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Health Psychology Past, Present, and Potential Cynthia D. Belar, Ph. D. , ABPP Health Psychology Past, Present, and Potential Cynthia D. Belar, Ph. D. , ABPP

◊ Historical Perspectives ◊ Growth of Education and Training ◊ Growth of Research ◊ ◊ Historical Perspectives ◊ Growth of Education and Training ◊ Growth of Research ◊ Growth of Professional Practice/Applications ◊ Potential (and preparation)

Health Psychology The aggregate of the specific educational, scientific, and professional contributions of the Health Psychology The aggregate of the specific educational, scientific, and professional contributions of the discipline of psychology to the promotion and maintenance of health; the prevention and treatment of illness; the identification of etiologic and diagnostic correlates of health, illness and related dysfunctions; and the improvement of the health care system and health policy formation. (Matarazzo, 1980, 1982, 2001)

Key Features of Health Psychology ◊ Breadth ◊ Biopsychosocial model ◊ Focus on prevention Key Features of Health Psychology ◊ Breadth ◊ Biopsychosocial model ◊ Focus on prevention and health promotion as well as illness and rehabilitation ◊ Focus on cost-effectiveness ◊ Interdisciplinary collaboration

◊ Clinical Health Psychology professional practice of health psychology ◊ Behavioral Medicine interdisciplinary field ◊ Clinical Health Psychology professional practice of health psychology ◊ Behavioral Medicine interdisciplinary field to which health psychologists contribute

Historical Perspectives ◊ Ancient Greece ◊ Middle Ages ◊ Renaissance Historical Perspectives ◊ Ancient Greece ◊ Middle Ages ◊ Renaissance

18 th Century “the reason why a sound body becomes ill, or an ailing 18 th Century “the reason why a sound body becomes ill, or an ailing body recovers, very often lies in the mind” (Gaub, cited in Lipowski, 1977)

19 th Century ◊ “psychosomatic” (Heinroth) ◊ Benjamin Rush ◊ Sigmund Freud ◊ Walter 19 th Century ◊ “psychosomatic” (Heinroth) ◊ Benjamin Rush ◊ Sigmund Freud ◊ Walter B. Cannon ◊ Ivan Pavlov

20 th Century Formalization as a Field of Inquiry Two major frameworks: psychodynamic and 20 th Century Formalization as a Field of Inquiry Two major frameworks: psychodynamic and psychophysiologic ◊ ◊ ◊ ◊ 1938 – Psychosomatic Medicine 1942 – American Psychosomatic Society Helen Flanders Dunbar Franz Alexander Harold G. Wolff Edmund Jacobson Hans Selye

20 th Century ◊ “Comprehensive Medicine” (Guze, Matarazzo, & Saslow, 1953) ◊ “Biopsychosocial Model” 20 th Century ◊ “Comprehensive Medicine” (Guze, Matarazzo, & Saslow, 1953) ◊ “Biopsychosocial Model” (Engel, 1977) ◊ Neal Miller (1969) ◊ Wilbert Fordyce (1976) ◊ Robert Ader (1974)

Landmark Events in Organized Psychology 1969 - The Role of Psychology in the Delivery Landmark Events in Organized Psychology 1969 - The Role of Psychology in the Delivery of Health Services (Schofield) 1975 - Section on Health Research in APA Division of Public Service 1977 - Yale Conference on Behavioral Medicine

1978 1978

Growth of Education and Training ◊ Early 1980’s – opportunities for E&T in HP Growth of Education and Training ◊ Early 1980’s – opportunities for E&T in HP • 42 doctoral (Belar, Wilson & Hughes, 1982) • 48 internships (Gentry, Street, Masur & Asken, 1981) • 43 postdoctoral (Belar & Siegel, 1983) ◊ 1983 - Arden House Conference defines education and training in Health Psychology

Core Knowledge Domains ◊ Biological bases of health, disease and behavior (basic anatomy and Core Knowledge Domains ◊ Biological bases of health, disease and behavior (basic anatomy and physiology, pathophysiology, pharmacology, psychoneuroimmunology, psychophysiology, neuroendocrinology) ◊ Cognitive-affective bases of health, disease and behavior (how learning, memory, perception, cognition, thinking, motivation and emotions influence health behaviors, are affected by physical illness/injury/disability, and can affect response to illness/injury/disability)

