Assessment for health psychology

Clmva~ Plyrholofl Rnwu’. Vol. 4. pp. 459-476, Printed in the L’SA. All rights reserved.

1984 Copyright

027%7358/84 $3.00 + .oo 0 1984 Pergamon Press Ltd.

ASSESSMENT FOR HEALTH PSYCHOLOGY Richard H. Dana University

of Arkansas

- Fayetteville

ABSTRACT. Four domains for health assessment are described: power and responsibility, life stress, personality, and psychiatric symptomatology. Major instruments are identified within each domain. Assessment opportunities and practices with coronary artery disease and geriatrics provide examples of application. Some implications for health assessment of the general population are presented. A general systems, or biopsychosocial framework for health assessment is suggested.

The practice of clinical psychology has burgeoned from delivery of services in psychiatric facilities to general medical hospitals, schools, public agencies, industry, and the private sector. Approximately 3000 clinical psychologists, or S%, are employed in medical, dental, and public health schools (Matarazzo, 1983). Assessment has matured from global descriptions of personality dysfunctions in psychiatric populations to encompass interview, observation, objective tests, and projective techniques applied to persons suffering from anxiety, addictions, brain syndromes, and depression in college, prison, and medical populations as well (Dana, in press-a). Assessors envision offering services to many of the 200 million persons in the general population who have “bad” habits and/or ineffective life styles. Health psychology is a new shibboleth that will make new populations available for assessment services. Matarazzo (1982) has recently provided a consensual definition for health psychology that includes assessment: 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, the identification of etiologic and diagnostic correlates of health, illness, and related dysfunction, and to the analysis and improvement of the health care system and health policy formation. (p. 4) Requests for reprints may be addressed to Richard H. Dana, Dept. of Psychology, University of Arkansas, J. William Fulbright College of Arts and Sciences, 216 Memorial Hall, Fayetteville, Arkansas 7270 1. Adapted from an invited paper presented at the Veterans Administration Medical Center, Little Rock, Arkansas, April 28, 1983. 459

Since Matarazzo’s definition indicates neither the composition of these correlates nor their interactions, four examples of domains for health assessment are included to provide a preliminary sketch. These assessment domains were selected to illusinstruments are identified trate contemporary assessment issues. Representative within each domain. The focus is primarily on self-report instruments. Behavioral observation as well as psychophysiologic indices have been omitted here, and pertinent reviews of these areas have appeared elsewhere (Boice, 1983; Levenson, 1983). Brief reviews of health assessment for two populations-coronary artery disease and geriatrics-are provided as examples and will be followed by some implications for health assessment of the general population, Finally, the desirability of a general systems, or bi~)psych~~st)ci~l framework for health assessment is suggested. DOMAINS FOR HEALTH ASSESSMENT Table 1 presents the fOur domains for health assessment: power and responsibility, life stress, personality, and psychiatric symptomatology. While this partitioning oversimplies the number of components and their interactive nature, the criterion for inclusion of components has been replicated with research findings that define the current status of assessment. Health assessment is not well represented by any catalog of instruments and research studies, but only by various attempts to conceptualize how these isolated pieces cohere and are amenable to subsequent empirical verification. These domains reflect the present status of the health assessment literature. Eventually, it should be feasible to supplement these domains for greater representation of levels within a biopsych~~s(~cial model and to dovetail each domain with instruments that pert.ain to curative, learning. or growth perspectives. Power and responsibility inhere in the relationship between caregiver and patient.. In medical model thinking the patient was viewed with sufficient impersonality to permit objectification as a “case,” a specific illness entity. Illness-health status was clearly categorical. Symptoms were used to infer illness processes with predetermined causes and specified, empirical’interventions. Both power and responsibility were the prerogative of the caregiver. The medical model assumed a passive, complaint, cooperative patient who accepted the services rendered without cavil or request for information. However, improvement in the health care system may ultimately rest upon citizen responsibility for well-being (Ginzberg, 1977). Since many physical conditions require shared responsibility for management and effective t.reatment, inft~rI~ation concerning the perceived source of locus of power becomes relevant to responsibility for treatment. TABLE

1. Health Assessment

Domains

Description

Power and ~~sl~onsit~~lity Who is respmsible (treatment)? Life Stress

for problems (illness) and solutions Expectations and compliance.

C;ontributions

Life events illness

Personality

Dispositions

Styles of‘ coping

Psychiatric

Symptoms

Beha&rs

as predictors

of future

for prevention

that complicate

medical

and/or

and exacerbation

treatment

of physical

psychiatric ot‘ illness illness

Assessment

Life stress contaminates pervasive and omnipresent,

461

our thinking about health and disease. Not only is stress but the major stressors are shared by all of us-losses

of relationship, occupation, possessions, and physical threats to life and well-being. Not all stressors are catastrophic for all persons but may be perceived as stimulating or challenging. Although stress is a fact of human life, the reactions to stress are largely fictions conjured up by experience. As a result we do have choices in dealing with stressors, and certain options are known to be relatively more efficacious. A health psychology can provide some empirical wisdom leading in the direction of cognitive flexibility and positive attitudes about the choices available to each person. The choices that we make for resource utilization precurse the subsequent physical and psychological impact of stressors. Personality dispositions that are exercised automatically increase or decrease the likelihood of physical and psychological dysfunction. These coping styles serve for adaptation as well as environmental shaping (Cohen & Lazarus, 1979). The particular coping style that is learned during early socialization determines the relative ease and scope of lifestyle changes required to incorporate the rudiments of responsible self-care. In addition, there are known moderator variables that influence the stress-disease equation. A lexicon of these variables based on research will provide opportunities for assessment that will identify the interventions required for successful stress innoculation. Health psychologists have a role in prevention of illness based on assessment of moderator variables. The contribution of psychiatric symptoms to physical illness is the least ephemeral of these issues. Psychiatric symptoms result in behaviors that complicate treatment of physical illness and require separate therapeutic regimens. Identification of psychopathology in general medical patients can potentially reduce the frustration of primary caregivers and permit referral or medication of these patients. Power and responsibility Psychologists have a long history of research interest in power and responsibility under the rubric of locus of control. Over 1000 published studies have provided correlates of external and internal control. Health-specific locus of control measures are now popular. A Multidimensional Health Locus of Control Scale (MHLC) was developed from an initial Health Locus of Control Scale by inclusion of internal control (IHLC), and separation of two independent external dimensions, reliance on powerful others (PHLC) and reliance on chance or fate (CHLC) (Wallston, Wallston, & DeVellis, 1978). The MHLC has six items in 6-point Likert format for each of these three subscales. Similar instruments for adults (Krantz, Baum, & Wideman, 1980) and children (Parcel & Myers, 1978) have had less research use. Research findings with the MHLC are conceptualized by eight different patterns of health locus of control ideology using high and low scores on each of three dimensions (Wallston 8c Wallston, 1982). For examples, high IHLC patients may expend energy/resources constructively or futilely depending on the illness, refuse treatments, and/or alienate caregivers who may subsequently blame them when responsibility for self fails. High PHLC is adaptive only if others do, in fact, respond favorably and consistently. This rubric may ultimately permit organization of disparate studies into coherent recommendations for differential treatments. In addition, the attempt has been made to build a network of relationships to other measures (Wallston & Wallston, 1981) in which PHLC is negatively related to self-

