|Partners for Mental Health - The Contribution of Professionals and Non-professionals to Mental Health (WHO, 1994, 110 p.)|
J.J. Dijkhuis, Ph.D.
Professor Emeritus of Clinical Psychology
University of Leiden, The Netherlands.
International Union of Psychological Science
The International Union of Psychological Science (IUPsyS) was founded in 1951 at the XIIIth International Congress of Psychology in Stockholm (Sweden). The Union represents over 200,000 psychologists through its National Member Societies in 50 different countries. Its primary purpose is the development of psychological science, whether biological or social, normal or abnormal, pure or applied. As a member of both the International Council of Scientific Unions and the International Social Science Council, it collaborates in a wide variety of scientific activities wherever human or animal behaviour is involved. International research and special projects are developed under an Executive Committee elected by the Union's Assembly which meets every four years at the time of the International Congress of Psychology. Publications include the International Journal of Psychology, specialized newsletters, and books growing out of special projects. The Union cooperates with WHO through its Committee on Psychology of health.
1. Organizations of psychologists
There are several organizations representing various types of psychologists. The most important of these can be distinguished as follows:
1.1 Global organizations
There are three large global organizations of psychologists; the first is the International Union of Psychological Science (IUPsyS). It includes members from 48 national societies. The second is the International Association of Applied Psychology (IAAP) and the third is the International Council of Psychologists. These organizations have their international congresses at regular times.
1.2 Regional organizations
Also there are two large regional organizations of psychologists, the European Federation of Professional Psychologists Associations (EFPPA) and the Inter American Psychological Society (IAPS). The EFPPA was founded in 1981 in response to the perceived need for European cooperation over a wide range of issues such as professional education and standards of practice programmes in the fields of health and employment, and applied research. Most European countries are represented in the EFPPA, including all the member states of the European Community, with the exception of Ireland. Other member countries include Austria, Estonia, Finland, Hungary, Iceland, Liechtenstein, Norway, Poland, Sweden and Switzerland. More countries in Eastern and Central Europe are applying for membership.
1.3 National organizations
All over the world, there are national organizations of psychologists. The largest, and most structured one is the American Psychological Association (APA). In its own statement: "The purpose of the APA is to advance psychology as a science, as a profession, and as a means of promoting human welfare. It attempts to accomplish these objectives by holding annual meetings, disseminating psychological literature, and working toward improved standards for psychological training and service."
2. The development of psychology (as relevant to health and health care)
2.1 Introductory remarks
The mind-body dualism - more prevalent in Western countries, as opposed to an holistic approach, more prevalent in Eastern countries - focused on the body, neglecting the mind. In this way, focusing on matter and neglecting the mind, medicine developed as a scientific discipline with the body as the object of research and theory. Medical practice was greatly influenced by this development. In the wake of this development, the biomedical approach began to dominate the domain of health care. And it still does, even though the awareness is growing that often psychological factors are influencing disease and illness.
Even psychiatry needed a long time to extend its biomedical approach to include a psycho -logical one. Admittedly, there was no scientific psychology to rely on. The science of psychology was initiated in the 1880s. Its precursors were philosophy and the humanities at large, as well as religion and common sense. The philosophical part was combined with the experimental method as developed in natural and physical science. In this way scientific psychology was born and the study of mind took its place next to the study of matter.
Why did it take so long for psychology to become a scientific discipline? And why did it rise so quickly after it came into existence? These questions are still to be answered. One assumption is that the complexity and the accelerating tempo of activities in the industrial society caused a great deal of maladjustment. There was the necessity of readaptation by changing lifestyles and patterns of relating to others. People became much more aware of their feelings. Scientific study of the "stream of consciousness" (William James) and of human behaviour in general was badly needed. The science of psychology originated from this need, exploring all emotional and behavioural aspects of human life. It covers the "mind-part" of the body-mind duality. In this respect it is complementary to the biomedical approach in health care. However, the mind-body duality as such still exists.
