Clinical Handbook of Health Psychology

Clinical Handbook ofHealth PsychologyA Practical Guide to Effective Interventions2nd revised and expanded edition

Edited byPaul M. Camic, Ph.D. & Sara J. Knight, Ph.D.

With a Foreword by Robert D. Kerns, Ph.D.

Hogrefe & Huber

Library of Congress Cataloguing-in-Publication Data

is available via the Library of Congress Marc Databaseunder the LC Control Number 2002111970

National Library of Canada Cataloguing-in-Publication Data

Clinical handbook of health psychology : a practical guide to effective interventions /Paul Camic & Sara Knight, editors. — 2nd rev. and expanded ed.

Includes bibliographical references and indexes.ISBN 0-88937-260-8

1. Clinical health psychology. I. Knight, Sara J., 1952– II. Camic, Paul M. (Paul Marc), 1955–

R726.7.C54 2003 616’.001’9 C2003-906312-7

Copyright © 2004 by Hogrefe & Huber Publishers

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ISBN 0-88937-260-8

Robert D. Kerns ForewordRobert D. Kerns

Foreword

Looking back over a twenty-five year careeras a clinical health psychologist, I can reflecton the relatively rapid emergence of a largeand expanding body of knowledge about therole of psychological and interpersonal fac-tors in the broadest possible array of healthand illness issues and the ever-increasing in-fluence the field has had on health practicesand health policy. Our field has evolved intoa sophisticated and rigorous science thatnow spans issues covering the entire lifespan and touching virtually every knownhealth problem. Its influences on educationfrom preschool through advanced profes-sional and scientific training, almost regard-less of the specific area of study, are increas-ingly apparent. Dissemination of knowledgeinformed by work in the field has garneredthe public’s interest in terms of lifestyle,prevention of illness and promotion ofhealth, and expectations for healthcare. Thebreadth, and depth, of our field is enor-mous, and its promise for promoting quali-ty of life, and even extending life, is compel-ling. Health psychology remains an excitingfield, and one that captures the imaginationand creativity of many who wish to influ-ence the health and wellbeing of thosearound us.

Educating others about the breadth andcomplexity of the field of health psychologyin a single text that is both meaningful andengaging clearly presents a series of challeng-es that few would have the nerve to under-take. Drs. Paul Camic and Sara Knight haveonce again risen to the occasion in their pub-lication of this second edition of their previ-ously successful book. Among all of the sim-

ilar texts in the field, this one is at the top ofmy list.

The strengths of this text are numerous,but most important from my perspective isthe success of these authors and their collab-orators in capturing the excitement and en-thusiasm that those of us who are immersedin this field continue to experience on a near-ly daily basis. The editors’ optimism aboutthe potential of the field comes through loudand clear. In this sense the text stands to pro-mote personal growth through an improvedunderstanding of the interface between im-portant psychological and interpersonal fac-tors and health outcomes, and to encouragepersonal action informed by this knowledgeand appreciation. At the same time it is likelyto capture the attention of future scientistsand health professionals and foster an inter-est in the pursuit of a deeper understandingof the potential relevance and importance ofthe field. For those considering a career inpsychology, the text provides a sound foun-dation for future study and investigation byoffering both information about the currentstate of the field and targets for future effortsto advance it.

Several additional strengths of the text areimportant to acknowledge. Contributing tothe readers’ understanding of even the mostcomplex and challenging concepts are con-sistent efforts to promote integration andlinkages across disparate domains and topicsthrough the promotion of a unifying biopsy-chosocial perspective. This perspective servesas an important framework that will likely re-main with the reader long after the course iscompleted. And, thankfully, and as opposed

to many other texts in the field, the “social”dimension of the model is actually empha-sized, rather than being given scant atten-tion. The authors are to be commended fortheir routine consideration of cultural influ-ences on health and behavior and of the cul-tural competence of practitioners. The con-cluding chapters that specifically addressissues such as the role of the social context,spirituality and religion, and ethnic minori-ties help to reinforce this critical, but oftenneglected, dimension.

The first chapter of the book, authored byits editors, sets the stage for a sequential andgraded consideration of the breadth of thefield and provides a firm foundation for thechapters that follow. The chapter begins witha brief historical perspective that highlightsthe emergence of the field and the challengesin defining a new area of investigation andpractice within the context of existing areas ofinquiry and the contemporary healthcare in-dustry. It is in this context that the biopsycho-social perspective is introduced as a unifyingframework for the remainder of the text.Emerging themes in our field are also intro-duced in this chapter, including the conceptsof environment of care, health and illness as acontinuum, integration of art and science,complementary and alternative medicine per-spectives and approaches, the social, cultural,and spiritual contexts of healthcare, and theinfluence of health economics. Discussion ofthese issues serves to encourage the reader tohave an eye to the future when consideringmore specific topics and areas of interest. Thesecond chapter on assessment similarly pro-vides a critical foundation for the remainderof the text by discussing a series of key param-eters of clinical assessment and the role of as-sessment in case conceptualization and in in-forming treatment planning.

The success of the authors of this text inproviding an integration of the science ofhealth psychology and practice is anothernoteworthy strength. This integrative per-spective is represented by the editors of thevolume and by the authors of each chapter.The scholarship represented in each of thechapters is clearly evident, and represents thecurrent status of theory and empirical foun-

dations. Just as important is the emphasis onthe practitioner’s perspective and experience.For example, Van Egeren’s chapter on assess-ment in health psychology tackles practicalissues such as the “reticent patient” that offerthe reader insight into some of the complex-ities and challenges of translating state-of-the-art science and empirical evidence intopractice. As already noted, the specific atten-tion to the cultural context in consideringthese translations is critically importantwhen considering the rapidly shifting demo-graphics of our society and our emergingglobal perspective.

The editors have made a wise decision inoffering a volume that is organized aroundthe consideration of specific diseases or areasof inquiry and practice. Again, their successin engaging leading scholars and practitio-ners in authoring these chapters representstheir appreciation of the trend toward spe-cialization in the field of health psychologyand the practical utility of this organization-al approach. Chapters on diseases or problemdomains in which health psychologists havehad their greatest influence in terms of scien-tific advances, practice, and policy have beenselected to substantially reflect the breadthof our field. Topics included are cardiology,pulmonary medicine, pain and pain manage-ment, dental medicine, diabetes mellitus,gastrointestinal disorders, human immuno-deficiency virus, multiple sclerosis, obstetricsand gynecology, oncology, and urologicaldisorders. The consistent organization ofeach chapter’s content aids the reader in ex-amining similarities and differences acrossthese areas of inquiry and practice and en-courages the development of a broad andwell-informed perspective on the field.