462

Richard H. Dana

care, CHLC is positively related to depression, while IHLC has been positively related to Type A behavior, self-motivation, and will to live in geriatric patients. Relationships between MHLC dimensions and information-seeking, preventive behavior, disability, and adherence to medical regimens appear to be largely studyand sample-specific. One problem with the use of the MHLC and similar measures is oversimplification. A person’s world view includes more than locus of control, and this oversimplification may be responsible for the current status of MHLC research results. Sue (1978) has examined locus of control (LC) and locus of responsibility (LR) simultaneously. LC pertains to the relative impact of one’s own actions (internal control) or chance-luck (external control) in determining life outcomes. LR refers to attribution of blame for life problems to either the self (internal responsibility) or to society (external responsibility). Four combinations of LC and LR describe orientations toward treatment. Internalized responsibility in our culture is a prerogative of affluent persons-predominantly white and middle-class-who have accepted the Horatio Alger dictum (Internal LC/Internal LR). Such persons want to share in their own health care and be responsible for major decisions. Minority persons may have minimal control over their lives, but may be militant in trying to assert self-resonsibility (External LC/Internal LR), or feel that control of their own lives is feasible in spite of external impediments of prejudice, discrimination, and exploitation (Internal LCYExternal LR). Many persons, however, experience neither the feelings of personal power nor responsibility and thus may be entirely passive in the face of medical regimens (External LC/External LR). Another conceptualization for coping/helping separates self-responsibility for problems and solutions (Brickman, Rabinowitz, Karuza, Gates, Cohen, SC Kidder, 1982). Locus of control is involved in self-responsibility for both problem and problem-solving or solution. Furthermore, existing models may be located within this format. The moral model invokes responsibility for problems and solutions. The compensatory model is blame-free for problems but not for solutions: persons must solve their own problems. The medical model neither blames persons for problems nor holds them responsible for solutions. The enlightenment model provides blame for problems but not for solutions. The complexity of these issues is clarified by some detail of what is likely to happen when action is expected, identification of others who must act, perceptions of self, and potential pathology. Moral model persons believe in striving and exhortation, peer involvement, a lazy self to be motivated, and a lonely process. Compensatory model persons are assertive, attempt to mobilize others, especially subordinates, but feel deprived and potentially alienated. Medical model persons expect to accept treatment from experts because they are ill and experience dependency throughout the process. Enlightenment model persons expect to submit and respond to discipline from authorities on the basis of guilt but feel frustrated. Assessment issues accompany each of these models. The effective assessor may be the self, peers, or an expert. The extent to which feedback of assessment results will be beneficial is largely determined by placement of the person within one of these models. Feedback for those in the moral and compensation quadrants is for information use by themselves or peers while enlightenment and medical model quadrants suggest that usage is primarily to enlist cooperation for treatment. While limitations are more difficult to formulate, within the moral model there may be unrealistic belief in unlimited personal resources. Within the enlightenment model,

Assessment

463

assessment may contribute to continued preoccupation with the problems while the compensation model favors negative attitudes toward assessment evidenced in lessened cooperation, suspicion, and attempts to control the process. The medical model is limited by expectations that others will make decisions based on assessment. Life Stress

Life stress can be damaging or provide growth-engendering possibilities for human beings. The measurement of life stress is now credible, sophisticated, and instrument-specific. The relationship between life stress and subsequent psychiatric or physical illness is undisputed, although the magnitude of the relationships is modest, typically correlating about .30 (Christensen, 1981). Stressors have been measured by endorsement of items from a list of life events weighted for amount of change or readjustment required. This instrument was originally called the Schedule of Recent Experiences (Holmes & Rahe, 1967), and life changes were evaluated within four time periods: last 6 months, 6-12 months, l-2 years, 2-3 years. The most recent version of this list, the Recent Life Changes Questionnaire (RLCQ) was designed for prospective studies (6 months) and has 55 items and provision for assessees to assign their own subjective weights as well as standard weights for impact of events. Relevant events have been added for Blacks (West, 1978), Native Americans and Hispanic-Americans (Brandenburg, 1978), for lower socioeconomic class persons (Paykel, Prusoff, & Uhlenhuth, 1971), f or children (Gertsen, Langner, Eisenberg, & Orzeck, 1974), college students (Marx, Garrity, & Bowers, 1975), and geriatric patients (Amster & Krauss, 1974). Applications have been made to athletic injuries (Bramwell, Masuda, Wagner, & Holmes, 1975), and traffic accidents (Vinokur & Selzer, 1975). One recent version, the Life Experiences Survey (LES) (Sarason, Johnson, 8c Siegel, 1978) separates perceved desirability and undesirability of events to permit scoring for positive, negative, and total change scores. These forms have been reviewed elsewhere in detail (Christensen, 1981). Setting-specific life stress has also been measured in health professionals and labeled burnout (Maslach & Jackson, 1982). Minor life stressors or daily hassles (Kanner, Coyne, Schaefer, & Lazarus, 1981) and tedium (Kanner, Kafry, & Pines, 1978) are also assessable. Since one person with a high level of stressors will experience illness while another person with equal stressors is symptom-free, there are moderators, or intermediaries, in the stress-illness equation. The contribution of life stress to health status has been recognized since Selye (1956) posited a General Adaptation Syndrome in which alarm leads to resource mobilization, resistance, and exhaustion. Subsequent models have attempted to clarify components of this model. Lazarus (198 1) has provided a heuristic model for development of assessment devices. This model recognizes that coping is a situation-oriented, shifting process that begins with perception or primary appraisal of the nature of stress, followed by secondary appraisal of the range of coping alternatives, and finally reappraisal based on the outcomes of coping. Once an event has been defined as stressful, there are relevant assessment opportunities at each step of this process. Medical patients have many potential sources of threat: to life itself, to bodily integrity, to self-concept, to future plans, to emotional balance, to fulfillment of customary social obligations, and resulting from need to adjust to a new psycho-

464

Kichard H. Danu

logical-social world. Cohen and Lazarus (1979) summarized non-intervention studies on stress-illness relationships with medical patients. For nonsurgery patients, unfavorable outomes are associated with depression (trait), with inhibited emotion, and with additional stressors, especially when coupled with few psychosocial assets, or an imbalance between assets and stressors. For surgery patients, unfavorable outcomes are associated with preoperative fear (state), depression (state), and vigilant coping Penonality

modes. Dispositions

Personality styles, or variables that moderate physical illness, and instruments for their measurement are presented in Table 2. These variables may mitigate stressillness relationships via support, challenge, particular cognitions and behaviors, or exacerbate the equation by a life style pattern. There are also other reviews of suspected moderators that provide overlap with variables presented here. Sarason, Levine, and Sarason (1982) review research on moderator variables, including stable personality characteristics (e.g., anxiety, hostility, locus of control, sensationseeking), prior experiences, and environmental factors (e.g., social support). Dana (1984) has posited personal efficacy belief, coping skills repertoire, social supports, world view (LC plus LR), investment in life projects, health status, economic status, educational status, social class and race. However, Antonovsky (1979) has prepared the most elegant and formal statement of moderator variables in his salutogenic model of health. Research

