Training and Career Prospects in Health Psychology

As the field of health psychology is so new, the profession is developing. Most health psychologists work in hospitals, clinics and academic departments of colleges and universities. In these positions, they either provide direct help to patients or give indirect help through research, teaching and consulting activities. The direct help includes the management of the patient's psychological adjustment and health problems. The indirect help is through research and theory formation. The qualification for becoming health psychologist includes completion of the doctoral degree in Psychology.

Most Health Psychologists follow one of two career categories:
1. Those who work mainly in clinical capacities with patients
2. Those who work mainly in academic or research capacities.
Some combine these areas and some do administrative work such as in governmental agencies or programs to promote health.
In United States, the number of psychologists working on health care exceeds 45,000. Laws enabling psychologists to obtain full staff status in hospitals giving them same privileges as physicians have been passed. In India, however, career prospects of health psychologists are yet to improve. The society is still blind in understanding the importance of psychology in the field of health and illness.
Besides hospitals, health psychologists have opportunities in colleges and universities, medical schools, health maintenance organizations, rehabilitation centers, pain centers and private practice and consultancy offices. Sometimes job descriptions for these setting s are broad, making eligible even professionals from non-psychology fields, such as nursing, public health and social work. However, broad job descriptions can increase the scope for psychologists also.
Training programs
Training in health psychology is offered at three educational levels. Undergraduate courses in health psychology or behavioural medicine, graduate programmes and postdoctoral programmes. Post-doctoral programmes are available particularly for people with doctoral degrees that did not focus on the relationship between health and psychology. However, in India, health psychology is not so grown up as in US and other western countries. In US, dozens of graduate programs now exist, specifically for training.

Health Psychology and Related Fields

Health Psychology is an interdisciplinary field concerned with the application of psychological knowledge and techniques of health, illness and health care. Various disciplines including Psychology and Medicine have done sufficient contributions to Health Psychology. Some of the follows.
Epidemiology, the scientific study of the distribution and frequency of disease and injury, has close relationship with Health Psychology. Epidemiologists determine the occurrence of illness in a given population and organize the data in terms of when and where the disease or injury occurred, and to which gender, age and racial or cultural groups. Some terms used in epidemiology are
a) Mortality: death, on a large scale.
b) Morbidity: illness, injury or disability.
c) Prevalence: the number of cases (previously reported or new) of a disease or of persons infected at risk.
d) Incidence: number of new cases.
e) Epidemic: The incidence, generally of an infection disease has increased rapidly.
Public Health is a field concerned with protecting, maintaining, and improving health through organized efforts in the community. They examine and give orientation about immunization, sanitation, health education and awareness and ways to provide community health services.
Sociology focuses on human social life. It examines groups or communities of people and elevates the impact of various social factors, such as the mass, media, population, growth, epidemics and institution. Medical sociology is a sub-field of sociology, studies a wide range of issues related to health.
Anthropology is the study of human cultures. Medical Anthropology examines differences in health and health care across cultures.
The combined information health psychologist obtain from Epidemiology, public health, sociology and anthropology describes the social systems in which health, illness and person exist and develop. Health Psychology is also related to some non-psychology careers also, such as nursing, physician assistants, dietitians, physical therapists, occupational therapists and social workers.

Current Perspectives of Health and Illness

As WHO defines, in the current perspective, health is a state of well being with physical, cultural, psychosocial, economic and spiritual attributes, not simply the absence of illness. The term Health Promotion was first coined in 1974 by the Canadian Minister of National Health and Welfare, Max Lalonde. According to him, health and illness are not dependent only on medical conditions, but also on the environment and living conditions. WHO (1986) defined Health Promotion as the process of enabling people to increase control over, and to improve their health. To reach a state of complete physical, mental and social well-being an individual or group must be able to identify and to realize aspiration to satisfy needs, to change or cope with the environment. Biopsychosocial model expands the Biomedical view by adding to biological factors the influence of psychological and social factors. It proposes that all three factors affect and are affected by the person’s health.
The role of biological factors in health
Biological factors include the genetic materials and processes by which we inherit characteristics from our parents. It also includes aspects of the person's physiological functioning. The body is made of enormously complex physical systems. The efficient, effective and healthful functioning of these systems depends on the way these components operate and interact with each other.
The role of psychological factors in health
Psychological factors include the behaviour and mental processes of the individual. Cognition, emotion and motivation play a major role in health and illness. Cognition is a mental activity that encompasses perceiving, learning, remembering, thinking, interpreting, behaving and problem solving. Emotion is a subjective feeling that affects our thoughts, behaviour and physiology. Some emotions are positive or pleasant (eg: joy and affection) and others are negative (eg: anger, fear and sadness). Motivation is the force which acts behind a particular behaviour. For instance, a person who is motivated to feel and look better might begin an exercise programme.
The role of social factors in health
Individuals are units of society. Each individual interacts with others and influence as well as gets influenced by others. Society also affects the health of individuals by promoting certain values of our culture. The values can be influenced by different other aspects such as medias and books. Sometimes Medias may encourage unhealthy behaviour. However, as a part of the society, one can write opinions to the mass media, and thus influence it back. Like society, community and family would influence the members they include.
The role of biological, psychological and social factors in health and illness is not hard to see. What is more difficult to understand is how health is affected by this interplay. Health professionals consider the impact of a person's life as a total (holistic) entity in understanding health and illness. According to Engel, this can be achieved by applying the biological concept of system. A system is a dynamic activity with components that are continuously inter-related. Thus body is a system, which includes immune and nervous system, family is a system, and therefore, community and society. These systems have components that inter-relate, such as exchanging energy, substances and information.
While examining Health Psychology, it is important to keep the life span perspective in reference. As people develop, each portion of the life-span is affected by happenings in earlier years, and each affects the happenings in years that will come. In life span perspective, characteristics of a person are considered with respect to their prior development, current level and likely development in future. Life span perspective adds an important dimension to the biopsychosocial perspective in the effort to understand how people deal with issues of health and illness.