Each chapter begins with a presentation ofinformation that serves to build a founda-tion about the disease or problem from amedical perspective. A consideration of is-sues particularly relevant to the health psy-chologist is subsequently introduced in amanner that, once again, promotes integra-tive thinking and consideration of the prac-tical interface of the practice of clinicalhealth psychology within the broader health-care system. Specific attention to the role of

vi Robert D. Kerns

assessment, case conceptualization andtreatment planning, and psychological inter-vention in the consideration of each disorderor problem domain is critical in further fos-tering this integrative and dynamic perspec-tive. The presentation of a range of clinicalproblems that serve as targets for health psy-chological involvement within each domainserves to enhance the readers’ awareness ofthe breadth of the field, opportunities forcontinued investigation, and the importanceof continued efforts to promote change inour healthcare delivery system. The liberaluse of tables helps to organize information.The routine inclusion of case examples servesto put a “real face” on the problems being ad-dressed by clinical health psychologists. Theconsideration of specific professional prac-tice issues in several of the chapters empha-

sizes the challenges being confronted bypractitioners in the field and ongoing healthpolicy issues.

All-in-all this is an exceptional volume thatwill appeal to educators and students alike.Congratulations to Drs. Knight and Camicand their coauthors for once again capturingthe energy and excitement of the field ofhealth psychology.

Robert D. Kerns, Ph.D.Professor of Psychiatry, Neurology and Psychology

Yale University

Chief, Psychology ServiceVA Connecticut Healthcare System

January 2004

Foreword vii

Table of Contents Table of Contents

Table of Contents

ForewordRobert D. Kerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

PrefacePaul M. Camic & Sara J. Knight . . . . . . . . . . . . . . . . . . . xi

Editors and Contributors . . . . . . . . . . . . . . . . . . . . . . . . xv

Section I: Foundations of Practice

1 Health Psychology and Medicine: The Art and Science of HealingSara J. Knight & Paul M. Camic . . . . . . . . . . . . . . . . . . . 3

2 Assessment Approaches in Health Psychology: Issues and PracticalConsiderationsLinda Van Egeren . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Section II: Physical Systems and Presenting Problems

3 Clinical Cardiac PsychologyAlbert J. Bellg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

4 COPD and Other Respiratory DiseasesSusan M. Labott . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

5 Chronic Pain ManagementKimeron N. Hardin . . . . . . . . . . . . . . . . . . . . . . . . . . 75

6 Dental-Related Problems and Health PsychologyRobert J. Moretti & William A. Ayer . . . . . . . . . . . . . . . . . 101

7 Diabetes Mellitus and Other Endocrine DisordersJames E. Aikens & Lynne I. Wagner . . . . . . . . . . . . . . . . . . 117

8 Gastrointestinal Conditions and DisordersPaul M. Camic & Laura M. Gaugh . . . . . . . . . . . . . . . . . . 139

9 Human Immunodeficiency Virus Infection and Acquired ImmuneDeficiency SyndromeSeth C. Kalichman & Kathleen J. Sikkema . . . . . . . . . . . . . . 167

10 Multiple SclerosisDavid C. Mohr & Darcy Cox . . . . . . . . . . . . . . . . . . . . . 183

11 Obstetric and Gynecological ConditionsSusan C. Klock . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209

12 Oncology and HematologySara J. Knight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233

13 Urological DisordersSteven M. Tovian . . . . . . . . . . . . . . . . . . . . . . . . . . . 263

Section III: Health and Illness – Community, Social,Spiritual, and Creative Involvement

14 Family, Friends, and Community: The Role of Social Support inPromoting HealthJean E. Rhodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289

15 Spirituality, Religion, and the Experience of IllnessRandolph G. Potts . . . . . . . . . . . . . . . . . . . . . . . . . . 297

16 Medical Art Therapy: Using Imagery and Visual Expression inHealingJanet K. Long . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315

17 Reduction of Health Risk in Ethnic Minority PopulationsMarian L. Fitzgibbon & Lisa A. P. Sánchez-Johnsen . . . . . . . . . 343

Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357

Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393

x Table of Contents

Paul M. Camic and Sara J. Knight Preface to the Second EditionPaul M. Camic & Sara J. Knight

Preface to the Second Edition

The emergence of health psychology over 25years ago, and its continuing growth and de-velopment as an area of research and an ap-plied area of practice, mean that it is now wellestablished as a distinct field within psychol-ogy. Significant contributions continue to bemade in the areas of health promotion, dis-ease prevention, health education, and treat-ment. With regards to treatment, health psy-chologists are currently involved with a widerange of disorders representing most of thebody’s physical systems. The focus of thisbook is on the treatment and assessment ofthese disorders, encompassing ten physicalsystems of the human body.

This book is intended to be a practical re-source for clinicians, psychology interns,and advanced graduate students, providinga reference for both the classroom and clin-ical settings. While this book is not a basicintroduction to clinical health psychologyfor undergraduates, it is suitable for gradu-ates students as well as new- or established-practitioners. We assume the reader is some-what familiar with the specialty of healthpsychology and the basics of clinical assess-ment, and is also knowledgeable about thekey interventions used in health psychology(e.g., brief psychotherapy, autogenic tech-niques, progressive muscle relaxation, bio-feedback, cognitive-behavioral therapy,learning and conditioning theories, funda-mental psychodynamics, hypnosis, relapseprevention, supportive therapy, etc.). Ourpurpose is to assist the reader in the transla-tion of research and theory in health psy-chology and medicine into evidenced-basedclinical interventions. We hope this text will

help clinicians understand not only thetechnical knowledge required to work withmedical patients, but also help them valuethe process of healing.

The idea for the first edition of this bookcame about when we both expressed a desirefor a clinical health psychology text suitablefor advanced graduate students and interns.At the time both of us taught in clinical psy-chology doctoral programs, encompassingthe scientist-practitioner (SJK) and scholar-practitioner (PMC) models, which offeredhealth psychology training as a specialtytrack. We were frustrated that most of thetexts in health psychology were either an in-troduction to the field, and thus overlybroad, or highly specialized and not suitableto the general health psychology practition-er. While there had been rich theoretical andempirical innovations in health psychology,there was little published guidance for thenew clinician on how to actually apply theseconcepts and findings in therapeutic rela-tionships with patients from diverse back-grounds seen in complex, multidisciplinaryclinical settings. Our hope at the time of de-veloping the first edition was to provide atext that was solidly grounded in empiricalscience, but also one that left room for clini-cal insight and creativity and an appreciationof the healing process. The very positive re-sponse to the first edition of the ClinicalHandbook of Health Psychology confirmed whatwe saw as a need to link empirical researchfindings, clinical practice, and the sometimesless than clear components of the culturallyinfluenced phenomenon of healing. We havecontinued this perspective in the second edi-

tion. This new edition includes advance-ments made in health psychology assessmentand treatment since the publication of thefirst edition in 1998 and involves new chap-ters and significant revisions of existingchapters.

