28 PART 1Foundations of Health Psychology
Americans Act, which provides every older person, regardless of income, with
sociocultural perspective
theoretical perspective that
focuses on how social and
hteto
cultural factors contribute to
health and disease
gender perspective theoret
cal perspective that focuses
on gender-specific health
problems and gender barriers Sociocultural Perspective
to health care
a variety of health benefits-from subsidized meals to counseling and other
services provided by over 20,000 community agencies. As a result, older Amer
icans have more opportunities today to remain in better health than their
counterpart ohorts who reached late adulthood earlier in our nation's history.
How social and cultural factors contribute to health and disease is the focus of
the sociocultural perspective. When psychologists use the term culture, they
refer to the enduring behaviors, values, and customs that a group of people
have developed over the years and transmitted from one generation to the
next. Within a culture, there may be one, two, or more ethnic
groups, large
groups of people who tend to have similar values and experiences because they
share certain characteristics.
In multiethnic cultures such as those of the United States and most
large
nations today, wide disparities exist in the life expectancy and health status of
ethnic minority groups and the majority population. Some of these differences
undoubtedly reflect variation in socioeconomic status (SES), a measure of sev-
eral variables, including income, education, and
occupation. For example,
the
highest rates of chronic disease occur among people who are at the lowest SES
levels (Flack et al., 1995).
Sociocultural variation is also apparent in health-related beliefs and
iors. For example, traditional Native American health behav
care practices are holistic
and do not distinguish
separate models for mental and physical illnesses
(Johnson et al, 1995). As another example, Christian Scientists
reject the use of medicine in their belief that sick people can betraditionally
cured
through prayer. And Judaic law prescribes that God gives health, and it isonly the
responsibility of each individual to protect it.
In general, health psychologists working from this perspective have found
wide discrepancies only among
not ethnic groups but also within these
groups. Latinos, forexample, are far from homogenous. The three major na-
tionality groups-Mexican-Americans, Puerto Ricans, and Cubans-differ in
education, income, overall health, and risk of disease and death
Dilworth-Anderson, Liu, & Schinke, 1995). (Bagley, Angel,
Gender Perspective
The gender perspective in health psychology focuses on the
specific health problems and gender barriers to health care. Menstudy of gender
and women
differ in their risk of a variety of disorders.
Throughout childhood, for exam
ple, boys outnumber girls in a range of behavioral and
psychological disorders.
 IntroducingHealth Psychology CHAPTER 1| 29

Sociocultural Bias in
Diagnosis
including sleep and eating problems, hyperactivity, autism, and antisocial be
Physicians were told that these
havior. Conversely, from age 8 through adulthood, girls and women outnum-
supposed "heart patients" were
ber boys and men in the diagnosis of depression, anxiety, and eating disorders identical in occupation, symp
toms, and every other respect ex
(Ussher, 1997). In addition, women tend to respond more actively than men to cept age, race, and gender. Al
illness symptoms and to seek treatment earlier.
The medical profession has a long history of treating men and women dif- though catheterization was the
appropriate treatment for the de-
ferently. For example, research studies have shown that women treated for scribed symptoms, the physicians
heart disease are given more prescriptions, are more likely to be put through were much more likely to recom-
unnecessary diagnostic procedures, and are not likely to receive the same qual mend it for the younger, white,
ity of medical care as men (Ayanian & Epstein, 1991). In one study, 700 physi- male patients than for the older,
female, or black patients.
cians were asked to prescribe treatment for eight heart patients with identical
Source: "The Effect of Race and Sex on
were actors who dif-
symptoms (Schulman et al., 1999). In fact, the "patients" Physician's Recommendations for Cardiac
fered only in gender, race, and reported age (55 or 70). Although diagnosis is a Catherization," by K. A. Schulman, J.
Berlin, W. Harless, J. F. Kerner, S. Sistrunk,
judgment call, most cardiac specialists would agree that diagnostic catheteriza- B. J. Gersh, R. Dubé, C. K. Taleghani, J. E
tion is the appropriate treatment for the symptoms described by each hypo- Burke,S. Williams, J. M. Eisenberg, andJ.
Escarce, 1999, New England Journal of
thetical patient. However, the actual recommendations revealed a small, but Medicine, 340, pp. 618-625.
nevertheless significant, antifemale and antiblack bias. For the younger, white,
and male patients, catheterization was recommended 90, 91, and 91 percent of
the time, 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 criticisnm of gender bias in
health research and care. In response, the National Institutes of Health (NIH)
has issued detailed guidelines on the inclusion of women and minority groups
in medical research (Burd, 1994). In addition, the NIH recently launched the
Women's Health Initiative, a l5-year study of 160,000 postmenopausal women
focusing on the determinants, and prevention, of disability and death in older
 30 PART 1Foundations of Health Psychology