2.2 Psychology: science and practice
It is generally accepted that scientific psychology started in 1879. In this year Wilhelm Wundt founded the first psychological laboratory in Leipzig. He established psychology as an experimental science of its own, although much work in the inquiry of consciousness had already been done by great 19th century's physiologists, like Fechner, Donders and also Helmholtz. Both, experimental and psychophysiological research have greatly influenced the development of scientific psychology. Gradually, its focus changed, from the conscious to the unconscious, to adaptive behaviour and learning, to cognition and emotion. Despite this reorientation, determining psychological variables by psychophysiological measurements has continued to play a major role in psychological research.
Soon after its inception, general psychology split up in several sub-disciplines: developmental psychology, differential psychology, social psychology. At the same time professional psychology originated. The application of psychological theory and research could possibly help to solve practical and emotional problems as may arise in educating children; in dealing with crises across the life span; in assessing people according to their different abilities in performing and coping; in managing conflicts between people.
Today psychology both as a science and a profession has its place in the larger universities of the Western and the Westernized world. Its growth was most impressive in the decades following World War Two. At least courses, and often complete teaching programmes, are available for those students who want complementary knowledge in psychology, or are preparing themselves for a professional career as a psychologist. In the highly industrialized countries, most universities which offer education programmes, also have their own centres of research in psychology. In addition there are quite a few research centres supported by governments or by special foundations.
In the developing countries scientific research in psychology and training in applied psychology are rapidly growing. It may be expected that the situation in these countries will not differ much from the USA, Canada, Western Europe, Australia and Japan before too long.
It should be mentioned that the situation in the former socialist countries, is complex. In the beginning, the ideology of the USSR did not permit psychology to develop at the same pace as was the case in North America and Western Europe. This changed after the sixties, and now, with the Soviet Union dissolved, and ideological changes taking place, it can be expected that psychological research will be exchanged with centres in the developed countries. It is not unlikely that professional psychology in the former USSR will develop as in most developed countries. Even in China, this development can be expected.
As opposed to the USSR and the People's Republic of China, the place of scientific and professional psychology, in the former socialist countries in Central and Eastern Europe is more similar to that in other European countries. They shared the same tradition before World War Two.
2.3 Psychologists in health care
Since psychologists are operating in health care under different designations, a terminological clarification may be needed. For decades clinical psychologists have been working almost exclusively in psychiatric settings. Gradually, they started to deliver services to other medical specialties, in general hospitals; their focus still being on mental health problems.
Often it is taken for granted that the term "clinical" refers to the medical setting, meaning: assisting people who have fallen ill. Clinical psychologists appear to have their expertise in the assessment and treatment of abnormal behaviour, and in the inquiry of psychological causes and effects of illness and diseases.
It is generally overlooked that the term clinical used in connection with psychology, has a twofold meaning. When it was first used, it denoted the clinical method in psychology. In contrast to methods used in experimental research, clinical research methodologically examined individual people, one at a time. When Witmer started the first psychological clinic, in 1896, at the University of Pennsylvania, he aimed at several forms of guidance (e.g. vocational, educational, industrial) based on the careful examination of the single case. In this sense "clinical" refers to the clinical method in counselling individuals regarding to normal problems.
Nowadays, clinical psychologists are combining both aspects. They are no longer confining themselves to psychiatric or general hospitals nor exclusively to mental health care. To an increasing extent, clinical psychologists are delivering their services in out-patient clinics, in private practices, or in other ambulatory systems, and even in schools and industry. Many clinical psychologists, working in general hospitals, had their share in this development. Their treatment was concerned more with changing life-styles than with solving deep emotional conflicts (1). In fact, they became clinical health psychologists.
Health psychology could not have risen so quickly if psychological research had not come out of the experimental laboratory. In most areas of scientific psychology the need was felt to test hypotheses in real life situations; the same as clinical psychology had done in regard to abnormal behaviour. As a consequence of this shift, psychology as a whole is contributing to the study of healthy behaviour, and its application to health care and health promotion. Much more psychologists entered the field of (clinical) health psychology.
Actually, psychologists have a lot to contribute to health care besides proficient individual help. This goes for informing health workers, training them in special skills, assisting in health education, developing and evaluating programs of health care; all on the basis of psychological theories and techniques. Moreover, psychologists may assist health care systems in dealing with organizational problems, or creating a humane climate, without getting involved in individual problems. Clinical health psychologists are dealing with individual people.
