Health concerns, even those that are not life threatening, profoundly affect people’s emotional, social, sexual, and vocational functioning and cause disruptions in valued life goals and roles. Counseling psychology’s core emphasis on enhancing optimal development across the life span is especially helpful when considering the interaction of disease with normal developmental processes, as well as during the long-term course of many chronic diseases and health concerns. The concept of the healthy personality, rather than the medical model of a person with disease or deficits, provides a much-needed perspective in the ongoing development of health counseling psychology. The influence of the famous 17th-century philosopher Rene Descartes, who believed that the mind and the body were separate entities, has been felt for centuries as Western countries have continued to bifurcate mental and physical health services. Yet it is difficult to talk about mental health issues without addressing issues of physical health. Likewise, chronic illnesses have psychological and psychosocial components. In spite of the interaction between the physical and psychological, both physical and mental health professionals often ignore the connection between these two areas.
The etiology of health problems has been conceptualized using different theoretical models, including the biomedical, psychosocial, and more recently the biopsychosocial models. Many practitioners and scholars view the biomedical model as too closely aligned with a body focus with its emphasis on disease symptoms, medication, and genetics; and the psychosocial model as too closely aligned with a mind focus with its emphasis on mood, behaviors, and relationships. In contrast, the biopsychosocial model attempts to bridge the gap between these two models by eliminating the dichotomy between mind and body that devalues the complexity of factors that contribute to health status.
A Biopsychosocial Model of Health Status
George Engel’s biopsychosocial model was the first to systematically consider the effect of psychological and social factors in conjunction with biological factors in predicting health outcomes. Representing a radical departure from viewing health and chronic disease as due primarily to biomedical factors, this model recognized the effect of psychosocial factors such as stress, coping skills, culture, environment, and context that lead to a more complete understanding of both body and mind. More recently, Mary Ann Hoffman and Jeanine Driscoll extended this model by conceptualizing health status as ranging on a continuum from illness to wellness. Unlike Engel’s model, which conceptualizes health as the presence or absence of disease or illness, this concentric model recognizes the reciprocal nature of biopsychosocial factors and views health status, or wellness, as not wholly defined as being free of disease or disability. Instead, the focus is on the quality of the individual’s life because individuals may have symptomatic complaints, but may still perceive they have a high quality of life due to coping mechanisms, social support, or institutional supports.
One piece of evidence for the biopsychosocial model is the high rate of comorbidity or co-occurrence of physical and psychological conditions in clients. Physical conditions can lead to psychological outcomes or can covary with these outcomes. The corollary is true in that mental health issues can have physiological ramifications. In other words, mental health acts as both a precursor and an outcome of physical health problems For example, it is well documented that negative emotions can intensify a range of health threats or diseases that may be influenced by the immune system—most notably, cardiovascular disease. Other research has shown that the effects of depression go beyond the negative effect on quality of life. Individuals who are chronically depressed for at least 6 years have nearly a 90% greater risk of developing cancer within the following 4 years. Eating disorders are largely viewed as a problem with psychosocial origins, but they cause significant physical ramifications. Conversely, anxiety and depression are more often found in those with chronic physical illnesses than in those without physical ailments.
Lifestyle factors such as smoking, poor dietary habits, risk taking, and lack of exercise often lead to illnesses and injuries. These illnesses can add strain to an already stressed and busy life and may lead to further illness and the onset of chronic disease. On the other hand, the presence of positive social supports may be as important as the presence of risk factors in maintaining and preventing premature death from disease. Finding positive aspects in response to a negative or traumatic life event can serve a protective function for a person’s health status. Following the diagnosis of a health problem such as cancer or HIV disease, finding benefits in refocusing on life’s priorities, reconnecting with significant others, or making important lifestyle changes has been linked to increased quality of life, more positive emotions, and better health outcomes. These studies show that the mere presence of disease or illness does not necessarily lead to negative outcomes or a poor quality of life. Rather, the interplay between physical health factors and psychological factors is complex and often crucial in determining health status or outcomes.
Counseling and Health Status
Counseling can provide insight into physical health issues by illuminating challenges, risks, strengths, and resources. The economic and the psychosocial costs of disease or poor health are enormous; illness and chronic diseases can lead to costs such as pain, loss of self-image, loss of valued roles, and changes in lifestyle. Direct costs include the tangible aspects of disease such as medical expenditures and loss of income and time. Indirect costs, those costs that are difficult to assess, include reduced productivity in work and home roles, reduced social and community interactions, strain for significant others who provide care, and strain on community resources. The interaction of physical and psychological factors is apparent from a recent national health initiative, Healthy People 2010, that identified 10 areas of major health concerns. These concerns include physical and psychological risk factors of physical activity, overweight and obesity, tobacco use, substance abuse, sexual behavior, mental health, injury and violence, environmental quality, immunization, and access to health care. Though mental health is considered a category in itself, each of the other health issues has either psychosocial contributors or consequences, which has implications for counseling.
Counselors routinely assist clients with reducing or eliminating harmful behaviors such as smoking or substance use, in identifying barriers to change, and in determining strategies to achieve more healthy lifestyles, such as using behavior modification to change eating or exercise habits. For example, increased physical activity has been shown to be beneficial for health outcomes and also can significantly reduce depressive symptoms. Psychological factors such as chronic and acute stress, negative emotions, social support availability, ways of dealing with conflict, coping style (including playfulness), and hostility can affect health and immune functioning and resiliency. Negative emotions that arise from stress can lead to inflammatory responses that pose multiple health-related problems such as arthritis and other autoimmune disease, cardiovascular disease, and some cancers. This has been referred to as distress-related immune dysregulation and likely poses a core mechanism that underlies many health risks. Psychological interventions may be effective in alleviating distress-related immune dysregulation.
When working with individuals, it is also important to consider the multiple levels of influence on health and health behaviors. Some scholars suggest the importance of looking at micro-level variables like biology, physiology, genetics, and behavior; meso-level variables like family structure, social support, and work obligations; and macro-level variables like physical accommodations, societal factors, access to care, interventions, and social policy. This multi-layered ecological approach complements a biopsychosocial model of health and wellness.
A holistic health integration of body and mind that incorporates multiple levels of influence appears to be most beneficial when working with distressed individuals. Recognizing that health disparities are pronounced along lines of gender, race and ethnicity, income, education level, disability status, geographical location, and sexual orientation, counselors can advocate for the consideration of and attention to these cultural factors in the overall treatment of physical and mental health. In moving toward a greater integration of physical and mental health issues, counselors can help individuals utilize their psychosocial resources to buffer the effects of chronic illness and to help those who are physically well maintain their health status.
- Engel, G. (1977, April 18). The need for a new medical model: A challenge for biomedicine. Science, 196, 129-136.
- Hoffman, M. A., & Driscoll, J. M. (2000). Health promotion and disease prevention: A concentric biopsychosocial model of health status. In S. D. Brown & R. W. Lent (Eds.), Handbook of counseling psychology (3rd ed., pp. 532-567). New York: Wiley.
- Kiecolt-Glaser, J. K., McGuire, L., Robles, T., & Glaser, R. (2002). Emotions, morbidity, and mortality: New perspectives from psychoneuroimmunology. Annual Review of Psychology, 53, 83-107.
- Kiecolt-Glaser, J. K., McGuire, L., Robles, T., & Glaser, R. (2002). Psychoneuroimmunology: Psychological influences on immune function and health. Journal of Consulting and Clinical Psychology, 70, 537-547.
- U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. (2005). Healthy people data 2010: Tracking the health of the nation. Available at http://www.cdc.gov/nchs/