Serious issues regarding health and social life in the United States stem from behavior learned during youth and adolescence (Ross, Powell & Elias, 2002). Among these are drug, alcohol and tobacco use, and sexual behaviors that put one at risk for disease and teen pregnancy.  Studies suggest that 50 percent or more of U.S. youths are at risk from the consequences of these behaviors (Ross, Powell & Elias, 2002; Zins & Wagner, 1997).  Long-term problems stemming from these behaviors contribute to unnecessary care and drive up its costs (Kolbe, Collins & Cortese 1997).  These problems also produce a school environment that is not conducive to learning, and therefore contributes to higher drop out rates and a worse education for those who do graduate (Kolbe, Collins & Cortese).  Intervention during the formative years of children could lead to prevention in these areas.

There are also evident disparities between race concerning these issues, with African Americans and Latinos being afflicted more so than Americans of European decent (Hartman, 2006).   American schools, by and large, do not graduate minority high school students who are ready to face the challenge of college or graduate school (Hartman).  Only half of the country’s 1.8 million Hispanic and African American students graduate from high school with a diploma (Hartman).

Since the 1960s, the United States Government has focused on creating public education programs that attempt to foster learning and thereby shrink poverty and its accompanying ills (Phillips & Styfco, 2007).  Most of these programs, such as Project Head Start, are aimed at boosting cognitive scores in impoverished children in pre-school so that they are at the level of children from middle class or high socioeconomic status (SES) by the time they enter first grade (Phillips & Styfco). These programs have had varying degrees of success.

Both psychologists and educators have hailed SEL as a way to fulfill the promise of education for the underserved.  It is defined as:

…the process through which children enhance their capacity to recognize and manage their emotions, appreciate their capacity to recognize and mange their emotions, appreciate the perspectives of others, establish pro-social goals,  and solve problems, and use a variety of interpersonal skills to effectively and ethically handle developmentally relevant tasks (Elias, Bruene-Butler, Blum & Schuyler, 2000, p. 254).

Studies suggest that social atmosphere improves when SEL is implemented in classrooms, (Kress & Elias, 2006).  A by-product of this is improved academic achievement and scores on standardized tests (Kress & Elias).  Some have called it SEL the missing piece of the academic puzzle (Elias, 2002).

This paper will briefly explore the foundations of developmental psychology in the United States, and how it has been intertwined with social programs that address poverty.  It will also critically discuss the literature regarding two major programs, Project Head Start and SEL. 

Review of Historical and Contemporary Scientific Literature

Origins of the Effort to Prevent Poverty

The origins of the prevention of poverty in the United States are intertwined with the origin of developmental psychology and its early research (Phillips & Styfco, 2007).  At the turn of the 19^th to the 20^th century, the social reform movement, led by individuals such as Jane Adams, sought to address problems afflicting children, especially for the poor and immigrant populations (Phillips & Styfco).

Applied research was born amidst the study of child labor, delinquency, and child and maternal health (Phillips & Styfco).  By 1912, the Children’s Bureau was created to “Collect and apply systematic evidence about the conditions of children at the highest levels of the federal government” (Phillips & Styfco, p. 12).  Psychologists involved in the child study movement interfaced with caseworkers, pediatricians and educators for social advocacy (Phillips & Styfco).  Initiatives included child guidance for juveniles, an early intervention similar to those instigated by Alfred Adler and carried further by his student Rudolf Dreikurs (Millren, Evans, & Newbauer, 2003).

The 1920s saw the move from a reform orientation, to experimental, empirical studies, and the furtherance of quantitative, statistical analysis (Phillips & Styfco, 2007).  Developmental psychology was considered a domain apart from public policy, and reform was in essence regarded as a separate domain (Phillips & Styfco).

The Second World War ushered in the use of scientists for the war effort (Phillips & Styfco, 2007).  Unlike other wars, however, when armistice was called, the government continued to enlist the assistance of psychologists during peacetime (Phillips & Styfco).  Continued competition with the Soviet Union during the cold war led to government funding of scientific research far surpassing that of private endowments (Phillips & Styfco). The 1960s saw the War on Poverty initiative of the Johnson administration and the creation of the National Institute of Child Health and Human Development (Phillips & Styfco).

The War on Poverty was originally focused on adults (Phillips & Styfco, 2007).   However, its focus shifted to impoverished children in order to help them perform better in school.  Developmental scientists, like Urie Bronfrenbrenner, later gaining recognition for his Ecological Systems theory, and Edward Zigler, were invited to Washington to found what eventually became the longest running educational program in U.S. history, Project Head Start (Zigler & Muenchow, 1992; Phillips & Styfco).

Head Start

Head Start was founded in 1965 (Zigler & Styfco, 2001).  Since its inception, Project Head Start has served over 15 million children and their families (Zigler & Styfco). Head Start is still in use and gives impoverished children access to preschool education (Zigler & Styfco). Its main goal is to “prepare children for school, and enhance their social competence,” and to holistically approach the nurturance of the child (Zigler and Styfco, p. 238).

Each Head Start program offers a variety of services, including health screening and referral, nutrition education and hot meals, mental health services, preschool education, social services for the child and family, and parental involvement. (Zigler & Styfco, 2001, p. 238)  A Head Start program is individually tailored to the community it serves (Zigler & Styfco).

Leadership in Project Head Start insisted that rigorous data collection and analysis for evidence-based feedback be involved from its onset (Phillips & Styfco, 2007).  Though it was aligned with Johnson’s Great Society initiative, and the resurrection of science in the service of social reform, it was not merely to be just social program, but also to be steeped in empiricism (Phillips and Styfco).  Numerous studies discuss the benefits of incorporating Head Start programs into communities (Zigler & Styfco, 2001).  A large body of evidence relates that children in Head Start preschool programs test higher on cognitive functioning than poor children who are not enrolled (Zigler & Trickett, 1978; Malakoff, Underhill & Zigler, 1998; Zigler and Styfco, 2001).

Other benefits of Head Start programming include healthcare access to poor families comparable to middle-class families, better relationships between parents and children, and securing employment for parents and caretakers of the children (Zigler & Styfco, 2001).  In short, Project Head Start attempted to transform all aspects of the lives of impoverished families.

Project Head Start has been the main preventative measure in early childhood education to the present.  Its popularity has waxed and waned through the years, and it was initially bounced from one Washington agency to another (Kuntz, 1998).   It still holds considerable support from both Republican and Democratic presidents and lawmakers (Phillips & Styfco, 2007).

