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date: 19 January 2020

Conclusion: The Achievements and Promise of Health Psychology

Abstract and Keywords

The preceding chapters in this handbook reveal that the influences that fostered the emergence of health psychology could become a threat to health psychology if psychologists abandon the unconventional ideas that led to the field’s successful development. Health, recovery, and longevity are best approached with a science-based biopsychosocial model that often goes well beyond the traditional biomedical approach to disease. Hugely important are social relations, individual differences in reactions and behavior patterns across time, and interactions between biological predispositions and psychosocial environments. Improving population health and minimizing health disparities will likely require changes and improvements that go well beyond anything possible within the traditional biomedical health care system. Sophisticated research methods and sound measurements are a critical challenge of the complex biopsychosocial model but also a hallmark of excellent health psychology research.

Keywords: Health psychology, social support, social integration, health, biopsychosocial model

In 2001, the American Psychological Association added “promoting health” to its statements of vision and purpose. This striking change marked a formal shift from a traditional focus on mental health to a more direct and broader emphasis on health. As late as the 1970s, not even a formal sub-field existed called “health psychology,” and few had viewed health promotion as an essential piece of psychology. Clearly, a deeper understanding of health has emerged, and health psychologists have been enormously successful in changing the position of psychology in health and health care.

Yet, as it assumes a significant role in studying and promoting health, the field faces many risks of a serious stumble. The productive factors that led to the early successes of health psychology are under continuing pressure. That is, the conditions that fostered the emergence of health psychology could become a threat to health psychology if psychologists abandon the unconventional ideas that led to its successful development.

Medical care and many health promotion efforts are still dominated by the biomedical model of health and disease, a model that is triumphant but seriously flawed. Also sometimes termed the “mechanical model” or the “traditional medical model,” the biomedical model fundamentally views health as the absence of disease. It views injury as a breakdown to be repaired and it views illness as a problem to be treated and cured. The predominance of this model is based in part on its tremendous successes. Broken bones can be x-rayed and set, tumors can be excised, hips can be replaced, and clots can be busted. Bacterial infections can be cured with antibiotics, many viral infections can be slowed with anti-viral medications, high blood pressure can be lowered, and hormonal deficiencies can be supplemented. Many of the disease scourges of human history can now be diagnosed and successfully treated. Proper procedures have been standardized, and scientific research in medicine is focused and highly rigorous.

(p. 888) Despite its tremendous successes, the failings and limitations of the biomedical model of disease, however, have also been well-documented (Cuff & Vanselow, 2004; Kaplan, 2011, Chapter 5, this volume; Kohn, Corrigan, & Donaldson, 2000; Mechanic, 1983). These faults are both humanistic and scientific. The humanistic concerns range from dehumanization (and insufficient respect for human dignity) through assorted ethical challenges. The highly scientific concerns include incomplete models of healing, limited attention to prevention, neglect of social factors, insufficient consideration of development, preventable medical errors, and inadequate integration of public health measures.

In the United States alone, upwards of 100,000 patients a year die or are seriously injured by medical errors, often involving interpersonal matters like faulty lines of authority, or psychological matters like flawed decision-making. Beyond the errors, millions more people remain far from optimal health. Strikingly, it is the case that large numbers of individuals do not follow sensible prophylactic measures, and large numbers of patients do not fully cooperate with medical advice or treatments, for a variety of reasons that are not well addressed by the biomedical model.

The effects of emotions and personality and motivation on healing (and self-healing) are not easily incorporated into traditional treatments and are often dealt with unscientifically or simply ignored in medical settings. Alcohol and drug abuse, and levels of obesity, are at record levels. Treatable pain often goes untreated. And, millions of cases of illness and injury are preventable through known, inexpensive measures, which are not well implemented or followed. Many of the these problems involve psychological and social issues and are addressed in detail in this Oxford Handbook.

Health psychology stepped in to fill these gaps and correct these errors. In response to the limitations of the traditional biomedical approach, health psychology has developed a deep understanding of how various psychological and social variables combine with the biological ones to affect health—the so-called biopsychosocial model (Friedman & Adler, 2011, Chapter 1, this volume; Pickren & Degni, 2011, Chapter 2, this volume). This is much more than a fancy name for holistic health care, and in fact health psychology is very heavily scientific. Because health psychology developed not only out of knowledge of biology and psychophysiology but was also heavily influenced by social and clinical psychology, medical sociology, philosophy, public health, and cross-cultural epidemiology and anthropology, health psychology has the concepts and methods to address matters that go beyond the boundaries of biology but are still very relevant to medical care and to health (Matarazzo, 1994).

