Analyze the concepts of health and mental health and provide examples of emotional, social, cultural, and physical dimensions of health.

Prior to beginning work on this discussion, read Chapter 9 in the course textbook and the articles Careers in Health PsychologyLinks to an external site., Pursuing a Career in Health PsychologyLinks to an external site., and Clinical Health PsychologyLinks to an external site..

Health psychology can be applied in numerous settings. Whether you are a health clinician, a leader within an organization, a daycare provider, a parent, or a licensed psychologist, understanding how one’s health can affect one’s psychological well-being is an important area for consideration.

Based on your goals, address all of the following topics associated with health psychology and how you can potentially use this information to support your goals, whether in the health field or other discipline. Remember that you can use your knowledge in these areas in differing ways. For example, if you are working in HR, you may be able to use this knowledge to support employee wellness. If you are working as an educator, confidentiality is very important.

Topics to discuss:

Nutrition and Exercise

Effective Stress Management

Confidentiality

Cultural Competence

For example, if you are going to graduate school to become a licensed clinical psychologist, how will this information help your clients? If you are a daycare provider, how could this be applied when designing activities for children? If you desire to be a manager or leader in an organization, how can this knowledge help you to support your employees more successfully?

As you discuss each area, be critically aware of appropriately applying APA-formatted citations to support your assertions about the topic. For additional support, see the resource Citing Within Your PaperLinks to an external site..

Discussion posts should equate to approximately 350 to 400 words.

Requirements: 400 words

Learning Objectives After reading this chapter, you should be able to ሁAnalyze the concepts of health and mental health and provide examples of emotional, social, cultural, and physical dimensions of health. ሁUnderstand the scope of health psychology and behavioral medicine. ሁDiscuss links between people’s sense of personal responsibility regarding their health and health lifestyle changes. ሁIdentify some current areas of focus in health psychology. ሁExplain key ethical considerations in health psychology research. ሁConnect topics in health psychology to career applications. Health PsychologyYolanda Harper, PhD—Ashford University9Adamkaz/E+/Getty Images

Section 9.1How Do We Define Health and Mental Health?This was Denae’s first appointment with the cardiologist after a routine physical suggested she might be showing early signs of coronary heart disease. Denae had been a dedicated run-ner in her twenties and thirties. After injuring a knee during a charity marathon, Denae quit exercising regularly, but continued to eat the same way she had been eating when she was running 15 miles a week. This caused her weight to creep up over the next several years. Her mood has become increasingly depressed as most of her social activities in the past were asso-ciated with running. At the time of her appointment, Denae was 50 pounds overweight. However, Denae did not return after the first appointment. With the increased weight gain, unhealthy diet, and lack of regular exercise, Denae’s joint pain became chronic, and she developed a dependency on the pain medication initially prescribed by her primary physician. In the past six months, Denae has found it increasingly difficult to get doctors to prescribe her the pain medications she seeks. Her primary physician will no longer renew her prescription and recommended she seek treatment for opioid dependency and return to the cardiologist. Denae has continued to obtain opioid medications by going to emergency rooms and pressuring her husband, James, to tell his doctor he has back pain. James is concerned about Denae’s use of pain medications, but he is highly conflict avoidant and does not confront her. Denae’s story raises a number of interesting questions for health psychology: ሁWhat are the biological, social, emotional, and relationship factors that contribute to Denae’s health conditions? ሁWhat would motivate Denae to exercise, adopt a healthy diet, and give up her addictive behaviors (i.e., smoking and opioid pain medications abuse)? ሁWhat personality characteristics does Denae have that put her at risk of developing addictions and overeating? ሁWhich stress management strategies could Denae learn in order to manage life challenges more effectively? ሁHow might positive psychology be of benefit to Denae?These are typical questions addressed by health psychologists, who apply psychological theories, research, and scientific methods to the promotion and maintenance of health, the prevention and management of illness and injury, the identification of psychosocial factors that contribute to physical illness and injury, the improvement of the healthcare system, and the formulation of health policy (Wahass, 2005). Can you think of at least three additional questions a health psychologist might ask about Denae’s illnesses and lifestyle choices?9.1 How Do We Define Health and Mental Health? In 1948, the World Health Organization (WHO) published the following definition, which has remained unchanged to date: “Health is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity” (para. 2). The WHO definition of mental health (last updated in 2014) is the following:Mental health is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. (para. 1)

Section 9.2What Is Health Psychology?Medical professions in the U.S. have been dominated by two major scientific viewpoints: the biomedical model and the biopsychosocial model. The biomedical model is a dualistic view that assumes humans are first and foremost biological organisms best understood by using principles of anatomy, physiology, biochemistry, and physics. Disease is believed to result from biological and chemical abnormalities, and interventions target physiological structures and systems. Under this view, health is defined as an absence of disease (Gold, 1985; Mehta, 2011). In contrast, the biopsychosocial model is a pluralistic view that assumes health, illness, and injury are multifaceted and include biological, psychological, environmental, sociocultural, and socioeconomic components. According to this point of view, optimal healthcare interven-tions pay attention to all components of the individual’s biopsychosocial system. Despite the publication of a definition of health that is clearly biopsychosocial in nature by the WHO in 1948, the biomedical worldview of health has continued to dominate U.S. mainstream medi-cal practice. Having a broader, international vantage point, the WHO definition was informed by many perspectives, including some of the world’s oldest health systems (e.g., traditional Chinese medicine and Ayurvedic medicine), which have long understood that there is a rela-tionship between physical health and psychological wellness. Advocates of biopsychosocial models criticize biomedical models as being simplistic and ignoring important sociocultural, environmental, and psychological factors needed to make accurate diagnoses and appropriate treatment decisions. Although the treatment of a viral or bacterial infection may seem clearly a matter of biology, attitudes and beliefs influence behavioral choices that can increase or decrease the risk of exposure to contagions. Cogni-tions, emotions, and personality characteristics influence responses to stressors which can strengthen or weaken the immune system (Brosschot, Gerin, & Thayer, 2006). These psy-chological characteristics can also influence how well a patient will adhere to prescribed treatments. Sociocultural factors (e.g., gender socialization, ethnic/cultural worldviews) and socioeco-nomic factors (e.g., level of income) can influence whether patients try home remedies or complementary treatments before turning to a traditional physician and how long they will tolerate uncomfortable symptoms before seeking help. Some practitioners advocate for expanding the biopsychosocial model into a biopsychosocial-spiritual model (Elias et al., 2015; Saad, de Medeiros, & Mosini, 2017) to emphasize the importance of spirituality in many patients’ lives. Biopsychosocial-spiritual models of health provide a context for understand-ing how biological, psychological, sociocultural, and spiritual characteristics contribute to the current level of functioning of individuals who identify religion or spirituality as important to them (Anandarajah, 2008; Sulmasy, 2002). Familiarity with these definitions and models of health and mental health are important to understanding the scope of health psychology and ways to work with a wide range of individuals in socioculturally appropriate ways. 9.2 What Is Health Psychology? As stated in the introduction, health psychologists apply psychological theories, research, and scientific methods to the promotion and maintenance of health, the prevention and man-agement of illness and injury, the identification of psychosocial factors that contribute to physical illness and injury, the improvement of the healthcare system, and the formulation

Section 9.2What Is Health Psychology?of health policy (Wahass, 2005). The biopsychosocial model is the prevailing paradigm for research, practice, and training within health psychology. One of the most frequently cited definitions of health psychology was offered by health psychologist and former American Psychological Association (APA) president, Dr. Joseph Matarazzo:Health psychology is the aggregate of the specific educational, scientific and professional contributions of the discipline of psychology to the pro-motion and maintenance of health, the prevention and treatment of illness, the identification of etiologic and diagnostic correlates of health, illness, and related dysfunction and the improvement of the health care system and health policy formation. (Matarazzo, 1980, p. 815)Per this definition, health psychology is concerned with each of the following:• Promoting healthy behaviors• Preventing and treating illness• Identifying causes of health and illness• Improving healthcare systems• Influencing health-related policiesDevoted to understanding psychological influences on health-related processes, health psy-chology asks questions such as: • How do healthy people stay healthy? • Why do some people become ill? • How do people respond to illness or injury? • How do people recover from a disease or adapt to chronic illness? • What factors contribute to recovery?• How can illness and injury be prevented?To accomplish these goals and answer these questions, health psychologists apply theory, research, and practical expertise from many different areas of psychology (e.g., learning, social, cognitive, developmental, and physiological psychology).The Emergence of Health Psychology According to Schwarzer and Gutiérrez-Doña (2000), health psychology emerged in the U.S. in the 1970s as a response to a number of factors, including• an increasing awareness that lifestyle choices such as drinking, smoking, and other drug abuse; unprotected sex; overeating; and insufficient exercise contribute to mil-lions of preventable deaths every year,• escalating costs of medical care and the development of cost-effective behavioral interventions to promote lifestyle changes to prevent the onset of illness,• a paradigm shift in the social sciences from the biomedical model to the biopsycho-social model described in Section 9.1, and• a significant increase in the number of health professionals acknowledging the valid-ity of the WHO conceptualization that health is not merely absence of illness, but rather the presence of well-being.

