APPLICATIONS OF HEALTH PSYCHOLOGY:OBESITY, HEALTH CARE TRENDS

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Clinical Psychology (PSY401)

Lecture 40

APPLICATIONS OF HEALTH PSYCHOLOGY

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

of human misery and the torrents of dollars pouring into the health care system. These include reducing our

consumption of salt and fatty foods, driving carefully and using seat belts, exercising regularly, avoiding

cigarettes, and decreasing stress. But giving advice and having people take it are two very different things.

Therefore, psychologists, other behavioral specialists, and medical professionals have mounted research

programs to learn how to treat and also prevent a variety of potentially harmful human behaviors. health:

cigarette smoking, alcohol abuse, and weight control.

1. CIGARETTE SMOKING

Increased awareness of the dangers of cigarette smoking has led to a steady decline since the mid-1960s in

the percentage of Americans who are habitual smokers (Brannon & Feist, 2000). However, rates of

smoking differ according to

gender, level of education, and income. One disconcerting trend is that the rate of smoking for women has

shown much less of a decline than that for men (Centers for Disease Control and

Prevention, 1994). In

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

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

two leading causes of death in the United States. Even though smoking increases one's e chances of

premature death from diseases such as coronary heart disease, cancers of the respiratory tract, emphysema,

and bronchitis, people still smoke. Why? Possible reasons include tension control, social pressure,

rebelliousness, the addictive nature of nicotine, and genetically influenced personality traits such as

extraversion. Tension control and social pressure are thought to be reasons for initiation of smoking,

whereas rebelliousness, addiction, and personality are seen primarily as maintaining factors.

A variety of techniques have been used to induce people to stop smoking, including educational programs,

aversion therapy (such as rapid smoking), behavioral contracts, acupuncture, cognitive therapy, and group

support (Brannon & Feist, 2000). Relapse rates are high (70-80%), however, and research findings about

which cessation approach is best are conflicting. Most smokers who do quit, do so on their own.

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

alone (such as warning messages on packages) does not appear to deter young people from smoking

(Brannon & Feist, 2000). What appears to be more effective is focusing on immediate rather than delayed

negative consequences, teaching coping skills, and increasing feelings of self-efficacy.

One of the early encouraging multiple-component prevention programs aimed at children and teenagers was

based on social learning principles and used peer role models (R. I. Evans, 1976). Videotaped presentations,

peer modeling, discussion groups, role playing, monitoring smoking, and checking repeatedly on attitudes

and knowledge about smoking were all used with elementary school children. Such an approach seems

superior to those used with adolescents that focus on long-term negative effects from smoking. The trick

seems to be to focus on immediate negative consequences (for example, from peers) rather than delayed

ones (such as emphysema).

2. ALCOHOL ABUSE AND DEPENDENCE

It is estimated that about 70% of men and 50% of women in the United States consume alcoholic beverages

(United States Department of Health and Human Services, 1993). Although some studies have suggested

positive health benefits from alcohol for light or moderate drinkers, consumption of alcohol has also been

associated with a number of negative outcomes. Heavy alcohol use has been associated with increased risk

for liver or neurological damage, certain forms of cancer, cardiovascular problems, fetal alcohol syndrome,

physical aggression, suicide, motor vehicle accidents, and violence (USDHHS, 1997). This extensive list of

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alcohol-related problems has made the treatment and prevention of alcohol abuse and alcohol dependence

(alcoholism) a high priority.

Over the years, many treatment approaches have been applied to problem drinkers; most of these treatments

preach total abstinence. These have ranged from medical treatments and medications such as disulfiram

(Antabuse) and naltrexone to traditional psychotherapy and group supportive strategies such as Alcoholics

Anonymous. However, alcoholism is a problem that has been extremely resistant to virtually all inter-

vention, and the relapse rate is high.

Another, more controversial, approach to the treatment of alcohol problems is controlled drinking (Sobell &

Sobell, 1978). As the name implies, this approach has as its goal light to moderate (but controlled) drinking.

Clients are taught to develop alternative coping responses (other than drinking) and to closely monitor

alcohol intake. The field is divided as to the merits of this approach, but research does suggest that

controlled drinking is a viable treatment option for some alcoholics (USDHHS, 1997).

Many alcohol treatment programs also incorporate relapse prevention training (Marlatt & Gordon, 1985).

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

terminated. Rather than see this as a failure (a sign that total relapse is imminent), clients are taught coping

skills and behaviors they can use in "high-risk" situations to make total relapse less likely.

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

strategies. Because of the difficulties with secondary and tertiary approaches to treatment or prevention,

more and more professionals have turned to primary prevention to forestall the development of problem

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

smoking are being developed.

