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HANDBOOK of PSYCHOLOGY VOLUME 9 HEALTH PSYCHOLOGY Arthur M. Nezu Christine Maguth Nezu Pamela A. Geller Volume Editors Irving B. Weiner Editor-in-Chief John Wiley & Sons, Inc. HANDBOOK of PSYCHOLOGY HANDBOOK of PSYCHOLOGY VOLUME 9 HEALTH PSYCHOLOGY Arthur M. Nezu Christine Maguth Nezu Pamela A. Geller Volume Editors Irving B. Weiner Editor-in-Chief John Wiley & Sons, Inc. This book is printed on acid-free paper. Copyright © 2003 by John Wiley & Sons, Inc., Hoboken, New Jersey. All rights reserved. Published simultaneously in Canada. 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Includes bibliographical references and indexes. Contents: v. 1. History of psychology / edited by Donald K. Freedheim „ v . 2. Research methods in psychology / edited by John A. Schinka, Wayne F. Velicer „ v . 3. Biological psychology / edited by Michela Gallagher, Randy J. Nelson „ v . 4. Experimental psychology / edited by Alice F. Healy, Robert W. Proctor „ v . 5. Personality and social psychology / edited by Theodore Millon, Melvin J. Lerner „ v . 6. Developmental psychology / edited by Richard M. Lerner, M. Ann Easterbrooks, Jayanthi Mistry „ v . 7. Educational psychology / edited by William M. Reynolds, Gloria E. Miller „ v . 8. Clinical psychology / edited by George Stricker, Thomas A. Widiger „ v . 9. Health psychology / edited by Arthur M. Nezu, Christine Maguth Nezu, Pamela A. Geller „ v . 10. Assessment psychology / edited by John R. Graham, Jack A. Naglieri „ v . 11. Forensic psychology / edited by Alan M. Goldstein „ v . 12. Industrial and organizational psychology / edited by Walter C. Borman, Daniel R. Ilgen, Richard J. Klimoski. ISBN 0-471-17669-9 (set) „ ISBN 0-471-38320-1 (cloth : alk. paper : v . 1) „ ISBN 0-471-38513-1 (cloth : alk. paper : v . 2) „ ISBN 0-471-38403-8 (cloth : alk. paper : v . 3) „ ISBN 0-471-39262-6 (cloth : alk. paper : v . 4) „ ISBN 0-471-38404-6 (cloth : alk. paper : v . 5) „ ISBN 0-471-38405-4 (cloth : alk. paper : v . 6) „ ISBN 0-471-38406-2 (cloth : alk. paper : v . 7) „ ISBN 0-471-39263-4 (cloth : alk. paper : v . 8) „ ISBN 0-471-38514-X (cloth : alk. paper : v . 9) „ ISBN 0-471-38407-0 (cloth : alk. paper : v . 10) „ ISBN 0-471-38321-X (cloth : alk. paper : v . 11) „ ISBN 0-471-38408-9 (cloth : alk. paper : v . 12) 1. Psychology. I. Weiner, Irving B. BF121.H1955 2003 150„dc21 2002066380 Printed in the United States of America. 10987654321 ➇ Editorial Board Volume 1 History of Psychology Donald K. Freedheim, PhD Case Western Reserve University Cleveland, Ohio Volume 2 Research Methods in Psychology John A. Schinka, PhD University of South Florida Tampa, Florida Wayne F. Velicer, PhD University of Rhode Island Kingston, Rhode Island Volume 3 Biological Psychology Michela Gallagher, PhD Johns Hopkins University Baltimore, Maryland Randy J. Nelson, PhD Ohio State University Columbus, Ohio Volume 4 Experimental Psychology Alice F. Healy, PhD University of Colorado Boulder, Colorado Robert W. Proctor, PhD Purdue University West Lafayette, Indiana Volume 5 Personality and Social Psychology Theodore Millon, PhD Institute for Advanced Studies in Personology and Psychopathology Coral Gables, Florida Melvin J. Lerner, PhD Florida Atlantic University Boca Raton, Florida Volume 6 Developmental Psychology Richard M. Lerner, PhD M. Ann Easterbrooks, PhD Jayanthi Mistry, PhD Tufts University Medford, Massachusetts Volume 7 Educational Psychology William M. Reynolds, PhD Humboldt State University Arcata, California Gloria E. Miller, PhD University of Denver Denver, Colorado Volume 8 Clinical Psychology George Stricker, PhD Adelphi University Garden City, New York Thomas A. Widiger, PhD University of Kentucky Lexington, Kentucky Volume 9 Health Psychology Arthur M. Nezu, PhD Christine Maguth Nezu, PhD Pamela A. Geller, PhD Drexel University Philadelphia, Pennsylvania Volume 10 Assessment Psychology John R. Graham, PhD Kent State University Kent, Ohio Jack A. Naglieri, PhD George Mason University Fairfax, Virginia Volume 11 Forensic Psychology Alan M. Goldstein, PhD John Jay College of Criminal Justice…CUNY New York, New York Volume 12 Industrial and Organizational Psychology Walter C. Borman, PhD University of South Florida Tampa, Florida Daniel R. Ilgen, PhD Michigan State University East Lansing, Michigan Richard J. Klimoski, PhD George Mason University Fairfax, Virginia v Because of their undaunting spirit, this volume is dedicated to the uniformed and volunteer men and women who unsel“shly offered their help to many during the aftermath of the September 11, 2001, atrocities. No doubt such care will impact greatly on the world•s healing. Handbook of Psychology Preface Psychology at the beginning of the twenty-“rst century has become a highly diverse “eld of scienti“c study and applied technology. Psychologists commonly regard their discipline as the science of behavior, and the American Psychological Association has formally designated 2000 to 2010 as the •Decade of Behavior.ŽThe pursuits of behavioral scientists range from the natural sciences to the social sciences and em- brace a wide variety of objects of investigation. Some psy- chologists have more in common with biologists than with most other psychologists, and some have more in common with sociologists than with most of their psychological col- leagues. Some psychologists are interested primarily in the be- havior of animals, some in the behavior of people, and others in the behavior of organizations. These and other dimensions of difference among psychological scientists are matched by equal if not greater heterogeneity among psychological practi- tioners, who currently apply a vast array of methods in many different settings to achieve highly varied purposes. Psychology has been rich in comprehensive encyclope- dias and in handbooks devoted to speci“c topics in the “eld. However, there has not previously been any single handbook designed to cover the broad scope of psychological science and practice. The present 12-volume Handbook of Psychol- ogy was conceived to occupy this place in the literature. Leading national and international scholars and practitioners have collaborated to produce 297 authoritative and detailed chapters covering all fundamental facets of the discipline, and the Handbook has been organized to capture the breadth and diversity of psychology and to encompass interests and concerns shared by psychologists in all branches of the “eld. Two unifying threads run through the science of behavior. The “rst is a common history rooted in conceptual and em- pirical approaches to understanding the nature of behavior. The specific histories of all specialty areas in psychology trace their origins to the formulations of the classical philoso- phers and the methodology of the early experimentalists, and appreciation for the historical evolution of psychology in all of its variations transcends individual identities as being one kind of psychologist or another. Accordingly, Volume 1 in the Handbook is devoted to the history of psychology as it emerged in many areas of scientific study and applied technology. A second unifying thread in psychology is a commitment to the development and utilization of research methods suitable for collecting and analyzing behavioral data. With attention both to specific procedures and their application in particular settings, Volume 2 addresses research methods in psychology. Volumes 3 through 7 of the Handbook present the sub- stantive content of psychological knowledge in five broad areas of study: biological psychology (Volume 3), experi- mental psychology (Volume 4), personality and social psy- chology (Volume 5), developmental psychology (Volume 6), and educational psychology (Volume 7). Volumes 8 through 12 address the application of psychological knowledge in “ve broad areas of professional practice: clinical psychology (Volume 8), health psychology (Volume 9), assessment psy- chology (Volume 10), forensic psychology (Volume 11), and industrial and organizational psychology (Volume 12). Each of these volumes reviews what is currently known in these areas of study and application and identi“es pertinent sources of information in the literature. Each discusses unresolved is- sues and unanswered questions and proposes future direc- tions in conceptualization, research, and practice. Each of the volumes also re”ects the investment of scienti“c psycholo- gists in practical applications of their “ndings and the atten- tion of applied psychologists to the scienti“c basis of their methods. The Handbook of Psychology was prepared for the pur- pose of educating and informing readers about the present state of psychological knowledge and about anticipated ad- vances in behavioral science research and practice. With this purpose in mind, the individual Handbook volumes address the needs and interests of three groups. First, for graduate stu- dents in behavioral science, the volumes provide advanced instruction in the basic concepts and methods that de“ne the “elds they cover, together with a review of current knowl- edge, core literature, and likely future developments. Second, in addition to serving as graduate textbooks, the volumes offer professional psychologists an opportunity to read and contemplate the views of distinguished colleagues concern- ing the central thrusts of research and leading edges of prac- tice in their respective “elds. Third, for psychologists seeking to become conversant with “elds outside their own specialty ix x Handbook of Psychology Preface and for persons outside of psychology seeking informa- tion about psychological matters, the Handbook volumes serve as a reference source for expanding their knowledge and directing them to additional sources in the literature. The preparation of this Handbook was made possible by the diligence and scholarly sophistication of the 25 volume editors and co-editors who constituted the Editorial Board. As Editor-in-Chief, I want to thank each of them for the plea- sure of their collaboration in this project. I compliment them for having recruited an outstanding cast of contributors to their volumes and then working closely with these authors to achieve chapters that will stand each in their own right as valuable contributions to the literature. I would like “nally to express my appreciation to the editorial staff of John Wiley and Sons for the opportunity to share in the development of this project and its pursuit to fruition, most particularly to Jennifer Simon, Senior Editor, and her two assistants, Mary Porter“eld and Isabel Pratt. Without Jennifer•s vision of the Handbook and her keen judgment and un”agging support in producing it, the occasion to write this preface would not have arrived. I RVING B. W EINER Tampa, Florida Volume Preface xi When we were “rst asked to serve as editors of the health psychology volume for this Handbook, we were very excited to be part of a larger set of editors whose landmark, but daunting, task was to corral an impressive list of leading psy- chologists to chronicle all of psychology. Having the oppor- tunity to invite internationally known psychologists to author speci“c chapters that would be both comprehensive and prac- tical in one volume offered a tremendous and exciting chal- lenge. We were also very pleased to have the opportunity to put together a comprehensive text on health psychology that could be useful to graduate psychology students interested in health psychology, health psychology researchers interested in having up-to-date information, clinical health psycholo- gists working with medical patients, and nonpsychology pro- fessionals (e.g., physicians, nurses) who wish to learn more about psychology•s contributions to health and health service delivery. It was these four audiences that we had in mind when we developed the structure for this volume on health psychology. We cover both conceptual and professional issues (Parts One and Two, Overview and Causal and Mediating Psychosocial Factors, respectively), as well as a plethora of disease- speci“c chapters (Part Three, Diseases and Disorders). This latter section focuses on 14 major disease entities or medical problems and provides information concerning prevalence, psychosocial causal factors, and treatment approaches. Because we view all phenomena as taking place within varying contexts, we also believe that health and health care need to be viewed within the context of varying developmen- tal stages, hence the inclusion of Part Four on Health Psychology across the Life Span. Last, because we believed there were additional contextual issues, such as gender (Chapter 22 on women•s health issues) and cultural/ethnic background (Chapter 23 on cultural diversity issues in health), as well as emerging related issues in the “eld (Chap- ter 24 on occupational health psychology and Chapter 25 on complementary and alternative therapies), we added Part Five titled Special Topics. Although we provided wide latitude to the various authors in terms of chapter structure and content, we insisted on com- prehensive and timely coverage for each topic. We believe each set of authors did a magni“cent job. We wish to thank them for their outstanding contributions. We also wish to thank Irv Weiner, Editor-in-Chief of the Handbook, for his in- defatigable support, feedback, and advice concerning this volume. Much appreciation also should be extended to the editorial staff at Wiley, Jennifer Simon and Isabel Pratt, for their support and advice. Finally, we need to underscore the huge assistance that Marni Zwick, soon to be a clinical health psychologist in her own right, gave to this project. Without her, this book would not have come to fruition. A RTHUR M. N EZU C HRISTINE M AGUTH N EZU P AMELA A. G ELLER Handbook of Psychology Preface ix Irving B. Weiner Volume Preface xi Arthur M. Nezu, Christine Maguth Nezu, and Pamela A. Geller Contributors xvii INTRODUCTION 1 PART ONE OVERVIEW 1 HEALTH PSYCHOLOGY: OVERVIEW AND PROFESSIONAL ISSUES 5 David F. Marks, Catherine M. Sykes, and Jennifer M. McKinley PART TWO CAUSAL AND MEDIATING PSYCHOSOCIAL FACTORS 2 STRESSFUL LIFE EVENTS 27 Ralf Schwarzer and Ute Schulz 3 COPING AND SOCIAL SUPPORT 51 Sharon Manne 4 PSYCHONEUROIMMUNOLOGY 75 Jeffrey