Health, Disease and Mind: Research Findings

The word health is derived from Old High German and Anglo-Saxon words meaning whole, hale and holy. Galen, the early Greek Physician, followed the Hippocratic tradition in believing that hygieia (health) and euxia (soundness) occur when there is a balance between the hot, cold, dry and wet components of the body. The four bodily fluids were believed to be blood, phlegm, yellow bile and black bile that were hot and wet, cold and wet, hot and dry and cold and dry respectively. Diseases were thought to be caused by external pathogens that disturbed the balance of the body's four elements. Galen believed that the body's constitution, temperament or state could be put out of equilibrium by excessive heat, cold, dryness or wetness. Such imbalances might be caused by fatigue, insomnia, distress, anxiety, or by the residues of food resulting from the wrong quantity or quality.

In Nineteenth Century, Rudolf Virchow, a German Pathologist, found microscopic organisms that disrupt normal operation of the body and cause disease. This resulted in the bout of Germ theory. The Germ Theory, along with Descartes' dualistic interactionism dominated Medicine and Physiology for 300 years. Both provided an important foundation for the Bio-Medical Model of illness. Hitherto, this model dominated medicine. The Bio-Medical Model has four characteristics.

1. Dualistic: Physical and psycho-social process are separate, and disease is not influenced by the latter.

2. Mechanistic: The body is like a machine. Disease occurs when the normal operation of the body-machine is disrupted by a foreign agent.

3. Deductionistic: Ignores the complexity of factors-some psychological and some physical-that are involved in the health of the whole person by focusing solely on one disease or physical system.

4. Disease oriented: Health is defined as the absence of disease and efforts rarely go beyond the elimination of the disease.

The Germ Theory and Bio-Medical Model led to the development of specific aggressive physical treatments, for diseases, such as;
a) Medication that destroy pathogens or ease pain and suffering were discovered in nature or created synthetically.
b) Vaccines to protect against viral diseases were discovered. (Eg. Polio)
c) Medical technology to diagnose disease was advanced (Eg: x-ray)
d) New surgical procedures (antiseptics and anesthetics) to reduce complication and save lives were discovered.

These resulted in greatest health advancement in human history. Many diseases like Hepatitis B, Influenza, Malaria, Mumps, Measles, Pneumonia, Rabies, Tetanus, Tuberculosis etc. which are found to be the results of pathogenic attack began to get treated. The three Ds of Bio-Medical Model is Diagnosis, Disease and Drugs

However, Bio-Medical Model has been challenged by two recent trends.
1) Changing patterns of illness
2) Escalating cost of health care.
The changing pattern of illness is the result of several factors.
1) The decline of contagious diseases, due partly to success of Bio-Medical Model.
2) The decline in the rate of infant mortality.
The increase in the non-contagious diseases is largely the result of people living longer and engaging in health compromising behaviour.

Psychiatrist George Engel (1977) was the first to propose a Bio-Psycho-Social Model of illness. He said that health and illness are a consequence of physical, psychological, and cultural variables. The three Ps of Bio-Psycho-Social Model - People, Prevention, Psychology - can be contrasted with the three Ds of Bio-Medical Model. By stating that a model of disease must take the patient into account, Engel repudiated the Bio-Medical Model and Dualism. Bio-Psycho-Social model stands for the idea; people are "individual mind-body complexes ceaselessly interacting with the social and physical environment in which they are embodied".
Bio-Psycho-Social Model is actually a return to holism, which existed at the time of Hippocrates - the Father of Medicine. According to Bio-Psycho-Social Model, health and illness are states of being that result from multiple factors and have multiple effects. These multiple factors include biological and physiological processes, pathogens and chemical imbalances, as well as psychosocial processes, personality and behaviour. The mind and body are not separate independent entities. They are two aspects of the whole person.