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

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

affective education (building self-esteem, increase decision-making skills); life skills (communication skills,

assertiveness training); resistance training (learn to resist pressures to drink alcohol); and correction of

erroneous perceptions about peer norms (USDHHS, 1997). Current research evidence suggests that

programs that incorporate peer resistance training and correction of misperceptions regarding peer norms

show the most promise (USDHHS, 1997).

3. OBESITY

Behavioral treatments for obesity have been more common than for any other condition. One reason for this

emphasis is that obesity is associated with such medical disorders as diabetes, hypertension, cardiovascular

disease, and certain cancers (Brannon & Feist, 2000). It is also a socially stigmatizing condition that impairs

the self-concept and inhibits functioning in a wide array of social settings. Often problems of weight can be

traced to childhood: 10-25% of all children are obese, and 80% of these individuals become obese adults

(Stunkard, 1979).

Although it is clear that obesity has a genetic component (Meyer & Stunkard, 1993), causes of obesity

undoubtedly represent complex interactions among biological, social, and behavioral factors, and exact

mechanisms are difficult to pin down. Traditional medical and dietary methods of treatment have not been

very effective; obese individuals lose weight but then quickly regain it. Furthermore, the dropout rate may

be high in traditional weight-control programs. Most behavior modification programs include components

aimed at restricting certain types of foods, teaching when and under what conditions to eat, encouraging

regular exercise, and maintaining modified eating patterns after the program has ended.

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

of such an approach is the Stanford Adolescent Obesity Project (Coates & Thoresen, 1981). A variety of

strategies were used with adolescents in the hope that control at this age would lead to prevention in

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

These interventions were noticeably more effective when parents were involved. Many investigators are

also exploring the possibility of using peer group discussion. A recent ten-year outcome study of a family-

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based behavioral treatment for childhood obesity suggests that early intervention in childhood can effect

important and lasting changes in weight control (Epstein, Valoski, Wing, & McCurley, 1994).

OTHER APPLICATIONS:

Treatment and preventive initiatives must be supplemented with techniques that encourage patients to cope

with medical procedures and to follow medical advice.

A. COPING WITH MEDICAL PROCEDURES

The' prospect of facing surgery, a visit to the dentist, or a variety of medical examinations has been enough

to strike fear into the heart of even the strongest. Faced with such procedures, many patients delay their

visits or even forgo them entirely. Health psychologists specializing in behavioral medicine have developed

interventions to help patients deal with the stress surrounding such procedures.

B. PREPARATION FOR SURGERY:

A sizable amount of research has been done on Nays to improve psychological preparation for surgery.

Similar to those used to prepare patients for medical examinations and procedures, interventions include

(1) relaxation strategies,

(2) basic information about the procedures to be used.

(3)information concerning the bodily sensations experienced during the procedures, and

(4) cognitive coping skills (Brannon & Feist, 2000).

HEALTH PSYCHOLOGY: PROSPECTS FOR THE FUTURE

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

now be time for the field to take a look at itself and decide how best to train health psychologists and

structure programs to achieve training goals (Belar, 1997).Now we will discuss several health care trends,

training issues for future health psychologists, and important issues for the field of health psychology to

address in the future.

HEALTH CARE TRENDS

By the end of 1997, 85% of Americans belonged to some kind of managed health care plan (Winslow,

1998). In managed care systems, containing costs is a high priority. we know the great impact managed care

has had and will have on clinical psychologists. The impact on health psychologists will be even greater

because these specialists often work in medical centers or primary care settings. Health psychologists, by

virtue of their training, are well suited to provide interventions that will serve to cut the costs of medical

care (Belar, 1997; Friedman, Sobel, Myers, Caudill, & Benson, 1995). As business and industry realize the

costs they must absorb from employees whose habits and lifestyles create absenteeism, inefficiency, and

turnover, it is expected they will use the skills of health psychologists more often.

Although there appears to be an ever-increasing need for clinical psychologists specializing in health or

behavioral medicine, it should also be noted that currently there appears to be a surplus of mental health

professionals. For example, Frank and Ross (1995) estimate that there are approximately 32.8 social

workers, 22.8 psychologists, 13.1 psychiatrists, and 4.3 psychiatric nurses for every 100,000 Americans (a

total of 73 mental health professionals per 100,000). The problem lies in the overlapping definitions of each

discipline; all claim to assess and treat similar problems. As the economic stakes become higher, it is likely

that these disciplines self-definitions will incorporate concepts and issues once thought to be uniquely

characteristic of health psychology and behavioral medicine. Frank and Ross (1995) call for more

coordination of health workforce planning at the national level.

