COUNSELLING PSYCHOLOGY IN MEDICAL SETTINGS

Counselling Psychology in Medical Settings: The

Promising Role of Counselling Health Psychology

Evangelos C. Karademas
Department of Psychology, University of Crete, Greece

Address for correspondence

Evangelos C. Karademas,
Department of Psychology, University of Crete, 74100, Gallos, Rethymnon, Greece.

Abstract

In recent decades a biopsychosocial understanding of health predominated, and

health problems stopped being just a physician‟s job. Consequently, the role of
experienced psychologists in health care is gradually becoming more important.
Counselling Psychology as a major field of psychological science with an enormous
knowledge and experience in dealing with a diversity of problems has only to offer
to the medical health care. Our purpose is to present the multiple roles of counselling
psychologists (e.g., as evaluators, advisors, therapists) in health and health care.
Issues regarding the training of 'health counselling psychologists' are also being
discussed. Finally, I argue about the opportunities and difficulties that counselling
health psychologists may meet in daily practice.

Keywords: counselling health psychology; medical health care; health care

provision.

During the second half of the 20 th century the field of human health and health
care was faced with significant changes and new challenges. Gentry (1984)
highlighted several aspects of this new environment in health and health care, such
as the failure of the biomedical model to fully explain health and illness, the shift to
chronic diseases as the main health problem, the realization of the role of
psychological and life-style factors in the manifestation and maintenance of health
problems, the development of sophisticated psychological theories about health.
These factors facilitated the formation of relatively new initiatives within the field of
psychological science, while new specialties and professional categories emerged.
During the ‟70s and ‟80s certain major national and international associations were
established with the aim to promote „behavioural medicine‟ or „health psychology‟,
whereas new relevant scientific journals were published (for a more detailed review,
Belar & Deardorff, 1995; Kaptein & Weinman, 2004). As a result, in the following
decades a new understanding of health and illness appeared, psychological research

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on health and health related factors increased, and health problems, especially
chronic diseases, stopped being just a physician‟s job. Patients were increasingly
referred to psychologists for treatment and symptom management, while
psychologists were involved in the efforts for health maintenance and health
promotion in almost every population (e.g., Ayers et al., 2007; Bennett, 2000;
Sarafino, 1999). Thus, the role of health, clinical and counselling psychologists in
health care gradually became more important.
The purpose of the present article is to briefly present the multiple roles of
counselling psychologists in health and health care, discuss relevant training
demands, argue about ethical issues, as well as about the opportunities and
difficulties of working in medical settings. Of course the whole issue is vast.
Therefore, the present document intends to be only a brief discussion of issues
related to counselling health psychology.

Counselling Psychology and health care

In 1982, Millon defined health psychology as “the application of knowledge and

methods from all substantial fields of psychology to the promotion and maintenance
of mental and physical health of the individual and the prevention, assessment and
treatment of all forms of mental and physical disorder in which psychological
influences either contribute to or can be used to relieve an individual‟s distress and
dysfunction” (p. 9). Counselling psychology as a major field of psychological science
with an enormous knowledge and experience in treating a diversity of problems has
only to offer to medical health care. As a developmentally based specialty that
emphasizes building on person‟s strengths, treating persons with respect and care,
taking into consideration and incorporating environmental factors and resources,
using psycho-education in treatment, employing the biopsychosocial model for
understanding health and managing health problems, and being familiar with
interdisciplinary collaboration, counselling psychology can significantly contribute in
health-related applications (Altmaier & Johnson, 1992; Roth-Roemer, Robinson
Kurpius, & Carmin, 1998).
Counselling psychology was directly related to health care for the first time in
1979, when Krumboltz, Becker-Haven and Burnett published an article on
counselling psychology in the Annual Review of Psychology, and discussed
treatments for certain health problems, including pain and insomnia. Following that,
a relevant chapter in the first edition of the Handbook of Counselling Psychology
was published by Thoresen and Eangleston (1984), while the same authors published
next year a similar article in The Counselling Psychologist (Thoresen & Eangleston,
1985). In 1998, a first edition exclusively dedicated to the role of Counselling
Psychology in health care was published (Roth-Roemer et al., 1998). This edition
focused on a variety of topics, like professional issues, areas of practice, and
interventions in special populations. Since then, several efforts to promote

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counselling psychology in health care have been developed. For instance, within the
Society of Counselling Psychology of the American Psychological Association
(Division 17) a section of Counselling Health Psychology has been established. This
section is dedicated to the science and practice of counselling psychology in health-
related contexts through research, intervention, training of young students or
professionals, and development of health policy initiatives (for more information,
http://www.div17.org/sections_chp.html). Also, the Division of Counselling
Psychology of the British Psychological Society acknowledges the breadth of places
that a counselling psychologist may work, including medical settings (for more
information, http://www.bps.org.uk/dcop/). Indeed, the role of counselling
psychologists in such settings is fast growing.

The role of counselling psychologists in medical settings

As experts in human behaviour, counselling psychologists can assume a diversity

of roles within health care services. They may evaluate and assess the psychological
functioning of the patients; act as advisors for the treatment team; provide training;
organize and implement research projects; provide counselling or other types of
psychosocial interventions to the patients and their families.

a) Carmin and Roth-Roemer (1998) underlined that psychologists are frequently

asked to perform a psychological assessment of medical patients. They are
asked to evaluate whether patients suffer from problems that might interfere
with or complicate medical assessment and treatment (such as cognitive
deficits, anxiety or mood disorders), or to differentiate between a medical and
a physical condition. In fact, Rief (2004) reported that about 20% of the visits
to a physician involve symptoms that cannot be explained by a typical
medical disorder, while Ansseau et al. (2004) in a sample of 2316 adult
patients found that 42.5% of them are met with some type of psychological
difficulty, mainly emotional, anxiety and somatoform symptoms.
Furthermore, there is a significant problem of under-diagnosing
psychological difficulties in typical health care services, like hospitals or
medical centers. Kunen, Smith, Niederhauser, Morris and Marx (2005)
reported that under-diagnosis reaches almost 75% of all relevant cases.
Moreover, mental health problems constitute a major financial burden to the
health system and the national economy (Layard, 2005).
Medical staff is rarely ready to identify and, of course, address
psychological difficulties (Layard, 2005). Therefore, the role of the
psychologist in assessing and addressing psychosocial problems, as well as in
alleviating the frustration that medical personnel often feels when dealing
with such problems, is crucial and in favour of both patients and staff.

