History of Health Psychology

The term health psychology has been acknowledged formally as a subdiscipline of the field of psychology since 1978, with the formation of the American Psychological Association’s Division of Health Psychology (Division 38). Psychology’s interest in general health and illness, however, extends to the very beginning of the discipline itself. Many of the earliest “psychologists,” for example, Wilhelm Wundt, William James, and Hermann von Helmholtz. were trained in medicine; understandably, the study of behavior and physiology were closely linked.

To understand the evolution of health psychology within the context of psychology, one can reach back to ancient Chinese medicine, Hippocrates (550 BCE). Galen (second century CE) and William Harvey (1628) to appreciate the continuing debate over holistic versus mechanistic approaches to health and disease. Over the years, advances in medical technology have perpetuated the Cartesian dualism separating mind and body, affecting the field of psychology as well, for example, the notion of behaviorism. Although the behaviorist viewpoint had internal integrity and scientific foundation in establishing, modifying, and maintaining behavior. it paid scant attention to the reciprocal influences that mind and body exert over one another and that affect health status.

As the discipline of psychology developed its professional as well as scientific identity, psychology’s role in health was primarily concerned with “mental health.” in keeping with trends of medical specialization and the consequent mechanistic approach to physical health, illness, and disorder. The development and success of vaccines and antibiotics in addressing acute infectious diseases further reinforced this perspective, leading to increased separation between the mental and physical domains. During this period, the development of clinical psychology established the professional role of the psychologist in the diagnosis and treatment of mental disorders.

In many ways, psychology’s proliferation of new subdisciplines allowed the field to keep abreast of changes in the political, economic, and social landscape that accompanied the extraordinary technological revolution of the twentieth century. A similar revolution occurred in the study of behavior. Space and medical technology breakthroughs created the instrumentation necessary to observe the inner workings of the human organism, thus enabling us to better comprehend the body’s response to environmental and behavioral challenges. Our understanding of the interplay between the brain and behavior has allowed us to comprehend better how the brain can, over time, directly and indirectly affect health status through metabolic, endocrine, and electrical pathways.

As breakthroughs in medical research in the industrialized world led to effective treatment and prevention strategies to overcome most of the acute infectious diseases, chronic degenerative diseases became the number one source of morbidity and mortality. The single factor, mechanistic approaches so effective in conquering the acute infectious diseases were notably unsuccessful in addressing cardiovascular disease, cancer, stroke, diabetes, and HIV/AIDS, among others. Although technology provided increasingly sophisticated diagnostic and treatment strategies, little success in preventing such diseases resulted from such efforts.

By the late 1960s and early 1970s, it had become evident that a more comprehensive approach to diagnosis, treatment, and prevention would be necessary if we were to make serious progress in controlling the growing epidemic of chronic disease and the dramatically escalating costs associated with “high-tech” medicine. Although psychologists were employed in medical schools beginning in the early years of the twentieth century, it was not until the 1960s and 1970s that significant numbers (over 2.500. or 5% of the APA membership at that time) became employed as medical school faculty. Psychologists became increasingly involved in consulting with various medical subspecialties, for example, pediatrics, geriatrics, surgery, obstetrics and gynecology, rehabilitation, cardiology, and neurology, as physicians became increasingly aware of the broader needs of their patients and the capabilities of their psychologist colleagues to respond to these needs. The psychologist’s research training proved particularly helpful in attempting to explore the multifactorial nature of chronic disease and the necessity to employ more sophisticated multivariable research paradigms (for example. time-series analyses, structural equation modeling) to address issues concerning etiology, diagnosis, treatment, and prevention.

Although there was growing interest in the role of behavioral factors in the development, treatment, and prevention of disease, the science base supporting this interest was very thin; funds to support basic and clinical behavioral research were needed. The growing concerns over the rapidly escalating national health costs associated with the rising prevalence of chronic disease prompted the U.S. Congress to broaden the mandate of the National Institutes of Health to include “the prevention and control” of chronic disease. As the principal source of funding for health research in the United States (over $15 billion in 1999), the NIH exerted enormous influence over the scope, direction, and content of basic, clinical, and public health research in this country and throughout the world.

