health pyschology chapter 1

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Preface

At Worth Publishers a company that lets nothing stand in the way of produc-ing the finest textbooks possible a number of people played key roles. Chiefamong these are Senior Publisher Catherine Woods, whose initial interest, vi-sion, and unflagging support gave me the push needed to start the project andsustained me throughout; Executive Editor Kevin Feyen, whose encourage-ment, sound thinking, and friendship were instrumental in helping constructand execute the plan for this edition; Associate Managing Editor Tracey Kuehn,Project Editor Dana Kasowitz, and Production Manager Sarah Segal, whoworked wonders throughout production to keep us on course; Art DirectorBabs Reingold Designer Lissi Sigillo and artists Matthew Holt and Todd Buck,whose creative vision resulted in the distinctive design and beautiful art pro-gram that exceeded my expectations; Media Editor Peter Twickler, who coordi-nated the production of an unparalleled supplements package; and ChristineBuese, who supervised the photo research that helped give the book its tremen-dous visual appeal. Finally, no one deserves more credit than Development Ed-itor Elaine Epstein, whose influence can be found on virtually every page.

As ever, my heartfelt thanks go to Pam, for her sage advice and unwaveringconfidence; to Jeremy, Rebecca, and Melissa, for helping me keep things in per-spective; and to the many students who studied health psychology with me andassisted in the class testing of this book. They are a constant reminder of theenormous privilege and responsibilities I have as a teacher; it is for them that Ihave done my best to bring the field of health psychology alive in this text.

To those of you who are about to teach using this book, I sincerely hope thatyou will share your experiences with me. Drop me a line and let me know whatworks, what doesn t, and how you would do it differently. This input will bevital in determining the book s success and in shaping its future.

Richard O StraubUniversity of Michigan, DearbornDearborn, Michigan [email protected]

oundations o HeaPsychology


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1Health and Illness: Lessonsfrom the astAncient ViewsThe Middle Ages and theRenaissancePost-Renaissance RationalityDiscoveries of the NineteenthCenturyThe Twentieth Century andthe Dawn of a New Era

Biopsychosocial Mind-Body)PerspectiveThe Biological ContextThe Psychological ContextThe Social ContextBiopsychosocial "Systems"Applying the BiopsychosocialModelFrequently Asked Questionsabout a Health PsychologyCareerWhat Do Health PsychologistsDo?Where Do HealthPsychologists Work?How Do I Become a HealthPsychologist?

Introducing ealthPsychology

emfin, lynn ppro aboa,d the 32-100 , am Mam,tania on what must have been an uncertain morning in the early1880s. Bound for America, her journey of hope began in Liverpool,England, in a desperate attempt to escape the economic distress andreligious persecution she and her fami ly suffered in Ireland. The country's troubles had begun decades earlier with an Gorta M6r (theGreat Hunger - a amine caused by the potato fungus that destroyedthe primary, and often only, food of most Irish families.

Caroline's journey was hardly unique. Between 1861 and 1926four milli on Irish left the country for similar reasons, an d young people like Caroline were brought up for export overseas. After a harrowing five- to six-week voyage across the Atlantic, crowded withother emigrants into a steerage compart ment t hat was rarely cleaned,theyendured the h umiliatingprocessing of immigrants at Ellis Island.Many of hose who were sick or without financial means or sponsorswere forced to return to their homeland.

As Caroline doggedly made her way in her adopted country, firstnorth to upstate New York and then west to Chicago, she found thatthings were better, but life was still hard. Doctors were expensive(and few in number), and she always had to guard against drinking impure water; eating contaminated foods; or becoming infectedwith typhoid fever, diphtheria, or one of the many other diseasesthat were prevalent in those days. Despite her vigilance, her survival (and later that of her husband and newborn baby) remaineduncertain. Life expectancy was less than 50 years, and one of everysix babies died before his or her first birthday. It would keep youpoor, just burying your children, wrote one Irishwoman to herfamily back home (Miller & Miller, 2001). Equally troubling wasthe attitude of many native-born Americans, who viewed the Irish

C HAP TER 1 I Introducing Health Psychologyas inferior, violent, and drunken. Most of the new immigrants toiled as laborers in the lowest-paid and most dangerous occupations, and were banished toghetto-like Paddy towns that sprang up on the outskirts of cities such as NewYork and Chicago.

More than a century later I smile as my mother recounts the saga of my greatgrandmother's emigration to the United States. Her grandmother lived a long productive life and left a legacy of optimism and indomitable Irishy that fortifiedher against the hardships in her life-and carried down through the generations.How different things are now, I think as our phone call ends, but how much of

Caroline's spiri t is still alive in my own children'Things are very different. Advances in hygiene, public health measures, and

microbiology have virtually eradicated the infectious diseases Caroline fearedmost. Women born in the United States today enjoy a life expectancy of over 80years, and men often reach the age of 73. This gift of ime has helped us realizethat health is much more than freedom from illness. More than ever before, wecan get beyond survival mode and work to attain lifelong vitality by modifyingour diets, exercising regularly, and remaining socially connected and emotionally centered.

M great-grandmother's story makes clear that many factors interact indetermining health. This is a fundamental theme of health psychology, a subfield of psychology that applies psychological principlesand research to the enhancement of health and the treatment and preventionof illness. Its concerns include social conditions (such as the availability ofhealth care and support from family and friends), biological factors (such asfamily longevity and inherited vulnerabilities to certain diseases), and evenpersonality traits (such as optimism).

The word health comes to us from an old German word that is represented, in English, by the words hale and whole, both of which refer to a stateof soundness of body." Linguists note that these words derive from the medieval battlefield, where loss of haleness, or health, was usually the result ofgrave bodily injury. Today, we are more likely to think of health as the absenceof disease rather than as the absence of a debilitating battlefield injury. Because this definition focuses only on the absence of a negative state, however,it is incomplete. Although it is true that healthy people are free of disease,complete health involves much more. A person may be free of disease but stillnot enjoy a vigorous, satisfying life. Health involves physical as well as psychological and social well-being.

health psychoapplication of psprinCiples and reenhancement ofprevention and illness. health a state phYSical, mental,well-being.

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The health of women is inextricablylinkedtotheirstatusinsociety.It benefitsfrom equality andsuffersfromdiscrimination.-World HealthOrganization

P R T 1 I Foundations ofHealth PsychologyWe arefortunatetoliveinatime when most of theworld'scitizenshavethe

promiseof alongerandbetterlifethan theirgreat-grandparents,withfarlessdisabilityand diseasethaneverbefore.However,thesehealthbenefitsarenotuniversallyenjoyed.Consider: Thenumber of healthyyears of life that canbeexpectedis atleast70years

in25(mostlydeveloped)countries of theworld,but isestimatedtobelessthan 40 yearsin 32other (mostlydeveloping)countries(WorldHealth Organization,2009).

Violence-,drug-, and alcohol-relateddeathsa nd injuries,an dsexualperilssuchas HIV,increasinglymarkthetransitionfromadolescencetoadulthood,particularlyamongmanyethnicminorities(Castro,Stein, Bentler,2009).

