Health psychology is a broadly defined area of research and clinical activity. For almost two decades, the field of health psychology has been guided by Matarazzo’s (1980) formulation: “Health psychology is the aggregate of the specific educational, scientific, and professional contributions of the discipline of psychology to the promotion and maintenance of health, the prevention and treatment of illness, and the identification of etiologic and diagnostic correlates of health, illness, and related dysfunction” (p. 815). More recently, commentators have emphasized the contributions of scientific psychology to the search for solutions to problems in the health care domain.
All definitions of health psychology have three common elements: (1) the examination of the relations between behavioral, cognitive, psychophysiological, and social and environmental factors and the establishment, maintenance, and detriment of health; (2) the integration of psychological and biological research findings in the design of empirically based interventions for the prevention and treatment of illness, and (3) the evaluation of physical and psychological status before, during, and after medical and psychological treatment. Health psychologists may therefore engage in a variety of health-related pursuits: research on the psychosocial causes and correlates of health and illness, intervention design, treatment, education, and evaluation of treatment outcome.
The primary goal of assessment in health psychology is to increase the validity of clinical judgments and to facilitate the study of health-related variables. This fundamental goal includes several subordinate assessment goals. First, assessment helps the health psychologist to differentiate the effects of physical disease from psychological reactions to illness. Careful assessment in a clinical context helps to determine when it is advisable to consult with a specialist, such as a medical specialist or a neuropsychologist. Second, careful assessment can aid in the psychological diagnostic process. Accurate diagnosis of psychiatric conditions is particularly difficult in medically ill individuals because physical illnesses can produce symptoms identical to those of some mental disorders (e.g., difficulty concentrating caused by pain may be attributed to depression).
Third, assessment of the characteristics of variables that cause, maintain, or otherwise influence health status and of the relationships among them is necessary to advance our understanding of health-related behaviors, generate good case conceptualizations, and implement effective interventions. Thorough assessment facilitates and guides treatment planning in the design of health psychology programs by initial screening and by identifying important causal variables. Fourth, the identification of variables that will influence the course of treatment aids treatment planning. Fifth, progress or decline (as in degenerative diseases such as muscular dystrophy) is monitored through the identification of individual baseline values and periodic assessment throughout treatment. Finally, the health psychologist may also be involved in evaluation of treatment outcome. For example, a special issue of Clinical Psychology Review (1996, 16, 6) was devoted to outcome studies of psychosocial and pharmacological treatments in behavioral medicine, including eating disorders, smoking cessation, erectile dysfunction, insomnia, headache, and chronic pain.
Targets of Assessment
Patient and environmental (family, health-care system, and sociocultural milieu) factors influence health and illness (Belar, Deardorff, & Kelly, 1987). Therefore, targets of assessment may include responses at the individual, group, or systems level in four distinct response modes: physiological, cognitive, affective, and behavioral. For example, individual assessment of the cognitive responses of a patient with HIV would include individual measures of the patient’s thoughts and attitudes toward HIV (e.g., expectations of survival), treatment (e.g., thoughts regarding the cost of medications), and other people in the environment (e.g., expectations of ostracism). Thorough assessment of the individual would also include measures of behavior (e.g., adherence to medical regimen), physiology (e.g., T-cell counts), interpersonal interactions, and environmental events (e.g., stressful life events). At the group level, attitudes of health-care providers and family members toward people with HIV would also be considered as factors that may influence the patient’s response to the illness. Assessment at the social systems level might include the larger context in which the case is considered, for example, prevailing societal attitudes toward HIV, characteristics of a particular group such as adolescents or women, or the effectiveness of sex education programs.
Many researchers and clinicians organize results of affective, cognitive, and behavioral assessments in the form of a functional analysis, which aids in treatment planning. A functional analysis is the identification of important, modifiable, causal variables and functional relationships among variables.
Conceptual Foundations of Assessment
Assessment methods and goals in health psychology are guided by several assumptions. First, health problems can involve multiple response modes. This means that comprehensive assessment should include measures of behavior, cognition, emotion, and physiology. Second, because each assessment instrument has idiosyncratic sources of variance, the concomitant use of several instruments helps to assure that a greater percentage of variance in the construct is measured without error and allows greater coincidence in interpretation of results. It is important to collect data from multiple sources, such as spouses, nurses, or caregivers, in addition to the patient’s self-report. Third, because many illnesses involve physiological, cognitive, and behavioral responses, it is important to assess responses across response modes and to assess their reciprocal influence. For example, thoughts and beliefs (cognitive response) regarding the anticipated experience of bypass surgery in a cardiac patient may lead to an increase in hypertension (physiological response) and to an avoidance of medical treatment (behavioral response).
