Health PsychologyHealth Psychology

Past, Present, and PotentialPast, Present, and Potential

Cynthia D. Belar, Ph.D., ABPPCynthia D. Belar, Ph.D., ABPP

◊ Historical PerspectivesHistorical Perspectives◊ Growth of Education and TrainingGrowth of Education and Training◊ Growth of ResearchGrowth of Research◊ Growth of Professional Growth of Professional

Practice/ApplicationsPractice/Applications◊ Potential (and preparation)Potential (and preparation)

Health PsychologyHealth Psychology

The aggregate of the specific educational, The aggregate of the specific educational,

scientific, and professional contributions of the scientific, and professional contributions of the discipline of psychology to the promotion and discipline of psychology to the promotion and maintenance of health; the prevention and maintenance of health; the prevention and treatment of illness; the identification of etiologic treatment of illness; the identification of etiologic and diagnostic correlates of health, illness and and diagnostic correlates of health, illness and related dysfunctions; and the improvement of the related dysfunctions; and the improvement of the health care system and health policy formation. health care system and health policy formation.

(Matarazzo, 1980, 1982, 2001)

Key Features of Health PsychologyKey Features of Health Psychology

◊ BreadthBreadth◊ Biopsychosocial modelBiopsychosocial model◊ Focus on prevention and health Focus on prevention and health

promotion as well as illness and promotion as well as illness and rehabilitationrehabilitation

◊ Focus on cost-effectivenessFocus on cost-effectiveness◊ Interdisciplinary collaborationInterdisciplinary collaboration

◊ Clinical Health PsychologyClinical Health Psychology professional practice of health psychologyprofessional practice of health psychology

◊ Behavioral MedicineBehavioral Medicine interdisciplinary field to which health interdisciplinary field to which health

psychologists contributepsychologists contribute

Historical PerspectivesHistorical Perspectives

◊ Ancient GreeceAncient Greece

◊ Middle AgesMiddle Ages

◊ RenaissanceRenaissance

1818thth Century Century

““the reason why a sound body becomes the reason why a sound body becomes ill, or an ailing body recovers, very ill, or an ailing body recovers, very often lies in the mind” (Gaub, cited in often lies in the mind” (Gaub, cited in Lipowski, 1977)Lipowski, 1977)

1919thth Century Century

◊ ““psychosomatic” (Heinroth)psychosomatic” (Heinroth)◊ Benjamin RushBenjamin Rush◊ Sigmund FreudSigmund Freud◊ Walter B. CannonWalter B. Cannon◊ Ivan PavlovIvan Pavlov

2020thth Century CenturyFormalization as a Field of InquiryFormalization as a Field of Inquiry

Two major frameworks: Two major frameworks: psychodynamic and psychophysiologicpsychodynamic and psychophysiologic ◊ 1938 – 1938 – Psychosomatic MedicinePsychosomatic Medicine◊ 1942 – American Psychosomatic Society1942 – American Psychosomatic Society◊ Helen Flanders DunbarHelen Flanders Dunbar◊ Franz Alexander Franz Alexander ◊ Harold G. WolffHarold G. Wolff◊ Edmund JacobsonEdmund Jacobson◊ Hans SelyeHans Selye

◊ ““Comprehensive Medicine” (Guze, Comprehensive Medicine” (Guze, Matarazzo, & Saslow, 1953)Matarazzo, & Saslow, 1953)

◊ ““Biopsychosocial Model” (Engel, Biopsychosocial Model” (Engel, 1977)1977)

◊ Neal Miller (1969)Neal Miller (1969)◊ Wilbert Fordyce (1976)Wilbert Fordyce (1976)◊ Robert Ader (1974)Robert Ader (1974)

2020thth Century Century

Landmark EventsLandmark Eventsinin

Organized Psychology Organized Psychology

1969 - 1969 - The Role of Psychology in the The Role of Psychology in the Delivery of Delivery of

