Psychosocial Dimensions of Medicine 1st Edition
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Contents
About the editors ix
About the authors xi
Introduction: In the general practitioners’ waiting rooms 1
Jennifer Fitzgerald
Section 1 Beyond a biomedical conceptualisation of care 5
Chapter 1 Beyond the biomedical 7
Jennifer Fitzgerald
Chapter 2 The patient in psychosocial context: person‑centred versus
family‑centred care 19
Gerard Byrne
Chapter 3 Quality of life 29
Robert A Cummins
Chapter 4 Lived experience and mental illness 43
Robert Bland and Ann Tullgren
Section 2 Individual differences and developmental processes 57
Chapter 5 Coping with illness and disability 59
Kenneth Pakenham
Chapter 6 Resilience, coping, and optimal functioning across the lifespan 73
Susan L Rowe, Michele D Dunbar, and Melanie J Zimmer-Gembeck
Chapter 7 Personality 90
Gerard Byrne
v
vi Contents
Chapter 8 Encountering emotion in healthcare 105
Jennifer Fitzgerald
Chapter 9 Principles of behaviourism in relation to health 118
Aaron DJ Frost and Grant J Devilly
Section 3 Relationship considerations 135
Chapter 10 Close relationships, health, and wellbeing 137
Judith A Feeney
Chapter 11 Parenting 151
Matthew Sanders and Alina Morawska
Chapter 12 Psychosexual and gender aspects 164
Darren Russell and Alemka Russell
Section 4 Social determinants of health: race and
economic status 177
Chapter 13 Understanding and acting on health inequities 179
Colin MacDougall
Chapter 14 Social and emotional wellbeing of Indigenous Australians 195
Helen Milroy
Chapter 15 Psychosocial factors in healthcare for Māori 208
Chris Cunningham
Chapter 16 Street health: practitioner service provision for Māori
homeless people in Auckland 220
Linda Waimarie Nikora, Darrin Hodgetts, Shiloh Groot, Ottilie Stolte, and
Kerry Chamberlain
Section 5 Existential and ethical issues 233
Chapter 17 Death 235
Judith Murray
Contents vii
Chapter 18 Spiritual aspects of care 248
Bruce Rumbold
Chapter 19 Facing terminal illness: a theological and personal perspective 264
Noel Preston
Chapter 20 Practical ethics in clinical care 276
Eleanor Milligan and Sarah Winch
Section 6 Prevention and promotion 289
Chapter 21 Prevention of alcohol-related harm for children
and adolescents 291
Hannah J Thomas, Adrian B Kelly, and John W. Toumbourou
Chapter 22 Enabling positive mental health 305
Suzy Green and Lindsay G Oades
Conclusion 319
Chapter 23 A biopsychosocial model applied 321
Jennifer Fitzgerald
Index 332
About the editors
Jennifer Fitzgerald BA (Hons) PhD (Clin)
Dr Jenny Fitzgerald is a clinical psychologist in Brisbane who is a Clinical
Lead Educator in the School of Medicine, University of Queensland, where
she coordinates courses in clinical communication skills and psychiatry for
Phase 1 medical students and a sex and couples therapy course for the UQ
clinical psychology program. Jenny also has a busy private practice where
she treats individuals with mental health problems and distressed couples.
She is an internationally certified trainer for Emotionally focused Therapy for
Couples and provides workshops throughout Australia for couples therapists.
With Michele Groves, Jenny edited Communication Skills in Medicine: Promot-
ing Patient-centred Care, published by IP Communications in 2010. Jenny is
co-author of An Emotionally focused Workbook for Couples: The Two of Us, pub-
lished in 2014 by Routledge.
Gerard J. Byrne BSc (Med), MBBS (Hons), PhD, FRANZCP
Gerard Byrne is Professor and Head of the Academic Discipline of Psychiatry
within the School of Medicine at the University of Queensland. He is also
Director of the Older Persons’ Mental Health Service at the Royal Brisbane
and Women’s Hospital and a Member of the Repatriation Medical Authority.
His research interests include anxiety, depression, and cognitive impairment
in older people.
ix
About the authors
Robert Bland AM PhD Professor of Social Work, Australian Catholic
University.