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The assessment of psychosocial functioning usually relies on the classical

clinical interview and use of diagnostic instruments, some of which are
especially designed for use within medical settings (for a review, Bennett,
2000; Belar & Deardorff, 1995). In the assessment process not only the patients
might be involved, but also family and relatives, or even the medical
personnel. However, assessment and diagnosis in a medical setting is subject
to limitations, such as the lack of a private place for the interview to take
place, lack of time, need for quick answers, medication side-effects etc.
Consequently, psychologists are often called to improvise in order to
effectively adapt and perform under these conditions (for a review and
related suggestions, Van Egeren, 2004).

b) Counselling psychologists are especially trained in consultation. This is

critical whenever they have to act as advisors or consultants to the treatment
team of a patient. This part of the counselling psychologists‟ role is important
as they can provide information regarding the psychological well-being of the
patients (BPS Division of Counselling Psychology, 2007; Kagan et al., 1988),
but also offer specific recommendations that will assist medical staff.
Moreover, counselling psychologists can provide medical staff with pieces of
advice or instructions on how to manage everyday difficulties (e.g., work-
load, difficulties in decision making, dealing with death and dying patients)
(BPS Division of Counselling Psychology, 2007; Earll & Bath, 2004). In their
efforts, counselling health psychologists have to consider information
regarding all major parts of the medical milieu: patients and their needs,
medical personnel, the environment, and any special conditions (Carmin &
Roth-Roemer, 1998). It is a rather difficult task and, therefore, psychologists
should be familiar with a diversity of factors both psychological and medical.

c) Additionally to their role as advisors or consultants, counselling

psychologists are frequently called upon to train physicians or nurses in
counselling related issues, such as effective communication, patient-medical
staff relationships, stress management, psychological factors associated with
health and illness and so on (Kagan et al., 1988). They can also teach specific
techniques for dealing with problems like pain or insomnia, or specific ways
for managing personal and professional difficulties, like burnout or troubled
communication (Walker, 2004). Training can also be addressed to the patients
as a component of an intervention program.

d) A most crucial aspect of the counselling psychologist‟s role within a health

setting is to provide counselling or other types of intervention to those in
need. According to Bennett (2000), and Belar and Deardorff (1995), a
psychologist can offer substantial help at every level of the patient‟s

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functioning: physical level (e.g., pain and other symptoms management,

reduction in psychophysiological arousal), emotional level (e.g., stress
management, dealing with symptoms of depression and anxiety), cognitive
(e.g., provide information, help in changing dysfunctional thoughts), and
behavioural (e.g., modification of maladaptive behaviours, increase
adherence to medical therapy). Furthermore, counselling psychologists can
offer help to the families of the patients (e.g., by means of providing
information, support, training etc.), as well as to the medical personnel for
dealing with special conditions, or to the broader socio-cultural milieu (e.g.,
by mobilizing a social support system, organizing and implementing
prevention efforts etc).
In fact, the range of possible intervention targets for the patients is quite
wide: from preparing patients for difficult operation procedures, to training
them to effectively cope with the post-surgery problems or with medical
treatment side-effects; from helping them to change unhealthy behaviours
(including weight control and smoking cessation) to providing counselling
for dealing with emotional and adjustment difficulties; and from breaking
bad news to helping the dying (Karademas, 2005).
In order to achieve their intervention goals, counselling health
psychologists may choose from an array of intervention strategies and
techniques: individual and group counselling, brief therapies, providing
information and training, crisis intervention, stress management,
motivational interview, guided imagery, behaviour analysis and
modification, cognitive restructuring and many more. The majority of these
techniques and strategies are based on the cognitive-behavioural model,
which has been found really effective in treating many health conditions,
including: cardiovascular disorders (e.g., Bellg, 2004; Gidron, Davidson, &
Bata, 1999); neoplasms (e.g., Khazam, 1996; Spira & Reed, 2002); diabetes
mellitus (e.g., Norris, Engelgau, & Narayan, 2001); HIV/ AIDS (e.g., Bor, du
Plessis, & Russell, 2004; Bor & du Plessis, 1997; Chesney & Antoni, 2002);
sexual health (e.g., Aarø et al., 2006); surgical procedures (e.g., Lang et al.,
2000; Petry, 2000); renal disease (e.g., Griva & Newman, 2007); urological
disorders (e.g., Nicolau, Toro, & Perez Prado, 1991); dermatology (e.g., Kent
& Keohane, 2001; Papadopoulos, Walker, Aitken, & Bor, 2000); obstetrics
(e.g., Klock, 2004); transplantation (e.g., Blumenthal et al., 2006) etc. Medical
patients are rather interested in short-term and focused interventions that can
facilitate their recovery, than long-term insight-oriented therapies (Carmin &
Roth-Roemer, 1998). These requirements are typically met by behavioural
(e.g., conditioning, operant conditioning, modeling), cognitive (e.g., self-
management, cognitive therapy), and cognitive-behavioural approaches (for
more details, Bennett, 2000; Bennett, Conner, & Godin, 2004; Lorig, 1996;

