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Health Psychology

Towards a Critical Health Psychology Practice

Isaac Prilleltensky and Ora Prilleltensky
J Health Psychol 2003 8: 197
DOI: 10.1177/1359105303008002659

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Towards a Critical Journal of Health Psychology

Copyright © 2003 SAGE Publications
London, Thousand Oaks and New Delhi,
Health Psychology [1359–1053(200303)8:2]
Vol 8(2) 197–210; 031659

Practice

ISAAC PRILLELTENSKY & ORA

PRILLELTENSKY Abstract
Peabody College at Vanderbilt University, Nashville, USA
The field of critical psychology
is exerting an influence in the
way various sub-disciplines
I S S AC P R I L L E LT E N S K Y is Professor of Human and within psychology operate. In
Organizational Development. this article we use a critical
psychology framework to
is a lecturer in Human and
O R A P R I L L E LT E N S K Y review the field of health
Organizational Development. psychology. Through the use of
values, assumptions and
practices we review progress in
health psychology and offer
recommendations for aligning
contemporary practices with
current thinking in critical
psychology. We discuss typical
expectations, critical
formulations and critical
practice for interventions with
individuals, groups and
communities along these
dimensions.

AC K N OW L E D G E M E N T S . We acknowledge the help of Geoff Nelson in

discussions leading to this article and related publications.

COMPETING INTERESTS: None declared.

ADDRESS. Correspondence should be directed to:

I S A AC P R I L L E LT E N S K Y ,
Department of Human and Organizational Keywords
Development, Peabody College, Box 90, Vanderbilt University,
Nashville, TN, 37203, USA. [email: [email protected]] critical psychology, power, ethics,
health professions
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JOURNAL OF HEALTH PSYCHOLOGY 8(2)

Introduction Health can be promoted, maintained and

restored in micro (e.g. close personal relations,
T H E P U R P O S E of this article is to offer critical family), meso (e.g. school, work) and macro
perspectives on the promotion of health and spheres (e.g. community, society). From a
wellness. Within the field of psychology, health critical psychology perspective, each one of
psychology has been the champion of health these contexts is suffused with power differen-
promotion and maintenance. In recent years, tials that privilege the powerful and discriminate
critical perspectives with respect to health and against the weak (Kawachi, Kennedy, & Wilkin-
wellness have made inroads into the social son, 1999; Kim, Millen, Irwin, & Gersham, 2000;
sciences (see Murray & Chamberlain, 1999; McCubbin, 2001; Petersen, 1994; Prilleltensky &
Stainton-Rogers, 1996; and special issue of Nelson, 2002). Freund and McGuire (1999)
Journal of Health Psychology on Reconstructing claim that power is a strong determinant of
Health Psychology, 2000, vol. 5, no. 3). Critical health. In their view, there is a strong connection
psychology frames health and wellness in ways between the two, illustrated by:
that differ from mainstream health psychology
the power of workers over their work pace;
(Crossley, 2001a). In this article we concept-
the power of people to control the quality of
ualize health and wellness from a critical
their physical environments; the power of
psychology perspective and formulate rec-
various groups or societies to shape health
ommendations for interventions with indi-
policy or to deliver what they consider
viduals, groups and entire communities. By so
healing; the power of people of different
doing, we wish to add to the growing body of
statuses to control, receive, and understand
literature on critical health psychology. This
information vital to their well-being; and the
literature critiques and interrupts mainstream
power of the mass media to shape ideas about
discourse which fail to address issues of power,
food and fitness. (Freund & McGuire, 1999,
privilege and the social embeddedness of health
p. 7)
and illness (Marks, 2002).
Health is central to wellness. It is a precursor Power is cardinal to the entire enterprise of
as well as a consequence of wellness. We critical psychology. It is instrumental in the
conceptualize wellness in broad terms that promotion of wellness, in resisting oppression
include psychological and physical health. Well- and in striving for liberation (Prilleltensky &
ness is a satisfactory state of affairs, brought Nelson, 2002). A recent special issue titled
about by the combined presence of values, Power, Control and Health (Journal of
resources, programmes and policies (Prillel- Community and Applied Social Psychology,
tensky, Nelson, & Peirson, 2001a, 2001b). Each McCubbin, 2001), further elucidates the inextri-
one of these four components contributes to cable relationship between health and power.
health. We regard health as an intrinsic as well Table 1 provides a synopsis of how critical
as an extrinsic value. It has merit on its own psychology values, assumptions and practices
accord, but it is also instrumental in bringing may guide the process as well as the content of
about self-determination, personal growth and critical health work (Fox & Prilleltensky, 1997).
opportunities in life. As a case in point, we note how the value of self-
The way the World Health Organization determination needs to be contextualized in
(WHO) defines health is reminiscent of our light of disability and chronic illness. The much
notion of wellness. According to the WHO, esteemed value of autonomy needs to be
health is more than the absence of illness, it rethought, and replaced, by the value of inter-
comprises positive physical and emotional dependence. The value of diversity reminds us
features that enable individuals and groups to that there are many ways of being, and living
pursue their goals in a context of equality and with a disability should not detract from a
justice (Tones, 1996). We resonate with this respected and dignified life. When we value
inclusive definition, as it encompasses values of physical independence above all else and regard
self-determination, caring and compassion, it as imperative to a positive sense of self, we
personal growth, democracy, equality and marginalize and exclude those who cannot
justice. attain it. Critically reflecting on the values and
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 02 Prilleltensky (jr/lk)
Table 1. Health psychology practice from a critical psychology perspective
Critical psychology tenets Possibilities for action
Values for

