Deborah J Wiebe, Lindsey Bloor, Timothy W Smith. The Health Psychology Handbook: Practical Issues for the Behavioral Medicine Specialist. Editor: Lee M Cohen. Sage Publications. 2003.
Over the past 30 years, evidence has continued to accumulate demonstrating that medical conditions both affect and are affected by psychosocial factors. Behavioral habits of daily life, such as physical activity, smoking, and diet, clearly affect the risk of developing the most common sources of morbidity and mortality (e.g., coronary heart disease, cancer, diabetes) as well as the course of such conditions. Other psychosocial factors, such as stressful life circumstances, social support, personality characteristics, and chronic negative emotions, affect the development and course of these same conditions through more direct psychobiological mechanisms. Finally, most acute and chronic medical conditions influence emotional adjustment, personal relationships, work and other aspects of functional activity, and overall quality of life.
One clear implication of the bidirectional associations between psychosocial factors and physical health is that psychosocial interventions might be useful in the prevention and management of medical conditions. This clinical application of basic research in behavioral medicine and health psychology has itself been the focus of an expanding body of research. Although the findings are not uniformly supportive, there is clear evidence that psychotherapy and other approaches to behavior change can be useful additions to routine medical care, both in the reduction of unhealthy risky behavior and in the management of the psychosocial impacts of medical conditions (Smith, Kendall, & Keefe, 2002). In some cases, such interventions are useful as primary or secondary treatments for the underlying medical conditions themselves.
This chapter reviews the conceptual approach that underlies such intervention efforts (i.e., the biopsychosocial model [Engel, 1977]) and provides examples of the wide variety of brief and group interventions used across medical conditions and settings. A comprehensive review is clearly beyond the current scope, but the chapter does describe the nature and use of such interventions in general health care settings and also reviews evidence of their efficacy and effectiveness. The skills and training necessary for the translation of traditional brief psychotherapy and group treatment interventions into the unique culture and context of medical care are also discussed. The chapter begins with a brief history of the developments that have created the opportunity—and even demand—for the expansion of general health care to include interventions traditionally conceptualized as mental health services.
Historical Developments
The growth in the importance of psychosocial interventions for the prevention and management of medical conditions was set into motion by changing patterns of disease over the last half of the 20th century. Until that time, acute medical conditions (e.g., infectious diseases) were the leading cause of death in the United States (National Office of Vital Statistics, 1947). By the end of the 20th century, chronic conditions had come to account for more than 70% of all deaths, primarily due to the effects of coronary heart disease, cancer, and cerebrovascular disease (Centers for Disease Control and Prevention, 1999). Certain behaviors (e.g., smoking, activity levels) contribute to the risk of these diseases, and given advances in medical care, patients suffering from these conditions can expect to live long enough that coping with their many impacts will become an important challenge. Finally, the management of these and other increasingly prevalent chronic conditions typically involves many behavioral processes (e.g., adherence to prescribed regimens, exercise-based rehabilitation, stress management interventions). Hence, patterns of morbidity and mortality have changed over the past century in such a way as to make psycho-social interventions an important component of current health care. The parallel rise in health care expenditures has created additional incentives for effective additions to traditional medical care (Kaplan & Groessl, 2002).
In an influential critique of the prevailing biomedical model as too simplistic and reductionistic to accommodate this increasing role of psychological and social factors in the major sources of morbidity and mortality, Engel (1977) argued that a biopsychosocial alternative is more appropriate. In this view, based in part on the general systems theory of Von Bertalanffy (1968), health and illness are seen as emerging from the reciprocal interplay of hierarchically arranged levels of analysis, ranging from the molecular to the individual to the sociocultural, with several levels in between. From a biopsychosocial perspective, understanding the source of illness and designing optimal approaches to medical care requires this multisystem analysis. In this expanded conceptual model, psychosocial interventions have an obvious place.
Influential predecessors to the current array of psychosocial interventions began to appear early in the development of the fields of behavioral medicine and clinical health psychology. Growing epidemiological evidence of the role of smoking, excess body weight, and physical inactivity in cardiovascular disease and cancer prompted the application of existing behavior change techniques to these health-relevant targets (e.g., Shapiro, Tursky, Stuart, & Shnidman, 1971; Stuart, 1967). Advances in the physiology of stress and its role in the development of several medical disorders (e.g., hypertension) combined with the available operant behavioral change methods to form the basis of early biofeedback treatments for several chronic conditions (e.g., Pickering & Miller, 1977). Early research demonstrating that the preoperative psychological state (e.g., anxiety, coping behaviors) influenced the postoperative course of surgical patients prompted the development of brief, structured psychosocial interventions for this population (Janis, 1958). Similarly, operant concepts and behavior change technology were successfully applied to the conceptualization and treatment of chronic pain (Fordyce, 1976).
| Table 5.1 Outline for the Clinical Application of the Biopsychosocial Model |
| I.