Social & Emotional Learning (SEL)

SEL developed in the era of evidence-based practice tested through rigorous data (Greenberg, Weissberg, Utne O’Brien, Zins, Fredericks, Resnik & Elias, 2003). It aims to work from the ground level, to shift the nature of curricula to include emotional and developmental issues, in order to eliminate behavior problems throughout the course of a child’s education (Deham & Weissberg, 2004).  Thus, SEL affords students a safe, friendly environment in which to learn (Deham & Weissberg).  Studies point not only to the emotional and developmental benefits, but also to SEL assisting in better grades for children (Kress & Elias, 2006).

SEL was developed from the concept of Emotional Intelligence (EI) developed by Salovey and Mayer in 1990.  It is described as a “combination of the interpersonal and intrapersonal intelligences put forth in Howard Gardner’s model of multiple intelligences,” and as a more streamlined version of the older Guilford and Hoepfner models of intelligences (Elias, 2002, p. 44). These intellectual domains are musical, linguistic, body/kinesthetic, and personal intelligences (Salovey & Sluyter, 1997).  Gardner argued that brain structures interact with social purposes or behaviors to create intelligences (Salovey & Sluyter). Daniel Goleman later enhanced and polpularized Salovey and Mayer’s original concept.  Goleman described specific skills related to emotional competence, including coping with frustration, monitoring and controlling affect and behavior, social problem solving, effective communication on verbal and non-verbal levels, controlling impulses, and initiating and maintaining friendships (referenced in Elias, 2002).

SEL consists of factors of self-management, self-awareness, responsible decision-making, and relationship management (Denham & Weissberg, 2004).  Theses factors are implemented based on normative models of child development (Denham & Weissberg).  As a child develops neurologically, higher cortical functioning is engaged; emotional development precedes cognitive development (Denham & Weissberg).  As they grow, children can better process their emotions through reason (Denham & Weissberg).  Therefore, SEL for the first grader is not the same for the second or twelfth grader; it is adjusted to meet the developmental needs of each grade. (Denham & Weissberg).  A child learns first through imitation and play (Bandura & Walters, 1963).  SEL lesson plans in the lower grades involve story telling and play that nurture social and emotional values (Pasi, 2001). Older children explore these areas in more complex and abstract ways (Pasi, 2001).

SEL is integrated into the life of a school.  Teachers incorporate SEL into the lesson plan at the preschool and kindergarten level, and adapt it through the changing grades.  Administrators adapt SEL into their disciplinary interventions and programming (Zins & Elias, 2006).  It is also incorporated into administrative and faculty interaction (Zins & Elias).

Due to the large amount of evidence for its efficacy, many U.S. school systems have begun to implement SEL in their classrooms (Zins & Elias, 2006). In 2003, Illinois was the first state to enact a law requiring SEL to be used in its public school systems (Collaborative for Academic, Social, and Emotional Learning, no date, A).  The Collaborative for Academic, Social, and Emotional Learning (CASEL) was instrumental in shaping Illinois Children’s Mental Health Act (ICMHA), passed in 2003 (Collaborative for Academic, Social, and Emotional Learning A; Zins & Elias).  Section 15 states:

(a) The Illinois State Board of Education shall develop and implement a plan to incorporate social and emotional development standards as part of the Illinois Learning Standards for the purpose of enhancing and measuring children’s school readiness and ability to achieve academic success…Every Illinois school district shall develop a policy for incorporating social and emotional development into the district’s educational program. The policy shall address teaching and assessing social and emotional skills and protocols for responding to children with social, emotional, or mental health problems, or a combination of such problems, that impact learning ability. (Illinois Children’s Mental Health Act, Public Act 93-0495, SB1951, n.d.).

This offers assurance that the benefits of SEL are available for all Illinois students.

CASEL, founded by Daniel Goleman in 1994, has been involved with implementation, dissemination, and research for SEL, and acts as a network among professional involved in SEL (Collaborative for Academic, Social, and Emotional Learning, n.d., A; Zins & Elias, 2006).  CASEL provides thorough assessment and consultation for schools considering an SEL curriculum, and extensive access to over 80 evidence-based programs that can be adapted to meet the needs of educators (Zins & Elais).

SEL works holistically, and attempts to include input from parents and community (Zins & Elias, 2006).  School psychologists are encouraged to be utilized in a systemic fashion rather than focusing on testing and individual interventions (Ross, Powell, & Elias, 2002).

Critical Discussion of the Literature

Head Start

Project Head Start’s strength is that it is a holistic initiative that has been shown to improve the functioning of the health and well being of low SES sectors of society (Aber, Jones & Raver, 2007). In order for Head Start to properly function, an ecological view, such as Bronfenbrenner’s (1977), must be applied to the developing child.  This was not the case (Zigler & Muenchow, 1992, p. 19).

Improved cognitive functioning and standardized test scores for Head Start children have been the main focus for scientists and pundits alike (Zigler & Trickett, 1978; Zigler & Styfco, 1994; Malakoff, Underhill & Zigler, 1998; Zigler and Styfco, 2001).  This emphasis on IQ scores has led to criticism, much if it from within the ranks of its founders (Malakoff, Underhill & Zigler; Zigler & Styfco).  Several studies point to Head Start and other early intervention programs boosting confidence and motivational levels of students, which are considered the main reason for increased standardized test scores and academic achievement (Zigler & Trickett; Malakoff, Underhill & Zigler; Phillips & Styfco).

Interpersonal rapport between students and teachers, and cultural competence are not taken into account with intellectual testing (Zigler & Trickett, 1978).  Students need to feel connected and trust in the environment in which education and testing is delivered.  There is no substantial cognitive difference between “culturally deprived” children, and middle-class children (Trickett & Zigler).  But, due to culturally biased test items, they may not respond correctly to questions on a Stanford-Binet or a Wechsler test (Zigler & Butterfield, 1968).  Cultural and motivational factors must be considered as part of assuring long-term effects of Head Start or programs like it (Malakoff, Underhill & Zigler).  Unfortunately, they are not taken into account, and are a probable reason for why Head Start programs do not have very sound evidence for long-term outcome (Zigler & Styfco).

At its onset, idealism and social policy alone drove Head Start (Ellsworth, 1998).  Scientific process was largely swept aside during the enthusiasm for social reform of the 1960s (Ellsworth, 1998).  This has occurred throughout the life of the program, making it the best funded, non-conclusive program (Ellsworth, 1998).  Perhaps if stronger emphasis were placed on science, it would have been more effective weapon in the War on Poverty.

