Secondary Prevention

In secondary prevention, problem identification and intervention occur much earlier in the process than in tertiary prevention. The duration or magnitude of a mental health problem can be short-circuited by identifying and intervening early in the problem's developmental course, thus, reducing its prevalence. On the other hand, if a problem is identified early enough in its course that it is not even considered a mental health problem, its incidence and, in turn, its prevalence can be reduced. Here, the potential problem can be thought of as being "cut off at the pass.'' In both forms of secondary prevention, intervention occurs at the level of the individual; intervention is not mass-oriented as it is in primary prevention. However, in the latter form of secondary prevention, problem identification can occur at the level of a population or setting.

Once individuals enter the mental health system, they seem to become entrapped within it. From a secondary prevention perspective, we might want to examine gateways to the mental health system—how individuals enter the system. In some communities this gateway is the State's Attorney's Office, who must file a petition in order to legally involuntarily commit someone who appears disturbed. The State's Attorney is often asked to file petitions for involuntary commitment on persons who would profit more from other services, for example, short-term housing, a friendship network, help in finding employment, or intensive outpatient counseling regarding a recent family crisis. Unfortunately, given limited resources and options, involuntary commitment is too often the easiest and most expedient action for the legal system.

In the Midwest during the 1970s, Delaney, Seid-man, and Willis developed and evaluated an innovative and successful crisis intervention program for individuals in jeopardy of being involuntarily committed to a psychiatric hospital. They negotiated an arrangement in which they would immediately be notified by the State's Attorney that they were considering filing a petition for involuntary commitment. Within 24 hours, the crisis intervention team would see the person in their natural environment, fully assess the problem, and develop a comprehensive plan of intervention, and set the plan into motion. State hospitalization was often deemed inappropriate or was used only as a last resort for a seriously disturbed individual. This program reduced the number of state hospitalizations in the area, provided persons with more appropriate services, thereby reducing many of the iatrogenic effects of hospitalization. (Were the focus of the program tertiary prevention, researchers would have aided the patients only after they had been involuntarily committed.)

Many secondary programs intervene with children since it is believed that the seeds of many problems are sown in childhood. Early detection and intervention is viewed as optimal. Since most children go to school, early identification programs often take place within schools, where populations of individuals can be screened.

One of the earliest exemplars of early detection and intervention programs was known as the Primary Mental Health Project developed by Cowen and his associates. Mass screening allowed early identification of children thought likely to manifest future adjustment problems. (This differs from a tertiary prevention program, which would focus on children that have already been identified as exhibiting problem behaviors.) The identified children were then assigned to minimally paid volunteer child aides (housewives or college students) to work one-on-one with them after

Community Mental Health school. These aides were trained and closely supervised by university personnel. By using paraprofessionals, the program extended the limited numbers and reach of mental health professionals.

Secondary prevention reduces incidence and prevalence by short-circuiting problems before they are fully realized. In this way it is clearly preferable to the rehabilitation strategies of tertiary prevention. However, intervention remains at the level of the individual and, thus, still runs the danger of stigmatizing and ''blaming the victim.''

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