Section 9.3Personal Responsibility and HealthThese factors were important consider-ations when the APA formally established the Division of Health Psychology (Divi-sion 38) in 1978. In 1986, the Interna-tional Association for Applied Psychology (IAAP) followed suit by establishing its Division of Health Psychology, which maintains a global focus on health and wellness. Psychiatrist George Engel (1913–1999) was an influential character who for-mally challenged the biomedical model in a key paper promoting the use of the bio-psychosocial model based on his work in psychosomatic medicine, an off-shoot of psychiatry (Engel, 1977). Psychoso-matic medicine focuses on ways psycho-logical, social, and behavioral factors interact to influence physiological processes. The impact of Engel’s work was seen in a notable increase in biopsychosocial publications and presentations in the 1980s and 1990s. During this time, biopsychosocial medicine came to be seen as “the progressive unification of the medical and behavioral sciences” (Dowling, 2005, p. 2039).Over the years, other terms have been used to identify subfields focused on applying a biopsy-chosocial approach to health. For example, before health psychology came to be the preferred term, medical psychology was often used to denote the subfield that applied psychological knowledge to the medical profession. Contemporary medical psychology has become inte-grated into health psychology as a subfield devoted to the study of psychological factors in the human experience of illness and wellness. You may also run into the term, behavioral medicine, which initially relied heavily on learning theories to investigate the conditions that maintained (reinforced) health and illness behaviors. Today, behavioral medicine is under-stood to be an interdisciplinary specialty that applies knowledge and techniques from the psychological and medical sciences to prevention, diagnosis, treatment, and rehabilitation. Additionally, you may find mind–body medicine being used by some as a general term for interventions targeting connections between mental and biological processes (Weil, 2017). Additional subfields have branched off from healthy psychology, such as environmental health psychology and occupational health psychology. These and other subfields are explored later in this chapter as potential career areas. 9.3 Personal Responsibility and HealthWith the discovery that lifestyle choices can impact health in positive or negative ways, questions arise regarding the amount of personal responsibility people have for maintain-ing health and facilitating recovery when coping with health challenges. Do you believe that your health is determined by genetics and resign yourself to let nature take its course? Or do Mukhina1/iStock/Getty Images Plus ሁHeath psychology emerged in the U.S. in the 1970s due to several factors, including increasingly unhealthy lifestyles and attitudes toward health among American citizens.

Section 9.3Personal Responsibility and Healthyou believe your behavior influences your quality of life such that you can minimize/protect against genetic limitations by following a healthy lifestyle? While some people are highly motivated self-changers (Prochaska, Norcross, & DiClemente, 1994), others may find it challenging to learn new habits without additional coaching and support. Locus of Control and Locus of ResponsibilityIn 1966, psychologist Julian Rotter’s (1916–2014) seminal work on external versus inter-nal control stimulated much research into personality and today is applied to many fields in psychology, including health psychology. Rotter described people with an external locus of control as attributing causes of events and future conditions to external forces (other people, society, luck, fate), while people with and internal locus of control tend to take responsibility for life conditions and believe they have the ability to shape their future (see Figure 9.1). Figure 9.1: Internal and external locus of control ሁExamples of thinking associated with the internal and external locus of control styles.Sue and Sue (2013) expanded on Rotter’s work and added the concept of the locus of respon-sibility. Locus of responsibility refers to extent to which people attribute past and present life experiences to external factors (external responsibility) or to themselves (internal respon-sibility). Then in this context, locus of control refers to the extent to which people believe internal or external factors have the power to affect their future circumstances. “Locus of responsibility is about beliefs in ‘who caused it?’ and locus of control is about beliefs in ‘who can change it?’” (Chang, 2006, p. 209). The four worldviews stemming from Sue and Sue’s model are as follows: (1) Internal responsibility, internal control: I caused it. I can change it. “My lifestyle choices got me to this point. If I want to improve my health, it is my responsibility.” Diagnosis oftype 2 diabetesNo diagnosis oftype 2 diabetesInternal locus of controlExternal locus of controlDiagnosis of type 2 diabetesNo diagnosis of type 2 diabetes“It’s my own fault. I should have exercised and changed my diet years ago.” “With my work schedule and family responsibilities, I don’t have time to exercise and prepare healthy meals. Plus, diabetes runs in my family. I was destined to be diabetic.”“Great! Making healthy food choices and exercising is paying off.” “Luck was on my side. I must not have inherited the diabetes genes from my family after all.”

Section 9.3Personal Responsibility and Health(2) Internal responsibility, external control: I caused it. It’s up to some-one/something else to change it. “My lifestyle choices got me to this point but there’s nothing I can do about it now. It’s too hard to change. I’ll just take my medication and, if I’m lucky, I’ll be okay.” Or “I’ll never get better unless my spouse cooks healthy meals and exercises with me.” (3) External responsibility, internal control: Someone/something else caused it. I can change it. “It’s not my fault. This condition runs in my family, and my spouse does most of the cooking and never wants to exercise. How-ever, it’s up to me to take control of my health. I will prepare healthy meals. I will exercise alone or join a fitness class.” (4) External responsibility, external control: Someone/something else caused it. It’s up to someone/something else to change it. “It’s not my fault. This condition runs in my family, and my spouse does most of the cooking and never wants to exercise. I could improve my health if my spouse were more supportive of my healthy lifestyle changes. If not, the doctor will prescribe me something to make me feel better.” Educational level and socioeconomic status are positively correlated with having an internal locus of control. For some, an external locus of control is related to religious beliefs or a part of a worldview about the relationship of people to nature. Thus, rather than assume a patient has a particular locus of control or responsibility based on demographics, the culturally com-petent health practitioner will talk with the patient to identify her or his worldview (Sue & Sue, 2013).How Do Individuals Make Healthy Lifestyle Changes?Behavior change requires behavioral intentions, a degree of perceived self-efficacy, and an expectation that positive outcomes will result from behavioral changes. Since the inception of health psychology, a number of behavioral models have been proposed in attempts to pre-dict and explain how people make positive behavioral changes (Conner & Norman, 1996; Weinstein, Rothman, & Sutton, 1998). To date, the most popular and practical evidence-based TEST YOUR KNOWLEDGETake on the role of a health psychology professional working with Denae, who we read about at the beginning of the chapter. During your clinical interview, you note that she makes comments consistent with an external locus of control and an external locus of responsibility. She blames her husband James’ irritability and work-related stress for her inability to tolerate pain without strong medications. She blames James for “always want-ing to go to unhealthy restaurants.” She believes there’s nothing she can do other than find creative ways to obtain pain medications and that surviving without them is too difficult. Since running is now painful, and her husband is also obese, she believes she will never be at a healthy weight again. How would you work with Denae to effect healthy change with-out stereotyping her?

Section 9.4Areas of Focus in Health Psychologymodel is the transtheoretical approach, also referred to as the stages of change model (Pro-chaska, DiClemente, Norcross, 1992). The transtheoretical approach, covered in detail in Developing a Treatment Plan in Section 6.2, consists of the five stages of precontemplation, contemplation, preparation, action, and maintenance. The transtheoretical approach offers recommendations for types of interventions to assist people in moving from one stage to the next. For example, Allen, age 52, has smoked since he was 13 years old. As far back as he can remember, his father and all of the adult men in his family smoked. Allen’s fiancé, Samira, is a former smoker and has asked Allen on numerous occasions to quit smoking. Allen saw no reason to stop smoking (precontemplation stage) until last month when his grandson was diagnosed with asthma and Samira had Allen watch a health education video on the impact of secondhand smoke on children with asthma (con-sciousness raising). After watching the video, Allen attempted to quit smoking but only made it two days without cigarettes (cycling from precontemplation to action to relapse and con-templation within a two-day period). Samira told Allen that she had the same difficulty giv-ing up cigarettes until she asked her physician to prescribe her a nicotine patch, which then helped her quit for good. Samira sharing her experience which Allen in the contemplation stage is an example of contact and discussion with a role model. Subsequently, Allen made an appointment with his physician (preparation stage) and obtained a nicotine patch to help reduce his craving (wearing the patch and refraining from smoking places Allen in the action stage). If he can stay away from cigarettes for a week or two, then he will move into the main-tenance stage. The transtheoretical approach is a useful framework for health psychologists as they try to help their clients make healthy lifestyle changes. The approach has also been translated into easy-to-understand language to enable individuals who are not mental health professionals to utilize it for personal self-improvement (Prochaska, Norcross, & DiClemente, 1994; Pro-chaska & Prochaska, 2016). Because everyone’s journey is unique and people respond to life challenges in different ways, models like the transtheoretical approach are useful because they are adaptable to the personal strengths, weaknesses, and growth opportunities of the individual. 9.4 Areas of Focus in Health Psychology Diet, lifestyle, and environment impact health quality across the lifespan. Many health condi-tions have documented links to behavioral choices (e.g., overeating, smoking, excessive con-sumption of alcohol, substance use, unprotected sexual intercourse, reckless driving). Health psychology research has identified risk factors for such behaviors. Risk factors are personal, social, or environmental characteristics associated with higher rates of the specific behav-iors (Schwarzer & Gutiérrez-Doña, 2000). For example, research on the etiology and progres-sion of cardiovascular disease (CVD) has revealed CVD to be associated with psychosocial influences such as depression, hostility, social isolation, and stress, in addition to a number of behavioral, physiological, and genetic factors. Strong negative emotions and stress are believed to impact the development etiology and progression of cancer. Treatment research developed within biopsychosocial frameworks investigate the efficacy of interventions for these and other acute and chronic diseases, including obesity, diabetes, upper respiratory ill-nesses, gastrointestinal disorders, asthma, arthritis, and chronic pain (Casellas-Grau, Font, & Vives, 2014; Everson-Rose & Lewis, 2005; Gallo & Luecken, 2008; Groarke et al., 2017).

