Assignment Topic: Concept of motivation in health psychology

Assignment Question:

Explore chronic pain from a psychological perspective in relation to rheumatoid disorder. A health issue of your choice (IE HIV/AIDS, Rheumatoid Disorders, Smoking Cessation)

1.    To clearly demonstrate how psychological theory can be applied to issues affecting health.

2.    To discuss the wider psycho-social impacts on health.

3.    To examine health strategies aimed at addressing the chosen health topic in relation to psychological well being.

Assignment Solution:

Under the umbrella of health psychology one can understand lifestyle as combination of actions and decisions that establish wellbeing and value of life. According to National Vital Statistics Report (1998) the current primary reasons of death (like heart disease, cancer, diabetes etc) are attributable to characteristics that make up each person’s lifestyle. Thus, a majority of the conditions that constitute the leading causes of death can be prevented if people would eat nutritious foods, reduce their alcohol intake, practice safe sex, eliminate smoking and exercise regularly. Thus various psychological theories/concepts can be applied to understanding issues effecting health.

One of such concept/theories is that of motivation. These above mentioned lifestyle changes can only be possible if the individual is motivated to make efforts towards this change. Intrinsic processes that stimulate, direct and sustain behaviors can be referred to as motivation. Maslow explained motivation in terms of needs an individual experiences across lifespan. He arranged these needs in a hierarchy and stated that individual moves up the ladder only when lower level needs are satisfied. The lowest in the hierarchy is physiological needs, then safety needs and above these social needs. These together were referred to as deficiency needs. Above these are two growth needs: esteem needs and self-actualization needs.

Attribution by the individual determines the motivation. Attribution style of the individual provides the basis for individuals to change. Attribution style is made up of three components: locus of control (internal versus external), stability (stable versus variable), and globality (global versus specific). The locus of control view was conceptualized by Rotter. Pessimistic set is one where an individual consistently attribute negative events to internal, stable, and global dimensions.

The second is the optimistic explanatory style where individuals attribute negative events to external, variable and specific factors (‘in this particular event things are not in my favor’). This type of attribution style helps to protect individual against stressors and health problems.  Optimistic people make self serving attributions by concluding that negative events are due to internal, stable and global issues. This particular attribution style is related to well being and people having this style is low on health problems.  This could be due to the fact that people with this particular style take responsibility of their lives and are motivated towards change for wellbeing. (Kamen-Siegel, Rodin, Seligman, and Dwyer, 1991).

Further support for this has been provided by Self-Determination theory (Deci & Ryan, 1985).  The theory suggests that motivation for health-promoting behaviors is highest when it is self-directed and lowest when these behaviors are prompted by others. It predicts that autonomously motivated weight loss will be maintained over time, whereas long term maintenance of weight loss achieved at the urging of others is less likely (William, 1996).

Another psychological theory directly related to health is that of stress. Lazarus (1991) explained that stress is a condition when an individual appraises that the demands from the environment exceed his/her resources to deal with them. This situation is seen as threatening and fight-flight reactions occur. One makes appraisals by understanding the demands from the environment and coping resources available to the individual. These appraisals are bound to change and differ in situations due to available coping resources, change in environmental demands and increase in individual’s abilities. As per cognitive-relational theory these appraisals are continuous as one keeps on interacting with the environments and facing various challenging situations. According to Lazarus (1991) there are two kinds of appraisals an individual makes. These are primary and secondary processes or appraisals. Primary appraisal refers to the stakes a person has in a certain encounter. In this case the individual understands and decides if the situation is stressful or not. These are followed by secondary appraisal processes where one decides whether one has resources to deal with stressors or not. If appraisal says that resources are less than one sees the situation as stressful. It involves looking at ones expertise, support from environment etc to see if these resources are enough to restore the balance between person and environment.