· Illness Factors A. o Pathophysiology B. o Risk factors C. o Prognosis D. o Diagnostic procedures E. o Treatment procedures II. · Patient Factors A. o DSM conditions (Axis I and Axis II) B. o Impact of illness on distress, social and occupational functioning, and quality of life C. o Conceptualization of disease and treatment D. o Personality traits and coping styles E. o Educational and vocational status III. · Social, Family, and Cultural Factors A. o Quality of marital and family relationships B. o Use and efficacy of social support C. o Relationships with the health care team D. o Cultural background IV. · Health Care System Factors A. o Health care setting and culture B. o Insurance coverage and disability benefits for medical condition C. o Geographical, social, psychological, and monetary barriers to accessing services |
| Source: Adapted from Smith and Nicassio (1995). Copyright © 1995 by the American Psychological Association. Adapted with permission. |
Together, these and other brief interventions provided clear evidence of the promise of extending traditional medical care to include psychotherapy and other behavior change approaches. As reviewed in what follows, the subsequent 30 years of research has produced many examples of innovative and valuable extensions of this prior work (Smith, Nealey, & Hamann, 2000).
Clinical Application of the Biopsychosocial Model
To be feasible and effective, any brief psychosocial intervention with medical patients must begin with an assessment based on the biopsychosocial model. The results of such an assessment identify not only important targets for intervention but also important moderating factors and contextual issues. An outline for this assessment is presented in Table 5.1 (Smith & Nicassio, 1995). This outline is not a formal procedural protocol but instead provides a general orientation or viewpoint that guides more specific informal and formal assessment procedures.
The first category involves information about the patient’s specific illness or condition. The pathophysiology, relevant risk factors, natural history and prognosis of the condition, and diagnostic and treatment procedures typically comprising its medical management are essential elements of the patient’s context and may help to prioritize specific intervention targets that could be usefully addressed through psychosocial interventions. Through general experience and specific collaborative discussions with other members of the multidisciplinary health care team, the clinical health psychologist must acquire adequate knowledge of the general condition and its typical management as well as of the patient’s specific case.
Similarly, characteristics of the patient can guide the identification of specific, potential intervention targets (e.g., depression, limitations in functional activity, knowledge of the disease and its medical/surgical management) or can suggest important moderators of the likely impact of the condition (e.g., coping styles, vocational history and status). This information, in turn, guides the selection and implementation of specific interventions.
Although often overlooked in traditional medical assessments, the patient’s social, family, and cultural contexts can also identify potential targets for intervention (e.g., social isolation, serious relationship conflict) or resources to maximize the benefits of other interventions (e.g., social support). The strengths and weaknesses of the patient’s relationships with key members of the health care team and the patient’s skills for managing and improving those relationships (e.g., assertiveness) are also important considerations in selecting targets or methods for intervention. The patient’s cultural/ethnic background is also an important consideration, especially if it is different from that of key members of the health care team given that it can complicate effective communication and collaboration over the long periods of time typically involved in the care of chronic disease.
Finally, the specific health care setting (e.g., inpatient vs. outpatient care, brief vs. prolonged hospitalization) is likely to make some interventions more feasible than others, as are prevailing attitudes toward psychosocial interventions among members of the health care team within the culture of a specific clinic or medical service. Insurance coverage and a variety of potential barriers to psychosocial intervention (e.g., access to safe, adequately supervised exercise facilities) are essential considerations in treatment planning. Only after a thorough consideration of each of these four general categories of the patient’s “biopsychosocial presentation” can appropriate interventions be identified and implemented in a manner most likely to maximize their potential benefits to the patient.
Intervention Options for Psychologists in Health Care Settings
Clinical health psychologists choose interventions from the full range of therapeutic options available to professional psychology, but unique features of the medical setting can challenge the psychologist and shape the form that interventions take. The diversity of medical and psychological problems seen across health care settings, each of which is associated with a complex bundle of biopsychosocial issues, requires the psychologist to be a broadly trained generalist. The time demands of health care settings and the cost containment features of the health care system push the clinician to be increasingly brief, efficient, and accountable. The interdisciplinary nature of care and the psychologist’s place in the medical hierarchy challenge the psychologist to be collaborative and resourceful in the delivery of services. These features have resulted in a strikingly heterogeneous and creative array of treatments. As outlined in Table 5.2, this sometimes daunting set of treatment issues and options can be structured by considering the level and mode of treatment in the context of one’s goals for intervening.
Goals of Intervention
Psychologists working in health care settings intervene to improve patients’ health and well-being across three broad and interrelated domains: (a) reducing the risk of developing disease among healthy individuals, (b) improving disease outcomes among those with developed illnesses, and (c) enhancing the quality of life and emotional health of those experiencing illness. Given compelling evidence that behavioral and psychosocial processes are integral to the development and course of many physical conditions, psychologists may intervene to reduce the incidence or progression of major illnesses. However, because illness can create profound psychosocial challenges, the goals of clinical health psychologists extend beyond attempts to improve physical health to maximize the daily functioning of patients and their families.
| Table 5.2 Intervention Options in General Health Care Settings |
| I.
