
may help to find a new job. Uncontrollable life events are best addressed with emotional
support, while people who are exposed to controllable events need practical problem solving
support in the first place (Cutrona and Russell, 1990). Based on an analysis of the problem,
type of needed support, and support opportunities in the social network, we can design a
tailored prevention strategy. This should aim in the first place to activate, enhance or expand
the preventive capacities of natural social support systems. In the case this turns out to be
insufficient or not easily possible, professionals can organise a temporary support system,
such as a support group for children of mentally ill parents (for other examples see Box 9.1).
9.2.4 Mapping social networks
To assess the need and opportunities to improve social support for a client or target group, it
is helpful to first draw a map of the social network of the client. This is possible through
different formats. Figures 9.5a and 9.5b offer exemplary illustrations of how social networks
of a group at risk can be mapped as a part of a problem analysis (see also chapter 11 on
stages of programme planning). They illustrate the example of a prevention professional who
makes a social network analysis to explore options for network interventions to prevent the
onset of eating disorders in adolescent girls. Such an analysis could also be made by the
target group itself, in this case adolescent girls already showing excessive and unhealthy
efforts to lose weight. As a first step, the girls are asked to map their current social network,
using circles and lines to represent their ties with the people in the network (Figure 9.5c).
Next, we ask them to describe and evaluate the quality of these relations. Are they
supportive, non-supportive or even destructive in their efforts to abandon deviant dieting
behaviours and their urge to lose weight? Do they fail to satisfy emotional needs that might
trigger their weight and shape concern? A group of female adolescents that share the same
problem could also make such an assessment collectively. As a next step, they discuss how
existing ties could be used to support them in their efforts to cope with their problem. How
could they activate such support? What kind of support do they need from whom? Finally, as
a group or together with a professional they could explore what kind of support systems
might be added to their network to make it more supportive. For instance, they could reflect
on how friends or the school could support them to counter peer pressure to unhealthy
dieting, and to work through the public images of beauty and develop media literacy.
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To stimulate these discussions professionals could ask them to both map and
appraise their actual social network and an ideal support network. Such an analysis might
offer a powerful incentive to change, for both themselves and the school environment. One
of the tasks of the prevention professional could be to bring in new perspectives on
alternative support systems. This example also clarifies, that a social network could both
serve as a support system, and as a system reinforcing deviant behaviour or blocking
healthy solutions. Preventive interventions aim to serve as catalyst to increase the
supportive value of a social network.
9.2.5 Functional analysis of social support
To identify the kind of additional support people need, or whether existing support needs
improvement, a functional analysis of supportive behaviours is required. Supportive
behaviour is functional when the:
1. Nature of the enacted support (type) is congruent with the intended aim of the support (goal)
2. Intended goal fits to the experienced or objective need of the recipient system
3. Offered support actually contributes to a change in a targeted risk factor or capacity, and
4. Intermediate outcomes are found to contribute to problem solution or goal attainment.
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In short, functional supportive behaviour is about the fit between offered support, need and
targeted preventive outcome. So, social support is not just about getting someone to support
someone else, but about the fit between offered and needed support, and if the support in
the end turns to be effective. A criterion for social support quality is some evidence for its
added value. In the next two sub-sections, we present a model to select functional goals for
social support and a classification of types of support.
9.2.6 Goals and targets of social support
When someone gives support to a friend who is dealing with a serious problem (e.g. a loss,
separation, illness, conflict), it mostly concerns first giving emotional support and
understanding. The purpose is to offer this friend comfort and to mitigate his feelings of
stress or sorrow. In the end, the needed support might also concern other needs of this
friend, such as getting a better picture of the problem, finding a good solicitor, accompanying
the friend during his visit to the hospital, or helping him prepare a strategy for conflict
management. To offer adequate support, the support system needs to assess what the
friend needs to be better able to solve his problem. In daily life, this assessment is usually
based on intuition, good knowledge of the friend and his situation, or simply by asking the
friend what kind of support he needs. In most cases, this will run smoothly without
complications.
Contributions from prevention professionals and in the end psychotherapists are
required when a person is not able to solve a serious emotional problem or risk, and there is
no support system available to help or the available support is not sufficient or effective. To
assess the needs of the person and to organise the best possible support, the professional
requires a frame of reference that helps him understand what the problem is and what
support is needed to solve the problem. He needs to understand what risk factors the person
is facing, which competence or other protective factors are lacking, and why the present
social network is unable to provide the support that is needed. As we have illustrated in
Figure 9.6, the integrated stress model that we discussed in chapter 7 offers such a
framework. It can be used to identify the needs of the target person or target group and,
thus, what the goals should be of the additional support that is needed.
Following the factors in the stress model, the goals of social support could be to help the
target person:

to reduce a stressor or other risk factor

to create positive experiences to compensate for the impact of a non-avoidable stressor

to get a better picture of the problem, its causes and its consequences

to mitigate feelings of stress and crisis

to adapt his goals and values to make them fit better to the situation

to increase his knowledge, skills, confidence and other capacities (strengths)

to find additional social support

to prepare the most effective coping response to the situation

to support or join the person in performing that response
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Effective social support requires that the support is well targeted. The stress model provides
a tool to assess for what a person needs support, and to make strategic decisions about
what the target of the support should be.
The model also offers room for choosing the best from alternative strategies to reach
the same support goal. Let us take the situation wherein a person asks a female friend: “Tell
me what I should do to prevent that my classmates continue to bully me?” The first option is,
to advise the best response to a bully straight away. However, she might decide that on the
long run it is more empowering for his friend to follow a different support strategy. She might
prefer to help her friend (recipient person) in getting a better understanding of how bullying
situations arise (perception and analysis). This might be sufficient for her victimised friend to
find a good response by herself to this and similar situations in the future. Secondly, she
could decide to focus at strengthening the person’s coping skills by suggesting a role-play,
or by statements that reinforces the person’s self-esteem and self-confidence, which could
help the person to be better able to cope with the situation. Thirdly, she might refer the victim
to adequate support from someone else, such as to consult a website for bully victims (e.g.
www.bullying.co.uk), to discuss the problem with her teacher, to involve a ‘peer mediator’, or
to follow a social skills and assertiveness training. As illustrated, the integrated stress model
provides a tool to discover alternative support strategies. This not only guides professionals,
but also offers a useful framework for those direct involved, such as the person or group at
risk and the direct support systems, and for support systems at meso level (e.g. school, local
health centre, online student counselling services).
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9.2.7 Types of social support: What could support systems offer?
After a support system has determined what a recipient person needs and what the support
goal should be, the next questions to answer are: What support should I offer to meet this
need? How should I offer it? This parallels the items ‘content’ and ‘method’, mentioned in the
support framework presented in Figure 9.3. For instance, would it be better to provide
information, to give advice, to serve as a role model, or to interfere in the social situation
directly? If a support system decides to provide information, what would be the most
effective way to do so? One could provide oral information in a supportive talk or give the
person, who might be in a crisis, the information through a short brochure or provide a
website-address that contains all the needed information. In these last cases, the information
might stay better available when the recipient person needs it the most and might have less
access to his memory. In addition, cultural sensitivity plays an important role in defining the
content and method of an effective support response. This applies especially to situations
wherein a support giver and a support recipient have a different cultural background. This is,
for instance, the case in supportive relations between immigrant families and schools or
health services. Cultural training of the staff, hiring indigenous or immigrant professionals or
involving immigrant volunteers could bridge cultural distances and make the support more
effective.
Box 9.3 offers a list of seven types of support a support system can offer. The
literature on social support makes a distinction between person-centred and situationcentred support. Person-centred support aims to affect the emotions, capacities or behaviour
of the recipient person directly, and includes four subtypes: cognitive, emotional,
appreciative and normative support. Situation-centred support aims to create alterations in
the social or physical environment that might help to reduce or solve the problem, and is
subdivided in three categories: material support, practical support and social or community
action.
When a support system or organisation decides to target their action on social risk
factors or health-promoting conditions in the social environment, the multilevel framework
offers even more alternatives for action. A support system may choose to target such
conditions directly (micro level action). This is the case when a parent of a bullied kid directly
approaches the parents of the bully to get the bullying behaviour stopped.
Alternatively, parents or other support systems might turn themselves to the media, local
politicians or school management. Triggered by a suicide of a bully victim, parents might
even consider forming a national interest group of parents to pressure the parliament,
ministry of education and national school organisations to take action.
9.2.8 Timing of social support
Offering effective support to a person, group or organisation is not just a matter of finding the
right aim, content and method, but also about good timing. Of course, the general rule is,
offer support when the person is most in need for it, not too early when the person might not
be motivated yet to make use of it, and not too late when the support is not useful anymore.
For making a decision on timing, the issue of sensitivity to change is of special
relevance. As Gerald Caplan already stated in his preventive crisis theory (1964), people are
more sensitive to change in a period of personal ‘crisis’. In such periods, support might be
more effective and change in opinions, attitudes and behaviour can be achieved with less
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Box 9.3
Types of social support
Person-centred support
Cognitive support
Offer information, advice, and feedback about:
- diagnosis, type and severity of a problem, risk level or a prognosis
- causes of the problem
- possible solutions, coping reactions, preventive behaviours
- possibilities for other social support or professional assistance
- expected consequences of different solutions
- feedback about consequences of actual coping behaviours of a person
Emotional support
-
Show empathy, comprehension, love
Listen; give attention, comfort, and encouragement
Offer solidarity, physical affection, affiliation, or express displeasure
Appreciative support
-
Show appreciation, affirmation, and trust in a person
Offer a compliment or reward for a specific coping behaviour by a person
Normative support
-
Set or express behavioural norms, give behaviour advice; show tolerance;
give normative feedback on a specific behaviour
Exert pressure through sanctions or using power
Modelling, comparison or reference function
Create awareness of value systems or ideologies of reference groups
Stimulate a person to deviate from suppressing, limiting or harmful social norms
Situation-centred support
Material support
Offer financial support, living space, transport, and other facilities
Practical support (also called Instrumental support)
-
Temporarily assume business, offer nursing, looking after a child
Take out for a dinner or film, have fun together
Help perform a coping behaviour or a common action
Social influence: social action and community action
-
182
Reduce social stressors on which you can exert control
Seek additional support from other persons in the network
Mediate with community leaders, local organisations, interest groups, government
Organise a new support or pressure group, or be a person’s advocate
investment then in stable periods. Caplan differentiates between two types of crisis,
developmental and accidental crises. Developmental crises refer to periods between two
developmental stages. They are usually called sensitive periods wherein a child or
adolescent is challenged to cope with new developmental tasks. In such a period, he might
be more sensitive to influences from his network and preventive support might be more
effective. Accidental crises are caused by exposure to a serious life event, such as a loss of
a loved one or traumatic event.
Developmental crises are more or less predictable, which makes it easier to prepare
effective support on time. For instance, parent education can prepare pregnant parents for
the changes and new tasks in their life after the birth of the child. At the start of secondary
school, when young adolescents become exposed to a world of new experiences and
challenges, they might be more open to education about healthy coping strategies, in
comparison to halfway their secondary school when their new adolescent lives and networks
are more stabilised. Accidental crises can be predictable and unpredictable. When they are
predictable, prevention should be focused on timely education and anticipatory guidance to
make those at risk well prepared for such stressful events. This applies, for instance, to
ambulance nurses, police and fire workers who will be regularly exposed to fatal accidents;
to soldiers who are sent to war area’s; to bank or shop personal at high risk for robberies; to
workers who are informed about the closure of their factory in six months; or to caregivers of
elderly becoming gradually more demented.
In sum, the provided theoretical framework helps us to understand the functional and
dysfunctional pathways in support networks of those who are facing serious problems or
major challenges in their life, starting from the awareness of a need for support to a targeted
health effect through the enactment and perception of tailored supportive actions. Such
actions might be taken at each of the discussed system levels.
9.3
Strategic options for professional action
This introduction to social support systems, social networks and supportive relationships at
multiple ecological levels aims to give understanding of how social support works or could
work for citizens, patients, communities or organisations. We have discussed what the
options are for social support and what their impact is on health and well-being. We wrote
this textbook, however, for health and mental health professionals, health promoters,
prevention experts and policy makers to inform them about options to improve mental health
in the population by preventive interventions and health promotion programmes. This brings
us to the question: What can professionals do to improve the availability and quality of
support systems for citizens? What are their strategic options for support-enhancing actions?
As stated earlier, support-enhancing activities are common in the field of prevention,
health promotion and care, but professionals lack an elaborated framework on social support
to guide their daily work, to open new opportunities for action, and to make their work more
effective. Based on the presented social support framework, in Box 9.4 we describe what
options for action exist for professionals who aim to improve social support among citizens
and in communities. In this box, we differentiate between actions aimed to improve the
accessibility and quality of existing support systems, and actions aimed to create new
183
Box 9.4
Strategic options for professionals using
a social support and social network strategy
What can professionals do to improve social support?
Make social support more accessible

Provide information on possibilities for social support and available support systems

Improve citizen’s skills and motivation to seek social support

Mobilise existing informal support systems to take action (e.g. family, friends, teachers)
Establish new support systems (temporary or permanent)

Non-professional support (e.g. befriending, self-help groups or organisations,
buddy system, community development)

Professional support (e.g. child helpline, victim support, interactive websites,
consultation hours in a local centre, consultancy agency for local organisations)

Mix of professional and non-professional support (e.g. support groups, trained peers,
volunteers)
Improve quality of existing informal support systems

Improve quality of existing support (e.g. fit to needs, content, used methods, timing,
intensity through education, consultation, training, evaluation, feedback)

Reduce negative impacts of social networks, e.g. by removing emotional barriers for
providing support to target group, prejudices, restricting practices

Improve informal network qualities, such as internal communication, accessibility,
common views, positive attitudes and skills for providing support, mutuality of support

Get informal support system supported by other informal support systems, or by support
organisations at meso and macro level (network development)
Improve existing professional support and support systems

Improve their accessibility, create awareness of needs of a target group

Train professional skills in supporting the target group, enhance cultural sensitivity

Stimulate professionals to adopt an evidence-based prevention programme

Improve collaboration between local professionals or organisations (networking)

Stimulate local policies, regulations and budgets that facilitate social support
support systems. Secondly, we make a distinction between actions to improve informal
support systems and to improve professional support systems.
In this time of economic crisis, governments heavily cut budgets of expensive
specialised health and mental health services and substitute them by less-expensive
solutions in primary health care. They propagate the strengthening of self-help, local support
networks and a more active role of local professionals in increasing community capacities to
cope with health and mental health problems. In turn, this requires us to explore how local
physicians, nurses, social workers, local organisations and community leaders can
184
strengthen their own capacities to perform this role. Prevention experts in public health and
mental health services could play a crucial role in this. In their roles as consultants, trainers,
educators and mental health advocates, the can help local professionals and organisations
to increase their capacities to support citizens in coping better with emotional problems.
Mental health consultation to local professionals by mental health experts (Caplan, 1963,
1970) is a powerful strategy to increase such capacities. Although this method became less
practiced by the highly specialised mental health services during the 1990s due to changing
ideologies and financing systems, in light of the current changes in the health and mental
health system (‘back to the community’), this method has again become highly relevant and
deserves a revival.
9.4
Effectiveness of social support
According to the presented framework, the aim of social support is to influence one or more
factors in the stress model to facilitate problem solving, goal attainment or preventive
behaviour in a target person or target group. For this purpose, different types of social
support and social support strategies are available. The ultimate question is, is there
evidence showing the effectiveness and added value of support-enhancing interventions by
professionals? As we discussed at the start of this chapter, ample evidence exists on the
impact of social support and social cohesion on physical health, mental health and wellbeing. This suggests that interventions that improve social support will also lead to better
mental health and less mental disease.
9.4.1 Evidence of effectiveness
In 2002, Hogan, Linden, and Najarian published a review on the outcomes of various social
support interventions in care and prevention. They identified 92 controlled studies, published
between 1970 and 2000. The studied interventions use several strategies, such as ‘direct
support vs. strengthening capacities to gain support’, ‘group support vs. individual support’,
and ‘strengthening professional support vs. lay support’. Of the 92 studies, 39 showed that
the effects of the social support interventions were better than the effects of standard care or
no care at all. In 12 studies, social support gave better results than other (also successful)
treatments, and 22 studies found at least some positive effects of social support
interventions. Seventeen studies found no effect and there were two studies in which the
participants were even worse off after the intervention. Overall, in 79% of the interventions
social support had positive effects.
A meta-analysis by Röhrle and Sommer (1997) of controlled outcome studies on 21
network-focused interventions compared their effect sizes (ESs) with those of nointervention control groups or other treatments. Their outcomes revealed a wide variation in
effectiveness between network-focused interventions. Several interventions (9) showed
relative high effect sizes (>.70), 3 showed moderate ESs (>. 30 to <.70), 7 small ESs (<.30
to >.00), while 4 interventions showed negative outcomes. When compared with the effect of
other types of treatment, in average no difference in ESs were found (mean ES =0.09).
Comparisons at 3 months follow-up found a mean ES of .32 when compared with no
intervention and .11 when compared with other types of interventions. A homogeneous
group of seven interventions, providing also follow up tests after 3 months, showed an
185
average effect size of .32, which is comparable with average effect sizes for other samples
of prevention programmes.
We may conclude first, that network-targeted interventions show still much room for
improvement, given their in average still small to moderate effectiveness and the large
variation in effectiveness between such practices. The studies also show that networktargeted interventions could be as effective as other type of professional interventions. The
presented theoretical framework might help prevention practitioners and experts to design
more effective interventions, and guide researchers in designing theory-driven outcome
studies.
9.4.2 Effect moderators and effective ingredients
In their meta-analysis, Röhrle et al. (1998) also searched for programme characteristics and
participant characteristics that moderate programme outcome. Such research might identify
the ingredients of the most effective strategies. Due to the still small number of comparable
outcome studies, only a few effect moderators were identified. For instance, long-term
network interventions (6 to 24 months) were found to be more effective than short-term
interventions (< 6 months), which stresses the need for investing in improvements of
structural support networks. Interestingly, positive effects were especially found among
women.
Special attention is given to the study of effective ingredients of peer support
interventions. In a qualitative study by Cuijpers (1993), using in-depth interviews, participants
in support groups for caretakers of dementia patients attributed the experienced positive
effects of the groups to the cognitive, practical, normative and emotional support they
received. Other studies mentioned the same active ingredients: being understood, having
the same problems, being accepted, comparing yourself with others, being valued,
exchanging experiences and getting information and advice.
Insights in how social support between peers works can also be found in the group
therapeutic literature. In particular, the American group therapist Yalom has done pioneering
work on this issue (Yalom, 1975), later followed by Bloch and Crouch (1985; Bloch, Crouch
& Reibstein, 1981). They suggest the following classification of active factors: selfunderstanding, learning interpersonal actions (interactions), acceptance (cohesion), selfdisclosure, catharsis, information and advice, universalism, altruism, learning by observation
and giving hope. In addition, the work of Haley et al. (1987) and Glosser et al. (1985) shows
that most of the above-mentioned factors and processes play a role in informal support
groups.
9.5
Toolkit for quality assessment and programme development
In this chapter on social support systems, we have presented several frameworks and tools
that may help prevention professionals and health promoters to make together with citizens
and organisations an assessment of the quality of their support systems and networks. We
consider all of them as essential elements of a comprehensive toolkit that could guide
professionals in applying a social support approach in prevention and health promotion. This
toolkit encompasses:
186






Overall social support and network framework (Figure 9.3)
Diagnostic checklist of possible bottlenecks (Box 9.2)
Mapping tools (Figure 9.5)
Theoretical framework for identifying support goals (Figure 9.6)
Overview of types of social support (Box 9.3)
Aid for making strategic choices (Box 9.4)
Based on the outcomes of a social network assessment they can make decisions about how
they can build strategies to improve the quality of support systems. The social support
approach offers prevention professionals powerful opportunities to strengthen the prevention
and health promotion capacity of communities. Therefore, this approach fits perfectly in a
modern empowerment strategy. Much more research is needed to get insight into their
effectiveness and what works best.
187
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Study questions for this chapter

Is there any evidence for the frequently assumed relation between social support and
health? What have empirical studies found?

What are the basic features of the social ecology model of Bronfenbrenner, and what
do you consider as the main contribution of this model to our understanding of social
support processes?

Social support is an interactive process between people. What are the basic
elements of the presented Social Support and Social Network framework?

What is the relevance of the distinction between offered and perceived social
support?

Which bottlenecks can occur in social support processes?

When is a supportive behaviour considered to be ‘functional’?

What is meant by the goals of social support?

Which theoretical model is well suitable to help us understand how social support
acts on a person who is in need for such support? What kinds of impact can social
support have according to this model?

What considerations have been discussed underpinning the importance of good
timing in offering social support?

The chapter presents a toolkit of instruments that professionals can use to assess
the strengths and weaknesses of support systems, social networks and processes of
support. What tools are included?

Which strategies are available for professionals to improve the functioning of social
support systems and supportive networks?

What is known about the effectiveness of support groups?

What are effective ingredients in support groups, such as peer support groups?

What do you consider as your most relevant learning point from this chapter?
190
10
Community approaches for mental health promotion
Reasons, Theory, Choices and Principles
10.1
Introduction
192
10.2
The context of prevention: developments in health care and society
193
10.2.1
Developments in Dutch MH-prevention from 1970
193
10.2.2
Scaling up of mental health organisations
195
10.2.3
Impact of new health legislation and economic problems
196
10.3
Communities: definitions, types, features and functions
199
10.3.1
What does ‘community’ mean?
199
10.3.2
Sense of community
199
10.3.3
Community characteristics and their relevance
200
10.3.4
Community functions
201
10.4
Strategies and scenarios for community-oriented prevention
203
10.4.1
Concept of ‘community approach’ and community interventions
203
10.4.2
Alternative community intervention scenarios
203
10.5
Professional roles and competencies
207
10.6
Collaboration and coalition development
208
10.7
Conclusion
211
Literature
212
Study questions for this chapter
213
191
10
Community approaches for mental health promotion
Reasons, Theory, Choices and Principles
10.1 Introduction
As we have seen in the previous chapters, many theories and interventions in prevention
and health promotion are directed at individuals or groups at risk. In this chapter,
‘communities’ are the central unit of analysis and the target of interventions and strategies of
change. Interest in community approaches is rapidly increasing over the last decades. It
refers to prevention and health promotion programmes targeted at whole neighbourhoods,
schools and other types of communities. The community approach is a response to the
limitations of micro-level oriented prevention strategies. Such strategies mainly imply
personalised, family- or group-based education, training and support methods, or early
individual and family treatment to strengthen competencies of those exposed to stressors of
life, to stimulate healthy behaviour and to enhance positive development. This personfocused approach is very common but has several disadvantages such as use of labourintensive methods, poor range in the population, leaving social causes of health and mental
health unaddressed, and mainly using top-down approaches. A community-approach targets
individuals in their social context, is population-oriented, involves social networks and local
organisations, and addresses public policies. Such efforts aim to improve health conditions
in a community, to utilise existing health promoting capacities in a community and empower
such capacities, and to contribute to ‘Competent communities’ that are able to protect and
effectively enhance mental health and well-being of its citizens.
For more understanding of the context and aims of the community approach, in section 10.2
we discuss interacting developments in prevention, public health, health care and society,
which provided the ground for the emergence of a community approach to health and mental
health. Linked to the developments in these domains a diversity of motivations can be
identified for supporting a community approach. Insight in these motivations is needed to
advocate successfully for a community approach in a world where the dominating health
system is primarily client- and person-focused. As we will see, different motivations result in
different types of community-oriented approaches. They also provide different criteria for
evaluating success of community-oriented programmes and policies. In section 10.3 the
meaning of the concept of ‘communities’ is further analysed and a differentiation in types and
functions of communities is presented. Which community-oriented strategies can be used to
promote mental health and to prevent mental disorders is discussed in section 10.4. Some
examples of community programmes are discussed partly derived from the developments in
our own country. Running successful community interventions requires a range of special
professional competencies, for which additional training is required (section 10.5). One of
these competencies is the capacity to develop effective collaborative relationships and
coalitions between different professionals, groups and organisations in a community (section
10.6).
192
10.2
The context of prevention: developments in health care and society
The field of prevention in mental health has gone through several transformations since its
emergence during the 1970s. These transformations are related to significant developments
in the health system and in the society as a whole. However, how prevention in mental
health has developed differs considerably between countries. This applies firstly to the
period during which such preventive practices first emerged and to the progress that is made
in developing and implementing effective programmes. Secondly, the type of organisations
and professionals that initiate and provide mental health promotion and preventive
interventions varies significantly between countries. For instance, in the Netherlands and
Finland, and to a lesser degree in Belgium, preventive programmes are provided by mental
health services, which is not the case in countries such as Germany, France and the United
States. In other European countries, such programmes are mainly initiated by sectors
outside the mental health system, such as primary health care centres, youth health care,
schools, religious organisations and workplaces. We will use the developments in the
Netherlands as an illustrative example to explain how prevention in mental health could
change over time through several transformations and how developments in health care and
society influence the interest in and chances of a community approach,
The different ways in which the community approach in mental health is motivated
and defined appears to be strongly related to the social changes outside the prevention
domain. This does not only apply to the Netherlands. Although community approach is less
common and less developed, we discuss the social context of this theoretical approach more
extensively than the earlier presented approaches because in our opinion it is crucial for
improving mental health conditions in populations.
10.2.1 Developments in Dutch MH-prevention from 1970
During the early 1970s, professionals working in local child- and family mental health and
addiction services started to develop the first prevention activities, for instance by offering
parenting education, training teachers and giving lectures at schools on alcohol, and by
starting support groups for single parents, children of divorce, mourning relatives, and those
who are work disabled. In those years, it was still an issue of invention and trial-and-error.
There existed no scientific knowledge on prevention, no professional training to acquire
prevention expertise, and no national prevention policy. Preventive practices mainly used
person-oriented educational methods, group work techniques used in therapeutic group
treatment, and self help and support group methods borrowed from community work
practices. Preventive practices were incidental, small-scale and short-term in nature.
The 1980s were characterised by a transition to a planning-driven and project-based
way of working, which means stage-wise working to reach well-defined goals using
reasoned intervention strategies within a defined period of time. During this period
prevention work gained a structural position in mental health and addiction policies,
outpatient mental health and addiction services and related budgeting systems. This resulted
in a fast growth of the number of preventive projects and prevention professionals around
the country (Van Doorm et al., 1986; Verburg & van Doorm, 1988). Parallel to the increase of
these preventive practices criticism was growing: interventions were considered too smallscale and scattered, targeting a too wide range of issues without priorities, absence of
193
quality criteria, poor efficiency, and no insight in outcomes and public impact (Hosman,
Verburg & Van Doorm, 1988).
During the 1990s, efficiency and effectiveness became priority issues on the
prevention agenda. In terms of efficiency, the new policy was to move from running one-time
projects to the development of tested ‘model programmes’, which could later be
disseminated and implemented at large scale. Such model programmes were considered as
high quality, transferrable prevention ‘products’ (product-based and supply-based
prevention). This approach was borrowed from industry and the profit sector, where the
development and large-scale implementation of standardised, high quality products became
an essential factor of economic progress during the 20th century. The main advantages of
adopting this commercial approach to the prevention field was its potential for a larger public
reach, more efficient use of developmental costs, and more quality control. If larger public
range of these products could be achieved, it could in the result in a significant impact on the
mental health of the population (public impact).
In this period of the 1990s, the first steps were made to explore the actual effects of
preventive interventions. Influenced by similar developments in medicine, ‘evidence-based
prevention’ became the norm. However, at that time insight in evidence-based prevention
effects was still marginal and mainly based on foreign research (Hosman, Price & Bosma,
1988; Bosma & Hosman, 1990). In addition, no insight existed in the fit between the supply
of preventive interventions and mental health needs of communities due to a lack of public
health orientation and epidemiological knowledge in mental health services.
This also applies to the lack of interest in social determinants of mental disorders and
poor mental health, notwithstanding the existence of a social movement of preventionists
during the 1980s that made a strong plea for a social-oriented prevention and developed
innovative social prevention practices in the Netherlands (Nuyten, Nijmeijer & Sterenborg,
1985; Terheijden, 1993; Baars & Kal, 1995) and the US (Joffe & Albee, 1981). These socialoriented ideas and innovative practices did not survive in a mental health system that
became more and more dominated by psychiatric ideologies, a-theoretical classification
systems (DSM) and by pharmaceutical and cognitive behavioural treatment.
The trend of the nineties continued and became even stronger after 2000. The
number of science-based and standardised prevention programmes increased significantly,
mostly targeted at individuals at risk and using micro-level intervention methods.
Programmes were partly developed in our own country and partly adopted and adapted from
successful model programmes in other countries. Methods of quality management became
widely used in practice (chapter 14). Controlled outcome studies in many countries, including
the Netherlands, have proved that mental health promotion and prevention programmes can
result in wide range of positive effects among those who participate in such programmes.
The same applies to prevention programmes targeting alcohol and drug use. This is without
a doubt a positive development.
There are also major criticisms. Notwithstanding the underlying dissemination
philosophy behind the idea of evidence-based model programmes, we have to conclude that
to date their public reach in populations and communities is still very marginal, which also
applies to their total public mental health impact. This challenges us to look for innovative
strategies and policies that have the potential for mental health effects in whole populations
or populations at risk. For instance, wouldn’t it be better to make prevention communityoriented instead of product-oriented. Secondly, the emphasis on ‘evidence-based’
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interventions contributed strongly to a selective support for person-oriented interventions, as
only this type of interventions fit into the dominating research methodology of randomised
controlled trials (RCTs). Research methodology to test the impact of social-oriented
interventions was poorly developed and had a low scientific status. All together, these
developments formed a major obstacle for investments in community-oriented programmes
and addressing social determinants of mental health. This person-centred approach fitted
well in the strongly individualised psychiatric culture that started to dominate in the mental
health services from the 1990s on caused by the central role of the DSM-classification, not
only within clinical assessment and treatment but also in the new financing systems for
mental health care including preventive services. In this culture, there was no room any
more for the social-oriented prevention of the 1970s and 1980s.
10.2.2 Scaling up of mental health organisations
From the early 1980s, the organisational system of mental health services in the
Netherlands has undergone major changes that had a deep impact on their preventive
activities. Around 1980 the scattered world of different mental health services became
nationally integrated in one integrated system of Outpatient Mental Health Care (RIAGGs)
for each health district, of which prevention became for the first time an official branch. This
was inspired by the emergence of Community Mental Health Centres in the US, but unique
in Europe. The basic philosophy of this new system was to provide the full spectrum of
outpatient curative and preventive services for children and adults in a defined health district
of around 400.000 inhabitants. The original RIAGGs had a public mental health mission.
Their mission was to close the gap between population and mental health care, to tailor their
services to the specific mental health needs in communities and cities within their district,
and to strengthen mental health capacities of primary health care and local organisations
through consultation and to develop local preventive activities.
At that time, outpatient services were organised separately from the large mental
hospitals. After 1990, however, a process of organisational upscaling started. First, in most
districts outpatient service organisations and mental hospitals merged into large districtbased mental health organisations. Next, large mental health organisations from different
districts began to merge, resulting into huge organisations, serving populations of between 1
to 2.5 million inhabitants. This upscaling in combination with a growing focus on specialised
individual treatment in mental health care, resulted in a growing gap between what happens
in the treatment room and the community environment and the social networks of the client.
These became separated worlds.
These developments created a huge barrier for mental health services to relate with
local social networks, to support primary health care and community organisations to
increase their capacities for early mental health treatment and prevention. In this context, it
is not surprising that for solving their mental health problems citizens became increasingly
dependent on treatment in specialised mental health services. Primary health care became
primarily a referring system to these specialised services, besides their role of prescribing
antidepressants and other psychopharmaceutic drugs. Between the 1970s and the 2010s,
the number of clients in specialised mental health services increased from around 100.000
to over 1.000.000. Although this increased accessibility can be viewed as a success in
reducing the number of untreated cases, it also raises major questions about the capacity of
citizens, social networks, communities and local primary health care to deal with emotional,
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behavioural and social problems. This is exactly what Iwan Illich (1974) warned against
when he wrote about social iatrogenesis (see the beginning of chapter 1).
10.2.3 Impact of new health legislation and economic problems
During the 1990s and 2000s, several new health and social Laws were implemented that
had a deep impact on the practice of prevention. The three laws are the Public Health Act,
the Social Support Act (Wet Maatschappelijke Ondersteuning), and the Care Insurance Act
(Zorgverzekeringswet). The different laws represent several changes in national health
policies and ideologies.
The first change can be labelled as decentralisation, which refers to a nationwide
transition of responsibilities for health, health policies and health care systems from the
national government to the local government. The idea behind this is that firstly local
governments are better able to attune policies and services to the needs of the local
population. Secondly, by moving the emphasis to local health policies and primary health
care, the huge national costs of the health system are expected to decrease. For instance,
The Social Support Act arranges that municipalities are responsible for policies, actions and
services to citizens in social need or at risk for poor mental health and well-being. However,
their budgets were significantly smaller than the available budgets under the AWBZ. This
Law replaced the original Special Health Costs Act (AWBZ) from which budgets were
provided to Regional Mental Health Services to, among other things, run Prevention
Departments, which could themselves decide on their targets and programmes. Under the
new Social Support Act, all kind of local organisations including prevention departments
could apply for local grants to finance a proposed prevention project.
The second change was related with the introduction of the new Care Insurance Act.
This law arranged that health insurance companies have the responsibility for financing
health care and mental health care. From then on mental health care was only financed
based on proof of the presence of an individual mental disorder, defined by the DSM-IV. In
addition, it arranged which services would be paid. Insured mental health services became
restricted to individual treatment, only marginally person-oriented preventive interventions
were insured for cases of subclinical disorders, which equals the definition of indicated
prevention (high level of psychiatric symptoms preceding the onset of a disorder). These
developments implied that budgets for preventive services were cut significantly in practice,
that mental health services (the cradle of Dutch mental health prevention) only got insurance
money for individualised indicated prevention, and not any more for primary prevention
programmes that are addressing populations at risk and community interventions.
Opportunities for these purposes needed to be found in limited municipal budgets. Through
this last development, an impulse emerged to integrate mental health promotion, universal
and selective prevention in local public health and social programmes that are more focused
at communities.
In addition, three other developments had and still have a major impact on prevention in the
mental health domain. First mental health care became a fast growing sector in the health
system. Then a fast increasing number of people applied for treatment by specialised mental
health services. This number grew to 1 million clients in a year coming from a population of
16 million inhabitants (Netherlands). This resulted in a huge increase of national mental
health care costs to a level that became unacceptable for government and parliament. As a
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result, mental health care budgets were cut by over 30%. In response, mental health
services first skipped as much as possible their investments in preventive services, which
were not considered a core business of mental health services anymore. This coincided with
the economic recession resulting in additional pressure to cut the costs of the mental health
system.
These developments triggered a political discussion about the role of the state and
fed neo-liberal criticism on the too costly ‘Nanny State’. Liberal ideologies emphasised that
responsibilities for health and well-being should be brought back to the citizens and their
informal networks. The government should interfere less in private lives, should appeal on
local communities and citizens to organise solutions and support themselves. In addition, the
role of primary health care should be strengthened, being the cheaper part of the health
system. This would save huge amounts of tax money. This ideology became more and more
the ruling one and was used as a justification for cuts in health system budgets in a
worsening economic climate due to the economic recession. So, in this case overburdened
mental health care, a libertarian ideology and economic arguments resulted in a renewed
interest in the role of community self-care. The core argument here is how could we keep the
health care system affordable and the dominating response is by cutting services, by
creating thresholds in the use of specialised and expensive care and calling upon citizens’
own responsibilities and the role of self-care.
For reasons of clarity, we stress that these motivations for an emphasis on
communities is different from interests in community approaches coming from those who are
linked to public health, health promotion and social and humanitarian ideologies. Their
interest in community policies and programmes is targeted at explicit investments in
empowering communities, supporting citizen groups and local organisations to improve their
impact of social and environmental conditions of their health, mental health and well-being.
Addressing social determinants of health is a traditional target of public health and health
promotion. We see an upcoming revival of interest in social determinants, social policies and
social programmes, as is evidenced by recent appeals by the WHO to invest in them and by
the recent insight in the growing gap in our societies between rich and poor, with a huge
evidence-based impact on health inequalities and significant differences in life expectancy.
In sum, the interest in community approaches is growing again, but the motivations
for this interest are very diverse. Different motivations lead to different solutions and to
different community approaches, also in the domain of mental health. Box 10.1 offers some
first examples of community-oriented programmes in the field of mental health and addiction.
Need for more conceptual and methodological clarification
Although there is some experience with community-approaches in mental health promotion,
much is still unclear about what this approach contains and how an effective communitybased programme should be designed. What does the term ‘community’ mean? What is the
theoretical base of an effective community programme? What are the core principles that
make a community-oriented programme effective? What kind of professional expertise is
needed for running such programmes? Community interventions are not an issue of top
down implementing standardised evidence-based programmes, but require working together
with local organisations and citizen groups on solving health, mental health or social issues
about which they are concerned, using both science-based and practice-based knowledge,
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including learning experiences from involved citizens. In this chapter, we will further discuss
these issues.
Box 10.1 Examples of Dutch community-based approaches
Local Preventive Consulting hours (Prevention Division of Parnassia (GGZ) in The Hague)
Preventive consulting hours give citizens easy access to preventive information and the option to
ask advice about mental health problems, alcohol or drug use and gambling. These office hours
are implemented in particular in health centres in the community, but also at mental health care
locations. One can ask questions by phone, via email, or through a personal interview. It usually is
a one-time contact, but sometimes more contacts are offered. The consulting hours are the front
door to prevention. Information and advice is given on appropriate preventive training and courses.
If necessary, visitors are referred to a mental health care service.
Systemic approach of alcohol problems (Alcohol Prevention Foundation, STAP)
How can alcohol problems be addressed at municipal level? American evaluation studies indicate
that there is more chance of success at the local level if a system-oriented approach is used. The
basic assumption is that to reduce alcohol consumption you can best begin by affecting the
alcohol friendly environment of young people. Young people make their own choices whether or
not to drink, but it's their environment that facilitates drinking and hardly puts a brake on alcohol
consumption. Wherever young people spend their free time alcohol is available: at home, with
friends, in the shack, in the sport canteen, in the disco, on holiday, at school parties. On TV, on the
internet and when going out, young people are faced with canny promotion campaigns. Young
people know little specific 'alcohol-free' moments apart from the workplace and traffic. Young
people under 18 have easy access to alcohol: parents or friends offer it and who wants to buy it for
himself often succeeds because not all providers pay attention to the age limits. STEP calls for
municipalities to make the best possible use of the beverage and catering regulations to combat
alcohol consumption by young people. In addition, municipalities can conduct a restrictive permits
and licensing policy, in cooperation with the food and consumer product safety authorities, and
intensify enforcement, set up a drinking shed policy and research the situation of groups causing
nuisance.
“Soup with Love” (Context, Prevention Division of the Parnassia Groep in Rotterdam)
Soup with Love is a community-oriented mental health prevention project aiming to prevent or
reduce mental health problems (particularly depression) among immigrant women. In the area
open committees are set up consisting of neighbourhood service providers and immigrant women
belonging to the target group. Also living room meetings are organised, by and for the women,
where they discuss their own proposed themes. A number of women are trained to become
recreational sports leaders and they coach their fellow female neighbours during exercising
activities. Organising workgroups and living room meetings in the community, in the homes of the
target group, is fun and sensible, but difficult and complicated. Complicated because recognising
depression in the culture of the target group is difficult. It is an alternative to the traditional
approach of "counselling and taking pills". The intervention uses the "empowerment"-principle by
training people from the target group to activate other citizens.
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10.3
Communities: definitions, types, features and functions
10.3.1 What does ‘community’ mean?
The concept of community is defined in very different ways. Surprisingly, already in the
middle of the 20th century scientific literature contained 94 different definitions of this concept
(Wikipedia). Definitions of community usually refer to a group of people that share some of
the following features: living in the same geographical area, having regular social contacts,
common interests and concerns, shared norms and values, are emotionally connected and
giving support to each other, using the same public or private services, and are governed by
the same local administration. People that live in the same neighbourhood, village or town
(geographical community) is the most common association.
‘Community’ also refers to people connected to each other within a specific
organisation, such as a school, company or local association of elderly (organisational
community). The children in a school or the employees of a company might come from
different neighbourhoods or cities. In another sense, people may feel connected to each
other through common identity or concern, which is not linked to a local geographical area or
organisation (communities of interest). This could apply to a religious community, ethnic
community (e.g. “the Moroccan community”), gay community, national association of family
members of mental patients, or a Facebook community. Finally, there are also professional
communities that may be an important target of mental health promotion actions. We could
target our preventive efforts, for instance, at a national association of district nurses to
advocate for more attention for preventing depression in pregnant women and young
mothers during their home visits and consultation hours in primary health care centres.
10.3.2 Sense of community
In several of the described cases the label ‘community’ is used when people share specific
objective features, such as living in the same neighbourhood, belonging to the same
secondary school, or being all members of a professional organisation. Communities defined
by such objective indicators could be relevant for us to get connected with target populations
or for other reasons that we will discuss later. These objective definitions should be
distinguished from the use of community in a subjective sense, as is the case in the concept
of ‘sense of community’ that was introduced in 1974 by Seymour Sarason, one of the first
leaders of the Community Psychology Movement. McMillan & Chavis (1986) define sense of
community as "a feeling that members have of belonging, a feeling that members matter to
one another and to the group, and a shared faith that members' needs will be met through
their commitment to be together". The relevance of this concept for mental health promotion
and prevention is its link with social support and social networks (chapter 9) and with the
concept of ‘social cohesion’, which represents a core target in current national and European
public health and social policies. Such policies are aimed at strengthening the role of
communities and its citizens to protect and promote their health and social well-being, and to
become less dependent on governmental actions and expensive professional care. Social
cohesion is defined as “the willingness of members of a society to cooperate with each other
in order to survive and prosper” (Stanley, 2003). These concepts have not only a strategic
value for mental health promotion as referring to conditions of community readiness to take
action for the sake of health and well-being, but also because they represent important
social determinants of mental health.
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10.3.3 Community characteristics and their relevance
To design effective community interventions prevention and health promotion professionals
need to have thorough knowledge of the specific profile of a community and its
characteristics. In box 10.2, we have listed the most relevant ones. Not all of them are part of
the known community definitions. They include, for instance, also poverty level, safety level,
unemployment rate, social cohesion, and availability of social services. The same types of
communities can show large differences on certain variables. For instance, age distribution,
level of social cohesion, poverty level and sense of community could vary significantly
between city neighbourhoods. These characteristics could be used to describe the profile of
a community and inform us about mental health needs and strategic options for mental
health promotion. They can be used by prevention and health promotion professionals
during the different phases of projects and programme planning. Based on the community
profile of needs and strengths a combination of evidence-based programmes could be
selected that fit the needs, strengths and culture of that community.
During the phase of community needs assessment such features can first be used to
select neighbourhoods or other communities that should be prioritised in health and
prevention policies because of their high needs and risks. Secondly, they can be used to
identify specific risks and strengths within a targeted community. For instance,
neighbourhood features such as social cohesion, poverty, safety and migration have found
to be social determinants of mental health. For this reason, some of them could be selected
as target of intervention or social policy. Professionals or other stakeholders could advocate
for public measures to compensate poverty, to reduce community violence or to increase
facilities for people to meet each other. They
themselves could also provide support to
Box 10.2 Characteristics of
citizens and local organisations to help them to
communities
increase social cohesion, to cope with violence
in public places, or to increase mental and
Social contact, networks, cohesion
social capital that is needed for successful job
Communication channels
finding.
Social structure and organisation
As illustration, we refer first to the JOBS
Social service level
Cultural norms and values
programme, a prevention programme designed
Common interests and concerns
by the University of Michigan and implemented
Shared history or experiences
in the US, Finland, the Netherlands and several
Social identity
other countries (Vuori & Price, 2005). By
Geographical boundaries
increasing social skills, job finding skills and
External dependency
social support among the unemployed, the
Population profile
JOBS programme was found not only to reduce
Safety and violence
unemployment but also to prevent the onset of
Work and unemployment
depression. In the case of a community with low
Income and poverty level
social cohesion and many elderly people, a
Migration and ethnic composition
Green space
local mental health promotion project could
Sport and recreational facilities
advocate for physical opportunities to meet,
Communication channels
organise training on how to make friends
(befriending programmes), enhance the use of
social media and stimulate the development of
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social networks. Such projects can increase the quality of life and reduce depression and
suicide among the elderly.
In addition, knowledge on the strengths of a community is essential for effective
prevention and health promotion. It offers insight in what kind of appeals can be made on a
community to use their own opportunities to deal successfully with local health and social
problems. For instance, in a neighbourhood with many young families, experienced mothers
could be invited to join a voluntary organisation ‘Mothers for Mothers’. In collaboration with
district nurses and with some additional training, they could offer home visits to pregnant
women and young mothers at risk. Such a support programme run by local mothers could
contribute to more parental competence and less risk, maternal depression and better
mother-child attachment. Helping communities to organise and utilise their strengths is a
core feature of what is called a social empowerment strategy in health promotion. It also
strengthens social cohesion in a community. Finally, such a strategy gives citizens a feeling
of ownership over mental health promotion programmes, which both strengthens positive
self-esteem in support mothers and increases the likelihood of sustainability of the
programme.
Finally, good knowledge of a community profile also offers strategic advantages,
such as assessing community readiness for involvement in a mental health promotion
programme, insight in potential stakeholders who can become involved to make a
community programme successful, knowledge about local communication channels that
could be used, and insight in local cultural values and customs that should be respected in
new programmes.
10.3.4 Community functions
Like knowledge of community characteristics, also insight in the functions communities have
for citizens is of great value for building effective community-based programmes. Some of
these functions were already mentioned in the preceding sections, such as offering
opportunities to meet other people, social support, feeling of belongingness and the
provision of services. In addition, communities exert also many other functions that are
relevant to the mental health of citizens. Prevention professionals who use communityfocused strategies need to have a good understanding of these functions and should use
this knowledge in their analysis of problems and development of intervention strategies. For
instance, communities are formed by people to fulfil basic human needs, such as the need
for social contact, the need for a safe environment and the need for care in the case of
illness. Local governments and community organisations have a role in helping citizens to
fulfil these needs. Communities, however, do not always function positively and effectively.
Unsafe or disorganised communities can also function as a source of stress or as a barrier
to the development of supportive social networks. Without aiming to be comprehensive, we
have sketched in Box 10.3 a range of functions that communities exert and to which mental
health promoting professionals could respond.
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Box 10.3
202
Functions of communities for quality of life, health & well-being

Communities are an important source for protecting and improving the health and wellbeing of citizens through, for instance, supportive social networks, social control,
community planning and development, community organisations, local working groups,
city and community councils, and collective approaches of local problems and health
conditions by social and public health policies.

