Health Psychology in Action

Mark Forshaw, David Sheffield, Mark Forshaw, David Sheffield

• Publisher: Wiley-Blackwell
• Year: 2012
• Print ISBN: 9780470667330, 9780470667347
• eBook ISBN: 9781119942177
• Edition: 1
• Topic: Psychology
• Subtopic: Physiological Psychology
• Index: Psychology

A definitive guide to the growing field of health psychology, which showcases contributions from academics and professionals working at the cutting edge of their discipline.

• Explores the field of modern health psychology, its latest developments, and how it fits into the contexts of modern healthcare, industry and academia
• Offers practical, real-world examples and applications for psychological theory in health care settings
• Provides a timely resource to support the new HPC registration of health and other psychologists
• Includes contributions from practitioners in a wide range of health care settings who share their own vivid personal experiences, as well as more general guidance to applying theory in practice

1

Applying Health Psychology to Dentistry: ‘People, Not Teeth’

Sarah Baker

Introduction: Why Dentistry?

I originally intended to become a sociologist but got unwittingly sidetracked into doing a psychology degree, which I began in 1987 at the University of Plymouth. I was not one of those people who knew what they wanted to do aged 10, so I fell into doing a PhD at the same institution. My thesis was on the psychophysiological indices of stress and a great amount of time, thought and energy went into devising ways of making people stressed. Once this was achieved, the rest of the time was spent in a dark soundproof room, my polygraph and I, stressing people and measuring their sweat. Three years later, I embarked on a research assistant job whilst writing up my thesis. Following years in a darkened room with a polygraph, this job, investigating psychophysiological reactions whilst playing video games, was rather fun. However, after a year I clearly could not put it off any longer; a responsible job was needed. I got my PhD and took up a postdoctoral research fellow position in the Department of Psychology at the University of Surrey. The Wellcome Trust–funded study on the psychophysiological and behavioural correlates of social phobia had much in common with the previous 5 years; I spent much of it in a small darkened room measuring the responses of socially phobic individuals whilst they had to interact with others. I realised a number of things early on; in order to spend time with people rather than a large machine (aka a polygraph), to get a bigger room (with lighting) and have job security, I would have to apply for lectureship positions. Given my anxiety of public speaking at the time, this was not something I warmed to. I duly became a Lecturer in Biological Psychology at Coventry University in 1997, followed by a Lecturer in Health Psychology at Keele University in 1998, where I stayed until 2005. The position in the Psychology Department at Keele was where I really learnt my research skills; particularly the importance of theory and methodology. However, I was also forming the opinion that research in health psychology, that is applied research, needed to move out of psychology departments into ‘the field’. I wanted, in the old cliché, to ‘make a difference’ through research; to make it useful and relevant to patient populations. I could only do that by putting my job where my mouth was. Moving to medicine was the obvious choice – there were now quite a few psychologists working in medical schools – but why have the route already mapped for you? I opted for Dentistry. I left the Psychology Department and travelled to the Dental School in Sheffield in 2005. There are 16 dental schools in the United Kingdom, including Sheffield, and I can count the number of psychologists working in these on one hand. Inevitably, ‘What is a psychologist doing in dentistry?’ or its alternative ‘So you do dental anxiety then?’ have been asked many times by dental undergraduates, dentists and even psychologists. It was an interesting, in some ways an impulsive choice but, most certainly, the right choice.

What's a Psychologist Doing in Dentistry?

Why would a psychologist be employed in a dental school? The cynical answer is that all such schools have to be accredited every 6 years and the teaching of behavioural science is a part of the undergraduate Bachelor of Dental Surgery (BDS) curriculum. However, many schools simply ask already employed clinicians to do this teaching because ‘Psychology is just common sense, isn't it?’ When psychologists are employed, it is generally because someone in a senior position has the foresight to understand the potential contributions a psychologist can make to teaching, research and service in dentistry.

This was so in my case. I joined a growing team in Dental Public Health consisting of clinicians (paediatric dentists, orthodontists and dental public health specialists) and two social scientists (sociologists). We are one of four departments in the School of Clinical Dentistry, alongside Oral and Maxillofacial Surgery, Oral Pathology and Adult Dental Care. The School itself is linked, physically and in terms of both teaching and research, with the Charles Clifford Dental Hospital. The dental hospital is one of five hospitals which make up Sheffield Teaching Hospitals NHS Foundation Trust, and provides casualty services and specialist diagnosis, treatment and management for adult and child dental patients. These specialties include restorative dentistry, oral and maxillofacial surgery, paediatric dentistry, orthodontics, cleft lip and palate services, craniofacial implant surgery and trigeminal facial pain.

