Dr.  Hope Landrine,  1954-2019: In Memoriam

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 Dr Hope Landrine, 1954-2019

Hope Landrine’s Life and Work

Dr. Hope Landrine was born in Yonkers, NY, USA on July 4, 1954, to John Albert Landrine and Sarah Alice Palmer. Sadly, after a brief illness, Hope Landrine died in Greenville, NC, USA on Sept 3, 2019.

Hope Landrine was the first director of the East Carolina University Center for Health Disparities Research, and professor of psychology and professor of public health in the Brody School of Medicine. Her bachelor’s degree in psychology was from Westminster College, her masters was from the City University of New York, and her doctorate in clinical psychology from the University of Rhode Island. Landrine was a prolific scientist with more than 125 articles and books dedicated to the health, and socio-political conditions of African-Americans, other ethnic minority populations, women, and those suffering  substance use and addictions. Landrine earned ‘fellow status’ in the American Psychological Association Divisions 9, 45, 38, 35, and 50 for her outstanding contributions to research on social issues, racial-ethnic minorities, health, and women and she was also awarded ‘fellow status’ in the Society of Behavioral Medicine. In 2012, she was honored with the APA Div. 45 Lifetime Achievement Award for Distinguished Lifetime Contributions to research on racial-ethnic minorities. In 2019, she received the James M. Jones Lifetime Achievement Award for her exceptional contributions to the understanding of racial and ethnic psychology.

Landrine’s work in public health was eclectic. Aware of the key role of culture, Landrine believed that plays, videos and songs, could capture people’s attention — and stay lodged in their memories — far longer than statistics in a pamphlet. “[The arts] are probably our best hope for changing hearts and minds and behaviors and attitudes,” she said. “People are more likely to listen to a song about health than take a class on health, let alone read a book on health. But if there’s a song on health and the song is clever enough that people hum it to themselves and learn the lyrics, then I think we can do something.” (Landrine, 2011).Landrine’s outstanding career focussed on racial and ethnic disparities in health and health behaviors, women’s health, discrimination and poverty continues as a beacon of inspiration. Landrine was raised in the inner city where poverty and gross inequities are a perpetual part of everyday existence. Landrine became a member of the ‘Young Socialist Alliance’ and the president of the Black Student Union before going home to read feminists books (Granek, 2007).

In developing her feminist identity, one summer in the early 1970s Landrine saw Betty Friedan’s The Feminine Mystique at her local public library . At the end of that summer, Landrine said she “went back to college as somebody else” (Granek, 2007).  Landrine attributed a change the course of her activism to a classic text on women’s health, Our Bodies Ourselves. When she graduated with a psychology degree, Landrine worked for the Cambridge Women’s Center until enrolling for a master’s at the City University of New York, where she was one the last students to be supervised by Stanley Milgram.

Landrine recalled “not really being interested in psychology as an undergraduate” and she “went there by default, not desire. And even as an undergraduate, I had concerns about it … I thought it was conservative. I perceived it … as a field that seemed to have the potential to defend the status quo – not challenge it – by locating problems within people instead of outside of them…I saw it as conservative and sexist on top of everything else! So, I graduated with no plan for graduate school; no desire to actually pursue psychology at all!” (Granek, 2007).  So true then, as to this very day.

Landrine’s interest in psychology was rekindled by her masters research that was concerned with the feminism and self-esteem. Later, her doctoral study in the University of Rhode Island clinical psychology program Landrine viewed psychiatric disorders as a product of inequality without any necessary involvement of psychological or intra-psychic processes. Her thesis “The Politics of Madness” was even in those days a radical, political approach to psychopathology. The president of  Division 35 of the American Psychological Association, Bernice Lott appointed Landrine to the task force on cultural diversity and, from 1990, Landrine became part of the editorial board of the Division’s journal, Psychology of Women Quarterly and served as the associate editor for several years.  Landrine was invited to write a book review for the first issue of the Journal of Health Psychology and she later contributed multiple articles and served as Associate Editor for two decades.

Hope Landrine’s contribution to health psychology and public health has been enormous and pathfinding.  Landrine’s focus on ethnic minorities, specifically those living in segregated and poor neighbourhoods, has planted seeds, grown trees and has created a forest of ideas and concepts for future workers to explore.

On culture and diversity

From Reviews : Culture and the Lathe of Failure by Hope Landrine, Journal of Health Psychology 1996 1:1, 143-144

“while waving the flag of cultural sensitivity, European– American health promotion programs continue nonetheless to define positive outcomes as the assimilation of European–American health beliefs and health behaviours by native Others. Likewise, while praising the importance of respect for cultural practices such as the oral tradition, European–American disease prevention programs continue nonetheless to rely on posters, flyers, videos and other visual and written media. ‘Sensitivity to diversity’ means that these visual and written materials have been translated into the language of the native Other, and has yet to mean that the Other’s oral tradition (the practice of learning through storytelling, utilizing the culturally significant relationship between story-teller and audience) is the medium for altering health behavior. The tendency to ignore rather than incorporate a cultural community’s indigenous healers, indigenous disease taxonomies, and techniques of traditional medicine are but a few, additional examples of the Western inclination to marginalize and dismiss the very cultural context to which interventions purport to be sensitive.”

“the new, unprecedented focus on cultural diversity is always a focus on an Otherness that is not White—it is Black or Brown or Yellow or Red but never White—such that culture is rendered a mere fetish relevant to minorities and ‘exotic’ peoples alone. Doing so not only derides and dismisses culture while touting it, but also focuses attention on discovering cultural ‘differences’ that reinforce and perpetuate the cultural stereotypes and ethnic stratification purportedly challenged by the focus on diversity.”

From Reviews : Clovis E. Semmes, Racism, Health and Post-Industrialism : A Theory of African-American Health Westport, CT: Praeger, 1996, by Hope Landrine, Journal of Health Psychology 1997 2:3, 428-430

“in the zeitgeist of political correctness and sensitivity to cultural diversity, few in health psychology and related disciplines would dare say what they really think, namely, that while culture plays a role in the health of Hispanics, Asians and a variety of indigenous peoples, it does not play a role in the health of American Blacks because (unfortunately) American Blacks don’t have a culture. Most of the culture they had was lost at sea during the Middle Passage some 400 years ago, and the remainder was beaten out of them, leaving only the scars of the slave masters’ whips behind; those scars, sadly, are their sole cultural legacy. Although never stated explicitly, such beliefs are implicit throughout health psychology. For example, numerous publications on cultural diversity and health describe the health beliefs and practices of a variety of cultural groups in detail—until the authors come to the chapter on Blacks. At that point, the discussion changes to focus on social rather than on cultural variables, i.e. on lack of access to medical care, poverty and low levels of education. These social factors are obviously important insofar as they figure prominently in excess morbidity and mortality among Black Americans—but such social variables play an equally important role in the health of other cultural groups as well, including destitute Mexican-American immigrants, impoverished American Indians, and countless indigenous peoples of Africa, Asia and South and Central America. Specifically, cultural variables nonetheless are viewed as also playing a role in the health of the latter groups, and indeed in the health of every cultural group except African Americans; only for Blacks do discussions of ostensibly cultural factors in health focus on social variables alone.”

On Racial Segregation and Cigarette Smoking Among Blacks

by Hope Landrine and Elizabeth A. Klonoff, Journal of Health Psychology 2000 5:2, 211-219

“THE UNITED STATES continues to be a racially segregated nation and was more segregated in the 1990s than it was in 1860, 1910, and 1940 (Massey & Denton, 1993). This ‘American Apartheid’ (Massey & Denton, 1993, p. 1) is neither the unfortunate remnant of a racist past nor the result of a black preference to live in black neighborhoods; rather, it is the outcome of ongoing racial discrimination in housing and in home loans (Massey & Denton, 1993). High levels of residential segregation characterize the lives of US blacks alone; other US minority groups are not subjected to similar levels of segregation (Massey & Denton, 1993).”

“In summary, this study was an exploratory one designed: (1) to examine for (the first time) the possibility that segregation can be measured at the individual level; and (2) to test (for the first time) the possibility that segregation may be an important social variable to include in research in health psychology. It seems clear that segregation can be measured at the individual level by using some or all of our items, or by developing other items that may be superior to ours. Likewise, these preliminary findings on segregation and smoking suggest that segregation indeed may be an important social variable to include in smoking research and so perhaps in other research in health psychology as well. We encourage development of other measures of segregation for use with individuals, and encourage studies examining this variable. In so doing, it may be beneficial for health psychology to conceptualize segregation theoretically in the manner that public health researchers do, namely: racial segregation is a social-contextual (macro-level) variable that shapes individual exposure and vulnerability to the social and psychological (micro- or individual-level) risk factors that are studied by health psychology and behavioral medicine.”

