towards a public health psychology†

Journal of Community & Applied Social Psychology

J. Community Appl. Soc. Psychol., 13: 71–75 (2003)

Praxis

Towards a Public Health Psychologyy

How could the rate of psychopathology in the population be reduced?

Successful intervention in particular individuals with particular diseases has no effect on

the rate of new cases in the population. Medicine can cure syphilis, middle ear infections,

yeast infections, etc. but the rate of these conditions in the population is pretty well

constant.

Likewise successful intervention in particular individuals with particular psychological

and emotional problems has no real effect on the incidence, or rate of new cases, of these

problems in the general population. Psychotherapy and other forms of individual ‘treat-

ment’ can sometimes reduce or eliminate phobias, anxiety, bizarre behaviour, depression

and social withdrawal in particular people but the rate of these conditions in the population

does not reduce either, in fact they appear to be increasing.

Psychotherapy may not be a successful way to reduce levels of distress at the level of

public mental health, but it does have the major advantage of demonstrating that at least

some kinds of psychological and emotional problems can be addressed socially with the

active participation of persons, that at least some kinds of psychological and emotional

problems are not the result of organic brain disorders or irreversible physical damage as

some mechanistic psychobiological accounts imply and that because at least some kinds of

psychological and emotional problems can be socially addressed they might be socially

preventable.

Those in the field of public health argue correctly that primary prevention is the only

practical way to reduce the incidence of any of the great plagues afflicting human beings.

The key strategies of primary prevention are well established: reduce or eliminate the nox-

ious agent responsible; reduce or prevent transmission of the noxious agent to the host;

and/or strengthen the resistance of the host to the noxious agent.

These three strategies apply to psychological and emotional problems just as much as

they do to physical illnesses. Racism, sexism and classism are noxious agents for mental

health which can be reduced or eliminated in the social environment just as noxious agents

for physical health like lead and other heavy metals in paint and petrol can be reduced or

eliminated in the physical environment. The transmission of the noxious agents of destruc-

tive stigma and disabling stereotypes of mental illness by our mass media and popular cul-

ture to users, who sometimes prefer to describe themselves as survivors, of mental health

services can be reduced or prevented just as the transmission of malaria by mosquitoes can

be reduced or prevented. The resistance of children to the noxious agents of toxic social

and educational environments can be strengthened by maximizing opportunities for them

to boost their own individual and collective self-esteem, increase their recognition and

Copyright # 2003 John Wiley & Sons, Ltd.

utilization of their own resourcefulness, competence and strength, for co-operative work-

ing, and for material empowerment, just as resistance to common childhood diseases like

mumps and whooping cough can be increased through maximizing opportunities for

improved nutrition and immunization.

These strategies are perhaps best considered sequentially rather than in parallel. The

most powerful strategy is to prevent the noxious agent. If this is not possible, the next most

powerful strategy is to prevent the noxious agent reaching the person. If this is not possi-

ble, the next most powerful strategy is to prevent the person from being damaged by the

noxious agent.

Prevention can be thought of as either voluntary or mandatory. Taking regular exercise

is an example of voluntary participation in the prevention of physical ill health. Joining a

support group is an example of voluntary participation in the prevention of mental ill

health. Living in environments in which the dumping of toxic waste is prohibited, working

in mandatory smoke-free environments and labouring in factories where dangerous equip-

ment is fitted with protective guards as a result of legislation are all examples of involun-

tary participation in the prevention of physical ill health. Living in a community where

racism, domestic violence and homophobia were effectively prohibited by law would be

an example of involuntary participation in the prevention of mental ill health.

In reality, the difference between voluntary and mandatory prevention can be blurred.

