GCAP 643 Health Psychology
Reflective Practice Assignment 3
Adam Clark   
Hello everyone,

I see health as dynamic. I believe health fluctuates in response to the interplay of our mental, physical and spiritual well-being. I personally emphasize physical health in my own maintenance but see clearly how my physical well-being influences my mental and spiritual states 
Adam Clark, January 2010
Introductions &
Starting Places
Hello everyone,

I believe health and illness exist on a continuum and that we can be more or less "healthy" depending on the definition and criteria we use to evaluate this state of mind and body. 
M. Justin, January 2010 
While I hadn’t been aware of it, up until this point in my life I had assumed, to a point, that health was something that you either had or you didn't. 

Medical sociologist Aaron Antonovsky’s point as quoted in Sarafino (2005) had a big impact on me. 

“We are all terminal cases. And we all are, so long as there is a breath of life in us, in some measure healthy” (p. 2).

I also believe in a balance between western and traditional, or indigenous, ways of healing. To add to this holistic perspective, I also believe that health, whether it is wellness or illness, cannot be achieved in isolation. 
Classmate B. Miller, January 2010
Biopsychosocial Concept of Health
Sharing
Insight
AH-HA
“Of course”, I thought, “Why would I think of it as a duality?” 

With the awareness that health isn’t an either/or, I became more aware of the grey in the various levels of wellness and illness dominance.  

Peer Sharing
And this helped link health psychology into my personal view sculpted by a postmodern approach that everything occurs in context.    

"The fundamental faith in a single reality that provides a common point of orientation across people, cultures, and historical periods has been eroded and replaced by a recognition, or even a celebration, of the multiple realities conditioned by individual, social, and temporal factors." 
Neimeyer and Raskin (2000) 
Connections
These connections lead to the introduction of the biopsychosocial perspective on health. In this I found a conceptual framework that described what I had been intuitively aware of for a long time. 

Since university I have known I’d either use exercise to maintain my mental wellbeing or quite problematically be addicted to an unhealthy substance of some form. To a certain degree, I think the fact that I ended up an athlete, is because of whom I’ve been close with. Through this course, I grew to further appreciate the importance of social and physical environmental factors- A. Clark

And so I began the journey of the course with a much more informed view of...
But What of Health Psychology in...
Setting in Motion New Practices
The Health Belief Model

The Theory of Planned Behavior

The Stages of Change Model

The Health Action Process Model
Advantages of The Health Belief Model
The health belief model formalized some of the implicit methods I had been using in counselling to help people change. In my work prior to this course I remember thinking thoughts like, “If they just knew how serious the situation is…” or “How can I help my client explore the advantages of changing the behavior and disadvantages of not making the change?” In many ways I was already working with a rudimentary form of a values-expectancy model. 

Learning more specifically to work with the factors that influence the perception of threat and to consider pros and cons in terms of benefits and barriers added greater insight and clarity to my ability to explore these topics with clients. 

Some Limitations of 
The Health Belief Model
While I value the perspective gained from this model, I was also aware that as a cognitive theory it is dependent on mental processes such as reasoning, anticipating, judging, and reflecting. This raised three specific concerns for me. 

1) While intention is a key element in behavioral change, both of those terms ‘behavior’ and ‘change’ involve action. As was evident in my own self-change project, a person can have very solid intentions but fail to make meaningful behavioral change. 

2) I work primarily with adolescents and greatly enjoy the wide variety of strengths and weaknesses I see in this group. However, from relatively recent developments in brain research, reflective judgment is believed to significantly develop over the late teens and early twenties (Arnett, 2007; Giedd et al., 1999; King & Kitchener, 2004). It stands to reason that a theory that heavily relies on yet to be developed cognitive functions in adolescents may be limited in its usefulness with that population. 

3) The health belief model places an emphasis on the individual's beliefs regarding the health behavior. While contextual factors can be considered within the health belief model, it does not explicitly utilize them to the degree that I believe they influence our intentions and actions.