on an array

of personality

dispositions,

or coping

styles,

has also been

reviewed by Millon (1982a). These characteristics are measured by the Millon Behavioral Health Inventory (MBHI) (Millon, Green, & Meagher, 1982a). Earlier instruments had come from rehabilitation settings and were behavioral in origin. Mossman, 8c Gresham, 1973) and The Activity of Daily Living Scale (Donaldson, Rehabilitation Indicators (Brown, Diller, Fordyce, Jacobs, & Gordon, 1980) measured self-care capacity while the Human Services Scale (Reagles & Butler, 1976) examined Maslowian need categories but all omitted subjective emotional reactivity. The MBHI is the first carefully constructed questionnaire to compile data on coping styles, known attitude and psychosomatic (e.g., allergic, gastrointestinal, cardiovascular tendencies) correlates of physical illness, and prognostic indices (e.g., pain treatment responsivity, life-threat reactivity, emotional vulnerability). Potentially this instrument can provide an economical substitute for many disparate measures. Millon, Green, and Meagher (1982b) cite positive comparisons with other scales and supportive validation data on pain management, life-threatening procedures, spinal cord injury, cerebral vascular accident, and chronic, progressive, degenerative diseases. Type A behavior pattern is a reaction to a challenging situation by a predisposed complex that person. This behavior-pattern is summarized by an “action-emotion” time urgency, excessive hostility contains a competitive achievement orientation, and suppression of these symptoms (Carver & Humphries, 1982) and is related to development and persistence or coronary heart disease. Measurement of Type A behavior began with a standard interview which led to successive versions of a selfreport questionnaire, the Jenkins Activity Schedule (Form C) (Jenkins, Zyzanski, & Rosenman, 1979). Research has focused on differences between Type A persons

465

Assessment

2. Selected Instruments

TABLE

Measurement

of Personality

Behavior

Jenkins

Pattern,

Activity

(Form

*

Variables Description

Instrument

Moderator

Type

for

Domain Moderator

C) (Jenkins,

& Rosenman,

Pattern:

Survey Zyzanski.

competitiveness,

achievement, imposed

1979)

tience,

striving,

haste,

challenge, Challenge

(Need for

Sensation-Seeking (Form

stimulation)

Scale

5) (Zuckerman,

1979)

self-

responsibility,

impa-

restlessness,

time

pressure

Factors:

thrill

seeking,

experience

and adventure

disinhibition,

seeking,

boredom

suscepti-

bility Rational

Cognitions

Behavior

(Shorkey

Inventory

& Whiteman,

Factors:

exacerbation

ousness,

guilt,

reference,

1977)

blame

of seri-

perfection,

demand

self-

for caring,

proneness,

acceptance

the unpleasant,

of

independent

decision-making/acceptance consequences, evaluations, Ways of Coping

Coping

Items

Checklist

future

Benner,

Cohen,

problem-focus

Folkman,

Kanner,

Lazarus,

behavior) ended

1980)

strategies;

Millon

Behavioral

Health

Inventory

(Millon,

Meagher,

1982a)

Green,

&

of single

event

Coping

styles:

erative,

forceful,

troversive,

and

open-

description

most stressful Dispositions

misfortune

(cognitive-

re how situation Personality

self-

for emotion-focus

(Schaefer, & Wrubel,

of

negative

and items

was appraised confident,

coop-

inhibited,

respectful,

in-

sensitive,

sociable Chronic spair, cent

attitudes: premorbid

stress,

somatic Support

Social

Support

Question-

naire

(Schaefer,

Coyne,

Lazarus,

and non-type

A persons

(Type

Functions: &

tion,

social

future

de-

pessimism,

re-

alienation,

anxiety emotional,

informa-

tangible

1981)

B) on a variety

of medically-relevant

dimensions

(Green, 1982). Measures of coping styles provide a different avenue toward identification of effective and/or self-defeating behaviors. Coping scales, or specific inventories of tactics, have been developed empirically (Bell, 1977; Sidle, Moos, Adams, & Cady, 1969). The Problem-Solving Inventory (Heppner & Peterson, 1978) was developed rationally to accord with problem-solving stages (D’Zurilla & Goldfried, 197 1) while The Ways of Coping Checklist (Schaefer et al., 1980) emerged from the Lazarus model (198 1) described earlier. This 68-item checklist provides factorial separation

466

Richard H. Dana

of problem-focus and requests a description of a stressful life event. Coping in a middle-aged community sample has been examined using this checklist (Folkman & Lazarus, 1980). A review of research on cognitions (Kendall & Braswell, 1982) has cited not only measures of beliefs but included other cognitive events such as patient expectancies, attributions, self-statements, imagery, and problem-solving. Approaches to definition of beliefs about the self and others include particular maladaptive beliefs, qualities of these irrational beliefs-particLllarly their rigidity-and dysfunctional 1981). Two major instruments, the Rational Bethought process (Sutton-Simon, havior Inventory (Shorkey & Whiteman, 1977) and the Irrational Beliefs Test (Lohr & Bonge, 1982) provide somewhat overlapping measures of those beliefs that are the focus of Ellis’ Rational Emotive Therapy. This research area does not lack instruments but as yet has not provided substantive information on the usefulness of these measures for treatment of medical patients. Reliance on relationship, support, and succor for well-being and good functioning is a precondition for group survival and development of individual humanness. Hsu (197 1) has conceptualized this affective buffering as Jen or Personage. Social support has been shown to minimize emotional disturbance (Froland, Brodsky, Olson, & Stewart, 1979). Social caseworkers who are low in anger and have positive feelings toward others were less likely to develop physical illness following high stress (Orr & Dana, 1982). Presumably because such persons have the personality prerequisites for good relationships with others, they are able to make good use of available social support. Kobasa (1982) has described a “hardy,” or stress-resistant, personality characterized by commitment, control, and need for challenge. While measurement of this syndrome is complex, there have been consistent findings for executives, lawyers, and gynecology patients. Measurement has included tallies of discrete elements to compose a Social Assets Scale (Luborsky, Todd, & Katcher, 1973) and a Social Network Index (Berkman & Syme, 1979) as well as assessments of perceived social support (Andrews, Tennant, Hewson, & Schonell, 1978; Gore, 1978). These approaches have been combined in research using the Social Support Questionnaire and Social Network Index (Schaefer, Coyne, & Lazarus, 1981). Separation of tangible, emotional, and informational social support is feasible and leads to more differentiated relationships between stress and moderation of illness. For example, low tangible support plus emotional support relate to depression and negative morale while informational support relates to positive morale in middle-aged community persons. Too much stimulation or arousal has been cited as one component of “future shock” and is a stressor to be considered in adaptation to contemporary social living. However, such stimulation or challenge can also serve as a moderator of stress for some persons. Persons who respond positively to challenge are often asocial risk-takers and independent, outgoing persons who assertively seek others as audience. A variety of measures have been developed f-or research purposes beginning with the Murray need Change. The Sensation-Seeking Scale (Zuckerman, 1979), Form V, has 40 items that define four factors of thrill and adventureseeking, experience seeking, disinhibition, and boredom susceptibility, although there has been scant application to medical patients.

