Background behaviour change and on psychological support for

Backgroundto the history of the field of Health PsychologyThe term health psychology has been officially recognizedas a discipline of the field of psychology since 1978, when the AmericanPsychological Association (APA) established a Division of Health Psychology(Division 38). Josep Matarazzo, the first President of the Division, was veryprecise about its objectives: ‘We must aggressively investigate and dealeffectively with the role of the individual’s behaviour and lifestyle in healthand dysfunction’ (Matarazzo, 1982). Nevertheless, psychology’s interests ingeneral health and illness comes from the very beginning of the disciplineitself.

As the discipline of psychology developed itsprofessional and scientific character, psychology’s role in health wasessentially focused on “mental health” (Schofield, 1969). In a period that was characterizedfor the advances in medicine, the development and success of vaccines andantibiotics led to a stronger disconnection between the mental and the physicaldomain. During this period, the role of clinical psychologists was set in thediagnosis and treatment of mental disorders. On the twentieth century, the Second World War had atremendous social and psychological impact. This did allow a chance forpsychoanalysis to become the most organized approach to understand and enhancemental health. It was considered the main approach to the psychological studyof illness for around 50 years. After almost half a century, clinicalpsychology became the dominant approach to the study of illness when it cameout with the ideas of behaviour analysis, cognitive psychology andpsychometrics and some aspects from biological psychology (Murray, 2014).

Psychologyexpanded into the general hospitals and the community put together clinicalpsychologists and general medical practitioners in order to broadenpsychologists’ interests into physical health problems. Furthermore, governmentreports of society’s unhealthy behaviours encouraged social psychologists toapply their theories and interventions to health issues. In the United Kingdom, in 1986, the BritishPsychological Society established a Health Psychology division whose purposeswere similar to those in the APA.

Members in this section were mostly clinicalpsychologists; this division had a specific focus on individual behaviourchange and on psychological support for people with physical health problems (Murray,2017). The clinical heritage within health psychology advocatedthe idea of distinct professional training routes with its own training demandsand official titles. This belief led to the growing professionalization ofhealth psychology.

From this point, several MSc programs were set, starting inLondon, and arrived to many other regions in the UK. The Health Psychology sectionturned into a Special Group in Health Psychology (SGHP) and the posteriorDivision of Health Psychology (DHP) in 1997.With the professionalization of health psychology inthe United Kingdom, the more analytical health psychologists went originallyfor the study of language, but taking into account as well the importance ofwider social and political processes (Murray, 2012; Murray, 2017). In the UK,clinical health psychology has come out as a separate discipline within thefield of clinical psychology, leading into a potential conflict with thosehealth psychologists who don’t have clinical training (Murray, 2017). It is notclear how the practice of health psychology will evolve in the forthcomingyears.

In 2015, Bennet suggested an option that would allocate clinical healthpsychologists in primary and secondary healthcare and health psychologists inillness prevention and public health. Development of health psychology varies depending onthe country. Currently in the UK, being a member of the BPS DHP is a prerequisitefor qualifying as a health psychologist. Furthermore, the professionalactivities of the health psychologists are regulated by the BPS (Michie,Abraham & Johnston, 2007).

Health psychology has grown rapidly with an increaseon the evidence that shows the relationship between behaviour and illness and,and the awareness of the psychosocial aspects of health and illness (Marks etal, 2015). These days in the UK, patients usually access health servicesthrough the general medical practitioner (GP) in their area, who if needed,refers them to other health professional for treating their condition. Recentresearch has shown how health psychology indeed contributes to health promotionin primary care settings (Thielke,Thompson & Stuart, 2011), but there isstill work to do for demonstrating its cost-effectiveness across other systemsof care. Philosophiesand theories underpinning the fieldIn the field of health psychology, many theories andframework have contributed to the actual development of the discipline. In 1946the World Health Organization (WHO) defined health as: ‘the state of completephysical, social and spiritual well-being, not simply the absence of illness.’This definition encompasses social and biological aspects but it seems itleaves out some important issues that also have an impact on health such as psychology,culture and economics. For this reason, Marks and his colleagues (2015) gave anew definition of health that describes it as: ‘a state of well-being withsatisfaction of physical, cultural, psychosocial, economic and spiritual needs,not simply the absence of illness.’During many years, philosophers, doctors,psychologists and many others have had much to say about what makes someonefeel well.

One of the most known theories about human’s wellbeing is Maslow’sHierarchy of Needs. In Maslow’s (1943) hierarchy of needs, he states thatpeople are motivated towards achieving some needs. These needs are organizedwithin hierarchical levels forming a pyramid and, starting from the bottom one,when a person’s need is accomplished, they seek to achieve the next one. Maslow’smodel is divided into basic needs – such as physiological, security, socialacceptance and self-esteem – and growth needs or the need forself-actualization, which is located on the top of the pyramid (McLeod, 2007).

Maslow’s hierarchy framework has had a big influencewhen talking about health and human wellbeing. However, as every good piece ofwork in research, there are always objections. According to Marks et al (2015),there are essential elements of human realization that are not mentioned inMaslow’s theory as, for instance, agency and autonomy – those are what givepeople the freedom to make a choice – and spirituality – the feeling that noteverything that matters is in the physical world. Following Maslow’s hierarchy, a number ofpsychological theories have attempted to give an explanation to human’ssatisfaction and wellbeing. The ‘Self Determination Theory’, which had animportant impact in psychology, suggested that there are three universal andinnate human needs: competence, autonomy and psychological relatedness (Ryan& Deci, 2000).

