Psychosocial Dimensions of Medicine

By DoctorZed Publishing

This book begins by introducing us to patients in two general-practice waiting rooms. In an Australian general practice seven patients are waiting to see doctors. In a New Zealand general-practice waiting room are two patients. The healthcare needs of each patient are outlined.

Of these patients and their circumstances, the editors and specialist chapter-authors ask a series of questions. What is life like for each? How might social role, economic status, and quality of social support impact on their lived experience of illness and injury? To what extent might psychosocial variables impact on the biomedical outcome of each? How might biomedical problems impact on psychosocial variables? What might be the emotional experience of each, their perception of stress, likely resilience, and potential for achieving quality of life despite their current medical circumstances? What factors might change their emotional experience? What will influence their psychological coping? What might be the cultural and spiritual resources or needs of each? How might health practitioners and the health system more generally respond to their biopsychosocial, cultural, and spiritual needs? To what extent, and how, could presenting problems have been prevented? How can positive attitudes to health and living be promoted?

To encourage health professionals to view a patient in his or her broad context, as a person, and as a person in a family, a cultural group, and in a society, with advantages to patient and clinician, Jennifer Fitzgerald and Gerard J Byrne have brought together experts in medicine, psychology, social work, pastoral theology, and social science. Following a section in which the conceptual foundations of a biopsychosocial approach to healthcare are outlined, chapters on individual differences and developmental processes, relationships, the social determinants of health, existential and ethical issues, and prevention and promotion are offered. In each chapter, to illustrate and personalise key points, authors refer to the patients in the waiting rooms.

• Language: English
• Publisher: DoctorZed Publishing
• Release date: Dec 1, 2015
• ISBN: 9780992518196

Book preview

Queensland.

Introduction:

In the general practitioners’ waiting rooms

Jennifer Fitzgerald

This consideration of psychosocial dimensions in medicine begins in two general practice waiting rooms. In an Australian general practice there are seven patients, some with accompanying persons, waiting to see the doctors. From the viewpoint of the reception desk, we can see:

•Sandra Jones with her two-months-old son, Ethan Jones, for routine immunisation. The baby is crying with hunger and Sandra looks concerned.

•Doug Johnson, an Indigenous male of 54 years, has diabetes mellitus. He has retinal disease and peripheral neuropathy. Doug looks bored.

•Ellen Butterworth, a 90-year-old female who lives alone, needs a script for her antihypertensive medication. Ellen looks happy and is talking to the neighbour who drove her to the clinic.

•Dan Bartlett is 64 years old, with emphysema. He smoked for forty years. Dan sits in a wheelchair with an oxygen cylinder strapped behind him. His wife died three months ago. His daughter-in-law Sue and her two small children accompany him. Dan looks downcast and sad; Sue looks harassed.

•Fatima Mahsoud is 44 years old, and recently released from an immigration detention centre. A translator from a local agency run by the Catholic Church accompanies her. Fatima suffers from depression and PTSD. She looks ‘blank’ and feels ‘numb’.

•Alice Yarrow, 49 years old, divorced mother of three teenagers, is returning for results of blood tests. She has recently been told she has metastases from her breast cancer, which was originally diagnosed and treated two years ago. Alice is alone and looks anxious.

•John Nguyen is 16 years old and attending for a review of a head injury, sustained last week in a car accident in which he was a passenger. The driver and John were both intoxicated at the time. John looks sullen as his mother talks sternly to him.

In a New Zealand GP’s waiting room we find two particular patients, each waiting alone. They are:

•Grant, a 41-year-old homeless Māori living on the streets of central Auckland. He is disconnected from his family and has a number of physical and mental ailments. Grant is feeling particularly depressed right now and is thinking about suicide. He recognises that his health is deteriorating, he is losing his teeth, and he has ulcers from excessive alcohol consumption. Grant looks despondent as he talks to the practice nurse.

•Rawiri Johnson is a 60-year-old Māori who has diabetes, obesity, fatty liver disease, and depression. He has a long history of addiction problems, and is divorced and living with his widowed sister. Rawiri’s face breaks into a smile when Hinemoa, the Māori health worker, calls his name.