467

Psychiatric Symptoms Table 3 presents

instruments

for measurement of the psychiatric symptom domain. symptom description, and specific for psychodiagnosis, Traditional instruments like the Minnesota Multiphasic with medical Personality Inventory (MMPI) h ave often been used inappropriately 1981). These patients need to be viewed patients (Bradley, Prokop, SC Clayman,

Representative examples symptoms are included.

within a context of factors relevant to a particular physical condition. The focus in the MMPI, for example, thus shifts from psychiatric diagnosis to the unique behavioral attributes of the patient or to differential responses of a defined group of medical patients to various treatments. As a result, the basis for practice will be to provide replicable MMPI profile subgroups within a particular patient population and subsequently to identify correlates of each profile subgroup (Bradley, 1981). These correlates include deProkop, Gentry, Van der Heide, & Prieto, mographic or medical attributes or behaviors. Often these profile subgroups will be generated from short-forms of the MMPI since medical patients may experience TABLE Measurement Psychiatric Symptom

3. Selected Instruments for of Psychiatric Symptom Domain

Instrument

Description

Psychopathology

Minnesota Multiphasic Personality Inventory (Greene, 1980)

Clinical scales: Hypochondriasis, Depression, Conversion Hysteria, Psychopathic Deviate, Paranoia, Psychasthenia, Schizophrenia, Hypomania.

Psychopathology (DSM-Ill)

Millon Clinical Multiaxial Inventory (Millon, 1982b)

Clinical scales: Basic personality patterns (Schizoid, Avoidant, Dependent, Histrionic, Narcissistic, Antisocial, Compulsive, Passive-Aggressive); Pathological personality disorders: (Schizotypal, Borderline, Paranoid); Clinical symptom disorders (Anxiety, Somatoform, Hypomanic, Dysthymic, Alcohol Abuse, Drug Abuse, Psychotic Thinking, Psychotic Depression, Psychotic Delusions).

Symptoms

Symptom Checklist (SCL-90) (Derogatis, 1979)

Primary symptom dimensions: obsessivecompulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, psychoticism. Three global indices: Global Severity lndex, Positive Symptom Distress Index, Positive Symptom Total.

Depression

Beck Depression (Beck, 1972)

Multiple choice items for specific behavioral signs of depression in psychiatric populations, weighted in severity.

Anxiety

State-Trait Anxiety Inventory (Spielberger, Gorsuch, & Lushene, 1970)

Inventory

Self-ratings for two forms of anxiety, trait (chronic) and state (transient/situational) in normal populations.

468

Richard H. Lkma

severe pain and other situational concerns that affect concentration, or have lanthere are litguage difficulty (Faschingbauer SC Newmark, 1978). Furthermore, erally hundreds of special scales which may be scored from the item pool, or used separately, for particular measurement purposes and to delineate symptomatology for patient subgroups. There are some sound reasons for preferring the Millon Clinical Multiaxial Inventory (MCMI) (Millon, 1982b) to the MMPI for medical patients. This test combines brevity with sophisticated c(~r~struction and uses DSM-III as a measurement focus. However, it lacks the MMPI history of application to medical patients and must be scored and interpreted elsewhere on a fee basis. Often it is helpful to have the description of pathological behaviors without the potentially stigmatizing labels. The question may be, “Are there behaviors of psychopathological origin which will complicate treatment or minimize good prognosis?” A brief screening test may suffice to provide this information. The first widely used instrument, the Cornell Medical Index (Brodman, Erdman, & Wolff, 1949), is now out-of-date. A sophisticated descendant is the Symptom Checklist90 (XL-90) which is based on the Hopkins Symptom Checklist (Derogatis, 1977). The XL-90 provides a systematic array of nine primary symptom dimensions and three global indices. Interpretation includes three levels: global, level of psychopathology, and presence or absence of specific symptoms. Finally, it is often helpful to have measures of symptoms which are frequently associated with certain medical conditons. These symptoms may require separate treatment in order to dampen their effects on the primary illness process. While there are many such measures, depression and anxiety are prototypical. The Beck Depression Inventory (Beck, 1972) approximates clinical judgments for intensity of depression. Since this instrunlent has only 21 multiple-choice items, it can be administered easily. The State-Trait Anxiety Inventory (STAI: Spielberger, Gorsuch, & Lushene, 1970) is also brief, carefully constructed and validated, and has the advantage of separating situational from chronic anxiety. This instrument should become a major component in health psychology assessment.

CLINICAL HEALTH ASSFSSMENT FOR TWO SPECIFIC POPUIATIONS Coronary Artery Disease resulted in 720,000 deaths in 1976, and established risk factors have failed to predict the onset of the disease for many persons. A biopsychosocial approach emphasizes that there is no consistent, all-inclusive biological marker and that beta-adrenergic response to specific stressors mediates between a coronary-prone behavior pattern and coronary artery disease (Glass, 1977). Most major studies of coronary artery disease include health assessment. The Structured Interview (SI) (Friedman 8c Rosenman, 1959: Rosenman & Friedman, 1961), theJenkins Activity Survey (JAS) (J en k ins, Rosenman 8c Friedman, 1967), and 20 cross-validated adjectives from the Adjective Checklist (Cough & Heilbrun, 1975) are representative assessment instruments for Type A behavior. An illustrative SI protocol and tabularization of Type A and Type B characteristics has been used to exemplify measurement in a recent review (Chesney, Eagleston & Rosenman, 1981). The JAS has three factor subscales-Speed and Intelligence, Job Involvement, and Hard-Driving. The SI and JAS have provided 72% agreement on

469

Assessment

classification of Type A behaviors. One illustrative study (Suinn & Bloom, 1978) used the JAS to identify those persons who received their Cardiac Stress Management Training. The Speed-Inpatient and Hard-Driving JAS subscales as well as STAI state and trait anxiety measures were significantly reduced as a result of training. However, persons at risk are not necessarily motivated to change in contrast with myocardial infraction patients (Chesney, Eagleston, & Rosenman, 1981). It is possible to identify some phase-specific instruments for assessment in the area of coronary artery disease. Table 4 suggests instruments which have typically not been used heretofore in this context but are representative of examples that could be developed for many major diseases. This table juxtaposes illness phases with known correlates. For example, factors related to reduced risk during the premorbid phase-meaningful relationships, love/support, physical activity-as well as factors that contribute to increased risk-anxiety, depression, and Type A behavior-can be assessed. During the hospital phase it is feasible to assess psychological responses that complicate treatment in a coronary care unit as well as those symptoms that may accompany transfer from this unit. Finally, during convalescence there are a variety of personality dispositions which may require alleviation as an adjunct to posthospital care.

