History and Systems of Health Psychology

Paula van Rein, PhD Psychology

Walden University, November, 2009

 

Abstract

This paper focuses on the historical developments that shaped the growing recognition that psychology, and specifically health psychology, has an important contribution to make as a health science. First, I discuss the historical evolution of ideas about health and illness. Then I look at the developments in psychology, medicine, and medical care that transformed the scientific perspective on health and healthcare. This paper explores the major models that shaped contemporary theoretical orientations. The emphasis lies on the historical context and development of the science of health psychology. In the last section of this paper, I consider the challenges health psychology faces and look forward to its future.

 

History and Systems of Health Psychology

The specialization I seek in my PhD Psychology program at Walden is Health Psychology. My paper for this class therefore presents a historical exploration of this particular area of counseling psychology. It explores the relationship between the evolving perceptions about health and the developing theories, and composes a coherent picture of health psychology as it presents itself today.

Since its early days in the 19th century, psychology has developed into a science that profoundly influences our daily lives. Psychology provides evidence-based interventions for problems, not only in a mental health care context but also in the workplace, in schools, and other social settings.

Applied health psychology has been involved in the prevention, detection, and management of illness and the maintenance of health and healthcare for the last few decades (Baum, Perry, & Tarbell, 2004). Particularly the biopsychological model has been important in the science and practice of health psychology (Brown & Lent, 2008). Health promotion and disease prevention are nowadays professional activities that merit attention from counseling psychologists (Chwalisz & Obasi, 2008).

 

Health and Illness Through the Ages

In this chapter, I look at health and illness as it was perceived throughout history. It will become clear that our ancestors did not think of health as something that they could influence with their behavior. It is only during the past few centuries, that people have a growing sense of responsibility for their physical well-being. I will describe the developments and the models used by scientists that ultimately lead to the realization that psychology has a role to play in medicine and healthcare.

 

Early Cultures – 1600

In early cultures people believed that evil spirits of angry gods caused illness. Hippocrates, ca. 460 B.C., was the first to generate a theory about the physiology of the human body. He recommended a good diet and abstinence from excess and linked emotion and disease by virtue of their common antecedents (Salovey, Rothman, Detweiler, & Steward, 2000). Among the great Greek philosophers, Plato in the 4th century BC was the first to consider mind and body as separate entities, with the body representing the physical, and the mind the abstract processes of perceptions, thoughts, and feelings. The soul, incorporating the nous (now the mind) was considered immortal (Bennett, 2007). This view remained the dominant perspective for more than a thousand years.

Galen, working in Rome in the 2nd century A.D., made important discoveries about the human anatomy by dissecting the bodies of animals (Hankinson, 1991). He concluded that illnesses can be localized in specific parts of the body and suggested that different ailments have different causes. Galen’s views were widely accepted and his ideas about physiology and disease had a long lasting impact on how people thought about health (Hankinson, 1991).

During the middle ages, the influence of the church slowed the development of medical knowledge by prohibiting dissection (Bennett, 2007). Sickness was again seen as God’s punishment. The Italian philosopher Thomas Aquinas however, suggested that body and mind were interrelated and introduced a holistic perspective that influenced later philosophers greatly (Hatfield, 2007). The Renaissance, in the 14th and 15th centuries, brought a more human-centered perspective on health and illness. This was a new perspective, replacing the old God-centered one of the preceding period. The Renaissance set the stage for the scientific revolution that began after 1600 (Safarino, 2008).

 

The 17th Century Through the 20th Century.

In the 17th century, empiricism, scientific inquiry through observation and experimentation, became an important new way to pursue knowledge. Rene Descartes, who lived from1596 to1650, for instance, introduced the notion of the body as a machine, much like a clockwork mechanism (Bennett, 2007). He also revisited the concept that body and mind were separate, but added the idea that body and mind communicate through the pineal gland, in an attempt to resolve the body-mind controversy (Hatfield, 2007). Descartes thought that the relationship between mind and body was more than one-directional (the puppeteer-puppet view) and described it as a mutual interaction between different essences, in which body and mind influence each other (Schultz & Schultz, 2008). Through his work, scientists and philosophers became interested in the physical body again. Scholars began to study the mind and mental processes scientifically. Dissection became an acceptable method of study again, since people now thought that the soul left the body at death (Grant, 2000).