SOME QUESTIONS FOR CONSIDERATION

What is life like for each of these people? How might their gender, social role, economic status, and quality of social support impact on the lived experience of illness and injury for each of them? What might the lived experience of these nine individuals be like if, with the same presenting medical need or problem, their economic status, educational attainment, and social support were radically different? For example, what would it be like for Ellen if she had no support from her neighbours? How might that be relevant to her treating doctor? What might it be like for Alice and for her doctor if a supportive husband accompanied her on her visits to the doctor and hospital, and if her children were grown up and independent? What if Dan’s wife were still alive, or if Doug were well educated and wealthy? Alternatively, what might happen to each of these people if any of them were to become homeless like Grant? To what extent might all these psychosocial variables impact on the biomedical outcome of each of these persons? How might the biomedical problems impact on the many psychosocial variables of all these patients?

Further, we might wonder about the emotional experience of each of these people, along with their perception of stress, likely resilience, and potential for achieving quality of life despite their current medical circumstances. What factors might change the emotional experience of each? What factors will influence psychological coping in those who are seriously ill or disabled? What psychosocial factors, past or present, might assist each of these patients to be resilient despite their current stage of life and circumstances? Thinking holistically, we might wonder also about the cultural and spiritual resources or needs of each of these patients. What meaning or benefit might some or all of these people find in their circumstances? To what extent are cultural issues impacting on the health of each of these people?

We might also consider how health practitioners and the health system more generally could or should respond to the biopsychosocial, cultural, and spiritual needs of all these people. What skills might the general practitioner need to provide quality care that extends beyond the biomedical needs of these patients? Who might the general practitioner need to call on to provide additional care? What is it like for the doctors themselves with practices in differing social classes of Australia or New Zealand? What is it like for the doctors and other staff in the Auckland clinic offering care to homeless people? What particular rewards and costs might be there for them?

While examining the potential relevance of the various psychosocial issues raised above, two further, associated questions must also be asked. To what extent (and how) could many of these presenting problems have been prevented? And, how can positive attitudes to health and living be promoted?

INTRODUCING THIS BOOK

This book, like Engel’s biopsychosocial model of care (Engel, 1977; see also Chapter 1), aims to ‘broaden the scope of the clinician’s gaze’ (Borrell-Carrió et al., 2004, p. 581). To address this goal we have brought together contributions from a range of experts in medicine, psychology, social work, pastoral theology, and social science, who provide an informative resource to challenge us as health professionals to view our patients in a broader context. Based on the evidence provided above, it is expected that such an expansion in understanding and knowledge of the patient as a person, and as a person in family, cultural group, and society, will lead to improved quality of healthcare. We aim also to extend readers’ understanding of the psychosocial determinants of disease, thereby potentially improving future efforts for health promotion and disease prevention.

With these goals in mind, our invited authors have addressed a wide range of topics. There are six sections in the book. In Section 1, Beyond a biomedical conceptualisation of care, consideration will be given to the patient in psychosocial context, the concept of quality of life, and the patient’s lived experience of illness or disability. Section 2 considers the patient as a person and looks at individual differences and developmental processes. These include coping with the stress of illness and disability, development across the lifespan, personality, emotion, and learning processes.

Section 3 shifts the focus from individual to social considerations. These chapters examine the importance of close relationships and social support for health and wellbeing, as well as the influence of parents and families on the developing child. This section also considers sexuality. In Section 4, some of the social determinants of health, namely race and economic status, are considered. To do this, authors have examined health inequities, focusing on

Indigenous Australians, social and emotional wellbeing of Indigenous Australians, psychosocial factors in healthcare for Māori communities, and homelessness in Māori communities.

In Section 5, existential and ethical issues are considered. These chapters look at death and spiritual aspects of care, and include a theologian’s reflection on his own experience of life-threatening illness. Medical ethicists reflect on the practicalities of ethical care and decision-making. The text concludes in Section 6, with a focus on the future; namely, prevention of alcohol and drug problems for children and adolescents and the promotion of mental health.