Core Knowledge Domains ◊ Social bases of health, disease and behavior (impact of relationships Core Knowledge Domains ◊ Social bases of health, disease and behavior (impact of relationships [including physician-patient relationships], social support, culture, religion, workplace, health policy and organization of health care delivery systems on health and help-seeking) ◊ Psychological bases of health, disease and behavior (behavioral risk factors for disease/injury/disability and nonadherence to medical regimens; relationships among stress, coping and health outcomes; developmental issues in health and illness; impact of psychopathology on illness and treatment; issues of diversity and health, e. g. , gender, sexual orientation)

Core Domains of Knowledge & Skill ◊ Health research methods ◊ Health assessment, consultation, Core Domains of Knowledge & Skill ◊ Health research methods ◊ Health assessment, consultation, and interventions • individual, families, groups, organizations, communities • primary, secondary and tertiary prevention ◊ Program development and evaluation ◊ Management and supervision ◊ Ethical, legal and professional issues ◊ Interdisciplinary collaboration

◊ 1990 – health psychology was the most frequently noted area of faculty research ◊ 1990 – health psychology was the most frequently noted area of faculty research in APA accredited clinical psychology doctoral programs ◊ 2004 – 3 APA accredited postdoctoral programs in clinical health psychology

Growth in Research ◊ 1979 - U. S. Department of Health, Education and Welfare. Growth in Research ◊ 1979 - U. S. Department of Health, Education and Welfare. Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention. ◊ 1982 - Institute of Medicine. Health and Behavior: Frontiers of Research in the Biobehavioral Sciences (50% of mortality from the 10 leading causes of death in the U. S. can be traced to behavior/lifestyle factors)

Establishment of Journals 1978 – Journal of Behavioral Medicine 1982 – Health Psychology 1986 Establishment of Journals 1978 – Journal of Behavioral Medicine 1982 – Health Psychology 1986 – Journal of Psychology and Health

Behavior in Medical Journals (Suls and Rothman, 2004) ◊ NEJM, Lancet, JAMA, Annals of Behavior in Medical Journals (Suls and Rothman, 2004) ◊ NEJM, Lancet, JAMA, Annals of Internal Medicine ◊ “behavior” doubled from 1974 -2001 (total # of articles increased by 3%) ◊ BUT – increase is from. 002% of total articles to. 004% (starting in 1986 -89)

2001 2001

Growth of Professional Practice 1984 - American Board of Health Psychology incorporated (ABHP) 1991 Growth of Professional Practice 1984 - American Board of Health Psychology incorporated (ABHP) 1991 - Board certification recognized by American Board of Professional Psychology (ABPP) 1997 - APA Council of Representatives recognizes Clinical Health Psychology as a specialty 1998 - ABHP renamed as American Board of Clinical Health Psychology

Service Areas for Health Psychology 1. Prevention of illness/injury 2. Coping with illness 3. Service Areas for Health Psychology 1. Prevention of illness/injury 2. Coping with illness 3. Preparation for stressful medical procedures 4. Adherence to medical regimens 5. Management of physical symptoms 6. Management of psychophysiological disorders 7. Problems of health care providers and health care systems. 8. Mental health disorders

There a variety of service areas for the application of knowledge in health psychology. There a variety of service areas for the application of knowledge in health psychology. Interventions can occur at a variety of levels. ◊ Individual/Family ◊ Health Care Provider ◊ Health Care System ◊ Population ◊ Health Policy

#1 Prevention of illness/injury #1 Prevention of illness/injury

Traumatic Injuries ◊ Reckless driving ◊ Poor body mechanics ◊ Falls ◊ Seatbelts/helmets ◊ Traumatic Injuries ◊ Reckless driving ◊ Poor body mechanics ◊ Falls ◊ Seatbelts/helmets ◊ Toxic storage ◊ Interpersonal violence

Behavioral Risk Factors ◊ Tobacco use ◊ Diet ◊ Exercise ◊ Unsafe sex ◊ Behavioral Risk Factors ◊ Tobacco use ◊ Diet ◊ Exercise ◊ Unsafe sex ◊ Alcohol and substance use

#2 Coping with illness #2 Coping with illness

Social Support ◊ Post MI survival (Berkman, 1995) ◊ Hemodialysis survival (Christensen et al. Social Support ◊ Post MI survival (Berkman, 1995) ◊ Hemodialysis survival (Christensen et al. , 1994)

Myocardial Infarction ◊ depression increases risk of mortality independent of cardiac disease severity ◊ Myocardial Infarction ◊ depression increases risk of mortality independent of cardiac disease severity ◊ impact of depression is as great as previous MI and impaired left ventricular ejection fraction ◊ anxiety and anger directed inward also increase risk Frasure-Smith et al. , 1995

