Some interventions in health psychology have strong empirical support for their efficacy. Others, however, are relatively new to Western health care and are currently being subjected to scientific scrutiny.
Goals of Treatment
The overall goal of treatment in health psychology is to modify behavioral, cognitive, and environmental variables that affect illness. Treatments may therefore incorporate purely cognitive, behavioral, or physiological approaches to therapy or utilize a combination of them. For example, a cognitive approach might entail changing presleep thoughts to treat insomnia. whereas a behavioral approach might involve altering exercise habits in a patient with essential hypertension or utilizing self-monitoring to increase medication compliance in a diabetic patient.
Many interventions with cognitive and behavioral components are labeled “cognitive-behavioral therapy.” Cognitive-behavioral therapy (CBT), however, is a treatment method that is empirically supported for depression and anxiety, both of which frequently occur in medically ill patients. The CBT method involves “collaborative empiricism.” as the therapist and patient work together to identify the patient’s thoughts regarding the situation (i.e., illness), to question the veracity of those thoughts and beliefs, to jointly develop ways of changing them, and to monitor the effects of the treatment. Cognitive-behavioral therapy with medically ill patients may be implemented in either individual or group format. Also, some therapists may use a CBT approach to address family issues when a member is ill. For example, the therapist might work with the family of a child with leukemia or focus on marital relationships with a cancer patient.
Components of CBT may include relaxation training, cognitive restructuring, education, and social support. Treatment goals of CBT are determined by type of illness and stage of illness. For example, treatment with cancer patients might address the anxiety that accompanies an uncertain prognosis, whereas pain management is a more immediate concern for arthritis patients, and coronary heart disease patients need to learn to make lifestyle changes. Also, in the early stages of illness, education regarding the medical aspects of the illness is important, whereas in the recovery and rehabilitation stages, it is important to aid patients in identification and utilization of coping skills (Spira, 1997).
Cognitive-behavioral therapy, as conceptualized by Aaron T. Beck, has also been applied to the problem of stress reduction- Beck (1993) outlines the basic tenets of a cognitive approach to stress reduction in Principles and Practice of Stress Management (Lehrer & Woolfolk. New York. 1993).
Cognitive-behavioral therapy has been used extensively with chronic pain patients (Gatchel & Turk. 1996). Outcome studies have shown that CBT can be effective in reducing reported pain intensity when compared with social support and standard medical treatment. Relaxation training and biofeedback are emphasized in pain management to help patients discover that they can exert some degree of control over their pain. The goals of therapy are, therefore, to increase patients’ expectations of success in pain management and to develop the skills to cope with present and future difficulties. These objectives are accomplished through the use of education, relaxation and imagery, biofeedback, and cognitive restructuring in relation to setting realistic goals.
Physiological approaches such as biofeedback and relaxation are used in isolation or, more often, in combination with other modalities. There are several standard protocols for relaxation training, including progressive relaxation training (PRT) and its abbreviated variants. Progressive relaxation adherents emphasize the importance of cultivating a detailed awareness of muscle tension by contracting and relaxing individual muscle groups and avoid using any form of hypnotic suggestion or imagery. Training proceeds sequentially in small steps, and skill acquisition may require up to 100 sessions to accomplish. In contrast, the abbreviated forms, such as passive relaxation, are designed to be effective in as few as seven sessions.
Although a substantial body of research attests to the effectiveness of relaxation therapy (RT) in patients with tension headache pain, insomnia, and hypertension, the specific effects of the various forms of RT on different physical conditions are still unclear. This is due to several things: many studies do not describe treatment protocols, comparative outcome studies have been equivocal, and reviewers differ in their conclusions regarding the relative efficacy of RT. The interested reader will find a thorough review of the research on RT in Lehrer and Woolfolk (1993). Overall, relaxation therapy is a helpful addition to treatments designed to reduce muscle tension and autonomic arousal.
Biofeedback provides the results of psychophysiological assessment to the trainee in order to facilitate a physiological change. Illnesses or disorders often treated with biofeedback include asthma, rheumatoid arthritis, temporomandibular disorders, irritable bowel syndrome, insomnia, Raynaud’s disease and phenomenon, hypertension, headache, urinary incontinence, and premenstrual syndrome (Gatchel & Blanchard. 1993). Most commonly, electromyography (EMG) biofeedback is given to assist the trainee in muscle relaxation. For example, chronic pain patients can see their muscle tension levels on a computer screen and watch them decline as they implement relaxation strategies. Theoretically, the patient can find the most effective relaxation technique more quickly with instantaneous knowledge of muscle tension. However, there has been some debate over the comparative efficacy of biofeedback compared with relaxation training.