One of the key contributions is that psychology is not reductionist. Psychology focuses on human behavior rather than on organs, cells, or hormones. It needs to understand neuroscience, genetics, and cell biology to know the parameters of how human behaviors and reactions are affected by and affect organs, cells, and hormones, but psychology ultimately returns to the person. Analogously, psychology is not collectivist. It is informed by the influences of families, religions, and cultures, but ultimately returns to the person. This is a huge conceptual advantage for understanding and promoting health, for ultimately it is the individual who thrives or declines, lives or dies.

If, however, psychology (or health psychology) tries to imitate the more narrowly focused concepts and procedures of medicine and physiology, it may endanger the very reasons for its success. Not only is biomedical research more and more narrow and focused (often for very good scientific reason), but medical systems (and physicians) too are ever more specialized, marking increasing expertise and sophistication but necessarily losing insight into bigger pictures and processes. Further, medical systems are ever more guild-like and hierarchical, with the great benefits of increasing control and standardization but with potential losses of flexibility and of full interdisciplinary collaboration with the wide variety of professions knowledgeable about matters of health. Fortunately, topics and issues that are seen as peripheral or puzzling by the field of medicine remain interesting and researchable to psychologists.

The field of health psychology is bringing together diverse insights. By providing a dynamic and multilayered view into the nature of health, research in health psychology not only repeatedly reveals important limits of a traditional biomedical model that attempts to cure disease, but also reveals improved ways to proceed. From the perspective of health psychology, it is not the case that we are healthy until we become “sick.” Further, it is not the case that mental problems or mental stresses are clearly distinguishable from physical problems or physical stresses. The human organism is launched with a particular genetic endowment into a specific yet complex and ever-changing environment, in which it reacts, copes, learns, strives, and ages, sometimes staying healthy and sometimes falling ill. But what does this mean in specific terms, and how are these matters represented in the Oxford Handbook of Health Psychology?

(p. 889) Health Psychology and Health

Startling new insights emerge from the health psychology perspective. For example, it is not necessarily the case that providing more doctors (whether physician or psychologist) or more access is the best way to improve the health and well-being of the population (Kaplan, 2011, Chapter 5, this volume; Schwarzer, 2011, Chapter 24, this volume). Perhaps equally surprising and important, health psychology research documents that pain control is essentially a biopsychosocial process not a biomedical one, and a biopsychosocial approach provides much better interventions (Thorn, 2011, Chapter 16, this volume).

Health psychology suggests there may never be a simple “cure” for heart disease, or obesity, or pain, or aging. Notions of biopsychosocial homeostasis emphasize that the body and its environments are always changing—that health is dynamic. Homeostasis models have been confirmed as very fruitful, have been extended to multiple levels, and have been considered in an evolutionary context (Cacioppo & Berntson, 2011, Chapter 6, this volume). Many chapters in this handbook focus on dynamic processes and multiple causal links simultaneously in operation (Carver, 2011, Chapter 8, this volume; Friedman, 2011, Chapter 10, this volume; Kemeny, 2011, Chapter 7, this volume; Temoshok, 2011, Chapter 23, this volume). From the perspective of health psychology, obesity and alcohol abuse are not fundamentally diseases in the sense that the term is usually used (Sher et al., 2011, Chapter 28, this volume; Van Walleghen et al., 2011, Chapter 29, this volume). Similarly, viewing aging as a disease leads to various difficulties, but a new view of resilient or successful aging, a multifaceted and interdisciplinary notion, is becoming a major issue with the aging of many populations worldwide (Rook, Charles, & Heckhausen, 2011, Chapter 15, this volume).

There are vast clinical implications of health psychology approaches, as many common, traditional assumptions about treatment do not stand up to scientific review (Cacioppo & Berntson, 2011, Chapter 6, this volume; Rohrbaugh & Shoham, 2011, Chapter 20, this volume; Sakairi, Sugamura, & Suzuki, 2011, Chapter 34, this volume; Thorn, 2011, Chapter 16, this volume; Wortman & Boerner, 2011, Chapter 19, this volume). When the biomedical approach is replaced with a biopsychosocial approach, the full panoply of contributors to well-being are unleashed. More and more, the structural impediments to a more encompassing view of well-being are dissipating, and new views of health and optimal treatments are emerging.

Special considerations enter the picture when the patient is very young or old or stigmatized (Rook et al., 2011, Chapter 15, this volume; Ruiz, 2011, Chapter 32, this volume; Tinsley, 2011, Chapter 21, this volume). For example, ways of thinking about and coping with cancer are hugely complex biopsychosocial matters (Malcarne, 2011, Chapter 17, this volume). Analogously, organ transplantation, increasingly the optimal treatment for many diseases, is inherently complexly biopsychosocial (Dew & DiMartini, 2011, Chapter 22, this volume).