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Rutter & Quine, 2002). An interesting tool, which provides guidelines for the
development of intervention programmes, for the application of theory, as
well as for the transformation of theory into practice and the selection of
appropriate methods and strategies, is the Intervention Mapping (see, Kok &
Schaalma, 2004). Intervention Mapping may be really useful for practitioners,
especially at the beginning of their career.
In any case, psychologists must be cautious when selecting a strategy, as
they have to take into consideration issues like the effectiveness of each
strategy, possible interference with the physical functioning and possible
side-effects of the medical treatment, the cost/ effectiveness ratio, time limits
and so on. Counselling health psychologists should also follow all necessary
steps to secure an evidence-based practice, which is the best way to promote
patients‟ well-being (Spring, 2007; Walker & London, 2007).
Additionally, in recent years, the intervention role of counselling
psychologists is expanding to new fields, including genetic testing and
related counselling services (Wang, Gonzalez, & Merajver, 2004), telehealth
counselling services (Miller, 2006), and spiritual issues and health (Thoresen,
1999). As our understanding of the role of psychosocial and behavioural
factors in health deepens, more and more efficient intervention programs are
developed in favour of the patients and the health care system. The
implementation of these programs, however, requires for highly trained and
capable experts, an issue that I will refer to later on.

e) Finally, counselling health psychologists may plan and implement research

activities. Psychological factors related to health and illness, adaptation to
illness, well-being and quality of life and many more, are the issues that
counselling health psychologists can study in order to gain a better
understanding of health and illness and achieve a better practice. A
significant field of research might also be the empirical testing and evaluation
of the several intervention strategies. In these efforts, psychologists should
collaborate with the medical personnel and include in their studies medical
and biological variables as well (Suls & Rothman, 2004).

Gatchel and Oordt (2003) underlined the fact that the approaches for providing
psychological services fall on a continuum, depending on the characteristics of each
health service. According to the authors, within this continuous lie four major
models. These models were described in relation to primary health care, but I think
we can easily adopt them in relation to any health care setting. In the “collocated
clinics” model, the psychologist is usually with a traditional psychological clinic and
not integrated into the health care clinic. Actually, medical and psychological (or
psychiatric) clinics remain two different entities. In the second model, the
psychologist may act as a provider within the medical clinic. Accordingly, he/she

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may provide counselling or therapy for both mental health and medical conditions.
The psychologist collaborates with the medical personnel, although he/she is still an
„independent provider‟ of health care. This model resembles the first one, but in this
case the psychological work is offered as part of the same clinic. In the third model,
the psychologist acts as a “behavioural health consultant”. She/he is a member of a
multidisciplinary team and responsible for the behavioural and psychological
aspects of treatment. The psychologist evaluates the patient and makes
recommendations to the case manager (the physician). She/he may see the patient
for a limited number of sessions (one or two) to monitor the implementation of the
recommendations or provide specific advice. In parallel, the psychologist can
provide targeted services to specific groups of patients (e.g., stress management to
heart attack patients). In case of more intense problems the psychologist may refer
the patient to other specialized psychological services. The final model refers to the
psychologist as the “staff adviser”, who consults only the medical staff. She/he has
no independent contact with the patients, but rather uses her or his expertise to assist
the medical staff with defining and treating the problem.
Each of the models presented by Gatchel and Oordt (2003) has advantages and
disadvantages and may be appropriate for one setting, but not for another. It lies
with the setting and the scientific staff to decide upon which model better fits their
needs. Of course, the models presented are not mutually exclusive (Gatchel & Oordt,
2003). A combination of these might be the most efficient and proper solution.
Likewise, Pruitt, Klapow, Epping-Jordon and Dresselhaus (1998) proposed a
stepped-care approach: the psychologist initially provides advice to the medical staff
in order to deal with a patient. Should no improvement occurs, the psychologist may
be engaged in a personal contact with the patient in order to make a more thorough
assessment and provide the appropriate treatment. If also no improvement is
achieved, then the psychologist may decide to provide a more extensive therapy or
refer the patient to another service.
I believe that counselling psychologists working within a medical setting should
(a) originally evaluate current conditions in the setting, (b) assess the needs of the
typical patients of that setting, as well as (c) of the medical personnel, (d) collaborate
with the other members of the scientific staff, and then (e) determine and finally
adopt the most appropriate model that will permit them to perform the necessary
diagnostic, intervention, consulting, training and research work.
At this point, I should emphasize the fact that especially in United Kingdom a
fast growing number of counsellors work in primary care and general practice. As
Foster (2000) reports, from almost no primary care counselling provision in 1980,
there were counsellors in 51% of the surgeries in England and Wales at the time “the
new National Health System” was launched. This expansion of counselling services
was rapid but, according to many, haphazard and fragmentary (Eatock, 2000; Melloc-
Clark, 2000). Still, the numbers of counsellors and counselling psychologists in

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general practice are growing and the National Health System is probably the major
employer of counsellors in UK (Eatock, 2000). However, their work is primarily
focused on mental health issues. Although mental health is of great importance for
all medical patients and their survival and quality of life, working as a mental health
professional is different than serving as a „counselling health psychologist‟. For
instance, a mental health professional focuses on psychosocial issues and their
association with health. On the other hand, a „counselling health psychologist‟
focuses not only to mental health issues, but also on many more topics related to
physical health (e.g., adherence, physical symptoms management, life-style etc), even
when no mental health difficulty is present. It is my opinion that counselling
psychologists working within primary care in UK could also assume the role of a
„counselling health psychologist‟ with success and expand their responsibilities
within the health care system. After all, there is evidence suggesting that their
services are effective and the help they offer substantial (Baker, Allen, Gibson,
Newth, & Baker, 1998; Bower, Rowland, & Hardy, 2003), while their contribution to
the development of primary care is more than significant (e.g., Lenihan & Iliffe,
2000).

Ethical issues

Beside competence, which is an always challenging aspect of practice, there is an

array of ethical issues related to the practice in a medical setting. Indeed, counselling
psychologists are sensitive to issues associated with the psychologist‟s
responsibilities and the patient‟s rights (Robinson Kurpius & Vaughn Fielder, 1998).
However, protecting rights within a health care service could be challenging at times,
especially regarding confidentiality and the proper use of psychological information
(Hudson-Allez, 2000). Sometimes it is difficult to uphold confidentiality in a medical
setting, due to three major factors: the psychologist usually has to share information
with the other members of the multidisciplinary team (e.g., physicians and nurses) or
keep notes in the patient‟s medical record (if there are no separate psychological
records); the psychologist might not be able to see the patient privately, but in
multibed rooms; the psychologist often needs to inform the patient‟s family, since
collaboration with family members is frequently critical for the treatment (Bennett,
2000; Belar & Deardorff, 1995; Hudson-Allez, 2000).
In order to deal with these challenges, the counselling health psychologist must
enrol brains and talent. She/he must also be sure that patients understand the
procedures of sharing information with medical personnel or keeping informed the
hospital record. He/she has to obtain consent to provide confidential information,
unless the patient is unable to make informed decisions (Bennett, 2000; Papas, Belar,
& Rozensky, 2004). Of course, patients should always be given the option of
declining psychological services, after a discussion on its purposes, aims, and
restrictions.