Section 9.4Areas of Focus in Health PsychologyAs health psychology emphasizes the importance healthy lifestyle choices and positive psy-chological states play in preventing and treating illness and injury, we will now review exam-ples of specific applications of health psychology to contemporary human concerns. The fol-lowing information is not intended to provide a comprehensive overview on these topics but rather to highlight select areas of interest for health psychologists. Improving Health Through ExerciseRegular physical activity is important for optimal mental and physical health. The benefits of exercise in preventing chronic diseases are well documented. Regular exercise can reduce the risk of hyperten-sion, stroke, coronary heart disease, and colon cancer as well as help with weight management.In addition to documented benefits for physical health, exercise has been identi-fied as effective in reducing depressive and anxiety symptoms (Drews, Antonuc-cio, & Kirsch, 2011; Mental Health Foun-dation, 2005). According to the National Alliance on Mental Illness (NAMI), for mild to moderate depression, aerobic exercise should typically be a key component to a treatment plan (National Alliance on Mental Illness, 2014). Many individuals with serious mental illness are at risk of developing chronic diseases (e.g., diabetes, hyperlipidemia, and cardiovascular disease) associated with medication side effects and sedentary lifestyles. Exercise improves mental health by • reducing anxiety, depression, and negative mood; • improving self-esteem and cognitive function; and • reducing social withdrawal.It is believed that these mood-related improvements occur because exercise increases blood flow to the brain and reduces physiologic reactivity to stress (Sharma, Madaan, & Petty, 2006). Health psychology can be applied to identify factors, which encourage people to exercise and then to develop interventions using that information to promote regular physical activity. For example, Weiss (2000) found that providing enjoyable experiences is a strongly motivating strategy for increasing activity levels in youth, helping youth develop positive attitudes about exercise, and making regular physical activity a lifestyle habit. Intervention strategies to maintain and enhance physical activity motivation in children include: making physical activ-ity fun, creating a motivational climate which fosters mastery, providing realistic “stretch” challenges that are attainable but not easy, and teaching children strategies such as goal set-ting and self-monitoring.In contrast to encouraging physical activity among children and adolescents, promoting phys-ical activity among older adults has a different set of challenges. Different activity recommen-dations and motivational strategies may be needed for older adults at risk for, or who have AzmanJaka/E+/Getty Images ሁExercise has been shown to improve mental health.

Section 9.4Areas of Focus in Health Psychologydeveloped, functional limitations or physical disabilities. Health psychologists work with older adults to overcome barriers to being physically active (e.g., cultural expectations, cop-ing with health disorders, time constraints). According to Brawley, Rejeski, and King (2003), conducting physical activity programs in a variety of different settings and utilizing diverse channels of communication can help alleviate some of these barriers. Behavior change strate-gies recommended for older adults must consider generational, cultural, gender, and socio-economic factors.Today, many new and evolving technologies such as accelerometers and smart phone applica-tions are available, along with helpful web resources and evidence-based programs (Sallis et al., 2015). Exergaming, or the use of video games requiring significant movement and physi-cal exertion, is also rising in popularity, and health psychology professionals are increasingly expected to be knowledgeable enough to give opinions about different video games marketed to increase physical activity. Contemporary health psychologists have numerous tools at their disposal to improve compliance with exercise recommendations in order to overcome patients’ barriers to being more active.Improving Health Through NutritionIn addition to working with individuals and communities to increase physical activity levels, health psychologists collaborate with professionals such as nutritionists to promote wellness through diet. Life expectancy is increasing in many parts the world, and this is having pro-found effects on many aspects of society, especially when health problems are present in the advanced years. Health psychologists work with other health professionals, to not just add quantity to our lives, but also quality.FoodPsychosocial factors impact nutritional status by the effects they exert on food choice and intake. Health psychologists work with patients to increase motivation to adhere to a healthy diet. There are a number of benefits of maintaining a healthy diet, including • protection against chronic diseases and certain injuries (e.g., broken bones due to osteoporosis related to nutritional deficiencies);• strengthening immune function, digestive health, vision, and oral health;• protecting cognitive and emotional functioning;• reduction of risk of undernutrition, unhealthy weight loss, nutrient deficiency, and other deficiency diseases (e.g., anemia); and• facilitation of illness recovery.A number of models have been used to educate the public about human nutritional needs. These include the basic four food groups model, the food pyramid models, and the current MyPlate model, which replaced MyPyramid in June 2011. MyPlate (https://www.choosemy-plate.gov/) is part of a U.S. Department of Agriculture communication initiative to help con-sumers make better food choices. MyPlate tools provide the ability to develop a personalized food plan based on age, sex, height, weight, and physical activity level. Top of FormWhile communication initiatives such as MyPlate are helpful in reminding people to eat healthfully, they are not intended to change behavior alone. This is where health psychologists, with their expertise in human motivation and change processes, are able to make significant

Section 9.4Areas of Focus in Health Psychologycontributions. For instance, health psychologists work with educational and health leaders to strengthen policies in order to provide healthier meals to students at schools; limit their access to low-nutrient, energy-dense foods during the school day (i.e., junk food in vending machines); and increase the frequency, intensity, and duration of physical activity at school (Story, Nanney, & Schwartz, 2009).WaterMaintenance of a healthy diet includes ensuring adequate fluid intake. The average adult requires approximately 30 ml per kg of body weight (approximately 1 ounce/2.2 pounds), which for an adult of 140 pounds is approximately 8 cups. Dehydration can lead to mental confusion and impairments in attention, concentration, and other cognitive and psychomotor functions. Inadequate hydration has been associated with excessive intake of sugary drinks, which, in turn, increases the risk for obesity, dental cavities, and reduced appetite for healthy foods. Health psychologists can assist patients and health professionals in understanding the impact of inadequate hydration on mental health and in developing strategies to maintain adequate water intake.A number of emotional and behavioral factors act as barriers to adequate hydration: intake of unhealthy fluids, fear of increased urination, and inappropriate responses to signs of thirst. Experiencing thirst is not a purely physiological response. To a large extent, thirst sensitivity is a learned behavior. Individuals must first perceive they are thirsty before being motivated to intake fluids. Prolonged voluntary or involuntary periods without adequate fluids are asso-ciated with learned behaviors of ignoring or misinterpreting physiological signs of the need for fluids. Children are especially at risk of not meeting recommended fluid targets because they are prone to denying thirst and refusing to drink unless given their preferred drinks. Educational and behavioral intervention strategies developed by health psychologists have been demonstrated to be effective in increasing children’s water intake (Kuhl et al., 2010). For example, Kuhl et al. (2010) designed an intervention that included teaching parents to iden-tify clear fluids and prescribed specific clear fluid goals for children. Children received stick-ers for compliance, and those who met at least 75% of their weekly goals could earn prizes.Obesity: A Special Health ConcernBeyond maintaining a healthy diet and getting adequate amounts of exercise, optimum health includes maintaining a healthy body weight to avoid illness associated with obesity. Obesity is a risk factor for diabetes, cardiovascular disease (CVD), and some cancers. Cardiovascular disease and cancers are major causes of death in the U.S. (Alters & Schiff, 2009). Health psy-chologists, along with other medical professionals, educate patients about health risks associ-ated with obesity and work with patients to attain healthy weight goals. Rather than focusing solely on weight as measured by scales, contemporary professionals focus on overall body composition, body-mass index (BMI), and waist-to-hip ratio. Strategies from the transtheo-retical model described earlier (and in Chapter 6) can be valuable in helping patients meet healthy weight goals.Health psychologists work with patients to adopt a mindset of healthy behavioral choices as lifelong lifestyle changes. Once patients are ready to move from precontemplation to the action stage, they may be encouraged to make gradual changes, develop eating and physical activity plans, keep records of what they consume, and evaluate their thoughts and feelings

Section 9.4Areas of Focus in Health Psychologyassociated with eating behaviors. Lose-weight-quick schemes are discouraged, as crash diets and diet fads tend to be ineffective in the long-term and are often associated with increased health risks. At the other extreme, health psychologists also often work with patients who exhibit disordered patterns of eating, such as binge eating, purging, and self-starvation (as covered in Chapter 6). Improving Health Through Effective Stress ManagementWhile humans have always encountered stress, the view of stress as a public health prob-lem is a contemporary conceptualization. Regarding stress, health psychologists ask: how do our perceptions of situations determine the stress we experience? There are many different cultural, theoretical, and scien-tific conceptualizations of stress. Seaward (2012) noted that while stress is associated with an absence of inner peace in Eastern philosophies, Western culture tends to view stress as a lack of emotional control. The following definition of stress integrates a vari-ety of viewpoints and is flexible enough to be interpreted in culturally-specific ways. Stress is the experience of perceived threats to well-being resulting from a series of psychophysiologi-cal responses and adaptations.The use of the word perceived highlights that what one person might interpret as a threat may be insignificant to someone else. A stressor, any real or imagined experience or stimulus that requires an adaptation response, may be innate or a learned behavior. For example, if you are exposed to a specific pollen that causes you to experience watery eyes and a runny nose, your body is innately perceiving this threat. On the other hand, if you text your partner and do not receive a reply, how you interpret that lack of response (by getting stressed out or staying calm) is a result of learned response patterns. Also noteworthy is that stressors are not nec-essarily exclusively positive or negative. Determining whether a stressor results in negative stress (distress) or positive stress (eustress) is based on how one perceives the stressor (Fevre, Kolt, & Matheny, 2006). Both marriage and divorce can be perceived as negative or positive stressors depending on the circumstances under which they occur, the personalities involved, and the quality of life the individual anticipates will follow. Stressors may emanate from a variety of sources (Davis, Eshelman, & McKay, 2008). Examples include1. Physiological: Lack of exercise, unhealthy nutrition, inadequate sleep, illness, or inju-ries; physiological changes during adolescence or during andropause or menopause; physical symptoms resulting from reactions to stressors.“I cannot and should not be cured of my stress, but merely taught to enjoy it.” —Dr. Hans SelyeAlvarez/E+/Getty Images ሁStressors can come from physiological, psychological, environmental, and social sources.

