Critical Health Psychology View of Stress

Stress is a natural subject for critical health psychology.

Critical health psychology is not so much an intersection of two fields, health psychology and critical psychology, as it is a union of the two in expanding beyond the traditional limits of medicine and clinical psychology.

Here is S. Taylor’s definition of health psychology, quoted by Isaac and Ora Prilleltensky: “Health psychology is the field within psychology devoted to understanding psychological influences on how people stay healthy, why they become ill, and how they respond when they do get ill.” [Prilleltensky 2003 pg. 200].

In other words, health psychology addresses the mental or extra-biological elements of illness and wellness.

Meanwhile, critical psychology “is not a special field but rather an approach to the entire field of psychology [that] attends to the pervasive influence of power in all we do… [and then seeks to] transform that awareness into practices that promote well-being and liberation…” [Prilleltensky 2002 pg. xii].

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As Tod Sloan puts it, “…the aim of critical psychology is to expose social sources of human suffering and to suggest alternative arrangements.” [Sloan 1996 pg vii]. Sloan again: critical psychologists all display “an insistence on examining the societal and cultural roots of psychological experiences that non-critical psychologists choose to view as purely psychological, merely interpersonal, or primarily biological.” [Sloan 1996 pg. 2].

According to Prilleltensky, “The critique leveled against health psychology is not only that it responds late to conditions, but also that it addresses individuals and not societal structures.” [Prilleltensky 2003 pg. 203]. Critical health psychology is then an expansion that “aims to analyse how power, economics, and macrosocial processes influence and/or structure health, health care, health psychology, and society at large.” [Marks 2002 pg. 15].

Hence traditional psychology studies, and works to treat, psychosomatic distress, while critical health psychology expands the field to study, and work to treat, socio-somatic distress.

Now stress, as a concept, immediately invokes the American Psychological Association’s “biopsychosocial model” quoted by Marks: “the product of a combination of factors including biological characteristics, behavioural factors, and social conditions.” [Marks 2002 pg. 10] The very concept of “stress,” and its consequences, involves the medical establishment in looking beyond merely biological factors for the aetiology of illness and disease. Stress is not a germ. Stress is not a congenital disorder. Once “stress” is treated as causative, the researcher is looking beyond the physical body to external conditions as mediated by the psychological engagement with these conditions. Surely such an inquiry does not stop short of including cultural, economic, and social conditions.

Unfortunately, in traditional medicine, it did. Stress is not merely an external—no external necessarily produces stress. Stress is an aspect of the interaction between the biological and the external condition in which it lives. The term “stress” is descriptive of a biopsychosocial, or even bio-psycho-socio-environmental engagement.

Critical health psychology (qua “health”) looks more directly at the social end of this system. The defect, or fault, lies with the conditions society inflicts on its members. Qua “critical,” it seeks proactively to challenge society to ameliorate stress-inducing conditions to promote and maintain health, rather than reactively seeking to respond after disease is manifest.

Older medicine looks more directly at the biological end of this system. The defect or “fault” lies with the organism’s failure at adapting.

Hans Selye, the leading pioneer in stress research, puts it this way: “Life is largely a process of adaptation to the circumstances in which we exist…” [Selye 1956 pg vii] and “…we cannot avoid stress… many common diseases are largely due to errors in our adaptive response to stress, rather than to direst damage by germs, poisons, or other external agents.” [Selye 1956 pg. viii]. Last, with italics his: “…many diseases appear to be essentially diseases of adaptation.”

Health psychologists would regard this as an excellent start. Critical health psychologists would regard it as defeatist, or as “blaming the victim.”

What is stress? Selye’s late summation: “Stress is a nonspecific response of the body to any demand.” [Selye 1983 pg. 2] Although stress is an identifiable syndrome, its causes are general: “Stress is the state manifested by a specific syndrome which consists of all the non-specifically induced changes within a biologic system.” [Selye 1956 pg. 54].

