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1
An introduction to
health psychology
CHAPTER OVERVIEW
This chapter examines the background against which health
psychology developed in terms of (1) the traditional
biomedical model of health and illness that emerged in the
nineteenth century, and (2) changes in perspectives of health
and illness over the twentieth century. The chapter highlights
differences between health psychology and the biomedical
model and examines the kinds of questions asked by health
psychologists. Then the possible future of health psychology
in terms of both clinical health psychology and becoming a
professional health psychologist is discussed. Finally, this
chapter outlines the aims of the textbook and describes how
the book is structured.
This chapter covers:
The background to health psychology
What is the biomedical model?
What are the aims of health psychology?
What is the future of health psychology?
How is this book structured?

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THE BACKGROUND TO HEALTH PSYCHOLOGY

During the nineteenth century, modern medicine was established. Man (the nineteenthcentury term) was studied using dissection, physical investigations and medical examinations. Darwins thesis, The Origin of Species, was published in 1856 and described the
theory of evolution. This revolutionary theory identied a place for Man within Nature
and suggested that we were part of nature, that we developed from nature and that we
were biological beings. This was in accord with the biomedical model of medicine, which
studied Man in the same way that other members of the natural world had been studied
in earlier years. This model described human beings as having a biological identity in
common with all other biological beings.

WHAT IS THE BIOMEDICAL MODEL?

The biomedical model of medicine can be understood in terms of its answers to the
following questions:
I What causes illness? According to the biomedical model of medicine, diseases either

come from outside the body, invade the body and cause physical changes within the
body, or originate as internal involuntary physical changes. Such diseases may be
caused by several factors such as chemical imbalances, bacteria, viruses and genetic
predisposition.
I Who is responsible for illness? Because illness is seen as arising from biological changes

beyond their control, individuals are not seen as responsible for their illness. They
are regarded as victims of some external force causing internal changes.
I How should illness be treated? The biomedical model regards treatment in terms of

vaccination, surgery, chemotherapy and radiotherapy, all of which aim to change the
physical state of the body.
I Who is responsible for treatment? The responsibility for treatment rests with the

medical profession.
I What is the relationship between health and illness? Within the biomedical model, health

and illness are seen as qualitatively dierent you are either healthy or ill, there is no
continuum between the two.
I What is the relationship between the mind and the body? According to the biomedical

model of medicine, the mind and body function independently of each other. This
is comparable to a traditional dualistic model of the mindbody split. From this
perspective, the mind is incapable of inuencing physical matter and the mind and
body are dened as separate entities. The mind is seen as abstract and relating to
feelings and thoughts, and the body is seen in terms of physical matter such as skin,
muscles, bones, brain and organs. Changes in the physical matter are regarded as
independent of changes in state of mind.
I What is the role of psychology in health and illness? Within traditional biomedicine,

illness may have psychological consequences, but not psychological causes.

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AN INTRODUCTION TO HEALTH PSYCHOLOGY

For example, cancer may cause unhappiness but mood is not seen as related to either
the onset or progression of the cancer.

THE TWENTIETH CENTURY

Throughout the twentieth century, there were challenges to some of the underlying
assumptions of biomedicine. These developments have included the emergence of
psychosomatic medicine, behavioural health, behavioural medicine and, most recently,
health psychology. These dierent areas of study illustrate an increasing role for
psychology in health and a changing model of the relationship between the mind
and body.

Psychosomatic medicine
The earliest challenge to the biomedical model was psychosomatic medicine. This was
developed at the beginning of the twentieth century in response to Freuds analysis of
the relationship between the mind and physical illness. At the turn of the century, Freud
described a condition called hysterical paralysis, whereby patients presented with
paralysed limbs with no obvious physical cause and in a pattern that did not reect
the organization of nerves. Freud argued that this condition was an indication of the
individuals state of mind and that repressed experiences and feelings were expressed in
terms of a physical problem. This explanation indicated an interaction between mind
and body and suggested that psychological factors may not only be consequences of
illness but may contribute to its cause.

Behavioural health
Behavioural health again challenged the biomedical assumptions of a separation of
mind and body. Behavioural health was described as being concerned with the maintenance of health and prevention of illness in currently healthy individuals through
the use of educational inputs to change behaviour and lifestyle. The role of behaviour
in determining the individuals health status indicates an integration of the mind
and body.