Section 9.4Areas of Focus in Health Psychology2. Psychological: Thoughts, interpretations of internal and external events, attitudes, emotional reactions.3. Environmental: Air or water pollution, weather, noise, traffic congestion, pollens. 4. Social: Beginning or ending a relationship, birth of a child, illness or loss of a loved one, job interviews, interpersonal conflicts, financial problems, deadlines, changes in employment status.It should be noted that the categories above are not discrete. For example, exposure to toxins can be viewed as an environmental and a physiological stressor. Stress may also be categorized as acute or chronic. Health psychologists are often concerned with the differential impact of acute stress and chronic stress. Acute stress manifests as tem-porary overarousals such as a rapid heartbeat, a short-term increase in blood pressure, cold hands or feet, sweaty palms, heart palpitations, or dizziness. Chronic stress is associated with elevated cortisol levels over a prolonged period of time (Nicolaides, Kyratzi, Lampro-kostopoulou, Chrousos, & Charmandari, 2015). As mentioned in Chapter 7, elevated levels of the hormone cortisol indicate the presence of stress. Prolonged cortisol elevations can con-tribute to the development of a number of illnesses, such as cardiovascular disease, diabetes, immune system suppression, fertility problems, and dementia (Jones & Quinn, 2006; Wein-stein, 2004). Stress and the Immune SystemHealth psychology professionals often work with patients experiencing, or at risk for devel-oping, a wide range of diseases associated with decreased immune functioning (e.g., cancer, HIV/AIDS, rheumatoid arthritis, inflammatory bowel disease). Psychology professionals often seek to help these individuals develop resilience and manage stress. As mentioned above, stressors may be positive or negative, and stress may be acute or chronic. The most publicized view is that stress hormones effect the immune system in pathological ways, especially in cases of chronic exposure to stress. While there is a wealth of research documenting the harmful impact stress can have on the immune system (Dhabhar, 2014; Nicolaides et al., 2015), contemporary research also focuses on the potential adaptive function of these effects. For example, when examining stress response–immune system interactions, Adamo (2017) found that while stress hormones can significantly reduce disease resistance, they also may increase the efficacy of stress-rel-evant physiological processes. In some circumstances, stress hormones can reconfigure the immune system to help compensate for the loss of some of the immune system’s resources. Short-term stress may lead to either immunopathological (autoimmune, pro-inflammatory) responses or immunoprotective (e.g., anti-tumor, anti-infectious, wound healing) responses (Dhabhar, 2014). In contrast, chronic stress is most often noted to suppress or worsen patho-logical immune responses and counter protective immune responses (Dhabhar, 2014). When utilizing biobehavioral interventions to promote health and healing in their patients, health psychology professionals should work closely with thehealth professionals who referred the patients (e.g., the primary care provider). Collaborative communication will help to tar-get interventions, as recommendations may vary based on whether an individual’s immune responses to stress are regulatory, pathological, or protective.

Section 9.4Areas of Focus in Health PsychologyBiopsychosocial Approaches to Managing Stress to Strengthen ResilienceHealth psychologists are especially attuned to recognizing the reciprocal effects of stress on illness and injury and the ways negative emotions contribute to illness and injury. Stress is implicated in most chronic health problems, including those affecting the immune sys-tem, as previously discussed. In addition, experiencing highly traumatic stressors (e.g., war, natural disasters, abuse) can contribute to the development of serious psychological dis-orders, including anxiety disorders, posttraumatic stress disorder, acute stress disorder, substance abuse, and personality disorders (Ginzburg, Ein-Dor, & Solomon, 2010; Leeies, Pagura, Sareen, & Bolton, 2010; MacIntosh, Godbout, & Dubash, 2015; Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010; Zammit et al., 2018). Stress management should be mul-timodal, utilizing biological, physiological, relaxation, and social/cultural strategies. See Table 9.1 for examples of various strategies in each category. The categories are not discrete, as strategies may contain elements from more than one category. For example, humor has social, cognitive/psychological, spiritual, and biological components (Mora-Ripoll, 2010). Techniques such as hypnosis, progressive muscle relaxation, and guided imagery combine biological and psychological elements. Table 9.1: Different strategies for managing stress BiologicalPsychological Relaxation Social/CulturalNutrition ExerciseDiaphragmatic breathingAdequate sleepDecrease sittingMassage therapy Physical therapy Clinical biofeedback AromatherapyCognitive restructuring and reframing Refuting irrational beliefsBehavior modificationGratitude journalCreative problem solvingMindfulness/focusingAnger inoculationHypnosisForgivenessDiaphragmatic breathingGuided imageryMeditationProgressive muscle relaxationAutogenic trainingListening to or creating musicCommunication skills trainingSocial orchestrationExpressive art, dance, or music therapyHumorSpiritualityTime-management/self-managementFinancial managementHealth psychologists and other practitioners of mind–body medicine work with individuals to increase their understanding of stress and the potential consequences of negative stress. They provide information and resources about stress responses and how to increase coping capacity and resilience in responding to stressors. Skills may be taught in individual or group sessions, in person or online, utilizing lectures, guided demonstrations, practice sessions, vid-eos, or reading materials.Breathwork (learning how to change breathing habits by practicing specific techniques) is one of the most frequently recommended tools for managing stress. Breathwork has been practiced for centuries and is sci-entifically documented to profoundly impact physiol-ogy (Weil, 2017). One breathing technique that is very simple and easy to learn is the 4-7-8 method, which of-“Practicing a regular, mindful breathing exercise can be calming and energizing and can even help with stress-related health problems ranging from panic attacks to digestive disorders.” —Andrew Weil, M.D.

Section 9.4Areas of Focus in Health Psychologyfers a quick way to slow down the heartbeat and breathing rate and allow the body to relax (Weil, 2016; Weil, 2017). With this method, you breathe in for four counts, hold the breath for seven, and then exhale for eight. For more breathing exercises, see the following website: https://www.drweil.com/health-wellness/body-mind-spirit/stress-anxiety/breathing-three-exercises/. Improving Pain Management Through AssessmentThe International Association for the Study of Pain (1994) defines pain as an unpleasant sensory and emotional experience, but pain is a highly subjective and personal experience. The meaning given to pain and the context in which it is occurs profoundly affects how it is experienced. For example, it has been found that civilians experiencing pain are more likely to report being in moderate or severe pain and to request medication than their military counterparts experiencing the same types of injuries while in combat (Abraham, Conner, Jones, & O’Connor, 2016). Early pain theories were almost exclusively focused on biologi-cal mechanisms (e.g., pain receptors, peripheral nerves, the brain). However, none of the early theories were able to explain the role of psychological factors in pain perception. Behavioral medicine and health psychology research have made important contributions to understanding how cognitive, emotional, and social factors can impact how pain is expe-rienced (Abraham et al., 2016). One category of pain, chronic pain, is frequently defined as pain that lasts longer than 12 weeks (National Institutes of Health, 2011). Living with chronic pain can be associated with feelings of fear, anxiety, anger, and depression. A person with chronic pain may develop cata-strophic thinking or begin avoiding activities perceived to cause or worsen pain. There are many behavioral changes chronic pain patients can make to improve their emotions and feelings of pain. In addition to recommending healthy lifestyle changes, health psychologists assist patients in learning effective ways to manage difficult emotions associated with pain through psychotherapies such as cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT). Patients with chronic pain may be referred to a psychologist for psychological assessments to determine whether or not a specific invasive medical procedure, such as a spinal cord stimulator, is appropriate. These assessments require integration of biological, psychologi-cal, social, and cultural information obtained from psychological testing, medical information, and patient interviews. Psychological evaluations for individuals with chronic pain typically include assessments of cognitive and emotional stability, level of understanding of the poten-tial risks and benefits of medical procedures, psychological factors that may limit benefits from medical procedures, and the potential for other interventions aimed at decreasing pain and improving function (Cosio, 2017). Another important role for health psychologists in this area is patient education. From the perspective of the transtheoretical approach, patient education is a strategy used to increase motivation for change. Health psychologists are sometimes hired to develop or implement patient pain education programs at hospitals and clinics. Health psychology professionals also use their expertise to help with the negative thoughts, feelings, and behaviors frequently experienced by patients with chronic pain (APA, 2013).

