Clinical health psychology

What is clinical health psychology

• A specialty that focuses on the interplay between psychological, social and biological factors in healthy and illness

• Aims to promote wellbeing and manage chronic illness

Context for development of clinical health psychology

• Growing evidence over the last 4 decades that behavior/ thoughts/ appraisals contribute to health status and quality of life 

• Dissatisfaction with limits of biomedical approach 

• Shift to individual responsibility and prevention 

What is the biopsychosocial model

• Biological: physiology, genetics, biochemistry and neurobiology

• Psychological: emotional factors, behavioral patterns and coping mechanisms.

• Social: economic factors, social support, cultural context and environmental factors

• Physical problems such as unstable blood sugar, shortness of breath and visible scars can adversely impact on psychological wellbeing and social integration eg comorbid depression

• Patients with long term conditions have unmet needs for psychotherapy and social support so providing this leads to improved physical health

How is clinical health psychology delivered 

• Usually offered in acute primary settings and primary care increasingly public health

• Services may specialize according to age eg pediatrics/end of life care or condition eg cardiology

• Rubric that psychological principles, theory and practice are utilized to help those with physical health problems and/or disability  

What is the focus of the delivery of clinical psychology

• Illness/symptoms

• Treatment

• Recovery/complications

• Quality of life

• Family/carers/staff

• Healthcare utilization

What might affect the impact of the diagnosis of a long term health condition

• Diagnosis

• Point in their life

• Adjustments made to this diagnosis

• Treatments or their absence

• Side effects

• Co-morbidities

• Palliation

Who might a clinical health psychologist see?

• Clients with health anxiety

• Clients with unexpected physical symptoms

• Clients with diagnosed health problems eg diabetes or cardiovascular

• Staff delivering care and it’s impact

• The system (primary/secondary/tertiary)

How do we work with adult clients who are ill

• Making sense of the condition

• Accommodating change

• Time of life

• Impact on self identity

• Impact on couples/systems

• Losses and gains

• Impacts of gender/ethnicity/religion or other protected characteristics

• Impact of caregiving

• Stigma

• Maintaining dignity and quality of life

How might you approach domains to explore?

• Telling the tale/sharing the story of illness

• Reducing the pace

• Normalizing the impact of illness

• Considering it’s emotional impact

• Meanings of illness and/or disability

• Impact on relationships

• Impact on lifestyle

What is the process whilst assessing a patient’s needs

• Respecting the individual’s agency/family authority 

• Addressing misunderstandings 

• Addressing communication issues with/without family 

• Identifying resources 

• Preparing for the future 

Models of working in clinical health settings 

• All main therapeutic models can be applied to working in clinical health settings eg CFT and ACT

• Specific health psychology models should be able to inform assessment, formulation and interventions (Ogden 2004, Conner, Norman 2015, French et al 2010)

What are illness perceptions

• A patient’s own implicit common sense beliefs about their illness

• Patients are provided with a framework or schema for coping with and understanding their illness

What factors influence illness perceptions

• Information presented by healthcare professionals

• Prior experience with the illness

• Cultural beliefs

• Information gained from the social context

What is the self regulatory model (Leventhal, 1980)

• Looks at illness perception

• Explains how people perceive, interpret and respond to health threats 

Stage 1 of the self regulatory model (Leventhal, 1980)

• Interpretation- when a person notices their symptoms

• Symptom perception- when a person notices bodily changes

• Social messages- information from others eg family

• Once a person interprets that something is wrong, they develop a mental model of what they think the illness is like 

• Identity, consequences, timeline, control/cure, causes, illness coherence, emotional representation 

• Parallel to these thoughts there is an emotional reaction including emotions such as fear, anxiety and depression

Illness perceptions/representations as part of stage 1 of the self regulatory model

• Identity, what the illness is like and what it involves 

• Consequences, what effects it will have on their life 

• Timeline, How long it will last 

• Control/cure, whether the illness can be managed or cured 

• Causes, What caused the illness 

• Illness coherence, How well the person understands the illness 

• Emotional representation, The emotional reaction linked to these beliefs 

Stage 2 of the self regulatory model (Leventhal, 1980)

• Coping

• Once the person has made sense of the illness, they try to deal with it

• Approach coping- taking active steps to address the problem

• Avoidance coping- ignoring or minimizing the problem 

Stage 3 of the self regulatory model (Leventhal, 1980)

• Appraisal

• After coping, people evaluate how well their coping strategies worked 

• If the strategy worked they feel better and continue similar behavior 

• If not, they may reinterpret the illness or new coping strategies 

• This creates a feedback loop, the outcome of coping and appraisal feeds back into how the person perceives and understands the illness 

The importance of beliefs (Lewin, 1997)

• A patient’s belief about illness profoundly shapes their behavior

• Behavior then influences physical health outcomes either positively or negatively

