MEDICAL PSYCHOLOGY Contributions to Behavioral Medicine Edited by CHARLES K. PROKOP Department of Psychiatry Texas Tech University Health Sciences Center School of Medicine Lubbock, Texas LAURENCE A. BRADLEY Department of Psychiatry and Behavioral Medicine Section on Medical Psychology Bowman Gray School of Medicine Winston-Salem, North Carolina ACADEMIC PRESS 1981 A Subsidiary of Harcourt Brace Jovanovich, Publishers New York London Toronto Sydney San Francisco COPYRIGHT © 1981, BY ACADEMIC PRESS, INC. ALL RIGHTS RESERVED. NO PART OF THIS PUBLICATION MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM OR BY ANY MEANS, ELECTRONIC OR MECHANICAL, INCLUDING PHOTOCOPY, RECORDING, OR ANY INFORMATION STORAGE AND RETRIEVAL SYSTEM, WITHOUT PERMISSION IN WRITING FROM THE PUBLISHER. ACADEMIC PRESS, INC. Ill Fifth Avenue, New York, New York 10003 United Kingdom Edition published by ACADEMIC PRESS, INC. (LONDON) LTD. 24/28 Oval Road, London NW1 7DX Library of Congress Cataloging in Publication Data Main entry under title: Medical psychology. Includes bibliographies and index. 1. Medicine and psychology. I. Prokop, Charles K. II. Bradley, Laurence A.[DNLM: 1. Psychology, Clinical. 2. Behavior. WM 105 M486] R726. 5.M43 616'.00119 80-1676 ISBN 0-12-565960-1 PRINTED IN THE UNITED STATES OF AMERICA 81 82 83 84 9 8 7 6 5 4 3 2 1 List of Contributors Numbers in parentheses indicate the pages on which the authors' Thomas G. Burish (395) Department of Psy- contributions begin. chology, Vanderbilt University, Nashville, Tennes- see 37240 Margaret A. Chesney (19) Behavioral Medicine A. Barney Alexander (373) Psychophysiology Program, Stanford Research Institute, Menlo Park, Department, National Asthma Center, Denver, California 94025 Colorado 80204 David A. dayman (497) Department of Be- Ivan Barofsky (55) Health Services Research and havioral Medicine and Psychiatry, West Virginia Development Center, Johns Hopkins Medical In- University Medical Center, Charleston, West stitutions, Baltimore, Maryland 21205 Virginia 25330 Jeffrey T. Barth (67, 241) Department of Thomas J. Coates (157) Department of Behavioral Medicine and Psychiatry, University of Psychiatry, Division of Pediatric Cardiology and Virginia Medical School, Charlottesville, Virginia Division of Heart Education, Johns Hopkins Hospi- 22908 tal, Baltimore, Maryland 21205 Douglas A. Bernstein (355) Department of Jean R. Eagleston (1 9)1 Center for Research on Psychology, University of Illinois, Urbana- Stress and Health, Stanford Research Institute, Champaign, Champaign, Illinois 61820 Menlo Park, California 94025 Thomas J. Boll (67, 241) Department of Psy- Seth Ersner-Hershfield (267) Center for Men- chology, University of Health Sciences, The tal Health, Newton Memorial Hospital, Newton, Chicago Medical School, North Chicago, Illinois New Jersey 07860 60064 W. Doyle Gentry (5, 91) Department of Laurence A. Bradley (1, 91, 485, 497) De- Psychiatry and Behavioral Sciences, University of partment of Psychiatry and Behavioral Medicine, Texas Medical Branch, Galveston, Texas 77550 Section on Medical Psychology, Bowman Gray School of Medicine, Winston-Salem, North Caro- Present address: Counseling Psychology Program, Stan- lina 27103 ford University, Stanford, California 94305. xi Russell Ε. Glasgow (355) Psychology Depart- Daniel S. O'Leary (B7)3 Department of Neurol- ment, North Dakota State University, Fargo, North ogy, University of Virginia School of Medicine, Dakota 58105 Charlottesville, Virginia 22901 Iris B. Goldstein C37) Department of Psychiatry, Cheryl Perry (1 57) Stanford Heart Disease Pre- University of California, Los Angeles, Los Angeles, vention Program, Institute for Communications California 90024 Research, Stanford University School of Medicine, J. Alan Herd (141) The Sid W. Richardson Stanford, California 94305 Institute for Preventive Medicine, The Methodist Edward J. PrietO (91) Department of Psychol- Hospital, Houston, Texas 77030 ogy, Fordham University, Bronx, New York 10458 David S. Holmes (423) Psychology Department, Charles K. Prokop (1,91, 485, 497) Depart- University of Kansas, Lawrence, Kansas 66045 ment of Psychiatry, Texas Tech University Health Judith A. Jensen (321 ) Department of Psychol- Sciences Center, School of Medicine, Lubbock, ogy, University of Utah, Salt Lake City, Utah 84132 Texas 79430 Philip C. Kendall (197) Department of Psychol- Lee Ann Slinkard (157) Department of Health ogy, University of Minnesota, Minneapolis, Min- Psychology, University of California, San Fran- nesota, 55455 cisco, San Francisco, California 94143 Joel Killen (1 57) Department of Counseling Psy- Linda C. Sobell (81, 267) Clinical Institute, chology, Stanford University, Stanford, California Addiction Research Foundation, Toronto, Canada 94305 Mark B. Sobell (81, 267) Clinical Institute, Sandra M. Levy (119, 307) National Cancer Addiction Research Foundation, Toronto, Canada Institute, Department of Health and Human Ser- Richard B. Stuart (321) Family and Commu- vices, National Institutes of Health, Bethesda, nity Medicine, University of