Psychological research contributed largely to the development of behavioural medicine. However, this new branch of health care should not be identified with health psychology, even though many clinical health psychologists are working in this field. As Matarazzo points out, there are three specific areas in the growing field of behaviour medicine. Sensu stricto, the term should be used for the broad interdisciplinary field of scientific investigation concerned with health. The term behavioural health could also be used for an interdisciplinary endeavour that concerns itself with the maintenance of health and the prevention of illness in currently healthy individuals. In his view, health psychology is a disciplinary-specific term defining the primary role of the science and profession of psychology. In his definition: "Health psychology is the aggregate of the specific educational, scientific, and professional contributions of the discipline of psychology to the promotion and maintenance of health, the prevention and treatment of illness, and the identification of etiologic and diagnostic correlates of health, illness, and related dysfunctions" (2).
The present state as well as the future of health psychology are discussed in two recent publications. Weinman identifies as the main areas of health psychology:
- Behavioural risk factors in disease.
- Behavioural maintenance of health.
- Health-illness cognitions.
- Communication/decision making/adherence.
- The treatment environment.
- Coping with illness, disability, etc.
He considers the development in health care and in medicine which are likely to be influential for health psychology, and emphasises the need for specific training of health psychologists (3).
2.4 Professional standards of psychologists
Clinical (health) psychologists are not only practitioners. Their training is based on the scientist-practitioner model, preparing them for both scientific and professional activities in their field of application. Ideally, all clinical (health) psychologists should be active in both areas. Due to their case-loads, few practitioners find time for scientific work. On the other hand, many clinical psychologists are doing research in universities or other centres.
Research in clinical psychology includes single case studies, evaluation of treatment, especially psychotherapy, the development of new methods, program evaluation, the study of behaviour in natural social environment, psychosocial epidemiology; to enumerate the main areas.
In assuring the quality of professional psychology, there are two important issues. One is setting standards for education and training; the other is setting standards for professional behaviour. These standards are needed not only for the commensurability between psychologists themselves, but even more for the information of the consumers of psychological services.
Although there seems to be a global consent that psychology should be practiced only on the basis of a university degree in psychology, still large problems remain. In the first place, university programs and degrees differ from one country to another. And secondly, organizations of professional psychologists consider regular university education insufficient to enter licensed practice, and hence demand postgraduate training.
In the USA, the American Psychological Association (APA) is the organization that is engaged in the accreditation of doctoral programs. "Accreditation is a system for recognizing educational institutions and professional programs affiliated with those institutions for a level of performance, integrity, and quality which entitles them to the confidence of the educational community and the public they serve." (4). The APA accredits doctoral education and training for professional psychology, more specifically for clinical psychology, counselling psychology and school psychology. The APA also accredits predoctoral internship training programs in professional psychology.
In Europe the situation is different. Some countries have systems similar to that of the USA, but most countries are still in the process of developing requirements for practice. In the General Assembly in 1990, the EFPPA-members agreed on optimal standards for training required for independent professional practice. "Preparation for independent practice of psychology comprises at least two components: a core programme and an advanced professional training in psychology. The core programme is concerned with the knowledge and skills relating to psychology as a scientific discipline and is common to all branches and specialisms within psychology. In the advanced component the student will acquire the knowledge and skills which are necessary for independent practice in a chosen field of professional psychology" (5).
The second main issue in promoting and maintaining a highly qualified practice, is setting standards for ethical and professional behaviour in practising applied psychology. Psychologists who are licensed for independent practice should act in accordance with those standards. The APA Ethical Principles includes principles related to responsibility, competence, moral and legal, confidentiality, welfare of the consumer, professional relationships, assessment techniques, and research activities (6). This code mandates that psychologists practice only within their areas of expertise. Moreover, the APA developed the Standards for Providers of Psychological Services, which details the minimally acceptable level of performance that all psychologists, who provide services, should reach or exceed.
Several national organizations of professional psychologists in Europe have developed similar ethical and behavioral codes. Formulating European codes is "work in progress" within the EFPPA.
