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At Worth Publishers-a company that lets nothing stand in the way of produc-
ing the finest textbooks possible-a number of people played key roles. Chief
among these are Senior Publisher Catherine Woods, whose initial interest, vi-
sion, and unflagging support gave me the push needed to start the project and
sustained me throughout; Executive Editor Kevin Feyen, whose encourage-
ment, sound thinking, and friendship were instrumental in helping construct
and execute the plan for this edition; Associate Managing Editor Tracey Kuehn,
Project Editor Dana Kasowitz, and Production Manager Sarah Segal, who
worked wonders throughout production to keep us on course; Art Director
Babs Reingold, Designer Lissi Sigillo, and artists Matthew Holt and Todd Buck,
whose creative vision resulted in the distinctive design and beautiful art pro-
gram that exceeded my expectations; Media Editor Peter Twickler, who coordi-
nated the production of an unparalleled supplements package; and Christine
Buese, who supervised the photo research that helped give the book its tremen-
dous visual appeal. Finally, no one deserves more credit than Development Ed-
itor Elaine Epstein, whose influence can be found on virtually every page.
As ever, my heartfelt thanks go to Pam, for her sage advice and unwavering
confidence; to Jeremy, Rebecca, and Melissa, for helping me keep things in per-
spective; and to the many students who studied health psychology with me and
assisted in the class testing of this book. They are a constant reminder of the
enormous privilege and responsibilities I have as a teacher; it is for them that I
have done my best to bring the field of health psychology alive in this text.
To those of you who are about to teach using this book, I sincerely hope that
you will share your experiences with me. Drop me a line and let me know what
works, what doesn't, and how you would do it differently. This input will be
vital in determining the book's success and in shaping its future.
Richard O. Straub
University of Michigan, Dearborn
Dearborn, Michigan 48128
Foundations of Health
Health and Illness: Lessons
from the Past
Ancient Views
The Middle Ages and the
Post-Renaissance Rationality
Discoveries ofthe Nineteenth
TheTwentieth Centuryand
the Dawn ofa New Era
Biopsychosocial (Mind-Body)
The Biological Context
The Psychological Context
The Social Context
Biopsychosocial "Systems"
Applying the Biopsychosocial
Frequently Asked Questions
aboutaHealth Psychology
What Do Health Psychologists
Where Do Health
Psychologists Work?
How Do IBecome a Health
Introducing Health
emfin, Flynn ,,,ppro aboa,d the 32-100 ,"am" Mam,-
tania on what must have been an uncertain morning in the early
1880s. Bound for America, her journey of hope began in Liverpool,
England, in a desperate attempt to escape the economic distress and
religious persecution she and her family suffered inIreland. The coun-
try's troubles had begun decades earlier with "an Gorta M6r" (the
Great Hunger)-a famine caused by the potato fungus that destroyed
the primary, and often only, food of most Irish families.
Caroline's journey was hardly unique. Between 1861 and 1926,
four million Irish left the country for similar reasons, and young peo-
ple like Caroline were brought up for "export" overseas. After a har-
rowing five- to six-week voyage across the Atlantic, crowded with
other emigrants into a steerage compartment that was rarely cleaned,
they endured the humiliatingprocessing ofimmigrants at Ellis Island.
Many of those who were sick orwithout financial means orsponsors
were forced to return to their homeland.
As Caroline doggedly made her way in her adopted country, first
north to upstate New York and then west to Chicago, she found that
things were better, but life was still hard. Doctors were expensive
(and few in number), and she always had to guard against drink-
ing impure water; eating contaminated foods; or becoming infected
with typhoid fever, diphtheria, or one of the many other diseases
that were prevalent in those days. Despite her vigilance, her sur-
vival (and later that of her husband and newborn baby) remained
uncertain. Life expectancy was less than 50years, and one of every
six babies died before his orher first birthday. "It would keep you
poor, just burying your children," wrote one Irishwoman to her
family back home (Miller & Miller, 2001). Equally troubling was
the attitude of many native-born Americans, who viewed the Irish
C HAP T ER 1 IIntroducingHealth Psychology
as inferior, violent, and drunken. Most of the new immigrants toiled as labor-
ers in the lowest-paid and most dangerous occupations, and were banished to
ghetto-like "Paddy" towns that sprang up on the outskirts of cities such as New
York and Chicago.
More than a century later, I smile as my mother recounts the saga of my great-
grandmother's emigration to the United States. Her grandmother lived a long, pro-
ductive life and left a legacy of optimism and "indomitable Irishy" that fortified
her against the hardships in her life-and carried down through the generations.
"How different things are now," I think as our phone call ends, "but how much of
Caroline's spirit is still alive in my own children'"
Things are very different. Advances in hygiene, public health measures, and
microbiology have virtually eradicated the infectious diseases Caroline feared
most. Women born in the United States today enjoy a life expectancy of over 80
years, and men often reach the age of 73. This gift of time has helped us realize
that health is much more than freedom from illness. More than ever before, we
can get beyond survival mode and work to attain lifelong vitality by modifying
our diets, exercising regularly, and remaining socially connected and emotion-
ally centered.
determininghealth.Thisis a fundamental themeofhealthpsychol-
ogy, a subfield ofpsychology that applies psychological principles
and research to the enhancementofhealthandthetreatmentandprevention
of illness. Its concerns include social conditions (such as the availability of
health care and support from family and friends), biological factors (such as
family longevity and inherited vulnerabilities to certain diseases), and even
personalitytraits (suchas optimism).
The word health comes to us from an old German word that is repre-
sented,inEnglish,bythewordshale andwhole, bothofwhichrefertoastate
of"soundnessofbody."Linguistsnotethatthesewords derive from theme-
dieval battlefield, where loss ofhaleness, orhealth,was usuallythe result of
ofdisease ratherthan as the absence ofa debilitating battlefield injury. Be-
causethisdefinitionfocusesonlyontheabsenceofa negativestate,however,
it is incomplete. Although it is true that healthy people are free ofdisease,
completehealthinvolvesmuchmore.Apersonmaybefree ofdiseasebutstill
notenjoya vigorous, satisfyinglife. Healthinvolves physical as well as psy-
health psychology the
application of psychological
prinCiples and research tothe
enhancementof health, and the
prevention and treatmentof
health astate ofcomplete
phYSical, mental, and social
The health ofwomen is inex-
tricably linked totheirstatus in
society. It benefitsfrom equal-
ity and suffersfrom
-WorldHealth Organization
PART 1 I Foundations ofHealth Psychology
Wearefortunatetolive inatimewhenmostoftheworld'scitizenshavethe
promiseofalongerandbetterlifethantheirgreat-grandparents,with far less
disabilityand disease than everbefore. However, these health benefits are not
The numberofhealthyyears oflife thatcan beexpectedis atleast70 years
in 25 (mostlydeveloped) countriesoftheworld,butis estimatedto beless
than40 yearsin 32 other(mostlydeveloping) countries(WorldHealthOr-
Violence-, drug-, and alcohol-related deaths and injuries, and sexual perils
suchas HIV,increasinglymarkthetransitionfromadolescencetoadulthood,
particularlyamongmanyethnicminorities(Castro,Stein,& Bentler,2009).
At everyage, deathratesvarybyethnicgroup.Forinstance,amongAmeri-
can men and women, those ofEuropean ancestry have a longer life ex-
pectancy than African-Americans, but both groups have shorter life
Italy,France,and manyothercountries(U.S. CensusBureau,2009).
Although menare twice as likelyas women to die ofanycause, beginning
in middleage women have higherdisease and disabilityrates (U.S. Census
health care than anyothercountrybutis ranked by theWorldHealth Or-
ganizaion only 37thoutof191 countriesin terms ofthe overall perform-
fairness offunding, andaccessibility byall individuals (World Health Or-
point out that the ranking moves up ordown, depending on the relative
ex;pectancy ofthose bornin the UnitedStates is lower than in mostother

Thesestatisticsreveal someofthechallengesinthequestfor globalwellness.
Health professionals are working to reduce the 30-year discrepancy in life ex-
In the United States,theDepartmentofHealth andHumanServices re-
port Healthy People 2010 focuses on improving access to health services,
eliminating health disparities between women and men, as well as among
various age and sociocultural groups, and in general on substantially im-
proving the health and quality oflife and well-being for all Americans. It
also notes thatnearlyone million deaths in this countryeach year are pre-
ventable (see Table 1.1). Healthy People 2020 expands these goals into spe-
cific actions and targets for reducing chronic diseases such as cancer and
takingstepsin32 otherareas.