biopsychosocial (mind-body)
perspective the viewpoint women. Among the targets of investigation in this eping study are
sweeping are e

that health and other porosis, breast cancer, and coronary heart disease.
osteo.
iors are determined behav By now,it's probablyclear to you that these perspectives overlap, that
teraction of biologicalby mecha-
the in-
view health and illness as the product of interacting actors. they all
They differ only in
nisms, psychological processes, the factors they emphasize. Although these perspectives answer
and social influences
tions about health, they complement, rather than contradict, one
different ques
another. T
gether, they help explain human health and illness. In a sense, the sociocultural
life-course, and gender perspectives are subsumed under the
biopsychosocial
perspective because that model, whether directuy or indirectiy, deals with
issues covered by the other allthe
will be on the
perspectives. For that reason, our focus in this tet
biopsychosocial perspective, to which we now turn.

Biopsychosocial (Mind-Body) Perspective

As history tells us,
looking at one causative factor paints an incomplete
of a
person's health illness. Health picture
or

biopsychosocial (mind-body) perspective. As depicted in psychologists therefore work from a

perspective recognizes that biological, Figure 1.4, this

psychological,
gether to determine individual's health and
an
and social forces act to-
health and disease must be vulnerability to disease; that is,
explained in terms of multiple contexts.
The Biological Context
All behaviors, including states of health and
text. Every thought, mood, and urge is a illness, occur in a biological con-
cause of the characteristic anatomical biological event made possible be-
structure and
person's body. Health biological function of a
ies that influence healthpsychology
draws attention to those aspects of our bod-
and disease:
mune, and endocrine
our
genetic makeup and our nervous, im-
systems (see Chapter 3).
Genes provide the blueprint for
iors-healthy and unhealthy, normal andbiology and our

abnormal.
predispose our behav-
dency to abuse alcohol has For example, the ten-
long been known to run in some
families (see
igure 14
Biologica
mechanisms The Biopsychosocial Model
According to the biopsychosocial
health behaviors are perspective, all
best explained in terms of
three contexts:
Psychological biological processes, psychologica
processes
BEHAVIOR processes, and social influences.
Source:
Psychology: A Biopsychosocial Approach, by C. Peter
son, 1997, New York:
Addison-Wesley Longman.
Socaln f u e n c e
 TntroducingHeath Psychology cHAPtER 31

Chapter 8). One reason is that alcohol dependency is at least partly genetic, al
though it does not seem to be linked to a single. specihc gene. Instead. some
people may inherit a greater sensitivity to akcohol's physical effects, experien-
ing intonication as pleasurable and the aftermath of a hangover as minor. Such
people may be more likely to drink, especially in certain psychological and so-
aal contexts.
A key element of the biological context is our species' evolutionary history
Our characteristic human traits and behaviors exist as they do because they
helped our distant ancestors to survive long enough to reproduce and send
their genes into the future. For example. natural selection has favored the ten-
dency of people to become hungry in the presence of a mouth-watering aroma
see Chapter 7). This sensitivity to food-related cues makes evolutionary sense
in that eating is necessary for survival--particularly in the distant past when
food supplies were unpredictable and it was advantageous to have a healthy
appetite when food was available.
At the same time, biology and behavior constantty interact. For example,
some individuals are more vulnerable to stress-related ilnesses because they
angrily react to daily hassles and other environmental "triggers (see Chapter
4). Among men, increased amounts of the hormone testosterone are positively
correlated with this type of aggressive reaction. This relationship, however, is
recaproca: 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 ocurs.