Ateveryage,deathratesvarybyethnicgroup.Forinstance,among American men and women,thoseof Europeanancestryhave alongerlifeexpectancy than African-Americans, but both groups have shorter lifeexpectancies than peopleinJapan,Canada,Australia,theUnitedKingdom,Italy,France,andmanyother countries(U.S.CensusBureau,2009).

Althoughmen aretwiceas likelyas women to dieof anycause,beginninginmiddleagewomenhavehigherdiseaseanddisabilityrates(U.S.CensusBureau,2009).

The UnitedStatesspendsahigherportion of itsgrossdomesticproduct onhealthcarethanany other country but is rankedbytheWorldHealth Organizaiononly37th out of 191 countriesintermsof theoverallperformanceof tshealthcaresystem, as measuredbysuchfactorsas responsiveness,fairness of funding, and accessibilitybyallindividuals (WorldHealth Organization,2000).Althoughthisrankinghasbeenchallengedbycritics,whopoint out that therankingmovesup or down,dependingon therelativeweightingof thevariousfactors,no one disputesthefactthattheaveragelifeex;pectancy of thoseborn intheUnitedStates is lowerthan in most other

~ f i J i l t l l i m l ~ ~ ~ ~ : Thesestatisticsrevealsome of thechallengesinthequestforglobalwellness.

Healthprofessionalsareworkingto reducethe30-yeardiscrepancyinlife expectancybetweendevelopedanddevelopingcountries;tohelpadolescentsmakeasafe,healthytransitiontoadulthood;andtoachieveadeeperunderstandingoftherelationshipsamonggender,ethnicity,socioculturalstatus,and health.

In the UnitedStates, the Department of Healthand Human Servicesreport Healthy People 2 1 focuses on improving accessto healthservices,eliminating healthdisparitiesbetweenwomen and men as well as amongvarious ageand socioculturalgroups,and ingeneralon substantiallyimproving the healthand qualityof life and well-beingforallAmericans.Italsonotesthat nearlyone milliondeathsin this country eachyearare preventable (seeTable1.1).Healthy People 2 2 expands thesegoals into specificactions and targets forreducing chronic diseasessuch ascanceranddiabetes,improving adolescenthealth,preventinginjuries and violence,andtaking steps in 32other areas.

C H P TE R 1 I IntroducingHealth Psychology

Preventable njury and eathHealthy People 2 1 and 2 2 report that,yearly: Control of underage and excess use of alcohol could prevent 100.000deathsfromautomobile accidents and otheralcohol-related injuries. Elimination of public possession of firearms could prevent35.000 deaths. Elimination of all forms of tobacco use could prevent 400.000deathsfrom cancer,

stroke. and heart disease. Better nutrition and exercise programs could prevent 300,000deathsfrom heart disease, diabetes, cancer, and stroke. Areduction in risky sexual behaviors could prevent 30,000deathsfrom sexuallytransmitted diseases. Full access to immunizations for infectious diseases could prevent 100,000deaths.Source: u.s. Department of Health and Human Services (2007). Healthy People 2010 midcourse review.Retrieved January 10 2010 from http://www.healthypeople.gov/Data/midcourse/

Thischapter introduces thefieldof healthpsychology,whichplaysan increasingly important roleinmeetingthe world'shealthchallenges.Considerafew of themorespecificquestionsthat healthpsychologistsseektoanswer: Howdoyourattitudes,beliefs,self-confidence, and personalityaffectyour physiologyand youroverallhealth?Whyareso many peopleturning toacupuncture,yoga,herbalsupplements(plusotherforms of alternativemedicine),as wellas do-ityourselfpreventivecare?Dotheseinterventionsreallywork?Whydo somanypeopleignoreunquestionablysound adviceforimprovingtheirhealth,suchasquittingsmoking,moderatingfoodintake, and exercisingmore?Whyarecertainhealthproblemsmore likelytooccuramong peopleof aparticularage,gender, or ethnicgroup?Why is beingpoor, uneducated,or lonelyapotentiallyseriousthreattoyour health?Conversely,whydo thosewhoarerelativelyaffluent,welleducated, and sociallyactiveenjoybetterhealth?

Healthpsychologyis thescience that seeksto answertheseand many otherquestionsabout howour wellnessinteractswithhow wethink,feel,and act.Webeginbytakingacloserlookattheconcept of healthand howithaschangedoverthecourseof history.Next,we'llexaminethebiopsychosocialperspectiveon healthpsychology,includinghow itdraws on and supports other healthrelatedfields.Finally,we'lltakealookatthekind of trainingneededtobecomeahealthpsychologistand whatyoucando withthat training.

A lthough allhuman civilizationshavebeenaffectedbydisease,eachhasunderstood and treatedit differently.At one time,people thoughtthat diseasewascaused by demons. Atanother,theysawit as aformof punishment for moralweakness.Today,wewrestlewith very different


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trephination an ancient medical intervention in which a holewas drilled into the human skullto presumably allow "evil spirits to escape.

PAR T 1 I Foundations of Health Psychologyquestions, such as, Can disease be caused by an unhealthy personality? Wewill consider how views regarding health and illness have changed by following a case study through the ages of Mariana, who in 2011 is a 20-year-oldcollege sophomore. Mariana presents to her family doctor with a badheadache, shortness of breath, sleeplessness, a racing heart, and a wild, frightened expression. How will she be treated? Current understanding of thesesymptoms would probably lead most health professionals to suggest Marianais suffering from anxiety. Her treatment today might be a combination of talktherapy, relaxation techniques, and possibly targeted drug therapy. But as wewill see, her trea tment t hroug h the ages would have varied widely. (You maywant to refer to Figure 1.1 throughout this section to get a sense of thechronology of changing views toward health and illness.)Ancient ViewsPrehistoric MedicineOur efforts at healing can be traced back 20,000 years. A cave painting in southern France, for example, which is believed to be 17,000 years old, depicts an IceAge shaman wearing the animal mask of an ancient witch doctor. In religionsbased on a belief in good and evil spirits, only a shaman (priest or medicineman) can influence these spirits.For preindustrial men and women, confronted with the often-hostile forcesof their environment, survival was based on constant vigilance against thesemysterious forces of evil. When a person became sick, there was no obviousphysical reason for it. Rather, the stricken individual's condition was misattributed to weakness in the face of a stronger force, bewitchment, or possession byan evil spirit (Amundsen, 1996).During this period of time, Mariana's symptoms might have been treatedwith rituals of sorcery, exorcism, or even a primitive form of surgery calledtrephination. Archaeologists have unearthed prehistoric human skulls containing irregularly shaped holes that were apparently drilled by early healers tonllQ\V c l i f a f = ( ; a \ s i n ~ d@ffimU to leave patients' bodies. Historical records indit a t ~ that trephtnatibfi Wa5 a widely practiced form of treatment in Europe,Egypt, India, and Central and South America.About 4,000 years ago, some peoples realized that hygiene also played a rolein health and disease and they made attempts at improving public hygiene. Theancient Egyptians, for example, engaged in cleansing rites intended to discourage illness-causing worms from infesting the body. In Mesopotamia (a part ofwhat is now Iraq), soap was manufactured, bathing facilities designed, andpublic sewage treatment systems constructed (Stone, Cohen, & Adler, 1979).Greek and Roman MedicineThe most dramatic advances in public health and sanitation were made inGreece and Rome during the sixth and fifth centuries B.C.E. In Rome, a greatdrainage system, the Cloaca Maxima was built to drain a swamp that later

A Timeline of Historical and Cultural Variations in Illness and Healing From the ancient use of trepremove evi I spirits to the current use of noninvasive brain scans to diagnose disease, the treatment of healthseen major advances over the centuries. A collection of treatments across the ages is shown (from left to rig(on an ancient Peruvian skull); acupuncture from China; early surgery in seventeenth-century Europe; and vacdistrict vaccinator in nineteenth-century London.

