Behavioral Intervention In Health Care

Laura B. Gordon

• Publisher: Routledge
• Year: 2019
• Print ISBN: 9780367168186
• eBook ISBN: 9780429724091
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

In this book, the author presents a behavioral-psychological perspective on intervention in health care, beginning with a definition of behavioral medicine and introducing the related issues of stress and patient compliance.

1
Introduction

ThiS book will illustrate the significance of behavioral intervention in a medical setting by describing medical problems that are essentially behavioral disorders or are determined in part by the behavioral responses of the patient. The cases discussed will provide a basis for understanding the overall role of behavioral intervention in specific health problems like insomnia, alcoholism, headache, obesity, pain, and hypertension. Other common problems such as grief reactions, decompensation, or decline in mental functions as a consequence of aging and various kinds of medical illness, and noncompliance with medically prescribed practices will also be considered. Although behavioral intervention is the main focus of this volume, counseling intervention approaches are also discussed. Frequently they provide necessary alternatives with which the health care professional should be familiar. Psychiatry has traditionally provided information about psychopathology to the medical profession, but it is the goal of this book to underscore the relevance of behavioral medicine to the entire health care field. An extensive bibliography appears at the end of each chapter, and the interested reader is encouraged to pursue these leads for further information.

What is Behavioral Medicine?

There has been increasing interest in what has been termed health care psychology, the application of behavioral principles to problems of physical health and illness. This approach emphasizes the psychobiology of health and directs attention to the interaction of psychosocial and biological processes in both health and disease. The emergence of behavioral medicine (Miller, 1975) has been a direct consequence of this interest. In general, behavioral medicine involves the application of behavioral principles to a broad range of medical problems beyond those psychological disorders with which clinical psychology has traditionally been concerned. More specifically, behavioral medicine is "an approach to illness states which utilizes assessment techniques to evaluate affective, cognitive, psychophysiologic, behavioral, and environmental aspects of illness and encompasses treatment techniques with a predominantly psychobehavioral component" (Morgan, Kramer, and Caylor, 1977:88). Behavioral medicine is most concerned with the psychological factors or behavioral contingencies that help maintain or serve to exacerbate the illness process.

it is important to differentiate the behavioral area of medicine from that of psychosomatic medicine. There is a tendency to view them as synonymous, but they are distinctly different. Psychosomatic medicine stresses the etiology and pathogenesis of physical disease. Behavioral medicine is primarily concerned with the prevention and treatment of disease through the use of behavioral techniques. A more complete description of behavioral medicine has been given by Schwartz and Weiss (1977:378): Behavioral medicine focuses on the development of behavioral science, its knowledge, and techniques in the understanding of physical health and illness, and the application of such knowledge and techniques to diagnosis, prevention, treatment, and rehabilitation. This definition stresses the psychobiological foundations of human behavior and points to their relevance to the fields of clinical psychology, nursing, and medicine.

The focal ideas of behavioral medicine revolve around an individual's susceptibility to illness, ability to cope, and response to the recommended treatment program. Perhaps the most basic tenet of behavioral medicine is that each person is responsible for his own behavior and well-being. The commonplace phrase "it's only psychological" indicates widespread contempt for difficulties having psychological roots or consequences and suggests that psychologically caused problems are somehow equivalent to mental illness. The word "psychological" can be easily misconstrued by patients, suggesting to them that they are relieved of responsibility for their own care. The effects of physical states of illness on the subjective feelings of the patient and on his ability to cope are primary considerations in behavioral medicine. There has been an increasing demand for this sort of health care service due to heightened psychological needs, decreased tolerance for discomfort coupled with expectations of immediaterelief, and a generally greater acceptance of disclosure of psychological complaints. Consideration of the psychological and social factors that influence health care will enable the professional to better prepare patients for medical treatment and to facilitate compliance with prescribed behavioral and pharmacological routines. When the approach to a problem takes place in the context of the patient's own behavior and experiences, he is more likely to feel responsible and to take an active role in developing satisfactory, effective coping mechanisms.

The unique psychology of each person must be considered in planning medical care. Psychological factors are especially important in treating chronic diseases that are the contemporary precursors of death. (This is in marked contrast to the early 1900s, when infectious disease was the leading cause of death.) Although current medical education is often geared to acute disease, arranging chronic care for a patient requires knowledge of the patient's psychological state. The use of too many medical specialists, for example, may cause confusion and discontinuity for the patient. Technology has produced a wide variety of drugs, but it has become increasingly difficult for physicians and nurses to persuade patients to comply with prescribed treatment regimens. Behavioral techniques provide one way to encourage compliance. For example, hypertension has been cited repeatedly as a major cause of morbidity and mortality, and although regular use of antihypertensive medication can dramatically lower this risk, a large body of research shows that less than one-half of the patients at risk adhere to medical advice and use their medication as prescribed. Attention to a behavioral component in medical treatment does not by itself ensure compliance with the prescribed treatment program. It is important for the health care professional to consult with other professionals and with their patients to evolve a comprehensive program that maximizes the probability of compliance.

Intervention Techniques

Intervention techniques in behavioral medicine are based on the principles of learning theory. The key to producing an adequate treatment program is understanding the processes by which an individual learns certain behaviors and the kinds of conditioning that person has been subjected to. The actual relationship between autonomic-visceral and somatic-motor mechanisms may be a matter of controversy (Black, 1968; DiCara, 1970), but it is clear that learning and conditioning do have a systematic effect on the body's physiological, anatomical, and biochemical systems. The impact of these two factors on a person's overall functioning must then be taken into account. A detailed discussion of learning theory is beyond the scope of this book, but a good review can be found in Hilgard and Bower (1966).