CHAPT ER 1 I Introducing Health Psychology 5
Preventable Injury and Death
Healthy People 2010 and 2020 report that, yearly:
Control of underage and excess use ofalcohol could prevent 100.000deathsfrom
automobile accidents and otheralcohol-related injuries.
Elimination of public possession offirearms could prevent35.000deaths.
Elimination ofall forms oftobacco use could prevent400.000deathsfrom cancer,
stroke. and heart disease.
Betternutrition and exercise programs could prevent300,000deaths from heart
disease, diabetes, cancer, and stroke.
Areduction in risky sexual behaviors could prevent30,000deaths from sexually
transmitted diseases.
Full access to immunizations for infectious diseases could prevent 100,000deaths.
Source: u.s. Department of Health and Human Services. (2007). Healthy People 2010 midcourse review.
Retrieved January 10, 2010, from
This chapter introduces the field ofhealth psychology, which plays an in-
creasinglyimportantrole in meetingtheworld's healthchallenges. Considera
fewof themorespecificquestionsthathealthpsychologistsseektoanswer:How
andyouroverallhealth?Whyareso manypeopleturningtoacupuncture,yoga,
herbalsupplements(plusotherforms ofalternativemedicine),aswell as do-it-
yourselfpreventivecare? Dothese interventionsreallywork? Whydoso many
peopleignore unquestionablysoundadviceforimprovingtheirhealth,such as
quittingsmoking, moderatingfood intake,andexercisingmore? Whyare cer-
der, orethnic group? Why is being poor, uneducated, or lonely a potentially
ent,well educated,andsociallyactiveenjoybetterhealth?
Healthpsychologyis thesciencethatseekstoanswertheseandmanyother
questionsabouthowourwellnessinteractswithhowwethink,feel, andact.We
beginbytakinga closerlookatthe conceptofhealthandhowithas changed
on health psychology, including howit draws on andsupports other health-
relatedfields. Finally,we'lltakealookatthekindoftrainingneededtobecome
ahealthpsychologistandwhatyou candowiththattraining.
understood and treated it differently. At one time, people thought
thatdisease was caused by demons.At another,theysaw it as a form
ofpunishment for moral weakness. Today, we wrestle with very different
trephination an ancient med-
ical intervention in which a hole
was drilled into the human skull
to presumably allow "evil spir-
its" toescape.
PART 1 IFoundationsofHealth Psychology
questions,suchas,"Candisease be causedbyan unhealthypersonality?"We
will considerhowviews regardinghealthandillnesshavechangedbyfollow-
ingacase studythroughtheages-ofMariana,who in2011 is a20-year-old
college sophomore. Mariana presents to her family doctor with a bad
ened expression. How will she be treated? Current understanding ofthese
issufferingfromanxiety.Hertreatmenttodaymightbe acombinationoftalk
therapy,relaxationtechniques,andpossiblytargeteddrugtherapy. Butas we
will see, hertreatmentthroughtheages wouldhavevariedwidely. (You may
want to refer to Figure 1.1 throughout this section to get a sense of the
ernFrance,forexample,whichis believedto be 17,000years old,depictsanIce
Age shamanwearingthe animal mask ofanancientwitch doctor. In religions
based ona beliefin good and evil spirits, onlyashaman (priest ormedicine
man) can influence thesespirits.
oftheir environment, survival was based on constant vigilance against these
mysterious forces ofevil. When a person became sick, there was no obvious
physicalreasonfor it. Rather,thestrickenindividual'sconditionwas misattrib-
utedtoweakness in theface ofastrongerforce,bewitchment,orpossessionby
anevilspirit(Amundsen, 1996).
During this period oftime, Mariana's symptoms might have been treated
with rituals ofsorcery, exorcism, oreven a primitive form ofsurgery called
trephination. Archaeologists have unearthed prehistoric human skulls con-
nllQ\'V d@ffimU toleavepatients'bodies.Historicalrecordsindi-
that trephtnatibfi Wa5 a widely practiced form oftreatment in Europe,
About4,000yearsago,somepeoplesrealizedthathygienealso played arole
age illness-causingwormsfrom infestingthebody. In Mesopotamia (a partof
what is now Iraq), soap was manufactured, bathing facilities designed, and
publicsewagetreatmentsystemsconstructed(Stone,Cohen,&Adler, 1979).
Greekand 'Roman Medicine
The most dramatic advances in public health and sanitation were made in
Greece and Rome during the sixth and fifth centuries B.C.E. In Rome, a great
drainage system, the Cloaca Maxima, was built to drain a swamp that later
A TimelineofHistoricaland CulturalVariationsin Illnessand Healing From theancientuse oftrephinationto
remove eviIspiritsto thecurrent use ofnoninvasivebrain scans todiagnose disease, thetreatmentofhealth problems has
seen majoradvances overthecenturies. A collection oftreatmentsacross the ages is shown(from lefttoright): trephination
(on an ancientPeruvian skull); acupuncturefrom China; early surgery in seventeenth-centuryEurope; and vaccination by the
districtvaccinatorin nineteenth-century London.
ANCIENT GREECE Illness caused
by an imbalanceofbodily humors;
gooddietand moderationin
livingwouldcure it.
Illness caused by evil
spiritsand treated by
MIDDLEAGES (476-1450)
Disease was divinepunishment

0 0 0 I I
:5:5:5 CE:5:5
I I' 'II I I 'I I I I' I
0 0 0 0 0 I 0
g Rg
I I I I 'I I I I I 'I 'I 'I I I I

'I I

Biopsychosocial causes of
disease. Modern,flexible
and punishmentbythe
"Pathogens" such as bad
godscaused illness.
1920sDisease influenced
airand bodyhumors'
Sorceryand primitive
by mindand emotionsand
caused illness. Treated
treated by psychoanalysis,
forms ofsurgeryand
by bloodletting, enemas,
psychiatry, and other
hygiene were treatments.
and baths.
I medical methods.
ANCIENT CHINA(1100-200 B.C,E,)
aphysical condition ofthe
Unbalanced forces ofnature
body, whichwas separate
caused illness. Treated with
fromthemind. Surgical
herbal medicineand
) "'i" '<.
J... '"
fA.( \.< ,.\.,,'1 h
.'" .I' 'I;
f "
"'.1' "
, " J'
- ,
1.' -.\
Credits (leftto right): Trephinated skull engraving by English School (nineteenth century) published 1878in "Incidents ofTravel and Exploration in the
Land ofthe Incas" by E. George SqUier: private collection/Bridgeman Art Library; Illustration showingacupunture: Corbis; "The Surgeon," engraving
by German School (seventeenth century): private collection/Bridgeman ArtLibrary; "Vaccination" engraving, 1871: Hulton Getty/Liaison Agency.
C HAP T E R 1 I Introducing Health Psychology

,- fJ-L -.
symptoms. Hippocrates was also interested in patients' emotions and thoughts
regarding their health and treatment, and thus he called attention to the-psy-
chological aspects of health and illness. "It is better to know the patient WhO / - /7
l1as the disease," Hippocrates said, "than it is to know the disease which the pa-
tlent has" (quoted in Wesley, 2003).'
.' The next great figure in the history of Western medicine was the physician _ / .
Claudius GaleJ! (129-200 C.E.). Galen was born in Greece but spent many years
iii R'iliii"e conducting dissection studies of animals and treating the severe in: --rz(e? /f'/?
juries of Roman gladiators. In this way, he learned much that was ./
unknown about health and disease. Galen wrote voluminously on anatomy, hr- '/"L.-t -
giene, and diet, buildin on the Hippocratic foundation of rational
and the careful description of eac patient s p- ysical symptoms. .
Galen also expanded the humoral theory of disease by developing an .-
orate system of pharmacology that physicians followed for almost 1,500 years.
His system was based on the notion that each of the four bodily humors had
i!s own elemenwy quality that determined the character of specific diseases.
for example, was hot and moist. Galen believed that drugs, too, had el-
ementary qualities; thus, a disease caused by an excess of a hot and moist
humor could be cured only with d.rugs that were cold and dry. Although such
views may seem archaic, Galen's pharmacology was logical, based on careful
observation, and similar to the ancient systems of medicine that developed in
China, India, and other non-Western cultures. Many forms of alternative med-
icine still use similar ideas today.