Throughout the book, our authors will comment on a range of psychosocial dimensions to consider in the care of the nine patients sitting in doctors’ waiting rooms. Through these clinical comments it is envisaged that readers will be enabled to integrate understanding of the patient as a person, and the person as a part of a wider social system. Thus, the intention is to apply theory and research to clinical practice, and to demonstrate the advantages to patient and clinician of a biopsychosocial model of care.

REFERENCES

Borrell-Carrió, F., Suchman, F., & Epstein, R. (2004). The biopsychosocial model 25 years later: principles, practice, and scientific inquiry. Annals of Family Medicine, 2, 576–582. doi: 10.1370/afm.245.

Engel, G. (1977). The need for a new medical model: a challenge for biomedicine. Science, 196, 129–136.

Section 1

Beyond a biomedical conceptualisation of care

Chapter 1

Beyond the biomedical

Jennifer Fitzgerald

A BIOPSYCHOSOCIAL MODEL OF CARE

Three decades ago a North American professor of psychiatry, George Engel, proposed the need for a new medical model. He challenged biomedicine of the time by arguing ‘A biopsychosocial model … would acknowledge the fundamental fact that the patient comes to the physician because either he does not know what is wrong or, if he does, he feels incapable of helping himself. The psychobiological unity of man requires that the physician accept the responsibility to evaluate whatever problems the patient presents and recommend a course of action, including referral to other helping professions’ (Engel, 1977, p. 133). Others later expanded this model to include consideration of ethnicity and culture (Kaplan, 1990; Matarazzo, 1980), and spirituality (Sulmasy, 2002).

From a biopsychosocial (BPS) viewpoint, a person’s health is influenced by both external and internal factors, such as poverty, availability of support structures, access to healthcare, legislation that affects health and exposure to pathogens (external factors), as well as ethnicity, genetic makeup, learned behaviours, developmental processes, and previous experience of illness (internal factors). All of these factors then impact on other factors such as lifestyle choices, personality, mood, the perception of symptoms, behaviour, and adherence to treatment. All in turn influence, and will be influenced by, physiological processes (Ayers & de Visser, 2011). In short, according to a BPS model, the disease affects the person, and the person affects the experience of and recovery from the disease.

Evidence for a biopsychosocial model

Before examining a sample of the extensive evidence for the benefits of assessing and addressing psychosocial factors in healthcare, it is important to note that some earlier research linking psychosocial variables with aetiology of disease has been flawed. Perhaps one of the most striking examples may be found in the area of peptic ulcer. For decades, personality factors and stress were propounded as risk factors for peptic ulcer, until Helicobacter pylori was identified as the causative agent in 1983 (Davey Smith, 2005). Growing up in a large family with poor facilities for hygiene is a social factor that leads to risk of H. pylori infection, but if the infection is treated the link between poor social circumstances and peptic ulcer weakens. As Davey Smith (2005) cautions, all researchers need to be aware of methodological issues related to confounding and bias.

Behaviours associated with poorer health outcomes, such as smoking, excessive alcohol consumption, poor diet, physical inactivity, risky sexual practices, and lack of adherence to treatment, may all be influenced by psychosocial factors including, for example, depression, job stress, and lack of social support (Steptoe, 2000). Despite the importance of behavioural change for many health outcomes, after controlling for health behaviours, associations may still exist between psychosocial factors and disease for some individuals, suggesting that behaviour change alone may not be telling the whole story. Psychophysiological processes have also been described as impacting aetiology and prognosis in medical disorders through three possible pathways: as cause, as inhibiting host response, and as disease modulator (Steptoe, 2005).

In terms of psychophysiology as cause, it is argued that some individuals are more responsive or more exposed to stimuli that provoke biological responses. Hence, when biological and genetic predispositions are present, over time, the development of disease is accelerated (Weiner, 1992). Longitudinal studies in patients with hypertension (Light et al., 1999) and atherosclerosis (Everson et al., 1997), for example, have reported that patients identified as ‘high stress responders’, when exposed to high job demands, were at increased risk for developing hypertension or atherosclerosis. In both these studies, disease progression was not associated with either high stress reactivity or high job demands in isolation.