The physiological effects of long term stressors areas had been highlighted by Selye (1976) in the General Adaptation Syndrome Model. As soon as there is a trigger from the environment there is activation of sympathetic nervous system where certain hormones are released and body is prepared for action. This is the alarm stage. If stress is continues then an individual moves to the second stage i.e. the resistance stage. Here the activation in the body is lesser than the alarm stage but there is excessive utilization of the body resources to resolve the stressors. Finally, if the balance is still not restored than the individual moves to exhaustion stage that drains out the resources fully. Here the well being is hampered and individual is likely to develop illness.

Another concept that can help explain consequences on health is nature-nurture factors. This approach highlights that a genetic predisposition combined by stressful and unhealthy life situations can explain many illnesses. A body of research showing that obesity tends to run in families spurred the search for the genetic basis of obesity. For example, familial studies consistently have shown that BMI is highly correlated among first-degree relatives (Bouchard, Perusse, Leblanc, Tremblay, & Theriault, 1988), and investigations of identical twins reared apart have suggested that the genetic contribution to BMI may be as high as 70% (Stunkard, Harris, Pedersen, & McClearn, 1990). In addition, researchers also believe that body-fat distribution, resting metabolic rate, and weight gain in response to over consumption are each controlled by genetic factors that may interact to predispose certain individuals to obesity (Chagnon et al., 2000). The influence of environmental factors is equally important. This can be seen in a comparison of groups that share the same genetic heritage but live in environments that support very different lifestyles. For example, research by Krosnick (2000) explained that the Pima Indians of Arizona live in a modern environment in US and suffer from high rates of obesity in the racial group. On the other hand the people of the same ethnic group living in rural Mexico don’t face this problem of obesity in their group. Thus, even if there genetics are same the lifestyle factors have made the difference in the prevalence rates of obesity. Ravussin, Valencia, Esparza, Bennett, & Schultz, (1994) found that Pimas in US ate food that had high fat content but indulges in less physical activity. One can conclude that even if there is a genetic predisposition, the kind of food we take and physical activities we indulge can make vast difference.

Health is many a times determined by presence or absence disease. Suffering is an integral part of the disease and to conquer disease one must reduce suffering. Schneider (2006) highlighted that while addressing issues in life threatening diseases one should look at psycho-social aspects and also offer spiritual support. Now days, a systematic evaluation of symptoms is done. Most of the patients are treated at home. Only some with acute symptoms are hospitalized. Not only the patient but family members and caregivers are also deeply affected. Thus, palliative care would include help from various professionals covering all dimensions of suffering. Suffering can be physical (pain) and psychological (depression, anxiety). It could also raise spiritual questions like “why am I suffering”? It could also lead to financial burden and change relationship roles. The treatment for therapy can prolong the illness but ultimately death has to be faced. At this time, care and comfort are crucial. Grief starts even before the actual death. This is called anticipatory grief. Quinn (2005) explained that as the end approaches, physical pain needs to be managed; efforts to comfort the patient are required, psychological and spiritual questions needs to be addressed.

Firstly, one needs to address the psychological disturbances that may arise. Over the past 20 years, intense concentration has been given to the psychiatric aspects of co-morbid disorders and psychosocial problems of life threatening diseases (Lichtenthal et.al., 2009). For example, psycho-oncology addresses the two major psychiatric and psychological dimensions of cancer. The first is the psychiatric comorbid disorders and psychological responses of patients at all stages of illness and their families and, the psychological stresses on health professionals delivering their care. Second are the psychological, behavioral, and social factors that influence cancer risk, detection, and survival.

Faulkener & Maguire (1994, c.f. Lester, 2005) have suggested that psychosocial adjustment to life threatening diseases is associated with six obstacles: managing uncertainty about future, searching for meaning, dealing with loss of control, having a need for openness, needs for emotional support and needs for medical support. They suggest that a failure to deal with these results in psychosocial problems. Episodes of extreme sadness and anxiety combined with symptoms of depression are experienced by many patients with serious physical illnesses. It is not necessary that these symptoms will be persistent till the end. All patients with life threatening illness might not develop feelings of misery, hopelessness and helplessness.