· Reasons for Intervention A. o Risk reduction B. o Disease outcomes C. o Maximizing functioning/quality of life II. · Levels of Intervention A. o Individual B. o Couples/Family C. o Group D. o Health care team III. · Modes of Intervention A. o Psychoeducation B. o Cognitive behavioral therapies C. o Interpersonal/Social support interventions |
Levels of Intervention
These goals can be met by intervening at a variety of levels. Individual therapy remains a strong option for clinical health psychologists, but interventions involving larger social units are increasingly common. The family unit is an important focus because illnesses can have adverse effects on families, and risk reduction and illness management occur within this broader family context. Family conflict and marital strife appear to be particularly disruptive to managing illness and maintaining quality of life among medical patients (e.g., Schafer, Keith, & Schafer, 2000; Zautra, Burleson, Matt, Roth, & Burrows, 1994) and may even pose a risk for future morbidity and mortality (e.g., Coyne et al., 2001). Hence, interventions that involve families or spouses may be more effective than those that focus solely on the individual (e.g., Anderson, Ho, Brackett, & Laffel, 1999; Epstein, Valoski, Wing, & McCurley, 1990; Keefe et al., 1996).
Group psychotherapy is also fairly common in medical settings. Group psychotherapies tend to be cost- and time-efficient because many educational, behavioral, and interpersonal issues can be addressed readily in a group format (Spira, 1997). Groups have the additional benefits of bestowing a sense of belonging for individuals dealing with the common stress of illness and providing important sources of support, information, and accountability for behavior change (Spira, 1997; Spiegel & Diamond, 2001). Although support groups have the potential to be iatrogenic (e.g., Helgeson, Cohen, Schulz, & Yasko, 2000), there is evidence that well-conducted, structured groups can be as effective as, or more effective than, individual therapy at promoting and maintaining behavior change (e.g., Wing & Jeffery, 1999).
A level that may be somewhat unique to medical settings involves interventions focusing on the health care team. As we witness a gradual shift away from an “acute medical intervention” model toward a “chronic illness management” model, patients are required to assume new responsibilities for day-to-day illness management, and health care professionals are compelled to incorporate behavioral interventions into medical practice (Gonder-Frederick, Cox, & Ritterband, 2002). Health care professionals might need the behavior change expertise of psychologists to do this effectively. Furthermore, because health care providers can be an efficient and powerful source of advice and counseling for patients, interventions to promote physicians’ communication skills and enhance the doctor-patient relationship can have broad effects. Finally, the continuing need for pragmatic, cost-effective interventions may result in the training of nonpsychologists for the delivery of brief psychological interventions.
Modes of Intervention
Given the range of issues and problems likely to be encountered across health care settings, psychologists cannot be wedded to any particular therapeutic orientation. This chapter focuses on three broad modes of intervention that can be used across individual, group, or family formats: psychoeducation, cognitive-behavior therapy (CBT), and interpersonal/social support. Psychoeducation generally provides patients with information (e.g., information about health risks, illness, treatments, or coping skills) to alter their attitudes and behaviors in a direction that will improve adjustment. Psychoeducation can provide patients with a medically accurate understanding of their condition and may be sufficient for some patients to adapt to the complex demands of managing illness.
CBT is pervasive in medical settings. These interventions include a myriad of specific behavioral and cognitive techniques that are often combined in a multicomponent fashion. Multicomponent CBT begins with education but commonly adds in skill-building features such as goal setting, self-monitoring, problem solving, stimulus control, relaxation and stress management, and cognitive restructuring. It is also increasingly common to include interpersonal skill acquisition such as assertion training and developing social support. CBT overlaps with psychoeducation to the extent that both modes teach specific skills (e.g., relaxation training), but CBT is delivered in a more progressive, individualized, and interactive manner to help patients not only recon-ceptualize their health problems and develop new coping skills but also consolidate (e.g., via rehearsal and role-play) and maintain these skills (e.g., relapse prevention).
Given compelling evidence on the importance of social relationships for one’s physical health and psychological well-being, interpersonal/social support interventions are also commonly used in medical settings. Aside from some well-defined interpersonal therapies, however, many of these interventions have not been described or studied systematically (Hogan, Linden, & Najarian, 2001). Some social support interventions focus on providing support during therapy per se. This may occur by direct support provision from the therapist; by simply including family, friends, and/or peers in therapy; or by including therapeutic activities that engage or promote support from important others. Other support interventions focus on developing patients’ social skills, which can then be used to nurture and strengthen their naturally occurring social support networks. Support interventions can occur at any level but most commonly capitalize on the supportive features of group therapy.
Examples of Brief Psychological Interventions in Health Care Settings
This section describes how these three modes of intervention—psychoeducation, CBT, and interpersonal/social support—have been used to achieve the three treatment goals in clinical health psychology, namely reducing risk, improving disease outcomes, and enhancing quality of life. This structure is one of convenience and should not be interpreted as implying independence across domains. For example, health behavior interventions are discussed in the context of risk reduction but may also improve disease outcomes (e.g., smoking cessation to reduce vascular complications among individuals with diabetes [Gonder-Frederick et al., 2002]) and enhance quality of life (e.g., exercise interventions to reduce depression with cancer [Andersen, 2002]). The approach taken for this limited review is to provide general themes from the most well-developed literatures (e.g., interventions tested with randomized clinical trials) as well as salient examples across the range of interventions. This section emphasizes brief interventions but occasionally discusses more intensive therapies if their effects are particularly impressive. Finally, despite clear advances in research on the efficacy of behavioral medicine interventions over the past decade, one should note that the interventions discussed here have often not been adequately tested in the health care settings in which they are likely to be used. Hence, for all of these interventions, there is more evidence of their efficacy in controlled trials than of their effectiveness in the conditions and contexts of their typical clinical use during medical care.