Depression, chronic stress, and other psychosocial variables are associated with downregulation of the immune system (Kiecolt-Glaser et al., 2002), which explains inhibition of host response as a psychophysiological factor in aetiology of disease. Kiecolt-Glaser and colleagues propose that resources such as close personal relationships that diminish negative emotions enhance health in part through their positive impact on immune and endocrine regulation. Close relationships, however, also carry responsibilities and potential stress. Caregivers with long-term stress from caring for a relative with progressive dementia have been found to have impaired immune response to vaccines (Kiecolt-Glaser et al., 1996). Further, psychosocial variables may also function as disease modulators, as found in the links between acute cardiac events and sudden outbursts of anger (Mittleman et al., 1995), stress associated with watching World Cup soccer matches (Wilbert-Lampen et al., 2008), depression (Rugulies, 2002), and anxiety sensitivity (Frasure-Smith et al., 2012).

By way of underscoring the links between biological and psychosocial aspects of health, key psychosocial variables and a selection of evidence for psychological interventions in cardiology and oncology are briefly reviewed.

PSYCHOLOGICAL INTERVENTIONS FOR IMPROVED HEALTH

Cardiovascular disease

Yusuf and colleagues (2004) reported convincing evidence for psychosocial variables as risk factors for coronary artery disease. The INTERHEART case-control study, conducted across 52 countries, assessed eight coronary risk factors (such as smoking, hypertension, obesity) and a composite index of psychosocial factors in 12 461 acute post myocardial infarction (MI) patients with 14 637 matched controls. The psychosocial index was created from brief assessments of depression, locus of control, perceived stress at home or at work, moderate or severe financial stress, and experience of adverse life events. This psychosocial index was found to be a robust predictor of risk for acute MI, comparable to the other major risk factors; further, this finding was independent of ethnicity or geographic context.

Rozanski and colleagues (2005) proposed that psychosocial factors promoting atherosclerosis and adverse cardiac events can be categorised into emotional factors (such as depression, anxiety, and hostility) and chronic stressors (such as low social support, low socioeconomic status, work stress, marital stress, and caregiver strain). Three points are of particular note here. First, the positive relationship between depression and adverse cardiac events has been reported even at mild levels of depressive symptoms (Lespérance et al., 2002). Second, the inverse relationship between the magnitude of social support and adverse clinical outcomes has been reported among both healthy subjects and those with coronary artery disease (Rozanski, Blumenthal & Kaplan, 1999). Third, emotional factors and chronic stressors often cluster together, with Rozanski and colleagues (2005) noting that any life situation that has the capacity to evoke negative emotional reactions may also promote heart disease. For example, Batten and colleagues (2004) reported that childhood maltreatment in females was a risk factor for both depression and cardiovascular disease in adulthood.

In terms of prevention, psychological and behavioural interventions are efficacious in reducing risk for cardiovascular disease, such as reduction in tobacco use, excessive alcohol consumption, inactivity, and depression (Anderson et al., 2003).

For patients with existing disease, a Cochrane Review (Barth et al., 2009) investigated the efficacy of smoking cessation interventions for patients with coronary heart disease (CHD). They reported that programs typically involved behavioural therapeutic approaches, telephone support, or self-help material. While there was heterogeneity among the 16 trials, and most patients were male, the authors nevertheless concluded that smoking cessation programs are effective in helping CHD patients to stop smoking if the program is delivered for more than one month.

The value of interventions to assist patients with CHD to increase physical activity is also clear. Joliffe et al. (2000) reviewed studies involving 7683 patients and demonstrated that the addition of exercise to existing cardiac care interventions reduced mortality by 27%. Also, Rees, Taylor, and colleagues (2004) established that over 1000 patients with mild to moderate heart failure randomised to intervention improved both exercise capacity and quality of life.

Other reviews of psychosocial interventions in cardiac rehabilitation point to the need for caution in making claims about the impact of all psychosocially oriented interventions on clinical outcomes. Importantly, Rees, Bennett, and colleagues (2004) examined 36 trials involving 12 841 patients with cardiac disease, and concluded that stress management and advice on risk factors did not show evidence for effect on total or cardiac mortality, although they did show small reductions in anxiety and depression for patients with chronic heart disease. These results may indicate that giving advice or brief education is only beneficial when it translates into change in health beliefs and behaviours for each patient.