Recovery from Illness Acute Myocardial Infarction ◊ patients with high anxiety in the 48 Recovery from Illness Acute Myocardial Infarction ◊ patients with high anxiety in the 48 hours after AMI had 4. 9 times risk for developing complications ◊ risk independent of clinical indicators Moser & Dracup, 1996

Interventions are more than health education. ◊ Social support ◊ Emotional support ◊ Systematic Interventions are more than health education. ◊ Social support ◊ Emotional support ◊ Systematic behavior change ◊ Increased self-efficacy

#3 Preparation for stressful medical procedures #3 Preparation for stressful medical procedures

Recovery from Surgery Meta-analysis ◊ N = 191 studies, major and minor surgery ◊ Recovery from Surgery Meta-analysis ◊ N = 191 studies, major and minor surgery ◊ Interventions information skill-building support ◊ Outcome • 79 -84% of studies reported beneficial effects • length of stay decreased by an average of 1. 5 days • • • Devine, 1992

#4 Adherence to Medical Regimens ◊ 1 out of 6 hospitalizations of seniors (GAO, #4 Adherence to Medical Regimens ◊ 1 out of 6 hospitalizations of seniors (GAO, ◊ ◊ ◊ 1995) 10% of all hospital admissions (DHHS, 1990) 2/3 not taking therapeutic dose of BP medication (JAMA, 1989) 50% of 1. 6 billion prescriptions taken incorrectly

#5 Management of Physical Symptoms ◊ Asthmatic episodes ◊ Pain ◊ Dyspnea ◊ Headache #5 Management of Physical Symptoms ◊ Asthmatic episodes ◊ Pain ◊ Dyspnea ◊ Headache ◊ Fecal incontinence ◊ Muscle spasms ◊ Anticipatory nausea ◊ Insomnia ◊ Vasospasms ◊ Cramping/diarrhea

COPD Rehabilitation Program 7 6 5 4 Pre Post 3 2 1 0 Inpatient COPD Rehabilitation Program 7 6 5 4 Pre Post 3 2 1 0 Inpatient Days Talcott et al. , 1996 Outpatient Visits ER Visits

Arthritis Self-Management N = 401 Physical Disability 9% Increase Visits to Physicians 43% Decrease Arthritis Self-Management N = 401 Physical Disability 9% Increase Visits to Physicians 43% Decrease Pain 20% Decrease Sense of Self-efficacy Significant Increase Lorig et al. , 1993

Fecal Incontinence ◊ 1. 2% over age 60 ◊ 2 nd most common reason Fecal Incontinence ◊ 1. 2% over age 60 ◊ 2 nd most common reason for institutionalizing the elderly ◊ BF is treatment of choice when caused by nerve injuries resulting in weakness of external anal sphincter or impaired ability to detect rectal distention (est. 60 -70% of adult patients) ◊ 72% of patients obtain at least 90% reduction Whitehead et al. , 1996

#6 Psychophysiological Disorders ◊ Irritable Bowel Syndrome ◊ Migraine Headache ◊ Tension Headache #6 Psychophysiological Disorders ◊ Irritable Bowel Syndrome ◊ Migraine Headache ◊ Tension Headache

#7 Problems of health care providers and health care systems. #7 Problems of health care providers and health care systems.

Medical Decision-Making ◊ Surgery (pain, ICD) ◊ Organ transplantation ◊ Complex management (home dialysis, Medical Decision-Making ◊ Surgery (pain, ICD) ◊ Organ transplantation ◊ Complex management (home dialysis, home ventilator) ◊ Fertility treatments

Needs of Other Health Professionals ◊ Education and Training ◊ Physician-Patient Communication ◊ Implementation Needs of Other Health Professionals ◊ Education and Training ◊ Physician-Patient Communication ◊ Implementation of Practice Guidelines ◊ Burnout Prevention

Needs of Health Care Organizations ◊ Self-Help Programs ◊ Program Development • disease management Needs of Health Care Organizations ◊ Self-Help Programs ◊ Program Development • disease management • staff development • community outreach • Infection control

Diabetes ◊ n = 11 studies, self-management training ◊ FBS level improvement ◊ Reduction Diabetes ◊ n = 11 studies, self-management training ◊ FBS level improvement ◊ Reduction in diabetes-related hospitalizations ◊ Reduction in serious foot lesions ◊ Reduction in diabetes-related health care costs ◊ Need: • extensive use of behavior change strategies • integrated team Clement, 1995

