APPLICATION OF HEALTH APPLICATION OF HEALTH PSYCHOLOGY PSYCHOLOGY

&&PREVENTION OF HEALTH PREVENTION OF HEALTH

PROBLEMSPROBLEMS

Lecture 40Lecture 40

Nearly everyone agrees that a few simple behaviors, if Nearly everyone agrees that a few simple behaviors, if widely practiced, would dramatically reduce the toll of widely practiced, would dramatically reduce the toll of human misery. human misery.

These include reducing our consumption of salt and These include reducing our consumption of salt and fatty foods, driving carefully and using seat belts, fatty foods, driving carefully and using seat belts, exercising regularly, avoiding cigarettes, and exercising regularly, avoiding cigarettes, and decreasing stress. decreasing stress.

But giving advice and having people take it are two But giving advice and having people take it are two very different things. very different things.

Therefore, psychologists, other behavioral specialists, Therefore, psychologists, other behavioral specialists, and medical professionals have mounted research and medical professionals have mounted research programs to learn how to treat and also prevent a programs to learn how to treat and also prevent a variety of potentially harmful human behaviors. variety of potentially harmful human behaviors. health: health: cigarette smoking, alcohol abuse, and weight control.cigarette smoking, alcohol abuse, and weight control.

CIGARETTE SMOKINGCIGARETTE SMOKING Increased awareness of the dangers of cigarette Increased awareness of the dangers of cigarette

smoking has led to a steady decline since the mid-smoking has led to a steady decline since the mid-1960s in the percentage of Americans who are 1960s in the percentage of Americans who are habitual smokers . habitual smokers .

However, rates of smoking differ according to gender, However, rates of smoking differ according to gender, level of education, and income. level of education, and income.

One disconcerting trend is that the rate of smoking for One disconcerting trend is that the rate of smoking for women has shown much less of a decline than that for women has shown much less of a decline than that for men . men .

In fact, among white-collar workers, the smoking rate In fact, among white-collar workers, the smoking rate for women now exceeds that for men.for women now exceeds that for men.

Cigarette smoking has been linked to an increased Cigarette smoking has been linked to an increased creased risk of cardiovascular disease and cancer.creased risk of cardiovascular disease and cancer.

Even though smoking increases one's e chances of Even though smoking increases one's e chances of premature death from diseases such as coronary premature death from diseases such as coronary heart disease, cancers of the respiraheart disease, cancers of the respiratory tory tract, tract, emphysema, and bronchitis, people still smoke. Why?emphysema, and bronchitis, people still smoke. Why?

Possible reasons include tension control, social Possible reasons include tension control, social pressure, rebelliousness, the addictive nature of pressure, rebelliousness, the addictive nature of nicotine, and genetically influenced personality traits nicotine, and genetically influenced personality traits such as extraversion. such as extraversion.

Tension control and social pressure are thought to be Tension control and social pressure are thought to be reasons for initiation of smoking, whereas reasons for initiation of smoking, whereas rebelliousness, addiction, and personality are seen rebelliousness, addiction, and personality are seen primarily as maintaining factors.primarily as maintaining factors.

A variety of techniques have been used to induce A variety of techniques have been used to induce people to stop smoking, including educational people to stop smoking, including educational programs, aversion therapy, behavioral contracts, programs, aversion therapy, behavioral contracts, acupuncture, cognitive therapy, and group support.acupuncture, cognitive therapy, and group support.

Relapse rates are high (70-80%), however, and Relapse rates are high (70-80%), however, and research findings about which cessation approach is research findings about which cessation approach is best are conflicting. best are conflicting.

Most smokers who do quit, do so on their own.Most smokers who do quit, do so on their own.

The best approach seems to be to prevent the habit The best approach seems to be to prevent the habit from starting in the first place. from starting in the first place.

Unfortunately, education alone does not appear to Unfortunately, education alone does not appear to deter young people from smoking . deter young people from smoking .

What appears to be more effective is focusing on What appears to be more effective is focusing on immediate rather than delayed negative immediate rather than delayed negative consequences, teaching coping skills, and increasing consequences, teaching coping skills, and increasing feelings of self-efficacy.feelings of self-efficacy.

One of the early encouraging multiple-component One of the early encouraging multiple-component prevention programs aimed at children and teenagers prevention programs aimed at children and teenagers was based on social learning principles and used peer was based on social learning principles and used peer role models .role models .