As the only psychologist in the School and Hospital, my overarching goal through my work has been to shift colleagues’ thinking to ‘people, not teeth’. So whilst my specialist contribution is the application of the theory, method and techniques from the discipline of psychology to oral health, my role is much broader and diffuse. Essentially it is as an advocate for the biopsychosocial paradigm. This may seem very basic to a psychology reader. However, dentistry is about teeth, gums and the oral cavity – the ‘bio’ – and it lags some way behind medicine in its consideration of and the importance placed on either the ‘psycho’ or ‘social’. Much of my work is therefore about building a bridge between the clinical and social science disciplines. As such, collaboration and interdisciplinarity are the key.

Interdisciplinarity

Interdisciplinary research is a mode of research by teams or individuals that integrates information, data, techniques, tools, perspectives, concepts and/or theories from two or more disciplines or bodies of specialized knowledge to advance fundamental understanding or to solve problems whose solutions are beyond the scope of a single discipline or area of research practice. (National Academy of Sciences, 2005)

Health is multifaceted and complex; key questions go beyond the expertise of one clinician or one academic and require the efforts and inputs of different disciplines. All of my research involves collaboration with individuals from outside of psychology in order to advance understanding in ways that would not be achievable by one discipline alone through the sharing of ideas, or integration of concepts, methodology or theory. As in all interdisciplinary work, I have to be both a generalist and a specialist. My job is to render the specialist expertise of a psychologist intelligible and relevant to dentists. This requires the skills to be able to analyse, evaluate and synthesise information from different areas of psychology in order to develop and address the pertinent research questions about particular phenomena in dentistry.

Inevitably there are conflicts and difficulty in achieving a way forward. The balance has to be found between the expertise you bring and shared decision making. The decision cannot be ‘made’ by one person. Interdisciplinarity therefore involves the 3 Cs: cooperation, conflict and compromise! Over time working in many interdisciplinary teams, I have come to appreciate that it is a skill, learnt like others through trial and error; the skill to speak your opinion and be confident enough to differ. You have to enjoy having different perspectives, listening to others and seeking a ‘third way’. In a way you are both representing and promoting a discipline; you are educating fellow academics and clinicians on what psychology is and what psychologists do.

The Importance of Theory

One of my key contributions to these teams has been putting forward the importance of a theoretical framework in which to guide research. Theory has not generally been seen as important in dentistry or in dental public health. Theory, however, is important for a number of reasons. Theory helps to address the what, why and how? questions; what is the problem? Why does it happen? What are the contextual influences? What can we do about it? Theory therefore provides the framework to help develop appropriate research questions, identify key variables, establish relationships, interpret findings and design and evaluate interventions.

Oral Health–Related Quality of Life

One of my primary research areas is the testing and development of theoretical models in the field of oral health–related quality of life (OHRQoL) through the use of structural equation modelling (Baker, 2007, 2009, 2010; Baker et al., 2007, 2008, 2010). OHRQoL is a multidimensional construct that refers to the extent to which oral conditions disrupt a person's normal functioning. OHRQoL has, over recent years, become an important focus for assessing the impact of a range of oral conditions on quality of life and well-being (e.g. Gift et al., 1997) together with the outcomes of clinical care such as the effectiveness of treatment interventions (e.g. Awad et al., 2000). Research in the field has largely been descriptive and atheoretical; there have been few studies that have assessed the range of psychosocial factors that influence OHRQoL or attempted to explicitly test the direct and mediated linkages between key variables within a theoretical model.

Why is providing answers to such questions important? Firstly, the validity of OHRQoL as an outcome measure in clinical trials is partly dependent on understanding the causal processes linking oral conditions to patient-reported outcomes. In order to understand the pathways underlying such effects, any proposed model needs to be valid and empirically tested (Shrout and Bolger, 2002). Secondly, developing knowledge of key pathways will help facilitate the design of intervention strategies by, for example, guiding clinicians as to where to most effectively intervene, with whom and in what way.

One model, which explicitly conceptualizes the relationship between clinical factors and quality of life, is that of Wilson and Cleary (1995). This model has become one of the most well-established biopsychosocial models used in a variety of health contexts including cardiovascular disease and HIV/AIDS (Wettergren et al., 2004). My research has been the first to test the validity of the model in relation to chronic oral health conditions, notably xerostomia (Baker et al., 2007) and edentulousness (Baker et al., 2008).

