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The role of psychology in health care delivery

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DOI: 10.1037/0735-7028.33.6.536

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Professional Psychology: Research and Practice Copyright 2002 by the American Psychological Association, Inc.
2002, Vol. 33, No. 6, 536 –545 0735-7028/02/$5.00 DOI: 10.1037//0735-7028.33.6.536

The Role of Psychology in Health Care Delivery

Ronald T. Brown and Wendy S. Freeman Robert A. Brown

Medical University of South Carolina University of Maryland

Cynthia Belar Lee Hersch

American Psychological Association Augusta Psychological Associates

Lynne M. Hornyak Annette Rickel

Washington, DC Georgetown University

Ronald Rozensky Edward Sheridan

University of Florida University of Houston

Geoffrey Reed
American Psychological Association

There is a wealth of professional opportunities for practicing psychologists, particularly given the recent
recognition of psychology as a health care profession. A number of dimensions are discussed that can be
used as a heuristic to outline the participation of psychologists in the general health care arena.
Dimensions include the breadth of disease categories in which psychology has been involved, the
involvement of psychologists at different stages of the progression of illnesses, and the diverse roles that
psychologists may play in health care. Examples are provided to exemplify the contributions psychol-
ogists have made to health care. Recommendations are made to strengthen psychology’s role in the health
care system. Recent challenges are also reviewed regarding the association of health care and the delivery
of services that demand the participation of psychologists.

Changes in the nature of health problems over time have been employment opportunities for psychologists within health care.
associated with increased opportunities for psychologists in health With medical advances and improvements in living conditions,
care. The purpose of this article is to highlight these expanding contemporary medicine has focused on psychological determi-

RONALD T. BROWN received his PhD in 1978 from Georgia State Univer-
sity. He is professor of pediatrics, chair, and associate dean in the College
of Health Professions at the Medical University of South Carolina in
Charleston.
WENDY S. FREEMAN received her PhD in 1999 from the University of
British Columbia. She is an assistant professor in the Department of
Psychology at the University of Manitoba in Winnipeg, Manitoba, Canada.
ROBERT A. BROWN received his PhD in 1962 from the University of Iowa.
He is an associate professor in the Department of Psychology at the
University of Maryland.
CYNTHIA BELAR received her PhD in 1974 from the Ohio University. She
is executive director of the Education Directorate of the American Psy-
chological Association.
LEE HERSCH received his PhD in 1977 from the United States International
University. He is in independent practice in Staunton, VA.
LYNNE M. HORNYAK received her PhD in 1983 from the Catholic Univer-
sity of America. She is in independent practice in Washington, DC.
ANNETTE RICKEL received her PhD in 1972 from the University of Mich-
igan. She is a program officer at the Rockefeller Foundation in New York
City.
RONALD ROZENSKY received his PhD in 1974 from the University of
Pittsburgh. He is professor and chair of the Department of Clinical and
Health Psychology in the College of Health Professions at the University
of Florida.
EDWARD SHERIDAN received his PhD in 1968 from Loyola University
(Chicago). He is senior vice-chancellor of the University of Houston
system and senior vice-president, provost, and professor of psychology at
the University of Houston.
GEOFFREY REED received his PhD in 1989 from the University of Califor-
nia, Los Angeles. He is assistant executive director for professional devel-
opment in the Practice Directorate of the American Psychological Asso-
ciation.
THIS ARTICLE WAS DEVELOPED as a result of the report of the Work Group
on Expanding the Role of Psychology in the Health Care Delivery System
that was established by the American Psychological Association Board of
Professional Affairs.
THE AMERICAN PSYCHOLOGICAL ASSOCIATION takes no responsibility for the
content of this article, nor does it endorse any information contained
herein.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Ronald
T. Brown, Medical University of South Carolina, College of Health Pro-
fessions, 19 Hagood Avenue, P.O. Box 250822, Charleston, South Caro-
lina 29425. Email: brownron@musc.edu