Utah, Salt Lake City, Maryland 20014 Utah 84132 Frank T. Masur III (441) University of Tennes- Laurie H. Van der Heide (91) Department of see, Center for the Health Sciences, Department of Psychology, Fordham University, Bronx, New Family Medicine, Memphis, Tennessee 38105 York 10458 Joseph D. Matarazzo (5) Department of Med- David Watson (1 97) Department of Psychology, ical Psychology, University of Oregon School of University of Minnesota, Minneapolis, Minnesota Medicine, Portland, Oregon 97201 55455 Thomas W. Miller (471) Department of Psy- David K. Wellisch (223) Department of Psychia- chology, Veterans Administration Medical Center, try and Behavioral Sciences, UCLA Neuropsychia- Buffalo, New York 14215 trie Institute, University of California, Los Angeles, Christine Mitchell (321) Weight Watchers In- Los Angeles, California 90024 ternational, Salt Lake City, Utah 84132 Harold A. Ziesat, Jr. (291) Department of Ted •. Nirenberg (2B7)2 Vanderbilt University, Psychiatry, University of Rochester Medical Center, Nashville, Tennessee 37240; and Alcohol Pro- Rochester, New York 14642 grams, Dede Wallace Center, Nashville, Tennessee 37204 2Present address: Sea Pines Behavioral Institute, Hilton 3Present address: Department of Psychology, University Head Island, South Carolina 29928, and Georgia Southern of Health Science, The Chicago Medical School, North College, Statesboro, Georgia 30458. Chicago, Illinois 60064. xii LIST OF CONTRIBUTORS Preface The relationship between the medical professions the relationship between these complementary disci- and psychology has undergone a dramatic change plines. In addition, the volume presents critical re- within the past 10 years. Many psychologists working views by outstanding clinical investigators regarding in medical settings have expanded their areas of ex- the status of diagnostic, treatment, and preventive pertise and have begun to participate directly in the approaches to a wide variety of medical disorders. assessment, treatment, and prevention of medical The volume is composed of four major sections. W. problems. Medical professionals, in turn, have come to Doyle Gentry and Joseph D. Matarazzo first trace the value many of the applied and research skills dis- history of the relationship between psychology and played by psychologists in medical settings. This new medicine and assess the current status of psychology's relationship between psychology and medicine is re- role within the medical center. The second and third flected in the establishment of several interdiscipli- sections deal with approaches to the assessment and nary training programs in behavioral medicine, the treatment-prevention, respectively, of various medi- formation of professional associations that emphasize cal disorders. The third section also examines several interdisciplinary efforts and behavioral-medical prac- special problems within the provinces of medical psy- tice and research, and the recent publication of nu- chology and behavioral medicine. The fourth section merous books concerning behavioral medicine and presents reviews of clinical and research topics of par- related topics. ticular interest to all medical psychologists and be- One effect of these events has been a prolifera- havioral medicine specialists. tion of definitions of the roles of both behavioral This volume will be of value to research inves- medicine and psychology within the medical field. In tigators and practitioners within the behavioral sci- addition, several of the books concerning behavioral ences and medicine. Critical and comprehensive re- medicine have been limited in focus either because of views of the assessment, treatment, and prevention of overly restrictive definitions of behavioral medicine medical disorders are provided. Thus, the volume and medical psychology, or because of narrow con- will be especially useful for teaching purposes both tent areas. This volume offers definitions of medical within medical and university settings and will serve psychology and behavioral medicine, and discusses as a source book for scholars and practitioners. xiii We acknowledge the cooperation and support of Joyce Davis, Peggy Mackiewicz, Shirley Feldman, and Highland Hospital Division of Duke University Med- Mary N. White. Special thanks are due to W. Doyle ical Center; the Department of Psychiatry, Texas Gentry who introduced us to the fields of medical Tech University Health Sciences Center, School of psychology and behavioral medicine and who sup- Medicine; the Department of Psychology, Fordham ported our efforts throughout the production of this University; the Fordham University Research Council; book. Finally, we would like to thank Academic Press and the Department of Psychiatry and Behavioral and all of our contributors for their expertise and Medicine, Bowman Gray School of Medicine. Invalu- effort. able secretarial assistance was provided by Anne Dick, xiv PREFACE The Relationship between Medical Psychology and Behavioral Medicine LAURENCE A. BRADLEY CHARLES K. PROKOP Definition of Behavioral