Critical health psychology, K Chamberlain, M Murray

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9 Critical Health Psychology Kerry Chamberlain and Michael Murray
Chapter Topics
Health Psychology: Development and Context
Some Limitations for a Mainstream Health Psychology
Possibilities for a Critical Psychology of Health
Problematics for a Critical Psychology of Health
The Future of Critical Perspectives in Health and Health psychology 154
health psychology: development and context The field of health psychology was formally established when a group of psychologists met in the late 1970s to discuss the relevance of psychological theory, research and practice to physical health and illness. That meeting, which took place in the United States, resulted in the formation of the American Psychological Association's Health Psychology Division. Health psychology, of course, did not arise independently of other developments occurring around it. Connections between medicine and psychology have been suggested and examined for centuries, and these became more explicit as the disciplines of biomedicine and psychology developed. Psychosomatic medicine, which considered particular health problems such as ulcers, asthma, migraine and arthritis to have psychological causes, developed in the 1930s and was strongly influenced by psychoanalytic theory. Behavioural medicine developed as an interdisciplinary approach to health issues in the 1970s, drawing from the strong interest in psychology at that time in behaviourism and the experimental analysis of behaviour. Health psychology has its roots in these developments, but differs from them in having a more strongly psychological, rather than interdisciplinary, focus, and also in encompassing a broader range of issues within its research and theorizing (Sarafino, 2005). Liaison psychiatry, a specialized subdiscipline of psychiatry concerned with psychiatric problems experienced by patients in medical settings, also developed alongside health psychology. Again, health
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psychology is arguably differentiated from this approach by its broader remit of research and theory (Kaptein & Weinman, 2004). A definition of health psychology was developed for the new APA Division of Health Psychology in 1979. This definition, unsurprisingly, reflected the current zeitgeist, and essentially defined health psychology as the contribution of all the educational, scientific and professional aspects of contemporary psychology to any and all areas of physical health, specifically including health promotion and maintenance, illness treatment and prevention, and the role of psychological factors in health and illness (Matarazzo, 1980). Later, the definition was extended to include the remaining aspects of health by identifying a role for health psychology in improving health care services and policies (Matarazzo, 1982). This definition of health psychology, with its four `core elements' (Kaptein & Weinman, 2004: 6) or `goals of health psychology' (Sarafino, 2005: 14), remains commonly in use today, although the degree to which health psychologists take up the challenges of policy development and improving health care services is rather limited. Health psychology, then, developed within the sphere of psychology at large and took on its dominant assumptions and methods: a psychology that saw itself as a science applying an agreed scientific method to the study of individuals and their psychological processes. Inevitably, given this genealogy, health psychology was, and largely remains, subject to the same general criticisms that critical psychologists have levelled against the discipline, as rehearsed throughout this text. Hence it is no surprise to find health psychology focused on the rational individual, placing an emphasis on measurement and statistics, adopting the use of various narrowly defined psychological models with limited theorization, and largely ignoring the social aspects of health and illness. More recently, some alternative approaches have developed. One common distinction is that proposed between `mainstream' health psychology and critical health psychology (e.g., Crossley, 2000; Murray & Chamberlain, 1999a), a distinction based upon the differing values, epistemologies and research methodologies favoured by each. Mainstream health psychology takes the conventional `scientific' approach to the field, and assumes that knowledge can be uncovered through traditional scientific research processes, that it is fixed and independent of the context in which it is found and the methods used to reveal it. It focuses on measuring, predicting and changing health and illness behaviours, and seeks to discover the `truth' about the relationship between psychological factors and health. The approach draws on the biopsychosocial model, and has developed a variety of social cognition models of health behaviour. It focuses strongly on the individual, and assumes that people behave in rational, thoughtful, and predictable ways. These assumptions and the use of traditional scientific methods serve to legitimate mainstream health psychology as a professional adjunct to biomedicine and a specialist partner with medicine in research into and treatment of illness (Murray & Chamberlain, 1999a). This is the dominant approach presented in most health psychology textbooks, the basis for most research in health psychology and for most health psychology interventions.