Fourth, the dynamic nature of illness mandates that multiple measures of a construct be taken at intervals short enough to capture the sometimes rapid changes characteristic of the illness. For example, surveys of pain and depression conducted weeks or months apart fail to accurately portray the relationship between pain and depression, both of which can change on a daily basis.
Fifth, it is important to select instruments that are valid for their intended use. A common problem is that of criterion contamination, the effect obtained when items on a measure relate to more than one condition. For example, many depression instruments contain items that can be endorsed in relation to pain or depression or both (e.g., fatigue, insomnia). Also, items may not be representative of the individual condition or relevant to the situation.
Assessment in health psychology is also guided by the principle of multicausality. An illness can have multiple causes, and the causes can often be different across persons with the same illness or in the same person at different stages of the illness. For example, fatigue in the early stages of a disease may be due primarily to an affective response to the diagnosis of a devastating illness, whereas fatigue at a later stage of illness may be a direct effect of the physical illness. Depression in the elderly is another striking example. In many cases, chronic physical illness occurs at a developmental stage in which environmental factors, such as multiple losses (e.g., of friends and loved ones, of independence, of productivity and usefulness) are common, which may contribute to initiating, exacerbating, or maintaining depression.
The clinical utility of the assessment method must be weighed against its cost. Does the information obtained from the assessment add sufficient valuable information about the person in question to warrant the cost of its use? Consider the hypothetical case of a medication noncompliant individual with a diagnosis of paranoid schizophrenia. Would the lengthy (and aversive to the patient) administration of a test such as the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) yield sufficient information about the factors that influence medication adherence for this patient to offset the time required to administer, score, and interpret it?
Finally, assessment in health psychology involves judgments derived from the obtained data (e.g., the variables that are affecting a patient’s recovery, the effectiveness of a psychosocial treatment). Clinical judgments can be affected by the norms that are used, by examining time-course plots of data over time, by comparisons of obtained measures with some criterion or goal (e.g., a goal for blood pressure).
Methods of Assessment
Methods of assessment currently in use include questionnaires, self-monitoring, direct behavioral observations, clinician-administered rating scales, and psychophysiological measures. Questionnaires and behavioral observations may be used with individuals or with all members of a family or group. The methods and validity considerations are described below.
A large number of self-report questionnaire measures are used in health-care settings and research on health psychology issues. In a survey of health psychologists, however, Piotrowski and Lubin (1990) found that a small number of instruments were in common use: the Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1967), the Symptom Checklist-90 (SCL-90; Derogatis, 1983), the Millon Behavioral Health Inventory (MBHI: Millon. Green, & Meagher, 1982), the Millon Clinical Multiaxial Inventory (MCMI: Millon, 1982), the Life Experience Survey (LES; Sarason, Johnson, & Siegel, 1978), the Jenkins Activity Survey (JAS; Jenkins, Zyzanski, & Rosenman, 1979), and the Sixteen Personality Factor Questionnaire (16PF; Cattell, Eber, & Tatsuoka, 1970). The most common depression measures included the MMPI-2 and the Beck Depression Inventory (BDI: Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). The most widely used measures for pain, addiction, and anxiety were the McGill Pain Questionnaire (MPQ; Melzack, 1975), the MacAndrew Alcoholism scale of the MMPI (MAC; MacAndrews, 1965), and the State-Trait Anxiety Inventory (STAI; Spielberger et al., 1983), respectively. Many health psychologists also administer neuropsychological tests such as the Wechsler Memory Scale-Revised (WMS-R; Wechsler, 1987) in screening for cognitive impairment in the medically ill.
Health psychologists have sought to identify personality traits that predispose an individual to illness onset, impede treatment efficacy, or predict treatment outcome. The Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher, Dahlstrohm, Graham, Tellegan, & Kaomme, 1989) and the Jenkins Activity Survey (JAS) are the most widely used individual questionnaires purported to measure personality. The MMPI-2 is an empirically derived instrument with four major advantages: (1) it is extensively researched and has well-known strengths and weaknesses, (2) it has well-established psychiatric norms, (3) it has widespread clinical use, and (4) it has a computer administration and scoring systems. Major disadvantages include the length of the instrument and criterion contamination in medical populations. The MMPI-2, for example, will not detect physical illnesses or conditions and therefore cannot determine if a complaint is of organic origin. The JAS is designed to identify predictors of Type A behavior, which is thought to be associated with coronary heart disease.