Perceived Skin Cancer Risk and Sunscreen Use among African American Adults

Latrice C. Pichon, Irma Corral, Hope Landrine, Joni A. Mayer, and Denise Adams-Simms, Journal of Health Psychology 2010 15:8, 1181-1189

We examined perceived skin cancer risk and its relationship to sunscreen use among a large (N = 1932) random sample of African American adults for the first time. Skin cancer risk perceptions were low (Mean = 16.11 on a 1—100 scale). Sun-sensitive skin type and a prior cancer diagnosis were associated with higher perceived skin cancer risk, but demographic factors were not. Unlike findings for Whites, perceived skin cancer risk was not associated with sunscreen use among African Americans.

Residential segregation, health behavior and overweight/obesity among a national sample of African American adults

Irma Corral, Hope Landrine, Yongping Hao, Luhua Zhao, Jenelle L. Mellerson, and Dexter L. Cooper, Journal of Health Psychology 2011 17:3, 371-378

We examined the role of residential segregation in 5+ daily fruit/vegetable consumption, exercise, and overweight/obesity among African Americans by linking data on the 11,142 African American adults in the 2000 Behavioral Risk Factor Surveillance System to 2000 census data on the segregation of metropolitan statistical areas (MSAs). Multi-level modeling revealed that after controlling for individual-level variables, MSA Segregation and Poverty contributed to fruit/vegetable consumption, MSA Poverty alone contributed to exercise, and MSA Segregation alone contributed to overweight/obesity. These findings highlight the need for research on the built-environments of the segregated neighborhoods in which most African Americans reside, and suggest that neighborhood disparities may contribute to health disparities.

Racial discrimination and health-promoting vs damaging behaviors among African-American adults

Irma Corral and Hope Landrine, Journal of Health Psychology 2012 17:8, 1176-1182

Studies have found relationships between racial discrimination and increased health-damaging behaviors among African-Americans, but have not examined possible concomitant decreased health-promoting behaviors. We explored the role of discrimination in two health-promoting behaviors, consuming ≥ 5 fruits/ vegetables daily (FVC) and physical activity (PA), for the first time, and likewise examined discrimination’s contribution to cigarette smoking, among a sample of N = 2118 African-American adults. Results revealed that discrimination contributed positively to smoking and to PA but was unrelated to FVC. These findings suggest that both adaptive and maladaptive health behaviors might be used to cope with the stress of discrimination.

Residential segregation and obesity among a national sample of Hispanic adults

by Irma Corral, Hope Landrine, and Luhua Zhao, Journal of Health Psychology 2013 19:4, 503-508

We explored the role of residential segregation in obesity among a national sample of Hispanics for the first time. Data on the 8785 Hispanic adults in the 2000 Behavioral Risk Factor Surveillance System were linked to 2000 census data on the segregation of 290 metropolitan statistical areas. Multilevel modeling revealed that after controlling for individual-level variables, the odds of being obese for Hispanics residing in high-segregated metropolitan statistical areas were 26.4 percent higher than for those residing in low-segregated metropolitan statistical areas. This segregation effect might be mediated by the obesogenic features (e.g. paucity of recreational facilities and abundance of fast-food outlets) of segregated Hispanic neighborhoods.

Self-rated health, objective health, and racial discrimination among African-Americans: Explaining inconsistent findings and testing health pessimism

Hope Landrine, Irma Corral, Marla B Hall, Jukelia J Bess, and Jimmy Efird, Journal of Health Psychology 2015 21:11, 2514-2524

African-Americans sometimes rate their health as Poor/Fair in the absence of chronic diseases. Theoretically, this lack of correspondence between self-rated health and objective health is due to racial discrimination that results in rating one’s health negatively and in terms of social rather than health variables. We tested this Health Pessimism model with 2118 African-Americans. Results revealed that Poor/Fair self-rated health was predicted mostly by objective health for the Low Discrimination group but mostly by demographic variables for the High Discrimination group, in a manner consistent with Health Pessimism. Inconsistencies among prior studies might reflect differences in the prevalence of high discrimination among their samples.

REFERENCES

Fabrega, H. (1974). Disease and social behavior: An interdisciplinary perspective. Cambridge, MA: MIT Press.

Granek, L. (2007). Interview with Hope Landrine: Health Psychology, August 18, 2007, San Francisco, CA, U.S.A.

Landrine, H. (2011). Erasing inequities. Hope Landrine strives to make health disparities a thing of the past. https://news.ecu.edu/2011/12/01/erasing-inequities/

Rebuilding Engel

Marks, David F. “Rebuilding Engel.” (2019): Theory & Psychology 0959354319884638.

Review of: Derek Bolton and Grant Gillett, The biopsychosocial model of health and disease: New philosophical and scientific developments. London, UK: Palgrave Pivot, 2019. 149 pp. ISBN 9783030118983

The authors, Derek Bolton and Grant Gillett, have mixed disciplinary backgrounds—Bolton in philosophy and clinical psychology; Gillett in medicine, neurosurgery, philosophy, and bioethics. They have written this book following many years of clinical experience, research, and theorising. They claim that “Biopsychosocial problem-solving is trans-disciplinary” (p. vii). Their work was supported in part by the Wellcome Trust at South London and Maudsley NHS Foundation Trust and King’s College London. For brevity’s sake, I refer to the biopsychosocial model as “BPSM.”

The lack of textual connections with psychology led me to wonder who the target audience for this book might be. The authors do not say. As far I can tell, there is nothing much here for the psychologist, nothing much for the medical doctor, nothing for the nurse, and slim pickings for the medical sociologist. One might surmise that the book is aimed at the philosopher of health and medicine (a fairly rare animal). Not keeping in mind any specific audience might mean that there isn’t one, save for the authors themselves and a few loyal chums with Christmas stockings to fill. In this case, mince pies might be kinder and easier to digest. More seriously, though, this book is definitely not light reading. However, it is a rewarding read which pays dividends for effort. I enjoyed it, and recommend it. Bolton and Gillett aim to:

“articulate a clear biopsychosocial model, drawing on Engel’s original, but updating it in the light of substantial developments in the sciences and philosophy in the past few decades. . . . [Their] methodology is to work with concepts and principles worked out in the sciences, but those of a fundamental theoretical status that borders into the ‘philosophical’ or even ‘metaphysical’” (pp. v–vi).

Metaphysics and medicine tend to make a fiery kind of cocktail. As if to add belt and braces, they speak of a “crisis” in the conceptual foundations of medicine and healthcare.(Another crisis? Does anything have to be a crisis before anybody pays attention?) The book’s rationale rests on the “vagueness” and lack of validity of the BPSM; that the BPSM is flawed. Both points are valid; others commented on the same things decades ago. Sociologist David Armstrong savaged the BPSM 30 years ago:

“Engel’s vision was of a social science subservient to the biomedical enterprise because he could not see that the ‘lesion’ or biological abnormality was anything but the very truth of illness. However he seemed unaware of sociological arguments which challenged this version of illness” (1987, p. 1214).

Bolton and Gillett overlook Armstrong’s critique. Sociology is not part of their brief. They ignore health psychology also. A psychology textbook, published 20 years ago, pointed out that Engel had left much unsaid (the point about vagueness) and, by some oversight, never actually defined the BPSM, leaving it open to interpretation, a medical kind of ink-blot test. The BPSM is not much more than a set of cosy beliefs and values in which to wrap a hard-boiled biomedical approach. Engel, so we thought, was serving old wine in new bottles and the BPSM wasn’t actually a model at all (Marks, Murray, Evans, & Willig, 2000, 2018).

I will briefly consider each of the four chapters, one by one. In Chapter 1, which concerns “The Biopsychosocial Model 40 Years On,” Bolton and Gillett consider that the model has a “reasonable claim to be the overarching framework for medicine and healthcare, invoked in clinical and health educational settings the world over” (p. v). They claim that the BPSM “has become the orthodox overarching model for health, disease and healthcare. It is much cited and taught in healthcare trainings of all sorts and in workshops and ward rounds the world over” (p. 5). Yet empirical evidence makes this claim somewhat doubtful, at least among the principal purveyors of the biomedical model, medical doctors themselves. Jaini and Lee (2015) found that the BPSM was being utilised in the curricula of only five U.S. medical schools. Nurse training, and the diverse array of para-medical fields, undoubtedly give the BPSM greater emphasis than medical curricula, but they probably always have because it serves their interest to do so. The greatest buy-in to the BPSM is in health psychology.

Setting aside the popularity issue, I return to the authors’ main theme in their first chapter, that the BPSM is an overarching theory of healthcare and the accusation of vagueness. Bolton and Gillett have a solution: “the scientific content and clinical utility of the BPSM is not to be found in general statements, but rather is specific to particular health conditions, and, further, specific to particular stages of particular health conditions” (p. 15). The authors seek a metaphor that allows a causal system of influence between the biological, psychological, and social levels of the BPSM. The metaphor, they suggest, must have a temporal, evolutionary, and developmental parameter. Now they are putting some meat, or soya, into the sandwich.

