Health Psychology. Michael Murray
change, and investigate interventions. The growth of interest in this subject has been truly amazing. Similar to psychology more generally, the primary focus of health psychology has been the behaviour, beliefs and experiences of individuals.
The book introduces alternative, critical approaches to health psychology which are not yet part of the mainstream. We advance the case that psychological issues are embedded in human social structures in which economics and social justice play crucial roles. The mainstream socio-cognitive framework appears to us to be of limited relevance in a world where issues of poverty, social injustice and conflict exist for millions of people, and psychological processes are conditioned by basic limitations of capability, freedom and power (Marks, 1996, 2002a, 2004; Murray and Campbell, 2003; Murray, 2014a, 2014b). We evaluate and critique contemporary psychological theories and models in that context.
In our view, to make a contribution to society, theory, research and practice in health psychology must engage with the real economy, develop approaches for industrial-scale behaviour change, and work with communities and the struggles of the dispossessed. An agenda for health psychology needs to include ‘actionable understandings of the complex individual–society dialectic underlying social inequalities’ (Murray and Campbell, 2003: 236). Preliminary thoughts on ‘actionable understandings’ and of the ‘individual–society dialectic’ are presented in this book. By having access to mainstream and alternative perspectives in a single volume, lecturers and students can reach an assessment of the field and how it could make more progress in the future.
We explain the significance of the biological and social contexts, and review theory and methods (Part 1), analyse the complexity and diversity of health behaviour (Part 2), discuss health promotion and disease prevention (Part 3), and explicate the significance of clinical health psychology for some of the major afflictions of the age (Part 4).
Table P1
Source: Adapted from Dahlgren and Whitehead (1991: 23)
The book uses a multi-level framework that takes into account both the biological determinants and the social context of health-related experience and behaviour. This multi-level framework, the ‘Onion Model’, assumes different levels of influence and mechanisms for bringing about change (see Table P1 and Chapter 1 for details).
Health psychology is a potentially rich field, but, if it is to become more than a ‘tinker’, it is necessary to master an appreciation of the cultural, socio-political and economic roots of human behaviour. In this book, we aim to apply an international, cultural and interdisciplinary perspective. We wish to demonstrate the great significance of social, economic and political changes. As the gaps between the ‘haves’ and the ‘have-nots’ widen, and the world population grows larger, the impacts of learned helplessness, poverty and social isolation are increasingly salient features of contemporary living.
Those concerned with health promotion and disease prevention require in-depth understanding of the lived experience of health, illness and health care. By integrating research using quantitative, qualitative and action-oriented approaches, we take a step in that direction.
The Biopsychosocial Model
The dominance of the biomedical system has been challenged by figures in the scientific establishment and by certain patient groups. These challenges are reflected in a call for more attention to the psychological and social aspects of health and, in particular, in the so-called ‘biopsychosocial model’ (BPSM) proposed by Engel (1977, 1980). According to Engel (1980) all natural phenomena can be organized into a hierarchy of systems ranging from the biosphere at one end of the hierarchy, to society and the individual level of experience and behaviour towards the middle, and then to the cellular and subatomic levels at the other end of the hierarchy. These different levels need to be considered if we are to fully understand health and illness. The BPSM has become the conceptual status quo of contemporary psychiatry (Ghaemi, 2009) and a banner for health psychology. Yet it is far from being established as a paradigm in medicine and health care where the biomedical model remains resiliently in force.
Long before Engel, William Osler (1849–1919) had stated: ‘The good physician treats the disease; the great physician treats the patient who has the disease.’ He also stated: ‘Listen to your patient, he is telling you the diagnosis.’ The traditional biomedical model remains the core of medical education, although there may have been a slight shift in the thinking of doctors in primary care and in liaison psychiatry towards a more holistic, BPS view of the patient (see Chapter 1). The BPSM remains a fertile idea for a transformed biomedical model by including the psychological and social aspects of illness along with the biological aspects. The BPSM has been influential, for example, in providing an account of the influence of racism on health outcomes (Clark et al., 1999) and in understanding adolescent conduct problems (Dodge and Pettit, 2003).
However, the BPSM has not been free of controversy – for example, when it has been extended as a cognitive behavioural theory of illness such as myalgic encephalomyelitis (ME) or chronic fatigue syndrome (CFS) by asserting that cognitions and behaviours perpetuate the fatigue and impairment in individuals suffering from the condition(s) (Wessely et al., 1991; Chapter 23). In psychiatry Engel’s BPSM became associated with a particular socio-cognitive model for illness experience. We argue that the socio-cognitive formulation has tended to constrain theorizing within health psychology (Chapter 8) and narrowed thinking about clinical conditions and stigma to the presumption of incorrect beliefs and attitudes (Chapter 22). It is important to distance Engel’s generic BPSM as a schematic approach to health care from specific formulations of the socio-cognitive model. In truth, there is a multitude of biopsychosocial theories and models that should not be lumped together under a single umbrella, because the devil is in the detail. The adoption of the BPSM by general practitioners can meet with resistance or even hostility by patients, either because they feel more comfortable with the traditional ‘doctor knows best’ model of biomedicine or because they deem the BPSM is not a good fit for their illness (e.g., myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS)).
Seventy years ago the World Health Organization (WHO) proposed a definition of health as: ‘a state of complete physical, mental and social well-being, not the mere absence of disease or infirmity’. This definition widened the scope of health care to consider well-being more holistically. The WHO definition has not been revised since its original publication in 1948. In Chapter 1 we suggest a wider definition, encompassing the economic, political and spiritual domains of daily living for these are also contributing conditions of well-being. Currently, some areas of health care are shifting from a concern with purely bodily processes to an awareness of broader concepts of quality of life and subjective well-being.
Another recent trend has been an ideological emphasis on patient choice and individual responsibility for health. Crawford (1980: 365) argued that ‘in an increasingly “healthist” culture, healthy behaviour has become a moral duty and illness an individual moral failing’.
Human Rights and the Responsibility to ‘Do No Harm’
The universal human rights of freedom of speech, thought and action within the law are an essential principle in health care. Health care is at the interface between policy and practice and as such must have a strong foundation in the rights of patients and populations as human beings. In recent years there has been a political shift wherein hate speech and divisive rhetoric by key political leaders have served to ‘unleash the dark side of human nature’. This political shift has been the subject of a report by Amnesty International (2017), which has brought to stark attention the ‘dark forces’ which are changing the geo-political environment … wherein