Journal of Primary Prevention, 6(4), Summer, 1986

Facts and Fallacies about Primary

Prevention
GEORGE W. ALBEE and THOMAS P. GULLOTTA
ABSTRACT: This paper clarifies eight common misconceptions about primary preven-
tion.

We have been distressed over the past few years by a paradoxical situ-
ation in the clinical field. On the one hand, many of the insights of
practicing clinicians have inspired the conception and design of pri-
mary prevention programs. But on the other hand, much of the most
strenuous and vociferous opposition to prevention efforts has come
from practicing clinicians. Clearly not only one's personal values but
one's career commitments and shared perceptions of useful models of
disturbance influence one's level of acceptance or rejection of new
ideas, particularly when these imply the possibility of a redistribution
of power and alternative modes of intervention.
Primary prevention has been called "An idea whose time has come"
(Klein & Goldston, 1977) and has been referred to as the "fourth men-
tal health revolution" (Albee, 1980). Yet we find misperceptions, mis-
understandings, and active opposition in many quarters to efforts at
primary prevention and to proposals for a modest reallocation of re-
sources to support prevention programs.
It has been recognized for a long time that the political ideology of
scientific and professional workers tends to influence their choice of
models to explain h u m a n behavior and h u m a n deviance (Pastore,
1949). And the model chosen, of course, determines the kind of inter-
vention action taken. We are under no illusion that any calm presenta-
tion of evidence is likely to change the ideology of those who are most
fierce in their opposition to primary prevention efforts. But we are
hopeful that a relatively factual and objective presentation of myths

George Albee is a professor of psychology at the University of Vermont, Burlington,

VT 05405.
Thomas Gullotta is executive director of Child and Family Agency of Southeastern
Connecticut.
Please send correspondence to: Thomas P. Gullotta, 171 Hubbard Street, Glastonbury,
CT 06033.

207 © 1986 Human Sciences Press

208 Journal of Primary Prevention

and realities, misunderstandings and facts, to counter them may be ac-

ceptable to those clinicians and others who may not be immersed in the
literature of prevention but who have open minds.

Misconception N u m b e r I

Almost anything we do as mental health professionals to help other hu-

man beings is a form of prevention. Indeed, the terms primary, secondary,
and tertiary prevention cover nearly every activity and program that is
part of the repertoire of mental health workers. So what is all the talk
about?

Clarification

This is the fault of preventionists. It is a legitimate misunderstanding.

Loyd Rowland, pioneering giant in the field of prevention, often railed
against the use of the term prevention in such confusing ways. He sug-
gested t h a t we ought to talk about prevention, early treatment, treat-
ment, and rehabilitation. Most persons seriously concerned with pre-
vention today focus on primary prevention only. By this they mean
proactive programs t h a t affect groups of unaffected people--those not
yet showing any signs of disturbance. In other words, prevention pro-
grams should be proactive, not reactive, should be planned for the pur-
pose of reducing incidence down the road, should be evaluated care-
fully for effectiveness (Cowen, 1982) and should pay careful attention
to the ethical questions involving work with groups under conditions
where informed consent often is impossible.

Misconception N u m b e r 2

Prevention is impossible without a knowledge of specific causes. Because

we do not know the specific cause of most mental illnesses, little or noth-
ing can be done to prevent them.

Clarification

This objection is couched in the allopathic model of medicine, and for

most conditions it does not apply to emotional disturbances. One of the
George W. Albee and Thomas P. Gullotta 209

