More on Mental Health Strengthening as a Priority For Us All
On the Big Ideas page we defined mental health according to the World Health Organization definition: "a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community" (WHO, 2014).
We believe that the value of such well-being is obvious. But the importance of working to build it in all of us - and the urgency with which we should carry out this work - becomes all the more evident when you consider our society's most glaring deviations from its ideals.
What deviations are these? In the United States, our hearts and minds have been struck most, perhaps, by the mass shootings which have brought matters of mental health into fervent national discussion. These discussions are misguided, write Metzl and MacLeir (2015). But these authors also cite statistics like the 32,000 handgun-related deaths which occur in the US, on average, every year. A reported 16,121 homicides took place in 2013 (CDC, 2013). And for youth ages 15-19, the top three causes of death are accidents, homicide, and suicide (CDC, 2010). However "mental illness" may or may not factor into any of this is a matter of (often contentious) debate. Yet it is undeniable that these levels of violence, accidental injury, and self- and other-destruction are not consistent with a vision of widespread well-being. These are not isolated numbers, either; these events have far-reaching impacts on the witnesses, the bereft, and beyond, shaping our interpersonal systems in a variety of ways.
But we could also consider any number of other deviations.
- Incarceration: The United States has the largest prison population in the world, with 5% of the world's population overall and 25% of the world's prisoners. Taking into account both those in prison or jail and those under parole or probation, 1 in 32 US adults is under some sort of correctional supervision. Among young people, jail time reduces productivity over the next decade by an estimated 25-30%, compared to youths arrested but not incarcerated. And economic investment in the prison system diverts enormous amounts of money from other causes on a national level; the US spends around 70 billion dollars on correctional systems each year. (NAACP, 2015.)
- Alcohol abuse: Binge drinking is reported in 18% of US adults (CDC, 2014). An estimated 17.8% of adults have alcohol dependence at some point during their lives, while an estimated 12.5% have alcohol dependence at some point during their lives (Hasin, Stinson, Ogburn, & Grant, 2007). Excessive alcohol consumption kills approximately 88,000 people in the US each year, and in 2006 it cost the nation an estimated 223.5 billion dollars (with 72% due to lost workplace productivity; 11%, to health care expenses; 9%, to law enforcement and criminal justice expenses, and 6%, to motor vehicle crash costs) (CDC, 2014).
- Other preventable deaths: Smoking, high blood pressure, and being overweight account for hundreds of thousands of premature deaths every year. Smoking, for example, is responsible for 1 in 5 deaths, which high blood pressure is responsible for 1 in 6 (Danaei et al., 2009). And this Danaei et al. team (2009), affiliated with Harvard's School of Public Health, have also attributed hundreds of thousands of preventable deaths to other poor lifestyle decisions, including inadequate physical activity and high salt intake.
Again, the message is clear: our society has a long ways to go in working for widespread well-being and productivity, resilience and positive contribution.
What about a more traditional diagnostic definition of mental health?
Meticulous national surveys based on the World Mental Health Survey Initiative Version of the World Health Organization Composite International Diagnostic Interview (or, designed to incorporate both DSM-IV and International Classification of Diseases, 10th Revision diagnoses) have found that the lifetime prevalence of "mental disorder" in the US is close to 50% (Kessler et al., 2005).
In other words: almost half of the people in the United States will be diagnosed with a mental health problem at some point in their lives.
Thus even considered in more specific diagnostic terms, mental health is a relevant concern for a huge fraction of society. And how many of the remaining 50% have experienced subclinical or otherwise non-diagnosed problems? Many, we're sure.
Many Mental Health Problems Are Rooted in Childhood
The same National Comorbidity Study found that half of all lifetime cases of mental illness start by age 14; 75%, by age 24 (Kessler et al., 2005). And in the study's Adolescent Supplement, about 22% of US youth met criteria at some point by age 18 for a disorder involving severe impairment or distress (Merikangas et al., 2010).
There May Be Particular Value in Broad-Spectrum Interventions
The National Comorbidity Study's Adolescent Supplement also found that 40% of participants with a disorder had disorders in more than one class (i.e. anxiety, mood, behavior, substance, and other); 18% of youth with a disorder had disorders in three or more different classes (Merikangas et al., 2010).
What does this mean for the mission of mental health strengthening?
Proper treatment or interruption of mental health dysfunction may not be a matter of finding the ideal depression treatment and the ideal anxiety treatment and the ideal oppositional defiant disorder treatment and the ideal ADHD treatment, etc., because those who struggle in one domain so often struggle in another domain. Nurturing methods of intervention that can cross diagnostic lines and target dysfunction in a more broad-spectrum manner appears to be of particular priority.