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Opportunities and difficulties of working in medical settings

Despite the opportunities that health care provides, and the significant
contribution that counselling psychology can make, only a relatively small number of
counselling psychologists seem to work in such services, while not many programs
provide systematic training for such a possibility. In fact, until early ‟90s only a small
percentage of counselling psychologists were working in the health domain (Good,
1992), despite the growing employment opportunities (see for example,
http://www.health-psychology.org.uk./menuItems/what_is_health_psychology.php).
Altmaier in 1984 reported that almost 60% of the counselling psychology training
programs in the USA had no health psychology course work, whereas more than half
reported practicum placements in health psychology. Furthermore, students
reported a moderate interest in the area. More recently, however, the interest in
health psychology practice appears to be increased, but not much. Neimeyer,
Bowman and Stewart (2001) reported data from 1989 to 1998 indicating that about
17% of graduates of counselling psychology programs in the US have been employed
in hospitals, whereas more than 80% were still placed in counselling and mental
health centres, in private practice, and in academia. In the same line, Stedman, Hatch,
Keilin, & Schoenfeld (2005) in their description of internship training of clinical and
counselling psychologists concluded that training still focus heavily on the
traditional clinical-provider role, while there is little evidence of innovation towards
new areas of research and practice (like health settings). In the United Kingdom, only
4% of the applied psychologists work with clients suffering from physical health
problems, according to recent surveys (BPS, 2007). On the other hand, about 40% of
the chartered counselling psychologists in England are employed at the National
Health System (BPS, 2005). Obviously, they work with mental health-related
problems. It is possible that the disadvantages of working in a physical health care
setting (i.e., coming to terms with the medical hierarchy, maintaining confidentiality,
as well as the difficulties in communicating with the medical personnel (Good, 1992)
are keeping young counselling psychologists from practicing their profession in such
settings, despite the existing advantages (e.g., the diversity of the roles a counselling
psychologist could assume). Moreover, the traditional focus of counselling
psychology and relevant training programs on the more typical mental difficulties
and psychosocial troubles, which usually does not include chronic diseases and
physical health, might be another significant reason for this trend.
Indeed, working within a medical setting might be really demanding and
complex. I will use the primary care services as an example. Primary care is defined
as the very first care provided to the patients when they enter the health care system
(Bray, 1996). As Gatchel and Oordt (2003) pointed out, psychologists working in such
settings usually have to give up some level of their autonomy. At the same time, they
have to see the entire population served by the clinic. As a result, they need to
develop specific skills for focused and quick assessments, provide brief practical

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advice, do their job in very short times, make decisions with limited amount of data,
develop skills for enhancing motivation to change, use brief interventions,
communicate efficiently with the medical staff (i.e., avoid jargon, be brief and
focused), tolerate a rather low position in the hierarchy (physicians are usually the
„chief‟), be flexible in their hours and available to patients and medical staff
whenever there is need. Psychologists in primary care might also have to be quite
„creative‟ in their practice in order to be more effective (e.g., use telephone or web
conferences, use the phone of even the fax to provide advice, advise the other
members of the team in „unusual‟ opportunities, e.g., during lunch). Furthermore,
counselling psychologists sometimes have to work hard to spotlight their identity
and their skills, since there is still considerable confusion and lack of information
regarding their role in care provision (e.g., Lewis & Bor, 1998). All these can be quite
burdensome to the psychologists and significantly tax their abilities to adapt.
Consequently, they often avoid primary care settings.
On the other hand, medical settings may provide opportunities for the
counselling psychologists to display their unique knowledge and skills, as in the case
of cross-cultural health care. The ways a person perceives symptoms, reacts to illness,
thinks about health and behaves are routed in her/his culture and culture-related
belief system (Pedersen, 1997). A growing literature describes the strong associations
between differences in culture, and health, well-being, health related beliefs and
behaviours (e.g., Arrendondo et al., 1996; Marks, Murray, Evans, & Willig, 2000;
Salant & Lauderdale, 2003), while there is evidence that cultural differences are
associated with perceptions about the cause or the appropriate treatment of a disease
(e.g., Karasz, 2005). Culture is so important for health and illness that many diseases
seem to be „caused‟ by local cultural habits (e.g., Boirin, 1997; Schensul, Mekki-
Berrada, Nastasi, Saggurti, & Varma, 2006). Nevertheless, a major problem in the
medical setting is the difficulty of the medical personnel to take into consideration
the role of culture or cross-cultural variables (Atkinson, 2002; Prislin, Suarez,
Simpson, & Dyer, 1998). Therefore, it lies with the psychologists to help medical
personnel realize the significance of culture and cultural differences, and also
promote „cultural sensitive‟ or „cultural focused‟ intervention programs (Pedersen,
1997), in order to facilitate patients‟ adaptation and enhance well-being and health.
Even with these opportunities, there is still a possibility that some counselling
psychologists worry about counselling psychology losing its identity (Tyler, 1980).
For example, Bernard (1992) and Good (1992) are afraid that counselling
psychologists working in medical settings will alienate from their colleagues. On the
contrary, Altmaier, Johnson and Paulsen (1998) support that no alienation will occur
and counselling psychologists will keep their identity. In the same line, Mrdjenovich
and Moore (2004) believe that counselling health psychology will maintain ties with
the substantial area of counselling psychology and will not turn to be a „subspecialty‟
of health psychology. These authors define professional identity as the sense of

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connection to the values and emphases of counselling psychology. If counselling

psychologists retain this sense of connection, then they will preserve their identity
and will be able to make a unique contribution to the field of medical care. I concur
with their opinion and, as Hudson-Allez (2000) suggests, I also believe that a
counselling psychologist, irrelevant of his/her working environment, should always
be an experienced practitioner with a solid counselling or psychotherapeutic
training. Such training combined with a constant integration of new
counselling/psychotherapeutic knowledge and techniques, and a continuous focus
on the patient as a „person‟ differentiates counselling psychologists from other
psychology specialists and help them keep their identity. And by keeping their
identity, they can effectively collaborate with medical staff and other specializations
in psychology (such as health psychologists) in favour of the patients and in order to
deal with the multiplicity and the complexity of their needs. After all, as Walsh,
Frankland, and Cross (2004) underline, “counselling psychologists also endeavour to
modify the medical model system of relating from within the medical world, without
compromising our [counselling psychologists‟] or their standards and ethos” (p. 326).