3. The methods of psychologists
Psychologists who are practising in health care use several tools and methods when working with people; in assisting them in solving their problems. Those tools and methods are developed as a means to gather objective data for making clinical decisions, and as a means to planning of change or developing strategies to produce desired changes (7, 8, 9). Both assessment and therapeutic change are dealt with in this section. In the whole range of psychological methods that constitute the interventional repertoire of psychologists in health care, psychotherapy takes a special place. Psychotherapy is not exclusively practiced by psychologists. For that reason it is discussed separately.
3.1 Psychological assessment
Initially, differential psychology focused on intellectual differentiation. Experimental researchers developed specific instruments to assess differences between individuals. Those instruments became the intelligence tests as used by practising psychologists. Issues like reliability and validity of tests led to the development of test theory; and test construction became a major part of psychometrics, i.e. the application of measurement and mathematics to psychology.
Characterizing people already had a long tradition, not only in daily life, but also in philosophy and literature, before it became modern psychological personology. In psychiatry, characterology had its place next to nosological categories. The application of methods of testing, and of psychological methods in general, to characterology and psychopathology, led to the term psychodiagnostics as it is commonly understood now.
Whereas ability is examined by performance tests, personality testing mainly consists of the use of questionnaires. A world-wide known example is the Minnesota Multiphasic Personality Inventory (MMPI), for exploring neurotic tendencies and the extraversion-introversion dimension. Other tests to gain information about emotional and motivational factors are the so-called projective techniques. Projective techniques are much less statistical and psychometric than standardized questionnaires.
Psychodiagnostics is part of psychological assessment. This holds for applied psychology in general, but particularly for clinical assessment. Psychologists in health care have a lot of questions to answer. As important as a correct diagnosis may be, the question which form of psychotherapy is suitable, cannot be answered by statistical prediction only. Clinical judgment and inference are still needed. For that reason, interviewing and observing the behaviour of the patient, are to be valued as indispensable procedures in the process by which psychologists acquire the necessary information for making decisions. This implies an optimal understanding of the patient. For about two decades there has been a decline in the role of psychodiagnostics in clinical assessment. Recently, a strong revival has taken place, not only due to the need for quick decisions, but also because of the development of new techniques and strategies.
3.2 The interventional repertoire
Even though psychotherapy constitutes a rather extensive part of the interventions of psychologists in health care, their interventional repertoire is not limited to the practice of psychotherapy. The scope of their activities is much larger. To mention a few, crisis intervention, rehabilitation of functions, stress-management, pain-management, terminal care, lifestyle-changes, have become major fields in which knowledge and methods are applied to restore and promote health.
Psychotherapy does not appear to offer proficient help in those cases, at least not in the short run. On the other hand, many methods aimed at helping people in these cases, are derived from psychotherapeutic systems; predominantly from behaviour therapy, or its basic tenets. Many new techniques of behaviour modification are developed as forms of instrumental learning as introduced by Skinner. All behaviour is conceived as learned in the interaction with the environment. Reward and punishment have the effect of increasing or decreasing the learning process. Assertive behaviour and other social skills can be learned in this way.
Many interventions of health psychologists are not individual-directed. They are aimed at influencing community behaviour, as for instance in the Finnish North Karelia Project. Furthermore, principles of health psychology can easily be understood by non-psychologists. They also can be made familiar with basic skills of changing health behaviour (10).
Clinical psychologists and psychiatrists have an equal share in rendering psychotherapeutic services. In a much smaller number specially trained social workers are practising psychotherapy. The practice of psychotherapy is a domain common to many professionals, e.g., clinical psychologists, social workers etc.
Counselling psychology is a special method of applied psychology that was established at a rather early stage. As counsellors, psychologists do not limit themselves to giving advice to their clients. In fact, their aim is much more to assist clients to make their own decisions.
Trained both in psychoanalysis and in experimental psychology, Carl Rogers, transformed counselling in a special branch of psychotherapy which came to be known as client-centered psychotherapy (11).
Psychologists also made large contributions to the development of other new forms of psychotherapy: behaviour therapy, systemic therapy, cognitive therapy; and a number of less known forms of psychotherapy (12).
Actually, estimates about the total number of psychotherapeutic forms range from 200 to 400.