Section 9.4Areas of Focus in Health PsychologyImproving Chronic Illness Through OptimismApplying the biopsychosocial model, health psychology professionals attend to the following aspects of chronic illness:• Biological: Physiological and mental changes; medical care; adherence to medical advice. • Psychological: Emotional outcomes; optimism; interpretations; locus of control and locus of responsibility.• Social: Family relationships; social support outside of the family; support groups and other therapeutic professional services.There are hundreds of diagnoses that can be directly or indirectly associated with chronic illness; however, the following six specific illnesses are among the most frequently treated by Career Spotlight: Dr. David Cosio Dr. David Cosio is a health psychologist who was charged with developing a pain educa-tion program at the Jesse Brown VA Medical Center. According to an article in The Health Psychologist, Dr. David Cosio is a health psychologist who was charged with developing a pain education program at the Jesse Brown VA Medical Center. According to an article in The Health Psychologist, The goals of the program are to share basic principles of pain relief and prevention, provide education about pharmacologic interventions, and introduce services offering nonpharmacological interventions for relief of chronic, noncancer pain. The program consists of an introduction class followed by twelve weekly one-hour classes that are led by guest speak-ers from over 20 different disciplines within the facility. The introduction class covers the ground rules, schedule of classes, and basic principles of the bio–psycho–social approach to pain self-management. A menu of treat-ment modalities is then scheduled on a rotating basis. Past research has shown that this formal patient pain education program improved patient readiness to adopt a self-management approach, improved experience of pain, and decreased depressive symptoms. According to Cosio, patients should at the very least learn what causes their pain and be assisted in developing an accurate understanding of the treatment and therapy options. In addition, health psychologists assist patients in developing multidisciplinary self-manage-ment plans and setting realistic goals for pain improvement. Approaches such as relaxation training, biofeedback, hypnosis, and mindfulness-based interventions assist in modifying overall pain perception, help restore functioning, and improve quality of life (Society for Health Psychology, 2017). Training to lead a program such as this generally requires a PhD in health psychology and potentially post-doctoral training or certification in other specialized areas, such as behavioral medicine.

Section 9.4Areas of Focus in Health Psychologyhealth psychology professionals (working in collaboration with other medical professionals): diabetes, asthma, chronic obstructive pulmonary disease, arthritis, osteoporosis, and HIV/AIDS (Snooks, 2009). Enhancing Optimism in Patients with Chronic Illnesses Numerous researchers have studied the relationship between optimism and health outcomes, such as adaptation to chronic disease. Three main types of optimism of interest to health psychologists are optimistic explanatory style, dispositional optimism, and self-efficacy. The optimistic explanatory style is characteristic of people who attribute negative events to exter-nal, transient factors (e.g., recent bad luck or a series of negative coincidences). People who exhibit a pessimistic explanatory style explain negative experiences in terms of internal and stable factors (e.g., I’ve always been this way and always will be). Substantial research sup-ports the finding that an optimistic explanatory style is positively correlated with health and negatively correlated with illness (Schwarzer & Gutiérrez-Doña, 2000).Dispositional optimism has to do with views about expected future outcomes, reflecting a positive outlook on the future and a stable tendency to believe that one will generally expe-rience positive/desirable outcomes in life. Dispositional optimism is associated with more resiliency and more effective coping with stress and illness, higher motivation to engage in health-promoting behavior change, and enjoyment of better overall health than those with negative generalized outcome expectancies (dispositional pessimism). According to Scheier et al. as cited in Schwarzer and Gutiérrez-Doña (2000), when male heart patients high in dispositional optimism who underwent bypass surgery were compared to their counterparts who were high in dispositional pessimism, the optimists recovered faster and were quicker to stand and walk. After six months, the lives of the optimists had almost normalized in terms of work and exercise, whereas pessimists continued to have significantly more post-operative difficulties and slower rates of rehabilitation. Another important characteristic here is self-efficacy, which refers to an individual’s belief in her or his ability to do what is needed to achieve desired outcomes (Carey & Forsyth, 2018). Bandura (1997) found that perceived self-efficacy predicts the degree of therapeu-tic change in a variety of settings. Patients with high self-efficacy beliefs are better able to control pain associated with chronic illness than those with low self-efficacy. Self-efficacy positively affects physiological factors such as blood pressure and heart rate which are often elevated when coping with life challenges. Cognitive-behavioral interventions of patients with rheumatoid arthritis aimed at enhancing their efficacy beliefs reduced pain and joint inflammation and improved psychosocial functioning (Schwarzer & Gutiérrez-Doña, 2000).Working to develop and enhance any of the three types of optimistic self-beliefs has been found to positively influence rehabilitation in chronic obstructive pulmonary disease patients (Schwarzer & Gutiérrez-Doña, 2000). Interventions to enhance beliefs in one’s cardiac and physical efficacy are associated with better recovery of cardiovascular function in postcoro-nary patients. Having well-established optimistic beliefs which positively guide emotional responses and behavioral choices increases the likelihood of long-lasting therapeutic effects on health and illness. All three forms of optimism are learned behavioral patterns. While acquiring optimistic cognitive strategies can be effective after a person is diagnosed with a

Section 9.4Areas of Focus in Health Psychologychronic illness, an optimal preventative wellness plan will include learning and reinforcing healthy optimism skills before illnesses develop to both deter the development of illness and aid in recovery in the event of the development of a serious illness (Schwarzer & Gutiérrez-Doña, 2000). Improving Cancer Outcomes Through PreventionAs with the other diseases we have discussed, there are specific biological and psychoso-cial risk factors associated with cancer. Biological risks may include inherited and acquired genetic mutations, exposure to toxins, exposure to radiation, or contracting viruses such as the human papillomavirus (HPV). Psychosocial risks include tobacco, alcohol or other drug use; unprotected sexual practices; obesity; overexposure to ultraviolet light; delays in seeking medical advice; and the impact of stress on the immune system. Demographic variables such as age, gender, and ethnicity are associated with risk for different types of cancers (Andersen, 2002).Health psychologists may work with patients with any type of cancer, with the most fre-quent referrals being patients with lymphomas; lung, breast, prostate, or colorectal cancer; and childhood cancers. Health psychologists work with individuals, groups, and communi-ties to employ primary, secondary, and tertiary preventions. Examples of primary prevention methods aimed at reducing the cancer risks include avoiding known risk factors and improv-ing health (e.g., exercise, healthy diets, wearing sunscreen). Secondary prevention includes screening for early detection (both medical and self-screening). Tertiary prevention assists patients in coping with having cancer and with cancer treatments (Snooks, 2009).Psychological and social variables are believed to play crucial roles in the evolution of can-cer in patients. Due to numerous studies documenting a negative relationship between emo-tional and personality risk factors and the onset and progression of cancer, there is a consen-sus among professionals that attention to psychosocial factors should be included in clinical treatment plans. Even so, the precise mechanisms by which personality and emotional factors contribute to cancer are not always well understood. It is often assumed that certain person-ality traits and negative emotionality are associated with increased stress responses, which in turn increase susceptibility to a number of illnesses, including cancer. In this section, we will present examples of research that is of interest to health psychologists and behavioral medicine professionals. Brief summaries of two studies are presented below. After reading each study, read the accompanying Test Your Knowledge feature box, where you will take the role of a health psychology professional and answer questions about a relevant scenario. You are encouraged to discuss the studies, scenarios, and associated questions with your instructor and classmates. Study 1: Personality, Emotions, and Coping Styles: Predictive Value for the Evolution of Cancer PatientsCardenal, Cerezo, Martínez, Ortiz-Tallo, and Blanca (2012) compared patients with cancer against control subjects without cancer on measures of the Big Five personality traits and of emotional functioning. Cancer patients were found to have higher levels of neuroticism and lower levels of conscientiousness, agreeableness, and extraversion than the control group

Section 9.4Areas of Focus in Health Psychologyparticipants on the Big Five personality assessment. On measures of emotional functioning, patients with cancer had higher levels of anxiety and some aspects of anger; however, there were no significant group differences in depression levels. Further analyses indicated that higher scores on measures of anger expression, resignation, and self-blame together with a lower conscientiousness score were associated with poorer outcomes at the two-year evalu-ation period for cancer patients. Study 2: Positive Psychology Interventions in Breast Cancer: A Systematic Review Positive psychology is an emerging area of empirical study in both clinical and health psychol-ogy. Casellas-Grau, Font, and Vives (2014) conducted a systematic review of positive psychol-ogy interventions in patients diagnosed with breast cancer. The following five categories of therapies were identified: mindfulness-based approaches, expression of positive emotions, spiritual interventions, hope therapy, and meaning-making interventions. Overall, the inter-ventions were found to promote positive changes in participants with breast cancer, such as enhanced quality of life, well-being, and optimism. The authors concluded “Some studies provided relevant evidence about the clear development of positive aspects from the breast cancer experience. Positive interventions applied to patients and survivors of breast cancer were found to be able to promote positive aspects” (p. 9).TEST YOUR KNOWLEDGE Your patient is Ben, a 61-year-old African-American male with prostate cancer. He is hap-pily married with two teenage children. He lives in a rural community, has been a deacon in his church for over 20 years, and has worked in the same tire factory since age 18. Two of his uncles died from prostate cancer in their 60s. Ben was first treated for prostate can-cer at the age of 52. After radiation therapy, he remained cancer free for six years. Ben does not exercise regularly and his diet is high in fats, carbohydrates, and sugars. Ben believes having excess weight is positive because, “If the cancer gets you, it’ll take longer to eat you up.” Approximately a year ago, Ben’s prostate cancer returned. Ben and his family drive three hours each way twice a week for his treatment, but the radiation and chemotherapy have not been successful and the cancer has metastasized and invaded his bones and lymph nodes. Ben has agreed to a psychological evaluation. You employ a biopsychosocial-spiritual model in your work with Ben and administer several psychological tests.1. Which measures (personality or emotional functioning) are more likely to represent stable characteristics of the individual and, thus, more likely to represent his character prior to obtaining a cancer diagnosis?2. From an intervention perspective, would it matter whether Ben had a long-standing history of anger or anxiety prior to developing cancer or only began to demonstrate anxiety and anger after receiving a cancer diagnosis? Why or why not?3. Why would you employ a biopsychosocial-spiritual model in your work with Ben rather than a simple a biopsychosocial model?