In Chapter 2, Bolton and Gillett argue that new concepts and principles of regulatory control apply in biology, and also run through the psychological and social domains. They argue that this enables a more unified science, and one that makes foundational differences between life and death, health and illness.

In Chapter 3, which is concerned with the issue of how “Psychology Regulates Activity in the Social World,” Bolton and Gillett argue that the core function of the psychological realm is agency. Few people would argue with that, except Dennett (2003), whose posture is that self and agency are delusions. Bolton and Gillett make a case that factors involved in health and disease “are increasingly seen to extend beyond the internal biological environment into the psychological, social, economic and political conditions of living” (p. 77). As if by fiat, the authors then argue that higher-level social factors are causal. I agree with them, but would have preferred proof of this and their Nobel Prize to follow, not energetic handwaving. At least, Bolton and Gillett set a clear agenda for making the BPSM a proper model.

Chapter 4 on “Biopsychosocial Conditions of Health and Disease” brings together the different strands of earlier chapters to discuss the major role of chronic stress in models of causal mechanisms linking psychosocial factors with biological damage, and spells out that “chronic stress is a quintessential biopsychosocial concept” (p. 109). Bolton and Gillett consider the Research Domain Criteria (RDoC) proposed by the N.I.M.H. for research in mental health as one illustration of a biopsychosocial research framework. In this, “Physical and mental health conditions are brought together in the new BPSM rather than being axiomatically separate—as they were in the old context of reductionism and dualism” (p. 109).

Measured against this goal, this engaging book mainly succeeds. One imagines that this excellent book will be read principally by the converted. In their next book, I hope that Bolton and Gillett will write a dumbed down version to convince medical doctors that the BPSM isn’t just one of “those topics” covered in the behavioural science course but a vital ingredient of their practice.

There can be little doubt that the medical model remains the dominant foundation of healthcare, and is likely to remain so. This book seems unlikely to change this any more than Engel.

References

Armstrong, D. (1987). Theoretical tensions in biopsychosocial medicine. Social Science & Medicine, 25(11), 1213–1218.

Dennett, D. C. (2003). The self as a responding—and responsible—artifact. Annals of the New York Academy of Sciences, 1001(1), 39–50.

Jaini, P. A., & Lee, J. S. H. (2015). A review of 21st century utility of a biopsychosocial model in United States medical school education. Journal of Lifestyle Medicine, 5(2), 49–59.

Marks, D. F., et al. (2000, 5th ed. 2018, 6th ed. 2021) Health psychology: Theory, research and practice. London: SAGE Publications.

Homeostasis, Exercise, and COVID-19 Isolation

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The Value of Exercise

A recent post explored human needs during COVID-19 isolation. The success of social isolation policies will depend on minimizing long-term depreciation of mental health. In this post, I explain the benefits of developing a system of daily exercise to bolster well-being.

Exercise is an under-utilised resource that is freely available to almost everyone, which can bring profound benefits if applied systematically. The impact of exercise is one of the most powerful examples of regulation created by homeostasis. Regular physical activity not only has obvious physical benefits but significant psychological benefits also. During COVID-19 isolation, exercise offers the capability to reset body and mind to a more optimum state of equilibrium.

Hawley et al. (2014) state: “Exercise represents a major challenge to whole-body homeostasis, and in an attempt to meet this challenge, myriad acute and adaptive responses take place at the cellular and systemic levels that function to minimize these widespread disruptions.”

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The Physiological Responses to Voluntary, Dynamic Exercise. Multiple organ systems are affected by exercise, initiating diverse homeostatic responses. Reproduced from ‘Integrative Biology of Exercise’ by Hawley et al. (2014).

Note of caution

Apart from its general ability to challenge homeostasis to reset the body’s biological equilibrium, exercise has a role in two domains of well-being:

(1) the immune system is strengthened through regular physical activity (Campbell and Turner, 2018; Simpson et al., 2020)

(2) psychological well-being is enhanced (Mandolesi et al., 2018).

However, exercise is no panacea.

Exercise must be applied with caution especially by people with chronic conditions. If a person has a heart condition, strenuous physical exercise may put them at risk (Keteyian et al., 2016).

In some chronic conditions such as ME/CFS, exercise tends to make many patients feel much worse (Geraghty et al., 2019).

However, if used safely and appropriately, the majority of people can quickly feel physical and mental benefits from regular exercise.

Physiological Mechanisms

Some significant effects of physical activity can be explained by physiological mechanisms (Lopresti et al., 2013). Exercise within the context of psychological health promotion has also been an active research area (Chekroud et al., 2018; Curioni and Lourenco, 2005; Mikkelsen et al., 2017; Tiggemann and Zaccardo, 2018). Some researchers have focused on neurophysiological mechanisms, which aim to identify the positive outcomes of the relationship between exercise and mental health (Eyre and Baune, 2012). Exercise is understood as a relationship between intensity and frequency, and positive outcomes are mostly based on which exercise protocol will determine a better neurophysiological response (Lopresti et al., 2013). Exercise is recognized as a mediator of primary monoamine neurotransmitters, namely, serotonin, noradrenaline and dopamine. These three neurotransmitters receive reciprocal regulation, while exercise intensity modulates the stimulation of monoamine system (Lin and Kuo, 2013). However, it is also important to recognize the affective responses of physical activities and psychological variables are likely to mediate the relationship between exercise and mental health (Rodrigues et al., 2019). There is a sound empirical basis for an integrated account of the emotional effects of exercise. A recent study with a representative US sample of 1.2 million individuals linked exercise to mental health and exercising was associated with reduced self-reported mental health burden. Furthermore, motivation and mindfulness-based techniques act as mediators for these relationships, which seem to account for the strongest effect of the exercise on fewer days of poor mental health (Chekroud et al., 2018).

Joy and Happiness

young-people-jumping_23-2148299823

In the context of social isolation, exercise can be an inherently rewarding activity that contributes joy, happiness and satisfaction (Ryan and Deci, 2017; Standage and Ryan, 2012). The positive outcomes also appear as a function of affective consequences of exercise or anticipation of its affective response – the hedonic principle of the law of effect (Marks, 2018). In general, the expected pleasure versus displeasure is a determining principle of the motivation to repeat behaviour (Kwasnicka et al., 2016; Williams, 2008).

Isolation and quarantine are a disagreeable experience, which may lead to sadness and even impose dramatic mental illness for those who undergo it (Brooks et al., 2020). In this context, a daily exercise routine can be crucial to modulating pleasurable situations at some point during the day. People can feel more deeply satisfied through the experience of choice and volition, reinforce their sense of autonomy and competence, and renew a sense of joy (Lubans et al., 2017; Ryan and Deci, 2017; Standage and Ryan, 2012).

The benefits of exercise depend on the degree of internalization of the behaviour. In our daily lives, exercises are normally performed in order to achieve goals, such as social aesthetic standards (Sperandei et al., 2016). These goals are separable from the purpose of the exercise (a person may not enjoy exercising, but will do it to obtain a result); and therefore, people are generally not ‘authentic’. The lack of authenticity represents a person doing an activity for contingent reward or punishment, feeling tense and pressured, lacking intentionality and being oriented to avoid guilt, angst and social judgement or to protect contingent self-worth. Contrarily, people are authentic when exercise choice is aligned with personal goals, interest and is assimilated with the individual’s characteristics, ability and identity (Deci and Flaste, 1995). Identity is associated with ongoing positive experiences attendant on the behaviour (Kwasnicka et al., 2016), such as exercising at home.

Notably, the COVID-19 pandemic causes fear and the lockdown imposes limits on people’s movement (Brooks et al., 2020; Xiang et al., 2020).

The rationale for the positive side of exercising at home is that exercise can be experienced without any strong social pressure, having a totally internal source of inspiration. The behaviour might be accompanied by higher self-esteem and lower psychological ill-being, since we are free to choose the:

  • types of exercise
  • schedule
  • frequency
  • intensity

The fulfilment of basic psychological needs appear within this context.

Authenticity and Self-Compassion

the-scientific-benefits-of-self-compassion-emma-seppala-clip

Another helpful process is that of self-compassion – the ability to treat oneself with the same concern and support in distressing situations; it is related to self-kindness, common humanity and mindfulness. In fact, it is associated with self-regulation when performing health-promotion behaviours (Holden et al., 2020; Semenchuk et al., 2018). Exercising at home, in a crisis situation, can be performed without self-criticism, which could hinder the process by increasing pressure and self-judgement, which in turn may provide adaptive coping, problem-solving and psychological well-being.

Research has provided empirical evidence on the positive relationship between self-compassion and exercise in providing exercise maintenance and enhancing positive emotions (Holden et al., 2020; Semenchuk et al., 2018).