PRILLELTENSKY & PRILLELTENSKY: CRITICAL HEALTH PSYCHOLOGY

personal wellness Content: Balance prevalent emphasis on autonomy with concern for caring and compassion and interdependence. Consider power

2/20/03
relational wellness differentials in hospital settings and their impact on patients’ empowerment and self-determination. Social cohesion, collaboration and
collective wellness democratic participation at community level benefit population health
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Process: Show caring and compassion for citizens seeking service, respect their social identities and foster their ability to pursue personal

2:36 PM
goals in light of chronic illness or disability. Involve community members in civic and health-related activities. Create partnerships with
community groups to achieve justice in health care

Assumptions about

Page 199
good life Content: Ensure that definition of problems and health includes voice of citizens seeking help and it is not circumscribed to professional
good society opinion. Consider role of corporate profit making in health problems. Promote focus on strengths and competencies of person as
knowledge perceived and described by person seeking help. Beware of the pursuit of pathology prevalent in hospital settings
ethics
role of worker Process: Act as resource collaborator instead of removed expert. Engage citizens in active roles throughout the process of help or self-
role of client help. Consider alternatives to medical treatments such as health promotion activities related to diet and lifestyle. Promote non-
professional interventions such as mutual-help groups. Afford people seeking help meaningful opportunities to present their point of
view concerning their health. Renew informed consent often and solicit input from patients as to direction and aims of helping relation
ship. Respect privacy of patients in medical settings

Practices
problem definition Content: Consider approaches that go beyond reactive and indicated interventions and that are proactive in nature. Address social and
scope of intervention economic origins of ill-health and maldistribution of resources and health in society
time of intervention
Process: Collaborate with advocacy and social justice groups in addressing the health needs of the entire population. Create solidarity
partnerships with community groups affected by ill-health. Promote political education and social action leading to health promoting
cultures and organizations
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JOURNAL OF HEALTH PSYCHOLOGY 8(2)