Medicine the definition implies that the only proper focus of The term "behavioral medicine" was first used by behavioral medicine is the study of the psychologi- Birk (1973) in the context of defining biofeedback cal sequelae of physical illness. Thus, prevention of as a learning theory based approach to the treat- physical illness is ruled out, and treatment is lim- ment of medical disorders. Pomerleau and Brady ited to attempts to indirectly influence the course (1979) have retained and expanded upon Birk's of physical disorders through the modification of use of the term, and have defined behavioral psychological factors. Following this definition, the medicine as role of practitioners of behavioral medicine is very similar to that of liaison psychiatrists in a medical (a) the clinical use of techniques derived from the ex- setting. The second difference between the defini- perimental analysis of behavior—behavior therapy tion offered by Asken and that offered by Pomer- and behavior modification—for the evaluation, pre- leau and Brady is that Asken's definition does not vention, management, or treatment of physical dis- limit the treatment interventions associated with ease or physiological dysfunction; and (b) the conduct behavioral medicine to those derived from the ex- of research contributing to the functional analysis and perimental analysis of behavior. understanding of behavior associated with medical A third, and more widely accepted, definition of disorders and problems in health care [p. xii]. behavioral medicine is that originally developed at the Yale Conference on Behavioral Medicine and A quite different definition of behavioral later articulated and amended by Schwartz and medicine has been offered by Asken (1979). He Weiss (1977, 1978). This amended definition of has defined behavioral medicine as "the study of behavioral medicine is psychological reactions that occur secondarily or as a result of physical illness and its treatment [p. 70]." This definition differs in two important ways The interdisciplinary field concerned with the de- from that offered by Pomerleau and Brady. First, velopment and integration of behavioral and biomed- 1 Medical Psychology Copyright © 1981 by Academic Press, Inc. Contributions to Behavioral Medicine All rights of reproduction in any form reserved. ISBN O-l2-565960-1 ical science knowledge and techniques relevant to the individual, group, and systems level [p. 67]." health and illness and the application of this knowl- Indeed, Asken has noted that medical psychology edge and these techniques to prevention, diagnosis, actually subsumes the area of behavioral medicine. treatment, and rehabilitation [1978, p. 250]. Another broad definition of the scope of activities within medical psychology has been provided by A major difference between the Schwartz and Gentry and Matarazzo in Chapter 2 of this volume. Weiss definition and those offered by the others is They have defined medical psychology as "the that Schwartz and Weiss emphasize the interdiscip- practice of psychology within the medical school linary nature of behavioral medicine. Thus, equal establishment. This includes not only clinical ser- emphasis is given to the contributions of the be- vices (i.e., practitioner), but also the important role havioral and biomedical sciences. An example of of the medical educator and researcher [p. 12]." this emphasis upon interdisciplinary efforts is pro- A far more restrictive view has been offered by vided by an examination of the masthead of the Pomerleau (1979). Pomerleau's definition limits Journal of Behavioral Medicine, the official journal of the activity of the medical psychologist to primarily the Academy of Behavioral Medicine Research. social and psychological assessment of persons The editorial board of the journal consists of 37 with medical disorders. Pomerleau does note, persons with Ph.D degrees, 17 persons with M.D. however, that some medical psychologists do par- degrees, and 5 persons with Ph.D. and M.D. de- ticipate in the treatment of medical disorders using grees. behavioral intervention strategies (Pomerleau, The definition of behavioral medicine provided 1979). by Schwartz and Weiss also differs from that of These definitions also differ from one another Pomerleau and Brady in that treatment interven- with regard to the theoretical orientations attrib- tions are not limited to those derived from learn- uted to medical psychologists. For example, Asken ing theory. The Schwartz and Weiss definition, and Gentry and Matarazzo believe that medical therefore, is consistent with that of Asken on the psychologists may adhere to any theoretical orien- dimension of the theoretical basis of treatment. tation. In fact, Gentry and Matarazzo point out Contrary to Asken, however, both Schwartz and that clinical and experimental psychologists of vary- Weiss, and Pomerleau and Brady agree that prac- ing schools of thought all may be considered to be titioners of behavioral medicine may intervene medical psychologists as long as they participate