Non-Western Medicine
At the same time that Western medicine was emerging, different traditions of
healing were developing in other cultures. For example, more than 2,000 years
ago the Chinese developed an integrated system of healing, which we knOW( "- //
today as traditional Oriental medicine (TOM). TOM is founded on the princi-
pIe that internal harmony is essential for good health. Fundamental to this har- ,
mony is the concept of qi (sometimes spelled chi), a vital energy or life force that
ebbs and flows with changes in each person's mental, physical, and emotional ...... r? d/'
well-being. Acupuncture, herbal therapy, tai chi, meditation, and other interven-
tions are said to restore health by correcting blockages and imbalances in qi.
Ayurveda is the oldest known medical system in the world, having origi-" / /
nerted in around the sixth century B.C.E., coinciding roughly with the life-
time of the Buddha. The word ayurveda comes from the Sanskrit roots ayuh, (. / '- t-4
which means "longevity," and veda, meaning "knowledge." Widely practiced in (;
India, ayurveda is based on the belief that the human body represents the en- /P .,
tire universe in a microcosm and that the key to health is maintaining a bal- ,
ance between the microcosmic body and the macrocosmic world. The key
this relationship is held in the balance of three bodily humors, or doshas: vata, ,.., I J
pitta, and kapha, or, collectively, the tridosha (Fugh-Berman, 1997). We'll ex- 1/I .
plore the history, traditions, and effectiveness of these and other non-Western
forms of medicine in Chapter 14.

PAR T 1 I Foundations of Health Psychology
became the site of the Roman Forum. Over time, the Cloaca assumed the func-
tion of a modern sewage system. Public bathrooms, for which there was a small
admission charge, were commonplace in Rome by the first century C.E. (Cart-
wright, 1972).
The first aqueduct brought pure water into Rome as early as 312 B.C.E., and
cleaning of public roads was supervised by a group of appointed officials who
also controlled the food supply. This group passed regulations to ensure the
freshness of meat and other perishable foods, and they arranged for the stor-
age of vast quantities of grain, for example, in an effort to forestall famine
(Cartwright, 1972).
In ancient Greece, the philosopher Hippocrates (460-377 B.C.E.) was estab-
lishing the roots ofWestern medicine when he rebelled against the ancient focus
on mysticism and superstition. Hippocrates, who is often called the "father of
modern medicine," was the first to argue that disease is a natural phenomenon
and that the causes of disease (and therefore their treatment and prevention) are
knowable and worthy of serious study. In this way, he built the earliest founda-
tion for a scientific approach to healing. Historically, physicians took the Hippo-
cratic Oath, with which they swore to practice medicine ethically. Over the
centuries, the oath has been rewritten to suit the values of various cultures that
were influenced by Greek medicine. A version widely used in U.S. medical
schools today was written in 1964 by Dr. Louis Lasagna of Tufts University.
Hippocrates proposed the first rational explanation of why people get sick,
and the healers of this period in history may have been influenced by his ideas
in addressing Mariana's problems. According to Hippocrates' humoral theory,
a healthy body and mind resulted from equilibrium among four bodily fluids
called humors: blood, yellow bile, black bile, and phlegm. To maintain a proper
balance, a person had to follow a healthy lifestyle that included exercise, suffi-
cient rest, a good diet, and the avoidance of excesses. When the humors were
out of balance, however, both body and mind were affected in predictable ways,
depending on which of the four humors was in excess. Mariana, for example,
might have been considered choleric, with an excess of yellow bile and a fiery
temperament. She might have been treated with bloodletting (opening a vein
[8 lind cooling batbs.
Although humoral theory was discarded as advances were made in anatomy,
physiology, and microbiology, the notion of personality traits being linked with
body fluids still persists in the folk and alternative medicines of many cultures,
including those of traditional Oriental and Native American cultures. More-
over, as we'll see in the next chapter, we now know that many diseases involve
an imbalance (of sorts) among the brain's neurotransmitters, so Hippocrates
was not too far off.
Hippocrates made many other notable contributions to a scientific ap-
proach to medicine. For example, to learn what personal habits contributed to
gout, a disease caused by disturbances in the body's metabolism of uric acid,
he conducted one of the earliest public health surveys of gout sufferers' habits,
as well as of their temperatures, heart rates, respiration, and other.,physical
... I will prevent disease
whenever I can, for prevention
is preferableto cure.
'-I willJ'emember that I remain
a member of society, with spe-
cial obligations to all my fellow
human beings, those sound of
mind and body as well as the
If I do not violate this oath,
may I enjoy life and art,
respected while I live and
remembered with affection
thereafter. May I always act so
as to preserve the finest tradi-
tions of my calling and may I
long experience the joy of heal
ing those who seek my help.
-Written in 1964 by Louis
Lasagna, Academic Dean of the
School of Medicine at Tufts
University, and used in many
medical schools today.
humoral theory a concept of
health proposed by Hippocrates
that considered wellness a state
of perfect equilibrium among
four basic body fluids, called
humors. Sickness was believed
to be the result of disturbances
in the balance of humors.
Epidemic literally, among the
people; an epidemic disease is
OAe that spreads rapidly among
many individuals in a commu-
nity at the same time. A
pandemic disease affects people
over a large geographical area.
mind-body dualism the
philosophical Viewpoint that
mind and body are separate
entities that do not interact.
anatomical theory the theory
that the origins of specific dis-
eases are found in the internal
organs, musculature, and skele-
tal system of the human body
cellular theory formulated in
the nineteenth century, the
theory that disease is the result
of abnormalities in body cells.
Discoveries of the Nineteenth Century
Once individual cells became visible, the stage was set for the,cellular theory
of disease-the idea that disease r "Its when body cells malfunction or die. It
was the French scient' t Louis Pasteur 1822-1895), however, who truly rocked
the world with senes 0 m iculous experiments showing that life can
onl come rom existing life. Until the nineteenth century, scholars believed in
spontalieous generation the idea that living organisms can be formed from
nonliving matter. For example, maggots and flies were believed to emerge
spontan'eously from rotting meat, To test his hypothesis, Pasteur filled two
flasks with a porridge-like liquid, heating both to the boiling point to kill any
Following the Renaissance, expected to focus exclusively on the
biological causes of disease. Hi 'ates' ncient humoral theor w s fin
discarded in favor of's anatomical theor 0 isease. Physicians at this
time would have considered internal causes fOi Mariana's symptoms, uch as
heart or brain malfunctions.
Science and medicine changed rapidly during the seventeenth and eigh-
teenth centuries, spurred on by numerous advances in techn,ology. Perhaps the
single most important invention in medicine during this period was the micro-
scope. Although a ground lens had been used for magnification in ancient
times, it was a Dutch cloth named. Anton van Leeuwenhoek
(1632-1723) who fashioned the first prac0:al microscope. Using his micro-
scope, Leeuwenhoek was the first to observe blood cells and the structure of
ske\WallmlJ18(i1leshot:k tht: lust to obst:rVt: blood cdis <lnd Lht: 01
skeletal muscles.
Post-Renaissance Rationality
.. .

sopher and mathematician Rene Descartes (1596-1650), whose first innova-
lion was the concept of the human body as a machine. He described all the
hasic reflexes of the body, constructing elaborate mechanical models to demon-
strate his principles. He believed that disease occurred when the machine broke
dow he physician's task was to repair the machine.
escarte is best known for tha ind and bod au-
Lono ous processes that mter t minimally, and that each is subject to
ent laws of causality. This viewpoint, which is called ind- od ualis (JI'
.' rtesian dualism), is based on the doctrine that htJmaos haw two natures...
. Descartes and other great thinkers of the Renaissance, in
a "effort to reak with the mysticism and superstitions of the past, vi orously
rejected the notion that the mind influences the body. <!-riana's condition nd
its connection to her emotional well-being was now even less likely to be prop-
erly understood. Although this viewpoint ushered in a new age of medical re-
search based on confidence in science and rational thinking, it created a lasting
bias in Western medicine against the importance of psychological processes in
health. As we'll see, this bias has been rapidly unraveling since the 1970s.
PAR T 1 I Foundations of Health Psychology
First Anatomical Drawings By
the sixteenth century, the taboo
on human dissection had been
lifted long enough that the Flem-
ish anatomist and artist Andreas
Vesalius (1514-1564) was able to
publish a complete study of the
internal organs, musculature, and
skeletal system of the human
The Middle Ages began with an The Middle Ages and the Renaissance
outbreak of plague that origi- C
nated in Egypt in 540 c.e. and The fall of the Roman Empire in the fifth century C.E. ushered in the Middle
qUickly spread throughout the ..'
Roman Empire, killing as many Ages (476-1450), an era between anClent and modern tunes charactenzed by a
as 10,000 people a day. So great ' return to supernatural explanations of health and .disease. in Euro .. !he
in number were the corpses that church exerte a power u m uence over a areas 0 I e at thiS tIme. RelIgIOUS
gravediggers could not keep up. interpretations colored medieval scientists' ideas about health and disease. In
The solution was to load ships the eyes of the medieval Christian church humans were regarded as creatures
with the dead, row them out to .' "
sea, and abandon them. With free Will who were not subject to the laws of nature. Because they had
souls, neither humans nor animals were considered to be appropriate objects
of scientific scrutiny, and dissection of both was strictly prohibited. Illness was
viewed as God's unishment for evildoing, and epidemic