Health ServicesHealth Services (Schofield) (Schofield)

1975 - Section on Health Research in APA 1975 - Section on Health Research in APA Division of Public Service Division of Public Service

1977 - Yale Conference on Behavioral 1977 - Yale Conference on Behavioral MedicineMedicine

19781978

Growth of Education and TrainingGrowth of Education and Training

◊ Early 1980’s – opportunities for E&T in HPEarly 1980’s – opportunities for E&T in HP• 42 doctoral 42 doctoral (Belar, Wilson & Hughes, 1982)(Belar, Wilson & Hughes, 1982)• 48 internships 48 internships (Gentry, Street, Masur & Asken, (Gentry, Street, Masur & Asken,

1981)1981)• 43 postdoctoral 43 postdoctoral (Belar & Siegel, 1983)(Belar & Siegel, 1983)

◊ 1983 - Arden House Conference defines 1983 - Arden House Conference defines education and training in Health Psychologyeducation and training in Health Psychology

Core Knowledge Domains Core Knowledge Domains

◊ Biological bases of health, disease and behaviorBiological bases of health, disease and behavior (basic (basic anatomy and physiology, pathophysiology, anatomy and physiology, pathophysiology, pharmacology, psychoneuroimmunology, pharmacology, psychoneuroimmunology, psychophysiology, neuroendocrinology)psychophysiology, neuroendocrinology)

◊ Cognitive-affective bases of health, disease and behaviorCognitive-affective bases of health, disease and behavior (how learning, memory, perception, cognition, thinking, (how learning, memory, perception, cognition, thinking, motivation and emotions influence health behaviors, are motivation and emotions influence health behaviors, are affected by physical illness/injury/disability, and can affected by physical illness/injury/disability, and can affect response to illness/injury/disability)affect response to illness/injury/disability)

Core Knowledge DomainsCore Knowledge Domains◊ Social bases of health, disease and behaviorSocial bases of health, disease and behavior (impact of (impact of

relationships [including physician-patient relationships], relationships [including physician-patient relationships], social support, culture, religion, workplace, health policy social support, culture, religion, workplace, health policy and organization of health care delivery systems on and organization of health care delivery systems on health and help-seeking)health and help-seeking)

◊ Psychological bases of health,disease and behaviorPsychological bases of health,disease and behavior (behavioral risk factors for disease/injury/disability and (behavioral risk factors for disease/injury/disability and nonadherence to medical regimens; relationships among nonadherence to medical regimens; relationships among stress,coping and health outcomes; developmental issues stress,coping and health outcomes; developmental issues in health and illness; impact of psychopathology on in health and illness; impact of psychopathology on illness and treatment; issues of diversity and health,e.g., illness and treatment; issues of diversity and health,e.g., gender, sexual orientation)gender, sexual orientation)

Core Domains of Knowledge & SkillCore Domains of Knowledge & Skill

◊ Health research methodsHealth research methods◊ Health assessment, consultation, and Health assessment, consultation, and

interventions interventions • individual, families, groups, organizations, communitiesindividual, families, groups, organizations, communities• primary, secondary and tertiary preventionprimary, secondary and tertiary prevention

◊ Program development and evaluationProgram development and evaluation◊ Management and supervisionManagement and supervision◊ Ethical, legal and professional issuesEthical, legal and professional issues◊ Interdisciplinary collaborationInterdisciplinary collaboration

◊ 1990 – health psychology was the most 1990 – health psychology was the most frequently noted area of faculty research in frequently noted area of faculty research in APA accredited clinical psychology APA accredited clinical psychology doctoral programsdoctoral programs

◊ 2004 – 3 APA accredited postdoctoral 2004 – 3 APA accredited postdoctoral programsprograms in in clinical health psychologyclinical health psychology

Growth in ResearchGrowth in Research◊ 1979 - U.S. Department of Health, Education 1979 - U.S. Department of Health, Education

and Welfare. and Welfare. Healthy People: The Surgeon Healthy People: The Surgeon General’s Report on Health Promotion and General’s Report on Health Promotion and Disease Prevention.Disease Prevention.