What is sometimes positioned as ‘voluntary’ can often actually be subject to overwhelm-

ing multi-level coercion. For example, there is widespread understanding that smoking

cigarettes increases the likelihood of physical ill health. Although nicotine addiction is

widely recognized as a consequences of cigarette smoking, ‘stopping smoking’ is popu-

larly positioned as a ‘voluntary’ way to prevent or reduce the likelihood of lung cancer and

other physical illnesses and individual smokers are subjected to exhortation to quit smok-

ing by health education lobbies. However, smokers are also subjected to massive advertis-

ing by the tobacco industries and are immersed in a popular culture that actually promotes

smoking. Ultimately government action against those who create, market and profit from

cigarettes, rather than against their victims who smoke cigarettes, is necessary to prevent

or reduce smoking related physical ill health.

Likewise, there is widespread understanding that being unemployed increases the like-

lihood of psychological ill health. Although depression, anxiety, damaged self-esteem and

demoralization are widely recognized as consequences of unemployment, ‘getting a job’ is

popularly positioned as a voluntary way to prevent or reduce the likelihood of unemploy-

ment and its consequent psychological problems and unemployed people are subjected to

exhortation to become re-employed by government and other lobbies. However, unem-

ployed people are not only subjected to a so-called flexible labour market characterized

by severe scarcity of jobs consistent with psychological health and poverty, they are also

subjected to a toxic social environment of disabling and damaging discourses. Ultimately

action against those who create and profit from unemployment, rather than against their

unemployed victims, is necessary to prevent or reduce unemployment related mental ill

health.

The apparent widespread preference for individual treatment over collective prevention

in respect of both physical and mental ill health occurs because of a variety of reasons.

People understandably want their own personal diseases and discomforts reduced or elimi-

nated once they have got them and can usually tell relatively quickly when treatment is

72 G. W. Albee and D. M. Fryer

Copyright # 2003 John Wiley & Sons, Ltd. J. Community Appl. Soc. Psychol., 13: 71–75 (2003)

successful because pain and discomfort are relatively soon reduced or disappear entirely.

Individual treatment is also very profitable to the medical and pharmaceutical industries,

so is likely to be vigorously defended from criticism and preventive competition. Most

profitable of all are chronic conditions whose worst symptoms can be controlled but whose

basic causes remain untouched. Diabetes is a good example of a physical disease that is

incredibly profitable to the industries that supply treatment, blood sugar monitoring

devices, insulin, hypodermic needles, drugs, etc. A cynic might say that if diabetes did

not exist it would almost be necessary to create it, as so many depend upon it for their

livelihood. If a method of preventing diabetes were discovered a multi-million dollar treat-

ment industry would be destroyed. Just as profitable, or more so, are the anxiety-control-

ling industries, including those who manufacture and market alcoholic drinks.

Tranquillisers that reduce anxiety in adults and energisers that counteract depression are

particularly profitable as prescribed and available so widely. Social factors like unemploy-

ment, poverty and inequality are major causes of anxiety and depression and thus creators

of consumers of tranquillisers and energisers. A cynic might say that if they did not exist, it

would almost necessary to create them, as so many depend upon them for their livelihood.

Some might even say that our social arrangements could hardly be better designed to gen-

erate anxiety and depression. If a method of socially preventing anxiety and depression

were discovered a multi-million dollar treatment industry would be destroyed.

Compared with individual treatment, prevention is more often done at the collective,

public, level than the individual private level, taking place before people know they need

it, often taking a long time to take effect, being hard to evaluate in terms of effectiveness

and those involved in prevention tend to be less visible and as public employees are lower

status than those who offer individual level treatment. Prevention efforts do not tend to be

profitable for the medical and pharmaceutical industries, indeed effective prevention

would drastically reduce the profits of these corporations. Moreover, effective and far

reaching prevention usually requires organizational, institutional and social change. This

is not only expensive but also involves conceding power and control, anathema to corpora-

tions and governments. For example, it is now beyond serious doubt that the size of the gap

between the average incomes of the rich and poor in a nation is clearly correlated with the

nation’s health, life expectancy, serious crime rates, including especially violence, and

mental health. The larger the gap the worse consequences these indices indicate; the nar-

rower the gap the better the health, the life expectancy, the lower the violent crime, the

better the mental health. Prevention of illness caused by inequality would require redistri-

bution of income and thus power on a massive scale. Finally prevention may require gov-

ernmental intervention, which can be presented as interfering with, so-called, free

enterprise and independence, sacred cows of the Western status quo. It would be unsurpris-

ing if substantial establishment material, political and ideological resources were devoted

to prevention of prevention.