R. Stowell, Lynanne McGuire, Ted Robles, Ronald Glaser, and Janice K. Kiecolt-Glaser PART THREE DISEASES AND DISORDERS 5 ASTHMA 99 Karen B. Schmaling, Paul M. Lehrer, Jonathan M. Feldman, and Nicholas D. Giardino 6 OBESITY 121 Joyce A. Corsica and Michael G. Perri 7 TOBACCO DEPENDENCE 147 Gary E. Swan, Karen S. Hudmon, and Taline V. Khroyan 8 ARTHRITIS AND MUSCULOSKELETAL CONDITIONS 169 Heather M. Burke, Alex J. Zautra, Mary C. Davis, Amy S. Schultz, and John W. Reich Contents xiii xiv Contents 9 DIABETES MELLITUS 191 Julie Landel-Graham, Susan E. Yount, and Susan R. Rudnicki 10 AIDS/HIV 219 Michael P. Carey and Peter A. Vanable 11 HEADACHES 245 Frank Andrasik and Susan E. Walch 12 PSYCHOSOCIAL ONCOLOGY 267 Arthur M. Nezu, Christine Maguth Nezu, Stephanie H. Felgoise, and Marni L. Zwick 13 PAIN MANAGEMENT 293 Dennis C. Turk and Akiko Okifuji 14 INSOMNIA 317 Charles M. Morin, Josée Savard, Marie-Christine Ouellet, and Meagan Daley 15 CORONARY HEART DISEASE AND HYPERTENSION 339 Mark O•Callahan, Amy M. Andrews, and David S. Krantz 16 CHRONIC FATIGUE SYNDROME 365 Leonard A. Jason and Renee R. Taylor 17 IRRITABLE BOWEL SYNDROME 393 Edward B. Blanchard and Laurie Keefer 18 SPINAL CORD INJURY 415 Timothy R. Elliott and Patricia Rivera PART FOUR HEALTH PSYCHOLOGY ACROSS THE LIFE SPAN 19 CHILD HEALTH PSYCHOLOGY 439 Lamia P. Barakat, Alicia Kunin-Batson, and Anne E. Kazak 20 ADOLESCENT HEALTH 465 Sheridan Phillips 21 ADULT DEVELOPMENT AND AGING 487 Ilene C. Siegler, Hayden B. Bosworth, and Merrill F. Elias PART FIVE SPECIAL TOPICS 22 WOMEN’S HEALTH PSYCHOLOGY 513 Pamela A. Geller, Maria C. Graf, and Faith Dyson-Washington Contents xv 23 CULTURAL ASPECTS OF HEALTH PSYCHOLOGY 545 Keith E. Whit“eld, Gerdi Weidner, Rodney Clark, and Norman B. Anderson 24 OCCUPATIONAL HEALTH PSYCHOLOGY 569 James Campbell Quick, Lois E. Tetrick, Joyce Adkins, and Charles Klunder 25 COMPLEMENTARY AND ALTERNATIVE THERAPIES 591 Christine Maguth Nezu, Solam Tsang, Elizabeth R. Lombardo, and Kim P. Baron Author Index 615 Subject Index 659 Joyce Adkins, PhD (USAF) DoD Deployment Health Center Department of Defense Washington, DC Norman B. Anderson, PhD Department of Health and Social Behavior Harvard University Boston, Massachusetts Frank Andrasik, PhD Institute for Human and Machine Cognition University of West Florida Pensacola, Florida Amy M. Andrews, BSN, RN Department of Medical and Clinical Psychology Uniformed Services University of the Health Sciences Bethesda, Maryland Lamia P. Barakat, PhD Department of Psychology Drexel University Philadelphia, Pennsylvania Kim P. Baron, MA Department of Psychology Drexel University Philadelphia, Pennsylvania Edward B. Blanchard, PhD, ABPP Center for Stress and Anxiety Disorders State University of New York at Albany Albany, New York Hayden B. Bosworth, PhD Health Services Research and Development Durham Veteran•s Administration Medical Center and Departments of Medicine and Psychiatry Duke University Medical Center Durham, North Carolina Heather M. Burke, MA Department of Psychology Arizona State University Tempe, Arizona Michael P. Carey, PhD Center for Health and Behavior Syracuse University Syracuse, New York Rodney Clark, PhD Department of Psychology Wayne State University Detroit, Michigan Joyce A. Corsica, PhD Department of Clinical and Health Psychology University of Florida Gainesville, Florida Meagan Daley, MPs École de Psychologie Université Laval Québec, Canada Mary C. Davis, PhD Department of Psychology Arizona State University Tempe, Arizona Faith Dyson-Washington, MEd Department of Psychology Drexel University Philadelphia, Pennsylvania Timothy R. Elliott, PhD Department of Physical Medicine and Rehabilitation University of Alabama at Birmingham Birmingham, Alabama Merrill F. Elias, PhD, MPH Department of Mathematics and Statistics, College of Arts and Sciences Boston University and Boston University Schools of Medicine and Public Health Boston, Massachusetts Jonathan M. Feldman, MS Department of Psychology Rutgers University New Brunswick, New Jersey Contributors xvii xviii Contributors Stephanie H. Felgoise, PhD Department of Psychology PCOM Philadelphia, Pennsylvania Pamela A. Geller, PhD Department of Psychology Drexel University Philadelphia, Pennsylvania Nicholas D. Giardino, PhD Department of Rehabilitation Medicine University of Washington Seattle, Washington Ronald Glaser, PhD Department of Molecular Virology, Immunology and Medical Genetics, Comprehensive Cancer Center, Institute for Behavioral Medicine Research The Ohio State University Columbus, Ohio Maria C. Graf, MA Department of Psychology Drexel University Philadelphia, Pennsylvania Karen S. Hudmon, DrPH Department of Clinical Pharmacy, School of Pharmacy University of California San Francisco, California Leonard A. Jason, PhD Center for Community Research DePaul University Chicago, Illinois Anne E. Kazak, PhD Departments of Pediatrics and Psychology The Children•s Hospital of Philadelphia Philadelphia, Pennsylvania Laurie Keefer, MA Center for Stress and Anxiety Disorders State University of New York at Albany Albany, New York Taline V. Khroyan, PhD Center for Health Sciences SRI International Menlo Park, California Janice K. Kiecolt-Glaser, PhD Department of Psychiatry Comprehensive Cancer Center, Institute for Behavioral Medicine Research The Ohio State University Columbus, Ohio Charles Klunder, PhD Behavioral Analysis Service, 59th Medical Wing (USAF) Lackland Air Force Base, Texas David S. Krantz, PhD Department of Medical and Clinical Psychology Uniformed Services University of the Health Sciences Bethesda, Maryland Alicia Kunin-Batson, PhD Department of Psychology The Children•s Hospital of Philadelphia Philadelphia, Pennsylvania Julie Landel-Graham, PhD Philadelphia, Pennsylvania Paul M. Lehrer, PhD Department of Psychiatry UMDNJ-Robert Wood Johnson Medical School Newark, New Jersey Elizabeth R. Lombardo, PhD Department of Psychology Drexel University Philadelphia, Pennsylvania Sharon Manne, PhD Division of Population Science and Psychooncology Program Fox Chase Cancer Center Philadelphia, Pennsylvania David F. Marks, PhD Department of Psychology City University London, United Kingdom Lynanne McGuire, PhD Department of Psychiatry The Ohio State University Columbus, Ohio Jennifer M. McKinley, MSc Department of Psychology City University London, United Kingdom Contributors xix Charles M. Morin, PhD École de Psychologie Université Laval Québec, Canada Arthur M. Nezu, PhD, ABPP Center for Behavioral Medicine Departments of Psychology, Medicine, and Public Health Drexel University Philadelphia, Pennsylvania Christine Maguth Nezu, PhD, ABPP Center for Behavioral Medicine Departments of Psychology and Medicine Drexel University Philadelphia, Pennsylvania Mark O’Callahan, BS Department of Medical and Clinical Psychology Uniformed Services University of the Health Sciences Bethesda, Maryland Akiko Okifuji, PhD Department of Anesthesiology University of Utah Salt Lake City, Utah Marie-Christine Ouellet, MPs École de Psychologie Université Laval Québec, Canada Michael G. Perri, PhD, ABPP Department of Clinical and Health Psychology University of Florida Gainesville, Florida Sheridan Phillips, PhD Department of Psychiatry University of Maryland School of Medicine Baltimore, Maryland James Campbell Quick, PhD Center for Research on Organizational and Managerial Excellence The University of Texas at Arlington Arlington, Texas John W. Reich, PhD Department of Psychology Arizona State University Tempe, Arizona Patricia Rivera, PhD Department of Physical Medicine and Rehabilitation University of Alabama at Birmingham Birmingham, Alabama Ted Robles, BS Department of Psychology The Ohio State University Columbus, Ohio Susan R. Rudnicki, PhD Behavioral Research Center American Cancer Society Atlanta, Georgia Josée Savard, PhD École de Psychologie Université Laval Québec, Canada Karen B. Schmaling, PhD College of Health Sciences University of Texas at El Paso El Paso, Texas Amy S. Schultz, MA Department of Psychology Arizona State University Tempe, Arizona Ute Schulz Health Psychology Freie Universitat Berlin Berlin, Germany Ralf Schwarzer, PhD Health Psychology Freie Universitat Berlin Berlin, Germany Ilene C. Siegler, PhD, MPH Behavioral Medicine Research Center and Department of Psychiatry and Behavioral Sciences Duke University Medical Center Durham, North Carolina Jeffrey R. Stowell, PhD Department of Psychiatry The Ohio State University Columbus, Ohio xx Contributors Gary E. Swan, PhD Center for Health Sciences SRI International Menlo Park, California Catherine M. Sykes, MSc Department of Psychology City University London, United Kingdom Renee R. Taylor, PhD Department of Occupational Therapy University of Illinois at Chicago Chicago, Illinois Lois E. Tetrick, PhD Department of Psychology University of Houston Houston, Texas Solam Tsang, MA Department of Psychology Drexel University Philadelphia, Pennsylvania Dennis C. Turk, PhD Department of Anesthesiology University of Washington Seattle, Washington Peter A. Vanable, PhD Center for Health and Behavior Syracuse University Syracuse, New York Susan E. Walch, PhD Department of Psychology University of West Florida Pensacola, Florida Gerdi Weidner, PhD Vice President and Director of Research, Preventive Medicine Research Institute Sausalito, California Keith E. Whitﬁeld, PhD Department of Biobehavioral Health The Pennsylvania State University University Park, Pennsylvania Susan E. Yount, PhD Center on Outcomes, Research, and Education Northwestern University Evanston, Illinois Alex J. Zautra, PhD Department of Psychology Arizona State University Tempe, Arizona Marni L. Zwick, MA Department of Psychology Drexel University Philadelphia, Pennsylvania Introduction The power of the imagination is a great factor in medicine. It may produce diseases in man and in animals, and it may cure them. P ARACELSUS , SIXTEENTH CENTURY 1 By no means should the above observation be equated with a contemporary de“nition of health psychology, but in his quote, the noted reformer and physician Paracelsus argues that disease, neither in its etiology nor in its cure, can be totally understood in terms limited to the realm of the soma . This is the essence of the “eld of health psychology that disease processes cannot be understood solely in terms of biological and physiological parameters. Instead, a biopsy- chosocial model better represents a more complete picture of disease, illness, health, and wellness. Rather than underscor- ing the primacy of somatic variables, such a model (see Schwartz, 1982) contends that biological, psychological, and social factors all constitute important and crucial indices of a de“nition of disease with regard to issues of etiology, patho- genesis, course, and treatment. Recent research suggests that less than 25% of physical complaints presented to primary care physicians have known or demonstrable organic or bio- logical etiologies, greatly highlighting the need for a more complete model (Nezu, Nezu, & Lombardo, 2001). Such a view is consistent with a planned critical multiplism perspec- tive (Shadish, 1986), which is a methodological approach whereby attempts are made to minimize the biases inherent in any univariate search for knowledge. During the past two decades, efforts by a wide range of psychologists inter- ested in disease and illness have provided varying types of support for this biopsychosocial model using this multivari- ate perspective. Starting with simpler questions, such as what types of psy- chological processes affect illness, the “eld of health psy- chology has since expanded greatly in terms of its scope, depth, and impact. For example, Taylor•s (1990) con“dent prediction that succinct papers reviewing the current status of health psychology would disappear due to the •diversity of issues studied and the complexity and sophistication of the models and designs used to explore themŽ (p. 47) appears to have been con“rmed. Initially, the “eld was composed of researchers and practitioners with common interests in issues related to health and illness who were trained in more tradi- tional (but varied) areas of psychology. The diversity of con- ceptual approaches, models, and designs brought together by these individuals have helped to establish a “eld that is broad in scope, eclectic, multidisciplinary, dynamic, and al- lowing for creative developments. Training programs in health psychology have tapped this breadth and students now have signi“cant exposure to neurology, endocrinology, im- munology, public health, epidemiology, and other medical subspecialties, in addition to a solid grounding in psychology (Brannon & Feist, 1992). Over the past two decades, health psychologists have be- come more integrated into the general “eld of health research and intervention, and have gained job opportunities in a range of health-oriented settings (Belar & Deardorf, 1995). Although psychology has been involved with health in some capacity since early in the twentieth century, very few psy- chologists worked in medical settings, and more as adjuncts than as full members of multidisciplinary teams. Recent is- sues of the APA Monitor, however, now advertise a wide array of health-related positions for psychologists in settings such as universities, medical schools, hospitals, health clin- ics, health maintenance organizations, and private practices, highlighting the growing demand for such services. The focus of clinical health psychology on empirically supported, brief, problem-centered, cognitive-behavioral interventions and skills training has been compatible with the demands of the managed care system, which must provide authorization for treatment plans. Moreover, the large and continually growing percentage of the gross national product that Americans spend on health care, more than any other indus- trialized country (over 13.5% in 1998; U.S. Health Care Financing Administration, 1999), highlights the need to contain costs through early detection and disease prevention. Health psychology research focusing on the development and 2 Introduction evaluation of prevention activities intended to assist with health maintenance and improvement is more cost-ef“cient and can help reduce the need for high cost health care ser- vices (Taylor, 