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The importance of psychosocial processes in health and illness is an established part of health care. The evidence on the role of behaviour and emotion in morbidity and mortality has been steadily accumulating over the last century. By the end of the First World War, the British Army had dealt with 80,000 cases of shell shock, including those of poets Siegfried Sassoon and Wilfred Owen. Millions of men and women suffered psychological trauma as a result of their war experiences. Since that time, and the experiences of many other wars, much research has been conducted to investigate the possible role of trauma, stress and psychological characteristics on the onset, course and management of physical illnesses. Health psychology has grown rapidly, and psychologists are increasingly in demand in health care and medical settings. Psychologists have become essential members of multidisciplinary teams in rehabilitation, cardiology, paediatrics, oncology, anaesthesiology, family practice, dentistry, and other fields, including defence, intelligence, policing and justice.

Figure 1.2 General Theory of Well-Being (GTWB)

Source: Marks (2015)

Increasing interest is being directed towards disease prevention, especially with reference to sexual health, nutrition, smoking, alcohol, inactivity and stress. A current ideology is ‘individualism’, in which individual ‘agents’ are deemed responsible for their own health. From this neoliberalist viewpoint, a person who smokes 40 a day and develops lung cancer is responsible for causing their own costly, disabling and terminal illness. Traditional health education has consisted of campaigns providing a mixture of exhortation, information and advice to persuade people to change their unhealthy habits. By telling people to ‘Just say no’, policy makers expect people to make the ‘right’ choices and change ‘unhealthy’ choices into ‘healthy’ ones. There has been notable success in tobacco control, which provides a benchmark for what may be achieved through health education, and policy in other clinical areas, such as coronary artery disease, obesity, diabetes and metabolic syndrome.

Against the ‘healthist’ view that keeping ourselves healthy means making responsible choices, there is little convincing evidence, beyond the example of smoking, that people who change their lifestyle actually do live longer or have a greater quality of life than people who ‘live and let live’ and make no real attempt to live healthily. Consider an example: a prospective study suggests that vegetarians live longer than meat eaters. But vegetarians may differ from the meat-eaters in many ways other than their choice of diet (e.g., religious beliefs, use of alcohol, social support). A statistical association between two variables, such as a vegetarian diet and longevity, does not prove causality or allow a prediction about any particular individual case. A vegetarian can still die of stomach cancer and becoming vegetarian does not necessarily lengthen the life of any specific individual. Epidemiology is a statistical science. It provides a statistical statement to which there will always be inconvenient exceptions, such as 90-year-old smokers.

The healthist assumption that a person must ‘live well to be well’ is prevalent today in industrialised countries and it can lead to victim blaming. If people become ill, it is seen as possibly being ‘their own fault’ because they smoke, drink, eat poorly, fail to exercise or use screening services, do not jog or join a gym, and so on. Health policy is run through with blaming and shaming individuals for their own poor health. The ‘smoking evil’ has been replaced by the ‘obesity evil’. More recently we have seen cases of blaming and shaming of people, including government advisors, for not following social distancing rules in the COVID-19 emergency.

Health campaigns are often based on the idea that by informing people they can make responsible choices. People are presumed to be free agents with self-determination. Yet human behaviour is influenced by so many factors in the social and economic environment, and especially by role models among family and friends or in the mass media. The herd instinct is as strong in humans as it is in bees, birds or sheep. Christakis and Fowler (2007) reported evidence that behaviour changes such as quitting smoking or putting on weight are associated with similar changes in networks of friends. Imitation is an important influence in human behaviour and one significant change approach, social cognitive theory, is based on this principle (Bandura, 1995).

The built environment, the sum total of objects placed in the natural world by human beings, is another influence on behaviour. Included within this are the images and messages from advertisers in mass media, and the digital environment. A ‘toxic environment’ has been engineered to draw people towards unhealthy products, habits and behaviours (Brownell, 1994). The obesogenic environment contains affordable but nasty, fatty, salty and sugary foods that readily cause weight gain and obesity on an industrial scale. Items for sale include foods such as ‘hot dogs’ containing ‘mechanically recovered meat’ and 0% real meat, and ‘chicken nuggets’ with 0% chicken. The proliferation of such low-priced items in supermarkets and 24/7 stores offer low-income consumers an unhealthy selection of options. A reliance on meat-eating and careless practices in markets has contributed to the spreading of dangerous viruses such as Ebola and COVID-19, with devastating impact.

In this book, arguments are presented on different sides of the ‘freedom and choice’ debate. It is accepted that our present understanding of health behaviour is far from definitive. However, we also need to adopt a critical position towards the discipline. Health psychology is still relatively young as a sub-discipline and there are many issues to be addressed. For the most part, health psychology has been formulated within an individualistic ideological formulation which is part of neoliberalist mass culture. The evidence presented in this book suggests that socio-cognitive approaches to behaviour change that target internalized processes in the form of hypothetical ‘social cognitions’ are ineffectual, inefficient and too small in scale (Marks, 1996, 2002a, 2002b). Apart from their theoretical shortcomings, mass dissemination of individualized therapeutic approaches through the health care system is unsustainable and unaffordable. Like it or not, in spite of the many critiques, the biomedical model remains the foundation stone of clinical health care.

Health psychologists work at different levels of the health care system: carrying out research; systematically reviewing research; designing, implementing and evaluating health interventions; training and teaching; doing consultancy; providing and improving health services; carrying out health promotion; designing policy to improve services; giving scientific advice to government; and advocating social justice for people and communities to act on their own terms. In this book we give examples of all these activities, and suggest opportunities to make further progress.

A community perspective on health work offers an alternative prospect for intervention. Community approaches are less popular within mainstream health psychology and have been the mainstay of community psychology. There could be valuable synergies between health and community psychology working outside the health care system. In working towards social justice and reducing inequalities, people’s rights to health and freedom from illness are, quite literally, a life and death matter; it is the responsibility of planners, policy makers and leaders of people wherever they may be to fight for a fairer, more equitable system of health care (Marks, 2004; Murray, 2014a).

Our definition of health psychology is given in Box 1.3. In discussing this definition, we can say that the objective of health psychology is the promotion and maintenance of well-being in individuals, communities and populations.

BOX 1.3 Definition of health psychology

Health psychology is an interdisciplinary field concerned with the application of psychological knowledge and techniques to health, illness and health care.

Although there are diverse points of view, health psychologists generally hold a holistic perspective on individual well-being, that all aspects of human nature are interconnected. While the primary focus of health psychology is physical rather than mental health, the latter being the province of clinical psychology, it is acknowledged that mental and physical health are actually ‘two sides of one coin’. When a person has a physical illness for a period of time, then it is not surprising if they also experience worry (= anxiety) and/or sadness (= depression). If serious enough, ‘negative affect’ (sadness and/or worry) may become classified as ‘mental illness’ (severe depression and/or anxiety), and be detrimental to subjective well-being and to aspects of physical health. Each side of the ‘well-being coin’ is bound to the other. The distinction between ‘health psychology’ and ‘clinical psychology’ is an unfortunate historical accident that is difficult to explain to non-psychologists (or even to psychologists themselves). There is also significant overlap between health and clinical psychology and ‘positive psychology’ as an integrative new field (Seligman and Csikszentmihalyi, 2000; Seligman et al., 2005), although not without critiques of exaggerated claims and poor methodology (e.g., Coyne and Tennen, 2010).