536
 PSYCHOLOGY IN HEALTH CARE
nants and sequelae of disease. In fact, the U.S. Public Health
Service has reported that lifestyle and behavioral factors consti-
tute 7 of the top 10 leading health risk factors in the United States
(cf. VandenBos, DeLeon, & Belar, 1991). The first goal of this
article is to highlight some of the dimensions that can be used to
describe the scope of opportunities for, and contributions of, the
psychology profession in the general health care field. The second
purpose is to outline some of the challenges our profession faces as
we continue to expand our roles within the health care system.
With the growth of behavioral medicine, psychologists have had
increasing opportunity to collaborate with other health care disci-
plines in addressing important health issues. Over the years, we
have witnessed the application of behavioral principles to a broad
range of medical problems (for review, see Beutler, 1992). Col-
laborative endeavors between psychology and medicine have con-
tributed to improving health outcomes and reducing mortality.
Although traditional medicine has largely focused on the treat-
ment of disease, recent concerns regarding the rising costs of
health care and the cost-effectiveness of treatments may help shift
the focus of health care toward preventive efforts; psychologists
are well positioned to contribute in this area. Our nation’s recent
emphasis on health promotion highlights the importance of psy-
chologists’ work toward the prevention of specific disorders and
diseases as well as health promotion. Finally, with the advent of
evidence-based medicine, psychologists have had unique opportu-
nities to contribute to the empirical basis of health care. Psychol-
ogists’ expertise in research and evaluation should allow signifi-
cant contributions to empirically based treatments, both physical
and psychological. These changes have provided psychologists
with many opportunities to expand beyond traditional practice to
exciting new domains in the delivery of health care. There are
already abundant signs that psychology’s impact is being felt in the
medical community. For example, it has been shown that in
primary care settings, medical utilization and medical costs can be
reduced via psychological interventions (cf. Sobel, 1995).
A Framework for Examining the Role of Psychology in
Health Care
To review the breadth of contributions psychology has made to
health care is beyond our scope in this article. However, it is
important to recognize psychology’s contributions to health care
for the purposes of reimbursement for services, federal funding,
and future training endeavors. Dimensions include the range of
disease states that psychologists have worked with, the diverse
services that psychologists provide, and the timing of psycholo-
gists’ contributions to health care, ranging from primary through
tertiary prevention.
Within the wide range of disease entities, psychiatric or mental
health disorders are conceptualized as health conditions having the
same importance as other disease categories. Psychologists have
been involved in virtually all of these disease categories through
research and/or clinical practice. For many of the diseases, there
are interventions grounded in psychological theory that may be
used to prevent, manage, or ameliorate the symptoms or sequelae
of the disease. To participate in the management of these disorders,
psychologists have developed a broad range of treatments, includ-
ing empirically supported interventions ranging from weight-
control programs to cognitive– behavioral therapy and a host of
537
other interventions that have been shown to significantly improve
health and well-being.
The Timing of Psychologists’ Contributions to Health
Care
Traditional psychological practice has emphasized a tertiary
care role in the mental health arena. However, psychologists have
played an integral role in public health initiatives, with researchers,
service providers, and policymakers calling for the inclusion of
prevention efforts in public health policies (e.g., Lorion, Myers, &
Bartels, 1994). Such calls for change in the delivery of health care
support psychology’s contributions in the areas of primary and
secondary prevention activities and across a broader range of
health conditions.
Primary prevention refers to those efforts aimed to decrease the
prevalence of a disease or disorder by reducing its incidence
(Caplan, 1964). Thus, primary prevention addresses risk and pro-
tective factors that may influence the onset of a disease in the
general population. The goals of primary prevention are to prevent
specific disorders and diseases and to foster the general enhance-
ment of health through education. Secondary prevention refers to
those efforts aimed at reducing the prevalence or severity of a
disorder via early identification and treatment (Caplan, 1964).
Prevention at this level encompasses work with at-risk popula-
tions, the assessment of early disease states, and the implementa-
tion of interventions to prevent the exacerbation of symptomatol-
ogy. Finally, tertiary prevention refers to efforts to minimize the
sequelae of established disorders or diseases via rehabilitation
(Caplan, 1964).
Primary prevention. Primary prevention, or health promotion,
has become a priority in health policy initiatives (e.g., Kaplan,
2000). This has been reflected in the growth and development of
programs to promote health and reduce those risk factors associ-
ated with illness. Programs to promote healthy dietary and exercise
habits in an effort to prevent or delay the onset of disease exem-
plify primary prevention. An example of a primary prevention
initiative is illustrated in an investigation conducted by Rodrigue
(1996) that evaluated a program designed to promote healthy
attitudes and behaviors related to sun exposure. The comprehen-
sive program not only provided factual knowledge regarding sun
exposure but also taught behavioral skills and addressed personal
risk factors and barriers to behavior change. Findings revealed that
the intervention was successful in changing participants’ attitudes
and beliefs about sun exposure, thereby increasing behaviors that
are consistent with reduced risk for skin cancer.
Secondary prevention. Psychologists play an important role in
secondary prevention efforts. Targets for secondary prevention