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Critical health psychology, in contrast, challenges many of mainstream health psychology's assumptions and practices.The critical approach argues that people are complex, changing and multi-faceted, rather than fixed `objects' that can be studied `scientifically'. It generally takes a social constructionist position, assuming that knowledge is variable and changing and always a product of the historical, social and cultural context in which it is located. Critical health psychology seeks understanding and insight into, rather than prediction of, human conditions and practices, and frequently employs qualitative interpretative research methods, although is not restricted to these. More fundamentally, critical health psychology seeks to challenge assumptions, including its own, and to identify how forms of knowledge and practice can empower or enfranchise people. Marks (2002) proposes an alternative classification of health psychologies with differing values, assumptions, objectives and research practices. He argues that, alongside clinical health psychology (the practice of mainstream health psychology), three other approaches can be identified ­ public health psychology, community health psychology, and critical health psychology. Public health psychology adopts a public health agenda, emphasizing the structural and social determinants of health and illness and engaging in multidisciplinary activities focused on epidemiological research and community health promotion interventions (see Marks, 2002; Hepworth, 2004). This changes the focus for causes of ill health from medicalized pathogens to social problems (Young, 2006). Community health psychology posits that social context is crucial in shaping opportunities for health, and considers social change fundamental to practice. It argues for a praxis that promotes community participation and creates community-level action for enabling and sustaining health-enhancing activities (see Campbell & Murray, 2004). Because both public health psychology and community health psychology can adopt (or not) a critical approach to practice, there can be considerable overlap between a critical approach and these other two (although this is more strongly marked in community than in public health psychology). Because our focus here is on the critical approach, we will continue with the mainstream/critical distinction, and illustrate critical work in the field drawing from public and community health psychology where applicable. However, we should also note that a critical approach is not readily defined or agreed on within the field, an issue that we discuss below. Further, a critical approach can also be applied at the clinical level, although this rarely occurs (see Chapter 5 in this volume).
some limitations for a mainstream health psychology
There are serious concerns, from a critical psychology perspective, about how mainstream health psychology conducts its research and practice. We comment on several below, noting that this is neither an exhaustive set nor an extensive discussion of any single issue.
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First, mainstream health psychology takes a highly individualistic approach to its research and practice. Given that health psychology is built substantially on theories and approaches drawn from social psychology, this may appear surprising. However, as Greenwood (2004b) has demonstrated, social psychology itself adopted this individualistic approach to its endeavours around the middle of the twentieth century (see also Chapter 6). As we see below, this focus severely limits the way in which research and practice can be both understood and integrated into the social context. Health psychology has widely adopted the biopsychosocial model (Engel, 1977) as a framework. This model proposes that health and illness arise from the interplay of biological, psychological and social factors. Although this proposal seems reasonable on the surface, it has been the object of substantial criticism. Spicer and Chamberlain (1996) argued that adoption of this model fails to solve the fundamental problem of how to integrate theorizing across the three domains it incorporates. Other critics have argued that the model retains an essentially biomedical perspective (e.g., Armstrong, 1987) and that its function within health psychology, which has been largely rhetorical rather than theoretical (Ogden, 1997), serves mainly to sustain health psychology as a partner in the medical agenda (e.g., Suls & Rothman, 2004). Stam, arguing that the model is neither explicit theory nor formal model, proposed that it is merely `a clever neologism masquerading as a model and its naпve distribution to undergraduates ought to lead us to urge publishers to place a warning label on textbooks indicating that they are a danger to the health of one's theoretical education' (2000: 276). One of the major areas of health psychology research and intervention involves an ongoing attempt to explain and predict health behaviours. This goal is important since there is considerable evidence many people engage in `unhealthy' behaviours such as smoking, eating poorly or engaging in `unsafe' sexual activities. This work comprises a substantial component of health psychology research activity, and frequently utilizes social cognition models such as the Health Belief Model, Protection-Motivation Theory, the Theory of Planned Behaviour, and the Determinants of Behaviour model. These models typically involve a set of individualized cognitions, attitudes and beliefs, combined into predictive pathways. However, illustrating a more general problem highlighted in Chapter 19, this process reduces theorizing to model building. This `pathology of flow-charting' (Spicer & Chamberlain, 1996) encloses key variables within boxes and connects them with causal arrows, places major emphasis on the variables included and largely ignores any conceptualization or theorization of the causal processes involved. In spite of substantial research involving such models, outcomes so far have been extremely limited. Mielewczyk and Willig (2007), in a highly Critical Review of this field, conclude that this approach is not only ineffective but, more fundamentally, inappropriate. They identify the limited explanatory power of these models and their failure to perform any better when enhanced in various ways, such as by limiting prediction to intention