Psychological distress is frequently associated with medical illness and influences patient response to illness. Commonly used measures that provide an index of psychological distress include the Symptom Checklist-90-Revised (SCL-90-R; Derogatis, 1983), the Brief Symptom Inventory (BSI; Derogatis, 1993), the General Health Questionnaire (GHQ: Goldberg, 1972), and the Psychosocial Adjustment to Illness Scale (PAIS: Derogatis & Derogatis, 1990). Although the SCL-90-R is relatively short, easy to score, and in wide use with the medically ill, the lack of medical norms limits the strength of inferences that can be drawn from this instrument in health psychology settings. The BSI is a 53-item short form of the SCL-90-R. The GHQ and its abbreviated forms, the GHQ-30 and the GHQ-12, are measures of health-related symptoms. Because the shorter forms contain fewer physical symptoms that may be endorsed as a result of medical conditions, they are presumably less subject to criterion contamination and are therefore more accurate measures of distress in the medically ill. The PAIS-SR, a companion self-report measure of the PAIS, has medical norms for the following illnesses: lung cancer, renal failure, burns, hypertension, cardiovascular disease, mixed cancer, and diabetes.
Similarly, an array of questionnaires is available to assess the effect of perceived stress on the onset, course, and outcome of illness. The Life Experience Survey (LES) is a 57-item survey of life events of the past year that requires the respondent to rate the impact of each event. Although it is intuitively appealing to infer that the subjective weighting of stressors on the LES reflects an accurate appraisal of the stress involved, the overall rating of life stressors must be interpreted with caution. Research using scales such as the LES has not indicated that the inclusion of a subjective appraisal increases the predictive validity of the instrument. For a more thorough discussion, the reader is referred to Cohen, Kessler, and Gordon (1995).
There are many self-report instruments for pain assessment. The McGill Pain Questionnaire is the most popular measure of pain. The short form (MPQ-SF) is composed of 15 descriptors, the Present Pain Index, and a visual analog scale (VAS) anchored with the terms “no pain” and “worst possible pain.” The descriptors are extracted from the sensory and affective categories of the MPQ. Visual analog scales are unbroken lines with descriptive anchors at the ends, which the patient marks with a hash mark to indicate level of pain intensity or affect. Numerical scales (1-10) are also frequently used in clinical practice to quantify pain. Visual analog and numerical scales provide quick and convenient information when used in conjunction with other pain assessment instruments.
Substance abuse is of increasing concern in health psychology. The MacAndrew Alcoholism Scale (MAC: MacAndrew, 1965) of the MMPI and MacAndrew Alcoholism Scale-Revised (Mac-R: Butcher et al., 1989) of the MMP1-2 are commonly used to assess addictive states. Results of assessments in medical populations should be interpreted with caution, however, as the MAC has a false positive rate that is unacceptably high when base rates of substance abuse in medical patients are considered. The interested reader should consult Gottesman and Prescott (1989) for further details.
Cognitive capacity screening measures are important in health psychology settings to aid in diagnosis and to identify patients who should be referred for more complete neuropsychological testing. Measures such as the Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh. 1975) are usually clinician-administered rating scales that are useful when the patient’s ability to self-report is impaired. The MMSE is quickly administered but may not be effective in detecting milder forms of dementia.
Quality of life (QOL) is a recent focus of assessment in medical patients. The construct is not well defined, and therefore no universally accepted measure of QOL exists. Practitioners may choose to administer a battery of tests that include measures of disease state, anxiety, depression, daily functioning. and social functioning and aggregate the results for an overall QOL measure or to use questionnaires such as the Quality of Well-Being Scale (Kaplan, Bush, & Barry, 1978) or Pediatric Oncology Quality of Life Scale (Goodwin, Boggs, & Graham-Pole, 1994).
Family interactions may affect the course and treatment of some illnesses and are often assessed in health psychology (Nicassio & Smith, 1997: Ramsey, 1989). The following instruments have been found valid with a variety of populations in health psychology.
The Family Adaptability and Cohesion Evaluation Scales (FACES III: Olson, Portner, & Lavee, 1985) is a 20-item self-report questionnaire that measures a family’s ability to change in response to stressful conditions and the degree to which the family members perceive that they are connected to the family. The FACES III is often administered twice: once to measure the perceived situation and once to determine each individual’s ideal description of the family.