efforts might include individuals at high risk for adverse health
outcomes due to risk factors that are biological (e.g., genetic
disorders), environmental (e.g., familial and sociological), and
ethnic or cultural (e.g., some diseases are more prevalent among
specific ethnic groups). Psychologists have successfully employed
secondary prevention efforts with premature and low-birth-weight
infants at risk for health problems and developmental and cogni-
tive delays. One example of the many successful mother–infant
programs that have been developed is the Infant Health and De-
velopment Program, which comprises pediatric follow-up plus
family support and psychoeducation, as well as educational day
538 BROWN ET AL.
care from birth to 3 years of age (Bradley et al., 1994). An
examination of the efficacy of this secondary prevention program
in a sample of low-income families recruited from hospitals in
eight cities across the United States yielded positive effects on
infant health and development beyond those provided by pediatric
follow-up alone.
Another example of secondary prevention is a study of middle-
aged executives presenting with risk factors predictive of coronary
heart disease (Roskies et al., 1987). Participants with marked Type
A behavior and excessive cardiovascular responses to laboratory
stressors received an intervention that comprised aerobic exercise,
weight training, or cognitive– behavioral stress management. Find-
ings revealed that although both aerobic exercise and weight
training had a positive impact on strength and fitness, only the
cognitive– behavioral intervention was associated with significant
reductions in Type A behaviors. These examples reflect only two
of the many investigations that have revealed improved health-
related outcomes when psychosocial interventions are incorpo-
rated into health care.
Tertiary prevention. For those individuals suffering from a
disease or an illness, psychologists frequently have employed
tertiary prevention efforts to alleviate suffering and to reduce
problems that are residual to the illness or disorder. Numerous
empirically supported behavioral interventions have been used to
manage pain (e.g., Kerns, Turk, Holzman, & Rudy, 1986). For
example, a number of psychosocial variables (e.g., cognitive dis-
tortions such as catastrophizing) have been found to be related to
the management of the excruciating pain associated with sickle-
cell disease (Gil, Abrams, Phillips, & Keefe, 1989). Gil et al.
examined a program that employed a cognitive-treatment para-
digm to train patients with sickle-cell disease to use active coping
strategies. The successful use of these strategies was associated
with reductions in patients’ reports of pain. In another study
focusing on tertiary intervention, patients with chronic fatigue
syndrome were assigned randomly to receive either medical care
or medical care coupled with cognitive– behavioral intervention
(Sharpe et al., 1996). Findings revealed that the addition of
cognitive– behavioral therapy to medical care was associated with
better outcome; of the patients receiving the cognitive– behavioral
intervention, 73% attained normal daily functioning, compared
with 27% of the patients who received traditional medical care
only.
Traditional perceptions of psychological practice generally fo-
cus on the domain of tertiary prevention. However, recognition of
the significance of the timing of interventions has grown over the
years as the focus of health care has placed greater emphasis on
disease prevention and cost reduction of long-term health care
costs. For some, this represents a paradigm shift from treating
diseases and disorders to the promotion of health and prevention of
disease, necessitating recognition that potential clients are not only
those who are ill but also those who are at risk for various adverse
health outcomes (Rae-Grant, 1991).
Service Activities Provided by Psychologists
The services provided by psychologists in health care delivery
are varied and include such activities as assessment, intervention,
and liaison.
Assessment. Psychologists may be asked to evaluate or assess
a range of factors associated with health, including mental health
status, factors contributing to disease processes, psychological
factors affecting manifestation of symptoms, styles of coping, and
psychological adaptation to, and consequences of, disease. For
example, the psychologist may be asked to assess the emotional
capacity of an individual about to undergo an organ transplant and
to determine whether the individual is capable of adhering to
complex medical procedures. Recently, normative data have been
published for a battery of psychological tests used to assess cardiac
(Sears, Rodrigue, Sirois, Urizar, & Perri, 1999) and liver transplant
(Streisand et al., 1999) candidates.
Assessment occurs at different times during the progression of a
disease or an illness. In the case of breast cancer, for example,
assessment at the level of primary prevention might involve the
evaluation of candidates for genetic screening for breast cancer
(Carter & Hailey, 1999). Secondary prevention efforts in the area
of assessment might involve the evaluation of depressive symp-
toms and anxiety among women recently diagnosed with breast
cancer. For example, Tjemsland, Soreide, and Malt (1996) exam-
ined acute traumatic stress responses in early breast cancer and
found that nearly half of the patients reported high levels of
intrusive symptomatology and that approximately one third re-
ported avoidance symptoms. Finally, assessment at the level of
tertiary prevention might involve the evaluation of posttraumatic
stress disorder symptoms following diagnosis and treatment of
breast cancer (Andrykowski, Cordova, Studts, & Miller, 1998) or
the assessment of memory functioning among women who had
received systemic chemotherapy for breast cancer (Wieneke &
Dienst, 1995).
Intervention. Psychologists’ intervention efforts, like their as-
sessment efforts, have been directed across a range of disease
categories and across different time frames in the progression of
disease. Intervention occurring at the time of primary prevention
(health promotion) might include programs in occupational and
educational settings designed to promote exercise and healthy