ANCIENT GREECE Illness causedby an imbalance of bodily humors;good diet and moderation inliving would cure it.PREHISTORIC PERIODIllness caused by evilspirits and treated bytrephination.

MIDDLE AGES (476-1450)Disease was divine punishment

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I I I I I I I I I I 'I I I I I0 I I

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TWENTYBiopsychdisease.methods

/ANCIENT EGYPT Demons ANCIENT ROME (200 B.C.E.)and punishment by the "Pathogens" such as badgods caused illness. 1920s Disease influeair and body humors'Sorcery and primitive by mind and emotioncaused illness. Treated treated by psychoanorms of surgery and by bloodletting, enemas, psychiatry, and otheygiene were treatments. and baths.I medical methods.RENAISSANCE Disease wasANCIENT CHINA (1100-200 B.C,E,) a physical condition of theUnbalanced forces of nature body, which was separatecaused illness. Treated with from the mind. Surgicalherbal medicine and techniques first used.acupuncture.(i;._ :,) 'i '


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C H P T E R 1 I Introducing Health Psychology ~ : o ~ ~ ~- fJ Lsymptoms. Hippocrates was also interested in patients' e motions and thoughts ~ .

regarding their health and treatment, and thus he called attention to the-psy ~ ~ chological aspects of health and illness. "It is better to know the patient WhO / . . ~l1as the disease," Hippocrates said, than it is to know the disease which the pa ~ ~ -tlent has" (quoted in Wesley, 2003).' ~

.' The next great figure in the history of Western medicine was the physicianClaudius GaleJ (129-200 C.E.). Galen was born in Greece but spent many yearsii R'iliii"e conducting dissection studies of animals and treating th e severe in: rz e? /f'/? ~

juries of Roman gladiators. In this way, he learned much that was p r e v i o u s l ~ ~ ~unknown about health and disease. Galen wrote voluminously on anatomy, hr '/ L.-t - ~giene, and diet, buildin on the Hippocratic foundation of rational e x p l a n a t i o ~ nd the careful description of eac patient s p- ysical symptoms. .

Galen also expanded the humoral theory of disease by developing an e l a b / / ~ .orate system of pharmacology that physicians followed for almost 1,500 years. ~ . . -His system was based on the notion that each of the four bodily humors hadi s own elemenwy quality that determined the character of specific diseases.~ or example, was hot and moist. Galen believed that drugs, too, had elementary qualities; thus, a disease caused by an excess of a hot and moisthumor could be cured only with d.rugs that were cold and dry. Although suchviews may seem archaic, Galen's pharmacology was logical, based on carefulobservation, and similar to the ancient systems of medicine that developed inChina, India, and other no n-Western cultures. Many forms of alternative medicine still use similar ideas today.Non-Western Medicine / At the same time that Western medicine was emerging, different traditions of ~healing were developing in other cultures. For example, more than 2,000 years / Jago the Chinese developed an integrated system of healing, which we knOW "- today as traditional Oriental medicine (TOM). TOM is founded on the princi pIe that internal harmony is essential for good health. Fundamental to this harmony is the concept of qi (sometimes spelled chi), a vital energy or life force that ~ bbs and flows with changes in each person's mental, physical, and emotional ~well-being. Acupuncture, herbal therapy, tai chi, meditation, and other interventions are said to restore health by correcting blockages and imbalances in qi

Ayurveda is the oldest known medical system in the world, having origi-nerted in I n d ~ around the sixth century B.C.E., coinciding roughly with th e life utime of the Buddha. The word ayurveda comes from the Sanskrit roots ayuh, (. / 'which means "longevity," and veda, meaning "knowledge." Widely practiced inIndia, ayurveda is based on the belief that the human body represents the en ~ tire universe in a microcosm and that the key to health is maintaining a bal ,ance between the microcosmic body and the macrocosmic world. The key t o f ~ this relationship is held in the balance of three bodily humors, or doshas: vata, ,.., Ipitta, and kapha, or, collectively, the tridosha (Fugh-Berman, 1997). We'll ex- 1 Iplore the history, traditions, and effectiveness of these and other non-Westernforms of medicine in Chapter 14. 6 ~ ~

P R T 1 I Foundations of Health Psychology

became the site of the Roman Forum. Over time, the Cloaca assumed the function of a modern sewage system. Public bathrooms, for which there was a smalladmission charge, were commonplace in Rome by the first cent ury C.E. (Cartwright, 1972).The first aqueduct brought pure water into Rome as early as 312 B.C.E., andcleaning of public roads was supervised by a group of appointed officials whoalso controlled the food supply. This group passed regulations to ensure thefreshness of meat and other perishable foods, and they arranged for the storage of vast quantities of grain, for example, in an effort to forestall famine(Cartwright, 1972).In ancient Greece, the philosopher Hippocrates (460-377 B.C.E.) was establishing the roots of Western medicine when he rebelled against the ancient focuson mysticism and superstition. Hippocrates, who is often called the "father ofmodern medicine," was the first to argue that disease is a natural phenomenonand that the causes of disease (and therefore their trea tment and prevention) areknowable and worthy of serious study. In this way, he built the earliest foundation for a scientific approach to healing. Historically, physicians took the Hippocratic Oath, with which they swore to practice medicine ethically. Over thecenturies, the oath has been rewritten to suit the values of various cultures thatwere influenced by Greek medicine. A version widely used in U.S. medicalschools today was written in 1964 by Dr. Louis Lasagna of Tufts University.

Hippocrates proposed the first rational explanation of why people get sick,and the healers of this period in history may have been influenced by his ideasin addressing Mariana's problems. According to Hi ppocrates' humoral theory,a healthy body and mind resulted from equilibrium among four bodily fluidscalled humors: blood, yellow bile, black bile, and phlegm. To maintain a properbalance, a person had to follow a healthy lifestyle that included exercise, sufficient rest, a good diet, and the avoidance of excesses. When the humors wereout of balance, however, both body and mind were affected in predictable ways,depending on which of the four humors was in excess. Mariana, for example,might have been considered choleric, with an excess of yellow bile and a fierytemperament. She might have been treated with bloodletting (opening a vein[8 l e e a ~ h ~ \ 1 ~ \ \ ~ lind cooling batbs.Although humoral theory was discarded as advances were made in anatomy,physiology, and microbiology, the noti on of personality traits being linked withbody fluids still persists in the folk and alternative medicines of many cultures,including those of traditional Oriental and Native American cultures. Moreover, as we'll see in the next chapter, we now know that many diseases involvean imbalance (of sorts) among the brain's neurotransmitters, so Hippocrateswas not too far off.