Communities can also function as important sources of stress for citizens, for instance,
through high levels of poverty, poor housing, discrimination, low social cohesion,
criminality, street violence and lack of accessible social and health services.

Through local organisations, local policies, elections, lobbying and community actions,
communities can influence social risk factors of mental health, e.g. improving social
cohesion, safety, opportunities for education and work. Relevant organisations are
present in different public and private sectors, such as schools, work, sport, housing,
health and justice.

Communities have their own communication channels that influence the knowledge,
attitudes, norms and behaviours of citizens. These can include local radio and TV,
local newspapers, social media and internet, community meetings and contacts within
local organisations. These channels can be used to reach citizens with messages
about health, mental health and opportunities to participate in mental health promotion
and prevention programmes.

Communities have specific cultural values and norms, which health promoters and
prevention professionals should take into account when they develop mental health
promotion and preventive interventions and define their objectives.

A successful and sustainable implementation of a prevention or health promotion
programme in a community can only be expected when it is supported by the local
community and local organisations.

Communities provide social instruments and opportunities that citizens need to reach
their goals in life and to deal with stressful circumstances. These social instruments
include, for instance, schools, religious communities, health services, community
organisations, volunteers, social networks, local rituals, social benefit systems

Communities represent for municipalities important units to make decisions about the
distribution of budgets for prevention, health promotion and social projects.

Relationships between different types of problems become visible especially within the
context of local communities. Some communities show an accumulation of multiple
problems that can best be approached by an integral and coherent local prevention
policy with involvement of a coalition of local organisations.
10.4 Strategies and scenarios for community-oriented prevention
10.4.1 Concept of ‘community approach’ and community interventions
There are different views on what a community approach means. A first division is based on
two kinds of choices. Do we aim to work community-centred, (a) primarily to attune
externally provided preventive services better to the needs and culture of the ‘local market’,
(b) to improve the accessibility and reach of available prevention programmes to citizens by
offering them through local health centres and within the communities people live in
(community-based work) or (3) to have the opportunity to influence social risk and protective
factors in neighbourhoods, schools and workplaces and to create mental health promoting
communities (community development).
The second choice refers to the difference between working ‘top down’ and ‘bottom
up’. Top down means that prevention policies and programmes are primarily based on
professional and scientific knowledge and on policies that have been decided upon by
professional organisations or by national or local politics. These policies can be based on
information from epidemiological research, monitoring systems and needs assessment
studies in local populations (community-targeted). Bottom up means that prevention and
health promotion are developed in close collaboration with citizens and local organisations.
They are challenged and supported to make their own assessments of local needs,
strengths and risks, to choose their own priorities, to develop or select their own health
promotion and preventive programmes and activities, and to evaluate the outcomes and
learn from it themselves. In sum, we can distinguish between four community approaches:
community-targeted
community- and market oriented
community-based
working within the community (nearby)
community-driven
working with the community (= bottom up)
community development
working at improving community conditions (= bottom up)
10.4.2 Alternative community intervention scenarios
Based on these dimensions and subdivisions we describe six different scenarios for
community-centred work. They are currently used in our country to explore options for
community work in prevention and to make choices.
Scenario model 1 (local consulting hours): Working in the community to increase the
accessibility of existing prevention programmes and services (products). During local
consulting hours, mental coaching can be offered and citizens in need can be
referred to intervention programmes. Prevention professionals and health promotors
work closely together with primary health care professionals and stimulate that they
also refer to available prevention programmes. This scenario is mainly aimed at
improving the reach of existing programmes that mostly are offered by organisations
outside the community to whole city or district populations. Much attention is paid to
marketing, being visible and accessible.
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Scenario model 2 (integrated in primary health care): Prevention professionals work
as part of primary health care teams or community centres. The aim is first to
increase the accessibility of preventive services (like in scenario 1), but also to
integrate such services in primary health care by collaboration with other
professionals and, secondly, to increase the preventive capacities of other primary
health care professionals through case-centred or professional-centred consultation,
educational methods and joint team meetings.
Scenario model 3 (community-oriented project): Responding to signals from local
organisations or by using other methods of needs assessment a specific prevention
programme is developed or selected and offered to the community. This may be a
school project on bullying prevention, a parenting education programme, or a project
for elderly on befriending and preventing depression. The prevention professional
acts as project leader. The professional can be working from an organisation located
outside the community.
Scenario model 4 (public health planning): Using epidemiologic research, monitoring
systems, interviews with community leaders and local organisations all health and
mental health needs are assessed. This can be done, for instance, by a district public
health or mental health centre. Based on the outcomes an integral health promotion
plan is designed for that community and a package of programmes is proposed by
the Centre that is tailored to the assessed needs of the community. Next negotiations
start with local organisations and community leaders to get the programme in the
package implemented. Some related problems could be addressed by specific
clusters of related interventions.
Scenario model 5 (Communities-that-Care): This model is described extensively in
box 10.4, overlaps with scenario model 4 with one crucial difference. CtC offers
communities a standardised and science-based framework for community work on
youth problems. From the start of the assessment process, local organisations and
citizens are given an active role in defining their own profile of needs, making their
own selection of programmes tailored to their needs, and taking responsibility for the
implementation and evaluation of outcomes. The CtC model applies a standardised
set of risk and protective factors for needs assessment and uses prevention
programmes and interventions that are nationally recognised and evidence-based.
CtC uses a standardised planning model combining a top-down and a bottom-up
approach. A professional acts as project leader and is supported by a
multidisciplinary local prevention team.
Scenario model 6 (community empowerment model): Citizens, local organisations,
local professionals and community leaders are stimulated and supported to deliver as
a coalition their own needs assessment, making use of questionnaires, social media,
panel groups, working committees and community meetings. They are not only
stimulated to make a profile of their needs but also of their strengths, which they can
use to deal with local problems. Identified problems in the community may also
include social conditions considered a threat to the health and well-being of citizens
in the community. This community analysis could also include making an inventory of
bottom-up ideas about possible solutions and actions.
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Box 10.4 Communities that Care
Alcohol and drug use, aggressive behaviour, depression, school drop-out, youth delinquency and
teenage pregnancy are common youth problems in many countries. In response, the last three
decades many evidence-based intervention programs, especially school-based programs have
been developed en implemented. Many of these programs are single programs that address one
specific problem (e.g. bullying or depression) or use one specific method (e.g. a classroom
approach or a range of course meetings). Communities-that-Care (CtC), however, represent a
more comprehensive response to these problems that uses a community approach (Hawkins &
Catalano, 2002). It was first introduced in the US during the 1990s and is to date adopted by
many countries around the world, including several European countries and Australia. In our
country it has been implemented in more than 20 municipalities (Steketee et al., 2006).
Communities that Care is not a prevention program in the traditional sense, but could best be
characterised as a theory-based, integral and organisational prevention approach to local youth
problems. It aims to develop safe and viable neighbourhoods, where children and youngsters can
feel appreciated and are stimulated to develop and use their capacities. Ultimately it is expected
that different types of youth problems, especially externalising problems (as substance use, youth
delinquency and school drop-out) can be reduced and prevented.
The essential features of CtC are:
1. A community approach of youth problems: these problems are analysed across whole
neighbourhoods, local citizens and organisations are actually involved in making this analysis,
choosing specific intervention programs, helping to implement them and evaluating results.
2. Problem analysis and selection of interventions are science-based. CtC targets a cluster of
related problems and 19 common risk factors and 14 protective factors that are anchored in 4
domains (family, individual children/youngsters, schools, community). By way of local
research problems and factors are identified that are most relevant for that community. They
are described in a community profile from which priorities are chosen.
3. Only evidence-based prevention programs are used. Based on the selected priorities,
community representatives choose the best fitting programs from a pool of programs that
have proven to be effective in communities or schools elsewhere. This pool is accessible
through a national database in which only effective programs are included that meet high
quality standards. For the Netherlands: www.nji.nl.
4. CtC works with a standardised implementation process of 3 years: (a) preparation period, (b)
introduction of CtC and getting community support, (c) making a community profile of
problems, risk factors and protective factors, and already ongoing activities (d) developing a
CtC prevention plan, and (e) implementation of the plan and outcome evaluation.
5. Outcome research: Evaluation studies are stimulated in the CtC communities through regular
monitoring of problem behaviour, risk and protective factors, participation in CtC interventions
using standardised indicators.
CtC is an example of a smart combination of a ‘top down’ and ‘bottom up’ strategy in which
citizens, local organisations, policymakers, prevention teams and scientists work closely together.
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Box 10.4 continued
Evaluation and effects of CtC

The CtC strategy seems implementable and contributes to community involvement and more
collaboration on prevention between multiple organisations and public sectors. It improves the
fit between local needs and provided prevention programs, and also the number and quality
of the provided programs in a community (Steketee et al., 2006)

Training of local professionals, community leaders and the local prevention team results in
significant improvements of their attitudes and relevant knowledge, and in better internally and
externally functioning of the local CtC coalition (Feinberg et al., 2002).

The experienced effectiveness of CtC is related with the quality of functioning of the local CtC
coalition and the level of ‘community readiness’ (problem awareness, already present
prevention activities, knowledge about prevention options, investment by local organisations,
leadership and available resources for prevention (Feinberg et al., 2004).

It takes 3 to 5 years to get evidence of community effects at the level of risk and protective
factors, and over 5 years to show community effects in terms of reduced alcohol and drug use
and youth delinquency.

In comparison to control communities, in CtC communities a reduction in risk factors and less
early delinquent behaviour was found (Hawkins et al., 2008).
Based on Feinberg et al., 2002; Hawkins et al., 2008; NIZW, 2000; and “Opgroeien in veilige wijken /
Growing up in safe communities” (Steketee et al., 2006).
Based on the outcomes an action plan is made. Next, projects, activities or proposals
for measures are developed by the local participants. These actions can also aim to
improve community conditions (e.g. more safety, more opportunities for jobs or
voluntary work, support systems, and more resources for prevention activities). After
community approval, participants play an active role in the implementation of these
activities to actually improve their community. A health promotor or prevention
professional could act here as a supportive advocate, as an expert consultant or as a
facilitator of the process. Core principle in this model is the empowerment of a
community to create themselves a health promoting living environment.
Together these six models compose more or less a dimension from low intensity to a high
intensity community approach, and from working top down to bottom-up. The Community
Empowerment Model is the most profound ‘bottom-up’ scenario.
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10.5 Professional roles and competencies
In community practice, many different disciplines are involved such as general practitioners,
public health nurses, paediatricians, social workers, psychologists, educationists, health
promoters who work in primary health care, schools, occupational health, local social or
mental health services, hospitals or services for elderly, district public health centres or
community organisations. In community practice, they fulfil different roles, which are partly
traditionally defined by their discipline. In the currently changing health settings and
community practices, professionals with the same discipline, for instance a psychologist, can
choose between divergent professional roles and tasks. These are linked with the different
scenarios for community work that we sketched in the preceding section. In their community
practice, they could do client-centred, professional-centred, organisation-centred or
programme-centred work. In Box 10.5, we describe nine role profiles. For simplicity here we
use only the term ’prevention’, with the intention also to include mental health promotion.
Professionals could focus at one profile or chosen for a combination.
Box 10.5
Possible professional roles and tasks in community prevention
Role, function, task
Description
Client-centred mental health
professional or consultant
Early detection and short-term psychological treatment in primary
health care; individual mental health consultancy and coaching.
(indicated or secondary prevention)
Client-centred and groupcentred educator and trainer
Providing preventive interventions and mental health promotion
activities directly to citizens or groups at risk
(universal, selective and indicated prevention)
Mental health or prevention
advocate
Advocates for more attention and investment in mental health
promotion and prevention by primary health care workers, local
organisations, policymakers, schools, companies and citizen
groups. Uses lobbying, media, reports, agenda setting techniques
Organisation- or
programme-centred
consultant or trainer
Offers consultancy, education and training to local organisations,
professionals, policymakers, companies, managers, community
leaders to increase their capacities in mental health and prevention
Programme or project
manager
(a) Initiating, developing, adapting and improving new prevention
programmes or projects
(b) Managing and co-ordinating local projects and programme
implementation
Network or coalition
developer or manager
Developing local collaboration, networks and coalitions of local
organisations and stakeholders to address collectively a local health
or social problem through a common integral policy, common
projects or actions, co-ordination of services, or mutual support.
207
Community developer
Working with local organisations and citizen groups at improving
community and social conditions for health, mental health and wellbeing of the community population. Emphasis on bottom-up and
empowerment strategies, and increasing their power to influence
local health and social policies.
Practice-oriented researcher
Needs assessment: epidemiological, indicator and record studies;
individual and group interviews, observational studies and literature
research to identify local problems, prevalence, risk factors and
strengths, groups at risk, social networks, activities, service use.
Evaluation and monitoring studies to assess process, quality and
reach of interventions and activities, community satisfaction,
intervention outcomes, public impact, and economic evaluation.
Fundraiser
In combination with other roles (e.g. advocate, project manager,
network manager), writing grant applications; negotiating with local
governments, funds, health insurers, companies or other
stakeholders about financial or technical support.
These different roles each require different capacities. For instance, to be a good mental
coach to citizens in need or a provider of preventive group courses for citizens at risk for
depression requires different knowledge and skills in comparison to the capacities that a
coalition developer, a programme manager or researcher needs.
In the end, to develop a competent community each of these roles need to be
covered. Some professionals may combine multiple roles, mostly they are distributed among
different professionals and organisations. This underscores the importance of effective
collaborative networks between local organisations and other stakeholders, and the need for
co-ordination and shared governance.
10.6 Collaboration and coalition development
To be successful, community-oriented work requires effective collaboration between relevant
local parties. We have stressed this already in chapter 3, section 3.4.5 where we described
the field of mental health promotion and prevention as a social arena with different
stakeholders each with their own interest. A challenge to professionals is to find creative and
effective ways to relate these interests and to bring stakeholders together in common multibenefit policies and actions.
Over the previous chapters, it has become evident that for reaching a significant mental
health impact in target populations and communities many tasks need to be performed that
require a wide variety of capacities. Specific capacities are needed for each of the phases of
programme development and planning, capacities from different disciplines that together are
able to influence various types of mental health determinants, and access opportunities to
different population segments, settings and media, different types of intervention
methodologies and different managerial capacities. Even when individual professionals each
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provide high quality preventive work in their daily practice, we need the investment of many
complementary capacities from different professionals and organisations to reach targeted
mental health goals in local populations. This again stresses the need for effective
interdisciplinary and interorganisational collaboration and co-ordination. Successes in public
health are always the result of ‘collective action’.
Methods of collaboration in prevention can vary widely in intensity and degree of
organisation. The list of examples below, illustrate this:
1. Periodically exchanging information between organisations to improve tuning of their
services and divisions of tasks, and continuity of care for citizens. This could also
apply to offered preventive services by different organisations.
2. Making agreements on improved collaboration between health organisations and
other service providers about the quality of their preventive services and
collaboration between professionals who serve similar clients or groups.
3. Development and implementation of a common prevention programme by multiple
organisations. This could apply for instance to improving social-emotional learning in
schools, or improving social contacts and networks between elderly and reducing
loneliness and depression.
4. Structural collaboration between organisations in providing primary health care to
citizens, youth care or services to reduce substance abuse.
5. Development of a common prevention policy by multiple organisations, for instance
in a community at high risk. This also includes managerial co-ordination of activities
and programmes by different organisations. Communities that Care offers a
framework for such a communal approach (Box 10.4). Another example is a common
agreement on collective action to reduce depression in a community or city.
6. Integrating preventive services of different organisations in a new joint organisation,
collectively owned by the delivering organisations. For instance, the founding of a
safe house for women and children who are exposed to severe domestic violence
(e.g. www.veiligheidshuizen.nl ).
Experience has learned that such collaborative relations are not always successful. Effective
collaboration and running effective coalitions is a challenge by itself and requires specific
skills. Studies on large numbers of collaborative projects (DHHS, 2002) and also our own
experience of over forty years of involvement in prevention and health promotion practice
have resulted in a range of insights in features and conditions of effective collaboration. They
can be used as guidelines for collaboration in the future. We have summarised them in Box
10.6.
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Box 10.6 Features of effective and sustainable collaboration and coalitions
in neighbourhoods, communities and municipalities
Structural conditions for successful coalitions
 All crucial ‘stakeholders’ participate
 Sufficient partners participate to create a ‘critical mass’ to influence local public or private
policies and decisions and to generate changes in social determinants of mental health.
 Collaboration at multiple levels: both at administrative and policy level (e.g. Boards,
CEOs, managers, local government), and at the level of practice and implementation
(e.g. practitioners, citizens)
 Visibility and recognition of a coalition or collaborative project in the community, for
instance, through public meetings, media attention and representation in local committees
and networks.
Relation between partners
 Mutual respect, understanding and trust
 Recognition of the added value of collaboration
 Collaboration should have benefits for all partners (Win-Win), and partners are willing to
take into account interests of other partners.
 Optimal use of ‘strengths’ of each partner (e.g. specific expertise, influence, contacts) and
effective concentration of these strengths in an common integral approach
Goals and outcomes
 Common vision, passion and targets and these are made explicit
 Goals and objectives are well-defined and feasible within the available time span
 Goals and objectives could be diverse as long as they are functionally related, different
partners might have primary interest in different parts of this goal system (see goal trees)
 Achieving visible results of collaboration and providing rewards and recognition
Process
 Open and regular communication
 Clarity and agreement on the division of roles and tasks within the collaborative network
 High quality of leadership in combination with
 Flexibility: response to new and unexpected developments and innovations
 Willingness to reach compromises
Capacity building

Training, education and consultation for participants when needed to perform new tasks
or actions resulting from the collaboration. These could be joint training activities or forms
of capacity building that partners offer each other based on their specific expertise
Resources
 Sufficient financial and personnel resources for co-ordination, support, joint activities
 Involve partners who have resources
 Safeguard continuity in resources to prevent premature endings of successful activities
 Recruit external community support from community leaders, local organisations, media
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10.7 Conclusion
This chapter on community approaches has discussed a rather new and timely development
in prevention. Community approaches are currently in a process of development worldwide.
Developments in fields such as environmental protection, citizen movements, war on poverty
and the stream of social innovation projects around the world (see for instance Stanford
Social Innovation Review) offer a wide range of learning experiences, models and guidelines
for successful community approaches. Prevention in mental health has been for too long a
bit isolated field restricted to the health domain and isolated intervention programmes.
Organising prevention using a community approach offers new opportunities to reach more
citizens, to address a wider range of risk and protective factors and to generate much more
public impact. Mental health promotion and prevention not only contribute to better mental
health and well-being, but also to a wide range of other social outcomes. Communities are
an excellent setting to make this broad spectrum of outcomes visible.
This discussion about community approaches has clearly showed that improving public
mental health not only requires prevention professionals and interventions that each show
high quality and evidence-based outcomes. It has also made evident that such impact
requires working near and with citizens, empowering citizens and local organisations to
increase their capacities to get more control over conditions that influence their life and
emotional well-being. In addition, the chapter illustrates that achieving significant
improvements in mental health of local populations requires a combined effort of multiple
professionals and organisations using a combination of science-based and practice based
interventions that are effective. The next four chapters offer additional insight in how
effective prevention strategies can be developed and how their effects can be made visible.
Finally, we have explained that a community approach is not just one specific strategy. The
term could refer to very different ways of working in and with communities. Which kind of
community approach is chosen depends heavily on what motivates professionals or policy
makers. These motivations could be based on different analyses about the determinants of
mental health (person-related or social), on different views on societies and the role of
citizens and governments (liberal versus social), and on a diversity of interests among
different stakeholders (e.g. mental health or economic interests). We end with the question:
What is your stand in this?
211
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geestelijke (on)gezondheid. Groningen: Wolters-Noordhoff.
Bosma, M. W. M. & Hosman, C. M. H. (1990). Preventie op waarde geschat. Een studie naar de
beïnvloedbaarheid van determinanten van psychische gezondheid. Nijmegen: Beta Boeken.
Feinberg, M.E., Greenberg, M.T., & Osgood, D.W. (2004). Readiness, functioning, and perceived
effectiveness in community prevention coalitions: A study of Communities that Care.
American Journal of Community Psychology, 33, 3/4, 163-176.
Feinberg, M. E., Greenberg, M. T., Osgood, D. W., Anderson, A., & Babinski, L. (2002). The effects of
training community leaders in prevention science: Communities That Care in Pennsylvania.
Evaluation and Program Planning, 25, 245–259.
Feinberg, Mark E; Riggs, Nathaniel R; Greenberg, Mark T. (2005). Social Networks and Community
Prevention Coalitions. The Journal of Primary Prevention, 26(4), 279-298.
Hawkins, J.D., Catalano, R.F., & Arthur, M.W. (2002). Promoting science-based prevention in
communities. Addictive Behaviors, 27, 6, 951-976.
Hosman C.M.H., van Doorm H., & Verburg, H. (1988) Preventie In-zicht. Lisse: Swets en Zeitlinger.
Hosman, C. M. H., Price, R. H., & Bosma, M. W. M. (1988). Evaluatie van preventieve interventies. In
C. Hosman, H., van Doorm, & H. Verburg (Eds.), Preventie in-zicht (299-308) (Dutch).
Amsterdam: Swets and Zeitlinger.
Illich, I. (1974). Medical nemesis. London: Calder & Boyars.
Joffe,J.M. & Albee, G.W. (1981). (eds) Prevention through political action and social change.
Hanover, N.H. : Published for the University of Vermont by the University Press of New
England.
McMillan, D.W., & Chavis, D.M. (1986). Sense of community: A definition and theory. Journal of
Community Psychology, 14(1), 6-23.
NIZW (2000). Communities that Care: Opgroeien in een veilige en leefbare wijk. Utrecht: Nederlands
Instituut voor Zorg en Welzijn.
Nuyten, C., Nijmeijer, B., & Sterenborg, H. (1985). Maatschappijgerichte preventie. Utrecht: Landelijk
Ondersteuningspunt Preventie-ggz.
Sarason, S.B. (1974). The psychological sense of community: Prospects for a community psychology.
San Francisco: Jossey-Bass.
Stanley, D. (2003). What Do We Know about Social Cohesion: The Research Perspective of the
Federal Government's Social Cohesion Research Network. The Canadian Journal of
Sociology, 28, 1, Special Issue on Social Cohesion in Canada, pp. 5-17.
Steketee, M., Mak, J., & Huygen, A. (2006). Opgroeien in veilige wijken. Communities that Care als
instrument voor lokaal preventief jeugdbeleid. Verwey-Jonker Instituut en Van Gorcum,
Utrecht/Assen)
Van Doorm, J.S., Otten, A., & Verburg, H., & (1986). Overzicht RIAGG preventieprojecten 1986.
Utrecht: Landelijk Ondersteuningspunt Preventie-ggz.
Verburg, H., & Van Doorm, J.S. (1988). Inventarisatie RIAGG preventieprojecten 1988. Utrecht:
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Vuori, J., Price, R. H., Mutanen, P., & Malmberg-Heimonen, I. (2005). Effective Group Training
Techniques in Job-Search Training. Journal of Occupational Health Psychology, 10(3), 261–
275.
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Study questions for this chapter

What are developments within prevention, within the health system and within society
that have increased or decreased the interest in community approaches?

What are the different motivations behind the interest in community-oriented policies
and activities in prevention? What are the implications of the different motivations for
how community approaches are defined and for chosen strategies?

What is the meaning of the concept of community? Are there different types of
communities?

What are important features and functions of communities? What is their relevance
for mental health promotion and prevention?

What are the differences between ‘community-targeted’, ‘community-based’,
‘community-driven’ and ‘community empowerment approaches’?

What kind of scenarios is possible within a community-oriented approach? What are
the underlying differences?

What are basic features of the ‘Communities-that-Care’ programme? What are
results of evaluation studies on this programme?

What kind of roles and functions could professionals perform within community
approaches? Does this call for different competencies?

What are features and conditions of effective collaborative relationships and
coalitions for prevention?
213
214
PART III
PLANNING AND STRATEGY
215
216
11
Planning models and processes of planned change
in mental health promotion and prevention
11.1
Introduction
218
11.2
Common stages in planned change
219
11.3
General characteristics and assumptions of stage models
220
11.4
Precede-Proceed Model
223
11.5
The Basic Planned Change Model
226
11.6
From a basic change model to a comprehensive population-based approach
234
11.7
Conclusion
236
Literature
237
Study questions for this chapter
238
217
11
Planning models and processes of planned change
in mental health promotion and prevention
Clemens M.H. Hosman
11.1
Introduction
The development, testing and successful implementation of an effective prevention
programme is a process that takes many years. Achieving an evidence-based impact on the
mental health condition of a whole population or population at risk is a long-term affair. This is
what we learn from earlier successful public health efforts to reduce, for instance, the
population rates of smoking, fatal traffic accidents, fatal coronary artery disease and HIV.
Currently, several programmes that target mental health problems have proven to be effective
in multiple controlled effect studies, and have been disseminated, adopted and implemented
in a wide range of countries across the world. Well-known examples are Triple P on parenting
education, Friends on anxiety prevention, the Coping with Depression Course for people with
depressive symptoms, Communities-that Care for youngsters at risk for externalising
problems, and the Nurse-Family Partnership programme based on home-visiting for pregnant
mothers at high risk. Taking these examples as a point of reference, we estimate the total
period from the first preparations for their designing to their ultimate international adoption and
implementation as a full-blown and effective programme at between 10 to 20 years. The
process from first invention through many improvements, try-outs and outcome studies to their
international dissemination, acceptance and use is a complex process, in which many and
very diverse tasks have to be accomplished, each successfully. Prevention and health
promotion professionals need to understand the ins and outs of such long-term planning
processes and how to manage them.
Of course, these long trajectories do not represent the work that is typical for
prevention professionals and health promoters in local community practices. They can adopt
an existing evidenced-based prevention programme, adapt it to the needs and culture of a
specific school or neighbourhood, and implement it. They also can develop a new preventive
intervention in response to local needs, or support a bottom-up initiative for a preventive
intervention by a primary health care centre, or by a coalition of local organisations and
citizens. Such bottom-up trajectories are, of course, much shorter. Also, when professionals
develop their own local preventive intervention, they need to follow the basic rules and
guidelines for effective programme development. To this end, they use development and
planning models that have proved their value over many years and across many communities
and countries. For our field, such models are described in multiple basic textbooks on planned
prevention and health promotion that we highly recommend to study. We give two examples
of excellent textbooks on programme planning:
Green and Kreuter, (1999). Health Promotion Planning: An educational and environmental
approach.
Bartholomew et al. (2006), Planning health promotion programs: Intervention mapping
approach. San Francisco: Jossey-Bass.
218
This chapter describes the different steps (stages) that need to be performed during the
process of programme development, implementation and evaluation. Models of staged
processes of planned change have been developed to guide processes of problem solving,
decision-making, counselling, psychotherapy, management and consultancy. “Planned
change’ refers to each process of intentional, prepared and goal-oriented change guided by
practice-based and science-based knowledge. Staged models have a long history that goes
back to the 1970s. The systematic use of stage models is regarded a general and necessary
feature of all successful processes of planned change, including the development of effective
prevention programmes.
In this chapter, we first elaborate on the meaning of the term 'stage' and what the most
common stages are in planning of change models. Next, we discuss the elementary principles
and assumptions of stage models. In the remainder of this chapter, we present three different
stage models that are used in the field of prevention and health promotion: the Basic Planned
Change Model, the PRECEED-PROCEED Model and the Development Trajectory of Effective
Population-based Prevention (DEPP).
11.2
Common stages in planned change
In many public and private sectors, ‘planning models’ and ‘stage models’ are used to guide
processes of solving complex problems or reaching challenging targets. This applies to
prevention and health promotion, as it does for areas such as organisation development,
marketing, psychotherapy, urban renewal, engineering, road construction, industrial
innovation, and governmental policy. Reducing the onset of depression in a local population
by 15%, or increasing the average level of social-emotional competence in children and
adolescents in local schools are examples of complex challenges. To accomplish such goals,
we need to plan carefully all the tasks that have to be performed in a coherent way and a
correct sequence in order to achieve in the end targeted mental health objectives.
Planning refers to thinking and decision making in advance about what needs to be
done, when, where, how and by who to achieve chosen goals. It concerns the process of
setting goals and objectives, and outlining all the tasks, strategies and conditions that we have
to realise in order to achieve the targeted objectives. Required conditions could include for
instance, raising money, getting political support, involving relevant stakeholders, and
developing knowledge and expertise to perform the planned tasks and strategies.
Despite the large variety in theoretical models of problem solving and planned change, they
share the notion that the likelihood of successful outcomes is increased when these processes
are divided in subsequent steps or stages, and managed accordingly.
The term stage refers to a cluster of related activities, which together form a specific
functional step in a longer process of planned change. In stage models, each stage has a
specific function, which means a separate goal and the performance of specific tasks.
Examples of such tasks are making a problem analysis, choosing an intervention strategy,
and assessing the outcomes. Successful completion of the activities belonging to a specific
stage is a requirement to perform the activities in the next stage successfully.
In prevention, health education and health promotion multiple stage models are in use.
They differ depending on their scope, context of use and the nature of their final goal. Some
219
are designed to guide a one-time
local project, others to develop
transferrable model programmes
or to implement them on a large
scale. Planning might concern the
nationwide prevention of a
specific disease in a defined
target group at risk, while in other
cases multiple highly related
problems and diseases might be
addressed. The different stage
models, however, also share
many similarities, for instance
most stage models have the same basic structure. Figure 11.1 reflects such a Basic Planned
Change Model that we introduced in the Introduction chapter. The model differentiates
between seven basic stages and their mutual relationships.
1. Orientation and defining starting position
2. Problem analysis
3. Goal and target population analysis
4. Strategic analysis and programme design
5. Operational analysis
6. Intervention
7. Evaluation
A full description of this basic model is presented in section 11.5. First, we discuss the core
characteristics and assumptions that all stage models have in common.
11.3
General characteristics and assumptions of stage models
As explained above, stage models are popular among professionals involved in processes of
planned change or solving complex problems. Which common principles do stage models
have? Below we describe the following six: segmentation of a problem, functional order, goal
orientation, rational thinking, cyclic character, and offering a structure for task allocation and
needed resources.
Segmentation in sub-problems
Problems are often so complex that one can become overwhelmed by the large number of
themes and issues that need to be addressed at the same time. Precisely for this reason, it is
difficult to resolve complex problems. One way of coping with this is to divide a complex
problem in several sub-problems or tasks, which each can become more easily resolved.
Segmenting a problem can be done in different ways. Take, for instance, the case of lowering
the high incidence of depression in a community. One way to segment such a challenge is to
divide the problem of depression into five segments, each addressing a different group at risk.
We could run five prevention projects simultaneously, each targeted at a different, but smaller
group. Even then, each project is still a challenge. Through stage models, the process of
220
achieving a targeted outcome (i.e. lowering depression incidence) can be segmented in
dealing with a range of subsequent smaller problems, each representing a specific task in this
problem solving process. For instance, first solving the problem of understanding what the
causes are of the high incidence of depression; secondly, the challenge of selecting and
formulating realistic and achievable preventive goals (e.g. Is a reduction of 15% achievable in
4 years?); thirdly, designing an effective preventive strategy; fourthly, getting the strategy
implemented community-wide; and fifthly, finding valid tools to evaluate whether the
implemented strategy has been successful and whether the incidence has been reduced.
Functional order
As is illustrated above, a complex problem could be segmented into smaller sub-problems that
are functionally related and need to be solved in a specific order. Typical stages in this process
of problem handling are problem orientation, problem definition, generation of solution
alternatives, decision-making, execution, and evaluation of the effects (D'Zurilla & Goldfield,
1971; Nezu, 1987). The functional order makes that each sub-problem can be considered as
a specific stage with its own targets. The resolution of each previous sub-problem is always a
prerequisite to work on a next one successfully. Each stage needs to result in a certain
outcome that provides the basis for working successfully on the challenges in the next stages.
When sub-problems are not resolved in the right order, the chance of resolving the total
problem becomes smaller. A typical pitfall among practitioners is to select very quickly a
standard intervention method after a problem is presented to them, without taking time to run
a deeper problem analysis and intervention analysis to understand what intervention method
might be the best to solve the problem and achieve the goal.
Mutual qualitative dependency
In addition, qualitative dependency is assumed between the stages. The better the results of
the previous stage, the more chance exists to successfully resolve the next stage. The quality
of each separate stage depends on three conditions: rational decision-making, sufficient and
valid information, and expertise. For example, running a problem analysis stage poorly might
lead to the selection of ‘risk factors’ that are only correlates of the targeted problem, not causal
factors. Addressing them in interventions will have no impact on the incidence of the problem
and will not result in any preventive effect.
Goal orientation
Stage models and separate stages have a goal-oriented character. Stage models are used as
a tool to achieve a certain end goal better. Each separate stage in the model has also its own
goals. The goals of all the subsequent stages together constitute a functional goal-chain that
in the end should result in achieving the ultimate goal of a programme or project. The nature
of these intermediate goals reflects the functions of the subsequent stages. Some examples
of stage related goals: having insight in the risk and protective factors of a problem and in the
groups most at risk; having defined all relevant intermediate and ultimate objectives; having a
realistic intervention plan available; having the plan translated in a concrete and
implementable programme, the successful implementation of the programme and having
reached a sufficient large part of the target population.
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Rationality
Both for stage models as a whole and for each individual stage, working systematically and
making rationally informed choices are necessary to resolve the targeted problem
successfully. Rationally informed choices require the availability and consideration of both
science-based and practice-based evidence. Not only a whole planning process, but also each
stage in itself represents a problem solving and decision process, in which several sub-stages
can be defined. For each stage (a) the aims and the planning of work needs to be defined, (b)
planned work needs to be executed professionally and in accordance with the plan, and (c)
the results need to be evaluated on their quality and relevance. For instance, during the
problem analysis stage: (a) a planning needs to be made for the problem analysis (e.g. type
of questions, assessment methods, way of analysing the results), (b) the planned problem
analysis needs to be executed, and (c) in the end it needs to be evaluated whether the problem
analysis has been done properly and whether it has served its purpose. Such a problem
analysis might include running an epidemiological study or organising a range of interviews
and focus groups. As we will discuss later, a problem analysis is also subdivided in answering
different analytical questions (section 11.5).
Stage models as a whole and each separate stage represent a rational process, in
which the best solutions are sought purposefully and systematically. This rationality maximises
the perspective on an effective prevention programme and serves to justify the choices made
to funding agencies, government, or clients.
Cyclic character
Although this is not true for all stage models, most of them use feedback mechanisms. This
means that in each stage certain problems can arise which make is necessary to return to an
earlier stage and to go through it once again, but in a different way or more precisely.
Sometimes professionals go through the stages of problem analysis, goal analysis and
strategy development several times, first globally and next increasingly more specified
(Hosman, 1994). A first global problem analysis can lead to a global, preliminary strategy
selection, which already gives some direction to a prevention programme, for instance offering
a preventive training to those at risk. For the elaboration of this strategy and to decide what
exactly needs to be trained and how, it is necessary to look again but more specifically at the
problem analysis. Results of try-outs can call for a redefinition of goals or a change in strategic
choices. Although a functional order usually refers to a linear process, in practice it is a cyclic
process with many feedback loops.
Structure for allocation of tasks, necessary skills and information
Each stage requires different professional tasks and therefore different skills and familiarity
with different fields of knowledge. For instance, problem analysis requires skills in using
different types of needs assessment methods (e.g. survey techniques, epidemiology, interview
techniques, and focus group method) and knowledge about theories and research on problem
development and causal factors. Strategy development requires thorough knowledge on
evidence-based prevention strategies and programmes, their outcomes and relevant effect
moderators. Evaluation requires skills in applying qualitative and quantitative evaluation
methods, and understanding the principles and strategies of controlled effect studies.
Moreover, working professionally with staged models requires the skill to make grounded
decisions in each stage. This means, that stage models also offer a framework to describe the
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different fields of information and expertise that professionals need to acquire through
professional training and experience (Price, 1987; Hosman and Brinxma, 1978; Diekstra and
Hosman, 1980). In summary, we conclude that:







Stage models can be used as a tool - planning instrument - to solve complex problems
and to control processes of change;
Complex problems are broken down in manageable sub-problems or tasks which are
functionally related;
Working on their solutions needs to be done in a certain order, in which the solution of
each sub-problem represents a separate stage in the total process;
Successful completion of a specific stage depends on the outcomes and quality of the
work in the previous stage;
Stage models and their separate stages are goal oriented, and characterised by a rational
decision process;
Stages are not completed in sequence, but there is regular feedback to previous stages,
which could lead to running previous stages again but in a more specific or better way;
The use of stage models provides a planning framework for the different types of
information needs and needs of professional expertise.
In the next sections of this chapter, we will discuss three types of such stage models: the
PRECEED-PROCEED planning model, the Basic Planned Change Model, and the
Developmental Trajectory for Effective Population-based Prevention. For another well-known
planning approach in health promotion, the Intervention Mapping Approach we refer to the
textbook on this approach by Bartholomew, Parcel, Kok, and Gottlieb (2006).
11.4
Precede-Proceed Model
The PRECEDE-PROCEED planning model, used in health education and health promotion
worldwide, is designed by Green and Kreuter (1999). Its unique feature is that it depicts a
systematic planning process in which a link is made between elements of a social-behavioural
model of health and stages in designing, implementing, and evaluating a health promotion
programme. PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in Educational
Diagnosis and Evaluation) involves problem analysis and intervention planning. PROCEED
(Policy, Regulatory, and Organisational Constructs in Educational and Environmental
Development) guides the implementation and evaluation of the programme designed during
the PRECEDE phases.
PRECEDE consists of five steps or phases (Figure 11.2):

Social diagnosis: involves determining the quality of life or social problems and needs of
a given population. Emphasis is on people’s own perceptions of such needs and involving
citizens in making a diagnosis of their own life and community. Also, other relevant
stakeholders can be involved in this diagnosis (e.g. community leaders).

Epidemiological diagnosis: consists of identifying the most important health problems in
the population (prevalence and incidence) and determinants of these problems (risk and
protective factors) with use of epidemiological research methods.
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
Behavioural and Environmental diagnosis: involves analysing the behavioural and
environmental determinants of a health problem that is prioritised during the social and
epidemiological diagnosis. In the behavioural diagnosis, a study is made of the type of
behaviours and lifestyle components that influence the onset of the targeted health
problem. These could concern risky behaviours and life styles (e.g. regular substance use,
smoking, counterproductive coping styles, anxious behaviour) but also health promoting
behaviours (e.g. exercise, healthy eating habits, support seeking, positive parenting). The
environmental diagnosis concerns the analysis of social and physical factors that may
influence behaviour or have a direct influence on health or quality of life (e.g. influence of
drug using peers, quality of foods in supermarkets, availability of fitness facilities, parental
mental illness, domestic violence, school policies).

Educational and Organisational diagnosis: identifies the factors that predispose to,
reinforce or enable behaviours and lifestyles identified in stage 3, and selects those
behavioural and environmental determinants that you want to influence. These could also
include behaviours of relevant stakeholders, such as teachers, caregivers or managers.
-
Predisposing factors provide the motivation or reason behind a behaviour; they include
knowledge, attitudes, cultural beliefs, readiness to change, etc.
-
Enabling factors make it possible for a motivation to be realised; that is, they "enable"
persons to act on their predispositions; they include skills, available resources,
supportive policies, assistance, and services.
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-

Reinforcing factors come into play after a behaviour has begun, and provide continuing
rewards or incentives, that contribute to repetition or persistence of the behaviour.
Social support, praise, reassurance, and symptom relief might all be reinforcing
factors.
Administration and policy diagnosis: involves ascertaining which health promotion and
preventive interventions or which policies and measures would be best suited to generate
the desired changes in behaviours or environments and in the factors that support those
behaviours and environments.
PROCEED is composed of four additional phases.

Implementation: converting a programme design to actual activities, and coordinating
the implementation and management of the programme.

Process evaluation: the evaluation of the quality and feasibility of a new policy or
programme, the quality of the used materials, staff, presentation and offered services,
and how participants and other stakeholders respond to the programme. This could
also include identifying unexpected negative outcomes or side effects of a programme.

Impact evaluation: involves evaluating the immediate effects of a programme on
intermediating goals such as behaviour determinants, behaviour and environmental
factors.