1990). Such economic factors have thus helped to facilitate the acceptance of psychologists in the health arena. The future seems bright for continued acceptance of and opportunities for health psychologists as the “eld has demon- strated its value through the contributions made in supporting a biopsychosocial model, as well as with regard to their ap- plied and clinical implications (e.g., primary, secondary, and tertiary prevention). Recent reports emanating from the U.S. Surgeon General•s Of“ce continue to highlight the causal im- portance of behavioral and psychological factors regarding the leading causes of mortality in the United States. For exam- ple, such reports suggest that various behavioral risk factors (e.g., substance abuse, stress, diet, tobacco use) are among the most important foci regarding health promotion and disease prevention (see also Healthy People 2000 ). As such, health psychologists are in a unique position to conduct research and develop programs geared to prevent and change unhealthy habits and behaviors, as well as to promote healthy ones. However, despite such advances, there is still a tremen- dous need for work in this area. For example, although an ex- orbitant amount of money is spent on health care in the United States, this does not necessarily translate to high- quality care for most Americans. Comparing mortality and morbidity rates among ethnic/racial groups reveals vast dif- ferences. For example, although there has been a general de- cline in mortality for all groups, overall mortality was 55% greater for Blacks than for Whites in 1997 (Hoyert, Kochanek, & Murphy, 1999). There also are signi“cant health discrepancies relating to socioeconomic status, eth- nic/racial status, and even gender (e.g., National Center for Health Statistics, 1999; Rodin & Ickovics, 1990). As such, there is a continuing need for health psychology efforts, both research and clinical, to expand in scope. Not only do we need to better understand how biological, psy- chological, and social factors interact with each other regard- ing various symptom clusters and medical disorders, but also we need to improve the manner in which health care delivery is provided. Research needs to be conducted regarding the impact of health care policy on health and well-being. Therefore, lest we begin to wish to sit on our laurels and believe that our job is nearly done in terms of health psychol- ogy research and clinical applications, we should remember the words of John Locke concerning overcon“dence: He that judges without informing himself to the upmost that he is capable, cannot acquit himself of judging amiss. This current volume should be viewed as but one major stop on a road that will continue far into the future. However, the road thus far has been very fruitful, as evidenced by the rich material contained in the various chapters in this volume. More importantly, such strides strongly justify continued travels. REFERENCES Belar, C. D., & Deardorff, W. W. (1995). Clinical health psychology in medical settings: A practitioner’s guidebook. Washington, DC: American Psychological Association. Brannon, L., & Feist, J. (1992). Health Psychology: An introduction to behavior and health (2nd ed.). Belmont, CA: Wadsworth Pub- lishing. Healthy People 2000: National health promotion and disease pre- vention objectives . [DHHS Publication No. (PHS) 91-50212]. Washington, DC: U.S. Government Printing Of“ce. Hoyert, D. L., Kochanek, K. D., & Murphy, S. L. (1999). Deaths: Final data for 1997. National Vital Statistics Reports, 47, 1…104. Nezu, A. M., Nezu, C. M., & Lombardo, E. R. (2001). Cognitive- behavior therapy for medically unexplained symptoms. A critical review of the treatment literature. Behavior Therapy , 32, 537… 583. Rodin, J., & Ickovics, J. R. (1990). Women•s health: Review and research agenda as we approach the 21st century. American Psychologist , 45 , 1018…1034. Schwartz, G. (1982). Testing the biopsychosocial model: The ulti- mate challenge facing behavioral medicine? Journal of Consult- ing and Clinical Psychology , 50 , 1040…1053. Shadish, W. R. (1986). Planned critical multiplism: Some elabora- tions. Behavioral Assessment, 8 , 75…103. Taylor, S. E. (1990). Health Psychology: The science and the “eld. American Psychologist , 45 , 40…50. U.S. Health Care Financing Administration. (1999). National health expenditures, 1998. Health Care Financing Review , 20 , Publica- tion 03412. PART ONE OVERVIEW CHAPTER 1 Health Psychology: Overview and Professional Issues DAVID F. MARKS, CATHERINE M. SYKES, AND JENNIFER M. M CKINLEY 5 THE DEFINITION AND SCOPE OF HEALTH PSYCHOLOGY 6 Relationships with Other Professions 8 The Clinical and Community Approaches to Health Psychology 8 Conditions That Promote and Maintain Health 9 Inalienable Right to Health and Health Care for All 10 Centrality of the Scientist-Practitioner Model 10 EDUCATION AND TRAINING IN THE UNITED STATES 10 EDUCATION AND TRAINING IN EUROPE 12 Rationale for Training 12 Complementing Other Fields of Applied Psychology 13 Professional Autonomy and Complementary Independence 13 Stages of Competency 13 Training Guidelines for Professional Health Psychologists 13 Implementation of Training 14 EDUCATION AND TRAINING IN THE UNITED KINGDOM 14 Professional Competence 15 Research Competence 16 Consultancy Competence 16 Teaching and Training Competence 16 Optional Competences 16 SIMILARITIES AND DIFFERENCES BETWEEN THE U.S., EUROPEAN, AND U.K. MODELS 17 A Common Core 17 Differences between Regions or Countries and Gaps in Training 17 CRITIQUE OF PROFESSIONALIZATION 18 ETHICAL AND POLICY ISSUES 19 Poverty and Inequality 19 Economics 20 New Technologies 20 The Aging Population 20 CONCLUSIONS 20 REFERENCES 21 The importance of psychological processes in the experience of health and illness is being increasingly recognized. More and more evidence is accumulating for the role of behavior in current trends of morbidity and mortality: Certain health be- haviors reduce morbidity and mortality (Breslow & Enstrom, 1980; Broome & Llewellyn, 1995; Marks, Murray, Evans, & Willig, 2000; Matarazzo, Weiss, Herd, Miller, & Weiss, 1984; Taylor, 1986). Maes and von Veldhoven (1989), reviewing all the English language handbooks on health psychology known at that time, counted 15 published during the period 1979 to 1989. Recent developments, especially in clinical practice, have been even more encompassing, and health psy- chologists are in increasing demand in clinical health care and medical settings. In the United States, the single largest area of placement of psychologists in recent years has been in medical centers. Psychologists have become vital members of multidisciplinary clinical and research teams in rehabilita- tion, cardiology, pediatrics, oncology, anesthesiology, family practice, dentistry, and other medical “elds (American Psy- chological Association [APA], 1996). With this increasing participation of psychologists in health services, guidelines for professional training programs and ethical practice have been developed in the United States, Europe, and elsewhere. This chapter reviews some of the professional and ethical is- sues that have been identi“ed and discussed in these regions. The emphasis is on education and training. In reviewing the “eld•s development in the United States, Wallston (1993) states, •It is amazing to realize that formal The authors would like to thank the members of the EFPPA Task Force on Health Psychology (convenor: David F. Marks): Carola Brucher-Albers, Berufsverband Deutscher Psychologen e.V.; Frank J. S. Donker, Nederlands Institut van Psychogen; Zenia Jepsen, Dansk Psykologforening; Jesus Rodriguez-Marin, Colegio O“cial de Psicologos; Sylvaine Sidot, Association Nationale des Organiza- tions de Psychologues; Brit Wallin Backman, Norsk Psykologforen- ing. Sections of this chapter are adapted from the Task Force report (Marks et al., 1998). 6 Health Psychology: Overview and Professional Issues recognition of the “eld of health psychology in the United States occurred less than 20 years ago. It is no longer correct to speak of health psychology as an •emerging• specialty within American psychology; for the last dozen or so years, health psychology has ”ourished as one of the most vibrant specialties within the larger discipline of psychology. Not only is it recognized as a specialty in its own right, health psychology has had a profound impact on clinical psychol- ogy, and has played a major (if not the major) role in developing and vitalizing the interdisciplinary “eld called •behavioral medicine•Ž (p. 215). The overlap with behavioral medicine in both theory and practice has been strong and, like behavioral medicine, health psychology is really an interdis- ciplinary “eld (Marks, 1996). Because the leading causes of mortality have substantial behavioral components, behav- ioral risk factors (e.g., drug and alcohol use, unsafe sexual behavior, smoking, diet, a sedentary lifestyle) are the main focus of efforts in the area of health promotion and disease prevention. Behavioral methods are also playing an increas- ing role in treatment and rehabilitation. Beyond the clinical domain, the relevance of psychology to public health, health education and health promotion has been discussed by health psychologists (Bennett & Murphy, 1997; Winett, King, & Altman, 1989) and health promotion specialists (Macdonald, 2000). Given its emphasis on behavior and behavioral change, psychology has a unique contribution to make to health care and public health. Health psychologists are currently con- ducting research on the development of healthy habits as well as the prevention or reduction of unhealthy behaviors. Both the impact of behavior on health as well as the in”uence of health and disease states on psychological factors are being explored. Psychosocial linkages in areas such as psycho- neuroimmunology, pain, cardiovascular disorders, cancer, AIDS/HIV, and other chronic diseases are being de“ned. Psychosocial mediators of effective public health promotion are being identi“ed. The United States has produced the most in”uential theo- retical and ideological frameworks and a large proportion of the empirical work. The Health Psychology Division of the APA (Division 38) is one of the largest and fastest growing in the association. Its journal, Health Psychology, has one of the largest circulations among psychology journals. However, in the 1990s, a considerable amount of research was initiated in Europe. Health psychology was no longer totally dominated by developments in the United States. The European Health Psychology Society (EHPS) has organized scienti“c meet- ings since 1986. Undoubtedly these have had an in”uential role in the proliferation of the European health psychology scene. Linked to the EHPS, the journal Psychology and Health is a respected review of health psychology and since 1985 has been the leading European journal. The establish- ment of the Journal of Health Psychology in 1996 has en- couraged an interdisciplinary and international orientation to the “eld and created a forum for new methods and theories, discussions, and debate, including critical approaches. An- other journal, Psychology, Health & Medicine has focused on psychological care for medical problems. Other journals that publish papers in this “eld are the International Journal of Behavioural Medicine and Social Science & Medicine. Sev- eral other academic journals focus on health psychology at a national level (e.g., British Journal of Health Psychology, Gedrag & Gezondheid: Tijdschrift voor Psychologie en Gezondheid, Revista de Psicologia de la Salud, Zeitschrift far Gesundheitpsychologie ). As in the United States and Europe, psychological associations in Canada, Australia, New Zealand, and elsewhere have boards, divisions, or branches specializing in health psychology and research and professional work in the “eld are expanding rapidly. In the light of these developments, it can be seen that health psychology is one of the most vibrant and dynamic “elds in Western psychology. As health psychology pro- gresses from a research “eld to health service delivery, it is inevitable that professional and ethical issues are at the forefront of discussion within the major psychological asso- ciations. This chapter re”ects the principle focus of this dis- cussion that is on education and training. THE DEFINITION AND SCOPE OF HEALTH PSYCHOLOGY The currently accepted de“nition of health psychology was originally proposed by Matarazzo (1982) as: [T]he aggregate of the speci“c educational, scienti“c, and pro- fessional contributions of the discipline of psychology to the promotion and maintenance of health, the prevention and treat- ment of illness, the identi“cation of etiologic and diagnostic cor- relates of health and illness and related dysfunctions, and the analysis and improvement of the health care system and health policy. Virtually every health psychology organization and textbook has adopted Matarazzo•s (1982) de“nition without criticism, debate, or discussion. For researchers in health psychology, this de“nition is a very “ne and appropriate one. Researchers invariably specialize and the fact that a de“ni- tion of their “eld is a very broad one is not a problem. For practitioners, however, the breadth of the Matarazzo The Deﬁnition and Scope of Health Psychology 7 de“nition can pose some serious dif“culties. In fact, at face value, the de“nition is quite grandiose, encompassing all of clinical psychology, counseling psychology, rehabilitation psychology, occupational psychology, and much else as well. No single health care professional can reasonably be ex- pected to possess and practice with genuine competence in all of the areas mentioned in Matarazzo•s de“nition and yet that is what the American, British, and most other psychological associations have agreed to. The •of“cialŽ de“nition of health psychology needs to be narrowed, or at least specialties within it, need to be de- “ned (e.g., clinical health psychologist, rehabilitation health psychologist, occupational health psychologist, healthpromo- tion psychologist). Otherwise there is a risk of becoming Jacks-and-Jills-of-all-trades, and master-of-none. McDermott (2001) recently