Reducing Risk of Developing Disease
It is well known that modifiable risk factors, such as smoking, inactivity, obesity, and risky sexual behaviors, play a major role in the health of the U.S. population. Behavioral interventions to reduce obesity or stop smoking are supported well enough that they are recommended options in the clinical practice guidelines emanating from federal agencies (e.g., Fiore et al., 1996; National Institutes of Health [NIH], 1997). This external validation of what behavioral scientists have known for years may increase the demands for integrating lifestyle change interventions into general health care. Psychosocial variables, such as personality, stress, negative emotions, and impaired social relationships, are also emerging as important factors in the development of illness. Thus, although they are not fully established, interventions to improve psychosocial risk profiles may become increasingly relevant for risk reduction.
Psychoeducation
Education and self-help information are mainstays of most effective risk reduction interventions. In health care settings, psychoeducation can occur in person or via telephone, print, or computer-generated information delivered to at-risk individuals or groups. Although generally considered necessary for risk reduction, education in isolation has fairly modest and short-term effects (Blumenthal, Sherwood, Gullette, Georgiades, & Tweedy, 2002; Dubbert, 2002; Niaura & Abrams, 2002). There is reason to believe that effectiveness can be improved by including family members in educational efforts (e.g., Morisky, DeMuth, Field-Fass, Green, & Levine, 1985), and by tailoring the information to the patients’ level of readiness to change (Dubbert, 2002). For example, Strecher and colleagues (1994) found that smoking family practice patients reported a doubling of 6-month quit rates when they received individually tailored smoking cessation letters rather than standard cessation letters (but see Curry, McBride, Grottos, Louie, & Wagner, 1995, for differing results).
A promising educational approach to risk reduction involves training physicians and other health care professionals to provide lifestyle change advice and counseling. Health care providers may be particularly persuasive messengers for risk reduction given their frequency of contact with high-risk individuals and the importance of physician advice in motivating interest to change. Controlled clinical trials suggest that physician advice and written or telephone follow-up are effective at increasing physical activity (e.g., Writing Group for the Activity Counseling Trial, 2001) and smoking cessation (e.g., Ockene et al., 2000; Pieterse, Seydel, DeVries, Mudde, & Kok, 2001). There is also evidence that interventions delivered by other health care providers (e.g., nurses, physician assistants) are effective and additive (Burns, Cohen, Gritz, & Kottke, 1994).
An area of emerging interest involves incorporating motivational interviewing into risk reduction advice and counseling. Originally developed to enhance motivation to address addiction, motivational interviewing represents a style of providing personalized behavior change feedback in an empathic, nonconfrontive, and empowering manner (Miller & Rollnick, 1991). Although somewhat mixed, preliminary data suggest that motivational interviewing has the potential to be useful across a range of health behaviors (for reviews, see Dunn, Deroo, & Rivara, 2001; Resnicow et al., 2002). If additional research supports these promising initial data, motivational interviewing may be well suited to medical settings because it is brief and appears to be transportable across behavioral domains and health care professionals.
Cognitive-Behavioral Therapy
Fairly standard group and individual CBT treatment programs are available for a variety of health behaviors. Multicomponent CBT shows substantial improvement over minimal education interventions for improving HIV risk behaviors (Kelly & Kalichman, 2002; NIH, 1997), physical inactivity (Dubbert, 2002), and smoking cessation (Compas, Haaga, Keefe, Leitenberg, & Williams, 1998; Niaura & Abrams, 2002). The importance of such interventions for preventing the development of disease was demonstrated dramatically in the Diabetes Prevention Trial (National Institute of Diabetes, Digestive, and Kidney Disease, 2001). Although the intervention was not brief, this multicenter, randomized clinical trial clearly demonstrated that behaviorally based lifestyle interventions can be as effective as, or more effective than, medications at preventing the development of diabetes among high-risk individuals.
Although impressive, such data must be interpreted and applied cautiously. In most cases, the interventions represent a bundle of educational, behavioral, and cognitive strategies, making it impossible to evaluate which components are most important for reducing risks. At best, this creates an inefficient approach to providing therapy in the time constraints of many health care settings (cf. Coyne & Racioppo, 2000). Second, although multicomponent CBT appears to be quite effective at promoting initial behavior change, there is a serious problem with relapse. More intensive interventions (e.g., more therapy sessions, multicomponent vs. single-component therapy, medication) appear to produce more prolonged changes (e.g., Blumenthal et al., 2002; Naiura & Abrams, 2002; NIH, 1997; Ockene et al., 2000). On the surface, such findings challenge the brief therapy environment of medical care. However, Wadden, Brownell, and Foster (2002) found that monthly 15-minute sessions conducted during patients’ regular medication checks maintained weight loss as effectively as did a more traditional behavioral group therapy program, suggesting that prolonged behavioral interventions can be creatively incorporated into health care settings.