Clearly, people who would stand to lose by prevention might consider a critical

intellectual attack on the ill-health causation and treatment model dangerous. It would

challenge the very foundations of capitalist societies, i.e. exploitation of the disadvantaged

by the advantaged. Those who are a danger to the powerful might expect retaliation. It is so

much safer to seek grants for teaching job-search skills to the unemployed or for studying

the brain chemistry of those labelled deviant than to tackle the oppressive structural labour

market and poverty related factors that are the underlying causes of the problems.

Public health psychology 73


A major source of much current human misery is the large corporation. Not only patho-

genic but psycho- and socio-pathic, corporations have no conscience, search relentlessly

and single-mindedly for the greatest possible advantage, ruthlessly maximizing profits for

their owners and shareholders whatever the consequences for those caught up with them.

Corporations have no capacity for empathy with those damaged or destroyed in the drive

to maximize profits.

Decisions that damage people through the maximization of profits are rarely attributable

to specific single corporate individuals but to company policy, as determined by Chief

Executive Officers or Boards of Directors. However these decisions lead to toxic dumping,

pollution of air and water, destruction of forests, genetic alteration of foods, reductions in

scale and quality of employment, poverty, stress-related illness, exploitation, erosion of

civil liberties and ruthless opposition to regulation and control which restrict corporations’

capacity to make money. The most powerful corporations are more powerful than many

elected governments, able to influence legislation, especially in relation to health, educa-

tion and welfare and to ensure massive public expenditures for the expenditure in support

of the medical model, including pharmacological consumption.

A second major root of the causes of much current human misery is patriarchal religion.

Every one of the world’s major religions is patriarchal and requires sexist attitudes and

behaviour of its adherents and acolytes. Major Western religions exclude women from ser-

ving as clergy, deny women the right to choose whether to have children; and in the US

even defeated a constitutional amendment that simply proposed to guarantee equal rights

to women. Some major religions make no bones about positioning women as the property

of their fathers, who can sell them to procurers who then sell them to brothel owners or to

families who use them as household slaves. Governments defending such practices are

almost entirely made up of male apologists, defenders, or proactive agents of the patriar-

chal religions that underscore such practices.

The priority for those seriously interested in prevention of mental and emotional ill

health and distress and promotion of positive mental health and social wellbeing is to find

effective ways to challenge and subvert damaging corporate, patriarchal and religious

powers. It is not hopelessly naı̈ve and individualistic to aspire to this. In limited ways

changes already have been forced on defenders of the status quo by the Trades Unions,

the civil rights movement, the women’s movement and the Green activists who have all

won major battles with governments and corporations in the not too distant past.

If decent mental health for all is to be achieved, perhaps it is now time to bring together a

coalition of national and international groups to expose the role of pathogenic corporations

and religions in the causation of mental and emotional ill health, and to develop prevention

strategies and recommendations for action. In other words to start to develop a critical

Public Health Psychology which could be as effective in preventing mental ill health

and promoting positive mental health in the future as Public Health Medicine has been

in preventing physical ill health and promoting positive physical health in the past. If

not now, when?

G. W. ALBEE

7157 Longboat Drive North

Longboat Key

FL 34228 1047, USA

74 G. W. Albee and D. M. Fryer


D. M. FRYER

Department of Psychology

University of Stirling

FK9 4LA, UK

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/casp.705

Public health psychology 75


towards a public health psychology†

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