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 in-
terpreted (see Chapter 5). Events that are appraised as overwhelming. perva-
Sive, and beyond our control take a much greater toll on us physically and psy-
chologically than do events that are appraised as minor challenges that are
temporary and surmountable. Indeed, some evidence suggests that, whether a
stressful event is actually experienced or merely imagined, the body's stress re
sponse is nearly the same. Health psychologists think that some people may be
chronically depressed and more susceptible to certain health problems because
they replay stressful events over and over again in their minds, which may be
functionally equivalent to repeatedly encountering the actual event. Through-
out this book we will examine the ways in which
thinking, perception, motiva
tion, emotion, learning, attention, memory, and other topics of central impor
tance to psychology are implicated in health.
Psychological factors also play an important role in the treatment of
chronic conditions. Consider the treatment of cancer-once a disease that au-
tomatically led to death. Although death is no longer automatic, treatments
such as chemotherapy force patients to endure the sometimes miserable
 Psychology
32 PART 1| Foundations of Health

and vomiting, to the powertul drugs admin.

reactions, including severe nausea
that some patients actually refuse
istered. The side effects can be so debilitating
The effectiveness of medica.
to potentially
continue the life-saving regimen.
tion is powerfully influenced by a patient's attitude, toward treatment. A pa
tient who believes a drug will only cause misery may experience considerable T
tension, which can actually worsen his or her physical reaction to the treat.
ment. This reaction can set up a vicious cycle in which escalating anxiety be-
fore treatment is followed by progressively worse physical reactions as the
treatment regimen proceeds. Psychological interventions can help patients
learn to manage their tension, thereby lessening their negative reactions to
treatment. Patients who are more relaxed are usually better able, and more
motivated, to follow their doctors' instructions.
Psychological interventions can also assist patients in managing the every.
day stresses of life, which seem to exert a cumulative effect on the immune sys-
tem. Negative life events such as bereavement, divorce, job los, or relocation
have been linked to decreased immune functioning and increased susceptibil-
ity to illness. By teaching patients more effective ways of managing unavoid.
able stress, health psychologists may help patients' immune systems combat
disease.

The Social Context

In placing health behavior in its social context, health psychologists are con-
cerned with the ways in which we think about, influence, and relate to one an-
other and to our environments. Your gender, for
example,
entails a particular
socially prescribed role that gives you your sense of being a woman or a man.
In addition, you are a member of a
particular family, community, and nation
you also have a certain racial, cultural, and ethnic identity and live within a
specific socioeconomic class. Each of these elements of your unique social con-
textinfluences your beliefs and
behaviors-including those related to health.
Consider the social context in which a chronic disease such as cancer
A spouse,
oc
curs.
significant other, or close friend provides an important source
of social support for many patients. Women and men who feel socially
cancer
connected to a network of caring friends are less likely to die of all types ot
cancer than their socially isolated
counterparts (see Chapter 10). Feeling sup-
ported by others may serve as a buffer that mitigates the output of stress hor-
mones and keeps the body's immune defenses strong during traumatic situa-
tions. It may also promote better health habits, regular checkups, and early
screening of worrisome symptoms-all of which may improve a cancer vic
tim's odds of survival.
Despite the signihcance of such social influences, remember that it would
be a mistake to focus exclusively on this, or any one context, in isolation.
Health behavior is not an automatic consequence of a given social context. for
example, although, as a group, cancer patients who are married tend to survive
longer than unmarried persons, marriages that are unhappy and destructve
 Introducing Health Psychotogy cHAPTER 33
offer no benefit in this regard and may even be linked
Comes.
to poorer health out systems theory the view
point that nature is best un-
derstood as a hierarchy of
Biopsychosocial "Systems" systems, in which each sys
tem is simultaneously com-
As these examples indicate, the biopsychosocial perspective emphasizes the
mutual influences among the biological, posed of smaller subsystems
health. It is also based on a systems
psychological, and social contexts of and larger, interrelated sys-
theory of behavior. According to this the tems
ory, health-indeed, all of nature-is best understood as a
tems in which each
hierarchy of sys-
is
system simultaneously composed of smaller subsystems
and part of larger, more
encompassing systems. Thus, each of us is a system
a body made of
up interacting systems such as the endocrine system, the car
diovascular system, the nervous system, and the immune system. Each of these
biological systems is, in turn, composed of smaller subsystems consisting ot
tissues, nerve fibers, fluids, cells, and genetic material. Moving in the other di-
rection, we are part of many larger systems, including our families, our
neigh
borhoods, our societies, and our culture.
Applied to health, the systems approach emphasizes a crucial point: A sys-
tem 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 and friends.
family Conceptu
alizing health and disease according to a systems approach allows us to under-
stand the whole person more fully.