Interestingly, more recent research (Furze, 2010) suggested that increasing exercise alone is not enough rehabilitation for patients with stable angina. Furze drew attention to the finding that common misconceptions (maladaptive beliefs) about living with angina are stronger predictors of future physical and psychological functioning than is the severity of the underlying condition. Following a review of 13 randomised controlled trials aiming to change maladaptive illness beliefs in patients with CHD (Goulding et al., 2010), Furze recommended that cardiac rehabilitation needs to include a cognitive behavioural component that helps patients dispel unhelpful beliefs about their illness.

Most recently, Oldridge (2012) reported a review of cardiac rehabilitation meta-analyses published since 2000, involving 71 clinical trials and 13824 patients. As expected, results clearly supported that cardiac rehabilitation (either exercise training alone or exercise training in addition to psychosocial, risk factor management, and/or education) was useful and effective. The author notes that generalisation of findings from these trials is limited to the extent that elderly patients, females, minority ethnic groups, patients from low socioeconomic groups, and patients with comorbidities have not been well represented in the studies reviewed. Unfortunately also, the review does not clarify more specific issues pertaining to the content of the rehabilitation, as raised for example by Furze; this suggests that research in the future will be needed to refine the essential content of cardiac rehabilitation programs and to identify the types of patients who will most benefit from such interventions. (See Rozanski et al. 2005, for recommendations for future directions in behavioural cardiology.)

Cancer

In terms of incidence and survival from cancer, associations have been found between psychosocial variables and health outcomes. For example, Chida and colleagues (2008) reviewed 165 studies examining the contribution of psychosocial variables to cancer incidence and survival, and reported that factors such as stressful life experiences, poor coping styles, and depression are associated with greater cancer incidence and poorer prognosis and survival.

While survival is of course a critically important topic in oncology, a growing body of research has also examined patient-reported outcomes, such as health-related quality of life, because of recognition that patient survival alone is not a sufficient indicator of patient outcome (Babin et al., 2008). In one study with patients with cancers of the head and neck, almost a quarter of patients ranked outcomes other than cure (such as pain, normal functioning, appearance, energy) as their highest priority (List et al., 2000). Psychological distress in response to cancer diagnosis and treatment varies, for a range of psychosocial reasons, as well as according to site and stage of disease. Greatest levels of psychological distress are found in patients with advanced disease in sites such as lung, brain, and pancreas that typically do not respond well to treatment (Schneiderman et al., 2010). These patients, in particular, need more research attention to improve our intervention responses to their intense distress.

The benefits, albeit modest, of psychological support for patients with cancer were evident in a meta-analysis of 45 randomised controlled trials, which found, on average, an improvement of 12% in measures of emotional adjustment, 10% in social functioning, 14% in treatment and disease-related symptoms, and 14% in overall improvement in quality of life compared with those not receiving psychological therapies (Meyer & Mark, 1995). Another meta-analysis of 116 interventions with cancer patients reported that patients receiving psycho-educational or psychosocial interventions had much lower rates of anxiety, depression, nausea, vomiting, and pain, and significantly greater knowledge about disease and treatment, than the control group (Devine & Westlake, 1995). These results underscore the value of working with psychosocial dimensions in cancer patients to promote physical and emotional comfort, improved mental health, and overall quality of life.

Research in the years since the early reviews of psychosocial interventions with cancer patients have examined some of the mechanisms by which such interventions achieved results, such as mediators and moderators of change. Stanton, Luecken, MacKinnon, and Thompson (2012) reviewed 16 randomised controlled trials that evaluated mediators of change for cancer patients (that is, the factors that changed in response to the intervention). Results suggested that alterations in cognitions (e.g. expectancies, illness beliefs), self-efficacy for using coping strategies, psychological and physical symptoms related to cancer (such as mood disturbance and pain), and psychosocial resources (such as self-esteem) mediated intervention outcomes.