TABLE 4. Specific Assessments for Premorbid, Hospital, and Posthospital Phases of Coronary Artery Disease Phase Premorbid

Variable Meaningful

Instrument

relationships

(Berkman

& Syme,

Social Network

Love/support (Medalie,

Leary

Kahn,

Adjective

Checklist

1973)

activity

(Paffenbarger

Interpersonal

Neufeld,

Riss, & Goldbourt, Physical

Index

1979)

Physical

activity

indices

& Wing,

1969) Psychopathology-anxiety/

State-Trait

depression

Beck

(Jenkins,

Anxiety

Depression

Inventory

Scale

1976) Jenkins

Type * (Friedman

& Rosenman,

Activity

Structured

Survey

Interview

1959)

Hospital

Psychological

responses

to

Millon Behavioral

Health

Inventory

illness (Cassem

& Hackett,

Transfer Care

from

1971)

Coronary

Unit

Interpersonal (Hirschfeld,

(Resnekov,

1977)

Korchin

& Chedoff,

State-Trait Posthospital

Convalescence (Hackett

& Cassem,

Beck 1975)

Dependency Klerman, Anxiety

Depression

Self-Esteem

Inventory

Gough, 1977)

Inventory

Inventory

Barrett,

Geria tries

Health assessment for geriatric patients is largely a future agenda. Not only does our culture fail to cherish and revere its seniors but we resent the costs of their care and tacitly accept the nostrums that age-attendant miseries are hopeless in persons who should only desire to fade away {Kastenbaum, 1982). Since there is decline in physical functioning and health, a focus on bodily complaints may not be inappropriate or necessarily psychopathological. Many other changes associated with age are more equivocal. Verbal aspects of intellectual function do not decline while psychomotor speed and problem-solving do decline, although the rates may differ for different persons. There are changes in social assets from loss, ensuing isolation, and enduring loneliness. The aged are especially at risk for psychiatric disorders (Kraus, Spasoff, Beattie, Holden, Lawson, Rodenburg & Woodcock, 1976). Personality-wise, the twin tasks are to make some ultimate sense of existence and to accept inevitable death. Solomon, Faletti, and Yunik (1982) outline assessment goals in the areas of diagnosis, etiology, and progress. While it is often diagnostically necessary to differentiate pathological from normal aging, we have yet to establish normative ranges of function for use instead of unsubs~ntiated assumptions about life events and adaptive capacities. There is little justification for conventional measures of psychopathology such as the MMPI and MCMI without an adequate normative basis for their interpretation. Since depression and affective disorders are common, short and focused instruments are preferable. It is crucial to emphasize that hostility, aggression, and paranoid ideas may have survival value in the aged by counteracting effects of “institutionalization” (e.g., apathy, dependency) and facilitating continuous self-definition (Levy, 1981). Knowledge of etiology can be a contribution to accurate diagnosis and relevant intervention. Functional assessment has been provided by Pfeiffer’s (1975) multidimensional approach that includes physical and mental health, social engagement and support, economic resources, and ability to carry out basic self-care activities. Assessment of progress may be more critical than diagnosis since information regarding adaptation to particular regimens and interventions is necessary for program evaluation and the design of adequate interventions. HFALTHASSESSMENTFOR THE GENERAL~PU~nON A health psychology for medical patients impacts on physical illness by recognizing the complexity of interrelated facets that contribute anxiety, discomfort, pain, discouragement, faulty thinking, depression, distrust, inattentativeness and noncompliance which may exacerbate or prolong illness. Assessment of these ingredients and providing for a research basis for such practice constitutes a contribution to health care. It is an easy extrapolation to assessment “bad" habits and ineffective lifestyles in the general population in order to provide baselines for subsequent interventions by means of workshops, group process, and community education. Health hazard appraisal, or health risk estimation, is germane for health maintenance and prevention of illness. Health hazard risk estimation by the physician began a decade ago (Robbins & Hall, 1970) but has not become popular. A variety of methods are now available directly to the general public (Hettler, Janty, & Moffat, 1977) at nominal cost. All have questionnaire, computer program, and report

of

Assessment

471

components. One recent instrument, the Personal Risk Profile (Bernstein & Duff, 1979) provides a 4%page report on general well-being, social supports, coping, heart disease/stroke, blood pressure, exercise, cholesterol, weight, Type A behavior, smoking, cancer risk, alcohol, motor vehicle accident, health age and life expectancy, and health attitudes. In the aftermath of screening, intervention may consist of providing information, training for self-care, a behavioral contract, and facilitating professional intervention. The general public requires these services in addition to honest feedback of the findings from health hazard appraisal with professional counseling assistance, if desired, in order to make effective use of the information. A secondary assessment task here would be to identify those personal resources, lifestyle strategies, and coping skills that constitute the ingredients for optimal follow-up on the findings from health hazard appraisal. There has been one study on the effectiveness of the health hazard appraisal message of projected personal risk (Cioffi, 1979). When feedback effects on perceptions of susceptibility and benefits of prevention were examined one month after appraisal, no significant differences in perceptions were found. Similarly, the manner of providing feedback (printed feedback versus printed feedback plus counseling session) did not affect perceptions. It is difficult to dissuade persons by information alone that their beliefs in personal invulnerability may be false. A solitary significant relationship between locus of control and low risk level suggests that those persons who are already aware of personal responsibility for self-care are more internally controlled. Clinical psychology service providers have been preoccupied with the human aftermath of emotional distress and, more recently, physical disease rather than with prevention by attention to soundness of personal lifestyle. However, the eventual focus for a health psychology is on prevention of illness by a lifestyle that has been called “high level wellness.” Ardell(l982) has provided a continuum to suggest the differences between illness-precursors, not being sick, sporadic efforts toward improved health, and whole person excellence or high level wellness. High level wellness involves lifestyle attention and self-responsibility for nutritional awareness, physical fitness, stress awareness and management, and environmental sensitivity. Authors like Ardell (1982) and Clark (198 1) have provided self-administered, selfscoring, and self-interpreted questionnaires to assess the status of a self-managed, wellness lifestyle. This wellness enterprise assumes that human growth (teleology) is feasible and has identifiable parameters contained in developmental theories (e.g., Loevinger, 1976). The area of high level wellness is largely beyond the purview of traditional health assessors and caregivers. This alternative service delivery system is identified partially with the holistic health movement (Mattson, 1982), partially with responsible popularizations of current research (Davis & McKay, 1980; Haney 8~ Boenisch, 1982), and partially with a consciousness-expansion reflected in contemporary writings (Ferguson, 1982). A BlOPSYCHOSOClAl.

FRAMEWORK FOR THE FUTURE

Schwartz (1982) sees health care as still predicated on medical model thinking that is categorical and single-cause, single-effect. A biopsychosocial model is multicategory, multicause, and multi-effect. Engel (1977) believes that a biopsychosocial model is adequate for the scientific tasks and social responsibility of our era. We

472

Richard H. Dam

are on the threshold of a health care system that is multidisciplinary, researchbased, and acceptant of a patterning of causes that represent a general systems framework of biological, psychological, and social levels. Pankratz and Taplin (1982) have emphasized that such a framework would provide equal assessment attention to biological, intrapersonal, interpersonal, family, organizational, and social systems in order to identify and prioritize interventions at any level. Furthermore, they envision a lexicon of assessment instruments for each level and an empirical literature that provides evidence for selection of curative, learning, or growth intervention strategies. Assessment for system-relevance must be predicated on assessor awareness that any and all systems may contribute to problems. Heretofore, psychologists have used only a very small number of instruments that focus on the intrapersonal and interpersonal levels. Assessors have also been predisposed to ignore verifiable organic origins for psychological symptoms (Hall, Popkin, Devaul, Faillance, & Stickney, 1978) as well as physical symptoms with psychological origins (Browning, 1974). Assessment research that is conceived within a general Miller, & Tyson, systems framework should provide for further partitioning among the four health assessment domains proposed here.