Interpersonal/Social Support Interventions
Risk reduction interventions often include procedures to enhance social support. Although the methodology and resulting data are quite varied, there may be benefits to socially based interventions for risk reduction. For example, obesity treatments that include spouses result in more weight loss for up to 3 months post-treatment (but not beyond) compared with those that do not (Black, Gleser, & Kooyers, 1990). Similarly, Epstein and colleagues’ (1990) family-based behavioral treatment for childhood obesity has produced remarkably sustained reductions in obesity and improvements in physical activity for up to 10 years. Such studies demonstrate the utility of embedding risk reduction into the broader social contexts in which risk behaviors occur.
There also may be benefits to reducing risk behaviors by promoting social support more directly. Wing and Jeffery (1999) found that support enhancement procedures (e.g., recruitment with friends, intragroup activities, provision and receipt of support, intergroup competitions) improved the effectiveness of behavioral group therapy for weight loss. In a very different context, Kelly and colleagues (1993) found that depressed patients with HIV responded to a supportive-expressive group intervention with reductions in depression, maladaptive interpersonal insecurities, and unsafe sex as compared with controls with no treatment.
Improving Disease Outcomes
Psychosocial interventions with medical patients may also be aimed at improving hard indicators of disease outcomes (e.g., mortality, cardiac events, blood glucose levels, immune functioning) by targeting behavioral or psychosocial risk. Because behaviors are integral to the treatment of many medical conditions, psychologists may be called on to improve adherence to medical interventions or to help patients meet the complex self-regulatory and lifestyle demands of chronic illness (e.g., diabetes self-management, home dialysis skills). At a different level, psychobiological processes related to stress, negative emotions, and social relationships also influence disease progression. Thus, psychologists in medical settings may be in a position to alter disease by intervening to reduce stress, minimize negative emotions, or enhance social support.
Psychoeducation
Psychoeducation is a necessary component in the comprehensive treatment of chronic illnesses. Such interventions provide information about the cause, course, and treatment of diseases as well as stress management (e.g., relaxation), coping, and illness management skills. Although not sufficient for all patients, psychoeducation improves adherence to treatment recommendations and, to a lesser extent, improves health outcomes (for a review, see Roter et al., 1998). Such interventions have been reported to yield clinically meaningful improvement in indexes of blood glucose control among patients with type 2 diabetes (i.e., at a magnitude that reduces serious diabetes complications [Norris, Lau, Smith, Schmid, & Engelgau, 2002]) and to decrease fatal and nonfatal myocardial infarction over a 10-year period among those with coronary heart disease (Dusseldorp, van Elderen, Maes, Meulman, & Kraaij, 1999). Dusseldorp and colleagues (1999) specifically found that psychoeducation improved disease outcomes among coronary heart disease patients primarily if it altered the behavioral or psychosocial risk factors hypothesized to mediate intervention effects. Psychoeducation appears equally beneficial across group or individual formats and when delivered by different health care providers (e.g., Linden, Stossel, & Mourice, 1996; Norris et al., 2002; Roter et al., 1998).
These impressive findings are qualified by evidence that it is difficult to maintain positive outcomes over time and that such interventions are more effective with more intensive or prolonged interventions (cf. Norris et al., 2002; Roter et al., 1998). Innovative methods to maximize efficiency without limiting effectiveness are currently being explored. Brief office-based interventions that can readily be incorporated into routine visits are now appearing, sometimes taking advantage of interactive computer technology. For example, Glasgow and colleagues (1997) reported that having the health care team review individualized, computer-generated information regarding patient goals and motivation for dietary behaviors resulted in reduced serum cholesterol levels over a 1-year period among patients with type 2 diabetes.
Cognitive-Behavioral Therapy
Several highly publicized studies have demonstrated that intensive, long-term CBT can improve disease processes. For example, Ornish and colleagues (1990, 1998) found that a multicomponent behavioral intervention for CHD patients (i.e., stress management, group therapy, and intensive changes in diet and exercise) resulted in regression of coronary atherosclerosis and reductions in the recurrence of coronary events compared with usual care. Friedman and colleagues’ (1986) well-known Recurrent Coronary Prevention Project randomized cardiac patients to group CBT consisting of relaxation training, stress management, and cognitive restructuring to reduce coronary-prone behavior. The intervention yielded diminished Type A behavior and a 44% reduction in the recurrence of nonfatal cardiac events compared with usual care.
