The 1st Conference of European Ministers of Health held in Madrid in September 1981 considered it was essential to draw up principles for the training of the different categories of health staff in order to promote prevention and education for health in Europe.
Following this Conference, the European Health Committee carried out a series of studies on the training of nurses and midwives, paediatricians and geriatricians.
This report deals essentially with the role of the research psychologist in prevention and education for health and with his or her training to perform that role properly in today's world.
It was prepared by Professor G. V. CAPRARA, Director of the Institute of Psychology at the University of Rome and Study Director of the 1984 Coordinated Medical Research Programme on new trends in the organisation of mental health services at primary care level.
The European Health Committee approved this text in June 1986. It should prove very useful in establishing the conditions for psychological intervention and the way psychology can help in prevention and education for health.
The history of psychology, as a scientific discipline and as an independent profession, is the history of the controversial emancipation of man, who begins to ask questions about himself and his own conditions of life in order to find some regularities and to explain, in terms of laws, what was traditionally attributed to God's will or to chance. Among the various scientific disciplines, psychology is the last one to free itself from religious and merely speculative thought, the object of its investigation being the investigating subject himself and that part of human nature which, through the notion of soul, had been traditionally shrouded by a sense of sacredness and mystery.
It has not been easy for psychology to free itself from the various spiritual and physical constraints: on one hand, in its origins, it was tributary to philosophy, and on the other hand, in terms of its status, it finds itself subordinated to the biological and medical disciplines; and still we cannot say that this undertaking has been accomplished. It has been necessary to confront many long-established views and to overcome considerable resistance in order to establish the new discipline and to consolidate its credibility.
It is not irrelevant to examine the status of psychology as a science and as a profession before considering the training of psychologists in prevention and education for health, since the answers are not clear-cut, expectations still to a great extent controversial, and the numerous misunderstandings not completely resolved. That this status is still uncertain in many countries is apparent from delays in establishing consistent curricula for the training of researchers and professionals; from the precariousness that characterises the practice of psychology, with its frequent lack of institutional regulations or professional organisation (consider, for instance, the controversial discussion about psychotherapy); and from the contradiction between a demand for psychology to deal with problems to which it can actually give some kind of answer and its inability to cope with common problems outside its sphere.
On the other hand, there are undoubtedly many possibilities for psychology, as confirmed by experience in countries where the development of the profession and of research has met more favourable conditions (in the USA for instance). It is clear that a great need for psychology does exist. At the same time, we must be clear as to what psychology can do and what we must do for psychology, in order to define its methods and approach. It is essential to define the methods if we are to define the spheres within which the intervention of psychology is plausible. It is also essential to define its perspectives on the basis of the actual problems to which it can reasonably contribute.
Clarity of definition is particularly important in relation to new problems, such as those connected with prevention and education for health, which involve not only a change towards updating and integrating traditional training programmes for psychologists, but probably also a fundamental review of the role of psychology as a whole, and, consequently, the role of the psychologist among health professionals and the demand for psychology from the community.
Psychology aims to define laws, i.e. constant relations that can be expressed in the form of quantitative ratios among the various phenomena that affect behaviour. This research into behavioural patterns involves the examination of cause and effect nexuses and concomitance or, rather, covariance nexuses among the different phenomena; by locating and explaining such nexuses and by relating them where possible to the different situations in which they express themselves, it becomes possible to forecast as well as to intervene, in order to modify the behaviour of both individuals and groups.
The cognitive, as well as the affective and motivational, processes which support overt behaviour, their relationship in the course of development and in different situations, and the influences of the physical and social environment have been the main subjects of psychology and have shaped the development of the various methods of research and intervention. In psychology, as in other disciplines, the elaboration of theories becomes a unifying act in which the known information is systematised and the course of new investigations is defined. It is rare to find theories with a high degree of formalisation as well as theories with a high degree of generalisation. In many cases it is more realistic to deal with guidelines, with wide-spectrum working hypotheses, and with research strategies rather than with theories. The elaboration of theories which command the widest degree of support is hindered not only by the complexity of the subject but also by the variety of ideological implications raised by the psychological investigation, in terms of personality, development, health and deviancy, and by the constraints imposed by different concepts of the world. It is therefore reasonable to claim the neutrality of this discipline only in programmatic terms. Beyond the specific topics which, at the conceptual as well as the operative level, are not always defined in the same way by the various approaches, the examination of preferred methods of investigation provides important data for the characterisation of the different formulations.
