Health Psychology

Introduction

Psychologists have been interested in psychological aspects of health and illness for over a century (e.g., Walter Cannon’s 1930s work on stress and Franz Alexander’s work on psychosomatics). In the late 1970s health psychology was formally established as a subdiscipline within psychology in North America and Europe. Despite the early plurality of approaches, it quickly became dominated by the positivist orientation of mainstream psychology and to rely upon a limited range of reductionist theories. In the 1990s a series of publications emerged which began to critique this dominant approach and offer a range of alternative approaches in terms of theories, methods, and practices.

Although drawing upon a range of critical theoretical and methodological ideas, these alternative approaches are united by desire to develop a psychological understanding of health and illness that is socially, culturally, politically, and historically situated and that contributes to the development of a range of participatory and emancipatory approaches to enhancing health and well-being. This perspective connects with related critical approaches to the study of health and illness within other social science and humanities disciplines. It also connects with critical approaches to health and illness from within various cultures.

Definition

Health psychology has been defined as the contribution of psychology to all areas of physical health, but particularly to health promotion and maintenance, illness treatment and prevention, and the role of psychological factors in health and illness and to improving health-care services and policies (Matarazzo, 1980). It draws upon various ideas across psychology but particularly from mainstream social and clinical psychology. From social psychology it has actively taken up social cognition models with an emphasis on identifying various cognitions that might predict (un)healthy practices. From clinical psychology it has drawn on models of stress management and cognitive/behavior modification. Underlying these reductionist approaches is a metaphor of the human being as a machine whose actions can be explained by identifiable laws and who can be modified by appropriate psychological interventions.

Critical approaches within health psychology challenge these assumptions and adopt a range of other theoretical, methodological, and practice standpoints. These are informed by various strands of critical theory and support a range of research methods and forms of intervention. Along with other critical psychologists, critical health psychologists share a common dissatisfaction with the positivist assumptions of mainstream psychology and its obliviousness to broader social and political issues. They share an interest in various critical ideas (e.g., social constructionism, postmodernism, feminism, Marxism) and pertinent qualitative and participatory methods of research (e.g., discourse analysis, action research, ethnography) for their relevance in understanding health and illness. Further, they share an awareness of the social, political, and cultural dimensions of health and illness (e.g., poverty, racism, sexism, political oppression) and promote an active commitment to reducing human suffering and improving quality of life, especially among those most in need within society.

Keywords

Health; Illness; Bio-psycho-social model; Theory of Planned Behavior; Social cognition; Social constructionism; Phenomenology; Qualitative methods; Social action

History

Although interest in psychological aspects of health and illness can be traced back to ancient history, the area of interest was formally established and named in the 1970s. Psychologists had been drawn into the debate about the nature of health care in the 1960s. This was a time of growing popular challenge to the traditional biomedical dominance of health care and a search for alternative approaches (e.g., Engel, 1977). Other social sciences had established an interest in health issues at that time (e.g., medical anthropology, medical sociology, health economics), and psychology’s growing interest can be considered part of this zeitgeist.

From the outset health psychology adopted a conservative orientation in terms of theory, research methods, and practice. The 1970s were typified by attempts by many western governments to reduce public expenditure, especially in health care. These fiscal moves were accompanied by a victim-blaming ideology, arguing that many health concerns were the result of injudicious behavior choices by individuals. Thus the focus of intervention should be on those individuals who needed to be convinced somehow of their wrongs and “educated” to make suitable behavioral changes. This was effectively a modern version of a moral crusade, aimed at creating a healthier society by convincing people of their wrongdoings and educating them to undertake better health practices. At its commencement, health psychology simply adopted this ideological perspective as unproblematic and readily appropriated the positivist, reductionist, and individualist approaches then dominant in psychology, alongside extant biomedical assumptions about disease, illness, and treatment, to the application of psychology to health. Thus, mainstream health psychology was established effectively as a servant to the dominant biomedical enterprise (Murray, 2013).

In the 1990s there was growing dissatisfaction with the theories and methods of health psychology (Crossley, 2000; Marks, 1996; Murray & Chamberlain, 1999; Yardley, 1997), and a more critical health psychology began to develop (Murray, 2004). Much of this early critique focused on the inadequacy of quantitative approaches to satisfactorily grasp the experience of health and illness. This critique mirrored the turn to language which was apparent across all of the social sciences at that time. The early social constructionist ideas on qualitative methods and discourse analysis were augmented with ideas from critical social and cultural psychology (Herzlich, 1978) and from critical social theory (e.g., Foucault, 1976). In particular, health and illness were viewed not as the property of socially separated individuals but as phenomena which develop in particular social relationships which are culturally and politically immersed (Radley, 1994). Further, critical health psychology was concerned not with developing new methods of surveillance and control but rather with enhancing the means for human emancipation.