greatest medical insights in history was the dictum of Rudolf Virchow,

a German pathologist who toward the end of the last century advanced
the hypothesis that each disease has a specific cause. Starting with
this brilliant insight, medicine made enormous strides in identifying
the specific microorganism or specific structural defect responsible for
each of a host of diseases. But this allopathic model clearly does not ap-
ply to most forms of emotional distress. Attempts to find a specific
defect, or an objective test, for most emotional disturbances have been
singularly unsuccessful. Indeed, the evidence is clear that there is a
non-specific relationship between kinds of stress and kinds of emo-
tional disturbance (Dohrenwend, 1975; Bloom, t977). Any clinician
knows that marital disruption, for example, is a stress that may result
in depression in one person, alcoholism in another, social withdrawal
in another, aggression and murderous rage in another, and calm resig-
nation in still another. Similarly, if one looks at a diagnostic group of
disturbed people, say 50 reactive depressives, it quickly becomes clear
that the predisposing and precipitating causes are quite different from
one another. In short, we cannot expect to find a one-to-one correspon-
dence. So the strategy called for in primary prevention is more gen-
eral: modifying, avoiding, eliminating harmful stressors, and promot-
ing stress resistant capabilities in groups of individuals by using
prevention's available technology.

Misconception N u m b e r 3

Prevention doesn't have a technology.

Clarification

No statement could be further from the truth. Prevention does have a

technology (Gullotta, in press). The tools of that technology include
education, competency promotion, community organization/systems
intervention, and natural caregiving. Specifically, education in the
hands of the prevention specialist is used to assist groups to alter their
behavior by providing information to change attitudes, teach social
problem solving skills, and by helping groups anticipate and prepare
for life change events. The tool of competency promotion involves group
210 Journal of PrimaryPrevention

activities that improve individual and group self-esteem as well as to

strengthen an internal locus of control. Community organization~sys-
tems intervention activities recognize that the inequities of institu-
tional and societal structure contribute to the mental health of certain
populations. Thus, interventions that seek to redress social inequities,
reform institutional practices, and promote equality of opportunity
will also promote emotional health. The final tool of natural caregiv-
ing extends beyond the self-help movement (Silverman, 1980) to ac-
knowledge the role each and every citizen has in assisting their fellow
human beings towards emotional health (Cowen, 1982). It is important
to note that the most successful prevention initiatives will be those
that utilize all four of the tools that comprise prevention's technology.

Misconception Number 4

There is precious little hard evidence to support the effectiveness of ef-

forts at primary prevention.

Clarification

There is a large and growing literature demonstrating the effective-

ness of prevention programs in eliminating or reducing the incidence
of later disturbance. Kessler and Albee (1977) have provided an exten-
sive bibliography of earlier work and Kornberg and Caplan (1980)
have reviewed the field of prevention of children's emotional distur-
bances. Annual volumes of the Vermont Conference on the Primary
Prevention of Psychopathology (Albee & Joffe, 1977; Forgays, 1978;
Kent & Rolf, 1979; Bond & Rosen, 1980; Joffe & Albee, 1981; Bond &
Joffe, 1982; Albee, Gordon, & Leitenberg, 1983; Rosen & Soloman,
1985) report dozens of effective prevention programs. Annual reviews
by Bloom (1980), Kelly, Snowdon, & Munoz (1978), and Cowen (1973)
provide additional support that prevention works.

Misconception Number 5

Preventionists really are trying to radicalize the political and economic

system under the guise of efforts at prevention. Just because there is a
correlation between the level of poverty and the rate of emotional distur-
George W. Albee and Thomas P. Gullotta 211

bances, and between powerlessness and depression, and between mar-

ginal status in society and high rates of disturbance, these correlations do
not prove causation (Lamb & Zusman, 1979). Both poverty and mental
disorder may be due to such common causes as genetic, constituional, bio-
chemical, and/or other internal defects.