Mastery and Self-control

Exercising at home can increase the individual’s sense of control. Research suggests that self-mastery is a crucial criterion for promoting positive effects on psychological outcomes (Mikkelsen et al., 2017; Ryan and Deci, 2017). In the face of this pandemic, we have seen many examples across the world showing that exercise can create a social arena in which individuals learn social skills and build social networks by adhering to exercise challenges, exercising in condominiums and encouraging others. These virtual social connections enhance feelings of autonomy and being fully alive. When autonomous forms of regulation guide behaviour, positive affective responses are expected (Ryan and Deci, 2017; Standage and Ryan, 2012). One example is the QuaranTrain launched at HAN University of Applied Sciences in the Netherlands, an online fitness programme promoting evidence-based information on exercise and resources to stay active during COVID-19 pandemic through blogs and videos (HAN University of Applied Sciences, 2020). They provide daily online support, according to World Health Organization advice on physical activity. Users post their workouts routines in social media using the trending hashtags #quarantrain and #quarantraining, with more than 5000 posts worldwide.

Self-efficacy and Self-esteem

Being engaged in exercise may result in higher levels of self-efficacy (Bandura, 1997) which can have the knock-on effect of improving one’s ability to carry out other activities (Mikkelsen et al., 2017). The relationship between changes in the ability to perform activities successfully and increased self-efficacy is fundamental, considering the observed association between depression and low self-efficacy (White et al., 2009). In the context of social isolation, physical activity may be one key to enhancing people’s feeling of competence. In addition, achievement of internal goals and satisfaction has been related to greater psychological wellness (Ryan and Deci, 2017; Standage and Ryan, 2012). This hypothesis has been confirmed by an experimental protocol in which mindfulness self-efficacy appeared to mediate the indirect effects of exercise on mental health and perceived stress (Goldstein et al., 2018), reinforcing the positive account of emotion for a better quality of life (Joseph et al., 2014).

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Mikkelsen et al. (2017) observed that exercise influences self-esteem through self-efficacy or mastery, and mood, distracting individuals from negative and worrying thoughts and rumination, improving the retrieval of positive thoughts and allowing time away from negative or stressful aspects of everyday life, and especially, the COVID-19 pandemic itself. These moderating factors might also explain the protection effect of exercise on mental health (Mikkelsen et al., 2017).

Physical activity programmes to improve self-esteem to people of all ages can be effectively delivered at home by DVD (e.g. see Awick et al., 2017) or by You Tube (e.g. PE with Joe).

Peer Support

Moreover, people in social isolation should try to create peer support through social networking services by involving friends and relatives in their exercise routines or challenges.

Resources

 

The negative impacts of COVID-19 lockdown on mental health can be ameliorated by the use of exercise, which should be as vigorously promoted as social distancing itself.

In this context, keeping moving seems to be the key.

Reference:

Thiago Matia, Fabio H Dominski and David F Marks (2020)

The ‘COMA-B’ System for Behaviour Change: Reset of the COM-B

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The COM-B System

In 2011, three psychologists, Susan Michie, Maartje M van Stralen and Robert West (MSW, 2011), proposed “a ‘behaviour system’ involving three essential conditions: capability, opportunity, and motivation…This forms the hub of a ‘behaviour change wheel’ (BCW).”

MSW mention two sources for the idea of the COM-B:

“a US consensus meeting of behavioural theorists in 1991 [see this], and a principle of US criminal law dating back many centuries…Under US criminal law, in order to prove that someone is guilty of a crime one has to show three things: means or capability, opportunity, and motive.”

They continue:

“This suggested a potentially elegant way of representing the necessary conditions for a volitional behaviour to occur…We have built on this to add nonvolitional mechanisms involved in motivation (e.g., habits) and to conceptualise causal associations between the components in an interacting system.”

A conceptual framework used by the courts to prove the innocence or guilt of accused felons may not be the most appropriate model to apply to the behavioural choices of non-criminals. The COM-B has been influential and highly cited (4220 times by 08/10/20).  However, the hub of the COM-B is incomplete and manifestly it does not work when applied to the most basic of choices in health behaviours such as smoking, drinking and the wearing of masks in a pandemic.  Here I explain why. Screen Shot 2020-04-03 at 10.34.04.png

 

In the COM-B system, Capability, Opportunity, and Motivation are said to ‘interact’ to generate Behaviour. C, O and M are claimed to be sufficient and necessary conditions for B. Before discussing the model, we need some definitions:

Definitions

MSW give the following definitions:

‘Capability’ is defined as the individual’s psychological and physical capacity to engage in the activity concerned. This includes having the necessary knowledge and skills. In plain language, ‘capability’ means ‘fit to’.

‘Motivation’ is defined as all those brain processes that energize and direct behaviour, not just goals and conscious decision-making, e.g. habitual processes, emotional responding, as well as analytical decision-making.  Thus motivation equates with ‘need to’.

‘Opportunity’ is defined as all of the factors that ‘lie outside the individual that make the behaviour possible or prompt it’.  Thus opportunity means ‘can do’.

The model suggests that if one is fit to, needs to and can do a particular behaviour, then one will do it. Unfortunately, there is a key process missing from this scheme, as I will demonstrate below. Taking into account the original context for the COM-B model – proving guilt or innocence in the courtroom – I will use an example from the same domain.

Robbing a Bank

According to the COM-B, capability and opportunity cause changes in motivation and changes in behaviour.  I refer to that fictitious character Joe Blow (pronouns: him/her/their). 

According to the COM-B:

Joe Blow (JB) would (X rob a bank, Y kiss the queen, Z fly to the moon, whatever) if it can be shown that JB is fit to, needs to, and can do X, Y or Z. Yet this account is plainly incomplete. A key element that is missing from the COM-B is wanting: JB must want to carry out X, Y or Z if he is to actually to do it.  If JB doesn’t want to, he/she/they simply won’t do it, no matter what.

Imagine the following:

1) JB is fit to rob a bank because he/she/they is physically strong and has a jemmy and a set of tools for breaking open doors and safes – (fit to).

2)  JB is hugely in debt (to a bank, as it happens) so he/she/they need(s) money very badly, and so has a strong motive to rob a bank – (needs to).

3) JB knows there is a back alley and a door with an alarm that a friend who works in the bank will leave switched off on any night of their choosing – (can do).

Thus, JB ticks all three boxes of the COM-B but JB still chooses not to rob a bank. Why so? It could be for a million and one  possible reasons.  JB does not rob the bank because:

robbing the bank would be wrong,

it would be risky – i.e if he is found out he would go to prison,

if found out, it would look bad in front of the neighbours,

it would upset the bank manager who he knows well drinks beers with in the local pub,

it would be an unreasonable and unfair

etc

For a host of different reasons, JB may desperately need money but does not want to rob the bank to get it.

In spite of JB ticking all three of COM-B boxes, the COM-B fails to correctly predict JB’s behaviour. There is a hidden barrier. In multiple situations people do not choose to do something, something for which they could be handsomely rewarded, because they simply do not want to do it.

Another similar individual who ticks all three COM-B boxes might actually proceed to commit the bank robbery. Imagine that Joe Blow has a twin, Les Blow (LB/him/her/their) who lives on the other side of town. JB tells LB about the bank, the back alley and the dodgy security guard.  LB now meets all three criteria – LB is fit to, needs to, and can do the bank robbery. However, LB has none of the moral and social scruples held by JB and proceeds to rob the bank.

The twins act differently under essentially similar circumstances, revealing a crucial difference between the twins.

The COMA-B Reformulation

The COM-B requires reformulation because a crucial process is missing. However, the COM-B does not work because there are other problems that prohibit a good fit to real world data. The diagram of the model shows five arrows representing so-called ‘interactions’, three of which point in both directions. Four of the ‘interactions’ do not exist and none works in both directions. 

Only one ‘interaction’ in the COM-B diagram is anywhere near causal.  In order to do something, a person also has to want to do it more than they want not to do it. This is a delicate balancing act that takes place when we make decisions in our everyday lives. The COM-B is reformulated as the ‘COMA-B’ in the diagram below.

(A = ‘Aspires to’, which makes a better acronym than using W for Wants : COMW-B).

amended COM-B model.png

Adding a box for wants to and placing arrows differently converts the COM-B into the COMA-B.  In removing arrows, it is necessary to distinguish enablers from causes. Fit-to capability and can-do opportunity are both enablers of need-to motivation; wants-to is actually causal.

Conclusion

There are three necessary conditions for any action X:

  1. having the capability to do X
  2. having the opportunity to do X
  3. wanting to do X

A fourth condition, need, triggers want, but is not sufficient to produce behaviour on its own.

The above discussion shows that the original COM-B framework is incapable of predicting behaviour and behaviour change.

Recently, the authors of the COM-B produced a reformulation, which will be discussed in another post.

Food, Diets and Dieting

Inequities

The world is full of contradictions, inconsistencies and inequities. On the one hand, it has been reported by the Food and Agriculture Organization of the United Nations (FAO, 2015) that 805million people are estimated to be chronically undernourished. Yet, it has been estimated that the volume of food produced is more than one and a half times what is needed to provide everybody on the planet with a nutritious diet (Weis, 2007). It is not about lack, it is about inequity. While 805 million starve, we also know that 1460 million are overweight or obese, and that number is increasing.

