Rachel Postupack and Ronald H. Rozensky
Department of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, Gainesville, FL, USA
Disease is not the accident of the individual, nor even of the generation, but of life itself. In some form, and to some degree or other, it is one of the permanent conditions of life.
Henry David Thoreau
Health is a state of complete physical, mental, and social well‐being and not merely the absence of disease or infirmity (World Health Organization, 1948). This formulation of health, adopted globally immediately after World War II, predates Engel's (1977) “new” “biopsychosocial” model of healthcare by decades and, as pointed out by Rozensky (2015), is as “new” as 190 CE when Galen postulated the integration of mind and body in medicine during the Roman Empire. Every textbook and article that discusses the history of clinical health psychology (Baum, Perry, & Tarbell, 2004; Belar, Deardorff, & Kelly, 1987; Friedman & Adler, 2007; Stone, Cohen, & Adler, 1979; Sweet, Rozensky, & Tovian, 1991) notes that “psychology has long been in the forefront of the scientific inquiry into the understanding of health” (Resnick & Rozensky, 1996, p. 1). While psychology clearly is a scientifically based discipline that both carries out research concerning health, disease, and treatment and provides direct clinical services to those who seek help with disease prevention or treatment for managing a wide range of medical diagnoses and problems, it was not until 2001 that “the American Psychological Association (APA) amended its mission statement to include the term ‘health.’” The American Psychological Association (APA) stated that psychology's focus is to “advance as a science and a profession, and as a means to promoting health and human welfare” (Rozensky, Johnson, Goodheart, & Hammond, 2004, p. xix).
First recognized formally as specialty in 1997 by the APA (2015a), “Clinical Health Psychology applies scientific knowledge of the interrelationships among behavioral, emotional, cognitive, social and biological components in health and disease to: the promotion and maintenance of health; the prevention, treatment and rehabilitation of illness and disability; and the improvement of the health care system. The distinct focus of Clinical Health Psychology (also referred to as behavioral medicine, medical psychology and psychosomatic medicine) is at the juncture of physical and emotional illness, understanding and treating the overlapping challenges.” This definition was built, in turn, on Matarazzo's (1980) definition as adopted by the APA Division of Health Psychology: “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, and the identification of etiologic and diagnostic correlated of health, illness, and related dysfunction” (p. 815).
Given these definitions, Belar (2008, p. 230) described both the venues in which health psychology services take place and the range of clinical issues addressed:
Clinical health psychology services may be integrated with primary care, urgent care, tertiary care, and dental care, and occur in clinic, hospital‐based, nursing care, rehabilitation, work site, and hospice settings.
Belar listed the nine problem areas addressed by clinical health psychologists:
Paralleling the history of health psychology is the development of the US federal government's Healthy People initiative (Department of Health and Human Services [US], 1979) that establishes goals for improving the quality of the nation's health with objectives focused on health promotion and disease prevention (Healthy People 2020, http://www.healthypeople.gov/). Rozensky (2012a) stated that along with psychology's traditions of efficacy, effectiveness, and community‐based research and treatment, the profession has engaged in this population‐based approach to the scientific study and treatment of the human condition. Further, Rozensky (2012a) reviewed societal and healthcare trends impacting health service psychology including competency‐based education, interprofessionalism, evidence‐based care, andteam‐based, patient‐centered care and changes in population demographics including a more diverse population that is aging with more chronic illness. As one of the recognized specialties under the broader umbrella of health service psychology, clinical health psychology has been a leader, throughout its history, in anticipating the various scenarios, or interactions of these trends, in preparing each new generation of health service psychologists to successfully function in an evolving research and healthcare environment.
With definitions in hand, trends in mind, and current clinical activities and services described, the history of clinical health psychology will be presented from the perspective of how the profession itself has advanced. This will include the scientific and clinical changes in the field as reflected in the evolution of philosophies and organizations that have promulgated a biopsychosocial understanding of health and illness.
The evolution of clinical health psychology in becoming a recognized specialty is rooted in the development of definitions that include the interaction of cognitive, behavioral, emotional, and psychological processes and physical health and the formation of professional organizations that focus on science and practice in those domains. The ancient Greeks provided the philosophical basis for modern Western medicine by shifting the focus from supernatural causes to recognition of the importance of actual bodily factors in health. They theorized that illness was caused by an imbalance of the four bodily humors: blood, phlegm, choler (yellow bile), and melancholy (black bile). Health could be restored then by bringing balance to these fluids (Friedman & Adler, 2007). Galen, a Greek physician in the Roman Empire, posited that the dominant humor in an individual's balance determined temperament and vulnerability to illness (Maher & Maher, 1994). This early integration of mind and body was later de‐emphasized in favor of focusing on primarily bodily or physical processes in the biomedical model.