assumptions that support our work will benefit ences, divisions or committees in the major
our research, teaching and clinical practice. psychological associations and extensive litera-
Power’s omnipresent character is highlighted ture. Taylor offers a useful definition of the field
in Table 1. Power differentials across the of health psychology. According to her:
medical divide have to be carefully attended to
Health psychology is the field within psychol-
by critical health psychologists. Chamberlain
ogy devoted to understanding psychological
(2000) notes the lack of attention paid to critical
influences on how people stay healthy, why
perspectives in health psychology. Similar senti-
they become ill, and how they respond when
ments are expressed by Stam: ‘In a related
they do get ill. Health psychologists both
sense, it is strange, if not suspicious, that discus-
study such issues and promote interventions
sions of the deeply contested, political and social
to help people stay well or get over illness.
issues that make up health care today are absent
(Taylor, 1995, p. 3)
from health psychology’ (p. 2000, p. 276). Our
own potential to abuse power in a setting that This broad-based definition reflects the dual
accentuates the privilege of professionals must focus on research and practice that characterizes
be monitored (Prilleltensky, 1999). the field of health psychology.
Advocacy is a key feature in health settings. As noted earlier, critical perspectives within
Patients have to negotiate their treatment with health psychology have gathered momentum in
professionals who are not always sensitive to the the past few years. Marks (2002) conceptualizes
psychological condition of the person seeking critical health psychology as one of four
help. One of us has worked in a rehabilitation alternative approaches evolving within the field,
hospital with patients who had sustained various alongside clinical health psychology, public
orthopaedic and neurological disorders. In one health psychology and community health
particularly memorable case, a patient had to psychology. Whereas the other approaches
negotiate with one of his treating therapists that focus on patients in the health care system
it is pointless to spend his therapy time on (clinical health psychology), schools and work
making himself a cup of tea. He had never done sites (public health psychology) and entire
this for himself prior to the stroke, and would communities (community health psychology),
certainly not begin to do so now—when it was ‘Critical Health Psychology aims to analyse how
extremely time-consuming and onerous. The power, economics and macrosocial processes
fact that he had to make a special case and gain influence and/or structure health, health care,
support from his psychologist, speaks volumes health psychology, and society at large’ (Marks,
about the risk of professional appropriation of 2002, p. 15). Although critical health psychology
decision making. But advocacy should extend brings to sharp relief the role of culture and
beyond the walls of the clinic or the hospital. In dominant societal structures, its power analysis
our discussion of roles for critical psychologists may be applied from the micro setting of
we distinguish between individual, group, relationships to the macro level of policy.
community and societal interventions (Winett, The importance of deconstructing the
1995). assumptions that underline research in health
psychology have been noted by Chamberlain
(2000) and Stam (2000), among others (Cross-
ley, 2000). Stam (2000) questions mainstream
Tasks and expectations
health psychology’s non-critical and non-
The term ‘health psychology’ first appeared in reflexive definition of health and illness. So long
the professional literature in the late 1970s as we define health as simply regaining the
(Marks, 2002). While the initial focus was on ability to perform, and adopt a likewise uncriti-
treatment compliance and on the client–pro- cal stance towards such constructs as ‘adjust-
fessional relationship, it has grown and evolved ment’ and ‘quality of life’, ‘we deny that we are
into a diverse field that has gained much recog- collectively, as a profession, defining a set of
nition within psychology and allied health outcomes for others’ (2000, p. 279). Only by
professions in the last 25 years. It is a growing negotiating the meaning of such constructs with
field with a few journals, international confer- affected individuals, can we hope to create
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PRILLELTENSKY & PRILLELTENSKY: CRITICAL HEALTH PSYCHOLOGY