In the 18th and 19th centuries, the improved techniques (such as the use of microscopes, and antiseptic techniques) supported the advancement of the science of medicine. People started to put more trust in the ability of physicians to heal the sick (Sarafino, 2008). The biomedical perspective gained acceptance: the idea that physical illness can be explained by imbalances in the body, from injury, chemical disturbances, or infections became widely accepted. Physical illness was seen as a purely physical affliction in this era. Psychological or sociological processes (mind) were considered separate from the bodily processes (Sarafino, 2008).

By the end of the 19th century, people still defined health as the absence of disease. Illness was viewed as a biological process (Papas, Belar & Rozenshy, 2004). The biomedical model suggested a mechanistic approach. Exposure to a disease-causing organism resulted in illness and the research efforts were focused on removing the pathogens to cure the disease. Typical biomedical remedies for specific diseases were penicillin, antibiotics, insulin, and vaccines. Brannon and Feist (2007) pointed to the compatibility of the biomedical model and its focus on disease in a time that infectious diseases were the leading causes of death.

 

Past Century

Only when chronic diseases replaced infectious diseases as the major causes of death, new questions arose concerning the validity of the biomedical model (Sarafino, 2008). Scientists searched for a more holistic approach that considered not only the biological aspects of health, but also the psychological, social, and even spiritual influences on a person’s health.

The biopsychosocial model incorporated these aspects and added another, important change in perspective: it viewed health as a positive condition and focused on well-being in the larger context of an individual’s life (Engel, 1977).

The United Nations established the World Health Organization (WHO) in 1946. Its constitution still defines health as “a state of complete physical, mental, and social well-being: not merely as the absence of disease or infirmity” (World Health, 1948).

 

 

Psychology and Health

This chapter deals with the historical developments of the psychologist’s role in healthcare, and the establishment of health psychology as a separate discipline. I discuss the important trends in health care and then continue to explore the biopsychosocial model. This new perspective on health integrated psychological and social aspects of well being into the traditional biomedical model. It provided health psychology with its foundations as the health science it is today. In 1978, the American Psychological Association established the Division of Health Psychology (APA Division 38, 1978).

 

Major Trends in Healthcare

Four important historical trends have changed the field of healthcare during the past century (a) the changing patterns of disease and health, (b) the escalating costs of medical care, (c) the changing definition of health, and (d) the emergence of the biopsychosocial model (Brannon & Feist, 2007). Behavior, and therefore psychology, became increasingly important in preventing disease and maintaining health.

 

Changing patterns of disease and death.

The patterns of the diseases that were the major causes of death changed over the course of the last 100 years. Several developments, such as vaccinations, safer drinking water, and better nutrition decreased the mortality from infectious diseases. On the other hand, diseases associated with age, lifestyle and individual behavior (e.g., addictions, excessive diets), mostly chronic in nature, became more important causes for illness and death. The idea that individuals were responsible for their own health through choices made, or dictated by their social-economical context, evolved (Marks, 2002). Because of these changing patterns, the emphasis in healthcare has shifted to include approaches that focused on promoting healthy behaviors and lifestyles.

          

           Escalating costs of medical care.

Standards of living were increasing rapidly and healthcare was in most countries an organized part of the macro-social environment individuals lived in (Marks & Sykes, 2002). During the past century, infant mortality decreased dramatically while life expectancy rose steadily. People in Western countries now expect to live long and healthy lives up to their late 60’s (Veenhoven, 2006). Innovative medical technology was increasingly expensive and inflation caused the costs of medical care to rise progressively (World Health Organization, 2008). This development demanded more emphasis on cost effective interventions. Health psychologists could provide such interventions, for instance by using their expertise to ameliorate living and working conditions, by health education and promotion, or by social and community training (Marks & Sykes, 2002).

 

           Changing definition of health.

As the patterns of disease changed, it became apparent that individuals could make active choices concerning their health and as such be held responsible for their behavior. People became increasingly interested in healthy behaviors:  healthy nutrition, nonsmoking (even seat belts in cars), and fitness became an important part of our daily lives (Brannon & Feist, 2007).

More openness toward the holistic perspective further invited people to look for alternative ways of healing. Many people started to realize that emotional or psychological distress and imbalance could indeed cause illness (Marks, Murray, Evans, Willig, Woodall, & Sykes, 2005). The realization that behavior was an important aspect of health awakened the need to reconsider the tradition mechanical/biomedical model. 

 

           The emergence of the biopsychosocial model of health.

The biomedical model seemed no longer adequate. In the 1970’s, Engel introduced  a new model that integrated aspects of both illness and the experience of being sick. Engel (1977) considered the biomedical model reductionistic and dualistic, and he opposed its pathogenic assumptions (Marks, 2002). In the biopsychosocial model, health was seen as multidimensional: psychological and social influences were as important as biological factors for an individual’s well-being (Matarazzo, 1980).

