Converging evidence shed new light on the potential for primary prevention in mental health for young people (Colizzi et al, 2020). Prevention in mental health should not be the responsibility of mental health professionals alone. Integrated and multidisciplinary services are needed to implement the range of interventions required to improve long-term outcomes. However, mental health professionals have responsibility for giving direction to social, political and other healthcare groups involved in meeting mental health care needs in young people.
Some of the concepts involved in prevention science are universal, targeted and indicated designations (Colizzi et al, 2020). Universal refers to interventions that are applied on a population or community basis. These interventions are given to everyone – an example would be education about the adverse effects of smoking or alcohol consumption during pregnancy or encouraging breastfeeding. Targeted interventions are aimed at groups that are high risk for problems and examples include home visitation programmes for those living in extreme poverty or immigrant groups suffering from trauma or dislocation. Indicated interventions are aimed at those who are already identified as having a disorder, often after screening.
An individualistic perspective focuses on life choices and behaviours of individuals when addressing societal problems. A structural or ecological perspective looks at how systemic factors at different levels impact individuals, families and other groups in a community (Kloos et al, 2021). The term ‘context’ refers to all the structural forces that influence a person’s life. These include family, social relationships, school, neighbourhood, religious and community organisations, cultural norms, gender roles and socioeconomic status. First-order change involves altering the individual members of group without changing the structural issues that cause the problem. Second-order change involves resolving a problem by changing relationships within a community, which includes shared goals, roles, rules, and power dynamics. This requires greater effort but is more likely to lead to positive long-term change. Community psychology concerns the relationships of individuals with communities and societies.
Community psychology uses ecological levels of analysis to clarify values, goals and strategies for intervention at the different levels (Kloos et al, 2021). This approach helps understand the interactions between systems. Thinking in these terms helps us see how a problem has many causes. A child’s problems at school are influenced by adults at school, in the local community and at national and global levels that are making policy decisions that determine the resources that child can access. Family, friend and teachers greatly impact the child but their thinking and values are influenced by the school system, the community, cultural, societal and global levels. There is overlap between different systems but generally they can be broken down as follows: Individuals, microsystems (Families, friends, classrooms, work groups), organisations (Schools, labour groups, local businesses, community coalitions, religious groups), localities (Neighbourhoods, cities, towns, rural areas), and macrosystems (cultures, societies, governments, corporations, mass media, social movements, belief systems).
The individual is the smallest ecological level (Kloos et al, 2021). This involves consideration of the person’s experiences, memories, thoughts, feelings, relationships, culture and other factors. The microsystem is the environment in which the person repeatedly engages in direct, personal interaction with others. Microsystems are more than the sum of their parts – social units with their own dynamics. A setting is an important concept that includes the physical environment but also relationships between individuals. It can span multiple places and can apply to microsystems as well as larger organisations. Organisations are large systems with solid, defined structures. They have titles, rules, missions, and policies. They are often made up of many microsystems and can be part of larger social units. Localities are geographic settings like counties, towns and neighbourhoods that often contain multiple organisations or microsystems including governments, economies, media, education and health systems.
Macrosystems are the largest system within an ecological framework that form the context that influence all the sub-systems within it (Kloos et al, 2021). Smaller ecological systems can influence macrosystems through social advocacy or mass action. Cultures, political parties, corporations, religions and government are examples of macrosystems. A population is a broadly shared characteristic that links people in a macrosystem (e.g. a traumatised group). Mediating structures are institutions that link individuals to public life. Formal organisations like schools are examples of this as well as less formal groups like a supporter’s club or a support group. They often act as a buffer in dealing with stress from larger institutions (racism, unemployment). Many mediating structures are often an under-utilised resource in the community. Sometimes new settings better meet the needs of individuals. These are often important intervention points when helping to empower communities.
The different levels help shift perspective about where to focus when improving social outcomes (Kloos et al, 2021). Examining an issue systematically across different levels of analysis can reveal many contributing factors to the problem. However, this shift in perspective is only the first step in creating change. What to change and how to change it are key in any change strategy. Two aspects are important here: problem definition and selection of interventions that are linked to the different ecological levels. The problem definition organises resources and actions. How a problem is framed will determine the interventions we use. If trauma is defined as an individual issue or a problem of the environment, the interventions we use will be quite different. If interventions focus just at the individual level of healing trauma and does not address higher levels of analysis there will be a constraint on solving the problem. Often, the change strategy does not match the level of analysis. Multiple interventions are required at many levels of analysis. If not, the issue will not be addressed effectively.
There are many ways we can fall short in our interventions (Kloos et al, 2021). It may be that action is necessary but not taken (therapeutic intervention for ACE’s). Or action is taken where it should not be (putting traumatised people in prison). Or action is taken on the wrong level of analysis. This is called an error of logical typing. Community psychology not only focuses on interventions at multiple levels but emphasises the community’s strengths and seeks to empower communities to act at all levels to attain social justice.
References
Colizzi, M., Lasalvia, A., & Ruggeri, M. (2020). Prevention and early intervention in youth mental health: Is it time for a multidisciplinary and trans-diagnostic model for care? International Journal of Mental Health Systems, 14(1). doi:10.1186/s13033-020-00356-9
Kloos, B., Hill, J., Thomas, E., Case, A. D., Scott, V. C., & Wandersman, A. (2020). Community psychology: Linking individuals and communities. American Psychological Association.