Health Psychology: An Overview for the Rehabilitation Professional

Ginseng Gray, SPT Wayne State University College of Pharmacy & Allied Health Department of Physical Therapy

KNOWLEDGE IS POTENTIAL POWER.
(Unknown)

Presentation Objectives
Define Health Psychology Examine Coping Strategies Discuss research relevant to rehabilitation Introduce the biopsychosocial medical model Students will understand the role of mental health in physical function Provide students with techniques to enhance compliance Provide students with objective assessment tools

What is Health Psychology?
The aggregate of specific educational, scientific and professional contributions of psychology to the promotion and maintenance of health, the prevention and treatment of illness, the identification of etiologic and diagnostic correlates of health, illness, and related dysfunction and the analysis and improvement of the healthcare system and health policy. (Matarazzo 1980)

Relevance to Physical Therapy
Definition of health psychology shares some common goals with the goals of physical therapy As defined by the APTA in the guide to PT practice PTs seek to restore optimal physical function whereas psychology seeks optimal mental function

Relevance to Physical Therapy
PT’s teach encourage and motivate using principles borrowed from the field of psychology There is a need to understand how to successfully teach and affect health behaviors of compliance and motivation

Health Psychology: Historic Beginnings
In 1852, physician Henry Holland questioned the relationship between mind and body, between psychological and somatic processes. (Mental Physiology) Freud believed that unacceptable or disturbing thoughts and emotions, kept unconscious could create a physical disorder or the appearance of one. (Prokop)

3 Foundations of Health Psychology
Field is built on principles of:
1) 2) 3)

Behavioral learning: classical conditioning Behavioral learning: operant conditioning Social learning: observational

Psychology 101: Review
Classical conditioning was made famous by Pavlov and his dogs, which salivated at the presentation of food BF Skinner tested the theory of operant conditioning, teaching animals to work for rewards Bandura was the first to develop the theory that thoughts influence the acquisition of behavior. Uncovering the underlying source of the behavior is important in preventing or altering the behavior.

COPING
Coping is the constantly changing cognitive and behavioral efforts to manage a stimulus that is appraised as stressful (Prokop, 1991) Differences in the ways people handle stress are learned

Self Efficacy: A coping strategy
An individual’s subjective perception of the ability to perform a task A set of expectations, not skills Can be applied to geriatric population at risk for falls (Tinetti & Powell, 1994) “IT IS OUR PERCEPTION THAT BRINGS ABOUT A DESIRED EFFECT” (Lehman & Roller, 1999)

Four Parts to Self-Efficacy
1) Performance

Accomplishment 2) Vicarious Accomplishment 3) Verbal Persuasion 4) Physiological Status

Self-Efficacy
Goreczny (1995), states that addressing self-efficacy improves and reduces disability and pain related behaviors in:
Exercise compliance  Workload Performance  Motor Skills  Pain tolerance

Question??
What are the four aspects of self-efficacy?
3) Performance Accomplishment (mastery) 4) Vicarious Accomplishment 5) Verbal Persuasion 6) Physiological status

Coping Strategies in Low Back Pain
Rosensteil & Keefe (1983) examined the use of coping strategies in chronic low back pain patients Three types of coping strategies emerged most frequently
   

1) Cognitive coping & suppression 2) Helplessness 3) Diverting attention & prayer Found to be predictive of behavioral and emotional adjustment =ABILITY TO CONTROL OR ADJUST PAIN

Positive vs Negative adjustment in LBP
18 16 14 12 10 8 6 4 2 0 Negative Adjustment Positive Adjustment Cognitive Suppressors Helpless Diverting and praying

Coping strategies in LBP: Results
Indicate an active approach to coping with pain more predictive than somatization scales, such as the McGill Pain questionnaire (Rosensteil & Keefe, 1983)

Effectiveness of Coping in Spinal Cord Injury (King, 1999)
The authors used the Coping Effectiveness Training (CET)program CET is a group based intervention that teaches appraisal skills, cognitive, behavioral coping, and how to obtain social support

Depression and Anxiety in SCI with the CET Intervention
18 16 14 12 10 8 6 4 2 0 Intervention Control Pre Post Follow-up

Emotional Disclosure
A cognitive behavioral intervention developed by Pennebaker Requires subjects to write or talk privately about stressful life situations, 15 minutes per day for 3-5 days

Emotional Disclosure
(Pennebaker, 1990) In healthy populations it is associated with
Better mood  Increased grade point average  Decreased absenteeism  Enhanced immunity

Emotional Disclosure and Rheumatoid Arthritis
The onset of RA is associated with stressful life events when compared to controls (Baker, 1982) Emotional disclosure in RA has been shown to alter symptoms in the following ways.