This new view of health as a positive condition transferred the emphasis from the negative to the positive aspects of health and made it compatible with the new trends in psychology, like positive psychology (Seligman & Csikszentmihalyi, 2000). Another important aspect of the biopsychosocial perspective was that it focused the attention of psychologists on people who were mentally healthy. The biopsychosocial model formed the conceptual base for health psychology. It presumed that the biological, psychological, and social processes that influence health and illness are interrelated (Suls & Rothman, 2004).

 

The Biopsychosocial Model, Medicine, and Psychology

The emerging biopsychosocial perspective recognized the importance of behavior in healthcare. As researchers realized that behavior influenced health, both physicians and psychologists felt a growing, mutual responsibility for public healthcare (Marks, 2002). Psychology, the science of behavior, became involved in the maintenance of health and the prevention and treatment of illness (Sarafino, 2008).

Although physicians had a limited education in psychology, the focus of their psychological studies had always been on mental illness (Matarazzo, 1980). From the 1960’s, however, this changed considerably. By the beginning of the 21st century however, the expanding role of psychologists in medical settings was generally accepted (Papas, Belar, & Rozenski, 2004).

 

Psychology’s Involvement in Healthcare     

Although humans have studied the relationship between body and mind from the earliest civilizations, medicine and psychology did not formalize their alliance (Matarazzo, 1980). After the Second World War however, the biopsychological model of illness (Engel, 1977) started to substitute the traditional biomedical model. Although the early research in psychosomatic medicine had lead to the belief that some diseases were solely psychosomatic, more and more scientists believed that health involved the multifaceted combination of genetics, physiology, social context, and personality embedded in ethnic background and cultural beliefs (Smith, Kendall, & Keefe, 2002). Science could no longer neglect the impact of psychological and social aspects on health, even though the body-mind dualism, inspired with the success of the biomedical remedies (e.g., vaccines and antibiotics) was hard to oppose (Johnston & Dixon, 2008).

Two new and interrelated disciplines evolved; behavioral medicine and health psychology. Developments in behavioral medicine include evidence-based treatments in clinical psychology and methods to measure their effects (Smith et al., 2002). Although the emphasis for behavioral medicine is still on mental health, Smith et al. (2002) recognized a trend towards an integration of mental and physical health.

As psychologists began to contribute to the expanding field of health science, health psychology emerged as a separate discipline for professional psychologists who worked at the interface of medicine and psychology. The American Psychological Association (APA) established the division of health psychology, Division 38 in 1978 (APA, n.d.).

 

Health Psychology

Health psychology is the application of psychological principals to physical health areas. Joseph Matarazzo (1982), the first president of Division 38, outlined four goals of health psychology: (a) to promote and maintain health, (b) to prevent and treat illness, (c) to identify the causes and diagnostic correlates of health, illness, and related dysfunction, and (d) to analyze and improve health care systems and health policy.

Historically, health psychology emerged at a time in which Western democratic societies started to expect their citizens to develop the ability to be responsible for their own health and well-being (Marks, 2002). Apart from their role in health care, an important task of health professionals was to inform and educate the public about the ways they could take that responsibility.

 

 

Heath Psychology: Challenges and Future

The biopsychological model has been important in the science and practice of health psychology. Knowledge about the behavioral factors that influence our health has developed considerably because of the maturation of research in this area (Smith, Kendall & Keefe, 2002).

As science recognizes the importance of behavior for health, psychology faces the challenge of redefining methodologies to guide changes in behavior that will lead to improved health and healthcare (Johnston & Dixon, 2008).

 

Applications for Health Psychology

The World Health Organization recognizes the demand for primary health care and the growing necessity for knowledge related to the performance of health systems as a whole (World Health Organization, 2008). In this perspective, Marks (2002) argued that psychological research could significantly improve public health by promoting health education and communication. Health promotion and disease prevention are now seen professional activities, public and community health psychologists work towards the improvement of health of the population. The value of psychological perspectives on health has also been introduced on a more individual level to the patients in the health care system by both counseling (Chwalisz & Obasi, 2008) and clinical health psychologists (Papas, Belar, & Rozensky, 2004).

Smith and Suls (2004) discussed the challenges health psychology faces now that it has been established how important the application of this field of psychology is for physical health. These scientists pointed to the priority to prove the effectiveness of its treatments and interventions. Furthermore, as people become more ethnically diverse and older, there is a need for an increased focus on contextual competence (Smith & Suls, 2004).