Effect evaluation ('outcome evaluation'): determining the ultimate effects of the
interventions on indicators of the health and quality of life of the population, or on a
specifically targeted health problem.
We emphasise here that the labels ‘impact’ and ‘effect’ are used in different ways in the
literature. In many other publications, impact usually refers to the range of ultimate outcomes
that a programme is able to generate in a targeted population. Besides population health
effects, such ‘public impact’ might also include social and economic benefits that result from
improved health.
PRECEDE and PROCEED function as a continuous cycle. Information gathered in
PRECEDE guides the development of programme goals and objectives in the implementation
phase of PROCEED. This same information also provides the criteria against which the
success of a programme is measured in the evaluation phase of PROCEED. In turn, the data
gathered in the implementation and evaluation phases of PROCEED offer a check on the
relationships that were studied in PRECEDE between the health or quality-of-life outcomes,
between behaviours and environments and these health and social outcomes, and a check
on the factors that were assumed to generate the desired behavioural and environmental
changes. These data might also suggest how programmes could be improved to reach their
goals and targets more closely.
Limitations
Despite the international popularity of the PRECEDE-PROCEED model, it also has some
drawbacks and limitations. First of all, the model does not really make a distinction between:
(a) one-time prevention programmes that are developed bottom-up with local citizens or
organisations (b) the development and testing of effective model programmes, and (c) the
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large-scale dissemination and implementation of best practices and evidence-based
programmes across many communities, nationwide or even internationally.
Secondly, PRECEED-PROCEED is centred around a specific social-behavioural
health model that does not sufficiently reflect the complexity of risk and protective factors that
play a role in the development of health and disease, nor how they emerge and their dynamic
interplay across the lifespan. Especially for the underpinning of preventive interventions in the
field of mental health, the included determinant model is insufficient and does not reflect
current theoretical frameworks on mental health. The developmental psychopathology
framework (chapter 6) and the integrated stress theoretical approach (chapter 7) offer in our
view a better starting point for the deduction of strategies that can prevent mental disorders
and improve mental health. A framework is needed that is able to integrate the numerous bits
of information from the many thousands of studies on risk and protective factors in mental
health. With such an integrative framework we will better understand what the summarised
research outcomes tell us, how different factors across multiple levels and across the life span
interact (chapter 4), and what this means for strategic options to preventive action.
Aside from these limitations, the PRECEED-PROCEED model has also many
strengths, as is evident from the wide use of this model in health promotion. The model offers
a very clear structure for planning and analysis and its 9 phases are transparently linked to
well-defined domains of relevant actions, factors, and outcomes. The book on Health
Promotion Planning (Green and Kreuter, 1999; Tones and Green, 2004) offers an elaborate
description of the model, its phases and its application to planning and research.
11.5
Basic Planned Change Model
The Basic Planned Change Model consists of seven stages that can be used to develop an
effective prevention programme (figure 11.1). The goal of this model is to provide practitioners
and researchers a framework for the stepwise design, implementation and evaluation of
prevention programmes. The model can also be useful for the development of evidence-based
model programmes aimed to be suitable for large-scale implementation. However, for the
planning of large-scale implementation of programmes the model should be extended with
additional stages that specially target the process of dissemination, adoption and
implementation of model programmes. Such an extended model is described in section 11.6.
Each stage in the basic model is elaborated in a number of sub-stages, in which specific subtasks and decision moments are discerned. These are summarised in Box 11.1 and described
below:
Stage 1: Orientation and defining starting position
When setting up a local prevention programme the first and very important action is to
orientate yourself at and define your starting position. This means answering questions like:
Who is or are the initiator(s) and leaders of the project? What interests and whose interests do they
represent? These might be interests of the target population or entirely different interests of other
stakeholders such as health care managers, school managers, government, companies or health
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Box 11.1
Stages of Basic Planned Change Model
Stage 1




Focus on a specific problem from the start? Which problem or theme?
Who is initiator? Other stakeholders involved? What are their interests?
Features of your own organisation and implications (e.g. mission, positioning,
disciplines, expertise, capacity restrictions, role in this project)
Access of your organisation to target populations
Stage 2






Analysing the starting position
Problem analysis: Policy or Programme-focused?
Problem description & Needs assessment
Analysis of determinants & development
Network analysis: who has what kind of influence?
Capacities & strengths assessment, and comparing needs with capacities
Drawing conclusions for goal setting, target population and strategy
Stage 3
Goal and target population analysis
Goal analysis and goal setting
 Multiple goals and hierarchy of goals
 Ultimate and intermediate goals (short-long term)
 Defining goals and ‘goal-trees’
Analyse and define target population
 Selecting, defining, segmenting target populations
 Ultimate and intermediate target populations
Stage 4
•
•
•
•
•
Stage 5






Implementation
Recruiting and involving participants
Actual implementation
Quality management of implementation (training and supervision;
programme fidelity; implementation monitoring; reducing drop out)
Enhancing frequency and duration implementation
Stage 7





Operational planning
Writing a programme manual and developing materials
Try-outs and improvements
Marketing and advocacy, getting community support & developing coalitions
Capacity building: personnel and training; financial resources
Planning evaluation
Stage 6



Intervention analysis and strategy development
Targeted determinants and target groups
Settings and system level
Intervention methods & mechanisms; one intervention or combination
Timing and dosage
Choice of provider
Evaluation and feedback
process evaluation and satisfaction
efficacy and effectiveness
reach in target population
costs and cost-effectiveness
feedback and improvements
Hosman 2014
227
insurers. The primary interests of these other stakeholders may concern a reduction of health
care costs, less school dropout or less production loss.
-
What is the problem and why is it necessary to take action? For example, there might be an
acute problem that must be resolved quickly (e.g. increased violence by juveniles in a
neighbourhood) or a long-standing problem, such as high levels of depression in society. It
might also be a problem that is expected in the future, e.g. increase of dementia due to the
growing number of elderly above the age of 80 years.
-
Who and which organisation(s) will be involved in the development and implementation of the
programme? Are these primary health care organisations and mental health care services, or
also governmental agencies, employers or citizen groups representing the target population?
-
From which point of view will the problem be approached: from a prevention expert and science
point of view, a mental health care point of view, a public administration point of view, an
economic point of view, or from the experienced needs and views of the involved citizens?
When a scientific approach is used, which theoretical model will dominate in the project?
-
What budget and human capacity possibilities does the prevention project have? What
constraints should it take into account?
Stage 2: Problem analysis
In this stage, an in-depth analysis is made of the problem, its background and social context.
This stage is subdivided in three types of analysis:
1. Problem description: involves (a) an analysis of the type of the problem, (b) an estimation
of the seriousness of the problem (expected short and long term health, social and economic
outcomes), (c) prevalence and incidence of the problem and (d) the identification of groups at
risk.
2. Determinant analysis: this analysis is preferably performed from one or more explicit
theoretical approaches with an open eye for different views. It includes: (a) identifying risk and
protective factors, their longitudinal development and their causal importance (attributable
risk); (b) estimation of their changeability; (c) identification of previous attempts by the
audience and its social network to influence the problem and the effects of these attempts; (d)
assessment of the strengths of the target population and their communities that could be
activated to find solutions; and finally (e) drawing conclusions about the need for professional
preventive support. Based on these questions it will be determined which aspects are eligible
for preventive interventions. The determinant analysis usually looks at factors at micro-, mesoand macro-level, both those that directly precede the onset of the problem and those that have
originated much earlier in the lifespan. To identify determinants theoretical approaches can
be used, that we have discussed in chapters 4 to 10.
3. Network analysis: The goal of this analysis is to get a clear picture of the social interactions
and social contexts of the target group and how they affect the development or persistence of
mental health problems or support mental health. Preventive interventions are often not
directly targeted at groups at risk, but at persons, groups or organisations in the social context
of the target group. They represent potential ‘intermediate’ target groups, as they have or
might have some influence on identified mental health determinants and could play a role in
preventing problems or improving mental health. Among them, we differentiate between
persons and groups at the micro level (e.g. family, friends, colleagues, and peers),
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organisations and systems at
the
meso
level
(e.g.
neighbourhood, school, work,
care institutions) and at macro
level (e.g. ministries, mass
media,
justice,
national
NGOs).
A network analysis can
be described in text, but
preferably also in a visual map
of the network that can be
used
for
communication
purposes or planning. This
map can be displayed in two
ways. One scheme consists of
a series of concentric and
increasingly widening circles
(Figure 11.3). The ultimate
target group is placed in the
centre, i.e. the group in which
eventually a preventive effect
has to be achieved. The circles
step-wise further from the
centre represent respectively
the micro-, meso- and macroenvironment. In each of these
environmental levels individuals, groups, organisations
or other systems can be
specified that might have
contact with people from the target group or have influence on them. The other possible
scheme consists of a series of small, independent circles that each are connected with other
circles by arrows. Each arrow represents a possible influence from one system or person on
the other. Figure 11.4 offers an example of such a map from bullying prevention. Chapter 9
on social networks provides a more detailed description of the method.
Stage 3: Goal and target population analysis
Goal analysis
Preventive interventions often have multiple goals. In Chapter 12, we will discuss the issue of
goals setting and differentiation between types of goals more extensively. First, you need to
define the primary long-term goals you want to achieve through a preventive intervention or
mental health promotion programme. Apart from defining the mental health objectives, it is
also important to define which social or even economic benefits might be achieved by your
mental health interventions. These are useful as secondary goals. This requires insight in how
mental health or mental disorders are related to other negative or favourable outcomes outside
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the mental health domain. For instance, stronger mental capacities might contribute to better
school achievements, more chance of getting a job, more satisfying relationships and being
more productive. We have discussed such positive personal, social, and economic outcomes
of mental health at the start of this book and when we discussed the functional model of mental
health (section 3.2.3). Defining such secondary goals and outcomes might provide a strong
base for getting wider public support for mental health promotion and prevention, collaboration
from different stakeholders, more investment of resources, and better conditions for
successful large-scale implementation of programmes.
Ultimate goals are only achievable when we first are able to achieve several
intermediate and proximal goals, such as reducing selected risk factors and strengthening
protective factors. We need to make use of functional goal chains (section 12.5), that describe
multiple goals as subsequent and functionally related steps, necessary to reach a final goal,
for instance, a significant reduction of depression or substance use in a community. Such goal
chains can also include goals we need to achieve in intermediate target groups (e.g. teachers,
parents, local community leaders, health insurers).
Target group analysis
Define as precisely as possible the target populations of your intervention, while making use
of inclusion and exclusion criteria. Especially in selective prevention, where we target
populations at high risk, it is common that such populations are defined too broadly. This
increases the risk of working inefficiently by including many persons that are not really in need
of such a programme. For instance, several prevention programmes target in general young
children of parents with a mental illness (COPMI), while we know that not all these children
are at high risk. Therefore, for specific programmes we could better narrow the target group
definition to only those children living in families wherein parental mental illness is associated
with an accumulation of risk factors and poor support systems.
As we have stressed earlier, it is common to differentiate between the ultimate target
population, in which you want to achieve preventive effects, and intermediate target groups
such as parents, teachers, GPs, employers or municipality officials. Intermediate target groups
are chosen from network analyses as we earlier discussed. Using such intermediate persons
or groups may serve a diversity of strategic aims. For instance, they could be necessary to
reach the final target population at risk, to get a risk factor changed that is under their influence
(e.g. child neglect), or to provide the actual intervention on a larger scale. Understanding what
their strategic role could be requires a good understanding of what role such network persons
or systems fulfil in relation to your target population. Finally, as an outcome of a network and
target group analysis, a functional chain of subsequent target groups could be defined. This
chain describes a series of persons, organisations or groups from which we assume that they
will consecutively influence each other, e.g. journalists  teachers and health care
professionals  parents  COPMI children. We sometimes assume in such cases that we
are able to create domino-effects across such a chain of target groups.
An important part of each target group analysis is segmentation: usually within each
target group, multiple segments can be defined. Segmentation can be needed because a
target group is not easily reachable through one setting or one communication channel.
Subgroups could be differentiated to reach the total target population better with recruitment
strategies that are adapted to each subgroup. People in the same target population at risk
might also have different profiles of risk factors, different cultural features or may be different
230
in readiness to change. Prevention programmes need to be adapted to such features. Special
programme versions might be needed for different age groups, cultural subgroups, or for lower
educated people. For instance, for COPMI we have designed special programmes for children
of 0-4, 4-8, 8-12, and 13-18 years old respectively.
Stage 4: Strategic analysis and programme design
This stage is focused on making a range of strategic choices, which together define the major
features of the preventive intervention you want to design. These include choices on multiple
strategic dimensions:
a. Determinants: Which risk and protective factors are targeted directly or indirectly
through the intervention? Which chains of causally related factors do we aim to
influence?
b. Target populations and segments: At which target groups or segments, intermediate
target groups or networks is the intervention programme targeted? Is the preventive
target population addressed directly or through intermediate target groups or
systems? Or both?
c. System levels: At which system levels is the intervention directed (micro, meso, and
macro)?
d. Settings: In which setting is a prevention programme offered and implemented (e.g.
primary health care, school, work, and neighbourhood)?
e. Intervention methods and mechanisms of change: Which intervention methods and
mechanisms of change are selected to generate the targeted changes in the target
population or environment? Examples of methods: group courses, self-help books,
staff training, organisational or policy advice, legislation. Examples of mechanisms:
modelling, emotional support, setting norms, rewards and sanctions.
f.
Timing and dosage: At which moment or phase along the live span will the
intervention be most effective? How long should be the duration of the programme
to make it effective?
g. Providers: Who should actually implement the interventions? Who is best able to
connect and support a target group? Health promotion specialists, caregivers,
community leaders, persons from the social networks, experts by personal
experience, peers?
(See chapter 13 for a more detailed discussion of these dimensions)
The choices on these dimensions together determine the profile of a prevention strategy. At
each of these dimensions not only one but several alternatives can be chosen (e.g. several
factors, several intermediate targets and multiple methods), also we need to choose whether
we go for a single intervention or a multicomponent prevention programme by combining
several interventions. Combined interventions can be performed simultaneously or
sequentially. The last is recommended if the results of intervention A serve as a precondition
for the successful implementation of intervention B. For example, in a school programme a
first intervention is often targeted at teachers (e.g. training) after which the trained teachers
can effectively provide school-based interventions directly to children and parents.
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Logic modelling
The final document of this stage includes a description of the chosen intervention strategy,
where choices on the strategic dimensions are briefly described and justified. In the case of a
multi-component programme, the individual sub-programmes are specified. To make such a
strategic plan and its underlying theory and assumptions visible, it is common to use logic
modelling also called a visual representation of the programme theory. Descriptions of how to
design a logic model can easily be found on the internet and in the following publications (W.K.
Kellogg Foundation, 2004; Funnel & Rogers, 2011; Taylor-Powell & Henert, 2008). A useful
framework for making a logic model is presented in Figure 11.5.
Working with logic modelling has several advantages. First, it is a tool to describe
briefly the whole idea of a mental health promotion or prevention programme. It serves,
therefore, as a useful tool to communicate about a programme design with stakeholders, to
stimulate reflection and debate, and finally common decision making on a new programme.
Secondly, logic modelling challenges programme designers and other stakeholders to make
their assumptions about the programme and how it will work explicit. The model requires
describing the “theory of change” that is underlies the programme. Thirdly, the model defines
the chain of aimed outcomes, which differentiates between “what we do”, short-term
outcomes, medium term outcomes and the final impact of the programme. By defining this
chain of outcomes, the model offers also a framework to guide outcome research. Finally,
having such a logic model available makes it easier to disseminate the programme to others
and to enhance large-scale implementation.
232
Stage 5: Operational analysis
This preparatory stage of the actual implementation involves the operational planning and
preparation and the concrete development of the chosen methodologies. It refers to a range
of practical tasks that need to be performed before the actual intervention can start
successfully. These include, for instance, time planning, writing a programme manual,
designing educational materials, generating support for the intervention from community and
health organisations, fund raising, training of programme providers, developing a supportive
website. Furthermore, in this stage a first try-out of parts of the programme can be done (pilot
study) after which materials and methods can be improved.
Stage 6: Intervention
In the intervention stage, all previous stages come together. During this stage, there is direct
contact with the intermediate or preventive target groups. This usually starts with recruiting
and selecting participants. Subsequently, the actual implementation of the chosen intervention
strategy takes place. Within the intervention, multiple sub-stages can be distinguished such
as motivating for change, learning new behaviour and ensuring the maintenance of new
behaviour. The stage model of Prochaska and DiClemente (1983, 2005) can be used to guide
the stepwise process of developing sustainable behaviour changes in target populations and
their segments. Sometimes the intervention stage overlaps with earlier stages of the cyclic
model. This is the case when target populations are invited to be actively involved in the
problem analysis, goal setting and strategy selection. This is, for instance, mostly the case in
community intervention programmes.
An important task during the implementation is safeguarding the quality of the
implementation. This could include organising continuous support to the actual programme
providers, and monitoring implementation quality and programme fidelity. During the
completion of the implementation, attention should be given to drawing explicit conclusions on
what has been achieved; discussion about the need for follow-up interventions, and
stimulating continuation of the implementation of the programme in the future to new groups
of participants.
Stage 7: Evaluation
This stage concerns the evaluation of the implementation and the programme outcomes, but
may also include an evaluation of the prevention project as a whole, including the process of
programme development. Different aspects of a prevention programme or project can be
analysed. We distinguish the following types of evaluation:
Process evaluation and reach evaluation
This covers questions like: What was the quality of the programme implementation? Which
problems occurred? How did participants evaluate the programme and the providers? What
were the most and least instructive parts? What part of the target population has been reached
so far? What are main bottlenecks in reaching the target population? How could the
programme be improved?
Effect evaluation
In effect evaluation, a distinction can be made between efficacy evaluation and effectiveness
evaluation. Efficacy evaluation refers to research, testing the effects of a new programme in
experimental and carefully controlled conditions: Does the programme work under ideal
233
circumstances? Effectiveness evaluation refers to research that examines whether the
programme also has the expected effects when it is carried out in daily practice, under less
controlled circumstances and on a larger scale. What effects does the programme have then?
Effects can be assessed at three levels. What intermediate effects are achieved in the
intermediate and ultimate target groups (determinants)? What effects can be seen in the
ultimate target groups in terms of better health or disease prevention? What benefits has the
programme achieved at social or economic level? For whom was the intervention most
effective and for whom the least? What are the short and long-term effects? Are we sure the
observed changes can be attributed to the impact of the programme?
Cost evaluation/ Cost-benefit ratio
What costs and other investments were needed to implement a project? How do the costs of
a project relate to the actual benefits (cost-benefit analysis)? For example, a study showed
that the Perry Preschool Program (skills development in children of 3-4 years in risk
populations) yielded economic benefits of $ 258,000 per person over a period of 40 years,
which is over $17 benefit for every dollar invested in the programme (Schweinhart et al, 2005).
Are there any 'costs' in terms of non-intended negative side effects? Could the invested costs
be reduced without decreasing the effect? Could the same effects also be achieved with less
labour intensive and expensive interventions (cost effectiveness analysis)?
Although we have described the seven stages of the model one after the other, the model is
of a cyclical nature. As previously explained, this means that it is possible to switch back to
earlier stages when necessary. Moreover, after the end of a process of programme
development in which all stages have been gone through, there might be a need to test a new,
improved version of the programme based on evaluation of the previous version.
11.6
From a basic change model to a comprehensive population-based
approach
Let us assume that a professional from a local child mental health service has used the Basic
Planned Change Model to run a school-based prevention programme to reduce aggressive
and bullying behaviour among grade 5 children in a local elementary school. The professional
was invited by the school to help them cope with this growing school problem. In collaboration
with teachers and parents, the professional developed and implemented a programme, which
was positively received by the school. Outcome indicators showed that the programme has
been reasonably effective in reaching its goal. The level of problem behaviours declined. If
this was the only aim of the prevention project, the cyclic process can be concluded by drawing
the conclusion that the intervention was successful. Mission completed!
Usually, however, the ambition of prevention or health promotion projects is much wider, and
not restricted to one school or community and to a one-time affair. A common ambition is to
create similar outcomes across a much wider population and to enhance sustainable
implementation of such a programme across many years. In such cases, the Basic Planned
Change Model is insufficient to guide the further steps and we need a much wider planning
framework. The Developmental Trajectory of Effective Population-based Prevention (DeTEPP
model), presented in figure 11.6, describes such a wider planning framework. Before we
234
discuss the main differences with the Basic Model, we sketch different options of how the
prevention project described above could be widened in ambition.
First, the initiating organisation might want to repeat the school-based programme on request
in some other schools and other parts of the same district. Basically, the same staged process
can be repeated as in the first described project, but the stages can be completed much faster
as much work has already been done during the earlier project. Goals, problem analysis,
strategy and practical methods and materials might need some adjustments to the specific
characteristics of the other schools or communities.
As second option, the developed programme is transferred from the agency
responsible for designing the model programme to another agency in the region to ensure the
large-scale implementation of the programme in the coming years. For instance, the
responsibility for the implementation could be transferred from the local child mental health
service to schools and in the future the programme could be provided by teachers or
psychologists from these schools. Performing such a transfer successfully requires several
additional steps. First, schools in the district need to be motivated to adopt the programme.
This requires advocacy activities to the schools to make them aware of the importance of
reducing aggressive behaviour and bullying, and the availability of a successful approach that
can be used by the schools themselves. Secondly, the programme, its materials and the way
to implement them need to be described in a transferrable manual. Thirdly, in some cases the
programme might need some adaptation to make it fit better to the specific needs and culture
of some schools. For instance, adaptation might be needed as some schools may differ in
cultural composition of kids in comparison to the situation in the first school. Fourthly,
investment in capacity building is needed to make the schools capable of providing the
programme themselves with sufficient quality. This could imply the development and
implementation of a teacher training and offering supervision or consultation when the
programme runs in the coming years. Finally, to safeguard a sustainable implementation of
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the programme, its provision needs to be institutionalised by making it a structural part of the
long-term school policy plan and finding the resources to make such a long-term
implementation possible.
It might also be the case that the programme is being developed to become a national
model programme and the first school has offered the opportunity to run a pilot project.
Developing an effective and evidence-based model programme that could be disseminated
nationwide will require pilot implementations in various parts of the country. It also requires
that the evaluation stage be well executed to get a valid understanding of the efficacy and
effectiveness of the programme. Before a programme can be distributed as a national model
programme, there should be convincing evidence that it works (evidence-based). This is
discussed in chapter 14 on evidence of effectiveness and chapter 15 about databases of
effective model programmes. Creating an effective model programme typically requires the
programme to be implemented and evaluated several times on a trial basis, after which it is
systematically evaluated and improved. This cycle of design, testing and improving a new
prevention programme is called a programme development project.
When this is done successfully and an effective model programme is available, the
stage of enhancing large-scale dissemination, adoption and implementation project is started.
This requires that the model programme gets national publicity to ensure that the programme
is executed in as many places as possible and achieves a large reach in the population. Only
a large-scale implementation can ensure preventive impact at population level, such as a
nationwide reduction of bullying or depression among children and adolescents (Figure 11.5;
also Hosman & Engels, 1999).
The DeTEPP model builds on the earlier discussed Basic Planned Change Model.
Actually, the basic model is integrated in the extended trajectory, as can be seen in the second
block on programme development in figure 11.6. The dissemination and large-scale focus is
represented in the lower blocks of the extended model.
Finally, it needs to be stressed once more that it is rather unlikely that a single
programme, even when implemented on a large scale, is able to generate a significant
population-wide mental health impact. Like in the earlier discussed successful case of
reducing traffic deaths, such population-wide effects, require large-scale implementation of a
combination of effective interventions and measures and well-planned governance of such an
integral approach. For this reason, we have included in the Trajectory Model a special planning
stage that stresses the need to reflect on combining multiple effective programmes into a more
comprehensive prevention approach, using well-selected packages of prevention
programmes. Chapter 17 offers an illustration of such an approach.
11.7
Conclusion
This chapter has stressed the need to invest in carefully planning our efforts to achieve
reductions in the onset of mental disorders and improvements of mental capital in target
populations. Successfully running the development and implementation of effective mental
health promotion requires a stage-wise process, composed of functionally related tasks that
need to be performed subsequently and each with high professional quality. We have
discussed several useful planning frameworks varying from a Basic Planned Change Model
that can easily be applied to all kind of mental health promotion and prevention projects, to a
Developmental Trajectory of Effective Population-based Prevention (DeTEPP-model). This
236
model, aimed at reaching population-wide effects, has several additional stages targeted at
combining effective interventions in a comprehensive prevention approach, and at the largescale dissemination, adoption and implementation of effective programmes.
A major challenge for professionals and researchers is to combine these planning
models with the necessary theories on the development of mental health and mental
disorders, as discussed in the preceding chapters 4 to 9. Green and Kreuter (1999) designed
a smart combination of both types of models into their integrated PRECEED-PROCEED
planning model. As we have stressed, the rather general health model they use as a centre of
their approach, does not sufficiently reflect the current theoretical models and scientific
knowledge on mental health development. For this reason, we challenge the readers of this
textbook to make their own combinations between these staged planning models and
theoretical approaches such as discussed in the chapters on developmental psychopathology,
the integrated stress model, social support and positive psychology.
In the next four chapters, several elements and stages of the presented planning
models are discussed more in detail. This applies to the tasks of goal setting (chapter 12),
strategy development (chapter 13), effect evaluation and evidence (chapter 14), and the largescale dissemination of evidence-based programmes (chapter 15).
Literature
Bartholomew, L.K., Parcel, G.S., Kok, G., & Gottlieb, N.H. (2006). Planning health promotion programs:
An intervention mapping approach (2nd ed). San Francisco: Jossey-Bass.
D'Zurilla, T.J., & Goldfield, M.R. (1971). Problem solving and behaviour modification. Journal
Of Abnormal Psychology, 78, 107-126.
Funnel, S.C., & Rogers, P.J. (2011). Purposeful program theory: Effective use of theories of change
and logic models. San Francisco: Jossey-Bass.
Green, L. W., & Kreuter, M. (1999). Health promotion planning. An educational and environmental
approach (3rd edition). Mountain View: Mayfield.
Hosman, C. & Engels, C. (1999). The value of model programmes in mental health promotion and
mental disorder prevention. International Journal of mental health promotion, 1(2), 1-14.
Hosman, C.M.H. & Brinxma, J.L. (1978). Naar een beleidsondersteunend informatiesysteem in de
preventie. In: H. de Bont, J. Hagendoorn, A. Otten, B. Prinsen & B. Wardekker (Eds.)
Gezondheid en Gedrag: Preventie in de ambulante Geestelijke Gezondheidszorg (pp.48-76).
Groningen: Wolters Noordhoff.
Hosman, C.M.H. (1994). Omgaan met doelen, in de preventieve geestelijke gezondheidszorg.
Nijmegen: Research Group on Prevention and Psychopathology.
Nezu, A.M. (1987). A problem-solving formulation of depression: A literature review and proposal of a
pluralistic model. Clinical Psychology Review, 7, 122-144.
Price, R.H. (1987). Linking intervention research and risk factor research. In J.A. Steinberg &
M.M. Silverman (Eds.) Preventing mental disorders: A research perspective. Rockville MD:
Department of Health and Human Services.
Prochaska, J. O., & DiClemente, C. C. (2005). The transtheoretical approach. In J. C. Norcross & M. R.
Goldfried (Eds.), Handbook of psychotherapy integration 2nd ed. New York: Oxford University
Press.
Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: toward
an integrative model of change. Journal of Consulting and Clinical Psychology, 51, 390-395.
Schweinhart, L.J., Montie, J., Xiang, Z., Barnett, W.S., Belfield C.R. and Nores, M. (2005). Lifetime
Effects: The High/Scope Perry Preschool Study Through Age 40. Ypsilanti, Michigan:
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High/Scope Press.
Taylor-Powell, E., & Henert, E. (2008). Developing a logic model: Teaching and training guide.
University of Wisconsin, Extension, Program Development and Evaluation.
Tones,K., & Green, J. (2004). Health Promotion: Planning and Strategies. London: Sage
W.K. Kellogg Foundation (2004). Logic Modelling Development Guide.
Study questions for this chapter

What are the main features and assumptions of stage models?

What are the main stages of the Basic Planned Change Model?

What are major sub-stages in the planned change model of the stage on problem
analysis, the stage of goals setting and target group analysis, and the stage of a
strategy development?

Are stage models linear models or circular models? Explain your answer.

What are typical features of the Developmental Trajectory of Effective Populationbased Prevention (DeTEPP), and how is this model related with the Basic Planned
Change Model? What are the differences between the two models?

In prevention and health promotion, different types of phase models are used. What is
the main difference between the PRECEDE-PROCEED model and two other
discussed planning models in this chapter? What are the strengths and what the
limitations of this model?

Why is segmentation of target populations needed? Offer different arguments.

What is a social network analysis? What role do network analyses have in the planning
of mental health promotion and prevention programmes?

What is ‘logic modelling’? How is logic modelling related to programme planning? What
are the advantages of logic modelling?

What are the implications if one aims to develop a prevention programme as a model
programme to be disseminated and implemented on a large scale?

Are you able to make a link between the theoretical approaches to mental health
discussed in chapters 4 to 10 and the planning models discussed in this chapter?

What kinds of evaluation studies can be distinguished?
238
12
Formulating goals in prevention
12.1
Introduction
240
12.2
Importance of defining goals
240
12.3
Elements of goals: goal variable, normative element, and specifying parameters
241
12.4
Types of goals and goal variables
242
12.5
Functional goal chains and goal trees
247
12.6
Conclusions
251
Literature
252
Study questions for this chapter
252
239
12
12.1
Formulating goals in prevention
Introduction
Quality and effectiveness of prevention programmes are for an important part determined by
how prevention experts, health promoters or other programme designers deal with goals. The
better the goals are supported by knowledge from science and practice, the more specific they
are defined, the more attention has been given to their feasibility and acceptance in society,
the more likely it is that prevention programmes will show the desired effects. In the previous
chapter, we have seen that goal analysis is the third planning stage in the development of
programmes.
Experience shows that prevention practitioners and policy makers in the health and
social domain have major problems with formulating clear, achievable and verifiable goals.
For a long time the value of conscientious goal setting was underestimated, their development
and formulation generally received limited attention. To date, the prevention and health
promotion sector increasingly needs to justify the quality and effectiveness of its programmes
(‘evidence based prevention’) which requires well-defined and well-reasoned goals.
In this chapter, we will start with explaining why carefully defined goals are so
important. Next, we discuss the basic elements of goal definitions and the different types of
goals that need to be defined to be able to design effective programmes. Finally, the issue of
goal chains and goal trees is addressed, which is about how different types of goals are related
and how these relations are based on the programme theory and theories of change.
12.2
Importance of defining goals
A core feature of operating professionally on a mental health promotion or prevention
challenge is a practitioner’s ability to work systematically towards achieving well-defined goals.
These goals can be very different in nature, such as reducing the number of people suffering
from depression, enhancing social support networks, getting stricter standards accepted on
the use of alcohol in traffic, or reducing stressful working conditions.
A goal can be described as a desirable situation to be achieved in the future, which
differs from the present. Goals give meaning and direction to preventive actions, since they
formulate the intended effects. Conversely, effects can be defined as the extent to which
previously defined goals have been achieved. Goals and effects are two sides of the same
coin. They are the central reference point from which choices are made concerning target
groups, programme content, and intervention strategies. Different opportunities for action are
weighed against each other by considering which of possible interventions contributes most
to achieving a predefined goal. Let’s take an example: suppose our goal is to reduce in the
population the prevalence of child abuse by 20% in the next five years. We need to discuss
what will be more effective to reach this goal: (1) invest in mass media campaigns informing
the public about the serious consequences of child abuse and possibilities for early detection
of child abuse, or (2) improving the opportunities for stress management and educational
support for young parents, particularly those living in stressful circumstances? Likewise, we
have to decide whether the large-scale implementation of one specific intervention will be
240
sufficient to reach a population-wide reduction of 20%, or that such a reduction would require
the implementation of a combination of multiple evidence-based interventions targeted at
different groups at risk and at different risk factors.
Moreover, goals provide the benchmark by which we can decide whether an
intervention has achieved the desired success. When goals are missing or when they are
extremely vague, we cannot estimate the success of our efforts and neither can we get
feedback on the need to improve a programme further. Goals are the backbone of evaluation,
as Donker stated in her book on programme evaluation (Donker, 1990).
Finally, explicitly defined goals also have a democratic value. They offer the
opportunity to all stakeholders in a prevention or health promotion project, including the
possible consumers or target population, to have some control over the direction and value of
such an activity. Explicitly formulated goals and objectives facilitate debate on the relevance
of a project and needs to adapt its direction. Stakeholders usually want to recognise their own
interests in the selected goals. The logic model of a programme, of which goal definitions and
aimed impact is an essential part, can be a helpful tool to initiate a debate among stakeholders
about goals (section 11.6).
In the past, training programmes for prevention and health promotion experts did not devote
much attention to the formulation and analysis of goals. Therefore, it is not surprising that
goals in prevention practice were often formulated in rather vague terms and professionals
struggled with making a thorough goal analysis. To illustrate this we summarise some findings
from a Dutch study by Hosman and his colleagues who analysed how goals were formulated
in policy documents, programme descriptions and project reports from mental health
prevention in the period between 1970 to 1990 (Bosma, Hosman, de Vries & Veltman, 1994,
box 12.1). The examples illustrate that when goals are poorly defined, it is hard to make any
judgments about the level of success of preventive practices. They also reflect the lack of
outcome research in prevention before 1990. Outcome studies started only after that period
and have strongly stimulated the use of well-defined and well-reasoned goals and objectives.
These observations have triggered us during the 1990s to reflect on the principles of
defining goals, the differentiation between multiple types of goals, and the relation between
them (Coping with goals in mental health prevention, Hosman, 1994). In the following section,
we will further discuss these issues.
12.3
Elements of goals: goal variable, normative element, and specifying
parameters
The formulation of a goal is composed of three types of elements. The first two elements are
the definition of a goal variable and a norm, and cannot be missed in any goal formulation.
The third element facilitates to make goals more specific. Together they form the basic
elements of each goal: as is reflected in the following formula:
GOAL = goal variable + normative element + specifying parameters
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Box 12.1
Goals and targets in the first decades of prevention
Especially, in the early years of prevention in mental health in the Netherlands, goals were
defined vaguely and often formulated in a barely verifiable manner. As illustration, we offer
some goal definitions from prevention programmes and policies, cited in the book Practice as
a source of knowledge by Bosma et al. (1994) on Dutch preventive practices from the mental
health sector between 1970 and 1990:
Improving contacts of people in a two-relationship, by talking and listening, finding
recognition in each other, making discoveries, also related to the possibilities within
yourself.
Prevention of psychological imbalance.
Creating opportunities for conversation.
Develop early activities (for parents) in order to prevent problems, to determine their
impact and solve problems.
Improving the functioning of teachers and educational organisations
Contribute to the emancipation of disabled persons.
Develop and implement activities related to dementia problems.
In none of these cases more specific versions of goal definitions were offered, neither
indicators to measure the level of their achievement. It is unclear what concepts such as
imbalance, possibilities within yourself, early activities for parents, and functioning of an
educational organisation exactly mean and how progress could be measured. Most
programme descriptions from that period describe only the targeted problem, target group
and used intervention methods, without a statement on the preventive goal.
From 1980 on, when a process of professionalisation of prevention and health promotion was
initiated through the formulation of national quality standards, the situation improved
(Prevention Report, 1980; Verburg & van Doorm, 1989), This is illustrated by the following
goal definitions found in projects between 1980 and 1990:
Maintain elderly (with psycho geriatric problems) as long as possible at home.
Reduce relapse and recurrence by 50% in psychotic patients with DSM-III diagnosis
of schizophrenia, living in district The Hague Centre-West, aged between 12-65 yrs.
registered in psychiatric services between 1/1/1986 and 1/4/1987.
Prevent a client career in hyperactive children. (= more than two years in treatment).
Realising at the municipal level, a cooperation platform that develops preventive policies
that support older people who are socially isolated or at risk to become so.
Problems with using goals in prevention not only concerned their formulation, but also a lack
of insight in different types of goals and how to use multiple goals within a prevention
programme.
From: Bosma, Hosman, de Vries & Veltman, Practice as a source of knowledge (1994).
242
The goal variable defines what we want to change, e.g. level of mental health, incidence of
depression, cases of child abuse, coping skills, emotional support, health care consumption,
availability of day care for chronic mental patients. The different types of goal variables that
can be distinguished in prevention programmes will be addressed in the next section 12.4.
The normative element describes the direction in which a goal variable is aimed to be changed
or even a specific value it should adopt as a result of an intervention. The direction is often
described only in broad terms such as: more, less, better, promote, enhance, strengthen, or
reduce. However, terms like 'more' or 'less' are vague. For example, if a project aims "to reduce
the number of depression in the elderly", this can refer to a reduction of 5%, 10%, 20%, or
even more. A reduction of 20% requires different investments and probably also different
prevention strategies in comparison to a reduction of 5%. Moreover, a reference date or period
needs to be specified as well, otherwise such quantifying statements are meaningless. An
alternative for scientists evaluating the efficacy of a preventive intervention would be to prove
in a controlled trial that the intervention has reduced or increased the targeted outcome to an
amount that is statistically significant. An effect size could offer an indication of the level of
efficacy.
Another example of a specific description of the normative element is taken from the
World Health Organization (WHO). In its action report “Health for all by the year 2000",
commonly established by the European countries in 1985, the following targets were defined
for the whole European region (WHO, 1985):
Target 5:
Around the year 2000 congenital syphilis should no longer occur in
the region.
Target 10:
Around the year 2000, cancer mortality in people under 65 should be
reduced in the region by at least 15%.
Target 12:
By the year 2000, the current rising trends in suicide and attempted
suicides in the Region should be reversed.
Several specifying parameters can be added to a goal definition, for instance time and place
indicators, to define more precisely where, when, in who and how a goal should be reached.
Adding specific parameters is optional in a globally defined goal, but highly desirable.
Box 12.2 summarises the different elements of a goal formulation. By adding specifying
parameters to a general goal as: "Reducing suicides”, this goal can be translated into a much
more specific and verifiable objective such as: "By offering to all general practitioners in city X
the training ‘Recognition and Treatment of Depression’ and assuming that 75% of the GPs will
participate, the number of suicides among GP patients in that city should be reduced by 20%
within three years”. That such an objective might be realistic is supported by an early study on
the impact of such a training offered to all general practitioners on the Swedish island Gotland
(Rihmer, Rutz, & Pihlgren, 1995). In the 2.5 years before the training 42% of all suicides were
committed after a person developed major depression, in the 2,5 years after the training this
was reduced to 12% and remained low over a period of 9 years after the training (16%).
Above we used both the term goal and objective. The term goal is usually applied to
statements about the general aim of an action or policy (e.g. reducing depression, improving
resilience of children), while terms as ‘objective’ and ‘target’ are used to refer to more specific
243
statements about what we want to achieve as in the case of the mentioned training for general
practitioners. To label a goals statement as an objective, it should be measurable and tangible.
Box 12.2
Basic elements and specifying parameters in goals
Basic elements
Target variable
Normative element
What do you want to change?
In what direction? To what extent?
Changed to which quality?
Specific parameters
Time
Place
Target group
Type of intervention
Costs
12.4
To be achieved by when?
How permanent should be the outcome?
Where? In what geographical area?
In who? In which group or population segment?
How? By which methods or strategy?
Reached against which maximum costs?
Which negative side effects should be avoided?
Types of goals and goal variables
The goal variable is the most essential element of each goal; it refers to 'what' should be
changed or achieved. Goals of preventive interventions can be very diverse. In this section,
we present a typology of goal variables and associated differences between goals.
In the previous chapters about theories, we explained that prevention programmes are usually
aimed at influencing multiple factors, which in the end should result in achieving a final
preventive objective. Separate interventions within a comprehensive multicomponent
programme can each influence a different risk factor or operate at a different system level. So,
to prevent depression in adolescents some interventions might be aimed at reducing the risk
factor 'child abuse' already early in life, while other interventions may try to improve problem
solving skills and self-esteem in all primary school children, and a third group of interventions
might be aimed at reducing negative cognitive styles in adolescents with beginning depressive
symptoms. Each type of intervention is aimed at a different proximal objective while they have
a common final objective, i.e. reducing the onset of depression during adolescence.
To design an effective programme, a programme developer needs to understand what
goals should be achieved first (proximal goals) to be able to prevent in the end the onset the
targeted problem (ultimate or distal goal). Proximal goals refer always to risk, protective or
positive factors that play a causal role in the developmental process of a targeted problem.
Likewise, the programme developer should understand the chain of forces that he has set in
motion to get a set of risk and protective factors changed in a desirable direction. Such factors
244
and forces for change are functionally related with each other: factor A influences factor B,
factor B influences factor C, and factor C is directly related to the incidence or prevalence of
a particular problem. To prevent a problem, the entire causal chain has to be targeted. In other
words, a chain of intermediate effects needs to be achieved to realise the intended preventive
end effect (domino effect).
We use the example of bullying prevention to illustrate this (figure 12.1). Prolonged
bullying has a significant effect on victims, such as high stress levels, traumatic experiences,
and social isolation. This might result in serious depression and anxiety problems, poor school
results, and even a risk of suicide. The challenge is to both reduce the bullying behaviour of
the bullies and to increase resilient and assertive behaviour of the victims. This requires that
we have some influence on the determinants of such behaviours, such as attitudes, social
skills, the availability prosocial behaviours, and supporting norms and practical support from
by-standers, parents and teachers. To get such norms and support available, peers, parents
and teachers need to be involved in the anti-bullying programme and should be stimulated to
provide such norms and support. This in turn might require educative actions, teacher training
and consultative support from experts on this subject. Finally, to get the problem recognised
at school level, to set school standards on social behaviour and to get all parties involved in
such a school-based approach of bullying, the school board, school management and parent
committees should decide that such a programme is needed and should be implemented. As
is reflected in figure 12.1 all these conditions are functionally related. A change in factor A is
more likely if we first are able to change a determining factor B. The structure of the final set
of intervention goals should reflect the described functional relations between the variables
that need to be changed. For this reason prevention professionals have to define ‘functional
goal chains’ and ‘functional goal trees’, as we further will discuss in section 12.5. This idea of
245
functionally related goals and effects is also used in logic modelling as we have discussed in
the previous chapter.
Before we continue our explanation of such chains and trees, we first differentiate between
different types of goals that are used in a functional goal system. We distinguish five types of
goals: social end goals, health end goals, intermediate goals, implementation goals and
condition-related goals. Figure 12.2 systematically shows the different levels at which effects
can be realised.
1. Social end goals
They describe the social, economic and other non-health effects of better mental health or
less mental disorders that are achieved by a prevention or mental health promotion
programme. These secondary outcomes could include, for instance, less physical health
problems, better job perspectives, less need of social benefits, less crime, fewer school
dropouts, higher labour productivity, and safer communities. From a health perspective, social
end goals may be ‘additional effects’, but for stakeholders from outside the health sector such
benefits may be the most important reason to be a partner in a mental health prevention
project. It is therefore important to include such aimed benefits in the goal system of a
prevention programme and in the evaluation of the intervention outcomes. What could be
considered as primary and what as secondary outcomes may differ between involved
stakeholders with different interests.
2. Mental health end goals
These describe the beneficial mental health effects that represent the core end goals of mental
health promotion and prevention programmes. These end effects could include:
246
a.
b.
c.
d.
e.
f.
Strengthening or maintenance of mental health (health promotion),
Less new cases of mental disorders, or serious mental suffering (primary prevention),
Shorter duration and lower severity of mental disorders through early intervention
(secondary prevention),
Improved quality of life of mental patients, less relapse/recurrence (tertiary prevention),
Improved quality of care: better available, accessible, earlier, more client friendly,
Less need for and less use of professional help.
3. Intermediate goals
These goals refer to the intended changes in biological, cognitive, emotional and social
determinants of mental health, mental disorders or care consumption. Which risk or protective
factors will be targeted, depends on the chosen theoretical model, the available evidence for
their influence on a targeted problem, and the level of their expected changeability with
available interventions tools. We differentiate between intermediate goals that aim to
influence:
a. determinants within the ultimate target group, also called preventive target group,
e.g. brain development, perceived stress, knowledge, attitudes, negative thinking
styles, self-esteem, subjective norms, perceived support, coping and health behaviour.
This could concern, for instance, all children of a primary school, young children of
parents with a mental illness, bully victims, adolescents with beginning depressive
symptoms, women involved in domestic violence, elderly in a low-income community.
b. determinants in the social environment. These could be located in a large variety of
persons, social networks or systems that could be addressed as ‘intermediate target
group’ in prevention programmes. Examples: parents of children at risk, peers, a
neighbourhood network, teachers, a whole school system, community organisations,
primary health care professionals, managers, policy makers, a client organisation, or
national organisation of district nurses. We may want to improve parenting skills,
emotional support from a network, mental health skills of district nurses, prosocial
school climate, or we may want to reduce domestic violence, bullying or discriminating
behaviour, social isolation in a community, poor labour conditions, or traumatic events
to which refugees or citizens in war areas are exposed.
4. Implementation goals
These concern targets we want to meet in providing preventive interventions on a large scale
and reaching a large part of the targeted population. Health population effects of preventive
programmes depend largely on how successful we are in reaching all the people in a
community or a targeted population at risk. In marketing, this is called ‘penetration level’.
Examples of implementation objectives are “Getting within the next 4 years an anti-bullying
programme implemented in at least 80% of the primary schools in a district”, or “to increase
the number of children and families of mentally ill parents that we reach with our preventive
programmes with 50% in the next 2 years”. Implementation goals may also pertain the quality
of how prevention programmes are implemented (e.g. programme fidelity, client satisfaction,
sensitivity to cultural differences, openness to consumer influence, good timing and sufficient
dosage). Meeting such quality standards are found to have influence on programme
effectiveness, as we will discuss in chapter 14.
247
5. Condition-related goals
The successful development and implementation of a prevention programme or health
promotion policy is only possible if we first assure that a range of necessary organisational,
financial and professional conditions are present. Some conditions might already be available,
for other conditions strong effort might be needed to get them achieved. Sometimes such an
investment could even require the structure of a small project. For instance, getting a grant for
the development, implementation and evaluation of a new programme requires the writing of
an extensive and well-grounded grant application that has to compete with others. It might
also require lobbying and developing a coalition of supporting organisations, Other examples
of such conditions are: having a supportive local prevention and health promotion policy,
sufficient manpower, expertise, leadership and management capacity, epidemiological and
other scientific knowledge about the targeted problem, attractive project materials (e.g.
workbook, videos or website) and community support for implementation. A challenging part
of the work of prevention and health promotion professionals is to facilitate the availability of
such conditions. This also requires special competence such as skills in policy development,
advocacy, lobbying, networking, negotiating and raising funds.
This section shows that goals can differ along various dimensions as we have summarised in
Box 12.3.
Box 12.3
Five key dimensions of goals in prevention
1. Hierarchical position in a functional goal chain or tree
End goal, intermediate goal, implementation goal, condition-related goal.
2. End goals related to the stage in health and problem development
Health promotion, primary, secondary or tertiary prevention
3. Goals related to the level of risk in the target population
Universal, selective or indicated prevention
4. Goals according to geographical area or population size
Group, neighbourhood, organisation, community, local or national goals
5. Goals differing along the time dimension
Short, medium or long term goals (when?)
Temporary or sustainable outcomes (how long?)
248
12.5
Functional goal chains and functional goal trees
We return to the discussion on goal chains. As discussed and illustrated, goals can have a
functional or hierarchical relationship with each other. Achieving goals higher in the chain
depends on first completing goals lower in the chain. Functional goal chains can differ in length
and complexity as is illustrated by the goal dimensions described in Box 12.3. A functional
goal chain may simply consist of two levels as is mostly the case in information brochures or
internet, which are based on the idea that providing information will improve knowledge and
attitudes, which then will help consumers to choose a more healthy or prosocial behaviour
(e.g. buying a healthy product, becoming a volunteer in local support programme for frail
elderly).
Longitudinal goal chains
In mental health promotion and preventing mental disorders such chains are usually much
longer and more complex. For instance, when we aim to reduce child abuse and neglect by
parents to prevent later onset of emotional disorders in children and adolescents, preventive
efforts could already start with providing preventive support to parents during pregnancy,
aiming to increase their stress management skills and parental competence, and reduce
smoking and alcohol during pregnancy. After birth, they may be in need of emotional and
informative support from home visiting nurses and get help in strengthening their social
network. When maternal postnatal depression is involved, preventive support could be
targeted at reducing depressive symptoms and improving mother baby interaction. This
should result in better parent-child attachment and a positive development of the emotionregulating brain system. Next, such a healthy start of life is assumed to contribute to the
development of emotional resilience, social competence and cognitive learning processes,
and to positive and proactive reaction styles instead of depressogene or aggressive reaction
patterns. These conditions should enhance the later development of social-emotional
competence, positive self-esteem and supportive social-emotional relations during early
adolescence which in turn should protect the adolescent against the development of
depression and serious social problems.
What is this example teaching us? First, it shows that a long chain of mediating causal
links is assumed between early preventive interventions and much later preventive outcomes,
such as prevented depressive disorders among adolescents. At each of the links in this long
chain, certain outcomes (intermediate goals) should be achieved before we can expect a lower
incidence of adolescent depression. Longitudinal research is needed to test if these mediating
outcomes are indeed achieved and contribute to fewer cases of depression. Secondly,
partially this long functional chain of intermediate and final outcomes will be considered as an
assumed domino effect resulting only from interventions very early in life. Even then, at the
start of life a combination of preventive actions might be needed that each should result into
outcomes that are in line with their proximal objectives. For instance, reducing the risk factor
maternal depression during pregnancy or postnatal, several determinants of maternal
depression and its impact on the child could be addressed. In children at special high risk,
additional preventive support could be offered at later sensitive periods during this causal
trajectory, for instance during late childhood and early adolescence, for instance to strengthen
their social competence, positive thinking and active coping. Such a long-term comprehensive
approach is built around a science-based chain of subsequent goals for action. Some of the
249
intermediate goals might be directly addressed through interventions, other intermediate goals
might be assumed to change indirectly because of a domino effect of an intervention. In sum,
prevention approaches are full of assumptions that need to be underpinned with sciencebased and practice-based evidence. This is exactly where the ‘assumptions’ and ‘evaluation”
domain in logic modelling are referring to (chapter 11).
250
Functional goal trees
Both the example on bullying prevention and that of a long term trajectory to prevent
adolescent depression through early life interventions, show that some preventive approaches
require the definition of not just one but several functional goal chains. These different goal
chains could refer for instance to the multiple ‘roots’ of a problem or the existence of separate
causal trajectories that each separately could result in the same disorder (see equifinality in
chapter 6). Functional goal trees combine multiple functional goal chains. In a very simple
way, this is illustrated in figure 12.4. When we want to achieve a certain goal at a higher level
in a functional goal chain, it is often necessary to meet not just one but simultaneously multiple,
related goals at a lower level. For instance, in the bullying example at the same time
intermediate goals need to be met among bullies and victims, and at a meso level also among
parents, teachers, school system and local community. Each chain in the functional goal tree
might be activated by a different preventive intervention. A simple version of this idea is
reflected in the lower part of figure12.4. For this reason, goal setting in multicomponent
programmes requires always a functional goal tree. This should also be reflected in the logic
model of a multicomponent programme or policy.
Multifinal goal trees
As we take the image of the tree in figure 12.4 as a visual symbol, the bottom part (“the roots”)
represents the multiple causes and multiple causal trajectories towards the same outcome,
represented by the trunk. This symbolises the concept of equifinality (chapter 6). The upper
part of the tree (the multiple branches growing from the trunk) symbolises the different
outcomes that could grow from the same set of roots and the same trunk. This reflects the
multifinality concept from developmental psychopathology. In terms of end goals, it means
that common risk factors or a same disorder (e.g. depression) could lead to a variety of
secondary outcomes. These could include for instance the prevention of several secondary
diseases, and a diversity of social and economic benefits in other sectors than health. To make
the public value of investments in prevention fully visible to relevant stakeholders, we
recommend to also fill in a multifinal goal tree and to use it as a frame of reference in outcome
research and in contacts with stakeholders. This could also be reflected in the last column of
a logic model.
12.6
Conclusions
We have stressed in this chapter the importance of running a well-grounded goal analysis for
every intervention, programme and policy, and of discussing goals with relevant stakeholders.
The likelihood of achieving successes in mental health promotion and prevention is highly
dependent on our ability to run a goal analysis and to formulate well-defined goals.
Understanding the basic elements of each goal definition is a first step. We presented a
classification of different types of goals and objectives and defined the dimension along which
they may differ.
On the one hand, together with stakeholders we have to make science-based and
practice-based choices between multiple, alternative goals that will guide our preventive
efforts. On the other hand, we need to understand how to combine and relate multiple goals
in goal chains or goal trees that will steer our search for an effective and comprehensive action
251
plan. Goal analyses drive intervention analyses and how we build effective programmes, as
well as the evaluation of new programmes. Both the goal analysis and intervention analysis
require a thorough insight in mental health and prevention theories and knowledge of the long
term and short-term processes that precede the development of mental disorders and positive
mental health.
Literature
Bosma, M., Hosman, C.H.M., de Vries, W.J., & Veltman, N.E. (1994). Practice as a source of knowledge
(Original Dutch title: De praktijk als bron van kennis).
Research
report.
Nijmegen:
Prevention Research Centre, Radboud University Nijmegen.
Donker, M.C.H. (1990). Principles and practice of program evaluation (Principes en praktijk van
programma-evaluatie). Utrecht: Nederlands centrum geestelijke volksgezondheid.
Hosman, C.M.H. (1994). Coping with goals in mental health prevention. (Original Dutch title: Omgaan
met doelen in de preventieve geestelijke gezondheidszorg). Prevention Research Centre.
Radboud University Nijmegen.
Rihmer, Z., Rutz, W., & Pihlgren, H. (1995). Depression and suicide on Gotland. An intensive study of
all suicides before and after a depression-training programme for general practitioners. Journal
of Affective Disorders, 35(4), 147–152.
Verburg, H. & Van Doorm, J.S. (1989). Overview of mental health prevention projects 1988. (Original
Dutch title: Inventarisatie RIAGG preventie projecten 1988. Utrecht: Landelijke Ondersteuning
Preventie-ggz.
World Health Organization (WHO). (1985). Target for Health for All: Targets in support of the
European Regional Strategy for Health for All by the year 2000. Geneva: World Health
Organization Regional office for Europe.
Study questions for this chapter

Explain why careful formulation of targets is so important.