The intensity of these interventions makes it unlikely they can be used on a wide-scale basis, but their success has spurred attempts to identify briefer interventions to improve disease outcomes. Although single-component stress management interventions (e.g., relaxation) are not broadly effective at altering disease progression (Linden & Chambers, 1994), they do appear to enhance the effectiveness of standard medical rehabilitation programs (Linden et al., 1996). In addition, brief group therapy employing multicomponent, cognitive-behavioral stress management (CBSM) (e.g., six to eight sessions of illness education, cognitive restructuring, coping skills training, relaxation or anxiety management, and/or provision of social support) appears to be quite promising. As examples, group CBSM has been found to (a) enhance blood glucose control at 1-year follow-up among patients with type 2 diabetes (Surwit et al., 2002), (b) reduce 6-year mortality rates among those with malignant melanomas (Fawzy et al., 1993), and (c) promote more positive emotional and immunological functioning among individuals infected with HIV (e.g., Antoni et al., 2000; Ironson et al., 1994). These intriguing data are qualified by notable nonreplications and mixed results in the broader literature. Miller and Cohen (2001) suggested that psychotherapy may have stronger effects when patients are highly distressed and when the disease condition is not overwhelming the psychobiological process. This possibility suggests that psychosocial interventions to improve disease outcomes should occur while the biological system is still malleable among patients who are seriously distressed.
Brief CBT for depression (Beck, Rush, Shaw, & Emery, 1979) is also important for medical populations. Although many patients adapt well to disease, depression is fairly common among primary care patients (Katon & Schulberg, 1992) and is clearly associated with poorer disease progression (e.g., Frasure-Smith, Lesperance, & Talajic, 1995). Brief CBT effectively reduces depression among medical patients (Coyne, Thompson, Klinkman, & Nease, 2002; Schulberg et al., 1996), with some evidence that it also improves medical outcomes. Lustman, Griffith, Kissel, and Clouse (1998), for example, found that 10 weeks of individual CBT for depression among patients with diabetes improved blood glucose control over the subsequent 6 months compared with diabetes education. Nevertheless, there are disturbing nonreplications of the medical effects of CBT for depression. In a recently completed multicenter trial, cardiac patients who met criteria for depression or low social support were randomized to CBT or usual care (National Heart, Lung, and Blood Institute, 2001). The intervention lessened depression and improved social support but did not have an overall effect on subsequent cardiac events.
Interpersonal/Social Support Interventions
Interpersonal therapy for depression (Klerman, Weissman, Rounsaville, & Chevron, 1984) also reduces depression among primary care patients (Schulberg et al., 1996). To the extent that such reductions can alter important biobehavioral or psychobiological processes, interpersonal therapy may eventually prove to be useful for improving the health of medical patients. At a broader level, provision of social support is a common feature of the multicomponent CBSM therapies described earlier and is hypothesized to be vital to the success of CBSM in improving physical health. This possibility, however, has not been carefully evaluated; the effects of support enhancement on disease outcomes have primarily been studied in the context of multicomponent therapies designed to improve psychosocial adjustment. There are, of course, dramatic demonstrations that support interventions can improve disease. Goodkin and colleagues (1999) recently reported that HIV-positive gay men who randomly received 10 weeks of group-based bereavement counseling were buffered against the increase in HIV viral load displayed by the normal care control. Spiegel, Bloom, Kraemer, and Gottheil (1989) found that women with metastatic breast cancer who engaged in 1 year of supportive-expressive group therapy had longer survival times than did those in the control group. Nevertheless, a large randomized clinical trial to replicate this effect recently revealed that supportive-expressive group therapy improved psychosocial adjustment but did not prolong survival (Goodwin et al., 2001). Additional research will be necessary to determine whether and when social support interventions in general, and supportive-expressive group therapy in particular, improve disease outcomes.
Maximizing Functioning and Improving Quality of Life
The adaptive demands of medical illnesses and treatments can be burdensome for patients and their families, exacting high costs in their emotional, social, occupational, and financial well-being. The experience of illness and its treatments may cause pain and disability, alter important social and occupational roles, erode financial and coping resources, and engender hopelessness, fear, and depression. In some cases, improved medical management of illnesses yields comparable declines in patients’ quality of life. In other cases, illnesses cannot be changed, but suffering and disability can be reduced. Thus, psychologists working in health care settings are often called on to improve patients’ emotional well-being (e.g., decrease depression and anxiety), symptom management (e.g., reduce pain or treatment side effects), and more general quality of life (e.g., return to activities of daily living, decreased isolation).
Psychoeducation
Educational interventions are commonly used as a first step toward improving the functioning of patients dealing with chronic or life-threatening illnesses. These brief interventions seek to improve patients’ capacities for coping by enhancing their understanding of the cause, treatment, and course of their diseases as well as of their coping options. Although the literature is difficult to evaluate given heterogeneity in method and quality, there is reason to believe that educational interventions are useful. Psychoeducation groups have been reported to have positive effects on emotional and functional adjustment and/or pain and discomfort among patients with cancer (Bottomley, 1997; Helgeson & Cohen, 1996; Meyer & Mark, 1995), diabetes (Clement, 1995), and coronary heart disease (Linden et al., 1996) as well as potentially many others. At least in the context of cancer, these interventions appear to be more effective among those who are most in need (e.g., highly distressed) and when they are delivered early in the disease process (Helgeson & Cohen, 1996; Kiecolt-Glazer, McGuire, Robles, & Glaser, 2002), suggesting that early screening to identify and then treat vulnerable patients may be useful.