The Theory of Planned Behavior
Other models, such as cognitive behavior therapy, help people carry out their intentions. A primary goal of the theory of planned behavior (TPB) is to change intentions (Fishbein & Ajzen, 2005). While still focused on cognition, the theory of planned behavior provides a framework for practitioners to effect intentions and behavior through the antecedent factors of the client's attitude toward the behavior, subjective norms, and perception of behavioral control (Bamberg, Ajzen, & Schmidt, 2003). 

Postmodern contextual factors are accounted for in the social perceptions that comprise the subjective norms. Efficacy, as a key factor that I believe influences agency and volitional change, is explicitly considered according to this theory. These factors further expandeded my understanding and ability to foster health behavior change. 

The Stages of Change Model
According Prochaska and DiClemente’s stages of change model (1992) the process of change begins with the contemplation stage and advances up through planning, action, and maintenance stages. 

Differently than the other models of health behavioral change, the stages of change model helped me consider the reality of my clients within a change continuum. It is a useful framework particularly for initial assessments to evaluate what kinds of conversations or reflections may be of benefit for a client. This is also useful as a descriptive anchor to monitor various breakthroughs or setbacks for clients as they change their relationship to a specific health related behavior and concern.

 Surpassing Theoretical Barriers
Partway through my research for the first assignment I came across a theoretical issue that I couldn’t let go of. Bandura (2004) argued that psychosocial models of health behavior are generally focused on different types of outcome expectations, attitudes regarding the behavior, and social norms. As a limitation, Bandura commented that they “are concerned only with predicting health habits. But they do not tell you how to change health behavior” (p. 146). This limitation was addressed by Fishbein and Ajzen (2005) through the suggestion of an initial intervention to develop intention and a second intervention to facilitate the desired behavior. 

I wanted a model that would help me design streamlined interventions to assist clients in creating health related change. I was looking for an approach that would enable me to accommodate the different stages a client could be in with a related health concern. I envisioned this as distinct from a more generic 
intervention method. I wanted something comprehensive and functional.

I found a much more comprehensive approach in Schwarzer’s (2008) health action process approach (HAPA). The HAPA (see Figure 1) begins with a motivational phase during which the focus is to establish intention. It includes multiple levels of self-efficacy, outcome expectancies, and risk awareness. The motivational phase is followed by a volitional phase that involves detailed action planning of where, when, and how the desired behavior will be enacted along with action controls. The HAPA concludes with the execution of the desired behavior. In the case example depicted here the desired behavior was physical exercise. 
I began this course feeling fairly confident with my understanding of self-efficacy. As such, I initially didn’t fully acknowledge the significance behind Schwarzer’s (2008) differentiation of self-efficacy into action self-efficacy, maintenance self-efficacy, and recovery self-efficacy. 

In hindsight following my mixed success with the self-change project, I see that my initial understanding of self-efficacy had been limited to an amalgam of action self-efficacy, as the optimistic beliefs about anticipated potential outcomes, and maintenance self-efficacy, as optimism about one’s ability to overcome barriers. 

I did not anticipate the importance of cultivating both high levels of distinct maintenance and recovery self-efficacy to sustain health related behavior change in times of adversity. I am eager to work with those concepts more both personally and professionally with clients. 
More About Self-Efficacy 
Collaboration
Working with Robyn was fantastic…here’s a March 16th excerpt from a portion of our behind the scenes communication that I benefitted from.

Adam, 
Good work, I like the exercise. I think my only critique would be that Part 2 seems a little short, or abruptly ended. Perhaps you could further walk the client into envisioning what this positive meal at home feels/looks like.” Something along the lines of, "Imagine your meal at home providing the same satisfaction as the meal at the restaurant.”

Hi Robyn,
Thanks! You are exactly right. Yesterday when I wrote that up I ran out of motivation for creating it right there. I'll add a little more along the lines of your suggestions and post it.