Tamagawa and colleagues (2012) conducted a systematic review of psychological moderators of psychosocial interventions in oncology. (A moderating variable has a contributory or contingent effect on the relationship between independent and dependent variables.) Patient characteristics at baseline were analysed and results identified 14 moderators which impacted outcomes (according to scores being high or low) that were grouped into personality traits, mental and physical quality of life, social environment, and self-efficacy. Patients with poorer quality of life, interpersonal relationships, and sense of control benefited more from interventions than patients who already had adequate resources. Taken together, these important reviews can guide future intervention efforts, in order to improve intervention efforts and manage costs efficiently.

Before concluding this very brief review of psychosocial factors and interventions in oncology care, it is important to note the likely interrelationships between psychosocial factors and health behaviour change in cancer survivors as reported by Park and Gaffey (2007). These authors note that social support, control-related constructs, and psychological distress have received most research attention, but conclude that health behaviour change may be predicted by a complex interrelationship among these and other factors. They recommend that more complex models of the interplay among cognition, emotion, and behaviour need to be tested in future research.

IMPLICATIONS FOR CLINICAL PRACTICE

Typically, multiple interacting causes and contributing factors are involved in any one patient’s case conceptualisation. While it may not be necessary, or indeed time efficient, to interview every patient from an exhaustive biopsychosocial list of considerations, a biopsychosocial approach will nevertheless provide a useful framework for dealing with the complexity of the ‘messy, fuzzy, unique and context-embedded problems’ (Fraser & Greenhalgh, 2001, p. 801) of the real world of medicine and healthcare. A general practitioner, in particular, is ideally placed to build up a psychosocial picture of each patient as a mosaic over time, rather than formally interviewing every patient from a checklist at their first consultation. Biopsychosocially oriented clinical practice (Borrell-Carrió et al., 2004) includes a philosophy of understanding suffering and disease in the context of multiple levels of organisation, and provides a way of understanding the patient’s experience as an essential aspect of accurate diagnosis, good health outcomes, and compassionate care.

Such an approach to care places demands on the clinician, but offers potential rewards as well. For example, Borrell-Carrió and colleagues (2004) recommend that clinicians need to be caring, trustworthy, and open, have an understanding of their own needs so that they don’t project their needs onto their patients, and have an understanding of their tendency to be biased against certain patients (e.g. on the basis of race or sex). They recommend that clinicians reflect with empathic curiosity: ‘What would it be like to be this patient, living with this disease/loss/disability/pain?’ From such an approach, there are no ‘good’ or ‘bad’ patients, only challenges to understand more about the particular patient and the discomfort that certain patients can trigger in particular clinicians. Working from this position of empathic curiosity can ease much of the tension experienced by doctors who become enmeshed in adversarial relationships with ‘difficult’ patients. Benefits for the doctor typically include warmer interactions with patients, satisfaction from witnessing better adherence of patients to treatment regimes and thus better outcomes, less risk of litigation, and loyalty from patients that often spans many decades.

Health professionals can influence their patients’ ways of thinking and feeling about their illnesses and also their treatment. Stewart (1984), for example, reported that when physicians engaged in more patient-centred interactions (e.g. eliciting patients’ thoughts and concerns), their patients adhered more carefully to a medication regime. This is an encouraging finding and is consistent with an extensive body of research documenting the benefits of building an empathic, collaborative relationship with patients in order to facilitate behavioural change (Steindl & Connor, 2010).

However, it needs to be noted that clinical skill development in isolation does not automatically alter the outcomes for patients. For example, cancer patients with a large number of concerns that are not addressed by their health professionals are at risk of developing anxiety and depression (Parle et al., 1996). In response to this finding, Maguire (2002) demonstrated that hospice nurses could be trained to improve their interviewing skills by facilitating patients’ talk and discussion of concerns. Despite a demonstrated increase in open-ended and psychologically focused questions, which elicited more expressed concerns from patients, the nurses were also found to engage in more blocking behaviours (such as focusing on physical symptoms, premature reassurance, and normalisation) that closed off exploration or discussion of painful emotions and deep concerns. It is likely that fear of our own fears and concerns can be a barrier to eliciting or working with patients’ fears and concerns (Creed, 2005). Maguire’s important study highlights the need for clinicians to be mindful, to engage in self-reflection, and to have educational preparation for ‘worst-case scenario’ comments, in order to develop a sense of self-efficacy and readiness to respond to what ever the patient may express.

