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An introduction to health psychology
Mind and Body connection
CHAPTER OVERVIEW
This chapter examines the background against which health psychology developed in terms of (1) the traditional biomedical model of health and illness that emerged in the nineteenth century, and (2) changes in perspectives of health and illness over the twentieth century. The chapter highlights differences between health psychology and the biomedical model and examines the kinds of questions asked by health psychologists. Then the possible future of health psychology in terms of both clinical health psychology and becoming a professional health psychologist is discussed. Finally, this chapter outlines the aims of the textbook and describes how the book is structured.
This chapter covers:
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The background to health psychology
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What is the biomedical model?
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What are the aims of health psychology?
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What is the future of health psychology?
THE BACKGROUND TO HEALTH PSYCHOLOGY
During the nineteenth century, modern medicine was established. ‘Man’ (the nineteenth-century term) was studied using dissection, physical investigations and medical examinations. Darwin’s thesis, The Origin of Species, was published in 1856 and described the theory of evolution. This revolutionary theory identifed a place for Man within Nature and suggested that we were part of nature, that we developed from nature and that we were biological beings. This was in accord with the biomedical model of medicine, which studied Man in the same way that other members of the natural world had been studied in earlier years. This model described human beings as having a biological identity in common with all other biological beings.
WHAT IS THE BIOMEDICAL MODEL?
The biomedical model of medicine can be understood in terms of its answers to the following questions:
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What causes illness? According to the biomedical model of medicine, diseases either come from outside the body, invade the body and cause physical changes within the body, or originate as internal involuntary physical changes. Such diseases may be caused by several factors such as chemical imbalances, bacteria, viruses and genetic predisposition.
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Who is responsible for illness? Because illness is seen as arising from biological changes beyond their control, individuals are not seen as responsible for their illness. They are regarded as victims of some external force causing internal changes.
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How should illness be treated? The biomedical model regards treatment in terms of vaccination, surgery, chemotherapy and radiotherapy, all of which aim to change the physical state of the body.
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Who is responsible for treatment? The responsibility for treatment rests with the medical profession.
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What is the relationship between health and illness? Within the biomedical model, health and illness are seen as qualitatively different – you are either healthy or ill, there is no continuum between the two.
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What is the relationship between the mind and the body? According to the biomedical model of medicine, the mind and body function independently of each other. This is comparable to a traditional dualistic model of the mind–body split. From this perspective, the mind is incapable of influencing physical matter and the mind and body are defined as separate entities. The mind is seen as abstract and relating to feelings and thoughts, and the body is seen in terms of physical matter such as skin, muscles, bones, brain and organs. Changes in the physical matter are regarded as independent of changes in state of mind.
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What is the role of psychology in health and illness? Within traditional biomedicine, illness may have psychological consequences, but not psychological causes.
AN INTRODUCTION TO HEALTH PSYCHOLOGY
For example, cancer may cause unhappiness but mood is not seen as related to either the onset or progression of the cancer.
THE TWENTIETH CENTURY
Throughout the twentieth century, there were challenges to some of the underlying assumptions of biomedicine. These developments have included the emergence of psychosomatic medicine, behavioral health, behavioral medicine and, most recently, health psychology. These different areas of study illustrate an increasing role for psychology in health and a changing model of the relationship between the mind and body.
Psychosomatic medicine
The earliest challenge to the biomedical model was psychosomatic medicine. This was developed at the beginning of the twentieth century in response to Freud’s analysis of the relationship between the mind and physical illness. At the turn of the century, Freud described a condition called ‘hysterical paralysis’, whereby patients presented with paralyzed limbs with no obvious physical cause and in a pattern that did not reflect the organization of nerves. Freud argued that this condition was an indication of the individual’s state of mind and that repressed experiences and feelings were expressed in terms of a physical problem. This explanation indicated an interaction between mind and body and suggested that psychological factors may not only be consequences of illness but may contribute to its cause.
Behavioural health
Behavioural health again challenged the biomedical assumptions of a separation of mind and body. Behavioural health was described as being concerned with the maintenance of health and prevention of illness in currently healthy individuals through the use of educational inputs to change behaviour and lifestyle. The role of behaviour in determining the individual’s health status indicates an integration of the mind and body.