In the early twentieth century, the split between mind and body was reflected in the distinction of psychiatry as a medical specialization focused on the influence of the mind to explain symptoms for which there was no biological basis. Interest in the contribution of mental disturbance to disease became the domain of the emerging field of psychosomatic medicine (Dunbar, 1943). Flanders Dunbar began the journal of Psychosomatic Medicine in 1938–1939, which is the official journal of the American Psychosomatic Society founded in 1942. Today their mission is to “promote and advance the scientific understanding and multidisciplinary integration of biological, psychological, behavioral, and social factors in human health and disease, and to foster the dissemination and application of this understanding in education and health care” (www.psychosomatic.org).
Moving into the 1960s and 1970s, growing insight into biological mechanisms prompted a philosophical shift in psychosomatic medicine to consider the bidirectional interactions between physiological and emotional states. George F. Solomon and Moos (1964) introduced the term psychoneuroimmunology (PNI) to refer to the theoretical connections between emotions, immunity, and disease. Research on stress and disease expanded and was based on the “fight or flight response” (Cannon, 1932) and understanding of physiological reactions to stress (Selye, 1956). Engel's (1977) descriptions of the biopsychosocial model contributed to the ongoing integration of the mind and body in contemporary healthcare science and practice. Herbert Benson demonstrated the utility of meditation or relaxation to counteract both acute and chronic stress while impacting health status in conditions like hypertension (Benson, 1983). These discoveries among others provided an evidence base for the introduction of behavioral treatments into medical settings. Emphasis on the integration of mind and body became known as behavioral medicine (Birk, 1973). Interdisciplinary from its inception, contributors to the science and practice of behavioral medicine included professionals from a range of professions including physicians, psychologists, bio‐behaviorists, and others. The Society of Behavioral Medicine and Journal of Behavioral Medicine were founded in 1978 to promote a “field concerned with the development of behavioral science knowledge and techniques relevant to the understanding of physical health and illness and the application of this knowledge and these techniques to prevention, diagnosis, treatment, and rehabilitation” (Schwartz & Weiss, 1978, p. 7).
In the 1980s behavioral health was distinguished from behavioral medicine as “an interdisciplinary field dedicated to promoting a philosophy of health that stresses individual responsibility in the application of behavioral and biomedical science knowledge and techniques to the maintenance of health and the prevention of illness and dysfunction by a variety of self‐initiated individual or shared activities” (Matarazzo, 1980). It is within this focus on the individual and a personal ability to affect change that impacts health that psychologists found a professional niche to more specifically define their scientific and clinical competencies to encourage health promotion as well as address challenges associated with illness and its treatment. The field of health psychology was defined as promoting the integration of psychological knowledge and biomedical information as it applies to health promotion, prevention, diagnosis, treatment, and rehabilitation (APA, 2015b; Matarazzo, 1980). To assist in the development of a cohesive field of specialization then, George Stone established the Journal of Health Psychology in 1982. Then in 1994, the Journal of Clinical Psychology in Medical Settings (JCPMS) was founded by Ronald Rozensky to further the role of health service psychologists as scientists and practitioners in medical settings as they addressed diseases and medical problems (Rozensky, 2006).
Established in 1892 the APA advances the creation, communication, and application of psychological knowledge on the national level (APA, 2015c). Today APA is home to 54 divisions, which are special interest groups that represent topic areas germane to the range of clinical, scientific, educational, and public interest foci of psychologists. Movement toward the foundation of the division of health psychology began in 1973 when APA's Board of Scientific Affairs directed that health research should be reviewed and disseminated at scientific meetings. This decision was influenced by William Schofield's (1969) paper describing psychologists' roles in health service delivery. A section of interest was added to Division 18, Psychologists in Public Service, in 1975 specifically to increase the application of psychological principles to health research and patient care as well as disseminate the results of this work. Steven Weiss and Joseph Matarazzo advocated for the foundation of an APA division devoted to health psychology. Their efforts were successful when Division 38 Health Psychology was established in 1978. The division continues its mission to promote and disseminate health‐related research through The Health Psychologist newsletter begun in 1979 and the Health Psychology journal that published its first issue 1980–1981 (Wallston, 1997). In August 2015 the Division of Health Psychology voted to change its name the Society for Health Psychology. It continues to provide an intellectual home to health psychologists and other professionals devoted to the intersection of psychological processes and physical health.