Behavioural medicine
A further discipline that challenged the biomedical model of health was behavioural
medicine, which has been described by Schwartz and Weiss (1977) as being an amalgam
of elements from the behavioural science disciplines (psychology, sociology, health education) and which focuses on health care, treatment and illness prevention. Behavioural
medicine was also described by Pomerleau and Brady (1979) as consisting of methods
derived from the experimental analysis of behaviour, such as behaviour therapy and
behaviour modication, and involved in the evaluation, treatment and prevention
of physical disease or physiological dysfunction (e.g. essential hypertension, addictive
behaviours and obesity). It has also been emphasized that psychological problems such

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as neurosis and psychosis are not within behavioural medicine unless they contribute
to the development of illness. Behavioural medicine therefore included psychology
in the study of health and departed from traditional biomedical views of health by
not only focusing on treatment, but also focusing on prevention and intervention. In
addition, behavioural medicine challenged the traditional separation of the mind and
the body.

Health psychology
Health psychology is probably the most recent development in this process of including
psychology into an understanding of health. It was described by Matarazzo as the
aggregate of the specic educational, scientic and professional contribution of the discipline
of psychology to the promotion and maintenance of health, the promotion and treatment of
illness and related dysfunction.
(Matarazzo 1980: 815)

Health psychology again challenges the mindbody split by suggesting a role for the
mind in both the cause and treatment of illness but diers from psychosomatic medicine,
behavioural health and behavioural medicine in that research within health psychology
is more specic to the discipline of psychology.
Health psychology can be understood in terms of the same questions that were asked
of the biomedical model:
I What causes illness? Health psychology suggests that human beings should be

seen as complex systems and that illness is caused by a multitude of factors and not
by a single causal factor. Health psychology therefore attempts to move away from a
simple linear model of health and claims that illness can be caused by a combination
of biological (e.g. a virus), psychological (e.g. behaviours, beliefs) and social (e.g.
employment) factors. This approach reects the biopsychosocial model of health and
illness, which was developed by Engel (1977, 1980) and is illustrated in Figure 1.1.
The biopsychosocial model represented an attempt to integrate the psychological (the
psycho) and the environmental (the social) into the traditional biomedical (the
bio) model of health as follows: (1) The bio contributing factors included genetics,
viruses, bacteria and structural defects. (2) The psycho aspects of health and illness
were described in terms of cognitions (e.g. expectations of health), emotions (e.g. fear
of treatment), and behaviours (e.g. smoking, diet, exercise or alcohol consumption).

Fig. 1-1 The biopsychosocial model of health and illness (after Engel 1977, 1980)

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AN INTRODUCTION TO HEALTH PSYCHOLOGY

(3) The social aspects of health were described in terms of social norms of behaviour
(e.g. the social norm of smoking or not smoking), pressures to change behaviour (e.g.
peer group expectations, parental pressure), social values on health (e.g. whether
health was regarded as a good or a bad thing), social class and ethnicity.
I Who is responsible for illness? Because illness is regarded as a result of a combination

of factors, the individual is no longer simply seen as a passive victim. For example, the
recognition of a role for behaviour in the cause of illness means that the individual
may be held responsible for their health and illness.
I How should illness be treated? According to health psychology, the whole person should

be treated, not just the physical changes that have taken place. This can take the
form of behaviour change, encouraging changes in beliefs and coping strategies and
compliance with medical recommendations.
I Who is responsible for treatment? Because the whole person is treated, not just their

physical illness, the patient is therefore in part responsible for their treatment. This
may take the form of responsibility to take medication, responsibility to change beliefs
and behaviour. They are not seen as a victim.
I What is the relationship between health and illness? From this perspective, health and

illness are not qualitatively dierent, but exist on a continuum. Rather than being
either healthy or ill, individuals progress along this continuum from healthiness to
illness and back again.
I What is the relationship between the mind and body? The twentieth century has seen a

challenge to the traditional separation of mind and body suggested by a dualistic

model of health and illness, with an increasing focus on an interaction between the
mind and the body. This shift in perspective is reected in the development of a
holistic or a whole person approach to health. Health psychology therefore maintains
that the mind and body interact. However, although this represents a departure from
the traditional medical perspective, in that these two entities are seen as inuencing
each other, they are still categorized as separate the existence of two dierent terms
(the mind/the body) suggests a degree of separation and interaction can only occur
between distinct structures.
I What is the role of psychology in health and illness? Health psychology regards psycho-