eating patterns. Secondary prevention, or early intervention, might
include teaching children at risk for depression to challenge pes-
simistic thinking (Jaycox, Reivich, Gillham, & Seligman, 1994),
implementing a smoking cessation program with cancer survivors
(Eriksen & Kondo, 1989), or providing stress-reduction interven-
tions to patients who have suffered myocardial infarctions in an
effort to prevent subsequent lethal coronary episodes (Frasure-
Smith & Prince, 1985). The Elmira Prenatal/Early Infancy Project
is an excellent example of a preventive intervention that targets an
at-risk population to prevent health, social, and psychological
problems in children and their mothers (Olds et al., 1998). The
program targets children deemed at risk (due to variables such as
young maternal age, single-parent status, or low socioeconomic
status) and makes available prenatal care, primary pediatric care,
and a range of social services. In a well-designed, randomized
control trial, this program has demonstrated positive results, in-
cluding reduced rates of child abuse and neglect, fewer emergency
room visits and accidents, and greater use of formal and informal
support services. Furthermore, long-term effects have been docu-
mented in a 15-year follow-up (Olds et al., 1998).
Finally, tertiary intervention includes traditional psychotherapy
efforts to ameliorate the residual effects of mental illness, as well
as efforts to promote adaptive coping among individuals suffering
 PSYCHOLOGY IN HEALTH CARE
from chronic or acute conditions. For example, Caudill, Schnable,
Zuttermeister, Benson, and Friedman (1991) studied the impact of
a behavioral group intervention targeting the psychological and
physical stress associated with chronic pain. Participants included
over 100 patients who had endured chronic pain for more than 6
years. Following the 10-week intervention, patients reported re-
ductions in physical pain and psychological distress. The program
also lowered the cost of subsequent health care by significantly
decreasing patient clinic visits over a 2-year period following
participation in the program (Caudill et al., 1991).
Liaison. Liaison activities can be defined as didactic activities
provided by psychologists to other health care providers. These
activities may involve educating other professionals regarding
psychological issues associated with health and the services that
may be provided by psychologists. Liaison activities highlight a
number of areas in which psychologists have expertise and might
involve lecturing to nursing staff regarding pain management,
assisting medical staff in addressing issues associated with death
and dying, or educating staff regarding those factors that will
maximize patients’ adherence to medical treatment regimens. At
the level of primary prevention, liaison activities might include
teaching school nurses how to educate children and adolescents
regarding the risks of smoking. At the level of secondary preven-
tion, liaison might involve providing in-service training to educate
teaching staff on how to facilitate a child’s return to school after
initial treatment for cancer. Finally, liaison activities at the late or
tertiary stage may include training staff at a cancer clinic to assess
and recognize problems in posttreatment adjustment among cancer
survivors.
Figure 1. Health service matrix role.
539
Some of the roles that psychologists may play and the timing of
specific services they may provide are conceptualized in Figure 1.
Timing of assessment and intervention are likely to assume greater
importance during the next several years as the focus shifts to
preventing disease and reducing the economic burden of health
costs. The health matrix model recognizes that service and pre-
vention activities may be applied across the spectrum of diseases
as psychology continues to make a contribution to health care.
Some of the specific services that psychologists can provide when
participating in the care of individuals with asthma are shown in
Figure 1.
Focus of Service
With respect to focus, psychologists may become involved in
the health care system at different system levels. Services may
target individuals, families, classrooms or schools, work sites,
communities or, more broadly, federal and state public policy.
Psychologists have long been involved in service delivery at the
individual and family level. At the school level, Cunningham and
colleagues (1998) implemented a student-mediated conflict-
resolution program in three elementary schools. These investiga-
tors found that this school-based, student mediation program re-
duced physical aggression observed on playgrounds by more than
50%. Psychologists have also been increasingly influential in the
shaping of federal and state policy. In fact, in 1995, the Public
Policy Office of the American Psychological Association (APA)
published A Psychologist’s Guide to Participation in Federal
Policy Making (APA, 1995). This volume developed partially out
540 BROWN ET AL.
of APA’s participation with the American Association for the
Advancement of Science Congressional Fellowship program.
Since 1974, 75 psychologists have been selected as APA Congres-
sional Fellows and have represented the field of psychology to
policymakers and scholars from other disciplines. Serving in the
U.S. Congress, they have furthered the enactment of specific
pieces of federal legislation, brought experts from across the nation
to testify at congressional hearings, and enlightened policymakers
about the value of psychological knowledge in addressing many of
society’s most pressing concerns (Rickel & Becker, 1997).
One example of psychology’s increasing voice in public policy
issues in the health arena is the work of Lizette Peterson and
colleagues (e.g., Peterson & Stern, 1997) regarding accidental
injuries, the leading cause of death among American children. In a
recent review, Tremblay and Peterson (1999) outlined how injury-
prevention efforts can be enhanced by using our knowledge of
behavioral principles and child development. They argued that the
training of clinical psychologists provides them with unique skills
with which to assess practices that place children at risk. They also
argued that psychologists must work collaboratively with others
(i.e., citizens, other professionals) to mount persuasive campaigns