argued that the Matarazzo de“nition is over- inclusive, encompassing any topic connected with health, in- cluding primary, secondary, and tertiary care in their entirety. McDermott states, •The over-inclusivity is likely to prove detrimental to the long-term well-being of health psychology since such a broad de“nition does not allow for the subject area to distinguish itself clearly from other subdisciplines, in particular from clinical psychology and behavioral medicineŽ (p. 7). McDermott•s solution to this problem is to replace the “rst Matarazzo de“nition with another, his de“nition of be- havioral health: . . . new, interdisciplinary subspecialty . . . speci“cally concerned with the maintenance of health and the prevention of illness and dysfunction in currently healthy persons. (Matarazzo, 1982, p. 807, cited by McDermott, 2001) This proposal is an elegant one. Secondary and tertiary care would thus remain the province of clinical psychology, leav- ing health psychology to become a true psychology of health. Correspondence suggests that Matarazzo (2001) essentially agrees with this proposal (Marks, 2002). Another critique questions the focus on the rejection of the biomedical model and argues for a more social orientation, drawing on the knowledge base of the social sciences. The “rst author has argued elsewhere for a new agenda in which •health psychology should accept its interdisciplinary nature, venture more often out of the clinical arena, drop white- coated scientism, and relocate in the richer cultural, sociopo- litical and community contexts of societyŽ (Marks, 1996, p. 19). Ogden (1998) has suggested that the challenge of the biomedical model in the form of the •biopsychosocialŽ model is a rhetorical strategy lacking any solid theoretical foundation. A more societal emphasis in health psychology, and psychology as a whole, will encourage psychologists to make a more signi“cant contribution in a world threatened by the sequelae of its industrial, scienti“c, and medical attain- ments but also by war, crime, and poverty. This step broadens the agenda rather than narrows it. It is a broadening of awareness about the social context of health experience and behavior and of the social and economic de- terminants of health. In no way does it dilute the psycholo- gist•s ability to deliver effective approaches to health issues. Economic and political changes have considerable, long- lasting in”uence on human well-being. Warfare remains an intermittent threat to human security. The gap between the •havesŽ and the •have-notsŽ widens, the Western population is aging, and the impacts of learned helplessness, poverty, and social isolation are becoming increasingly salient fea- tures of society. Global warming and energy addiction re- main unabated. The health and psychological impacts of these phenomena present many challenges that lead us to re- peat what Taylor already wrote over 10 years ago, •The only aspect of health psychology that is more exciting than its dis- tinguished past and its impressive present, is its promising futureŽ (Taylor, 1986, p. 17). Ascurrentlyde“ned, healthpsychology istheapplication of psychological theory, methods, and research to health, physi- cal illness, and health care. Human well-being is a complex product of genetic, developmental, and environmental in”u- ences. In accordance with the World Health Organization (WHO) de“nition, health is seen as well-being in its broadest sense, not simply the absence of illness. Expanding the WHO de“nition, well-being is the product of a complex interplay of biological, sociocultural, psychological, economic, and spiri- tualfactors.Thepromotionandmaintenance ofhealthinvolves psychosocial processesatthe interface between the individual, the health care system, and society (Marks et al., 2000). Health psychology is concerned with the psychological aspects of the promotion, improvement, and maintenance of health. The ecological context of these psychological aspects of health includes the many in”uential social systems within which human beings exist: families, workplaces, organiza- tions, communities, societies, and cultures (Marks, 1996; Marks et al., 2000; Whitehead, 1995). Any psychological ac- tivity, process, or intervention that enhances well-being is of interest to health psychology. Equally, any activity, process, or circumstance which has psychological components and which threatens well-being is of concern to health psychol- ogy. Interventions need to be considered in the light of the prevailing environmental conditions that contain the contex- tual cues for health-related behaviors. A behavioral change resulting from an intervention delivered in one speci“c envi- ronment (e.g., a classroom, hospital, or prison) will not nec- essarily transfer to other environments. 8 Health Psychology: Overview and Professional Issues The mission of professional health psychology is to pro- mote and maintain well-being through the application of psy- chological theory, methods, and research, taking into account the economic, political, social, and cultural context. The pri- mary purpose or •visionŽ of professional health psychology is the employment of psychological knowledge, methods, and skills toward the promotion and maintenance of well- being. The latter extends beyond hospitals and clinics„it in- cludes health education and promotion among the healthy population as well as among those who are already sick. The application of psychological knowledge, methods, and skills in the promotion and maintenance of well-being is a multifaceted activity; it is not possible to de“ne the “eld narrowly because of the many different settings and situa- tions in which psychologists may have a role in promoting and maintaining human health. It also must be acknowledged that the psychologist often will be working with laypeople, many of whom are patients•relatives, acting as informal care- givers: •People are not just consumers of health care, they are the true primary care providers in the health care system. In- creasing the con“dence and skills of these primary care providers can make health and economic senseŽ (Sobell, 1995, p. 238). Relationships with Other Professions Health psychology is an interdisciplinary “eld with theoreti- cal and practical links with many other professions (e.g., medicine, nursing, health promotion, and social work among many others). Health psychology overlaps with many other sub“elds or professional activities of psychology. Particular examples include sub“elds such as clinical psychology and activities such as psychotherapy. These overlapping sub“elds and activities are concerned with the independent application of psychological principles and methods to health, illness, and health care. However there are similarities and synergy between health psychology, clinical psychology, psychother- apy, and other applied psychological “elds that have common foundations and overarching objectives. The primary goals are (a) the promotion and maintenance of good health and quality of life; (b) the prevention and improvement of ill health, disability, and the conditions of impairment and hand- icap through psychological intervention; and © adherence to the ethical guidelines speci“ed by the national societies. Health psychology is primarily concerned with physical health, illness, and health care although it is recognized that mental and physical health are highly interrelated. Clini- cal psychology is primarily concerned with assessing, predicting, preventing, and alleviating cognitive, emotional, and behavioral disorders and disabilities. Psychotherapy is primarily concerned with the treatment of psychological and psychologically in”uenced disorders by psychological means. Although it is recognized that these three “elds over- lap, they are independent professions of psychologists with university degrees that have their own postgraduate training needs and curricula. Health and clinical psychologists, and those psychologists who conduct psychotherapy, work with: 1. Individuals, couples, families, groups, and communities; 2. People of all ages; 3. In institutions, organizations, and companies; 4. In the public, private, and voluntary sectors. They undertake: (a) assessment and diagnosis; (b) interven- tion and treatment; © teaching and training; (d) supervision, counseling, and consultancy; (e) evaluation, research, and development for a range of areas of life, including promotion of well-being; prevention of deterioration of health; interven- tion in psychological aspects of physical health; intervention in psychological aspects of mental health; and promotion of optimum development and aging. These individuals are responsible for: 1. The delivery of good services with respect to standards of quality and control; 2. Planning of new services; 3. Informing and in”uencing the health care system and health policy; and 4. Contributing toward multidisciplinary working in the health care system. Areas of overlap exist between health psychology and many other types of psychology: community psychology, organizational/occupational psychology, work psychology, rehabilitation psychology, educational psychology, and fo- rensic psychology. To the extent that the psychology disci- pline is concerned with arriving at a better understanding of behavior and experience and in the improvement of well- being, all aspects of psychology have relevance to the psy- chology of health in its broadest sense. The Clinical and Community Approaches to Health Psychology There are two different approaches to health psychol- ogy. The “rst is based on the biopsychosocial model and working within the health care system. It is founded on Matarazzo•s (1980) de“nition of health psychology. It The Deﬁnition and Scope of Health Psychology 9 locates professional health psychology within the clinical domain, in hospitals, and outpatient settings. The environ- ment in which the practice occurs is the health care market- place. Another name for it is •clinical health psychology.Ž The second approach is community research and action. This forms a signi“cant part of community psychology, working on health promotion and illness prevention among healthy people as members of communities and groups. This approach is consistent with Matarazzo•s (1980) de“ni- tion of behavioral health, but it locates behavioral health not purely within the individual but within its social, economic, and political context. A summary of the two approaches is presented in Table 1.1. Each approach has its strengths and weaknesses. There is a need for both and they complement each other. Each requires appropriate training and education. A third hybrid approach would be to attempt to integrate the clinical and community approaches within a single profession or disci- pline. This is an ambitious target that may be too dif“cult to achieve. It would be comparable to putting clinical and pub- lic health medicine together as a single endeavor. It seems unlikely that this will happen and, sadly, the paths of the community and clinical health psychologist may be forced to diverge. The training pathways are already separate, as we shall discuss next. Conditions That Promote and Maintain Health Cohesion, harmony, and meaningfulness are key characteristics of psychosocial well-being; fragmentation, disharmony, and De“nition Theory/philosophy Context Focus Target groups Objective Orientation Skills Discourse and buzz words Research methodology •[T]he aggregate of the speci“c educational, scienti“c, and professional contributions of the discipline of psychology to the promotion and maintenance of health, the prevention and treatment of illness, the identi“cation of etiologic and diagnostic correlates of health and illness and related dysfunctions, and the analysis and improvement of the health care system and health policyŽ Matarazzo (1982). Biopsychosocial model: Health and illness are: “the product of a combination of factors including biological characteristics (e.g., genetic predisposition), behavioral factors (e.g., lifestyle, stress, health beliefs), and social conditions (e.g., cultural inﬂuences, family relationships, social support)” APA Division 48 (2001). Patients within the health care system, i.e., hospitals, clinics, health centers. Physical illness and dysfunction. Patients in hospital and clinics. Therapeutic intervention. Top-down service delivery. Clinical and therapeutic. Evidence-based. Effective. Cost-effective. Intervention. Controls. Outcomes. Randomized controlled trials . Effectiveness trials, typically using quantitative or quasi-experimental methods. “Advancing theory, research and social action to promote positive well-being, increase empowerment, and prevent the development of problems of communities, groups, and individuals” Society for Community Research and Action (2001). Social and economic model: “Change strategies are needed at both the individual and systems levels for effective competence promotion and problem prevention” Society for Community Research and Action (2001). Families, communities, and populations within their social, cultural, and historical context. Physical and mental health promotion. Healthy but vulnerable and/or exploited persons and groups. Empowerment and social change. Bottom-up, working alongside. Participatory and facilitative. Empowering. Giving voice to. Diversity. Community development. Capacity building. Social capital. Inequalities. Action research: Active collaboration between researchers, practitioners, and community members utilizing multiple methodologies. TABLE 1.1 Two Approaches to Health Psychology: The Health Service Provider and Community Action Models Characteristic Health Service Provider Model Community Action Model 10 Health Psychology: Overview and Professional Issues meaninglessness are key characteristics of illness. Having the resources to deal effectively with life events and chang- ing social and economic circumstances is a necessary con- dition for health. Resources can be classi“ed into “ve main categories: biological, sociocultural, psychological, economic, and spiritual. The availability and appropriate combination of these resources creates the conditions for well-being. Their absolute or relative nonavailability, creates the conditions for ill health. A primary goal of health psychology is to es- tablish and improve the conditions that promote and main- tain the quality of life of individuals, communities, and groups. Inalienable Right to Health and Health Care for All All people have an inalienable right to health and health care without prejudice or discrimination with regard to gender, age, religion, ethnic grouping, social class, material cir- cumstances, political af“liation, or sexual orientation. The Health-For-All 2000 strategy of the WHO (1985), originally formulated in Alma Ata in 1978, served as an aspirational goal for all countries. As the year 2000 approached, it was ap- parent that the ambitious goals of Alma Ata would not be achieved, at least, by the year 2000. In 1995, the forty-eighth World Health Assembly renewed the Health-For-All global strategy as a •timeless aspirational goalŽ and urged me