1. Health assessment includes interactive life stress, personality dispositions, and 2. The power and responsibility domain sessment within a context of attribution 3.

4.

domains for power and responsibility, psychiatric symptoms. pertains to health locus of control asof responsibility for problems and their

solutions. Life stress provides a carefully documented relationship with psychiatric or medical illness. Stress mediation has been conceptualized to delineate assessment opportunities and the stress-illness equation contains moderator variables that dramatically affect illness outcomes. The personality domain has a pervasive contribution to illness that has recently been articulated by a variety of assessments. These measures are both global and specific and constitute some starting points for specification of moderator

variables. 5. The psychiatric symptoms domain contains traditional instruments used in novel ways with medical patients as well as new or altered devices for specific assessment purposes. 6. Health assessment for specific medical populations is illustrated by the areas of coronary artery disease and geriatrics. 7. Health assessment is being extrapolated to the general population in the form of computerized interpretation of health risk estimation and by a recent proliferation of self-assessment devices. The authors of these instruments hope to increase awareness of holistic health and foster self-managed wellness lifestyles. 8. Assessment for a health psychology may be conceptualized within a biopsychosocial model of service delivery that posits multicauses and multieffects.

Assessment

473

Amster, L. E., & Krauss, H. H. (1974). The relationship between life crises and mental deterioration in old age. International Journal of Aging and Human Development, 5, 51-55. Andrews, G., Tennant, C., Hewson, D., & Schonell, M. (1978). The relation of social factors to physical and psychiatric illness. American Journal of Epidemiology, 108, 27-35. Antonovsky, A. (1979). Health, stress, and copmg. San Francisco: Jossey-Bass. Ardell, D. (1982). 14 Days to a wellness lifestyle. Mill Valley, CA: Whatever Publishing Co. Beck, A. T. (1972). Depression: Causes and treatment. Philadelphia: University of Pennsylvania Press. Bell, J. M. (1977). Stressful life events and coping methods in mental-illness and -wellness behaviors. Nursing

Research,

26,

136-

14

1.

Berkman, L. F., & Syme, S. L. (1979). Social networks, host resistance, and mortality: A nine year followup study of Alameda County residents. American Journal of Epidemiology, 109, 186-204. Bernstein, J. E., & Duff, J. F. (1979). The Personal Health Profile: A new health risk estimation instrument, Proceedings of the Fifteenth Annual Meeting of Prospective Medicine and Health Hazard Appraisal (pp. 50-53). Bethesda, MD: Health and Education Resources. Boice, R. B. (1983). Observational skills. Psychologzcal Bulletin, 93, 3 -29. Bradley, L. A., Prokop, C. K., Gentry, W. D., Van der Heide, L. H., & Prieto, E. J. (1981). Assessment of chronic pain. In C. K. Prokop and L. A. Bradley (Eds.), Medicalpsychology: Contributions to behavioral mediczne (pp 92- 137). New York: Academic Press. Bradley, L. A., Prokop, C. K., & Clayman, D. A. (1981). Medical psychology and behavioral medicine: Summary and future concerns. In C. K. Prokop and L. A. Bradley (Eds.), Medzcal psychology: Contributiolls to behavioral medicine (pp. 497-502). New York: Academic Press. Bramwell, S. T., Masuda, M., Wagner, N. N., & Holmes, T. H. (1975). Psychosocial factors in athletic injuries. Journal of Human Stress, 1, 6-22. Brandenburg, C. E. (1978). V&&ion of the Social Readjustment Ratzng Scale with Mexican-Americans and Native Americanr. Unpublished doctoral dissertation, University of Nevada at Reno. Brickman, P., Rabinowitz, V. C., Karuza, J., Jr., Coates, D., Cohen, E., & Kidder, L. (1982). Models of helping and coping. Amencan Psychologist, 37, 368-384. Brodman, K., Erdman, A. J., & Wolff, H. G. (1949). Cornell Medical Index Questionnaire. New York: Cornell University Medical College. Brown, M., Diller, L., Fordyce, W., Jacobs, D., & Gordon, W. (1980). Rehabilitation indicators: Their nature and use for assessment. In B. Bolton & D. W. Cook (Eds.), Rehabilitatzon client assessment (pp. 102- 117). Baltimore: University Park Press. Browning, C. H., Miller, S. F., & Tyson, R. (1974). The psychiatric emergency: A high risk medical patient. Comprehensive Psychiatry, 15, 153- 156. Carver, C. S., & Humphries, C. (1982). Social psychology of the Type A coronary-prone behavior pattern. In G. S. Sanders &J. Suls (Eds.), Social psychology of health and illness (pp. 33-64). Hillsdale, NJ: Erlbaum. Cassem, N. H., & Hackett, T. P. (1971). Psychiatric consultation in a coronary care unit. Annals of Interual Medicine, 75, 9- 14. Christensen, J. F. (198 1). Assessment of stress: Environmental, intrapersonal, and outcome indices, In P. McReynolds (Ed.), Advances in psychological assessment, Vol. 5. (pp. 62- 123). San Francisco: JosseyBass. Chesney, M. A., Eagleston, J. R., & Rosenman, R. H. (1981). Type A behavior: Assessment and intervention. In C. K. Prokop & L. A. Bradley (Eds.), Medrcalpsychology: Contributions to behavioral mediczne (pp. 19-36). New York: Academic Press. Cioff, J. P. (1979). The effect of health status feedback on health beliefs: An inquiry into the prebehavioral outcomes of a health hazard appraisal. Proceedings of the Fifteenth Annual Meeting of Prospective Medictne and Health Hazard Appraisal. Bethesda, MD: Health and Education Resources, 41-47. Clark, C. C. (1981). Enhancing wellness: A guide for self-care. New York: Springer Publishing Co. Cohen, F., & Lazarus, R. S. (1979). Coping with the stresses of life. In G. C. Stone, F. Cohen, & N. E. Adler (Eds.), Health psychology: A handbook (pp. 217-254). San Francisco: Jossey-Bass. Dana, R. H. (in press-a). Clinical assessment. In G. S. Tryon (Ed.), The professional practzce of psychology. Not-wood, NJ: Ablex. Dana, R. H. (1984). Personality assessment: Practice and teaching for the next decade. Journal of Personality Assessment, 48, 46-57.

474

Richurd H.