The Family Inventory of Life Events and Changes (FILE; McCubbin, Patterson, & Wilson, 1981) is a 71-item questionnaire that assesses the individual’s report of the cumulative effects of life events of the past year on family functioning. The FILE has nine subscales: Intrafamily Strains, Marital Strains, Pregnancy and Child-bearing Strains, Finance and Business Strains, Work-Family Transitions and Strains, Illness and Family Care Strains, Family Losses, Family Transitions In and Out, and Family Legal Strains.
The Family Inventory of Resources for Management (FIRM; McCubbin, Comeau. & Harkins, 1981) is a 98-item measure designed to identify a family’s coping resources. The FIRM has four subscales that assess esteem and communication, mastery and health, extended family support, and financial well-being.
The Coping Health Inventory for Parents (CHIP; McCubbin et al., 1983) is designed to assess coping strategies of parents of a chronically ill child. The measure is an I\o-item checklist with three subscales; Coping I (Maintaining Family Integration, Cooperation, and an Optimistic Definition of the Situation), Coping II (Maintaining Social Support, Self-Esteem, and Psychologic Stability), and Coping III (Understanding the Medical Situation through Communication with Other Parents and Consultation with Medical Staff).
Behavioral observation and participant monitoring or report can add valuable information on individual and family functioning. In the behavioral observation method, trained observers collect data on discrete behaviors and the antecedents and consequences of those behaviors. For example, the responses of others have been shown to influence the frequency and magnitude of pain behaviors in pain patients. Behavioral observation of familial interactions by external observers would provide information about the situation and pain behaviors without the potential bias inherent in participant reporting. The Living in Family Environments (LIFE; Hops et al., 1988) coding system is an example of a behavioral observation method that allows recording and analysis of familial interactions as they occur. Unfortunately, behavioral observation conducted in situ is most often utilized in research. as the method is not cost efficient for use in therapy. An alternative approach is observation in an analogue situation, such as a clinic setting.
Participant monitoring and behavior rating scales provide data from a perspective other than that of the patient. For example, a spouse or other family member may be asked to record the frequency, magnitude, or duration of a child’s pain or different types of responses to the patient’s pain behaviors. The Spouse Diary (Flor, Kerns, & Turk, 1987) and the Significant Other Response scales from the West Haven-Yale Multidimensional Pain Inventory (WHYMPI; Kerns, Turk, & Rudy. 1985) address this aspect of assessment.
Self-monitoring in the form of daily diaries of symptoms and their antecedents and consequences provides a rich source of data that can be subjected to time series analyses and can capture the dynamic nature of illness. Examples include ambulatory blood pressure monitoring in patients with cardiac conditions, pain diaries, sleep diaries, food diaries in patients with eating disorders, and diaries of gastrointestinal symptoms in patients with irritable bowel syndrome (IBS). Recently, handheld computers have been used to monitor pain, thoughts, emotions, eating behaviors, and smoking. The computer provides a prompt at predetermined times and records responses. Accuracy of self-monitoring will be enhanced if an easily understood rationale is presented to the patient and the recording process is quick and convenient.
Psychophysiological measurements are an important part of the assessment picture for many physical conditions. Essential hypertension, for example, is one of the major foci of health psychology research and clinical activities. Heart rate (used as an indicator of the patient’s overall state or autonomic balance) and blood pressure are critical factors in cardiovascular disease. Heart rate is measured via an event per unit time meter (EPU T) and blood pressure via a sphygmomanometer. Portable devices allow the continuous measurement of blood pressure under the more realistic conditions of everyday life.
Additionally, biological factors such as muscle tension and autonomic arousal can contribute significantly to a patient’s subjective experience of distress. Muscle tension is measured by electromyography (EMG). a procedure in which surface electrodes or thin needles inserted into the muscle tissue record electrical activity of the muscle. Pain management programs often utilize EMG to monitor tension levels as patients learn to relax in the presence of chronic pain. Skin conductance, pulse rate, and skin temperature are used as measures of the autonomic arousal that accompanies a stress response. Because some patients can attain deep muscle relaxation and still evince substantial autonomic arousal, electrodermal response (EDR), a measure of skin conductance, is useful as an adjunct assessment of the extent to which a stress response is reduced. Blood pressure readings are important in studies of hypertension, and electroencephalography (EEG), or measurement of brain waves. is an integral part of work with sleep disorders. Other psychophysiological measures used in health psychology settings include measures of pupil size and eye movements (Andreassi, 1995).
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