Psychotherapy can be applied in all settings to a whole range of target groups. Whether or not there is specificity in various psychotherapeutic techniques for the treatment of certain disorders or conflicts is still an unresolved problem. Elements of the same body of theory and techniques can be found in all four main systems of psychotherapy.
Why are some people helped by psychotherapy and others not? This issue regards the question Who will benefit from psychotherapy? Under this title Luborsky a.o. reported their research findings on predicting psychotherapeutic outcomes. These findings show that psychodynamic psychotherapy is both complex and effective.
To an increasing extent, the cost-benefit ratio is becoming another main issue in regard to psychotherapy; especially since hourly individual psychotherapy is the predominant procedure for almost three quarters of all outpatient visits and even half the inpatient visits.
4. Current developments
In the preceding sections an overview of the development of psychology, both as a science and a profession, pertaining to health and health care, has been given. For decades psychologists have been using their tools and skills in mental health care. Initially, their contributions were limited to mental health institutions. Gradually they widened their scope. This coincided, as Diekstra and Jansen explained, with changing concepts on health care (13). Today, large numbers of psychologists of various designations are rendering services, not only to individuals who are mentally disturbed or have fallen ill, but they also have their share in health maintenance and health promotion. Until recently, psychologists contributed only on a small scale to prevention. This situation is changing rapidly. Health-risk behaviour can be modified by a variety of psychological interventions. In this section a number of noteworthy developments in psychological health care will be summarized.
4.1 Physical disorders
A great deal of research in determining psychological factors in disease and stress, has been carried out by psychologists; and is still being done. Psychological factors contribute to the genesis of such diseases as: coronary heart disease, cancer, respiratory or neurological disorders. On the other hand, emotional or behavioural disorders may be caused by physical illness, pain, and even medical treatment, for instance surgical stress.
Unhealthy behaviour that may cause physical illness or disorders is highly related to specific patterns of life-style. Changing patterns of life-style is a major endeavour in health psychology (14). Psychologists develop programs for assessing life-style patterns and in assisting individuals to change them.
Management of stress and anxiety is also a major issue in health care which psychologists are investigating. In spite of Selye's contention that "stress is the spice of life", the number of people for whom stress is too spicy, is increasing. Psychologists can assist them in learning to cope with stress (15). The same goes for the management of anxiety (16).
4.2 Suicide prevention
For a long time, it was generally assumed that suicide was mainly committed by adults, who live in highly developed societies, and was connected with severe mental disturbances. Large scale psychological research has established none of these assumptions to be true. The incidence of suicide in developing countries is rather frequent, and the suicide rate in adolescents is extremely high; in fact, similar to the frequency in highly developed countries.
Moreover, the relationship between suicide and severe psychopathology is still unclear. Those data stimulated psychologists to continue research and to develop programmes to aid suicidal individuals, especially adolescents. In those programmes, cognitive therapy is found to be very useful.
4.3 Clinical neuropsychology
Neuropsychological insights developed rapidly during World War One, when brain-damaged soldiers were referred to psychologists for the assessment of specific brain dysfunctions. This is often considered to be the beginning of clinical neuropsychology. Another stimulus came from the assessment and training of veterans of World War Two and the Korean War. The confluence of clinical practice with experimental research brought forth the psychological component of neuroscience (17). A wide array of techniques proved to be beneficial in the assessment of cognitive factors in brain injuries, and in other disorders and diseases, such as diabetes mellitus or Cushings' syndrome. But psychologists also developed techniques and programmes for training. Neuropsychological assessment is also used in predicting everyday functioning; for instance, whether a certain person should be allowed to drive.
Currently, much emphasis is on the rehabilitation of patients who are physically disabled or recovering from somatic diseases. Psychologists no longer limit themselves to training and counselling the many workers who assist in rehabilitating people; or to programme evaluation. They are also developing and applying new training programmes on the basis of neuropsychological studies (18).
Several techniques of behaviour modification have proven to be of great value in the rehabilitation of disabled patients, and to enhance their compliance with medical treatment.
Because of demographic changes, the care of elderly people with progressive and irreversible, intellectual impairment takes a large proportion of the health care budget. This number is growing, because the greying of the population is increasing (19).