Section 9.5Ethical Issues in Health Psycholog9.5 Ethical Issues in Health Psychology Health psychologists are expected to follow the APA Ethics Code (http://www.apa.org/eth-ics/code/index.aspx; 2010a), as discussed in previous chapters. Ethical challenges you might face in the healthcare field, whether or not you are a licensed psychologist, often have to do with competence, informed consent, respect for patients’ dignity and confidentiality, and the balance between patient and family rights (Hanson, Kerkhoff, & Bush, 2005).Concerning the issue of competence, the APA Ethics Code provides the following: “Psycholo-gists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experi-ence, consultation, study, or professional experience” (APA, 2010a, para. 25).Ashton and Sullivate (2016) point out that it is important for health professionals to have a network of competent colleagues they can consult regarding issues related to assessment, treatment, research, cultural competence, and ethical issues. If you are ever in doubt about a decision or dealing with something outside your area of expertise, ask an expert in your network who can offer a second point of view.Obtaining truly informed consent and discussing confidentiality can be challenging in medi-cal environments. Patients are frequently referred by a medical practitioner rather than being self-referred. Due to a lack of motivation or interest in psychological services, patients may view mental health referrals as delaying “real” treatment, or even as an insult/invalidation of the seriousness of their medical condition. Thus, psychologists must clarify why they were referred, their role in the treatment process, limits to confidentiality, and patient rights and responsibilities regarding consent. Potential risks and benefits of recommended treatment TEST YOUR KNOWLEDGELynne is a 49-year-old White-American female raised in a rural mid-western community. She practiced family law for twenty years, but after her divorce at the age of 45, she began keeping bees. She now earns a living selling honey and handmade crafts online and at com-munity events. Lynne lives alone and has no children. Overall, she is satisfied with her life and has no desire to remarry, as her 10-year marriage was very stressful and obtaining a divorce was an arduous three-year process. Lynne is approximately 30 pounds over-weight. She has mild arthritis, but she walks for about 15–20 minutes at least twice a week. She eats a lot of healthy foods but also a large number of sweets. In your assessment of Lynne, you find that she is neither overly optimistic nor overly pessimistic. She believes she developed cancer due to genetics, environmental toxins, years in a stressful marriage, and “bad luck.” She is hopeful that she will fully recover but is also making sure her affairs are in order “in case my luck doesn’t change.” Lynne does not smoke and rarely drinks. She attends a small Lutheran church. She believes her choices can make her progress for better or worse. 1. What questions would you ask Lynne to learn more about her optimism?2. How would you describe her locus of control and locus of responsibility? 3. Based on the information available, do you think Lynne is a good candidate for a posi-tive psychology intervention? Why or why not?

Section 9.5Ethical Issues in Health Psychologapproaches should be explained in a manner that ensures the individual understands (Ash-ton & Sullivan, 2016).Ashton and Sullivan (2016) recommend that psychological notes be written as if the patient were reading the chart. Avoid subjective or judgmental comments, write in behavioral terms, and use direct quotes from the patients to show that you care about your patients and are listening to their concerns. Not only is this the ethical thing to do, it is also important because psychological records may be viewed by a number of different medical professionals and, in some cases, by the patients themselves.When providing educational information, professionals at all levels must ensure the accu-racy and relevance of the information being shared, encourage people to ask questions, and provide answers that are as accurate as possible. As in the case with many questions of psy-chological interest, there are often not clear right or wrong answers. Psychological decisions and recommendations, like many life choices, result from a complex integration of research knowledge, professional practice expertise, personal life experiences, and educated guesses that interact with the biopsychosocial realities and characteristics of the patient. Being hon-est and transparent about information, perceptions, and personal world views when assist-ing with decision-making is important to practicing ethically. Per the Ethics Code, psychologists are to refrain from entering into personal relationships that might reasonably be expected to impair their objectivity, competence, or effectiveness in performing their professional duties or risk exploitation or harm to the person with whom the professional relationship exists (APA, 2010a). This principle can present ethical chal-lenges in small communities where psychologists are likely to encounter patients in social settings. Ethical challenges may also arise with clients from specific cultural groups who may prefer to enlist the services of professionals they know in other social or community contexts.Most healthcare professions that recent psychology graduates might enter have their own professional standards and codes of ethics (e.g., social work, health education, hospice, child-care, elder care). Typically, you will be accountable to the ethical and professional codes of any licensed professional supervising you, as well as those associated with the accrediting body of the organization you are working in. Many of the principles communicated in the APA Ethics Code represent values seen in many fields. An overarching concern when dealing with patients, especially those in vulnerable populations, is cultural competence, which is intro-duced in the next section. TEST YOUR KNOWLEDGESome people believe that business and organizations have a responsibility to promote the health and well-being of their employees and the communities in which they do business. Others believe the only responsibility of businesses and organization have is to provide the services they are licensed provide in a legal and ethical manner. What they pay in taxes and insurance premiums is more than adequate to support employee and community health. Beyond that, employees and individuals in the community are responsible for main-taining their own health. Which view aligns most closely with your own position? Explain your reasoning for the position you take.

Section 9.5Ethical Issues in Health PsychologCultural CompetenceHealth psychology professionals are employed in a variety of settings and may work with patients from various backgrounds. Recommendations regarding the need for cultural com-petency have been key aspects of psychological thinking and practice for more than 50 years (DeAngelis, 2015). Cultural competence is the ability to understand, appreciate, and effec-tively interact with people from particular sociocultural groups as defined by psychosocial characteristics and identities including gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status. Identities and sociocultural experiences are complex. Most people have multiple identities and roles which are significant to them. Thus, psychologists may be assigned clients who are similar to them in one or more dimensions and different from them in other dimensions. Unless they have training and expertise in how to work effectively with diverse types of people, they may lack cultural competence even with people who appear to be similar to themselves. One of the most highly cited and utilized models for understanding the development of cul-tural competence was created by Cross, Bazron, Dennis, and Isaacs (1989) and has been employed extensively in mental health, education, and health settings to train professionals to work with diverse clients, patients, and students. As seen in Figure 9.2, the continuum includes six levels ranging from least culturally competent to most culturally competent: cul-tural destructiveness, cultural incapacity, cultural blindness, cultural sensitivity, cultural com-petency, and cultural proficiency. 1. Cultural destructiveness: Practitioners invalidate the cultural realities of others by denying, rejecting, or engaging in actions that suppress the expression of diversity and encourage cultural homogeneity.2. Cultural incapacity: Practitioners acknowledge the reality of various types of diversity but lack the ability to respond effectively to the needs and preferences of diverse groups.3. Cultural blindness: Practitioners hold the philosophy of “I don’t see differences.” “I treat everyone the same.” Thus, they support universal approaches to education, treatments, service provision, etc.4. Cultural sensitivity (also referred to as pre-competence): Practitioners are aware of the importance of understanding cultural diversity and are willing to learn and develop competency skills and knowledge.5. Cultural competency: Practitioners demonstrate acceptance and respect for cultural differences and the ability to work effectively where multiple types of diversity are present.6. Cultural proficiency: Practitioners promote cultural diversity proactively and demon-strate well-developed intercultural relationship skills.

Section 9.5Ethical Issues in Health PsychologFigure 9.2: The cultural competency continuum ሁA cultural competency continuum based on the Mason, Benjamin, and Lewis framework (1996).Source: Mason, J. L., Benjamin, M. P., & Lewis, S. A. (1996). The cultural competence model: Implications for child and family mental health services. In C. A. Heflinger & C. T. Nixon (Eds.), Families and the mental health system for children and adolescents: Policy, services, and research (pp. 165–190). Thousand Oaks, CA: Sage Publications.Individuals do not necessarily have to begin at cultural destructiveness—where one begins and one’s progression depend on previous learning, socialization, openness, and awareness (Mason, Benjamin, & Lewis, 1996). Also, people may be at different levels of proficiency for different types of diversity. For example, one person may be able to demonstrate cultural competency or even proficiency working with patients who are of Vietnamese heritage, but have little experience with patients of Cuban or Algonquin heritage. Another may be highly Cultural destructiveness(Intentionally deny, reject, or outlaw any other culture)Cultural incapacity(Accept the existence of other cultures;unable to work effectively with others)Cultural blindness(Assume that all people are basically alike;advocate a universal approach and services for all people)Cultural sensitivity(Willing to learn about and understand other cultures)Cultural proficiency(Proactive in promoting cultural diversity;seek opportunities to improve cultural relationships)Cultural competency(Able to work effectively in cross-cultural situations;develop standards, policies, practices, and attitudes)