The experimental method has in the main characterised laboratory research. It is suitable for those areas in which it is possible to isolate and to treat distinctly several variables and is intended to identify and express the relationships between the examined phenomena in terms of functions or at least in quantitative terms; but above all it aims to explain such relationships in terms of cause and effect. This method is the one that brings psychology nearest to the other natural sciences and gives credit to its legitimacy as a science. Unfortunately the characteristics of the subject and the methodology are such that they often prove to be hardly compatible and consequently many important phenomena remain unconsidered by experimental research.
The correlational method, by examining the correspondences existing among different behaviour patterns occurring at the same moment and among identical behaviour patterns occurring at different times, aims to deduce hypotheses and models pertinent to more or less specific, complex, stable aspects of mental activity. For a long time the correlational method has been favoured for the study of individual differences and has probably been the most widespread among a variety of empirical approaches based on the acquisition and analysis of numerical data. Unlike the experimental method, with which it shares a "quantitative" tendency, the correlational method gives explanations in terms of concordance and covariance (A varies with B), rather than explanations of a causal type (A determines B).
The clinical method aims to deduce hypotheses and patterns relative to the development and the balance of the overall personality, by reconstructing the biography. It is also intended to find especially within a direct relationship with the subject, through the analysis of communication and interpersonal relationship, what is singular and unique and therefore characteristic of a personal style. For several reasons the clinical method appears to be the most psychological of all since it is the one that pays most attention to subjectivity in the strict sense-to finding those unique and unrepeatable factors which characterise life experiences and affect behaviour. On the other hand, the clinical method is the one that presents the most frail and uncertain validation criteria and consequently the most exposed to suggestion and arbitrariness.
Each of these methods employs particular techniques suitable for the recording and analysis of the phenomena under consideration, and has tailored itself to the various spheres of research and intervention in which it has been used more frequently. The experimental method has made its mark chiefly on investigations concerning basic processes; it has been and still is a substantial part of the formative store of basic research. On the other hand, the correlational and clinical methods have guided psychological intervention mainly in the field of application.
The complexity of the discipline justifies the presence of different investigation methods and makes a certain tolerance and a certain eclecticism acceptable, especially in those research and intervention sectors, as is frequently the case with psychology, in which there is a considerable gap between the kind of demand received by the psychologist and the kind of answer that he is sure he can provide, as well as between the kind of phenomena that can be explained and foreseen in a reliable way and the kind of problems for which a solution is required.
This is probably true of research and psychological interventions aimed at prevention and health promotion. In this sphere the discrepancy between the ambition to fulfil objectives and the complexity of the problems leaves enormous room for experimentation in methods and techniques, and makes such tolerance absolutely necessary. The advances made by this discipline in accumulating information and developing its capacity for explanation and prediction, have been uneven for several reasons, not only, as already mentioned, because of the complexity of the subject. Frequently the more significant the subject of the investigation is, the less distinguishable are the various phenomena and processes from which it results. Frequently, the more subtle and exact the indications prove to be, the more they are at the same time partial and limited.
On the whole there is a considerable discrepancy between research that can be carried out in a laboratory (which, as a rule, as we have already said, concerns particular aspects of general mental activity) and research that concerns more global aspects of the individual/environment relationship (which, necessarily, can only take place outside the laboratory, where the phenomena form and reform). The first type of research has taken advantage of a tradition and a working style which are substantially the same as those found in the other natural sciences. It has also taken advantage of the advances made in developing those instruments which today make possible experimentation, recording and analyses previously completely inconceivable. This has provided laboratory psychologists with a greater respectability within the traditional scientific community and a more coherent development of their activities.
Psychological, psychophysiological, and neuro-psychological researchers, in particular, operating as they do in borderline areas (often in close co-operation with biologists, physiologists, neurologists, and geneticists), and dealing with the biological functions and mechanisms which support the various cognitive and emotional processes, have taken advantage of the working conditions, as well as the financial means, acquired by disciplines with a longer tradition.
In contrast, the development of psychological research in the clinical, educational and social (in a broad sense) spheres has been more problematic. In these cases, whether one takes into consideration the balance or malaise of the individual, or the dynamics of learning in terms of the relationship between teacher and pupil, or the pressure that a group can exert upon its own members in forming an attitude, one is always working with a plurality of factors which are hardly distinguishable and separable in their effects. In these cases, as already mentioned, it becomes difficult to reconcile the ambition of the project with the rigour of the methodology, and to avoid a variety of limitations arising from the connotations that psychological investigation and intervention may assume in the face of behaviour and values which are essential parts of certain forms of social organisation.