Videotaped presentations, peer modeling, discussion Videotaped presentations, peer modeling, discussion groups, role playing, monitoring smoking, and groups, role playing, monitoring smoking, and checking repeatedly on attitudes and knowledge about checking repeatedly on attitudes and knowledge about smoking were all used with elementary school smoking were all used with elementary school children. children.

Such an approach seems superior to those used with Such an approach seems superior to those used with adolescents that focus on long-term negative effects adolescents that focus on long-term negative effects from smoking. from smoking.

The trick seems to be to focus on immediate negative The trick seems to be to focus on immediate negative consequences (for example, from peers) rather than consequences (for example, from peers) rather than delayed ones (such as emphysema). delayed ones (such as emphysema).

Programs similar to Evans's in Houston have been Programs similar to Evans's in Houston have been undertaken in other states. undertaken in other states.

Other prevention programs that use student rather Other prevention programs that use student rather than adult models to encourage teenagers not to than adult models to encourage teenagers not to smoke have been successful as well . smoke have been successful as well .

Programs that teach refusal skills (practicing Programs that teach refusal skills (practicing responding to audio taped offers of cigarettes) also responding to audio taped offers of cigarettes) also seem to reduce rates of smoking.seem to reduce rates of smoking.

ALCOHOL USE AND DEPENDENCEALCOHOL USE AND DEPENDENCE It is estimated that about 70% of men and 50% of It is estimated that about 70% of men and 50% of

women in the United States consume alcoholic women in the United States consume alcoholic beverages. beverages.

Although some studies have suggested positive health Although some studies have suggested positive health benefits from alcohol for light or moderate drinkers, benefits from alcohol for light or moderate drinkers, consumption of alcohol has also been associated with consumption of alcohol has also been associated with a number of negative outcomes. a number of negative outcomes.

Heavy alcohol use has been associated with Heavy alcohol use has been associated with increased risk for liver or neurological damage, certain increased risk for liver or neurological damage, certain forms of cancer, cardiovascular problems, fetal alcohol forms of cancer, cardiovascular problems, fetal alcohol syndrome, physical aggression, suicide, motor vehicle syndrome, physical aggression, suicide, motor vehicle accidents, and violence. accidents, and violence.

This extensive list of alcohol-related problems has This extensive list of alcohol-related problems has made the treatment and prevention of alcohol abuse made the treatment and prevention of alcohol abuse and alcohol dependence (alcoholism) a high priority.and alcohol dependence (alcoholism) a high priority.

Over the years, many treatment approaches have Over the years, many treatment approaches have been applied to problem drinkers. been applied to problem drinkers.

These have ranged from medical treatments and These have ranged from medical treatments and medications such as disulfiram (Antabuse) and medications such as disulfiram (Antabuse) and naltrexone to traditional psychotherapy and group naltrexone to traditional psychotherapy and group supportive strategies such as supportive strategies such as Alcoholics Alcoholics AnonymousAnonymous. .

However, alcoholism is a problem that has been However, alcoholism is a problem that has been extremely resistant to virtually all intervention, and the extremely resistant to virtually all intervention, and the relapse rate is high.relapse rate is high.

Another, more controversial, approach to the Another, more controversial, approach to the treatment of alcohol problems is treatment of alcohol problems is controlled drinkingcontrolled drinking..

As the name implies, this approach has as its goal As the name implies, this approach has as its goal light to moderate (but controlled) drinking. Clients are light to moderate (but controlled) drinking. Clients are taught to develop alternative coping responses (other taught to develop alternative coping responses (other than drinking) and to closely monitor alcohol intake. than drinking) and to closely monitor alcohol intake.

The field is divided as to the merits of this approach, The field is divided as to the merits of this approach, but research does suggest that controlled drinking is a but research does suggest that controlled drinking is a viable treatment option for some alcoholics . viable treatment option for some alcoholics .

Many alcohol treatment programs also incorporate Many alcohol treatment programs also incorporate relapse prevention relapse prevention trainingtraining. .

The majority of clients treated for alcohol problems The majority of clients treated for alcohol problems have a relapse episode soon after treatment is have a relapse episode soon after treatment is terminated. terminated.