Section 9.6Career Applications in Health Psychologyproficient with individuals who identify as lesbian or gay, but lack competency for working with individuals who identify as transgender. According to cultural competency models, the goal is to work toward competency and pro-ficiency. As no one can be competent or proficient with every type of diversity, there are times when psychologists and others who work in healthcare-related settings need to con-sult with colleagues or refer patients to other practitioners. It is important to be aware of your own levels of cultural competence as well as the cultural competence levels of profes-sionals around you. Key components in the process of developing cultural competence include (1) awareness of one’s own worldviews, (2) development of life-affirming attitudes toward others, (3) knowl-edge of other cultural practices and worldviews, (4) the ability to effectively employ cultur-ally-relevant knowledge and skills, and (5) emotional self-regulation skills.When professionals lack cultural competence, there is a risk of perceiving cultural and family models which are very different from their own as dysfunctional. In addition, when work-ing with families from groups that we do not often associate with outside of a professional context, it is easy to develop a distorted view of the culture. It can be difficult differentiating healthy cultural difference from dysfunction. Thus, developing cultural competence requires a significant amount of knowledge as well as contact with healthy individuals and families from various cultures and of various levels of acculturation. For example, Sara (a health psychology intern) was assigned a Mexican-American family whose youngest son, Miguelito, was referred due to behavioral problems and gastrointestinal distress. When interviewing the family, Sara learned that the parents had taken Miguelito to a curandera who gave him herbs and specific prayers and rituals for the family to perform. She initially assumed this was a mark of dysfunctional thinking, but after talking to a Mexican-American colleague, she learned that it was quite common for Mexican-Americans to consult curanderas alongside licensed medical professionals. In fact, depending on the family circum-stances, degree of acculturation, and openness to psychological interventions, collaborating with the curandera as a complementary treatment professional may have been indicated. When psychologists lack the necessary cultural competence, just like when other forms of professional competence are lacking, at best, even if no harm occurs, the patient may not receive the type of care needed. This may lead to dropping out of therapy. At worst, the thera-pist may impose her or his values upon the patient and engage in what Sue and Sue (2013) refer to as cultural oppression. 9.6 Career Applications in Health PsychologyWe have reviewed a few health-related challenges and diseases with which health psycholo-gists frequently intervene. However, this is certainly not an exhaustive list. Health psycholo-gists are also concerned with the prevention and management of substance use disorders, which represent major public health concerns in the U.S. While more often the focus of clini-cal and counseling psychologists, the biopsychosocial approach to understanding and treat-ing many mental health disorders relies on integrating knowledge from a variety of disci-plines, including health psychology. In addition, any of the medical conditions presented in this chapter may demonstrate comorbidity with any number of mental disorders, such as

Section 9.6Career Applications in Health Psychologyanxiety disorders, depressive disorders, trauma- and stress-related disorders, neurocognitive disorders, eating disorders, and personality disorders. The tools presented in this chapter are relevant to many of these conditions as well.In addition to working with individuals, groups, and communities in ways previously dis-cussed in this chapter, health psychologists may also take on administrative and leadership roles in hospitals, clinics, and other medical facilities (e.g., pain clinics, cancer treatment centers). Their duties may include training professionals from a variety of disciplines other than psychology. They may contribute as interdisciplinary team members and offer impor-tant insights during case conferences. Additionally, health psychologists conduct research in inpatient and outpatient treatment settings to advance knowledge about the evaluation and treatment of medical conditions.The role of psychology has continued to expand in the areas of policy development and in the legislative process. Successful health psychologists also need to have a command of basic business skills. Cosio (2017) teaches health psychology trainees five steps on how to improve their ability to accomplish their work:1. Educate yourself well by doing preliminary research about the topics being presented. 2. Demonstrate command of the research and provide well-constructed reports and other visuals to the stakeholders. 3. Be prepared to address concerns of contemporary healthcare facilities related to customer/patient satisfaction. 4. Highlight past successes and sell the benefits of psychotherapeutic interventions. 5. Display confidence and enthusiasm during delivery. As shown throughout this chapter, health psychology can lead to a variety of interesting and rewarding careers. The following sections outline some of the more common options pursued by people with an interest in health psychology.Community Health Psychology“Community health psychology is concerned with the theory and method of working with communities to combat disease and to promote health” (Campbell & Murray, 2004, p. 187).Community health psychologists work to increase awareness and performance of health-pro-moting behavior in communities identified as being at-risk for specific health problems. For example, health psychologists working with communities with high rates of sickle-cell dis-ease may work with patients on issues such as pain management, adjusting to hospitalization or frequent medical visits, and ways to communicate effectively with healthcare providers. Occupational Health PsychologyOccupational health psychologists study the impact of work environments on employees’ well-being. Health psychologists working with organizations are concerned with employee wellness and organizational health, with the goal of preventing illness and injuries in the work environment. Topics of interest include occupational safety and health hazards, sources of job stress and burnout, health promotion programs, the role of employee assistance pro-grams, and the interface of work and non-work factors in maintaining occupational health

Section 9.6Career Applications in Health Psychology(National Institute for Occupational Safety and Health, 2013). People working in positions related to occupation health psychology may consult with organizational administrators with the goal of improving work environments or creating work environments that workers enjoy and look forward to coming to. Other positions related to occupational health psychology may be found in employee assistance programs (EAPs), in which staff connect employees to behavioral health services or provide individualized or on-site training in how to achieve a healthy work–life balance.Public Health PsychologyAs public health focuses on promoting the health of entire populations, public health psy-chologists focus on health at the population level, in contrast to the individual or community level. A public health psychologist may work for a nonprofit organization, university, or gov-ernmental agency to conduct research on disease and injury prevention and ways to promote healthy lifestyle behaviors on a national or international level. Public health concerns such as controlling disease outbreaks; food and water safety; avoiding leading causes of death such as stroke and diabetes, heart disease, or cancer; and suicide prevention are often addressed by professionals in public health psychology. A closely related field is public health social work, in which social workers may address the same concerns as public health psychology professionals at the individual or community level toward ensuring that communities and the individuals in them are as healthy as pos-sible. Their work may include the implementation of community-wide programs, or helping individuals navigate complex health organizations and administrative bureaucracy to receive needed services (Quah, 2015; Winett, King, & Altman, 1989). Environmental Health Psychology Environmental health psychologists explore the role social and physical environmental con-ditions play in promoting wellness and the development of acute and chronic health chal-lenges. Environments contributing to both positive and negative health outcomes include family environments, peer groups, work, and communities (Taylor, Repetti, & Seeman, 1997). Examples of unhealthy environments are those which undermine the development of healthy social connections, threaten safety, and are abusive, violent, or conflictual. Healthy environ-ments are life-affirming, clean, safe, and provide opportunities for positive interpersonal rela-tionships (Taylor et al., 1997). Environmental psychologists may work as private consultants, providing expertise to public officials, government agencies, and organizational leaders in a variety of industries. In some cases, housing, planning, and environmental agencies, envi-ronmental nonprofit organizations, or architecture firms may employ them directly. Environ-mental health psychologists may also work for schools, prisons, and assisted living facilities (EnvironmentalScience.org, 2018). Pain PsychologistsPain psychologists work with individuals experiencing physical pain, including chronic pain and pain associated with illness and various treatments. They may also work with patients with psychosomatic disorders, where the pain perceived is actually a result of a psychological disorder. Health psychology professionals understand that chronic pain can negatively impact participation in daily activities and cause strain in interpersonal relationships. Depressive

Summaryand anxiety symptoms may accompany chronic pain, and psychology professionals use their expertise to teach emotional self-regulation techniques as well as ways to make adaptive behavioral choices toward improving pain management (APA, 2013). Common work settings for health psychologists specializing in pain management include pain management clinics, hospitals, and private practice.Other Careers Employing Health Psychology KnowledgeA number of professions utilize health psychology information to benefit individuals and com-munities. Examples such as health educators and behavioral interventionists were discussed in previous chapters. Increasingly, job titles such as health coach/counselor or wellness coach are used to describe the roles of individuals working in private practices, clinics, and hospitals who counsel others on making health-promoting behavioral decisions. In addition, weight management centers, smoking cessation programs, and select athletic clubs may employ per-sonnel who utilize health psychology knowledge. While the careers which formally include the title “psychologist” are typically reserved for professionals with doctorate degrees, many health settings employ professionals, assistants, and specialists with bachelor’s or master’s degrees who utilize expertise from the field of health psychology. If any of these career areas interest you, it might be a good idea to meet with a careers services specialist who can assist you in exploring career alternatives in health psychology and related fields. Summary Health psychology examines ways in which biological, psychological, and social factors influ-ence health and illness. Health psychologists use psychological theories, research, and prac-tice-based evidence to promote health, prevent illness, educate the public, improve health-care systems, and impact public health policy. Health psychologists are specially trained to assist patients and their loved ones in coping with the psychological and emotional aspects of health and illness and injury. Many health psychology interventions are aimed at support-ing patients in making lifestyle choices to improve health and to prevent or manage illness. Health psychology is concerned with health promotion and health education on individual, group, and community levels. Many health psychologists use their skills to affect advances in healthcare service delivery and quality of care through training, leadership roles, advocacy, and the dissemination of research.Concept Check1. Negar’s physician referred her to a health psychologist to provide assessment and adjunctive treatment to help manage her migraines. Negar tells the psychologist that she has too much stress in her life. The psychologist informs Negar that the level of stress people experience depends largely ona. the number of commitments they have.b. how they appraise the events in their lives.c. their physical hardiness.d. how predictable stressful events are.2. Which of the following definitions of health is most consistent with the World Health Organization’s biopsychosocial model?a. Health is the absence of illness or injury.