Although it is well-established that doctors and other health care providers function best when they communicate effectively with their patients, progress in improving communication should be based on a scientific understanding of practitioner–patient relations (Hall & Roter, 2011, Chapter 14, this volume; Rohrbaugh & Shoham, 2011, Chapter 20, this volume). Cooperation with treatment can never be fully addressed through simple protocols that parallel the protocols for disease management. That is, here too, the social science insights differ in a fundamental sense from a biomedical treatment model. Proper, effective communication, cooperation, and adherence are not at all what physicians call “the art of medicine.” Rather they comprise the science of the art of medicine, a science that is contingent and probabilistic.

A popular model of health and disease involves stress, psychophysiological impairment (such as immune dysfunction), and resultant disease. There is no doubt that unusual challenges to the body (including psychological challenges) can disrupt internal homeostasis (Cacioppo & Berntson, 2011, Chapter 6, this volume; Carver, 2011, Chapter 8, this volume; Kemeny, 2011, Chapter 7, this volume; Segerstrom, 2011, Chapter 30, this volume; Temoshok, 2011, Chapter 23, this volume). But such links are not fully established as prime contributors to morbidity and mortality in humans. Because so many biological and psychological and social factors simultaneously contribute to health across time, there are few good studies showing specific effects of stressors, physiological mediators, and long-term significant disease or mortality risk. This is an area in which health psychology especially needs to be cautious in its claims, broad in its vision, and rigorous in its models and studies.

In fact, health behavior keeps emerging as a critical component of good health. That is, good nutrition, physical activity, sound sleep, cooperation with treatment, and avoidance of drug abuse and other risky activities are highly correlated with each other and with avoidance of chronic stress and (p. 890) psychophysiological health, and so it is nearly impossible to tease apart simple “stress” effects in humans (Aiken, 2011, Chapter 25, this volume; Sher et al., 2011, Chapter 28, this volume; Friedman, 2011, Chapter 10, this volume; Schwarzer, 2011, Chapter 24, this volume; Van Walleghen, Steeves, & Raynor, 2011, Chapter 29, this volume; Wilson, 2011, Chapter 27, this volume). Although some in the biomedical community disparage health psychology by asserting that there is little evidence for “pure” (nonbehavioral) effects of stress on illness, the reality is that it makes little sense to separate psychological and emotional states and motives from the various health behaviors that make up a person’s day, week, or year. Lifespan and life-course perspectives on health emphasize the processes by which well-being is maintained in the face of ongoing challenges and age-related changes in functioning (Friedman, 2011, Chapter 10, this volume; Hampson & Friedman, 2008; Rook, Charles, & Heckhausen, 2011, Chapter 15, this volume). It is not enough to give people lists of health tips and recommendations; rather, it is important to set people on healthier long-term life paths (Friedman & Martin, 2011).

Health psychology continues to extend significantly its traditional role in assisting individuals to cope with disease, stress, and aging. How people think about, verbalize, and cope with challenges can have important direct and indirect effects on whether they enter the sick role and how they interface with the medical care system (Benyamini, 2011, Chapter 13, this volume; Carver, 2011, Chapter 8, this volume; Dew, 2011, Chapter 22, this volume; Malcarne, 2011, Chapter 17, this volume; Pennebaker & Chung, 2011, Chapter 18, this volume; Renner & Schupp, 2011, Chapter 26, this volume; Rohrbaugh & Shoham, 2011, Chapter 20, this volume; Rook, Charles, & Heckhausen, 2011, Chapter 15, this volume; Stanton & Revenson, 2011, Chapter 11, this volume; Tinsley, 2011, Chapter 21, this volume). Research on adaptation to chronic diseases has led to multifaceted conceptualizations of adjustment, as well as to attention to the reciprocal influences and intersections of emotions, cognition, behaviors, life roles, and culture. Similarly, studying personality as a predictor of health forces attention beyond a more narrow focus on psychoimmunology or unhealthy habits; it brings the view of how the pieces fit together in the whole person (Friedman & Adler, 2011, Chapter 1, this volume; Friedman, 2011, Chapter 10, this volume). By using a conceptual approach that goes well beyond treating “mental” health and leaving “physical” health to physicians, these health psychology efforts come much closer to the true nature of overall well-being. In fact, we may know that full success has been achieved when the term “wellness” has disappeared from use because the term “health” has become sufficiently and properly broadened.