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rather than behaviour (thereby losing the major intent), or by adding further variables or using different mixes of variables (thereby destroying the theoretical significance of the `theories' in the first place). Mielewczyk and Willig (2007) conclude that the theoretical, methodological and performance-based limitations of social cognition models mean these models should be replaced by research approaches that can examine the specificity of particular health behaviours in naturally occurring contexts. As Mielewczyk and Willig point out, there is probably no such thing as a `health behaviour' (in the abstracted sense that it is used in this research). Rather, social practices involving behaviours with implications for health (such as smoking) are necessarily embedded in context; they need to be studied in context to understand their meaning and the logics of their enactment. For example, Laurier, McKie, and Goodwin (2000) illustrate how the act of smoking a cigarette varies across the day; how the meaning of the first cigarette in the morning, the last cigarette of the day, the social cigarette in the bar and the snatched smoke during work are all fundamentally different. Furthermore, as Mielewczyk and Willig (2007) note, changing the focus of our research has implications beyond how we do our research. It extends to how we might practise health psychology to reduce the threat and burden of illness. As they argue, social practices determine not only how we should, can, and do (or do not) behave, but equally constitute who we should, can (or cannot) be, and how we can be. Inattention to context extends far beyond personal behaviours; there is equal inattention to wider social issues that affect health and illness. Many years ago, Crawford (1980) noted a concern with `healthism' ­ how contemporary societies, and the citizens that constitute them, are preoccupied with health as an agenda, as a project, and as an integral part of everyday living. Crawford (2006) argues that this concern has not receded but increased in intensity and that the pursuit of health has become `one of the more salient practices of contemporary life, commanding enormous social resources, infusing every major institutional field and generating an expansive professionalization and commercialization, along with attendant goods, services and knowledge' (2006: 404). He also argues that this `new health consciousness' is strongly connected to the ways medicine extends its control and power over everyday life activities, a process labeled medicalization (Conrad, 2007), and to ideologies of consumption and personal control, so that `personal responsibility for health is widely considered the sine qua non of individual autonomy and good citizenship' (Crawford, 2006: 402). Medicalization is pervasive, producing a range of new disorders. These are highly gendered, mostly target women, and are largely identified as mental health `problems' (see Chapter 5). However, many relate to physical health `problems' such as excessive sleepiness (for which there is a drug treatment), andropause (declining testosterone levels in older men, treated with testosterone replacement drug therapy), obesity (treated with surgery or drugs), bodily enhancement such as breast enhancement (treated with surgery), with
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other forms developing as pharmaceutical and genetic technologies advance (see Conrad, 2007). Pharmaceuticalization is equally pervasive, raising concerns about the role of large international pharmaceutical companies in creating illness (Applbaum, 2006; Busfield, 2006) and in turning healthy people into patients (Moynihan & Cassels, 2005) and `neurochemical selves' (Rose, 2004, 2007). Many health psychologists, oblivious to the concerns of biopower and control (Rose, 2006) raised by medicalization, pharmaceuticalization and health consumerism, are unwittingly implicated in the production of these new forms of disorder and their treatments. We could continue with further limitations. For example, adherence to medication is a prominent agenda in mainstream health psychology because it is generally agreed that only about 50 per cent of medications are taken as directed. A review of mainstream research covering three decades concluded that, in spite of more than 200 studied variables, none consistently predicted adherence (Vermeire, Hearnshaw, Van Royen, & Denekens, 2001). A more critical view suggests that, rather than being assessed as a static or fixed phenomenon, adherence is better considered a fluctuating choice made in the social contexts of everyday life (e.g., Wilson, Hutchinson, & Holzemer, 2002). Another limitation concerns the body's centrality in health and illness and associated issues of embodiment ­ having and being a body ­ materially, socially and symbolically. Mainstream health psychology has given scant attention to bodies and embodiment, and its biomedical view of the body is inappropriate for addressing concerns with suffering and healing (Radley, 2000). These are just some of mainstream health psychology's limitations that a critical perspective reveals, limitations that shape and inform possibilities for a critical health psychology.