What elements does a target formulation contain? Give an example.

How can you ensure that targets are formulated more specific?

What types of targets are distinguished in this chapter and along what dimensions
could you classify targets in preventive interventions?

What is meant by a functional goal chain and a functional goal tree? How are the
concepts of equifinality and multifinality related to a functional goal tree?

To what does a multifinal goal tree refer?

Choose your own prevention theme (e.g. depression, child abuse, COPMI) and
formulate different types of goals that you consider needed as basis for a successful
prevention programme.
252
13
Intervention analysis and strategy development
13.1
Introduction
254
13.2
Intervention analysis
254
13.3
Dimensions of intervention strategies
256
13.4
Strategy dimension 1: Target groups and network
257
13.4.1
Ultimate target groups
257
13.4.2
Network analysis and intermediate target groups
260
13.5
Strategy dimensions 2 and 3: Determinants and goals
263
13.5.1
Choosing which factors to influence
263
13.5.2
From determinants to intervention strategies
264
13.5.3
Criteria for selection of intervention factors
266
13.5.4
Determining the number of target factors: Mono or Multi factor approach?
268
13.5.5
Influencing factor chains
269
13.6
Strategy dimension 4: Intervention system levels
270
13.7
Strategy dimension 5: Methods and mechanisms
271
13.8
Strategy dimension 6: Setting
273
13.9
Strategy dimension 7: Time and Timing
275
13.10
Stategy dimension 8: Providers and implementation
278
13.11
Conclusions
280
Literature
280
Study questions for this chapter
281
253
13
Intervention analysis and strategy development
Clemens Hosman
13.1
Introduction
This chapter discusses how intervention strategies are designed to prevent mental disorders
and to promote mental health, and what strategic options are available. It describes strategy
development as a stepwise process of multiple choices and decisions. For most professionals
translating available knowledge of mental health and processes of change into an effective
prevention strategy is still a major challenge. The varying degree of effectiveness found in
tested prevention programmes shows that this is indeed still a core bottleneck in our field.
When we have insight in the risk factors of a problem, how can they be tackled through an
effective prevention strategy? There are few models available to guide such a translation.
Programme designers and practitioners need a framework that can guide the choices they
need to make in developing an intervention programme. This chapter provides such a
framework, both to guide the development of new intervention programmes and to improve
existing programmes.
13.2
Intervention analysis
An intervention analysis refers to the process that aims to design an effective prevention
strategy and programme, based on the results of a problem analysis, network analysis, goal
and target group analysis, and using science-based and practice-based knowledge on
effective processes of planned change (Figure 13.1). The intervention analysis should answer
the question: Given the problem, its determinants and social context, and given the goals that
the major stakeholders want to achieve, which intervention strategy is best able to achieve the
aimed effect in the target group, at minimum costs? Implementability, expected
effectiveness, expected reach in the target population and expected costs of an intervention
are four important criteria to assess the value of a programme design and to make a choice
between candidate programme designs. When we can choose between multiple designs, the
254
preference should go to the programme that has the best perspective to be implemented on
a large scale, to be highly effective, and to reach a large part of the target population against
relatively low costs.
What do we mean by the term ‘intervention strategy’? We define an intervention
strategy as reasoned decisions on the design of a mental health promotion or prevention
programme that describes how we want to reach an aimed mental health or preventive goal
in a target population. A strategy always implies making a range of choices. The core question
in this chapter is: What kind of choices? How do we choose? Why is a choice better than the
other?
Next, the chosen strategy needs to be translated into a practical programme. This
includes for instance, identifying the core messages and tasks, making educational materials
and a website, writing recruitment brochures, and designing exercises for participants, all
summarised in a transferrable manual. Once other conditions are covered as well, including
training the providers, financing the implementation and signing contracts with target
organisations (e.g. schools and businesses), the programme implementation can be started.
The first times a newly designed programme is implemented, usually evaluations of
such try-outs still show a range of weaknesses. Just as in business, a new product needs a
series of try-outs, improvements and experimental versions before the product reaches
sufficient quality and maturity, and can be considered a complete and effective product.
Hence, regular evaluations are needed to test the quality of a prevention programme. These
try-outs may lead to the improvement of the contents of a programme (e.g. making educational
texts more comprehensible and attractive), or might require certain changes in the original
strategy. For example, after try-outs of an anti-bullying programme targeted at teachers and
children, one might decide to add intervention components targeted at the parents. The
feedback lines in Figure 13.1 from evaluation back to intervention analysis; strategy and
programme represent this learning and improvement process.
The probability that an intervention analysis will lead to an effective prevention programme
depends on the extent to which deliberate choices are made based on high quality information.
This requires an understanding of:
- dimensions on which intervention strategies are based;
- alternative options on each dimension to choose from;
- criteria (considerations) for making the best choice between these alternatives
- type of information and its quality needed for applying selection criteria in making a
choice between strategic alternatives.
We give an example. Part of strategy development is making a choice on the dimension of
‘determinants’. When we aim to prevent depression, we need to understand what the different
risk and protective factors of depression are. As we are not able to address all known risk
factors in one prevention programme, we are forced to make a choice. Which risk factor(s)
should we target and what kind of criteria should we apply in making such a selection. One of
these criteria should be the level of attributable risk of the risk factors. An intervention will be
more effective in reducing depression onset when we target at risk factors that have the most
impact on onset. To apply this criterion, we need to have valid information available on the
attributable risk of different risk factors. The quality of this information differs significantly if we
retrieve it from one correlation study in comparison to information from a meta-analysis based
255
on 10 prospective studies. Of course, attributive risk is only one of the criteria to apply for
making such a selection. We will discuss the issue of selection of target determinants in
section 13.5.
Although many choices need to be made during the development of a prevention
strategy, when it involves the design of a single intervention choices are still fairly easy. It
becomes more difficult when, as often is the case, a multi-component programme should be
designed consisting of a combination of different interventions. The selection process
becomes more complex because the best choices for each intervention should be tailored to
the choices of other interventions.
13.3
Dimensions of intervention strategies
The design of an intervention or programme requires answers to many questions. Some
questions are very common, such as on which target group should we focus, and what
intervention method should be used. Other questions, however, get less systematic attention,
such as: What is the best timing for this intervention? What should be the minimal duration to
generate a preventive effect? Does segmentation of the chosen target population offer a better
perspective to large reach? Which change mechanisms work best with this target population
and social context? In practice, frequently no efforts are made to find deliberate answers to
such questions, which lowers the perspective on success.
The strategy model, described in this chapter, differentiates between eight strategic
dimensions (Figure 13.2) and some sub-dimensions. On each dimension, the professional has
to make a reasoned choice between a range of options. In combination, the choices within
these dimensions define the identity of a specific prevention strategy. They provide the
blueprint of a particular prevention programme. Differences between two prevention
programmes can always be traced to differences in choices at one or more of these
dimensions.
We first introduced these dimensions in the chapter 11 (Basic Planned Change Model, section
11.5). Above, they are depicted in the circle of strategic dimensions (Figure 13.2). In the next
256
sections, we will discuss each of the eight dimensions separately. In each of these dimensions
a leading question is applicable:
1.
2.
3.
4.
5.
6.
7.
8.
Target group and network: Who?
Determinants: What change?
Goals: What goals should be achieved successively?
System Level: intervene at what system level?
Setting: In what setting?
Methods and mechanisms: How to bring about change?
Time: When and how long?
Provider: By whom?
Box 13.1 presents an elaborate overview of questions linked to each strategic dimension.
13.4
Strategy dimension 1: Target groups and network
In general, we differentiate between two types of target groups: the ultimate target groups in
which we want to achieve mental health benefits, and intermediate target groups that we
involve to reach and influence an ultimate target group, or to change risk or protective factors
in the social environment of the ultimate target group. We discuss them separately.
13.4.1 Ultimate target groups
Mostly when we speak about target groups in prevention we refer to ultimate target groups.
The term ‘ultimate’ is used when a programme is in the first place targeted at an intermediate
target group, such as parents, teachers, or public health nurses. For reasons of simplicity, we
will use ‘target groups’, adding ‘ultimate’ only when relevant. We use the terms ‘target group’
and ‘target population’ interchangeably, as is common in our field.
How do we define and select a target group? What kinds of target group or population
definitions are used in mental health promotion or prevention programmes? Just as an
illustration, we list a range of common target groups in preventive work in our country:

people with depressive symptoms

low SES women with depressive complaints

suicide attempters

parents, or more specifically: parents with poor parenting skills

primary school children

victims of domestic violence or child abuse

children with early-stage behavioural problems

children of parents with a psychiatric problem or addicted parents

babies and infants of depressed mothers

pregnant women under stress

patients with a first psychotic episode

employees suffering from work stress

whole population of the city of Maastricht and surroundings
257
Box 13.1
Making choices on strategic dimensions
Target groups and network
At which target population, intermediaries or network is an intervention targeted? Are
they defined with use of inclusion and exclusion criteria?
Are whole population groups approached? Groups at risk? How defined?
Does the target population need segmentation in subgroups?
Which target groups will be approached directly, which indirectly and through what
intermediary target groups (e.g., nurses, teachers, community leaders)?
Goals
Which goal chains need to be realised by the interventions? Mental health, health,
social and goals? Intermediate goals in different target groups? Implementation goals?
Capacity enhancing goals?
Determinants
Which risk and protective factors should be influenced to get a preventive effect?
Problem-specific risk factors or broad-spectrum risk factors?
System levels
At which system level or levels is the intervention targeted (micro, meso, macro level)?
Settings
In which setting(s) can target groups be reached and determinants be influenced?
(E.g. school, work, health care, justice, Internet)
Methods and Mechanisms (input)
Which intervention methods and influence mechanisms need to be used to be effective?
- Intervention methods, e.g. education, legislation, training, organisational advice
- Influence mechanisms, e.g. knowledge transfer, persuasion, modelling, reward,
sanctions
Timing and dosage
At what moment (e.g. media attention), developmental stage of the lifespan, and stage
of problem development should an intervention be offered to be most effective?
Short or long-term intervention? Which frequency and duration of sessions, messages?
Providers
Who could most successfully provide the intervention?
Volunteers, peers, teachers, community leaders, primary health care workers, mental
health professionals, prevention or health promotion specialists?
Screening this list of examples, it is evident that target groups are defined in different ways.
First, they may be defined by demographic features such as gender, age or social indicators
(e.g. low SES, children, women, and employees). Secondly, according to the difference
between universal, selective and indicated prevention, secondary prevention and relapse
prevention, target groups can be defined according to their risk level (low, high or ultra-high
258
risk) or problem stage (e.g. with symptoms, first episodes, past episodes, or none of them).
Thirdly, target groups can be identified by the presence of a risk factor (e.g. child abuse,
maternal depression, stress). Fourthly, they could be defined by geographical characteristics
(e.g. health region, city of Maastricht, or a specific neighbourhood). Fifthly, target groups might
also be defined by the setting in which they could be reached, for instance, school children,
patients of general practitioners, or visitors of house parties. It is also common to combine
such target group definitions, such as in the case of low SES women with depressive
complaints living in a high-risk neighbourhood in the City of Maastricht.
Limiting the width of a risk group definition: A major issue in defining a target group is how
broad or small we define such a group or population. In mental health promotion, it is common
to address large groups, such as all schoolchildren in certain grades, pregnant women,
parents or elderly. In such cases, we aim to improve mental health conditions in all persons
belonging to such a group. Many prevention programmes, however aim to target groups at
high risk, for instance children of parents with a mental illness (COPMI), employees with work
stress, or patients with a first psychotic episode. The challenge is to define groups at high risk
in a such way that the group (a) includes a high number of people that will actually develop a
mental disorder in the future and (b) a very low number of people who will not develop such
disorders. The better we are able to make such predictions and selections, the more efficient
we will use the limited resources for prevention. It is, however, not possible to know with 100%
certainty who will and who will not develop a mental disorder in the future. For this reason, we
are bound to the concept of ‘high risk groups’, that include by definition also persons who
never will develop a disorder (false-positives).
There exists a large variation in how precisely we define groups at high risk. The less
precise, the more persons we include that do not need the offered preventive support. What
can we do to avoid including them? The main strategy is to increase the number of risk
predictors as inclusion criteria in the target group definition. McGorry and his colleagues, who
aim to prevent the onset of first psychotic episodes in young adolescents (McGorry, Killackey,
& Yung, 2008), provide a well-known example. Originally, they defined the group at risk as
those adolescents showing an increased number of (pre) psychotic symptoms (precursors).
However, many of such precursors do not specifically point at a developing psychosis. As a
result, their risk groups included many adolescents who actually did not develop a first
episode. To improve their risk definition, they redefined their target group as adolescents at
ultra-high risk by combining the presence of precursors with an indication of a family history
of psychotic illness.
The same issue applies to defining the group of children at risk because they have a
parent with a mental disorder. Several of the interventions discussed in chapter 17 are
targeted at “children of parents with a mental illness” (COPMI). This raises two problems. First,
defined as such it refers in our country of 16 million people to a population of 1.2 million
children. To address them all with supportive preventive interventions is an impossible task
that far transcends the available resources for prevention in our field. Secondly, although being
a population at high risk we do know that a substantial part of these children will cope well
with their situation and will not develop serious problems. To reduce this target group in size
and to prevent the inclusion of a large group of risk false positives, the children at high risk
could be identified by the presence of a mental disorder in their parents in combination with a
range of other risk factors (e.g. chronicity of the parental disorders, poor parenting conditions,
259
lack of social support). As we discussed in section 4.2, it is especially the accumulation of risk
factors that put people in a high-risk position.
Segmenting target groups: Another common practice in dealing with a large population at risk
is the use of segmentation, that is subdividing the target group in multiple segments. This is a
technique frequently used by commercial companies to better attune their products to the
needs of their customers and in the end to increase their market. The large diversity in types
of smart-phones, tablets and phone-internet contracts serves as a good example. In the end,
more customers will be reached, there will be more customer satisfaction and the product will
be sold more often.
For the same reasons this marketing principle is applied to target populations in
prevention and health promotion. Segmenting target groups in our field has two major
purposes, reaching a larger part of the target population and better serving the varying needs
and adapting to various cultures within the target population. To segment a target population,
the same features can be used as we have suggested above when discussing the different
ways target groups can be defined: demographic variables, stage of problem development
and level of risk, type of risk factor, geographical nominators, and setting or channel through
which a segment could be reached. We take the target group of people with elevated levels
of depressive symptoms as an example (indicated prevention). Depression prevention to this
as target population has been segmented in age groups (adolescents, adults, elderly), using
other demographic and cultural variables (e.g. low SES women, ethnic minorities), risk factors
(e.g. refugees, children of depressed parents, victims of domestic violence), or setting for
case-finding (e.g. patients of GP’s, hospital patients with a heart attack). For each of these
subgroups special recruitment strategies have been applied and tailored interventions have
been developed.
13.4.2 Network analysis and intermediate target groups
A next choice in this target group analysis is whether to involve intermediate target groups in
the prevention strategy (Figure 13.3). These are persons or entities in the social network of
the target group or in the wider environment that are addressed because they are in a position
to affect the development of risk or protective factors.
Their influence may be based on different roles, e.g. caregiver, companion, primary
health care professional, teacher, school dean, employer, journalist, hospital, government, or
police. They can influence the target group e.g. on the basis of their frequent contacts with the
target group, their position of trust, emotional bond, their role as information source, while they
exert normative functions or by their possibility to give sanctions or rewards. Figure 13.3
shows that different types of strategies can be chosen to influence the ultimate target group,
in this example, adolescent girls who are at risk of developing an eating disorder. A direct
approach of the target group is possible, but also several indirect approaches or a combination
of both. Target group chains consist of a series of intermediate target groups that can exert
influence on each other successively. For instance, a prevention programme can be targeted
at teachers who address both the girls at risk directly, as well as the students in the classroom
as a whole and the parents. In these last two cases, the aim is to improve their support to the
girls at risk and to reduce negative modelling behaviour. In making the choice for using an
indirect strategy, it is important to be aware of the advantages and disadvantages of such a
strategy. We discuss them in Box 13.2.
260
Box 13.2 Benefits and disadvantages of an indirect approach
Benefits of an indirect approach
Indirect intervention strategies are often used in prevention programmes because they have
several benefits. The most important benefits are:
- More efficient: an indirect approach can reach a much larger part of the ultimate target
group. Compare for example, a depression prevention course of 8 meetings with 10
participants in a group to a training course for 15 general practitioners who together might
reach about 5000 persons with elevated levels of depressive symptoms.
- Less social distance: local key figures are better informed about the social situation of the
target group and have a smaller social distance to this group. This makes them better able
to adapt educational messages to the target group and its specific situation, e.g. a teacher,
neighbourhood, social worker.
- More influence: a prevention expert does not always have the right position to influence a
target group, e.g. because the target group does not know him or the social distance is too
large. Local key figures have more influence because of their social position as reference
person, opinion maker, teacher role, charismatic leader, communication position.
- Prevention of proto-professionalisation and social iatrogenesis (chapter 1): an indirect
strategy can strengthen the preventive qualities of non-professional care systems in society.
This can contribute to long-term problem solving in the target groups and key persons and
they become less dependent on professional health care to solve their psychosocial
problems.
- Prevention of stigmatisation: when an intervention is directly aimed at a certain group at
risk, this might lead to stigmatisation, e.g. children of addicted parents. This is less likely
with an indirect strategy, because the risk group is offered the preventive support in a subtler
way through existing informal or service-related contacts e.g. a general practitioner or
teacher.
Disadvantages of an indirect approach
The indirect approach has also some disadvantages. One disadvantage is that intermediate
groups, such as teachers or community nurses, can be less knowledgeable than prevention
experts are on how to perform preventive interventions with high quality. They might be less
motivated to implement the interventions as intended or with a lower dosage than is needed.
When a prevention expert transfers the implementation of effective prevention programmes
to primary care professionals or other key figures, he loses control on the implementation,
and its quality and continuity. Take for instance the case that a prevention expert has
designed and implemented a social skills training for children in a school. They train the
teachers to implement the programme themselves in the future, but there is always a chance
that the school or the teacher will decide not to run the programme in the next year due to
lack of time.
In Figure 9.5 in chapter 9 on social support, a wider network analysis of this group at risk for
eating disorders is presented that also includes relevant social systems at meso and macro
level.
261
Running a network analysis.
For the choice of who to involve
in an indirect strategy, we first
need to run a social network
analysis as described in
section 11.5 (Basic Planned
Change Model) and chapter 9
on social support and social
networks. To do so, we need to
draw a map of the social
network or potential social
network around the target
group, as is illustrated in figure
13.4 using the example of
children of parents with a
mental illness (COPMI). The
relations within a social
network can be mapped, by
positioning the target group
(COPMI) as a circle in the
middle, and the individuals or
social systems that have
contact with the target group
placed at a shorter or longer
distance from the centre
connected by lines. The length
of the line reflects the social
distance to the target group.
relevant,
mutual
When
connections
between
the
partners in the social network
can also be drawn. In figure
13.4, the first figure depicts the
"ideal situation", the lower
diagram shows the situation as
often encountered in COPMI
children: important contacts
with people from the social
network are missing.
Next,
answering
the
following questions can further
extend a network analysis:
262

What preventive functions do the various persons and social systems in the network
have towards the target group and what is their impact on risk and protective factors?
For example: providing emotional support, informational support, setting standards
and penalties, model function, practical help, providing social influence.

Is there a need to improve the quality of certain support functions within the network?

Is there a need for better coordination between separate support systems in the social
network, for example to improve cooperation between district nurses and mental health
professionals?

Is it possible and desirable to expand the social network and thus its preventive
capacity, e.g. by bringing the target group in contact with fellow sufferers?
For a more extensive discussion of social networks and functions, we refer to chapter 9.
13.5
Strategy dimensions 2 and 3: Determinants and goals
The third dimension involves the selection of risk and protective factors that will be directly or
indirectly influenced by preventive interventions. This could concern factors such as
knowledge, attitudes, coping skills, child abuse, parenting behaviour, social support by peers,
poverty, or a school policy on bullying. For a more extensive discussion, we refer to the
chapters on theoretical approaches and on specific mental health problems such as
depression and COPMI.
13.5.1 Choosing which factors to influence
Preventive programmes never aim directly to reach a preventive end goal, for instance
preventing the onset of a depressive disorder. Preventive interventions primarily aim to
influence certain risk, protective or mental health promoting factors within a target group or in
their social environment. If we are successful in changing these factors (proximal goals), it is
expected that shortly or on the long run the intended preventive end effect will follow.
The nature of the chosen prevention strategy depends among others on the kind of
determinants that are targeted. Take for example the prevention of work incapacity due to
mental problems, such as depression or burnout. When oncoming work incapacity is attributed
to a lack of stress management skills among employees, preventive efforts require a different
strategic approach than when work circumstances are seen as the most important cause. In
the first case, a stress management-training programme for employees at risk would be a
proper strategy, while in the second case policy making on setting quality norms for work
conditions, and consultancy to managers and the board of directors would be more
appropriate.
To choose which determinants an intervention programme should target at, the
programme designer should have thorough knowledge on malleable causes and the
developmental processes of a targeted problem. After the problem analysis is completed
successfully, such knowledge should be available. Next translating the analytical knowledge
of multiple determinants into an effective intervention strategy is one of the most challenging
parts of designing a preventive intervention. Practitioners experience problems with making
such translations, as we have observed in our study among project managers in this field
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(Bosma, Hosman, de Vries and Veltman, 1994). At least four considerations or questions play
an important role:

What kind of strategic options do the different theoretical approaches offer?

What justifies the choice for specific risk or protective factors as target of intervention, while not
choosing others?

Which strategic intervention options are available to influence a selected determinant?

How to deal with multicausality? Should prevention programmes try to influence each of the
known determinants? What consequences do mutual relationships between determinants have
for making a strategy design?
13.5.2 From determinants to intervention strategies
As discussed in previous chapters, a variety of theoretical models exists to guide strategy
development. These include biological models, cognitive-behavioural models, stress models,
social and community models, and models specifically designed to describe the
developmental processes of specific disorders. Each of these can be chosen as a framework
to select factors as target for mental health promotion or preventive interventions. For
instance, in chapter 5, we discussed how the different factors in cognitive-behavioural models
could each be used as focus for intervention to influence health behaviour (Box 5.2), such as
the reduction of smoking and alcohol use.
In the scientific literature on mental disorder prevention, stress and coping models are
often used. These models are very suitable to identify alternative preventive strategies. For
instance, in preventing the onset of depression or anxiety disorders strategies can be focused
on reducing stressful life conditions, increasing problem solving skills and positive thinking, or
strengthening social support and social networks. Box 13.3 presents an overview of prevention
strategies that can be based on the factors and processes in the Integrated Stress-theoretical
Model (IS-model, chapter 7). Each of the factors offers an entrée point for multiple preventive
interventions.
The intervention options described in Box 13.3 are mainly targeted at individuals or
groups of people, so at micro level. The IS-model can also be applied to higher system levels,
such as schools, companies, neighbourhoods or national policies. In schools, for instance, it
is possible to identify school-based stressors (e.g. frequent violent behaviour, burnout of
teachers), school ideologies (norms and policies), school competencies to deal with social
problems, provision of opportunities for social-emotional learning, and the presence of a
supportive network (e.g. parent involvement, student mentors, emotional support by teachers).
The application of the IS-model to the school level can be used to design prevention strategies
that aim to improve the functioning of the school and provide a supportive and mental healthpromoting environment to children and adolescents.
The IS-model and the developmental psychopathology approach also include a
developmental dimension, which offers a framework for making important strategic choices on
the time dimension. For instance, it instigates a choice when to address risk factors and
protective factors, in the period preceding the onset of a mental disorder, when problems are
already beginning to emerge; or to address them during the period in the lifespan where they
start to develop, mostly very early in life. Aggressive behaviour can be more effectively
addressed when such sustainable behaviour styles start to emerge in childhood than when
such behaviours are already deeply rooted in a person and the peer environment during
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adolescence. In this respect, also the growing knowledge of the impact of stress exposure
during pregnancy and infancy on the developing cognitive-emotional brain systems of the child
is highly relevant for making a strategic decision about timing of interventions.
In sum, when deciding which factors should be the focus for preventive interventions the
following questions need to be answered. Should an intervention strategy address:
1.
2.
3.
4.
5.
6.
Risk factors and/or protective factors?
Problem specific factors and/or non-specific factors?
Factors at micro level, meso level or macro level?
Biological, behavioural, physical or social factors?
One factor or a combination of factors?
At which developmental period of the life span?
Box 13.3 Prevention strategies derived from the Integrated Stress
Model
1. Influence stressors

Reduce external stressors: eliminate or reduce sources of stress in the environment,
e.g. discrimination, child abuse, bullying, bad work circumstances

Reduce internal stressors: eliminate or reduce sources of stress caused by own
behaviour, e.g. too much drinking, aggressive behaviour, work too much

Stressor avoidance: prevention exposure to stressors or remove someone from a
threatening situation, to prevent long term exposure, e.g. avoid unsafe places,
outplacement of children, women protection shelters

Stress induction (stress inoculation): temporarily increase stress to increase
resilience e.g. vaccination, survival trekking, confrontation with stressors through role
play
2. Satisfy compensating needs

Improve compensating situations: situational possibilities to satisfy other needs, e.g.
extra relaxation possibilities, extra compensation for heavy work, extra support

Behaviour influence: promote behaviour that results in the satisfaction of other needs
in stress situation, e.g. learn to do nice things in times of stress, learn self reward,
choosing a more satisfying pass time
3. Influence goals, values and needs





Alerting: alerting of own goals, needs and values, e.g. alerting to a repressed need
for attention or support
Prioritising: make priorities among the competing goals that need to be achieved,
e.g. in times of too much stress or conflicting interests
Adaptation: adapt goals to possibilities and restriction, e.g. adapt demands, make
more realistic goals
Emancipation: breaking through adaptations to repressing ideologies and values in
society, e.g. after insights on the role of our education and sex-stereotyped ideas.
Valuing positive prevention: promote prevention-oriented goals and values, e.g.
through education about negative consequences of risky life styles, positive
psychology
265
4. Increase competences (problem solving capacities)

Problem specificity: improving non-specific, generally applicable skills and/ or
problem specific competencies, e.g. enhance problem-solving skills and selfconfidence, or knowledge or specific mourning rituals or parenting skills

Stage-related: improve skills needed for a specific stage in the problem solving
process (problem analysis, think of solutions), e.g. understanding the causes of
recurrent depression, learning more ways to reduce the risk of a depressive episode

Factor specific: cognitive, emotional, social, physical, positional (influence) and/or
physical competences, e.g. improve knowledge, confidence, social skills, physical
fitness or dominance, influencing attitudes, biochemical processes and genetic
characteristics
5. Improve social support and reduce social limitations

Improve support seeking skills: e.g. information about support possibilities, learn
to ask and receive social support, learn to make friends

Create new support systems: formal or informal support systems of temporary or
permanent nature, e.g. non-professional support through self help groups,
counsellors and fellow patients, or professional support through help lines, crisis
relief

Improvement quality of informal support: activation of support from family,
friends, colleagues or peers, improve their support capabilities through
education, training or advice

Improve quality of professional support: improve accessibility of help
(awareness, image, range, price), make support more responsive to needs of the
target group, more customer-friendly and less iatrogenic (damage by care),
better cooperation and coordination between various services
6. Improve feedback and learning processes

Enhance learning abilities: improve the ability of individuals or organisations to
learn from previous experiences and their own behaviour, e.g. by promoting
positive attitudes towards feedback, learning to accept feedback, capacity for
critical self-reflection, translating feedback into successful solutions

Feedback from network: improving the size and quality of feedback, e.g. improve
ability to give constructive feedback, reducing the issue of bias and demotivating feedback