In other words: when you subtract the specific changes wrought by a given agent, what is left—“That which is non-specifically induced by many agents” [Selye 1956 pg. 55]—gives you the picture of stress.

Now, while Selye included “the non-specific” in the very definition of stress, he did not move far from specificity with regard to what he called stressors. For Selye, “…the stressor is naturally ‘that which produces stress.” [Selye 1956 pg. 64]. His focus seems to be on specifically biological stressors.

This is partly a methodological problem. Selye was primarily an endocrinologist, and his research, primarily on rats and newly hatched chicks, featured surgical techniques (including removal of glands and organs), chemical techniques (including hormone purification and pharmacological bio-assays), and morphological techniques (including examination of deformation of organs). [Selye 1956 pp. 70-72].

If stress has a specifically psychological component, biological study of rats will yield thin results. How much thinner the results with regard to the subjects of critical psychology.

When it comes to stressors, critical health psychology will certainly pay attention to their non-specificity, and may well postulate a perhaps societal “constellation of agents” (e.g. racism, poverty, social stigma) which operate in concert to create a kind of “contextual stressor”. This, mediated by a person’s psychology, would yield a non-specific response—stress—to the non-specific stimulus of such a “stressor field.”

Late in his book, Selye defines a useful concept: “Gestalt means literally ‘form or ‘shape,’ and is used in this sense for a configuration of separate structures or systems (physical, biologic, or psychologic) so integrated into a pattern as to constitute a functional unit.” [Selye 1956 pg. 219]. A critical health psychologist may not confine his investigations to merely physical or biological stressors mediated by psychology, but will continue outward in a search for a socio-econo-cultural “Stressor Gestalt.”

Interestingly: Selye is an endocrinologist, as exhibited by the animal testing described above, yet in concluding his book he waxes on not only the somatic aspects (how to combat disease by strengthening the body’s own defenses against stress) and the psychosomatic implications (how we must clearly distinguish the part played by the stressor from that of our own adaptive, or maladaptive, measures of disease and surrender, particularly with regard to “the stress of everyday life”), but also the philosophic implications: “Stress is usually the outcome of a struggle for the self-preservation (the homeostasis) of parts within a whole. This is true of individual cells within man, of man within society, and of individual species within the whole animate world.” [Selye 1956 pg. 253].

He then concludes by saying that a fine antidote for stress is altruism. A critical health psychologist would call that a “howler”.

Selye has indeed taken a step towards health psychology, seeking an emotional and psychological avenue towards health maintenance and promotion, but he fails to give up his patient-centric view to advance to critical health psychology. At best, this is clinical health psychology.

Selye’s work did begin with his general observation of what he called “the syndrome of just being sick.” This observation started him on the track of stress, but he failed to move in the other direction towards what might be called “the quality of just being sickening.” This is a job for critical health psychologists.

Some steps towards critical health psychology then begin to appear in the work of T.H. Holmes and R.H. Rahe, who created a “Social Readjustment Rating Scale” published in the Journal of Psychosomatic Research in 1967.

Holmes and Rahe culled thousands of “life charts” (created by Adolph Meyer) to identify some 43 “life events” that cluster at the time of disease onset. They grouped these events into two categories: “…those indicative of the life style of the individual, and those indicative of occurrences involving the individual.” [Holmes, Rahe 1967 pg 217]. By occurrences they meant e.g. the death of a spouse, marriage, change in financial state, etc., saying “the emphasis is on change from the existing steady state and not on psychological meaning, emotion, or social desirability.” [Holmes, Rahe 1967 pg. 218]. They then showed that the magnitude of life changes was significantly related to the timing and seriousness of illness.

Here, like Selye, by methodology Holmes and Rahe, in confining “life events” to the individual, failed to attain the scope of critical health psychology. What about “societal events” like war or terrorist attacks? If a “change in financial state” is significant, what about nationwide economic collapse? Might a black person in a racist environment, or a woman in a sexist environment, react differently to job loss, or are all life events to be regarded equally, regardless of social context?