Another important task is the discussion the need and promotion of social support. Firstly, the role is to facilitate changes within patient’s environment. Diminished support may relate to individual to individual family members feeling threatened as a result of cancer diagnosis and/or having developed psychological problems that require intervention in their own right (Buss et. al, 2007). Friends and relatives may avoid patterns, resulting in less social support being available. When relatives are uncertain about how best to help the patient, therapists can arrange to provide advice on practical cognitive behavioral management strategies and how to overcome some of the obstacles to providing social support. Significant others may need help to evaluate beliefs about the consequences of expressing negative emotion (‘if I talk to her about her cancer then I will make things worse’). The management of communication problems which have been triggered by the illness is much easier than scenarios in which communication problems are long standing feature of the patient’s life and disease is just another example of how it can become manifest.

Grief refers to the subjective emotions and affect that are a normal response to the experience of

loss. Grieving, also known as bereavement refers to the process by which a person experiences the grief. It involves not only the content (what a person thinks, says, and feels) but also the process (how a person thinks, says, and feels). All people grieve when they experience life’s changes and losses. Often, grieving is one of the most difficult and challenging processes of human existence; rarely is it comfortable or pleasant. Anticipatory grieving occurs when people facing an pending loss begin to struggle with the very real possibility of the loss or death in the near future (Holland et.al., 2009). Mourning is the outward expression of grief. Rituals of mourning include having a wake, holding religious ceremonies, and arranging funerals.

Anticipatory grief is a term that is most associated with terminal illness with a prognosis of impending death within a stated time. Heart disease, arthritis, and cancer are some of the conditions where such losses are involved. Many of these losses could be more satisfactorily resolved if time was spent understanding what has already changed and anticipating what is going to be lost. One error is to assume that because a person is terminally ill, anticipatory grief is present. Many patients and families continue to deny the impending death or to hope that recovery might yet be possible. These believe needs to be challenged.

The above discussion points to the understanding that life threatening illness can have a broader psycho-social impact on health. Now we will be looking at AIDS and psychological strategies to manage one of its core symptom i.e. pain.

Despite recent advances in treatment options, pain related to HIV/AIDS remains a challenging job. Lebovits, Lefkowitz, McCarthy et al. (1989) found that a sizeable clinical challenge in HIV/AIDS is pain related which is further associated with psychological distress, negative impact on health-related quality of life, and greater impairment of functional ability.  Depending on the demographic characteristics, methodology and management set-up 25 to 80% complaint of pain as significant symptom (review by Douaihy et.al. 2007). Due to such a severe experience of pain there is a negative effect on daily functioning and overall quality of life. Study by Frich  & Borgbjerg (2000) found that pain typically interfered with activities of daily living and quality of life issues, such as general activity level, walking, working, ability to interact with others, sleeping, and overall enjoyment of life. Also, psychiatric conditions, such as depression and anxiety are usually exacerbated by pain. Despite its wide impact pain often remains undiagnosed or under diagnosed.  Therefore, with the fluctuating nature of HIV disease pain assessment needs to be continuous. One needs to identify nature of pain, duration, alleviating and aggravating factors to plan further management. For assessment of pain variety of comprehensive and reliable assessment scales are readily available.

Another important aspect in managing HIV/AIDS is recognizing and treating comorbid psychiatric disorders. This is also important in managing patients with chronic pain as these psychiatric disorders are associated with poor compliance, poor psycho-social functioning and high mortality (Larue, Brasseur & Musseault, 1994).

Subjective experience of pain is influenced by emotionality, thus pathological anxiety can effect perception of illness burden in a person with chronic pain. Smith et. al. (2002) found that experience of pain intensity and its functional impact is predicted by PTSD.

Pain in HIV/AIDS can be seen as chronic due to reasons life changing epidemiology, increase in life span of people with HIV/AIDS due to advances in medical sciences, limitations in functioning, psychological distress that are all engulfed in various psychosocial issues.  In any kind of illness when pain is understood as chronic, the management has to be ongoing. In cases where pain is a multidimensional experience requiring long term management, one can apply chronic pain models for assessment and treatment. To understand the intertwined biological, psychosocial and interpersonal dimensions management can be based on biopsychosocial framework. Therefore, multiple goals and strategies are to be build in treatment of HIV/AIDS. For providing all round care including medical, psychological and social management a multidisciplinary team is required. For successful treatment combined efforts for pain symptoms are required to meet short and long term goals.