to target the reduction of accidental injuries in children. Finally,
Tremblay and Peterson delineated obstacles that may have stunted
federal emphasis on injury prevention and provided specific sug-
gestions to improve public policy.
Setting
Psychologists have rendered services in many different types of
settings. In the past, the traditional setting has been the private
office, followed by community mental health centers. Other set-
tings have included hospitals, correctional institutions, schools,
nursing homes, and assisted-living facilities. For example, the
work of Cowen and colleagues (see Cowen et al., 1996) has
focused on the school setting as a venue for preventive efforts. The
Rochester Primary Mental Health Project screens children en
masse soon after they begin school. Children designated as at-risk
for maladjustment participate in therapeutic activities with parents
who serve as child aides. This program is notable for its active,
systematic screening for early school maladjustment, its contextual
relevance, and the manner in which it has wedded research and
clinical service and used research findings to improve service
delivery.
Cunningham, Bremmer, and Secord-Gilbert (1994) developed a
community-based parent-training program in an effort to increase
the availability, accessibility, and cost effectiveness of intervention
services for parents of children with behavioral problems. In a
randomized trial comparing the community-based program with
traditional, clinic-based parent training, parents of children with
severe behavior problems were more likely to enroll in the com-
munity program. Also, families who participated in the community
program reported greater improvements in child behavior and
better maintenance of these improvements than did families who
received clinic-based services (Cunningham, Bremner, & Boyle,
1995).
A 1998 study by APA found that the vast majority of APA’s
licensed practitioner members were continuing to provide tradi-
tional mental health services in independent practice settings
(Phelps, Eisman, & Kohut, 1998). However, newer graduates were
more likely to be working in some form of medical setting,
suggesting a trend to move from independent practice to multidis-
ciplinary settings. In large part, this has been due to changes in the
funding of mental health services, but it may also reflect the fact
that the most frequently cited content of training in clinical pro-
grams is in health or behavioral medicine (Sayette & Mayne,
1990). This clearly illustrates that the practice of psychology is not
limited to private offices or mental health clinics. It is expected
that there will be increasing opportunity for psychologists to
participate in nontraditional health care settings.
Domains of Functioning
Although psychological services traditionally have targeted psy-
chosocial and cognitive functioning, which may include emo-
tional, behavioral, and neuropsychological functioning, there has
been increasing recognition that psychologists have contributed to
the enhancement of functioning in other domains. Psychologists
have been involved in the prevention and management of physical
symptoms and disorders. For example, psychologists have played
an important role in targeting physical functioning in cardiac
rehabilitation and programs for the management of pain, weight,
and diabetes. Also, psychologists have assessed problems and
designed interventions in the academic domain (e.g., assessment of
learning problems). In the occupational domain, industrial-
organizational psychologists have made numerous contributions to
reducing work-related stress, increasing employee productivity,
and enhancing safety in the workplace. For example, Der-
Karabetian and Gebharbp (1986) examined the effects of em-
ployee participation in a physical fitness program and found that
participation in the program was associated with greater job sat-
isfaction and fewer days missed from work due to illness. Psy-
chologists have also made efforts to help diminish the frequency of
accidents or injuries in the workplace. For example, Sulzer-
Azaroff, Loafman, Merante, and Hlavacek (1990) implemented an
injury prevention model in a large industrial plant and found that
the intervention increased target safety behaviors among employ-
ees and significantly reduced the number of accidents and injuries
resulting in time lost from work.
The Role of Psychologists in Health Care
As highlighted above, psychologists have made significant con-
tributions to health care as providers of a variety of clinical
services. In addition, the unique training of psychologists in re-
search design and methodology makes the discipline an ideal
resource in health care research. Psychologists have worked with
other health professionals across an array of disciplines (e.g.,
medicine, nursing, and occupational therapy) in conducting their
research. As researchers, psychologists have also worked to de-
velop measures to assess specific areas (e.g., quality of life) and
have empirically validated interventions, studied health service
utilization, and delineated risk and protective factors for predicting
health outcomes. Increasingly, psychologists have been called
upon by pharmaceutical companies to design and evaluate clinical
trials. For example, psychologists have led research teams that
have conducted pharmacokinetic studies to examine drug concen-
trations over time and provide essential information for determin-
ing appropriate dosing and dose frequency (e.g., Pelham et al.,
 PSYCHOLOGY IN HEALTH CARE
1999). In the consultation and liaison domain, psychologists have
provided services to research groups regarding statistical analyses
and have also designed clinical trials involving multiple research
centers.
Psychologists have established a presence in a number of im-
portant health institutions over the years. To secure a future for
psychology in which its contribution to health and well-being is
maximized, psychologists must be assertive in networking and
working cooperatively within other health care disciplines. One
such organization is the Children’s Oncology Group, a consortium
funded by the National Cancer Institute and mandated to conduct
research in the area of pediatric cancer epidemiology, prevention,
and control. An important committee of the Children’s Oncology