Hippocrates made many other notable contributions to a scientific approach to medicine. For example, to learn what personal habits con tributed togout, a disease caused by disturbances in the body's metabolism of uric acid,he conducted one of the earliest public health surveys of gout sufferers' habits,as well as of their temperatures, heart rates, respiration, and other.,physical

. . . I will prevent diseasewhenever I can, for preventionis preferableto cure.-I willJ'emember that I remaina member of society, with special obligations to all my fellowhuman beings, those sound ofmind and body as well as theinfirm.If I do not violate this oath,

may I enjoy life and art,respected while I live andremembered with affectionthereafter. May I always act soas to preserve the finest traditions of my calling and may Ilong experience the joy of healing those who seek my help.-Written in 1964 by LouisLasagna, Academic Dean of theSchool of Medicine at TuftsUniversity, and used in manymedical schools today.

humoral theory a concept ofhealth proposed by Hippocratesthat considered wellness a stateof perfect equilibrium amongfour basic body fluids, calledhumors. Sickness was believedto be the result of disturbancesn the balance of humors.

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Epidemic litepeople; an epiOAe that spreamany individunity at the sampandemic diseover a large ge mind-body philosophical Vmind and bodyentities th at do anatomical tthat the originseases are foundorgans, muscultal system of t cellular theothe nineteenth theory that disof abnormalitie

Discoveries of the Nineteenth CenturyOnce individual cells became visible, the stage was set for the ,cellular theoryof disease-the idea that disease r "Its when body cells malfunctio n or die. Itwas the French scient' t Louis Pasteur 1822-1895), however, who truly rockedthe e d i c ~ l world with senes 0 m iculous experiments showing that life canonl come rom existing life. Until the nineteenth century, scholars believed inspontalieous generation the idea that living organisms can be formed fromnonliving matter. For example, maggots and flies were believed to emergespontan'eously from rotting meat, To test his hypothesis, Pasteur filled twoflasks with a porr idge-like liquid, heating both to the boiling point to kill any

Following the Renaissance, expected to focus exclusively on thebiological causes of disease. Hi 'ates' ncien t humoral theor w s findiscarded in favor of s anatomical theor 0 isease. Physicians at thistime would have considered internal causes fOi Mariana's symptoms, uch asheart or brain malfunctions.Science and medicine changed rapidly during the seventeenth and eighteenth centuries, spurred on by numerous advances in techn,ology. Perhaps thesingle most important invention in medicine during this period was the microscope. Although a ground lens had been used for magnification in ancienttimes, it was a Dutch cloth m e r c l ~ a n t named. Anton van Leeuwenhoek(1632-1723) who fashioned the first prac0:al microscope. Using his microscope, Leeuwenhoek was the first to observe blood cells and the structure ofske\WallmlJ18(i1leshot:k tht: lust to obst:rVt: blood cdis


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germ theory disease is causebacteria, and oisms that invad biomedical mnant view of twmedicine that millness always hcause, pathogen a vor some other mthat causes a pa psy chosomatoutdated brancthat focused onand treatment odiseases causedpsychological p

CHAP TE R 1 I Introducing Health Psychology

Psychosomatic edicineThe biomedical model advanced health care significantly through its focuson pathogens. However, it was unable to explain disorders at had no bservable physical cause, such as those uncovered b SI gmund Freud(1856-1939), who was initially trained as a physician. F r e u d S - - p - ; : r f u ~ - e ~ hibited symptoms such as loss of speech, deafness, and even paralysis. Freudbelieved these maladies were caused by unconsciou motional can icts thathad been "co r te 0 a sic reud labeled sue I lnesses con-vers on disorders te medical c o m ~ n i t y was forced to accept a new-a egory of disea e.

In the 1940s, Franz Alexander advanced the idea that an individual's psy_chological conflicts could cause specific diseases. When physicians couldfind no infectious agent or other direct cause for rheumatoid arthritis,Alexander became intrigued by the possibility that psychological factorsmight be involved. According to his nuclear conflict model, each physical disease is the outcome of a f u n d m ~ h o l o g i l conflict(Alexander, 1950). For example, individuals with a rheumatoid personality," who tended to repress anger and were unable to express emotion, werebelieved to be prone to developing arthritis. Alexander helped establish psychosomatic medicine, a reformist movement within medicine named fromthe root words psyche which means "mind," and soma which means "body."Psychosomatic medicine is concerned with the diagnosis and treatment ofphysical diseases thought to be caused by faulty processes within the mind.This new field flourished, and soon the journal Psychosomatic Medicine waspublishing psychological explanations of a range of health problems that included hypertension, migraine head ul s .d' dbronchial asthma. At this time, ar'a i ht have be treated b Freud'sh ~ that delves into one's childhood and attemptsto uncover unresolvedcorlfli'cts.

croorganism that invades the body. The model makes no provision for psychological, social, or behavioral variables in illness. In this sense, the biomedicalmodel embraces reductionism/;the view that complex phenomena {such ashealth and disease)"'derive ultimately from a single primary factor. Second, thebiomedical model is based on the,;artes.i..an doctrine of mind body dualigJ1that, as we have seen, considers mind and body as separate and autonomousentities that interact minimally. Finally, according to the biomedical model,health is. uothi.Qg more than the absence ~ Accordingly, those who~ o m this perspective focus on investigating the causes of physical iIl-'nesses rather than on those factors that promote L2hysica1 ~ Q o g j , a l , qd .social vitalitJ.- Physicians working strictly from tl e . edical perspecti ve~ o u l d f o c u ~ on the physiological causes 2f ana's eadache racing heart,and shortness of breath rather than considering whether a psychological problem could be contributing to these s)'1lnptoms.. .

PAR T 1 I Foundations of Health Psychology1I : . ~ ' ; -

The Twentieth Century and the Dawn of a New ra

12

microorganisms. One of the flasks had a widemouth into which air could flow easily. The otherflask was also open to air, but had a long curvedneck that kept any airborne microbes from fallinginto the liquid. To the amazement of skeptics, nonew growth appeared in the curved flask. However, in the flask with the ordinary neck, microorganisms contaminated the liquid and multipliedrapidly. By showing that a genuinely sterile solution remains lifeless, Pasteur set the stage for thelater development of aseptic (germ-free) surgicalprocedures. Even more important, Pasteur's successful challenge of a 2,OOO-year-old belief is apowerful demonstration of the importance of

Louis Pasteur in His Labora- keeping an open mind in scientific inquiry.t ry Pasteur's meticulous work in . . . " '. I t' b ct . . th I b Pasteur s dlscovenes helped sha e the erm theor of disease-the Idea thatISO a mg a ena 111 e a - oratory, then showing that life bacteria, viruses, an other microorganisms that invade body cells cause themcan come only from existing life, to malfunctionJhe ~ e r m theory, which is basically a refinement of the cellupaved the way for germ-free sur [ ar theory, forms the theoretical foundation of modern medicine.gical procedures. Following a ~ t e u r m e Q J c ~ n o ~ l e d g ~ ~ } l Q . P X Q g 1 u r ~ developed rapidly.