possibilities for a critical psychology of health
One of the original drivers of the critical turn within health psychology was the growing interest in language and discourse within critical social science. This led critical health psychologists to use various Qualitative research methods to give voice to the experience of health and illness (Chamberlain, Stephens, & Lyons, 1997; Murray & Chamberlain, 1998, 1999b). Although this linguistic turn provided insights into the experience of the `other', several critiques (e.g. Murray & Campbell, 2003) raised concerns about the new approach: it was largely limited to individual interviews, still treated research participants as passive subjects, still failed to capture broader social contexts adequately, and gave limited consideration to how research could contribute to social and personal transformation. These criticisms led to a wider array of more innovative qualitative and participatory methodologies that could not only provide greater insight into the experience of participants but also contribute to transformation and change. Several critical researchers have turned for inspiration to Action Research (e.g., Jacobs, 2006) and to the arts
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(e.g., Camic, 2008; Murray & Gray, 2008), opening up a new array of approaches that are still being developed. We next consider examples of these to illustrate possible new directions for a critical health psychology. Our understandings of health and illness are constructed and reconstructed in our everyday social interactions within the broader societal context that exists in a world of inequality, conflict and pain. Within any society certain discourses and social representations attain hegemonic power (ArribasAyllon & Walkerdine, 2008; Howarth, 2006) and inhibit, oppress and marginalize individuals, groups and larger collectives. However, the power and truth status of such representations can be challenged. For example, Freire's work on critical literacy discussed how dialogue and debate can allow people to develop critical consciousness and learn to `perceive social, political and economic contradictions and to take action against oppressive elements of reality' (1970: 17). Freire's pedagogy emphasized working with people to develop this critical consciousness, so that the poor and disenfranchised can begin to reassess themselves and the nature of their social reality. Critical health psychologists can play an active role in this process. This work by Freire (1970) and other critical theorists (e.g., Martнn-Barу, 1994) led to the development of Participatory Action Research. Brydon-Miller describes this as `a collaborative process in which the researcher works with community members to identify an area of concern to that community, generate knowledge about the issue, and plan and carry out actions meant to address the issue in some substantive way' (2004: 188). Rather than acting as expert, the researcher is positioned as a co-learner, with community participants acting as co-researchers; together they engage in a joint project to identify, challenge and change the sources of oppression in their lives. In the health arena, this approach has been used in community settings, particularly with disadvantaged communities, as in Cornish's (2006) collaborative project with sex workers in India. Her research was embedded within a wider project based upon `respect for sex workers and their profession, recognizing their profession and their rights, and reliance on their understanding and capability' (Jana & Banerjee, 1999: 11). Cornish drew upon Freire's (1973) concept of problematization, the process by which learners begin to question the established social order and consider alternatives. In this setting, fatalistic acceptance of the nature of sex work was challenged through making workers aware of their rights, comparing them with other groups of workers, and gaining evidence of sex workers' success. The success of this and similar projects (e.g., Lubek et al., 2002) shows the potential for this approach in promoting health and the importance of attention to the psychological processes that underlie its practice. Historically, the arts have been used for a variety of purposes, to entertain, distract, excite, or build collective bonds (see Dissanayake, 2007). Within a critical perspective, the arts can reveal sources of discomfort and energize communities to take action to transform those situations. Used in this way, the arts become enjoined with action research (Murray & Gray, 2008). We consider some examples that illustrate these exciting possibilities.