Psychoeducational approaches have also been developed to improve patients’ reactions to stressful medical procedures and to interacting more generally with the health care system. It is well established, for example, that orienting patients to painful and difficult medical procedures (e.g., surgery, chemotherapy) via sensory, procedural, and coping information results in improved recovery (e.g., reduced hospital stays, pain medication, and anxiety [Contrada, Leventhal, & Anderson, 1994]). Educational interventions to improve patients’ interactions with health care professionals have also shown benefits for patient adjustment. Brief interventions to improve physician communication (Rutter, Iconomou, & Quine, 1996) and to help health care professionals empower patients (Anderson et al., 1995; Gonder-Frederick et al., 2002) may increase patient satisfaction and minimize disease-induced functional limitations.
Cognitive-Behavioral Therapy
Medical patients often experience painful or debilitating symptoms associated with medical treatments and illness. Behavioral and cognitive techniques have been used with success to improve symptom management, often more effectively than education alone. For example, techniques such as relaxation, biofeedback, guided imagery, and hypnosis appear to be useful for reducing pain and nausea associated with cancer treatments (Compas et al., 1998). Specific behavioral techniques, such as relaxation, CBT, and some forms of biofeedback, have been deemed to be efficacious for treating migraine and tension headache pain (Holroyd, 2002), and multicomponent CBT (i.e., relaxation, cognitive restructuring, coping skills training, and goal setting) appear to be effective at improving pain, physical activity, and psychological distress among patients with arthritis (for reviews, see Compas et al., 1998; Keefe et al., 2002).
In contrast to their qualified success at improving disease outcomes, CBT for depression and the multicomponent CBSM group therapies described earlier consistently improve patients’ psychosocial well-being. CBT is effective at treating major depression among patients who seek treatment in primary care, regardless of whether or not there is a concomitant presenting medical condition (Schulberg et al., 1996). Similarly, CBSM appears to enhance emotional functioning, coping abilities, functional abilities, and/or quality of life among patients coping with cancer (Meyer & Mark, 1995) and HIV (e.g., Lutgendorf et al., 1998). We are also beginning to document the psychosocial processes through which CBSM appears to be effective. Lutgendorf and colleagues (1998) found that the effects of CBSM on depression were mediated by altered coping (i.e., increased cognitive coping and social support) in a sample of HIV-positive gay men.
Interpersonal/Social Support Interventions
There is a large enough literature with cancer patients to conclude that professionally run support groups can improve patient quality of life (Compas et al., 1998; Hogan et al., 2001; Bottomley, 1997). In particular, supportive-expressive group therapy (e.g., encouragement of emotional expression, provision and receipt of emotional support, hypnosis for pain management) has been found to improve mood and pain reports among those with metastatic breast cancer (Goodwin et al., 2001; Spiegel, Bloom, & Yalom, 1981), and to be more effective than CBT at reducing mood disturbance among patients with HIV (Kelly et al., 1993). Broadly speaking, however, data on the effectiveness of support groups are fairly inconsistent. This may be because of heterogeneity in how support groups are conducted. For example, there is reason to believe that peer-run support groups can yield negative outcomes. Helgeson and colleagues (2000) developed a group education intervention for cancer patients that was delivered either with or without peer discussion and opportunities for peer support. Relative to controls, the peer support group displayed impaired psychosocial adjustment (e.g., increased negative affect and conflict with family and friends) that was maintained over 6 months.
Some treatments have focused on improving emotional well-being and quality of life by intervening more directly with interpersonal processes. For example, interpersonal therapy for depression enhances recovery from postpartum depression (O’Hara, Stuart, Goman, & Wenzel, 2000), a finding that is particularly important given that postpartum depression causes great individual and family suffering and impairs infant development but often is not treated pharmacologically if women are breast-feeding. Relatedly, interventions that promote spousal caregiving or couples skills (e.g., communication, problem solving, engaging in the caregiving role) have the potential to aid in managing pain and reducing depression (Keefe et al., 1996), and an intervention to promote teamwork between adolescents with diabetes and their mothers lessens family conflict and improves diabetes management (Anderson et al., 1999).
Specialized Training and Skills
Given the complexity of issues that psychologists encounter when working in general health care settings and the array of treatment options that may be used to meet these challenges, how does one learn to translate traditional psychological interventions into the unique context of medical care? Excellent guidelines for the training and skills necessary to function effectively as a clinical health psychologist are available elsewhere (e.g., Belar & Deardorff, 1995; Belar et al., 2001; McDaniel, Belar, Schroeder, Hargrove, & Freeman, 2002) and are described in detail in Table 5.3. The knowledge and skills most unique to the brief therapy environment of health care settings are highlighted here.
A biopsychosocial perspective is fundamental to providing brief psychosocial treatments in medical settings. Although specific clinical assessment and intervention skills are necessary, they are woefully insufficient if delivered without consideration of this broader context. Patients enter the medical system for a variety of reasons, some of which may be only tan-gentially related to their presenting complaints. Assessing patients as part of a biopsychosocial system helps the psychologist to untangle the complex web of issues that often present as medical symptoms. Through this process, the psychologist can more effectively evaluate the need and prioritize the goals for psychological interventions and then implement the most appropriate level and mode of intervention. A biopsychosocial perspective is developed not only through didactic knowledge of the biological, psychological, and sociocultural aspects of health and illness but also through mentored experiences in health care settings serving various medical populations. Such experiential learning can be crucial to solidifying a sophisticated understanding of the dynamic interrelationships among biomedical, psychological, and sociocultural processes in general as well as their specific instantiation with a given patient. Mentored experiences across health care settings also provide invaluable training on how to navigate the numerous challenges of functioning as a clinical health psychologist in the culture of medicine (e.g., communicating with physicians, getting paid for psychological services).
| Table 5.3 Specialized Skills and Training for Providing Brief Interventions in Health Care Settings |
| I.