We are asking that the users of this hand-book think about the concept of healing asthey consider an intervention strategy. Heal-ing is after all, what our patients are seeking,in one way or another. Healing is also a diffi-cult concept to measure. We believe healingtakes place in all effective therapeutic relation-ships. Healing, for some, may mean being ableto breathe without a ventilator and finallyleaving the hospital. For others it may meanchemotherapy has stopped the progression ofcancer cells and they are beginning to feel a bitof joy at being alive. For some of the people wework with, healing may mean coming toterms with dying or with pain that will alwaysremain part of their lives.

In two initial organizing chapters, we in-troduce the concept of healing as an art andscience. Here, we provide a context for thecurrent practice of health psychology inter-ventions and assessment in light of currenttrends and controversies. Chapters 3 through12 are the primary focus of this handbook.Each chapter discusses the biopsychosocialaspects of an area of health psychology prac-tice, including cardiovascular disease, respi-ratory illnesses, chronic pain, dental health,diabetes and other endocrine disorders, gas-trointestinal disease, multiple sclerosis, hu-man immunodeficiency virus, reproductiveconcerns, cancer, and urologic dysfunctions.For each, we consider referral questions,screening and psychological assessment, psy-chological interventions, and ethical andprofessional practice issues.

How to help someone heal is one of themost difficult questions we encounter inclinical practice. To begin to address the com-plexities of the healing process, our conclud-ing chapters consider a number of themesthat intersect the practice of health psychol-ogy–social relationships, spirituality, person-al expression, and culture.

Certainly psychodynamic and humanisticpsychotherapy as well as relaxation training,

hypnosis, cognitive-behavioral therapy, andbiofeedback can all help to reduce symptoms,but this may not be the same as helpingsomeone to heal. Many turn to their belief ina higher power to help them do this. Whilemany health psychology practitioners seemuncomfortable about an immeasurable“God” or a belief in spirituality, most otherNorth Americans do not share this discom-fort. Utilizing a patient’s spiritual beliefsystem is vitally important in the healingprocess for many people, whether the psy-chologist agrees with the beliefs or not.Chapter 15 considers this issue.

Another area that can contribute to heal-ing is personal expression through the arts.Such well known institutions as Duke,UCLA, and the University of Florida MedicalCenter among many others, have formallydeveloped arts-medicine programs for adultand pediatric medical patients. Expressivetherapy training, which uses visual, move-ment, and sound arts, is rarely available inclinical or health psychology graduate pro-grams. We have included a chapter introduc-ing the field of medical art therapy. Thischapter discusses basic tools such as imageryand visual expression that health psycholo-gists can employ in their work.

Family, friends, and community can alsobe part of the healing process, and this is ad-dressed in Chapter 14. A clinical interventionwithout considering the environment of theclient may fail. The environment of one’sfamily, friendship network, and living andworking communities often needs to be in-volved in the process of helping the patient“to get better.” The health psychologist’s useof family and community should considerbroadly the social network that is importantto the patient’s health and well-being: Invit-ing grandparents to a family session mayhelp insure the success of a nutritional pro-gram for a Latino teenager recently diag-nosed with AIDS more efficiently than atherapy using behavioral reinforcement; ac-knowledging a female patient’s female part-ner (significant other) as a family memberwhen the diagnosis of multiple sclerosis isgiven invites cooperation of that familymember in the battle with this disease.

xii Paul M. Camic & Sara J. Knight

Finally, while we have much to offer ourpatients to alleviate suffering and to improvewell-being, our interventions are only as ef-fective as they are consistent with the cultur-ally based preferences and values of patientsand their families. The final chapter, Chapter17, considers the cultural context of healing,and echoes our call for the inclusion of clin-ical material and research relevant to multi-cultural populations. This chapter discussesthe challenges of involving minorities inhealth risk reduction interventions and pro-vides a framework for insuring that our in-terventions reflect the concerns of individu-als from diverse backgrounds.

We hope the information contained in thesecond edition of this text adds to your un-derstanding of the physical systems and cor-responding interventions that are the focusof the work of clinical health psychologists.

Health psychology is an exciting and expand-ing field. We have enjoyed our many years ofinvolvement as participants in the birth andmaturation of this specialty. Both of us haveworked as clinicians, instructors, researchers,and supervisors and have many people tothank who have been helpful in our develop-ment along the way.

To the many patients who taught usabout suffering and healing, to our supervi-sors and mentors, to our students and col-leagues, to our partners and families, wethank each of you. We would also like tothank Larry Wilson for his artwork for thecover of this volume and our editors at Ho-grefe & Huber for their continued supportand confidence.

Paul M. Camic, Chicago, ILSara J. Knight, San Francisco, CA

Preface to the Second Edition xiii

Editors and Contributors Editors and Contributors

About the Editors

Paul M. Camic, Ph.D., Professor of Psychology & Cultural Studies, Columbia College Chica-go and adjunct Professor of Clinical Psychology, Chicago School of Professional Psychology.Recent publications include Qualitative Research in Psychology: Expanding Perspectives in Method-ology and Design with J. Rhodes and L. Yardley (2003), American Psychological Association.

Sara J. Knight, Ph.D., is a faculty member in the Departments of Psychiatry and Urology atthe University of California San Francisco and the San Francisco Department of VeteransAffairs Medical Center. Her work focuses on understanding patient preferences, medical de-cision-making, and comprehensive outcomes in cancer treatment, particularly prostate can-cer, and in end of life care. She is the recipient of an Advanced Research Career DevelopmentAward from the Health Services Research and Development Service of the Department ofVeterans Affairs. Grants from the Department of Veterans Affairs and the National CancerInstitute have supported her research. She lives in Belmont, California, with her husband LyndD. Bacon, their dog Samantha, and Onion the cat.

Contributors

James E. Aikens, Ph.D.Department of Family MedicineUniversity of MichiganAnn Arbor, MI

William A. Ayer, D.D.S., Ph.D.Department of Psychiatry andBehavioral SciencesNorthwestern University FeinbergSchool of MedicineChicago, IL

Albert J. Bellg, Ph.D.Cardiac Psychology ServicesAppleton Heart InstituteAppleton, WI

Paul M. Camic, Ph.D.Department of Liberal EducationColumbia College ChicagoChicago, IL

Darcy Cox, Psy.D.Department of NeurologyUniversity of California at San FranciscoSan Francisco, CA

Marian L. Fitzgibbon, Ph.D.Department of Psychiatry andBehavioral SciencesNorthwestern University FeinbergSchool of MedicineChicago, IL

Laura M. Gaugh, Psy.D.Chicago School of Professional PsychologyChicago, IL

Kimeron N. Hardin, Ph.D.Bay Area Pain CenterSan Jose, CA

Seth C. Kalichman, Ph.D.Department of PsychologyUniversity of ConnecticutStorrs, CT

Susan C. Klock, Ph.D.Departments of Obstetrics andGynecology and PsychiatryNorthwestern University FeinbergSchool of MedicineChicago, IL