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Photography, painting, and other Visual Arts have become popular within health care as a form of adjunct therapy, but more recently critical health psychologists have explored these as forms of research and intervention. Perhaps the most prominent technique is photovoice (Wang, 2003), which involves people using cameras to capture their everyday experiences and then using the resulting photographs not only to explore their experiences but to campaign against disadvantage. The technique, used originally with Chinese peasant women (Wang, Burris, & Xiang, 1996), has since been adopted widely and used successfully across a range of settings (see Baker & Wang, 2006; Hodgetts, Chamberlain, & Radley, 2007). The approach is related to Freire's (1970) notions of critical consciousness and aligns with perspectives on empowerment drawn from feminist and community development theory. Another example of arts-based participatory intervention is that of Washington and Moxley (2008), who worked with a group of older African American homeless women to develop strategies for combating homelessness, a significant health issue (Hodgetts, Radley, Chamberlain, & Hodgetts, 2007). These women provided narrative accounts and photographic representations of their experiences. The project culminated in a public exhibition that included their photographs and extracts from their accounts, together with other artifacts of their homeless experience such as poems they had written, scrapbooks they had made, and material artifacts they had collected from the streets. The project was designed to draw attention to the issue of homelessness in the community and also to empower the women to campaign for change in housing provision and improvements in health. Visual research methods have been extended further in participatory action research through placing video recorders, rather than cameras, in the hands of participants. For example, Stewart, Riecken, Scott, Tanaka, and Riecken (2008) worked with a group of Canadian indigenous youth in collective action about health concerns to produce short videos about issues such as drug and alcohol use, diabetes and depression. The youth were involved in all stages of the project from identification of the key health issues and development of the script to camera work, video editing and presentation of the video. Through this process the youth grew in understanding their community, their culture, and the meaning of local health issues and also developed competencies to change health outcomes. Performance, including music, dance and drama, is another art form used in therapy that has potential for critical research and practice, particularly when used to critically engage with oppression. Denzin (2003) proposed performance ethnography and argued for a renewed social science, an oppositional performative social science to challenge oppression and injustice through performance. Some critical health psychologists have taken this up. Gray and Sinding (2002) began their project by collecting stories from cancer patients. With the assistance of a professional playwright, they transformed those stories into a dramatic work that was performed by actors and cancer patients in hospitals, communities, and on radio. The performances were a resounding
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success, helping audience members understand the implications of cancer and helping cancer sufferers learn positive ways to live with the condition. Murray and Tilley (2006) collected stories of fish harvesters about accidents and risktaking, and then worked with a songwriter to transform the stories into a song that was widely played in different settings, including union meetings and concerts, and on radio and television. Murray and Tilley also worked with residents of fishing communities to develop a series of artistic products including paintings, writings, plays and concerts. This research provided powerful evidence that the arts provide an effective means of engaging communities and promoting community awareness of Health and Safety issues. Sullivan, Petronella, Brooks, Murillo, Primeau, and Ward (2008) used another performative technique, Theatre of the Oppressed (Boal, 1992), to engage marginalized communities in taking action to transform their living conditions and promote their health. This approach involves developing a dramatic performance, culminating in a public presentation where the audience is encouraged to participate in a dramatic dialogue, transforming them from spectators to spect-actors (Boal, 1992). Sullivan and his colleagues collaborated with Hispanic workers living in a highly polluted neighbourhood to develop a variety of forum theatre performances. The core group of actors researched the environmental health hazards of their neighbourhood and developed the performances. The impacts of this forum theatre included `community empowerment and organizing, teaching concepts, building issue awareness, connecting citizens with movements and widening coalitions' (Sullivan et al., 2008: 168). Forum theatre is becoming a widely used technique for community engagement, collective empowerment and social transformation. We have concentrated here on recent innovative arts-based practices, but critical health psychologists have also continued with language-based narrative and discursive research to provide insights into sociostructural changes and accompanying issues of power and disenfranchisement. For example, Willig (1998) uses critical discourse analysis to examine how sexual activity is variously constructed and considers the implications of these constructions for sexual practices. Madison (2005) describes how critical ethnographic approaches can be used to examine issues as diverse as the functions of Non-Government Organizations in a developing country, gay identity, and community theatre. Hodgetts and Chamberlain (2006), in considering how media are deeply implicated in the construction of shared understandings of health, discuss how health psychologists can utilize critical approaches to media research. New Media forms have also attracted attention, although so far more from social scientists in other disciplines than from health psychologists. For example, Seale (2005) discusses new directions for critical Internet health studies, using representations of cancer experience on the web as an illustration. Gillett (2003) considers media activism played out in Internet use by people with HIV/AIDS. Health psychologists have had only limited involvement in critical analyses of key social processes that are transforming the health
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arena, such as health consumerism, medicalization and pharmaceuticalization. For example, health psychologists have not been prominent in the critical emerging debates around the moral panic of the `obesity epidemic' and the construction of obesity as a disease (see Campos, Saguy, Ernsberger, Oliver, & Gaesser, 2006; Jutel, 2006; Pieterman, 2007). They have had some presence in critical debate about new drug technologies like Viagra (e.g., Potts & Tiefer, 2006), and a more limited presence in debate around processes of disease mongering and the role of `big Pharma' in creating and fostering New Diseases (e.g., Moynihan & Henry, 2006; Tiefer, 2006). These issues are starting to attract more attention within critical health psychology as researchers deconstruct dominant meanings of health, illness and health care, work with participants to further understand health and illness experience, and seek to achieve change and transformation in an increasing range of ways. However, possibilities for a critical health psychology do give rise to some problems of their own.