Xerostomia is a common chronic health condition, affecting one quarter of adults and 40% of elderly people, and is a side effect of over 400 therapeutic drugs (e.g. antidepressants). Xerostomia is also seen as a sequela of damage to salivary glands in autoimmune (e.g. rheumatoid arthritis), and other systemic diseases (e.g. multiple sclerosis); and as a consequence of radiation for treatment of head and neck cancer. Symptoms can often be severe and debilitating with a reduced ability to speak, chew, swallow, taste and sleep (Pankhurst et al., 1996). To date, nearly all research in the area has been clinical in nature; yet, in the absence of a curative treatment, the overriding therapeutic goal is long-term management. As such, where treatment is not about cure but increasing patient comfort, there is a strong case for understanding the impact of the condition on patients’ everyday lives.

The aim of our study was to test an integrative conceptual model to provide a more comprehensive picture of the impact of xerostomia on the daily lives of patients. The study was a secondary analysis of data collected as part of a randomised control trial of a device for the management of xerostomia (Robinson et al., 2005) using structural equation modelling (SEM). SEM is a powerful statistical technique that allows simultaneous testing of complex interrelationships between variables specified within a priori models (Kline, 2005). As such, it is currently the best technique for assessing and modifying theoretical models.

Our findings supported Wilson and Cleary's conceptual model of patient outcomes as applied to xerostomia and highlighted the complexity of (inter-)relationships between key clinical and psychosocial variables (Baker et al., 2007). The results, together with our other SEM studies with both patient and general populations (Baker, 2007, 2009, 2010; Baker et al., 2008, 2010), have a number of important theoretical and clinical implications. Firstly, modelling indirect and mediated effects has helped reconcile why systematic observations between clinical and subjective measures found in previous (oral) health research have generally been weak. Secondly, they re-emphasize the importance of patient-reported outcomes (e.g. OHRQoL) being routinely assessed, alongside traditional clinical indicators, disease-specific symptom measures and wider well-being, in both research and clinical practice. Thirdly, interventions aimed solely at the biological-clinical level, which do not take into account patient experiences of their symptoms, will not be fully effective.

The Impact of Oral Health on Children, Adolescents and Their Families

Disfigurement to the face, hands and body affects about 400,000 people in Britain. These visible differences can arise from congenital craniofacial anomalies or be acquired as a result of trauma, or dermatological conditions. Cleft lip and/or palate (CL/P) is the most common congenital condition of the head and neck region affecting between 1 in 600–700 babies. Treatment requires multiple surgical procedures from birth through infancy, childhood, adolescence and into adulthood, and frequent clinic attendances to deal with problems related to impaired facial growth, speech impairment, hearing difficulties and dental anomalies. As such, CL/P can bring a range of additional life stressors which may impact not only on the person but also on the family unit.

To date, as with much of the appearance literature, the vast majority of research on CL/P has explored this from a perspecti...

Table of contents

• Cover
• Title Page
• Copyright
• About the Editors
• List of Contributors
• Preface
• Acknowledgements
• Chapter 1: Applying Health Psychology to Dentistry: ‘People, Not Teeth’
• Chapter 2: Promoting the Application of Health Psychology in Primary Health Care
• Chapter 3: Health Psychology in the NHS: The Long and Winding Road …
• Chapter 4: A Journey into Health Psychology and Beyond
• Chapter 5: Health Psychology in Cyberspace
• Chapter 6: Working in Academia: A Different Kind of Practice, but Practice Nonetheless
• Chapter 7: Shared Decision Making
• Chapter 8: Writing, Training, Teaching, Researching, Consulting, Quality Assurance and the Kitchen Sink
• Chapter 9: What Are the Roles of a Health Psychologist in Clinical Practice? Defining Knowledge, Skills and Competencies
• Chapter 10: Health Psychology: The Missing Ingredient from Health and Safety?
• Chapter 11: Keeping Up Appearances in Health Psychology
• Chapter 12: Social and Political Health Psychology in Action
• Chapter 13: Tailoring Behavioural Support and Tailoring Health Psychology Careers
• Chapter 14: Working with Chronic Pain
• Chapter 15: Combining Practice and Academia as a Health Psychologist
• Chapter 16: Health Psychologists in Action – Working for the Pharmaceutical Industry
• Chapter 17: The Rapid Growth of Health Psychology in Medical Schools and Clinical Practice
• Chapter 18: The Lived Experience of a Qualitative Health Psychologist
• Chapter 19: Health Psychology in Sickle Cell and Other Long-Term Haematological Conditions
• Chapter 20: Afterword
• Index