Behavioural medicine
A further discipline that challenged the biomedical model of health was behavioral medicine, which has been described by Schwartz and Weiss (1977) as being an amalgam of elements from the behavioral science disciplines (psychology, sociology, health education) and which focuses on health care, treatment and illness prevention. Behavioural medicine was also described by Pomerleau and Brady (1979) as consisting of methods derived from the experimental analysis of behaviour, such as behaviour therapy and behaviour modification, and involved in the evaluation, treatment and prevention of physical disease or physiological dysfunction (e.g. essential hypertension, addictive behaviours and obesity). It has also been emphasized that psychological problems such
As neurosis and psychosis are not within behavioural medicine unless they contribute to the development of illness. Behavioural medicine therefore included psychology in the study of health and departed from traditional biomedical views of health by not only focusing on treatment, but also focusing on prevention and intervention. In addition, behavioural medicine challenged the traditional separation of the mind and the body.
Health psychology
Health psychology is probably the most recent development in this process of including psychology into an understanding of health. It was described by Matarazzo as the
aggregate of the specific educational, scientific and professional contribution of the discipline
of psychology to the promotion and maintenance of health, the promotion and treatment of
illness and related dysfunction.
(Matarazzo 1980: 815)
Health psychology again challenges the mind–body split by suggesting a role for the mind in both the cause and treatment of illness but differs from psychosomatic medicine, behavioural health and behavioural medicine in that research within health psychology is more specific to the discipline of psychology.
Health psychology can be understood in terms of the same questions that were asked of the biomedical model:
¦ What causes illness? Health psychology suggests that human beings should be seen as complex systems and that illness is caused by a multitude of factors and not by a single causal factor. Health psychology therefore attempts to move away from a simple linear model of health and claims that illness can be caused by a combination of biological (e.g. a virus), psychological (e.g. behaviours, beliefs) and social (e.g. employment) factors. This approach reflects the biopsychosocial model of health and illness, which was developed by Engel (1977, 1980) and is illustrated in Figure 1.1. The biopsychosocial model represented an attempt to integrate the psychological (the ‘psycho’) and the environmental (the ‘social’) into the traditional biomedical (the ‘bio’) model of health as follows: (1) The bio contributing factors included genetics, viruses, bacteria and structural defects. (2) The psycho aspects of health and illness were described in terms of cognitions (e.g. expectations of health), emotions (e.g. fear of treatment), and behaviours (e.g. smoking, diet, exercise or alcohol consumption).
AN INTRODUCTION TO HEALTH PSYCHOLOGY
The social aspects of health were described in terms of social norms of behaviour
(e.g. the social norm of smoking or not smoking), pressures to change behaviour (e.g. peer group expectations, parental pressure), social values on health (e.g. whether health was regarded as a good or a bad thing), social class and ethnicity.
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Who is responsible for illness? Because illness is regarded as a result of a combination of factors, the individual is no longer simply seen as a passive victim. For example, the recognition of a role for behaviour in the cause of illness means that the individual may be held responsible for their health and illness.
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How should illness be treated? According to health psychology, the whole person should be treated, not just the physical changes that have taken place. This can take the form of behaviour change, encouraging changes in beliefs and coping strategies and compliance with medical recommendations.
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Who is responsible for treatment? Because the whole person is treated, not just their physical illness, the patient is therefore in part responsible for their treatment. This may take the form of responsibility to take medication, responsibility to change beliefs and behaviour. They are not seen as a victim.
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What is the relationship between health and illness? From this perspective, health and illness are not qualitatively di.erent, but exist on a continuum. Rather than being either healthy or ill, individuals progress along this continuum from healthiness to illness and back again.
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What is the relationship between the mind and body? The twentieth century has seen a challenge to the traditional separation of mind and body suggested by a dualistic model of health and illness, with an increasing focus on an interaction between the mind and the body. This shift in perspective is re.ected in the development of a holistic or a whole person approach to health. Health psychology therefore maintains that the mind and body interact. However, although this represents a departure from the traditional medical perspective, in that these two entities are seen as in.uencing each other, they are still categorized as separate – the existence of two di.erent terms (the mind/the body) suggests a degree of separation and ‘interaction’ can only occur between distinct structures.