Applying the Biopsychosocial Model

To get a better feeling for the usefulness of biopsychosocial explanations of
healthy behaviors, consider the example of major depresive disorder, which is
iagnosed when signs of depression (including lethargy, felings of worthless-
ness, and loss of interest in family and friends) last 2 weeks or longer without
any notable cause.
Like most psychological disorders, depression is best explained in terms of
several mechanisms (see Figure 1.5 on page 34). Research studies of families,
identical and fraternal twins, and adopted children clearly demonstrate that
peo-
ple who have a biological relative who was diagnosed with depression before age
30 are much more likely to be
diagnosed with depression than are people with
out a relative who suffers from depression (Pauls, Morton, & Egeland, 1992). In
addition to genetics, other factors in the biological context of this disorder in-
clude low levels of certain brain neurotransmitters,
especially norepinephrine
and serotonin (see Chapter 3). Antidepressant medications (such as Prozac and
Paxil), electroconvulsive shock therapy, and repetitive physical exercise (for ex
ample, running, swimming, and biking) are effective treatments largely because
they increase the availability of these brain chemicals (Jacobs, 1994).
On the
psychological side, there is considerable research evidence that nega-
tive thinking, including self-defeating attitudes, contributes to depression.
 Health Psychology
341PART 1 |Foundations of

ABiopsychosocial Model of
Genetic Depression
predispositions Depression is best understood as
Insuficient
occuring in thre contexts: biolog
norepinephrine ical (genetic predispositions and
and serotonin neurotransmitter imbalances), psy.
Stressful activity Depressive chological (negative thinking and
events disorders self-defeating beliefs), and social
(stressful events, conditioned help
Negative lessness, and an individualistic
thinkng
culture that encourages self-blame
Culture for personal failure).
Source: Psychology: A Biopsychosocial Ap-
proach, by C. Peterson, 1997, New York:
Addison-Wesley Longman.

Depressed people tend to think about themselves, their world, and the future
grim ways (see Chapter 5). When unavoidable or uncontrollable painful
events occur, people who are vulnerable to depression tend to explain the
events as due to causes that are internal ("It's all my fault"), global ("It's going
to affect everything I do"), and stable (Tl never get over this"). In
cognitive
therapy, psychologists work with depressed clients to challenge and redirect
these negative beliefs.
On the social side, depression is often brought on by stressful experi-
ences-losing a job or a loved one, getting divorced, anything that challenges
a
person's sense of identity and self-esteem (Kendler, Neale, Kessler, Heath,&
Eaves, 1993). Martin Seligman (1991) has proposed that
and depression may be socially conditioned in
self-defeating beliefs
not influence
people who learn that they can-
important events in their lives. Just as laboratory animals who
receive unavoidable electric shocks become
passive and withdrawn, so too do
people who experience uncontrollable painful events.
As is true of other
psychological disorders, culture exerts an important in-
fluence on a
person's vulnerability to depression. Major depressive disorder is
much more common among
of individualism, which
young Westerners-perhaps
because of the rise
encourages the self-focused individual to accept per
sonal responsibility for all
problems. In contrast, in more close-knit, coopera-
tive non-Western cultures such as
Japan, depression is much rarer-perhaps
because problems are less
likely be tied to self-blame for personal taulure
to
(Seligman, I1995). Moreover, there is a birth cohort effect on
depression: Young8
North American adults are three times as
likely to report suffering
today as were their grandparents at any time during their lives depression
Canada, 1999). (Statistics,
 Introducing Health Psychology | CHAPTER 1 | 35