Organise additional feedback: temporarily provide additional feedback by peers
or experts (experienced experts) through diagnostic research, professional
consultations, awareness-raising questions, involve experts-by-experience”
13.5.3 Criteria for selecting targeted factors
Theories and empirical research about the development of mental health and mental disorders
include always multiple determinants as we have seen. Each of them represents a possible
target for intervention. Professionals and programme designers have to choose from them.
On which factors should a prevention or mental health promotion programme focus? Making
a reasoned decision requires that we are able to apply explicit selection criteria. What are
relevant criteria to take into consideration in making such a choice? We suggest the following:
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1. Impact of a factor on the onset of the targeted problem (see also section 4.2): The
larger the impact (attributable risk), the larger the preventive effect that can be
expected from successfully influencing this factor (preventable fraction). The maximum
achievable preventive effect will - even with a perfectly successful intervention - never
be greater than the influence of this factor on the health problem. The same applies to
determinants of positive mental health. The importance of an etiological factor depends
not only on the strength of its association with the onset of a problem, but is also
determined by the prevalence of that factor in the population (Population Attributable
Risk, PAR). Which part of the population is exposed to that factor? The larger this
proportion, the more people could benefit from successfully addressing that factor
through interventions and public measures.
2. The spectrum of expected outcomes. As we have discussed several times in this
textbook, a risk factor, protective factor or mental health promoting factor shows mostly
a wider impact than just at the onset of the targeted mental disorder or mental health
indicator. They might also influence the onset of other mental disorders and physical
diseases, or contribute to a range of social or economic benefits. Choosing between
determinants as target for intervention requires that we take into account a wider
spectrum of possible positive outcomes. This will increase the public value of an
intervention programme and will make the intervention attractive to a wider group of
stakeholders and possible sponsors.
3. Changeability. Some factors are more easily changeable with currently available
intervention strategies than other factors. For instance, is it easier to increase
knowledge and skills or to change attitudes and beliefs, than to change personality
features or social factors such as poverty and war-related trauma’s? Some factors are
not or hardly changeable such as genetic profiles, death of a partner, or natural
disasters (e.g. earthquake). The level of influence we can achieve is of course relative.
It depends on the available knowledge, current state of intervention technology, power
positions and available resources. The main source for assessing the extent to which
a factor can be influenced is, of course, earlier research on interventions that aim to
change such factors. A common indicator for changeability is the mean effect size of
such interventions, computed across multiple controlled intervention trials. In addition,
outcomes of qualitative intervention studies offer useful information on how
interventions work and what their value is for consumers.
To illustrate the relevance of some of these criteria, we offer a simple calculation example.
Suppose a particular risk factor explains 18% in the emergence of a specific disorder and a
prevention programme is effective in changing that risk factor in 60% of the participants, then
the expected reduction of the risk by the intervention is 0.60 x 18% = 11%. If the intervention
only reaches 20% of the target group in the society, then the maximal impact of the intervention
in the entire population will not be more than a risk reduction of 2.2%. So, the larger the
influence of a factor is on explaining the problem, the better this factor can be influenced, and
the more people can be reached by the intervention, the more impact we can expect from a
preventive intervention on the incidence of the problem in the population.
In addition, also other considerations need to be taken into account such as the public
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acceptability of the measure to influence those factors and the associated costs. These are
criteria connected to the choice of the intervention method, which will be discussed later.
13.5.4 Determining the number of targeted factors: Mono or Multi factor approach?
A next strategic choice relating to determinants is choosing between a single-factor approach
and a multi-factor approach. It is commonly accepted that health and diseases should be
considered as multicausal and this applies to mental health and mental disorders as well. Even
when people are exposed to a very powerful risk factor or 'agent' (virus, bacteria, earthquake,
child abuse or other traumatic event, etc.), the effects on health are also dependent on the
presence of many other factors (e.g. immunity, emotional resilience, coping skills, social
support, protective measures).
One might conclude from this that a multi-factor approach should be preferred above
a single-factor approach, and this is what many authors have concluded in the past (Mrazek
and Haggerty, 1994, Yoshikawa, 1994; Bosma & Hosman, 1990). The more determinants are
changed in a favourable direction, the more likely prevention investments will result in less
new problems in a target population. A multifactorial approach is, however, not necessary and
even not desirable in all cases. There are several good reasons to state that under certain
conditions programmes should be targeted at only a few or even just a single mental health
determinant. The first reason is the need for efficiency and limiting the cost of prevention
programmes. It is likely that multifactorial programmes are more expensive because they
frequently use a multicomponent approach. Secondly, the more causal factors you want to
address within a restricted time span of a prevention programme, the less time can be spent
on each factor. This could mean in the end that none of the factors gets sufficient time and
attention (programme dosage) to be changed, resulting in an ineffective programme. Third, in
terms of attractiveness of programmes, a focus on a determinant that has wide interest for the
target population or involved stakeholders (e.g. parenting, domestic violence, emotional
resilience, support systems in a community) might strategically be preferred over a programme
that has a psychiatric disorder as a central focus.
In the following cases, a single-factor approach may be sufficient or preferable:
1. When a prevention programme, targeted at a single common risk or protective factor, is
able to generate a broad spectrum of positive mental health, health and social effects
(broad-spectrum prevention, section 3.3.3).
2. When a problem analysis and multiple prospective studies have provided evidence that
from a range of known causal factors the attributable risk (AR) of one factor exceeds by far
the AR of the other factors.
3. When a single-factor programme or measure has the potential to reach a large proportion
of the population against low or reasonable costs. This applies, for instance, to internetbased programmes that aim to disseminate knowledge on positive parenting, nationwideimplementation of an anti-bullying programme at schools, or a public campaign to reduce
domestic violence.
4. When multiple risk factors interact with each other and the impact of Factor A (e.g. high
stress level) depends on the presence or absence of a factor B (e.g. problem solving
capacity, social support). In such cases, programmes that either reduce the source of
stress, or increase coping skills, or strengthen social support systems might be sufficient
to prevent the onset of a serious mental health problem.
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5. When a programme targets a risk factor that triggers a chain of other risk factors over time.
This applies, for instance, to children who are exposed to early traumas.
6. When the onset of a mental disorder (e.g. depression) is caused by an accumulation of
risk factors. Removing one risk factor might reduce the number of risk factors below an
evidence-based threshold, or to a level of stress that people are able to deal with.
To conclude, making a choice for a single-factor or multifactorial approach requires careful
consideration and thorough understanding of how determinants are related to mental health
problems and other outcomes, and how determinants are mutually related.
13.5.5 Influencing factor chains
We already mentioned the possibility that risk factors could form a causal chain that may
extend even across several stages in the life span. For example, factor A during infancy or
early childhood influences factor B, factor B affects factor C, factor C affects factor D, and the
latter has a direct impact on the emergence of disorder X during adolescence. Mostly causal
chains are assumed that concern shorter periods: peers using drugs show modelling
behaviour to young adolescents, communicate about drug use and successfully exert
pressure to try-out drug use. Consequently, some adolescents may start to experiment with
drug use. In response, they receive appraisal and status from their deviant peers. This first
experimentation and peer feedback lowers the threshold for drug use in near the future.
In all prevention programmes, such causal chains are assumed, explicitly or implicitly.
Commonly, it is expected that a successful influence on factor A will also have a beneficial
effect on later risk factors in the chain and that these mediating effects ultimately will reduce
the likelihood of problem behaviour X or disorder Y. It is a common assumption that influencing
early factors in the chain will trigger a preventive domino effect. Below we give some examples
of domino effects based on assumptions related to the integrated stress model.
-
Stress inoculation training includes temporary planned increase of stressors under
relatively safe conditions that is assumed to strengthen the resilience of the target group
(emotional competence), which will increase adequate coping behaviour in future stressful
situations, which ultimately will contribute to a lower risk of psychiatric problems.
-
A social skills training aims to encourage help seeking behaviour, which is expected to lead
to offered social support from the direct environment. This support could contribute to
compensatory positive experiences, more realistic goals, more knowledge (competence),
or to social influence in eliminating stressful working conditions (stressors).
-
By training GPs in dealing better with grief issues in their patients, the GP learns more skills
to support a grieving patient. The perceived support the GP will help the patient to cope
with mourning and reduces the chance that it results in unresolved grief and ultimately
reduces the risk of depression or an adjustment disorder.
Often, however, these effect chains remain implicit, which makes is difficult to check for
thinking errors or deficiencies in a programme. At each link in the effect chain, the process
can stagnate, so the domino effect fails. In such a case, we consider to add additional
interventions later in the chain where the probability of stagnation is the biggest, to secure the
effect chain.
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13.6
Strategy dimension 4: Intervention system levels
Suppose you want to reduce the onset of eating disorders, specifically anorexia. A common
strategy is to identify female adolescents at risk due to their beginning pathological dieting
behaviours. The same applies to female models on the catwalk who represent a well-known
group at high risk for eating disorders. Next, such females are offered face-to-face or through
the Internet, a cognitive behavioural programme targeted at challenging their beliefs making
use of cognitive dissonance theory principles. Outcome research shows that this is an effective
strategy to change their beliefs and behaviour, resulting in substantial evidence-based
reductions of incidence of eating disorders (Taylor et al., 2006). Among females who
participated and had a high risk because of beginning risky dieting practices the onset of new
cases of eating disorders dropped over 40% across a follow-up period of 3 years. The
limitation is, however, that it works only with females at risk who are willing to participate in
the internet-based intervention programme.
A totally different strategy at macro level, however, can be found in Spain where
legislation has been accepted stating that women with a Body Mass Index (BMI) of lower than
18 are not allowed on the catwalk, which is a powerful measure that applies to all female
models, which means in principle a 100% reach. To date, no studies are available on the
outcomes of such a legislative measure. These two examples show that different intervention
methods each at different system levels have their own strengths and potential to be effective.
Box 13.4
System levels in approaching target groups
Level
Individual
Examples
individual education or advice
Family
treatment to prevent relapse domestic violence
Group
group training or prevention course
Network
advising a self-help organisation
Organisation
school-based social emotional learning education
Local community
implementing Communities-that-Care programme
Population category
Entire population
websites, brochures and DVD’s on parenting education
Educative soap series to reduce stigma on discussing
mental health problems
Defining a target group does not mean that it is clear how this target group can best be reached
and at what system level. It is possible to develop contacts with preventive and intermediate
target groups at different system levels, as illustrated in Box 13.4.
In more general terms, we differentiate between interventions at micro level (individual,
family, group), meso level (district, school, business), and macro level (legislative, social
ideologies, mass media, subsidies, anti-discrimination policies). Preventive interventions
provided by health care or mental health care professionals usually are completely restricted
to the micro level, i.e. they target individuals, aiming to influence person-based risk or
protective factors and using micro-level methods of change. Given the evidence for social
determinants of mental health and mental disorders, and the need to increase the mental
270
health promoting quality of health services, schools, workplaces and communities,
investments in interventions at meso and macro level are highly needed.
Activities directly targeted at individuals, families, groups, schools or community
leaders offer more opportunities for personal influence, interaction feedback and adapting the
intervention to the circumstances of the target group. This is more difficult when actions are
targeted at higher system levels (e.g. through policies, measures, legislation, mass media).
On the other hand, through higher-level interventions many more people can be reached. The
choice of system level will therefore depend among others on the relationship between
investment, expected impact and expected reach.
13.7
Strategy dimension 5: Methods and mechanisms
This dimension involves two types of choices that are closely related and together determine
how an intervention programme aims to achieve aimed changes in risk and protective factors.
It involves both the choice of one or more specific intervention methods and the choice of
specific influence mechanisms.
Box 13.5
Working mechanisms and active ingredients
Information
Emotional support
Persuasion
Recognition
Self-discovery
Appreciation
Self-reflection
Reward & punishment
Feedback
Setting norms & standards
Incentives
Conflict strategy
Modelling
Coercion and power
Exercises, assignments
Preventive medication
Homework
Economic support
The choice of an influence mechanism revolves around the question which active forces or
ingredients we want to use to exert influence on a risk or protective factor. We may use, for
instance, information, providing emotional support, giving feedback, modelling or setting
norms. These are basically the same questions as those made in psychotherapy, i.e. what are
the active ingredients or critical change factors that the psychotherapist applies in a
therapeutic approach, for example modelling, instrumental conditioning, a warm therapeutic
relationship or behavioural training (Bergin & Garfield, 1994, 2013; Arkowitz, 1997). Box 13.5
lists a number of mechanisms and ingredients that are frequently applied in the context of
preventive and health promotion interventions.
Prevention works with a large variation in intervention methods. An overview of
possible methods at different system levels is presented in Box 13.6. From this list
professionals or other stakeholders select one and preferably a combination of several
methods. The choice of methods and influencing mechanism are not completely separate.
Some intervention methods can be defined by their use of specific influence mechanisms. For
271
instance, preventive laws make use of norms, punishment or coercion. In the consultation
method (Caplan, 1970) information is used, but also advice and stimulation of self-discovery.
Workshops often use assignments, modelling, practical exercise, self-discovery and feedback.
For a successful intervention, it is important to choose an intervention method and a selection
of influence mechanisms that fit well to the nature of the target group, the social context and
the type of determinant that we want to influence.
Box 13.6
Preventive intervention methods at micro, meso and
macro level
MICRO LEVEL
Treatment methods
Early case-finding and recognition and early treatment, crisis intervention and crisis
support, preventive oriented family therapy, preventive medication
Individual education
Oral education, personal advice or consult, home visits, written materials (e.g.
brochure, flyer, indicator, manual)
Self-observation
Keeping a diary, doing self-research, using a screening or checklist, or electronic
reminders and self-tasks through smartphones and tablets
Self- help methods and social support:
⋅ Self-help booklets and using self-help websites
⋅ Mobilising and improving social support by family, friends, neighbours, colleagues,
peers, buddies and volunteers, access to support groups provided by
nonprofessional organisations, writing and sharing ego-documents
Referral and Mediation
Referral to self-help organisations and professional help; mediation (e.g. divorce)
Group methods and training
Local talk groups, ‘play and talk’ groups for children, body work groups, fitness,
skills training and lectures
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Box 13.6 cont’d
MESO LEVEL
Health care organisations
Developing and implementing organisation-wide protocols for preventive oriented care
Introducing system of stepped care and blended approach (face-to-face + E health)
Group education (intermediaries)
Graduate or postgraduate curriculum or course;
Symposium, forum discussion, info market;
Group consultation or training, workshops;
Written education (manual, professional guidelines or E-education
Consultation and supervision (intermediaries)
Case-oriented consultation; professional-oriented consultation;
Programme-oriented consultation; professional supervision
Network development, collaboration and coalition development (intermediaries)
Working group, project group; local task forces and committees
local professional networks, inter-organisational collaboration and coalitions;
community organisation
Organisational consultancy (e.g. to schools, companies, hospitals, NGO’s)
Consultancy on: self-help, work processes, quality of work environment, developing
and implementing quality monitoring systems, organisational policies and policy plans
Staff training and capacity building; hiring a temporary prevention expert
Supporting inter-organisational collaboration
Developing new organisations or services
Local consultation office, parenting shop, support desks for groups at risk, telephone
hotline, counsellor (e.g. for sexual harassment), employment agency and innovative
work projects for mental patients or people with mental retardation; establishing a new
self-help organisation
13.8
Strategy dimension 6: Setting
A next choice concerns the setting in which we try to offer a preventive intervention. This
choice needs special consideration if we want to reach our target populations, to find optimal
opportunities for influence, and to integrate mental health promotion and prevention in their
daily environment.
We have earlier stressed that public reach is a crucial condition for creating mental
health impact in target populations. Poor reach means poor preventive impact. Settings offer
a crucial opportunity to reach people. For instance, when we try to reach persons with an
increased level of depressive symptoms, a good choice would be the setting of general
practice, as adults mostly already have regular contact with their family doctor (GP) to
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Box 13.6 cont’d
MACRO LEVEL
Mass media education
⋅ Press releases, article in journal, glossy or newspaper, advertisements, open letters
⋅ Broadcasting items (news at prime time, information programmes)
⋅ TV item or programme: prime time news, information programmes, documentary,
educational amusement and educative soap-series, school TV
⋅ E-health, websites, social media
⋅ Educational film or movie
Publications
⋅ Writing a literature review or research report on prevention programmes and policies,
disseminating programme manuals
⋅ Exhibitions, educative theatre productions
⋅ National conferences, symposia, and debates
⋅ Databases of effective programmes
Curriculum-development in professional training
⋅ Development of new masters on prevention and (mental) health promotion;
integrating prevention and mental health promotion in existing training curricula,
master programmes
Social action and advocacy
⋅ Debates and negotiations with social key figures, politicians and / organisations
⋅ Developing inter-organisational coalitions, pressure and lobby groups and new
interest organisations (NGO’s)
⋅ Asking questions in the parliament
⋅ Getting people on influential positions, influencing function profiles for vacancies of
crucial positions
⋅ Test trial at Court of Justice
Preventive legislation and national policies
⋅ Advocacy for and preparation of new national preventive or health policies and
legislation. reinforcing obedience to preventive of laws and regulations
⋅ Developing and influencing policies of national funding agencies
discuss health issues. Moreover, a programme to which a GP refers will be seen as a reliable
and effective opportunity to improve your health and well-being. A recommendation by a GP
will also motivate a patient to take action. To reach youngsters with depressive complaints the
school, social media and the Internet might be better settings to reach them.
Other examples of settings to reach a preventive target audience include nurseries,
neighbourhood centres, mental health centres, hospitals, nursing homes and workplaces.
Figure 11.3 in the chapter that discusses the Basic Planned Change Model depicts a range of
settings across different system levels. Settings might also be chosen to be able to reach
274
intermediate target groups or relevant stakeholders. By involving and training, for instance,
GPs, nurses, teachers and peer counsellors we broaden the range of people that could
implement certain preventive interventions or offer advice in finding preventive solutions for
problems. At the same time, such training could help to integrate prevention in communities
in a sustainable way.
Regularly, a multi-setting approach is needed, because one specific setting might offer
insufficient opportunities to reach your target group or to influence all relevant determinants.
For example, in an effective prevention policy that aims to reduce alcohol consumption among
young people, preventive interventions should be aimed at the school, sports and
entertainment settings, schools and primary health care.
Settings are not only relevant for reaching target populations, a setting might also be
chosen because the target problem and its causal factors are heavily intertwined with that
setting. Organisations, professionals or other persons in such a setting might be in a position
to have influence on such factors. For instance, for a ‘Prevention of bullying’ programme is the
school setting of course an obvious choice. A significant proportion of bullying behaviour of
children and young people happens in or around schools. Teachers, school environment and
school climate influence the extent of bullying. The same idea applies to work settings, where
managers and occupational health physicians might have impact on work conditions.
13.9
Strategy dimension 7: Time and Timing
This dimension has two sub-dimensions on which choices have to be made: timing and
duration of a preventive intervention. Both choices appear to affect the efficacy of programmes
as we found in a large meta-analytic study across around 150 programmes (Llopis, 2002).
Timing can be further subdivided in timing along the lifespan, timing along a process of
problem development, and timing across subsequent stages of the problem solving process.
Timing: the Intervention Moment
Those involved in programme designing have to choose at which age or developmental stage
along the lifespan, an intervention might have the largest effect. Especially in children and
adolescents, it is possible to distinguish developmental periods and related ‘sensitive periods’
for change. These are mostly transitional periods when a child goes from one stage to the
next stage, or periods where new risk or protective factors start to emerge. In such periods, a
child is the most sensitive for learning certain skills or external risk factors do not have a
structural impact on the child yet. Such transitional and sensitive periods are also present later
in life when people start to live together, getting a first job or a first child, or when children
leaving home, retirement is near, or becoming widowed. During such periods, people have to
adapt to new challenges, tasks and roles. It is assumed that they are more open to change in
these periods, such as learning new knowledge, attitudes, cognitive skills and behavioural
skills.
Stage of problem development
At what stage of the development of a problem can a preventive intervention be addressed?
It is possible to distinguish the following stages (see also chapter 3 on subdivisions of
prevention):
275
•
•
•
•
•
No problem present (primary prevention)
Exposure to risk factors (primary prevention)
Beginning symptoms / complaints (secondary prevention)
Recovery period after a pathological episode with risk of relapse (tertiary prevention)
Presence of serious and lasting problems or psychopathology to prevent chronicity,
irreversible impairments and disability (tertiary prevention)
For primary prevention, when no problems are experienced yet, prevention strategies should
take into account that the target groups might be less motivated to participate in prevention
programmes. In those cases, extra energy must be put in motivating audiences to change
their attitudes and behaviour. This might require the involvement of, for instance, parents or
idols to motivate people to such health behaviours, or to show that such behaviours could also
result in other short-term benefits.
Stage of problem handling
Another key question is, at what point in a problem solving process stagnation occurs. It is not
always necessary to support the people in a target group in all stages of a problem solving
process. This increases the danger of proto-professionalisation or social iatrogenesis as we
have discussed in the chapter 1 of this book. If, for instance children or parents have trouble
to understand the consequences and causes of parental depression, providing sufficient
information through the internet could be sufficient, especially when they have sufficient skills
to turn that information in an effective coping strategy. The following stages can be
distinguished:
•
•
•
•
•
•
•
Awareness of a problem or risk
Problem analysis: its nature and causes
Emotional problem perception: crisis perception
Generating and choosing solutions
Using and improving solutions
Evaluating effects
Maintaining health behaviour
Such stages are described in all models of problem-solving processes, as is illustrated by the
transtheoretical model of change of Prochaska & DiClemente (section 5.5) and the integrated
stress model of Hosman (chapter 7).
Timing: Linking actions to News items and topicality
Especially in cases where people in target groups have difficulties in recognising a risk or
developing problem, as is often the case in primary prevention, it requires much effort to
motivate people to change their behaviour or to take part in a prevention programme. Instead
of heavily investing in recruiting and motivating such people, you might also consider whether
it is possible to connect the issue to current events that show up in the news. For example,
news items on violent events in schools or public places or a suicide of a bullied youngster
might offer a good opportunity to address the issue of prevention of aggressive behaviour in
schools. Another, but different example is the media coverage of suicides of famous idols (e.g.
Kurt Cobain). Extensive and detailed attention in media to such a suicide is found to offer an
incentive to some youngsters to copy such behaviour, thus increasing the number of suicides
276
among young people who find themselves in serious problem situations. It is therefore very
important that such incidents trigger immediately preventive actions to mass media (i.e., to
stimulate them to low-profile coverage of such a suicide) and youth (e.g. offering telephone
support for who are in need).
Sometimes, it is better to delay the start of a prevention programme until there is a
situation where the problem is a major news item. This may occur because of a public incident,
the release of a major research or policy report, a documentary on TV, or a debate in the
parliament that attracts much attention. Another option is to link the item to the media coverage
of "World Mental Health Day” (October 10), World Health Day (April 7) or Human Rights Day
(December 10).
Duration and intensity of intervention
Regarding the duration of prevention programmes the following types of interventions can be
distinguished:
•
•
•
•
Single session interventions (e.g. a lecture, school meeting, symposium)
Short or long term temporary interventions (e.g. a training, course, 3-year curriculum)
Periodic interventions (regular returning attention and actions, e.g. via the media)
Permanent interventions (e.g. speed limits, telephone helpline, E-mental health, whole school
mental health promotion policy)
In the context of integrated prevention programmes, for instance in schools, a cycle can be
established from primary to secondary school with different types of age appropriate
interventions. For effective crisis intervention, it is important to have a quick succession of
supportive sessions within a short period. For primary prevention programmes targeting
children it is usually needed to spread the interventions (e.g. sessions of a course) over a
longer period of time. Too short interventions often prove to be ineffective.
In general, to achieve preventive effects, programme designers are required to make
a reasoned estimation of the needed dosage and duration of an intervention programme. In
the prevention of child abuse, home-based parenting support of less than one-year duration
is considered not to be effective. At the other hand, when interventions take too long, they
may suffer from weakening attention and fast increasing costs without leading to increased
effectiveness. A meta-analytic study by our Nijmegen Prevention Research Centre showed
an interaction between the duration of programmes and the age of the audience in their effect
on the impact of prevention programmes. It was found that in children and youth long-term
prevention programmes are more effective and short-term programmes were less so, while
for older populations precisely the opposite was the case (Jane-Llopis, Hosman, Jenkins, &
Anderson, 2003). Single one-time interventions, for instance a lecture or one classroom
session, are generally considered as meaningless and not resulting in any preventive effect.
277
13.10 Strategy dimension 8: Providers and implementation
The term provider of a programme could refer both to an organisation that offers a mental
health promotion or prevention programme to target groups and to the professional educators
or change agents that actually implement a programme. The last types of providers have often
face-to face contact with participating clients, but the contact could also be restricted to the
use of written materials, mass media methods and the Internet.
Characteristics of the provider
As numerous education and intervention studies have shown, interventions are more likely to
be effective when the provider shows a combination of the following characteristics:
-
Understanding the audience, their culture and speaking its language;
Highly motivated;
Charisma;
Equality (companion, peer-like);
Expertise as professional or by experience;
Credibility and reliability.
In some cases, it is important to use an expert as intervention provider, for example, when it
is necessary to transfer science-based knowledge to practice, or when programmes are
complex. This could be a health promotion or prevention expert, or a mental health
professional. When it comes to experience with the problem, emotional support, or influencing
behaviour standards, it may be important that the intervention be provided by a volunteer from
the local community, by a peer, or someone who has personal experience with the problem.
In ‘support groups’, one often works with a combination of professional experts and peers.
Another important issue in the implementation of a prevention programme is whether the
programme is implemented exactly as planned and described in the original script. This is
particularly important when it comes to implementing an existing and elsewhere developed
model programme. On the one hand, the advice is that such a programme should be
performed exactly as described by the makers. This is called programme fidelity. The
argument is that effectiveness of an evidence-based programme is only guaranteed if the
programme is executed according to the original manual, which was used in the effectiveness
study. The omission of key elements of change during implementation could lead to a loss of
effectiveness. Omitting parts of an intervention could happen when there are limited resources
and time constraints, or because the new provider or the participants want to give their own
flavour or identity to a programme. On the other hand, to keep a programme effective when
implemented in a new situation, it is recommendable to adapt a standard programme to the
needs and characteristics of the target group and social context in a new situation. No group
and no situation is exactly the same. In addition, allowing the new providers and participants
to adapt a programme to their needs and culture will also create a feeling of pride and
ownership, which enhances the sustainability of the implementation of the programme in the
new situation.
For these reasons, it is desirable that the developers of an effective prevention
programme indicate what in the programme is considered as essential, so what are
indispensable elements and components, and what is eligible for adjustment. For the new
providers and participants, it is essential to have knowledge on what those essential working
elements are and they are familiar with science-based and practice-based knowledge on effect
278
moderators, also called the principles of effectiveness. We will discuss this issue more
extensively in chapter 15.
13.11 Conclusions
This chapter argues for the use of more rational choices in programme development. From an
effectiveness point of view, it is important that prevention specialists and professionals
become more aware of the often implicit choices they make in the design of prevention
programmes. More conscious choices, by carefully weighing the benefits and drawbacks of
different alternatives, will reduce the chance of erroneous decisions.
This chapter presented an analytical framework to support scientists and professionals
in building effective prevention strategies, using both science-based and practice-based
knowledge. It aims to stimulate among them a more critical attitude towards strategy building.
It also showed that in theory multiple strategies might be possible to reach a targeted
preventive goal. Designing prevention programmes requires that one makes a range of explicit
strategic decisions on eight dimensions. The decisions together define the unique identity of
a programme.
The presented framework could nevertheless create a '1000-choices problem’ for
practitioners. Theoretically, the number of strategies to choose from in designing a programme
increases exponentially, the more decisions need to be made. When there are eight strategic
dimensions on which we have to make a decision, and suppose with only 5 alternatives per
decision, this would already result in 360.625 theoretically different strategies, assuming these
decisions are made independently of each other. For practitioners, who try to argue all the
choices, the danger is that it becomes too complex and unmanageable. Rational decisionmaking is important for effective professional action, but in practice, it has also its limits.
In practice, this danger is less real. First, making ranges of decisions in solving health,
social or political problems, is common in many professions. Being able to cope with
complexity belongs to professional competence. Secondly, many choices you have to make
are not independent but related. For instance, when you decide that a health risk is primarily
a problem of individual health behaviour, it limits the range of relevant intervention methods
tremendously. Thirdly, making intuitive decisions in complex situations based on professional
experience is also part of normal practice. Likewise, a family doctor needs to make numerous
decisions in daily practice, without consciously comparing all possible choices. Still we assume
that such decisions are grounded in scientific and professional knowledge.
In general, instead of comparing all possible alternatives, the framework could also be
used to select at each decision point not all, but at least several alternatives, to compare them
on pros and cons, and make in the end a more reasoned decision. The framework can also
be used in teams or among involved stakeholders to discuss critically the logic model of a
specific intervention proposal. The framework can make us aware of certain alternative
strategic options that are worth considering.
279
Literature
Arkowitz, H. (1997). Integrative theories of therapy. In P. L. Wachtel & S. B. Messer (Eds.), Theories of
psychotherapy: Origins and evolution (pp. 227–288). Washington, DC: American Psychological
Association.
Bergin, A. E., & Garfield, S. L. (Eds.). (1994). Handbook of psychotherapy and behavior change (4th
ed.). New York: John Wiley & Sons, Inc.
Bosma, M. W. M., & Hosman, C. M. H. (1990). Preventie op waarde geschat. Een studie naar de
beïnvloedbaarheid van determinanten van psychische gezondheid. Nijmegen: Beta.
Bosma, M. W. M., Hosman, C.M.H., de Vries, W.J. & Veltman, J.E. (1994). Ontwikkelen van
preventieprogramma’s: praktijk als bron van kennis. Nijmegen: Vakgroep Klinische Psychologie
en Persoonlijkheidsleer, KU Nijmegen.
Caplan, G. (1970). The theory and practice of mental health consultation. London: Tavistock
Publications.
Jane-Llopis, E., Hosman, C., Jenkins, R., & Anderson, P. (2003). Predictors of efficacy in depression
prevention programmes. Meta-analysis. The British Journal of Psychiatry : The Journal of
Mental Science, 183, 384–397.
McGorry, P., Killackey, E., & Yung, A. (2008). Early intervention in psychosis: concepts, evidence and
future directions. World Psychiatry, 7, 3, 148–156.
Mrazek, P. J., & Haggerty, R. (Eds.). (1994). Reducing risks of mental disorder: frontiers for preventive
intervention research. Washington: National Academy Press.
Taylor, C. B., Bryson, S., Luce, K. H., Cunning, D., Doyle, A. C., Abascal, L. B., … Wilfley, D. E. (2006).
Prevention of eating disorders in at-risk college-age women. Archives of General Psychiatry,
63(8), 881–888.
Yoshikawa, H. (1994). Prevention as cumulative protection: Effects of early family support and
education on chronic delinquency and its risks. Psychological Bulletin, 115, 28-54.
280
Study questions for this chapter

What do we mean by intervention analysis and on which previous analyses should an
intervention analysis be based?

The development of effective interventions requires a careful decision or choices.
Which insights are necessary to be able to make a well thought-out choice for these
decisions?

What is meant by target group segmentation and give an example (e.g. for COPMI and
depression)? Explain why target group segmentation is important for effective
prevention.

Prevention programmes can use direct intervention strategies and indirect strategies,
in which so called ‘intermediaries’ are targeted. What are the benefits and drawbacks
of these indirect intervention strategies?

What are the 8 choice dimensions on which decisions need to be made for the
development of a prevention strategy? Explain each dimension.

Think of a prevention programme for a mental health problem, or pick one from the
reader or the lectures. Describe which choices have been made on the 8 choice
dimensions for that specific intervention.

Which different types of intervention strategies can be derived from the different
models on health?

Which considerations are important when a choice should be made about the
determinant(s) to tackle in a prevention strategy?

Interventions can consist of multifactor or mono-factor approaches. Normally
multifactor approaches are preferred. In which situations will a mono-factor approach
be sufficient?

Which influence mechanisms can be used in preventive interventions?

Give some preventive intervention methods that can be used in prevention strategies
at micro, meso and macro level.
281

What kind of choices can be made on the time dimension of a prevention strategy,
what considerations from developmental psychopathology are important for the
choices on the time dimension? Explain this with the theme COPMI, depression or
another theme.

What prevention instruments can be used in society to improve the mental health of a
population? Give some examples for each instrument. What instrument is the most
efficient in your opinion?
282
PART IV
EVIDENCE AND EFFECTIVENESS
283
284
14
Evidence of Effectiveness and Improving Effectiveness
in Prevention and Mental Health Promotion
14.1
Introduction
286
14.2
When is a prevention or promotion programme successful?
287
14.3
Current stage of evidence-based prevention and mental health promotion
290
14.4
Going to scale and across borders
294
14.5
Contributions from health promotion
295
14.6
Learning from failures and successes:
Principles and Effect Management
296
Conclusion
301
14.7
Literature
302
Study questions for this chapter
304
285
14 Evidence of Effectiveness and Improving Effectiveness
in Prevention and Mental Health Promotion
Clemens M. H. Hosman
14.1 Introduction
The last two decades, significant progress has been made in the development of evidencebased prevention and mental health promotion programmes. In general, prevention science
became a recognised multidisciplinary field worldwide, with contributions from psychiatry,
psychology, sociology, biology, neurosciences and health economy. Systems for rapid
international exchange of prevention knowledge and evidence-based model programmes are
emerging. National and international databases offer information on available effective
programmes, for instance to increase social-emotional competence and parenting skills, and
to prevent child abuse, aggressive behaviour and conduct disorders, depression, anxiety
disorders, eating disorders, and alcohol and drug abuse. By designing easy accessible online
exchange systems for policy makers, researchers, local organisations, and practitioners, we
have a powerful tool to enhance prevention and mental health promotion practices across
countries and communities, and to increase their effectiveness.
To understand fully the long-term and complex causal trajectories of mental disorders and the
social and physical outcomes of poor mental health, several decades of further etiological
research are needed. Nevertheless, there already is a lot of scientific information available
about malleable risk trajectories, mental health promoting conditions and effective
interventions. To date, this knowledge offers a useful base for preventive action, i.e. to design
and implement effective prevention and promotion policies and programmes. The outcomes
of many controlled studies indicate significant preventive outcomes could be expected in the
next decades not only in the mental health domain but also in other domains that are narrowly
related to mental health, such as better physical health and less mortality, better school
achievements, more productivity at work, a safer environment, and less youth delinquency.
Effectiveness and economic evaluation studies have shown that improving mental health can
generate a wide range of health, social and economic benefits (Hosman, Llopis & Saxena,
2004; Jané-Llopis, Barry, Hosman & Patel, 2005).
This chapter has several aims. First, we discuss how we can evaluate the success of
prevention or mental health promotion programmes. This requires further elaboration of
concepts such as outcome indicators, evidence, effectiveness and efficacy. Secondly, a short
impression is given of the status of evidence-based prevention and promotion in mental health.
Thirdly, the growing international exchange and adoption of programmes is discussed and the
related question about the need of programme fidelity versus the need of adapting
programmes to local conditions and cultures (re-invention). Finally, as the number of
intervention studies has increased dramatically over the last decades, so has the knowledge
on effect moderators. This knowledge is essential for designing more effective new
programmes in the future, improving existing programmes and adapting programmes when
they become implemented in new settings. This is the last theme of this chapter.
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14.2 When is a prevention or promotion programme successful?
What are criteria of success for a mental health promotion or preventive intervention? The first
answer is: There is not just one criterion for success or failure! It depends first on who is judging
and from which perspective. Secondly, it depends where in the process of multiple needed
steps towards the ultimate goals you locate criteria for success. Thirdly, it also depends on
which criteria you or other stakeholders want to use for the level of evidence needed to make
a satisfying decision about the level of success.
Stakeholders and their perspectives
There are different criteria possible depending on the position and perspective from which you
look at outcomes. This could be very different among stakeholders. Take for example the
positions of a city government, a health insurance company, school management, a company,
a university researcher, and a community leader, and health practitioner, manager of a mental
health centre, prevention expert, or consumers. They might have a genuine and common
interest in reductions of mental disorders or an increase in mental capital of local citizens, but
is very likely that they also use different criteria to conclude whether a preventive practice has
been successful. In some cases, the primary interest might even be something else then
improved mental health. For instance, health insurance companies are primarily interested in
cost reductions, thus the potential of prevention to reduce the need for specialised and
expensive treatment. Local governments might be especially focused on what a prevention
programme could contribute to less social problems in specific neighbourhoods, more social
cohesion, and less need for social services and welfare. Departments of Justice might be more
interested in the impact of improved mental health on reductions in violence and delinquency.
Schools and companies might evaluate their potential investment in terms of its benefits in
terms of their contribution to a better organisation climate, more goodwill to parents or
consumers, achievements that are more academic and productivity. Consumers will ask what
such interventions mean for their subjective well-being and quality of daily life. Outcomes such
as social inclusion and good citizenship might be the special concern of community leaders
and local governments.
It is very important to take these different perspectives into account in your advocacy
for mental health, and when you are defining interventions, goals and selecting outcome
indicators for evaluation. This requires that you have a good insight into both the determinants
and the multiple individual, social, and economic outcomes of mental health. A stakeholder
might primarily be interested in a specific determinant or outcome. To give yourself a good
idea of the relevant stakeholders and their interests, it is recommendable to run a stakeholder
analysis.
Each of the multiple steps needs to be successful
Secondly, the criteria are different depending on where in the stepwise process of outputs and
outcomes you want to measure success. We remind you that usually a mental disorder is the
end of a long-term developmental trajectory. An intervention could be targeted at a specific
step in this trajectory. For instance, an intervention could be targeted at improving the quality
of the mother–baby interaction while ultimately aiming at a reduction of internalising and
externalising problems in childhood and adolescence. In addition, the development and
implementation of a successful intervention until the final prevention of a mental disorder
287
Box 14.1 Successes and failures of interventions measurable in multiple
stages of the intervention and outcome process

Local support for a preventive intervention

Implementation of a preventive intervention

Participation level in the target population

Changes in determinants of mental health / mental disorders
˗
biological, psychological, social, physical and societal factors
˗
risk factors and protective factors

Direct indicators of improved mental health, e.g. more problem solving skills

Reduction in mental and behavioural disorders, e.g. depression, eating disorders

Improved physical health, e.g. less cardiovascular diseases, mortality

Earlier use of health care (secondary prevention) or less use of care (primary prevention)

Social outcomes, e.g. better school achievements, less violence, more social cohesion

Economic outcomes, e.g. less health costs, more productivity, less costs for justice system
represent a process of multiple steps. Each step needs to be successfully completed and is
thus connected to an intermediate goal, for instance the successful completion of a pilot
intervention, the successful recruitment of many participants from the target population, the
active involvement of participants in a learning process, and the successful reduction of a
powerful risk factor. The extensive planning model offers a good illustration of these multiple
steps that each needs to be performed well. For instance, to reduce bullying among all
schoolchildren, anti-bullying programmes need to be implemented in a large group of schools,
which in itself is a huge challenge. Attaining such a goal is certainly a success in itself.
Prevention practitioners will already consider it as a major success when they are able to
create a high participation of children, parents and teachers in many schools within their health
district. Nevertheless, this is only a first step towards the ultimately desired outcomes, a
significant drop in bullying behaviour in the youth population.
In sum, successful promotion and successful prevention is based on a long chain of
successive achievements. This could even require multiple successive interventions by
different agencies and parties. Mental health promotion has many different success criteria
and together these criteria represent a chain of interrelated outcomes. Box 14.1 shows
outcome criteria linked to these different levels and perspectives.
Efficacy and Effectiveness
Most of the currently available knowledge on the effects of interventions is based on efficacy
studies only. Efficacy refers to the evaluation of the effects of first or second implementations
of a new intervention under relatively ideal and controlled conditions. Such experimental trials
of new programmes are usually accompanied by a high level of scientific input, inspiring
leadership by the programme designer, special attention to adequate training of intervention
providers, and a check on programme fidelity during implementation. The word effectiveness
is used when a controlled study shows that a programme still shows positive outcomes when
implemented at a large scale within the routine of daily practice and under much less controlled
288
conditions. It is a common experience that under such conditions it is more difficult to repeat
the effects found in efficacy studies. For instance, in daily practice a programme might be
implemented with less fidelity due to local circumstances, time pressure or lack of skills among
programme providers. In prevention and mental health promotion, only a minority of the
available evidence-based programmes have provided this robust evidence of effectiveness.
Level and duration of effect
Even when studies have shown that effects of an intervention are significant, the level of effect
could highly vary from small, medium to high effects. In addition, effects found in outcome
studies might represent only short-term effects that could fade away over time. For this reason,
it is important to include follow-up tests in outcome studies in addition to a pre-post test. Even
better would be to use longitudinal outcome studies on the effects after 5, 10 or even 20 years.
The opposite is also found, namely that short-term tests do not show efficacy, but long-term
evaluation does. This is what we call a sleeper effect. The working ingredients of preventive
intervention might take time to show their effects. For instance, this could be the case because
intervention increases resilience against risk factors to which a person is exposed somewhere
in the future. It might also be attributed to the long-term developmental processes that are
addressed by the intervention.
Reach in the target population and population-wide impact
Even if a programme is found to be highly effective in several controlled studies, it will have a
poor impact on the prevalence and incidence of a problem in the community when the
programme reaches only a marginal part of the target population at risk. This is currently one
of the main bottlenecks in prevention and health promotion. Population impact is a function of
both the effectiveness and reach of a programme. Therefore, reach is also a crucial criterion
of success and should be included as an indicator in outcome studies.
Level of evidence
The next issue is how much evidence is available for the found level of effect of an intervention.
Conclusions could be based on qualitative studies only or on controlled studies. Controlled
studies could be quasi-experimental or based on randomisation of individuals or randomisation
of schools, practices or even cities (cluster-randomisation). These designs differ in the quality
of evidence they produce. Usually randomisation is preferred to create a high level of evidence,
with a low risk of incorrect conclusions.
However, this needs some comment. First, this reasoning applies only to what is called
internal validity, i.e. how certain are we that the outcomes can be attributed to the exposure to
a prevention programme. For instance, reductions of problems can also be found as many
problems are time bound and reduce over time, like in the case of a depressive episode. The
presence of data from a control group could provide more certainty about the impact of the
intervention. Secondly, some interventions cannot be studied in a randomised design. For
instance, the introduction of new national measures or legislation to reduce alcohol and drug
abuse cannot be studied in a randomised design. Similarly, community interventions and
programmes consisting of multiple interventions (e.g. to reduce child abuse, or community
violence) ask for a different type of design, such as a quasi-experimental study, a time-series
design or a series of qualitative studies. To evaluate the external validity (i.e. ability to
generalise outcomes to new situations of implementation) qualitative studies are very
289
important, as they provide information about the specific context of a successful
implementation.
The level or quality of evidence depends not only on the quality of the research design but also
on the number of outcome studies. The more studies on the same intervention or on similar
interventions show significant effects, the more robust the evidence is. To decide on a national
implementation of a prevention programme, an expensive investment, those who are
responsible for such a decision usually require that significant positive effects have been found
in multiple studies executed by different research groups and in different sites. To come to
conclusions about the average effectiveness of certain preventive interventions, a mean effect
size is computed using the statistical outcomes of multiple intervention studies. A single effect
size is a standardised score, based on the difference in changes between the experimental
and control group divided by the pooled standard deviation.
14.3 Current stage of evidence-based prevention and mental health promotion
Where are we to date in the process of
developing and implementing effective
Box 14.2
programmes to promote mental health
Online databases of evidence-based
and prevent mental disorders? Below
prevention and promotion programmes
we give a short impression.
in mental health
Over the last three decades,
we estimate that over two thousand
Dutch databases effective interventions:
outcome studies have been published.
Nederlands Jeugd Instituut; www.nji.nl
Based on reviews covering separate
Rijksinstituut Volksgezondheid en Milieu
domains
within
mental
health
http://www.loketgezondleven.nl/leefstijlinterventies/
promotion
and
prevention,
we
estimate that currently over a hundred
NREPP database of US Ministry of Mental
programmes exist for which some
Health and Substance Abuse (SAMHSA)
evidence exists of their efficacy. These
https://www.samhsa.gov/ebp-resource-center
‘evidence-based’ programmes and
their research outcomes are described
OJJDP database Delinquency Prevention
in several online national and
www.ojjdp.gov/mpg
international databases (Box 14.2).
CASEL: Social-emotional learning and
The aim of these databases of
school-based programmes www.casel.org
effective programmes is to stimulate
that they are widely adopted and
Norwegian database Youngmind
implemented. For this reason, they are
www.ungsinn.no
also called ‘model programmes’.
Especially, the last ten years
the number of replication studies has increased significantly. For some programmes, even
several dozens of outcome studies have been implemented, showing robustness of their
efficacy, even when implemented in different countries (e.g. Coping with Depression Course,
Triple P, and Bullying Prevention Programme).
There is also evidence that implementation in different settings or countries not always
results in similar positive results. For instance, in the 1990s we adopted the PREP programme
290
in the Netherlands, a successful American programme on preventing relationship problems
and divorce in young couples. In contrast to an American study, we did not find any efficacy of
the programme in our Dutch randomised trial (Van Widenfelt, Hosman, Schaap, & van der
Staak, 1996).
Although the number of controlled outcome studies is quickly growing, still many
prevention and promotion programmes are implemented in local practices not having been
tested whether they really work. As an illustration, we refer to a survey of the European Mental
Health Promotion Network on promotion and prevention programmes for children between 0 –
6 years old in 17 European countries (Mental Health Europe, 1999). In this study about the
situation in the late 1990s, we collected information about the ‘best practices’ in these
countries. Of the 197 programmes we identified the far majority (89%) could not provide any
scientific evidence on their efficacy or effectiveness. Most providers could only present some
anecdotic evidence of effects based on qualitative studies. In the Netherlands, the National
Research and Development Council (ZonMw) has financed dozens of controlled outcome
studies to increase our knowledge on the effects and cost-effectiveness of prevention
programmes.
What can we conclude from the many controlled outcome studies?
Several international review studies,
among others for the World Health
Organization (WHO), the International
Union for Health Promotion and
Education (IUHPE), US Institute of
Medicine (IOM), and for the European
Union, show an interesting diversity of
evidence-based positive outcomes
(Mrazek & Haggerty, 1994; Hosman et
al, 2004; Jané-Llopis et al., 2005;
Anderson, Jané-Llopis, Hosman,
2011; IOM, 2009), as summarised in
Box 14.3:
1) Improvements in a large variety of
protective factors for mental health,
2) Reductions of many different risk
factors,
3) Reductions in serious mental and
behavioural problems
mental disorders, and
and
some
4) A broad range of positive social and
economic outcomes.
Also, the authoritative report of the US Institute of Medicine offers an impressive overview of
current achievements in preventing mental disorders and promoting mental health in children
and adolescents (IOM, 2009). If you are interested in this excellent overview, use the following
website: https://www.ncbi.nlm.nih.gov/books/NBK32776/. Currently, many meta-analyses on
the outcomes of prevention programmes are available. They show that mostly mean effect
sizes are between .20 and .35, indicating that in average prevention programmes have still
291
only a small to moderate effect. These mean effect sizes are in a way misleading, for they
summarise the outcomes of programmes that show a large variation in efficacy and
effectiveness: from very effective and moderately effective programmes to non-effective
programmes and sometimes even programmes showing negative effects. These outcomes
stress the importance of testing whether programmes really work and what room there is for
further improvements.
Changing protective and risk factors
The most well-established effects are the positive outcomes of interventions in terms of
improvements in risk and protective factors. Improvement of protective factors include, for
instance, more self esteem, better problem solving and social skills, more stress management
competence, feelings of mastery, and improved social support. Each of these outcomes have
been found in numerous intervention studies, especially in studies on preschool and schoolbased programmes aimed to increase resilience in children and adolescents.
Furthermore, there is ample evidence that preventive interventions are able to reduce
important risk factors in mental health, for example preterm deliveries, child abuse and neglect,
poor parenting skills, exposure to violence and bullying, risk behaviours in children and
adolescents, and social isolation. Especially in the early life situation, preschool age, and
elementary and secondary school a large range of efficacious programmes are currently
available (Greenberg et al., 2003) (see also databases at www.casel.org and www.nji.nl).
Preventing the onset of mental disorders
The evidence for significant reductions of mental disorders because of preventive
interventions is rapidly growing but still limited. To date, controlled studies have shown
successful reductions in the onset of mental disorders, such as conduct disorders,
depression, anxiety disorders, and eating disorders. In these cases, malleable risk and
protective factors are successfully addressed resulting in lower incidence of disorders.
Many studies have shown that preventive interventions can reduce high levels of
psychiatric symptoms before they reach a clinical stage. For example, in depression,
longitudinal studies have shown that high levels of depressive symptoms are predictive for the
onset of later clinical depression. Especially in children and adolescents, reductions in
depressive symptoms could reduce the risk of later depression. Studies of Clarke and others
(2001, 2002) and Garber et al. (2009) on the Coping with Depression Course for adolescents
at risk showed a drop of the onset of first depressive episodes of around 60% to 30%,
depending on the duration of the measured outcome period.
A meta-analysis on 19 RCTs of selective and indicated prevention programmes for
depression showed an average reduction of 22% in the incidence of depression (Cuijpers et
al., 2008, on 19 RCTs). A Dutch prevention-oriented stepped care programme for elderly (<
75 yrs.) showed even 50% reduction in onset of anxiety and depressive disorders in
comparison to elderly in a control condition up to 24 months after the intervention (‘t VeerTazelaar et al, 2009, 2011). The most effective element of these depression prevention
programmes is found to be their cognitive behavioural approach, i.e. using training methods to
change negative thinking styles in positive ones.
In addition, several studies show that the implementation of relapse and reoccurrence
prevention during or following treatment for depression could reduce its recurrence by 40% or
more (e.g. Kuhner, Angermeyer & Veiel, 1996; Ma & Teasdale, 2004; Bockting et al, 2005).
292
When mental health services would decide to implement such relapse prevention strategies
systematically in the practice of mental health care, such a measure can have a very significant
impact on the development of depressive episodes in the community and lower the existing
prevalence rates. This is especially important for depression, given the high risk of relapse and
reoccurrence without such (40% within one year and 50% in 2 years).
As an illustration of a programme that successfully aims to reduce conduct disorders, we
offer below a description of the Fast Track Programme and the outcomes of several
controlled studies run by the Conduct Problems Prevention Research programme.
The Fast Track Program, a multi-year school-based and home-based programme
targeted at preventing antisocial behaviour and conduct disorders. The programme
includes among other parent training, home visiting, academic tutoring, social skills
training, and friendship groups for those at risk, combined with a universal classroom
intervention aimed to enhance social and emotional competence. In a longitudinal
randomised-controlled study, intervention effects were detected as early as grade 3 and
were robust through grade 9. Among the highest risk group in grade 9 assignment to
intervention was responsible for reducing the risk of conduct disorders by 75%, of ADHD
by 53%, and 43% of all externalising psychiatric disorder cases. Outcome studies also
showed a significant preventive impact on juvenile delinquency and arrests. Children
participating in the programme showed also reduced use of health, paediatric and
emergency department services relative to control youth. Among control-group youth,
the use of general health services for health and mental health purposes were roughly
30% higher and 56% higher.
Among children at moderate risk, the programme had only a limited effect. (Conduct
Problems Prevention Research Group, 2007, 2010, 2011). While this Fast Track is an
example of an intensive and time-consuming prevention programme doubts exists if this
programme can also be considered as cost-effective and recommendations are
presented to find more economic strategies to find the same outcomes (Foster, 2010).
For more information, see the programme’s website: www.fasttrackproject.org
Social and economic outcomes of prevention
Another important outcome of mental health promotion and preventive interventions are their
social and economic outcomes and the evidence for their cost-effectiveness. Prevention
studies have found evidence for increases in school achievements, productivity at work, safer
environments, and less domestic violence, juvenile delinquency, arrests, and reductions in
unemployment as a result of mental health promotion. Several programmes, such as the JOBS
program and the Perry Preschool Program show financial benefits several times the costs of
such programmes. An analysis of over 50 early prevention and promotion programmes for
children showed in average a benefit of 17.000 $ against 7.000 $ programme costs per child,
which means a Return-of-Investment of 2.4 (Aos et al., 2004). To advocate for investments in
mental health and to recruit financial and political support for mental health promotion and
prevention, such outcomes are of vital importance.
In box 14.4, an example is presented of the Perry Preschool Program for young children, which
has showed a wide range of social and economic long-term effects.
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Box 14.4 The High/Scope Perry Preschool Project
The overall objective was to prepare economically disadvantaged children for success in school.
Children received two-and-a-half hours sessions of “high quality early childhood education”, five
days a week for one or two years (depending on age). The programme was designed to promote
cognitive, social, behavioural, and language development, and to broaden each child's base of
information and experience. Children set daily goals for themselves.
The preschool component was coupled with home visits for 90 minutes each week, with the
goal of promoting parental interest in their child's learning.
A longitudinal randomised control study over 15 years showed among others the following
outcomes (figures between brackets show the results for the control group):
 less developmental delay
 better school achievement
 less school dropout
At age 19:
 Employment rates 59% (32%)
 Detention and arrest rate 31% (51%)
 Less use of welfare benefits
At age 27:
 Arrest rates for drugs dealing 7% (25%)
 Homeowner 36% (13%)
 Income of $2000 or more 29% (7%)
At age 40:
 Arrest rates for violent crimes 32% (48%)
 Government assistance (e.g. welfare, food stamps) 59% (80%)
 Employment rates 76% (62%)
 Homeowner 37% (28%)
At age 27, the economic benefit was already 7 times the costs of the programme.
At age 40, the economic benefit even grew to 13 times the costs of the programme.
The programme is also implemented in the Netherlands by the name of Kaleidoskoop
(Schweinhart and Weikart 1988, 1997; Schweinhart, 2004)
14.4 Going to scale and across borders
Effective programmes will only have a significant impact on the mental health of populations
when such programmes are scaled up, i.e. are widely disseminated and implemented in many
communities and even countries. Public impact is defined by effectiveness + reach. The earlier
discussed national databases are one of the tools to enhance broad implementation after
evidence of effectiveness is found.
Mental health promotion and prevention become increasingly an international market place.
Many effective model programmes are now being exchanged between countries. After
adoption by another country frequently replication studies are done to test if a programme also
works in the new environment and culture and if tailoring is needed. An example of a successful
programme that is scaling up, even across borders, is the so-called JOBS programme,
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developed by the Michigan Prevention Research Center (Price & Vinokur, 1995). The
programme is based on training unemployed people for 5 half days. Participants learn a range
of skills, such as job seeking skills, communication skills, and skills to cope with emotional
problems and setbacks. The programme has been repeatedly shown to be effective in reducing
unemployment, as well as reducing new depressive episodes (Vinokur et al., 1995; Vuori et
al., 2005). In a period of 2.5 years, this course reduced serious depressive episodes with
almost 40% in a group of unemployed people with high risk for depression. After the
intervention, 25% in the prevention group had a depression, compared to 39% in the control
group. Even for those who later became unemployed again the training protected them against
the risk of depression. The results of a cost-benefit study resulted in a positive net benefit of $
12.619 over a 5-year period for the participants. This programme is currently implemented in
several states of the US, in some European countries (Finland, Netherlands and Ireland) and
even in China. In a period of economic recession and high uncertainty among citizens about
their jobs, this programme offers an interesting option.
In the Netherlands, we have adopted many evidence-based programmes that were originally
developed in the United States, United Kingdom, Norway, Israel, and Australia. For example,
programmes on parent education, reduction of child abuse, prevention of depression,
aggression, bullying, and behavioural disorders and on the development of psychosocial
resilience in children. The most well known example is the ‘Coping with Depression Course’,
in the early 1980s developed by Lewinsohn and Munoz in the US, translated, and adapted to
the Dutch culture in the 1990s. This cognitive behavioural indicated prevention programme
can be offered by all mental health centres in the Netherlands and is found to be effective in
preventing the onset of depression. Tailored versions have been made for different target
groups at risk and an internet version is available. In most of these cases, controlled replication
studies on their efficacy have been performed or are currently ongoing, supported by the Dutch
National Prevention Research Programme (ZonMw). Some successful Dutch programmes,
such as The COPMI Mother-Baby Programme, are adopted by other countries (chapter 16).
14.5 Contributions from health promotion
An important question is whether we should rely only on programmes specifically designed for
mental health problems. Can we expect that intervention programmes designed outside the
domain of mental health to contribute to positive mental health outcomes as well? Over the
last decades, a major investment took place worldwide in developing health promotion
programmes aimed at enhancing health life styles (e.g. exercise, no smoking, healthy eating
habits) and at reducing obesity, cardiovascular diseases, and cancer. In addition, the United
Nation and related international organisations invest in reducing poverty, starvation, and AIDS
in low-income countries, especially in Central-Africa. These conditions represent known risk
factors for mental health for those who are exposed to it and their children. Therefore, we might
expect that programmes that are successfully addressing these risk factors might also have a
preventive impact on mental health.
Exercise programmes (e.g. fitness, tai chi) seem also to influence mental health (van
Waerden, 2011). There are indications from several studies, both in Western countries and in
Asia that exercise also results in better cognitive skills, more positive mental health and less
295
depression in adults and elderly. Several intervention studies have showed that exercise
improves the memory functioning in the elderly (memory span, short-term memory span)
(Fletcher et al., 1999).
There is strong evidence that improving nutrition in socioeconomically disadvantaged
children can lead to healthy cognitive development and improved educational outcomes,
especially for those at risk or who are living in impoverished communities (Jané-Llopis, Barry,
Hosman & Patel 2005). The most effective intervention models are those that combine
nutritional interventions (such as complementary feeding, growth monitoring, food
supplementation) with counselling, and psychosocial care (e.g. warmth, attentive listening).
Such programmes are also cost-effective (WHO, 2002a). For example, iodine is known to play
a key role in preventing mental and physical retardation and impairment in learning ability
(WHO, 2002b). Global efforts, such as those supported by UNICEF (2002), have led to 70%
of the world’s households using iodised salt. This means 91 million new-borns are protected
from iodine deficiency and therefore from the associated mental and physical health problems.
Poor quality housing has been used as an indicator of poverty and as a target to
improve public health and reduce health inequalities. A systematic review suggested that
housing improvement has a promising impact on self-reported physical and mental health,
perceptions of safety and social and community participation (Thomson, Petticrew & Morrison,
2001).
Over the last 25 years, the Healthy Cities programme of the WHO has had a great
impact on the health policy of many cities in Europe. A large range of social and environmental
interventions has been implemented as part of this programme. Mental health promotion,
however, was poorly represented as a specific target. Nevertheless, it is very probable that
Healthy City programmes also have a positive impact on mental health because of safer
environments, stimulating exercise, housing projects, and more playgrounds for children,
greater social inclusion of minority groups, and better social networks.
14.6 Learning from failures and successes: Principles and Effect Management
As stated earlier in this chapter, besides successes of preventive programmes, efficacy studies
show failures as well. Outcomes of a meta-analysis by the Nijmegen Prevention Research
Centre on 149 studies from different countries revealed that large differences exists in the
outcomes of prevention programmes in the field of mental health, ranging from negative
effects, to no, minor, and large effects (Figure 14.1) In addition, outcome studies show that
effects sometimes fade away in the year after the intervention, effects are frequently only found
in subgroups of the target population, and effects can be restricted to only a part of the outcome
indicators. This means in the first place that we should not take the efficacy or effectiveness of
a programme for granted just because it looks innovative, or that the programme designers
and providers are proud of their products. Even satisfied responses from participants offer no
guarantee that the preventive goals are achieved.
Failures and unsuccessful programmes can be considered as valuable learning
experiments. They are crucial for further building our prevention science. Comparisons
between successful and unsuccessful programmes help us to answer questions such as: What
are the crucial programme differences between the two groups? What are successful and
unsuccessful strategies of dissemination and implementation? In general, what are the basic
296
principles of effective mental health promotion and prevention? For whom does a specific
prevention programme work and for whom not or only marginally? How can we use such
knowledge to improve the quality of programmes, better select the target population for whom
it works, or for tailoring versions of an existing programme to the need of specific segments of
a target population? Studies on these differences have resulted in insight into a range of effect
predictors that can be translated into guidelines for effect management by programme
designers and practitioners. Professionals working in this field are not only the providers of
preventive interventions, but are also expected to play a role as ‘effect manager’.
Effect management refers to the process of continuously improving the efficacy, effectiveness,
cost-effectiveness, and reach of preventive interventions by translating evidence-based and
practice based knowledge on effect predictors into guidelines for effect improvement and by
implementing these principles in prevention policy and practice. Principles of effect
management can be applied during: (1) The development, dissemination, implementation, and
institutionalisation of new programmes; (2) the selection, adoption, and adaptation of ‘model’
programmes that have been developed in other communities or countries; and (3) for the
improvement of already implemented programmes.
Effect moderators, also called effect predictors are factors that influence the ‘evidence-based’
effects of preventive interventions on those who participate in such programmes but also the
effects of such programmes or programme combinations on the population at large. Effect
moderators can be found in the following domains:

Characteristics of the way a programme is developed (e.g. planning-based, theory-based,
history of try-outs, and pilot studies, involving representatives of the target population)

Characteristics of the programme itself (e.g. SMART goals, type of method, duration,
dosage, tailored to target population, type of provider, combinations of interventions)

Characteristics of the participants and target population (e.g. motivation, risk level, gender,
pre-existing attitudes, participation level)

Characteristics of the social context of implementation (e.g. community support, community
values and norms, competing messages, supporting legislation, and policies)
297

Quality of programme implementation (e.g. training of providers, programme fidelity)

Characteristics of how a programme is disseminated and adopted across communities,
schools, workplaces, regions (e.g. database, accessibility and tryability of new
programmes)

Available resources (e.g. budget, supporting policies, personnel, training facilities,
knowledge, expertise, management, leadership, interorganisational collaboration)

Characteristics of outcome research (e.g. quality of research design and measurement
instruments, number of outcome studies, meta-analysis).
Figure 14.2 shows a theoretical model of how the different clusters of effect predictors are
related to each other. In effect management each of these clusters could be taken as a target
and starting point to find opportunities to improve the effectiveness of a prevention programme.
For instance, when for certain participants a depression prevention programme is not
efficacious, one could re-design the programme to make it more responsive to a variety of
participants, or one could design multiple ‘tailored’ versions of a programme, one for each of
the different segments in the target population (e.g. specific versions for immigrant groups,
youngsters, elderly, low-income women). When a programme reaches only a small group of
individuals from the target populations by using group methods, one could consider the use of
internet or mass media to reach a larger proportion. When a group of local practitioners wants
to develop a programme based on their experiences with a mental health problem (e.g.
aggressive behaviour among youngsters), a more effective version could be developed by
making use of the available scientific knowledge on determinants of aggressive behaviour.
Sometimes preventive effects do not become visible in a controlled outcome study, when
studies measure only short-term outcomes, which is often the case. Follow up measures after
a year, five years or even longer are frequently lacking. This would require a change in the
research design.
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Some effect predictors further elaborated
Single outcome studies but also systematic reviews, meta-analyses, and in-depth discussions
with policy makers, programme designers, providers, and consumers are providing more
insight in what the ingredients are of effective programmes, practices, and policies (e.g.
Greenberg et al., 2003; Nation et al., 2003; Jané-Llopis, 2004; Stice et al., 2004, 2009). Below
we have highlighted some of these findings.
- Programme development and resources: Take a long-term perspective when developing
an evidence-based programme. The most successful programmes that are currently
available, have taken around 10 to 20 years to be developed from start till the moment of
repeated evidence of its effectiveness. Given the large investment that is needed for
developing and implementing very successful programmes and the limited budget
available, it is recommended not to spread available budgets for programme development
across too many programmes and to focus on the most promising ones.
- Participant and target population: Segmentation of problem and target groups makes it
possible to make more tailored interventions for specific subgroups, as stated earlier.
Outcome research has confirmed this hypothesis. Tailoring increases the effectiveness of
a programme. For instance, in most cases but not all, outcome studies show that
preventive effects are greater among those who are more ‘at risk’ due to an accumulation
of risk factors. Careful risk assessment and identifying individuals or groups most at risk
will increase effectiveness.
- Timing of intervention (programme): Developmental psychopathology studies have shown
that mental health and mental disorders mostly have a long-term developmental trajectory
that starts already early in life. This stresses the importance of intervening as early as
possible in such a developmental trajectory and at ‘sensitive periods’. Sensitive periods
are those periods wherein a risk or protective factor is starting to emerge or wherein
children, adolescents or adults are in a transitional period and therefore more open to
change. For example, to prevent serious conduct problems it is recommended to intervene
already in preschool and early elementary years, instead of waiting until adolescence
when risk factors have become strongly interrelated and stabilised. Known sensitive
periods are at the start of new developmental periods (pregnancy and early life, early
adolescence, beginning relationships) or in a period of crisis (e.g. divorce, death of a loved
one, losing a job).
- Programme strategy: Over the last decade, there is a movement from single interventions
to multi-component and integral programmes (i.e. consisting of multiple interventions or
programmes). There is evidence from many sources that programmes are more effective
when they use multiple methods, and address for instance not only children but also
simultaneously parents, peers, teachers, the school system, and the local community as
a whole. Multi-component programmes could also encompass multiple settings to reach
more people or address multiple risk and protective factors.
- Targets of programmes (risk and protective factors): Prevention is frequently focused at a
specific disorder or a specific unhealthy behaviour, e.g. depression or excessive drinking.
In such an approach, we try to influence as many responsible factors as possible.
However, epidemiological and evaluation studies have shown that different problems and
disorders have frequently common risk and protective factors. Therefore, an alternative
299
would be to focus at common factors to create a broad-spectrum effect (multiple
outcomes). Such a wider approach requires the use of a wider set of outcome indicators
to make the full spectrum of expected positive outcomes visible.
- Targets of programme (community programmes): Epidemiological research has shown
that different mental health and social problems are frequently related and show a high
level of co-morbidity. These problems are usually concentrated in certain populations or
neighbourhoods at high risk. When problems trigger each other, it can be more effective
and efficient to use a comprehensive community approach, as is used for example in the
Communities that Care Program. In this programme, a specific cluster of evidence-based
prevention programmes that best fits the ‘at risk’ community is selected based on a
community needs assessment, involving multiple parties in such a community. In general,
an innovative option is not to focus on separate problems, but to use an integral approach
to address ‘smart clusters’ of narrowly related problems.
- Duration and dosage of programmes: programmes that are too short run the risk to be
ineffective or to produce only short-term effects. Several studies have shown that, at least
in children, expanding the contact time over a longer period is more effective then offering
the same contact in a much shorter period (e.g. couple of weeks). Interventions that exist
of only one session (e.g. school hour, afternoon) usually do not show effect.
- Dissemination and used methods in programmes: One of the main problems in current
practice is the limited reach in the community, as we stated above. More effort and
attention needs to be given to the development of support to large-scale dissemination
and implementation of successful programmes. This is currently a serious bottleneck in
many European countries. Another option is to select intervention methods that have a
larger reach in the community, such as the internet (E-health) and mass media (chapter
18).
- Implementation: Effectiveness does not only depend on the quality of a prevention
programme, but also on the quality of its implementation. Programmes have been found
to be more effective when programme providers (practitioners) receive more training and
supervision, and show fidelity to the originally designed, evidence-based programme
(programme fidelity).
PREFFI 2.0
Over the last 20 years, a lot of new knowledge has been developed on what makes prevention
programmes more effective and what could be serious barriers to efficacy and effectiveness.
To make the knowledge on effect predictors more accessible and usable the Dutch National
Institute of Health Promotion and Disease Prevention and the Prevention Research Centre of
the Radboud University and Maastricht University have collaborated since the end of the 1990s
on the development of an effect management tool for practitioners, programme designers and
policy makers. This tool is called the PREvention EFFect management Instrument, known as
the PREFFI. The current version, the PREFFI 2.0 offers a large list of effect predictors divided
into 8 clusters and a system to assess the quality of prevention programmes and to improve
the perspective on effectiveness (Molleman et al, 2003; 2005a; 2005b). The 8 clusters roughly
parallel the domains specified in Figure 14.2. The PREFFI 2.0 is found to be a reliable and
valid instrument. This instrument is used widely in Dutch prevention and health promotion
300
practices and its framework is also used in selecting promising and evidence-based
programmes for national databases (next chapter).
The PREFFI 2.0 is also translated in several European languages (English, French,
Norwegian, and Croatian) and used in other countries. Currently, our Prevention Research
Centre collaborates with Croatian prevention researchers to further study the validity and
reliability of the instrument, to improve the instrument, and to study the impact of a PREFFItraining on the quality and effectiveness of prevention programmes in Croatia. A Dutch and
English website is available on the PREFFI (www.preffi.nl)
14.7 Conclusion
To conclude, there is ample evidence that mental health promotion and preventive
interventions are able to change many risk and protective factors. Controlled studies show that
they can significantly reduce the risk of mental disorders and improve mental health (mental
capital). Also, evidence of their cost-effectiveness has been found. In addition, these
programmes are also able to generate a wide range of health and social outcomes outside the
domain of mental health. This shows their wide public value for different domains of life. On
the other hand, there is still a long way to go, and measures are needed to improve the
effectiveness of such programmes and their wide reach in the population. The many studies
that have been published on the outcomes of mental health promotion and prevention
programmes also have generated insight in what makes such programmes effective, for whom,
and under what conditions. A wide range of effect predictors have been identified and
translated in guidelines for effect management (PREFFI 2.0). Taking into account that until the
early 1980s almost no scientific knowledge existed on prevention in this domain, we may
conclude that huge progress has been made in the last three decades.
Notwithstanding this progress, we are currently exposed to several huge challenges. The
evidence on existing mental health promotion and prevention programmes need to be further
expanded. New programmes need to be developed and tested for risk factors and mental
health problems that are not sufficiently addressed yet. Especially, more knowledge is needed
on opportunities to influence social risk factors that have a significant impact on mental health
(e.g. economic recession, poverty, individualisation and poor social cohesion in communities,
economic migration, AIDS, social conflicts). Another important challenge is to understand how
preventive and health promoting interventions targeted at the social environment of pregnant
women, parents, and young kids could influence the neurobiological systems that function as
the hardware of mental capital and emotional resilience responsible for chronic psychiatric
vulnerability. Finally, we are just beginning to develop a theory on what constitutes effective
prevention and mental health promotion. Future outcome studies should not only study
whether a programme is effective or not, but give more priority to understand what the
ingredients and conditions are of effective programmes, policies, and practices.
301
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Price, R.H., & Vinokur, A.D. (1995). Supporting Career Transitions in time of
organizationaldownsizing: The Michigan JOBS Program. In M. London (Ed.). Employees,
careers, and job creation: Developing growth-oriented human resource strategies and
programs (pp. 191-209). San Francisco: Jossey-Bass Publishers.
Schweinhart, L. J. (2004). The High/Scope Perry Preschool Study through age 40: Summary,
conclusions, and frequently asked questions. Ypsilanti, MI: High/Scope Educational
Research Foundation.
Schweinhart, L. J., & Weikart, D. P. (1997). The High/Scope Preschool Curriculum Comparison Study
through age 23. Early Childhood Research Quarterly, 12, 117 - 143.
Schweinhart, L. J., & Weikart, D. P. (1988). Education for young children living in poverty: Childinitiated learning or teacher-directed instruction? Elementary School Journal, 89, 213 -225.
Stice, E., Bohon, C., Nathan Marti, C., & Rohde, P. (2009). A Meta-Analytic Review of Depression
Prevention Programs for Children and Adolescents: Factors that Predict Magnitude of
Intervention Effects. Journal of Consulting and Clinical Psychology, 77, 3, 486–503.
Stice, E., & Shaw, (2004). Eating disorder prevention programs: A meta-analytic review. Psychological
Bulletin, 130, 2, 206–227.
Thomson H, Petticrew M, Morrison D. (2001). Health effects of housing interventions: a systematic
review of intervention studies. British Medical Journal, 323,187-190.
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Van ‘t Veer-Tazelaar, P.J., van Marwijk, H.W., van Oppen, P., et al. (2009). Stepped-care prevention of
anxiety and depression in late life: a randomized controlled trial. Archives of General Psychiatry,
66, 297–304.
Van ’t Veer-Tazelaar, P.J., van Marwijk, H.W., van Oppen, P., et al. (2011). Prevention of late-life anxiety
and depression has sustained effects over 24 months: a pragmatic randomized trial. American
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women from disadvantaged communities (2011). (Doctoral dissertation) Retrieved from
http://digitalarchive.maastrichtuniversity.nl/fedora/get/guid:a02e4ca7-a5d3-40e1-90ec14852dd1d2d8/ASSET1
Van Widenfelt, B., Hosman, C., Schaap, C., & van der Staak, C. (1996). The prevention of relationship
distress for couples at risk: A controlled evaluation with nine-month and two-year follow-ups.
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WHO (2002a). Prevention and promotion in mental health. Mental health: evidence and research.
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Study questions for this chapter

Why is it not possible to use just one criterion for success or failure of mental health
promotion and preventive interventions? What different criteria exist to evaluate the
outcomes these interventions? Which stakeholders play a role in this and what are the
implications of their involvement?

What is the difference between ‘efficacy’ and ‘effectiveness’?

What are the major building stones of ‘evidence’ for the efficacy and effectiveness of
prevention and promotion programmes?

What influences the impact of programmes on the mental health of whole populations
or populations at risk?

Overall, what do we currently know about the evidence-based effects of mental health
promotion and prevention? Are existing prevention and mental health promotion
programmes effective? What kind of evidence-based effects are found? Are we able to
prevent mental disorders, which disorders and to what degree?

To create preventive effects on mental health, would it be recommendable to focus
interventions specifically on mental health issues and mental health targeted
programmes?

What is meant by the term ‘effect predictor’? Why is it important? Which effect
predictors can be distinguished? How could they be clustered and how are they
interrelated?

What is the meaning of effect-management? What strategies for effect management
could be derived from the model described in figure 14.2? Could you offer some
recommendations on how the effectiveness of prevention programmes can be
improved?

What does the author consider as major challenges for future prevention research?
304
15
Database of effective youth interventions
15.1
Introduction
306
15.1.1
The Netherlands Youth Institute
306
15.2
Database aims
306
15.2.1
Principal aims
306
15.2.2
Database in development
307
15.3
Database contents
307
15.4
Recognition
308
15.4.1
Inclusion criteria
308
15.4.2
Recognition criteria
308
15.4.3
Types of recognition
309
15.5
Classification systems for effect studies
311
15.6
An example: Triple P
311
Literature
313
Study questions for this chapter
313
305
15
Database of effective youth interventions
15.1 Introduction
In the light of a growing interest in the Dutch youth sector in evidence-based practice and ‘what
works’, a database of effective youth interventions, and an associated website
(www.nji.nl/jeugdinterventies) have been developed. The Database of Effective Youth
Interventions gives professionals, policy-makers, researchers, and financers, information on
effective youth interventions carried out in the Netherlands. All interventions included in the
database have been assessed by the national Youth Intervention Admissions Committee using
stringent criteria and have been acknowledged as effective intervention. The database holds
information on interventions whose effectiveness has either been demonstrated by effect
studies in the Netherlands, or for which this effectiveness can be assumed on solid theoretical
grounds. This also applies to interventions developed outside the Netherlands and which have
proved to be effective over there. The database is publicly accessible via the website; the
information held in the database is in Dutch.
15.1.1 The Netherlands Youth Institute
The Database of Effective Youth Interventions is developed and maintained by the
Netherlands Youth Institute (or NJi, after its Dutch name Nederlands Jeugdinstituut). The NJi
is the Dutch national institute for compiling, verifying, and disseminating knowledge on child
and youth matters, such as youth care, parenting support, and child education. The NJi
considers it important to be able to share its knowledge and activities to improve the quality
and effectiveness of care services for young people and their carers at an international level.
Information on the database and its associated developments is primarily intended for
professionals and organisations who share the NJi’s task of linking practice and research and
making the results accessible.
15.2 Database aims
15.2.1 Principal aims
The database principally intends to stimulate and support practitioners striving to supply the
highest possible quality of care services to young people and their carers. As a knowledge
broker, the NJi hopes the Database of Effective Youth Interventions will help care workers in
the field to benefit from scientific insights into the effectiveness of youth interventions, both in
the Netherlands and abroad. The Netherlands have a rich tradition of practical expertise in
providing services to young people and their parents or carers. At the same time, however,
most approaches have received little or no research attention and practical developments have
only scarcely been linked to scientific effect research. To optimise the provision of care
services they must be linked to research and practice. In recent years, there has been a strong
demand for the combination of practice development and effect studies. The Database of
Effective Youth Interventions and its associated website set out to meet this demand: They
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make scientific findings on the effectiveness of youth interventions accessible to care workers
in the field and at the same time, they stimulate the improvement of the care provisions on
offer. In other words, the database and the website bring research and practice together.
15.2.2 Database in development
The NJi works closely with other parties in the youth sector to implement and further develop
the database, so that they can offer information on a wide range of prevention, support,
treatment, and sanction programmes. The database is not intended as a tool for financiers to
select and use only those interventions that are indicated as being particularly effective; the
current level of knowledge about what works and does not work is inadequate for this purpose.
Moreover, it is essential that practice is given a free rein to develop new interventions and to
assess the effectiveness of existing but untested practices. The Database of Effective Youth
Interventions can assist in this process by providing inspiring and well-documented examples
of effective interventions.
15.3 Database contents
Interventions in youth and child-rearing
The Database of Effective Youth Interventions contains information on the effectiveness of
interventions for children, young people (up to 24 years), their parents/carers, and the care
environment. The term ‘intervention’ is an umbrella term that covers programmes, projects,
training methods, forms of treatment and supervision, sanctions, etc. A youth intervention is a
goal-directed and systematic approach that differs from what is usual for the group concerned,
and which aims to improve the psychological, social, cognitive, and physical development of
children and young people where this development is under (possible) threat. The
interventions are carried out by youth health care providers, pedagogic facilities, youth
workers, (special) education institutes, ‘community schools’, youth welfare organisations, and
juvenile justice organisations, amongst others. Provisions related to the curriculum have not
been included in the database.
Effective interventions
Only those interventions that have been recognised by the National Youth Interventions
Admissions Committee are included in the Database of Effective Youth Interventions. On the
1st of October 2014, the database included 223 interventions. These are interventions that the
Committee holds to be effective in practice- or at least in theory, by which is meant that a clear
description and solid theoretical foundation is available which makes it plausible that the
intervention might work. The Committee is a central body with a national working area.
Applying strict criteria for evidence of effectiveness, only for 27 of the 223 interventions strong
evidence was found for effectiveness based on RCTs.
Description components
Every intervention in the database is described in the same way. The description of an
intervention contains information on its aim(s), target group(s), approach, and materials, and
on the conditions for its effectuation, such as an implementation plan and a quality assurance
system. Moreover, it must include a problem analysis based on actual scientific theory and a
theoretical foundation regarding the supposed effectiveness of the intervention. If available,
the description must also include details of any Dutch effect study that shows that the
307
intervention did indeed achieve its goals, and that this achievement was caused by the
intervention. Any foreign effect studies into intervention equivalents or similar interventions are
also briefly described.
Not included
Those interventions which are inadequately documented, or which do not have an adequate
theoretical foundation, have not, yet been included in the database. These interventions do
however appear in a separate section (‘not yet included’) of the website. Interventions that are
not eligible for inclusion in the database also appear in their own section of the website (‘not
eligible for inclusion’) together with the reason for their ineligibility.
15.4 Recognition
The Admission Committee works with a set of procedures and with well-established, carefully
considered criteria. These procedures and criteria are transparent and accessible to third
parties. The Committee currently employs two kinds of criteria: inclusion criteria and
recognition criteria. Interventions must meet all inclusion criteria in order to be eligible for an
assessment on the grounds of the recognition criteria.
15.4.1 Inclusion criteria
There are four inclusion criteria:
1) There must be documentation on the intervention, which provides information on its aim(s) and
target group(s). There must be a Dutch-language manual or protocol and where available, Dutch
data on research, evaluation, or experience. There must also be a contact person or organisation
who can provide information on request.
2) The intervention must represent a goal-directed and systematic activity that differs from what is usual
for the target group.
3) The most important aim of the intervention must be reducing problems for young people and their
parents or carers, preventing such problems from occurring, or stimulating development. The
intervention must apply to young persons, to their parents or carers, or to their care environment. In
other words, interventions must be intended to promote competent behaviour or the quality of the
child-rearing environment.
4) The intervention must be directed towards young people between the ages of 0 and 18 years (an
extension to 24 years is possible), their parents/carers, or the child-rearing environment.
15.4.2 Recognition criteria
If a submitted intervention description meets all these inclusion criteria, it is then assessed
using the recognition criteria, which have to do with the intervention’s theoretical foundation,
the soundness of its methodology, its practical implementation, and any available research on
its effectiveness.
1) Criteria for theoretical foundation
-
There must be an analysis of the problem, including data on the nature, severity, scale, and
distribution of the factors associated with this problem if relevant.
-
There must be a theoretical foundation that encompasses the problem, the target group(s), the
aim(s), and the approach.
308
-
Target group(s), aims, and working methods must form a logical, coherent whole.
2) Criteria for soundness of methodology
-
The target group(s) must be closely defined and described, including, for instance, attributes
such as its culture, its own experience of its problems, its motivation, its potential, and its
acceptability.
-
There must be data on indications and counter-indications
-
Explicit aims must be stated.
-
The working methods must be described at the level of concrete activities as fully as possible.
-
The order, frequency, intensity, duration, and timing of contacts and activities must be given.
-
The materials required and their availability must be clearly described.
3) Criteria for practical implementation
-
The intervention must be transferable.
-
The implementing organisation possesses HKZ registration. HKZ stands for Harmonisatie
Kwaliteitsbeoordeling in de Zorgsector, or Harmonisation of Quality Assessment in the Care
Sector. A HKZ certificate indicates that the implementing organisation meets predetermined
quality standards of care supply.
4) Criteria for effect studies
-
If available, Dutch effect studies of the intervention (including attributes and research results)
must be described.
-
The effects of the intervention must be given in figures, and are positive.
-
The degree of effectiveness of the intervention must be stated (for instance, in the form of an
effect size).
-
Where different studies indicate different effects, then the overall effect must be given.
15.4.3 Types of recognition
The Committee can accord three types of recognition to interventions: ‘effective in theory’,
‘demonstrably effective’ and ‘cost-effective’.
 Effective in theory
All interventions included in the Database of Effective Youth Interventions are effective in
theory at least. For this recognition to be conferred, the theoretical foundations of the
intervention must be of a satisfactory standard, there must be a full description of its effects on
all required elements, and the intervention has to meet a set of preconditions and requirements
for quality assurance. A clear argument must be put forward as to why the proposed activities
would achieve the stated aims of the intervention. These interventions will not have been
subjected to empirical research indicating the effectiveness of this approach in the
Netherlands.
 Demonstrably effective
Interventions which are effective in theory and for which Dutch studies have shown that the
stated aims are achieved, respectively that this is caused by the intervention, can be
considered for recognition as ‘demonstrably effective’. Two dimensions play a role in the
empirical substantiation of an intervention: the quality of the research study and the
persuasiveness of the resulting evidence.
309
 Cost effective
Interventions, which the Admissions Committee accords as being cost effective, are deemed
not only effective, but also practical and efficient to carry out. Current developments have
shown that very little can be said now about the cost effectiveness of interventions; too little is
known about the cost of interventions and research into cost-effectiveness in practice is scarce.
It is the Committee’s intention to be able to confer this type of recognition in the future.
A developmental model
The distinction between ‘effective in theory’ and ‘demonstrably effective’ is based on a
developmental model concerning the evidence of effectiveness. This implies a tentative
recognition of the intervention, based on a comprehensive description and on theoretical and
practice-based evidence. The model consists of a so-called ‘staged’ system from the
assessment of the quality of intervention. In this model, four levels of evidences regarding the
effectiveness of an intervention are distinguished: descriptive, theoretical, functional, and wellestablished evidence. The levels of evidence can be seen as phases in the development of an
intervention. The model shows that each developmental phase of an intervention can be tied
to an appropriate study design. In general, one can say that the greater the freedom to choose
a study design, the less certainty there is about the effectiveness of the interventions, which
means a lower level of evidence. According to the four levels of evidence, the effectiveness of
an intervention/ the developmental phase of an intervention can be classified as follows:
1) Potentially effective: the essential elements of the intervention (e.g. goals, target group, methods
and activities, requirements) have been made explicit.
2) Effective in theory: as above (potentially effective), but the intervention now has a plausible
rationale (i.e. a programme theory) to explain why it should work and with whom.
3) Effective in practice: as above (effective in theory), but is has now also been demonstrated that
the intervention clearly leads to the desired outcomes (e.g. goals are attained, target problems
decrease, competences increase, clients are satisfied).
4) Efficacious: as above (effective in practice), but there is now sound and substantial evidence that
the outcome is caused by the intervention and/or clear evidence showing which ingredients of the
intervention are responsible for the outcomes.
Developmental trajectory
The levels in the proposed model lead for evidence-informed practice to evidence-based
practice. Thus, they provide not only a classification scheme, but also a developmental
trajectory that leads to an empirically supported evidence-based practice. Reassessment of a
recognised intervention after five years will include an assessment of the progress that is made
according to the developmental model. In this way, the developmental model forms a stimulus
for those working in the field to strive for obtaining more insight into the effectiveness of the
interventions they develop and use, plus it invites scientists and practitioners to work together
to improve the quality of care provision step by step.
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15.5 Classification systems for effect studies
The developmental model concerning the effectiveness of an intervention can be linked to the
classification system for effect studies. Figure 15.1 shows the relationship between the
developmental phases of an intervention and their associated research types, together with
the classification system used to categorise the effect research.
Fig 15.1
Classification of effect studies and the developmental model
Developmental level
Types of research
Descriptive studies
Observational studies
Analysis of documents
Conduct of interviews
Classification system
1. The intervention is
potentially effective
-
2. The intervention is
effective in theory
- Reviews
- Literature studies
- Implicit knowledge studies
3. The intervention
is effective in practice
- Quasi experimental studies
- Theory of change studies
0
- Norm references approaches
- Benchmark studies
- Monitoring studies (pre-post)
*
- Client satisfaction studies
- Goal attainment studies
- Quality assurance studies
4. The intervention is
efficacious
(well- established)
- Randomised Controlled Trial
- Repeated case studies (n=1
design)
The threshold for inclusion in
the Database of Effective
Youth Interventions:
recognition as ‘effective in
theory’ from the National
Youth Interventions
Admissions Committee
**
***
****
*****
15.6 An example: Triple P
We have selected the parenting programme Triple P as an example of a programme that is
described in this database as an effective programme with strong evidence. The programme
was developed in Australia but currently implemented in many countries around the world. To
find the programme description and research evidence for its effectiveness we recommend the
reader to go to:



the original Triple P database from Australia (www.triplep.net/glo-en/home/)
the Nji database (www.nji.nl/nl/Databank/Databank-Effectieve-Jeugdinterventies),
Wikipedia (https://en.wikipedia.org/wiki/Triple_P_(parenting_program))
311
312
Literature
Matsumoto, Y.; Sofronoff, K.; Sanders, M. R. (2010). "Investigation of the effectiveness and social
validity of the Triple P Positive Parenting Program in Japanese society". Journal of Family
Psychology 24 (1): 87–91. doi:10.1037/a0018181
Mihalopoulos, C.; Sanders, M. R.; Turner, K. M. T.; Murphy-Brennan, M.; Carter, R. (2007). "Does
the Triple P Positive Parenting Program provide value for money?". Australian and New
Zealand Journal of Psychiatry 41: 239–246. doi:10.1080/00048670601172723
Nowak, C.; Heinrichs, N. (2008). "A comprehensive meta-analysis of Triple P-Positive Parenting
Program using hierarchical linear modeling: Effectiveness and moderating variables".
Clinical Child Family Psychology Review 11: 114–144. doi:10.1007/s10567-008-0033-0.
Sanders, M. R. (2008). "Triple P-Positive Parenting Program as a public health approach to
strengthening parenting". Journal of Family Psychology 22 (3): 506–517.
doi:10.1037/0893-3200.22.3.506
Study questions for this chapter
For the study of this chapter, you can use the evaluation report on Triple P as an example (see
database NJI) to answer the following questions:

With what purpose / which aims, has the Database of Effective Youth Interventions been
created?

What levels of scientific evidence are available to classify a particular intervention?

The database distinguishes different types of recognition for an intervention. Describe
what each of these types implies.

Based on what assessments does the Admission Committee decide whether an
intervention is ‘effective in theory’ or ‘demonstrably effective’?

Briefly describe the content and target group for each of the five Triple P intervention
levels.

Try to link each of the Triple P levels to the different prevention types (e.g. universal,
selective, indicated, primary, secondary, tertiary prevention).

How would you describe the main differences between the Triple P programme and
other prevention programmes such as the Coping with Depression Course (chapter 13
and 17 or the Mother Baby Intervention (see chapter 16)?