problematics for a critical psychology of health
One important issue arises from the meaning of `being critical'. For many mainstream health psychologists, this merely involves being self-critical within their existing framework (e.g., Owens, 2001; Vinck & Meganck, 2004). However, as Hepworth (2006b) and others have argued, a critical approach involves a more extensive and wide-ranging critique that seeks to challenge the very bases of practice at theoretical and epistemological levels as well as at the more practical level of method. Criticality must involve unencumbered critique, and this requires critical examination of the assumptions, values and practices of critical health psychology itself. As McVittie (2006) comments, notions of fairness and justice underpinning the critical agenda must be critiqued for their function in context, rather than serve as broad all-encompassing value directions. Hence, calls to action (e.g., Campbell & Murray, 2004; Marks, 2004), calls for a critical health psychology that is `not content with describing reality, but rather seeks to transform reality' (Murray & Poland, 2006: 383), raise a dilemma for critical health psychologists (and equally for other critical psychologists, as noted elsewhere in this book). When we espouse a need for our research and practice to inform and emancipate the disadvantaged and oppressed, we also need to reflect on what this means for others who may not be included amongst those we consider, or who do not consider themselves, disadvantaged and oppressed (see also Hepworth, 2006a; McVittie, 2006). We also need to be aware that emphases within critical psychology are constantly changing and developing. A critical approach is neither fixed nor stable. Hepworth (2006a) suggests that there have been three phases of critical health psychology: the rejection of reification (critiquing and rejecting the existence of `facts' and `objects' of health); the rise of consensuality and subjectivism (the expansion and pluralism of theories and methods); and calls for
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justice and fairness (an emphasis on action and equality). While we agree that these phases can be identified, we suggest they are more interrelated and integrated than this stage-based argument suggests. However, they do background a debate about directions for research practice: whether critical health psychology should focus on revealing disparity and disadvantage or on changing it. At one level this is essentially a debate around methodologies, with discursive and narrative research directed largely towards revealing issues of power and control and action-oriented methods directed to changing the status quo. We propose that both have benefit, and in practice are interconnected in any critical engagement. In the examples above, we can see that action-oriented research produces knowledge at several levels, revealing concerns and circumstances, constructing new knowledge, empowering and changing participants, and changing communities. These different types of projects vary in terms of what they can accomplish, but each can contribute to the critical agenda. Another debate relates to the division between qualitative and quantitative approaches. For some, a critical approach should be qualitative, based on social constructionist epistemology and interpretative methodology. However, we agree with Parker (2007) that, although critical psychologists have been suspicious of the move to quantify everything, there is value in knowing how much of something is occurring as well as how it is experienced. Knowing both can be important in supporting an action orientation to change. Thus, a critical approach does not require qualitative methodologies, although, as our examples above illustrate, `there is a sound rationale for why qualitative methods are at the forefront of critical approaches' (Hepworth, 2006b: 405). Finally, critical psychologists need to be aware that almost all forms of social action have been subject to critique, which can lead to justifications for a lack of action. We side with Hepworth (2006a, 2006b) about the need for action, and for research and practice designed to produce insight and change rather than merely describe why change is needed. We turn away from `the same old neutral observer, rational scientist bullshit' (Murray & Gray, 2008: 149). In a world of widespread pain and suffering, we join with others in promoting social change to bring about a healthier world.
