J Family Community Med. 2005 May-Aug; 12[2]: 63–70. Advances in the biomedical and the behavioral sciences have paved the way for the integration of medical practice towards the biopsychosocial approach. Therefore, dealing with health and illness overtakes looking for the presence or absence of the disease and
infirmity [the biomedical paradigm] to the biopsychosocial paradigm in which health means a state of complete physical, psychological and social well-being. Psychology as a behavioral health discipline is the key to the biopsychosocial practice, and plays a major role in understanding the concept of health and illness. The clinical role of psychologists as health providers is diverse with the varying areas of care giving [primary, secondary and tertiary care] and a variety of subspecialties.
Overall, psychologists assess, diagnose, and treat the psychological problems and the behavioral dysfunctions resulting from, or related to physical and mental health. In addition, they play a major role in the promotion of healthy behavior, preventing diseases and improving patients’ quality of life. They perform their clinical roles according to rigorous ethical principles and code of conduct. This article describes and discusses the significant role of clinical health psychology in the
provision of health care, following a biopsychosocial perspective of health and illness. Professional and educational issues have also been discussed. Keywords: Psychology, health psychology, biopsychosocial, and behavioral medicine “Biomedical knowledge is essential for providing sound medical care, but it is not sufficient. The nature of dysfunctions and the physicians’ transaction
with the patient must also be informed by the psychosocial understanding. “Neither the mindless nor the brainless can be tolerated in medicine” [Lean Eisenberg, 2000]. This statement is a quotation from the editorial address of the British Journal of Psychiatry as its entry into the 21st century. Eisenberg is one of the leading figures of psychiatry. Like other authoritative figures in medicine, L. Eisenherg found himself at the turn of the century, with the reality of
integration. His statement clearly emphasizes the importance of integrating the biomedical, behavioral and psychosocial sciences in understanding the way the brain and the mind work and interact to generate normality or abnormality. In this integrative approach, clinical health psychology must play a significant role. Unfortunately, for many professionals in the medical field, this role is unclear. Advances in
psychological, medical, and physiological research have led to a new way of thinking about health and illness. This is reflected in the biopsychosocial model that views health and illness as the product of a combination of factors including biological characteristics [e.g. genetic predisposition], behavioral factors, [e.g. lifestyle, stress, health beliefs] and social conditions [e.g. cultural influences, family relationships and social support]. This conceptualization of health and illness has
many scientific and practical benefits. At the top of this list is the fact that people can reduce their risk of developing major medical problems, receive more effective treatment, and reduce their health care cost when they seek treatment from an interdisciplinary team including behavioral health providers. It is worth noticing here, that in the recent past, dealing with health and illness was based on the biomedical paradigm in which the biological aspects were the main focus
of the scientist and practitioner. Good health was simply seen as the absence of diseases and injuries, and their presence meant ill health. The proper treatment for that model meant that there were biological interventions in order to improve the biological damage. As a result, health providers were divided into two groups, the physicians who followed the biomedical thinking and who had complete authority to deal with patients, and their assistants whose role it was to follow the physicians’
orders. At present, the understanding of the body-mind-behavior relationship has dramatically changed medical system and practice. This change, from the biomedical paradigm to the biopsychosocial medicine, characterizes the current holistic model of health provision. Overall, the biopsychosocial model reflects the belief that biological, psychological, and social factors interact in an interdependent or systemic way to maintain health or cause
illness.1 This approach [biopsychosocial paradigm] has become universal, and has been endorsed and adopted by the World Health Organization.2 Because behavior plays a vital role in mental and physical health, behavioral health is becoming the cornerstone of the
biopsychosocial practice. Cassidy described the way behavior may positively or negatively affect the body by stating that lifestyles, life-events, and bad behavior are directly related to health and illness; the way we think about events determines our response to them in developing healthy or unhealthy behaviors and changes in behavior. Attitudes to health determine whether we hear or listen to advice from health professionals, and a person's personality may predispose the body to certain
dysfunctions.3 Psychology as the science of behavior and mental processes emphasizes training and knowledge about such aspects [e.g. development over the lifespan, learning, motivations, experiences, emotions, cognition, social behavior and attitudes, personality etc]. Moreover, it strives to understand how biological, behavioral, and social factors influence health and