Clarification

One of the most frequent arguments heard from those who oppose ef-
forts at primary prevention denies the importance of social factors in
causation. The higher rates of psychopathology observed among poor
people are shrugged off as correlations t h a t do not prove causation.
There are several epidemiological observations, however, t h a t sup-
port the importance of poverty and/or powerlessness as a major caus-
ative factor in emotional disturbance. One of these arguments is
apparent from historical fact. As each successive immigrant group oc-
cupied the impoverished ghettos of our central cities, t h a t particular
group had the highest rates of mental retardation and mental distur-
bance (once called idiocy and lunacy). As each successive immigrant
group moved up into the middle class world, their rates of distress de-
clined to the traditional middle-class rate while the new arrivals in the
slums showed excessively high rates. So at first there were the Irish,
and then the Scandinavians, and then the Eastern European Jews,
and then the Southern Italians. Today, it is the Blacks, Chicanos, and
Puerto Ricans who occupy the deteriorating inner cities. As each immi-
grant group, in turn, occupied the lowest rung on the economic ladder
their rates of emotional illness were highest. As they left the ghettos
and joined the middle class, their rates fell. The contention t h a t "down-
ward drift" accounts for the higher rates of distress among the poor
overlooks this fact and the continuing situation of large groups of pow-
erless people who have never reached middle-class status and there-
fore could not have "drifted downward" (i.e., migrant farm workers,
Native Americans). No changes occurred in the genes of those able to
e s c a p e - - b u t changes did occur in their economic security, self-esteem,
coping skills, emotional competence, and support systems. Is it too rad-
ical an idea to suggest t h a t powerlessness is a cause of distress and
t h a t a redistribution of power may be preventive?
Further, a great m a n y prevention programs are quite independent
of political ideology. Encouraging the use of seat belts to prevent brain
damage (and other stress-causing injuries and death), reducing lead
212 Journal of Primary Prevention

and other heavy metal poisoning, genetic counseling, improved nutri-

t i o n - t h e s e and m a n y other approaches are relatively non-political.
Efforts at education in parenting, at providing secure and loving
care for infants and children are also relatively independent of politi-
cal ideology. Most clinicians, and most preventionists, accept the an-
cient belief that the child is parent of the a d u l t - - t h a t the child's emo-
tional relations and experiences determine significantly the quality of
his or her adult relationships and effectiveness as a parent.
The psychoanalytic tradition emphasizes the critical and long time
importance of the period during infancy and to age six in forming im-
portant components of adult personality. For example, Hartmann,
Kris, and Loewenstein (1946) have said:

We assume that the essential elements in the structure of personality ex-

ist in children of our civilization at the age of five or six. Developmental
processes occurring after that age can be described as modifications, as
enrichment, or in pathological cases as restriction of the then-existing
structure.

Clinical experience confirms the dictum t h a t the earlier and more se-
vere the rejection experienced by the child the more devastating the
consequences for the adult personality and the more resistant the indi-
vidual to remediation efforts. Prevention efforts to provide support for
the children of psychotic parents are not a function of political ideology
(Anthony, 1977). However, it is true that m a n y severe sources of stress
involve sexism, racism, ageism, and the exploitation of the powerless.
Some prevention programs do require social change!

Misconception Number 6

Isn't primary prevention often just a function of changing personal life

styles, ways of behaving that involve individual choice and freedom?
Aren't these nobody's business but that of the persons themselves?

Clarification

Primary prevention efforts do run into difficulty whenever a program

t h a t is known to be effective in preventing undesirable outcomes re-
quires t h a t persons stop doing things they find pleasurable, start doing
George W. Albee and Thomas P. Gullotta 213

things they find aversive, or change fixed and long-standing habit pat-
terns. For example, it is very probable that several serious and life-
threatening diseases could be reduced significantly if people would re-
duce their intake of alcohol and quit smoking cigarettes. Similarly,
other physical problems and, we suspect, considerable unhappiness
and low self-esteem could be reduced if people would control and re-
duce their intake of highly saturated fats. Such "simple" measures as
getting eight hours of sleep a night, eating three balanced meals a day
and avoiding in between meal snacks, getting regular exercise, drink-
ing alcohol moderately, avoiding smoking, if followed as a consistent
lifelong pattern, would result in significantly better health and longer
life. But these are matters of personal choice and freedom. Preven-
tion's role in these matters is to make information available, to encour-
age personal life-style change, but not to force or require change. Long
ago John Stuart Mill (1863) pointed out t h a t "over our own bodies each
of us is sovereign"--we may be exhorted, pleaded with, but not re-
quired or enjoined, or forced to forebear. In short we may do whatever
we please to our own bodies. This is not to say, however, t h a t society
may not interfere when persons behave in ways t h a t may injure them-
selves or damage others. People are not free to abuse or neglect their
spouses and children, to drive while drunk, or to dump toxic chemicals
into our drinking water.