Training counselling psychologists for the medical settings

Training in counselling psychology is insufficient for practice in a medical

setting. Moreover, with the exception of rehabilitation counselling, post-graduate
and doctoral programs in counselling psychology are very slow or even reluctant to
add health-related courses and practice (Alcorn, 1998; Stedman et al., 2005). In this
section I will discuss certain aspects of training in counselling health psychology in
brief. For a more extensive description of the educational and training demands
linked to counselling health psychology I refer to Alcorn (1998), Michie, Abraham
and Johnston (2004), Papas et al. (2004), as well as to the BPS Board of Examiners in
Health Psychology (2001).
Although, counselling psychologists are traditionally trained in those areas that
are commonly used within the field of health care, including psycho-education,
human relationships, and behaviour modification, they should also be trained in a
“health psychology” philosophy, as well as in specific skills. According to the
American Psychological Association Council of Representatives (1997), for instance,
psychologists working in medical health settings should be familiar with and have a
broad understanding of several issues and quite a lot areas of knowledge, such as:
biological, cognitive, affective and social bases of health, disease and behaviour;
anatomy and human physiology; health behaviours and related factors; illness and
disability effects on cognition, emotion and behaviour; the role of a diversity of
factors, such as culture, patient-doctor relationships, health policy, stress etc. In the
same line, in United Kingdom health psychologists need to be able to develop theory
and conduct research, assess and intervene in order to improve health care and
health outcomes even in complex situations, use ethical awareness to develop best

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practice, train other health professionals, as well as consult health care personnel and
managers (Michie et al., 2004).
Alcorn (1998) proposed an integration of certain courses with the core curriculum
in counselling psychology. These courses are: introduction to health psychology,
medical aspects of disability, psychopharmacology, medical terminology,
neuropsychology, and community health. He also stressed the importance of the
integration of science and practice (which, nevertheless, is common ground among
counselling psychologists), as well as the necessity for training in the
multidisciplinary nature of the work in medical health settings.
Equally, if not more, important are the internship experiences in medical settings
and hospitals for the counselling psychologists interested in health psychology. Well-
designed internships in different medical clinics, rehabilitation centres, pain clinics,
medical schools or similar settings, under the supervision of experts, are essential for
a good practice. Internships should be designed in a way to help young trainees
adapt their knowledge and skills in the health setting, as well as prepare them to deal
with a variety of difficulties and problems. It should also be noted that internship in
specific settings (e.g., pain clinics) is a possible pathway through which professional
specialization can be achieved.
The specific form that training in counselling health psychology should take
depends on many factors: the educational system of each country, the form of the
health care system, history, needs, and special conditions. For instance, in the USA to
qualify for board certification in clinical health psychology, a doctoral degree in
psychology (e.g., in Counselling Health Psychology) is needed, among other
requirements regarding training, internship, continuing education and current
professional work (ABPP, 1999). Counselling psychologists seem to applaud the
development of health psychology as a post-doctoral specialty field (Alcorn, 1998).
Likewise, a post-doctoral training in health psychology-related issues might be a
solution for British counselling psychologists. (It should be noticed here that also the
European Association for Counselling Psychology (EACP) accepts as full members
only those counselling psychologists who are qualified at a doctoral level (see the
Statuses of the EACP, http://www.counselling-psychology.eu). Alternatively, as the
British educational system is flexible, the establishment of a „joint‟ counselling (and)
health psychology training program could be an answer to the question. A first step
might be the establishment of a special interest group within the Division of
Counselling Psychology of the BPS, which will encourage the development of these
efforts. Such a group is already operating within the Division of Clinical Psychology
since 1998 (http://www.bps.org.uk/dcp-facchp/). On the other hand, in countries
like mine, Greece, where PhD is strictly an academic title that requires no
professional training, other solutions appear to be more appropriate: the inclusion of
health psychology-related courses in the counselling psychology post-graduate
curricula, or internship in health settings and on-the-job training might fit better.

European Journal of Counselling Psychology 2009, Vol. 1, No. 1

29
 COUNSELLING PSYCHOLOGY IN MEDICAL SETTINGS

It should be stressed, however, that post-graduate and doctoral training

programs in Health Psychology, as a specific applied field of Psychology, has been
established across Europe (e.g., in United Kingdom, The Netherlands, Portugal,
Greece) for many years (for relevant information, http://www.ehps.net). The
experience gained from these programs could be useful for the development of
counselling health psychology training programs. After all, health psychologists and
counselling psychologists can both work within the same medical settings in a
complementary way.

Conclusion

Counselling health psychology, which refers to the science and practice of

counselling psychology in the medical health related context, is a promising area for
psychologists. As society and health care policy makers become more and more
familiarized with the biopsychosocial perspective on health and illness, and as our
work in medical settings becomes more effective, the opportunities for counselling
psychologists in health care services will also grow (Layard, 2005). Counselling
psychologists will eventually become an integral part of health care provision and,
more important, patients will benefit from their presence and services. However, for
a successful integration to take place, counselling psychologists must be properly
educated. It is a challenge for training programs in counselling psychology to satisfy
the emerging needs.
With continuing education and increased advocacy for integrated health care
services, counselling health psychologists will meet their goals in providing
improved services.
Besides the existing opportunities and difficulties, counselling health psychology
is a field with a great future. Health care will be faced with a number of challenges in
the near future. Changes in education and training, research and practice (e.g., in the
areas of behavioural genetics, telehealth, women and minorities issues, organ
transplantation) are already taking place. Within this context, counselling health
psychology has a lot to offer and a lot to gain.