Frequently Asked Questions

aboutHealth.Psychology
have seen how views
regarding the nature of illness and health
W have changed over the course of history, examined trends that
helped shape the new field of health psychology, and discussed the
rious 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 all psychologists, health psychologists may serve as teachers, research scien-
rists, and/br dinicians. Their role as teachers is obvious: They train the next
generation of students in health-related felds. As research scientists, they iden-
tify the psychological processes that contribute to health and illness, investigate
issues concerning why people do not engage in healthful practices, and evalu-
ate the effectiveness of specific therapeutic interventions.
Health psychologists are on the cutting edge of research testing the biopsy-
chosocial model in numerous areas, including HIV/AIDS, compliance with med-
ical treatment regimens, and the effects of psychological, cultural, and social vari-
ables on immune functioning and various disease processes (for example, cancer,
hypertension, diabetes, chronic pain). Because the biopsychosocial model was first
developed to explain health problems, until recently the majority of this research
has focused on diseases and health-compromising behaviors. However, a new
movement in psychology, called positive psychology, is encouraging psychologists
to devote more research attention to optimal, healthy human functioning (Selig-
man & Csikszentmihalyi, 2000). The scope of this research-covering topics as
diverse as happiness, psychological hardiness, and the traits of people who live to a

ripe old age-shows dearly that the biopsychosocial model guides much of it.
in-
Applied health psychologists, who generally focus on health-promoting
terventions, are licensed for independent practice in areas such as clinical and
counseling psychology. As clinicians, they use the full range of diagnostic as
sessment and therapeutic techniques in psychology to promote health and as-
sist the physically ill. Assessment approaches frequently include measures of
cognitive functioning, psychophysiological assessment, demographic surveys,
and lifestyle or personality assessment. Interventions may include stress man-
agement, relaxation therapies, biofeedback, education about the role of psy
chological processes in disease, and cognitive-behavioral interventions.
Both individual and group interventions are commonly used. Further
more, interventions can be either direct or indirect. Direct intervention
would involve, for example, designing and implementing a program of re.

laxation training to help a patient cope with chronic pan. An indirect inter.
vention would be consulting with a patients physician to determine
whether the patient's psychological traits are intluencing his or her medical

treatment.
Interventions are not limited to those who are already suffering from a
health problem. Healthy or at-risk individuals may be taught preventive
healthy behaviors. Often health psychology interventions of this type focus on
buffering the negative impact of stress by promoting enhanced coping mecha
nisms or improved use of social support networks.
As the Human Genome Project moves toward pinpointing the precise role
every human gene, society will confront an explosion ot intormation, which
promises wondrous advances in disease diagnosis, treatment, and prevention
while raising challenging ethical and legal questions. Health psychologists are
expected to play essential roles in providing the research and clinical support
needed to grapple with this information. For example, in the research arena,
health psychologists are likely to be called on to explore issues such as the age
at which children should be permited to give informed consent for medical
treatment, the impact on the developing person of knowing that one is geneti-
callyvulnerable to a later chronic disease, and the impact of individual DNA
profiles on interpersonal relationships.

Where Do Health Psychologists Work?