Misconception Number 7

In spite of preventionists' claims that their programs are before the fact,
proactive, and group focused, many published reports labeled as preven-
tion seem like early treatment and sometimes are directed at individuals.

Clarification

One of the problems in defining the primary prevention of mental and

emotional disturbances is t h a t often we cannot be sure of the actual
time of onset of an emotional disturbance. It is relatively easy to define
the onset of a specific disease like syphilis or strep throat, or the begin-
ning of a discontinuous process like pregnancy or a fractured bone. But
when does a person first become emotionally disturbed? Who can point
to the moment of onset of schizophrenia, or depression, or adolescent
rebellion, or an obsessive personality? Even certain abnormal organic
214 Journal of Primary Prevention

mental processes are slow and insidious. When does normal forgetful-
ness become senile dementia? At what point does the ingestion of lead
paint by a child with pica cause sufficient brain damage to be a patho-
logical condition?
It is clear that we can decide arbitrarily to define primary preven-
tion as a program that is instituted before the onset of the condition to
be prevented. When the time of onset is unclear and ambiguous, pri-
mary prevention may blend into early intervention.
Also, most traditional diseases are the exclusive physical pathology
of the individual affected. While other people (like a spouse, children,
relatives, friends) may be indirectly affected (often seriously) by the
suffering or incapacity of an individual with a physical illness, the ill-
ness itself is still the exclusive property of the affected individual. The
actual physical pain associated with a stomach ulcer is not experienced
directly by anyone else. The intense agony of the person with a mi-
graine headache belongs to that person alone. But mental and emo-
tional conditions are nearly always disturbed interpersonal relation-
ships. We become neurotic or psychotic in significant measure in our
relationships with other people. It is the relationships that are dis-
turbed. When do these disturbances begin? Do disturbed sexual rela-
tionships exist before overt sexual experiences result in failures or
frustrations?
Let us consider a number of separate interventions to see whether
they qualify as primary prevention. What about amniocentesis? Here
a physician inserts a needle through the abdomen into the uterus of a
pregnant woman to obtain a sample of the amniotic fluid surrounding
the growing fetus. From cultures of this test sample it is possible to tell
a number of important things about the growing fetus. Most impor-
tantly, it is possible to determine whether the expected child is af-
flicted with any of several physical and/or mental conditions including
especially degenerative diseases and clinical forms of mental retarda-
tion. Is this procedure an example of primary prevention? If the grow-
ing fetus is discovered to have a chromosomal anomaly known to lead
to Down's Syndrome - - a kind of mental retardation with several spe-
cific, known organic f e a t u r e s - - a n d if then this (future) retarded child
is deliberately aborted, is this an example of primary prevention? The
question is complicated. Clearly the process is proactive if we consider
birth to be the zero point of a child's life. It is not proactive for those
who consider conception to be the beginning of individual life. This
procedure, if widely used, would result in the reduction in the number
of mentally retarded children born, and in this sense it is primary pre-
George W. Albee and Thomas P. Gullotta 215