illness. Thus, psychologists as behavioral health providers play a major role in understanding how biological, behavioral, and social factors influence health, and illness. They are equipped with training, skills, and knowledge to understand how basic behavioral and cognitive processes [e.g. cognition. emotion, motivation, development, personality, social and cultural interaction] prepare the body to develop dysfunctions. They are trained, on the other hand, to perceive how
these behavioral and cognitive functions are altered, the factors that contribute to their alteration, and how these dysfunctions are diagnosed and treated. In dealing with such problems, they are also trained and skilled to use several psychological, psychodiagnostic and psychotherapeutic techniques which help and affect the abilities of individuals to function in diverse settings and roles. In addition, they help people to modify their behavior and lifestyle so as to prevent and recover from
health problems. Consequently, demands for psychologists in hospitals and medical settings have dramatically increased and clinical health psychology has become one of the most important disciplines in health care.4–5 In the following section, an
overview of the main clinical specialties of psychology is given. The development of Psychology as a health specialty and discipline has led to the emergence of several sub-fields and subspecialties. These sub-fields include clinical psychology, health psychology [also referred to as medical psychology or behavioral medicine], clinical neuropsychology, counseling psychology, rehabilitation
psychology, community psychology, and pediatric psychology with subspecialties in each field. Clinical psychology is the application of psychological knowledge and skills, research and intervention techniques to health and illness, particularly as related to mental health.5 The American
Psychological Association defines clinical psychology as “a clinical discipline that involves the provision of diagnostic, assessment, treatment plan, treatment, prevention, and consultative services to patients of emergency room, inpatient units, and clinics of hospitals”.6 Another definition given by the Canadian Psychological Association sees it as a broad field of practice and
research within the discipline of psychology applying psychological principles to the assessment, prevention, amelioration, and rehabilitation of psychological distress, disability, dysfunctional behavior, and health-risk behavior, and to the enhancement of psychological and physical well-being.7 Overall, the field of clinical psychology integrates science, theory and
practice to understand, predict and alleviate maladjustment, disabilities, and discomfort as well as to promote human adaptation, adjustment, and personal development. It, therefore, focuses on the intellectual, emotional, biological, psychological, social, and behavioral aspects of human function in different cultures and at all socioeconomic levels.8 Clinical
psychology has several subspecialties such as child and adolescent psychology, clinical adult psychology, clinical gero-psychology, clinical psychology of learning disabilities, clinical psychology of substance abuse and clinical forensic psychology. Health psychology [sometimes referred to as medical psychology or behavioral medicine] can be defined as the aggregate of the specific
educational, scientific and professional contributions of the discipline of psychology to the promotion and maintenance of health, the prevention and treatment of illness, the identification of etiological and diagnostic correlates of health, illness and related dysfunction, and the improvement of the health care system and health policy formation.9 Health Psychologists apply psychological research and methods to the prevention and management of disease, the promotion and maintenance of health, the identification of psychological factors that contribute to physical illness, the improvement of the health care system, and the formulation of health policy.10 The American Psychological Associations’
Division of Health Psychology outlined the objectives of health psychology as understanding the etiology, promotion and maintenance of health, prevention, diagnosis, treatment and rehabilitation of physical and mental illness; the study of psychological, social, emotional and behavioral factors in physical and mental illness; and the improvement of the health care system and formulation of health
policy.11 Thus, health psychologists are interested in how biological, psychological, and social factors affect health and illness. Therefore, they are engaged in the promotion and maintenance of health-related behavior, the prevention and treatment of illness and analysis and improvement of the health care system. Clinical neuropsychology focuses on the brain-behavior relationship and how behaviour and behavioural problems are affected by the way the brain functions.12 A clinical neuropsychologist specializes in the diagnostic assessment and management of individuals with brain
impairment.13 Clinical neuropsychologists are usually located in the departments of clinical psychology, neuroscience and neurosurgery. Counseling psychology is a specialty in the field of psychology in which the practitioners help people as individuals and groups, to improve their well-being,
