Primary prevention of mental and emotional disturbances emphasizes the reduction of unnecessary stress, including powerlessness, and the enhancement of social competence, self-esteem, and support networks. This approach holds that it is possible to reduce the incidence of mental and emotional disorders. It argues that one-to-one psychotherapy is a hopeless approach because of the unbridgeable gap between the large numbers in need and the small numbers of helpers. Further', it holds that chemical or organic treatment is a reactionary form of symptomatic relief that is part of a long history of oppression and failure. Support for a primary prevention alternative derives from: (a) the successful application of public health methods in promoting population health; (b) a growing body of research literature that demonstrates the role of poverty, meaningless work, unemployment, racism, and sexism in producing psychopathology; and (c) the effectiveness of programs promoting social competence, self-esteem, and social support networks in reducing psychopathology. Opposition to primary prevention comes from: (a) those who argue for a defect model explanation of psychopathology; (b) those whose personal commitment is to one-to-one therapy; and (c) those Calvinists who believe that neither individual human beings nor society is perfectible because of the stigma of original sin.
Prevention efforts to reduce psychopathology use strategies similar to public health measures for disease prevention. However, an important distinction to be maintained is that many mental conditions are not discrete diseases," they are often learned patterns of socially deviant behavior or idiosyncratic thought that result from stress, powerlessness, and exploitation. Prevention efforts aimed at reducing psychopathology will often require social change and a redistribution of power. Efforts to change the power structure and to reduce social class inequalities are opposed by persons who accept (a) the belief that class differences are natural and even desirable from a social Darwinian perspective, and (b) the "Just World" belief that says that people deserve whatever happens to them. Prevention workers are more likely to accept the fatalistic view that people, only through their own political efforts, can improve the quality of life for most of humankind if they accept the fact that there is no "divine plan'" and that evolution has no goalThe field of primary prevention of psychopathology owes enormous intellectual and ideological debts to the field of public health. Both fields make proactive efforts with groups, often high-risk groups, to reduce the incidence rates of undesirable conditions. Both fields are less visible than the more glamorous and more publicized fields of individual treatment. But there is one problem in trying to follow public health strategy too closely in prevention efforts in psychopathology: There is an important difference in the nature of the conditions to be prevented.Public health has long been concerned with preventing specific diseases or pathological organic conditions, most of which can be defined and identified fairly precisely and objectively. The history of public health involves, to cite a few examples, efforts to prevent plague, rabies, and tuberculosis and, more recently, polio and smallpox, black lung, brown lung, asbestos damage, and lead and mercury poisoning. Today the field of public health is increasingly concerned with the contribution of life-styles to disease: For example, tobacco and alcohol use is associated with diseases like lung cancer and cirrhosis, and improper nutrition, excess stress, obesity, and lack of exercise are associated with coronary artery disease and stroke. Although the shift of attention to behavioral causes is a significant change in focus, one re- Opposition to Prevention Through Social ChangePsychiatrists Lamb and Zusman (1979), for example, sharply attacked the growing interest in social change ef-
The new prevention science put forward by the National Institute of Mental Health and by the Institute of Medicine advocates strict experimental interventions with controls to reduce risks for psychiatric disorders. Articles by R. F. Muñoz, P. J. Mrazek, and R. J. Haggerty (1996, this issue), K. Heller (1996, this issue), and D. Reiss and R. H. Price (1996, this issue) support, elaborate, and discuss this agenda. Issues that seem controversial include (a) the use of risk reduction of psychiatric disorders as the criteria for acceptable research, (b) rejection of studies of competence promotion as not aimed at specific disorders, and (c) rejection of prevention studies, done before the counterrevolution that occurred in 1980 and thereafter, that advocated social and political change aimed at achieving social equality for disadvantaged groups. Arguments against the restricted new approach are presented.
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