logical factors not only as possible consequences of illness but as contributing to

its aetiology. Health Psychologists considers both a direct and indirect association
between psychology and health. The direct pathway is reected in the physiological
literature and is illustrated by research exploring the impact of stress on illnesses
such as coronary heart disease and cancer. From this perspective the way a person
experiences their life (I am feeling stressed) has a direct impact upon their body
which can change their health status. The indirect pathway is reected more in the
behavioural literature and is illustrated by research exploring smoking, diet, exercise
and sexual behaviour. From this perspective, the ways a person thinks (I am feeling
stressed) inuences their behaviour (I will have a cigarette) which in turn
can impact upon their health. The direct and indirect pathways are illustrated in
Figure 1.2.

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Fig. 1-2 Psychology and health: direct and indirect pathways

WHAT ARE THE AIMS OF HEALTH PSYCHOLOGY?

Health psychology emphasizes the role of psychological factors in the cause, progression
and consequences of health and illness. The aims of health psychology can be divided
into (1) understanding, explaining, developing and testing theory and (2) putting this
theory into practice.
1 Health psychology aims to understand, explain, develop and test theory by:
(a) Evaluating the role of behaviour in the aetiology of illness. For example:
I Coronary heart disease is related to behaviours such as smoking, food intake,
lack of exercise.
I Many cancers are related to behaviours such as diet, smoking, alcohol and
failure to attend for screening or health check-ups.
I A stroke is related to smoking, cholesterol and high blood pressure.
I An often overlooked cause of death is accidents. These may be related to
alcohol consumption, drugs and careless driving.
(b) Predicting unhealthy behaviours. For example:
I Smoking, alcohol consumption and high fat diets are related to beliefs.
I Beliefs about health and illness can be used to predict behaviour.
(c) Evaluating the interaction between psychology and physiology. For example:
I The experience of stress relates to appraisal, coping and social support.
I Stress leads to physiological changes which can trigger or exacerbate illness.
I Pain perception can be exacerbated by anxiety and reduced by distraction.
(d) Understanding the role of psychology in the experience of illness. For example:
I Understanding the psychological consequences of illness could help to
alleviate symptoms such as pain, nausea and vomiting.
I Understanding the psychological consequences of illness could help alleviate
psychological symptoms such as anxiety and depression.

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AN INTRODUCTION TO HEALTH PSYCHOLOGY

(e) Evaluating the role of psychology in the treatment of illness. For example:
I If psychological factors are important in the cause of illness they may also
have a role in its treatment.
I Changing behaviour and reducing stress could reduce the chances of a further
heart attack.
I Treatment of the psychological consequences of illness may have an impact on
longevity.
2 Health psychology also aims to put theory into practice. This can be implemented by:
(a) Promoting healthy behaviour. For example:
I Understanding the role of behaviour in illness can allow unhealthy behaviours
to be targeted.
I Understanding the beliefs that predict behaviours can allow these beliefs to be
targeted.
I Understanding beliefs can help these beliefs to be changed.
(b) Preventing illness. For example:
I Changing beliefs and behaviour could prevent illness onset.
I Modifying stress could reduce the risk of a heart attack.
I Behavioural interventions during illness (e.g. stopping smoking after a heart
attack) may prevent further illness.
I Training health professionals to improve their communication skills and to
carry out interventions may help to prevent illness.

WHAT IS THE FUTURE OF HEALTH PSYCHOLOGY?

Health psychology is an expanding area in the UK, across Europe, in Australia and New
Zealand and in the USA. For many students this involves taking a health psychology
course as part of their psychology degree. For some students health psychology plays a
part of their studies for other allied disciplines, such as medicine, nursing, health studies
and dentistry. However, in addition, to studying health psychology at this preliminary
level, an increasing number of students carry out higher degrees in health psychology as
a means to develop their careers within this eld. This has resulted in a range of debates
about the future of health psychology and the possible roles for a health psychologist.
To date these debates have highlighted two possible career pathways: the clinical health
psychologist and the professional health psychologist.