Traditionally, most psychologists accepted teaching or research positions at
universities and four-year colleges. Because of declining college enrollments,
however, faculty positions in many of psychology's subfields have not kept
pace with the increasing numbers of interested applicants. Employment op-
portunities for health psychologists with applied or research skills, however,
have been very good throughout the developed world,
particularly in hospital
settings (DeAngelis, 1995). In fact, the number of psychologists working in
health-related fields more than doubled during the 1980s (Enright, Resnick,
Deleon, Sciara, & Tanney, 1990). This trend continues today, in response to
society's increased emphasis on health promotion and meeting the needs ot
particular groups, such as the elderly (Kaplan, 2000).
Besides colleges, universities, and hospitals, health psychologists work in a
variety of venues, including health maintenance organizations (HMOs), med
ical schools, pain and rehabilitation clinics, and in private practice (see igure
.6). An increasing number of health psychologists can be found in the work
place, where they advise employers and workers on a variety of heath related
ISsues. They also help establish on-the-job interventions to help enployes
lose weight, 9uit smoking, and learn more adaptive ways of managing stres.
 Introducing Health Psychology| CHAPTER 1| 37

How Dol Become a Health Psychologist?

Preparing for a career in health psychology usually requires an ad- Where Do Health Psychologists
vanced degree in any of a number of different educational programs Work?
Some students enroll in medical or nursing school and eventually be- Besides colleges, universities, and hospi-
come nurses or doctors. Others train for one of the allied health
tals, health psychologists work in a variety
pro- of venues, including health maintenance
fessions such as nutrition, physical therapy, social work, occupational organizations (HMOS), medical schools,
therapy, or public health. An increasing number of interested under pain and rehabilitation clinics, and in inde-
graduates continue on to graduate school in psychology and acquire pendent practice. An increasing number of
health psychologists can be found in the
the research, teaching, and intervention skills described earlier. Those
workplace, where they advise employers
who ultimately hope to provide direct services to patients typically and workers on a variety of health-related
take their training in linical or counseling psychology programs issues.
Many students who wish to pursue a career in health psychology Source: 1993 Doctorate Employment Survey. by
obtain general psychology training at the undergraduate level and M. Wicherski and ). Kohout, 1995, Washington, DC:
American Psychological Association.
then receive specialty training at the doctoral, postdoctoral, and in-
ternship levels. At the undergraduate level, health psychology courses
currently are offered at about one-third of all colleges and universi Other
ties. Because of health psychology's biopsychosocial orientation, stu- 11%
dents are also encouraged to take courses in anatomy and physiology Colleges
25%
abnormal and social psychology, learning processes and behavior Hospitals
and clinics
therapies, community psychology, and public health.
Most health psychologists eventually obtain a doctoral degree
(Ph.D.) in psychology. To doctorate in psychology, students
earn a
Medical schoos
complete a four- to six-year program, at the end of which they con- 16%
Independent practice
duct an original research project. In 2000, there were 65 identiied 27%
doctoral training programs in health psychology
Graduate training in health psychology is generally based on a
Other
curriculum that covers the three basic domains of the biopsychoso- academic
in Schools Settings
in the biological domain includes courses
cial model. Training 10
3%
neuropsychology, anatomy, physiology,
and psychopharmacology.
includes courses in each of the major
Training in the psychological domain
subfields (biological, developmental, personality, etc.) and theoretical perspec
etc.). And training in
tives (social-cultural, cognitive, behavior, neuroscience,
the ways in
the social domain focuses on the study of group processes and
which the various groups (lamily, ethnic, etc.) influence their members health.
As we begin the new century, medicine is benehting trom a dazzling array
of new techniques of diagnosis and treatment. In less than one hundred years,
to the wonders
physicians have progressed from using leeches in bloodletting
of nuclear medicine, magnetic resonance imaging, and genetic engineering.
decdared Americas war on cancer,
Only 30 years ago, when President Nixon
of diseases such
precious little was known about the basic cellular biology
as

cancer. Oncologists had only the basic weapons of radiation, chemnotherap

discoveries during the last
and surgery at their disposal. Revolutionary new