two great ou ursts 0 p a ue a ac erial Isease carne y rats and other
dents t at occurred durin the Middle Ages, were believed to be a sign of
. God's wrath Mariana's "treatment in this era would surely have involved at-
"mpts to fmoe evil 'pi,'ts out of "body. Th,re wm f,w ,oi,ntifi, ad..n'"
\'1}< eX \' al in European medicine during these thousand years.,' ,
\ 1 In the late fifteenth century, a new age--=the RenaIS -was born. Begm-
jJJv ning with the reemergence of scientific inq iry, the
0( -Jt; C' zation of anatomical' stud and medical
\J ISS IOn was I ed sufficient ate anatomist and artist Andreas
(1514-1564) was able to publish an authoritative, seven-volume study
, of
'>0'''' """''' ",",,,,.,,,,,, and skeletal system of the h TI.E!!l
bo. e son 0 a ruggist, Vesalius
was fascinated by nature, especially
the anatomy of humans and animals.
In the pursuit of knowledge, no stray
dog, cat, or mouse was safe from his
:r In medical school, Vesalius turned
i his dissection scalpel on human cadav-

i ers. Wh'at he found 'pt6v'ed som'e ofilhe
medical writings of Galen and earlier
physicians to be clea'rly inaccurate.
How, he wondered, could an unques-
tionable authority such as Galen have
made so many errors in describing the
body? Then he realized why: Galen had
never dissected a human body! Vesal-
ius's volumes became the cornerstones
of a new scieritific medicine based on
anatomy (Sigerist, 1958, 1971).
One of the most influential Renais-
sance thinkers was the French philo-

germ theory the theory that
disease is caused by viruses,
bacteria, and other microorgan-
isms that invade body cells,
biomedical model the domi-
nant view of twentieth-century
medicine that maintains that
illness always has a physical
pathogen a virus, bacterium.
or some other microorganism
that causes a particular disease,
psychosomatic medicine an
outdated branch of medicine
that focused on the diagnosis
and treatment of physical
diseases caused by faulty
psychological processes,
C HAP TE R 1 I Introducing Health Psychology
Psychosomatic Medicine
The biomedical model advanced health care significantly through its focus
on pathogens. However, it was unable to explain disorders at had no b-
servable physical cause, such as those uncovered b SIgmund Freud
(1856-1939), who was initially trained as a physician.
hibited symptoms such as loss of speech, deafness, and even paralysis. Freud
believed these maladies were caused by unconsciou motional can icts that
had been "co r te 0 a sic reud labeled sue I lnesses con-
vers on disorders, ate medical was forced to accept a new
-a egory of disea e.
In the 1940s, Franz Alexander advanced the idea that an individual's psy_
chological conflicts could cause specific diseases. When physicians could
find no infectious agent or other direct cause for rheumatoid arthritis,
Alexander became intrigued by the possibility that psychological factors
might be involved. According to his nuclear conflict model, each physical dis-
ease is the outcome of a conflict
(Alexander, 1950). For example, individuals with a "rheumatoid personal-
ity," who tended to repress anger and were unable to express emotion, were
believed to be prone to developing arthritis. Alexander helped establish psy-
chosomatic medicine, a reformist movement within medicine named from
the root words psyche, which means "mind," and soma, which means "body."
Psychosomatic medicine is concerned with the diagnosis and treatment of
physical diseases thought to be caused by faulty processes within the mind.
This new field flourished, and soon the journal Psychosomatic Medicine was
publishing psychological explanations of a range of health problems that in-
cluded hypertension, migraine head ul s .d' d
bronchial asthma. At this time, ar'a! i ht have be treated b Freud's
that delves into one's childhood and attempts
to uncover unresolvedcorlfli'cts.
croorganism that invades the body. The model makes no provision for psycho-
logical, social, or behavioral variables in illness. In this sense, the biomedical
model embraces reductionism/;the view that complex phenomena {such as
health and disease)"'derive ultimately from a single primary factor. Second, the
biomedical model is based on the,; doctrine of mind-body dualigJ1...
that, as we have seen, considers mind and body as separate and autonomous
entities that interact minimally. Finally, according to the biomedical model,
health is. uothi.Qg more than the absence Accordingly, those who
this perspective focus on investigating the causes of physical iIl-'
nesses rather than on those factors that promote L2hysica1 a.qd
+. .....
social vitalitJ.- Physicians working strictly from tl e . edical perspective
on the physiological causes 2f a' ana's eadache racing heart,
and shortness of breath rather than considering whether a psychological prob-
lem could be contributing to these s)'1lnptoms.
. .
PAR T 1 I Foundations of Health Psychology
': .1
. -;:--
The Twentieth Century and the Dawn of a New Era
microorganisms. One of the flasks had a wide
mouth into which air could flow easily. The other
flask was also open to air, but had a long curved
neck that kept any airborne microbes from falling
into the liquid. To the amazement of skeptics, no
new growth appeared in the curved flask. How-
ever, in the flask with the ordinary neck, microor-
ganisms contaminated the liquid and multiplied
rapidly. By showing that a genuinely sterile solu-
tion remains lifeless, Pasteur set the stage for the
later development of aseptic (germ-free) surgical
procedures. Even more important, Pasteur's suc-
cessful challenge of a 2,OOO-year-old belief is a
powerful demonstration of the importance of
Louis Pasteur in His Labora- keeping an open mind in scientific inquiry.
tory Pasteur's meticulous work in ,.. . " '
. I t' b ct . . th I b Pasteur s dlscovenes helped sha e the erm theor of disease-the Idea that
ISO a mg a ena 111 e a - __---
oratory, then showing that life bacteria, viruses, an other microorganisms that invade body cells cause them
can come only from existing life, to malfunctionJhe theory, which is basically a refinement of the cellu-
paved the way for germ-free sur- ['ar theory, forms the theoretical foundation of modern medicine.
gical procedures. Following developed rapidly.
,...... In 1846, an American dentist, introduced the
, - ether :s an anestbetir, This great made it possible to operate on
patients, who experienced no pain and thus remained completely elaxed.