The chapters in this Oxford Handbook of Health Psychology repeatedly reveal that a hugely important determinant of health, recovery, and longevity is social relations—variously termed social support or social integration. Social contact with others, a sense of belonging, and participation in social groups have been well documented to be significantly tied to many key aspects of health (including recovery from illness), and not always in a simple manner (Benyamini, 2011, Chapter 13, this volume; Capitanio, 2011, Chapter 35, this volume; Suls, 2011, Chapter 12, this volume; Taylor, 2011, Chapter 9, this volume; Todorova, 2011, Chapter 33, this volume). As noted, such matters are inherently outside the predominant biomedical approach to health, and in fact, in Western countries, family members are often pushed out of doctors’ offices and hospitals, and may be referred to ancillary support groups. Most medical interventions are targeted at individuals, with insufficient attention to families and communities, despite known problems with this narrow approach. Of course, family members should not be crowding around the operating table, but the incompatibility in some such spheres of the technical biomedical demands and the psychosocial milieu in which the individual lives illustrates the many challenges that remain for a true biopsychosocial approach.

Perhaps nowhere is the importance and challenge of health psychology so apparent as in the issues of socioeconomic, ethnic, and cultural variations and disparities. These are areas that are inherently psychosocial. Minimizing (or eliminating) disparities will likely require changes and improvements that go well beyond anything possible within the traditional biomedical health care system. Communities, politics, ethnic identities and customs, social structures, and historical trajectories are key (Capitanio, 2011, Chapter 35, this volume; Gil-Lacruz, 2011, Chapter 31, this volume; Ruiz, 2011, Chapter 32, this volume; Sakairi, Sugamura, & Suzuki, 2011, Chapter 34, this volume; Taylor, 2011, Chapter 9, this volume; Todorova, 2011, Chapter 33, this volume).

Finally, and perhaps most importantly, sophisticated research methods and sound measurements are a critical challenge of the complex biopsychosocial model but also a hallmark of excellent health psychology research (see especially Aiken, 2011, (p. 891) Chapter 25, this volume; Kaplan, 2011, Chapter 5, this volume; Smith, 2011, Chapter 3, this volume; Westmaas, Gil-Rivas, & Silver, 2011, Chapter 4, this volume). Biomedical-based research often tries to be atheoretical and data-driven, in an attempt to be more “objective” when dealing with matters of psychology and social relations, but social science by necessity often needs to employ rich concepts and complex models embedded with statistics and probabilities in an intricate nomological net (Cronbach & Meehl, 1955). Trying to oversimplify a construct like social support or stress or personality will, paradoxically, lead to research studies that are imprecise and misguided, as well as to treatment recommendations that are sterile or too simple.

Pushed by the U.S. Congress, the U.S. National Institutes of Health (NIH) opened the Office of Behavioral and Social Sciences Research (OBSSR) in 1995. The OBSSR aims to integrate a social and behavioral perspective across the research areas of the NIH, with an important goal being the initiation and promotion of studies to evaluate the contributions of behavioral, social, and lifestyle determinants in the development, course, treatment, and prevention of illness. Although much progress has been made, it remains to be seen whether a sociobehavioral perspective can be successfully overlaid on a biology-based and disease-focused health system; perhaps a more fundamental reorientation will be required.

Conclusion

When the first issue of the journal Health Psychology was published (in 1982) under the editorship of George Stone, Stone himself wrote the first article. It was entitled “Health Psychology: A new journal for a new field” and outlined Stone’s wide-ranging model of the “health system.” Stone then raised a core issue, asking rhetorically, “With such an enormous range of approaches and topics, it is certainly appropriate to ask whether health psychology can exist as a cohesive and integrated field of specialization” (Stone, 1982, p. 3). The field of health psychology is still grappling with this matter. Sociobehavioral science research using health as an outcome now appears in a wide range of journals throughout psychology, the social sciences, and medicine, not only those dedicated to health psychology. And psychologists are now found throughout health care systems.

The secret to remaining cohesive and meaningful may lie in the forces that led to the successful and rapid emergence of health psychology in the first place. Health psychology will likely thrive as long as it continues to take advantage of its unusual abilities to integrate psychological, social, and biological concepts; to use sophisticated social science measures and statistical techniques; to view health as much more than the absence of disease; and to use the individual—the whole person rather than cells, organs, families or societies—as the unit of analysis. This, in turn, will likely require new and more sophisticated theories and models of health.

The first issue of Health Psychology also contained an address from the health psychology division’s second president, Stephen M. Weiss, who was head of the recently formed behavioral medicine branch at the National Institute of Heart, Lung, and Blood (Weiss, 1982, p. 81; speech delivered in 1980). Weiss, hopeful but somewhat nervous about the future of the small field of health psychology, proclaimed, “If there ever was a time of opportunity for Health Psychology, that time is now.” These words were a hope and a plea as much as a prediction, but the words were indeed prophetic, and the field of health psychology exploded during the following three decades—in research, in teaching, and in practice. As this Oxford Handbook of Health Psychology makes clear, health psychology is still growing and rapidly evolving, and it contributes significantly to other areas of psychology, health care, and the biosocial sciences. And, so long as health psychology maintains its core intellectual strengths, it will be continually enriched from these associated fields.

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