Health Psychology. Michael Murray
of hypothetical ‘social cognitions’ are ineffectual, inefficient and too small in scale (Marks, 1996, 2002a, 2002b). Apart from their theoretical shortcomings, mass dissemination of individualized therapeutic approaches through the health care system is unsustainable and unaffordable. Like it or not, in spite of the many critiques, the biomedical model remains the foundation stone of clinical health care.
Health psychologists work at different levels of the health care system: carrying out research; systematically reviewing research; designing, implementing and evaluating health interventions; training and teaching; doing consultancy; providing and improving health services; carrying out health promotion; designing policy to improve services; giving scientific advice to government; and advocating social justice for people and communities to act on their own terms. In this book we give examples of all these activities, and suggest opportunities to make further progress.
A community perspective on health work offers an alternative prospect for intervention. Community approaches are less popular within mainstream health psychology and have been the mainstay of community psychology. There could be valuable synergies between health and community psychology working outside the health care system. In working towards social justice and reducing inequalities, people’s rights to health and freedom from illness are, quite literally, a life and death matter; it is the responsibility of planners, policy makers and leaders of people wherever they may be to fight for a fairer, more equitable system of health care (Marks, 2004; Murray, 2014a).
Our definition of health psychology is given in Box 1.3. In discussing this definition, we can say that the objective of health psychology is the promotion and maintenance of well-being in individuals, communities and populations.
BOX 1.3 Definition of health psychology
Health psychology is an interdisciplinary field concerned with the application of psychological knowledge and techniques to health, illness and health care.
Although there are diverse points of view, health psychologists generally hold a holistic perspective on individual well-being, that all aspects of human nature are interconnected. While the primary focus of health psychology is physical rather than mental health, the latter being the province of clinical psychology, it is acknowledged that mental and physical health are actually ‘two sides of one coin’. When a person has a physical illness for a period of time, then it is not surprising if they also experience worry (= anxiety) and/or sadness (= depression). If serious enough, ‘negative affect’ (sadness and/or worry) may become classified as ‘mental illness’ (severe depression and/or anxiety), and be detrimental to subjective well-being and to aspects of physical health. Each side of the ‘well-being coin’ is bound to the other. The distinction between ‘health psychology’ and ‘clinical psychology’ is an unfortunate historical accident that is difficult to explain to non-psychologists (or even to psychologists themselves). There is also significant overlap between health and clinical psychology and ‘positive psychology’ as an integrative new field (Seligman and Csikszentmihalyi, 2000; Seligman et al., 2005), although not without critiques of exaggerated claims and poor methodology (e.g., Coyne and Tennen, 2010).
Rationale and Role for Health Psychology
There is a strong rationale and role for the discipline of health psychology. First, the behavioural basis for illness and mortality requires effective methods of behaviour change. Second, a holistic system of health care requires expert knowledge of the psychosocial needs of people.
In relation to point 1, all the leading causes of illness and death are behavioural. This means that many deaths are preventable if effective methods of changing behaviour and/or the environment can be found.
BOX 1.4 KEY STUDY: The Global Burden of Disease study
An important epidemiological perspective comes from measures of ‘disability’ or ‘disablement’. The Global Burden of Disease (GBD) study projected mortality and disablement over 25 years. The trends from the GBD study suggest that disablement is determined mainly by ageing, the spread of HIV, the increase in tobacco-related mortality and disablement, psychiatric and neurological conditions, and the decline in mortality from communicable, maternal, perinatal and nutritional disorders (Murray and Lopez, 1997).
The GBD study was repeated in 2010 and figures were prepared by age, sex and region for changes that had occurred between 1990 and 2010. Global figures for life expectancy show increases for all age groups (Figure 1.3).
The GBD uses the disability-adjusted life year (DALY) as a quantitative indicator of the burden of disease. It reflects the total amount of healthy life lost that is attributed to all causes, whether from premature mortality or from some degree of disablement during a period of time. The DALY is the sum of years of life lost from premature mortality plus years of life with disablement, adjusted for the severity of disablement from all causes, both physical and mental (Murray and Lopez, 1997).
Figure 1.3 Percent change in total DALYs, 1990–2010
Source: Institute for Health Metrics and Evaluation (2014), www.healthdata.org/infographic/percent-change-total-dalys-1990-2010
The data in Table 1.3 indicate that nearly 30% of the total global burden of disease is attributable to five risk factors. The largest risk factor (underweight) is associated with poverty (see Chapters 4 and 5). The remaining four risk factors are discussed in Part 2 of this book (see Chapters 8–13).
There were changes in the total DALYs attributable to different causes between 1990 and 2010, as shown in Figure 1.3. Good progress is evident in DALYs for the lower respiratory tract and diarrhoea, but a huge increase of 354% occurred in DALYs for HIV patients. Moderate but significant increases in DALYs occurred for heart disease, stroke, low back pain, depression and diabetes.
The statistics on death and disablement indicate the significant involvement of behaviour and therefore provide a strong rationale for the discipline of health psychology in all three of its key elements: theory, research and practice. If the major risk factors are to be addressed, there is a pressing need for effective programmes of environmental and behavioural change. This requires a sea change in policy. The dominant ideology that makes individuals responsible for their own health may not be the most helpful approach. The environment is a hugely important factor. In our opinion, a psychological approach in the absence of environmental change is like whistling in the wind.
Table 1.3
Health psychologists are at the ‘sharp end’ of the quest to produce health behaviour change on an industrial scale. The fact that people are highly constrained by their environment and socio-economic circumstances militates against such change. In a sense, without adaptations of the environment, this effort is disabled. There are strong constraints on the ability of health care systems to influence health outcomes at a population level because of the significant social and economic determinants that structure the health of individuals and communities. The environment must change, and by that route there can be behaviour change on a societal scale. Attempting to change behaviour without first attending to the environment is akin to ‘the tail wagging the dog’, mission impossible.
A second rationale for health psychology is growing recognition that a purely medical approach to health care is failing to meet the psychosocial needs of many patients. This has led to a search for an alternative perspective that values holistic care of patients and attempts to improve services through higher quality psychosocial care. In spite of their very high costs, health