What is Health Psychology: Yesterday and Today

What is Health ?
What is Health psychology?
Methods and perspectives in psychology

Early History
The development of health psychology as a discipline
The early stages:
          Applying the principles of behaviorism to health
      Expansion to include cognition and personality  
      More attention on coping  

Why has Health psychology come into prominence?  
         Changing profiles of health and illness in Canada  
        Multiple perspectives are needed

Health Psychology today  
        A biopsychosocial Approach
        Prominent theories

Working in health Psychology  
        Clinical and counseling psychologists
        Research Careers in health psychology

International Health Psychology

  What is Health?
Marks, Murray, Evans & Estacio (2011) present several models of health, including a historical account of its philological roots. The term arises from old English and Old German terms of Hale, Whole, Holy and Heil or Hail. These gave rise to the greeting "Hello". Here one can see the interest in wholeness, being un harmed or morally good.

They present the ideas of Galen (CE129-200)on health based upon his system of humours

Marks et al. present more modern conceptions that include need satisfaction as seen in Maslow's (1943) hierarch of needs with an emphasis on agency, autonomy and spirituality.

Doyal & Gough (1991) expand on this suggesting that there are 11 intermediate needs.
1.Adequate nutritional food and water     7.Significant primary relationships with others
2.Adequate protective housing                8.Physical security    
3.A safe environment for working            9.Economic security   
4.A safe physical environment                10.Safe birth control and child-bearing
5.Appropriate healthcare                        11.Appropriate basic and cross-cultural education
6.Security in childhood

Ultimately they introduce the notion that our culture and values will determine our notions of Health and other psychological abilities.

Most "western" notions of health focus on individualism and the "medical model" of disease without little regard for environmental (i.e. toxic or obesogenic) qualities.

Alternatively one might consider a more communitarian approach that include social justice, political and power issues.

What is Health psychology?

 Health psychology involves psychology's primary role in the science and profession of behavioural medicine and health care practices, disease development, treatment and prevention.


Methods and Perspectives in Psychology

Typically health psychology makes use of the same methods and perspectives of general psychology.

Psychology is built upon the hypothetical deduction model of theory and research. This means that psychologists work to develop theories that give rise to specific hypotheses about the outcomes of experiments or research studies.

Statistical tools are used to help make decisions about hypotheses and theories through a process called inferential statistics.  As such no theory is ever really proven (only falsified) but is accepted or acknowledged as probable based upon the likelihood that similar results could occur due to chance or random variation in the sample.

Theories and models abound, but often are presented in a piecemeal fashion where few or no grand or over arching theories exist.  As such we have many many “theories” that are applied to various aspects of human behaviour and psychology.

Scientific perspectives are also accepted by psychologists and other scientists as “givens” that guide their thinking and provide a framework for their research and models.

Multiple perspectives exist within psychology, each providing a ‘paradigm’ for what is the nature of reality and  understanding what counts as evidence.

When two or more competing models of explanation come head to head, proponents of each attempt to make the case for their theory, like barristers making a case in a court of law. 

As in that context, the rules of decision making are also human products where there may be debates over the rules of evidence as well as the results.

Marks et al discuss evidence based research, which has become prominent in resent years, but point out that it too is biased with assumptions, values and limitations in developing "knowledge".

These types of practices are judged to be sound based upon the assumptions of epistemology and methodology.

Critical thinking is important, as well as a readiness to consider alternate models as correct.

As such, Marks et al point out that a cross-cultural approach might better suited for understanding Health Psychology insofar as our notions of health and healing are grounded in the worldviews and values that we hold.

The Health Onion is:
1. Wholistic,
2. Concerned with all health determinants ( not just treatment),
3. Based on individuals at the core then layers of community, living and working, socio-economic, cultural and physical environmental determinants,
4. Places each layer in context of its neighbours (with structural constraints),
5. interdisciplinary,
6.makes no claim of layers being more important than others,
7. acknowledges the complex nature of health determinants.

Here it is important to consider the global perspectives of Natural and Human science as drivers behind the practices that psychologists follow in their research or knowledge production of health experiences.

Table 1.5 presents important features of these views.

Other methods used (See Marks et al (2015):(Participatory) Action Research; Diaries, Blogs and Narratives; Discourse Analysis, Ethnographic Methods; Focus Groups, Grounded Research; Historical Analysis; Intrepretive-Phenomenological Analysis; Interviews; Power Analysis...