The clinical health psychologist

A clinical health psychologist has been dened as someone who merges clinical
psychology with its focus on the assessment and treatment of individuals in distress . . .
and the content eld of health psychology (Belar and Deardor 1995). In order to
practise as a clinical health psychologist, it is generally accepted that someone would rst
gain training as a clinical psychologist and then later acquire an expertise in health
psychology, which would involve an understanding of the theories and methods of

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health psychology and their application to the health care setting (Johnston and
Kennedy 1998). A trained clinical health psychologist would tend to work within the
eld of physical health, including stress and pain management, rehabilitation for
patients with chronic illnesses (e.g. cancer, HIV or cardiovascular disease) or the development of interventions for problems such as spinal cord injury and disguring surgery.

A professional health psychologist

A professional health psychologist is someone who is trained to an acceptable standard in
health psychology and works as a health psychologist. Within the UK, the British Psychological Society has recently sanctioned the term Chartered Health Psychologist. Across
Europe, Australasia and the USA, the term professional health psychologist or simply
health psychologist is used (Marks et al. 1998). Although still being considered by a
range of committees, it is now generally agreed that a professional health psychologist
should have competence in three areas: research, teaching and consultancy. In addition,
they should be able to show a suitable knowledge base of academic health psychology
normally by completing a higher degree in health psychology. Having demonstrated
that they meet the required standards, a professional/chartered health psychologist
could work as an academic within the higher education system, within the health
promotion setting, within schools or industry, and/or work within the health service.
The work could include research, teaching and the development and evaluation of
interventions to reduce risk-related behaviour.

WHAT ARE THE AIMS OF THIS BOOK?

Health psychology is an expanding area in terms of teaching, research and practice.
Health psychology teaching occurs at both the undergraduate and postgraduate level and
is experienced by both mainstream psychology students and those studying other healthrelated subjects. Health psychology research also takes many forms. Undergraduates are
often expected to produce research projects as part of their assessment, and academic
sta and research teams carry out research to develop and test theories and to explore
new areas. Such research often feeds directly into practice, with intervention programmes
aiming to change the factors identied by research. This book aims to provide a comprehensive introduction to the main topics of health psychology. The book will focus
on psychological theory supported by research. In addition, how these theories can be
turned into practice will also be described. This book is now supported by a comprehensive website which includes teaching supports such as lectures and assessments.

A note on theory and health psychology

Health psychology draws upon a range of psychological perspectives for its theories. For
example, it uses learning theory with its emphasis on associations and modelling, social
cognition theories with their emphasis on beliefs and attitudes, stage theories with their
focus on change and progression, decision-making theory highlighting a cost benet

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analysis and the role of hypothesis testing and physiological theories with their interest
in biological processes and their links with health. Further, it utilizes many key psychological concepts such as stereotyping, self-identity, risk perception, self-ecacy and
addiction. This book describes many of these theories and explores how they have been
used to explain health status and health related behaviours. Some of these theories have
been used across all aspects of health psychology such as social cognition models and
stage theories. These theories are therefore described in detail in Chapter 2. In contrast,
other theories and constructs have tended to be used to study specic behaviours. These
are therefore described within each specic chapter. However, as cross-fertilization is
often the making of good research, many of these theories could also be applied to other
areas.

A note on methodology and health psychology

Health psychology also uses a range of methodologies. It uses quantitative methods
in the form of surveys, randomized control trials, experiments and case control studies.
It also uses qualitative methods such as interviews and focus groups and researchers
analyse their data uses approaches such as discourse analysis, interpretative phenomological analysis (IPA) and grounded theory. A separate chapter on methodology has not
been included as there are many comprehensive texts which cover methods in detail. The
aim of this book is to illustrate this range of methods and approaches to data analysis
through the choice of examples described throughout each chapter.

THE CONTENTS OF THIS BOOK

Health psychology focuses on the indirect pathway between psychology, and health
emphasizes the role that beliefs and behaviours play in health and illness. The contents of
the rst half of this book reect this emphasis and illustrate how dierent sets of beliefs
relate to behaviours and how both these factors are associated with illness.
Chapters 24 emphasize beliefs. Chapter 2 examines changes in the causes of death
over the twentieth century and why this shift suggests an increasing role for beliefs
and behaviours. The chapter then assesses theories of health beliefs and the models
that have been developed to describe beliefs and predict behaviour. Chapter 3 examines
beliefs individuals have about illness and Chapter 4 examines health professionals health
beliefs in the context of doctorpatient communication.
Chapters 59 examine health-related behaviours and illustrate many of the theories
and constructs which have been applied to specic behaviours. Chapter 5 describes
theories of addictive behaviours and the factors that predict smoking and alcohol
consumption. Chapter 6 examines theories of eating behaviour drawing upon developmental models, cognitive theories and the role of weight concern. Chapter 7 describes
the literature on exercise behaviour both in terms of its initiation and methods to
encourage individuals to continue exercising. Chapter 8 examines sexual behaviour and
the factors that predict self-protective behaviour both in terms of pregnancy avoidance
and in the context of HIV. Chapter 9 examines screening as a health behaviour and