It also has been argued that Head Start defines, or rather, pigeonholes, minorities and impoverished people in a negative light (Ellsworth, 1998).  The very essence of the program covers up the roots of poverty in power differentials in the United States (Kuntz, 1998).  The process of Head Start is to change the victim, not the system that victimizes (Kuntz, 1998).  It should be noted that there was a great deal of initial controversy and resistance to Project Head Start not from communities, but from school administrators, who felt that their power was to be absconded by un-trained, un-educated, community organizers (Kuntz, 1998).  Within a few years, Head Start as a grass-roots effort to empower communities was in many ways rendered ineffectual as an ecological intervention (Kuntz, 1998).

SEL

A solid foundation of empirical evidence may be viewed as the main strength of SEL (Greenberg, Weissberg, Utne O’Brien, Zins, Fredericks, Resnik & Elias, 2003).  Greenberg, Weissberg et al catalog studies that suggest SEL is effective stimulating positive youth development, promotes mental health, is effective in reducing drug and alcohol use and truancy, and enhances academic achievement.

A meta analysis of 207 studies compared outcomes for student who were enrolled in SEL programming to those who were not (Collaborative for Academic, Social, and Emotional Learning, n.d., B).  Those who received SEL programming significantly improved in the domains of Social and emotional skills, attitudes about themselves, others and their schools, conduct issues, emotional stress, distress and depression (Collaborative for Academic, Social, and Emotional Learning, n.d., B).  These students also had standardized test scores eleven percent higher than students who were not enrolled in SEL programs.  The authors of this meta analysis rightly claim that these results qualify SEL programs for further implementation and research.

Efficacy for SEL programming may be well documented, but there are still controversies.  Some contend that the main construct underlying SEL, EI, is not altogether valid (Zeidner, Roberts & Matthews, 2004; Zeidner, Roberts & Matthews, 2008).  Reliability and validity of EI measurements, such as the Mayer-Salovey-Caruso Emotional Intelligence Test, are called in to question (Palmer, Gignac, Manocha, & Stough, 2005).  Zeidner et al call for better conceptual definitions of EI, better measurement tools, and better behavior criteria (2004). Zeidner, a major skeptic of EI, states that SEL initiatives may work because other programs, such as anti-bullying interventions, are often implemented simultaneously, thus confounding efficacy results (Bennett, 2009).

SEL works as an intervention, controversies aside.  Why? It may be that SEL is the educational equivalent of empathy and rapport implemented within a school system.  In the common factors model of psychotherapy, the two main factors for successful outcome has been attributed to the client’s personal strengths (40%), followed by the empathy and rapport (30%) (Duncan, Miller & Hubble, 1997).  These are also the main elements involved in the efficacy of SEL programs.  Perhaps the way to proceed with defining operation definitions of SEL would be to study measures of empathy and rapport as a starting point.  This may help to frame SEL assessment.

Impediments:  What Was the Goal, and Where Are We?

The support for and the implementation of Head Start had an impact on educational outcomes for the impoverished (Zigler & Styfco, 2001).  But is it too grandiose to think that poverty can be reduced or eliminated through education?  The goal seems far too large, and indefinable to be properly addressed.  Debate as to whether Head Start should be based on science, or just have funding thrown at it due to the beliefs of policy makers, hindered proper study of its efficacy (Zigler & Styfco; Ellsworth, 1998; Kuntz, 1998).  In addition, lawmakers and school administration focused too heavily on cognitive test results, immediate results, rather than attaching more importance on studies and long-term planning (Zigler & Styfco; Ellsworth; Kuntz).  In order for Head Start to begin to fulfill the dream of dissolving poverty, it will likely need to be restructured to focus more on community needs.

SEL seems to be the best current possibility for reform at the local level, and for providing hope to the underprivileged.  However, in order to be effective, it will need to be implemented on a national level to ensure that each state is involved in SEL programming.  Perhaps Illinois will be the torchbearer for the rest of the country.

SEL’s benefits, supported by rigorous studies, certainly suggest the reduction of the behavioral problems among our country’s youth cited earlier (Kolbe, Collins & Cortese 1997). Longitudinal studies still need to be undertaken, and only time will tell whether this will translate into a reduction of poverty.

SEL produces better academic results and higher standardized test scores; lawmakers and educators will both find this advantageous (Kress & Elias, 2006).  Under the No Child Left Behind Act of 2002, school systems and states must have high enough standardized test scores in order to receive Federal funding (Lagana-Riordan & Aguilar, 2009).  As in the case of Head Start (Kuntz, 1998), the possible risk for SEL implementation is that educators and administrators will fall under the spell of raised test scores, and forget its original, transformative mission.

A positive aspect of CASEL is that it is a non-profit organization, invested in finding evidence to support its goals.  SEL is not a policy controlled by government, as was Head Start, and can operate, relatively speaking, independently of politics. However, it may be blindsided, as Head Start was, by idealism, or at worst, CASEL personnel could become driven by groupthink (Zeidner, Roberts & Matthews, 2004; Zeidner, Roberts & Matthews, 2008).  Critiques of SEL are currently at the level of open discourse, as a dialectic working toward a synthesis of pros and cons (Zeidner, Roberts & Matthews, 2004).  Hopefully, this will continue, and the main proponents of SEL will keep an open eye toward improvement of operational definitions of EI and SEL, and toward its implementation.  SEL is still young, and as of yet, there are no longitudinal studies to back its promise.  Most likely, CASEL will instigate such research.

Synopsis of Future Action

Head Start did not fulfill its promise, and its leading advocates within psychology suggest that this is due to lack of scientific rigor, and a focus away from ecological implementation (Ellsworth, 1998; Phillips & Styfco, 2007; Zigler & Muenchow, 1992; Zigler & Styfco, 2001).  Others (Ellsworth, 1998; Kuntz, 1998) suggest that idealism eschewed science.  Power struggles also hindered a grass-roots effort for systemic change (Kuntz, 1998).

It appears that SEL will be unhindered by such issues, at least along the lines of lack of scientific foundations and proper debate.  Yet there are often struggles within a school system when SEL is initiated.

Often educators believe that SEL curriculum will deter the delivery of academic programs in their classroom (Kress, Norris, Schoenholz, Elias, & Seigel, 2004).

In our work…we have met many school personnel who readily embrace social and emotional skills as a key component in the goals and purview of educational experience. However, it is not uncommon for even the best-intentioned educator to run up against some real challenges….How does SEL articulate with the various “standards” we are accountable for?  How will we integrate SEL into the existing curriculum? (Kress, Norris, Schoenholz, Elias, & Seigel, 2004, p.  71).