...... In 1846, W i l l i a m _ M o r t o ~ 8 1 9 - 1 8 6 8 an American dentist, introduced the, - ether :s an anestbetir, This great a d ~ a n c e made it possible to operate on

1 patients, who experienced no pain and thus remained completely elaxed.~ ~ Fifty years later, t e German h sicist Wilhelm Roent en 1845-1 3 dis,tV - covered x-rays and, for the first time physicians wen;; t)ble to observe i ~ r -;1 organs in a living perso.n direct)y. Before the end of the century,researchers had identified the microorganisms that caused malaria, pneumonia, diphtheria, syphilis, typhoid, and other diseases that my greatgrandmother's generation feared. Armed with this information, medicinebegan to bring under control diseases that had plagued the world sinceantiquity.


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4 PAR T 1 I Foundations of Health Psychology CHAP T E R 1 I Introducing Health PsychologyThe Emergence o Health PsychologyIn 1973, the American Psychological Association APA) appointed a task forceO explore psychology's role in the field of behavioral medicine, and in 1978,

the APA created the division of health psychology (Division 38). Four yearslater, the first volume of its official journal, Health Psychology, was published.In this issue, Joseph Matarazzo, the first president of the division, laid down thefour goals of the new field:1. To study scientificallythecausesororiginsof specificdiseases;that is, their

etiology. Health psychologists are primarily interested in the psychological, behavioral, and social origins disease. hey investigate whypeople engage in health-compromisingbehaviors,such as smoking or un-

~ u ~ x /2. To promotehealth. Health p s y h o l o i s t ~ consider ways to get people to en

gage in health-enhancingbehaviors such as exercising regularly and eatingnutritious foods.

3. To prevent ndtreatillness. Health psychologists design programs to help people stop smoking, lose weight, manage stress, and minimize other risk factorsfor poor health. They also assist those who are already ill in their efforts to adjust to their illnesses or comply with difficult treatment regimens.

4. To promotepublichealthpolicy nd theimprovementof thehealthcaresystem. Health psychologists are very active in all facets of health educationand consult frequently with government leaders who formulate public policy in an effort to improve the delivery of health care to all people.

As noted in Table 1.2, a number of twentieth-century trends helped shapethe new field of health psychology, pushing it toward the broader biopsychosocial perspective, which is the focus of this text.

Twentieth Century Trends That Shaped Health PsychologyTrend esult1. Increaseo' Life Expectancy Recognize the need to take better care ofourselves to promote Vitality through alonger life.2. Rise of Lifestyle Disorders (for example, Educate people to avoid the behaviorscancer, stroke, and heart disease) that contribute to these diseases forexample, smoking and a high-fat diet).3. Rising Health Care Costs Focus efforts on ways to prevent disease

and maintain good health to avoid thesecosts.4. Rethinking the Biomedical Model Develop a more comprehensive model ofhealth and disease-the biopsychosocialapproach.


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biopsychosoperspective thhealth and othdetermined bybiological meclogical processinfluences. life-course retical perspecon age- relatedand illness.

,IS pleasurable and the aftermath of a hangover as minor. Such people may bemore likely to drink, especially in certain psychological and social contexts.

A key element of the biological context is our species' evolutionary history, andan evolutionary perspe tive guides the work of many health psychologists. Ourcharacteristichuman traits and behaviors exist as they do because they helped ourdistant ancestors survive long enough to reproduce and send their genes into thefuture. Fo r example, natural selection has favored the tendency of people to become hungry in the presence of a mouth-watering aroma (see Chapter 7). Thissensitivity to food-re.lated cues makes evolutionary sense in that eating is necessary for survival-particularly in the distant past when food supplies were unpredictable and it was advantageous to have a healthy appetite when food was available.

At the same time, biology and behavior constantly interact. For example,some individuals are more vulnerable to stress-related illnesses because theyangrily react to daily hassles and other environmental triggers (see Chapter4). Among men these triggers are correlated with aggressive reaction related toincreased amounts of the hormone testosterone. This relationship, however, isreciprocal: Angry outbursts can also lead to elevated testosteron e levels. One ofthe tasks of health psychology is to explain how and why) this mutual influence between biology and behavior occurs.

C H P T E R I IntrodUcing Health Psychology

Life-Course PerspectiveWithin the biological context, the life-course perspective in health psychology focuses on important age-related aspects of health and illness (Jackson,1996). This perspective would consider, for example, how a pregnant woman'smalnutrition, smoking, or use of psychoactive drugs would affect her child'slifelong development. Her child might be born early and suffer from low birthweight (less than 2,500 grams [5 pounds]). Low birth weight is one of he mostcommon, and most preventable, problems of prenatal development. Consequences include slowed motor, social, and language development; increasedrisk of cerebral palsy; long-term learning difficulties; and even death (Jalil andothers, 2008).

The life-course perspective also considers the leading causes of death interms of the age groups affected. The chronic diseases that are the leadingcauses of death in the overall population are more likely to affect middle-agedand elderly adults. Young people are much more likely to die from accidents.The Psychological ContextThe central message of health psychology is, of course, that health and illness aresubject to psychological influences. For example, a key factor in how well a personcopes with a stressful life experience is how the event is appraised or interpreted(see Chapter 5). Events that are appraised as overwhelming, pervasive, and beyo ndour control take amuch greater toll on us physically and psychologiglly tha.n..doevents that are appraised as minor challen es that are temporary and surmQllnt ndeed, some evidence suggests that, whether a stressful event is actually ex-BEHAVIOR

High stress levels Poor coping skills Strong feelings of personalresponsibility

Anxiety Headaches Racing heart Feeling breathless Lump in the throat Insomnia

PSYCHOLOGICAL PROCESSES, Genetic vulnerability

to anxiety

SOCIAL INFLUENCES

BIOLOGICAL MECHANISMS

High levels of actualresponsibility at work andhome and in the community Lack of social su pport

P R T I Foundations of Health Psychology

As history tells us, looking at just one causative factor paints an incomplete picture of a person's health or illness. Health psychologiststherefore work from a biopsychosocial mind-body) perspective. Asdepicted in Figure 1.2, this perspective recognizes that biological psychologicaland sociocultural forces act together to determine an individual's health andvulnerability to disease; that is, health and disease must be explained in termsof multiple contexts.The Biological ContextAll behaviors, including states of health and illness, occur in a biological context. Every thought, mood, and urge is a biological event made possible becauseof the characteristic anatomical structure and biological function of a person'sbody. Health ps cho logy draws attention to those aspects of our bodies that influence ea th and disease: our genetic makeup an our nervous, immune, and

enoocnne SVstenfs seeChapter 3).Genes provide a guideline for our biology and predispose our behaviors

healthy and unhealthy, normal and abnormal. For example, the tendency toabuse alcohol has long been known to run in some families (see Chapter 8).One reason is that alcohol dependency is at least partly genetic, although it doesnot seem to be linked to a single, specific gene. Instead, some people may inherit a greater sensitivity to alcohol's physical effects, experiencing intoxication

C g J : I i - B . ; a ; : P ' I L o : " - _

The Biopsychosocial odelof Mariana s Anxiety Accord-ing to the biopsychosocialperspective, all health behaviorsare best explained in terms ofthree contexts: biologicalprocesses, psychologicalprocesses, and social influences.This diagram illustrates howthese three processes couldinfluence anxiety, as experienced by Mariana in the casestudy example p. 6).