Early History

Psychosomatic Medicine begins with Studies in Hysteria (1895) by Sigmund Freud and Joseph Breuer who outlined the relationship between the mind and body, showing that the mind can cause physiological symptoms.

Mind-Body Problem revisited -Cartesian Dualism - Mind affects body & body affects minds

Health Psychology had a more formal beginning as early as 1911 when APA had a symposium on "The Relations of Psychology and Medical Education"

First world war found psychologists working in applied areas where people like Ned Bott (1887-1974) at the University of Toronto began studies and practice in the rehabilitation of soldiers returning from war.  Not only did he develop machines to carryout physical therapy (mechanotherapy) but he also recognized the mind and the active role of the individual in his or her rehabilitation.

 Also in  the early part of the 20th century physiological studies examined aspects of human biology that later became standard studies in biological psychology, such as those by Walter Cannon (1935) on stress and strain in the autonomic nervous system.

 World Health Organisation (WHO) recognized the physical, mental and social components to being healthy and enjoying a good quality of life in the 1940s post war time.

Wolff (1950) brought to bear the relationship between  stress and adaptation in health and disease states

Hans Selye (1956), The Stress of Life, interest grew on the  relationship between thoughts and physiology (akin to placebo effects).

Schwartz & Weiss (1977) Behavioural Medicine is born out of psychosomatic medicine

Behavioural Medicine emerged later (1977) as a broad and interdisciplinary field of study that involves: scientific investigation, clinical practice, and education that addresses health, illness, and related physiological functions.

Topics include: Stress & Coping, Coronary Heart Disease, Hypertension, Pain, Smoking, Food abuse/disorders, Ulcers, Migraines, Asthma, Diabetes, Compliance with Medical Intervention, Patient & Care Provider Behaviours.

Development of Health Psychology as a Discipline

According to your text the development of health psychology as a discipline  begins with behavioural medicine and the Yale Conference of 1977.

          The early stages: Applying the principles of behaviorism

1983 –Neal Miller’s article outlines behavioural medicine as the synthesis of laboratory research and applied clinical work.

He outlines the biomedical model that is based upon germ theory, suggesting that disease arises through infecting of bacteria or other micro-organisms.  

Miller came from a  behaviourist background but also was involved in bridging it with psychoanalysis. His work came to focus on the relationship between behaviour, personality and health reframing other concepts in terms of behavioural reinforcement.


        Expansion to include cognition and personality

Krantz in the 1980s also came to review the field but brought more attention to mental (cognitive) and idiosyncratic (personality) factors than did Miller’s review.

Type A personality came to garner a great deal of attention and methods of cognitively restructuring one’s situation came to be more prominent as a form of therapy, as part of the larger ‘cognitive revolution’ in psychology.

        More attention on coping and responses to stress came to the forefront during the 1980s as well, as Health Psychology was taking a larger profile in the field. Thus coping styles such as blunters and monitors were emerging as psychology was turning toward more individual attributions of disease.

        Psychoneuroimmuniology (PNI) – Is another area of health psychology that has emerged since the 1980s.  With a greater emphasis on the immunological aspects of HIV/AIDs and Cancer, more and more attention was paid to the relationship between the mind and the immune system. 

Technological advances in the study of immunocompetence also made possible the detailed analysis of psychological states and immune responses.


Why has Health Psychology come into Prominence?

         Changing profiles of health and illness in Canada

As in the united states, health and illness profiles have changed over the past century. What were once regular concerns are no longer of great concern while other diseases are of greater concern to our aging population. (See figure 1-1)  

Lifestyles have also changed with mechanization and more ‘whitecollar work’ while activity and diet have come into focus as well ( see figure 1-2)

Canadians have indicated that Health Care (and education) are of highest importance. Psychologists too are turning more and more towards issues of health as part o their research and practice.  

Marks et al also discuss global trends in mortality statistics.

 Furthermore they also present a refinement of epidemiological statistics in the form of Disability Adjusted Life Years (DALY) "the sum of years of life lost from premature mortality plus years of life with disablement adjusted for severity of disablement from all causes, both physical and mental." (p. 13)

      Multiple perspectives are needed

Poole et al (2008) identify the role that studying health psychology plays in understanding statistics about medical issues, including reports from <health Canada> For example when considering reports about cancer biomedical researchers will focus on one aspect of the disease, while psychologists will likely focus on another.