Fifty years later, t e German h sicist Wilhelm Roent en 1845-1 3 dis-
,tV" - covered x-rays and, for the first time physicians wen;; t)ble to observe
;1 organs in a living perso.n direct)y. Before the end of the century,
researchers had identified the microorganisms that caused malaria, pneu-
monia, diphtheria, syphilis, typhoid, and other diseases that my great-
grandmother's generation feared. Armed with this information, medicine
began to bring under control diseases that had plagued the world since
14 PART 1 IFoundationsofHealth Psychology
CHAPTER 1 IIntroducingHealth Psychology 15
The Emergence of Health Psychology
In 1973,theAmericanPsychologicalAssociation (APA) appointedataskforce
LO explore psychology's role in the field ofbehavioral medicine, and in 1978,
the APA created the division ofhealth psychology (Division 38). Four years
later, thefirst volume ofits officialjournal,Health Psychology, was published.
In thisissue,JosephMatarazzo,thefirstpresidentofthedivision,laiddownthe
four goals ofthenewfield:
1. To studyscientificallythecausesororiginsof specificdiseases; thatis, their
etiology. Health psychologists are primarily interested in the psycho-
logical, behavioral, and social origins of disease. Theyinvestigate why
peopleengagein health-compromisingbehaviors,suchassmokingorun-
2. Topromotehealth. Health considerways togetpeopletoen-
gage in health-enhancingbehaviorssuchas exercisingregularlyandeating
3. Topreventandtreatillness. Healthpsychologistsdesignprogramstohelppeo-
justtotheirillnessesorcomplywithdifficult treatmentregimens.
4. To promotepublichealthpolicyandtheimprovementofthehealth care sys-
tem. Health psychologists are very active in all facets ofhealth education
icy inaneffortto improve the deliveryofhealthcareto all people.
As noted in Table 1.2, a numberoftwentieth-centurytrends helpedshape
thenewfield ofhealthpsychology,pushingittowardthebroaderbiopsychoso-
cial perspective,which is thefocus ofthistext.
Twentieth-Century Trends That Shaped Health Psychology
Trend Result
1. Increaseo'Life Expectancy Recognize the need totake bettercare of
ourselves to promoteVitality through a
2. Rise ofLifestyle Disorders (forexample, Educate people to avoid the behaviors
cancer, stroke, and heartdisease) thatcontribute to these diseases (for
example, smokingand ahigh-fatdiet).
3. Rising Health Care Costs Focus effortson ways topreventdisease
and maintain good health toavoid these
4. Rethinking the Biomedical Model Developamorecomprehensive model of
health and disease-thebiopsychosocial
biopsychosocial (mind-body)
perspective the viewpoint that
health and other behaviors are
determined by the interaction of
biological mechanisms, psycho-
logical processes, and social
life-course perspective theo-
retical perspective that focuses
on age- related aspects of health
and illness.
,IS pleasurable and the aftermath of a hangover as minor. Such people may be
more likely to drink, especially in certain psychological and social contexts.
A key element of the biological context is our species' evolutionary history, and
an evolutionary perspective guides the work of many health psychologists. Our
characteristic human traits and behaviors exist as they do because they helped our
distant ancestors survive long enough to reproduce and send their genes into the
future. For example, natural selection has favored the tendency of people to be-
come hungry in the presence of a mouth-watering aroma (see Chapter 7). This
sensitivity to food-re.lated cues makes evolutionary sense in that eating is neces-
sary for survival-particularly in the distant past when food supplies were unpre-
dictable and it was advantageous to have a healthy appetite when food was available.
At the same time, biology and behavior constantly interact. For example,
some individuals are more vulnerable to stress-related illnesses because they
angrily react to daily hassles and other environmental "triggers" (see Chapter
4). Among men these triggers are correlated with aggressive reaction related to
increased amounts of the hormone testosterone. This relationship, however, is
reciprocal: Angry outbursts can also lead to elevated testosterone levels. One of
the tasks of health psychology is to explain how (and why) this mutual influ-
ence between biology and behavior occurs.
C HAP T E R 1 I IntrodUcing Health Psychology
Life-Course Perspective
Within the biological context, the life-course perspective in health psychol-
ogy focuses on important age-related aspects of health and illness (Jackson,
1996). This perspective would consider, for example, how a pregnant woman's
malnutrition, smoking, or use of psychoactive drugs would affect her child's
lifelong development. Her child might be born early and suffer from low birth
weight (less than 2,500 grams [5 pounds]). Low birth weight is one of the most
common, and most preventable, problems of prenatal development. Conse-
quences include slowed motor, social, and language development; increased
risk of cerebral palsy; long-term learning difficulties; and even death (Jalil and
others, 2008).
The life-course perspective also considers the leading causes of death in
terms of the age groups affected. The chronic diseases that are the leading
causes of death in the overall population are more likely to affect middle-aged
and elderly adults. Young people are much more likely to die from accidents.
The Psychological Context
The central message of health psychology is, of course, that health and illness are
subject to psychological influences. For example, a key factor in how well a person
copes with a stressful life experience is how the event is appraised or interpreted
(see Chapter 5). Events that are appraised as overwhelming, pervasive, and beyond
our control take amuch greater toll on us physically and psychologiglly
events that are appraised as minor challen es that are temporary and surmQllnt-
ndeed, some evidence suggests that, whether a stressful event is actually ex-
High stress levels
Poor coping skills
Strong feelings of personal
Racing heart
Feeling breathless
Lump in the throat
Genetic vulnerability
to anxiety
High levels of actual
responsibility at work and
home and in the community
Lack of social su pport
PAR T 1 I Foundations of Health Psychology
s history tells us, looking at just one causative factor paints an in-
complete picture of a person's health or illness. Health psychologists
therefore work from a biopsychosocial (mind-body) perspective. As
depicted in Figure 1.2, this perspective recognizes that biological, psychological,
and sociocultural forces act together to determine an individual's health and
vulnerability to disease; that is, health and disease must be explained in terms
of multiple contexts.
The Biological Context
All behaviors, including states of health and illness, occur in a biological con-
text. Every thought, mood, and urge is a biological event made possible because
of the characteristic anatomical structure and biological function of a person's
body. Health ps chology draws attention to those aspects of our bodies that in-
fluence ea th and disease: our genetic makeup an our nervous, immune, and
enoocnne SVstenfs (seeChapter 3).
Genes provide a guideline for our biology and predispose our behaviors-
healthy and unhealthy, normal and abnormal. For example, the tendency to
abuse alcohol has long been known to run in some families (see Chapter 8).
One reason is that alcohol dependency is at least partly genetic, although it does
not seem to be linked to a single, specific gene. Instead, some people may in-
herit a greater sensitivity to alcohol's physical effects, experiencing intoxication
The Biopsychosocial Model
of Mariana's Anxiety Accord-
ing to the biopsychosocial
perspective, all health behaviors
are best explained in terms of
three contexts: biological
processes, psychological
processes, and social influences.
This diagram illustrates how
these three processes could
influence anxiety, as experi-
enced by Mariana in the case
study example (p. 6).
19 18 PAR T 1 I Foundationsof Health Psychology
perienced or merely imagined, the body's stress response is nearly the same.
Health psychologists thinkthat some people may be chronicallydepressed and
moresusceptibleto certain health problems because theyreplaystressful events
over andover again intheir minds,whichmaybe functionally equivalent to re-
peatedlyencounteringtheactualevent. Throughoutthis book,we will examine
thehealthimplicationsof thinking,perception,motivation,emotion,learning,at-
Psychological factors also playan iinportantrole inthetreatmentofchronic
tion and surgery, as well as acupuncture and other alternative treatments-is
powerfully influenced bya patient's attitude. A patientwho believes a drug or
othertreatmentwill onlycause miserableside effects mayexperienceconsider-
treatmentis followed byprogressivelyworse physicalreactions as thetreatment

beeffective mayactuallyexperienceagreatertherapeuticresponsetothattreat-
ment. Psychological interventions can help patients learn to managetheirten-
sion,thereby lessening negative reactions to treatment. Patients who are more
relaxed are usuallybetterable, andmore motivated,tofollow theirdoctors'in-
Psychologicalinterventionscanalso assist patients in managingthe every-
tem. Negative life events suchas bereavement, divorce,jobloss, orrelocation
have beenlinkedto decreasedimmunefunctioningandincreasedsusceptibil-
The Social Context
Turn-of-the-century Irish immigrants like my great-grandmother surmounted
thatstrongly reflectedanethic of family andcommunalsupport.
hi!JlSelf,butall forone2DQther;'wrotePatrieO'Qlllaghan.tohissisterbackhome,
:;;he describedthis system ofpatronage.Inplacinghealthbehaviorin iJ social
health psychologists considerthe ways in which we thinkabout,tItfiu-
l- . t.\ andfelate to andtoourenvironment;LYourgender,forexam-
c . \,#,'1 'pIe;ei1failsaparticular, !:2J.e thatrepresentsyoursenseofbeing
, eJ:l awomanoraman.Inad'd.itiOn,youareamemberofaparticularfamily,commu-
c andnation; you also have a certainracial, cultural,andethnicidentity,and
d< youlivewithinaspecificsocioeconomicclass.Youareinfluencedbythesamehis-
. , _<X. andsocialfactors as othersinyourb' of born
birth cohortagroup of peo wlthmafewyearsofeac er. Forexample,thosewhoIlVed 100 ears
pie who, because they were 1 I d' fr d' h . did . d 'd
born ataboutthe same time, more eyto Ie om lseasest atwelD eve0 e countnesto ayconSI er re-
experiencesimilar historical and ventabe, ercuosis an diphtheriacrable 1.3),andinfantmortalityin
social conditions. 1treCJi1ItedStateshasdroppedsignificantly(Figure 1.3).Eachoftheseelementsof
C HAP T ER 1 I Introducing Health Psychology
LeadingCauses ofDeath in theUnited States, 1900and 2005
Percent of
1900 Percent 2005* All Deaths
Pneumonia 11.8% Heartdisease 26.6%
Tuberculosis 11.3% Cancer 22.8%
Diarrhea and enteritis 8.3% Stroke 5.9%
Heart disease 5.2% Chronic lower
respiratory diseases 5.3%
Liver disease 5.2% Accidents 4.8%
Accidents 4.2% Diabetes mellitus 3.1%
Cancer 3.7% Influenza and pneumonia 2.9%
Senility 2.9.% Alzheimer's disease 2.6%
Diphtheria 2.3% Kidney disease 1.8%
Septicemia 1.4%
Sources: Healthy People 2010, by u.s. Department of Health and Human Services, Washington. DC: U.S.
Government Printing Office. Deaths: Final Data for 2005, by H. C. Kung. D. L. Hoyert. J. J. Xu. &S. L.
Murphy (200B). National Vital Statistics Reports. 56(10). Table B.
Note that the leading causes of death in 2005 were not new diseases; they were present in earlier times,
but fewer people died from them or they were called something else.
spouse,significantother,orclose friend provides an importantsource ofsocial
supportfor manycancerpatients.Women andmenwhofeel sociallyconnected
Onereason for the dramatic
o decrease in infant mortality
sincethe 1900s is widespread
c.:: 120
immunization, which made LU
contagiousfatal diseases
I 100
rare in infancy.