◊ 1982 - Institute of Medicine. 1982 - Institute of Medicine. Health and Health and Behavior: Frontiers of Research in the Behavior: Frontiers of Research in the Biobehavioral SciencesBiobehavioral Sciences ( (50% of mortality 50% of mortality from the 10 leading causes of death in the U. from the 10 leading causes of death in the U. S. can be traced to behavior/lifestyle factors)S. can be traced to behavior/lifestyle factors)

Establishment of JournalsEstablishment of Journals

1978 – 1978 – Journal of Behavioral MedicineJournal of Behavioral Medicine

1982 – 1982 – Health PsychologyHealth Psychology

1986 1986 – Journal of Psychology and Health– Journal of Psychology and Health

Behavior in Medical Journals Behavior in Medical Journals (Suls and Rothman, 2004)(Suls and Rothman, 2004)

◊ NEJM, Lancet, JAMA, Annals of Internal NEJM, Lancet, JAMA, Annals of Internal MedicineMedicine

◊ ““behavior” behavior” doubleddoubled from 1974-2001 from 1974-2001

(total # of articles increased by 3%)(total # of articles increased by 3%)◊ BUT – increase is from .002% of total BUT – increase is from .002% of total

articles to .004% (starting in 1986-89)articles to .004% (starting in 1986-89)

20012001

Growth of Professional Practice Growth of Professional Practice

1984 - American Board of Health Psychology 1984 - American Board of Health Psychology incorporated (ABHP)incorporated (ABHP)

1991 - Board certification recognized by American 1991 - Board certification recognized by American Board of Professional Psychology (ABPP)Board of Professional Psychology (ABPP)

1997 - APA Council of Representatives recognizes 1997 - APA Council of Representatives recognizes Clinical Health Psychology as a specialtyClinical Health Psychology as a specialty

1998 - ABHP renamed as American Board of 1998 - ABHP renamed as American Board of Clinical Health PsychologyClinical Health Psychology

Service Areas for Health PsychologyService Areas for Health Psychology1. Prevention of illness/injury1. Prevention of illness/injury2. Coping with illness2. Coping with illness3. Preparation for stressful medical3. Preparation for stressful medical proceduresprocedures4. Adherence to medical regimens4. Adherence to medical regimens5. Management of physical symptoms 5. Management of physical symptoms 6. Management of psychophysiological6. Management of psychophysiological

disordersdisorders7. Problems of health care providers and7. Problems of health care providers and health care systems. health care systems. 8. Mental health disorders8. Mental health disorders

There are a variety of service areas for the There are a variety of service areas for the application of knowledge in health application of knowledge in health psychology. psychology.

Interventions can occur at a variety of levelsInterventions can occur at a variety of levels..◊ Individual/FamilyIndividual/Family◊ Health Care ProviderHealth Care Provider◊ Health Care SystemHealth Care System◊ PopulationPopulation◊ Health PolicyHealth Policy

#1#1

Prevention of illness/injuryPrevention of illness/injury

Traumatic InjuriesTraumatic Injuries

◊ Reckless drivingReckless driving◊ Poor body mechanicsPoor body mechanics◊ FallsFalls◊ Seatbelts/helmetsSeatbelts/helmets◊ Toxic storageToxic storage◊ Interpersonal violenceInterpersonal violence

Behavioral Risk FactorsBehavioral Risk Factors

◊ Tobacco useTobacco use◊ DietDiet◊ ExerciseExercise◊ Unsafe sex Unsafe sex ◊ Alcohol and substance useAlcohol and substance use

#2#2

Coping with illnessCoping with illness

Social SupportSocial Support

◊ Post MI survival (Berkman, 1995)Post MI survival (Berkman, 1995)