Physical Dysfunction following Emotional Disclosure in RA
(Kelley, Lumley & Leisen, 1997)
3.5 3 2.5 2 1.5 1 0.5 0 Baseline 2 weeks 3 months Disclosure Control

Affective Disturbances in RA with Emotional Disclosure
(Kelley, Lumley & Leisen, 1997)
4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Baseline 2 Weeks 3 Months Disclosure Control

Question??
Name the three foundational principles of Health Psychology.
3) Operant Conditioning 4) Classical Conditioning 5) Social/Observational Learning

Body Mind Medicine
Hans Seyle is known as the great pioneer of body-mind medicine (Vogel, 1991) He was the first to discuss the role of stress in the fields of medicine and psychology

Body Mind Medicine
70% of visits to primary care physicians are for problems related to stress and lifestyle (Vogel, 1999) Methods of intervention 1. Educational 2. Cognitive-Behavioral -skills training, pacing, distraction, imagery, and decreasing catastrophizing

Biopsychosocial Medicine: A New Medical Model
An alternative medical model which approaches patient management with a team of professionals at initial onset (Dea, 2000)
Adult Primary Care Team Six MDs One LPN

Behavioral Med

Health Educator

One PT

Personal Health Improvement Program (PHIP)
Meditation Based Program created by Matthew Budd of the Harvard Pilgrim Plan Kaiser Permanente, a California HMO, tested the Personal Health Improvement Program in its CAD members

Bromwyn & Ford, 2000
Studied the effects of PHIP in Kaiser Permanente’s members with Coronary Artery Disease Lifestyle Modification Program - Nutrition (vegetarian diet) -Exercise (yoga, group and home exercise) -Social (support group)

Results: Overall Disease Distress in CAD with PHIP
0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0
Overall Diseases Distress Psychological Distress Functional and Health Status

Before PHIP

Post-PHIP

6 Month Followup

Cost Comparison Before and After PHIP Referral in patients with CAD 1,800
1,600 1,400 1,200 1,000 800 600 400 200 0 Control PHIP Group 1,650 1,709 1,270 1,010 1,119 760 6 months prior 6 months after 12 months after

COMPLIANCE or should we say, COLLABORATION
Compliance to a medical protocol, is a form of passive adherence (Prokop, 1991) An alternative term suggested is collaboration This makes the activity a project for the healthcare professional and the client

How many patient’s comply? (Hoepful,1980)
25% to 64% of patients comply with medical advice or directions Wide range varies due to many populations

compliant noncompliant

Health Belief and Compliance
The Health Belief Model is a theoretical framework to explain and predict health related behaviors.(Goreczny, 1995) According to the HBM, the following factors interact to produce behavior change
   

Perceived vulnerability & severity Belief in effectiveness of prevention Perceived costs Presence of environmental cues

Can the Health Belief Model Predict Compliance?
Chen & Neufield, Occupational Therapists, evaluated factors that would predict compliance in patients with UE Dysfunction

Results
35% of the subjects were 100% compliant Self-efficacy emerged as the most important factor in achieving compliance Therefore encouraging self-efficacy should be the emphasis of collaborative home exercise programs and consultations

Compliance and Cardiac Rehabilitation (Lane, 2001)
Identified factors that would predict attendance to cardiac rehab 76% attended all sessions Prior exercise experience was a significant predictor of attendance.

Physical Capabilities Scale
(Fitzgerald and Feuerstein(1992) Eight item, self efficacy scale for rating expected performance in strength testing and endurance Assessment tool to measure effectiveness of cognitive behavioral interventions

Can you identify non-compliers?
Salisbury (1996), has identified methods of assessing patient health beliefs, motivation and stress. Health beliefs are attained by asking the patient their perceived cause of illness. Provides the clinician with a start point and an idea of what behaviors can be changed Only one behavior should be changed at a time.

Question??
What is compliance considered? And what is a better term?
 Passive Adherence  Better term=Collaboration

STAGES OF MOTIVATION THEORY: a review
Also called the Transtheoretical Model Delineates stages of readiness for change
1) Precontemplation 2) Contemplation 3) Preparation 4) Action 5) Maintenance

Interventions to Increase Physical Activity (ACSM, 2000)
Suggestions: Use of a sign/reminder Balance Sheet: Write down pros/cons of anticipated participation and outcomes Lottery or Contest: Provide prizes for behavioral changes or compliance levels Phone Calls/Postcards

Conclusion
Economic pressures create a need for the most efficient and effective treatments The cost reductions of Kaiser Permanente are not isolated to California

•Understanding mechanisms of behavioral change are vital to all rehab professionals •More research is needed to standardize behavioral interventions

Summary
Self efficacy, perception of ability is a major factor in effective coping Emotional disclosure can positively mood and immunity Biopsychosocal medicine is a first contact team approach to care Compliance can be improved by teaching/encouraging self efficacy

Question??
Name some methods of increasing physical activity compliance 1. Sign 2. Balance Sheet/Pros & Cons 3. Contests 4. Phone calls/postcards

FINAL QUESTION
Complete the following statement: Knowledge is __________ _________ POTENTIAL POWER!!

Thanks for your Attention.

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