No life event happens in a vacuum. Without critical psychology, researchers cannot attain anything like an “objective” evaluation of life events themselves. Perhaps there is no such thing.

Perhaps it doesn’t matter. Regarding stress research, a major consideration emerges: “…whether it is the objective presence of life events that should be the focus of interest, or the person’s appraisal of them as being stressful.” [Cooper, Dewe 2004 pg. 49]

Richard Lazarus, the leading stress researcher of the late twentieth century, emphasized the latter, arguing that stress is always a product of appraisal. “[Lazarus] set out the argument that it was the appraisal process that linked the person and the environment, and so it was just not possible to return to objective environmental events or to purifying an event of some contaminating subjective influence.” [Cooper, Dewe 2004 pg. 49].

It seems that such an emphasis on appraisal throws out the baby with the bathwater. Yes, appraisal mediates the person-environment interaction, but any interaction still has two poles.

For example, the emphasis on appraisal led researchers to seek categories of “response types,” the best-known being the so-called Type A or “coronary-prone” personality. The critical health psychologist then asks: might there be a “Type A” society? “…the anger/hostility aspect of Type A behaviour may be a more powerful predictor of risk than other Type A components.” [Cooper, Bright 2001]. What about the effects of a society in which anger/hostility are cultural norms?

The traditional psychologist looks to “individual differences” and treats “culture” or “society” as a kind of blank slate. The critical health psychologist steps back and looks at “individual cultures,” or cultures that exhibit individual characteristics and may admit of improvement, and goes beyond this not only to say they must improve for the good of the health of the citizens but also to work for that improvement to make more positive the individual person’s interaction with the culture in which he is embedded.

Tod Sloan, in Damaged Life, addresses this question on a historical scale by examining “the widespread notion that the process of modernization has pathological psychosocial consequences.” [Sloan 1996 pg. viii]. Of course, “appraisal” mediates the individual’s engagement with modernity, but perhaps there is a power in reality that is evolving to overwhelm any subjective position.

Sloan again:

Could it be that societal modernization is systematically linked to increased emotional suffering on a broad scale? Could it be that many of the material and technological achievements we glorify in the name of progress are actually producing forms of individuality that are less optimal than those that might have emerged if societal development had taken a different course? If so, could one define a set of socio-political strategies that would address effectively the problematic features of modernity?

Clearly, these questions involve the issue of stress, although they are foreign to the work of Selye. Perhaps modernity itself comprises a “stressor Gestalt.”

Sloan’s last question expands his inquiry into critical health psychology. Considering socio-political stressors is not beyond the field of psychology, nor is suggesting and even working towards amelioration of these sources of psychological and physical suffering.

Here the job of the psychologist moves well beyond the facilitation of what Lazarus emphasized as “coping.” In treating stress as a primarily a function of the individual’s response to his surroundings, Lazarus distinguished two forms of appraisal: primary appraisal, which answers the question “is anything at stake?” (harm, threat, challenge, etc.), and secondary appraisal, which answers the question “what can be done?” (coping options). [Cooper, Dewe 2004 pg. 73].

A traditional psychologist may believe that his sole function is to help the patient through the process of “coping” with his stressors. After all, the patient is the locus of the suffering. This corresponds to Selye’s promotion of altruism, or perhaps “positive thinking,” as the antidote to stress, or the challenges of modernity, or poverty, or racism. or what-have-you. A century ago, this was certainly true of the treatment of women.

A critical health psychologist will be considerably more proactive. Although she does not mention “stress,” critical psychologist Ute Holzkamp-Osterkamp makes no bones about this in her discussion of Lazarus’ understanding of emotion and coping: “[In Lazarus] emotional events are related essentially only to the adaptation to existing life circumstances. The active production of life circumstances by individuals as a precondition for a successful agreement of the subjective and objective moments is shoved to the periphery of discussion from the start.” [Holzkamp-Osterkamp 1991 pg. 111].