What can be concluded on the scientific evidence for the Triple P intervention as a
whole, or for each of its different levels?
313
314
PART V
THEMES
PROGRAMMES
EFFECTIVENESS
Children of Mentally Ill Parents (COPMI)
Depression
E-health interventions
Child abuse
Anxiety disorders
315
316
16
Prevention of emotional problems and psychiatric risks
in children of mentally ill parents:
the science base to a comprehensive approach
16.1
Introduction
318
16.1.1
Epidemiology and impact on children
318
16.2
Disorder-specific transmissions or broad-spectrum risk?
319
16.2.1
A developmental model of mental health and psychopathology of offspring
320
16.3
Parent-related factors
321
16.3.1
16.3.2
16.3.3
Characteristics of parental psychopathology predicting increased risk
Risk factors during pregnancy
Parenting competence and parent–child interaction
321
323
323
16.4
Family conditions
324
16.5
Child-related factors
324
16.6
Factors in the extra familial environment: networks, community, and care
326
16.7
Conclusions
326
16.7.1
16.7.2
16.7.3
16.7.4
Estimating the level of risk
Risk and protective factors
Value of a theoretical framework
Needs for further research
327
327
328
328
Literature
329
Study questions for this chapter
334
317
16
Prevention of emotional problems and psychiatric risks
in children of mentally ill parents:
the science base to a comprehensive approach
16.1
Introduction
Over the past four decades studies have established a strong connection between mental
illness among parents and increased lifetime psychiatric risk for their children. The
transgenerational transmission of mental illness represents one of the most significant causes
of psychiatric morbidity. Over the last twenty years, a comprehensive preventive approach has
been developed in the Netherlands to support children of mentally ill parents (COPMI) and
their families by offering a wide range of preventive services, mostly from community mental
health centres. From the start, the approach was jointly developed by practitioners and
scientists, using a combination of bottom-up and top-down strategies guided by scientific
evidence regarding intergenerational transmission of psychopathology, process evaluation,
and outcome studies.
The aim of this chapter is to summarise the knowledge base of the Dutch prevention policy
and programme for COPMI, in particular the knowledge on malleable risk and protective factors
in the transmission of psychiatric and related problems from parents to children. We present a
developmental theoretical model that serves as a framework to integrate the extensive
knowledge on these transmission processes from the fast growing number of studies in this
field. The model is also used to guide the development of the comprehensive Dutch
programme as a whole. The major assumption is that an effective approach to reduce the risk
of psychiatric problems and enhance the social-emotional development of COPMI needs to be
grounded in both practice-based and theory-based knowledge and related evidence.
16.1.1 Epidemiology and impact on children
The need to prioritise COPMI in our national and local prevention and health promotion policies
is based on knowledge from a wide range of sources including epidemiological and clinical
studies, clinical and preventive practices, and extensive contacts with the children and their
families. These sources all pointed out that children of parents with a mental illness are at
much higher risk of developing mental disorders and multiple other adverse outcomes at some
point in their lives than children of healthy parents. Longitudinal studies have shown that the
risk of developing mental disorders among these children lies between 41% to 77% (Beardslee
et al, 1993; Downey & Coyne, 1990; Goodman et al., 1994; Orvaschel, Walsh-Ellis & Ye, 1988;
Rutter & Quinton, 1984; Weissman et al., 1987). Evidence for this elevated risk has been found
across the whole diagnostic spectrum of parental psychiatric disorders, including substance
abuse (Cuijpers et al, 1999; Edwards et al., 2006; Steinhausen, 1995), anxiety disorders
(Beidel & Turner, 1997; O’Connor et al., 2002), panic disorder (Biederman et al., 2001),
obsessive compulsive disorder (Black, Gaffney, Schlosser, & Gabel, 2003), depression
(Beardslee et al., 1998; Weissman et al., 2006), dysthymic disorder (Lizardi et al., 2004),
bipolar disorder (DelBello & Geller, 2001, Birmaher et al., 2009), eating disorders (Park et al.,
318
2003), suicide (Bronisch & Lieb, 2008), and personality disorders (Coolidge et al., 2001;
Westman, 2000).
For instance, in a study among the offspring (7-12 yrs) of parents with an anxiety
disorder, 33% of the children had an anxiety disorder as well, compared to 8% of children
whose parents had no mental illness (Beidel et al., 1997). Rates for the occurrence of major
depression by the end of adolescence have been found to be as high as 40% in offspring of
depressed parents (Beardslee et al., 1993). Among children of depressed parents, rates of
depression have been found to be two or three times (Weissman et al., 2006) to even eight
times (Wickramaratne & Weissman, 1998) higher than among children whose parents have
no mental illness. The Dutch NEMESIS study found a lifetime prevalence of
abuse/dependence disorders of 28.5% among children of problem drinkers, compared to 17%
among children of other adults (Cuijpers et al., 1999). Parental mental illness affects not only
the lifetime psychiatric risk of their offspring, but has also multiple mostly related adverse
outcomes, such as a higher risk of stress reactivity, living in high-conflict and divorced families,
exposure to child abuse and neglect, identity problems, poor academic achievement and
school failure, problems in developing intimate relationships, and a higher risk of suicidal
behaviour (e.g. Ashman et al., 2002; Cicchetti et al., 1998; Goodman & Gotlib, 1999; Leinonen
et al., 2003a).
Children of parents with a mental illness represent a large segment of the population.
Even in a small country such as the Netherlands, with 16.8 million inhabitants, there are about
1.6 million of such children younger than 22 years, including 900,000 younger than 12 years
of age. Although this group as a whole has found to be at elevated risk, this does not count for
all COMPI because risk levels may vary significantly among them. As will be discussed in this
article, the level of risk is depends highly on the presence of an accumulation of risk factors
and the role of protective factors.
16.2
Disorder-specific transmissions or broad-spectrum risk?
There is much debate on the question whether the transmission of mental disorders from
parents to children is disorder-specific or not. Are children specifically at risk of the same
disorders as their parents? Is the transmission dominated by disorder-specific risk factors or
do children of parents with different mental disorders share common risk factors that in turn
might cause an increased risk for multiple disorders? Answers to these questions are critical
to the designing of effective prevention programmes. For instance, are children of depressed
in need of different preventive support than children whose parents suffer from a generalised
anxiety disorder, alcohol addiction, schizophrenia or a borderline personality disorder?
There is strong evidence that children of parents with a mental disorder have an
increased risk of developing the same disorder as their parents, but there exists also
overwhelming evidence that these children are at increased risk of developing a wide range of
other disorders, reflecting a so-called broad-spectrum effect (Bijl et al., 2002; Lieb et al., 2002;
Lizardi et al., 2004). For instance, longitudinal studies by Wickramartne and Weissman (1998)
found that, compared with children of parents without psychiatric disorders, children of parents
with major depressive disorder had an eight times greater risk of childhood-onset and five times
greater risk of early-adulthood-onset major depressive disorder, three times greater risk of
anxiety disorder, and five times greater risk of conduct disorder and alcohol dependence
(Weissman et al., 1997; Weissman et al., 2006). Increased risk of multiple disorders has also
319
been found among children of parents with schizophrenia (Keshavan et al., 2008; Niemi et al.,
2004; Hans et al., 2004; Tienari et al., 2000) and substance abuse (Clark et al., 2004; Cuijpers
et al., 1999; Harter, 2000).
The finding of a variety of disorders in the offspring of parents with a specific disorder
does not necessarily point exclusively at the role of broad-spectrum risk factors. The multiple
disorders found in offspring might simply reflect the frequent prevalence of comorbid disorders
in parents, as this is common in psychiatric patients in general. For instance, in a study of the
offspring of parents with substance abuse disorders by Clark et al. (2004), the increased risk
of each of several disorders in the child sample could be predicted by the corresponding comorbid disorders in the parents.
As a prelude to the discussion of risk factors in the next section, the most likely
conclusion from current risk factor research is that both disorder-specific and common factors
are responsible for the increased risk of psychopathology in offspring (e.g. Avenevoli &
Merikangas, 2006). Disorder-specific risk factors include genetic and biochemical factors, but
also parental modelling behaviour and reinforcement of pathological coping styles (e.g.
substance abuse, externalising behaviour, emotional eating, overprotective behaviour). Also,
many common risk factors have been identified in the transmission of risk across different
parental diagnoses. They might be common outcomes of the parental disorder (e.g. insensitive
responsiveness, neglect, abuse, exposure to family conflict and violence, parentification) or
refer to common risk factors influencing the onset of psychopathology in both parents and
offspring (e.g. poverty, exposure to neighbourhood violence, substance abuse, and domestic
violence). Such factors are not only common mediators across different parental diagnoses
but they themselves are likely to increase the risk of a wide range of problems in offspring. For
this reason, we label them as common or broad-spectrum risk factors. Protective factors that
have been found to buffer the impact of risk factors are also mostly not disorder-specific (e.g.
care by the other parent, the child’s own problem-solving skills, and social support by family,
friends, or teachers).
These findings suggest that prevention programmes for COPMI should address both
common and disorder-related factors. Addressing common factors might increase the
likelihood of a broad-spectrum of favourable outcomes and improve the cost-effectiveness of
interventions. In addition, it will increase the feasibility of such programmes. Implementation
would be much more complicated if separate interventions are to be provided in relation to
each individual parental diagnosis, and recruitment strategies are to be governed by diagnostic
labels. We conclude that the children’s situations have much in common across different
parental diagnoses. On the other hand, children and their parents might have specific
questions and needs relating to the parental disorder (e.g. knowledge about the disorder, how
to cope with symptom behaviour). These disorder-specific issues should also be addressed as
part of a comprehensive approach.
16.2.1 A developmental model of mental health and psychopathology of offspring
To guide the development of preventive interventions and the overall prevention policy for
COPMI in the Netherlands, we developed a theoretical model that describes the main domains
of risk and protective factors in the development of mental health and psychopathology in
children of parents with mental illness (Van Doesum, Hosman, & Riksen-Walraven, 2005). This
model (Figure 16.1) is based on a range of principles, mainly derived from the field of
developmental psychopathology. First, the model differentiates between multiple interacting
320
domains and systems of influence: parents, children, family, social network, professionals, and
the wider community. To each of these domains specific risk factors and protective factors are
linked providing the basis for identifying relevant intervention targets.
Secondly, in line with other scientists working in this field (Goodman & Gotlib, 1999), we
differentiate between various mechanisms of transgenerational risk transmission: (a) genetic
risk transmission, (b) prenatal influences, (c) parent–child interactions, (d) family processes
and conditions, and (e) social influences from outside the family.
Thirdly, the theoretical framework differentiates between successive developmental
stages in the child’s life, starting from pregnancy. Each stage is assumed to be linked to
specific developmental processes and tasks, sensitive periods, and age-related onset of risk
factors and psychiatric disorders. Together they point at the need to develop multiple
preventive interventions along the life span, each tailored to the developmental needs and
risks of a specific stage.
Fourthly, the concepts of equifinality and multifinality are used to describe two major
views on cause-and-effect relations in the developmental trajectories of psychopathology.
Equifinality refers to the view that a single disorder or problem can be the result of multiple
causes or developmental trajectories. This means that a specific disorder in the offspring (e.g.
depression) can be the result of different risk trajectories and the exposure to different types
of parental diagnosis. The concept of multifinality is based on the notion that a particular risk
factor (e.g. a specific parental diagnosis) can result in multiple outcomes such as multiple types
of disorders or social outcomes in children. This means that targeting risk factors or protective
factors that are common across children and families with different parental diagnoses is a
feasible prevention strategy that might result in a wide range of favourable outcomes. Ample
empirical evidence for both concepts has been found in developmental psychopathology
research, as reflected in numerous articles in the peer-reviewed journal Development and
Psychopathology.
Fifthly, the model aims to provide both insight in the development of psychiatric and
related problems in COPMI, as well as in the conditions promoting their resilience and socialemotional development. Sixth, we have used this framework to organise and integrate the
current knowledge from numerous empirical studies published on this subject in the last two
decades. Finally, the model and the related knowledge base are used for translational
research, i.e. to identify and study opportunities for preventive interventions and to guide the
development of effective multi-component programmes and a comprehensive prevention
policy for COPMI.
The next sections summarise some of the main findings from empirical research linked to the
main domains in the model. Limitations of space prevent us from discussing each risk factor
and protective factor in detail. Instead, we summarise major findings and discuss some
illustrative studies.
16.3
Parent-related factors
16.3.1 Characteristics of parental psychopathology predicting increased risk
In addition to the mere presence of a mental disorder in a parent, studies have identified
several characteristics of parental mental illness that are associated with increased risk in their
offspring, such as chronicity of the disorder, parental age of onset, timing in the developmental
321
stages of the child, family history of psychopathology, comorbidity, and psychopathology in
both parents.
Fig.16.1
A developmental model of transgenerational transmission of
psychopathology
Many studies have replicated the finding that it are especially the children exposed to
recurrent and chronic parental disorders who are at major risk (e.g. Ashman et al., 2002; 2008;
Beardslee et al., 1987; Foster et al., 2008; Horowitz et al., 2004). For instance, among mothers
suffering from postnatal depression or a later depressive episode without subsequent
episodes, some studies found no increased risk of depression in offspring (Halligan et al.,
2007). There is some evidence showing that the presence of multiple disorders (comorbidity)
in parents increases the risk in offspring (Kim-Cohen et al., 2006; Goodman, 2007).
Ample evidence exists for the impact of both parents having a mental disorder. When
both parents suffer from the same disorder, the risk for this disorder in offspring is higher than
if only one parent suffers from it. This risk increase is larger in the case of bipolar disorders
(Birmaher et al, 2009) and substance abuse disorders (Clarke et al., 2004) than in the case of
major depression (Lieb et al., 2002). The Netherlands Mental Health Survey and Incidence
Study (NEMESIS, N=7,076) found a lifetime prevalence of psychiatric disorders of 48% to 55%
in the offspring of parents with a history of a single psychiatric disorder (Bijl et al, 2002). When
both parents suffered from psychopathology, the risk increased to 66.5%.
The age of onset of parental disorders has also been found to have predictive value. In
their longitudinal study, Wickramartne et al. (1998) found a much higher relative risk of
depression in offspring when the onset of the parental depression occurred before the age of
30, compared to a later onset (RR=13.1 versus RR=4.1). This could be caused by a stronger
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impact of genetic factors in early transmissions of psychopathology; it also could refer to the
impact of adverse social circumstances and maternal psychological vulnerabilities frequently
found in young, especially teenage mothers.
In addition, the timing of exposure to a parental mental illness across the child’s lifespan
influences both the type of impact on the child and the level of risk. Most of the current
knowledge suggests that the largest impact occurs during the early stages of the child’s
lifespan, including the pregnancy period. This might be attributable to the impact of disorderrelated parental behaviour and exposure to early stressors that interfere with a healthy
development of cerebral functioning and emotion-regulation systems (Maughan et al., 2007;
Ronsaville et al., 2006)
16.3.2 Risk factors during pregnancy
Several studies have identified risk factors during pregnancy. High levels of stress and anxiety
during pregnancy impair the functions of the growing brain and emotion-regulation systems in
the HPA-axis, and increase the risk of high stress reactivity and emotional and behavioural
problems during childhood and adolescence (e.g. Ashman et al., 2002; Huizink et al, 2003;
O’Connor et al., 2002; Robinson et al., 2008; Ronsaville et al., 2006; Van den Bergh &
Marcoen, 2004). Such stress can be caused by high levels of antenatal anxiety, bereavement
and other loss experiences, but also by economic hardship, domestic violence or divorce, not
uncommon in the context of parental disorders. These conditions might also be responsible
for risk behaviours, such as smoking and alcohol use during pregnancy, which have a proven
negative impact on children’s functioning and may cause problem behaviour up to adolescence
(e.g. Wakschlag et al., 2002).
16.3.3 Parenting competence and parent–child interaction
As many studies have found, the transgenerational transmission of psychiatric risk is
significantly mediated by the way parents interact with their children and by poor parenting
skills. Parental psychopathology increases the likelihood of insensitive responsiveness, low
involvement in their children, low monitoring or even hostility and rejection, and child
maltreatment (e.g. Bifulco et al., 2002; Duggal et al., 2001; Harnish et al., 1995; Elgar et al.,
2007; Leinonen et al., 2003a; Murray et al., 2003). It is especially when these behavioural
patterns are present during the early years of life that they trigger deregulated emotion
patterns, negative emotionality, insecure attachment and decreased perceived competence in
children (Hipwell et al., 2000; Maughan et al. 2007; Rogosch et al., 2004). These outcomes
have been found across different parental diagnoses, such as major depression, anxiety
disorders, substance abuse disorders, antisocial personality disorder and borderline disorder
(e.g. Leinonen et al., 2003a).
Parents might also provide children with pathological model behaviour and coping styles
over a prolonged period, which will be copied by their offspring, for instance in the case of
anxious and overprotective behaviour, emotional eating and the use of alcohol as mood
manager. There is also evidence that these behavioural risk factors are transmitted across
multiple generations. Parents who show neglectful, abusive or violent behaviour have
frequently themselves been a victim of such behaviours during their childhood (Sidebotham &
Heron, 2006). Positive parenting was found to have a protective influence on the development
of future conduct problems in children of depressed mothers (Chronis et al., 2007). This
stresses the relevance of parent education as a valuable preventive strategy for COPMI.
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16.4
Family conditions
Enduring family discord, domestic violence, financial hardship and family-related life events
could be both consequences of as well as risk factors for parental psychopathology. Depending
on its severity and durations, the presence of a mental disorder in one of the parents could
have a profound impact on marital relationships and family life. Several studies have found
that such conditions mediate the impact of parental disorders on a child (e.g. Ashman et al.,
2008; Avenoli & Merikangas, 2006; Cicchetti et al., 1998; Leinonen, et al 2003b). When they
do not play a mediating role, i.e. when they are present independent of parental
psychopathology, such conditions moderate the risk in offspring because they contribute to an
accumulation of risk factors in the child’s life. Irrespective of the type of parental disorder, a
well-evidenced relation has been found between the number of risk factors and the onset of
psychopathology in offspring (Appleyard et al., 2005; Dickstein et al., 1998; Nair et al., 2003;
Rutter & Quinton, 1984; Sameroff, 2000; Whitaker et al., 2006). It is not clear yet if this is a
linear relation, or a curvilinear relation indicating a threshold effect. This suggests that
identifying the presence of an accumulation of risk factors and reducing their number might be
an adequate preventive strategy for COPMI.
The other parent could play a protective role or could represent an additional risk factor.
For instance, the presence of a parent who is caring and supportive to the child and
understands the disorder of their partner can successfully buffer the negative impact of a
maternal depression (Chang et al. 2007; Crockenberg & Leerkes, 2003). However, if the
partner also suffers from a mental disorder or shows violent or abusive behaviour, this will
further increase the risk to the child (e.g. Birmaher et al, 2009; Clark et al., 2004). In the case
of one-parent families, not uncommon in the case of COPMI, support from the other parent
might be absent at all.
16.5
Child-related factors
The children themselves also play an important role in the way the situation of their parent and
family impacts on them. Vulnerable children run an increased risk in the context of adverse life
conditions (e.g. parental mental illness), while highly resilient children do well even under harsh
conditions (e.g. Werner & Smith, 2001).
The major child-related risk factors identified in multiple studies include: difficult
temperament, behavioural inhibition, negative emotionality, stress reactivity, insecure
attachment, negative self-esteem, poor cognitive and social skills, lack of knowledge about the
parental disorder, parentification and self-blame (see reviews by Beardslee et al. 1998;
Goodman & Gotlib, 1999; Göpfert et al, 2004).
Vulnerabilities can operate as mediating factors between parental mental illness and the
child’s risk of psychopathology when they are caused by the impact of the parental disorder or
by related parental risk factors. For instance, several studies suggest that insecure attachment
mediates the relation between parental psychopathology and socio-emotional development in
children (Cicchetti et al., 1998; Rangarajan, 2008). Vulnerabilities might also be present
independent of a parental disorder and function as moderators of the impact of a parental
disorder on the child.
324
Vulnerabilities in mentally ill parents might be transmitted genetically to their children
(e.g. temperamental features), and might be counterbalanced by resilient characteristics
inherited from one or both parents. Even when genetic risks are present, current genetic
research suggests that their expression is influenced by interactions between genetic factors,
neurobiological processes and environmental conditions (Caspi & Moffit, 2006; Rutter et al.,
2006). Some of these processes and conditions might be modified through preventive
interventions. For instance, neurobiological processes during pregnancy in depressed mothers
have been successfully influenced through massage (Field, 2009). Prenatal massage therapy
was found to reduce postpartum depression, as well as lowering cortisol levels and improving
neonatal behaviour in the new-borns.
Resilience factors refer mainly to the opposite of these risk factors, for example positive
emotionality, safe attachment, cognitive and social competence, positive self-esteem, selfreliance, relevant knowledge about parental disorders and perceived social support (e.g.
Beardslee & Poderefsky, 1988; Hammen, 2003). Although the preventive role of resilience
factors in the socio-emotional development of children has been extensively studied and
recognised within the realm of developmental psychology and positive psychology, surprisingly
little research has been done to study their role in the transmission of parental
psychopathology. An illustrative example of this research is offered by a study by Silk et al.
(2006) on the role of emotion regulation in children of depressed mothers, aged 4 to 7. Findings
suggest that positive reward expectation in children has a significant protective influence on
the development of internalising problems in a context of maternal depression. Prevention and
health promotion efforts targeted at COPMI and their families may strengthen the resilience of
the children and reduce their vulnerability.
First, knowledge about environmental risk and protective factors during pregnancy,
infancy and later stages as discussed in this article could be used to enhance the development
of resilience and prevent the onset of vulnerability factors in children. Examples of malleable
determinants of socio-emotional vulnerabilities in children include maternal stress, depression
and anxiety during pregnancy, and early maternal insensitivity, lack of parental warmth and
child abuse and neglect (e.g. Ronsaville et al., 2006; Huizink et al., 2003; Van Doesum et al,
2008).
Secondly, screening of vulnerability and resilience features in children can be used to
correct risk factors that are already present and to enhance the children’s strengths in the
context of parental mental illness.
Finally, the roles of age and gender have been studied repeatedly as moderators in
socio-emotional development and problem behaviour in the offspring of parents with mental
illness. Overall, as stated above, one may conclude that the outcomes of exposure to parental
mental illness are related to the age and developmental stage of the child, but that the impact
is expected to be most powerful during the first years of life. The moderating role of gender
has also been the subject of numerous studies. It is obvious that gender plays a moderating
role, especially in predicting the risk of internalising versus externalising problems in offspring,
but its impact seems largely depending on contextual factors (e.g. parental gender, family
composition).
325
16.6
Factors in the extra familial environment: networks, community, and care
Just as in other domains, the social environment outside the family can play both a protective
and a risk-increasing role for COPMI. Most knowledge about the factors in this domain has
come from retrospective and qualitative studies, such as in-depth interviews with adolescents
and adult children of parents with mental illness (e.g. Drijver & Rikken, 1989; Knutsson-Medin
et al., 2007). Social networks may offer cognitive, emotional and practical support to the
parents and the children, for instance by providing compensatory care when a parent is actually
or emotionally non-available, or by offering parenting advice, a listening ear or opportunities
for respite and positive events. Network persons could include grandparents, neighbours,
friends, teachers or peers living in similar circumstances. A large-scale prospective study in
the US showed that the onset of internalising problems in children of depressed mothers was
lower when the mothers received social support and the children received care from caregivers
other than the mother (Lee et al., 2006).
Schools are regularly identified by COPMI as settings where they can escape from harsh
family circumstances and where they can find opportunities for diversion and positive
experiences. Schools, neighbourhoods and social networks can also become a source of
additional stress and social isolation, due the prevalent stigma attached to mental illness.
COPMI report frequent exposure to negative responses from peers and even bullying, and are
reluctant to take friends home.
A common complaint of COPMI is the lack of attention and support they get from the
mental health professionals treating their parent. These complaints have been reported in
studies in the US, Sweden, New Zealand, Australia and the Netherlands (e.g. Knutsson-Medin
et al., 2007; Fudge & Mason, 2004; Drijver & Rikken, 1989). From our own experiences in
mental health care, it is obvious that there is a widespread lack of awareness and sensitivity,
especially among professionals in adult care, regarding the impact that problems of adult
patients have on their children. Even when such awareness exists, children do not get the
support they deserve due to a lack of child-targeted skills among professionals treating adults
and the lack of collaboration between adult and childcare. Lack of support and information
about the parent’s condition might increase the likelihood of self-blame and parentification.
In sum, factors in each of the domains of our model contribute to the socio-emotional
development of COPMI. The multicausality of the risk to the offspring of parents with a mental
illness stresses the need to assess carefully the accumulation of risk factors within and across
domains, and the interactions between risk factors and protective factors. This multicausal
context, as summarised in figure 16.1, offers a wide range of options for preventive
interventions to reduce transgenerational transmission of psychiatric risks and to enhance
positive socio-emotional development in COPMI.
16.7
Conclusions
Although this review does not aim to cover all relevant epidemiological and developmental
studies that have been published, it makes clear that the transmission of psychiatric problems
from parents to children is extensively studied, especially during the last two decades. There
exists a fast growing body of knowledge that can be used to guide the development of effective
interventions and a comprehensive approach reducing psychiatric and other risks in COPMI
326
and promoting their healthy emotional development. In this last section, we highlight some
major conclusions, discuss their implications and identify further needs for research.
16.7.1 Estimating the level of risk
The estimated level of risk among COPMI varies widely across studies, depending on the
features of the population under study, the study design and the length of the period over which
the risk is calculated. A more systematic comparison of risk levels across studies is needed to
make estimations on the public mental health gains that theoretically could be derived from a
highly effective and comprehensive prevention strategy. However, irrespective of the variations
in expected risk level, longitudinal epidemiological studies have generally shown that the
transmission of psychiatric problems from parents to children is responsible for a significant
part of new psychiatric morbidity and lost opportunities for offspring to develop resilience and
positive mental health. This phenomenon seems true independent of parental diagnosis. While
the number of COPMI in the population and their risk level are substantial, and the outcomes
of living with a parent with a mental illness can be pervasive, making COPMI a priority target
in local and national public health policies seems warranted.
16.7.2 Risk and protective factors
As summarised in this review several causal mechanisms and a wide range of mediating and
moderating risk factors play a role in the transmission of psychiatric and related problems from
parents to children. Both risk and protective factors are located in the child, the parents, the
social network and the wider social environment (figure 16.1). Multiple studies have shown that
parental disorders and risk factors might have broad-spectrum effects, increasing the risk on
a range of different outcomes and disorders in the child. Many of these factors seem malleable
and together they offer a wide window of opportunities to interfere in these transmission
processes and to reduce the risk of adverse outcomes and to enhance positive socialemotional development in offspring.
Given its possible implications for developing prevention programmes and policies, it
seems important to understand better the similarities and dissimilarities of the transmission
processes across different parental diagnoses. For instance, are children of parents suffering
from chronic depression, anorexia nervosa, substance abuse or schizophrenia exposed to
similar risk factors indicating the need for common preventive interventions; or do risk factors
and needs for support vary between these diagnoses. Current preventive interventions for
COPMI and their families are dominantly based on the assumption that they share common
needs, such as getting recognition for their problems, information on the illness, breaking
through the circle of silence, learning to communicate about the illness and to deal with stigma,
and improving parenting skills and social support. COPMI interventions address children of
different parental diagnoses mostly as one integral target population, only differentiating in
providing knowledge on the specific parental disorder to which the child is exposed. Research
on outcomes of parental disorder suggests that the transmission of risk is ruled by both
common and disorder-specific risk factors. Specific parental disorders might call for tailored
interventions, such as specific training in how to deal with anxious or paranoid behaviour of a
parent, or how to educate children in substance use when as a parent you are addicted
yourself. A more systematic review on outcomes of different parental diagnoses that is
currently run by a common research project of the Radboud University Nijmegen (Netherlands)
and The Monash University (Australia) could set more light on this issue.
327
On the one hand, this review underscores the need to base our prevention practices and
policies on a deeper knowledge of all the individual and social factors and processes that
influence the emotional and social development of COPMI. On the other hand, the discussed
findings support Rutter’s original finding (Rutter & Quinton, 1984) that the impact of parental
mental illness is influenced by the mere number of accumulating risk factors: the more risk
factors, the higher the risk for COPMI. This finding is in line with our conclusion that COPMI
vary widely among each other in their level of risk. A part of COPMI are doing reasonably well
or increasing even their resilience when a healthy balance is present between risk and
protective factors. This approach might have several implications for practice. First, more
attention should be given to the assessment of risks and strengths in COPMI and their families
to identify which are in serious need for intensive preventive support due to an accumulation
of risk factors, and which are not or could be sufficiently supported by simple interventions (e.g.
information through internet). Redefining ‘need’ is this way, might generate more tailored and
thus more effective interventions, and might also reduce the problem of limited resources and
low reach of COPMI interventions as currently reported across multiple countries. This
approach identifies two further research priorities, namely the need for valid risk assessment
tools applicable in daily practice and for knowledge on levels of risk factors that are normal for
children and levels of accumulated risks that seriously threaten their social-emotional
development. Some risk factors, such as chronic disorders, might trigger a chain of
accumulating adverse conditions for the child.
16.7.3 Value of a theoretical framework
The fast growing number of studies on parental mental disorders and COPMI confront those
who are involved in programme development and practice to support these children and
families with a fast expanding body of research outcomes that might be hard to oversee and
integrate. The theoretical model we have developed in the Netherlands and presented in this
article (figure 1) aims to support policy makers, programme designers, practitioners,
consumers and researchers with a framework in multiple ways. According to our Dutch
experiences, it could help (1) to organise the multiple science-based and practice-based
findings in a transparent way and to better understand the mediating and moderating
interrelations between causal factors (developmental trajectories), (2) to identify opportunities
for new preventive interventions and mental health promotion, to develop ‘programme theories’
and to improve the effectiveness of existing interventions, (3) to design a comprehensive,
multipronged policy that respond to the multicausal pathways influencing the well-being of
COPMI, (4) to evaluate the multiple outcomes of COPMI interventions, and (5) to identify gaps
in our current knowledge and to formulate new research questions on the mediating and
moderating processes in the relation between mentally ill parents and their offspring.
16.7.4 Needs for further research
In the above discussion already several research needs have been identified, related to relative
and absolute levels of risk, impact of the type of parental disorder, and to critical thresholds in
the number of accumulating risk factors. In expanding the knowledge base for designing
effective prevention programmes and policies also more knowledge is needed on the influence
of sensitive periods along the life span where risk and protective factors might have a
significant stronger and more long lasting impact then in other periods (e.g. pregnancy, infancy,
and early adolescence). We further conclude that the outcomes of certain parental mental
328
illnesses are extensively studied (e.g. depression, substance use) while over the impact of
other parental disorders substantial knowledge is lacking, such as in the case of prevalent
personality disorders (e.g. borderline). The same applies to children of incarcerated forensic
patients, who are hard to reach due to the additional stigma linked to parental criminal history.
In sum, the growing insight into the processes that mediate and moderate the
transmission of risks and strengths from parents with a mental disorder to their children offers
perspectives for developing a comprehensive and effective preventive approach. Sharing
across countries science-based and practice based knowledge and how this knowledge can
be used for practice and policy, as was the aim of this article, hopefully contributes to improve
the lives of next generations of COPMI.
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Study questions for this chapter

What is known about the incidence and risk for psychiatric disorders in COPMI
children?

What kind of problems do children have to face due to living with a parent with a
psychiatric disorder?

Is transgenerational transmission of psychiatric risk disorder-specific, so do the children
get the same disorders as their parent, or does it have a broad-spectrum effect? Is
there evidence for difference in risk levels for children with different parental
diagnoses?

What is meant by the concepts ‘equifinality’ and ‘multifinality’? Could you offer an
example of multifinality in the case of COPMI?

Which transmission mechanisms play a role in the transmission of psychiatric disorders
from parent to child?

What are the risk and protective factors that play a role in the development of
psychiatric disorders in COPMI children? Make a difference between disorder specific
and non-specific risk factors.

Would the presence of a single risk factor be sufficient to make COPMI a high risk
population? Deliver arguments for your answer.

Which stand is taken in this chapter on the impact of the number of risk factors?

What are the values of a theoretical model of risk factors in intergenerational
transmission of psychiatric disorders?

On which general theoretical model(s) or approach(es) is the here presented model of
risk factors based?
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17 Prevention of emotional problems and psychiatric risks in
children of mentally ill parents in the Netherlands: Interventions
Karin T. M. van Doesum and Clemens M.H. Hosman
17.1
Introduction
336
17.2
Interventions focusing on children
337
17.2.1
17.2.2
17.2.3
17.2.4
17.2.5
17.2.6
Play-and-talk groups for children up to age 15
Support groups adolescents (aged 16-23 yrs) & adult children (aged > 23 yrs)
Web-based interventions
Open educational meetings for youngsters and adolescents (aged 16-25 years)
Local activity days for children aged 8-16 years
‘Opkikkertje’ Parent and Child Groups (children aged 1-5 years)
337
338
338
338
338
339
17.3
Interventions focusing on parents and families
339
17.3.1
17.3.2
17.3.3
17.3.4
17.3.5
17.3.6
Child and parent talks
Psycho-educational family intervention
Parent training
www.kopopouders.nl website
KOPP Mother–baby intervention
Squeak says the mouse’ for 4-8 year-old children of stressed families
339
340
340
340
341
341
17.4
Interventions for the professionals
342
17.4.1
17.4.2
17.4.3
17.4.4
Education: workshops, conferences, lectures
Implementation of routines
Preventive case management
Training intervention providers
342
342
342
343
17.5
Interventions focused on the context and community
343
17.5.1
17.5.2
17.5.3
Activities by family or user organisations
Activities in the community
School-based activities
343
343
343
17.6
Conclusions
344
17.6.1
17.6.2
17.6.3
17.6.4
17.6.5
17.6.6
Solving barriers to implementation and increasing reach
More efficient use of resources
Increasing the effectiveness of the programme
New opportunities for interventions
Research needs
International collaboration
345
345
346
346
347
347
Literature
348
Study questions for this chapter
350
335
17 Prevention of emotional problems and psychiatric risks in
children of mentally ill parents in the Netherlands: Interventions
17.1
Introduction
Children of parents with a mental illness are 1.5 times more likely to develop a mental disorder
at some point in their life (50%) compared to children with a healthy parent (30%) (Trimbosinstituut Factsheet, 2012). Over the last twenty years, a comprehensive preventive approach
has been developed and implemented in the Netherlands to support these children of mentally
ill parents and their families by offering a wide range of preventive services. From the start, the
approach was jointly developed by practitioners and scientists. The interventions are based on
the developmental model of transgenerational transmission of psychopathology (Hosman &
Van Doesum, 2009) and put in practice by the practitioners. In the last 15 years, prevention
teams from all over the country met several times a year to exchange newly developed
materials and interventions for COPMI, discuss experiences with implementation, work on
programme innovation and quality management, and develop national guidelines. These
preventive practices are supported by a network of research centres and national institutes,
and a national programme for prevention research and development. Practically all Dutch
mental health services, addiction clinics, and some local public health services and national
organisations, offer preventive interventions for COPMI and their families. Interventions
Fig. 17.1 Overview of interventions in the prevention programme for children of
parents with mental illness in the Netherlands
336
have been developed. Across these domains a wide range of intervention methods have been
used (e.g. educational materials, family meetings, group methods, internet, protocols, and
conferences).
Together these interventions constitute the current national Dutch prevention
programme for COPMI. For many years, they were exclusively focused on children of mentally
ill parents, but now children of parents with substance abuse disorder also have access to
these interventions. This chapter describes the interventions in more detail, including findings
from (process) evaluations. The final section offers a discussion of the strengths and
weaknesses of the current multicomponent programme and the main challenges ahead.
17.2
Interventions focusing on children
This first cluster of interventions is directly targeted at children of different age groups, with the
aim of supporting and informing them, to improve their competence and diminish their burden.
These interventions mainly make use of group-based methods, the internet and written and
audio-visual materials.
17.2.1 Play-and-talk groups for children up to age 15
The groups are open to children of parents with a mental illness or substance abuse disorder
in a specific age range (i.e. 6-8, 8-12 and 13-15 yrs). The intervention is described in a
standardised protocol. Children participate in a group, which runs parallel to two group
sessions for parents. First, the group trainers meet with the child and the parents during an
individual interview. This is followed by eight group sessions in which the children receive
information about the problems of their parents and social support from the group, and are
trained in strategies to enhance their competence in coping with their parents’ problems. The
sessions aim to decrease risk factors and strengthen protective factors, by breaking through
social isolation and the taboo on talking about psychiatric and substance abuse problems in
the family, providing information about the parent’s disorder, fostering mutual recognition
between children in similar situations, decreasing the burden on children, and stimulating and
searching for social support. Techniques used include education, group conversations, roleplaying and homework instructions. In addition, the programme includes relaxation/leisure
activities. For the youngest children, the programme contains more leisure activities. The two
parental meetings are scheduled halfway through and at the end of the child programme.
These meetings are intended to inform parents about the aim and content of the intervention
for their children, to improve their understanding of and involvement with the child’s situation,
and to provide parenting advice and information on the outcomes of the intervention.
The Prevention Research Centre of the Radboud University Nijmegen assessed the
effectiveness of this Dutch support groups for children aged 8–12 years (Van Santvoort et. al.
2014). Children from 254 families were randomly assigned to the intervention or a control
condition. The results showed that children in the intervention group experienced a greater
decrease in negative cognitions and emotions and sought more social support, immediately
after participation and 3 months later, as compared to control group children. No difference
was found in problem development. In both groups there were lower rates of problem
development in the children.
337
17.2.2 Support groups for adolescents (aged 16-23 yrs) and adult children (aged > 23 yrs)
The group sessions have the same aims as the above play-and-talk groups and also consist
of eight meetings. The content of the programme is more flexible and chosen in consultation
with the participants, to tailor the programme to their needs. Common topics are heritability,
feelings of guilt and shame, feeling responsible for the parent, leaving home and starting to
make a plan for the future. Participants can bring in additional topics. In a pilot evaluation study,
participants reported that they had acquired more knowledge about the mental disorder of their
parents, felt supported by the group members and felt happier after the group sessions
(Beurskens & Siebes, 1998).
17.2.3 Web-based interventions
A website called ‘kopstoring’ (www.kopstoring.nl) was developed especially for and by children
of mentally ill parents or parents with a substance abuse disorder. It offers information about
mental disorders and substance abuse disorders, stories of children and a forum where they
can leave messages. There is also an e-mail service available and the opportunity to chat with
professionals. Furthermore, visitors can join an online psycho-educative programme for
adolescents and young adults aged between 16 and 25 years. They meet at a fixed time in
eight online weekly chat sessions and one evaluation session. Besides improving the mental
health of the children themselves, this prevention programme is designed to educate children
about their parents’ illness and create understanding between children and parents. There are
eight themes; each week another theme is prepared by the participants and discussed.
Themes include describing the situation at home and roles in families; thoughts, feelings and
self-blame; questions about addiction and mental problems; coping with different behaviours;
parentification; using social networks and leading your own life and preparing for your own
future. The programme is similar to that of the above face-to-face support group and also
includes homework. An evaluation of the ‘Kopstoring’ intervention showed significant effects
on the key clinical outcome measures. The quality of life of the participants improved and
deterioration was prevented (Van der Veen & Van der Zanden, 2007). A randomised controlled
effect study and a cost-effectiveness study on the psycho-educative programme, initiated by
Maastricht University, started in 2010 (Woolderink et al. 2010).
17.2.4 Open educational meetings for youngsters and adolescents (aged 16-25 years)
These meetings aim to inform adolescents and adult children about mental illness, ways to
cope with having a parent with mental illness and ways to get support. During the meetings,
they receive information about mental illness in the family, tips on ways to cope and information
on ways to get support for themselves. The meetings are also used to recruit participants for
the support groups. The meetings are organised by local mental health centres and family
organisations. The ‘Labyrint /In Perspectief’ family organisation organises a special national
day for children of mentally ill parents, based on a specific theme, offering opportunities for
children to meet and exchange experiences.
17.2.5 Local activity days for children aged 8-16 years
During school holidays, activity days for children and adolescents are organised throughout
the country in cooperation with mental health centres, addiction clinics, volunteer aid
organisations, community workers and family organisations. Depending on the age category,
338
there are opportunities for sports, (street) dance, creative activities and play. The aim is to give
children of mentally ill parents an opportunity to relax, to have fun and meet peers.
17.2.6 ‘Opkikkertje’ Parent and Child Groups (children aged 1-5 years)
The main aim of these parent and child groups is to improve the quality of the parent–child
interaction and support parents in raising their children. The target group is mothers with a
mental illness, mothers who experience parenting stress or mothers with children from multiproblem families. Although these groups do not necessarily all work in exactly the same way,
the overall programme usually involves about 8 group meetings for parents and children
together and one follow-up meeting. The themes of the meetings include positive interaction
with your child, daily child care, structuring and setting limits, emotions of your child and your
own emotions, improving positive behaviour and improving social support. The programme
offers both psycho-education and exercises, for instance on playing with your child (Boeder,
2006). Results of a pilot outcome study focusing on depressed mothers and their children
showed improvement in their depression status (lower levels of depression), improvement of
their parenting skills and decreases in their parenting stress, and they also reported fewer
behaviour problems among the children. A group of 21 mainly depressed mothers participating
in the group were compared with 20 healthy mothers from the same region (Sijtma, 2008).
17.3
Interventions focusing on parents and families
A range of interventions specifically focuses on parents and entire families, to make them
aware of the impact of the home situation for the children, as well as to support and inform
them, to improve the quality of the parent–child interaction and to stimulate social support for
children and parents. They include individual psycho-educational sessions, a psychoeducational family intervention, parent training, mother–baby intervention and a web-based
programme.
17.3.1 Child and parent talks
As a routine service, mental health services initiate psycho-educational and supportive
meetings with children and parents after the intake of each adult patient who has children living
at home (aged 0-23 years). A trained mental health professional invites the family for three
separate conversations: an initial conversation with the patient and his/her partner, followed
by two conversations with the parents and the children involved. The main aims are: improving
the children’s coping skills and offering them emotional and social support, improving the
parents’ competence by increasing their awareness of their children’s perspectives, and
informing them of the consequences a parent’s mental illness may have for the children. In
response to conversations with the children, concerns might be reported to parents about early
indications of problems that the children experience, and advice is offered about the available
additional help and support. Information brochures are available for parents and for children in
different age groups, which can be used in the meetings. After the meetings, the children and
parents can choose to participate in other preventive interventions (groups, parent training,
website etc.). In case of a family crisis, the talks are offered in the same week to support the
children and parents immediately. These family talks are generally highly appreciated.
Evaluation showed that parents became more aware of what it means for a child to have a
339
parent with a mental illness; there was more mutual understanding between parents and
children, and they were better informed about available support (Kok, Konijn & Geelen, 1994).
This intervention is implemented in all mental health hospitals in the North of Norway (Reedtz,
Lauritzen & Van Doesum, 2012).
17.3.2 Psycho-educational family intervention
This intervention was developed by Dr. William Beardslee of the Children’s Hospital in Boston
(USA), especially for families with a parent with affective disorder and children aged between
9 and 14 years. The Dutch version of this intervention targets a wider age range of children
living at home (4 to 21 years) as well as families with any parental mental disorder (rather than
only affective disorder). Only families where parents acknowledge the presence of this parental
mental illness are included. This ‘whole-family approach’ consists of 6 to 8 sessions. First,
parents are invited to report the history of their situation, after which they are taught about
improving the resilience and strength of their children, and their concerns are discussed.
Subsequently, the children are seen in separate sessions to provide information and to discuss
their concerns, and finally the prevention specialist works with the family until the family feels
comfortable about having a whole-family meeting to discuss the mental illness, to develop a
shared coping strategy and to agree on positive steps to promote healthy functioning of the
children. The key mechanism of this intervention is to start a process of communication
between the family members about the parent’s mental illness. The results show that talking
helped children understand their parents better and that parents understood their children’s
perspective and learned how to support their children (Beardslee, 2003). Experiences with this
intervention in Netherlands have also been favourable, especially in families with depressed
and anxious parents. No controlled outcome studies have been performed in the Netherlands
so far.
17.3.3 Parent training
The main aim of the parent training course is to support both parents in raising their children.
The training course includes an average of six group sessions with the following topics: how
to talk to children about mental illness, what is important in the children’s development, how
can you support your children, what is good-enough parenting, the role of family and friends in
taking care of the children and exchanging experiences between parents. Although the
participants reported that they were highly satisfied with the training course, the threshold to
participate in parent group training appears to be high for these parents, as became evident
from problems with recruitment for the training course. Parents are usually referred to the
course by their individual therapists, who have to be motivated to do so, which is frequently
not the case. Experiences with recruitment presenting parent training as a regular part of the
treatment programme for parents have been more positive (Zonneveld et al., 2000).
17.3.4 www.kopopouders.nl website
In response to the problems with recruitment for parent training courses and new
developments in online availability of information and support, a new website was launched in
2007, designed especially for parents with a mental illness or substance abuse disorder. It
offers information and practical guidelines for raising children and refers to web clips with
parents talking about their situation. Furthermore, the site offers an online training course,
supported by mental health professionals. The aims of the course are the same as those of
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the face-to-face parent training course, with topics like your role as a parent, the impact of your
problems on your child, feelings of guilt and shame, what is good-enough parenting and what
practical pedagogical support is available, as well as the opportunity to exchange experiences
between participants. A pilot evaluation showed that parents who participated for one year
improved their parenting competence (n=39). Participants were on the whole highly satisfied
with the online course (Van der Zanden et al., 2009). Recently, a self-help version of
‘Kopopouders’ is available as well.
17.3.5 KOPP Mother–baby intervention
The mother–baby intervention is an early intervention programme that aims to improve the
quality of the interaction between mentally ill mothers and their infants, and to promote a secure
attachment relation in order to prevent developmental problems in the children.
Home visitors (qualified prevention specialists) affiliated to one of the regional community
mental health centres visit mothers and infants at home, where they record the mother–child
interaction on videotape, usually involving the mother bathing her baby. Video feedback is
used as the core intervention method, provided parental consent is obtained. The use of video
feedback offers room for tailoring the method to the individual mothers and their context, for
instance by adapting the dosage and adding various techniques like baby massage, modelling
and practical pedagogical support. The intervention comprises a total of 8 to 10 home visits.
(Van Doesum et al., 2005).
In 2007, a study was completed examining the effect of the mother–baby intervention on
the quality of mother–child interaction, infant–mother attachment security and infant socioemotional functioning, in a group of depressed mothers with infants aged 1–12 months. The
randomised controlled trial compared an experimental group (n=35) receiving the intervention
(8–10 home visits) with a control group (n=36) receiving parenting support by telephone. There
were pre- and post-assessments and a follow-up assessment after 6 months. The intervention
significantly improved the quality of the mother–infant interaction, and prevented the
deterioration that was found in the control group. Infants in the experimental group had higher
scores for attachment security and early emotional competence (Van Doesum et al., 2008).
The follow-up study after 5 years showed in the total sample no lasting intervention benefits,
but in families reporting a higher number of stressful life events, children in the intervention
group had fewer externalising behaviour problems as rated by their mothers than children in
the control group. In the context of multiple stressful life events, the intervention served as a
buffer by preventing the development of externalising problems in the child. The results warrant
cautious interpretation because of the relatively small sample size and differential attrition
revealing the mothers that completed the follow-up assessment to have improved less on
maternal sensitivity following the intervention than the mothers who did not participate in the
follow-up (Kersten-Alvarez, Hosman, Riksen-Walraven, Van Doesum & Hoefnagels, 2010).
17.3.6 ‘Squeak says the mouse’ for 4-8 year-old children of stressed families
‘Squeak says the mouse’ is a Dutch children’s song and is used as the name of a preventive
programme for children of families that are under stress due to parental mental illness,
substance abuse or chronic physical illness, relationship problems and sometime domestic
violence. It is a community approach and is targeted at children and families in disadvantaged
areas. The aims are to break through isolation, and to improve the social competence of the
children, as well as parent–child interaction and parenting skills. The programme comprises
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15 play-and-talk group meetings for children and five parent meetings. In addition, each family
gets tailored support from a family counsellor. The meetings are organised in a community
centre near the families’ homes. In the programme, prevention psychologists of a mental health
centre collaborate with local social workers and community workers. Experiences have been
positive, with more children from high-risk and low-SES families being reached compared to
the play-and-talk groups, and improved cooperation between professionals of different
organisations. Parents and children reported being highly satisfied with the programme.
17.4
Interventions for the professionals
The interventions in this domain are targeted at professionals in a wide range of services who
usually have contact with parents and children having to cope with parental mental illness.
These include professionals of community mental centres, in-patient and outpatient clinics,
youth health care, social workers and community care workers, school doctors and
counsellors, child protection workers and students in professional training. The aims of the
interventions for the professionals are: raising their awareness of the risk to children of mentally
ill parents and training them to talk to children and their families, detect problems in children of
mentally ill parents at an early stage and offer help and support for the families.
17.4.1 Education: workshops, conferences, lectures
In one or two meetings, professionals are informed about the risk to children of mentally ill
parents, the risk factors, and the availability of preventive interventions. The programme often
also includes a training course on talking to children about the mental illness of the parent and
talking with families. Professionals have perceived these meetings as very useful and fitting in
with their daily practice. Participants reported having become more aware of the position of
these children and better able to detect problems in children at an early stage. An additional
advantage of these meetings is that they foster cooperation between different disciplines and
organisations.
17.4.2 Implementation of routines
Mental health centres have developed routines to integrate consistent attention for children of
adult patients into the intake and treatment of adult patients. These routines vary between
centres. They focus on children of mentally ill parents at an early stage and are offered as part
of the treatment. They include various elements or combinations of them, such as checking
whether the patient has any children, child and parent talks or psycho-educational family
interventions as part of the treatment package, presenting an overview of available preventive
services, and offering educational brochures for children and parents, and additional help when
children are already having serious problems.
17.4.3 Preventive case management
In one of the provinces in the west of the Netherlands, mental health services (the Parnassia
Group) started a new case management programme for multi-problem families with chronic
parental mental illness and an accumulation of risk factors for poor parenting. This Preventive
Basic Care Management Programme, known for short as Basic Care Management (BCM), is
an innovative and theory-driven programme focusing on support for the children in a patient’s
family who do not yet show serious mental health problems. The protocolled programme aims
342
to ensure the presence of sufficient ‘basic care’ for the child to allow it to develop good mental
health and to prevent behavioural problems. The intervention includes three elements: the
systematic assessment and monitoring of risk and protective factors and parenting behaviour
and the assessment of early signs of child behavioural problems; organising and coordinating
supportive services, tailored to the risk factors identified in these families; and monitoring and
evaluating the implementation of the indicated services and their effects. There are usually
regular meetings between a Basic Care Manager, professionals from services involved and
the parents, to decide on action plans, enhance access to services and evaluate the progress
made by the family. Pilot studies have shown positive effects of BCM on parenting behaviour
and risk factors (Wansink, 2002; 2006). In 2009, a four-year randomised controlled trial was
started by Radboud University Nijmegen and the Parnassia Group, to investigate the
effectiveness of the BCM.
17.4.4 Training intervention providers
At national level, various training courses are offered to educate professionals in implementing
the psycho-educational family programme, the mother–baby intervention, the ‘Squeak says
the mouse’ programme, the support groups and other protocols. All training courses are
organised by Trimbos Instituut, the Netherlands Institute for Mental Health and Addiction, with
senior prevention specialists and mental health workers serving as trainers.
17.5
Interventions focused on the context and community
These interventions aim to change the prejudice and stigma surrounding mental illness, break
through social isolation of families with parents suffering from mental illness and improve social
support for the children and their families.
17.5.1 Activities by family or user organisations
These include support and psycho-educational groups for family members of mentally ill
patients organised throughout the country by family or user organisations, in some cases in
cooperation with mental health centres.
17.5.2 Activities in the community
Educational meetings or workshops are held for people in the community to educate them
about mental illnesses and inform them how to get support. Participants are family members,
friends, volunteer workers but also the persons with mental health problems themselves.
17.5.3 School-based activities
School-based programmes are available in which professionals talk to pupils about psychiatry
and mental illness. Information materials on mental disorders and substance abuse disorders
are available for use in school curriculums. There are also opportunities to invite a former
mental health patient as a guest speaker. A school programme focusing on normalising mental
illness, involving guest teachers, is nationally disseminated by the Pandora Foundation, a
mental health advocacy organisation with a history of almost five decades. Teachers can be
provided with educational materials about early detection of mental health problems in
children, and tips on how to support them. These materials relate especially to children of
mentally ill parents.
343
Together, the interventions described above constitute the current National Prevention
Programme for COPMI in the Netherlands, initiated by the prevention departments of mental
health services and addiction clinics. This programme is in essence a dynamic programme,
i.e. new elements are regularly developed by local organisations, piloted and evaluated across
health districts and disseminated for national implementation. Some of the above interventions
are already nationally available to parents and children (e.g. mother–baby intervention, parent
and child talks, play and support groups, national websites), while others are still in a
developmental stage and have only been implemented in certain provinces (e.g. the
Preventive Basic Care Programme, the Psycho-educational family programme and group
sessions for parents and children aged 1-5 years).
17.6
Conclusions
The ultimate aim of the Dutch COPMI policy is to have a comprehensive and sustainable
prevention programme in place that:
1) Successfully prevents transgenerational transmission of psychiatric disorders and
optimises socio-emotional development in COPMI,
2) By using a combination of interventions tailored to the needs of the identified target
populations in the different domains of our model;
3) That addresses directly or indirectly the major evidence-based risk factors and protective
factors in this transmission process;
4) That is implemented nationwide with a high degree of reach in the target populations, and
5) that is able to provide evidence for the effectiveness and cost-effectiveness of its
components.
During the last twenty years, great progress has been made in the development of this
science-based multicomponent programme, as we have illustrated in this article. COPMI has
become a priority theme in the Dutch prevention sector. Currently, all mental health services
and several other organisations provide preventive services for COPMI. A range of manualised
preventive interventions has been developed across the different domains described in Figure
17.1. Interventions are tailored to the needs of children in different developmental stages. A
nationwide network of prevention experts and trained mental health professionals is available
to implement them. Several research projects are ongoing to extend our knowledge about the
effectiveness of the interventions and to provide guidelines for their further improvement. The
national COPMI prevention network and several institutes and universities have developed a
system for further policymaking, capacity building, quality management, research and
reflection. Over the years, many foreign colleagues have visited our programme, and
workshops and training courses have been held in other European countries where people
were interested in learning from the Dutch experiences and sharing best practices.
Reflection on our current practices and achievements has also revealed some
weaknesses and challenges for the near future. Major current limitations concern the
implementation process and reach, efficiency issues and the effectiveness of the programme
and its components.
344
17.6.1 Solving barriers to implementation and increasing reach
One major concern is the as yet limited reach of the available interventions in the targeted
populations. The lower a programme’s reach, the lower its public health impact. Although
preventive interventions for COPMI are provided by all mental health services, they still reach
only a marginal proportion of COPMI and their families. This is due to a combination of causes,
such as lack of awareness of their availability, the tendency to rely heavily on labour-intensive
group- and family-based interventions, limited willingness to refer among the parents’
therapists, and a low implementation rate caused by a shortage of resources and trained
capacity for implementation.
There is a clear need for further improvement of the infrastructure for the COPMI
programme. This firstly concerns the implementation of routines in all mental health centres.
Although COPMI interventions are offered in all centres, only a few have standard routines in
place for the children of patients, e.g. standard rules about recording whether the patient has
any children, giving information to the children, talks with the whole family and providing
information on preventive services. A national policy is needed that requires adult mental
health centres to take responsibility for offering preventive interventions to the children of their
patients. The Norwegian parliament passed a new law (Effective in 2010) stating that adult
mental health centres have to meet the children’s needs (in terms of information and support).
In addition, extra resources are needed to train adult mental health care workers to talk to the
children of patients. Funding is needed for time to talk with the children. The current funding
system is based on adult patient contacts, and the children are not regarded as patients.
Secondly, long-term cooperation is needed between adult and youth care. These departments
currently function mostly as completely separate units with no regular connections. Support for
COPMI needs to become a shared responsibility, and both adult and youth care workers
should be directly involved in offering interventions to these children and families. Thirdly,
capacity building is also needed among health and primary care professionals, especially in
terms of awareness raising, early detection and screening, and options for referrals to
preventive interventions. Community workers should be trained in offering low-threshold
interventions (like the ´Squeak says the mouse´ programme), and public health nurses should
be trained in providing the mother–baby intervention to mothers with depressive symptoms.
17.6.2 More efficient use of resources
The limited resources and reach also highlight the need to consider options for more efficient
use of the available resources. To facilitate access to educational support, a system of internetbased services was introduced in 2006 as part of a preventive stepped-care approach. The
experiences so far confirm that this educational strategy indeed can successfully reach a much
larger proportion of COPMI and their families.
A second strategy to increase efficiency is to define more strictly who is in need of
preventive interventions, especially the more labour-intensive interventions. As discussed by
Hosman & Van Doesum (chapter 15), the limited resources available should be specifically
used for those COPMI who are most at risk. This would require the use of cost-effective risk
assessment procedures in the recruitment strategies. Apart from the as yet experimental Basic
Care service, this is currently not yet the case in the Netherlands; most interventions are
targeted at the population of COPMI as a whole, overestimating the need.
345
A third strategy is to optimise the use of mainstream opportunities for prevention and
health promotion. The current COPMI programme is composed of interventions that are
specifically designed for COPMI and their families. The advantage of this is that well-tailored
interventions are usually found to be the more effective ones. A danger, however, is that the
COPMI programme becomes an isolated segment of the Dutch prevention system. Likewise,
these children and families might come to be treated in an isolated programme, which may
cause underuse of other options for preventive support. A challenge for the coming years is to
explore how COPMI and their families could also make better use of mainstream prevention
and mental health promotion programmes that are not specifically designed for them but
address common factors described in our theoretical model. Several of the identified risk
factors and protective factors, such as parenting competence, child abuse and neglect, family
discord and divorce and children’s problem-solving capacities are not unique to the situation
of COPMI. More generic evidence-based programmes are available for several of these
issues. They are described in the Dutch national database on effective interventions for youth
that currently covers over 80 intervention programmes (www.nji.nl/jeugdinterventies, chapter
14). A good example is Triple P, a multicomponent programme adopted from Australia and
aimed at enhancing parenting competence, which might also be relevant to parents with a
mental illness (Sanders, 1999). It might be possible to integrate into such programmes
additional options for information on COPMI issues, or to make use of tailored versions, such
as Pathways Triple P, specifically targeted at parents at risk of child abuse. From the
perspective of enhancing social integration of families with parental mental illness, it might also
be preferable to involve COPMI not only in specifically tailored interventions but in more
generic health promotion programmes as well.
17.6.3 Increasing the effectiveness of the programme
Another challenge is the issue of combining interventions to optimise their effect. Although a
wide range of interventions have been made available to address the risk of transgenerational
transmission, it is questionable if one specific intervention, for instance the mother–baby
programme, can be sufficient to achieve the intended sustainable outcomes, i.e. normal socioemotional development and prevention of psychopathology in the offspring. It is likely that such
outcomes are only achievable in response to combinations or successions of interventions
with sufficient duration and dosage. For instance, evaluations of school-based prevention
programmes suggest that multi-component and multi-year programmes are necessary to
achieve significant and sustainable outcomes in children (Domitrovich & Greenberg, 2000).
This also involves the issue of cost-effectiveness: which combinations offer the best balance
between high effectiveness and low costs?
17.6.4 New opportunities for interventions
Comparing the current Dutch programme with the theoretical model and research presented
in this chapter reveals some opportunities for strengthening our preventive approach.
Addressing the risk factors which are already present during pregnancy and which are likely
to cause long-term vulnerabilities in offspring is currently considered a major gap in our
approach. The growing knowledge about the harmful impact of stress, anxiety and substance
abuse on the developing cognitive and emotion-regulation systems in the brains of children
highlights the need to explore if interventions during pregnancy to reduce these risk factors
might have preventive effects in infants and children. Some intervention studies suggest that
346
this might be the case. Examining the value and opportunities of routine prenatal screening for
risk factors in primary care and well-baby clinics seems to us a valuable investment, provided
the outcomes are linked to the provision of prenatal or postnatal preventive interventions for
parents with mental illness or at risk of postnatal disorders. Recently a new intervention is
developed for pregnant women with a mental illness; ‘Pregnant and then?’ by Dimence. This
intervention includes psycho-education, massage therapy, stress management training, and
early treatment. Studies show some promising outcomes. For instance, Field et al. (2009)
found evidence for reduced prematurity, low birth-weight and postpartum depression due to
massage therapy during pregnancy and early treatment of depression. A pilot evaluation on
the programme ‘Pregnant and then?‘ with a pre and post-measurement showed that the
participants are highly satisfied and the women had lower stress levels after participating in
the programme (Van Laarhoven, 2012).
In addition, some studies suggest that remission of maternal depression in response to
treatment might also result in better mother–infant relationships and improvement in children’s
symptoms and functioning (Gunlicks & Weissman, 2008; Poolaban et al., 2007; Pilowsky et
al., 2008), although an explicit focus on the mother–infant relationship during the treatment
might be essential (Forman et al., 2007). Recently, an online preventive programme ‘A Pink
Cloud?’ (Hoezo Roze Wolk?) is developed for depressed mothers with a baby until 12 months.
The programme contains cognitive behavioural exercises but also a special part focused on
the mother-child relationship. It is available for mothers in the East of the Netherlands in the
area of the Mental Health Organisation Dimence.
17.6.5 Research needs
Our review has also revealed several topics that need to be investigated to fill the gaps in our
current knowledge (see also chapter 15). A better understanding of the developmental
trajectories of COPMI requires more research into the role of disorder-specific versus generic
risk factors. Limited research has so far been done on the influence of protective factors in
transgenerational transmission, even though several prevention programmes specifically
focus on such factors. In terms of intervention studies, more research is needed into
implementation processes, and the relative effectiveness and cost-effectiveness of different
prevention strategies, with special attention to long-term outcomes and ‘broad-spectrum’
outcomes.
17.6.6 International collaboration
The last decades have seen a rapidly emerging interest in preventive interventions for children
and families of mentally ill parents across the world. In Europe, this has resulted in several
international conferences on this subject. There is growing international collaboration in terms
of sharing knowledge, expertise, materials and programmes. For instance, the psychoeducational family programme developed by William Beardslee (US) is now implemented in
Finland, the Netherlands, Norway, Belgium and Sweden; and the Dutch play-and-talk group
intervention has been adopted in Norway. The Scandinavian countries have a long history of
working together within the Nordic forum, a network of COPMI professionals. In addition,
longstanding research collaboration exists between the USA and Finland, and between the
Netherlands, Norway and the UK. Furthermore, contacts have been made with colleagues in
Australia, where a strong nationwide COPMI network supports initiatives, implementation and
research. Since the knowledge about preventive interventions for COPMI and the number of
347
efficacy studies are rapidly growing, the need for international cooperation and support in
capacity building has increased.
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Study questions for this chapter

Which prevention strategies and methods are used to prevent mental disorders in
children?