The relation between Medicine and Psychology can be traced back at least to the period of ancient Greece. This relationship is more formalized by the works of Sigmund Freud in Twentieth Century. He noticed that some patients showed symptoms of physical illness without any organic disorders. He attributed these illnesses to unconscious mental conflicts and called the disorder conversion hysteria. He believed that mental conflicts were being converted into physical symptoms.

Today, conversion hysteria is among a category of psychological disorders called somatoform. Under dualistic tradition, physicians have been involved only when there is a verifiable organic pathology. Somatoform disorders was regarded as a domain of psychiatrists or psychologists.
The ancient Greek Holists, Hippocrates among them, believed that mind and body should not be separated and studied independently. In Twentieth Century, Freud's psychiatric contemporaries showed interest in researches combining psyche (mind) and soma (body), which came to be known as psycho-somatic medicine. The term psychosomatic does not mean a person's symptoms are imaginary. It means that mind and body are both involved. Until 1960s or so, research in psychosomatic medicine focused on psycho-analytic interpretation for specific, real health problems including ulcer, high blood pressure, asthma, migraine headaches, and rheumatoid arthritis. After 1960s, it focused on new approaches. Currently, it is a broader field concerned with the inter-relationships among psychological and social factors, biological and physiological functions and the development and course of illness.

Two new fields emerged in 1970s to study the role of Psychology in illness. One is Behavioural Medicine and the second one, Health Psychology.

The field of Behavioural Medicine was launched in association with the National Academy of Sciences. This field has two defining characteristics.

1. Its membership is inter-disciplinary, including Psychology, Sociology and various areas of Medicine.

2. It grew out of the perspective of behaviourism, which proposed that people's behaviour results from learning (conditioning).

Conditioning methods has shown a good deal of success as therapeutic approaches in helping people modify problem behaviours such as over eating and emotions such as anxiety and fear.
Behaviourism served as an important foundation for Health Psychology - a field that is principally within the discipline of Psychology. In APA, the division of Health Psychology was introduced in 1978. The Journal "Health Psychology" began publication four years later.

Matarazzo, the First President of the division in APA, outlined four goals of Health Psychology.

1. To promote and maintain health: Psychologists study such topics as why people do and don't smoke cigarettes, use safety belts in cars, drink alcohol and eat particular diets. Health Psychologists can help in the design of school health education programmes and media campaigns to encourage healthful lifestyles and behaviour.

2. To prevent and treat illness: Psychological principles have been applied effectively in preventing illness, such as in reducing high blood pressure and therefore, the risk of heart disease and stroke. For those people who become seriously ill, psychologists with clinical training can help them adjust to their current condition, rehabilitation programme and future prospects, such as reduced work or sexual activity.

3. To identify the causes and diagnostic correlates of health, illness and related dysfunction: Psychologists study the causes of disease. Psychologists also study physiological and perceptual processes which affect people's experience of physical symptoms.

4. To analyze and improve health care systems and health policy: Psychologists contribute toward this goal by studying how characteristics or functions of hospitals, nursing homes, medical personnel and medical costs affect patients. The resulting knowledge enables them to make recommendations of improvement, suggesting ways to help physicians and nurses become more sensitive and responsive to the needs of patients and to make the system more accessible to individuals who fail to seek treatment.

According to Matarazzo (1982), Health Psychology is the aggregate of the specific educational, scientific, and professional contribution 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 dysfunction and to the analysis and improvement of the health care system and health policy formation. Matarazzo's definition has been adopted by the American Psychological Association (APA), the British Psychological Society and other organizations. It serves as Health Psychology's official definition.