Summaryb. Health is a state of physiological well-being.c. Health is the optimal condition of social, economic, environmental, mental, physical, and spiritual well-being. d. Health is a state of complete resiliency and the ability to effectively manage all stressors.3. When presented with a medical diagnosis such as diabetes, obesity, cancer, or car-diovascular disease, which of the following individuals will be most likely to follow a plan to adopt a healthier lifestyle without the need for others to help keep them motivated?a. Mary, who has an external locus control and an external locus of responsibilityb. Marcus, who has an external locus of control and an internal locus of responsibilityc. Alex, who has an internal locus of control and an internal locus of responsibilityd. Drea, who has an internal locus of control and an external locus of responsibility4. Laura has been diagnosed with cystic fibrosis. To assist her in managing life stress-ors, which can worsen her symptoms, she is referred to Ms. Katrina Underwood, a master’s-level counselor who works in a practice with several social workers and a health psychologist. Ms. Underwood consults with the health psychologist to devel-op an intervention plan for Laura based on the biopsychosocial model. Goals for the plan might include which of the following (select all that apply).a. Adherence to prescribed medical treatmentb. Compliance with nutritional recommendationsc. Counseling/therapy to enhance emotional and social adaptation (e.g., cognitive behavioral therapy, family therapy)d. Relaxation skills traininge. All of the above5. Bill’s friends and family believe that he has a drinking problem. When Bill is con-fronted by his loved ones, he claims that his drinking is not problematic, despite the fact that he has earned two DUIs (driving under the influence) in the last three months, binge drinks to the point of blacking out, and misses work at least twice per month due to being hungover. According to the stages of change model, in which stage is Bill? a. precontemplationb. contemplationc. preparationd. actione. maintenancef. terminationAnswers1. b. The answer can be found in Section 9.4.2. c. The answer can be found in Section 9.1.3. c. The answer can be found in Section 9.3.4. e. The answer can be found in Section 9.4.5. d. The answer can be found in Section 9.3.

SummaryQuestions for Critical Thinking 1. Review the scenario about James and Denae presented at the beginning of the chap-ter. Identify several factors that enhance one’s ability to cope with stress and provide at least one specific behavioral strategy for each factor. 2. Which forms of diversity are you most likely to work with professionally (specific ethnic or cultural groups, sexual diversity, gender differences, age, socioeconomic status, regional, rural/urban, military populations, persons with disabilities, etc.)?3. How much contact do you have with healthy members of those communities or groups? 4. Does your contact include multiple generational levels and variability in educational level, income level, and immigration history (e.g., first generation immigrants, sec-ond generation, third generation, etc.)? 5. What steps are you willing to take to develop cultural competence skills for working with diverse populations?6. Give practical examples of how you can utilize cultural knowledge and understand-ing to make culturally competent distinctions between what is a healthy cultural difference and what is dysfunctional.Key Termsacute stress Temporary overarousals in response to stressors, which may include rapid heartbeat, short-term increases in blood pressure, cold hands or feet, sweaty palms, heart palpitations, or dizziness.behavioral medicine An interdisciplinary specialty which applies knowledge and tech-niques from the psychological and medical sciences to prevention, diagnosis, treatment, and rehabilitation. biomedical model A dualistic view of health that assumes humans are first and foremost biological organisms best under-stood by using principles of anatomy, physi-ology, biochemistry, and physics. biopsychosocial model A pluralistic view of health that assumes health, illness, and injury are multifaceted and include biologi-cal, psychological, environmental, sociocul-tural, and socioeconomic components. biopsychosocial-spiritual model A view of health that assumes biological, psycholog-ical, sociocultural, and spiritual characteris-tics contribute to the current level of func-tioning of individuals who identify religion or spirituality to be of importance to them.chronic pain Pain that lasts longer than 12 weeks.chronic stress Elevated cortisol levels over a prolonged period of time. cultural competence The ability to under-stand, appreciate, and effectively interact with people from particular sociocultural groups as defined by any of a number of psychosocial characteristics and identi-ties including gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status.exergaming The use of video games requiring significant movement and physical exertion.

Summaryhealth A state of total physical, mental, and social well-being and not simply the absence of illness. health psychologists Psychologists who apply psychological theories, research, and scientific methods to the promotion and maintenance of health, the prevention and management of illness and injury, the identification of psychosocial factors that contribute to physical illness and injury, the improvement of the healthcare system, and the formulation of health policy.health psychology A branch of psychology concerned with promoting healthy behav-iors, preventing and treating illness, identi-fying causes of health and illness, improving healthcare systems, influencing health-related policies, and investigating why people stay healthy, why people become ill, and how people deal with both illness and health.locus of control A framework for describ-ing the attributions individuals make about whether internal attributes or external forces have the power to change their circumstances. locus of responsibility A framework for describing the attributions individuals make about whether internal or external factors are responsible for causing their present life outcomes. medical psychology A precursor to health psychology that applied psychological knowledge to the medical profession. It is now a subfield of health psychology.mental health A state of well-being in which every individual can access their own potential, can cope successfully with com-mon life stressors, can work effectively, and is able to make a contribution to his or her community. pain An unpleasant sensory and emotional experience that is highly subjective and dependent on context.psychosomatic medicine A medical sub-field, emerging from psychiatry, that studies ways psychological, social, and behavioral factors interact to influence physiological processes.risk factors Personal, social, or environ-mental characteristics associated with higher rates of specific health behaviors. self-efficacy Belief in one’s ability to do what is needed to achieve desired outcomes.stress The experience of perceived threat to well-being resulting from a series of psycho-physiological responses and adaptations.stressor Any real or imagined experience or stimulus that requires an adaptation response.Professional ResourcesWeb Resources American Psychological Association, “Tips for Acting Boldly to Change Diet and Exer-cise for Kids”: http://www.apa.org/topics/children/healthy-eating-tips.pdf This pamphlet provides tips to assist parents and caregivers in helping their children estab-lish lifelong habits of healthy eating and exercise.Division 38 of the American Psychological Association, The Society of Health Psychology: chttps://societyforhealthpsychology.org

SummaryDivision 38, the Society for Health Psychology, promotes the understanding of health and illness through research, education, and service activities and encourages the integration of biomedical knowledge with psychological best practices. On this site you can find a list of training programs in health psychology (American Psychological Association, 2018). Division 8 of the International Association for Applied Psychology (IAAP), Division of Health Psychology: https://iaapsy.org/divisions/division8/Division 8 Health Psychology aims at connecting health psychologists around the world. Divi-sion 8 maintains a global focus on health and wellness.National Institute for Occupational Safety and Health (NIOSH), “Occupational Health Psychology (OHP)”: https://www.cdc.gov/niosh/topics/ohpThis webpage provides and overview of occupational health psychology.National Institute on Drug Abuse (of the National Institutes of Health), “Commonly Abused Drugs Charts”: https://www.drugabuse.gov/drugs-abuse/commonly-abused-drugs-charts This webpage provides information about commonly used drugs and provides links to infor-mation about treatment options for drug addiction and drug use trends.World Health Organization: http://www.who.int/en/ The World Health Organization is a specialized agency of the United Nations that is concerned with international public health.World Health Organization, mental health homepage: http://www.who.int/mental _health/en/This website provides information about current WHO initiatives, information about mental disorders, and access to the mental health action plan 2013–2020.Recommended ReadingAmerican Psychological Association (APA). (2018). Health psychology promotes wellness. Retrieved from http://www.apa.org/action/science/health/index.aspxThis web article provides an overview of health psychology as a discipline and the role of health psychologists.National Center for Complementary & Alternative Medicine (NCCAM). (2013). Chronic pain and complementary health practices. Retrieved from https://nccih.nih.gov/health/providers/digest/chronic-pain This web article from the NCCIH Clinical Digest provides information about pain conditions and current evidence of complementary health approaches to fibromyalgia, headache, irri-table bowel syndrome, low-back pain, neck pain, osteoarthritis, and rheumatoid arthritis.Seaward, B. L. (2012). Managing stress: Principles and strategies for health and well-being. Burlington, MA: Jones & Bartlett Learning.

SummaryThis book provides tools to identify and manage stress while teaching skills to attain and maintain health and balance.Multimedia Weil, A. (2014, May 23). How to perform the 4-7-8 breathing exercise [Video File]. Retrieved from https://www.youtube.com/watch?v=YRPh_GaiL8sThis video demonstrates Dr. Andrew Weil teaching the 4-7-8 breathing technique.Fun Facts• Although people believe that comfort foods provide them with mood benefits, com-fort foods do not provide comfort beyond that of other foods (or no food; Wagner, Ahlstrom, Redden, Vickers, & Mann, 2014).• People who laugh more are better able to tolerate both physical and emotional pain (Mora-Ripoll, 2010).• Dogs demonstrate behavioral indicators of stress that if recognized early offer opportunities to intervene. However, few pet owners are able to identify subtle stress-related behaviors. While some owners are highly attuned to their pets and are able to help protect the welfare of their dogs, many would benefit from educational efforts to improve their ability to interpret their dog’s behavior (Mariti et al., 2012)• Engaging with music by dancing or attending musical events has been associated with higher subjective well-being than not engaging with music in these forms (Weinberg & Joseph, 2017).

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