Thanks again. You pinpointed it exactly :-)

Key Learning
There is not room for ego in collaboration. 

Share Openly. Offer and Appreciate Flexibility.

Robyn you were wonderful in all regards. 
Thank you!!

In Defense of Hope

As perhaps has been evident in this reflective view of the course, I value comprehensive and technically accurate methodology. 

With cycling as the metaphor, my biggest pastime, and one aspect of my life that helps me stay on the healthy side of the continuum, I am meticulous but not preoccupied with my equipment. I want to know my bike won’t fail me at speed but I also agree with seven time Tour de France champion and cancer survivor, Lance Armstrong, “It’s not about the Bike” (Armstrong, 2000). 

In a similar reminder about methodolatry, with health, it is not about the method, it’s about the meaning (Chamberlain, 2000). 

“to hope under the most extreme circumstances . . . is part of the human spirit to endure and give a miracle a chance to happen”  

Jerome Groopman, 2004

In spite of the significant of the theoretical and perspective shifts outlined in this reflective assignment, it is perhaps not surprising that I have come to believe that the true meaning of our work in counselling isn’t a theory or an approach. 

The meaning of what we do is in the power of hope. Rather than a concept, hope is something we maintain ourselves and foster in others. In the words of Groopman (2004) hope helps us “overcome hurdles we could otherwise not scale, and move forward to a place where healing can occur” (p. 177).

HOPE
References

Armstrong, L. (2000). It's not about the bike. New York: G. P. Putnam's Sons.

Arnett, J. (2007). Adolescence and emerging adulthood: A cultural approach. New Jersey: Pearson Education, Inc. (Chapter 4)

Bamberg, S., Ajzen, I., & Schmidt, P. (2003). Choice of travel mode in the theory of planned behavior: The roles of past behavior, habit, and reasoned action. Basic & Applied Social Psychology, 25(3), 175.

Bandura, A. (2004). Health promotion by social cognitive means. Health Education and Behavior, 31, 143-163. doi:10.1177/1090198104263660.

Chamberlain, K (2000). Methodolatry and qualitative health research. Journal of Health Psychology, Vol. 5, No. 3, 285-296. doi:10.1177/135910530000500306

Fishbein, M., & Ajzen, I. (2005). Theory-based behavior change interventions: Comments on Hobbis and Sutton. Journal of Health Psychology, 10(1), 27-31. doi:10.1177/1359105305048552.

Giedd, J., Blumenthal, J., Jeffries, N., Castellanos, F., Liu, H., Zijdenbos, A., et al. (1999). Brain development during childhood and adolescence: a longitudinal MRI study. Nature Neuroscience, 2(10), 861. Retrieved from Academic Search Complete database.

Groopman J. (2004) The anatomy of hope: How people prevail in the face of illness. Random House, New York. 

King, P., & Kitchener, K. (2004). Reflective judgment: Theory and research on the development of epistemic assumptions through adulthood. Educational Psychologist, 39(1), 5-18. Retrieved from ERIC database.

Neimeyer, R.A, & Raskin, J.D. (2000). On practicing postmodern therapy in modern times. In Robert A. Neimeyer and Jonathan D. Raskin (Eds.), Constructions of disorder: Meaning-making frameworks for psychotherapy, pp 3-14. Washington, DC: American Psychological Association. 

Prochaska, J., & DiClemente, C. (1992). In search of how people change. American Psychologist, 47(9), 1102. Retrieved from Academic Search Complete database.

Sarafino, E. P. (2008). Health psychology: Biopsychosocial interactions (6th ed.). Hoboken, NJ: Wiley. Chapter 6: Health-related behavior and health promotion.

Schwarzer, R. (2008). Modeling health behavior change: How to predict and modify the adoption and maintenance of health behaviors. Applied Psychology: An International Review, 57(1), 1-29. doi:10.1111/j.1464-0597.2007.00325.x.