Another problem that often arises is whether an educator can find time in the already busy academic day to incorporate SEL into the lesson plan (Kress, Norris, Schoenholz, Elias, & Seigel 2004).  It is suggested that educators be reassured that SEL will give their students a long–term, academic edge (Kress, Norris, Schoenholz, Elias, & Seigel).  It can be pointed out that there is already an overlap between most SEL programs and state approved lesson plans.  Helping the educator see the correlation is the first step in easing their worries (Kress, Norris, Schoenholz, Elias, & Seigel).

Kress & Elias (2006) also recommend the use of the same tools from the SEL curriculum with the faculty of a school while doing consulting work.  This can bring about a warmer, more co-operative environment among faculty and administration (Kress & Elias). Kress & Elias created a four-step program that involves creating emotional self awareness and empathy, self reflection, continued learning, positive, assertive communication, and focusing on the importance of mentoring and support (Kress & Elias).

The next question is whether SEL will reach its goal of affecting communities as well as schools.  CASEL will need to continue with studying the affects of SEL, both long and short-term.   It would be best if these studies were not limited to the schools themselves, but to the community at large within a school district.  This current review of the literature did not find any evidence that this is being undertaken.  Indicators of economic progress, reduction in violence, and better living conditions within communities must be taken into consideration in longitudinal studies. Only in this way will we know if SEL is a panacea for poverty, and not merely as placebo to assuage the guilt of the dominant groups of American society, as Head Start has been described (Kuntz, 1998).

Lastly, Head Start may be a good pre-school foundation for SEL programming.  There is some indication that combining SEL and Head Start is efficacious (Domitrovich, Cortes,  & Greenberg 2007).  Such integration could be a means to gently introduce SEL to the larger community and school system, thus creating smoother transitions to a larger curriculum.

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Definitions & Understandings of Stigma

In his classic text on stigma as “spoiled identity,” Goffman (1963) describes stigma as a visible or invisible ‘mark’ that disqualifies its bearer from full social acceptance. Mental illness marks affected individuals as having “blemishes of individual character,” the acquisition of which “spoils” their identities and removes them from their place within the social hierarchy. While some argue that stigma should be clearly distinguished from discrimination, others define stigma as a multilevel interaction between affective, cognitive, behavioral, and contextual aspects. Campbell & Deacon (2006) elaborate:

The failure of individual-level approaches to effect widespread stigma reduction has led to an alternative focus on the links between stigma and wider macro-social inequalities (e.g. gender, ethnicity). Such analyses suggest that stigma is not something that individuals impose on others, but a complex social process linked to competition for power, tied into existing mechanisms of dominance and exclusion (Parker and Aggleton, 2003). Macro-social analyses imply that interventions such as anti-discrimination legislation or poverty-reduction will assist in stigma reduction. But taking this view can mean that researchers pay little attention to the individual psychological dimensions of stigma (2006, p. 412).

Those individual psychological dimensions, it is argued, have their basis in a universal human need to project fears of uncertainty and danger onto stigmatized ‘out-groups.’ The universality of this need can be seen in the separation and stigmatization of out-groups across cultures—the targets of stigma vary widely based on local power differentials, but the process of stigmatization can be seen anywhere (Joffe, 1999). For example, the stigmatization of HIV/AIDS sufferers in late-twentieth century United States culture helped to reinforce “middle American” morality through its association with marginalized out-groups who failed to meet prevalent social expectations: intravenous drug users, homosexual men, and prostitutes (Crawford, 1994). While applications of this principle to the stigma currently associated with mental illness can certainly be surmised, no research on the moral bases of mental health stigma could be found.

Why Mental Health Stigma is a Problem

Regardless of its causes, mental illness stigma has been found to pose a major barrier to some of the most basic tasks of life, such as establishing and maintaining friendships, employment, and housing. Stigma has also been found to significantly interfere with access to and outcomes for both psychological treatment and general medical treatment (Sadow & Ryder, 2008). Through shame, humiliation, and damage to the affected individual’s sense of self, stigma negatively impacts the likelihood of service utilization and treatment compliance. Consequently, patients who score higher of measures of stigmatizing attitudes are at higher risk for negative outcomes (Gould, Greenberg, & Hetherton, 2007; Corrigan, 2004). Stigmatizing attitudes have also been observed among students and professionals from many segments of medical and psychological service. As a result, people diagnosed with mental illness receive fewer medical services and a reduced range of insurance benefits; (Sadow & Ryder, 2008).

Review of Interventions for Mental Health Stigma

Corrigan & O’Shaughnessy (2007) list three main avenues for addressing the stigma associated with mental illness: protest, education, and contact. While each of these avenues has some degree of validity on its face, the efficacy of interventions based on any of these principles leaves much to be desired. Of the three, only direct contact has shown any effectiveness in reducing stigmatizing attitudes toward mental illness over an extended period of time.

Protest Interventions

Protest tactics involve directly challenging negative or stigmatizing representations of mental illness in the popular media in order to undermine the cultural maintenance of those representations. The primary means of protesting stigmatization in popular media is by way of economic boycott. Organized boycotts and threats of boycott from advocacy groups targeting the producers, distributors, and advertisers responsible for entertainment commodities have been successful in removing stigmatizing materials from public view in at least two instances.

An ABC television series called Wonderland depicted a person with mental illness behaving in a violent and sadistic manner. After intense targeting from mental health advocacy groups directed both at the network and the show’s advertisers, the show was discontinued after just a few episodes. Another instance cited by Corrigan & O’Shaughnessy (2007) is the advertising campaign leading up to the release of the comedy film Crazy People. Advocacy groups threatening Paramount Pictures with potential economic consequences convinced the company to remove movie posters depicting a large cracked egg with arms and a caption reading “Warning: Crazy people are coming.”

Despite these apparent successes, no empirical research has demonstrated that such efforts have a positive impact on the general public’s prejudices toward individuals with mental illness. In fact, the opposite may be true; some research suggests that protest strategies may produce an “attitude rebound.” The negativistic nature of protest interventions, which fail to provide positive alternatives to the attitudes they seek to undermine, seems to inspire an overall worsening of the public’s stigmatizing attitudes (Corrigan et al., 2001).

Educational Interventions

The educational approach, on the other hand, seeks to cultivate accepting attitudes toward mental illness by disseminating accurate information and dispelling myths about mental illness, such as the popular beliefs that persons suffering from mental illness are more likely to commit violence, or that mentally ill individuals are unable to be productive in the work force (Corrigan & O’Shaughnessy, 2007; Corrigan et al. 2001). The basis for this approach rests on a number of studies that have found individuals who are more knowledgeable about mental illness to hold fewer stigmatizing attitudes. Additionally, educational strategies for reducing stigma tend to be attractive to both researchers and policy-makers because they are affordable and easily reproducible. Some educational instruments that have been used in this way in the past include public service announcements, flyers, books, and informative videos.