Psychologists contribute in the assessment of "real" senility, such as Alzheimer's disease, but also and even more, to the detection of impairments which result from organic processes or tissue loss. Since most of those impairments are reversible, or can be compensated, psychologists use devices to help people cope with their complaints or redress the impairments (20).
Gerontopsychologists can be of great assistance to elderly people, and society, in changing attributions and attitudes. Undoing learned helplessness in elderly people by cognitive behaviour therapy is very effective. Since more and more aged people are searching for the meaning of life, also other forms of psychotherapy are conducive.
4.5 Community psychology
Community-based treatment of mental patients is not unknown in the history of psychiatry. For centuries it was practiced in the Belgian village of Geel. Another, more recent experiment with treating mentally ill is carried out in the village of Aro (Nigeria). However, community-psychology in mental care, was mainly promoted by the US Community Mental Health Centers Act of 1963. The American Psychological Association, urged research in the new centers, and psychologists were trained in community mental health. Both clinical and social psychologists contributed to the development of this new branch of applied psychology, based on system thinking and on ecological theories. A better understanding of the interactions of individual and community, and of the influence of social structures, will stimulate health care and encourage promotion of health. By developing consultative strategies, community psychology has greatly assisted in establishing self-help groups for individuals who are sharing common problems, such as: alcohol or drugs abuse, being victims of injury or the like; or establishing other social networks. Psychosocial epidemiology, investigating the effects of ecosystems, delivers a major contribution to the development of community psychology.
4.6 Organizational psychology
Paid employment takes a large part in an individual's life, especially in industrialized countries. In industrial organizations as well in other organizations where people are employed, there are many sources of stress, related to the job to be performed, the needed skills, the responsibility of the individual, his role in the organization, and the concerns with his career. For decades, organizational psychology was involved in analysing the structures and the climate of organizations, and also in developing and supervising strategies for organizational change. Recently, clinical health psychologists entered organisations, to assist individual workers and managers in coping effectively with tasks and roles in their work environment. A great deal of research is done, both by clinical and social psychologists in determining stressors in organizations, and also in the relationship between work and family. How do workers manage conflicting commitments? How do crises and stress spill over from one system into the other? Is stress provoked by environmental factors or are stress effects caused by individual coping styles? Selye suggests the last solution, but then there is no agreement as yet on the use of the term stress. Anyhow, much effort is put into the analysis of external factors provoking stress, for instance the culture of one corporation as compared to another.
4.7 Cross-cultural psychology
Differences between industrialized and traditional societies are, time and time again, provoking stress in dealing with international affairs. Politicians are struggling with this problem, but also multinational companies, or people who migrate, are often confronted with ways of living and thinking, controversial to their own.
Living in our own country we are familiar with controversies generated by the different cultures of urban and rural communities. And, to an ever increasing extent, we are confronted with cultural variety, due to international travel and migration. Native groups, minorities and refugees are not only inviting to coexist, but are also demanding our special understanding when they are in need of help.
Cross-cultural studies are necessary contributions to health psychology. For a long time, cross-cultural research has largely been the domain of cultural anthropology mainly conducting ethnographic studies. Early experimental research in psychology started from the premise that psychological characteristics are evenly distributed throughout the humans species. However, empirical studies clearly indicate that cultural and environmental variables influence patterns of behaviour, expression of emotions and even intellectual functioning.
The number of cross-cultural studies rapidly increased after 1950. The great expansion of this new subdiscipline is the result of the increased academic activity of psychologists in developing countries, and also of the introduction of applied psychology in matters of selection and training. The relationship between language and cognition, differences in cognitive style and perception, divergent forms of child-rearing are important fields of cross-cultural psychological inquiry.
Health care in many parts of the world struggles with the problem, how means and measures, proven to be effective in the health care systems in the developed countries, can be implemented in the developing societies; and how traditional healing can be integrated with modern technology. The awareness of cultural factors in health and health care is growing. Many health psychologists are contributing to health care in developing or least developed countries.
They investigate cultural differences in health and disease, including psychiatric disorders. They develop and standardize assessment procedures that can be used by health workers in primary health care, without extensive training in psychology. They are also teaching and training people in universities and paramedical schools.