in either at the preventive level or directly upon the some form of activity in a medical school setting. disorder itself. The adequacy of the definition of Pomerleau, however, implies that the assessment behavioral medicine provided by Schwartz and activities of medical psychologists may be per- Weiss will be examined in the section entitled formed within the context of psychodynamic, "Medical Psychology's Relationship to Behavioral trait-oriented, or behavioral paradigms, but he re- Medicine." stricts treatment interventions to those derived from learning theory. Definition of Medical Psychology Current definitions of medical psychology are less Medical Psychology's Relationship to precise than those of behavioral medicine. The Behavioral Medicine various definitions differ both in terms of the An examination of these numerous definitions il- scope of activities included, and the theoretical lustrates that there is a lack of consensus regarding orientations of those involved. With regard to the the attributes that differentiate behavioral scope of activities within medical psychology, medicine from medical psychology, and those that Asken (1979) has provided the broadest definition. are shared by the two disciplines. It is essential to He has defined medical psychology as "the study clarify the commonalities between behavioral of psychological factors related to any and all as- medicine and medical psychology in order to re- pects of physical health, illness and its treatment at duce the risk that important contributions from 2 LAURENCE A. BRADLEY, CHARLES K. PROKOP one discipline might be overlooked by the other may serve to retard the development of clinical ad- (cf. Asken, 1979). It is equally important to iden- vances. In contrast, the inclusion of a wide variety tify the differences between the disciplines in of professionals and theories within behavioral order to educate (a) professionals involved in medicine, as advocated by Schwartz and Weiss, en- health care services; (b) recipients and evaluators courages the development of new clinical ap- of those services; and (c) governmental funding proaches that may be critically evaluated from a agencies with respect to what particular skills they variety of perspectives. In addition, the Schwartz may expect members of the individual disciplines and Weiss definition sufficiently emphasizes the to possess. In addition, it is important to clarify the prevention of medical disorders and the mainte- differences between medical psychology and be- nance of health as stressed by Stone et al. (1979) havioral medicine in order to foster the develop- without additional descriptive terms. Therefore, ment of distinct theoretical viewpoints and bodies we accept the current definition of behavioral of empirical data that may eventually enrich one medicine provided by Schwartz and Weiss and en- another and thereby lead to improved health care. courage other professionals to concur. Stone, Cohen, and Adler (1979) have attempted Similar to Schwartz and Weiss' definition of be- to explicate the differences and similarities be- havioral medicine, Masur's (1979) conception of tween medical psychology and behavioral medical psychology avoids an overly restrictive medicine. In doing so, they have defined both dis- view of the role of psychology in the medical set- ciplines as subspecialties of a new area which they ting. While Masur has clearly articulated that the have labeled "health psychology." Although their problem areas addressed by medical psychology emphasis upon the prevention of disorders and are identical to those addressed by behavioral the maintenance of health is desirable, the creation medicine, he has not specified the unique con- of a new descriptive label may increase the confu- tributions made by medical psychology to the sion that currently exists among professionals re- problems of health maintenance and to preven- garding medical psychology and behavioral tion, diagnosis, treatment, and rehabilitation of ill- medicine. Masur (1979) has attempted to clarify ness. We believe that medical psychology provides the relationship between the two disciplines by three relatively unique contributions to the larger conceptualizing medical psychology as the con- field of behavioral medicine. First, certain ap- tributions of psychology to behavioral medicine as proaches to assessment may be best provided by defined by Schwartz and Weiss (1978). Medical medical psychologists. For example, training in (a) psychology is described as encompassing the de- the assessment of brain-behavior relationships; (b) velopment of "intervention strategies and educa- the construction of psychometric instruments and tional systems directed at improving prevention, interpretation of patients' responses to these in- diagnosis, treatment, management, and rehabilita- struments; and (c) the functional analysis of be- tion of patients with physical diseases [Masur, havior that encompasses measurement of overt 1979, p. 259]." Masur has succeeded in adding and covert controlling