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What is the role of psychology in health and illness? Health psychology regards psychological factors not only as possible consequences of illness but as contributing to its aetiology. Health Psychologists considers both a direct and indirect association between psychology and health. The direct pathway is re.ected in the physiological literature and is illustrated by research exploring the impact of stress on illnesses such as coronary heart disease and cancer. From this perspective the way a person experiences their life (‘I am feeling stressed’) has a direct impact upon their body which can change their health status. The indirect pathway is re.ected more in the behavioural literature and is illustrated by research exploring smoking, diet, exercise and sexual behaviour. From this perspective, the ways a person thinks (‘I am feeling stressed’) in.uences their behaviour (‘I will have a cigarette’) which in turn can impact upon their health. The direct and indirect pathways are illustrated in Figure 1.2.
WHAT ARE THE AIMS OF HEALTH PSYCHOLOGY?
Health psychology emphasizes the role of psychological factors in the cause, progression and consequences of health and illness. The aims of health psychology can be divided into (1) understanding, explaining, developing and testing theory and (2) putting this theory into practice.
1 Health psychology aims to understand, explain, develop and test theory by:
(a)
Evaluating the role of behaviour in the aetiology of illness. For example:
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Coronary heart disease is related to behaviours such as smoking, food intake, lack of exercise.
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Many cancers are related to behaviours such as diet, smoking, alcohol and failure to attend for screening or health check-ups.
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A stroke is related to smoking, cholesterol and high blood pressure.
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An often overlooked cause of death is accidents. These may be related to alcohol consumption, drugs and careless driving.
(b)
Predicting unhealthy behaviours. For example:
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Smoking, alcohol consumption and high fat diets are related to beliefs.
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Beliefs about health and illness can be used to predict behaviour.
(c)
Evaluating the interaction between psychology and physiology. For example:
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The experience of stress relates to appraisal, coping and social support.
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Stress leads to physiological changes which can trigger or exacerbate illness.
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Pain perception can be exacerbated by anxiety and reduced by distraction.
(d)
Understanding the role of psychology in the experience of illness. For example:
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Understanding the psychological consequences of illness could help to alleviate symptoms such as pain, nausea and vomiting.
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Understanding the psychological consequences of illness could help alleviate psychological symptoms such as anxiety and depression.
AN INTRODUCTION TO HEALTH PSYCHOLOGY 7
(e) Evaluating the role of psychology in the treatment of illness. For example:
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If psychological factors are important in the cause of illness they may also have a role in its treatment.
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Changing behaviour and reducing stress could reduce the chances of a further heart attack.
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Treatment of the psychological consequences of illness may have an impact on longevity.
2 Health psychology also aims to put theory into practice. This can be implemented by:
(a)
Promoting healthy behaviour. For example:
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Understanding the role of behaviour in illness can allow unhealthy behaviours to be targeted.
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Understanding the beliefs that predict behaviours can allow these beliefs to be targeted.
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Understanding beliefs can help these beliefs to be changed.
(b)
Preventing illness. For example:
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Changing beliefs and behaviour could prevent illness onset.
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Modifying stress could reduce the risk of a heart attack.
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Behavioural interventions during illness (e.g. stopping smoking after a heart attack) may prevent further illness.
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Training health professionals to improve their communication skills and to carry out interventions may help to prevent illness.
WHAT IS THE FUTURE OF HEALTH PSYCHOLOGY?
Health psychology is an expanding area in the UK, across Europe, in Australia and New Zealand and in the USA. For many students this involves taking a health psychology course as part of their psychology degree. For some students health psychology plays a part of their studies for other allied disciplines, such as medicine, nursing, health studies and dentistry. However, in addition, to studying health psychology at this preliminary level, an increasing number of students carry out higher degrees in health psychology as a means to develop their careers within this .eld. This has resulted in a range of debates about the future of health psychology and the possible roles for a health psychologist. To date these debates have highlighted two possible career pathways: the clinical health psychologist and the professional health psychologist.
The clinical health psychologist
A clinical health psychologist has been de.ned as someone who merges ‘clinical psychology with its focus on the assessment and treatment of individuals in distress . . . and the content .eld of health psychology’ (Belar and Deardor. 1995). In order to practise as a clinical health psychologist, it is generally accepted that someone would .rst gain training as a clinical psychologist and then later acquire an expertise in health psychology, which would involve an understanding of the theories and methods of
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