Actually, such activity does not make it into the discourse of traditional psychology at all, but since a critical psychologist like Holskamp-Osterkamp treats it as central, she sees it as being actively marginalized. In her view of Lazarus’ position,

Emotions as an expression of the subjective situation is [sic] thus not dealt with in its function of assessing the individual’s relation to the environment and as a guideline for the active influence upon the objective conditions of life. Instead, it is dealt with under the tacit assumption of the immutability of existing power relationships and the necessity of individual subordination to these as a universal source of threat that can only be overcome or at least subdued within the individual, thus avoiding concrete alteration of circumstances.

It is not the objective living conditions that are to be altered to correspond to the subjective situation; rather, the subjective situation must be adjusted to the existing living conditions or relations of authority, which are not to be questioned, but accepted or assessed as emotionally positive. Deviations from this expectation are blamed solely upon the individual as an aberration of feeling. [Holzkamp-Osterkamp 1991 pg. 113].

Here Holzkamp-Osterkamp actively disputes Selye’s view of stress as involving “diseases of adaptation.” She scorns adaptation. Stress, for her, is a call to action. She continues: “[Lazarus] fails to recognize that it is precisely the task of psychological work to promote the process of self-determination and the individual’s active influence on relevant living conditions, instead of supporting the denial of subjective needs through a generalized avoidance of conflicts and thereby contributing essentially to an acceptance of emotionality as “disturbing” factor.” [Holzkamp-Osterkamp 1991 pg. 114].

“Precisely”? Most psychologists would side with Lazarus in believing that promoting such active influence is more the job of a revolutionary.

Holzkamp-Osterkamp, Sloan, and the Prilleltenskys are a new breed of psychologist. Their position is really a moral stance: they believe their knowledge and insights are not complete until they are realized in action. Understanding stress as merely the maladaptation of its victims is sheer malpractice.

Confucius believed that a man could not be said to “know morality” unless he lived in a moral way. Critical health psychologists believe likewise: a psychologist operating in a vacuum, who fails to address and treat the psychology of society as a whole, is no psychologist at all.

References:

Cooper, Cary L. and Dewe, Philip (2004) Stress: A Brief History; Blackwell Publishing; ISBN 1 4051 0744 8

Cooper, L. and Bright, J. (2001) “Individual Differences in Reactions to Stress” reprinted in Jones, F. and Bright, J. Stress: Myth, Theory and Research Prentice-Hall pg. 111-132

Holmes, T.H. and Rahe, R.H. (1967) “The Social Readjustment Scale” in Journal of Psychosomatic Research Vol. 11 pp. 213 – 218

Holzkamp-Osterkamp, Ute (1991) “Emotion, Cognition, and Action Potence” in Tolman, Charles W. and Maiers, Wolfgang; Critical Psychology: Contributions to an Historical Science of the Subject; Cambridge University Press ISBN 0 521 39344 2

Marks, Davis F. (2002) “Freedom, Responsibility and Power: Contrasting Approaches to Health Psychology” in Journal of Health Psychology Vol 7 (1) pg. 5 – 19

Prilleltensky, Isaac and Nelson, Geoffrey (2002) Doing Psychology Critically: Making a Difference in Diverse Settings; Palgrave MacMillan ISBN 0 333 92283 2

Prilleltensky, Isaac and Prilleltensky, Ora; (2003) “Towards a Critical Health Psychology Practice” in Journal of Health Psychology Vol. 8 (2) pg. 197-210 [largely a reprint of Chapter 8 of Doing Psychology Critically, above]

Selye, Hans (1956) The Stress of Life; McGraw-Hill Book Company, Inc. L.O.C 56-10432

Selye, Hans (1983) “The Stress Concept: Past, Present, and Future,” reprinted in Stress Research: Issues for the Eighties, ed. Cooper, Cary; John Wiley & Sons, ISBN 0 471 10246 6

Sloan, Tod (1996) Damaged Life: The Crisis of the Modern Psyche; Routledge, ISBN 0415043514