stimuli, is rarely provided in clarity only to the extent that other professionals settings other than psychology training programs. accept Schwartz and Weiss' definition of be- Second, there are some approaches to treatment havioral medicine. It is critical, therefore, to exam- and to rehabilitation that currently are unique to ine the value of the Schwartz and Weiss definition medical psychology. For example, to date, the only of behavioral medicine before further assessing published reports of the effectiveness of stress in- Masur's position. oculation training for various disorders have been The Schwartz and Weiss definition of behavioral produced by psychologists. In addition, cognitive medicine possesses a distinct advantage in that it retraining approaches to the rehabilitation of cen- avoids the unduly restrictive quality of the defini- tral nervous system dysfunction are currently tion offered by Pomerleau and Brady. Limiting being investigated primarily by psychologists. It behavioral medicine to a single theoretical orienta- should be noted that psychologists are frequently tion or professional discipline at this early stage involved in the training of other professionals in THE RELATIONSHIP BETWEEN MEDICAL PSYCHOLOGY AND BEHAVIORAL MEDICINE 3 prevention, treatment, and rehabilitation ap- the other behavioral medicine specialties. The vol- proaches. Therefore, several disciplines that con- ume concludes with discussions of special topics of tribute to behavioral medicine may be expected to relevance to both medical psychology and be- adopt these treatment approaches as they have havioral medicine. The unique contribution of this adopted other approaches (e.g., operant condi- volume to behavioral medicine, as in the case of tioning, self-management) developed by psycholo- other medical psychology efforts, is its emphasis gists. upon critical evaluations of the current literature. Although several psychological treatment ap- We hope that the calls for methodological refine- proaches may become less identified with medical ments expressed in this volume will encourage psychology alone, psychology may be expected to those involved in medical psychology and be- enjoy a third unique role in prevention and treat- havioral medicine to be cautious in their clinical ment activities in the sense that psychologists re- claims, as well as rigorous and innovative in their ceive specialized, intensive training in experimen- research efforts (cf. Miller, 1974). tal design and statistics. Psychologists, therefore, are particularly well-suited to evaluate a wide va- riety of diagnostic techniques as well as preventive References and treatment interventions. Asken, M. Medical psychology: Toward definition, In summary, medical psychology focuses upon clarification, and organization. Professional Psychology, the same problem areas as do other behavioral 1979, 10, 66-73. medicine specialties. The contributions of medical Birk, L. (Ed.). Biofeedback: Behavioral medicine. New York: psychology that differentiate it from the larger Grune and Stratton, 1973. field of behavioral medicine are its unique assess- Masur, F. T. An update on medical psychology and be- ment approaches and its capability to provide em- havioral medicine. Professional Psychology, 1979, 10, pirical evaluations of diagnostic, preventive, and 259-264. Miller, Ν. E. Introduction: Current issues and key prob- treatment methods. The results of these evalua- lems. In N. Miller, T. Barber, L. DiCara, J. Kamiya, D. tions may provide for major advances and im- Shapiro, & J. Stoyva (Eds.), Biofeedback and self-control, provements in the quality of medical care and 1973. Chicago: Aldine, 1974. health maintenance. Pomerleau, O. F. Behavioral medicine: The contribution The construction of this volume is consistent of the experimental analysis of behavior to medical with the relationship between medical psychology care. American Psychologist, 1979, 34, 654-663. and behavioral medicine presented in this chapter. Pomerleau, O. F., 8c Brady, J. P. Introduction: The scope Following a discussion of the history and current and promise of behavioral medicine. In O. F. Pomer- status of medical psychology, the volume presents leau 8c J. P. Brady (Eds.), Behavioral medicine: Theory and practice. Baltimore: Williamsand Wilkins, 1979. comprehensive reviews of the major problem areas Schwartz, G. E., 8c Weiss, S. M. What is behavioral of interest to both medical psychologists and be- medicine? Psychosomatic Medicine, 1977, 39, 377-381. havioral medicine specialists. These include re- Schwartz, G. E., 8c Weiss, S. M. Behavioral medicine re- views of the assessment and treatment approaches visited: An amended definition. Journal of Behavioral that are relatively unique to medical psychology as Medicine, 1978, /, 249-251. well as the preventive and treatment approaches Stone, G. C, Cohen, F., 8c Adler, Ν. Ε. (Eds.). Health psy- that are shared by those in medical psychology and chology: A handbook. San Francisco: Jossey-Bass, 1979. 4 LAURENCE A. BRADLEY, CHARLES K. PROKOP