the future of critical perspectives in health and health psychology
Critical health psychology maintains an ongoing critique of mainstream health psychology but this should not condemn it to the sidelines forever, to being always `on the edge of the mainstream looking in' (Marks, 2002: 16). We can recognize changes. One relates to the increasing acceptance of qualitative research methods, demonstrated in several ways: the British Psychological Society's (BPS) requirement that undergraduate and graduate health psychology curricula include qualitative research; the rapid growth of the new BPS Qualitative Psychology Section and pressure to develop a similar division
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within the American Psychological Association; increasing acceptance and use of qualitative research by mainstream health psychology researchers; and the emergence of qualitative research articles in mainstream journals such as Health Psychology. Further, as we see in other chapters of this text, similar critiques and developments are occurring within other areas of applied and professional psychology. Moreover, we noted earlier that health psychology is heavily influenced by its master discipline, medicine, which faces similar pressures. These have led to a growing acceptance of narrative medicine and medical humanities, more detailed engagements with the lifeworlds of the sick, and the development of a more critical public health. All these moves will undoubtedly influence the practice of health psychology over the next few decades. These changes also mean that critical health psychology research has increasingly begun to ask different questions ­ questions that focus more on experience, that give voice to the ill and disadvantaged, and that bring to the fore issues of inequality more in tune with critical approaches. These new questions reveal problematic issues for mainstream health psychology arising from its focus on the specific problems of the particular case. This focus should, but does not, extend to the experience of the person in broader social context and to the role of helping in that person's lifeworld. However, the nature of mainstream health psychology research sets the agenda for, and drives the forms of, practice, so that, like in medicine, assessment, diagnosis and treatment prioritize the problem rather than the person. The turn to qualitative, interpretative, and emergent research coming from critical health psychology has potential to change the drivers for treatment and care and bring the person back into view. Certainly the reflexive engagement promoted within critical approaches can facilitate this result. Through such processes, as critical health psychology moves to accomplish its agenda of social change and action, it may become more mainstream. Such progress would not obviate the need for any critical approach to always question its own values, assumptions, practices and outcomes. However, because the near future is likely to see an expanding medicalization of everyday life, an increasingly technologized health care, and an ongoing ideology of neo-liberalism and consumption with health remaining highly valued, critical health psychology's `mainstreaming' does not appear imminent. An ongoing, but changing, social justice agenda will remain, as will an explicit need for critical approaches that hold this agenda in focus at the forefront for health care. A critical approach will always remain necessary. We agree also with Hepworth's argument for a `need to work across disciplines to further strengthen critical approaches to health' (2006b: 407). We can learn from other critical disciplines. For instance, critical gerontology raises similar challenges for mainstream gerontology and geriatrics. Phillipson and Walker suggested critical gerontology should aim to develop `a more value-committed approach to social gerontology ­ a commitment not just to understand the social construction of ageing but to change it' (1987: 12). Bernard and Scharf (2007) emphasized the need to bring
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back into discussions of ageing considerations of context, values, and commitment to change. Similar debates occuring in other disciplines relevant to health, such as geography, sociology and anthropology, can be informative for critical health psychology. Stam contends that arguments against the mainstream also serve `to affirm the ground of the contest' (2006: 388). These arguments have now penetrated health psychology, establishing the critical agenda to reduce inequality. While we see evidence of work in this direction, advancing that agenda remains the ultimate challenge for critical health psychologists.
main chapter points 1 Health psychology is concerned with the application of psychological knowledge to issues of physical health and illness. It arose from a series of related developments concerned with body­mind connections and physical health. 2 The chapter distinguishes between mainstream and critical approaches, and comments on the assumptions, theories and practices underlying each. 3 Limitations of the mainstream approach involve the assumptions, theories and models of health behaviour, the research methods employed, and the lack of attention to social processes that shape health and illness. 4 A critical psychology of health focuses on research seeking transformation and change, using participatory action research and performance-based arts approaches. Other forms of research seek insight into the sociostructural processes and power relations that sustain disadvantage. 5 Problematic issues for a critical psychology of health include the meanings of criticality and debates around methodology. 6 The changing nature of psychology and related disciplines suggests that critical perspectives in health and health psychology will advance, although a critical reflexive approach will always be required.