Rather than see this as a failure (a sign that total Rather than see this as a failure (a sign that total relapse is imminent), clients are taught coping skills relapse is imminent), clients are taught coping skills and behaviors they can use in "high-risk" situations to and behaviors they can use in "high-risk" situations to make total relapse less likely.make total relapse less likely.

Alcohol abuse and dependence are complex problems Alcohol abuse and dependence are complex problems that will probably require multimodal treatment that will probably require multimodal treatment strategies. strategies.

Because of the difficulties with secondary and tertiary Because of the difficulties with secondary and tertiary approaches to treatment or prevention, more and approaches to treatment or prevention, more and more professionals have turned to primary prevention more professionals have turned to primary prevention to forestall the development of problem drinking. to forestall the development of problem drinking.

For both drinking and drug abuse, programs similar to For both drinking and drug abuse, programs similar to those designed to prevent adolescents from smoking those designed to prevent adolescents from smoking are being developed. are being developed.

Often these programs are implemented through Often these programs are implemented through health-education courses in high school or media health-education courses in high school or media campaigns. campaigns.

School-based prevention programs typically involve School-based prevention programs typically involve one or more of the following components: one or more of the following components:

Affective education (building self-esteem, increase Affective education (building self-esteem, increase decision-making skills); decision-making skills);

Life skills (communication skills, Life skills (communication skills, assertiveness training);assertiveness training);

Resistance training (learn to resist pressures Resistance training (learn to resist pressures to drink alco hol); and to drink alco hol); and

Correction of erroneous perceptions about Correction of erroneous perceptions about peer norms .peer norms .

Current research evidence suggests that Current research evidence suggests that programs that incorporate peer resistance programs that incorporate peer resistance training and correction of misperceptions training and correction of misperceptions regarding peer norms show the most regarding peer norms show the most promise (USDHHS, 1997).promise (USDHHS, 1997).

OBESITYOBESITY Behavioral treatments for obesity have been more Behavioral treatments for obesity have been more

common than for any other condition. common than for any other condition. One reason for this emphasis is that obesity is One reason for this emphasis is that obesity is

associated with such medical disorders as diabetes, associated with such medical disorders as diabetes, hypertension, cardiovascular disease, and certain hypertension, cardiovascular disease, and certain cancers. cancers.

It is also a socially stigmatizing condition that impairs It is also a socially stigmatizing condition that impairs the self-concept and inhibits functioning in a wide the self-concept and inhibits functioning in a wide array of social settings. array of social settings.

Often problems of weight can be traced to childhood: Often problems of weight can be traced to childhood: 10-25% of all children are obese, and 80% of these 10-25% of all children are obese, and 80% of these individuals become obese adults .individuals become obese adults .

Although it is clear that obesity has a genetic Although it is clear that obesity has a genetic component, causes of obesity undoubtedly represent component, causes of obesity undoubtedly represent complex interactions among biological, social, and complex interactions among biological, social, and behavioral factors, and exact mechanisms are difficult behavioral factors, and exact mechanisms are difficult to pin down. to pin down.

Traditional medical and dietary methods of Traditional medical and dietary methods of treatment have not been very effective; obese treatment have not been very effective; obese individuals lose weight but then quickly regain individuals lose weight but then quickly regain it. it.

Furthermore, the dropout rate may be high in Furthermore, the dropout rate may be high in traditional weight-control programs. traditional weight-control programs.

Most behavior modification programs include Most behavior modification programs include components aimed at restricting certain types components aimed at restricting certain types of foods, teaching when and under what of foods, teaching when and under what conditions to eat, encouraging regular exercise, conditions to eat, encouraging regular exercise, and maintaining modified eating patterns after and maintaining modified eating patterns after the program has ended.the program has ended.

Again," however, early prevention may be the Again," however, early prevention may be the best and safest road to weight control. best and safest road to weight control.

An excellent example of such an approach is the An excellent example of such an approach is the Stanford Adolescent Obesity Project. Stanford Adolescent Obesity Project.

A variety of strategies were used with adolescents in A variety of strategies were used with adolescents in the hope that control at this age would lead to the hope that control at this age would lead to prevention in adulthood. prevention in adulthood.

The strategies used were self-observation, cue The strategies used were self-observation, cue elimination, and social and family support. elimination, and social and family support.

These interventions were noticeably more effective These interventions were noticeably more effective when parents were involved. when parents were involved.