• Therefore beliefs are not just thoughts, they have physiological consequences

What can we do with illness perceptions with regards to working with patients (in regards to the self regulatory model)

• Eliciting illness perceptions:

• Measure using IPQ-R, illness perception questionnaire (Moss, Morris et al, 2002)

• Ask questions during consultations

• Addressing illness perceptions:

• Self management programmes

• Rehab programmes

• Behavior change techniques

• CBT

• Providing psychoeducation/information

What are the 3 approaches to coping with illness

• Coping with the crisis of illness

• Adjustment to the physical illness

• Benefit finding, post traumatic growth

What is the crisis theory (Moos and Schaefer, 1984)

• Relates to grief and mourning of change after crisis

• This coping process includes:

• Cognitive appraisal, adaptive tasks and coping skills 

What is the cognitive adaption theory (Taylor et al 1984)

• How individuals adjust to threatening events

• Coping process includes:

• Search for meaning, search for mastery and process of self enhancement

What is post traumatic growth

• Previous theories focus on the return to normality but that is often something that is lost and has a negative focus

• PTG is based in positive psychology

• Although some negative consequences for lifestyle and quality of life, people can consider life to be improved

• Silver lining questionnaire (Sodergren et al, 2002)

• Positivity can be improved by rehabilitation

What makes people more likely to adhere to treatment

• Perception of symptoms

• Belief of it’s seriousness

• Belief in treatment

• Family and social input

What are some determinants of health

• Work environment

• Living and working conditions 

• Unemployment 

• Water and sanitation 

• Individual lifestyle factors 

Risk factors of dementia (as an example)

• Physical inactivity

• Smoking

• Excessive alcohol consumption

• Air pollution

• Obesity

• Hearing impairment

• Diabetes

• Hypertension

Psychosocial interventions in early stage dementia

• Adjustment eg CFT

• Managing stress, distress, anxiety and depression eg CFT and CBT

• Improving and maintaining cognitive function

• Maintaining quality of life eg cognitive stimulation therapy CST

Risks to CVD

• Up to 80% of premature CVD deaths are preventable

• High blood pressure, high cholesterol, diet, obesity and smoking explains the vast majority of CVD

• In some cases exposure to these risk factors is increasing

What is the potential role of psychology in CVD

• Illness onset could be due to beliefs or behaviors

• Illness representation leads to coping with illness

• Heart attack may occur

• Illness as a stressor may contribute to this

• Outcomes include longevity, recovery and quality of life

Interventions to CVD

• Cardiac rehabilitation, British association for cancer research specify need for a psychologist to be part of a cardiac rehab team

• Self management support interventions, the heart manual

• Mindfulness based stress reduction, self efficacy and quality of life of cardiovascular patients could be improved by this

• CBT, effective treatment for reducing depression and anxiety in patients with CVD

Risks to cancer

• Obesity and alcohol increase the risk of several types of cancer

• Stopping smoking, reducing alcohol consumption and engaging in physical activity an improve diet and reduce excess weight

Interventions to cancer 

• (HOPE), Help overcome problems effectively programme 

• Self management support programmes 

• ACT interventions 

• Meaning focused group therapy 

How does smoking act as a mediator to disease

• The leading cause of preventable ill health and death in England

• Puts people at risk of developing cancer, CVD and respiratory disease

• Was responsible for nearly 75,000 deaths in 2019 (Health foundation, 2020)

How does exercise act as a mediator to disease

• Physical activity helps to prevent and manage obesity and protects against a range of diseases

• Has positive effects on mental health and can support social inclusion

• In 2019, estimated 10,000 deaths were attributable to low physical activity

How does alcohol act as a mediator to disease

• Can negatively impact nearly every organ in the body 

• Causes liver disease, heart disease and cancer 

• Main reason for 320,000 hospital admissions in 2019/20 

• Harmful alcohol also has a significant social impact, increases the risk of accidents and violence (Health foundation, 2020)

How are assessments a practical consideration as a clinical health psychologist

• Legitimacy, patients may question the legitimacy of seeing a psychologist in a medical setting, the psychologist must clearly explain their role

• Engagement, patients may be defensive if they don’t understand why they have been referred to a psychologist, trust must be established quickly

• Physical difficulties, there are practical barriers to assessment such as noisy wards or lack of space, psychologists must be flexible and sensitive

• The therapist may potentially feel overwhelmed since it is not their domain and need familiarity of medical terminology

• Expertise of an individual, patients may have their own expertise for various reasons, psychologists must approach patients as experts in their own experience and avoid patronisation

How are healthcare settings a practical consideration as a clinical health psychologist

• It is crucial the psychologist is able to preserve the clients dignity, privacy and confidentiality

• This fosters honesty, trust and compassion