Sara J. Knight, Ph.D.Departments of Psychiatry and UrologySan Francisco Department of VeteransAffairs Medical CenterUniversity of California at San FranciscoSan Francisco, CA

Susan M. Labott, Ph.D., ABPPDepartment of PsychiatryUniversity of Illinois at ChicagoChicago, IL

Janet K. Long, M.A., M.F.C.C. (LMFT),A.T.R.-B. C., C.T.P.California College of Arts and CraftsCalifornia Institute of Integral StudiesOakland, CA

David C. Mohr, Ph.D.Departments of Psychiatry and NeurologySan Francisco Department of VeteransAffairs Medical CenterUniversity of California at San FranciscoSan Francisco, CA

Robert J. Moretti, Ph.D.Department of Psychiatry andBehavioral SciencesNorthwestern University FeinbergSchool of MedicineChicago, IL

Randolph G. Potts, Ph.D.LeBonjeur Children’s Medical CenterMemphis, TN

Jean E. Rhodes, Ph.D.Department of PsychologyUniversity of MassachusettsBoston, MA

Lisa A. P. Sánchez-Johnsen, Ph.D.Cancer Research Center of Hawai’iUniversity of Hawai’i at ManoaManoa, HI

Kathleen J. Sikkema, Ph.D.Departments of Psychiatry, Psychology,Epidemiology and Public HealthYale UniversityNew Haven, CT

Steven M. Tovian, Ph.D., ABPPDepartment of Psychiatry andBehavioral SciencesEvanston Northwestern HealthcareNorthwestern University FeinbergSchool of MedicineEvanston, IL

Linda Van Egeren, Ph.D.Department of PsychologyMinneapolis Department of VeteransAffairs Medical CenterUniversity of MinnesotaMinneapolis, MN

Lynne I. Wagner, Ph.D.Center on Outcomes, Research andEducationEvanston Northwestern HealthcareDepartment of Psychiatry andBehavioral SciencesNorthwestern University FeinbergSchool of MedicineEvanston, IL

xvi Editors and Contributors

Sara J. Knight & Paul M. Camic Health Psychology and Medicine

Section I

Foundationsof Practice

Sara J. Knight & Paul M. Camic 1Health Psychology and Medicine:The Art and Science of Healing

A Brief EvolutionaryHistoryThe use of psychological therapies in thetreatment of health problems has a very longhistory. Early Egyptians, Ancient Greeks, aswell as Asian cultures believed imbalanceswithin the mind and soul can cause physicalillness. Pergamum, on the west coast of AsiaMinor in approximately 100 B. C., offeredtreatments consisting of rest, massage, herb-al potions, time spent at spas and more rad-ically, a change in lifestyle for physical andmental distress. Many indigenous cultures inNorth and South America and Africa havehad, as part of their belief systems, the impor-tance of the soul’s affect on the body. The at-tention and curiosity concerning what influ-ences physical health, has been a matter ofspeculation and inquiry for nearly all cul-tures throughout recorded history.

The contemporary beginnings of healthpsychology as a discipline can be traced to thetwo leading psychologists of the early 20thcentury, William James at Harvard and G.Stanley Hall at Clark. James (1922) contend-ed that the cause of work-related nervousproblems was not the amount or nature ofthe work, but in the needless hurry, tensionand anxiety produced by one’s approach tothe task. Hall (1904) believed health to be amedial value in development, and not some-thing that should be left only to physicians.He was especially concerned with hygiene,preventive medicine and the concept of

wholeness, all of which he felt to be embed-ded philosophically in the ideal of health.

The period between 1930 and the mid-1950s saw psychology nearly exclusively fo-cus on the assessment of mental disordersand all things involving intelligence, motiva-tion, memory and the mind. The problems ofphysical health and well-being were left tophysicians and most notably to the emergingfield of psychosomatic medicine. As psycho-somatic medicine concepts grew in popular-ity, however, by the end of the 1950s, morepsychologists began to investigate problemsof mind-body interaction. Psychoanalytictheories strongly influenced psychosomaticmedicine. While this theoretical view provedintellectually rich, few cures were produced.In contrast, the growing awareness of behav-iorism in the 1950s and 1960s producedalternative, empirically-derived behavioralexplanations for psychosomatic illnesses.Gradually, through the 1970s and 1980s, theunderlying psychoanalytic perspective to-ward mind-body problems gave way to amore empirically supported psychophysio-logical approach.

The psychophysiological approach is basedon a bidirectional model involving physiolog-ical factors, the immune system, behaviors,emotions and the environment (simply put,we are discarding the one-way cause and effectstreet for the avenue that is interactive anddefinitely two-way). The bidirectional modelis the basis for the clinical method of assess-ment and treatment known as the biopsycho-social paradigm, which currently dominates

clinical health psychology. As the name im-plies, a biopsychosocial approach takes intoconsideration the three domains of biologi-cal-physiological, psychological-behavioraland social-environmental, when evaluatingclients. This paradigm allows clinicians tomore fully consider complex interactions(e. g., the effects of racism, sexism or homo-phobia on emotions and physical function-ing), in addition to assessing “traditional” bi-ological and psychological domains. Inherentin this approach is the view that the healthpsychologist is a member of the health careteam and has much to contribute to the well-being and welfare of people. Health psycholo-gists are seen as health care, rather than men-tal health care, professionals thus dissolvingthe artificial boundary between problems ofthe mind and problems of the body.

The Healing RelationshipThe biopsychosocial model became the focusof practitioners and scientists from a varietyof disciplines — psychology, nursing, medi-cine, public health — who began to describetheir work and its conceptual basis as behav-ioral medicine. The Yale conference on be-havioral medicine in 1977 offered one of itsfirst definitions as “the field concerned withthe development of behavioral-scienceknowledge and techniques relevant to theunderstanding of physical health and illnessand the application of this knowledge andthese techniques to prevention, diagnosis,treatment, and rehabilitation. Psychosis,neurosis, and substance abuse are includedonly insofar as they contribute to physicaldisorders as an endpoint” (Schwartz & Weiss,1977). While psychologists figured promi-nently in the inception of behavioral medi-cine, the field is inclusive of any discipline, in-cluding health psychology, that might play arole in its science and practice.

Health psychology evolved as a specialtywithin professional psychology. Beginning inthe late 1970s as a Division within the Amer-ican Psychological Association, the field hasgrown rapidly. In 1980, a definition of healthpsychology was adopted by the Division:

“Health psychology is the aggregate of thespecific educational, scientific, and profes-sional contributions of the discipline of psy-chology to the promotion and maintenanceof health, the prevention and treatment ofillness, the identification of etiologic and di-agnostic correlates of health, illness, and re-lated dysfunction, and the analysis and im-provement of the health care system andhealth policy formation” (Stone, 1987). Withminor modifications, this definition remainsthe “official” definition of the Division ofHealth Psychology.