Educational approaches are also the most-studied form of intervention for reducing mental health stigma. Unfortunately, the research seldom supports their effectiveness. Many studies have found significant reductions on stigmatizing attitudes through exposure to college courses or informational sessions, but the magnitude and duration of the effects tends to be very limited. Furthermore, the effects of educational interventions correlate to participants’ knowledge of mental illness prior to participation in the educational programs, indicating that the effects of education-based interventions may primarily reflect the attitudes of participants who had already agreed with the programs’ messages (Corrigan & O’Shaughnessy, 2007).

One notable implementation of the educational approach to stigma reduction has been the UK Royal Navy’s trauma risk management (TRiM) program, which seeks to improve recognition of and response to PTSD by reducing the stigma associated with the diagnosis. The TRiM program trains nonmedical personal in basic assessment of trauma risk and the administration of psychological first aid. The training encompasses only traumatic stressors and seeks only to facilitate early referral to appropriate counseling services. According to Gould, Greenberg, & Hetherton (2007), “the aims for participants are to understand PTSD and stress reactions, so that negative representations of mental illness are modified, and the problems associated with other posttraumatic management strategies (e.g., PD) are addressed” (p.507).

While the TRiM program does encourage individuals to share their experiences of stress and stress-related problems in order to reduce stigma, the program’s primary intervention is to provide education about the effects of traumatic stress and ways of assessing for risk and symptoms of PTSD. A brief longitudinal study of personnel who volunteered to receive this training found both significantly improved attitudes toward stress-related ailments and increased help-seeking. However, in light of evidence that attitudinal effects are unlikely to be maintained over the long-term, the study was severely limited by lack of follow-up. Additionally, the authors note that highly stigmatizing individuals tend to be those least likely to volunteer to attend educational packages, further weakening the evidence for this intervention’s effectiveness. In spite of these shortcomings, the study’s authors argue that the tightly integrated structure of the military organization makes it more susceptible to real-world improvements as a result of this type of intervention than the population at large (Gould et al., 2007).

Direct Contact Interventions

Among the general population, the most effective methods of reducing stigma appear to be those which facilitate direct contact between individuals with mental illness and members of the general population. Researchers have consistently found that greater levels of personal familiarity with mentally ill individuals tend to equate with fewer prejudicial attitudes toward mental illness. Additionally, while some reduction of stigmatizing attitudes can result from the disclosure of popular figures such as celebrities who disclose their experiences with mental illness, greater effects result from the disclosures of individuals perceived to be more similar to the recipient of the message, people “just like me” (Corrigan & O’Shaughnessy, 2007).

One program that has sought to reduce stigma using this direct-contact approach is the National Alliance for Mental Illness (NAMI) In Our Own Voice program, in which mentally ill individuals share their history and experiences with treatment in a workshop format. Audience members are encouraged to asked questions and interact with the presenters. Preliminary research has shown good initial responses from program participants along with promising reductions in stigmatizing attitudes several weeks after their participation in the program (Corrigan & O’Shaughnessy, 2007).

There are several difficulties in implementing contact-based interventions, not least of which is that they require disclosure from individuals living with mental illness. This type of disclosure puts the mentally ill participants at risk to experience the exact stigma which the interventions would hope to circumvent. While much greater reductions result from programs which put mentally ill individuals in contact with members of the general population, the effect may be insufficient to warrant this added risk. Furthermore, there is some evidence that the segments of the population who hold the most stigmatizing attitudes are also the least likely to become involved in this type of program (Corrigan & O’Shaughnessy, 2007).

One area in which this risk may be both minimized and justified is in the training of future health professionals. Sadow & Ryder (2008) have performed a number of studies aimed at decreasing stigmatizing attitudes towards mental illness among this group, typically with poor results. Various educational efforts that did not include personal contact with mentally ill individuals, including training programs which utilized videos of presentations by such individuals were not effective in reducing stigma among nursing students. However, when personal presentations by individuals with mental illness were presented in the classroom and followed by an opportunity to process the experience with a psychologist, stigmatizing attitudes were significantly decreased among this group. This is an important finding given our previous discussion of the dangers of mental health stigma among healthcare providers.

In their review of contact-based interventions to reduce stigma among schoolchildren, Pettigrew & Tropp (2000) identify five factors which they see as necessary for optimal stigma-reducing contact: equal status between majority and minority groups; a shared goal between members of both groups; a cooperative, rather than competitive, framework for accomplishing the common goal; institutional support for the interactions between members of each group; and minority members who moderately disconfirm the prejudicial stereotypes about their group. However, the efficacy of these school-based programs has been disappointing, with most studies showing mixed results or no differences in stigmatizing attitudes among the exposed children. On top of this, the risk of amplifying stigmatization is increased when working with children, as Corrigan & O’Shaughnessy (2007) argue:

The threat of “coming out of the closet” once again becomes a key factor in realising this kind of contact. Decisions need to be made as to whether children with mental illness will disclose their group status in order to facilitate contact effects. This means that some parents of children with mental illness, who are rightfully concerned about their child’s socialisation and education, must risk their child being stigmatised to attempt this kind of friendship building. Moreover, the mother and father must risk experiencing family stigma that suggests, for example, that bad parenting produced their child’s mental illness (p. 94).

Another notable shortcoming of contact-based approaches to reducing stigma is that they may be limited in the scope of attitudinal change they can realistically effect. While contact with mentally ill individuals helps to undermine beliefs that such individuals pose an immediate physical danger, it is less likely to affect other types of stigmatizing thoughts and feelings, such as overall anxiety and thoughts about “us versus them” (Masuda et al., 2007).

A Large-Scale Combined Interventive Approach

The World Psychiatric Association (WPA) has been working to implement a combined program including all three of the discussed strategies for stigma reduction through their “Global Program Against Stigma and Discrimination Because of Schizophrenia — Open The Doors.” In cooperation with the German Research Network on Schizophrenia, this program has been implemented as a large-scale controlled trial throughout Germany since 2001. Anti-stigma intervention programs, schizophrenia awareness intervention programs, and a no-intervention control condition were each assigned to two German cities. Cities were relatively homogenous in terms of population, with each city being home to a university-affiliated department of psychiatry and offering free psychiatric services to the community (Gaebel et al., 2008).