· consumerism: the organized practices of consumers involving the consumption of services (including health care); the ways in which services have become commodified for delivery or sale to consumers. · disease mongering: the creation or promotion of relatively minor conditions or diseases by pharmaceutical companies with the aim of increasing sales of medications. · embodiment: the experience of both being and having a body.
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· health consumer: a model of the patient as an informed and empowered person actively involved in his or her own health care, treatment and decision-making. · medicalization: the expansion of medicine into everyday life; the processes through which problems become defined and treated as medical concerns, as illnesses, syndromes or disorders. · performative social science: a form of social science that actualizes the performative in everyday life and uses various art forms to engage the audience, provide insight and motivate action for change. · pharmaceuticalization: the increasing use of drugs to manage the problems of everyday life and the promotion of drug-based solutions to such problems; similar to medicalization. · photovoice: an approach to research using various forms of camerawork to engage participants and audiences and provide deeper understandings of issues.
reading suggestions Crossley (2000) and Murray (2004) discuss relevant issues for critical health psychology. Lyons and Chamberlain (2006) is a general text emphasizing a critical approach to health psychology. Radley (1994) provides important coverage of health and illness in a social world. Aboud (1998) provides a global perspective. Moss and Teghtsoonian (2008) provide critical discussions around contestation, power and illness. Murray and Chamberlain (1999b) cover qualitative methodologies and related Research Issues. The Journal of Health Psychology regularly contains articles from a critical perspective ­ see especially Special Issues on reconstructing health psychology (Volume 5, Issue 3), Community Health Psychology (Volume 9, Issue 2), Public Health Psychology (Volume 9, Issue 1), Health Psychology and the Arts (Volume 13, Issue 2), the Prilleltenskys' (2003) article and following commentaries, Hepworth's (2006a) article and ensuing commentaries on critical health psychology. See also Crossley's (2001) article in Psychology, Health & Medicine and the subsequent commentaries. Other journals that carry critical health psychology articles include Health, Social Science & Medicine, Critical Public Health, and Sociology of Health and Illness.
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· Global Forum for Health Research ­ Promoting the potential of research and innovation to address the health problems of the poor: · ISCHP (international society for Critical Health Psychology): ischp09/
Fox et al-3779-Ch-09:Fox et al-3779-Ch-09.qxp 9/2/2008 8:48 PM Page 158 · New View Campaign ­ Challenging the medicalization of sex (Leonore Tiefer): · ­ Caroline Wang's site on the photovoice method for research: · ­ International charity to bring about positive social change for marginalized communities: · SiRCHESI (Siem Reap Citizens for Health, Educational and Social Issues) ­ Grassroots health promotion (Ian Lubek): research/lubek/cambodia/ · Many local websites relevant to health and illness can be located through Internet searches. These are often organized around or connected to a specific illness. Such sites can offer support and resistance but many also support biomedical power and imperialism. ?uestions 1 Consider a serious life-threatening illness, such as cancer or renal disease, or a chronic on-going illness, such as diabetes or epilepsy. Discuss the differences in how your chosen illness is understood by mainstream clinical health psychology and by critical health psychology. Consider these differences from an experiential perspective (by the person with the illness) and from a treatment perspective (by the health professional). 2 Consider a disputed illness, like ME (myalgic encephalitis), OOS (occupational over-use syndrome) or SAD (seasonal affective disorder). Discuss the ideology and politics of their presentation and treatment. 3 Locate a set of Internet websites that relate to an illness (e.g., cancer information) or a health issue (e.g., obesity, breast augmentation) and discuss their content from a critical perspective. How do they function to sustain or resist a biomedical imperative? How is the illness or health issue constructed by those experiencing it? By those providing services in relation to it? 4 In what way can social psychological theory inform participatory action research for understanding and enhancing health?

K Chamberlain, M Murray

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