This and other widely cited definitions ofhealth psychology frame it in terms of itsgoals — the application of psychological the-ory and research in the prevention and treat-ment of medical disorders (Matarazzo, 1980;Millon, 1982). Other goals are directed tohealth care systems and health policy (Mata-razzo, 1992). Whereas clinical psychology hasits roots in inpatient psychiatry, health psy-chology is more identified with medicine andsurgery. The focus of health psychology isnot on treating mental illness. Rather, healthpsychology is oriented toward an integrationof psyche and soma so as to bring about op-timum health to those people with a medicalillness or disease. It incorporates the socialaspects of health and the health care system.

The goals outlined in these definitions ofhealth psychology have given direction andfocus to an emerging field. For clinical healthpsychologists working in medical settings,these goals have given shape to clinical servic-es. The health psychologist’s work is directedtoward the health of the entire person. It isnot limited by mind-body dualistic thinkingbut sees the mind very much connected tothe body and sees the environment impactingon, and being impacted upon by, the patient.

Regardless of the setting where we meetwith our patients, of the types of problemsthat we treat, or of the treatments we use, itis the quality of the relationship between pro-fessional and client that begins and sustainsthe healing process. It is this process of heal-ing — meaning to restore to wholeness andhealth — that both mystifies and comforts usas clinicians. This is the process throughwhich the clinical health psychologist, other

4 Sara J. Knight & Paul M. Camic

health professionals, and the patient worktogether toward the goals of physical, psy-chological and social health implied in thebiopsychosocial model. For clinical healthpsychologists, this is the process throughwhich we translate theory and research intothe art of care. Perhaps the Etruscan priestsof 300 B. C. E. Tuscany, or the Hopi tuhikya of1600 A. D. southwestern North America, orthe present day Aztec curanderos of Mexico, allhave this ability in common. Although theword healing has never appeared to ourknowledge in any Division of Health Psy-chology, Society of Behavioral Medicine orAmerican Psychosomatic Society journal, itis what we as health professionals do.

In a clinical guidebook for health psychol-ogy, we are especially interested in conveyingthe health psychologist’s role in the healingprocess. By healing, however, we do not meanthat it will always be possible for patient to at-tain a state of complete health. Throughoutthe text there are examples of healing that in-volve an individual’s adjustment to chronic orlife threatening disease and healing that oc-curs at the end of life. Our purpose in develop-ing this text was to describe across a range ofmedical specialties the translation of healthpsychology to clinical practice. To establishour objectives and scope, we drew heavilyfrom previous definitions of health psycholo-gy. To bring alive the science and art in clinicalhealth psychology, however, we emphasize thehealth psychologist’s contributions to thehealing process. With these principles andgoals, our working definition of clinicalhealth psychology has been the integration ofknowledge from behavioral, social, and bio-medical sciences and from the clinical arts andthe application of this knowledge to the heal-ing of human beings — psychologically, phys-ically, socially, and spiritually — at all pointsalong the health and illness continuum.

Emerging ThemesThe Environment of Care

With their work based on the biopsychoso-cial model, health psychologists are con-

cerned with medical, psychological, social,community, and spiritual context of healthcare. The work of health psychologists, there-fore, is not limited to the office setting, thetraditional venue for clinical psychology.Health psychologists practice in medical andsurgical clinics and inpatient units, in com-munity health clinics, in schools, on reserva-tions, in health maintenance organizations,on managed care boards, in rehabilitationsettings and in nursing homes.

Outside the therapist’s office, most clini-cal health psychologists find themselvesworking in complex, multidisciplinary envi-ronments. Those working in medical andsurgical clinics and inpatient units, for exam-ple, are likely to interact with physicians frommultiple specialties in medicine and surgery,nurses from multiple specialties, unit clerks,pharmacists, dieticians, occupational thera-pists, physical therapists, medical techni-cians, social workers, chaplains, hospital ad-ministrators, volunteers, and others. Add tothat, in a teaching hospital, the clinicalhealth psychologist works with physicians,nurses, and others at various levels of train-ing and experience.

Intervention Targets Along theHealth and Illness Continuum

The health psychologist’s work is broad inscope. The focus of health psychology is notexclusively on the healthy individual. Healthpsychologists work with individuals of vari-ous levels of health and illness along a con-tinuum from complete health to dying anddeath (Antonovsky, 1987). The health psy-chologist may direct an intervention to dis-ease prevention in an individual who has notexperienced an illness, but who engages in be-haviors that present a risk for disease, such assmoking. Other health psychologists focuson existing symptoms, such as in a patientwho experiences chronic pain or urinary in-continence. In chronic and life threateningillness, health psychologists may use psycho-logical methods to reduce patient sufferingand to promote adjustment to illness. Evenat the end of a patient’s life, a health psychol-

Health Psychology and Medicine 5

ogist may help an individual and family re-solve conflicts or accomplish an important,yet unfulfilled, life goal.

Integrative Treatment

The tools employed vary nearly as much asthe settings where patients are seen and theproblems which patients bring to treatment.Supportive psychotherapy, behavior analysis,brief dynamic therapy, existential therapy,biofeedback, hypnosis, expressive therapy, avariety of stress reduction and relaxationtraining strategies, and cognitive-behavioraltherapy, among others, are frequently usedinterventions. Health psychologists rely on avariety of treatment modalities as well. Indi-vidual, group, family, and couples therapiesplay important roles in the health psycholo-gist’s repertoire.

The biopsychosocial model considers pa-tient needs as multifactorial and dynamic. Of-ten the health psychologist integrates treat-ment systems and modalities to provide careas the patient’s needs evolve during the courseof an illness. Early in the course of a patient’sillness, the health psychologist might usestructured approaches, such as stress inocula-tion training, to strengthen the patient’s abil-ity to cope with disease and treatment. Laterin the illness, the health psychologist mightrely more on existential approaches as the pa-tient’s needs turn to understanding the mean-ing of surviving a life threatening event or offacing dying and death.

The very nature of health psychology prac-tice and the integration of treatment modali-ties, brings health psychologists into situa-tions in which they may assume multiple roleswith patients. For example, the health psy-chologist meeting with the patient in a hospi-tal room may interact with family membersand other staff members involved in the pa-tient’s care. In such situations, health psychol-ogists may incorporate multiple treatmentmodalities such as individual and family ther-apy. The clinical health psychologist’s flexibil-ity and ability to integrate treatment modali-ties may be important in providing timely,cost effective interventions that otherwisewould not be possible due to lengthy referral

processes and the expense of involving multi-ple professionals (Tovian, 1991). On the otherhand, according to their professional and eth-ical standards, psychologists avoid multipleroles in their work with patients, especiallywhere dual roles may compromise the best in-terest of the patient. Because of the adversepotential of dual roles, these situationsrequire thoughtful consideration of profes-sional standards and ethics, especially in eval-uating the impact on patient well-being. Con-sequently, to avoid assuming multiple roleswith a patient, the health psychologist maycoordinate care across several health care pro-fessionals, each providing an aspect of care,such as group support, individual treatment,and marital therapy, all important in address-ing the patient’s complex needs.