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assesses the psychological factors that relate to whether or not someone attends for a
health check and the psychological consequences of screening programmes.
Health psychology also focuses on the direct pathway between psychology and
health and this is the focus for the second half of the book. Chapter 10 examines
research on stress in terms of its denition and measurement and Chapter 11 assesses
the links between stress and illness via changes in both physiology and behaviour
and the role of moderating variables. Chapter 12 focuses on pain and evaluates the
psychological factors in exacerbating pain perception and explores how psychological
interventions can be used to reduce pain and encourage pain acceptance. Chapter 13
specically examines the interrelationships between beliefs, behaviour and health using
the example of placebo eects. Chapters 14 and 15 further illustrate this interrelationship in the context of illness, focusing on HIV and cancer (Chapter 14) and obesity and
coronary heart disease (Chapter 15). Chapter 16 explores the problems with measuring
health status and the issues surrounding the measurement of quality of life.
Finally, Chapter 17 examines some of the assumptions within health psychology
that are described throughout the book.

THE STRUCTURE OF THIS BOOK

This book takes the format of a complete course in health psychology. Each chapter could
be used as the basis for a lecture and/or reading for a lecture and consists of the following
features:
I A chapter overview, which outlines the content and aims of the chapter.
I A set of questions for seminar discussion or essay titles.
I Recommendations for further reading.
I Diagrams to illustrate the models and theories discussed within the text.
I A focus on research section, which aims to illustrate two aspects of health

psychology: (1) testing a theory, which examines how a theory can be turned into
a research project with a description of the background, methods used (including
details of measures), results and conclusions for each paper chosen; and (2) putting
theory into practice, which examines how a theory can be used to develop an intervention. Each focus on research section takes one specic paper that has been
chosen as a good illustration of either theory testing or practical implications.
I An assumptions in health psychology section, which examines some of the assump-

tions that underlie both the research and practice in health psychology, such as
the role of methodology and the relationship between the mind and body. These
assumptions are addressed together in Chapter 15.
In addition, there is a glossary at the end of the book, which describes terms within
health psychology relating to methodology.

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11

QUESTIONS

1 To what extent does health psychology challenge the assumptions of the

biomedical model of health and illness?
2 Discuss the interactions described by the biopsychosocial model of health.
3 Discuss the role of the whole person in health psychology.
4 What are the implications of health psychology for the mindbody debate?
5 Design a research study to evaluate the role of the biopsychosocial model in
predicting an illness of your choice.

FOR DISCUSSION
Consider the last time you were ill (e.g. flu, headache, cold, etc.). Discuss the extent
to which factors other than biological ones may have contributed to your illness.

FURTHER READING

Carroll, D., Bennett, P. and Davey Smith, G. (1993) Socio-economic health

inequalities: their origins and implications, Psychology and Health, 8: 295316.
This paper discusses the problematic relationship between inequality and
health status and illustrates an integration of psychological factors with the
wider social world.

Johnston, M. and Weinman, J. (1995) Health Psychology, in British Psychological

Society: Professional Psychology Handbook, pp. 618. Leicester: BPS Books.
This chapter describes the different skills of a health psychologist, where they
might be employed and the types of work they might be involved in.

Kaplan, R.M. (1990) Behaviour as the central outcome in health care, American
Psychologist, 45: 121120.
This paper provides an interesting discussion about the aims of health
psychology and suggests that rather than focusing on biological outcomes,
such as longevity and cell pathology, researchers should aim to change
behaviour and should therefore evaluate the success of any interventions on the
basis of whether this aim has been achieved.

Maes, S. and Kittel, F. (1990) Training research health psychologists, Psychology

and Health, 4: 3950.
This paper discusses the interrelationship between research, theory and
practice in health psychology and focuses on the specific skills involved in being
a research health psychologist.

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