bundet

mber states to •adapt the global health policy . . . into national or subnational context for implementation, selecting ap- proaches speci“c to their social and economic situation and cultureŽ (WHO, 1995). Professional psychological organiza- tions across the globe can lend their support to the WHO•s re- newed strategy. Centrality of the Scientist-Practitioner Model The scientist-practitioner model provides the ideal model for professional training in health psychology. It is a common principle across programs in all Western countries. This ac- cords with the position statements on health psychology training provided by an expert group working in the United States (Sheridan et al., 1988) and in Europe (Marks et al., 1998). Professional health psychologists normally require some form of practitioner skills training in health care set- tings in addition to research and evaluation skills. Only by demonstrating competency both in the provision of health care and in evaluation and research will professional health psychologists be able to meet the future challenges and de- mands of health care systems and society more generally. In the next section, we review the professional status of health psychology in the United States. EDUCATION AND TRAINING IN THE UNITED STATES At present, health psychologists in the United States are di- vided fairly evenly between academia and the health care system, some having a foot in both camps. Health psychol- ogy in the United States is being taught, researched, and prac- ticed in two different traditions. The “rst tradition, which can fairly be described as the mainstream, focuses on the clinical issues of patients in the health care system. Responsibility for accrediting professional health psychology programs in the United States lies with the American Psychological Association (APA) Division 38. Division 38 employs the biopsychosocial model that de“nes health and illness as: •the product of a combination of factors including biological characteristics (e.g., genetic predisposition), behavioral fac- tors (e.g., lifestyle, stress, health beliefs), and social condi- tions (e.g., cultural in”uences, family relationships, social support).Ž We will return to this model later, but the model is an extension, rather than a replacement, of the biomedical model (Marks, 2002). The second approach is that of community health psychology as represented by Division 27 of the APA, the Society for Community Research and Action (SCRA). The mission of the SCRA is described as follows: The Society is devoted to advancing theory, research, and social action to promote positive well-being, increase empowerment, and prevent the development of problems of communities, groups, and individuals. The action and research agenda of the “eld is guided by three broad principles. Community research and action is an active collaboration between researchers, practi- tioners, and community members and utilizes multiple method- ologies. Human competencies and problems are best understood by viewing people within their social, cultural, and historical context. Change strategies are needed at both the individual and systems levels for effective competence promotion and problem prevention. Membership of the SCRA includes psychologists and peo- ple from related disciplines such as psychiatry, social work, sociology, anthropology, public health, and political science, including teachers, researchers, and activists. Community psychology is concerned with healthy psychosocial develop- ment within an ecological perspective. It focuses on health promotion and disease prevention, rather than waiting for ill- ness to develop and to diagnose and treat the symptoms. Education and training for health psychologists in the United States is offered using both models that will be described in turn.Among clinical service providers, education Education and Training in the United States 11 and training in health psychology was “rst discussed in the early 1980s. A National Working Conference on Education and Training in Health Psychology at Arden House recom- mended that two years of postdoctoral training be mandated for licensed practitioners in health psychology. The confer- ence proposed a three-stage continuum of education from pre- doctoral studies leading to the PhD through a predoctoral internship year followed by a mandatory two-year postdoc- toral residency. The predoctoral content of education is the traditional coverage of biological and social bases of behavior, individ- ual differences, history and systems, ethics, and professional responsibility. Within this generic general psychology educa- tion, there should be a health psychology track including speci“c instruction in the theory and science of human phys- iology, pathophysiology, neuropsychology, social systems theory, psychopharmacology, human development across the life cycle, and psychopathology. Students are expected to ac- quire special skills during this predoctoral phase including: assessment, intervention techniques, broad consultation skills, short-term psychotherapy, family interventions, group dynamics, sensitization to group and ethnic norms, and prospective epidemiologic research training (Sheridan et al., 1988). This list of topics covers a huge range of knowledge and skills but the conference viewed these as a basic founda- tion for effective functioning in a general hospital setting. A postdoctoral implementation committee, appointed at the Arden House Conference, added other areas of mastery at the postdoctoral level including: Coping strategies for chronic illness. Pain intervention techniques. Presurgery and postsurgery counseling. Compliance programs for speci“c illness groups. Stimulus reduction prevention programs and strategies. Counseling for parents with high-risk infants. Psychotherapy for persons with eating disorders. Programs for the chemically dependent. Stress reduction for cardiovascular disorders. Training in supervisory techniques, and Advanced liaison skills. The Arden House recommendations were elaborated on in a position statement published by the postdoctoral imple- mentation committee (Sheridan et al., 1988) who described the rationale for requiring this training, a model, and criteria for developing programs. The scientist practitioner model used in clinical psychology training was adopted and Matarazzo•s (1980) de“nition of health psychology was the foundation stone. The model is based on the programs that exist for medicine and dentistry and as such should be no less rigorous and quality controlled. The committee pro- posed a •modelŽ of postdoctoral training with the following points: Candidates should possess a PhD or PsyD from an APA- approved program with a track or specialty in health psychology and have completed a formal one-year pre- doctoral residency. General hospitals and outpatient clinics are likely to be the principal setting for health psychology training and at least 50% of any postdoctoral trainee•s time should be spent in such settings. Two years of integrated, specialty training. Postdoctoral faculty should be predominantly psychol- ogists, yet interdisciplinary, with doctoral degrees, licensed, and have established expertise in the areas advertised by the programs. At least one supervisor per rotation. A resident will have a minimum of two rotations in the “rst year and, normally, two in the second year. At least six of the following techniques and skills: 1. Relaxation therapies. 2. Short-term individual psychotherapy. 3. Group therapy. 4. Family therapy. 5. Consultation skills. 6. Liaison skills. 7. Assessment of speci“c patient populations (e.g., pain patients, spinal cord injury patients). 8. Neuropsychological assessment. 9. Behavior modi“cation techniques. 10. Biofeedback. 11. Hypnosis. 12. Health promotion and public education skills. 13. Major treatment programs (e.g., chemical dependence, eating disorders). 14. Compliance motivation. Sheridan and coworkers (1988) conclude their report with a brief review of the key issue of funding: Who pays for health psychology training? In the late 1980s, federal funding of training posts through the NIH and Alcohol, Drug Abuse, and Mental Health Administration was under threat and it seemed likely that Medicare and Medicaid would not pick up the tab. The removal of public and private training funds meant that training providers would be forced to pass the 12 Health Psychology: Overview and Professional Issues training costs on to the trainees themselves in tuition fees. However, in spite of this changing climate, a large proportion of training places in doctoral programs have remained fully or partly funded. The very impressive range of expertise listed by the post- doctoral implementation committee surely requires an educa- tional program extending into a minimum of two years, and arguably, much longer. It cannot be doubted that to carry out any six of the 14 areas of competence would certainly require a minimum of two years. Approximately 50 clinical and counseling doctoral pro- grams in North America offer a concentration in health psy- chology. Another few are concerned exclusively with health psychology. Almost all of these programs require candidates to complete a one-year internship/residency before obtaining their doctorates. The Guide to Internships in Health Psychol- ogy developed by Division 38•s Committee on Education and Training lists APA-accredited psychology internship pro- grams at about 70 establishments in the United States and “ve in Canada. These internships devote a minimum of half of the intern•s time to training in health psychology. Another dozen institutions offer minor rotations with less than half- time spent on health psychology. Stipends for predoctoral in- ternships are generally in the range of $15 to $20 thousand. At postdoctoral level, there are around 30 training programs in the United States. Weiss and Buchanan (1996) published a list of international training opportunities, some of which may be substituted for an internship in the United States. Once a postdoctoral quali“cation has been obtained, a health psychologist in the United States can apply for a state license and be listed in the National Register of Health Service Providers. The second training model for health psychologists exists within graduate programs in community psychology. A sur- vey on behalf of the Council of Program Directors in Com- munity Action and Research (CPDCRA) by Lounsbury, Skourtes, and Cantillon (1999). The survey revealed 43 pro- grams offering graduate training in community psychology, 21 of which have a primary emphasis on community psychology. Twelve of the programs are community/clinical programs that typically have grown out of preexisting clini- cal psychology programs and offer doctorates. These pro- grams accepted approximately 80 students in 1998 from a total of 1,700 applications. Health promotion, in the sense of positive well-being, is a prominent theme in these programs and the graduates. Field placements occur in a variety of settings including mental health settings. Graduates most often take clinical or community work positions. With a growing awareness of the community psychology, such pro- grams are likely to expand. It can be seen from this brief description that both of the approaches to health psychology described previously (see Table 1.1) are being developed in the United States. EDUCATION AND TRAINING IN EUROPE Professionalization of health psychology in European coun- tries is on average 10 to 20 years behind the United States but follows a similar philosophy and rationale. In some countries (e.g., France, Portugal), it is 50 years behind, in others (e.g., Austria, Netherlands), it is not behind at all. Responsibility for policy regarding professional psychology in Europe lies with an umbrella organization called the European Federa- tion of Professional Psychologists• Associations (EFPPA). Under the umbrella of EFPPA, national member associations operate with a mixture of national and transnational agendas and policies. Member associations balance the desirability of subscribing to pan-European principles with national priori- ties and interests. A Task Force on Health Psychology was established by EFPPA in 1992 with the following objectives: 1. To de“ne the nature and scope of health psychology and its possible future development to the year 2000. 2. To specify training needs and objectives for profes- sional health psychologists consistent with the agreed de“nition. 