Clearly defining and establishing psychology's role in health care also requires efforts at delineating

psychology's unique contributions amid an increasing supply of other health-related professions ... efforts

to establish clear professional boundaries and identities among the various health care groups should be

based on dialogue, coordination, and cooperation to ensure that the health care needs of the population are

met by qualified, ethical, and competent professionals.

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TRAINING ISSUES IN HEALTH PSYCHOLOGY

A major source of health psychologists continues to be clinical psychology programs. The scientist-

practitioner and clinical scientist models adopted by most clinical psychology programsenable them to train

clinicians well suited for health psychology. Until recently, no other psychology specialty offered the

combination of academic, scientific, professional, and hospital experiences required for work in medical

settings. At the same time, Stroebe and Stroebe (1995) make a case for the background of social

psychologists, Again, the roles of methodology, quantitative analysis, and research design are emphasized.

Other psychology subspecialties are also well represented in health psychology. Many of the people cited in

this chapter are experimental or physiological psychologists-not just clinicians or social psychologists.

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

psychology. The student enters a clinical, social, or experimental program and then, in addition to the core

experience, does some specialized research or takes a practicum or two in a health-related topic. Perhaps

this is augmented by an internship at a health care site. But essentially, the health experiences are grafted

onto an already existing program in clinical psychology or some other related discipline.

Many people are now calling for health psychology to be a standard, core training component for all

professional psychologists for example, Frank & Ross, 1995). Because of the importance of health issues

and the broadening of the definition of clinical and professional psychology, training in areas such as

psychopharmacology, neuropsvchoiogy, and psychoneuroimmunology is considered essential. Further,

future health psychologists must be trained so that they can design and conduct studies to empirically

evaluate health outcomes. Currently, some clinical psychology graduate programs offer "tracks" in health

psychology or behavioral medicine, but this is the exception rather than the rule. In any case, curricular rec-

ommendations for health psychology training continue to be offered (Brannon & Feist, 2000).

OTHER CHALLENGES

Any newly emerging field has problems the defining roles of its members: health psychology is no

exception. Years ago. S. E. Taylor t 1984) identified several of these problems. One problem is simply role

ambiguity. No one is totally prepared to say just what a health psychologist should do-especially in a

practical work setting. Health psychologists may actually find themselves without psychology colleagues or

role models in the health setting, which only adds to their confusion.

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

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

academic settings.

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

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

tentative and contemplative while thinking about research, theoretical models, and interventions.

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

health psychologists need to document the cost-effectiveness of their interventions (Friedman et al., 1995).

In this era of health care reform, insurance companies and government agencies are scrupulously examining

ways to drive down the cost of health care.

Given the many successful and cost-efficient interventions performed by those specializing in health

psychology and behavioral medicine, ask Friedman et al. (1995), why haven't these interventions been

integrated to a greater extent into our health care system? They suggest several possible reasons:

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

2. Biological origins of diseases and illnesses have been emphasized, causing many to overlook the

possible benefits of psychosocial explanations and behavioral interventions.

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

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

psychotherapy.

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Clinical Psychology (PSY401)

Clearly, physicians, insurance companies, the 'federal government, and the general public need to be

educated regarding the role of health psychologists, as well as the potential financial and clinical benefits of

their interventions.

Another challenge for the field concerns ethnicity and health. The health profiles (such as life expectancy

and health status) of various ethnic minority populations in the United States appear to differ greatly from

one another, and more research is needed on health-promoting and health-damaging behaviors among

members of these groups (N. B. Anderson, 1995). Informative articles reporting on the health status of

African Americans, Asian Americans, and Hispanic Americans (Flack et al., 1995), behavioral risk factor

related to chronic diseases in ethnic minorities (Meyers, Kagawa-Singer, Kumanyika, Lex, & Marlddes,

1995), and the use of health care systems by ethnic minorities (Penn, Snehendu, Kramer, Skinner, &

Zambrana, 1995) have recently appeared in a special issue of Health Psychology. These reports and others

point out the need to further assess the relations between behavior and health in special populations.

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

true in virtually every area of clinical psychology so far. However there is still a gap between the field's

promise and its accomplishment. as any experienced clinician will tell you, it is very hard to change human

behavior over the long haul.neverthe less, health psychology most assuredly deserves our enthusiasm as

well as our caution. Many people are optimistic about the future of health psychology, given the pressing

demands of improved health care. Infact Belar(1997)and others believe that health psychology is uniquely

suited to be the specialty for the professional practice psychology in twenty-first century.

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