References

Aarø, L. E., Flisher, A. J., Kaaya, S., Onya, H., Fuglesang, M., Klepp, K., & Schaalma,
H. (2006). Promoting sexual and reproductive health in early adolescence in
South Africa and Tanzania: Development of a theory- and evidence-based
intervention programme. Scandinavian Journal of Public Health, 34, 150-158.

American Board of Professional Psychology (ABPP) (1999). American Board of Clinical

Health Psychology certification procedures. Columbia, MO: ABPP.

30 European Journal of Counselling Psychology 2009, Vol. 1, No. 1

 COUNSELLING PSYCHOLOGY IN MEDICAL SETTINGS

Alcorn, J. D. (1998). Training for health settings. In S. Roth-Roemer, S.R. Robinson

Kurpius, & C. Carmin (Eds.), The emerging role of counselling psychology in
health care (pp. 30-54). New York: W.W. Norton & Company.

Altmaier, E. M., & Johnson, B. D. (1992). Health related applications of counselling

psychology: Toward health promotion and disease prevention across the life
span. In S.D. Brown & R.W. Lent (Eds.), Handbook of counselling psychology (2nd
ed., pp. 315-347). New York: Wiley.

Altmaier, E. M. (1984). Survey of Health Psychology training among Counselling

Psychology Programs. Paper presented at the 92nd Annual Convention of the
American Psychological Association. Toronto, Canada.

Altmaier, E. M., Johnson, B. D., & Paulsen, J. S. (1998). Issues in professional identity.
In S. Roth-Roemer, S.R. Robinson Kurpius, & C. Carmin (Eds.), The emerging
role of counselling psychology in health care (pp. 7-29). New York: W.W. Norton
& Company.

American Psychological Association Council of Representatives (1997). Archival

description of clinical health psychology as a specialty in professional
psychology. Minutes of the Council of Representatives Meeting, August, 1997.
Washington, DC: APA Council of Representatives.

Ansseau, M., Dierick, M., Buntinkx, F., Cnockaert, P., De Smedt, J., Van Den Haute,
M., & Vander Mijnsbrugge, D. (2004). High prevalence of mental disorders in
primary care. Journal of Psychosomatic Research, 56, 49-55.

Arrendondo, P., Toporek, R., Brown, S. P., Jones, J., Locke, D. C., & Sanchez, J. (1996).
Operationalization of the multicultural counselling competencies. Journal of
Multicultural Counselling and Development, 24, 42-78.

Atkinson, S. (2002). Political cultures, health systems and health policy. Social Science
& Medicine, 55, 113-124.

Ayers, S., Baum, A., McManus, C., Newman, S., Wallston, K., Weinman, J., & West,
R. (2007). Cambridge handbook of psychology, health and medicine. Cambridge:
Cambridge University Press.

Baker, R., Allen, H., Gibson, S., Newth, J., & Baker, E. (1998). Evaluation of a primary
care counselling service in Dorset. British Journal of General Practice, 48, 1049-
1053.

Belar, C. D., & Deardorff, W. W. (1995). Clinical Health Psychology in Medical Settings.
A practitioner’s guidebook. Washington, DC: American Psychological
Association.

European Journal of Counselling Psychology 2009, Vol. 1, No. 1

31
 COUNSELLING PSYCHOLOGY IN MEDICAL SETTINGS

Bellg, A. J. (2004). Clinical cardiac psychology. In P. Camic & S. Knight (Eds.), Clinical
handbook of health psychology (pp.30-57). Göttingen: Hogrefe & Huber.

Bennett, P. (2000). An introduction to clinical health psychology. Buckingham: Open

University Press.

Bennett, P., Conner, M., & Godin, G. (2004). Changing behaviour to improve health.
In S. Michie & C. Abraham (2004), Health psychology in practice (pp. 267-284).
Oxford: Blackwell.

Bernard, C.B. (1992). Counselling psychologists in general hospital settings: The

continued guest for balance and challenge. The Counselling Psychologist, 20, 74-
81.

Blumenthal, J. A., Babyak, M. A., Keefe, F. J., Davis, R.D., LaCaille, R. A., Carney, R.
M., Parekh P. I., Freedland, K. E., Trulock E., & Palmer, S. M. (2006).
Telephone-based coping skills training for patients awaiting lung
transplantation. Journal of Consulting and Clinical Psychology, 74, 535-544.

Boirin, M. J. (1997). An ecological paradigm for a health behaviour analysis of

“konzo”, a paralytic disease of Zaire from toxic cassava. Social Science &
Medicine, 45, 1853-1862.

Bor, R., & du Plessis, P. (1997). The impact of HIV/AIDS on families: An overview of
recent research. Families, Systems, & Health, 15, 413-427.

Bor, R., du Plessis, P., & Russell, M. (2004). The impact of disclosure of HIV on the
index patient‟s self-defined family. Journal of Family Therapy, 26, 167-192.

Bower, P., Rowland, N., & Hardy, R. (2003). The clinical effectiveness of counselling
in primary care: A systematic review and meta-analysis. Psychological
Medicine, 33, 203-215.

Bray, J. H. (1996). Psychologists as primary care practitioners. In R. J. Resnick & R.H.

Rozensky (Eds.), Health psychology through the life span: Practice and research
opportunities (pp. 89-100). Washington, DC: American Psychological
Association.

British Psychological Society (2005). English survey of applied psychologists in health and
social care and in the probation and prison service. Leicester: The British
Psychological Society.

British Psychological Society (2007). New ways of working for applied psychologists in
health and social care. Leicester: The British Psychological Society.