alleviate their distress, resolve their crises, and increase their ability to solve problems and make decisions.14 Most of those who seek help from a counseling psychologist are clients who do not have major psychological disorders. Counseling psychologists, however, work in a variety of settings such as, hospitals and medical centers, academic institutions, prisons, schools,
business/industry, community health, etc. and with people of all ages e.g. children and adolescents, adult, and the elderly. Counseling psychologists then help people to adjust to change or make changes in their lifestyle. They assist individuals and groups in areas related to personal wellbeing, interpersonal relationships, work, recreation, health, and crisis management. They may practice independently or work with clinical psychologists, child psychologists, and health psychologists or as
academic counselors. Rehabilitation psychology is an applied clinical specialty in professional psychology concerned with the treatment and science of disabling and chronic health condition.15 Rehabilitation psychologists deal with stroke and accident victims, people with mental retardation, and
those with developmental disabilities caused by such conditions as cerebral palsy, epilepsy, and autism. They help disabled individuals adapt to their situation, frequently they work with other health care professionals. They deal with such issues as pain management, personal adjustment, interpersonal relations at home and the work place. They have become more involved in public health programs to prevent disabilities. They also testify in the courts as expert witnesses on the causes and effects
of the disabilities and rehabilitation required to improve the quality of life. Pediatric psychology is an interdisciplinary field that addresses the full range of physical and mental development, health and illness issues affecting children, adolescents and families.16 Pediatric psychologists,
therefore, diagnose, assess, and treat the psychological problems affecting the physical health of children and adolescents or resulting from dysfunction of the physical health. Moreover, they are involved in the improvement of the mental health services, the promotion of health and development, and the prevention of illness and injury to children and adolescents. Community psychology moves beyond individuals
to deal with problems of mental health and human relationships in communities.17 Community psychologists assist people to achieve their goals in areas such as health welfare and community projects. The services of the health care psychologist would be required in the following
areas.18–20 To provide important diagnostic interventions, and preventive services for the psychological problems in primary health care, illness prevention, and behavioral health
promotion.Abstract
INTRODUCTION
THE CLINICAL SUB-FIELDS OF PSYCHOLOGY
Clinical Psychology
Health Psychology/ Medical Psychology
Clinical
Neuropsychology
Counseling Psychology
Rehabilitation Psychology
Pediatric Psychology
Community Psychology
PSYCHOLOGISTS AND THE HEALTH CARE
Primary care
Secondary care
To give psychological assessments and diagnoses, psychological treatments, and rehabilitation. These services are provided to a variety of age groups and special groups of patients. These would include children, adolescents, adults, the elderly, and people with special needs such as those with learning disabilities, the brain-damaged, and the mentally retarded.
Tertiary care
A psychologist is a member of the treatment team caring for the psychological aspects of patients suffering from acute and chronic life-threatening diseases such as cancer, respiratory and renal disease. In addition, the role of clinical neuropsychologist in the identification, assessment, patient care and cognitive rehabilitation of brain-damaged patients is increasing.
PSYCHOLOGISTS’ ROLES IN HOSPITALS AND OTHER MEDICAL CENTERS
Psychologists in hospitals and other health care facilities may work independently, or as a part of a team. First as clinical psychologists, they are mental health providers and usually render service through mental health units and psychiatric hospitals. Second, as health or medical psychologists, they are behavioral health providers and deal with the behavioral dimensions of the physical health and illness. They provide the clinical and health services to both inpatient and outpatient units as well as to patients who function independently and to those new patients who need evaluation.21 The American Board of Clinical Psychology as a training body states that the services provided by psychologists typically include: diagnosis and assessment, intervention and treatment, consultation with professionals and others, program development, supervision, administration, psychological services and evaluation and planning of these services and teaching and research and contributing to the knowledge of all of these areas.22
Assessment
One of the core roles of psychologists in hospitals and primary health care is clinical assessment. They use psychological tests and measurements for specific purposes. For instance, to assess current functioning in order to make diagnoses [e.g., confirmation or refutation the clinical impression and differential diagnosis of the abnormal behavior such as depression, psychosis, personality disorders, dementia etc. and non-psychiatric issues e.g. relationship conflicts, compliance, learning differences, educational potential, career interest etc]; identify the treatment needs, assign appropriate treatment and give prognosis, monitor treatment over time, and ascertain risk management.