3. To examine different models and options for the training of health psychologists and to select from among them suitable models for EFPPA countries. The Task Force disseminated its working papers in a series of newsletter reports, conference symposia, and workshops (Donker, 1994, 1997; Marks, 1993, 1994a, 1994b, 1994c, 1994d, 1997a, 1997b; Marks, Donker, Jepsen, & Rodriguez- Marin, 1994; Marks et al., 1995a; Marks & Rodriguez-Marin, 1995; Rodriguez-Marin, 1994; Sidot, 1994; Wallin, 1994). An interim progress report was accepted by the EFPPA General Assembly in 1995 (Marks et al., 1995b). The Final Report was adopted by the General Assembly of EFPPA in Dublin in 1997 and published by Marks et al. (1998). The EFPPA approach followed the health service provider model of Table 1.1 al- though it addressed some issues that are amenable to the com- munity action approach. Rationale for Training The rationale for developing training of health psychologists in Europe is the rapid growth of new developments in research Education and Training in Europe 13 and practice ”owing out of this interdisciplinary “eld. At the same time, changes in health policy in many countries are generating new roles for psychologists. With a growing awareness of the importance of psychosocial factors in the promotion and maintenance of well-being, the demands for professional health psychology services within European health care systems are expected to increase. As Garcia- Barbero (1994) stated, •Health professionals clearly need more appropriate training to meet the challenges of the health for all policy, to meet the health needs of the population, to re- duce health costs, to assure quality, and to permit the free movement of suf“ciently quali“ed health professionals.Ž Under the national ethical codes of the psychology pro- fession, there is an absolute responsibility to ensure that psychologists only practice in areas of competence. This prin- ciple requires that health psychologistsbetrainedandassessed for their competence before they enter into unsupervised prac- tice. Psychologists wishing to practice in new areas therefore have a responsibility to become appropriately trained and experienced. Complementing Other Fields of Applied Psychology As noted earlier, there are overlapping competencies between health psychologists and other applied psychologists work- ing in health “elds and it is likely that there will be shared, generic components of training. All psychologists working in health “elds have a common foundation of basic education in psychology. Psychologists with experience and/or training in “elds of applied psychology wishing to have a professional quali“cation in health psychology should be permitted to re- ceive accreditation of their prior experience and/or training. The proposed training should be speci“cally designed to ful- “ll this objective of complementarity. Professional Autonomy and Complementary Independence The ultimate objective of training should be professional autonomy and complementary independence. The latter re- quires mutual respect of experience and training, without in- trusions, infringements, or subordination across health care professions. Stages of Competency It is recognized that practitioner-training passes through stages in which a person will, at “rst, practice under supervision of another fully experienced practitioner. Following an appropri- ate level of supervised, placement experience with a range of settings and client groups, the psychologist will be competent to practice in his or her own right. However, training is never “nal and practitioners require continuous professional devel- opment through the acquisition of new skills and with the de- velopment of new technologies and the updating of knowledge following the advancement of research. Training Guidelines for Professional Health Psychologists Different educational systems and traditions affect the struc- ture of curricula for training professional psychologists in dif- ferent European countries. In several meetings, the Task Force deliberated on the idea of formulating a “xed set of minimal standards for the whole of Europe. Three case studies of train- ing at different levels of development were analyzed in depth (training in Denmark, Germany, and Holland). Symposia and workshops were held at international conferences at which training models for different countries were compared and contrasted (Donker, 1994; Marks et al., 1995a; Rodriguez- Marin, 1994; Rumsey et al., 1994a; Sidot, 1994; Wallin, 1994). Large, possibly irreconcilable, variations are evident in the models and methods of training and in the amount of ex- perience deemed necessary for nationally accredited recogni- tion as professional psychologists across different countries. One country (Austria) has a law specifying the tasks to be per- formed by professional health psychologists. In the remain- der, the tasks and responsibilities of professional health psy- chologists (and, for most countries, other applied psychologists as well) are dependent on a complex array of na- tional, regional, and local agreements. Training practices are equally diverse. In a few countries, training programs are well advanced and have been implemented by national associations (e.g., Berufsverband Osterreichischer Psychologen, 1995; Dansk Psykologforening, 1996). Other associations are making progress in formulating and implementing training guidelines (e.g., British Psychological Society: Edelmann et al., 1996; Rumsey et al., 1994b; Berufsverband Deutscher Psychologen: Rielander, 1995). However, many European countries still do not yet train health psychologists in any speci“c and specialized manner. If health psychology is to achieve its full potential in European health care systems, training will need to be imple- mented much more widely than is presently the case. This will only be possible within the particular legal and professional conditions that determine the organization of psychology and health care in different countries. A principle of subsidiarity must therefore operate. However, it will be necessary to at least have a framework for training in each country and these guidelines provide that framework. 14 Health Psychology: Overview and Professional Issues The EFPPA task force placed the training requirements of professional health psychologists into eight categories: 1. Academic Knowledge Base (Psychology). Professional health psychologists require an in-depth understanding of: Lifespan perspectives and developmental processes. Health-related cognitions. Social factors and ethnicity. Psychoneuroimmunology. Psychophysiological processes. Primary, secondary, and tertiary prevention in the con- text of health-related behavior. Risk factors. The health and safety of individuals in the workplace. Personality, health, and disease. Stress, illness, and coping. Health care professional-patient communication. Psychological aspects of medical procedures. Coping with life events. 2. Academic Knowledge Base (Other). Professional health psychologists require understanding of relevant aspects only of: Epidemiology. Ethics. Genetics. Health policy. Health sociology. Health economics. Human biology. Immunology. Medical anthropology. Medicine. Physiology. Pharmacology. Neuroendocrinology. Cultural and religious studies. 3. Application of Psychological Skills to Health Care. Profes- sional health psychologists require a working knowledge of: Communication skills. Consultancy skills. Counseling skills. Assessment and evaluation. Psychological interventions aimed at change in indi- viduals and systems (e.g., families, groups, worksites, communities). 4. Research Skills. Professional health psychologists require a working knowledge of research skills in speci“c appli- cation to health and health care. 5. Teaching and Training Skills. Professional health psychol- ogists require skills for teaching and training students and other health and social care professionals including super- visory skills. 6. Management Skills. Professional health psychologists re- quire a working understanding of organizations and teams. 7. Professional Issues. Professional health psychologists re- quire a working understanding of: The place and status of health psychology in society. Professional identity and autonomy. Legal and statutory obligations and restrictions. Transcultural issues. International perspectives on professional health psy- chology. 8. Ethical Issues. Professional health psychologists are required to follow the ethical code of their national associations. Implementation of Training The future development of health psychology as a profession depends on putting theory and policy into practice through the implementation of high-quality training. Currently, there are relatively few European countries where this has yet happened. Training programs need to be introduced in all European countries within the framework of each member- country•s national laws, regulations, and practices. Section three speci“es “ve skill areas that were seen, not as optional, but as mandatory. The assumptions of the Matarazzo de“nition, the biopsychosocial model, and work- ing in clinical settings are held in Europe as strongly as in the United States. The Education and Training Committee of the EHPS has published a reference guide of graduate programs in health psychology in Europe (McIntyre, Maes, Weinman, Wrzesniewski, & Marks, 2000). There are many masters and PhD level programs but few DPsych or PsyD programs have yet been developed. The traditional PhD is an academic qual- i“cation providing little or no training in practitioner skills. With some exceptions (e.g., the Netherlands), European programs have a long way to go before they match most U.S. programs for the depth and breadth of coverage. EDUCATION AND TRAINING IN THE UNITED KINGDOM Responsibility for the accreditation of education and training in psychology in the United Kingdom lies with the British Psychological Society (BPS). The Society approved regula- tions for a full professional quali“cation in health psychology Education and Training in the United Kingdom 15 in 2001. This quali“cation is essential to all those wishing to work professionally in the health psychology “eld. On com- pletion, candidates are eligible for full membership of the Division of Health Psychology permitting the member to use the title •Chartered Health PsychologistŽ and to have his or her name listed in the Society•s Register. The training system is based on the health service provider model of Table 1.1. No programs using the community action model have yet been accredited by the BPS Health Psychology Division. In the United Kingdom, community action programs are more likely to be located in departments of geography or in health promotion units than in departments of psychology (e.g., Cave & Curtis, 2001; Lethbridge, 2001). To date, with one or two notable exceptions (e.g., Bennett & Murphy, 1997), there has been relatively little interest in the community approach within British health psychology. Education and training of health psychologists in the United Kingdom is in three stages: (a) undergraduate, (b) postgraduate stage 1 (MSc), © postgraduate stage 2 (MPhil, PhD, PsychD, or DPsych). To enroll as a candidate for the stage 1 postgraduate quali“cation in Health Psychol- ogy, the applicant must: 1. Be a graduate member of the British Psychological Soci- ety and hold the Graduate Basis for Registration; and 2. Either hold, or be enrolled in, a postgraduate research de- gree relevant to health psychology and include an empiri- cal research project, or 3. Be a chartered psychologist seeking lateral transfer from another area of psychology. The postgraduate stage 1 is often completed as a BPS- accredited MSc degree in health psychology in any one of about 20 institutions. Otherwise candidates may take an examination set by the Board of Examiners in Health Psy- chology (BEHP). This examination comprises four written papers, a research project, and an oral examination on the research project. The topics covered in the written examina- tion papers are: Health-related behavior: Cognitions and individual differences. Psychosocial processes in illness and health care delivery. Research and development in health psychology. Context and related areas. The research dissertation must be a piece of supervised, self-selected original health-related research in accordance with the BPS ethical guidelines, and should not exceed 14,000 words. Following successful completion of the stage 1 quali“ca- tion, candidates may proceed to stage 2. To enroll as a candi- date for the stage 2 quali“cation, the applicant must: 1. Be a graduate member of the BPS and hold Graduate Basis for Registration. 2. Hold either the stage 1 quali“cation in health psychology, or a postgraduate BPS accredited quali“cation in health psychology, or have a statement of permission to proceed to the stage 2 Quali“cation from the BEHP. 3. The stage 1 quali“cation involves the attainment of a health psychology knowledge base and postgraduate re- search skills. The stage 2 quali“cation builds on stage 1 by assessing professional level capability in research, consultancy, teaching, and training and also generic pro- fessional competence in relation to psychological prac- tice. From September 2004, applicants for Chartered Health Psychology status who began their training after September 1, 2001, will have to demonstrate competence in 21 units„19 core units and two optional units. The 19 required units are divided into 73 speci“c components in four domains. Professional Competence Health psychologists should be able to maintain personal and professional standards in their practice and act ethically. Core competencies include: 1. Implement and maintain systems for legal, ethical, and professional standards in applied psychology„security and control of information; compliance with legal, ethical, and professional practices; procedures to ensure compe- tence in psychological practice and research. 2. Contribute to the continuing development of self as a professional applied psychologist„process of self- development; knowledge and feedback to inform practice; access to competent consultation and advice; professional development; best practice as standard. 3. Provide psychological advice and guidance to others„ assess opportunity, need, and context for giving psycho- logical advice; provide psychological advice; evaluate advice given. 4. Provide feedback to clients„evaluate feedback require- ments; preparation and structure; methods of communica- tion; presentation of feedback. 16 Health Psychology: Overview and Professional Issues Research Competence Health psychologists must be capable of being independent researchers. Core competencies include: 1. Conduct systematic reviews„de“ne topic and search pa- rameters; employ appropriate databases and sources; sum- marize “ndings. 2. Design psychological research„identify relevant research “ndings; generate testable hypotheses; de“ne resources and constraints; methodology; validation of measures; pre- pare, present, and revise research designs. 