The Art and Science of Care

While existing definitions of health psycholo-gy emphasize scientific and technical knowl-edge, Belar and Deardorf (1985) highlight thehealth psychologist’s personal qualities, suchas warmth, openness, flexibility, as crucial as-pects of the practice of health psychology. Be-cause of the centrality of the professional andpatient relationship in health care, it is impor-tant for the health psychologist to under-stand and be aware of these personal qualitiesand their stimulus value that may assist or in-terfere with forming therapeutic relation-ships with patients. Each health psychologistwill contribute a distinct set of skills, experi-ences, and personal qualities to the relation-ship with the patient. Each patient brings tothe relationship distinct concerns, needs, andresources. Ultimately, this relationship formsthe context within which the health psychol-ogist translates theory, research, and clinicalknowledge into practice. It is this relationshipthat makes health psychology an art, as well asa science.

Complementary and AlternativeTherapies

Interest in complementary and alternativemedicine (CAM) approaches is not new. In

6 Sara J. Knight & Paul M. Camic

North America, the last two centuries haveseen spiritualists, herbalists, healers, homeo-paths, naturopaths, osteopaths, hypnothera-pists, acupuncturists, chiropractors, rolfers,acupressurists and psychologists, speakabout their abilities to help people heal, cure,manage and cope with physical ailments. Re-cent interest in CAM encompasses entire sys-tems of medicine such as Chinese medicineand Ayurvedic medicine as well as specific in-terventions such as botanicals, massage ther-apy, and imagery. Although many psycholo-gists may bristle at the suggestion they are an“alternative” approach to traditional medicalpractices, this is how we are seen by manypeople seeking help for physical symptoms.Even when psychological intervention is notseen as an alternative therapy, but as compli-mentary treatment, it may be the psychologistwhom the patient confides about their inter-est in alternative approaches. It is for thesereasons that the health psychologist needs tobe familiar with CAM.

A 1993 study by Eisenberg of over 1500adults found extensive use of alternativetherapeutic approaches. In this study, 34% re-ported using at least one unconventional (al-ternative) therapy. The most frequent use ofalternative therapies was for back problems,anxiety, depression, headache, chronic painand cancer. The most common therapiesused were relaxation, massage, imagery, spir-itual healing, weight loss programs, prayerand exercise programs. An earlier study byVerhoef (1990) reported on the extensive useof alternative medicine by patients with gas-trointestinal disorders.

The interest in complementary and alter-native therapies has not gone unnoticed bythe National Institutes of Health with its es-tablishment of the National Center for Com-plementary and Alternative Medicine. It isthe responsibility of this office to develop ba-sic and clinical research initiatives, educa-tional grants and contracts, and outreachmechanisims to further study and educateprofessionals and the public about comple-mentary and alternative approaches to med-ical therapies. In 1996 responding to bothFederal governmental initiatives and populardemand, Kings County (Seattle) in Washing-

ton State, became the first municipality inthe United States to open a publicly fundedalternative medicine clinic. Clinics such asthese do not disregard traditional allopathicmedicine, but rather incorporate other ap-proaches as complimentary.

Within the practice of clinical and counsel-ing psychology, it is health psychology andbehavioral medicine that are seen as alterna-tive approaches. In addition, meditation,hypnosis, eye movement desensitization andretraining (EMDR), biofeedback, imageryand relaxation therapies are all viewed as al-ternatives to counseling and psychotherapy.An oncologist may be just as critical of a per-son with cancer seeing an herbalist as a psy-choanalyst may be of someone seeking relax-ation training for anxiety. It is not ourposition to either endorse or criticize alterna-tive medicine approaches. Instead, we urge allhealth psychologists to be aware that manyof our patients will engage in alternativetreatments that either they have self-initiatedor have sought out a professional. Helpingthe patient assess the quality and effective-ness of the alternative therapy is an impor-tant role of the health psychologist. Often,incorporating the alternative therapy as acomplimentary approach, along side the tra-ditional treatment, provides a good balancefor patient and health care professionals.

Social, Cultural and SpiritualConsiderations

The last ten years has seen a tremendous in-crease in interest in the health of diverse pop-ulations and in understanding the complexrelationships among the interaction of socialrelationships, culture, spirituality, andhealth. It is as if psychology had just discov-ered the importance of these interrelation-ships, which have been known to anthropol-ogists and sociologists since the beginning ofthe 20th century. As North America truly be-comes more culturally diverse and, as a stu-dent described to one of us (PMC), muchmore like a salad than a melting pot, walkingthe line between what is politically correct inrecognizing cultural differences and what is

Health Psychology and Medicine 7

clinically useful, is not always uncomplicat-ed. Seeking to help underserved and poorlyserved populations, while at the same timenot wanting to clump all members of any cul-tural or ethnic group into one category (e. g.,all Latinos value spirituality; all Asians preferbehavioral and medical explanations; all les-bians are monogamous, etc. . . . ) is challeng-ing indeed. In developing this text, we askedeach contributing author to include clinicalexamples utilizing members of different cul-tural groups when possible.

Finance and the Healing Process

The issue of whether a patient has a “physi-cal” disorder or a “mental” problem contin-ues to influence the delivery of health careservices. Until recently, most insurance com-panies and managed care entities insistedthat patients seen by a clinical health psy-chologist receive a Diagnostic and StatisticalManual (DSM) (i. e., psychiatric) diagnosis toobtain reimbursement. However, many ofthe patients seen in health care settings byclinical health psychologists are referred fortreatment of the psychological and social di-mensions of physical health problems, ratherthan for treatment of the psychiatric disor-ders that are represented in the DSM classi-fication system. Consequently, although ahealth psychologist may be directly treating amedical condition, without an accompany-ing psychiatric diagnosis, treatment may notbe approved and services may not be reim-bursed. In the last several years, and afterAmerican Psychological Association PracticeDirectorate advocacy, the American MedicalAssociation committee responsible to Cur-rent Procedural Technology (CPT) codes ex-panded this system to reflect psychosocialservices to patients and families with physicalhealth diagnoses. These health and behaviorCPT codes provide a means for health psy-chologists to bill for assessment and inter-vention services that address the psychologi-cal, cognitive, behavioral, and social factorsinfluencing a person’s physical health andwell-being. The health and behavior codes re-flect a wide range of services provided by clin-ical health psychologists including individ-

ual, group, and family interventions used inthe management of pain, fatigue, and othersymptoms in cancer care or cognitive and be-havioral approaches to dietary and exercisebehaviors recommended in diabetes treat-ment.