Thermal biofeedback is another form of biofeedback that is used to treat disorders thought to involve a psychological component. Numerous studies have documented the efficacy of thermal biofeedback in the treatment of vascular headaches such as migraine and in Raynaud’s disease. Raynaud’s is a condition in which peripheral vasospasm occurs, often triggered by cold temperatures. Thermal biofeedback training can reduce the frequency and intensity of vasospastic attacks, but classical conditioning treatment in which the patient is conditioned via warming the hands while the body is exposed to cold temperatures has been found to be equally effective.
As indicated, many interventions, including some relatively new to Western health care, incorporate several treatment modalities simultaneously. Such combinations are found in meditation, hypnosis, autogenic training, and various “alternative” approaches such as tai chi, yoga, and chi gong. There are various forms of meditation, including transcendental meditation (TM), clinically standardized meditation, respiratory one meditation, and mindfulness meditation. Research designed to identify the active components of TM revealed that four properties were necessary to produce a meditative state: a quiet place, a comfortable position, a focal point, and a passive attitude. Subsequently, clinically standardized meditation and respiratory one meditation were developed and are in wide use in health psychology settings. Both involve the subvocal repetition of a word or sound and are examples of concentration meditation. In contrast, mindfulness meditation involves increasing awareness of bodily sensations, thoughts, and emotions. The central concept is that continuous awareness of physical and mental states and concentration on the task at hand constitute the most efficient and therefore least stressful condition.
Hypnosis can be an effective treatment for chronic pain, insomnia, and other stress-responsive conditions. Two basic categories exist: heterohypnosis, in which hypnosuggestions are delivered by another individual, and autohypnosis, or self-hypnosis. The potent action of suggestion may be the active component of hypnosis for medical patients; for the chronic pain patient, it may be suggestions of deep relaxation for stress management or of comfort and well-being and analgesic suggestions, such as transforming the pain sensation into a cold sensation. Perhaps because many factors (relaxation, imagery, hypnotizability, expectations) affect hypnosis, the few controlled, clinical trials conducted to date have produced equivocal results regarding the efficacy of hypnosis as a therapy for pain.
Similarly, autogenic training involves the use of “passive concentration” on physical sensations, mental imagery, and self-hypnotic techniques. Patients repeat statements about muscular relaxation, vascular dilation, cardiac activity, respiratory activity, visceral organ function, and the cooling of the forehead. Training takes about eight weeks and requires that the patient practice daily. Autogenic training has been found to be effective in cases of headache pain and hypertension.
Foci of Research in Health Psychology
In addition to implementing the interventions described above, health psychologists engage in research focused on a broad array of treatment modalities that impact health and are implemented by practitioners in other disciplines. Foci of research include factors that affect adherence to health-related programs (e.g., diet, exercise, medication compliance, smoking cessation). For example, cognitive-behavioral stress management, massage therapy, aerobic exercise, acupuncture, yoga, and tai chi have been investigated for their physiological and psychological effects. The most formally defined of these approaches, cognitive-behavioral stress management, contains a strong behavioral component in addition to a cognitive focus: relaxation/imagery, education, cognitive restructuring, assertiveness training, and social support. It has been used effectively with AIDS patients.
Clinical and Research Settings
Health psychologists design and implement treatments in primary intervention, secondary intervention, and tertiary care settings (Resnick & Rozensky, 1996). Primary prevention can be defined as the prevention of illness in healthy individuals via the institution of behavioral changes to reduce the probability of illness. Weight reduction, smoking cessation, exercise programs, sex education for sexually transmitted diseases, and HIV education are well-known examples of primary prevention efforts. There has also been recent concern over the establishment of healthy work environments.
Secondary prevention involves the identification of a population at risk for developing a health problem and implementation of preventive treatment. The increase of condom use in adolescents, regular participation in prenatal care in welfare mothers, and exercise adherence in menopausal women are recent secondary prevention foci of research and intervention in health psychology.
In tertiary care settings, clinical health psychologists work with other health-care providers to treat existing illness. The overall goal in these situations is to facilitate recovery, if possible, or to prevent decline or relapse. Subordinate goals may include increasing adherence to a medical regimen, developing effective responses to symptoms and stressful situations (i.e., coping strategies), and enhancing quality of life.
To summarize, valid assessment is of fundamental importance in all endeavors in health psychology. Psychologists in health care are now involved in assessment in clinical practice and research. Clinical health psychologists design new interventions in a variety of settings, implement psychological interventions, and evaluate treatment outcome. As the field of health care evolves to utilize new insights in medicine and related fields, the evaluative role of the psychologist in health care must also evolve.
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