However, none of these theories and frameworks has beenenough to fully understand what is needed for a person’s happiness andwell-being. Throughout history, scholars have tried to explain thenature of a joyful and happy life or, as it’s known in health care, quality oflife (QoL). The World Health Organization (1995) defines Quality of Life as ‘anindividual’s perception of their position in life in the context of the cultureand value systems in which they live, and in relation to their goals,expectations, standards and concerns. It is a broad ranging concept, affectedin a complex way by the person’s physical health, psychological state, level ofindependence, social relationships, and their relationship to salient featuresof the environment.’ A sixth field on spirituality and religiousness was addedafterwards by the WHOQoL Group (1995).

The concept of Quality of Life overlapswith the concept of subjective wellbeing, which has been defined as: ‘anumbrella term for different valuations that people make regarding their lives,the events happening to them, their bodies and minds, and the circumstances inwhich they live’ (Diener, 2006). In 2011, Diener and Chan outlined evidence that havinga positive perception of subjective wellbeing adds four to ten years tosomeone’s life. According to this data, it can be said that, somehow, there isan association between mortality and subjective wellbeing. One of the mainpurposes of health psychology, then, is to understand the links betweensubjective well-being and health (Marks et al, 2015).

In order to accomplish this purpose, the relevance ofpsychosocial processes and people’s behaviour in health and illness is becomingmore frequently recognized. One of the most broadly used models in healthpsychology that is worth to mention here is the Biopsycosocial Model of health.In contrast to the Biomedical Model, the Biopsychosocial Model proposed by Engel(1977) suggests that behaviours, thoughts and feelings do influence thephysical state. He argued that psychological and social factors have an impacton people’s biological functioning and so are determinants of health andillness. This model describes how psychology, society and behaviour have animpact on a person’s health situation.  Another important model for exploring the socialhealth factors that can determine people’s health and wellbeing is theDahlgren-Whitehead Rainbow model (1991).

This model outlines the relationshipbetween the individual, their environment and their health. Individuals arerepresented in the core layer, and around them there are four layers ofinfluences on health – from the inner to the outer one they are individuallifestyle factors, community influences, living and working conditions and generalsocio-economic, cultural and environmental conditions. These two frameworks have helpedresearchers to build a number of hypotheses about the determinants of health,their influences on different health outcomes and the interactions betweenthem. Although the main focus for health psychology used tobe clinical settings, psychologists have become key members ofmultidisciplinary teams (Michie & Abraham, 2004). Health psychology isdeveloping into an increasingly demanded discipline in health care and medicalsettings.Current issues concerning healthpsychologistsHealth psychologists (HPs) implement the theory,methods and research of psychology to a more applied context whose aim is tohelp people to avoid and manage illnesses, and to promote and maintain health. Healthpsychology searches for the best way to communicate to people for promotinghealth protective behaviours (Rothman & Salovey, 1997).

Health psychologists’ competences are useful at alllevels of the healthcare system. At the level of direct patient care, they helppatients to psychologically adjust to illness and treatment, reducing thestress associated with the clinical procedures, delivering health education,facilitating their decision making and delivering health interventions forpromoting healthy behaviours (Hallas, 2007). These health professionals provideservices in both hospital and community, and through the different stages ofthe illness, from diagnosis to palliative care. Directpatient care and educationOn the one to one basis, health psychologists may beasked to assess patients to recognize the way in which they are dealing withtheir condition. Assessment interviews are different depending on the patient’shealthcare needs but will usually focus on interviews evaluating affection andmood state, perceptions, attitudes and emotional reactions towards illness, copingstyle, social support, cognitive aptitude and their response to the environment(Butt, 2016).

Health psychologists must know how to extract information inthese interviews and communicate it afterwards to other healthcareprofessionals, in order to direct them to the medical options that best suitthe patient. Regarding health psychology interventions, these canbe carried out within primary or secondary prevention services (Hallas, 2007). Healthpsychologists design and carry out cognitive-behavioural interventions withindividual patients and groups for changing health behaviours.

Health behavioursrefer to the actions and behaviours of an individual person, a group or/and anorganization. For example, when someone is stressed at work it could beattributed to the person’s coping strategies, but it could also be related withthe manager’s decision-making behaviour, which would be the organization inthis case (Kok & Schaalma, 2007). Within the category of health behaviours,there are included the used of medical services, the adherence to medicaldiets, and the self directed behaviours such as nutrition, physical activity,smoking and consuming alcohol. All these behaviours are usually divided betweenhealth-enhancing and health-impairing behaviours (Bennett, Conner & Godin,2007). Behaviour management is a key factor for preventingand dealing with chronic diseases (Matarazzto, 1982). Healthpsychologists need to understand and to intervene to changes in both psychologicaland behavioural processes on illness and healthcare. Changingbehaviour of patients and health professionals can be advantageous for thehealthcare system (Kaplan, 1990) and should be one of the main goals of healthpsychology.

Health psychology training to healthcareprofessionalsHPs are also employed to train other healthcareprofessionals so they can better understand de psychological impact of illnessand treatment and improve the professional – patient communication (Gatchel& Oort, 2003). The fields of knowledge that HPs could teach mayinclude the Biopsychosocial Model of health, statistics and methods of researchand theories and techniques of behaviour change (Winefield, 2007). They may aswell use their expertise in intervention design and implementation to supportother healthcare professionals in delivering interventions and developing theirown design (Hallas, 2007). In more applied contexts, health psychologists maytrain on skills such as communication and interview, adherence to treatment,promotion of a healthy lifestyle and handling work stress for healthprofessionals.Another important part when it comes to professionals’education is the supervision from professional health psychologists to otherpeople training for being one of them (Horn, 2007). Supervision implicates anexchange of information between the supervisor and the trainee.

The supervisormust identify what the trainee needs and guide him or her in the right way forunderstanding, experiencing and reflecting over the acquired knowledge. 

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