There is also water scarcity with 1.2 billion people lacking access to clean drinking water and 2.5 billion people having no access to a toilet, less than the number of people with a mobile phone (United Nations, 2015). As the world population increases from 7.3 billion today to around 9.6 billion in 2050 (+31.5%), the supply of fresh drinking water available will remain about the same. Yet, around 70 per cent of the world’s water is used in agriculture. Annual grain crops are planted on about 70 per cent of the world’s cropland and provide 80per cent of the world’s food (Pimentel et al., 2012), 70 per cent of which is stock feed for farm animals, which in turn produce dairy and meat.

Over the next 25 years, a lot more food will be needed for the extra 31.5 per cent and the only way it can be produced is through agriculture, creating a vicious circle. The FAO (2015) predicts that the global demand for livestock products will increase by 70 per cent by 2050 with an estimated 1 billion poor depending on livestock for food and income. The livestock sector contributes to human-induced Greenhouse Gas emissions for 14.5 per cent and is a large user of natural resources, especially water.

As Father Time waves his sickle over the remaining decades of this century, there will be a worsening water scarcity. Thanks in part to a ready supply of beef burgers, fried chicken, milk, eggs and cola. Many recent editorials in medical and scientific journals have addressed issues relating to food, diets and dieting (e.g. Drewnowski, 2014; Edmonds and Templeton, 2013; Fitzgerald, 2014; Gold and Graham, 2011; Ndisang et al., 2014; Pagadala and McCullough, 2012; Potenza, 2014; Sniehotta et al., 2014; Stuckler and Basu, 2013; The PLoS Medicine Editors, 2012; Yanovski, 2011).

Special Issue

The Special Issue on ‘Food, Diets and Dieting’ provides a state-of-the-art overview of psychological studies by international researchers on this topic area. The Call for Papers for a Special Issue on ‘Food, Diets and Dieting’ was timely; we received unprecedented interest with many high-quality submissions. Following peer review, the number of accepted papers finally reached the total of 42. The contributions have been divided into two sets for publication in the May and June 2015 issues of Special Issue: Food, diets and dieting. These publications in Journal of Health Psychology are complemented in our companion, open access journal, Health Psychology Open, by a theoretical review paper and a series of commentary papers (Marks, 2015).

According to the McKinsey Global Institute (2014) obesity is responsible for around 5 per cent of global deaths and the global economic impact is US$2.0trillion, or 2.8per cent of global gross domestic product (GDP), roughly equivalent to the impact from smoking or armed violence, war and terrorism. In the United States, in 2004, direct and indirect health costs associated with obesity were US$98 billion. That figure probably has doubled by now.

Depending on the source, it is reported that the direct medical cost of overweight and obesity combined has been estimated to be 5–10per cent of the US health care spend. 42million children under the age of 5 were overweight or obese in 2013. Prevalence of overweight or obesity in adults doubled from 6 per cent in 1980 to 12 per cent in 2008. By 2050, it is predicted that obesity will affect 60 per cent of adult men, 50 per cent of adult women and 25per cent of children making the United States, Britain and much of Europe a mainly obese society.

Globalization is Driver

The main driver of the obesity epidemic and increased prevalence of other non-communicable diseases is unregulated corporate globalization (Swinburn et al., 2011). From the point of view of human health, globalization flies a banner of progress and freedom yet brings illness and an early death to millions of people with non-communicable ‘diseases of affluence’. Transnational corporations are scaling up their promotion of tobacco, alcohol, cola and other sugary beverages, ultra-processed food and unhealthy commodities generally throughout low- and middle-income countries. Moodie et al. (2013) have observed that sales of unhealthy commodities across 80 low- and middle-income countries are strongly interrelated. They argue that wherever there are high rates of tobacco and alcohol consumption, there are also a high intake of snacks, soft drinks, processed foods and other unhealthy food commodities. Moodie et al. (2013) argued that the alcohol and ultra-processed food and drink industries are using similar strategies to the tobacco industry to undermine effective public health policies and programmes. Furthermore, it is suggested that unhealthy commodity industries should have no role in the formation of national or international policy for non-communicable disease policy. Therefore, it follows that the only evidence-based mechanisms that can prevent harm caused by unhealthy commodity industries are public regulation and market intervention.

Food Affordability

The work of Drewnowski and others has demonstrated a strong relationship between affordability of food and beverages and their energy density measured in terms of fat and sugar (Drewnowski, 2014; Drewnowski and Specter, 2004). A systematic review of 27 studies across 10 countries showed that a healthful diet costs around US$550 per year more than an unhealthy one (Rao et al., 2013). In England, another study suggested that the healthiest dietary pattern costs double the price of the least healthy, costing £6.63/day and £3.29/day, respectively (Morris et al., 2014). That is a difference of £1219 per annum.

The inverse relationship between income and prevalence of overweight and obesity follows from two related facts: (a) cheaper foods and drinks are energy-dense and (b) a healthful diet is unaffordable for the majority of people. In 2008, an estimated 1.46 billion adults worldwide had a body mass index (BMI) of 25kg/m2 or greater, and of these, 205million men and 297million women were obese. Taking into account, the rate of increase in obesity, this half-billion figure is projected to increase at least 30 per cent by 2050. The World Health Organization (WHO) (2014) estimates that around 3.4million adults die each year as a result of overweight or obesity. The WHO (2013) published a plan to halt the rise in diabetes and obesity as a part of a vision: ‘A world free of the avoidable burden of noncommunicable diseases’. WHO interventions revolve around ‘mobilizing sustained resources Marks 471 … in coordination with the relevant organizations and ministries’ which consists of high-level meetings between governmental representatives and publishing position statements.

Evidence and logic suggest that economic prosperity is the enabler for obesity and, furthermore, leading authorities have concluded that Obesity is the result of people responding normally to the obesogenic environments they find themselves in. Support for individuals to counteract obesogenic environments will continue to be important, but the priority should be for policies to reverse the obesogenic nature of these environments. (Swinburn et al., 2011) Policy reversals to reduce obesogenicity by regulation face robust resistance from the food and drinks industry. Yet without regulation to change the price imbalance between unhealthful and healthful foods, the obesity epidemic is unlikely to go away. In the meantime, hundreds of millions of individuals continue inexorably along the path of overweight and obesity, with the associated unpleasant illnesses and an early death. It follows that health care systems must be competent to offer effective interventions to prevent, treat and ameliorate the impact of overweight or obesity. Authorities decree that a ‘balanced diet’ with regular physical activity is of crucial importance to a healthy body. Yet, in spite of thousands of studies, hundreds of campaigns and scores of dedicated institutes and journals based on this creed, there are currently no validated public health interventions able to achieve sustained long-term weight loss. Today, the muchtouted idea of the ‘balanced diet’ seems little more than worn out myth. Some basic questions require answers: What is causing the obesity epidemic? What can be done about it? and What is the role of health psychologists (if any)? (Marks et al., 2015; Marks, in press). The obesity epidemic is comparable in importance to the smoking epidemic. Arguably, it will prove to be even more significant in human history than smoking. It took 50 years of consolidated pressure to reduce the prevalence of smoking related diseases. Progress has been frustratingly slow. Still, in 2015, only one industrialized country in the world has plain or standard packaging of cigarettes (Australia) with a second one planning to follow next year (England). With no significant interventions on the horizon for obesity prevention, for example, unhealthful food taxation, the obesity epidemic can continue unabated to run its course, until food and water shortages have their ultimate impact on human society.

Enough Knowledge Now to Tackle Obesity

There is enough knowledge now to tackle the obesity epidemic. Unfortunately our political leaders lack the spine to do what is necessary. Our market-led governance is in the pocket of the paymasters who influence the election of our presidents and prime ministers. If the food chain could be rationally developed, the food and water crises could be curbed within two decades from now. This Special Issue contains a collection of in-depth psychological studies on food, diets and dieting. These studies are relevant to the issue of why certain foods are eaten or avoided by individual consumers and how the choices of consumers are influenced by family, social and economic conditions. Diets and dietary changes involve complex systems of variables which operate on a mass scale. Improved understanding of psychological functioning around food, diets and dieting holds one key to improving nutritional health. A better understanding of behaviour alone is not enough; changes to the food environment are also necessary. Our governmental leaders need to wake up, loosen their ties to their industrial paymasters and take effective action.

References

Drewnowski A (2014) Healthy diets for a healthy planet. The American Journal of Clinical Nutrition 99(6): 1284–1285.

Drewnowski A and Specter SE (2004) Poverty and obesity: The role of energy density and energy costs. The American Journal of Clinical Nutrition 79(1): 6–16.