One venue that illustrates the robust growth of psychologists engaged in health and healthcare research, education, and clinical practice is number of psychologists in academic health centers and hospitals. Noting that environment as “a true healthcare home” for psychologists (p. 353), Rozensky (2012b) reviewed a series of published surveys from the early 1950s through the first decade of the twenty‐first century carried out by such notables as Matarazzo and Mensh. The number of psychologist in medical school was less five per school in the 1950s to 20.7 per school in the late 1970s with at least 3,894 psychologists identified in academic medical settings at the end of the twentieth century (Williams & Wedding, 1999). Rozensky noted that the most recent data finds more than half (54.5%) of psychologists work in institutional settings with 12.4% in hospitals and 4.6% in medical school alone (APA, 2009).
In 1991, the American Board of Professional Psychology (ABPP) formally recognized clinical health psychology as a specialty in professional psychology and began granting board certification in the field based on peer evaluation (Belar & Jeffrey, 1995). In 1997 the APA (1997) archived a formal definition of the specialty of clinical health psychology, and it remains a recognized specialty to date. Today, contemporary clinical health psychologists are seen as working interprofessionally in clinical practice. They learn side by side with other healthcare professionals during their education and training in the context of the changes in healthcare both predating and promulgated by the implementation of the Patient Protection and Affordable Care Act (Public Law No: 111–148, 2010, March 23). As part of the evolution of health psychology's place in the healthcare system, the growing acceptance of the use of Health and Behavior (billing) Codes reflects both the system's integration of mind and body and the integration of psychologists on the healthcare team. Allowing clinical health psychologists to directly bill these Health and Behavior Codes for treating and helping patients manage specific medical problems reflects, financially, the recognition of both psychologists' healthcare competencies and systemic integration (Kessler, 2008) as not just mental health providers but members of the integrated healthcare team. Along with their clinical services and educational activities, health psychologists also participate in team science to ensure research integrates mind and body and ensures interprofessionalism as part of science (Rozensky, 2014).
Clinical health psychologists conduct research and practice at the intersection of physical and mental health in a variety of settings addressing diversified patient populations and problems. The formulation of education and training guidelines has been an essential component in the development and maintenance of professional competencies for both current and future psychologists (Fouad et al., 2009; Health Service Psychology Education Collaborative, 2013; Rodolfa et al., 2005).
In 1983 the Arden House National Working Conference on Education and Training established the first set of education and training guidelines for the field of clinical health psychology (Stone, 1983). The conference recommended that training at the doctoral level remain “broad and general” to develop an integration of theory, research, and practice based on knowledge and understanding of the biopsychosocial model. Predoctoral clinical internships completed in settings where both psychological and physical healthcare services take place were encouraged by the Arden House participants as a part of each student's professional development.
In general, doctoral programs in health service psychology have maintained their commitment to the integration of science‐ and evidence‐based practice (Belar & Perry, 1992) where students acquire foundations in scientific psychology, research, ethics, diversity, theory, and clinical practice (Kaslow, Graves, & Smith, 2012) as core competencies in their broad and general education and training. In that manner, curricula for programs with a specific major area of study in clinical health psychology include knowledge of biological, affective, cognitive, social, and cultural bases of health and illness. Additional education may be provided on special topics such as pathophysiology, psychoneuroimmunology, and pharmacology (Belar, 2008). Ideally training is conducted in clinical settings conducive to the development of competencies to conduct health‐related clinical assessments and interventions, health‐oriented research, and the competencies to function as a part of healthcare delivery system including consultation services and engagement in interprofessional, team‐based collaboration (Belar, 2008; France et al., 2008). It was recommended that accreditation for health psychology training programs begin at the postdoctoral level (France et al., 2008), but it is clear that many accredited doctoral programs in health service psychology offer major areas of study in clinical health psychology.
France et al. (2008) provided a competency model for clinical health psychology that details knowledge and applied skills in assessment, intervention, consultation, research, training in supervision, and management administration. Kaslow, Dunn, and Smith (2008) detail the core foundational and functional competencies for health service psychologists practicing in academic health centers, while Kerns, Berry, Franstve, and Linton (2009) extend the description of competencies to issues related to developing lifelong competencies in clinical health psychology. Across competency models, the importance of ensuring clinical health psychologists possess the interprofessional competencies to function successfully within a healthcare team (Fouad & Grus, 2014) and understand the characteristics of a truly competent team (Interprofessional Education Collaborative, 2011) is key to the ongoing evolution of the specialty of clinical health psychology.