REDUCING HEALTH PROBLEMS AND BURDEN OF DISEASE

The leading underlying causes of death in Australia in 2010 reported by the Australian Bureau of Statistics (2013) were malignant cancers (29.5%), ischaemic heart disease (15.1%), cerebrovascular diseases (7.8%), dementia and Alzheimer’s disease (6.3%), chronic lower respiratory diseases (4.3%), and diabetes (2.7%). Further, Begg and colleagues (2007) report on the burden of disease (this includes mortality and disability summarised as disability-adjusted life years; DALYs). Cancer and cardiovascular disease were the leading causes of the burden of disease and injury in Australia in 2003, with 80% of that burden being from premature deaths. The amount of burden that was attributable to current and past exposures to risks to health was considered in terms of lifestyle factors, physiological states, and social and environmental factors. Tobacco was responsible for the greatest burden in Australia (7.8% of total burden), followed by high blood pressure (7.6%), high body mass (7.5%), physical inactivity (6.6%), and high blood cholesterol (6.2%).

These troubling statistics provide food for thought. Is a solely biomedical approach to care likely to be adequate to prevent and address these leading causes of disability and death? Given that tobacco use, obesity, excessive alcohol consumption, lack of exercise, lack of social support, or lack of adherence to relevant medical treatment contributes directly to the leading causes of death, and that all of these variables are amenable to psychosocial intervention, it is expected that skill in working with psychosocial variables will not only be helpful, but crucial, in future health prevention and intervention efforts.

Self-reflection

•What understanding, attitudes, and skills do I need to facilitate optimum self-management and behaviour change in patients such as those in our waiting rooms?

•What fears and concerns of my own do I need to address in order to be open and accepting of these patients’ expression of their fears and concerns?

•What particular types of patients elicit discomfort in me? What can I learn about myself in response to these patients?

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Chapter 2

The patient in psychosocial context: person-centred versus family-centred care

Gerard Byrne

INTRODUCTION

In this chapter, we examine person-centred care and family-centred care from several overlapping perspectives. In so doing, we hope to convey that these are not new concepts and that these types of care have been intuitively practised by better clinicians and healthcare providers for a long time. We also tackle several more controversial aspects of person-centred and family-centred care in the hope of challenging the reader to consider these issues for herself or himself.

Background

Providing care to the sick requires a judicious combination of biomedical science and clinical art, with each component titrated to the needs of the patient. In recent decades, we have seen the rise of evidence-based medicine as a corrective against the cult of medical individualism (Fothergill, 1919) and the potentially dangerous maverick physician. This evidence-based medicine has arisen largely out of the discipline of clinical epidemiology (Sackett et al., 1996), which embodies a quantitative approach to population-level health data, and has been assisted by the rise of the randomised controlled clinical trial. There has also been a vogue for simple, protocol-driven, interventions, which have improved outcomes for surgical patients (Gawande, 2009). These have arisen out of pilots’ checklists that have made commercial aviation much safer than it used to be.

The application of epidemiological data and the findings from clinical trials to individual patients is not straightforward. Epidemiological data are often distorted by residual confounding, leading to spurious findings that are subsequently overturned. In contrast, clinical trials are generally conducted on highly selected groups of patients in order to limit confounding. For example, clinical trials of new antidepressants are often conducted in people with major depression who are aged 18–64 years, without comorbid substance use or significant general medical problems, and who are not pregnant or breastfeeding. As a consequence, it is often difficult to generalise the findings from such clinical trials to adolescents, older people, physically ill people, and many women. Thus, both epidemiological data and clinical trial data have their limitations when the physician or other health worker attempts to assist an individual patient.

Fortunately, the clinician, particularly the general practitioner (GP; primary care physician) is often in a good position to contextualise treatment options for an individual patient with specific and sometimes unique needs. This is particularly so if the clinician has known