Group is the psychology committee that is responsible for devel-
oping protocols to evaluate the long-term psychological effects of
the cancer experience and to examine late effects, or potentially
deleterious long-term effects, on cognitive functioning that may be
associated with the disease and its treatment (e.g., Lockwood, Bell,
& Colegrove, 1999). The Centers for Disease Control and Preven-
tion is another example of a major health organization that has
recognized that psychology makes a unique contribution to public
health and is an important discipline within the health care arena,
alongside other disciplines such as epidemiology, laboratory sci-
ences, and other traditional biomedical sciences (Snider & Satcher,
1997).
Psychologists have also been educators, providing in-service
training about health and mental health issues to schools, busi-
nesses, and health organizations. They have taught and supervised
trainees in psychology and other disciplines (e.g., nursing, medi-
cine, social work). In addition, psychologists have been involved
in disseminating psychological expertise to the public by partici-
pating in community education programs.
In addition to clinical, research, and teaching activities, psychol-
ogists have had increasing opportunities in the areas of adminis-
tration and management within the health care arena. For example,
psychologists have filled such administrative roles as administer-
ing grants or conducting program evaluation and outcome assess-
ments. Psychologists might also serve as multidisciplinary team
leaders in various medical clinics (e.g., a cystic fibrosis clinic) or
program directors for health programs such as cancer wellness
centers or summer camps for children with chronic illness.
Perhaps one of the greatest contributions psychologists have
made to health care is the development of theoretical and concep-
tual models to aid in the understanding of peoples’ attitudes and
behaviors related to health, the influence of stress on illness and
related behavior, and people’s adjustment to illness (Taylor, 1990).
For example, the transtheoretical model of behavior change devel-
oped by Prochaska and colleagues (Prochaska & Velicer, 1997)
focuses on individuals’ decision-making processes along a contin-
uum of readiness to change a problem behavior or adopt a desir-
able, health-enhancing behavior. The model outlines five stages
through which an individual may progress: precontemplation,
comtemplation, preparation, action, and maintenance. A number of
processes have been outlined that occur as individuals progress
through these stages of behavior change (Prochaska & Velicer,
1997). Knowledge of these processes and stages of change has
helped in the design of intervention strategies to facilitate behavior
changes that will ultimately impact health outcome. The transac-
tional model has been applied to a number of health-related be-
541
haviors and outcomes, including smoking (DiClemente et al.,
1991), exercise (King et al., 1998), condom use to prevent the
transmission of HIV (O’Campo et al., 1999), self-management
strategies of patients with arthritis (Keefe et al., 2000), and receipt
of mammography (Rakowski et al., 1998).
Summary
The above dimensions highlight the diverse ways in which
psychologists can participate in health care. Over the years, psy-
chologists have made significant research and clinical contribu-
tions to the prevention and treatment of an expanding array of
diseases (Resnick & Rozensky, 1996). Opportunities for psychol-
ogists in primary and secondary prevention will likely continue to
grow because of national efforts to decrease the cost of health care
and the resultant changes in health care delivery. It is reasonable to
expect that this growth will be sustained as psychologists continue
to make viable contributions to the prevention of disease states, to
an understanding of the psychosocial influences on the onset and
course of illness, and to a delineation of important psychosocial
factors in the management of illness and delivery of health-related
services. Psychological services have targeted multiple domains of
functioning, ranging from the psychological and physical function-
ing of individuals to levels of safety in the workplace.
Challenges and Opportunities as Psychology Continues to
Grow as a Health Care Profession
As has been demonstrated in psychologists’ clinical practice and
research, psychology can be conceptualized as a health profession
(Belar, 2000). As financial pressures grow in the health care
system, psychology will thrive best by promoting its contributions
to the primary care domain in preventing mental and physical
health problems and managing existing ailments and by continuing
to interact and share its knowledge with other health care disci-
plines so as to maximize its contribution to human welfare. To
illustrate the breadth of health issues and concerns addressed by
psychology as a profession within the health care domain, we have
highlighted only a few of the clinical and scientific contributions
that psychologists have made. The growth of psychology in the
health care arena is exemplified in the remarks of former U.S.
Department of Health and Human Services Secretary Donna Sha-
lala, who said that the year 2000 marked the largest increase in
federal funding for behavioral research across federal government
organizations, including the National Science Foundation and the
National Institutes of Health (NIH), and that it is anticipated that
behavioral research programs will be a core component for each of
the NIH programs (cited in Foxhall, 2000). As psychology con-
tinues to grow as a health care profession, several challenges and
opportunities emerge. These challenges are conceptualized at the
clinical, organizational, and systemic levels in Table 1.
Ethical issues encountered in health care settings are apt to be
different than in settings in which psychologists have traditionally
practiced, and there will be differences in the application of psy-
chologists’ ethical standards within health care settings (Koocher
& Keith-Spiegel, 1990). Changes in health economics and service
delivery systems (e.g., managed care) have also brought about
increased attention to ethical issues encountered within heath care
settings. Thus, some revision and augmentation of ethical stan-
542 BROWN ET AL.