\Many investigators are also exploring the possibility of \Many investigators are also exploring the possibility of using peer group discussion. using peer group discussion.

A recent ten-year outcome study of a family-based A recent ten-year outcome study of a family-based behavioral treatment for childhood obesity suggests behavioral treatment for childhood obesity suggests that early intervention in childhood can effect that early intervention in childhood can effect important and lasting changes in weight control.important and lasting changes in weight control.

OTHER APPLICATIONSOTHER APPLICATIONS Treatment and preventive initiatives must be Treatment and preventive initiatives must be

supplemented with techniques that encourage patients supplemented with techniques that encourage patients to cope with medical procedures and to follow medical to cope with medical procedures and to follow medical advice.advice.

COPING WITH MEDICAL COPING WITH MEDICAL PROCEDURESPROCEDURES

The' prospect of facing surgery, a visit to the dentist, The' prospect of facing surgery, a visit to the dentist, or a variety of medical examinations has been enough or a variety of medical examinations has been enough to strike fear into the heart of even the strongest.to strike fear into the heart of even the strongest.

Faced with such procedures, many patients delay their Faced with such procedures, many patients delay their visits or even forgo them entirely. visits or even forgo them entirely.

Health psychologists specializing in behavioral Health psychologists specializing in behavioral medicine have developed interventions to help medicine have developed interventions to help patients deal with the stress surrounding such patients deal with the stress surrounding such procedures.procedures.

PREPARATION FOR SURGERYPREPARATION FOR SURGERY::

A sizable amount of research has been done on A sizable amount of research has been done on ways to improve psychological preparation for ways to improve psychological preparation for surgery. Similar to those used to prepare surgery. Similar to those used to prepare patients for medical examinations and patients for medical examinations and procedures, interventions include: procedures, interventions include:

(1) relaxation strategies, (1) relaxation strategies, (2) basic information about the procedures to be (2) basic information about the procedures to be

used. used. (3)information concerning the bodily sensations (3)information concerning the bodily sensations

experienced during the procedures, and experienced during the procedures, and (4) cognitive coping skills (Brannon & Feist, (4) cognitive coping skills (Brannon & Feist,

2000). 2000).

HEALTH PSYCHOLOGY: PROSPECTS FOR HEALTH PSYCHOLOGY: PROSPECTS FOR THE FUTURETHE FUTURE

Health psychology is a growing field, and more Health psychology is a growing field, and more psychologists are entering it every year.psychologists are entering it every year.

Therefore, it may now be time for the field to Therefore, it may now be time for the field to take a look at itself and decide how best to train take a look at itself and decide how best to train health psychologists and structure programs to health psychologists and structure programs to achieve training goals (Belar, 1997).achieve training goals (Belar, 1997).

Now we will discuss several health care trends, Now we will discuss several health care trends, training issues for future health psychologists, training issues for future health psychologists, and important issues for the field of health and important issues for the field of health psychology to address in the future.psychology to address in the future.

HEALTH CARE TRENDSHEALTH CARE TRENDS By the end of 1997, 85% of Americans belonged to By the end of 1997, 85% of Americans belonged to

some kind of managed health care plan. some kind of managed health care plan. In managed care systems, containing costs is a high In managed care systems, containing costs is a high

priority. priority. We know the great impact managed care has had and We know the great impact managed care has had and

will have on clinical psychologists. will have on clinical psychologists. The impact on health psychologists will be even The impact on health psychologists will be even

greater because these specialists often work in greater because these specialists often work in medical centers or primary care settings. medical centers or primary care settings.

Health psychologists, by virtue of their training, are Health psychologists, by virtue of their training, are well suited to provide interventions that will serve to well suited to provide interventions that will serve to cut the costs of medical care . cut the costs of medical care .

As business and industry realize the costs they must As business and industry realize the costs they must absorb from employees whose habits and lifestyles absorb from employees whose habits and lifestyles create absenteeism, inefficiency, and turnover, it is create absenteeism, inefficiency, and turnover, it is expected they will use the skills of health expected they will use the skills of health psychologists more often.psychologists more often.

Although there appears to be an ever-increasing need Although there appears to be an ever-increasing need for clinical psychologists specializing in health or for clinical psychologists specializing in health or behavioral medicine, it should also be noted that behavioral medicine, it should also be noted that currently there appears to be a surplus of mental currently there appears to be a surplus of mental health professionals. health professionals.