Edmonds EW and Templeton KJ (2013) Childhood obesity and musculoskeletal problems: Editorial Clinical Orthopaedics and Related Research 471(4): 1191–1192.

Fitzgerald DA (2014) Mini-symposium: Childhood obesity and its impact on respiratory wellbeing: Editorial title: Childhood obesity is the global warming of healthcare. Paediatric Respiratory Reviews 15(3): 209–284.

Food and Agriculture Organization of the United Nations (FAO) (2014) The State of Food Insecurity in the World: Strengthening the Enabling Environment for Food Security and Nutrition. Rome: FAO. Available at: http:// http://www.fao.org/3/a-i4030e.pdf

Food and Agriculture Organization of the United Nations (FAO) (2015) Livestock and the environment. Available at: http://www.fao.org/ livestock-environment/en/

Gold MS and Graham NA (2011) Editorial: Hot topic: Food Addiction & Obesity Treatment Development (Executive Guest Editors: Mark S Gold and Noni A Graham). Current Pharmaceutical Design 17(12): 1126–1127.

McKinsey Global Institute (2014) Overcoming obesity: An initial economic analysis. Discussion paper. London. Available at: http://www. munideporte.com/imagenes/documentacion/ ficheros/025183D9.pdf

Marks DF (2015) Homeostatic theory of obesity. Health Psychology Open. Marks DF, Murray M, Evans B, et al. (2015) Health Psychology: Theory, Research and Application (4th edn). London: SAGE.

Moodie R, Stuckler D, Monteiro C, et al. (2013) Profits and pandemics: Prevention of harmful effects of tobacco, alcohol, and ultraprocessed food and drink industries. The Lancet 381(9867): 670–679.

Morris MA, Hulme C, Clarke GP, et al. (2014) What is the cost of a healthy diet? Using diet data from the UK Women’s Cohort Study. Journal of Epidemiology and Community Health 68(11): 1043–1049.

Ndisang JF, Vannacci A and Rastogi S (2014) Oxidative stress and inflammation in obesity, diabetes, hypertension, and related cardiometabolic complications. Oxidative Medicine and Cellular Longevity 2014: 506948.

Pagadala MR and McCullough AJ (2012) Editorial: Non-alcoholic fatty liver disease and obesity: Not all about BMI. The American Journal of Gastroenterology 107: 1859–1861.

Pimentel D, Cerasale D, Stanley RC, et al. (2012) Annual vs. perennial grain production. Agriculture, Ecosystems & Environment 161: 1–9.

Potenza MN (2014) Obesity, food, and addiction: Emerging neuroscience and clinical and public health implications. Neuropsychopharmacology 39(1): 249–250.

Rao M, Afshin A, Singh G, et al. (2013) Do healthier foods and diet patterns cost more than less healthy options? A systematic review and metaanalysis. BMJ Open 3: e004277.

Sniehotta FF, Simpson SA and Greaves CJ (2014) Weight loss maintenance: An agenda for health psychology. British Journal of Health Psychology 19: 459–464.

Stuckler D and Basu S (2013) Getting serious about obesity. BMJ: British Medical Journal 346: f1300.

Swinburn BA, Sacks G, Hall KD, et al. (2011) The global obesity pandemic: Shaped by global drivers and local environments. The Lancet 378(9793): 804–814.

The PLoS Medicine Editors (2012) PLoS Medicine series on Big Food: The food industry is ripe for scrutiny. PLoS Medicine 9(6): e1001246.

United Nations (2015) Water Scarcity. Available at: http://www.un.org/waterforlifedecade/scarcity. shtml

Weis T (2007) The Global Food Economy. London: Zed Books. World Health Organisation (WHO) (2014) Obesity and overweight. Fact Sheet No 311. Available at: http://www.who.int/mediacentre/factsheets/ fs311/en/http://www.who.int/mediacentre/ factsheets/fs311/en/

World Health Organization (WHO) (2013) Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020. Geneva: WHO.

Yanovski SZ (2011) Obesity treatment in primary care – Are we there yet. New England Journal of Medicine 365(21): 2030–2031.

First published in the Journal of Health Psychology 2015

Special issue on the PACE Trial

We are proud that this issue marks a special contribution by the Journal of Health Psychology to the literature concerning interventions to manage adaptation to chronic health problems. The PACE Trial debate reveals deeply embedded differences between critics and investigators. It reveals an unwillingness of the co-principal investigators of the PACE trial to engage in authentic discussion and debate. It leads one to question the wisdom of such a large investment from the public purse (£5million) on what is a textbook example of a poorly done trial.

The Journal of Health Psychology received a submission in the form of a critical review of one of the largest psychotherapy trials ever done, the PACE Trial. PACE was a trial of therapies for patients with myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS), a trial that has been associated with a great deal of controversy (Geraghty, 2016). Following publication of the critical paper by Keith Geraghty (2016), the PACE Trial investigators responded with an Open Peer Commentary paper (White et al., 2017). The review and response were sent to more than 40 experts on both sides of the debate for commentaries.

The resulting collection is rich and varied in the perspectives it offers from a neglected point of view. Many of the commentators should be applauded for their courage, resilience and ‘insider’ understanding of experience with ME/CFS.

The Editorial Board wants to go on record that the PACE Trial investigators and their supporters were given numerous opportunities to participate, even extending the possibility of appeals and re-reviews when they would not normally be offered. That they failed to respond appropriately is disappointing.

Commentaries were invited from an equal number of individuals on both sides of the debate (about 20 from each side of the debate). Many more submissions arrived from the PACE Trial critics than from the pro-PACE side of the debate. All submissions were peer reviewed and judged on merit.

The PACE Trial investigators’ defence of the trial was in a template format that failed to engage with critics. Before submitting their reply, Professors Peter White, Trudie Chalder and Michael Sharpe wrote to me as co-principal investigators of the PACE trial to seek a retraction of sections of Geraghty’s paper, a declaration of conflicts of interest (COI) by Keith Geraghty on the grounds that he suffers from ME/CFS, and publication of their response without peer review (White et al., 4 November 2016, email to David F Marks). All three requests were refused.

On the question of COI, the PACE authors themselves appear to hold strong allegiances to cognitive behavioural therapy (CBT) and graded exercise therapy (GET) – treatments they developed for ME/CFS. Stark COI have been exposed by the commentaries including the PACE authors themselves who hold a double role as advisers to the UK Government Department of Work and Pensions (DWP), a sponsor of PACE, while at the same time working as advisers to large insurance companies who have gone on record about the potential financial losses from ME/CFS being deemed a long-term physical illness. In a further twist to the debate, undeclared COI of Petrie and Weinman (2017) were alleged (Lubet, 2017). Professors Weinman and Petrie adamantly deny that their work as advisers to Atlantis Healthcare represents a COI.

After the online publication of several critical Commentaries, Professors White, Sharpe, Chalder and 16 co-authors were offered a further opportunity to respond to their critics in the round but they chose not to do so.

After peer review, authors were invited to revise their manuscripts in response to reviewer feedback and many made multiple drafts. The outcome is a set of robust papers that should stand the test of time and offer significant new light on what went wrong with the PACE Trial that has been of such high significance for the nature of treatment protocols. It is disappointing that what has been the more dominant other side refused to participate.

Unfortunately, across the pro-PACE group of authors there was a consistent pattern of resistance to the debate. After receiving critical reviews, the pro-PACE authors chose to make only cosmetic changes or not to revise their manuscripts in any way whatsoever. They appeared unwilling to enter into the spirit of scientific debate. They acted with a sense of entitlement not to have to respond to criticism. Two pro-PACE authors even showed disdain for ME/CFS patients, stating: We have no wish to get into debates with patients. In another instance, three pro-PACE authors attempted to subvert the journal’s policy on COI by recommending reviewers who were strongly conflicted, forcing rejection of their paper.

The dearth of pro-PACE manuscripts to start off with (five submissions), the poor quality, the intransigence of authors to revise and the unavoidable rejection of three pro-PACE manuscripts led to an imbalance in papers between the two sides. However, this editor was loathe to compromise standards by publishing unsound pieces in spite of the pressure to go ahead and publish from people who should know better.

We are proud that this issue marks a special contribution by the Journal of Health Psychology to the literature concerning interventions to manage adaptation to chronic health problems. The PACE Trial debate reveals deeply embedded differences between critics and investigators. It also reveals an unwillingness of the co-principal investigators of the PACE trial to engage in discussion and debate. It leads one to question the wisdom of such a large investment from the public purse (£5 million) on what is a textbook example of a poorly done trial.

ME/CFS research has been poorly served by the PACE Trial and a fresh new approach to treatment is clearly warranted. On the basis of this Special Issue, readers can make up their own minds about the scientific merits and demerits of the PACE Trial. It is to be hoped that the debate will provide a more rational basis for evidence-based improvements to the care pathway for hundreds of thousands of patients.