Dana

Davis, M., & McKay, M. (1980). The relaxation and stress-reductzon workbook. (‘2nd ed). Richmond, CA: New Harbinger Publications. Derogatis, L. R. (1977). XL-90 {Revised} Version iClnnuaE-1. Batitmore: Author. Donaldson, S. W., Mossmann, P. L., & Gresham, G. E. (1973). A unified ADL evaluation form. Archives of Physical Medicine and Rehubilttation, 54, 175- 179. D’Zurilla, T. J., & Coldfried, M. R. (197 1). Problem-solving and behavior modification. Journal of Abnormal Psychology, 78, 107- 126. Engel, G. L. (1977). The need for a new medical mode!: A challenge for biomedicine. Science, 196(4286), 129- 135. Faschingbauer, T. R., & Newmark, C. S. (1978). ~hortfor~ ofthe MMPI. New York: Lexington Books. Ferguson, M. (1981). The aquarian conspiracy. Los Angeles: Tarcher. Folkman, S., 8c Lazarus, R. S. (1980). An analysis coping in a middle-aged community sample. Journal

of

ofHealth

and Social Behavior,

21, 219-239.

Friedman, M., & Rosenman, R. H. (1959). Association of specific overt behavior pattern with blood and cardiovascular findings-blood cholesterol level, blood ciotting time, incidence of arcus senilis, and clinical coronary artery disease. Jozmrnul af‘the A~~r~~n Medical As~oc~ut~o~, 169( 12). !286- 1296. Froland, CL, Brodsky, G., Olson, M., & Stewart, L. (1979). Social support and social adjustment: implications for mental health professionals. Communify Meutal Health Journal, 15, 82-93. Gersten, J. C., Langner, T. S., Eisenberg, J. G., & Orzeck, L. (1974). Child behavior and life events: Undesirable change or change per se? In B. S. Dohrenwend and B. P. Dohrenwend (Eds.), .Stres.ful life event: Their nature and effycts (pp. 159- 170)). New York: Wiley. Cinzberg, E. (1977). The sacred cows of health manpower. Mnn and Medicine, 2, 235-242. Glass, D. C. (1977). Behavior patterm, .sfrm, and conmar?, d&me. Hillsdale, N-J: Erfbamn. Gore, S. (1978). The effect of social support in moderating the health consequences of unemployment. Journal

of Health and Social Behavior,

19, I57-

165.

Cough, H. I-l., & Heilbrun, A. B. (1075). The adJectiue chrckhxt. Palo Alto: Consulting Psychologists Press. Green, C. J, (1982). Psychological assessment in medical settings. In ‘I’. Millon, C. Green & R. Meagher (Eds.), Handbook ofclzuical health psychology (pp. 339-37.5). New York: Plenum Press, Greene, R. L. (1980). The MMPI: Au iutrrpretive manual. New York: Prune 8i Stratton, Hackett, T. P., 8r Cassem, H. N. (1975). The psychologic reactions of patients in the pre- and posthospital phase of myncardia! infraction. Po.~t~~ldz~~te Medicine. 57(5), 43-46. Hal!, R. C. W., Popkin, M. K., Drvaul, R. A., Faillance, L. A., & Stickney, S. K. (1978). Physical illness presenting as psychiatric disease. Archives of C~neral Psychintq, 35, 1315- 1320. Haney, t:. M., & Boerriscti, E. W.. Jr. (1082). Stwrnnp. San his Obispo, (LA: Impact. Heppner, F. P., & Peterson, C. H. (1978).The development, factor analysis. and initial validation of a problem-solving instrument, Paper !xesented at the meeting o!’ the American Educational Research Association, Toronto. Hettler, B., Janty, C., & Mof‘f’at, C:. (1977). A comparison of seven methods of health hazard apprasia!. Pr0ceeding.s of the Thirt&&r A7171uni Meeting, Society of Pm~prrtivr Medtcine, San Diego, pp. 36-44. Hirschfeld, R., Kterman, G., Cough, H., Barrett. J., Korchin, S., & Chedoft. P. (1977). A measure of interpersonal dependency. Journal of Per.~onnhty A.~xmnent, 41, 6 1O-6 1X. Holmes, T. S., & Rahe, R. H. (1967). The Social Read.justment Rating Scale. Journal of P.ychosomntic Research.

11, 213218.

Hsu, F. L. K. (1971). Psychological homeostasis and Len: Conceptual tools for advancing psychoiogica! anthropology. Amencan A?zthroFo~o~t. 73, 23-44. Jenkins, C. D. (1976). Recent evidence supporting psychological and social risk factors for coronary disease. New England Journal of Medrrine, 294( IX), 9X7-994. Jenkins, C. D., Rosenman, R. H., % Friedman, M. (1976). Development of an objective psychological test for the coronary-prone behavior pattern in employed men. ,Jour-nal of Chronzc Dt.seares, 20, 37 l379.

-Jenkins, C. D., Zyzanski, S.J.. 8t Rosenman, R. I-l. (I 979). Jenkins ,~ct~~~jtySurvey ,~f~~~~. New York: The PsychologicaI Corporation. Kanner, A. D., Kafry, D., & Pines, A. (3978). Conspicuous in its absence: The lack of positive conditions as a source of stress. Journal of Human Stress, 4, 33-39. Kanner, A. D., Coyne, J. C., Schaefer, C., 8c Lazarus, R. S. (1981). t:omparisons of. two modes of stress measurement: Daily hassles and uplifts versus major life events. Journal of Brhar~ioral Medzcine, 4, I 9.

Kastenbaum,

R. (1982).

Healthy.

wealthy, and wise? Health

care provision

l’or the elderly

f-rom a

Assessment

475

psychological perspective. In G. S. Sanders, J. Suls (Eds.), Social psychology of health and illness (pp. 307-326). Hillsdale, NJ: Erlbaum. Kendall, P. C., & Braswell, L. (1982). On cognitive-behavioral assessment: Model, measures, and madness. In C. S. Spielberger, & J. N. Butcher (Eds.), Advances in personality nrsessment. Vol. 1. (pp. 3582). Hillsdale, NJ: Erlbaum. Kobasa, S. C. (1982). The hardy personality: Toward a social psychology of stress and health. In G. S. Sanders &J. Sub (Eds.), Social psychology of health and illness (pp. 3-32). Hillsdale, NJ: Erlbaum. Krantz, D. S., Baum, A., & Wideman, M. V. (1980). Assessment of preferences for self-treatment and information in medical care. Journal of Personality and Socral Psychology, 39, 977-990. Kraus, A. S., Spasoff, R. A., Beattie, E. J., Holden, D. E. W., Lawson, J. S., Rodenburg, M., &Woodcock, G. M. (1976). Elderly applicants to long-term care institutions: Il. The application process: Placement and care needs. Journal of the American Geriatrics Society, 24(8), 364-467. Lazarus, R. S. (1981). The stress and coping paradigm. In C. Eisdorfer, D. Cohen, A. Kleinman & P. Maxim (Eds.), ModeO for clinical psychopathology (pp. 177-222). New York: Spectrum. Lazarus, R. S., Averill, J. R., & Opton, E. M., Jr. (1974). The psychology of coping: Issues of research and assessment. In G. V. Coelho, D. A. Hamburg, &J. E. Adams (Eds.), Coping and adaptation (pp. 219-315). New York: Basic Books. Levenson, R. W. (1983). Personality research and psychophysiology: General considerations Journal of Research in Personality, 17, l-2 1. Levy, S. M. (1981). Treatment of the chronically ill geriatric patient. In C. K. Prokop & L. A. Bradley (Eds.), Medical psychology: Contributiolzr to behavioral medicine (pp. 119- 137). New York: Academic Press. Loevinger, J. (1976). Ego-development. San Francisco: Jossey-Bass. Lohr, J. M., & Bonge, D. (1982). The factorial validity of the Irrational Beliefs Test: A psychometric investigation. Cognitive Therapy azd Research, 6, 225-230. Luborsky, L., Todd, T. C., & Katcher, A. H. (1973). A self-administered social assets scale for predicting physical and psychological illness and health. Journal of Psychosomatic Research, 17, 109- 120. Marx, M. B., Garrity, T. F., & Bowers, F. R. (1975). The influence of recent life experiences on the health of college freshman. Journal of Psychosomatic Research, 10, 87-89. Maslach, C., &Jackson, S. E. (1982). Burnout in health professions: A social psychological analysis. In G. S. Sanders & J. Sub (Eds), Social psycholoa of health and illness (pp. 227-251). Hillsdale, NJ: Erlbaum. Matarazzo, J. D. (1982). Behavioral health’s challenge to academic, scientific, and professional psychology. American Psychologist, 37(l), 1- 14. Matarazzo, J. D. (1983). Education and training in health psychology: Boulder to bolder. Health Psychology, 2(l), 73-l 13. Mattson, P. H. (1982). Holistic health in perspective. Palo Alto, CA: Mayfield. Medalie, J. H., Kahn, H. A., Neufeld, H., Riss, E., & Goldbourt, U. (1973). Five-year myocardial infraction incidence. Il. Association of single variables to age and birthplace. Journal of Chronic Diseases, 26, 329-349.