6


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8 PAR T 1 I Foundations of Health Psychologyperienced or merely imagined, the body's stress response is nearly the same.Health psychologists think that some people may be chronically depressed andmore susceptible to certain health problems because they replay stressful eventsover and over again in their minds, which may be functionally equivalent to repeatedly encountering the actual event. Throughout this book, we will examinethe health implications of thinking, perception, motivation, emotion, learning, attention, memory, and other topics of central importance to psychology.

Psychological factors also play an iinportant role in the treatment of chronicconditions. The effectiveness of all health care interventions-including medication and surgery, as well as acupuncture and other alternative treatments-ispowerfully influenced by a patient's attitude. A patient who believes a drug orother treatment will only cause miserable side effects may experience considerable tension, which can actually worsen his or her physical response to the treatment. This reaction can set up a vicious cycle in which escalating anxiety beforetreatment is followed by progressively worse physical reactions as th e treatmentregimen proceeds. On the other hand, a patient who is confident a treatment will~ ~ \ ~ be effective may actually experience a greater therapeutic response to that treat ment. Psychological interventions can help patients learn to manage their tension, thereby lessening negative reactions to treatment. Patients who are morerelaxed are usually better able, and more motivated, to follow their doctors' instructions.

Psychological interventions can also assist patients in managing the everyday stresses oflife, which seem to exert a cumulativeeffect on the immune system. Negative life events such as bereavement, divorce, job loss, or relocationhave been linked to decreased immune functioning and increased susceptibility to illness. By teaching pat ients more effective ways of managing unavoidablestress, health psychologists may help patients' immune systems combat disease.The Social ontextTurn-of-the-century Irish immigrants like my great-grandmother surmountedpoverty and prejudice in the United States by establishing Irish-American associ

~ t o n s that strongly reflected an ethic of family and communal support. ~ hi!JlSelf, but all for one 2DQther;' wrote Patrie O' Qlllaghan.to his sister back home,

:;; he described this system of patronage. In placing health behavior in iJ social~ c o n t e x . h health psychologists consider the ways in which we think about, tItfiul- . t.\ and felate to o ~ r and to our environment;LYour gender, for exam

. \ ,#,'1 'pIe;ei1fails a particular, o c i a l l l . p r e s c r i b e d :2J.e that represents your sense of being, eJ:l a woman or a man. In ad'd.itiOn, you are a member of a par ticular family, commuc E ~ ~ n i t y and nation; you also have a certain racial, cultural, and ethnic identity, andd< ~ you live within a specific socioeconomic class. You are influenced by the same his. , _


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. Jf s0 I O d a t ; ~ 1 t 7 Y h O I O g y to a 1 t . k of""ingfriend, aco1", likcly ~ typ"of , , , , l tn th,i'socially isolated counterpart s (see Chapter 10). Ieeling sUQQ.orted by othersserve as a buffer hat mjtigates the outEut ofstress hormones and keeps the bo.cJis

immunedefenses str durin trauma tic situation t may also promote betterealili a Its, regular checkups, and early c r e e n i n ~ ofworrisome symptoms-all'Orwhich may ifhprove a cancer victim's odds ofsurvival.Sociocultural PerspectiveWithin the social context, the sociocultural perspective c o n s i ~ r s how socialand cultural factors cont ribu sease. When psychologists uset e ter u tur they refer to the endurin g behaviors, values and cust oms thata group 0 people have deve oped over t e years and transmit ted from one generatio 0 t e next. Ithin a cult re, there rna)' be tWo or more ethnic r ups-large groups ofpeople who t e n ~ t o have i n i l ~ values and experiences because;"1. f. ,.,A-" they share certain characteristics. .l In multiethnic cultures such as those ofthe United States andmost large, tJ.--, nations, wide disparities still exist between the life expectancy andhealth, status ofethnic minoritygroups andthe majority population. These dispar

, .-:: y great-grandmother and others whoemigrated to America. Some ofthesedifferences undoubtedly ..j$fleq v a r i ~ i o n in ~ c i o e c o n o m i c stat.i:S-JSES ,- ",)which is a measure ofseveral variables, including lOcom


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treatment for eight heart patients with identical symptoms (Schulman and ot hers, 1999). The patient s were actors who differed only in gender, race, and reported age (55,or 70). Altho.ugh diagnosis is a judgment call, most cardiacspecialists would agree that diagnostic catheterization is the appropriate treatment for the symptoms described by each hypothetical patient. However, theactual recommendations revealed a small, but nevertheless significant, antifemale and antiblack bias. For the younger, white, and male patients, catheterization was recommended 90, 91, and 91 percent of the tirpe, respectively; for theolder, female, and black patients, 86, 85, and 85 percent of the tim e, respectively.

Problems such as these, and the underrepresentation of women as participants in medical research trials, have led to the criticism of gender bIas inhealth research and care. In response, the National Institutes of Health (NIH)issued detailed guidelines on th e inclusion of women and minority'groups inmedical research (USDHHS, 2001). In additio n, in 1991 the NIH launched theWomen's Health Initiative (WHO, a long-term study of more than 161,000postmenopausal women focusing on the determinants and prevention of disability and death in older women. Among the targets of investigation in thissweeping study were osteoporosis, breast cancer, an d coronary heart disease.The clinical trials that formed the basis of the WHI tested the effects of hormone therapy, diet modification, and calcium and vitamin D supplements onheart disease, bone fractures, and breast cancer (WHI, 2010).

Despite the significance of such sociocultural and gender influences, remember that it would be a mistake to focus exclusively on this, or anyone context, in isolation. Health behavior is not an automatic consequence of a giv.ensocial, cultural, or gender context. For example, although as a group cancer'patients who are married tend to survive longer than unmarried persons, marriages that are un happy and destructive offer no benefit in this regard and maytlVtlD ll@ lirlli l t@ ]:J@@fH health m H ~ l m e Biopsychosocial Systems

)JY IrA \ s these examples indicate,< V _ I ~ utual influences among the biological, psychological, and social contexts of\ ealth. It is also based on a systems theory of behavior. According to this the

\ v ory, health-indeed all of nature-is best understood as a hierarchy of systemsj u,l in which ,h ;y ,m i, ;imultan'ou;ly wmpo d of ,mall ;ub .,tem, and-?fi , a r t oflarger, more encompassing systems (Figure 1.4).

, One way to understand the relationship among systems is to envision a tar-)' get with a bull's eye at the center and concentric rings radiating out from it.

systems theory the viewpoint ' Now conside r each of us as a system made up of interacting systems such as thethat nature is best understood endo crine system, the cardiovasc ular system, the nervou s system, and the imas a hierarchy of systems, in mune system. (Also keep in mind that within each of our biological systemswhich each system is simultane usly composed of smaller there .are smal.ler su bsystems, consIstll1g of Issue,s, nerve fibers, flUIds, cells, andsubsystems and larger, inten e- genetIC matenal.) If you move out from the bull s eye at the center and mto thelated systems, radiating outer rings, you can see larger systems that interact with us-and

Systems ThThe systems encing Marianshortness ofness and racthe case studinclude her bbiological sysendocrine, canervous), as wneighborhoodother externashe is part.

i y l l r ~ ; T t L

C HAP T E R 1 I IntrodUcing Health Psychology

pplying the Biopsychosocial Model

these rings include our families, our neighBorhoods, our communities, our societies, and o ur cultures.