A specialty is defined as an area of psychological practice that requires advanced knowledge and skills acquired through an organized sequence of education and training (Commission for the Recognition of Specialties and Proficiencies in Professional Psychology, 2015; CRSPPP). Specialization allows professionals to focus on content that they must learn, refresh, and maintain to retain competence in a field as it continues to develop (Kaslow et al., 2012; Rozensky & Kaslow, 2012). The Commission for the Recognition of Specialties and Proficiencies in Professional Psychology (CRSPPP) establishes policies and procedures that are used by APA to review and recognize health service specialties with clinical health psychology being one of those recognized specialties. To identify individual specialists, individuals competent to deliver quality health psychology services, the ABPP (www.abpp.org) offers board certification for practitioners at the postdoctoral level who pass a peer‐review, competency‐based exam. Achieving board certification is particularly helpful for clinical health psychologists who work in integrated medical settings because board certification is considered the standard of practice for our colleagues in medicine and related health professions (Rozensky & Kaslow, 2012).
Clinical health psychologists face the ongoing challenge of learning and maintaining a current, relevant, evidence‐based perspective to meet the ethical requirements of competent practice within their specialty. To help students and professionals describe their level of education and training in clinical health psychology, the Council of Clinical Health Psychology Training Programs (CCHPTP) developed the Clinical Health Psychology Specialty Taxonomy (http://cospp.org/guidelines) based on the APA policy designed to ensure consistent descriptions of the levels of education and training within specialties across the sequence of learning from graduate school, to internship, and through post‐licensure, lifelong learning (Rozensky, Grus, Nutt, Carlson, Eisman, & Nelson, 2015). That CCHPTP taxonomy lists the expectation for a major area of study in clinical health psychology at each stage of training. Recognizing that each year there is a continuing influx of new scientific and clinical information and that there is a decreasing half‐life of professional knowledge, each psychologist must establish a commitment to lifelong learning on the part of the competencies required of being a specialist (Wise et al., 2010). Incorporating the lifelong learning process into the broader context of the competency movement involves the evaluation of professional skills, practices, and outcomes (Neimeyer & Taylor, 2011). In addition to formal structures for continuing education and competency‐based assessments, a self‐study/self‐assessment can be used to develop learning plans for specialization throughout a professional's career (Belar et al., 2001). Clinical health psychology has embraced a competency‐based model of education and training from the early days of the Arden House Conference through professional psychology's evolution to a “culture of competence” (Roberts, Borden, Christiansen, & Lopez, 2005, p. 359).
Each step in the history of clinical health psychology has been motivated by the spirit of that time—spirit based on politics within and external to the profession, scientific developments in psychology and medicine, technological evolution, vicissitudes in contemporary healthcare and healthcare financing, and changes in educational philosophy. The future of clinical health psychology will be based on contemporary zeitgeist composed of those same motivating forces today and tomorrow.
Contemporary clinical health psychology exists within the broader context of healthcare reform as detailed in the Patient Protection and Affordable Care Act (Public Law No: 111–148, 2010, March 23) and its ongoing implementation. That law recognizes the importance of evidence‐based healthcare, quality care including credentialing and specialization, team based, and interprofessionalism in both education and practice (Rozensky, 2011, 2013). And clearly, education and training in all branches of health service psychology, including clinical health psychology, must address these issues in its curricula and practical training (Rozensky, 2014).
In order to understand where clinical health psychologists will be employed in the future, a clear national workforce analysis philosophy must be operationalized, and data collected and studied in order to inform educators and practitioners alike as to societal need and employment opportunities (Rozensky, Grus, Belar, Nelson, & Kohout, 2007). Questions like how many psychologists will be needed in primary care, in cardiac care, in rehabilitation psychology, in psycho‐oncology, etc. will help the field have a picture of the future and provide direction to students and early career psychologists planning their education and practice focus.
Many scholars have described the history and successful evolution of the specialty of clinical health psychology and highlighted the various individuals and organizations that have helped define the education, training, science, and practice of clinical health psychologists. This history reflects a robust science whose application is key to helping those who wish to learn to prevent disease, improve their health, or seek to manage their illness or their reaction to that illness. Clinical health psychologists clearly are dedicated to improving the human condition, and each recognizes, in their day‐to‐day work, what Shakespeare said some 400 years ago, “What wound does not heal but by degree?”
Rachel Postupack, MS, completed her graduate education in the Department of Clinical and Health Psychology at the University of Florida, where she is currently completing her predoctoral internship. She is focusing her clinical experiences on providing services to underserved medical populations. Her research has focused on pain, distress, cytokines, coping, and quality of life for patients with cancer.
Ronald H. Rozensky, PhD, ABPP, is a professor in the Department of Clinical and Health Psychology in the College of Public Health and Health Professions at the University of Florida where he served as department chair and associate dean for International Programs. He is the founding editor of the Journal of Clinical Psychology in Medical Settings and board certified in both clinical and clinical health psychology.