Dorien Nieman

Fowler, P. J. (2017). Prevention in mental health care: Balancing neuroscience with social justice. [Review of the book Prevention in Mental Health Care: Time for a New Approach. D. Nieman]. PsycCRITIQUES, 62(26).

http://dx.doi.org/10.1037/a0040915

Abstract

Reviews the book, Prevention in Mental Health Care: Time for a New Approach by Dorien Nieman (see record 2016-52467-000 (record/2016-52467-000)). The book provides a novel integration of emerging advances in cognitive neuroscience with a phenomenological approach to mental health assessment and treatment. The synthesis reveals new opportunities for earlier identification and better response to psychological distress. Implications are immense for the future of mental health care; however, the focus on subjective experiences of human suffering must be balanced with collective action to eliminate the root causes of disparities in mental illness.

The future of prevention must include new and better clinical tools, but also continue to promote social justice. The balance better ensures population-level improvements in mental health. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

© 2017 American Psychological Association.

REVIEW

Prevention in Mental Health Care: Time for a New Approach by Dorien Nieman calls for a paradigm shift in defining and promoting mental health. It represents the most recent contribution to a long tradition of advocacy for mental health prevention training and practice (Albee, 1986; Albee & Dickey, 1957; O’Neil & Britner, 2009). The text expands prior work by highlighting the implications of recent advances in cognitive neuroscience on prevention and connects these advances with insights from Western philosophy on the human psyche. The synthesis of science in the context of the subjective experience of psychological distress represents a strength, yet the book pays little attention to the social justice issues that underlie disparities in human suffering around the world—a theme of prior calls for prevention and promotion of mental health.

Regardless, Prevention in Mental Health Care provides an interesting resource for practitioners in psychiatry, psychology, social work, and public health, as well as philosophers and artists describing the human experience.

The need for prevention and promotion has been a battle cry for a relatively small but persistent group of mental health professionals and researchers for at least 60 years. In 1957, George Albee and colleagues completed an analysis of the mental health workforce for the Joint Commission on Mental Illness and Health (Albee & Dickey, 1957). The commission aimed to identify strategies that would achieve provision of the National Mental Health Act of 1946, which included prevention of mental illness. Albee illustrated the structural deficiencies in training and practice that would make reducing the burden of mental illness impossible. He showed that the supply of clinicians could not keep up with the demand for treatment based on current practice and workforce projections. Albee expanded the argument throughout his distinguished career to advocate for different approaches to assessment and treatment, emphasizing primary prevention to reduce exposure to oppression and inequality that drove population rates of psychological distress (Albee, 1965, 1986, 2006). His legacy continues to motivate efforts outside of the mainstream of mental health professionals to develop policies and practices that promote mental well-being, such as in the Society for Community Research and Action, the Society for Prevention Research, and the Prevention Section of the Society of Counseling Psychology.

Prevention in Mental Health Care continues the tradition of advocating for prevention. The text focuses on the need for enhancements in the assessment of mental health that more directly connects with treatment. The first two chapters provide a wonderful synopsis of the problems with the current classification systems. Nieman clearly articulates the limitations of the Diagnostic Statistical Manual of Mental Disorders (DSM), as well as provides a clear explanation for its continued use. I especially appreciated recognition of the undue influence of the medical model in psychiatry and the various lobbies that actively maintain power. These dynamics were replicated in computer simulations that explored the lack of the mental health prevention workforce (Fowler, Brown, Fleming, & Hovmand, in press).

Nieman offers a phenomenological approach to assessment and treatment of mental illness as a needed antidote for the field. Instead of focusing on symptoms, she argues for paying greater attention to the lived experience of those seeking help in guiding directions for providing support. By listening, we may better differentiate normative pain experienced in life versus indication of mental illness, which she connects later in the book with existential and humanistic philosophers. The approach destigmatizes psychological distress, as well as provides greater opportunities for early and less intense intervention. This contrasts with the DSM that focuses on discovery of problems and fails to consider etiology or treatment in assessment.

The book provides insights from cognitive neuroscience as a potential method for phenomenological assessment. Referencing research on biological markers and clinical staging, the text emphasizes cognitive impairment as a useful framework for understanding and promoting mental health. Nieman reviews common cognitive impairments that underlie a host of mental health disorders, and she argues these are more reliably detectable through behavioral and biological assessments. Clinical examples also illustrate how impairments emerge in therapeutic situations and how they inform diagnosis and direct intervention. Prevention efforts would benefit in a couple of fundamental ways. Reliable assessments would quickly distinguish pervasive impairments that indicate need for more intensive rehabilitation, while more local impairments could inform humanistic interventions that help people endure difficult transitions, making mental health services more efficient. At the same time, assessments could also identify impairments prior to the manifestation of associated symptoms. This would revolutionize the application of preventive interventions tailored to individual capacities.

The promise of more efficient and individually tailored mental health prevention must be balanced with a greater recognition of the systematic injustices that drive rates of psychological distress. Prevention in Mental Health Care argues for a redesign of mental health services that explicitly recognizes pain and suffering as a valuable part of life. This is important and complements a long history of philosophical and religious traditions, such as the Buddhist distinction between pain and suffering. However, people in marginalized groups suffer more than others. Mental health care will struggle to keep up with demand for services until these systemic inequities are addressed.