Applied to health, the systems approach emphasizes a crucial point: A sys-tern at any given level is affected by and affects systems at other levels. For example, a weakened immune system affects specific organs in a person's body,which in turn affect the person's overall biological health, which in turn mightaffect the person's relationships with his or her family and friends. C onceptualizing health and disease according to a systems approach allows us to understand the whole person more fully.

To get a better feeling for the usefulness of biopsychosocial explanations ofhealthy behaviors, consider the example of alcohol abuse which is a maladaptive drinking pattern in which at least one of the following occurs: recurrent drinki n des ite its interference with l e obli ations; continueddrin ll1g despite legal, social, or interpersonal problems related to its use;.. 0::;.. .....-. _

PAR T 1 I Foundations of Health Psychology2


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4

. ~ ~ .

v ~ ng to cope with life events or overwhelming social demands. Peer pressure,l ~ f e . , difficult home and work environments, and tension reduction also may con-

l } t r ibute o problem drinking. And more generally, as many college students. know, certain social contexts promote heavy drinking. Research studies have, :ll . shown that college students who prefer large social contexts involving both

men and women tend to be heavier drinkers than those who prefer smallerf r ~ ~ j 1::>', Genetic Negative thinkingpredispositions Self defeating beliefs

AlcoholsensitivityBIOLOGICAL MECHANISMS PSYCHOLOGICAL PROCESSES

Stressful events~ l i U f : : l i : : : : : I u . ; ; J . : : I L . _ Culture/environment thatpromotes excessive drinking Alcohol abuse Biopsychosocial odel of Individualistic culture thatAlcohol Abuse Alcohol abuse encourages self blame foris best understood as occurring personal failure. BEHAVIORin three contexts: biological.psychological. and social. SOCIAL INFLUENCES

P R T 1 I Foundations of Health Psychologyand recurrent drinking in situations in which intoxication is dangerous. Likemost disordered behavior, alcohol abuse is best explained in terms of severalmechanisms that include both genetic and environmental components(Ball, 2008) (Figure 1.5). Research studies of families, identical and fraternal twins, and adopted children clearly demonstrate that people (especiallymen) who have a biological relative who was alcohol dependent are significantly more likely to abuse alcohol themselves (NIAAA, 2010). In fact, formales, alcoholism in a first-degree relative is the single best predictor of alcoholism (Plomin and others, 200l). n addition, people who inherit a genevariant that results in a deficiency of a key enzyme for metabolizing alcoholare more sensitive to alcohol's effects and far less likely to become problemdrinkers (Zakhari, 2006).

On the psychological side, although researchers no longer attempt to identify a single alcoholic personality;' they do focus on specific personality traitsand behaviors that are linked with alcohol dependence and abuse. One suchtrait is poor r e g u l t i o n characterized by an inability to exercise control overdrinking (Hust ad, Carey, Carey, Maisto, 2009). Another is negative emoJisln-ality marked by irritability and agitation. Along with several others, these traitscomprise the alcohol dependency stndrome that is the basis for a diagnosis of alcohol abuse (Li, fuwfti; -GraJlt,2007).

On the social side, alcohol abuse sometimes stems from a history of drink

CH P T R 1 I Introducing Health PsychologyIllixed-sex contexts. In addition, men who often drink in same-sex groups(whether large or small) report more frequent drunkenness than men whodrink more often in smaD mixed-sex groups. This suggests that college menwho drink heavily may seek out social contexts in which this behavior will betolerated (LaBrie, Hummer, & Pedersen, 2007; Senchak, Leonard, & Greene1998). Fortunately, researchers have also found that heavy college drinkingdoes not necessarily predict similar post-college drinking behavior. Studentstend to stop heavy drinking sooner than nonstudents maturing out of hazardous alcohol use before it becomes a long-term problem (NlAAA, 2006;White, Labouvie, & Papadaratsakis, 2005).

W e have seen how views regarding the nature of illness and health havechanged over the course of history, examined trends that helpedshape the new field of health psychology, and discussed the varioustheoretical perspectives from which health psychologists work. But you maystill have questions about the profession of health psychology. Here are answersto some of the most frequently asked questions.

hat Do Health Psychologists DoLike aD psychologists, health psychologists rna serve as teachers research scien-tists and/or clinicians. s teac ers, 1ea psychologists train students in hea threlated fields such as psychology, physical therapy, and medicine. As researchscientists, they identify the psychological processes that contribute to health andillness, investigate issues c o n c e r n i n ~ w tices, and evaluate the7f fe . e eSSJlf ific therapeutic intervention~ i th psychologists are on the cutting edge ot research testing the biopsychosocial model in numerous areas, including Alzheimer's disease, HIV /AIDS,compliance with medical treatment regimens, and immune functioning andvarious disease processes. Because the biopsychosocial model was first developed to explain health problems, until recently the majority of this research hasfocused on diseases and health-compromising behaviors. However, the latetwentieth-century movement in psychology, called positive psychology encourages psychologists to devote more research attention to optimal, healthyhuman functioning (APA, 2010). The scope of this research-covering topicsas diverse as optimism and happiness, psychological hardiness, and the traits ofpeople who live to a ripe old age-shows clearly that the biopsychosocial modelguides much of it (see Chapter 6).

Clinical health psychologists who generally focus on health-promoting interventions, are licensed for independent practice in areas such as clinical and counseling psychology. As clinicians, they use the full range of diagnostic assessment,


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r W e i g h ~ O 1;ieaJih-, -

( HAP T E R 1 I Introducing Health Psychology

2. How does the overall health of your schbenefit when different contexts, systemtheories about health are taken into co

3. Your friend Tran is thinking about purshealth psychology. What general advice him, and how would you suggest he chcareer in the field?

Respond to each question below based on what youlearned in the chapter. (TIP: Use the items in Summing Upto take into account related biological, psychological, andsocial concerns.)

1. Considering how views of health have changed overtime, what would be a good description of health foran individual today? How do gender, culture, and thepractice of health influence your description?

I 1 hers train for one of the allied health professions, such as nutrition, physical111l,;rapy, social work, occupational therapy, or public health. An increasing1IIImber of interested undergraduates continue on to graduate school in psy, I ulogy and acquire research, teaching, and interventi on skills. Those who ulIimately hope to provide direct services to patients typically take their trai ningIn clinical or counseling psychology programs.

Many students who wish to pursue a career in health psychology beginwith general psychology training at the undergraduate level. Because ofhealth psychology s biopsychosocial orientation, students are also encourilgcd to take courses in anatomy and physiology, abnormal and social psychology, learnin g processes and behavior therapies, community psychology,,md public health.

Most health psychologists eventually obtain a doctoral degree (Ph.D. orl sy.D.) in psychology. To earn a Ph.D. in psychology, students complete a(our- to six-year program, at the end of which they conduct an original research project. PsyD programs generally provide slightly more clinical rience and clinical courses but less research training and experience thanPh.D. programs.

Graduate trai ning in heal th psychology is generally based on a curriculumthat covers the three basic domains of the biopsychosocial model. Training inthe biological domain includes courses in neuropsychology, anatomy, pm:siology, and psychopharmacology. Training in the psychological dornalo-includescourses in each of the major subfields (biological, developmental, personality,etc.) and theoretical perspectives (social-cultural, cogniti\re, behavior, neuroscience, etc.). And training in the social domain includes cpurses on groupprocesses and ways in which the various group s (family, ethnic, etc.) influencetheir members health.