Time on Task Is Often Lacking in Mental Health Intervention, if Intervention Happens at All
In a 2002 study Strayhorn cited findings from three meta-analyses of psychotherapy with children, which reported an average of 7, 10, and 7 hours of training, respectively. He commented: "If these durations of training, which would represent only a drop in the bucket for most educational efforts, can produce some positive effects, we should not give up hope that longer and more intensive trainings may produce larger effects" (Strayhorn, 2002). By the same token, it seems premature to conclude that "skill training" in general is ineffectual when a certain variety of training is carried out for relatively few hours (as many have concluded regarding Abikoff and Gittleman (1985), widely cited as evidence that skill training is not helpful for ADHD despite the fact that skill training took place for only 32 hours total). To come to such conclusions regarding language learning, say - to conclude that the fact that 32 hours of introductory Spanish study failed to produce Spanish fluency, or even competence, for example - would be laughable. According to popular definitions, a "high performance skill" is one for which more than 100 hours of training are required (e.g., Schneider, 1985). In one survey of adult high achievers (including concert pianists and competitive swimmers), the amount of practice time reported to be logged by the end of high school averaged 6,000 to 8,000 hours (Bloom, 1985). And in another, music instructors estimated the time investment necessary for "good operating" ability on the harmonica to be around 50 hours (de Bono & de Saint-Arnaud, 1982).
Yet in skill training for psychological skills, character skills, or the skills of positive development, other examples of similarly lacking time investments abound, whether in skill training for early-onset Conduct problems (Webster-Stratton, Reid, & Hammond, 2001); ADHD (Tamm et al., 2010); Autism Spectrum Disorders (Beaumont & Sofronoff, 2008); or others.
These examples come from research interventions. In practice, under real life conditions, the time put into mental health training is often even less. The National Comorbidity Study Replication, for example, found that during a 12 month period - and among those receiving treatment for mental health concerns - the median number of clinic visits was 2.9 (Wang et al., 2005). Even if the totality of these three or so visits per year were devoted to skill training, the time investment would be minimal, even by research standards (not to mention expert standards!).
Regarding treatment access, Burke et al. concluded that "more than 2.5 million patients, 12 or older, with mild or moderate mental illness, and more than 375,000 with substance abuse disorders, may have gone without needed behavioral health services in 2010" (Burke et al., 2013). And as Gopalan et al. report, "Approximately 75% of children with mental health needs do not have contact with the child mental health service system" (Gopalan et al., 2010). If we are to expect behavioral skill-training to occur at all - much less, many hours worth - we must look beyond the walls of the traditional mental health system.
The Mental Health System Is In Need of "Rebooting"
Given the insufficiencies of the mental health system as it currently exists, Kazdin and Blase have called for a "rebooting" of mental health research and practice, arguing that the system as-is is failing to bring about adequate accessibility of evidence-based procedures (Kazdin & Blase, 2011). In response, Yates (2011) called for "methods that use less therapist time, use less client time, minimize client transportation costs as well as brick-and-mortar space, and use less of other increasingly scarce and costly resources."
An Ounce of Prevention is Worth a Pound of Cure
As Greenberg and colleagues put it: "We have not reached the point where we are able to serve all children effectively... It is clear that to reduce levels of childhood mental illness, interventions need to begin earlier, or ideally, preventive interventions need to be provided prior to the development of significant symptomology." (Greenberg, Domitrovich, & Bumbarger, 2001.) Such preventive interventions are backed by a significant body of research (see Durlak & Wells, 1997; Durlak & Wells, 1998; Greenberg et al., 2001).
But perhaps the greatest promise of such preventive interventions lies not in their potential to preempt symptom onset in some but rather in their potential to promote positive health and development in all. And this brings us back to the notion that broad-spectrum efforts, with their emphasis on wider mental health strengthening, are of particular priority (working not just to eliminate disorder, but also to build health; see Durlak & Wells, 1997 for example). As Catalano and colleagues (2004) put it: "Youth development practitioners, the policy community, and prevention scientists have reached the same conclusions about promoting better outcomes for youth. They call for expanding programs beyond a single-problem-behavior focus and for considering program effects on a range of positive and problem behaviors."
Luckily, the goals of promoting positive development and preempting problem onset appear to go hand-in-hand. Catalano et al. continue, "We are finding new evidence that offers an empirical demonstration of why increasing positive youth development outcomes is likely to prevent problem behavior. This evidence demonstrates that the same risk and protective factors that studies have shown predict problem behaviors are also important in predicting positive outcomes (Catalano, Hawkins, et al. 2002; Pollard, Hawkins, and Arthur 1999). Given this similar etiological base, it is likely that decreasing risk and increasing protection is likely to affect both problem and positive outcomes."
Many successful prevention-oriented programs call upon skill training methods (see Greenberg et al., 2001, Durlak & Wells, 1997 for examples). As early as 1980, Kornberg and Caplan reviewed 650 papers on biopsychosocial risk factors and preventive interventions, concluding that "competence training to promote adaptive behavior and mental health is one of the most significant developments in recent primary prevention research" (as cited in Catalano et al., 2004).