For example, Frank and Ross (1995) estimate that For example, Frank and Ross (1995) estimate that there are approximately 32.8 social workers, 22.8 there are approximately 32.8 social workers, 22.8 psychologists, 13.1 psychiatrists, and 4.3 psychiatric psychologists, 13.1 psychiatrists, and 4.3 psychiatric nurses for every 100,000 American. nurses for every 100,000 American.

The problem lies in the overlapping definitions of each The problem lies in the overlapping definitions of each discipline; all claim to assess and treat similar discipline; all claim to assess and treat similar problems. problems.

As the economic stakes become higher, it is likely that As the economic stakes become higher, it is likely that these disciplines self-definitions will incorporate these disciplines self-definitions will incorporate concepts and issues once thought to be uniquely concepts and issues once thought to be uniquely characteristic of health psychology and behavioral characteristic of health psychology and behavioral medicine.medicine.

TRAINING ISSUESTRAINING ISSUES A major source of health psychologists continues to be A major source of health psychologists continues to be

clinical psychology programs. clinical psychology programs. The scientist-practitioner and clinical scientist models The scientist-practitioner and clinical scientist models

adopted by most clinical psychology programsenable adopted by most clinical psychology programsenable them to train clinicians well suited for health them to train clinicians well suited for health psychology. psychology.

Until recently, no other psychology specialty offered Until recently, no other psychology specialty offered the combination of academic, scientific, professional, the combination of academic, scientific, professional, and hospital experiences required for work in medical and hospital experiences required for work in medical settings.settings.

The roles of methodology, quantitative analysis, and The roles of methodology, quantitative analysis, and research design are emphasized. research design are emphasized.

Other psychology subspecialties are also well Other psychology subspecialties are also well represented in health psychology.represented in health psychology.

For the most For the most part, part, health psychology is still a kind of health psychology is still a kind of ad hoc appendage to doctoral programs in ad hoc appendage to doctoral programs in psychology. psychology.

The student enters a clinical, social, or experimental The student enters a clinical, social, or experimental program and then, in addition to the core experience, program and then, in addition to the core experience, does some specialized research or takes a practicum does some specialized research or takes a practicum or two in a health-related topic. or two in a health-related topic.

Perhaps this is augmented by an internship at a health Perhaps this is augmented by an internship at a health care site. But essentially, the health experiences are care site. But essentially, the health experiences are grafted onto an already existing program in clinical grafted onto an already existing program in clinical psychology or some other related discipline.psychology or some other related discipline.

Many people are now calling for health psychology to Many people are now calling for health psychology to be a standard, core training compobe a standard, core training component nent for all for all professional psychologists for example, Frank & Ross, professional psychologists for example, Frank & Ross, 1995). 1995).

Because of the importance of health issues and the Because of the importance of health issues and the broadening of the definition of clinical and professional broadening of the definition of clinical and professional psychology, psychology,

Training in areas such as psychopharmacology, Training in areas such as psychopharmacology, neuropsychology, and psychoneuroimmunology is neuropsychology, and psychoneuroimmunology is considered essential. considered essential.

Further, future health psychologists must be trained so Further, future health psychologists must be trained so that they can design and conduct studies to that they can design and conduct studies to empirically evaluate health outcomes.empirically evaluate health outcomes.

Currently, some clinical psychology graduate Currently, some clinical psychology graduate programs offer "tracks" in health psychology or programs offer "tracks" in health psychology or behavioral medicine, but this is the exception rather behavioral medicine, but this is the exception rather than the rule. than the rule.

In any case, curricular recommendations for health In any case, curricular recommendations for health psychology training continue to be offered.psychology training continue to be offered.

OTHER CHALLENGESOTHER CHALLENGES Any newly emerging field has problems the defining Any newly emerging field has problems the defining

roles of its members: health psychology is no roles of its members: health psychology is no exception. exception.

Years ago. S. E. Taylor t 1984) identified several of Years ago. S. E. Taylor t 1984) identified several of these problems. these problems.

One problem is simply role ambiguity. No one is totally One problem is simply role ambiguity. No one is totally prepared to say just what a health psychologist should prepared to say just what a health psychologist should do-especially in a practical work setting. do-especially in a practical work setting.