At the time of the expanded mandate, less than 0.5% of the NIH budget was devoted to behavioral re­search (as of 1999, that figure approximates 10%). However, during this same period, the federal Center for Disease Control proclaimed “lifestyle” to be the principal culprit in the 10 leading causes of death in the United States. “Lifestyle” translated into what people did (for example, what and how much they ate, smoked, drank; how physically active they were; how “connected” they were with others; how they coped with environmental demands; and what their living conditions were like). Based on this analysis, changing health-related behaviors became the major focus of the emergent behavioral research enterprise within the NIH. The establishing of relevant programs, review committees, and advisory panels stimulated the growth of “biobehavioral” research, principally undertaken by psychologists in collaboration with physicians, physiologists, biologists, and epidemiologists. This coincided with the emerging interest within psychology itself to establish a separate “health psychology” entity within the American Psychological Association.

Although there was strong interest in establishing a “health” identity within APA, the general reluctance to establish new divisions during the mid-1970s resulted in the creation of a “health” section within Division 18. Within only 2 years, however, it was obvious that a more visible testament to psychology’s commitment to “health” was necessary to press the federal scientific research establishment to commit much needed resources for research, as well as to respond to the increasing demands for psychological research and services from the health establishment itself.

While the formal recognition of the APA Division of Health Psychology occurred in 1978, several earlier events related to psychology’s role in health and well-being took place that helped shape the scope and direction of the field. “The Role of Psychology in the Delivery of Health Care,” a paper on psychology and health (Schofield, 1969), stimulated the APA’s Board of Scientific Affairs in 1973 to appoint a Task Force on Health Research under the leadership of William Schofield to address the role of psychology on health issues other than “mental health.” This group published its formal report in the American Psychologist, which concluded, “there is probably no specialty field within psychology that cannot contribute to the discovery of behavioral variables crucial to a full understanding of susceptibility to physical illness, adaptation to such illness, and prophylactically motivated behaviors” (APA Task Force on Health Research, 1976, p. 272).

Late one evening in mid-1977, a small group of psychologists met in Bethesda, Maryland, following an NIH study section meeting, to consider how to create a more substantive presence for biobehavioral research concerned with health and illness. The need for a separate APA division exclusively devoted to “health” was agreed upon by all present. Duties were assigned to each person in the room: obtaining the necessary signatures of 10% of the active membership of the APA, establishing a committee to draw up charter and bylaws, contacting influential members of the APA Council of Representatives to enlist their support, developing a dialogue with officers of existing divisions to assure them that the presence of a division of health psychology would not adversely affect their programs. Surprisingly, there was essentially no opposition, and the division became a reality the following year, with an initial membership of 600 psychologists. As testament to the need for such an entity, within 3 years, 2.000 additional psychologists had joined Division 38, a tribute to the dedication of the half-dozen “founder” psychologists drawn together and motivated by a common vision.

The story would not be complete without reference to two related streams of activity that directly affected the momentum of health psychology’s development. During this period (actually beginning in the late 1960s), a growing dissatisfaction with the dominance of the psychoanalytic orientation in “psychosomatic medicine” lead to a “separatist movement” among more behaviorally inclined researchers and clinicians, guided principally by the work of Neal Miller (considered the father of “behavioral medicine”). This group saw “biofeedback” and the application of behavioral principles to problems of health and illness as a more scientifically credible effort to understand and intervene upon mind-body interactions.

In 1977 and 1978, the Yale Conference on Behavioral Medicine and the Academy of Behavioral Medicine Research meeting at the Institute of Medicine. National Academy of Sciences formally defined the multidisciplinary field of “behavioral medicine” as “the interdisciplinary field concerned with the development and integration of behavioral and biomedical science knowledge and techniques and the application of this knowledge and these techniques to prevention, diag­nosis, treatment and rehabilitation” (Schwartz & Weiss, 1978, p. 250).

Advances within the field of behavioral medicine have come primarily from health psychologists working with primary care and specialty physicians, as well as epidemiologists, virologists, physiologists, and molecular biologists, among others. Parenthetically, many have erroneously equated health psychology and behavioral medicine; clearly, behavioral medicine is an “umbrella” under which representatives from many disciplines can collaborate on health-related issues. The scope of behavioral medicine extends, by definition, well beyond the boundaries of any one discipline—it requires participation of two or more disciplines to address the relevant issues at the multiple levels: genetic, physiological, psychosocial, behavioral, environmental— involved in understanding the complexity and interactions of the diagnostic, treatment, and prevention issues of chronic disease.

A second parallel development was initiated by Jo­seph Matarazzo, first president of Division 38, in his conceptualization of “behavioral health,” which he defined as an interdisciplinary field “that stresses individual responsibility in the application of behavioral and biomedical knowledge and techniques to the maintenance of health and the prevention of illness and dysfunction” (1980, p. 807).