Table 1
Challenges to Psychology as a Health Care Profession With Regard to Clinical, Organizational,
and Systemic Activities

Clinical Organizational Systemic

Provide greater delivery of Revise ethical standards of psychologists Integrate behavioral health and
services in the primary care to reflect clinical activities in health physical health through
setting care settings research and grant activities

Manage comorbid psychological
problems on inpatient
services and outpatient clinics
Develop skills for interdisciplinary (e.g.,
psychologists, physicians, nurses)
clinical communication so
psychologists may work in health care
settings
Develop data at the local and
national levels focused on
cost offset and clinical
utility

Evaluate patients’ suitability for Develop CPT codes that recognize Broaden training opportunities
transplantation psychological services in clinical for psychologists in various
health care settings health care settings

Use family therapy to increase Develop curriculum that enhances Increase psychopharmacology
adherence to various medical training of psychologists to actively training for practicing
procedures for individuals engage in clinical activities within a psychologists
with asthma health care environment

Use psychological testing to Explore health service provider licensure

evaluate the toxicities for psychologists
associated with chemotherapy
to treat breast cancer

Arrange for full voting membership of

psychologists on medical staff

Note. CPT ⫽ current procedural terminology.

dards, as well as promulgation of new ethical guidelines relevant
to unique ethical dilemmas that may be encountered in health care
settings, may be required. Salient issues in health settings include
withholding and withdrawing treatment, informed consent for
medical procedures, evaluation of capacity to consent and ele-
ments of informed medical decision making, confidentiality, and
record keeping. In traditional medical settings, patients are often
relegated to a dependent position and exposed to a number of
providers who will be making decisions regarding their care. This
is in contrast to traditional psychological practice in which there
are typically fewer parties involved (e.g., often only the client and
provider). Psychologists providing services to individuals with a
chronic illness face particular challenges regarding confidentiality
that include communication of information to the referral source,
charting information in a traditional medical chart, and discussing
the patient’s psychological status with a multidisciplinary team or
the patient’s family members. Such issues are apt to be more
commonly encountered in medical settings and thus warrant spe-
cial consideration.
As the practice of psychology in medical settings and broader
areas of health has grown, service delivery has expanded beyond
the psychological services covered by the traditional mental health
current procedural terminology (CPT) code system. So that appro-
priate reimbursement may occur, new procedure codes that recog-
nize treatment of specific medical conditions with psychological
interventions are needed. Following several years of advocacy, an
APA proposal for a new series of CPT codes to reflect the services
provided by psychologists to patients with diagnoses of physical
health conditions has been approved for publication by the Amer-
ican Medical Association committee overseeing CPT codes (“APA
Wins Approval for New CPT Codes,” 2000). Although psychol-
ogists in traditional practice have been required by health insurers
to pair procedural codes with mental health diagnoses, the new
series of codes recognize psychologists’ and other health profes-
sionals’ contribution to the assessment and management of bio-
psychosocial factors associated with physical health problems and
traditional medical treatments. The 2002 CPT manual will intro-
duce six new codes: two for health and behavior assessment
services and four for health and behavior intervention services.
This exciting new development represents formal recognition of
the psychology profession’s contributions to health care beyond
traditional mental health services.
Although the approval for publication of these new codes is an
important step, reimbursement for these codes will be challenging.
In recent years, we have witnessed a rapid growth in health service
delivery systems (e.g., HMOs, preferred provider organizations)
that may restrict access to and reimbursement for services pro-
vided by psychologists. To facilitate changes in reimbursement
systems, psychologists must continue to generate data showing
both the clinical utility and the cost savings of psychological
interventions in general medical systems.
The education and training of graduate students in psychology
has, over the past 3 decades, increasingly focused on preparing
students for broader roles in health care. However, as opportunities
for psychology in health care expand, we must better prepare our
new graduates to function in the realm of primary health care by
expanding education and training efforts, exposing trainees to
interdisciplinary training models, and mentoring new graduates as