While the new CPT codes represent a ma-jor shift in considering the psychological andsocial aspects of health, it unfortunately re-mains unusual outside of managed care set-tings to receive reimbursement for healthpromotion activities and other health en-hancement strategies. Hence, the business ofhealth care in the United States remains fo-cused on treating illness, not on modifyingbehaviors, prevention, or on learning newcoping skills. Although this volume does nothave within its scope a discussion of healthcare policy or health promotion, clearly thisis an important area for health psychologyand medicine.

Health psychology has much to contributeregarding health promotion and health riskbehaviors. Research continues to expand theintervention possibilities in these areas.However, without a change in current healthcare policy, promotion and prevention activ-ities continue to be under financed. Sadly,nothing short of a fundamental shakeup ofboth organized medicine and the insuranceindustry will likely change this situation.Less money is to be made in health promo-tion and illness prevention activities andtherefore less prestige is associated with theseareas of research and intervention.

New Opportunities

As health psychology has evolved, new rolesand opportunities for clinical practice haveemerged. In the five years, since the first edi-tion of the Clinical Handbook of Health Psy-chology, there has been greater recognitionof the integral relationship between mentaland physical health (Baum & Posluszny,1999; U.S. Department of Health and Hu-man Services, 1999; WHO, 2001). In 2001 theAccreditation Council for Graduate MedicalEducation (ACGME) instituted a require-ment that residency programs develop pilotprograms that promote an integrated collab-

8 Sara J. Knight & Paul M. Camic

orative approach to care, partnering withother health professionals such as psycholo-gists. This has opened new opportunities forhealth psychologists in end-of-life care andpalliative medicine (Twillman, 2002), prima-ry care (McDaniel, Belar, Schroeder, Har-grove & Freeman, 2001), and geriatric medi-cine (Zeiss & Thompson, 2003) and othermedical specialties that cut across the areasof practice represented in this edition of theClinical Handbook of Health Psychology.Health psychologists find themselves as be-fore practicing in an increasingly complexmultidisciplinary environment and in unfa-miliar clinical settings. This has led to exam-ination of the current and potential contri-butions of psychologists to these areas and adelineation of the education and trainingneeds of psychologists to equip them to workin these settings. While new opportunitiesare challenging, many health psychologistsfind the expansion and integration of behav-ioral health and medical care to be among themost exciting and rewarding aspects of thiswork.

ConclusionProgress toward integrating a biopsychoso-cial paradigm in health care has been slow.The World Health Organization (WHO,1997) has described the relationship betweenphysical health and mental health services asoften counterproductive and called for “anew alliance” between physical and mentalhealth disciplines. In many ways, however,health psychology exemplifies the movementtoward integrating psychological, social andbiomedical knowledge.

The chapters which follow describe thehealth psychologist’s participation in the pa-tient’s healing process. Each author providesa broad and rich view of the clinical practiceof health psychology in their areas of practicewithin medicine. Each gives a brief introduc-tion to the biomedical concepts basic to prac-tice in the area. Each describes how the healthpsychologist might integrate behavioral andsocial science knowledge and methods inclinical practice. The chapters reflect the

multidisciplinary context of the work of thehealth psychologist, the characteristic inte-gration of treatment systems and modalities,and the psychologist’s participation in heal-ing relationships with patients. Four closingchapters discuss themes important to heal-ing — social networks, spirituality, personalexpression, and ethnic diversity.

Describing health psychology as involvinga lifetime of learning, Miller (1987) empha-sizes that it will be important for students ofhealth psychology to have confidence inlearning on their own. For most of us inhealth psychology, our careers started withthe challenges of learning unfamiliar termsand protocols, developing relationships withprofessionals from diverse disciplines, andnegotiating new environments outside theoffice setting. We struggled with the applica-tion of behavioral and social science knowl-edge in the context of rapid changes in med-ical technology and health care financing.For many of us, the continued learning ispart of the appeal of clinical health psychol-ogy. For the reader, we offer the text in thisspirit to provide a basis for and to capture theexcitement of professional development inclinical health psychology.

ReferencesAmerican Psychological Association (1998). Inter-

professional health care services in primary care set-tings: Implications for the education and training ofpsychologists. Washington, DC: American Psy-chological Association.

Antonovsky, A. (1979). Health, stress, and coping.San Francisco: Jossey-Bass.

Baum, A., & Posluszny, D.M. (1999). Health psy-chology: Mapping biobehavioral contributionsto health and illness. Annual Review of Psycholo-gy, 50, 137–163.

Belar, C.D., & Deardorff, W.W. (1995). Clinicalhealth psychology in medical settings: A practitioner’sguidebook. Washington, DC: American Psycho-logical Association.

Eisenberg, D., Kessler, R.C., Roster, C., Norlock,F.E., Calkins, D.R., & Delbanco, T.L. (1993).Unconventional medicine in the United States:Prevalence, costs, and patterns of use. New Eng-land Journal of Medicine, 328, 282–283.

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Hall, G. (1904). Health, growth and heredity. NewYork: Teachers College Press.

James, H. (1922). On vital reserves: The energies ofmen. Cambridge: Harvard University Press.

McDaniel, S.H., Belar, C.D., Schroeder, C., Har-grove, D.S., & Freeman, E.L. (2002). A trainingcurriculum for professional psychologists inprimary care. Professional Psychology: Research andPractice, 33, 65–72.

Marwick, C. (1992). Alternative therapies studymoves into new phase. Journal of the AmericanMedical Association, 268, 3040.

Matarazzo, J.D. (1980). Behavioral health and be-havioral medicine. American Psychologist, 35,807–817.

Miller, N.E. (1987). Education for a lifetime oflearning. In G. Stone, J. Matarazzo, N. Miller, J.Rodin, C. Belar, M. Follick , & J. Singer (Eds.),Health psychology: A discipline and a profession. Chi-cago: University of Chicago Press.

Millon, T. (1982). On the nature of clinical healthpsychology. In T. Millon, C.J. Green, & R.B.Meagher (Eds.), Handbook of clinical health psy-chology. New York: Plenum.

Schwartz, G.E., & Weiss, S.M. (1978). Behavioralmedicine revisited: An amended definition.Journal of Behavioral Medicine, 1, 249–251.

Stone, G. (1987). The scope of health psychology.In G. Stone, J. Matarazzo, N. Miller, J. Rodin, C.Belar, M. Follick & J. Singer (Eds.), Health psy-

chology: A discipline and a profession. Chicago: Uni-versity of Chicago Press.

Tovian, S.M. (1991). Integration of clinical psy-chology into adult and pediatric oncology pro-grams. In J.J. Sweet, R.H. Rozensky & S.M. To-vian (Eds.), Handbook of clinical psychology inmedical settings. New York: Plenum.

Twillman, R.K. (2001). The role of psychologistsin palliative care. Journal of Pharmaceutical Carein Pain and Symptom Control, 9, 79–83.

U.S. Department of Health and Human Services(1999). Mental health: A report of the surgeon gener-al. Rockville, MD: U.S. Department of Healthand Human Services, Substance Abuse andMental Health Services Administration, Centerfor Mental Health Services, National Institutesof Health, National Institute of Mental Health.