Kerry Chamberlain Professor of Social and Health Psychology at Massey
University, New Zealand, and a critical health psychologist with interests in
everyday life and disadvantage.
Robert Cummins PhD Professor and Director of Australasian Centre of
Quality of Life, Deakin University, Victoria, Australia.
Chris Cunningham PhD Professor and Director of the Research Centre for
Maori Health and Development, Massey University, Wellington, New
Zealand.
Grant J Devilly PhD Associate Professor, Menzies Health Institute, Queens-
land, and School of Applied Psychology, Griffith University, Queensland.
Michele D Dunbar PhD School of Applied Psychology, Griffith University,
Queensland.
Judith Feeney PhD Social psychologist and Associate Professor at The Uni-
versity of Queensland.
Aaron DJ Frost PhD Clinical Psychologist, Director of Benchmark Psychol-
ogy and Adjunct Senior Research Fellow, Griffith University, Queensland.
Suzy Green, DPsych (Clinical) Founder, The Positivity Institute.
Shiloh Groot PhD Lecturer in Community Psychology at the University of
Auckland and a member of the New Zealand Coalition to End Homelessness.
Darrin Hodgetts PhD Professor of Societal Psychology at Massey University
who has worked in the fields of community medicine and media and
communications.
Adrian B Kelly PhD Associate Professor and Principal Research Fellow in the
Centre for Youth Substance Abuse Research at the University of Queensland.
Colin MacDougall PhD Professor of Public Health, Discipline of Public Health,
Southgate Institute for Health, Society and Equity, Flinders University.
Eleanor Milligan PhD Associate Professor in Medical Ethics and Profes-
sional Practice at Griffith University School of Medicine, Queensland.
xi
xii About the authors
Helen Milroy MB BS CertChildPsych W.Aust., FRANZCP Commissioner,
Royal Commission into Institutional Responses to Child Sexual Abuse, Aus-
tralia (current); Winthrop Professor and Director of the Centre for Aboriginal
Medical and Dental Health at the University of Western Australia and a Con-
sultant Child and Adolescent Psychiatrist with the Specialist Aboriginal
Mental Health Service, Department of Health, Perth (on leave). Helen is a
descendant of the Palyku people of the Pilbara region of Western Australia.
Alina Morawska PhD Deputy Director (Research) at the Parenting and
Family Support Centre, University of Queensland.
Judith Murray BA (Hons Psych) PhD DipEd BEdSt BNurs RN Associate
Professor in Counselling Psychology at The University of Queensland in
addition to being a registered nurse in Haematology and Oncology at The
Princess Alexandra Hospital, Brisbane, Queensland.
Linda Waimarie Nikora PhD Professor of Psychology and Director of the
Maori & Psychology Research Unit, University of Waikato, Hamilton, New
Zealand.
Lindsay G Oades PhD Associate Professor in Positive Psychology, Centre for
Positive Psychology, University of Melbourne.
Kenneth Pakenham PhD Clinical and health psychologist, and Professor at
The University of Queensland.
Rev Noel Preston AM PhD Ethicist, theologian and social commentator.
Now retired, he is Adjunct Professor in the Key Centre for Ethics, Law, Justice
and Governance at Griffith University, Queensland, Associate Minister at the
West End Uniting Church, and volunteer Chaplain at the Wesley Hospital,
Brisbane.
Susan L Rowe PhD candidate in the School of Applied Psychology and the
Behavioural Basis of Health Research Centre, Griffith Health Institute, Grif-
fith University, Queensland.
Bruce Rumbold PhD Health sociologist and practical theologian, Director of
the Palliative Care Unit, Department of Public Health, La Trobe University.
Alemka Russell BA Grad Dip Applied Psychology, Master of Psychology
(Health) Psychologist, Cairns Hospital, Queensland.
Darren Russell MBBS FRACGP DipVen FAChSHM FRCP (London) Direc-
tor of Sexual Health, Cairns Sexual Health Service, Adjunct Associate Profes-
sor, James Cook University, Queensland, and Clinical Associate Professor,
University of Melbourne, Victoria.
Matthew Sanders PhD Professor of Clinical Psychology and Director of the
Parenting and Family Support Centre at the University of Queensland.