· In-Depth Knowledge of the Biopsychosocial Model A. o Biological aspects of health and illness B. o Psychological aspects of health and illness 1. § Cognitive aspects of health and illness (e.g., illness models, irrational beliefs) 2. § Affective aspects of health and illness (e.g., bidirectional associations between depression and disease) 3. § Behavioral aspects of health and illness 4. § Developmental aspects of health and illness C. o Sociocultural aspects of health and illness D. o Knowledge of the dynamic interrelationships among A, B, and C II. · Knowledge of Common Conditions and Issues Seen Across Health Care Settings A. o Pathophysiology B. o Risk factors C. o Presenting signs and symptoms D. o Diagnostic and treatment procedures E. o Prognosis F. o Biopsychosocial issues involved in A to E III. · Skills in the Biopsychosocial Assessment of Common Medical Conditions A. o Traditional psychological assessment skills and knowledge of their limitations B. o Skill at detecting mental health problems among medical patients C. o Knowledge of specialized instruments (e.g., relevant personality traits, coping styles, patient conceptualizations of illness, disease-specific adjustment) D. o Knowledge of medical assessment procedures E. o Brief interviewing skills F. o Triage skills IV. · Clinical Skills for Brief Interventions in Health Care A. o Individual, couples, family, and group therapy skills B. o Psychoeducation knowledge and skills 1. § Social learning theory 2. § Motivational interviewing C. o Multicomponent cognitive behavioral therapy 1. § Relaxation training/stress management 2. § Problem solving and coping skills training 3. § Assertiveness training 4. § Cognitive restructuring 5. § Brief motivational interventions 6. § Relapse prevention D. o Supportive therapy skills E. o Interpersonal and family systems theory/therapy F. o Crisis management V. · Interdisciplinary Collaboration Skills A. o Well-developed and positive professional identity as a psychologist B. o Understanding the training, goals, and perspectives of other disciplines C. o Familiarity with the languages of other disciplines D. o Communication and social skills VI. · Awareness of Sociopolitical Issues Across Health Care Settings |
| Source: Adapted from McDaniel, Belar, Schroeder, Hargrove, and Freeman (2002). |
Clinical health psychologists must also develop a detailed understanding of the medical conditions commonly encountered across health care settings and their associated diagnostic and treatment procedures. Such information is integral to the patient’s context and allows psychologists to identify important biobehavioral or psychobiological processes that may become targets for intervention, to anticipate stressful transitions in the disease and treatment process, and to work more collaboratively with the interdisciplinary health care team. Nevertheless, clinical health psychologists must embed this knowledge in the broader biopsychosocial context and not lose sight of their unique perspective on the psychosocial aspects of medical care.
The delivery of effective psychosocial interventions in health care settings requires psychologists to work collaboratively with members of an interdisciplinary health care team—who themselves have unique and sometimes opposing perspectives on patient care—in the context of a health care system that might not fully appreciate the systemic approach. Although good social skills and knowledge of the training and perspectives of other professions are important, the development of a solid professional identity as a psychologist may be most crucial to accomplishing this difficult task (cf. McDaniel et al., 2002).
In this context, one must remember that the specialized skills of the clinical health psychologist emerge out of general core training in the broader discipline of psychology and its traditional applications to mental health. Mental health problems are common in health care settings, and clinical health psychologists who have not developed this broader expertise may encounter patient problems that they are unequipped to handle (cf. Smith, in press). Patients with diabetes who have comorbid eating disorders require more than illness management interventions, and serious pathology among family members can completely undermine the best that psychotherapy has to offer if it is not recognized or addressed. Developing this broad expertise in traditional areas of clinical psychology can be difficult due to competing demands and the daunting challenges of learning a rapidly expanding literature and developing skills at the interface of psychology and medicine. The importance of doing so, however, has been recognized in the training guidelines for health psychology (e.g., McDaniel et al., 2002).
Conclusion
Clinical health psychologists have made remarkable strides in integrating a biopsychosocial perspective into medical care and in developing novel approaches to meet the unique challenges of health care settings. As reviewed in this chapter, brief and group psychotherapies hold considerable promise in this endeavor. Although the emerging literature evaluating these interventions is favorable, there are nagging inconsistencies with few examples of programmatic support for specific interventions and few tests of their effectiveness in the medical contexts where they are typically used. In this climate of hope and caution, the biopsychosocial model provides an invaluable framework. This model does not provide a prescriptive blueprint for working with medical patients. Rather, its strength lies in its flexibility to be useful across patients and health care settings, its ability to accommodate rapidly changing medical technology and treatments, and the often necessarily novel and creative clinical interventions that emerge from its application.