Which types of prevention programmes are effective in the reduction of risk factors and
the reinforcement of protective factors in COPMI children?

What are important conditions for realising a broad implementation of effective
prevention programmes?

Describe some examples of preventive activities targeted directly at COPMI children
and interventions focused at intermediate target groups.

Go back to chapter 12 where the eight dimensions of a prevention strategy are
described. Compare the Mother-baby intervention and the Support group intervention
for COPMI between 8 and 12 years. On which of these dimensions do these two
interventions differ? What are the differences?

What are opportunities to further improve or innovate these COPMI interventions?
You also could try to apply knowledge on effect predictors discussed in chapter 13.
350
18
Prevention of Anxiety Disorders
18.1
Introduction
352
18.2
Epidemiological Profile
352
18.2.1
18.2.2
Prevalence and incidence
Populations at risk
352
354
18. 3
Risk and protective factors
354
18.3.1
Psychological risk and protective factors
357
18.4
Preventive strategies
359
18.5
Evidence-based preventive strategies
359
18.5.1
18.5.2
Indicated, selective and universal prevention in childhood and adolescence
Indicated prevention for adults
360
363
18.6
Promising developments
364
18.7
Conclusions and recommendations
365
Literature
367
Study questions for this chapter
371
351
18
Prevention of Anxiety Disorders
Clemens M.H. Hosman, Heleen Drijver
18.1
Introduction
Feelings of fear and anxiety are a part of normal, healthy life, especially in situations that are
perceived as threatening. Fear and even panic are considered as alarm reactions of the
organism to danger. Fear is the emotional response to real or perceived imminent threat,
whereas anxiety is anticipation of future threat (American Psychiatric Association, 2013). When
perceptions of danger are realistic and anticipatory in nature, feelings of fear and anxiety can
trigger adequate preventive behaviour, such as avoiding dangerous situations, asking for help
or performing social behaviour that reduces escalation to violent encounters. Fear and anxiety
are postulated as part of evolved defence mechanisms that keep organisms away from
anticipated life-threatening situations or to prepare the body for vigorous defensive action.
However, when feelings of anxiety are intense and overwhelming they can paralyse animals
and human beings, and reduce their ability to adequate cognitive and behavioural functioning.
Regular biased perceptions of threat and excessive feelings of anxiety, that a person finds
difficult to control, can significantly impede their functioning in school, work, parenting, marital
relationships and the development of social skills and friendships (e.g. LaGreca & Lopez,
1998). In such situations, persons might suffer from an anxiety disorder.
The
DSM-5
(American
Psychiatric
Association, 2013) differentiates among a range of
DSM-5 Classification Anxiety Disorders
(APA, 2013)
anxiety disorders (see Box).
18.2
Epidemiological Profile
18.2.1 Prevalence and incidence
Separation Anxiety Disorder (SAD)
Selective Mutism
Specific Phobia
Social Anxiety Disorder (Social Phobia)
Panic Disorder
Panic Attack Specifier
Agoraphobia
Generalized Anxiety Disorder (GAD)
Substance/Medication-Induced
Anxiety
Disorder
Anxiety Disorder Due to Another Medical
Condition
Other Specified Anxiety Disorder
Unspecified Anxiety Disorder
Children and adolescents
Among children, anxiety disorders represent the
most common form of psychopathology.
Epidemiological
studies
show
prevalence
estimates, ranging from 5.7 to 17.7%, with half of
study estimates above 10% (Costello & Angold,
1995). The lower prevalence rates have been
found in studies using more stringent diagnostic criteria. Reviewing epidemiological knowledge
on anxiety disorders in children and adolescents, Malcarne and Hansdottir (2001) report a rate
of 3–5% for separation anxiety disorder, around 6% for special phobia and between 1.7 and
14.3% for overanxious disorder. Panic disorders and agoraphobia are rare in children.
Dutch researchers conducted interviews with young people (Verhulst et al., 1997) and
young adults (De Graaf et al., 2010). The half year prior to the study more than 10 percent of
the Dutch youth from 13 to 17 years had an anxiety disorder. This comes down to about
114,000 young people. In the category 18 to 24 years the percentage of anxiety disorders was
352
11.7 over the past year. The most common anxiety disorders in both age groups are the social
anxiety disorder and specific phobia. These disorders are more common in girls than in boys.
For the timing of preventive interventions, it is important to have insight in the age of
onset of disorders and their precursors, as well as in the time lap between onset and clinical
diagnosis. Most anxiety disorders in children (Separation Anxiety Disorder (SAD), Generalized
Anxiety Disorder (GAD), Social Phobia, specific phobias) first appear in middle childhood, i.e.
between 7-9 years, while a mean age of onset is found in adolescence (Malcarne & Hansdottir,
2001; Hazen & Stein, 1995). The mean age of onset of generalised social phobia is much
earlier (11 yrs) than for nongeneralised phobia (17 yrs) and agoraphobia (27 yrs) (Mannuzza
et al., 1995; Emmelkamp, Bouman & Scholing, 1989). Anxiety disorders in adolescence and
adulthood are frequently preceded by anxiety disorders and behavioural inhibition in young
children (Francis & Radka, 1995). For prevention, it is necessary to consider the whole
developmental trajectory of anxiety problems, including sequences of subsequent anxiety
disorders. Evidence from both retrospective and prospective studies of children suggests that
a high proportion of children do not ‘outgrow’ anxiety disorders (Majcher & Pollack, 1996;
Spence, 1996). Unless successfully treated, anxiety disorders in childhood frequently persist
or develop into some other anxiety disorder. Finally, with respect to secondary prevention, it is
relevant to know that clinical diagnoses of anxiety at the first contact with mental health care
follow mostly not earlier then 3 to 4 years after onset.
Adult population
According to the US National Comorbidity Study Replication in 2001/2003 (NCS-R) (Kessler,
Petukhova, Sampson, Zaslavsky, & Wittchen, 2012) one third of the adult population was
estimated to develop an anxiety disorder at some time in their lives. In about 21%, an anxiety
disorder was found currently or in the past 12 months. Lifetime prevalence for the most
common anxiety disorders was 13.0% for social phobia and 13.8% for specific phobia. In terms
of year prevalence, correspondingly, the highest rates were found for social phobia (8.0%) and
specific phobia (10.1%), and much lower rates for panic disorder (3.1%), agoraphobia (1.7%),
and generalised anxiety disorder (2.9%).
According to NEMESIS-2 (De Graaf et al., 2010) lifetime prevalence for the Netherlands
for anxiety disorders was 19.6%. The year prevalence was 10.1%. Virtually all anxiety
disorders are more common among women than among men. A cross-cultural study by WHO
at 15 primary health care sites, using similar diagnostic instruments, showed a considerable
variation in generalised anxiety rates, ranging from 0.9 to 22.6%. The highest rates were found
in capital cities within the South American region (18.7 – 22.6%), while the lowest rates were
found in Ankara, Shanghai and Seattle (0.9 – 2.1%). This points to the role of cultural factors
in the onset, diagnoses or reaction to anxiety disorders across regions.
Comorbidity
Anxiety disorders show a high level of comorbidity, both between anxiety disorders and with
other disorders. Around half of the patients with a principle anxiety disorder have one other
anxiety or depressive disorder (Brown & Barlow, 1992). Especially for GAD, high levels of
comorbidity are found, such as a 90% lifetime comorbidity rate in the NCS community study
(Wittchen et al., 1994). Anxiety disorders are most comorbid with depression, ranging from
15.9 to 61.9% across studies (Brady and Kendall, 1992), with anxiety disorders mostly as the
primary disorder. Several prospective studies have identified anxiety disorders and especially
multiple anxiety disorders as a significant risk factor for the development of later depression
(Woodward & Ferguson, 2001; Reinherz, Paradis, Biaconia, Stashwick & Fitzmaurice, 2003;
353
Stein et al., 2006). Comorbidity has been found also with Attention Deficit Disorder (ADD),
oppositional disorder, and alcohol abuse and dependence (Mannuzza, Schneier, Chapman et
al., 1995; Kessler, Sonnega, Bromet et al., 1995). Furthermore, high levels of comorbidity exist
with Cluster C type of personality disorders (avoidant, dependent and obsessive compulsive),
which points to the prevalent chronic character of the symptoms in those who are suffering
from anxiety disorders.
Health and economic burden:
Andlin-Sobocki and Wittchen, (2005) estimated that in 2004 anxiety disorders cost more than
41 billion euros in the European Union. There is also convergence in studies that anxiety
disorders account for a substantial amount (at least 35%) of all disability and sick leave days
due to mental disorders (Wittchen & Jacobi, 2005). In the top ten of diseases with the greatest
burden of disease in the Dutch population in 2015, anxiety disorders take the fifth place (Men:
6th place, women 2nd place). Burden of disease is expressed in Daly's (Disability Adjusted
Life Years). The DALY is a composite measure of health loss and is made up of two
components: the years lost due to premature death (years of life lost) and the years lived with
disease, taking into account the severity of the disease. Virtually all disease burden caused by
anxiety disorders is formed by the years lived with the disease.
(www.volksgezondheidenzorg.info/onderwerp/angststoornissen)
18.2.2 Populations at risk
Several population categories have been identified with increased vulnerability to anxiety
disorders, namely children of parents with an anxiety disorder, those with history of anxiety
sensitivity or behavioural inhibition as a child, persons with a high level of neuroticism and
those already showing increased levels of anxiety symptoms. Empirical evidence for their risk
is presented in the next section.
18. 3
Risk and protective factors
The onset of anxiety disorders is the outcome of a combination of biological, environmental
and psychological factors across the lifespan, both risk and protective factors. Some are
related to one specific anxiety disorder only, others play a part in the onset of several or all
anxiety disorders, in the development of both anxiety and depressive disorders, or contribute
to the risk of psychopathology in general. Several excellent reviews of risk and protective
factors in anxiety disorders and preventive interventions have been published, that we
gratefully have used as one of the sources for this chapter (Malcarne & Hansdottir, 2001;
Donovan & Spence, 2000; Roth & Dadds, 1999; Zuckerman, 1999; Spence & Dadds, 1996;
Lau & Rapee, 2011; Stockings et al., 2016).
Demographic profile
According to the findings in the NCS study (Kessler et al., 1994), the ECA study (Regier,
Narrow & Rae, 1990; Robins & Regier, 1991) and NEMESIS-2 (De Graaf et al., 2010), the
incidence of most anxiety disorders in women is twice as high as in men. Taken as a whole,
anxiety disorders are prevalent across all the age categories, although the incidence of
individual anxiety disorders varies with age. Incidence is negatively related to income, social
class and employment status, with rates twice as high in the lowest income group as in the
highest one, and among the unemployed versus the employed. There is no indication that
354
anxiety disorders are related to ethnicity when other demographic variables are controlled.
Furthermore, rates of anxiety disorders were higher in those who are separated or divorced,
and especially in single parents (Zuckerman, 1999). These findings do not allow any causal
interpretation because, for example, lower income and divorce might also be a consequence
of anxiety disorders or other psychopathology.
Parental anxiety disorders
Children of parents with anxiety disorders are at greater risk to develop anxiety disorders
across their lifespan than children of parents without such disorders (parental panic disorder:
Biederman, Faraone, Hirshfeld-Becker et al., 2001; Van Santvoort et al., 2013). Such a history
is especially found to be predictive for comorbidity of anxiety disorders in combination with
other disorders in children. For instance, the Dutch National Mental Health Survey (de Graaf,
Bijl, Smit, Vollebergh, & Spijker, 2002) found among adult offspring of parental
psychopathology odd ratios of 1.28 for pure anxiety disorders, 1.81 for anxiety disorders
comorbid with mood disorders and 2.29 for comorbidity with substance use disorders. The
study did not offer a differentiation concerning the type of parental disorder.
Several mechanisms could be responsible for the impact of parental anxiety on offspring.
Although the knowledge on such mechanisms is still meagre, it seems likely that both genetic
influences and parental behaviour play a mediating role in this.
Genetic and temperamental factors
Twin studies have shown evidence for genetic effects in the onset of anxiety disorders,
although the estimated impact of environmental factors seems to be much larger. In such
studies only modest heritability (23-39%) was found, in comparison to non-shared
environmental effects (61-73%) (Zuckerman, 1999). Research on genetic transmission of
anxiety to children is mainly focused on the study of ‘Behavioural inhibition (BI) to the
unfamiliar’, a temperamental construct that is found in approximately 10 –15% of the children.
BI refers to withdrawal, timidity, excessive shyness, emotional restraint in children and seeking
comfort of parent or caretaker when exposed to unfamiliar people, places or contexts. Next to
a strong genetic component, stability of behavioural inhibition might be mediated by parental
behaviour (Donovan & Spence, 2000). Several prospective studies (e.g. Kagan et al., 1990),
some over a period of 7-12 years, have found evidence for behavioural inhibiting
characteristics in early childhood as risk factors for anxiety disorders in middle childhood and
adolescents (Malcarne & Hansdottir, 2001). In addition, neuroticism/negative emotionality is
hypothesised as another temperamental risk factor in the onset anxiety disorders. People with
anxiety disorders, except specific phobia, show higher scores on neuroticism and negative
affectivity and lower scores on extraversion scales then people without such disorders.
Evidence suggests that this relation is mediated by a higher occurrence of stressful life events
and avoiding coping styles in those with higher levels of neuroticism and negative emotionality
(Watson, David & Suls, 1999). Neuroticism/negative emotionality is also found as a risk factor
in other disorders. For instance, a large twin study found neuroticism to be also a significant
predictor for the onset of major depression (Kendler, Neale, Kessler et al., 1993).
As genetic factors as such are not eligible as targets for preventive interventions, they
might be used to identify children at risk who may benefit from available preventive
interventions, for example by enhancing the development of problem-focused coping skills and
through parent education.
355
Environmental influences
In addition to genetic factors, there is ample evidence for environmental influences in the
development of anxiety and anxiety disorders, especially concerning the impact of parental
behaviour and traumatic experiences. It is likely that environmental influences are mediated
by several biological and psychological mechanisms. Evidence found in both animal and
human studies suggests that early adverse life events create a neurobiological vulnerability
that predisposes individuals to the development of affective and anxiety disorders in adulthood
(Heim & Nemeroff, 1999; Heim et al., 1997). Such events can result in long-lived alterations in
neurological systems that regulate mammalian stress responses, and especially generate
increased activity of the corticotrophin-releasing factor (CRF). Increased CRF neuronal activity
has been found in patients with major depression and some anxiety disorders. As Heim and
Nemeroff conclude, genetic disposition coupled with early stress in critical phases of
development may result in a phenotype that is neurobiological vulnerable to stress and may
lower an individual’s threshold for developing depression and anxiety upon further stress
exposure.
Convincing evidence exists for the mediating role of learning mechanisms, such as
direct classical conditioning, vicarious learning, and information transmission. Direct classical
conditioning occurs when individuals are exposed to traumatic experiences. Vicarious learning
refers to conditioning caused by the observation of fear reactions in a model. For example,
children of anxious parents can model their parent’s anxious or phobic behaviour. When such
parents conceal their fears in the presence of their children, the impact on children’s behaviour
disappears (Muris, Steeneman, Merckelbach et al., 1996). The role of information transmission
in anxiety development is illustrated in child studies of Barrett, Rapee, Dadds, and Ryan,
(1996) and Barrett, Dadds and Rapee (1996). They suggest that parents of anxious children
differ in the way they teach their children to interpret and respond to ambiguous threat cues,
and are more likely to suggest avoidant solutions than pro-social solutions. Both environmental
factors as well as learning processes are viable targets for preventive interventions.
Parental behaviour and parent-child interactions
It is highly likely that intergenerational transfer of anxiety problems is not only genetic in nature,
but that parental anxiety also has direct influence through the behaviour of parents. The above
examples illustrate this. Several parental behaviours have been empirically identified to
increase anxiety reactions and even the risk of anxiety disorders in children, especially
overanxious behaviour, overprotectiveness and overcontrol by parents (reviews by Malcarne
& Hansdottir, 2001; Donovan & Spence, 2000). For example, evidence has been found
suggesting that parental overcontrol tends to interfere with children’s acquisition of effective
problem-solving skills, resulting in low efficacy and low expectancies for success (Costanzo,
Miller-Johnson & Wencel, 1995; Krohne & Hock, 1991). In addition, mothers with anxiety
disorders or depression show more aversive control and are less responsive to their children
what fosters insecure attachment. Interactions between insecure attachment and behavioural
inhibition would put children at greatest risk. However, most of this research is only
retrospective and hard evidence on such interactions from prospective research is missing.
Trauma and stressful life events
Exposure to fear-evoking, health-damaging and especially life-threatening stressors is one of
the most significant risk factors in the onset of anxiety disorders.
The impact that traumatic experiences can have on children is often undervalued through
references to their resilience and plasticity. Numerous studies have shown that childhood
356
trauma may have serious and long-lasting effects. Also in large-scale epidemiological studies,
adult psychopathology is strongly associated with childhood trauma. For example, among
adults with a history of childhood trauma the Dutch National Mental Health Survey found odd
ratios of 1.66 for anxiety disorders, 2.66 for mood disorders, and 5.28 for comorbidity of mood,
anxiety and substance use disorder (de Graaf, et al., 2002). However, such figures need to be
interpreted with care while they might be influenced by biased memory processes.
Child abuse is worldwide one of the most prevalent traumatic events among children.
Approximately one third of the children exposed to child abuse develop PTSD (Ackerman,
Newton, McPherson, Jones, & Dykman, 1998) (Famularo, Fenton, Kinscherff & Augustyn,
1996), while also phobic disorders, ADHD, oppositional defiant disorder, and separation
anxiety disorder are highly prevalent among such victims (Ackerman et al., 1998). In a
controlled, prospective study over a period of 25 to 30 years among 1.196 abused and
nonabused children, Widom (1999) found a lifetime prevalence of PTSD of 30.6 to 37.5%
depending on the type of abuse. Adolescents or young adults who were both physically and
sexually abused during childhood appeared to be at the highest risk, between 45 and 55%,
while PTSD among the nonabused is estimated at 3.8% (Ackerman et al., 1998; Schaaf &
McCanne, 1998). Longitudinal research among abused/neglected and nonabused/neglected
children suggests that the long-term risk of adult psychopathology might be mediated by a
significant increase of vulnerability factors in abused children (Sanchez, Ladd & Plotsky, 2001;
McGloin & Widom, 2001). Risk factors for child abuse and neglect are discussed more
extensively in chapter 16. These include evidence for the intergenerational transfer of parental
child maltreatment and PTSD.
Traumatic events during infancy and early childhood are of special importance since
evidence from neurodevelopmental research suggests that such experiences can have an
adverse influence on the organisation of the developing brain (Perry, Pollard, Blakley et al.,
1995). Accumulating evidence (as reviewed by Sanchez, Ladd & Plotsky, 2001) shows that
early traumatic experiences in children are associated with long term alterations in coping style,
emotional and behavioural regulation, neuroendocrine responsiveness to stress, social
‘fitness’, cognitive function, brain morphology, neurochemistry, and expression levels of central
nervous system genes that have been related to anxiety and mood disorders.
Exposure to trauma is discussed here especially in relation to the onset of ASD and
PTSD; nevertheless, we need to consider exposure to traumatic events as a non-specific risk
factor, while it can trigger also a variety of other psychiatric disorders, especially anxiety
disorders, major depression and substance abuse.
Not only traumatic events but also other stressful events that are more common to the
daily life of children, such as first school entry, school transitions, bullying, hospital admissions,
surgery, dental treatment, family conflict and the death of a family member, can trigger
persistent anxiety reactions and increase the risk of anxiety disorders, such as phobia and
GAD (Donovan & Spence, 2000; Spence, 1994).
18.3.1 Psychological risk and protective factors
Personality characteristics as risk factors
The presence of personality disorders of the avoidant, dependent and obsessive compulsive
types increases the risk of the development of anxiety disorders. For example, the avoidant
defence mechanism is what turns a panic disorder into agoraphobia (Zuckerman, 1999). An
individual panic attack is not only a potential precursor of a panic disorder, but could also trigger
the onset of agoraphobia, as an avoidance reaction to panic attacks and their complications.
357
As will be discussed below, some preventive interventions are specifically targeted at persons
who have experienced only one panic attack and who are considered at risk for panic disorder
or related disorders.
There is ample evidence to conclude that cognitive learning and other conditioning
processes play a significant role in the onset of anxiety disorders. For example, persons with
panic disorders, social phobia and GAD show a sense of lack of control and consequent
feelings of helplessness and low self-efficacy, an increased sensitivity to threat stimuli, biases
in information-processing, and negatively biased self-perceptions (Zuckerman, p.125, 286;
McNally, 1990; Barlow, 1991). Specifically, panic attacks are mediated by catastrophic
interpretations of unexpected body sensations.
Feelings of lack of control and biased perceptions of negative evaluations by others
might be the outcome of negative life events over which the child had little or no control, such
as child abuse or being a regular victim of bullying. Such experiences are believed to foster a
psychological diathesis that put children at risk for anxiety and other disorders. According to
Chorpita and Barlow (1998), long-term influence of perceptions of low control would be to
intensify behavioural inhibition and would ultimately lead to the experience of generalised
anxiety. Furthermore, Muris (2002) found that low self-efficacy was associated with high levels
of anxiety disorder symptoms and depressive symptoms, even when controlling for trait
anxiety. In addition, some support was found for a relation between the specific domain of selfefficacy and particular types of anxiety problems. Social efficacy was most strongly connected
to social phobia, academic self-efficacy to school phobia, and emotional efficacy to generalised
anxiety and panic.
Several of the above-mentioned risk factors are not specific for anxiety disorders. Risk factors
such as insecure attachment, lack of self-perceived control and low self-efficacy are also
predictive of increased risk of depression or psychopathology in general.
Some evidence is found for ‘anxiety sensitivity’ as cognitive risk factor, especially for
panic disorder. Anxiety sensitivity refers to someone’s fearful response to anxiety symptoms
that are based on beliefs that these symptoms have harmful consequences (McNally, 1996).
Such sensitivity can be a consequence of earlier panic attacks, but also of misinterpretations
of heart attacks, or through observational learning of parental ‘fear-of-fear’ behaviour. Trait
anxiety, however, denotes a general tendency to respond fearfully to stressors.
Protective factors
Social support is considered as a generic protective factor reducing the onset of psychiatric
and physical disorders, especially when one has to face stressful or traumatic life events.
Empirical evidence, as reviewed by Donovan and Spence (2000), has shown that family social
support reduced the development of anxiety problems when children are exposed to stressors
such as community violence, divorce and sexual abuse. For example, in a prospective study
among 11 to 14-year olds who were exposed to community violence White, Bruce, Farrell and
Kliewer (1998) found less increase of anxiety level when they received social support from
their family.
Furthermore, it is suggested that emotion-focused and avoidant coping strategies are
associated with higher levels of anxiety then problem-focused coping. The available evidence
points mainly to the more generic impact of coping styles on the development of psychiatric
problems, and only marginal evidence is available for its protective role on the development of
anxiety problems.
358
18.4
Preventive strategies
To reduce the onset or recurrence of anxiety disorders a wide range of intervention strategies
have been developed that can be differentiated with respect to their timing, type of addressed
disorder(s), target population, targeted risk or protected factors and the choice of methods and
mechanisms of change.
Timing refers to choices in terms of the targeted period across the life span (e.g. infancy, late
childhood or adolescence), interventions before or after an anxiety-provoking event (proactive
or reactive), or the targeted stage of problem development (e.g. primary, secondary or
recurrence prevention). Interventions, designed to prevent the onset of anxiety problems, are
mostly directed at populations at risk (selective or indicated prevention) and only incidentally
at universal populations. In terms of addressed risk and protective factors, interventions are
focused at reducing the onset of or exposure to stressful events that might trigger anxiety
reactions, decreasing vulnerability and increasing resilience, coping skills or anxiety mastery
of people who might be or have been exposed to such events, and to strengthen emotional or
other types of support.
Box 18.1 comprises the main preventive strategies that are currently implemented. They
include a wide range of methods and techniques, such as for example in vivo- or videomodelling by parents and peers, information, stress inoculation, skills training, exposure
techniques, and environmental measures.
The overview of current preventive strategies reflects that a successful community
approach to prevent anxiety disorders needs to be intersectoral, i.e. requires the involvement
of a range of health sectors (e.g., primary health care, public health organisations, outpatient
mental health services, hospitals), as well as many other public sectors, such as schools,
workplaces, traffic, transportation, fire-arms and the safety sector. This includes actions and
policies that might not primarily be focused at mental health, but having the potential to reduce
the number of and exposure to severe traumas, for instance armed bank or shop robberies.
18.5
Evidence-based preventive strategies
What do we know about the efficacy and effectiveness of these strategies? In comparison to
other sectors of prevention (e.g. prevention of antisocial behaviour), controlled outcome trials
on interventions specifically designed to prevent anxiety disorders are scarce. Most of the
available research concerns selective and indicated prevention of anxiety disorders in early
and middle childhood and prevention of phobia related to medical procedures. To date, there
appears to be no controlled evaluation of the effectiveness of treating parental anxiety in
preventing childhood anxiety (Donovan & Spence, 2000).
359
Box 18.1
Overview of strategies to prevent anxiety disorders
1. Reducing environmental conditions that can trigger severe and enduring anxiety reactions
Preventable conditions include, for instance, marital violence, child abuse, armed robberies, shootings, workrelated accidents; traffic accidents. Examples of preventive strategies: safety measures in traffic, workplaces
and neighbourhoods, safety legislation, gun control, violence prevention programmes, prevention of bullying
in schools.
2. Reducing the exposure to threatening situations, or its duration
For example, evacuation plans in cases of a threatening disaster, removing individuals from disaster scenes,
and protecting them from direct exposure to disaster stressors; early detection and intervention in bullying,
child abuse or other forms of domestic violence (e.g. child protection measures); and reducing children’s
access to violent movies.
3. Enhancing emotional resilience, and reducing personality characteristics that make
children and adolescents prone to anxious reactions and vulnerable to anxiety disorders
This includes both universal prevention and mental health promotion (e.g. in school settings) and selective
prevention (e.g. for children of anxious parents)


pre-school programmes and parent-focused programmes to reduce overprotection, anxious model
behaviour and insecure attachment, and to increase positive reinforcement and teaching coping skills;
for example, by training of appropriate parenting strategies (e.g., parent education courses, video
home training) or early treatment of parental anxiety disorders.
school-based programmes: teacher training and direct training of children’s cognitions and skills,
generic in nature (e.g., problem and social solving skills, self-efficacy) or anxiety-related (e.g., safety
behaviour, coping with threat and fear).
4. Anticipatory education and training
Strengthening relevant coping skills in those who are at increased risk of exposure to threatening situations
using information, stress inoculation, skills training, disaster training, leadership training and personnel
selection. Main target populations at risk:



professionals (e.g. fire-fighters, rescue teams, police officers, bank personnel, soldiers),
potential disaster victims (e.g. workers in chemical industry, inhabitants in areas at risk of natural
disasters), and
persons who have to face stressful life events or life conditions, such as school transitions, unpleasant
or painful medical treatment (e.g. prevention of dental fears, pre-operation education), elderly with
reducing hearing and sight capacities).
5. Indicated prevention
Interventions directed at children, adolescents or adults already showing increased levels of anxiety
symptoms that might foreshadow the onset of an anxiety disorder. For example, persons at risk because they
have suffered from a first panic attack, or who show increased levels of social anxiety but no disorder.


Training in early detection and treatment skills of teachers, personnel officers, primary health care
workers (general practitioners, nurses)
Courses or training programmes or for those with increased levels of anxious symptoms.
6. Recurrence prevention
Interventions offered at people who have recovered from a past anxiety disorder and who are at risk of
recurrence of a similar or other anxiety disorder.
360
18.5.1 Indicated, selective and universal prevention in childhood and adolescence
As inhibited temperament has been identified as a major risk factor in anxiety disorders, Rapee
and Jacobs (2002) studied the possibility to reduce withdrawn and inhibited characteristics in
4- to 5-year old children. Mostly such temperamental characteristics are assumed hardly
malleable. They offered the mothers a six-session programme to educate them in managing
their children’s fears and their own anxiety. In their uncontrolled pilot study, they found marked
reductions in mother’s perceptions of withdrawn temperament and anxious symptoms.
Interestingly, the reduction on temperamental characteristics became only significant 6 months
after the intervention. Notwithstanding the limitations of the study, the pilot has shown that it is
potentially possible to reduce withdrawn behaviour in preschool children.
In Canada, LaFreniere and Capuano (1997) used a randomised controlled trial to
evaluate the efficacy of a preventive intervention for anxious-withdrawn preschool children and
their mothers (N=43). The home-visiting programme covers 20 sessions with the mothers
across 6 months, and includes reading materials on child development and parenting,
feedback from observations by the home visitor, video home-training, child-directed play
sessions, individual coaching and stimulation of building a more effective social support
network. These methods were used to increase mother’s insight in the developmental needs
of the child, promoting the parents’ competence to respond sensitively to these needs, reduce
parenting stress and to provide social support. The outcomes showed a significant
improvement in appropriate maternal control, social competence in the children of the
participating families over those in the control condition. However, the improvement of
children’s anxious-withdrawn behaviour in the treatment condition reached only marginally
significance when compared with changes in the control group. No effect of the programme
was found for the aimed reduction in parental stress and maternal affect. Australian
researchers
have
made
significant
FRIENDS Anxiety Prevention Programme
progress in preventing child anxiety
disorders by modifying a successful
 A cognitive behavioural programme for
cognitive-behavioural
treatment
children of 7 to 16 years old that
programme for anxiety disorders, into a
 assists them in developing skills to cope
prevention format (Lowry-Webster, Barrett
with and manage anxiety more effectively
& Dadds, 2001; Dadds, Holland, Laurens et
 builds emotional resilience, problem solving
al., 1999; Dadds, Spence, Holland et al.,
abilities, and self confidence
1997).
This
so-called
FRIENDS
 ten one-hour group sessions and two
programme is based on the Coping Koala
booster sessions
programme (Barrett, Dadds & Rapee,
1996), an Australian modification of the
 three parental sessions on managing their
child’s and their own anxiety
Coping Cat anxiety programme for children
(Kendall, 1990). FRIENDS is widely used in
 workbooks for children and parents
public and private schools, community
 designed for school, hospital and
health centres and hospitals across
community settings
Australia, and adopted by other countries
 based on extensive scientific research and
such as Sweden, the United States, and the
controlled outcome studies
Netherlands.
Several controlled prevention trials have shown evidence for its efficacy, when used in
universal, selective or indicated target populations. In the first prevention trial FRIENDS was
applied simultaneously as early intervention for children with mild anxiety disorders (secondary
prevention), and as indicated prevention for at risk children, who had anxiety features but
361
remained disorder free (Dadds, Spence, Holland et al., 1997). Children (7-14 yrs) were
identified through a school-based screening procedure involving children, teachers and
parents.
Of those who had anxiety features, but no disorder at pre-treatment, 54% of the monitoring
only group progressed to a diagnosable disorder at 6-month follow-up, compared with 16% in
the intervention group. These differences in onset of anxiety disorders were reinforced by
comparable differences in child and family adjustment. Also, in the secondary prevention
group, the intervention resulted in a significant reduction of anxiety disorders at 6 months
follow-up. At 24 months follow-up, the outcomes were still significant for the whole group, with
a 39% diagnosis rate in the monitoring group and 20% in the intervention group (Dadds,
Holland, Laurens et al., 1999). This reduction was almost exclusively found in the children with
a mild to moderate pre-treatment disorder, while at that time the reduction in the disorder-free
group was only marginal (16% vs. 11%). The efficacy of FRIENDS and related programmes
as a secondary prevention tool has been demonstrated in many trials. For instance, in an early
treatment study by Muris and Mayer (2000), schoolchildren were screened for anxiety
disorders and offered the Coping Koala Program; half of them as individual treatment and for
the other half a group format was used. In both versions, around 75% of the children showed
a clinically significant treatment effect, with large effect sizes between 0.8 and 1.1.
In a pilot study, the FRIENDS programme was used as selective prevention instrument
for adolescents at high risk, i.e., former–Yugoslavian teenage refugees (Barrett, Moore &
Sonderegger, 2000). The results of the quasi-experimental trial revealed that students
participating in the programme showed a significant decrease in anxiety, while the waiting list
group showed an increase in internalising problems. Similar results were found in a second
quasi-experimental study among children and adolescents from immigrated families from
multiple countries and regions (Barrett, Sonderegger & Sonderegger, 2001). Participants
showed greater improvements in self-esteem, level of anxiety and future outlook than those
belonging to the waiting list group. These outcomes suggest that the programme is efficacious
across risk groups of different cultural origin.
The FRIENDS programme has also been implemented as a universal preventive
intervention, involving all children in school classes from grades 5 to 7 (Lowry-Webster et al.,
2001). The preliminary outcomes of their controlled trial (N=594) suggest that the intervention
resulted in a significant reduction of anxiety symptoms, regardless of the initial risk status. In
addition, 75.3% of children in the intervention group who were at risk at pre-test (high anxious
group) were no longer at risk at post-test, compared to 54.8% of children who were at risk at
pre-test in the comparison group and who remained at risk at post-test. Among the clinically
depressed children at pre-test, the intervention resulted also in lower levels of self-reported
depression.
Prevention of specific phobia and panic disorder
The longest tradition concerning selective and indicated prevention of anxiety exists in the field
of prevention of anxiety for stressful medical treatments, such as dental, operation and
hospitalisation fears (e.g. Melamed & Siegel, 1975). Reviewers of controlled trials in this field,
mostly dating from the 1970’s and 1980’s, conclude that the provision of only preparatory
information on medical procedures has not been found to reduce fear, pain and disruptive
behaviour (Spence, 1996; King, Hamilton & Ollendick, 1988). Positive effects, however, have
been found by using modelling videotapes, and especially by a combination of training of
coping skills plus modelling.
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Effective multiple outcome programmes
To reduce the risk of anxiety problems, programmes do not need to be designed specifically
for that purpose. Many studies on multiple outcome programmes have found reductions in
anxiety symptoms and risk factors for anxiety disorders (Roth & Dadds, 1999). For example,
in their meta-analytic study of 108 controlled prevention studies, covering 149 programmes on
diverse mental health topics, Llopis and Hosman identified 13 multiple outcome programmes
that showed medium to large effect sizes (ES > .50) on anxiety indicators and a mean effect
size of .84. Most of these programmes were not primarily designed to prevent anxiety
problems, but target issues such as coping with parental divorce, coping with child problem
behaviour, job stress management, and depression and fitness. Such programmes have
shown significant effects on a range of other outcome criteria in addition to anxiety, such as
depression, problem behaviour, school and school achievement. For example, several
controlled trials on prevention programmes for children of divorce have found significant
reductions in anxiety and behavioural problems in comparison to children in control groups.
Given the high comorbidity between anxiety and depressive disorders, interventions
addressing risk and protective factors in the onset of depression might also generate a
reduction in the onset of anxiety disorders. This was indeed found in a randomised control
study by Seligman, Schulman, DeRubeis et al. (1999) on a cognitive-behavioural programme
to prevent depression. The programme consists of 8 weekly group sessions of 2 hours, and 6
individualised meetings continuing until almost one year after the end of the group intervention.
The programme included topics such as challenging negative thinking and irrational beliefs,
behavioural activation and assertiveness, and interpersonal and coping skills. Over the 3-year
follow-up period participants did not only show a trend of less major depressive episodes in
comparison to the control group, but also significantly less episodes of generalised anxiety
disorder and less anxiety symptoms.
Topper et al. (2017) performed a RCT evaluating the efficacy of a preventive intervention for
anxiety disorders and depression by targeting excessive levels of repetitive negative thinking
in adolescents and young adults. The intervention, based on CGT, was delivered by group or
by the internet. Both versions reduced the levels of worry and rumination. After a year there
was a significantly lower rate of depression prevalence (average: 15%) and generalized
anxiety disorder (average: 17%) compared to the waiting list (32%, and 42%). Reductions in
repetitive negative thinking mediated the effect of the interventions on the prevalence of
depression and generalized anxiety disorder.
Stockings et al. (2016) performed a meta-analysis to examine the joint efficacy of universal,
selective and indicated preventive interventions upon both depression and anxiety among
children and adolescents while accounting for comorbidity. These preventive interventions
prove to be efficacious in the short term. Their advice is to repeat the exposures in school
settings across childhood and adolescence.
Additionally, many preschool and school-based programmes have been developed
successfully targeting generic resilience factors that reduce the vulnerability for anxiety
problems in children and adolescents, faced with stressful and anxiety-provoking conditions.
18.5.2 Indicated prevention for adults
To date, no studies are available showing that panic disorders can be prevented by reducing
risk factors and strengthening protective factors in people who never have suffered from a
panic attack. Interviews with panic disorders patients revealed that they contacted mostly nonpsychiatric medical services at the time of their first panic attack, when a panic disorder was
not yet present (Amering, Berger, Dantendorfer et al., 1997). This points to a missed
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opportunity for indicated prevention. Gardenswartz and Craske, (2001) (prevention of panic
disorder) developed a one-day prevention workshop for this group, including psychoeducation
about the aetiology and nature of panic and agoraphobia, and the use of cognitive behavioural
techniques for relaxation and cognitive restructuring. In the six months follow-up period almost
14% in the waiting-list group developed a panic disorder while only 2% among those who
participated in the workshop.
Meulenbeek and colleagues developed an intervention called ‘No Panic!’. People presenting
subthreshold and mild panic disorder benefit from this brief intervention. It is a group
intervention for panic symptoms based on cognitive–behavioural therapy, and offered by
community mental health centres, in a sample of self-referred people presenting with
subthreshold or mild panic disorder. (Meulenbeek et al., 2010). In contrast to these findings:
the Internet-based guided self-help course ‘No Panic’ appears to be ineffective for individuals
with panic symptoms. However, intervention completers did derive clinical benefits from the
intervention. (Van Ballegooijen et al., 2013)
Moreno-Peral, Conejo-Cerón, Rubio-Valera et al. (2017) conducted a systematic
review and meta-analysis in order to evaluate the effectiveness of preventive psychological
and/or educational interventions for anxiety in varied population types. The interventions were
based on the principle of CBT, psychoeducation, or acceptance and commitment therapy
('Voluit Leven' see Fledderus, Bohlmeijer, Pieterse, & Schreurs, 2012). The pooled effect size
(43% reduction in the incidence of anxiety) was modest compared to sizes found in treatments.
Enough yet for Moreno-Peral and colleagues to encourage that more programs should be
more widely implemented.
18.6
Promising developments
Using treatment protocols for prevention: Studies in the field of anxiety disorders have
illustrated that transforming successful treatment programmes into a prevention format and
applying them to selected or indicated populations is a promising venue, as is illustrated in the
FRIENDS programme and prevention of panic disorder programmes. This suggests that the
range of preventive tools could be further extended by identifying other treatment protocols
that lend themselves to application in a preventive setting as well. For example, efficacious
treatment programmes for social phobia in adolescents (Albano, 2000). Test situations offer
another focus of anxiety reduction with a long tradition. Current programmes to reduce test
anxiety are mainly focused at treating students who have already serious problems with test
situations (Spence, 1994). Effective methods include among others relaxation training, positive
self-talk training, modelling, cognitive restructuring and training in study skills. Such treatments
could be adapted for preventive use in whole school classes or with students with only
moderate test anxiety.
Recently, the internet has become a viable instrument to reach persons with anxiety
problems. Online support groups for anxiety disorder sufferers have been evaluated positively
by participants depending on the level of support from online friends, the frequency of
accessing the online group and perceived sense of community in the group (Glasser-Das,
1999). Such online support groups could also be used as an instrument for indicated
prevention. However, to date, no outcome data are available.
Bibliotherapy in coping with panic attacks is another low cost intervention with a
potentially wide reach in the community. Bibliotherapy, such as Franklin’s Self Mastery
Training, in co