To achieve these purposes, psychologists use psychometric tests, which are standardized and validated tools to assess a wide range of functions including intelligence, personality, cognitive neuropsychology, motivations, aptitudes, health behavior, and intensity of mental health problems etc. The tests used include behavioral assessment and observation encompassing the rating scales; intellectual assessments, e.g., IQ tests; neuropsychological tests e.g., Halstead Reitan tests; personality scales [objective and projective tests]; diagnostic interviews [structured and semi-structured]; psychophysiological and bio-behavioral monitoring e.g. biofeedback; mental status examination; forensic assessments; psycho-educational measurements and vocational tests.
Professional psychologists are the only mental and physical health professionals who have the legal right to use, administer, and interpret the psychological assessments.12
Treatment
A major activity engaged in by psychologists in delivering health care is intervention or treatment, providing a wide variety of clinical interventions for individuals, groups, couples, and families with physical and mental health problems. These interventions are directed at preventing, treating, and correcting emotional conflicts, personality disturbances, psychopathology, and the skill deficits underlying human distress and dysfunction.8 They provide a variety of psychological interventions such as cognitive behavior therapy; behavioral modification; family and couple therapy; biofeedback; rehabilitation; group psychotherapy; psychoanalysis; client-centered therapy; pain management; neuropsychological rehabilitation; interpersonal psychotherapy etc.
Research has indicated that less than 25% of physical complaints presented to physicians have known or demonstrative organic or biological signs and that a substantial number of physical or medical symptoms presented by patients are unexplained medically [functional symptoms] that respond well to the psychological intervention.23 Therefore, psychological interventions are effective and cost-effective for the improvement of physical and mental health and the quality of life.
Consultations
Many psychologists provide psychological consultation for health care professionals, businesspersons, schools, organizations, communities etc. For example, a psychologist may help a physician to better manage noncompliance with unpleasant medical procedure. A businessman may consult a psychologist to help reduce conflicts among workers or provide stress management. Psychologists’ consultation might include assessment, teaching, research, and therapy.
Administrative Privileges
As experts in human behavior, psychologists are considered as efficient and competent administrators. Because the understanding of human behavior in social contexts is considered the backbone of management, therefore psychologists find themselves in administrative positions in hospitals and other residential treatment settings. Clinicians from psychology serve as chairpersons of departments, units, or divisions in hospitals e.g. neuropsychology, mental health, rehabilitation, and occupational health. They could be directors of graduate training programs in mental health, student counseling-psychological centers, hospital outpatient departments, and directors of hospitals. Moreover, they participate in assigned committees and are active members of their departments. In administration, psychologists manage budgets, lead multidisciplinary professional and support staff; they develop policies and procedures for planning and personnel issues etc. Finally, they participate and contribute to all quality management activities of hospitals and other care settings.
Teaching and Training
A considerable portion of the time of many psychologists who work in medical settings is spent in academic activities [teaching and training]. They teach all courses of psychology, human behavior and behavioral sciences included in the curricula of undergraduate and postgraduate medical, dental, nursing and other allied health professionals as well as psychology students, interns and residents, and train health professionals.
Research and Supervision
With their training and qualifications, clinical and health psychologists are research-oriented. Examples of their research activities include; [a] the development and standardization of clinical tools for diagnostic assessment tests and examination of their reliability and validity; [b] adapting and testing the efficacy of both psychological and biological interventions to promote health and overcome disorders; [c] studies to reveal the cultural and cross-cultural aspects of psychological abnormalities; [d] ascertaining the impact of both positive and negative human behavior on the physical health; and [e] supervising projects, thesis and dissertations of candidates whose researches have psychological components.