Millon, T. (1982a). On the nature of clinical health psychology. In T. Millon, C. Greene, & R. Meagher (Eds.), Handbook of clinical health psychology (pp. l-27). New York: Plenum Press. Millon, T. (1982b). Millon Clinical Multi&al Inventory Manual. Minneapolis: Interpretive Scoring Systems. Millon, T., Green, C. J., & Meagher, R. B. (1982a). Millon Behavioral Health Inventory Manual. Minneapolis: Interpretive Scoring Systems. Millon, T., Green, C. J., & Meagher, R. B. (1982b). A new psychodiagnostic tool for clients in rehabilitation settings: The MBHI. Rehabilztation Psychology, 27, 23-35. Orr, P. L., & Dana, R. H. J. (1982). Life events, resistance resources. and health status of social caseworkers. Journal of Sociology and Social Welfare, 9(Z), 245-257. Paffenbarger, R. S., Jr., & Wing, A. L. (1969). Chronic disease in former college students. I. The effects of single and multiple characteristics on risk of fatal coronary heart disease. Amencan Journal of Epidemiology,

90(6),

527-535.

Pankratz, L. D., & Taplin, J. R. (1982) Issues in psychological assessment. In J. R. McNamara & A. G. Barclay (Eds.), Critical issues, developments, and trends in professional psychology (pp. 115- 151). New York: Praeger. Parcel, G. S., & Myers, M. P. (1978). Development of an instrument to measure children’s health locus of control. Health Education Monographs, 1978, 6, 149-159.

E. f-f.

Paykel, E. S., Prusoff, B. A., & ~Jhlenhuth, ~.~~C~~~~, 25, 340-347.

Resnekov,

1,. (1977).

Intermediate

coronary

(3971). Scaling

care units.jounuzl

of life events.

Arrfii2rr.c 0f G~twrul

oft/wAmwircz?ti~ledz~n/A.\.tortntion.

237( 16),

1697--169X.

Rosenman, R. H., X Friedman, M. (1961). Association of.specific behavior pattern in women with blood and cardiovasrular findings. Circulation, 24, I 173 - 11X4. Sarason, 1. G., Johnson, J. H., 8e Siegel, J. M. (197X). Assessing the impact otlite changes: Development and ~lmicul f”.ycholoq: 46. 932-946. of the Life Experience Survey._/ our-nnl of Coruultiq Sarason, I. G,, Levine, H. M., & Sarason, B. S. (I!)%?). Assessing the impact ot hfe changes. in T. Millon, C.
of &hmioml

Medicinr,

4, 38

I-

406.

Schwartz. (G. E. (1982). Testing the biopsychosocial model: The ultimate challenge facing behavioral medicine. Jounult of (;u7~iz~lti~~ and Chrtimi ~.s~rh[~l#~, 50, 1040- 1053. Selye, H. (19.56). Thr ~frm of I@. New York: MrC:raw-Hill. Shorkey, C., & Whiteman, V. (1977). Development of- the Rational Behavior Inventory: Initial validity and reliability, Educ&mnl md P.syholopal Mmnuwnunt, 37, 527-554. Sidle, A., Moos, R., Adams, J., & C:ady, P. (1969). Development of a coping scale. Arrhiw~ of Gwuml Psyhiatry. 20, 226-232. Solomon, J., Faletti, M.. 6c Y&k, S. (1982). The psychologist as geriatrir clinician. In T. Millon, C. Green, (L R. Meagher (Eds.). ff~lufb[~(}k rijrhnrrni hp~~tfl p,~vrff(~lo~ (pp. 227-249). IVex, York: Plenum. Spielberger. C. D., Gorsurh, R. I,., K- Lushenc, R. ( 1970). ?/us Stotr-Twit ,47~swf~ Inzwtoq :2lanunl. Pdkl Alto:‘?:onsulting Psychologists Press. Sue, D. W. (1978). Eliminating cultural oppression in counseling: ‘I‘oward a general theory. Jow?uz/ of Counsling Psyrhology, 25(5), 4 19-428. Suinn, R. M., & Bloom, L. J. (1978). Anxiety management training for- Pattern A behavior. Journal 01 ~rhu~l~~jr~l ~f~di~i?l~, 1. 25-36.

Vinokur, A., & Seizer. M. I.. (1975). Desirable versus undesirable life events: Their relationship to stress and mental disorder. Journnl q’ ~~r.wnnlzt~ and So&l P.\ycholo~, 32, 329-337. Wallston, K. A., & Wallston, B. S. (19H’L). Who is responsible for your health? The construct of health locus of control. In (;. S. Sanders &J. Suls (Eds.), .Sorir~I p,s~~.h~)~f~~(4 hrrtlth md illtms (pp. 65-95). Hillsdale, NJ: Erlbaum. Wallston, K. S., 6i Wallston, B. S. (1981). Health locus of control scales. in H. Lefcourt (Ed%), Rmwrrh with the lmo o/ control con.~tmcf. (Vol. 1 ). (pp. 180-243). New York: Academic Press. Wallston, K. A., Wallston, 8. S.. % DeVellis, R. (197X). Development of the Multidimensional Health Locus of Control (MHLC) Scales. Hrolth Educntum Monogma~t~.~, 6, 16 1- 170. West, J. P. (1978).The Soc-ial Readjustment Rating Scale: A study of life events and prediction of illness onset on the Afro-American. ~Jrlpu~fisl~~~l doctoral dissertation, University of Nevada at Reno. Zuckerman, M. (1979). ~~tuntion-,\~~kln~: Llqwnd the ~~tjf?lff~ lmrf of rrwwtr~. ~~illsclale~ NJ: Erlbaum.