Most of the patients come to seek medical attention for pain at primary care centers. Thus, a key issue in consultation is patient’s readiness to apply self-management approach. For this, clinicians need to motivate the patients to participate in these therapeutic strategies like cognitive-behavioral therapy. This approach is centered around the patient where assessment of concerns of patients is made, a therapeutic relationship is built and self care practices are taught. Douaihy et.al. (2007) researched upon effectiveness of this approach. Patient barriers to alternative methods of pain management can be reduced by this approach.

First important step is psychoeducation that helps the patient gain knowledgeable about their pain condition and treatments. These sessions help in motivating the patient making them active participants. Essential issues include discussions on physiology of pain, role of medications, the role of exercise in pain control, strategies to manage stress and sleep disturbances, weight management and nutrition, sexual activities, and healthy lifestyle behaviors. These interventions can be provided in individual or group settings.

As explained earlier that social support is often lacking in such illnesses. Thus, supportive therapy helps the patients to reassure that they are not alone in their suffering. These reassurances can help in decreasing anxieties relating to illness by also providing them a place to express their fears in a nonjudgmental atmosphere. It further help them build coping strategies.

Isolation of the patient and higher disability results from disengagement from family. Therefore, active involvement of family and significant others helps optimize management of pain. Unintentionally family can contribute to patient’s pain behavior and operant conditioning principles can increase or maintain such pain behaviors. Here family members are advised not to give attention to pain behaviors like by moving to other room and positively reinforce steps taken to improve functionality.

Higher intensity of pain, psychological distress and disability in patients with HIV/AIDS is associated with negative, inappropriate, and catastrophic thoughts related to pain (Payne et.al., 1994).  Cognitive-behavioral therapy aims to on restructure these negative automatic thoughts into a more realistic appraisal of the patient’s current condition. When a realistic perspective regarding the past, present, and future can be achieved, patients may be better able to cope with their pain. Homework assignments, relaxation techniques, physical activity, coping skills (including positive affirmation and relapse prevention techniques) can be incorporated into the therapy (Marcus et.al, 2000). Study by Evans et.al. (2003) found that pain and suffering can be reduced in patients with HIV/AIDS-related neuropathic pain using cognitive-behavioral therapy. Some of the tools used are Biofeedback, self-hypnosis/hypnosis, and meditation.

A study by Vincent (2004) tried to evaluate effectiveness of an 8-week therapeutic recreation intervention in reducing pain and anxiety using yoga. This was done in patients with Human Immunodeficiency Virus (HIV) infection and Acquired Immune Deficiency Syndrome (AIDS) who were experiencing difficulties with pain and anxiety. This was measured through pain and anxiety rating scales which were administered at pre- and post-sessions.  Findings suggested that the yoga technique is effective in self-perceptions of pain and anxiety in this population.

Often there is a lot of hesitation to accept referral for psychotherapy in patients with HIV/AIDS-related pain. They may resist any kind of change and remain guarded. One should work collaboratively to make patients with HIV/AIDS understand the need for psychological management and should not tell them that pain is “in their head”.

Despite recent advances in treatment modalities pain still remains an unanswered problem. Adequate treatment for pain by health care providers is not available. Further quality of life is considerably affected by this unmanaged chronic pain. The appropriate strategy is a multidisciplinary team approach focusing on continuous pain assessment, evaluation of underlying etiology and understanding to attentional, cognitive, affective, and social components of the patient’s pain experience. Ideally, a primary care physician; infectious disease specialist; and specialists in pain management, psychiatry, and addiction medicine would be included in this team.

Further research is required to examine the interrelationships among pain, psychological disorders, drug use, and health outcomes. Additional strategies need to be worked upon for pain management.

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