research and practice that is relevant, effective formulations and critical practice for inter-
and empowering. ventions with individuals, groups and communi-
Writing about the proliferation of qualitative ties along these dimensions.
research projects in health psychology, Cham-
berlain (2000) warns that an increased emphasis
Interventions that promote
on methodology issues often comes at the
individual wellness
expense of critically reflecting on the assump-
tions which support the research. Like their Typical expectations In working with indi-
quantitative counterparts, most qualitative viduals, health psychologists are expected to
studies in health psychology fail to adopt a help with a variety of issues, ranging from
critical perspective and ignore the philosophical reactive to proactive interventions. We distin-
positions of the researcher. In a similar vein, guish in Table 2 among indicated, high risk and
Wilkinson (2000) demonstrates how different universal populations.
feminist research traditions (positive empiricist, Health psychologists often engage in reactive
experiential and discursive) can be effectively interventions in medical settings. Services
applied to breast cancer research that is offered directly to patients or through consul-
informed by a critical perspective. tation with other professionals include coping
Although we acknowledge the growing with acute or chronic pain, compliance with
importance of critical health psychology medical treatments, rehabilitation towards
research, the rest of this article will be devoted restoration of physical functioning, preparation
to health psychology practice. Health and for surgery and stressful medical procedures and
medical settings continue to be the largest psychosocial rehabilitation (Belar & Deardorff,
employers of psychologists in recent years 1996; Bennett, 2000). Proactive interventions
(Stam, 2000). The services offered by health occur usually in worksites, community health
psychologists include coping with physical centres or educational institutions. They usually
illness, pain management, psychosocial rehabili- take the form of programmes to stop smoking or
tation after accidents, promotion of healthier drinking or to improve diet. We note below
lifestyles, support groups for sufferers of chronic some reservations with respect to individual and
disease and the like. These activities fall into two group interventions.
broad categories: clinical services in medical
settings (Belar & Deardorff, 1996; Bennett, Critical formulations Institutional settings
2000), and health promotion programmes in like hospitals prescribe and perpetuate roles for
community settings (Bennett & Murphy, 1997). all the players within it. The sick role of the
Taking into account these two major domains, patient diminishes his or her power and self-
Table 2 describes potential interventions for determination, whereas the role of expert of
critical health psychologists. The interventions physicians increases their ability to make
vary along timing, population and ecological decisions for others. In such hierarchical places,
levels. Across the top of Table 2 we can see all the actors are at risk. Some, like patients and
different units of interventions: individuals, low status workers, are at risk for reduced ability
groups and organizations and community and to control their lives and environments. Others,
society. Each unit of intervention is guided, like high status professionals, are at risk for
respectively, by a set of personal, relational and abusing power and engaging in patronizing
collective values. behaviour: ‘The dominance of the medical
The three rows in Table 2 distinguish among profession, for instance, is expressed and re-
clinical interventions for people who already inforced through the micro level of medical
have problems (reactive/indicated), pro- encounters. In the hospital, the consultant’s
grammes for people who are at high risk of round has long been an expression of power
developing health complications (proactive/ over medical students, nurses, and patients’
high risk) and health promotion initiatives for (Hardey, 1998, pp. 83–84).
the population at large (proactive/universal). In the interaction between patients and
The Table informs the analysis that follows. medical professionals, the power and expertise
We discuss typical expectations, critical of the latter runs the risk of diminishing the
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JOURNAL OF HEALTH PSYCHOLOGY 8(2)
202

Table 2. Ecological levels, values and potential critical psychology interventions in health settings
Timing and population of intervention Values and ecological levels

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Values for Personal Wellness Values for Relational Wellness Values for Collective Wellness
self-determination, protection of collaboration, democratic participation support for community structures, social
health, caring and compassion and respect for diversity justice
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Individual Wellness Group and Organizational Wellness Community and Societal Wellness

2:36 PM
Reactive indicated • Self-determination in rehabilitation • Assertiveness training for hospital • Securing access of minorities, refugees
• Power sharing in treatment plans for patients dealing with professionals and the poor to all health services
coping with illness and chronic pain • Communication training for • Lobbying for funding of health services