Since that time, we have seen the rise of more critical health psychology research, evidenced in critical presentations at mainstream health psychology conferences and in research publications, largely based on qualitative methodologies, appearing in core health psychology journals. In the late 1990s, the first conference devoted to developing a critical health psychology perspective was held, and subsequently the International Society of Critical Health Psychology (ISCHP) was formed. This organization currently has over 600 members internationally and holds a biennial conference. It deliberately attracts critical scholars from outside the English-speaking world (e.g., Santiago Delefosse, 2002), from other disciplines (Tuhwai Smith, 2012) and various health activists.

Traditional Debates

Models: Mainstream health psychology enthusiastically adopted the biopsychosocial model of illness, originally suggested by Engel (1977), as a foundation for its work. The widespread use of this schematic model essentially masked the fact that health psychology has never effectively managed to theorize connections between the biological and the psychological or the psychological and the social (Spicer & Chamberlain, 1996). The model has been roundly criticized for its limited theoretical assumptions which do little to increase our understanding of the experience of illness or to threaten traditional biomedical dominance in health care (Stam, 2000; Santiago-Delefosse, 2011).

Another consistent focus of health psychology has been on the adoption and refinement of a range of questionably useful social cognitive “models” of health and illness. These bolstered a major agenda for health psychology on modelling and predicting behavior change. There has been a sustained interest in trying to identify the psychological causes of supposed unhealthy practices and the subsequent development of interventions aimed at those psychological factors. Models, such as the Theory of Reasoned Action/Planned Behavior, were used to specify a limited number of psychological variables, certain beliefs, and perceived social norms, which were considered to predict or cause specific intentions, which in turn were held to cause particular behaviors. Much early research in health psychology was concerned with devising measurements to assess these variables and the extent to which they were associated with unhealthy behavior. Interventions were subsequently developed which targeted these psychological variables with the aim of reducing these unhealthy behaviors. When research failed to substantially validate these models, attention was turned to theory (actually model) development by expanding the range of variables incorporated in attempts to extend the fit of the models. Their use has brought substantial critiques, about the reliance on self-report measures and their ability to successfully assess the complexity of health behaviors (e.g., Mielewczyk & Willig, 2007).

Methods: Traditionally health psychology has used a range of quantitative methods, largely self-report questionnaires, and relied very substantially on statistical analyses to validate its findings. This has led mainstream health psychology to be dominated by methodological and statistical empiricism and to be weakly involved with theorizing. Theories are largely adopted as a product rather than being seen as a process, and the connection between theory and method, and the way that these determine knowledge, receives very little attention in mainstream health psychology. Further debate centers on how knowledge is a function of the methods used to determine it and how a focus on the “received view” of science, with its emphasis on standardized measurement and statistical analysis, constrains what can be asked, investigated, and known (see Danziger, 1990). Associated with this is the constructionist debate that knowledge is always provisional and historically, socially, and culturally located, making the empirical quest for generalizable laws inappropriate at best and worthless at worst.

Critical Debates

Epistemology: Perhaps the most fundamental debate is around epistemology and the nature of how we can research and understand human behavior and experience. Challenges to the mainstream positivist approach as an appropriate basis for critical health psychology have been strong and sustained, but there have also been debates about the utility and form of social constructionism as an epistemological framework for psychology. These debates underlie other critical debates in the field. The location of critical health psychology on the margins of the discipline provides it with the opportunity of learning from the theories and methods of neighboring disciplines.

Experience of Health and Illness: Mainstream investigation of illness experience has largely been confined to the mapping and measurement of various “illness cognitions”. After initial research posited a set of illness representation dimensions, these were reified through the development of standardized questionnaires which have been widely used. Such an approach failed to capture the lived experience of illness and how it is socially and culturally shaped. Within critical circles, concern with understanding health and illness experience was reflected in the marked growth of interest in qualitative methods in the 1990s (e.g., Chamberlain, Stephens, & Lyons, 1997; Murray & Chamberlain, 1999; Yardley, 1997). While discursive approaches were preeminent, there has been a growing interest in various phenomenological approaches. There remains the need to shift the focus from innovation in methods to greater theorization of health and illness experience and practice (Chamberlain, 2000).

Health Behaviors and Cognitions: Much of mainstream health psychology has concentrated on identifying the cognitions associated with individualized behaviors, especially negative health behaviors (e.g., smoking, drinking, exercise, diet). Critical health psychologists consider these cognitive approaches to be mechanistic and asocial, and also critique the reification of these health behaviors. Instead, critical health psychologists seek to explore the meanings and complexities of health-related practices and how these are socially and culturally located (e.g., Marks, 1996).

Context: Health and illness are often abstracted from their everyday social and cultural context in the empiricist quest for uniform predictive relationships. In contrast, critical health psychology emphasizes the importance of context and the variability of behavior in context. A sociocultural approach to illness is still relatively underdeveloped, as is an understanding of the role of power in everyday relationships and representations. Critical health psychologists have also become interested in wider social agendas for health, examining the role of groups, communities, institutions, and the media in shaping representations and practices of health and illness.