It is necessary to consider this problematic nature of psychology when one faces the psychosocial problems of prevention and education for health. When the agenda includes such subjects as normality, deviancy, the conditions that induce the full development of a person, and the obstacles that must be prevented or removed in order that that development should not be limited or compromised, one cannot avoid also taking into consideration the social system as a whole. It then becomes indispensable to look into people's way of thinking in order to understand what must be done to change their way of acting. And one may expect that the difficulties will be greatest in those cases in which heavy constraints of both an ideological and cultural nature have hindered the subject from interrogating him or herself; where, mainly among those responsible for orienting the community in the matter of health, the approach is not based on problem-orientation and interdisciplinary work; and where the conditions exist for conflict and lack of co-operation.
The spheres in which the psychologist can play a major role in defending and promoting health are early relationships (particularly that between mother and child, starting from the desire for conception), family relations, broad socialisation and educational processes, the organisation of work and marginalisation.
In many countries the psychologist has consolidated a professional legitimacy in these spheres as a support to other "stronger" professional figures (mainly that of the physician, whose prevalently dyadic relationship with the patient has been borrowed by the psychologist). In these cases the demand has traditionally been for adjustment and adaptation as well as for verification of the criteria used to select data from the external world. In many cases the psychologist has actually been an agent of consensus and psychology a sort of spare ideology for the dominant ideologies. When the psychologist began to present himself as an agent of change, he probably misled himself into thinking that he could speed things up, underestimating the “environmental”resistance to change, and he has rarely been explicit and convincing about the direction that that change should be given.
The discomfort that psychology has been experiencing during the last twenty years reflects the difficulty of such change and of the continuing search for a new identity. Nonetheless, this process, now underway, seems to be irreversible. The demand for psychology is increasing continuously and the answer cannot consist only of tests and screening of treatments which either have an uncertain result or are endless, or of mere maintenance through an alleviation of anxiety and conflict. The experience of countries such as the United States emphasises the importance of introducing new professional psychological skills into political and economic planning, when it is necessary to evaluate and, where appropriate, to modify those attitudes and styles of behaviour which support choices fundamental to people's quality of life, as well as consumption, use of services, working and investment patterns.
The knowledge acquired by psychological research in the development, clinical and social spheres is already enough to enable the development of programmes aimed at a provisional identification of a variety of risk situations, at developmental monitoring and supporting the socialisation and integration of physically or mentally handicapped people. In particular, psychology has a relevant contribution to make to accustoming people to observe and communicate about their own behaviour and relationships and to propagating a greater sensitivity and attention towards those situations and those relationships networks which may produce, maintain, or, on the contrary, solve a conflict, a discomfort, a disease: in other words, contributing to education for health.
Both prevention and education for health involve a transmission of information and modification of attitudes. As the facts have proved, the transmission of information emphasised in various programmes has not necessarily been absorbed or automatically changed social behaviour. It is, therefore, necessary but not sufficient. Prevention and education for health are effective only insofar as the transmitted information turns into new ways of thinking and acting; new modes of producing and using knowledge are therefore necessary.
Prevention and education for health involve a more extensive integration of different scientific and professional disciplines, as well as an acceptance of responsibility and participation on the part of those concerned with establishing and maintaining those conditions that maximise the possibilities of personal development and welfare.
The areas at the forefront of prevention and education for health are: hygiene, primary socialisation, and the organisation of school and work. The first recipients that must be singled out in a prevention and education for health campaign are those who, because of their competence and the position they hold within the social organisation, are regarded as repositaries of special authority as to what it is necessary to know and to do in order to promote, maintain or recover physical and mental health.
On this subject physicians and educators act as real social multipliers of consent and change as regards health and adaptation problems in a broad sense. The physician's influence is pervasive at every level of a person's life: from childhood to old age, from free time to working hours. The educator's influence is crucial as it supports or even substitutes for the family in providing models of behaviour and identification oriented towards a complete psycho-social development in a child or an adolescent, as well as encouraging the interventions needed to reduce, through their early identification, the potential damage that may be caused by personal handicaps or by shortcomings in the social environment. It is necessary to equip health personnel, and particularly those who deal with primary care, with a type of expertise that goes beyond the store of information and skills provided by traditional curricula. This is an expertise in communication, in participation, and in anticipation. On this expertise depends the capability to spread, by means of information, new styles of behaviour that are able to overcome all the inertia, mistrust and resistance common to habit and tradition.