About the authors xiii
Ottilie Stolte PhD Lecturer in Community Psychology at the University of
Waikato, New Zealand, has a human geography background, and interests in
unemployment, inequalities, and community studies.
Hannah J Thomas BA (Hons I) PhD candidate and Research Assistant, Centre
for Youth Substance Abuse Research at The University of Queensland.
John W Toumbourou PhD Professor and Associate Dean, Faculty of Health,
Deakin University, Victoria.
Ann Tullgren, who has bipolar disorder, is a social worker, educator, writer,
and consumer activist.
Sarah Winch PhD Senior Lecturer in healthcare ethics at the School of Medi-
cine, The University of Queensland.
Melanie J. Zimmer-Gembeck PhD Professor in the School of Applied Psy-
chology and Menzies Health Institute of Queensland, Griffith University,
Queensland.
Introduction:
In the general practitioners’ waiting rooms
Jennifer Fitzgerald
This consideration of psychosocial dimensions in medicine begins in two
general practice waiting rooms. In an Australian general practice there are
seven patients, some with accompanying persons, waiting to see the doctors.
From the viewpoint of the reception desk, we can see:
• Sandra Jones with her two-months-old son, Ethan Jones, for routine immu-
nisation. The baby is crying with hunger and Sandra looks concerned.
• Doug Johnson, an Indigenous male of 54 years, has diabetes mellitus. He
has retinal disease and peripheral neuropathy. Doug looks bored.
• Ellen Butterworth, a 90-year-old female who lives alone, needs a script for
her antihypertensive medication. Ellen looks happy and is talking to the
neighbour who drove her to the clinic.
• Dan Bartlett is 64 years old, with emphysema. He smoked for forty years.
Dan sits in a wheelchair with an oxygen cylinder strapped behind him.
His wife died three months ago. His daughter-in-law Sue and her two
small children accompany him. Dan looks downcast and sad; Sue looks
harassed.
• Fatima Mahsoud is 44 years old, and recently released from an immigra-
tion detention centre. A translator from a local agency run by the Catholic
Church accompanies her. Fatima suffers from depression and PTSD. She
looks ‘blank’ and feels ‘numb’.
• Alice Yarrow, 49 years old, divorced mother of three teenagers, is return-
ing for results of blood tests. She has recently been told she has metastases
from her breast cancer, which was originally diagnosed and treated two
years ago. Alice is alone and looks anxious.
• John Nguyen is 16 years old and attending for a review of a head injury,
sustained last week in a car accident in which he was a passenger. The
driver and John were both intoxicated at the time. John looks sullen as his
mother talks sternly to him.
1
2 INTRODUCTION
In a New Zealand GP’s waiting room we find two particular patients, each
waiting alone. They are:
• Grant, a 41-year-old homeless Māori living on the streets of central
Auckland. He is disconnected from his family and has a number of
physical and mental ailments. Grant is feeling particularly depressed right
now and is thinking about suicide. He recognises that his health is deterio-
rating, he is losing his teeth, and he has ulcers from excessive alcohol con-
sumption. Grant looks despondent as he talks to the practice nurse.
• Rawiri Johnson is a 60-year-old Māori who has diabetes, obesity, fatty liver
disease, and depression. He has a long history of addiction problems, and
is divorced and living with his widowed sister. Rawiri’s face breaks into a
smile when Hinemoa, the Māori health worker, calls his name.
Some questions for consideration
What is life like for each of these people? How might their gender, social role,
economic status, and quality of social support impact on the lived experience
of illness and injury for each of them? What might the lived experience of
these nine individuals be like if, with the same presenting medical need or
problem, their economic status, educational attainment, and social support
were radically different? For example, what would it be like for Ellen if she
had no support from her neighbours? How might that be relevant to her treat-
ing doctor? What might it be like for Alice and for her doctor if a supportive
husband accompanied her on her visits to the doctor and hospital, and if her
children were grown up and independent? What if Dan’s wife were still alive,
or if Doug were well educated and wealthy? Alternatively, what might happen
to each of these people if any of them were to become homeless like Grant? To
what extent might all these psychosocial variables impact on the biomedical
outcome of each of these persons? How might the biomedical problems
impact on the many psychosocial variables of all these patients?