Methods: The dominant research approach within health psychology has been the positivist use of standardized questionnaires to measure a range of “psychosocial variables”, with research generally designed to explore the relationships between these variables, often using elaborated statistical modelling to examine covariation. The early focus of critical health psychology was around developing alternative, qualitative approaches favoring interviews and focus groups as key methods of data collection. This remains the dominant approach and, although we see the emergence of new methods including visual and ethnographic techniques, there is an urgent need to explore new methods of research. Some critical health psychologists, especially those with a community health psychology orientation, have utilized the potential of participatory action research as a research framework.

Practices: A focus for mainstream health psychology practice has been on the development of individualistic and rationalistic education-type packages, designed by the expert to change individual behaviors. Critical health psychologists work under a very different model of praxis, considering knowledge as provisional and located within social and cultural contexts. They work with individuals, communities, and within broader social movements to promote human flourishing and to challenge unhealthy conditions, while remaining sensitive to issues of power, advantage, and benefit.

International Relevance

Health psychology developed within and is still dominated by the Anglo-Saxon world. Professional societies, journals, and training programs are firmly established in North America and in the UK. The expansion of health psychology into Europe and other regions has largely been modelled on the dominant approaches of the Anglo-Saxon world. The growing political influence of the Global South as well as the impact of globalization and the mass movement of peoples throughout the world have highlighted the cultural limitations of this dominant approach. In addition, major new social and environmental challenges are emerging throughout the world ranging from economic and financial crises to wars and major environmental issues. Critical health psychology has been to the fore in critiquing the limitations of classical individualistic models of health which are popular in the Western world. It continues to deconstruct these models and develop alternative approaches to understanding health and illness which connect with social and cultural changes. It is also aware of how social and political forces shape inequalities in health throughout the world and the need to work with others to expose these inequalities and to develop new social arrangements that can combat such inequalities. Critical health psychologists have begun to explore their potential contribution to promoting health in a variety of settings internationally (e.g., Lubek, Wong, McCourt, Chew, Dy, & Kros, 2002).

Practice Relevance

The application of health psychology in various settings brings to the fore not only practical issues but also ethical and moral issues. The use of psychology historically as a tool of control by the powerful is well documented, and critical health psychologists are keen to develop a range of collaborations in the development of practice. In particular, they are keen to ensure that they work to advance peoples’ well-being rather than colonizing them with psychological “expertise.” Critical health psychology, on the one hand, draws attention to the experience of suffering and the forces that contribute to suffering. On the other hand, it works collaboratively with individuals, groups, and communities to challenge forces of oppression whether they be located in personal relationships or in wider society.

At the clinical level, critical approaches have contributed to enhancing our understanding of the illness experience and in developing innovative clinical interventions, for example, through the use of arts-based methods (e.g., Gray & Sinding, 2002). At the community level there has been considerable research exploring the character and value of community health action (e.g., Campbell & Murray, 2004; Stephens, 2008) and in developing participatory approaches which can challenge both local and wider social forces which contribute to ill health. At the societal level critical approaches remain underdeveloped, but they function to draw attention to health inequalities and also to link people into broader social movements to combat various forms of oppression and marginalization.

Future Directions

There is increasing interest in critical approaches within health psychology. This is apparent in the growing number of critical textbooks (e.g., Lyons & Chamberlain, 2013; Marks, Murray, Evans, & Estacio, 2011), journal articles, and conference presentations. As is often the case, many ideas raised initially by critical psychologists have been accepted into the mainstream. We see this particularly with the growing use of qualitative methods, although much of this research is descriptive or remains deductive, testing ideas from classic social cognition models. The need for ongoing critical reflection and critique of theories, methods, and practices continues. Theoretical approaches used in critical research within health psychology have been adopted largely from critical social psychology. Recently, interest in psychoanalytic theory has arisen within critical psychology, but as yet these ideas have not been widely employed within critical health psychology. The dominant methodological approach within critical health psychology has been the use of interviews and focus groups, but there is a need to expand into other methods which have been developed in neighboring disciplines. Although critical health psychology has promoted the use of participatory methods in both research and practice, attention needs to be given to developing and extending the scope and reach of such transformatory methods.

The establishment of the International Society of Critical Health Psychology was a major initiative in linking critical thinkers and practitioners in health psychology worldwide. The growing number attending its conferences is one marker of its success but also of the need to develop further training opportunities for emerging critical scholars. The society promotes research and scholarship in critical approaches to health psychology and provides opportunities for debate and discussion in this field. It offers a forum for scrutinizing, challenging, and questioning what is said and done in the purported pursuit of promoting and improving “health” by health psychologists and others. It operates as a community of scholars (in the widest definition of that term and absolutely not restricted to people with formal affiliations to a university or other academic body), offering each other mutual support in the pursuit of critical approaches to health. In particular, it aims to nurture and help career-young and emerging scholars in the field, and engage with and learn from communities and groups conventionally excluded or underrepresented.

We should not lose sight of the need for critical health psychology to be continuingly critical of its own theories, methods, and practices and the extent to which these shape our field of interest. Such reflexivity should not be confined to researchers but involve others since the experience of health and illness is common to all of us. Finally, we need to be aware of the broader social and political forces that shape the health agenda internationally and the need to form alliances to promote greater health and well-being.