Several strategies were employed in the anti-stigma intervention cities. Educational programs were targeted at influential groups such as health professionals and educators, and direct-contact programs were initiated. These consisted of “lectures at adult education centers, art exhibitions, cinema events, readings, theatre events, and charity concerts. Most events included panel discussions with mental health professionals as well as people who were affected by mental illness as participants. Prior to the events, press conferences were held and/or press mailings were distributed. Furthermore, press workshops about schizophrenia and its misconceptions in the public were conducted to improve the reporting in the mass media about schizophrenia and mental illness in general” (Gaebel et al., 2008, p.185) Protest actions were also orchestrated to discourage structural discrimination and stigmatizing messages.

The researchers hypothesized a reduction in total mental health stigma in anti-stigma intervention cities, with no comparable reduction in the cities receiving awareness programs or no intervention. Stigmatizing attitudes were measured using pre- and post-testing of representative samples of each cities population via telephone survey. The results showed small but significant reductions in stigmatizing attitudes in the anti-stigma intervention cities, with most of the change relating to measures of perceived social distance in transient situations. The average citizen in these cities reported significantly more comfort having incidental day-to-day interactions with persons with schizophrenia in 2004 than in 2001, but was no more likely to be involved in repeated social or professional contact with these individuals (Gaebel et al., 2008).

An Alternative Approach: Cognitive Restructuring

A fourth method for reducing mental health stigma is the use of cognitive restructuring. For example, Sadow & Ryder (2008) describe a method of “turning the tables” on stigma within healthcare training programs by using the technique of “inspirational recruitment,” in which poorly paid and unpleasant work is elevated to the status of a noble cause. They cite a previous study in which this technique increased the rate at which psychiatry students were able to be recruited into otherwise undesirable positions working with severe mental illnesses in public health clinics.

Few other studies have utilized this more psychologically informed approach to stigma reduction, and we are aware of no studies which attempt to reduce stigma among the general population using similar techniques. However, modern understandings of perception and belief certainly make cognitive restructuring an attractive option, particularly in light of the previously cited evidence for its potential. This is a direction that stigma researchers should definitely be turning toward in the coming years, in both community psychology settings and clinical training programs.

Acceptance and Commitment Therapy As a Stigma Intervention

A similarly oriented approach is the use of Acceptance and Commitment Therapy (ACT) to reduce stigma. This approach addresses stigma only indirectly; ACT “uses acceptance, mindfulness, and value-directed behavioral change strategies in order to increase psychological flexibility” (Masuda et al., 2007, p. 2765). According to Masuda et al., research has supported the idea that increased self-acceptance produces increased empathy. While contact-based education only undermines beliefs about danger, ACT addresses the overarching avoidance of discomfort by increasing acceptance.

For example, in a study on substance abuse counselors, multicultural training reduced stigmatizing attitudes toward racial and cultural groups immediately after the intervention, but not at three-month follow-up. On the other hand, an ACT intervention which encouraged counselors to reflect on the automatic nature of judgmental processes and the “paradoxical effect of deliberate attempts to eliminate both self-stigma and stigmatizing attitudes” (Masuda et al., 2007, p. 2766) showed much better results. The ACT intervention reduced both stigmatizing attitudes among the counselors as well as measures of workplace burnout at follow-up.

Refocusing on more general factors like mental flexibility as contributors to stigma can also help to clarify the mixed results typically seen when other tactics are used. One study subjected college students to a single 2 1/2 hour ACT workshop focused on stigmatizing attitudes toward mental illness. Prior to the intervention, it was found that students with a lower level of general mental flexibility were more stigmatizing than their more flexible counterparts. The ACT intervention reduced stigma in both flexible and inflexible individuals, and in fact showed a particularly high comparative effectiveness for psychologically inflexible study participants. The authors speculate:

This pattern of results suggests that some forms of stigma may reflect uninformed attitudes about legal, cultural, and institutional practices related to mental illness. In more experientially avoidant individuals, however, stigmatizing views may become entangled in psychologically avoidant processes linked to the perceived threats of the stigmatized condition (Goffman, 1963) and to the inability to deal with the thoughts and feelings that arise as a result. These differences might help explain the somewhat inconsistent results for education in the stigma literature (Masuda et al., 2007, p.2769).

Conclusions

There has been much research on the effects of mental health stigma, but quite a good deal less research has examined potential interventions for reducing its presence or impact. This area of study is also significantly less ideologically sophisticated at present. None of the primary avenues for reducing stigma have proven satisfactory, although direct-contact programs have shown some promise and education programs have been effective within controlled social contexts such as military organizations.

A greater level of psychological savvy is needed in developing interventions for this purpose. Along these lines, some preliminary research on cognitive restructuring efforts and ACT-based interventions have shown a great deal of promise. It is unlikely that these early efforts cannot be bested by additional consideration for individual, social, and community psychological understandings.

While stigmatizing attitudes among the general public have been fairly well-studied, self-stigma and mental health service users’ reactions to stigma are more poorly understood. Bagley & King (2005) argue that the success or failure of expensive public campaigns to reduce the stigmatization of mental illness should be measured by the resulting feelings and experiences of the individuals affected by the stigma. To this end, they argue that primary interventions for newly-diagnosed cases of mental illness should include counseling aimed at mediating the effects of and improving responses to stigmatizing interactions.

Alternatively, an argument could be made for a more general measurement of the efficacy of anti-stigma efforts. The success or failure of these programs should hinge on the increased utilization of services and increased effectiveness of services utilized. This latter goal is likely to be too heavily confounded to be adequately measured as an effect of anti-stigma interventions. Therefore, future anti-stigma research should use the likelihood of the general public to utilize services, along with actual service utilization, as measures of outcome for anti-stigma interventions.

References

Bagley, C. & King, M. (2005). Exploration of three stigma scales in 83 users of mental health services: Implications for campaigns to reduce stigma. Journal of Mental Health, 14(4), 343-355.

Campbell, C., & Deacon, H. (2006) Unravelling the contexts of stigma: From internalisation to resistance to change. Journal of Community & Applied Social Psychology, 16(6), 411-417.

Corrigan, P. (2004). How stigma interferes with mental health care. American Psychologist, 59, 614–625.

Corrigan, P.W. & O’Shaughnessy, J.R. (2007). Changing mental illness stigma as it exists in the real world. Australian Psychologist, 42(2), 90-97.

Corrigan, P. W., River, L., Lundin, R. K., Penn, D. L., Uphoff-Wasowski, K., & Campion, J. (2001). Three strategies for changing attributions about severe mental illness. Schizophrenia Bulletin, 27, 187–195.