vention of medical retardation. But, wait. It involves action on one spe-

cific case at a time. And, we have said, primary prevention involves an
approach to high risk groups. But suppose we were to test every single
pregnant woman for the presence of a damaged fetus. Does the process
now become primary prevention?
Consider t h i s facet of the question. By aborting a fetus t h a t would
become a seriously retarded child we are preventing the prospective
parents from the years of anguish and suffering t h a t often accompany
life in a family with a child t h a t is severely retarded. Is this primary
prevention of emotional distress (in the prospective parents)? But
there are m a n y damaged fetuses t h a t would be born as physically
handicapped children who would live constructive and productive
lives. Enough physically handicapped persons have made major contri-
butions to art, science, and literature so that the outcome of a thera-
peutic abortion may not be defensible as primary prevention on m a n y
accounts.
Let us look at a related area. Some 37 states now require a blood test
at birth to determine whether the infant is a "PKU baby." This condi-
tion involves the inability to digest a certain kind of protein which, as
a consequence, results in a buildup of toxic substances in the blood
which in t u r n produce mental retardation. If the early test is positive,
the infant can be fed a special diet which prevents the accumulation of
the noxious material thereby preventing mental retardation. Is this
primary prevention? We are considering the diagnosis of a person with
a genetically caused defect in metabolism leading to an intervention to
neutralize the defect--is this treatment or prevention? Clearly large
groups of infants are involved in the screening procedure but the in-
fant identified already has the condition (which has not yet produced
damage) and so the intervention seems more like early treatment. On
the other hand if every infant were given the special diet would the
process then be primary prevention?
What about programs t h a t involve treatment of already affected per-
sons but t h a t have secondary effects involving the prevention of emo-
tional disturbance in others. To be more specific, would group therapy
for sexist males be primary prevention of distress in their wives, in
their future wives? Or what about mainstreaming handicapped chil-
dren in school, beginning with kindergarten, with the goal of prevent-
ing the development of negative self-images and poor self-concepts in
the handicapped children?
It is clear t h a t there are problems with rigid definitions of primary
prevention. We need not obsess over these as long as we recognize t h a t
216 Journal of Primary Prevention

the purpose of prevention programs, as a rule, is to reduce the inci-

dence of later serious problems in groups of non-affected people and es-
pecially those at high risk. Because of the difficulty in defining onset
specifically, approaches to the high-risk individuals may merge into a
gray area.

Misconception N u m b e r 8

Prevention programs take money and support away from essential treat-
ment programs. Why should money be diverted into programs of uncer-
tain validity and vague outcome when there are waiting lines of suffering
people who need help today?

Clarification

We are a long, long way from meeting the identified needs of the soci-
ety for intervention with disturbed people. The most recent N.I.M.H.
epidemiological study (1984) concludes t h a t 43 million American
adults are mentally ill. These 43 million people have been identified
repeatedly, and include persons with depression, alcoholic addiction,
incapacitating neurotic anxiety, organic brain conditions associated
with old age, and the serious forms of functional psychosis. But in any
given year, the entire mental health system (hospitals, clinics, individ-
ual practitioners) is able to see only about seven million separate per-
sons! And it is important to note that not all of these seven million
come from the "hard core" mentally disordered group. Many of the dis-
tressed individuals being seen in our mental health centers and in
therapists' private offices are people with problems in l i v i n g - - t h o s e
undergoing marital disruption, divorce, those who has lost a loved one,
those who are out of work, those with identity p r o b l e m s . . , living con-
cerns t h a t bring them to the therapists' chair or couch. So we are actu-
ally seeing m a n y fewer t h a n one in five of the seriously disturbed peo-
ple and only a small proportion of people with problems.
In spite of twenty years of intensive effort, since the Report of the
Joint Commission on Mental Illness and Health (1960), and with m a n y
millions of federal dollars poured into the support of professional train-
ing, for the construction of community mental health centers, and for
the support of research, we are still falling further behind.
Is there any real hope? Not if we continue our mental health busi-
George W. Albee and Thomas P. Gullotta 217

hess as usual. Over and over again, surveys have found that individual
psychotherapy and individual "treatment" represents "the backbone"
of the efforts being made in our centers. As long as we labor on that
particular treadmill the situation will remain hopeless.
Two strategies for resolving our shortfall make sense. The first of
these is to find alternatives to one-to-one intervention provided by a
highly trained professional. We need to develop mutual aid groups, to
encourage and develop self-help programs, to find paraprofessional
workers who want to get out into the community, and to use existing
networks and support systems.
The second strategy is to put more effort into primary prevention.
We must recognize the fact that no mass disorder affecting large num-
bers of human beings has ever been controlled or eliminated by at-
tempts at treating each affected individual. This is not only sound pub-
lic health doctrine, but it is as applicable to the field of mental health
as it is to the field of public health.

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