In light of the aforementioned Center for Disease Control report targeting lifestyle as the single most important factor in the 10 leading causes of death, psychologists appeared uniquely qualified to make a major contribution to “disease prevention and health promotion.” Over the past 20 years, health psychologists have been conducting research essential to the development of scientifically grounded intervention and prevention strategies—and clinical health psychologists are implementing these strategies.

Both of these developments created internal pressures within health psychology to establish overall professional objectives, education and training standards, research domains, and associated policy and ethical guidelines. The 1983 Arden House Conference on Education and Training in Health Psychology provided critical curricular guidelines to the many departments of psychology that were establishing health psychology programs. It also confirmed the commitment of health psychology to the professional path enunciated by the Boulder “scientist-practitioner” model and provided guidelines for the relationship of health psychology to other subdisciplines of psychology and to other health professions. The Harpers Ferry Conference on Research in Health and Behavior established biobehavioral research priorities in cardiovascular disease, cancer, AIDS, psychoneuroimmunology, smoking, child health, and health policy.

Many eminent psychologists deserve mention for their major contributions to the development of health psychology: Neal Miller (learning theory, biofeedback), Robert Ader (psychoneuroimmunology), Paul Obrist and Bernard Engel (psychophysiology of stress), Neil Schneiderman and Stephen Manuck (behavioral cardiovascular pathophysiology). William Fordyce (pain), David Jenkins and David Glass (Type A behavior), Ju­dith Rodin (environmental modification). Albert Bandura (self-efficacy). Richard Lazarus and Irving Janis (social factors and stress), Margaret Chesney and Karen Matthews (women’s health), Nathan Maccoby and Howard Leventhal (health communication), to name but a few. Other pioneers such as Joseph Matarazzo. Patrick DeLeon, George Stone, Gary Schwartz, and Doyle Gentry, among others, provided critical conceptual and policy guidance during the formative years of health psychology.

Health psychology has been fortunate to have articulate spokespersons who promoted the field through quality science. Dissemination of research findings, however, required avenues to share these findings with the broader scientific community. Several new journals were launched in health psychology and the companion area of behavioral medicine. Health Psychology (the APA Division journal) was followed by Psychology and Health (European Society of Health Psychology) and the Journal of Health Psychology. The Journal of Behavioral Medicine, Annals of Behavioral Medicine, Behavioral Medicine, and the International Journal of Behavioral Medicine all came into being within the same time frame, which permitted substantive outlets for scientific productivity in both areas.

Educational and training opportunities were also developing during this period. Following the Arden House Conference, formal health psychology programs (departments, divisions, centers, laboratories) were established in universities throughout the United States and abroad (an International Directory of Health Psychology Training Programs developed by the APA Office of International Affairs and Division 38 lists programs in 25 countries on all continents). National organizations representing health psychology also have been established throughout the world (in Spain, England, Australia, Germany, Sweden, Japan, Venezuela, to name but a few). An International Association of Health Psychology was established and the first International Congress of Health Psychology was held in Tokyo in 1993. Expanding the mission of psychologists into the prevention and control of chronic disease and the promotion of health at the individual, occupational, and public health levels will provide a wealth of emerging opportunities for our discipline in the new millennium.

References:

1. American Psychological Association Task Force on Health Research. (1976). Contributions of psychology to health research. American Psychologist, 31, 263-274.
2. Matarazzo, J. D. (1980). Behavioral health and behavioral medicine: Frontiers for a new health psychology. American Psychologist, 35, 807-817.
3. Miller, N. E. (1969). Learning of visceral and glandular responses. Science, 163. 434-445.
4. Schofield, W. (1969). The role of psychology in the delivery of health services. American Psychologist, 24, (893­-896).
5. Schwartz, G. E., & Weiss. S. M. (1978). Behavioral medicine revisited: An amended definition. Journal of Behav­ioral Medicine, 1(3), 249-251.
6. Stone, G., Weiss. S. M., Matarazzo. J. D., Miller, N. E., Rodin, J., Belar. C., Follick. M., & Singer, J. (Eds.). (1987). Health psychology: A discipline and a profession. Chicago: University of Chicago Press.
7. Wallston, K. (1997). A history of Division 38 (Health Psychology): Healthy, wealthy and Weiss. In D. Dewsbury (Ed.). Unification through divisions of the American Psychological Association (Vol. 2. pp. 239-267). Washington. DC: APA Press.