Further, we might wonder about the emotional experience of each of these
people, along with their perception of stress, likely resilience, and potential
for achieving quality of life despite their current medical circumstances.
What factors might change the emotional experience of each? What factors
will influence psychological coping in those who are seriously ill or disabled?
What psychosocial factors, past or present, might assist each of these patients
to be resilient despite their current stage of life and circumstances? Thinking
holistically, we might wonder also about the cultural and spiritual resources
or needs of each of these patients. What meaning or benefit might some or all
of these people find in their circumstances? To what extent are cultural issues
impacting on the health of each of these people?
IN THE GENERAL PRACTITIONERS’ WAITING ROOMS 3
We might also consider how health practitioners and the health system
more generally could or should respond to the biopsychosocial, cultural, and
spiritual needs of all these people. What skills might the general practitioner
need to provide quality care that extends beyond the biomedical needs of
these patients? Who might the general practitioner need to call on to provide
additional care? What is it like for the doctors themselves with practices in
differing social classes of Australia or New Zealand? What is it like for the
doctors and other staff in the Auckland clinic offering care to homeless
people? What particular rewards and costs might be there for them?
While examining the potential relevance of the various psychosocial issues
raised above, two further, associated questions must also be asked. To what
extent (and how) could many of these presenting problems have been pre-
vented? And, how can positive attitudes to health and living be promoted?
Introducing this book
This book, like Engel’s biopsychosocial model of care (Engel, 1977; see also
Chapter 1), aims to ‘broaden the scope of the clinician’s gaze’ (Borrell-Carrió
et al., 2004, p. 581). To address this goal we have brought together contribu-
tions from a range of experts in medicine, psychology, social work, pastoral
theology, and social science, who provide an informative resource to chal-
lenge us as health professionals to view our patients in a broader context.
Based on the evidence provided above, it is expected that such an expansion
in understanding and knowledge of the patient as a person, and as a person
in family, cultural group, and society, will lead to improved quality of health-
care. We aim also to extend readers’ understanding of the psychosocial deter-
minants of disease, thereby potentially improving future efforts for health
promotion and disease prevention.
With these goals in mind, our invited authors have addressed a wide range
of topics. There are six sections in the book. In Section 1, Beyond a biomedical
conceptualisation of care, consideration will be given to the patient in psy-
chosocial context, the concept of quality of life, and the patient’s lived experi-
ence of illness or disability. Section 2 considers the patient as a person and
looks at individual differences and developmental processes. These include
coping with the stress of illness and disability, development across the lifes-
pan, personality, emotion, and learning processes.
Section 3 shifts the focus from individual to social considerations. These
chapters examine the importance of close relationships and social support for
health and wellbeing, as well as the influence of parents and families on the
developing child. This section also considers sexuality. In Section 4, some of
the social determinants of health, namely race and economic status, are con-
sidered. To do this, authors have examined health inequities, focusing on
4 INTRODUCTION
Indigenous Australians, social and emotional wellbeing of Indigenous Aus-
tralians, psychosocial factors in healthcare for Māori communities, and
homelessness in Māori communities.
In Section 5, existential and ethical issues are considered. These chapters
look at death and spiritual aspects of care, and include a theologian’s reflec-
tion on his own experience of life-threatening illness. Medical ethicists reflect
on the practicalities of ethical care and decision-making. The text concludes
in Section 6, with a focus on the future; namely, prevention of alcohol and
drug problems for children and adolescents and the promotion of mental
health.
Throughout the book, our authors will comment on a range of psychoso-
cial dimensions to consider in the care of the nine patients sitting in doctors’
waiting rooms. Through these clinical comments it is envisaged that readers
will be enabled to integrate understanding of the patient as a person, and the
person as a part of a wider social system. Thus, the intention is to apply
theory and research to clinical practice, and to demonstrate the advantages to
patient and clinician of a biopsychosocial model of care.
References
Borrell-Carrió, F., Suchman, F., & Epstein, R. (2004). The biopsychosocial
model 25 years later: principles, practice, and scientific inquiry. Annals of
Family Medicine, 2, 576–582. doi: 10.1370/afm.245.
Engel, G. (1977). The need for a new medical model: a challenge for biomedi-
cine. Science, 196, 129–136.
Section 1
Beyond a
biomedical
conceptualisation
of care