◊ Hemodialysis survival (Christensen et Hemodialysis survival (Christensen et

al., 1994)al., 1994)

Myocardial InfarctionMyocardial Infarction◊ depression increases risk of mortality depression increases risk of mortality

independent of cardiac disease severityindependent of cardiac disease severity◊ impact of depression is as great as impact of depression is as great as

previous MI and impaired left previous MI and impaired left ventricular ejection fractionventricular ejection fraction

◊ anxiety and anger directed inward also anxiety and anger directed inward also increase riskincrease risk

Frasure-Smith et al., 1995

Recovery from IllnessRecovery from Illness Acute Myocardial Acute Myocardial

InfarctionInfarction◊ patients with high anxiety in the 48 patients with high anxiety in the 48

hours after AMI had 4.9 times risk for hours after AMI had 4.9 times risk for developing complicationsdeveloping complications

◊ risk independent of clinical indicatorsrisk independent of clinical indicators

Moser & Dracup, 1996

Interventions are more than Interventions are more than health education.health education.

◊ Social supportSocial support◊ Emotional supportEmotional support◊ Systematic behavior changeSystematic behavior change◊ Increased self-efficacyIncreased self-efficacy

#3#3

Preparation for stressful Preparation for stressful medical proceduresmedical procedures

Recovery from SurgeryRecovery from SurgeryMeta-analysisMeta-analysis

◊ N = 191 studies, major and minor surgeryN = 191 studies, major and minor surgery◊ InterventionsInterventions

• informationinformation• skill-buildingskill-building• supportsupport

◊ OutcomeOutcome• 79-84% of studies reported beneficial effects79-84% of studies reported beneficial effects• length of stay decreased by an average of 1.5 length of stay decreased by an average of 1.5

daysdays

Devine, 1992

#4#4Adherence to Medical RegimensAdherence to Medical Regimens

◊ 1 out of 6 hospitalizations of seniors (GAO, 1 out of 6 hospitalizations of seniors (GAO, 1995) 1995)

◊ 10% of all hospital admissions (DHHS, 1990)10% of all hospital admissions (DHHS, 1990)◊ 2/3 not taking therapeutic dose of BP 2/3 not taking therapeutic dose of BP

medication (JAMA, 1989)medication (JAMA, 1989)◊ 50% of 1.6 billion prescriptions taken 50% of 1.6 billion prescriptions taken

incorrectlyincorrectly

#5#5Management of Physical Management of Physical

SymptomsSymptoms

◊ Asthmatic episodesAsthmatic episodes◊ PainPain◊ Fecal incontinenceFecal incontinence◊ Anticipatory nauseaAnticipatory nausea◊ VasospasmsVasospasms

◊ DyspneaDyspnea◊ HeadacheHeadache◊ Muscle spasmsMuscle spasms◊ InsomniaInsomnia◊ Cramping/diarrheaCramping/diarrhea

COPD Rehabilitation ProgramCOPD Rehabilitation Program

Talcott et al., 1996

Inpatient Days Outpatient Visits ER Visits0

1

2

3

4

5

6

7

Pre

Post

Arthritis Self-ManagementArthritis Self-Management

Lorig et al., 1993

N = 401

Physical Disability 9% Increase

Visits to Physicians 43% Decrease

Pain 20% Decrease

Sense of Self-efficacy Significant Increase

Fecal IncontinenceFecal Incontinence◊ 1.2% over age 601.2% over age 60◊ 2nd most common reason for institutionalizing the 2nd most common reason for institutionalizing the

elderlyelderly◊ BF is treatment of choice when caused by nerve BF is treatment of choice when caused by nerve

injuries resulting in weakness of external anal injuries resulting in weakness of external anal sphincter or impaired ability to detect rectal sphincter or impaired ability to detect rectal distention (est. 60-70% of adult patients)distention (est. 60-70% of adult patients)

◊ 72% of patients obtain at least 90% reduction72% of patients obtain at least 90% reduction

Whitehead et al., 1996

#6#6Psychophysiological DisordersPsychophysiological Disorders

◊ Irritable Bowel SyndromeIrritable Bowel Syndrome◊ Migraine HeadacheMigraine Headache◊ Tension HeadacheTension Headache

#7#7Problems of health care Problems of health care

providers and health care providers and health care systemssystems. .