::::; 60
o 40
Z 20
Z 01 _
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010
InfantMortalityin the
United StatesLess than one
hundred years ago, 15 percent
of babies born in the United
States died before theirfirst
birthday. For thosewho sur-
vived, life expectancy was only
slightly more than 50 years.
With improved health care,
today more than 90 percentof
newborn babies survive to at
least1year of age.
Sources: Historical Stati,!ics of the
United States: Colonial Times to 1970.
by u.s. Bureau of the Census. 1975,
Washington, DC: U.S. Government
Printing Office. p. 60: Infant Mortality
Rates by Race-States. The 2010 Statis
tical Abstract. by U.s. Census Bureau.
Washington, DC: U.S. Government
Printing Office, Table 113.
to a"1t.kof ""ingfriend,aco 1", likcly typ"of "",,,,ltnth,i'
sociallyisolated counterparts (see Chapter 10).IeelingsUQQ.orted by others
immunedefensesstr durin traumaticsituation tmayalso promotebetter
ealili a Its,regularcheckups,andearly ofworrisomesymptoms-all
'Orwhich mayifhproveacancervictim'soddsofsurvival.
Sociocultural Perspective
Within thesocial context,the socioculturalperspective howsocial
and cultural factors contribu sease.When psychologists use
t eter cu tur theyrefertotheenduringbehaviors,values andcustomsthat
agroup0 peoplehavedeve opedovert eyearsandtransmittedfromonegen-
eratio 0 t enext. Ithinacult re,thererna)'betWoormoreethnic groups-
largegroupsofpeoplewho have valuesandexperiencesbecause
;"1. f. ,.,A-" theysharecertain characteristics. .
l/ In multiethnicculturessuchas thoseofthe UnitedStatesandmostlarge
, tJ.--, nations, wide disparities still exist between the life expectancy and health
, statusofethnicminoritygroupsandthemajoritypopulation.Thesedispar-
, .-:: ygreat-grandmotherandotherswhoemigratedtoAmerica.Someofthese
differences undoubtedly..j$fleq in stat.i:S-JSES),
- ",)which is a measure ofseveral variables, including lOcom<;"education..and
occupation. For example, the highest ofchronic among
people;hoare atthelowestSES levels (Mackenbachandothers,2008).Ev-
idence also suggests that bias, prejudi'ce, and stereotyping on the part of
health care providers may also be factors. Minoritiestend to receive lower-
qualityhealthcarethanwhitesdo, evenwheninsurancestatus,income,age,
and severity ofconditions are comparable (Devi, 2008; Smedley, Stith, &
Socioculturalforces also play an importantrole in the variation in health-
. ../ relatedbeliefs and behaviors. Forexample,
r:!'- care practices re holistic and do not distinguish separate models for mental
/ p As anotnerexample, fltlan . ntlst .raditionallyre-
\\--. \1,,)( ject the use ofmedic' in their belief t at sick eo e can be cured only
\nJJJ through pray:r. n u aic a prescribesthat God gives health, and it is the 1
J" responsibilityofeach indivl ual to protectit. ---- -
A/t; n general, health psyc 0 oglsts workingfrom thesociocultural perspec-
V- tive have found wide discrepancies notonly amongethnic gmups butalso
__rJV within these groups. Latinos, for example, are far from honlbgeneous.The
. . three major nationality groups-Mexicans, Puerto Ricans, and Cubans-
V_differ in education, income, overall health, and risk ofdisease and death
(Angel, Angel, &Hill, 2008; Bagleyand others, 1995).Socioeconomic,reli-
gioLls, andotherculturalpatternsmayalso explainwhyvariationsin health
__ :-A IT ,.d areapparentnotjustamongethnicgroups,butalso from region toregion,
,,,Ieto''''',and,Yen INmon,n'ighbo<hoodtoanoth".Fo,exampl',out
CHAPTER 1 IIntroducingHealth Psychology 21
ofevery 1,000 live births, the number ofinfants who die before reaching
their first birthdayis much greater in the District ofColumbia (7.04 per-
cent),Mississippi (6.60percent),andLouisiana (6.12percent) thaninMon-
tana (2.64 percent), Washington (2.99 percent), and Iowa (3.25 percent)
(Heronandothers,2009).As one researcherstated,in termsofyouroverall
health,"theway youage depends on where you live" (Cruikshank,2003).
Also within thesocialcontext,thegenderperspectivein healthpsychologyfo-
cusesonthestudyofgender-specifichealth behaviors,problems,andbarriers
to health care. Withthe exceptionsofreproductive-system problemsand un-
dernourishment, menare morevulnerable thanwomen to nearlyeveryother
health problem. In many men consider preventive health care un-
manly,butwomentendtorespondmoreactive! thanmentoillnesssymptoms
andtoseektreatme arler WI iams,2003).Theeffectis cumulative,andby
age 80, women outnumbermen 2to 1(U.S. CensusBureau,2010).
. ...::.---- .
Themedical profession has alonghistoryoftreatingmen and womendif-
ferently. Forexample,researchstudieshaveshownthatwomentreatedforheart
diseasearemorelikelyto be' 8< Friend,2006);they
arelesslikelythanmento receiveco"tlose!i!!&..abouttheheart-healthybenefits-of
exerase,nutrition andwei htredu tion(Stewartandothers,2004)ortoreceive
anduse drugs for-ih.e treatmentoftheirheart (Vittinghoff
and offiers, 2003). In a classic study, 700 physicians were asked to prescribe
Sociocultural Bias inDiagnosis Physicians were toldthatthese supposed "heart
patients" were identical in occupation, symptoms, and every otherrespect
race, and gender. Although catheterization was the appropriatetreatmentforthe
described symptoms, thephysicians were much more likelyto recommend itforthe
younger, white, male patientsthan forth'e ,?Ider, female. orblack patients.
Source: Schulman. K.A., and others. (1999). The effect ofrace and sex onphy:>kbn's recommendations for cardiac calherization. NewEflg/and
JoumafofMedicine, 310. 618-625.
treatment for eight heart patients with identical symptoms (Schulman and oth-
ers, 1999). The "patients" were actors who differed only in gender, race, 'and re-
ported age (55,or 70). Altho.ugh diagnosis is a judgment call, most cardiac
specialists would agree that diagnostic catheterization is the appropriate treat-
ment for the symptoms described by each hypothetical patient. However, the
actual recommendations revealed a small, but nevertheless significant, antife-
male and antiblack bias. For the younger, white, and male patients, catheteriza-
tion was recommended 90, 91, and 91 percent of the tirpe, respectively; for the
older, female, and black patients, 86, 85, and 85 percent of the time, respectively.
Problems such as these, and the underrepresentation of women as partici-
pants in medical research trials, have led to the criticism of gender bIas in
health research and care. In response, the National Institutes of Health (NIH)
issued detailed guidelines on the inclusion of women and minority'groups in
medical research (USDHHS, 2001). In addition, in 1991 the NIH launched the
Women's Health Initiative (WHO, a long-term study of more than 161,000
postmenopausal women focusing on the determinants and prevention of dis-
ability and death in older women. Among the targets of investigation in this
sweeping study were osteoporosis, breast cancer, and coronary heart disease.
The clinical trials that formed the basis of the WHI tested the effects of hor-
mone therapy, diet modification, and calcium and vitamin D supplements on
heart disease, bone fractures, and breast cancer (WHI, 2010).
Despite the significance of such sociocultural and gender influences, re-
member that it would be a mistake to focus exclusively on this, or anyone con-
text, in isolation. Health behavior is not an automatic consequence of a giv.en
social, cultural, or gender context. For example, although as a group cancer'pa-
tients who are married tend to survive longer than unmarried persons, mar-
riages that are unhappy and destructive offer no benefit in this regard and may
tlVtlD l'l@ lirlli@l t@ ]:J@@fH health
Biopsychosocial "Systems"