The primary belief underlying all behavioral interventions is that a connection exists between the autonomic and voluntary nervous systems and that autonomic processes are far more susceptible to voluntary control than was originally thought. All behavior is subject to the limitations and inclinations of the individual. Maladaptive behaviors are seen as being maintained by current, observable events, and behavioral medicine is concerned with the assessment and treatment of medical or medically related problems caused by those ongoing environmental influences. In the past, medical problems were usually treated with traditional medical prescriptions alone, but now reports of behavioral interventions in medical illness in the literature (Katz and Zlutnick, 1975) suggest growing enthusiasm for including the behavioral approach.

Behavioral intervention is useful for treating many physical, psychological, and psychophysiological disorders. The techniques of behavior modification include progressive relaxation, biofeedback, desensitization, flooding, modeling, aversive therapy, thought stopping, and social skills training. (A description of some routine use of these techniques can be found in Chapter 2.) The key to successful behavioral treatment is the detailed assessment of the patient that should precede every treatment attempt. Every responsible treatment plan usually begins with some kind of assessment, but assessment frequently constitutes the major part of behavioral intervention. Behavioral assessment requires an operational definition of the presenting problem, that is, the way that the problem is manifested behaviorally. Insomnia or overeating are examples of operational definitions. The practitioner must also evaluate the skills the individual will need to acquire before the desired goal behavior can be attained and must look at the environmental factors that are preventing the patient from learning those baseline skills. A functional analysis of behavior must also be conducted in order to learn which environmental factors are maintaining a problem. This functional analysis describes events that precede or follow a specific behavior so that a decision about the utility of a specific behavioral approach can be made.

A total behavioral assessment requires consideration of six major areas: (1) the personality of an individual will affect what illness occurs and how that person will cope with it. People react to the stress of illness with a specific constellation of cognitive, emotional, physiological, and behavioral responses based on their underlying psychological style (Lipowski, 1977; Millon, Green, and Meagher, 1979). (2) Premorbid pessimism influences the course of illness and the recuperative period. For example, premorbid depression has been shown to result in a more prolonged, difficult postoperative period (Boyd, Yeager, and McMillan, 1973). (3) Interpersonal support serves to moderate life stressors (Cobb, 1976). (4) Excessive concern about bodily functions constitutes a major stress and can adversely affect a person's ability to cope with illness (Lucente and Fleck, 1972). (5) Psychological problems underlying the illness state as well as the psychosomatic correlates of a disease must be carefully assessed. (6) And finally, the process of sorting out which patients will respond well or poorly to a medical procedure should lead to methods of classification that will decrease the frequency of poor outcome. All of these variables must be considered for every problem presented in order to allow maximum utility of behavioral techniques that will encourage an individual to learn more appropriate, health-productive behaviors.

Illness Prevention

A common misconception is that behavioral medicine is focused on treating health problems, much as traditional medicine is geared to the treatment of disorders. In fact, behavioral medicine is equally involved with preventive measures. Although necessarily this discussion is primarily concerned with treatment, a brief look at prevention is warranted as well. Faulty habits and various maladaptive behaviors or lifestyles are often implicated in the development of certain physical disorders. It is possible to gradually change these habits and lifestyles through programs using behavioral principles, thereby significantly reducing the risk of medical disorder. The way an individual copes with stress may strongly influence his general adjustment and propensity to physical illness. For example, the person who overeats as a means of coping with chronic anxiety is likely to become obese, which will not only result in poor self-esteem but may also contribute to a number of undesirable physical complications.

Consider the relationship of Type A and Type Β personalities to coronary heart disease (jenkins, Zyganski, and Rosenman, 1978). The classic Type A individual is described as hostile, competitive, unable to relax, pressured, loud, and impatient. Much research has focused on the use of behavior modification techniques to alter various aspects of Type A behavior (Suinn and Richardson, 1971; Suinn, 1974; Suinn, 1975a). There is as yet little evidence to demonstrate that such interventions can produce long-term change, and there is no current data to indicate that altering Type A behaviors will reduce the incidence or recurrence of coronary heart disease. However, the work of Peterson, Keith, and Wilcox (1962) and Clark et al. (1975) reveals that cholesterol does increase during periods of stress. A program for prevention of heart disease, then, might well focus on the alteration of dietary habits or on reducing stress. In view of society's reinforcements of Type A behavior (such as material success and media glorification of achievers), the modification or reduction of such behavior is exceedingly difficult (Zeldow, 1980). Nevertheless, the techniques of behavioral medicine allow the health care professional to identify the psychosocial variables that predispose a patient to stress and eventual medical difficulty and to integrate them into a corrective health regimen.

The skills needed for coping with stress must, of course, be viewed in an environmental context. During each contact, the practitioner can focus on the specific inter...

Table of contents

• Cover
• Half Title
• Series Page
• Title
• Copyright
• Dedication
• Contents
• 1 INTRODUCTION
• 2 CHANGING BEHAVIOR
• 3 BEHAVIORAL INTERVENTION
• 4 COMPLIANCE BEHAVIOR
• 5 HOSPITALIZATION: MANAGEMENT, REFERRAL, AND CONSULTATION
• 6 PRESENT STATUS AND FUTURE DIRECTIONS
• INDEX