Crawford, R. (1994). The boundaries of the self and the unhealthy other: Reflections on health, culture and AIDS. Social Science and Medicine, 38(1), 1347–1365.

Gaebel, W., Zäske, H., Baumann, A.E., Klosterkötter, J., Maier, W., Decker, P., & Möller, H. (2008). Evaluation of the German WPA “Program against stigma and discrimination because of schizophrenia — Open the Doors”: Results from representative telephone surveys before and after three years of antistigma interventions. Schizophrenia Research, 98, 184-193.

Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice-Hall.

Gould, M., Greenberg, N., Hetherton, J. (2007). Stigma and the military: Evaluation of a PTSD psychoeducational program. Journal of Traumatic Stress, 20(4), 505-515.

Joffe, H. (1999). Risk and the other. Cambridge: Cambridge University Press.

Masuda, A., Hayes, S.C., Fletcher, L.B., Seignourel, P.J., Bunting, K., Herbst, S.A., Twohig, M.P., & Lillis, J. (2007). Impact of acceptance and commitment therapy versus education on stigma toward people with psychological disorders. Behaviour Research and Therapy, 45, 2764-2772.

Pettigrew, T. F., & Tropp, L. R. (2000). Does intergroup contact reduce prejudice: Recent meta-analytic findings. In S. Oskamp (Ed.), Reducing prejudice and discrimination (pp. 93–114). Mahwah, NJ: Lawrence Erlbaum & Associates.

Sadow, D., & Ryder, M. (2008) Reducing stigmatizing attitudes held by future health professionals: The person is the message. Psychological Services, 5(4), 362-372.

The first major victory is this campaign came in 1996, when Congress passed a law mandating equal annual and lifetime dollar limits for mental health benefits. A more recent piece of legislation has extended this parity in benefits to co-payments, deductibles, out-of-pocket limits, and caps on the number of inpatient or outpatient visits. The passage of this law is being hailed as a tremendous success by advocacy groups. However, the law has problematic limitations that may actually serve to increase systemic barriers to mental health treatment, particularly among the working poor and the lower middle class.

In this analysis we will examine the consequences of the present mental health parity law, and the structural barriers that continue to limit access to mental health services. We will examine the consequences of these limitations, both for the affected individuals and for the society as a whole. Finally, we will propose changes to the current policies which could remedy the problems we outline.

Why Mental Health Parity Is Needed

The Substance Abuse and Mental Health Services Administration (SAMHSA) conducted a comprehensive National Survey on Drug Use and Health in 2002, and found that more than five million individuals meeting criteria for serious mental illness “perceived themselves as having an unmet need for treatment in the year prior to the survey” (Bender, 2003). Of these, nearly 2.5 million severely mentally ill individuals cited insufficient financial resources as the primary reason that they were unable to receive appropriate treatments.

This means that, as of 2002, nearly 1% of the entire population of the United States is comprised of severely mentally ill individuals who want treatment but are unable to afford it (U.S. Census Bureau, 2003). This figure does not include individuals whose mental illnesses are distressing but not debilitating, who likely number in the tens of millions, nor does it include individuals suffering from substance abuse disorders, of whom there may be more still. The magnitude of the problems we face in ensuring treatment of psychological and addictive disorders constitutes a public health crisis.

This crisis reaches beyond the mental health system by putting an undue strain on the nation’s medical infrastructure. According to O’Donohue & Cucciare (2005), “research consistently shows that patients with psychological problems use more [medical] services than those without diagnosable psychological problems.” For example, one recent study tracked a sample of individuals admitted for inpatient treatment of various medical conditions. At four years, patients who demonstrated psychological factors such as depressive or aggressive tendencies had been readmitted for further medical treatment at a rate twice that of their counterparts with no psychological comorbidity. The total number of days of inpatient care utilized for the treatment of physiological conditions also doubled for these patients (Saravay, Pollack, Steinberg, Weinschel, & Habert, 1996).

The good news is that psychotherapeutic treatment reliably reduces medical service utilization. Mumford, Schlesinger, Glass, Patrick, & Cuerdon (1998) describe a history of research demonstrating that the delivery of mental health services is strongly predictive of decreased utilization of medical services across the board. They conclude that the evidence for a general cost-offset effect following outpatient psychotherapy is “widespread and persistent” (p. 85), with the most substantial savings coming from a decrease in inpatient service utilization.

Steps Toward Mental Health Parity Implementation

As we have mentioned, the first step toward mental health parity in the United States came with the passage of the Mental Health Parity Act of 1996 (MHPA). The act required that insurance policies which included mental health coverage do so at the same annual and lifetime dollar value as their coverage for general medical and surgical services (NASW, 2002). However, disparities between co-payments, deductibles, and out-of-pocket expenses were not affected by the bill, nor were any of the millions of insurance policies which provided no mental health coverage at all.

The U.S. Congress expanded on this effort to improve mental health coverage for Americans in 2008, by passing the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). The MHPAEA addressed a number our concerns regarding the MHPA. It required that employers whose insurance plans include mental health and/or substance abuse coverage eliminate any remaining disparity with medical coverage, including co-payment amounts, total out-of-pocket expense limits, deductibles, and annual limits on inpatient and outpatient visits (Bernstein, 2008).

However, the MHPAEA still placed no requirements on payees to provide mental health coverage to their beneficiaries. This means that, as before, only patients whose medical coverage includes optional mental health benefits will be able to benefit from the new law. Individuals’ whose insurance coverage does not include optional mental health coverage will remain without access, as will the millions of uninsured Americans (Jenkins, 2008).

Problematic Impacts of Mental Health Parity Legislation

Like the 1996 Act, The MHPAEA places a substantial financial burden on employers and other insurance payers without placing any additional regulation on insurance providers and managed care organizations. Opponents of comprehensive parity legislation have argued that any new regulations on the insurance industry would precipitate the loss of other, unprotected health care benefits in order to offset the cost (Carroll, 2004). However, placing the burden on employers will likely result in severe consequences for lower and middle class workers.

We can predict this because it is essentially what took place after the passage of the MHPA, which represented much less of an imposition on employers. According to the National Association of Social Workers, the “U.S. General Accounting Office reported in May 2001 that 86 percent of employers surveyed reported that they had complied with the requirements of the 1996 Act.  Nevertheless, the vast majority of those employers substituted new restrictions on mental health benefits, thereby evading the spirit of the law” (NASW, 2002, Background and legislative history section, ¶ 10). With the new requirements being much more demanding, it is likely that many employers will simply see no benefit in continuing to provide mental health coverage, particularly for employees who are not considered valuable enough to warrant competitive benefits packages.