#8 Mental health disorders #8 Mental health disorders

U. S. Surgeon General Reports 1999, 2000, 2001 ◊ 1 in 5 American adults U. S. Surgeon General Reports 1999, 2000, 2001 ◊ 1 in 5 American adults experience a mental disorder in a given year ◊ 1 in 10 children and adolescents ◊ 1 in 5 older persons

Most Americans seek mental health care from their family physician. ◊ 50% of all Most Americans seek mental health care from their family physician. ◊ 50% of all individuals with a mental disorder go to primary care providers ◊ 80% of psychotropic medication is prescribed by primary care providers ◊ Patients have long-standing relationships with primary care providers

Problem 50 -66% of mental health problems are not detected by primary care providers Problem 50 -66% of mental health problems are not detected by primary care providers • lack of knowledge • lack of training and experience • poor interviewing skills • lack of time

Need for Integration of Psychological Services in Primary Care ◊ Acknowledges the defeat of Need for Integration of Psychological Services in Primary Care ◊ Acknowledges the defeat of mind-body dualism ◊ Facilitates dealing with high comorbidity of medical and psychological problems • pain-depression • COPD-anxiety ◊ Reduction in overall health care costs

Why has there been such growth in Health Psychology? Why has there been such growth in Health Psychology?

◊ Deficiencies in biomedical model ◊ Increased maturity of behavioral science ◊ ◊ ◊ ◊ Deficiencies in biomedical model ◊ Increased maturity of behavioral science ◊ ◊ ◊ research and practice Increased disease burden from chronic disease HIV/AIDS epidemic Focus on prevention Increased concern with quality of life Increased cost of health care

Why is there such potential for Health Psychology? Why is there such potential for Health Psychology?

◊ Deficiencies in biomedical model ◊ Increased maturity of behavioral science ◊ ◊ ◊ ◊ Deficiencies in biomedical model ◊ Increased maturity of behavioral science ◊ ◊ ◊ research and practice Increased disease burden from chronic disease HIV/AIDS epidemic Focus on prevention Increased concern with quality of life Increased cost of health care

Healthy People 2010 10 Leading Health Indicators ◊ responsible sexual ◊ ◊ substance abuse Healthy People 2010 10 Leading Health Indicators ◊ responsible sexual ◊ ◊ substance abuse behavior mental health tobacco use environmental injury and violence quality physical activity ◊ immunization obesity ◊ access to health care ◊ ◊ ◊

Drivers of Health Policy ◊ To Err is Human (IOM, 1999) ◊ Crossing the Drivers of Health Policy ◊ To Err is Human (IOM, 1999) ◊ Crossing the Quality Chasm (IOM, 2001) ◊ Health Professions Education Summit (IOM, 2002) ◊ Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medial School Curriculum (IOM, 2004)

Competencies for Quality Health Care 2002 Health Professions Education Summit ◊ Informatics ◊ Interdisciplinary Competencies for Quality Health Care 2002 Health Professions Education Summit ◊ Informatics ◊ Interdisciplinary Teams ◊ Evidence-Based Care ◊ Quality Improvement ◊ Patient-Centered Care

Preparing to reach our potential: ◊ Changing demographics ◊ Context Competence (e. g. , Preparing to reach our potential: ◊ Changing demographics ◊ Context Competence (e. g. , culture, race/ethnicity, history, religion, politics, economics, community, discrimination)

Health Informatics ◊ Communication (e. g. , email) ◊ Knowledge management (e. g. , Health Informatics ◊ Communication (e. g. , email) ◊ Knowledge management (e. g. , evidence-based databases) ◊ Decision support

Telehealth Telehealth

Need more attention to: ◊ Clinical decision-making ◊ Practice guidelines ◊ Dissemination of guidelines Need more attention to: ◊ Clinical decision-making ◊ Practice guidelines ◊ Dissemination of guidelines

Need increased attention to: ◊ Genetics ◊ Organ and tissue transplantation ◊ Assisted reproductive Need increased attention to: ◊ Genetics ◊ Organ and tissue transplantation ◊ Assisted reproductive technology ◊ Primary care

Globalization Globalization

Environment Environment

Advocacy ◊ Graduate Education & Training ◊ Research ◊ Health Policy Advocacy ◊ Graduate Education & Training ◊ Research ◊ Health Policy

There is great potential for psychologists in health research and care. ◊ Research ◊ There is great potential for psychologists in health research and care. ◊ Research ◊ Health promotion and disease prevention ◊ Assessment and triage ◊ Consultation (case centered and systems centered) ◊ Psychological ◊ ◊ ◊ interventions Program development Administration Team building Supervision Education and Training