Medical Decision-MakingMedical Decision-Making

◊ Surgery (pain, ICD)Surgery (pain, ICD)◊ Organ transplantationOrgan transplantation◊ Complex management (home dialysis, Complex management (home dialysis,

home ventilator)home ventilator)◊ Fertility treatmentsFertility treatments

Needs of Other Health Needs of Other Health ProfessionalsProfessionals

◊ Education and TrainingEducation and Training◊ Physician-Patient CommunicationPhysician-Patient Communication◊ Implementation of Practice GuidelinesImplementation of Practice Guidelines◊ Burnout PreventionBurnout Prevention

Needs of Health Care Needs of Health Care OrganizationsOrganizations

Needs of Health Care Needs of Health Care OrganizationsOrganizations

◊ Self-Help ProgramsSelf-Help Programs◊ Program Development Program Development

• disease managementdisease management• staff developmentstaff development• community outreachcommunity outreach• Infection controlInfection control

DiabetesDiabetes◊ n = 11 studies, self-management trainingn = 11 studies, self-management training◊ FBS level improvementFBS level improvement◊ Reduction in diabetes-related hospitalizationsReduction in diabetes-related hospitalizations◊ Reduction in serious foot lesionsReduction in serious foot lesions◊ Reduction in diabetes-related health care costsReduction in diabetes-related health care costs◊ Need: Need:

• extensive use of behavior change strategiesextensive use of behavior change strategies• integrated teamintegrated team

Clement, 1995

#8#8Mental health disordersMental health disorders

U.S. Surgeon General ReportsU.S. Surgeon General Reports

1999, 2000, 20011999, 2000, 2001

◊ 1 in 5 American adults experience a 1 in 5 American adults experience a mental disorder in a given yearmental disorder in a given year

◊ 1 in 10 children and adolescents1 in 10 children and adolescents◊ 1 in 5 older persons1 in 5 older persons

Most Americans seek mental health Most Americans seek mental health care from their family physician.care from their family physician.

◊ 50% of all individuals with a mental 50% of all individuals with a mental disorder go to primary care providersdisorder go to primary care providers

◊ 80% of psychotropic medication is 80% of psychotropic medication is prescribed by primary care providersprescribed by primary care providers

◊ Patients have long-standing Patients have long-standing relationships with primary care relationships with primary care providersproviders

ProblemProblem

50-66% of mental health problems are 50-66% of mental health problems are not detected by primary care providersnot detected by primary care providers• lack of knowledgelack of knowledge• lack of training and experiencelack of training and experience• poor interviewing skillspoor interviewing skills• lack of timelack of time

Need for Integration of Psychological Need for Integration of Psychological Services in Primary CareServices in Primary Care

◊ Acknowledges the defeat of mind-body Acknowledges the defeat of mind-body dualismdualism

◊ Facilitates dealing with high comorbidity of Facilitates dealing with high comorbidity of medical and psychological problemsmedical and psychological problems• pain-depressionpain-depression• COPD-anxietyCOPD-anxiety

◊ Reduction in overall health care costsReduction in overall health care costs

Why has there been such growth Why has there been such growth in Health Psychology?in Health Psychology?

◊ Deficiencies in biomedical modelDeficiencies in biomedical model◊ Increased maturity of behavioral science Increased maturity of behavioral science

research and practiceresearch and practice◊ Increased disease burden from chronic diseaseIncreased disease burden from chronic disease◊ HIV/AIDS epidemicHIV/AIDS epidemic◊ Focus on prevention Focus on prevention ◊ Increased concern with quality of lifeIncreased concern with quality of life◊ Increased cost of health careIncreased cost of health care

Why is there such potential Why is there such potential for Health Psychology?for Health Psychology?