Following graduate training, many health psychologists complete two ormore years of specialized training in the form of an internship in a hospital,clinic, or other medical setting. Some advocates have suggested that such training should culminate in board certification of health psychologists as primaryhealth care providers themselves (Tovian, 2004, 2010).

PAR T 1 I Foundations of Health Psychology

Where Do Health Psychologists WorkTraditionally, most psychologists accepted teaching or research positions atuniversities and four-year colleges. Employment opportunities for health psychologists with applied or research skills also include working in gover nmentagencies that conduct research, such as the National Institutes of Health andthe Centers for Disease Control and Prevention.

In medical settings, health psychologists teach health care providers, conduct research, become involved in health care policy development, and providea variety of other services. They help patient s cope with illness and the anxietyassociated with surgery and other medical interventions, as well as intervene topromote patients adherence to complicated medical regimens. In this capacity, clinical health psychologists often work on interdisciplinary hospital teams.As part of a new model of integrated care these teams improve medical treatment outcomes, lower costs, and offer a successful model for future heal th caresystems (Novotney, 2010).

In addition, medical residency programs in the United States now have a clearmandate to improve physician training in areas such as sensitivity and responsiveness to patients culture, age, gender, and disabilities. Increasingly,healili psychologists are helping physicians become better listeners andcommunicators (Novotney, 2010). As we ll see, tllis mandate stemsfrom mounting evidence iliat this type of care results in better healilioutcomes and helps control health care costs (Novotney, 2010).

Health psychologists may also be found working in health maintenance organizations (HMOs), medical schools, pain and rehabilitation clinics, and private practice (Figure 1.6). An increasingnumber of health psychologists may also be found in the corporat eworld, where they advise employers and workers on a variety ofhealth-related issues. They also establish on-the-job interventionsto help employees lose weight, quit smoking, and learn more adaptive ways of managing stress.

education, and therapeutic techniques in psychology to promot e health and assist the physically ill. Assessment approaches frequently include measures of cognitive functioning, psychophysiological assessment, demographic surveys, andlifestyle or personality assessment. II r ltio ns ay include stress ana ement, relaxation therapies, biofeedback, education about the role of psychologic:irprcResses irrdlsease, and cognitive behavi oral interventi ons. Interv entions arenot limited to those who are already suffering from a healili problem. Healthy orat-risk individuals may be taught preventive healiliy behaviors.

How Do I Become a Health PsychologistPreparing for a career in health psychology usually requires an advanced degree in any of a number of different educational programs. Some students enroll in medical or nursing school and eventually become nurses or doctors.

Other 3

~ U f : : H ~ : : : u u : : ; : O : L _Where o Health Psycholo-gists Work Besides colleges,universities, and hospitals,health psychologists work in avariety of venues, includinghealth maintenance organiza-tions HMOs), medical schools,pain and rehabilitation clinics,and independent practices. Anincreasing number of healthpsychologists can be found inthe workplace, where theyadvise employers and workerson a variety of health-relatedissues.Source: 2 9 Doctoral PsychologyWorkforce Fast Facts Washington DC:American Psychological Association.

Business/government 7


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Summing Up1. Health is a state of complete physical, mental, and social

well-being. Health psychology's goals are to promotehealth; prevent and treat illness; investigate the role ofbiological, behavioral, and social factors in disease; andevaluate and improve the formulation of health policyand the delivery of health care to all people.

Health and Illness: Lessons from the Past2. In the earliest know n cultures, illness was believed to re

sult from mystical forces and evil spirits that invaded thebody. Hippocrates, Galen, and other Greek scholars developed the first rational approach to the study of healthand disease. Non-Western forms of healing, includingTOM and ayurveda, developed simultaneously.

3. In Europe duri ng the Middle Ages, scientific studies ofthe body (especially dissection) were forbidden, andideas about health and disease took on religious overtones. Illness was viewed as punishment for evildoing,and treatment frequently involved what amounted tophysical tortu o

4. French philosopher Rene Descartes advanced his theoryof mind-body dualism-the belief that the mind andbody are auto nomous processes, each subject to different laws of causality. During the Renaissance, Descartes'influence ushered in an era of medical research based onthe scientific study of the body. This research gave rise tothe anatomical, cellular, and germ theories of disease.

5. The dominant view in modern medicine is the biomedical model, which assumes that disease is the result of avirus, bacterium, or some other pathogen invading thebody. Because it makes no provision for psychological,social, or behavioral factors in illness, the model embraces both reductionism and mind-body dualism.

6. Sigmund Freud and Franz Alexander promoted theidea that specific diseases could be caused by unconscious conflicts. These views were expanded into thefield of psychosomatic medicine, which is concernedwith the treatment and diagnosis of disorders causedby faulty processes within the mind. Psychosomaticmedicine fell out of favor because it was grounded inpsychoanalytic theory and predicated on the outmoded idea that a single problem is sufftcient to trigger disease.

P R T I Foundations of Health Psychology

7. Behavioral medicine was an outgrowth of the behaviorist movement in American psychology. Behavioral medicine explores the role of learned behavior in health anddisease.

Biopsychosocial Mind-Body) Perspective8. Health psychologists approach the study of health and

illness from several overlapping perspectives. The lifecourse perspective in health psychology focuses attention on how aspects of health and illness vary with age,as well as how birth coho rt experiences (such as shifts inpublic health policy) influence health.

9. The sociocultural perspective calls attention to how social and cultural factors, such as ethnic variations in dietary practice and beliefs about the causes of illness,affect health.

10 The gender perspective calls attention to male-femaledifferences in the risk of specific diseases and conditions, as well as in various health-enhancing and healthcompromising behaviors.

11 The biopsychosocial perspective in effect combines theseperspectives, recognizing that biological, psychological,and social forces act together to determine an individual's health and vulnerability to disease.

12. According to systems theory, health is best understood asa hierarchy of systems in which each system is simultaneously composed of smaller subsystems and part oflarger, m ore encompass ing systems.

Frequently Asked Questions about a HealthPsychology Career13. Health psychologists are engaged in three primary activ

ities: teaching, research, and clinical intervention. Healthpsychologists work in a variety of settings, includinghospitals, universities and medical schools, health maintenance organizations, rehabilitation clinics, privatepractice, and, increasingly, the workplace.

14 Preparing for a career in health psychology usually requires a doctoral degree. Some students enter health psychology from the fields of medicine, nursing, or one ofthe allied health professions. An increasing number enroll in graduate programs in health psychology.

C H P T ER I Introducing Health Psychologyey erms and C Q n c e p t s l i L R e m e m b ~ e l r

he.llth psychology, p. 3 cellular theory, p. biopsychosocial (mhealth, p. 3 germ theory, p. 12 perspective, p. 16I rep hi nation, p. 6 biomedical model, p. 12 life-course perspecthumoral theory, p. 8 pathogen, p. 12 birth cohort, p. 18epidemic, p. 10 psychosomatic medicine, p. 13 sociocultural perspmind-body dualism, p. 11 behavioral medicine, p. 14 gender perspective,;ll1atomical theor y, p. etiology, p. 15 systems theory, p. 2

health pyschology chapter 1

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