References

Geraghty, KJ (2016‘PACE-Gate’: When clinical trial evidence meets open data access. Journal of Health Psychology 22(9): 11061112Google ScholarSAGE JournalsISI
Lubet, S (2017Defense of the PACE trial is based on argumentation fallacies. Journal of Health Psychology 22(9): 12011205Google ScholarSAGE JournalsISI
Petrie, K, Weinman, J (2017The PACE trial: It’s time to broaden perceptions and move on. Journal of Health Psychology 22(9): 11981200Google ScholarSAGE JournalsISI
White, PD, Chalder, T, Sharpe, M. (2017Response to the editorial by Dr Geraghty. Journal of Health Psychology 22(9): 11131117Google ScholarSAGE JournalsISI

The Editorial has been abridged and the photograph of Dr. Keith Geraghty added.

Post-Traumatic Growth

Post-Traumatic Growth 

Experiences of life disruption, threat, distress, or adversity can lead to positively evaluated “growth” (Tedeschi and Calhoun, 1995). It has been observed for centuries that benefit finding and posttraumatic growth (PTG) can follow the occurrence of traumatic events including accidents, warfare, death of a loved one, and cancer diagnosis and treatment (Stanton, 2010).

Benefit finding and growth represent a fundamental restorative principle of homeostasis that is continually active towards the achievement of stability, equilibrium and well-being. Adaptation to any life-threatening illness, such as cancer, is facilitated by homeostasis systems that include the drive to find meaning, exert mastery or control over the experience, and bolster self-esteem. Growth and benefit-finding are frequently reported by cancer survivors as they gain awareness of their illness, its treatment and prognosis.

Measurement of PTG

The theoretical model of PTG proposed by Tedeschi and Calhoun suggests growth occurs in different ways.  Developing new relationships, finding new appreciation for life, new meanings in life, discovering personal strength, experiencing spiritual change, and realizing new opportunities are all possibilities. The experiences of benefit finding and growth are undeniable. The methods and measurements used for their study, however, raise more questions than answers.

Among cancer populations, reported prevalence rates of perceived PTG range from 53 to 90% and vary according to the type of cancer, time since diagnosis, heterogeneity and ethnicity of the sample, choice of measurement, and many personal factors (Coroiu et al., 2016). Posttraumatic growth is measured using scales such as “The Posttraumatic Growth Inventory” (PTGI), a 21-item measure of positive change following a traumatic or stressful event (Tedeschi and Calhoun, 1996). Respondents rate the degree to which positive change had occurred in their life “as a result of having cancer.” A total PTGI score and five subscale scores (New Possibilities, Relating to Others, Personal Strength, Spiritual Change, and Appreciation of Life) are calculated.

What the Critics Say

Critics have been less than enthusiastic about measuring PGI in this manner. James Coyne and Howard Tennen (2010) argue that: “Every PTG scale asks participants to rate how much they have changed on each scale item as the result of the crisis they faced. Thus, a respondent must: (a) evaluate her/his current standing on the dimension described in the item, e.g., a sense of closeness to others; (b) recall her/his previous standing on the same dimension; (c) compare the current and previous standings; (d) assess the degree of change; and (e) determine how much of that change can be attributed to the stressful encounter. Psychological science, which purportedly guides positive psychology, tells us that people cannot accurately generate or manipulate the information required to faithfully report trauma- or stress-related growth (or to report benefits) that results from threatening encounters…The psychological literature demonstrates consistently that people are unable to recollect personal change accurately” (Coyne and Tennen, 2010, p. 23).

The five steps a-e certainly are a tall order, and it seems highly doubtful that anybody could achieve them with any accuracy. It seems naïve to analyse numbers that research participants place on scales from the PTGI as though they are valid indices of ‘post-traumatic growth’ when no attempt is made to validate these measures.  In spite of these criticisms, many studies have been conducted using the PTGI scale.

Quack Science 

Quite rightly, Coyne and Tennen (2010) have damned the flawed methods and measures concerning PTG: “We are at a loss to explain why positive psychology investigators continue to endorse the flawed conceptualization and measurement of personal growth following adversity. Despite Peterson’s …warning that the credibility of positive psychology’s claim to science demands close attention to the evidence, post-traumatic growth—a construct that has now generated hundreds of articles—continues to be studied with flawed methods and a disregard for the evidence generated by psychological science. It is this same pattern of disregard that has encouraged extravagant claims regarding the health benefits of positive psychological states among individuals living with cancer” (p. 24).

As long as psychologists use shoddy methods, invalid measures and draw quack conclusions, they will not be taken seriously by outsiders.

Based on a section of: David F Marks et al. (2018) Health Psychology. Theory, Research & Practice (5th ed.) SAGE Publications Ltd.

The PACE Trial: A Catalogue of Errors

What was the PACE Trial?

Rarely in the history of clinical medicine have doctors and patients been placed so bitterly at loggerheads. The dispute had been a long time coming. Thirty years ago, a few psychiatrists and psychologists offered a hypothesis based on a Psychological Theory in which ME/CFS is constructed as a psychosocial illness. According to their theory, ME/CFS patients have “dysfunctional beliefs” that their symptoms are caused by an organic disease. The ‘Dysfunctional Belief Theory’ (DBT) assumes that no underlying pathology is causing the symptoms; patients are being ‘hypervigilant to normal bodily sensations‘ (Wessely et al., 1989; Wessely et al., 1991).

The Psychological Theory assumes that the physical symptoms of ME/CFS are the result of ‘deconditioning’ or ‘dysregulation’ caused by sedentary behaviour, accompanied by disrupted sleep cycles and stress. Counteracting deconditioning involves normalising sleep cycles, reducing anxiety levels and increasing physical exertion. To put it bluntly, the DBT asserts that ME/CFS is ‘all in the mind’.  Small wonder that patient groups have been expressing anger and resentment in their droves.

Top-Down Research

‘Top-down research’ uses a hierarchy of personnel, duties and skill-sets. The person at the top sets the agenda and the underlings do the work. The structure is a bit like the social hierarchy of ancient Egypt. Unless carefully managed, this top-down approach risks creating a self-fulfilling prophecy from confirmation biases at multiple levels. At the top of the research pyramid sits the ‘Pharaoh’, Regius Professor Sir Simon Wessely KB, MA, BM BCh, MSc, MD, FRCP, FRCPsych, F Med Sci, FKC, Knight of the Realm, President of the Royal College of Medicine, and originator of the DBT.  The principal investigators (PIs) for the PACE Trial, Professors White, Chalder and Sharpe, are themselves advocates of the DBT.  The PIs all have or had connections both to the Department of Work and Pensions and to insurance companies. The objective of the PACE Trial was to demonstrate that two treatments based on the DBT, cognitive behavioural therapy (CBT) and graded exercise therapy (GET), help ME/CFS patients to recover. There was zero chance the PACE researchers would fail to obtain the results they wanted. 

Groupthink, Conflicts and Manipulation

The PACE Trial team were operating within a closed system or groupthink in which they ‘know’ their theory is correct. With every twist and turn, no matter what the actual data show, the investigators are able to confirm their theory. The process is well-known in Psychology. It is a self-indulgent processes of subjective validation and confirmation bias.  Groupthink occurs when a group makes faulty decisions because group pressures lead to a deterioration of “mental efficiency, reality testing, and moral judgment” (Janis, 1972). Given this context, we can see reasons to question the investigators’ impartiality with many potential conflicts of interest (Lubet, 2017). Furthermore, critical analysis suggests that the PACE investigators involved themselves in manipulating protocols midway through the trial, selecting confirming data and omitting disconfirming data, and publishing biased reports of findings which created a catalogue of errors.

‘Travesty of Science’

The PACE Trial has been termed a ‘travesty of science’ while sufferers of ME/CFS continue to be offered unhelpful or harmful treatments and are basically being told to ‘pull themselves together’. One commentator has asserted that the situation for ME patients in the UK is: The 3 Ts – Travesty of Science; Tragedy for Patients and Tantamount to Fraud” (Professor Malcolm Hooper, quoted by Williams, 2017). Serious errors in the design, the protocol and procedures of the PACE Trial are evident. The catalogue of errors is summarised below. The PACE Trial was loaded towards finding significant treatment effects.