32 European Journal of Counselling Psychology 2009, Vol. 1, No. 1

 COUNSELLING PSYCHOLOGY IN MEDICAL SETTINGS

British Psychological Society, Division of Counselling Psychology (2007). Professional

practice guidelines. Leicester: The British Psychological Society.

British Psychological Society, Board of Examiners in Health Psychology (2001).

Regulations for the qualification in health psychology. Leicester: The British
Psychological Society.

Carmin, C., & Roth-Roemer, S. (1998). Working in medical settings: diagnostic,

practice, and professional issues. In S. Roth-Roemer, S. R. Robinson Kurpius,
& C. Carmin (Eds.), The emerging role of counselling psychology in health care (pp.
77-93). New York: W.W. Norton & Company.

Chesney, M. A., & Antoni, M. H. (2002). Innovative approaches to health psychology:

Prevention and treatment lessons from AIDS. Washington, DC: American
Psychological Association.

Earll, L., & Bath, J. (2004). Consultancy: What is it, how do you do it, and does it
make any difference. In S. Michie & C. Abraham (2004), Health psychology in
practice (pp.230-250). Oxford: Blackwell.

Eatock, J. (2000). Counselling in primary care: past, present and future. British Journal
of Counselling, 28, 161-173.

Foster, J. (2000). Counselling in primary care and the new NHS. British Journal of
Guidance & Counselling, 28, 175-190.

Gatchel, R. J., & Oordt, M. S. (2003). Clinical health psychology and primary care.
Washington, DC: American Psychological Association.

Gentry, W. D. (1984). Handbook of behavioural medicine. New York: Guilford.

Gidron, Y., Davidson, K., & Bata, I. (1999). The short-term effects of a hostility-
reduction intervention on male coronary heart disease patients. Health
Psychology, 18, 416-420.

Good, G. E. (1992). Counselling psychologists in hospital/medical settings:

Dilemmas facing new professionals. The Counselling Psychologist, 20, 67-73.

Griva, K., & Newman, S. (2007). Quality of life in end-stage renal disease and
treatments. In F. Anagnostopoulos & E.C. Karademas (Eds.), Special issues in
health psychology: A Greek perspective (pp. 97-130). Athens: Livani Publishing.

Hudson-Allez, G. (2000). What makes counsellors working in primary care distinct

from counsellors working in other settings? British Journal of Guidance &
Counselling, 28, 203-213.

European Journal of Counselling Psychology 2009, Vol. 1, No. 1

33
 COUNSELLING PSYCHOLOGY IN MEDICAL SETTINGS

Kagan, N., Altmaier, E. M., Dowd, E. T., Hansen, J. C., Mills, D. H., Schlossberg, N.,
Sprinthall, N. A., Tanney, M. F., & Vasquez, M. J. (1988). Professional practice
of counselling psychology in various settings. The Counselling Psychologist, 16,
347-365.

Kaptein, A., & Weinman, J. (2004). Health psychology. Oxford: Blackwell.

Karademas, E. C. (2005). Health psychology: Theory and clinical practice. Athens:

Typothito.

Karasz, A. (2005). Cultural differences in conceptual models of depression. Social

Science & Medicine, 60, 1625-1635.

Kent, G., & Keohane, S. (2001). Social anxiety and disfigurement: The moderating
effects of fear of negative evaluation and past experience. British Journal of
Clinical Psychology, 40, 23-44.

Khazam, A. (1996). You don’t have to die from cancer. Melbourne: Hill of Content.

Klock, S. C. (2004). Obstetric and gynecological conditions. In P. Camic & S. Knight

(Eds.), Clinical handbook of health psychology (pp. 209-232). Göttingen: Hogrefe
& Huber.

Kok, G., & Schaalma, H. (2004). Using theory in psychological interventions. In S.

Michie & C. Abraham (Eds.), Health psychology in practice (pp. 203-229).
Oxford: Blackwell.

Krumboltz, J. D., Becker-Haven, J. F., & Burnett, K. F. (1979). Counselling

psychology. Annual Review of Psychology, 30, 355-402.

Kunen, S., Smith, P.O., Niederhauser, R., Morris, J. A., & Marx, B. D. (2005). Race
disparities in psychiatric rates in emergency departments. Journal of
Consulting and Clinical Psychology, 73, 116-126.

Lang, E. V., Benotsch, E. G., Fick, L. J., Lutgendorf, S., Berbaum, M. L., Berbaum, K.
S., Logan, H., & Spiegel, D. (2000). Adjunctive non-pharmacological analgesia
for invasive medical procedures: A randomised trial. The Lancet, 355, 1486-
1490.

Layard, R. (2005). Mental health: Britain‟s biggest social problem? Retrieved October
15, 2007 from:
http://www.strategy.gov.uk/downloads/files/mh_layard.pdf.

Lenihan, P., & Iliffe, S. (2000). Counselling the community: the contribution of
counselling psychologists to the development of primary care. Counselling
Psychology Quarterly, 13, 329-343.

34 European Journal of Counselling Psychology 2009, Vol. 1, No. 1

 COUNSELLING PSYCHOLOGY IN MEDICAL SETTINGS

Lewis, S., & Bor, R. (1998). How counselling psychologists are perceived by NHS
clinical psychologists. Counselling Psychology Quarterly, 11, 427-437.

Lorig, K. (1996). Patient education: A practical approach. London: Sage.

Marks, D. F., Murray, M., Evans, B., & Willig, C. (2000). Health Psychology: theory,
research and practice. London: Sage.

Mellor-Clark, J. (2000). Developing practice and evidence for counselling in primary

care: the agenda. British Journal of Guidance & Counselling, 28, 253-266.

Michie, S., Abraham, C., & Johnston, M. (2004). Health psychology training: the UK
Model. In S. Michie & C. Abraham (2004), Health psychology in practice (pp. 7-
45). Oxford: Blackwell.

Miller, T. W. (2006). Telehealth issues in consulting psychology practice. Consulting

Psychology Journal: Practice and Research, 58, 82-90.

Millon, T. (1982). Behavioural health‟s challenge to academic, scientific and

professional psychology. American Psychologist, 37, 1-14.