Need for Health Psychology: Research Findings

Observing the current environment, one can see that some people are ill more frequently than most people do. This difference between the people can result from medical sources, such as variation in physiological processes and exposure to harmful micro-organisms. Psychological and social factors also play roles in it. Two of them, which have to be given more attention are life style and personality of a person.
Nineteenth Century was absolutely revolutionary in the case of health and illness. Infectious diseases declined sharply. Nutrition and personal hygiene improved. This brought changes in the life style of the individuals.
Today, the chief health problems in the technological societies are chronic diseases. The risk factors behind these may be biological, or it may be behavioural. For example, people who smoke cigarettes have higher risk of developing cancer and other illnesses than non-smokers do. Any risk factor is associated with a health problem. It does not necessarily cause the problem. For instance, poverty is a risk factor for cancer, but it does not cause the disease.
Life Style and Illness
Many risk factors result from the way people live or behave. Some behavioural risk factors associated with five leading causes of death are
1) Heart disease: Smoking, high dietary cholesterol and lack of exercise.
2) Cancer: Smoking, high alcohol use, and diet.
3) Stroke: Smoking, high dietary cholesterol and lack of exercise.
4) COPD (Chronic lung diseases, eg: emphysema): Smoking.
5) Accidents (including motor vehicle): alcoholic drug use driving vehicles too fast, and not using seat belts.
Many of the people who are the victims of these illness and accidents live for at least a short while and either recover or eventually succumb. Part of today's high medical costs result from people's life styles that contribute to their health problems. Most health care efforts and funds are directed towards treating illness, not preventing it.
One reason of people behaving in unhealthy way is due to the cravings for immediate pleasure. Another reason is social pressure. Some such behaviours may become strong habits. Quitting them becomes very difficult. These people need information about the way to protect their health.
Personality and Illness
The term personality refers to a person's cognitive, affective and behavioural tendencies that are fairly stable across time and situation. Researchers have found evidence linking personality traits and health. For example, people whose personalities include high levels of anxiety, depression, anger/hostility or pessimism seem to be at risk for developing a variety of illnesses, particularly heart disease. These four emotions are reactions that often occur when people experience stress.
People differ in the way they deal with stressful situation. Many people approach these situations with relatively positive emotions. Their outlook is more optimistic than pessimistic. The link between personality and illness is not a one way route. Illness can affect one's personality, too. People who suffer from serious illness and disability often experience feelings of anxiety, depression, anger and hopelessness.
Optimum Health
As WHO defines, health is a state of complete physical, mental and social well-being and not merely the absence of disease and illness. This definition points out that health requires not just optimal physical functioning, but optimal mental and social functioning as well. Thus health is broadly related to the overall quality of life. It involves the internal state and the external community.
Psychology and Health
The definition of optimum health clearly implies a role of psychologists in health. Psychologists have been interested in physical health for a long time, but health psychology has taken a while to develop to its current state.

Mind-Body Relationship: Research Findings

Ancient philosophers like St.Augustine and St.Thomas believed that there was a complete division between mind and body. It was the philosophers from Seventeenth Century, for the first time pointed out that mind and body were related in significant way.

Descartes (1596-1650) was well aware of the physiological knowledge of the actions of muscles, nerves and other biological structures, the circulation of blood (discovered by Harvey) and of digestion correctly. He knew that muscles operate in opposing pairs. He speculated the functioning of nerves to be important for sensation and for movement. He also speculated that nerves are hollow tubes which carry animal spirits in different direction. Animal spirits are the material substances which could move quickly. Descartes said that human body is just like a machine, when it is considered without its soul. He pointed out that animals are only machines with various kinds of reflexes, instincts and other automatic actions. Animals have no souls, and therefore, they are automata. This is a mechanical view about the nature of the body. The view assumes that body refers to all that is unanimate. There is a soul or mind in every person. It is a thinking substance, which has the power to direct and alter the mechanical activities of the body. Soul refers to all that is in us.

For Descartes, mind and body consists of two different substances. Body consists of extended matter, but soul consists of unextended matter. However, they are connected in some activities such as sensation, emotions and perceptions. Thus the relationship between the mind and body is one of the interactions. Pineal gland is the point of interaction, because it is the only one which has no pairs. For instance, the images from the two eyes set up action in animal spirits, which stimulates pineal gland making an impression on it. Through mind, one would sense the impression. If the mind wishes to remember something, the pineal gland gets activated, set up animal in pores of brain to find out traces left by the objects or events encountered previously. Descartes' psychological interactionism served as a model for several modern psychological schools like psychoanalysis and functionalism.

Gotfried Leibnitz (1646-1716), a great mathematician, wrote in his Nouveaux Essais about psychological parallelism, which relates spirit or mind monads to body monads, an alternative theory to Descartes' interactionism. The monad is an element of all being and a point of force. It is indestructible, uncreatable and inimitable, but it is not static. For Leibnitz, world is an infinite pluralism of independent monads. A human individual is made up of many monads. Some monads have higher degree of consciousness and some have lower degree of consciousness (unconsciousness). Leibnitz called lower degree of consciousness as petiles perception (little perception). For example, the sound of single falling drop of water may be regarded as petiles perception. These monads will not interact. Each monad is self contained. Thus, mind monads and body monads are not usually related. They follow a parallel course (Parallelism). Leibnitz concepts of degree of consciousness and unconsciousness were the major source for Freud and Jung. It was not Freud, but Leibnitz, who used the term conscious first.

Benedict Spinoza (1632-1677), pointed out that mind and body could not be separated from each other. They are different aspects of same substances. As they are different aspects, bodily activities do not affect or cause changes in mental activities and mental activities do not affect bodily activities (Psychological double aspecticism).

Recent approaches denied the existence of mind. It is called Monism. The first support in modern period for monism was given by J.B.Watson.