Since a great deal of such mistrust, resistance and habit is largely shared by health personnel themselves, it is obvious that they themselves must overcome them as a first step. Until this is achieved, whatever efforts are made for change will risk being, if not frustrated, at least seriously compromised. To have overlooked or, in any case, underestimated the importance of the personal involvement of those professionals who interpret and judge, at the primary level, people's choices on the subject of health, has been the main mistake made by many programmes which have not been able to go beyond a mere list of good intentions. To ignore social mediation, which must be pre-arranged and ensured even in the context of well-planned programmes, is an omission which has often significantly compromised their implementation and success.
The experience of many countries in the matter of integrating handicapped people is indicative of the risks of further marginalisation and rejection which a praiseworthy intention of social recovery may run if it does not consider the "cultural" compatibilities of the personnel concerned. The Italian experience in psychiatric help shows how the mentality of both the health staff and the public (beliefs, habits, attitudes, expectations) conditions the implementation of reforms, which have been accepted in principle and sometimes sanctioned by legislation. The result of many initiatives in prevention concerning pharmaco-dependence, alcohol and tobacco abuse, drug addition, shows on the other hand the limits (at best partial and inadequate) of those initiatives which ignore the symptomatic character and the roots of the deviant behaviour they aim to prevent.
Early prevention is the most effective and inexpensive. The physician is most suited to advising a pregnant woman to undergo regular clinical checkups, to follow a special diet, and take special precautions, to teach a mother how to observe and what to report about her child, to ensure a normal psycho-physical development and permit a timely intervention where necessary. Again the physician has more frequent access to the family and is best suited to detect peculiarities, conflicts and imbalances in affective relations which could pose a risk for the psycho-physical safety of its members and particularly of the more vulnerable younger ones.
On the other hand, the teacher is best placed in detecting and reporting difficulties a child may encounter in social relations when it first comes into contact with an environment outside the family. The teacher is in a privileged position in interpreting the tensions and changes of adolescence through the peer group. In this respect, one must examine whether the training of the physician and the teacher are adequate and, if not (as many curricula indicate), proper training should be given absolute priority.
The socio-health services have been reorganised in many countries and advisory and training centres have been set up to co-ordinate the various preventive and educational initiatives at the school, work and family level.
However, the impact of such centres is highly dependent on the receptiveness of the clients. Those most in need are often the most reluctant to contact the new services, due to ignorance, and mostly for lack of confidence. Lack of motivation stultifies every educational action and participation in common health projects.
Preventive and educational action involves a change in deeply ingrained habits, and a greater awareness of one's own health and that of the community as a whole.
This process involves a new approach to the problems of environmental protection, and unavoidably, a change in production processes and organisational structures. The setting up of advisory and epidemiological centres shows real will for reform if accompanied by those mechanisms necessary to make them work. Staff need training and clients need information: the service/client relationship needs in many cases to be built anew. In this respect, the role of the mass media and the involvement of the various political and labour organisations are crucial. A prevention and education for health programme aimed at instilling a new mentality which favours the protection and the promotion of health rather than mere treatment is long and complex.
In fact, such a process involves not only a significant change in the role of health staff and a radical modification of habits, production processes, and man's relationship with his own body and his own environment, but also a clear-cut economic policy on the priority to be given to health problems in the development of a country.
In this process, the psychologist contributes by providing cognitive data on specific problems of psychological and social adaptation, as well as helping to identify obstacles to more responsible attitudes and behaviour in health. The resources and possibilities available have to be assessed in relation to the desired change; instruction and training programmes should be directed at improving the effectiveness of staff in direct contact with the clients.
It is therefore evident that the psychologist's role is also destined to undergo a deep change.
An analysis of the academic curricula in advanced training for psychologists shows that in the majority of countries the programmes are rarely adequate to face the problems arising out of the new concept of prevention and education for health.
Although psychologists are many and their specialisation covers various fields (school, industry, sports, etc.), the prevailing models are substantially two: the researcher, who is interested in identifying the underlying process of behaviour patterns, and the clinician, who is interested in explaining the behaviour of a given individual.
The former risks losing sight of the subject whose behaviour he wants to explain, through too much concern for methodology; the latter, in trying to understand the subject's experiences, tends to move away from the model and base his interpretation on discretionary data. In both cases, in the laboratory as well as at the clinic, the person risks being alienated from the context of social relations in everyday life. Such models must be bypassed if we are to meet the new demands on psychology emerging from the social environment.
Psychological research will no longer be confined to the laboratory; nor should psychological intervention necessarily imply a dyadic relationship between therapist and client. The distinction between research and clinical intervention is no longer meaningful.
Research is increasingly carried out in the social environment, and the client is more frequently a group, and the therapist a team. On the other hand research in the social environment is at the same time an intervention in that environment. Likewise, a psychological intervention, especially in the social sphere, contains the elements of an experiment.