Mrdjenovich, A.J., & Moore, B.A. (2004). The professional identity of counselling
psychologists in health care: a review and call for research. Counselling
Psychology Quarterly, 17, 69-79.

Neimeyer, G. L., Bowman, J., & Stewart, A. E. (2001). Internship and initial job
placements in counselling psychology: A 26-year retrospective. The
Counselling Psychologist, 29, 763-780.

Nicolau, R., Toro, J., & Perez Prado, C. (1991). Behavioural treatment of a case of
psychogenic urinary retention. Journal of Behaviour Therapy and Experimental
Psychiatry, 22, 63-68.

Norris, S. L., Engelgau, M. M., & Narayan, K. M. (2001). Effectiveness of self-

management training in type 2 diabetes: A systematic review of randomized
controlled trials. Diabetes Care, 24, 561-587.

Papadopoulos, L., Walker, C., Aitken, D., & Bor, R. (2000). The relationship between
body location and psychological morbidity in individuals with acne vulgaris.
Psychology, Health & Medicine, 5, 431-438.

Papas, R. K., Belar, C. D., & Rozensky, R. H. (2004). The practice of clinical health
psychology: Professional issues. In T. J. Boll, R. G. Frank, A. Baum & J. L.
Wallander (Eds.), Handbook of Clinical Health Psychology (vol. 3, pp. 293-319).
Washington, DC: American Psychological Association.

European Journal of Counselling Psychology 2009, Vol. 1, No. 1

35
 COUNSELLING PSYCHOLOGY IN MEDICAL SETTINGS

Pedersen, P. B. (1997). Recent trends in cultural theories. Applied & Preventive

Psychology, 6, 221-231.

Petry, J. J. (2000). Surgery and complementary therapies: A review. Alternative

Therapies in Health and Medicine, 6, 64-74.

Prislin, R., Suarez, L., Simpson D. M., & Dyer, J. A. (1998). When acculturation hurts:
The case of immunization. Social Science & Medicine, 47, 1947-1956.

Pruitt, S. D., Klapow, J. C., Epping-Jordon, J. E., & Dresselhaus, T. R. (1998). Moving
behavioural medicine to the front line: A model for the integration of
behavioural and medical sciences in primary care. Professional Psychology:
Research and Practice, 29, 230-236.

Rief, W. (2004). Somatoform disorders – new approaches to classification,

conceptualization, and treatment. Journal of Psychosomatic Research, 56, 387-
390.

Robinson Kurpius, S. E., & Vaughn Fielder, K. (1998). Ethical issues and the health
care setting. In S. Roth-Roemer, S. R. Robinson Kurpius, & C. Carmin (Eds.),
The emerging role of counselling psychology in health care (pp. 55-73). New York:
W. W. Norton & Company.

Roth-Roemer, S., Robinson Kurpius, S. R., & Carmin, C. (1998). The emerging role of
counselling psychology in health care. New York: W. W. Norton & Company.

Rutter, D. R., & Quine, L. (2002). Changing health behaviour: Intervention and research
with social cognition. Buckingham: Open University Press.

Salant, T., & Lauderdale, D. S. (2003). Measuring culture: a critical review of

acculturation and health in Asian immigrant populations. Social Science
& Medicine, 57, 71-90.

Sarafino, E. P. (1999). Health psychology. Biopsychosocial interactions (3rd ed.). New

York : Wiley.

Schensul, S. L., Mekki-Berrada, A., Nastasi, B., Saggurti, N., & Verma, R. K. (2006).
Healing traditions and men‟s sexual health in Mumbai, India: The realities of
practiced medicine in urban poor communities. Social Science & Medicine, 62,
2774-2785.

Spira, J. L., & Reed, G. M. (2002). Group psychotherapy for women with breast cancer.
Washington, DC: American Psychological Association.

Spring, B. (2007). Evidence-based practice in clinical psychology: What it is, why it

matters; What you need to know. Journal of Clinical Psychology, 63, 611-631.

36 European Journal of Counselling Psychology 2009, Vol. 1, No. 1

 COUNSELLING PSYCHOLOGY IN MEDICAL SETTINGS

Stedman, J. M., Hatch, J. P., Keilin, W. G., & Schoenfeld, L. S. (2005). The structure of
internship training: Current patterns and implications for the future of
clinical and counselling psychologists. Professional Psychology: Research and
Practice, 36, 3-8.

Suls, J., & Rothman, A. (2004). Evolution of the biopsychosocial model: Prospects and
challenges for health psychology. Health Psychology, 23, 119-125.

Thoresen, C. E. (1999). Spirituality and health: Is there a relationship? Journal of Health

Psychology, 4, 291-300.

Thoresen, C. E., & Eangleston, J. R. (1984). Counselling, health, and psychology. In S.

D. Brown & R. W. Lent (Eds.), Handbook of counselling psychology (pp. 930-955).
New York: Wiley.

Thoresen, C. E., & Eangleston, J. R. (1985). Counselling for health. The Counselling
Psychologist, 13, 15-87.

Tyler, L. E. (1980). The next twenty years. The Counselling Psychologist, 8, 19-21.

Van Egeren, L. (2004). Assessment approaches in health psychology: Issues and

practical considerations. In P. Camic & S. Knight (Eds.), Clinical handbook of
Health Psychology (pp. 11-26). Göttingen: Hogrefe & Huber.

Walker, A. (2004). Studying and changing health care professionals‟ behaviour. In S.

Michie & C. Abraham (2004), Health psychology in practice (pp. 267-284).
Oxford: Blackwell.

Walker, S. B., & London, S. (2007). Novel tools and resources for evidence-based
practice in psychology. Journal of Clinical Psychology, 63, 633-642.

Walsh, Y., Frankland, A., & Cross, M. (2004). Qualifying and working as a
counselling psychologist in the United Kingdom. Counselling Psychology
Quarterly, 17, 317-328.

Wang, C., Gonzalez, R., & Merajver, S. D. (2004). Assessment of genetic testing and
related counselling services. Social Science & Medicine, 58, 1427-1442.

European Journal of Counselling Psychology 2009, Vol. 1, No. 1

37