4.8 Psychologists in primary health care
Cuban psychologists are participating on different levels in the health care systems, but a considerable part of them is contributing to primary health care (21). There is a tendency that psychologists get more and more involved in primary health care. This is the case in rural regions of Norway. Also, to an increasing extent Dutch psychologists are rendering services in primary health care.
Following the trends in the traditional health system in the Western world, psychologists started to contribute to special areas of health care. Clinical psychologists can be distinguished in several branches in accordance with the medical specialties. As has been shown in 2.3., this situation is changing since the rise of health psychology. Much more psychological knowledge and skills are available to clinical psychologists, and also many more psychologists are working in health care, in promoting health: consulting health care systems or in individual care; and quite often on both levels.
As stated by Diekstra and Jansen: "Psychologists, or at least a substantial part of them, should be trained as mental health generalists able to work within the realm and constraints of the primary level or to train, consult, and supervise other PHC (=primary health care - JJD) workers. The training of such a brand of psychologists will therefore have to be quite different from the usual "school-oriented" training in many traditional curricula for clinical psychology. As a result psychologists in health care will find themselves falling essentially into two groups: the specialists and the generalists." (13)
Even if one does not agree with the authors on all implications of their statement, one has to admit that psychologists in health care will either be specialists or generalists. In both capacities psychologists can contribute considerably to the practice of health care.
As generalists, psychologists can join the strategy of the World Health Federation for attaining Health for All by the Year 2000, as presented in the Declaration of Alma Ata (1978).
In the consultation meeting which was organized by the Regional Office for Europe of the World Health Organization in collaboration with the European Federation of Professional Psychologists (1984), participants agreed that psychologists could make greater contributions to programme development within the Regional Office (22).
The contribution of psychologists to programme development will especially apply to public health psychology. Diekstra has identified five central problem areas for the near future:
- The behavioural origins of ill health and disease.
- The relationship between health care and quality of life.
- Early acquisition of health-sustaining behaviours.
- Psychosocial and mental health consequences of emergency and disaster situations.
- The health of health care workers.
He exemplifies those problems and suggests courses of action (23).
Both scientifically and professionally, psychologists are very well placed to encourage the interaction of theory and practice in health care.
5. Concluding remarks
Although psychology made a late start, it had a rapid growth. Today psychological research and education are in the programmes of universities all over the world and also in developing countries.
Professional psychology developed at a slower pace. After its breakthrough following World War Two, its expansion is remarkable. For instance, in Latin America there are more than 150,000 psychologists. Organizations are essential in setting standards for training and practice of professional psychologists.
Professional psychologists have a large array of methods and instruments at their disposal, to assess problems and to aid people in bringing about change. Within a wide range of interventional procedures for behavioural and attitudinal change psychologists contribute significantly to the development of psychotherapeutic techniques.
Psychologists entered mental health care by focusing on the investigation of abnormal behaviour, and the assessment and treatment of mental disorders. Gradually, they also became involved in assessing psychological factors in somatic diseases and assisting patients to reduce or eliminate those factors. However, abnormal psychology shall continue to be of concern to clinical psychologists, but more and more maintaining and restoring health will be the focus of psychologists who are active in health care.
This shift was largely caused by the rise of health psychology. All subdisciplines of psychology are contributing to this new area of theory and practice.
A great variety of psychologists will be available for rendering services in health care. With their education and training they will be of immense value "because they should be able to assess the subjective aspects of health with respectable accuracy and validity." (24).
Psychologists in health care may be employed in individual health care, in prevention and in various forms of health promotion. They will need a training for specific tasks in health care (25, 26, 27, 3). Professional organizations are setting new standards for training and practice. At the moment, there are only standards for individual health care.
Psychologists in health care are well equipped to take their part in effectuating The Mental Health Programme of the World Health Organization (28).
I am very grateful to colleagues who assisted me in writing this article. Dr. Y. Poortinga kindly supported me in conceiving this paper and commented extensively on its first draft. Prof. dr. R. F. W. Diekstra and Prof. dr. S. Maes generously supplied me with literature on many topics I discuss in this paper. Dr. K. Peltzer gave me permission to use an article still to be published.
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