 Economists, sociologists and medical geographers will focus on other aspects of health and illness as well as medical anthropologists and epidemiologists. 

As they also report, Engel (1997) introduced the biopsychosocial approach.

Marks et al report that this bio-psycho-social approach tends to be a refined version of the natural science "medical model"  which may be contrasted with a Human Science narrative, social representative or social constructionist perspective.

Health Psychology Today

      A bio-psycho-social approach

Has taken a forward role in the field in contemporary health psychology. While it to the forefront in the 1980s it has a long standing tradition elsewhere in psychology and philosophy of science.

This is seen in the works of Erik Erikson, John Dewey, Wilhelm Wundt and Karl Popper among others.

 The BPS approach implies that clear communication among social science researchers and health care providers is crucial to understand the big picture of health and illness.

Medical practitioners typically are grounded in the perspective of the biomedical model while other researchers may be more concerned with social relations, interactions and the role of the mind and subjective experiences.


      Prominent theories in health psychology

1) Health Belief Model  (HBM)– stipulates that we have ideas that we believe to be true that have an impact on our health (Becker, 1974; Rosenstock, 1974 cited in Poole et al, 2005).  In particular beliefs about behaviours and their impact on health are of interest. 

Health belief systems, or clusters of ideas are also of interest insofar as they may be related such as inevitability, impact of consequences, and ability to control. 

 Examples gives include: efficacy belief or one’s estimate of the workability of a course of action or treatment as well as cost-gain belief that pertains to one’s evaluation of the outcome of an action.

<See table 1-1> for beliefs regarding HIV/AIDS

An individual may harbour contradictory beliefs which may or may not be resolved by cognitive dissonance.

Values also play a role here where one may hold a health belief but place little or no value in good health.

There may also be economic, gender and political differences in the affordability of holding or valuing specific health beliefs.

The health belief model has had variable success in predicting health behaviour. Some studies reported by Poole et al report some success while others have had little.

  <See Table 1-2>

2) Theory of Reasoned Action (TRA) – is similar to the belief model but it assumes that prior to action is intention (Fishbein & Ajzen, 1975). 

It involves both attitudes about specific behaviours as well as one’s beliefs about others’ perceptions and expectations as they play a role in our development of subjective norms.  

Based upon our own understanding of our attitudes and subjective norms we develop intentions for action.

<see Table 1-3> for examples of two possible outcomes.

According to Poole et al., The Theory or Reasoned Action does a good job to predict HIV risk avoiding behaviour and cancer screening behaviour.

3) Theory of Planned Behaviour (TPB)- is an extension and 'update' on the TRA.  It is expected to provide increased predictive power based upon perceived behavioural control[over and above intentions or beliefs] (Fishbein & Azjen, 1975).

Locus of Control is central to this theory which pertains to one’s perception of one’s ability to control one’s fate or the outcome of a disease or condition.

Various measures have been developed such as the Multidimensional Health Locus of Control Scale (MHLC) for assessment and prediction of behaviour. This provides scores on three scales: internal, external and “powerful other.” 

 Institutionalization often leads to loss of control and lesser health outcomes.

Learned helplessness is a condition resulting from severe loss of control and has been associated with depression and poor health.

Gurung (2006) discusses the cultural aspects of planned behaviour, indicating that it applies differently in different cultures, e.g. increased peer influence on adolescent smoking among Whites & Latinos vs. African Americans in contrast to the increased parental influence on alcohol use among African Americans vs. than whites. 

 Here the subjective norms (cultural values) may add predictive value to the TPB.

4) The stages of Change model : The Trans-theoretical Model – describes the ways in which carryout change through six stages (Prochaska & DiClemente, 1983). Eg, smoking cessation.

1) precontemplation, 2) contemplation, 3) preparation 4) action, 5) maintenance, 6) termination, (7? relapse). 


Working in Health Psychology

        Clinical and counseling psychologists
Research Careers in health psychology

International Health Psychology

Aboud (1998) has extended the general model of health psychology to an international perspective which covers such topics as:

Genetic and biological factors (sickle cell anemia, age, gender)
Physical environment (viruses, parasites, food availability)
Health Services (skills, motivation, habits, attitude, of staff)
Health Behaviours (infant care, eating, hygiene, family planning)
Political, Economic, & Social Institutions (education, family, religion, commerce, entertainment)

Study Questions