Although the importance of social integration for health and longevity is established through extensive studies, scientists do not know why engaging in diverse types of relationships would have a positive influence on health. According to Gergen and Gergen (2001), relational resources are a powerful factor in an individual’s sense of well-being, because of the impact socially embedded interpretations have on the way people feel about their health, or the  aging process. Research in this area would be an interesting project; it would provide health psychologists with the knowledge to design interventions and integrate social networks to influence health relevant behaviors (Cohen & Janicki-Deverts, 2009). 

New technologies (e.g., the internet, WebTV) also create new possibilities to reach individuals and the public with help, information, and education. Although the biopsychosocial model forms the conceptual base of its perspective, health psychology needs to take into account the organizational, cultural, and economical influences on health and healthcare (Smith & Suls, 2004). Smith and Suls (2004) offered several recommendations and identify areas of potential growth with an emphasis on transdisciplinary collaboration in the development of new theories that cultivate the multilevel, multisystem, and multivariate nature of health processes.

Health psychology combines cognitive behavioral theory with the practice of clinical and public healthcare. Leventhal, Musumeci, and Contrada (2007) argued that it is not only desirable to complement descriptive theory with process models of health behavior but also to efficiently translate research findings into practical implications. In their view, health behavioral research needs to build a bidirectional relation with the community and the clinic. They argue that it is critical for the development of process-oriented social-cognitive behavioral models of health behavior, that behavioral interventions meet the criteria for evidence-based practice such as effectiveness and usability (Leventhal et al., 2007).

 

Research in Health Psychology

Health psychologists look for ways to specify how the relation between biological, psychological, and sociological processes works. It wants to be a practical and applicable science. Suls and Rothman (2004) for instance, discussed the importance of bridging the gap between research and practice, and policy. In their view, often, important findings do not result in practical implementations, nor do theoretical models make their way to applications.

Yardley and Moss-Morris (2007 studied the developments in health psychology research. They emphasized the importance to test the validity of the theoretical models, search for causal relationships between interventions and long-term effects, and define key constructs to clarify meaning of new terminology.

Marks and Yardley (2004) discussed the qualitative research through interviews, narratives, or texts to explore health an illness concepts and experience. Health psychologists also favor participatory action research. This is a mode of research designed as a part of an intervention, and is particularly suited in a context with a goal of increasing understanding and promoting social or community change (Marks et al., 2005).

 

New developments

There are also new scientific developments that will influence the field of health psychologists in an important way. Garland and Howard (2009) presented the newest findings that validate and expand the possibilities of the biopsychosocial model Engel (1977) first presented. These scholars suggested that neuroplasticity and psychosocial genomics (concerned with the expression of genes) reveal that even the adult brain can develop with learning experiences or mental training. Neuroplasticity research has just begun to study psychological interventions, and the results are promising: neuroplasticity may play a causal role in the therapeutic effectiveness of psychosocial interventions (Garland & Howard, 2009). This is an important development for counseling health psychologists.

Another interesting development is the evidence-based recognition that the relationship between nature and nurture is bidirectional. Studies imply that social and learning experiences can shape gene expression (Kandel, 1998). The power of thought and emotion may literally change our brain. These developments have far-reaching consequences for health psychology. The growing realization that humans can actually change their physical body by altering the way they think is opening new scientific avenues for health sciences. A human being seems to be an active agent in the creation of his/her own neurobiology and therefore of his/her own live (Garland & Howard, 2009).

 

Discussion

The goal of this paper was to address the developmental history of my area of specialization: health psychology. In these pages, I sketched the broad historical overview of this subdivision of psychology and presented the history of its major concepts and models. I also looked at some of the challenges and mentioned a few trends that are influencing health psychology.

This modest research project gave me an opportunity to explore the field in psychology that I am about to enter. I am intrigued by the possibilities my new academic specialization is offering. The latest trends in neurobiology and psychobiology are promising. As a psychotherapist in private practice, I counsel clients who face serious illnesses. Some are dying. My work makes me primarily interested in the evidence-based interventions health psychology has to offer. I feel dedicated to finding ways to assist people in their healing processes, in their struggles to accept the consequences of their deteriorating health, or in making the right choices when confronted with death. The writing of this paper has provided me with valuable insights into the historical context of this field of expertise and made me aware of the importance of the scientific, theoretical aspects of health psychology. It also introduced me to the research that is done in this field.

At the end of this essay, I realize how little I know about health psychology. This writing project gave me the opportunity to explore the history and basic principles of my new area of expertise and enabled me to lay the foundations for my further studies in health psychology.

 

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