A Catalogue of Errors

The claimed benefits of GET and CBT for patient recovery are entirely spurious. The explanation lies in a sequence of serious errors in the design, the changed protocol and procedures of the PACE Trial. The investigators neglected or bypassed accepted scientific procedures for a RCT, as follows:

Error Category of error Description of error
1Ethical issue: Applying for ethical approval and funding for a long-term trial when the PIs knew already knew CBT effects on ME/CFS were short-lived. On 3rd November 2000, Sharpe confirmed: “There is a tendency for the difference between those receiving CBT and those receiving the comparison treatment to diminish with time due to a tendency to relapse in the former” (www.cfs.inform/dk). Wessely stated in 2001 that CBT is “not remotely curative” and that: “These interventions are not the answer to CFS” (Editorial: JAMA 19th September 2001:286:11) (Williams, 2016).
2Ethical issue: Failure to declare conflicts of interest to Joint Trial Steering Committee.Undeclared conflicts of interest by the three PIs in the Minutes of the Joint Trial Steering Committee and Data Monitoring Committee held on 27th September 2004.
3Ethical issue: Failure to obtain fully informed consent after non-disclosure of conflicts of interest.Failing to declare their vested financial interests to PACE participants, in particular, that they worked for the PHI industry, advising claims handlers that no payments should be made until applicants had undergone CBT and GET.
4Use of their own discredited “Oxford” criteria for entry to the trial.Patients with ME would have been screened out of the PACE Trial even though ME/CFS has been classified by the WHO as a neurological disease since 1969 (ICD-10 G93.3).
5Inadequate outcome measures.Using only subjective outcome measures.The original protocol included the collection of actigraphy data as an objective outcome measure. However, after the Trial started, the decision was taken that no post-intervention actigraphy data should be obtained.
6Changing the primary outcomes of the trial after receiving the raw data. Altering outcome measures mid-trial in a manner which gave improved outcomes.
7Changing entry criteria midway through the trial. Altering the inclusion criteria for trial entry after the main outcome measures were lowered so that some participants (13%) met recovery criteria at the trial entry point.
8The statistical analysis plan was published two years after selective results had been published. The Re-definition of “recovery” was not specified in the statistical analysis plan.
9Inadequate control Sending participants newsletters promoting one treatment arm over another, thus contaminating the trial.
10Inadequate controlLack of comparable placebo/control groups with inexperienced occupational therapists providing a control treatment and experienced therapists provided CBT.
11Inadequate controlRepeatedly informing participants in the GET and CBT groups that the therapies could help them get better.
12Inadequate control Giving patients in the CBT and GET arms having more sessions than in the control group.
13Inadequate controlAllowing therapists from different arms to communicate with each other about how patients were doing.

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Lack of transparency

Blocking release of the raw data for five years preventing independent analysis by external experts.

Cover-Up

Blocking release of the raw data for five years and preventing independent analysis by external experts was tantamount to a cover-up of the true findings. An editorial by Keith Geraghty (2016) was entitled ‘PACE-Gate’. ME/CFS patient associations were rightly suspicious of the recovery claims concerning the GET arm of the trial because of their own experiences of intense fatigue after ordinary levels of activity which were inconsistent with the recovery claims of the PACE Trial reports. For many sufferers, even moderate exercise results in long ‘wipe-outs’ in which they are almost immobilized by muscle weakness and joint pain. In the US, post-exertional relapse has been recognized as the defining criterion of the illness by the Centers for Disease Control, the National Institutes of Health and the Institute of Medicine. For the PACE investigators, however, the announced recovery results validated their conviction that psychotherapy and exercise provided the key to reversing ME/CFS.

Alem Matthees Obtains Data Release

When Alem Matthees, a ME/CFS patient, sought the original data under the Freedom of Information Act and a British Freedom of Information tribunal ordered the PACE team to disclose their raw data, some of the data were re-analysed according to the original protocols. The legal costs of the tribunal at which QMUL were forced to release the data, against their strenuous objections, was over £245,000. The re-analysis of the PACE Trial data revealed that the so-called “recovery” under CBT and GET all but disappeared (Carolyn Wilshire, Tom Kindlon, Alem Matthees and Simon McGrath, 2016). The recovery rate for CBT fell to seven percent and the rate for GET fell to four percent, which were statistically indistinguishable from the three percent rate for the untreated controls. Graded exercise and CBT are still being routinely prescribed for ME/CFS in the UK despite patient reports that the treatments can cause intolerable pain and relapse. The analysis of the PACE Trial by independent critics has revealed a catalogue of errors and provides an object lesson in how not to conduct a scientific trial. The trial can be useful to instructors in research design and methodology for that purpose.

Following the re-analyses of the PACE Trial, the DBT is dead in the water. There is an urgent need for new theoretical approaches and scientifically-based treatments for ME/CFS patients. Meanwhile, there is repair work to be done to rebuild patient trust in the medical profession after this misplaced attempt to apply the Psychological Theory to the unexplained syndrome of ME/CFS. The envelope theory of Jason et al. (2009) proposes that people with ME/CFS need to balance their perceived and expended energy levels and provides one way forward, pending further research.

Ultimately, patients, doctors and psychologists are waiting for an organic account of ME/CFS competent to explain the symptoms and to open the door to effective treatments. Patients have a right to nothing less.

An extract from: David F Marks et al. (2018) Health Psychology. Theory, Research & Practice (5th ed.) SAGE Publications Ltd.

“A classic in the field”

Warm thanks to the following seven endorsers of  Health Psychology (4th & 5th Editions) quoted below:

Fourth Edition:

“This book has become a classic in the field – sophisticated,  accessible and interesting.   It is of great use to students, teachers and practitioners of Health Psychology world wide.”

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Leslie Swartz, Distinguished Professor of Psychology, Stellenbosch University, South Africa.

“This is a remarkable book. It is exceptionally complete, thoughtful, and deep.  It avoids the superficial accounting of many texts and does not shy away from controversy. It is fully rooted in today’s science of health psychology.”

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Stevan E. Hobfoll, Ph.D. Professor of Behavioral Sciences, Medicine, and Preventive Medicine, Rush University Medical Center, Illinois, USA.

 

“A very nice introductory text that takes a biopsychosocial approach to health and illness, and recognizes the importance of culture, health literacy, and issues such as racism and health inequities/disparities that continue to impact disadvantaged communities.”

Cheryl Holt

Cheryl L. Holt, University of Maryland, USA.

 

“Like other textbooks, this book provides a comprehensive introduction to the field of health psychology. Unlike other books however, this one takes a holistic-systems approach to health, and uses the novel concept of the Health Onion to do so: The myriad determinants of health are presented as different layers – biological, familial, behavioral, neighborhood, social and cultural – that must be scientifically-examined and peeled away to understand health. Consequently, the book contains many valuable chapters that other textbooks lack, including chapters on macro-level influences (Chapter 2), social justice and social inequality (Chapter 3), and cultural factors (Chapter 4). Moreover, the examples provided to illustrate each layer of the influences on health are global ones, and include health and its psychology in Europe, the USA, Asia, Africa, and elsewhere. This unique approach helps students understand that the health of individuals is a part and product of the family, social-network, neighborhood, and society in which they are embedded. Hence, this revised edition provides an excellent overview of health and of the science of health psychology in their local and larger contexts.”

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Hope Landrine, Professor of Public Health and of Psychology, Brody School of Medicine, East Carolina University, USA.

 

Just as the Journal of Health Psychology is not like any other journal in the field, this new edition of David Marks’ “Health Psychology” textbook is different from all the other textbooks in the field. It will broaden your perspectives as it educates your mind.

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Kenneth A. Wallston, Professor of Psychology, Emeritus, School of Nursing, Vanderbilt Institute for Global Health, USA.

 

Fifth Edition:

An essential text for both graduate and undergraduate health psychology courses, the authors elegantly and comprehensively explore health psychology in the 21st century.  The fifth edition further advances a critical perspective on health while introducing readers to emerging issues such as long-term conditions and end-of-life care.

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Christopher Godfrey, Professor of Psychology, Pace University, USA. 2018-01-01

Marks and colleagues’ capacity to provide a global perspective, while including elements of social justice, with a consideration of the social and political determinants of health, makes this text an invaluable companion when introducing undergraduates to the field of health psychology.

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Nancy L. Worsham, Professor of Psychology, Gonzaga University, USA.  2018-01-01

 

 

 

“Absolute joy to read”

Click below for a Preview of the Editor’s Introduction and Chapter 1: Matarazzo, J. D. (1982). Behavioral health’s challenge to academic, scientific, and professional psychology. American Psychologist37(1), 1.

`This book was an absolute joy to read and offers a comprehensive review of health psychology…. This book should become a classic – necessary reading for students in all branches of health. Nursing students will find it invaluable, but other students – and their teachers – will also find it very useful. SAGE have added a valuable and important text to their already impressive list, and Marks can be complimented on his scholarly organisation of complex topics into an accessible and readable whole. No library should be without it and serious students should invest in a copy of their own’

Health Matters


‘The Health Psychology Reader provides a concise guide to Health Psychology. It is set out in 5 key sections and explores key theories and research in the area. This is a great, stimulating text to health psychology students at all levels.’

Miss Gemma Wilson

School of Social Sciences and Law, University of Teesside
April 22, 2012

‘This book is clear, informative and easy to read. A good text for students on an M.Sc. Health Psychology module.’

Ms Lynda Hyland

School of Health and Social Sciences, Middlesex University Dubai
March 6, 2012
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‘A great compilation of key readings for psychology students and researchers.’

Dr Benjamin Gardner

Health Behaviour Research Centre, University College London
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