Health psychologists may actually find themselves Health psychologists may actually find themselves without psychology colleagues or role models in the without psychology colleagues or role models in the health setting, which only adds to their confusion. health setting, which only adds to their confusion.

Second. issues of status also arise. In health settings, Second. issues of status also arise. In health settings, the physician is clearly at the top of the heap.the physician is clearly at the top of the heap.

Sometimes the psychologist enjoys much less status Sometimes the psychologist enjoys much less status in a medical center setting than. for example, in an in a medical center setting than. for example, in an academic settings. academic settings.

Furthermore, the psychologist and the heath care Furthermore, the psychologist and the heath care professional may have competing goals. professional may have competing goals.

The latter may be interested only in identifying The latter may be interested only in identifying immediate ways of helping the patient. immediate ways of helping the patient.

The psychologist may be more tentative and The psychologist may be more tentative and contemplative while thinking about research, contemplative while thinking about research, theoretical models, and interventions.theoretical models, and interventions.

As one way of establishing their identity and presence As one way of establishing their identity and presence in settings traditionally dominated by physicians.in settings traditionally dominated by physicians.

Health psychologists need to document the cost-Health psychologists need to document the cost-effectiveness of their interven tions. effectiveness of their interven tions.

In this era of health care reform, insurance companies In this era of health care reform, insurance companies and government agencies ate scrupulously examining and government agencies ate scrupulously examining ways to drive down the cost of health care. ways to drive down the cost of health care.

Given the many successful and cost-efficient Given the many successful and cost-efficient interventions performed by those specializing in health interventions performed by those specializing in health psychology and behavioral medicine, ask Friedman et psychology and behavioral medicine, ask Friedman et al. (1995), al. (1995),

Why haven't these interventions been integrated to a Why haven't these interventions been integrated to a greater extent into our health care system? They greater extent into our health care system? They suggest several possible reasons:suggest several possible reasons:

Many of the data supporting the role of health Many of the data supporting the role of health psychology are unknown to physicians.psychology are unknown to physicians.

Biological origins of diseases and illnesses have been Biological origins of diseases and illnesses have been emphasized, causing many to overlook the possible emphasized, causing many to overlook the possible benefits of psychosocial explanations and behavioral benefits of psychosocial explanations and behavioral interventions.interventions.

patients may be resistant to psychological patients may be resistant to psychological interventions and explanations). interventions and explanations).

Clinical health psychology and behavioral medicine Clinical health psychology and behavioral medicine are still confused with traditional, long-term are still confused with traditional, long-term psychotherapy.psychotherapy.

Clearly, physicians, insurance companies, the Clearly, physicians, insurance companies, the 'federal government, and the general public 'federal government, and the general public need to be educated regarding the role of need to be educated regarding the role of health psychologists, as well as the potential health psychologists, as well as the potential financial and clinical benefits of their financial and clinical benefits of their interventions.interventions.

Another challenge for the field concerns Another challenge for the field concerns ethnicity and health. ethnicity and health.

The health profiles (such as life expectancy and The health profiles (such as life expectancy and health status) of various ethnic minority health status) of various ethnic minority populations in the United States appear to differ populations in the United States appear to differ greatly from one another, and more research is greatly from one another, and more research is needed on health-promoting and health-needed on health-promoting and health-damaging behaviors among members of these damaging behaviors among members of these groups. groups.

It is easy to become carried away with the enthusiasm It is easy to become carried away with the enthusiasm generated by an exciting new field. generated by an exciting new field.

This has been true in virtually every area of clinical This has been true in virtually every area of clinical psychology so far. psychology so far.

However there is still a gap between the field’s However there is still a gap between the field’s promise and its accomplishment. promise and its accomplishment.

As any experienced clinician will tell you, it is very As any experienced clinician will tell you, it is very hard to change human behavior over the long haul.hard to change human behavior over the long haul.

Never the less, health psychology most assuredly Never the less, health psychology most assuredly deserves our enthusiasm as well as our caution. deserves our enthusiasm as well as our caution.

Many people are optimistic about the future of health Many people are optimistic about the future of health psychology, given the pressing demands of improved psychology, given the pressing demands of improved health care. health care.

In fact Belar(1997)and others believe that health In fact Belar(1997)and others believe that health psychology is uniquely suited to be the specialty for psychology is uniquely suited to be the specialty for the professional practice psychology in twenty-first the professional practice psychology in twenty-first century. century.