 PSYCHOLOGY IN HEALTH CARE
they forge their identities as an integral part of the health care
system. Education and training should address not only basic
knowledge and skills but also the unique ethical, legal, and pro-
fessional issues that may emerge in health care settings.
Expanding psychologists’ scope of practice mandates that we be
accountable and evaluate our competency in these new areas.
Aside from the universal requirement to master core domains of
knowledge and skills and the ethical imperative to practice within
the boundaries of one’s competence, there are no specific stan-
dards for practitioners who wish to expand their scope of practice
within the health care arena. Although this permits flexibility in the
development of practice areas, the lack of standards offers little
guidance to those who wish to extend their practice. Hence there
is great need for training opportunities for psychologists already
engaged in practice. This may be accomplished by means of
continuing education programs that are sponsored at national or
state levels. Readers who are interested in expanding their scope of
practice in health care are encouraged to examine the recent
self-assessment guidelines reviewed by Belar et al. (2001) that
enable practitioners to evaluate their competence and identify
areas where knowledge and skills need to be enhanced before
engaging in specific areas of practice.
As psychology’s role in health care continues to grow, issues
pertaining to licensure and board certification also emerge. This
may necessitate revisiting licensure statutes, as they may be overly
restrictive with regard to practice, particularly within a health care
setting. Some states restrict the management of physical diseases
in their medical licensing acts. This has important implications for
the practice of psychology. For example, behavioral approaches
have been demonstrated to be successful in the management of
several physical conditions; to restrict management of these con-
ditions by those licensed under the medical practice act is not
compatible with current empirical data that are actually published
in well-respected medical journals. Some states have facilitated
practice in health psychology by offering a health service provider
certificate for the clinical psychology license.
Another issue that has arisen as psychology continues its jour-
ney from being perceived as a mental health profession to a health
care profession is prescription privileges. Levels of preparation for
psychologists’ involvement in psychopharmacology have been
delineated in order to provide guidance for training (Smyer et al.,
1993). Level 1 refers to the provision of basic psychopharmaco-
logical education in psychologists’ graduate training. This level is
incorporated in APA’s recommendations for program accredita-
tion. Level 2 refers to basic training needs for collaborative prac-
tice with physicians. This level is particularly relevant to psychol-
ogists who practice in health care settings and involves a more
in-depth understanding for the purpose of consulting with physi-
cians regarding pharmacotherapy. Finally, Level 3 refers specifi-
cally to prescription privileges.
As psychology’s role in health care delivery grows in recogni-
tion, it is this third level that has been the subject of much debate
(for review, see Phelps, Brown, & Powers, 2001; Sammons &
Schmidt, 2001). The debate pertaining to prescription privileges
notwithstanding, psychologists have established themselves in
psychopharmacological research, and many are knowledgeable
about pharmacological interventions and are asked to provide
recommendations regarding the prescription of psychotropic med-
ications. Regardless of legislative and legal decisions that impact
543
this issue and continuing debates within our own and the psychi-
atric profession, psychologists will continue to make important
contributions to pharmacological research and will be called upon
by health care teams for input regarding multimodal intervention
including psychotropic medication. Therefore, some training in
psychopharmacology is essential for psychologists practicing in
any aspect of health care.
Conclusion
We must work to educate members of our profession, the public,
and policymakers about the multiple and varied contributions that
psychologists can make to the field of primary care and in working
with medical populations. As with any change, some apprehension
may ensue as the realm of psychology expands beyond the con-
fines of traditional roles. However, it will be adaptive for the
discipline as a whole to be flexible with regard to the increasing
diversity of settings in which psychologists may practice and to
collaborate with professionals in other health care disciplines. As
we move ahead in the new millennium, we hope that psycholo-
gists’ contributions to public health will continue and that an
increasing number of psychologists will be prepared to meet the
opportunities and challenges arising from our evolving health care
system.
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Received June 25, 2001
Revision received April 3, 2002
Accepted May 22, 2002 䡲