Verhoef, M. (1990). Use of alternative medicine bypatients attending a gastroenterology clinic.Canadian Medical Association Journal, 142, 121–125.

World Health Organization (1997). The WorldHealth Organization report: 1997. Geneva: WorldHealth Organization.

World Health Organization (2001). World health re-port. Mental health: New understanding, new hope.Geneva: World Health Organization.

Zeiss, A.M., & Thompson, D.G. (2003). Providinginterdisciplinary geriatric team care: What doesit really take? Clinical Psychology: Science & Prac-tice, 10, 115–119.

10 Sara J. Knight & Paul M. Camic

erstellt von ciando

Linda Van Egeren Assessment Approaches in Health Psy-chologyLinda Van Egeren 2Assessment Approachesin Health Psychology:Issues and Practical Considerations

The fundamental conceptual frameworkwíthin health psychology is the biopsychoso-cial model (Belar & Deardorff, 1995; Smith &Nicassio, 1995). Engel (1977) in his landmarkarticle described the limitations and inade-quacies of the focus on biological processesand the exclusion of psychosocial factors inthe traditional approach to medical care. Heproposed the biopsychosocial model as an al-ternative. The biopsychosocial conceptualframework provides an integrated systems ap-proach for the assessment of biological, psy-chological, and social factors that contributeto health and illness. This model assumesmultifactorial, bi-directional, and indirect aswell as direct causal mechanisms. Smith andNicassio (1995) point out that the biopsycho-social model does not provide a unifying the-ory but rather a broad conceptual framework.Applying the biopsychosocial model to assess-ment means that health psychologists need toassess and utilize data across all three do-mains to provide a comprehensive under-standing of the patient. Some of the assess-ment approaches and targets of assessmentoverlap with those familiar to mental healthprofessionals. However, information relatedto the pathophysiology of medical diseases,medical procedures, the health care system,and the conceptual framework of health careproviders are also essential elements of the as-sessment process and are unique to the medi-cal setting (Smith & Nicassio, 1995). The chal-lenge for the health psychologist is to truly in-

tegrate these different sources of informationto provide an understanding of the interrela-tionship of biological, psychological, and en-vironmental factors with the end result of in-creasing clinical utility.

In this chapter, I discuss issues and practi-cal considerations in (a) conceptualizing thepurpose of the assessment, (b) interviewingmedical patients, (c) considering sociocultur-al issues in the assessment process, (d) the useof traditional assessment approaches withmedical patients, and (e) the future of biopsy-chosocial assessment in health psychology.The intent of this chapter is to identify someorganizing issues which are useful in guidingpsychological assessment of medical pa-tients. It is beyond the scope of this chapterto review specific assessment approaches inhealth psychology. Assessment strategies re-lated to specific medical problems are de-tailed in chapters three through thirteen. Theimportance of assessing the social network ofthe patient will be discussed in chapter four-teen. Chapter fifteen introduces assessmentissues concerning spirituality and religion.Chapter sixteen presents the emerging as-sessment possibilities of visual expressionand imagery.

Purpose of the AssessmentThe purpose for conducting an assessmentfocuses the content of the information being

gathered and determines the selection of in-struments and methods. The two most com-mon purposes of psychological assessmentare diagnosis and treatment planning. Thesetwo purposes are general functions of assess-ment shared with psychologists in mentalhealth settings and have been identified byhealth psychologists as the two most fre-quent purposes for assessment (Stabler &Mesibov, 1984; Piotrowski & Lubin, 1990). Inrecent years, screening has become increas-ingly prevalent in medical settings and espe-cially in primary care. Derogatis and Lynn(2000) note that screening is best describedas a “preliminary filtering technique” that isdesigned to identify individuals in need offurther evaluation. In addition to the func-tion of assessment in diagnosis and treat-ment, the function of screening and its im-pact on the assessment process in health psy-chology will be discussed in this section.

Diagnosis

When the focus of assessment is diagnosis,typically this means diagnosis utilizing theDiagnostic and Statistical Manual of Mental Dis-orders (4th ed; DSM-IV; American PsychiatricAssociation, 1994). There has been wide-spread adoption by the mental health com-munity in the United States of the DSM-IVas the diagnostic system for psychologicaldisorders. Scientific journals and reviewboards for funding utilize DSM-IV categories(Follette & Hout, 1996). DSM-IV diagnosesare also widely used in clinical settings andare required for third-party reimbursement.

There are advantages to having a commonsystem of classification which can be utilizedfor multiple purposes (e. g., treatment deci-sions, facilitating communication amongprofessionals of different disciplines, admin-istrative decisions). However, a number ofproblems have been noted with the DSM-IVsystem of diagnosis (see Follette, 1996). Re-gardless of your stance on the relativestrengths and weaknesses of the DSM-IV, theDSM-IV is the classification system that isused in medical settings. The InternationalClassification of Diseases (10th ed; ICD-10;World Health Organization, 1992) is the clas-

sification system used by physicians and isthe system of classification for medical disor-ders that interfaces with the DSM-IV. There-fore, it is important to learn to use the DSM-IV system well and to be familiar with theICD-10 system. I will discuss four diagnosticissues: the problem of tautological reason-ing, limitations of the DSM-IV in conceptu-alizing problems from a biopsychosocialmodel, the problem of diagnostic categoriesthat have pejorative connotations, and thelimitations of a mental health nosologicalsystem when used in medical settings.

The problem of inferring causality to a di-agnosis for the very symptoms that definethe diagnostic category is an example of tau-tological reasoning. For instance, attributinga patient’s angry outburst to the diagnosis ofborderline personality disorder given that in-appropriate anger was one of the symptomsthat resulted in the diagnosis is tautological.The problem with tautological reasoning isthat it gives an illusion of an explanationrather than a true understanding. The fol-lowing example illustrates this point. A phy-sician consulted with me regarding the diag-nosis of a patient she had had a difficultinteraction with during a medical appoint-ment. The physician clearly wanted to under-stand this patient better so that she couldwork more effectively with her in the future.Instead of focusing on the issue of diagnosis,the consultation was focused on assessingthe interaction with the patient and on devel-oping a useful strategy for future visits.

Diagnoses that contribute to mind-bodydualism are especially problematic from abiopsychosocial perspective. Mind-body du-alism underlies referral requests for a psycho-logical assessment of the functional etiology(as opposed to organic etiology) of the pa-tient’s physical symptoms. Toner (1994) hasnoted that “nearly every medical specialty hasidentified a functional somatic syndrome”(p. 157). The DSM-IV diagnostic category ofpain disorder associated with psychological factorshas replaced the earlier category of psychogenicpain and is a much-needed improvement.With this diagnostic category, it is possible toidentify both psychosocial and medical fac-tors as contributory to the pain. However,

12 Linda Van Egeren