)JY IrAI \ s these examples indicate,

utual influences among the biological, psychological, and social contexts of
\< ealth. It is also based on a systems theory of behavior. According to this the-
\" v ory, health-indeed all of nature-is best understood as a hierarchy of systems
'j 'u,l in which ",h ;y",m i, ;imultan'ou;ly wmpo"d of ,mall" ;ub".,tem, and

-?fi ,art oflarger, more encompassing systems (Figure 1.4).
, One way to understand the relationship among systems is to envision a tar-
-)' get with a bull's eye at the center and concentric rings radiating out from it.
systems theory the viewpoint ' Now consider each of us as a system made up of interacting systems such as the
that nature is best understood " endocrine system, the cardiovascular system, the nervous system, and the im-
as a hierarchy of systems, in mune system. (Also keep in mind that within each of our biological systems
which each system is simultane- .'..
ously composed of smaller there .are smal.ler subsystems, consIstll1g of tIssue,s, nerve fibers, flUIds, cells, and
subsystems and larger, inten'e- genetIC matenal.) If you move out from the bull s eye at the center and mto the
lated systems, radiating outer rings, you can see larger systems that interact with us-and
Systems Theory and Health
The systems potentially influ-
encing Mariana's headache,
shortness of breath, sleepless-
ness, and racing heart (review
the case study example, p. 6)
include her body's internal
biological systems (immune,
endocrine, cardiovascular, and
nervous), as well as her family,
neighborhood, culture, and
other external systems of which
she is part.

C HAP T E R 1 I IntrodUcing Health Psychology
Applying the Biopsychosocial Model
these rings include our families, our neighBorhoods, our communities, our so-
cieties, and our cultures.
Applied to health, the systems approach emphasizes a crucial point: A sys-
tern at any given level is affected by and affects systems at other levels. For ex-
ample, a weakened immune system affects specific organs in a person's body,
which in turn affect the person's overall biological health, which in turn might
affect the person's relationships with his or her family and friends. Conceptu-
alizing health and disease according to a systems approach allows us to under-
stand the whole person more fully.
To get a better feeling for the usefulness of biopsychosocial explanations of
healthy behaviors, consider the example of alcohol abuse, which is a mal-
adaptive drinking pattern in which at least one of the following occurs: re-
current drinkin des ite its interference with l' e obli ations; continued
drin ll1g despite legal, social, or interpersonal problems related to its use; ... "0::;.. _ .....-. _
PAR T 1 I Foundations of Health Psychology 22
ing to cope with life events or overwhelming social demands. Peer pressure,
difficult home and work environments, and tension reduction also may con-
l}) "tribute to problem drinking. And more generally, as many college students
. . know, certain social contexts promote heavy drinking. Research studies have
",":ll V . ,shown that college students who prefer large social contexts involving both
men and women tend to be heavier drinkers than those who prefer smaller

, Genetic
Negative thinking
Self-defeating beliefs
Stressful events
Culture/environment that
promotes excessive drinking Alcohol abuse A Biopsychosocial Model of
Individualistic culture that
Alcohol Abuse Alcohol abuse
encourages self-blame for
is best understood as occurring
personal failure.
in three contexts: biological.
psychological. and social. SOCIAL INFLUENCES
PAR T 1 I Foundations of Health Psychology
and recurrent drinking in situations in which intoxication is dangerous. Like
most disordered behavior, alcohol abuse is best explained in terms of several
mechanisms that include both genetic and environmental components
(Ball, 2008) (Figure 1.5). Research studies of families, identical and frater-
nal twins, and adopted children clearly demonstrate that people (especially
men) who have a biological relative who was alcohol dependent are signifi-
cantly more likely to abuse alcohol themselves (NIAAA, 2010). In fact, for
males, alcoholism in a first-degree relative is the single best predictor of al-
coholism (Plomin and others, 200l). In addition, people who inherit a gene
variant that results in a deficiency of a key enzyme for metabolizing alcohol
are more sensitive to alcohol's effects and far less likely to become problem
drinkers (Zakhari, 2006) .
On the psychological side, although researchers no longer attempt to iden-
tify a single "alcoholic personality;' they do focus on specific personality traits
and behaviors that are linked with alcohol dependence and abuse. One such
trait is poor characterized by an inability to exercise control over
drinking (Hustad, Carey, Carey, & Maisto, 2009). Another is negative emoJisln-
ality, marked by irritability and agitation. Along with several others, these traits
comprise the alcohol dependency stndrome that is the basis for a diagnosis of al-
cohol abuse (Li, fuwfti;&-GraJlt,2007).
On the social side, alcohol abuse sometimes stems from a history of drink-
C HAP TE R 1 I Introducing Health Psychology
Illixed-sex contexts. In addition, men who often drink in same-sex groups
(whether large or small) report more frequent drunkenness than men who
drink more often in smaD mixed-sex groups. This suggests that college men
who drink heavily may seek out social contexts in which this behavior will be
tolerated (LaBrie, Hummer, & Pedersen, 2007; Senchak, Leonard, & Greene
1998). Fortunately, researchers have also found that heavy college drinking
does not necessarily predict similar post-college drinking behavior. Students
tend to stop heavy drinking sooner than nonstudents-maturing out of haz-
ardous alcohol use before it becomes a long-term problem (NlAAA, 2006;
White, Labouvie, & Papadaratsakis, 2005).
e have seen how views regarding the nature of illness and health have
changed over the course of history, examined trends that helped
shape the new field of health psychology, and discussed the various
theoretical perspectives from which health psychologists work. But you may
still have questions about the profession of health psychology. Here are answers
to some of the most frequently asked questions.
What Do Health Psychologists Do?
Like aD psychologists, health psychologists rna serve as teachers, research scien-
tists, and/or clinicians. s teac ers, 1ea psychologists train students in hea th-
related fields such as psychology, physical therapy, and medicine. As research
scientists, they identify the psychological processes that contribute to health and
illness, investigate issues
tices, and evaluate the7ffe . e eSSJlf ific therapeutic intervention
th psychologists are on the cutting edge ot research testing the biopsy-
chosocial model in numerous areas, including Alzheimer's disease, HIV/AIDS,
compliance with medical treatment regimens, and immune functioning and
various disease processes. Because the biopsychosocial model was first devel-
oped to explain health problems, until recently the majority of this research has
focused on diseases and health-compromising behaviors. However, the late
twentieth-century movement in psychology, called positive psychology, encour-
ages psychologists to devote more research attention to optimal, healthy
human functioning (APA, 2010). The scope of this research-covering topics
as diverse as optimism and happiness, psychological hardiness, and the traits of
people who live to a ripe old age-shows clearly that the biopsychosocial model
guides much of it (see Chapter 6).
Clinical health psychologists, who generally focus on health-promoting inter-
ventions, are licensed for independent practice in areas such as clinical and coun-
seling psychology. As clinicians, they use the full range of diagnostic assessment,