◊ Deficiencies in biomedical modelDeficiencies in biomedical model◊ Increased maturity of behavioral science Increased maturity of behavioral science

research and practiceresearch and practice◊ Increased disease burden from chronic diseaseIncreased disease burden from chronic disease◊ HIV/AIDS epidemicHIV/AIDS epidemic◊ Focus on prevention Focus on prevention ◊ Increased concern with quality of lifeIncreased concern with quality of life◊ Increased cost of health careIncreased cost of health care

Healthy People 2010Healthy People 2010 10 Leading Health Indicators10 Leading Health Indicators

◊ responsible sexual responsible sexual behaviorbehavior

◊ tobacco usetobacco use◊ injury and violenceinjury and violence◊ physical activityphysical activity◊ obesityobesity

◊ substance abusesubstance abuse◊ mental healthmental health◊ environmental environmental

qualityquality◊ immunizationimmunization◊ access to health access to health

carecare

Drivers of Health PolicyDrivers of Health Policy

◊ To Err is Human To Err is Human (IOM, 1999)(IOM, 1999)◊ Crossing the Quality ChasmCrossing the Quality Chasm (IOM, 2001) (IOM, 2001)◊ Health Professions Education Summit Health Professions Education Summit

(IOM, 2002)(IOM, 2002)◊ Improving Medical Education: Enhancing Improving Medical Education: Enhancing

the Behavioral and Social Science Content the Behavioral and Social Science Content of Medial School Curriculumof Medial School Curriculum (IOM,2004) (IOM,2004)

Competencies for Quality Health CareCompetencies for Quality Health Care2002 Health Professions Education Summit2002 Health Professions Education Summit

◊ InformaticsInformatics◊ Interdisciplinary TeamsInterdisciplinary Teams◊ Evidence-Based CareEvidence-Based Care◊ Quality ImprovementQuality Improvement◊ Patient-Centered CarePatient-Centered Care

◊ Changing demographicsChanging demographics◊ Context Competence (e.g., culture, Context Competence (e.g., culture,

race/ethnicity, history, religion, race/ethnicity, history, religion, politics, economics, community, politics, economics, community, discrimination)discrimination)

Preparing to reach our potential: Preparing to reach our potential:

Health InformaticsHealth Informatics

◊ Communication (e.g., email)Communication (e.g., email)

◊ Knowledge management Knowledge management (e.g., evidence-based databases)(e.g., evidence-based databases)

◊ Decision supportDecision support

TelehealthTelehealth

Need more attention to:Need more attention to:

◊ Clinical decision-makingClinical decision-making◊ Practice guidelinesPractice guidelines◊ Dissemination of guidelinesDissemination of guidelines

Need increased attention to:Need increased attention to:

◊ GeneticsGenetics◊ Organ and tissue transplantationOrgan and tissue transplantation◊ Assisted reproductive technologyAssisted reproductive technology◊ Primary carePrimary care

GlobalizationGlobalization

EnvironmentEnvironment

AdvocacyAdvocacy

◊ Graduate Education & TrainingGraduate Education & Training◊ ResearchResearch◊ Health PolicyHealth Policy

There is great potential for There is great potential for psychologists in health research and psychologists in health research and

care.care.

◊ ResearchResearch◊ Health promotion and Health promotion and

disease preventiondisease prevention◊ Assessment and triageAssessment and triage◊ Consultation (case Consultation (case

centered and systems centered and systems centered)centered)

◊ Psychological Psychological interventions interventions

◊ Program developmentProgram development◊ AdministrationAdministration◊ Team buildingTeam building◊ SupervisionSupervision◊ Education and Education and

Training Training