There is today a demand for research that promotes the desired changes in attitudes to behaviour concerning health preservation and risk reduction. The intervention of the psychologist, however, is not only clinical, but public and social. The recipients of the diagnosis and treatment are in fact individuals who always form part of a network of social relations.
In primary, secondary and tertiary prevention, the future role of psychology must be able to combine the rigour of the "experimenter" with the sensitivity of the "clinician". In that sense, curricula should, methodologically speaking, combine the best tradition of both experimental and clinical training. In particular, these curricula must give a general methodological competence in planning, co-ordinating, and experimenting with various initiatives in prevention and education for health; they must also impart knowledge that can be used in prevention and education for health programmes for populations at risk.
In the former case the psychologist, as a technician promoting social change, should be conversant with different analysis and intervention methods, so as to assess, initially, whether the programmes in the various fields can be successfully implemented and to monitor in itinere the effectiveness of such programmes. Monitoring should aim at identifying and forecasting what steps have to be taken to overcome resistance to those behaviour patterns which are the subject of the various prevention programmes. The psychologist should be an agent of reform able to take training initiatives to increase the effectiveness of the preventive action of staff in direct contact with people, mainly by developing their skill in testing the psychological variables that lead to a change of attitudes and behaviour and make the transmitted information usable. As a matter of fact, to inform only is not enough.
In many cases where a change is aimed at, psychology is involved only with the underlying behaviour that is to be corrected or avoided. The psychologist's role, however, becomes crucial in those cases where people do not correct nor avoid certain behaviours simply by being told that those behaviours are harmful. People entertain false ideas on their safety, and sometimes obstinately follow behaviours in spite of their obvious harmfulness. Certain behaviours are strengthened rather than modified by mere information which does not take into account the significance of such behaviours, the resistance that they may provoke and the possible positive aspects of ignoring the information. It is very doubtful whether mere information regarding prevention of the various forms of addiction is effective. Moreover, these initiatives are too costly and time consuming for what they are intended. To think that it is enough to inform in order to induce people to establish a better relationship with their own body and their own environment is probably a prejudice reminiscent of illuminism. Attitudes and behaviour change when replaced by more advantageous ones. One must therefore understand the advantages of certain behaviour patterns that should be abandoned, if one is to convince people of the advantages that might result from adopting new forms of behaviour.
The knowledge of health staff in psychology is crucial in this matter. So is the psychologist's role as a technician promoting psychosocial change and as an agent of change.
Information through research into the causes of a variety of disorders and their remedies should be translatable into prevention and education for health programmes. In particular, the psychologist has the knowledge for preventive and educational action in a variety of fields related to health.
Important information about ensuring the best conditions for psychological development has been accumulated mostly at the child developmental level and particularly the earlier stages. This information provides accurate advice to the person caring for the child and those who are, within and outside the family, responsible for its development and education. With regard to family relations, psychologists can give clear advice on the identification of risk elements and measures to contain them.
Likewise at school, psychologists can give sufficiently accurate information to complement the teacher's action in reducing the risks of isolation and marginalisation of those at risk.
At work, there exists today a vast literature on preventive action against certain forms of work organisation and characteristics of the work environment that may entail a risk to a worker's mental and physical safety. It is undoubtedly the case that in several areas the psychologist's role could be more effective in spreading a psychological knowledge which is essential at a collective level.
On the other hand, the contribution of psychology is more doubtful in those cases where preventive action aims at reducing the incidence of disorders of a biological origin and that traditionally have lain outside the province and the interest of the psychologist. Coronary disease is probably one of the sectors to which more psychological research should be committed.
The phenomena connected with ageing constitute another sector for psychological research into prevention where it can contribute successfully. All the different forms of psychological disorders which limit and modify the subject's social life in his/her choices, as well as the image that the subject has of him/herself are of great interest to psychology, which can contribute to treatment and rehabilitation.
In general, in revising traditional curricula it would clarify the role of the psychologist in the numerous aspects of prevention and health education requiring a psychological intervention if the following aspects were considered.
More emphasis must be laid on methodology, quantitative aspects, the methods and techniques of interventions in the social environment, and on cognitive elements (all to a great extent alien to traditional curricula), as well as on economic, demographic and legislative aspects.
The needs and aims are clear; but programmes have to be drawn up according to the different situations. Experiments have to be carried out in a social context and assessed on the basis of explicit and objective results. Experimentation must therefore take its time and be flexible.
Met toelating van de Raad van Europa op deze site gepubliceerd op 30.01.2003