3. Conduct psychological research„obtain required re- sources and access to data and/or participants; research protocol; pilot existing methods; conduct research. 4. Analyze and evaluate psychological research data„ analyze and interpret data; evaluate research “ndings; written account of research project; review research process; review and evaluate relationships between cur- rent issues in psychological theory and practice. 5. Initiate and develop psychological research„conduct re- search; monitor and evaluate research in accordance to protocols; explain and critique implications of research for practice; evaluate potential impact of research devel- opments on health care. Consultancy Competence Health psychologists must be capable to apply psychological knowledge to health care and health promotion practice. Core competencies include: 1. Assessment of requests for consultancy„determine, pri- oritize, and con“rm expectations and requisites of clients; review literature for relevant information; assess feasibil- ity of proposal. 2. Plan consultancy„aims, objectives, and criteria; imple- mentation plan. 3. Establish, develop, and maintain working relationships with clients„establish contact with client; contract; de- velop and maintain, and monitor and evaluate, working relationships with clients. 4. Conduct consultancy. 5. Monitor the implementation of consultancy„review consultancy; implement necessary changes; review client expectations and requisites; implement quality assurance. 6. Evaluate the implementation of consultancy„design and implement evaluation; assess evaluation outcomes. Teaching and Training Competence Health psychologists must be capable to train others to un- derstand and apply psychological knowledge skills, practices and procedures. Core competencies include: 1. Plan and design training programs that enable students to learn about psychological knowledge, skills, and practices„assess training needs; identify training pro- gram; select methods; produce materials; employ appro- priate media. 2. Deliver training programs„implement training methods; facilitate learning. 3. Plan and implement assessment of such training programs„ identify assessment methods and select regime; determine availability of resources for assessment procedures; produce assessment materials; ensure fair appreciation of assessment methods; keep record of progress and outcomes. 4. Evaluate such training programs„evaluate outcomes; iden- tify contributing factorsofoutcomes;identify improvements. Optional Competences Two of the following eight optional units of competence must also be attained: 1. Implement interventionstochangehealth-relatedbehavior. 2. Direct the implementation of interventions. 3. Communicate the processes and outcomes of interven- tions and consultancies. 4. Provide psychological advice to aid policy decision mak- ing for the implementation of psychological services. 5. Promote psychological principles, practices, services, and bene“ts. 6. Provide expert opinion and advice, including the prepara- tion and presentation of evidence in formal settings. 7. Contribute to the evolution of legal, ethical, and profes- sional standards in health and applied psychology. 8. Disseminate psychological knowledge to address current issues in society. The trainee health psychologist undergoes a period of supervised practice equivalent to two years of full-time work (a “ve-day week for 46 weeks a year). This provides direct experience of professional life and facilitates the develop- ment of skills and abilities relevant to health psychology. Candidates• total work experience should encompass at least two different categories of clients and be health-related work of a psychological nature. Health-related work may Similarities and Differences between the U.S., European, and U.K. Models 17 include paid employment, academic work, training and de- velopment activities, and voluntary work. Candidates must arrange supervision from an approved Chartered Health Psychologist. A contract of supervision, indicating payment, is drawn up. Candidates devise a formal supervision plan that includes a work plan outlining core competencies addressed with target dates, details of evidence that will demonstrate satisfactory completion of competen- cies, name of supervisor, expected date of completion of stage 2, and any additional training and development activi- ties needed. To achieve the stage 2 quali“cation, candidates must demonstrate competencies in all 19 areas. No exemp- tions are permitted. All candidates are bound by the BPS Code of Conduct. The role of the supervisor is to: Oversee the preparation and review of the supervision plan. Countersign the supervision plan, supervision log, and supporting evidence, and “ll in the required sections of the completion forms. Provide information. Listen to the views and concerns of the candidates con- cerning their work in progress and advise as appropriate. Encourage re”ection, creativity, problem solving, and the integration of theory into practice. The examination consists of an oral examination and the submission of a portfolio of evidence of competencies. The portfolio should include a practice diary, supervision log, records of completion, supporting evidence, and any addi- tional clari“cation. Candidates are enrolled for a minimum of two years, and a maximum of “ve years. When full member- ship of the Division of Health Psychology has been gained, members become Chartered Health Psychologists and they are listed in the British Psychological Society•s Register. SIMILARITIES AND DIFFERENCES BETWEEN THE U.S., EUROPEAN, AND U.K. MODELS It is informative to compare the three health service models developed in the United States, Europe, and United Kingdom. A summary of the competencies included in the three models are presented in Table 1.2. A Common Core It can be seen that there is a solid core of three competen- cies that all three models include in one form or another: teaching/training, consultancy, and research. All practicing health psychologists need to acquire these skills for their pro- fessional work whether they are working in the United States or Europe. In the United States, health psychologists are trained to carry out therapies and interventions alongside their clinical colleagues. Perhaps more than in some other areas of applied psychology, the core competencies of the health psychology practitioner in the United Kingdom show considerable overlap with those of the academic psycholo- gist. However, this is likely to change as the profession be- comes more con“dent about what it has to offer. Differences between Regions or Countries and Gaps in Training Some skills that are seen as essential in one region or country are seen as optional in others, for example, interventions aimed at change in individuals and systems, counseling, management, liaison, and health promotion skills. There are some signi“cant omissions in training requirements that war- rant further discussion by the relevant committees. For exam- ple, the BPS curriculum omits training in assessment and evaluation, communication, counseling, and management skills. The APA curriculum also omits communication, coun- seling, and management. Can health psychologists really practice to their maximum potential without competence in these areas? Merely having access to research information about these subjects is insuf“cient: Knowing about is not the same as knowing how. Table 1.2 reveals a number of gaps in training in the United States and United Kingdom medical textbooks in- variably have chapters about doctor-patient communication, comment on its de“ciencies, and recommend special training on communication skills for medical doctors. Why should health psychologists be any better at communication, without special training, than physicians? Without mandatory train- ing, these competencies are left to individual practitioners to pick up when, where, and however they can. The quality of services and health improvements may be less than optimum as a consequence. Another surprising gap is the lack of as- sessment and evaluation training in the U.K. training curricu- lum. These are basic competencies that are used everyday within clinical psychology. Assessment is a necessary stage in the choosing and tailoring interventions for individual clients. Evaluation of effectiveness is paramount to the as- sessment of ef“cacy and effectiveness. Perhaps these differences and gaps re”ect the histories and cultures of professional psychology in different regions and countries. Perhaps they re”ect a desire not to encroach on other established psychological professions such as clinical, 18 Health Psychology: Overview and Professional Issues „ „ Health promotion and public education skills. Consultation skills. Assessment of speci“c patient populations (e.g., pain patients, spinal cord injury patients). Short-term individual psychotherapy. Group therapy. Family therapy. Relaxation therapies. „ „ „ „ Liaison skills. Neuropsychological assessment. Behavior modi“cation. Biofeedback. Hypnosis. Major treatment programs (e.g., chemical dependence, eating disorders). Compliance motivation. Doctoral dissertation. Communication skills. Teaching and training skills. „ Consultancy skills. Assessment and evaluation. Psychological interventions aimed at change in individuals and systems. Professional issues. Ethical issues. Counseling skills. Management skills. „ Research skills. „ Teaching and training competence. „ Consultancy competence. „ Implement interventions to change health related behavior. Professional and ethical issues. „ „ Direct the implementation of interventions. Communicate the processes and outcomes of interventions and consultancies. Provide psychological advice to aid policy decision making for the implementation of psychological services. Promote psychological principles, practices, services, and bene“ts. Provide expert opinion and advice, including the preparation and presentation of evidence in formal settings. Contribute to the evolution of legal, ethical, and professional standards in health and applied psychology. Disseminate psychological knowledge to address current issues in society. Research competence. TABLE 1.2 Health Psychology Competencies Mandated by Professional Associations in the United States, Europe, and the United Kingdom. Skills or competencies in bold are required. Others are optional United States/APA (1988): Europe/EFPPA (1997): United Kingdom/BPS (2001): At Least 6 of 14 Techniques 10 Competencies in 8 Domains 21 Units across 4 Domains counseling, and occupational psychology. Perhaps they also re”ect the lack of consensus about the de“nition of health psychology. Should it strive to become the overarching health care profession of Matarazzo•s (1980) de“nition, or a more specialized profession focusing on the maintenance of health and prevention of illness in currently healthy persons in line with Matarazzo•s (1980) de“nition of behavioral health, as recommended by McDermott (2001)? Only the fu- ture will tell which of these models wins the day. CRITIQUE OF PROFESSIONALIZATION The development of an outline of a set of core competencies for health psychologists has led to a great deal of discussion and debate. One of the main issues of concern has been whether health psychology is ready yet to become a profes- sion, and if so, how this change in status is to be accom- plished. Developing the profession too early may result in a profession with too little to deliver, a •naked emperorŽ (Michie, 2001). Worse, a naked emperor, or empress, might cause offense and do harm to, rather than improve, the health of his or her subjects! The construction of a core set of competencies took the APA and EFPPA “ve years and the BPS six years to com- plete. Similar periods will, no doubt, be required for any new system to be thoroughly tried and tested. Judgments about what a health psychologist should know and be able to do are based on extant beliefs, values, and aspirations, and little else but intuition. Consequentially, committee decisions about the objectives and content of education and training are highly contentious. Ethical and Policy Issues 19 Despite being a relatively new area of applied psychology, health psychology is developing at an astonishing rate. New health psychology programs are being introduced, textbooks are appearing continuously and going into second, third, and fourth editions, and the academic journals are expanding and ”ourishing. Health psychology has a real potential to have a positive impact on the health of society. Yet the de“nition of health psychology is still in contention and there are at least two quite different approaches to the “eld. In a recent essay, the “rst author suggested that four styles of working are be- ginning to emerge: clinical, public, community, and critical health psychology (Marks, 2002b). In a recent debate in the BPS Division of Health Psychol- ogy•s newsletter, Health Psychology Update, Bolam (2001) asked, •Whom does professionalization advantage, and at what cost?Ž Bolam suggested that any abstract attempt at a de“nition inevitably obscures the complex web of social, in- stitutional, historical, and economic forces from which health psychology has emerged. He suggested that the argument that health psychologists •owe it to the publicŽto be professional is only part of the story. Bolam felt little con“dence in the claim that health psychology has a unique set of techniques to offer the health care system. Bolam argued that professional- ization is really about •self-promotion and the struggle to increase access to resources and power.Ž What health psy- chologists gain comes at a cost, however, and identity is not only about claiming what health psychologists are, but also what they are not. Health psychologists should challenge the biologically reductionist tendencies and the hierarchical structures of biomedicine by introducing new discourses about people and health. Bolam suggests that •Instead of chal- lenging the biologically reductionist tendencies and hierarchi- cal structures of biomedicine by introducing new discourses of people and health, we replicate the very mistakes we could help to remedy, merely aspiring to be further up the table.