This means that by placing the burden of providing additional coverage on employers, the MHPAEA has essentially given employers an incentive to drop existing mental health coverage for low-wage employees. Workers who previously had inadequate access to mental health services are likely to see even their inadequate mental health benefits disappear. Such a change will disproportionately affect the working poor, a group whose high levels of external stress create a greater need for the very services they will be losing access to.

Meanwhile, advocacy groups such as the American Psychological Association are lauding this new law as a huge victory in the fight to end discrimination against sufferers of psychological illness (APA, 2008). What has actually taken place is the passage of federal legislation which effectively institutionalizes the medical discrimination which was already taking place within the insurance industry. Furthermore, the Act has freed the insurance industry from any responsibility for ending that discrimination, instead placing the burden on a group which has far less interest in the provision of those benefits to the individuals who need them most.

Solving The Problem Of Mental Health Parity

The laws that have been passed so far are out of line with the basic ideology underlying mental health parity, which is that mental illness is a medical condition. Based on this premise, it is reasonable that sufferers of mental illness be able to expect treatment comparable to that which they would receive for any other illness. Any medical service plan that excludes coverage for psychological conditions is therefore unfairly discriminating against sufferers of a particular set of conditions in a way that has been outlawed when it has occurred in the past.

There are two main counter-arguments that can be made against this premise. The first is that mental illnesses are not medical conditions (Kershaw, 2008). However, as executive director of the Suicide Prevention Action Network USA in Washington Jerry Reed (2007) points out, a growing body of research has solidly established distinct physiological correlates of individual mental illnesses. Furthermore, mental illness results in a far greater number of fatalities each year than HIV/AIDS. There are nearly 30,000 mental illness-related suicides in the United States each year (Reed, 2007).

The second major counter-argument against our premise of mental health parity is that insurers should have the right to exclude certain classes of conditions as they see fit. As we have already discussed, legislative precedent contradicts this idea. Congress has already specifically outlawed this type of exclusion both for the elderly and for patients diagnosed with HIV/AIDS (Wellstone, 2002). This precedent takes on added weight when we consider that the level of fatality resulting from mental illness is much higher than that of the very disease for which Congress previously intervened.

Given, then, that the premise of mental health parity is sound, it becomes the duty of insurance providers to include mental health coverage as a part of basic medical benefit packages. Placing the burden of improving mental health coverage onto the individuals and organizations purchasing the coverage is not in keeping with the philosophy that mental illness and its treatments are equivalent and of equal importance to all other medical conditions and services. The way to implement that philosophy would be to require that insurance providers simply include mental health services under the existing terms of their coverage for general medical services.

Aside from being philosophically sound, this method of implementing mental health parity is also highly pragmatic. Insurers stand to benefit financially from offering better coverage for mental health services. Full mental health parity would represent a total cost increase of about 1.5% for most managed care organizations (Carroll, 2002). That increase would be more than offset within just a few years by the resulting reduction in general medical service utilization (Mumford et al, 1998). Employers, on the other hand, may stand to realize some increases in worker productivity as a result of better access to mental health services (see, for example, Wang, et al, 2007; Hartmann & Zepf, 2004; Hafner, Haug, & Kachele, 2004; Jordan, Grissom, Alonzo, Dietzen, & Sangsland, 2008), but ultimately have far less demonstrable interest in the provision of these services.

We therefore conclude that the most logical, feasible, and enforceable method of implementing mental health parity is to require insurance providers to include mental health treatments in their definitions of general medical treatments. By prohibiting the segregation of mental illness from physiological illness, equitable coverage is ensured without the substantial loopholes seen in the 1996 Parity Act and again in the 2008 Act. Furthermore, this method of enactment provides an ultimate financial benefit to the very organizations it holds responsible for implementation.

The problem in implementing this strategy is, of course, a political one. The insurance lobby is both exceptionally powerful and highly resistant to legislation which would increase its obligations. They have, unsurprisingly, supported legislation which offloads responsibility for mental health coverage onto businesses. For this reason, the business lobby seems like a natural ally in our attempts to redefine medical coverage to include mental health services. However, it is arguable that they have enough to gain to make substantial involvement worth their while.

The primary stakeholders in this redesignation seem to be healthcare providers and patient groups. Providers stand to gain from the opportunity to expand their mental health services, while patient groups have an interest in ensuring that comprehensive services are available. It may be possible to enhance the support of both groups by forming grass-roots organizations for individuals and families whose medical status has been affected by inadequate mental health care. These groups could act as emissaries between other stakeholder groups.

References

American Psychological Association (APA). (2008, October 3). Landmark victory: Mental health parity is now law [Press release]. Retrieved November 17, 2009 from http://www.apa.org/releases/parity-law1008.html

Bender, E. (2003). Cost, confidentiality keep many from MH treatment. Psychiatric News, 38(19), 13.

Bernstein, E. (2008, October 16). How New Law Boosts Coverage Of Mental Health Care. Wall Street Journal.  Retrieved November 17, 2009 from http://online.wsj.com/article/SB122411631825638659.html

Hafner, S., Haug, S., & Kachele, H. (2004). Need for mental health services in employees. Psychotherapeut 49(1), 7-14.

Hartmann, S., & Zepf, S. (2004). Improvement of general psychological functioning achieved by psychotherapy: A comparison of three psychotherapeutic methods. Psychotherapeut, 49(1), 27-36

Kershaw, S. (2008, March 20). The murky politics of mind-body. The New York Times, WK1-WK4.

Mumford, E., Schlesinger, H.J, Glass, G.V., Patrick, C., & Cuerdon, T. (1998). A New Look at Evidence About Reduced Cost of Medical Utilization Following Mental Health Treatment. Journal of Psychotherapy Practice and Research, 7, 65-86.

National Association of Social Workers (NASW). (2002). Mental Health Parity. Retrieved November 17, 2009, from http://www.socialworkers.org/advocacy/updates/2003/021103_mental.asp

United States Census Bureau. (2003). Statistical abstract of the United States: Population 1900 to 2002 (HS-1). Retrieved November 17, 2009 from http://www.census.gov/statab/hist/HS-01.pdf

Wellstone, P. (2002, June 19). It’s time to act on mental health parity issue. The Hill, p.42.

Wang, P.S., Simon, G.E., Avorn, J., Azoca, F., Ludman, E.J., McCulloch, J., Petukhova, M.Z., & Kessler, R.C. (2007). Telephone screening, outreach, and care management for depressed workers and impact on clinical and work productivity outcomes. JAMA: Journal of the American Medical Association, 289(12), 1401-1411.

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