THE PRACTICAL ISSUES IN PSYCHOLOGY
Educational Qualification
A licensed clinical health psychologist must possess a bachelor degree in psychology. It should include courses on the development of human beings, personality, individual differences, normal and abnormal behavior, biological, cognitive, social and cultural aspects, psychometric and psychological testing, experimental designs and statistics, as well as internship in clinical work. Postgraduate studies [MS and PhD] in clinical or health psychology are necessary and mandatory. For example, in UK and US a Doctorate degree in clinical or health psychology is the minimum requirement to get the title of a psychologist. It is preferably to be followed by a postdoctoral fellowship in a subspecialty of clinical/health psychology.
Professional and practice issues
As a profession, psychology is represented in virtually every health care delivery system. Therefore, in state and federal programs and in most communities throughout the United States, psychologists are recognized as providing needed, valuable and cost effective health services.19 The USA psychologists, however, are recognized as members of the hospital medical staff with full privileges.19 They have recently had certain codes on the Current Procedural Technology24 in order to provide the psychological care [behavioral health assessments and interventions] to patients with physical diagnosis, rather than just mental health diagnosis. Moreover, some United States granted prescription privileges to psychologists to prescribe psychotropic medications. In this direction, military psychologists of the US Department of Defense [DoD] have prescribed psychotropic medications since years. This initial program [prescription privileges for military psychologists] had been thoroughly evaluated by the American governmental bodies such as Vector Research, Inc., the US General Accounting Office, and the American College of Neuropsychopharmacology. The results were that the program has achieved the primary objective for which it was established by demonstrating that licensed psychologists can be trained to provide safe, high-quality cost-effective pharmacological care.25 Consequently, the National Psychological Associations of United States are asking the legislative authority to enact a bill to grant psychologists prescription privileges after they have undergone specific training program in psychopharmacology. This project is strongly supported by the American Psychological Association that launched a task Force on psychopharmacology to train psychologists as prescribers.26
In this regard, R. E Kendell, another key figure of psychiatry commented: “….in California, clinical psychologists may well be on the brink of acquiring the right to prescribe antidepressant and neuroleptics, and what happens in California has a habit happening here [in Britain] 10 years later.27
Be that as it may, a huge number of psychologists are opposed to the prescription privilege for psychologists, advocating that psychology needs to remain as separate as possible from psychiatry, and psychologists, as health providers, have evidence-based methods of interventions just as effective as psychotropic medications.
Ethical issue
Psychologists like other health providers have ethical principles and code of conduct. This consists of: [a] general principles [e.g. competence, integrity, professional and scientific responsibility, respect for people's rights and dignity, concern for the welfare of others and social responsibility]; and [b] specific ethical standards related to their role with their patients and experiments.
RECOMMENDATIONS
The integration of biomedical and behavioral sciences is now a reality in medical education and the practice of medicine in the 21st century in the USA, Europe, and some developing countries. Unfortunately, the health care systems including medical education and training in most of the developing countries are still restricted to the biomedical paradigm that cannot meet their health needs.
The intellectual challenge, as Lisenberg stated in integrating neurobiology information with behavior in its social context and that “neither the mindless nor the brainless can be tolerated in medicine.”28
Consequently, the adoption of the biopsychosocial approach is necessary for a holistic response to the individuals’ suffering and community health needs.
CONCLUSION
Until the mid-1960s, the major role for psychologists in treating illness was to assess psychopathology in patients. With the growth of knowledge on the importance of behavioral and psychosocial factors in the etiology and maintenance of dysfunctions, psychologists have developed more expertise in diagnosing and treating the behavioral aspects of illness. Consequently, psychologists have begun to define themselves as health care rather than mental health care providers.29
This article has outlined and discussed the clinical role of psychologists in health care delivery as diagnosticians, therapists, academicians, researchers, and administrators in the era of the biopsychosocial practice. The paper, however, is restricted to the management roles of psychologists in medical settings and, does not expose to the psychologists’ roles in promoting health and preventing illness.
The practice of psychologists in health care delivery requires sophisticated teaching, intensive training, and high professionalism in their attitude to the ethical principles and code of conduct.
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