Ž This leads to a concern that the current mainstream train- ing proposals in the United States, Europe, and the United Kingdom are strongly in”uenced by the biopsychosocial model that could sti”e the development of the “eld. Michie (2001), on the other hand, contra Bolam, argued that professionalization •does not just bene“t health psychol- ogists…but also bene“ts recipients of psychological ser- vices, employers, policymakers, and the public. It bene“ts everybody to know who we are and what we doŽ (p. 18). A de“nition, at least of the core concept, is essential for the progress of science and for strategic development of its ap- plication. Professionalization helped to ensure minimum standards of practice and accountability. Sykes (2001) entered the debate with the thought that it was the health psychologists•responsibility to practice only in those areas where they have been trained and have a level of competence. Consumers, patients, clients, and communities need to feel con“dent that health psychologists have been fully trained to deliver evidence-based services. Clients have a right to know who health psychologists are and what ser- vices they are competent to deliver. Have the current education and training proposals left un- recognized a lot of work that health psychologists do, or could do? For example, health psychologists can work not only within the health service delivery model but from a communitarian perspective, following a model of community action and research. Community action requires a unique set of skills. These include communication and negotiation skills, the art of unlearning, appropriately empowering others, ”exibility, a great amount of perseverance, and a be- lief in a vision. Working alongside others on an equal footing is the order of the day, not offering a service, but sharing an action. This type of work is as much in need of a professional approach as any other. Thus, the debate has turned full circle and re”ects the differences between the two models of training discussed earlier, the clinical treatment of illness ap- proach versus the community health promotion approach. Despite these differences in opinion, there is a central theme in the debate: making health improvement the main priority for health psychology. Such debates should be viewed positively because an applied discipline must contin- uously re”ect and be open to change. ETHICAL AND POLICY ISSUES Professional health psychologists are expected to comply with the ethical codes of their national associations. However, ethics must not be viewed simply as a set of principles for dealing with special or speci“c circumstances when dilem- mas occur. Every action, or inaction, in health care has an eth- ical dimension (Seedhouse, 1998). In this section, we review issues of a policy nature that highlight ethical issues for health psychologists and all other health care professionals. Poverty and Inequality All people have an equal right to health and health care. That contemporary societies have large health variations is readily apparent (Carroll & Davey Smith, 1997; Wilkinson, 1996). Of major signi“cance in both developed and developing so- cieties is poverty. In pursuit of health-for-all, the health care system must strive to equalize the opportunities of all members of society. This principle requires psychologists to provide their services (whenever possible) to all people 20 Health Psychology: Overview and Professional Issues regardless of gender, age, religion, ethnic grouping, social class, material circumstances, political af“liation, or sexual orientation. When access is low, or when there is evidence of greater needs, special efforts should be made to target ser- vices to those with the poorest access or greatest need (e.g., refugees, the homeless, lower income groups). Policy deci- sions concerning the allocation of resources to these needy groups both inside and outside of the health care system are about ethics as much as politics. Economics The demand for health care exceeds supply. This fact has economic implications for services. First, it is necessary to provide services according to the health needs of all client groups. Second, it is necessary to analyze health care eco- nomically. This means that cost-bene“t analyses and evi- dence of cost-effectiveness should be utilized in making decisions about services. It is likely that some psychological interventions are able to provide more cost-effective options than pharmacological and medical treatments (Sobell, 1995). However, the evidence to provide de“nite support of this claim is often not available. If psychological interventions are to be more widely employed, it is necessary that more ef- fort and resources be devoted to economic analyses of their cost-effectiveness. Third, whether we like it or not, health services have to be rationed. Unless we accept the philoso- phy that those who receive a service are those who can af- ford it (or the insurance premiums), the decision about who receives or does not receive a service is both political and ethical in nature. In many countries, psychology services are in short supply and among the least accessible and most ra- tioned. Yet rationing is rarely discussed in the psychology literature. New Technologies New scienti“c and medical technologies are having dramatic effects on the cost-effectiveness, ef“ciency, and competence of health care (e.g., microsurgery, organ transplantation, ge- netic testing/screening, gene therapy, in vitro fertilization). Genetic information and its communication to individuals and families are sensitive issues that have both psychological and ethical implications (Lerman, 1997). Following the produc- tion of a sheep clone, •DollyŽ (Wilmut, Schnieke, McWhir, Kind, & Campbell, 1997), the cloning of humans is likely soon to become technically possible. In spite of reassurances from a professor of fertility studies (Winston, 1997), this prospect raises profound ethical questions among health professionals, patients, and families (Human Genetics Commission, 2000). There may be biological, psychosocial, or moral implications that have not yet been adequately conceptualized. Not only do new technologies increase the need for public understanding and debate, they require medical scientists and health professionals to be completely open and honest about the bene“ts, risks, and possible sequelae of treatments and procedures. Communication, counseling, and informed con- sent are becoming increasingly vital elements of health care (Marteau & Richards, 1996). However, it is recognized that providing people with genetic information on risk may not in- crease their motivation to change behavior and in some cases may even decrease their motivation (Marteau & Lerman, 2001). In these areas, psychologists should play a major role. The Aging Population Demographic data show that the Western population is aging. In Europe in January 1993, there were 117 million people aged 50 years and over (32%) and nearly 75 million aged 60 and over (20%) in the 15 countries of the European Union. The latter will increase to over 25% by the year 2020. In terms of health policy, the most signi“cant increase is in the numbers of people who are 80 years or more, particularly women, large numbers (48%) of whom live alone, especially in northern Europe (Walker & Maltby, 1997). An increasingly prevalent combination of frailty, poverty, and social isolation is making older age a time of signi“cantly reduced quality of life. This is particularly true for the in- creasing numbers of people suffering from Alzheimer•s dis- ease, or other forms of dementia, and their informal caregivers (European Alzheimer Clearing House, 1997). A report from the Eurobarometer surveys suggests that poverty, age discrim- ination, fear of crime, and access to health and social care are signi“cant barriers to social integration among older people (Walker & Maltby, 1997). On the more positive side, the sur- veys suggest that, •Just under one-quarter of older people were very satis“ed with their lives, more than half fairly satis- “ed and only one in “ve not satis“edŽ (p. 122). Promotion of social integration of older people, particularly those living alone, presents a major challenge for the future. Health psy- chologists will need to work closely with other professionals to “nd new ways of enhancing social integration and well- being of older members of the population and their caregivers. CONCLUSIONS Health psychology is a research “eld that entered the market- place of health care quite recently. Competing and contrasting de“nitions suggest different approaches to the enterprise. The References 21 mainstream approach is modeled on health service provision similar to clinical psychology, but dealing principally with physical health and illness. It is founded on what is termed the •biopsychosocialŽ model. This approach is sometimes re- ferred to as •clinical health psychology.ŽAnother approach is modeled on community action and research and deals with the promotion of well-being in its social and community context, a kind of psychological health promotion. The different ap- proaches have different philosophies, methods of working, models of training, goals, and objectives. Up to the present, lit- tle effort has been directed toward integrating these two ap- proaches. Perhaps they are resistant to integration. Professionalization in health psychology is a problematic exercise. Some contend that it has occurred too soon, before there is suf“cient evidence to play on the same “eld with the •big-hittersŽ of the more established health professions (medicine, nursing, dentistry). Others argue that it is neces- sary to credentialize practitioners as soon as possible with registration procedures following approval of their training and supervised experience. Others argue that the health ser- vice provider model limits the development of health psy- chology. While the debate continues, education and training programs are proceeding apace. Training programs in the United States were established at least 10 years earlier than in most of the rest of the world. Core elements of health psychology competence agreed to by three independent panels are research, consultancy, and teaching and training. Other skills, viewed as optional by some panels and as mandatory by others, include: interventions for individ- uals and systems; communication skills; counseling skills; and assessment and evaluation skills. New programs are cur- rently being developed and it would be a valuable exercise to evaluate progress in another decade•s time. REFERENCES American Psychological Association. (1996). Division 38„Health psychology home page [Online]. Bennett, P., & Murphy, S. (1997). Psychology and health promotion. Buckingham, England: Open University Press. 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PART TWO CAUSAL AND MEDIATING PSYCHOSOCIAL FACTORS CHAPTER 2 Stressful Life Events RALF SCHWARZER AND UTE SCHULZ 27 STRESS AND CRITICAL LIFE EVENTS: THEORETICAL PERSPECTIVES 28 The Response-Based Perspective 28 The Stimulus-Based Perspective 28 The Cognitive-Transactional Process Perspective 28 THE NATURE OF STRESSFUL LIFE EVENTS AND DISASTERS 30 Natural and Technological Disasters 30 Controllability 31 Impact of Disasters 31 Victims of Disasters 31 Posttraumatic Stress Disorder (PTSD) 31 ASSESSMENT OF STRESSFUL LIFE EVENTS 32 HEALTH OUTCOMES OF STRESSFUL LIFE EVENTS 34 RESEARCH EXAMPLES OF STRESSFUL LIFE EVENTS 36 Natural Disasters 36 Technological Disasters 37 War and Genocide 38 Conjugal Loss and Bereavement 38 Criminal Victimization 40 Migration 41 STRESSFUL LIFE EVENTS IN THE LIGHT OF INDIVIDUAL DIFFERENCES: GENDER, CULTURE, ETHNICITY, AND AGE 42 Gender 42 Gender and Culture 43 Culture and Ethnicity 43 Age 44 FUTURE DIRECTIONS 44 REFERENCES 45 November 11, 2000, Salzburg, Austria: Around 170 people, mostly children and youths, are believed to have been killed when a blaze erupted on a cable train in the Austrian Alps. Res- cuers at the scene of the inferno in the province of Salzburg say there is •no hope of any more survivorsŽ after just a handful of people out of an estimated 180 passengers escaped alive. (CNN online) The tragedy in Austria reported by CNN left behind hundreds of relatives and friends of the victims, devastated and mourn- ing over the loss of loved ones. Some of the mourners might never fully recover from the shock and the pain, others might be able to return to the lives they were living before the event had occurred. Among those affected are also the few sur- vivors, whose lives will probably never be the same, and the rescue personnel. Although those affected by the tragedy may have similar “rst responses, namely, shock, disbelief, and numbness, the speci“c impact on each individual may be dif- ferent. Some have lost a child or spouse; others have faced death in the tunnel inferno. Unfortunately, major accidents such as “res, airplane crashes, or gas explosions, just to name a few, happen quite frequently in industrial societies. Never- theless, they take most people by surprise, require major readjustment efforts, and alter the course of their lives. Some experiences may have a long-lasting impact on a person•s mental and physical health, while others exert only a short- term in”uence. We start this chapter with a brief overview of theoretical concepts and critical issues related to stressful life event re- search and discuss some characteristics of major events and disasters, and the attempts to measure the unique ways peo- ple experience them. We also present some empirical “ndings on the relationship between speci“c life events and health impairments. Examples are drawn from a variety of natural and technological disasters, war, bereavement, criminal vic- timization, and migration. Not included in this chapter are those health effects that might be due to individual differ- ences in personality, coping, and social support. Life events and coping are inevitably intertwined. In many studies, cop- ing has been identi“ed as a mediating link between stress and imminent health outcomes (see the chapter by Manne in this volume).