Unfortunately, the need for "rebooting" remains, as preventive interventions also face severe problems of access, including limited time and limited resources (Tolan & Dodge, 2005).
Academic Struggles Are Also Very Real for Very Many People
Whatever we may think of such international comparisons, it is true that many young people in the US struggle with even basic academic skills. A report by the Annie E. Casey foundation, for example, revealed that 80% of low-income 4th graders and 60% of all kids are not reading proficiently. Controversies about implementation of the Common Core State Standards have only exacerbated student stress and fears of underperformance.
Academic Functioning and Psychological Functioning Are Hugely Interdependent
One seminal study, for example, used multiple regression to conclude that "reading scores accounted for a larger proportion of the variance in the later behavior problem scores than did school-age IQ scores." Furthermore, "when reading ability was entered in the regression equation before IQ, then reading but not IQ significantly predicted change in problem behavior during the primary school years." (Stanton et al., 1990.) In other words, reading ability was a strong predictor of behavior, above and beyond the effects of IQ. In terms of positive strengthening, reading ability represents a potentially powerful protective factor.
In another study, researchers implemented both social skills training and academic skills training with low-achieving socially rejected children, examining their relative impacts on the youth's social status (Coie & Krehbiel, 1984). They found that pure academic training was most efficacious (beyond social skills training, combined academic and social skills training, and control), producing advancements in both academic performance and social status. The authors suggested that successfully giving these youth basic math and reading skills gave them less opportunity for disruptive behavior, enabling them to focus more on completing classroom tasks.
One-on-one Work Can Be a Magical Thing
Regarding ADHD symptoms and disruptive behavior, for example, even the DSM-IV acknowledged: "Signs of the disorder may be minimal or absent when the person... is in a one-on-one situation (e.g., the clinician's office), or while the person experiences frequent rewards for appropriate behavior" (American Psychiatric Association, 1994). Strayhorn & Bickel (2002) found that tutor-rated ADHD symptoms were much lower in one-on-one tutoring sessions than in classrooms; in fact, the effects of one-on-one conditions, in terms of reduced symptom expression, were as large as reported effects of stimulant medications.
The one-one-one context makes it far easier to ensure that students are working on skills that are of just the right level on the hierarchy of difficulty. Strayhorn (2002) summarized the importance of work at the correct level of difficulty, particularly as far as self-control training is concerned. He quotes Shunk and Zimmerman (1997), who proposed that: "Learning is optimized when the needed form of social instruction is matched to the students' level of regulatory skill on the task in question. Either premature or delayed reliance on self-regulatory processes can retard the speed of learning and the ultimate degree of achievement (Zimmerman & Kitsantas, 1997)."
When the one-on-one context is provided by a strong interpersonal bond, even better. Lewis (2000) cited evidence that personality growth across the lifespan often involves an internalization of models from strong, affective dyadic bonds. And Bell and Calkins (2000) asserted that relationships provide the context for any development of emotional regulation skills. (Both cited in Strayhorn, 2002.)
On Fantasy Rehearsal
As Strayhorn described (2002): "In one way of doing a fantasy rehearsal of self-control skills, the individual imagines himself at a choice point at which a long-term goal and a short-term temptation are in conflict. He describes the situation aloud and then voices a desirable pattern of thoughts, emotions, and behaviors, as if carrying them out in the present. Often in real-life choice points, emotions run too high to permit calculations about rewards and punishments. Fantasy rehearsal allows the child to build up habit strength for the adaptive handling of such situations, during moments of calm and control."
In other words, fantasy rehearsal enables a more direct application of skills to real-world-esque situations (something that would be impossible or unethical otherwise, for example in learning to handle criticism and rejection or in learning to control anger). And this element of skill training appears to be crucial; as Catalano and colleagues (2004) write, "To produce meaningful effects on specific target behaviors, it also appears necessary to include opportunities in social competence promotion programs for students to practice and apply learned skills to specific, relevant social tasks (Hawkins and Weis 1985)." With fantasy rehearsal, the possibilities for practice of such specific, relevant social tasks are almost endless.
On Ancestors of OPT
In 1993, Strayhorn, Strain, and Walker wrote The Case for Interaction Skills Training in the Context of Tutoring As a Preventive Mental Health Intervention in Schools, in which they studied a model of peer tutoring in psychological skills.
In 2003, Strayhorn and Bickel studied an in-person version of the model, in A Randomized Trial of Individual Tutoring for Elementary School Children With Reading and Behavior Difficulties.
In 2005, Strayhorn studied the impacts of phone tutoring, in terms of reading outcomes, finding that children in the study went from progressing at 0.5 grade levels per year before tutoring to progressing 2 grade levels per year during tutoring (Pilot Study of Telephone Tutoring in Reading Skills).
Our Ongoing Research Efforts
More information will be available soon. In the meantime, contact Jillian Strayhorn for details if interested.