( HAP T E R 1 I Introducing Health Psychology 27
2. How does the overall health of your school population
benefit when different contexts, systems, models, and
theories about health are taken into consideration?
3. Your friend Tran is thinking about pursuing a career in
health psychology. What general advice would you give
him, and how would you suggest he choose a specific
career in the field?
Respond to each question below based on what you
learned in the chapter. (TIP: Use the items in Summing Up
to take into account related biological, psychological, and
social concerns.)
1. Considering how views of health have changed over
time, what would be a good description of health for
an individual today? How do gender, culture, and the
practice of health influence your description?
I )1 hers train for one of the allied health professions, such as nutrition, physical
111l,;rapy, social work, occupational therapy, or public health. An increasing
1IIImber of interested undergraduates continue on to graduate school in psy-
, I'ulogy and acquire research, teaching, and intervention skills. Those who ul-
Ii mately hope to provide direct services to patients typically take their training
In clinical or counseling psychology programs.
Many students who wish to pursue a career in health psychology begin
with general psychology training at the undergraduate level. Because of
health psychology's biopsychosocial orientation, students are also encour-
ilgcd to take courses in anatomy and physiology, abnormal and social psy-
chology, learning processes and behavior therapies, community psychology,
,md public health.
Most health psychologists eventually obtain a doctoral degree (Ph.D. or
l'sy.D.) in psychology. To earn a Ph.D. in psychology, students complete a
(our- to six-year program, at the end of which they conduct an original re-
search project. PsyD. programs generally provide slightly more clinical
rience and clinical courses but less research training and experience than
Ph.D. programs.
Graduate training in health psychology is generally based on a curriculum
that covers the three basic domains of the biopsychosocial model. Training in
the biological domain includes courses in neuropsychology, anatomy, pm:siol-
ogy, and psychopharmacology. Training in the psychological dornalo-includes
courses in each of the major subfields (biological, developmental, personality,
etc.) and theoretical perspectives (social-cultural, cogniti\re, behavior, neuro-
science, etc.). And training in the social domain includes cpurses on group
processes and ways in which the various groups (family, ethnic, etc.) influence
their members' health.
Following graduate training, many health psychologists complete two or
more years of specialized training in the form of an internship in a hospital,
clinic, or other medical setting. Some advocates have suggested that such train-
ing should culminate in board certification of health psychologists as primary
health care providers themselves (Tovian, 2004, 2010).
PAR T 1 I Foundations of Health Psychology
Where Do Health Psychologists Work?
Traditionally, most psychologists accepted teaching or research positions at
universities and four-year colleges. Employment opportunities for health psy-
chologists with applied or research skills also include working in government
agencies that conduct research, such as the National Institutes of Health and
the Centers for Disease Control and Prevention.
In medical settings, health psychologists teach health care providers, con-
duct research, become involved in health care policy development, and provide
a variety of other services. They help patients cope with illness and the anxiety
associated with surgery and other medical interventions, as well as intervene to
promote patients' adherence to complicated medical regimens. In this capac-
ity, clinical health psychologists often work on interdisciplinary hospital teams.
As part of a new model of integrated care, these teams improve medical treat-
ment outcomes, lower costs, and offer a successful model for future health care
systems (Novotney, 2010).
In addition, medical residency programs in the United States now have a clear
mandate to improve physician training in areas such as sensitivity and responsive-
ness to patients' culture, age, gender, and disabilities. Increasingly,
healili psychologists are helping physicians become better listeners and
communicators (Novotney, 2010). As we'll see, tllis mandate stems
from mounting evidence iliat this type of care results in better healili
outcomes and helps control health care costs (Novotney, 2010).
Health psychologists may also be found working in health main-
tenance organizations (HMOs), medical schools, pain and rehabil-
itation clinics, and private practice (Figure 1.6). An increasing
number of health psychologists may also be found in the corporate
world, where they advise employers and workers on a variety of
health-related issues. They also establish on-the-job interventions
to help employees lose weight, quit smoking, and learn more adap-
tive ways of managing stress.
education, and therapeutic techniques in psychology to promote health and as-
sist the physically ill. Assessment approaches frequently include measures of cog-
nitive functioning, psychophysiological assessment, demographic surveys, and
lifestyle or personality assessment. II r ltions ay include stress ana e-
ment, relaxation therapies, biofeedback, education about the role of psychologi-
c:irprcResses irrdlsease, and cognitive behavioral interventions. Interventions are
not limited to those who are already suffering from a healili problem. Healthy or
at-risk individuals may be taught preventive healiliy behaviors.
How Do I Become a Health Psychologist?
Preparing for a career in health psychology usually requires an advanced de-
gree in any of a number of different educational programs. Some students en-
roll in medical or nursing school and eventually become nurses or doctors.
Other 3%
Where Do Health Psycholo-
gists Work? Besides colleges,
universities, and hospitals,
health psychologists work in a
variety of venues, including
health maintenance organiza-
tions (HMOs), medical schools,
pain and rehabilitation clinics,
and independent practices. An
increasing number of health
psychologists can be found in
the workplace, where they
advise employers and workers
on a variety of health-related
Source: 2009 Doctoral Psychology
Workforce Fast Facts. Washington, DC:
American Psychological Association.
government 7%

Summing Up
1. Health is astateofcompletephysical, mental,andsocial
well-being. Health psychology's goals are to promote
health; prevent and treat illness; investigate the role of
biological, behavioral, and social factors in disease; and
evaluate and improve the formulation ofhealth policy
andthedeliveryofhealthcare to all people.
Health and Illness: Lessons from the Past
2. Intheearliestknowncultures,illnesswas believed tore-
body. Hippocrates,Galen, and otherGreekscholars de-
velopedthefirst rationalapproachtothestudyofhealth
and disease. Non-Western forms ofhealing, including
3. In Europe during the Middle Ages, scientificstudies of
the body (especially dissection) were forbidden, and
ideas about health and disease took on religious over-
tones. Illness was viewed as punishmentfor evildoing,
and treatment frequently involved what amounted to
4. French philosopherRene Descartesadvanced his theory
of mind-body dualism-the belief that the mind and
bodyare autonomous processes, each subject to differ-
entlawsofcausality. Duringthe Renaissance, Descartes'
influenceusheredinaneraofmedicalresearch basedon
theanatomical,cellular,andgerm theoriesofdisease.
5. Thedominantview in modernmedicineis the biomed-
ical model,which assumes thatdisease is the result ofa
virus, bacterium, orsome otherpathogen invading the
body. Because it makes no provision for psychological,
social, or behavioral factors in illness, the model em-
bracesbothreductionismand mind-bodydualism.
6. Sigmund Freud and Franz Alexander promoted the
idea thatspecific diseases could be caused by uncon-
scious conflicts. These views were expanded into the
field ofpsychosomatic medicine, which is concerned
with the treatmentand diagnosis ofdisorders caused
by faulty processes within the mind. Psychosomatic
medicine fell outoffavor because it was grounded in
psychoanalytic theory and predicated on the out-
moded idea thatasingle problem is sufftcient to trig-
ger disease.
PAR T 1 I Foundations ofHealth Psychology
7. Behavioral medicinewasanoutgrowthofthebehavior-
istmovementin Americanpsychology. Behavioral med-
Biopsychosocial (Mind-Body) Perspective
8. Health psychologists approach the studyofhealth and
illness from several overlapping perspectives. The life-
course perspective in health psychology focuses atten-
tiononhowaspects ofhealthand illness varywithage,
aswellas howbirthcohortexperiences (suchas shiftsin
publichealth policy) influencehealth.
9. Thesocioculturalperspectivecalls attention to howso-
cial andcultural factors, such as ethnicvariations in di-
etary practice and beliefs about the causes of illness,
10. The gender perspective calls attention to male-female
differences in the risk of specific diseases and condi-
tions,aswell as in varioushealth-enhancingandhealth-
11. Thebiopsychosocialperspectiveineffectcombinesthese
perspectives, recognizing that biological, psychological,
and social forces act together to determine an individ-
ual'shealthandvulnerabilityto disease.
a hierarchyofsystems inwhich each system is simulta-
neously composed of smaller subsystems and part of
larger, moreencompassingsystems.
Frequently Asked Questions about a Health
Psychology Career
13. Healthpsychologistsareengagedinthreeprimaryactiv-
psychologists work in a variety ofsettings, including
tenance organizations, rehabilitation clinics, private
14. Preparing for a career in health psychology usually re-
chology from the fields ofmedicine, nursing, oroneof
the allied health professions.An increasingnumberen-
roll in graduateprogramsinhealthpsychology.
C HAP T ER 1 I IntroducingHealth Psychology 29
Key Terms and _
he.llth psychology,p. 3 cellulartheory, p. II biopsychosocial (mind-body)
health,p. 3 germtheory, p. 12 perspective,p. 16
I rephi nation,p. 6 biomedical model,p. 12 life-courseperspective,p. 17
humoral theory, p. 8 pathogen,p. 12 birthcohort,p. 18
epidemic,p. 10 psychosomaticmedicine,p. 13 socioculturalperspective,p. 20
mind-bodydualism,p. 11 behavioralmedicine,p. 14 genderperspective,p. 21
;ll1atomicaltheory,p. II etiology,p. 15 systems theory,p. 22