Page 202
professionals dealing with in deprived areas
vulnerable patients

Proactive high risk • Smoking cessation with emphasis on • Exercise programme for • Self-help/mutual aid and support
exploitation of community by disadvantaged populations at high groups for people caring for disabled
tobacco companies risk for heart disease family members
• Diet and exercise programme for • Organizational interventions to • Community-wide programmes to
overweight people with emphasis on reduce stress in patients and staff improve diet, lower alcohol
ill effects of consumerism consumption and increase exercise

Proactive universal • Self-instruction guide on breast • Organizational development to • Critique and boycotts of media and
examination improve working atmosphere corporations making profits at expense
• Self-instruction guide on HIV • Bill of rights and responsibilities for of population health
prevention patients and staff in hospitals • Promote social cohesion and
egalitarian social policies
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PRILLELTENSKY & PRILLELTENSKY: CRITICAL HEALTH PSYCHOLOGY

self-determination of the former in multiple patient’s complaint of physical pain may not
ways. First, they do so by prescribing treatments conform to known anatomical structures. This
without adequately consulting patients or may lead to some scepticism regarding the legit-
explaining the basis of the decision in accessible imacy of the complaint, and to a hypothesis of a
language. Second, by failing to elicit and possible underlying psychological mechanism.
patiently explore patients’ lived experience of An inability to find a clear organic basis for a
their illness, and the feasibility of adhering to patient’s complaint often results in various such
the prescribed treatment within the context of hypotheses being generated and perpetuated by
patients’ diverse life circumstances. Third, by different professionals. If a law suit is pending
creating distance and fostering asymmetrical against an employer or the state, diagnosis
relationships among themselves and their becomes even more complicated.
patients, often as a shield against doctors’ own The point of this hypothetical situation is to
feelings of helplessness in the face of human show how complicated assessment and choice of
suffering that cannot be easily alleviated. These treatment can become. When we combine all of
are but a few examples of disempowering treat- the contextual factors implicated in diagnosis and
ment of patients, which has received growing treatment, a fairly complicated picture emerges.
recognition in the sociology of health and A critical appraisal of the situation would take
illness. Numerous studies demonstrate the into account power differentials in problem
control of physicians over the content, length formulation, risk of diminished self-determi-
and nature of interaction with patients (Curtis, nation of patients, potential labelling of patients
2000; Samson, 1999; Weitz, 1996). It has also and access by patients to needed resources. In
been found that many physicians promote synthesis, critical psychology adds another
stereotypical roles for women and that they dimension to helping. Selection of best cognitive
react in a defensive and even hostile manner or behavioural strategies is not enough (Crossley,
when challenged by their female patients 2001a, 2001b). Patient participation and em-
(Hardey, 1998). (For an overview of encounters powerment in method of help are also crucial.
between health care professionals and patients, However helpful clinical interventions might
see also Crossley, 2000.) In this context, the be, health psychology has been criticized for
psychologist is at risk for abusing his or her concentrating too much on individuals and for
relative high status, and for being discounted by preferring a reactive mode of intervention.
medical practitioners who run hospitals and According to Winett, ‘to be effective health
assume ultimate decision-making powers with psychologists need to adopt an intervention
respect to patients. orientation more diverse in terms of timing and
We are not contesting the need to apply level than their apparent preference for tertiary
proven strategies of coping and behaviour prevention with clinical, individual-level inter-
modification to client health issues. However, ventions’ (1995, p. 344). Studies show that
we must remember that all of this takes place in remedial interventions for high risk conditions
a context suffused by power differentials where such as obesity, high cholesterol and smoking,
the perspective of the client or other health are not very effective (Smedley & Syme, 2000;
professionals, such as physiotherapists or social Wilkinson, 1996). Once entrenched, these
workers, may be lost due to their relative lack of patterns of behaviour are hard to change. In any
power. There is, then, the physical construction case, even when they are effective, they do not
of illness and the social construction of illness address the constant flow of new cases with such
(Freund & McGuire, 1999). As Radley reminds adverse conditions.
us, ‘it is not just what it means to be ill that is The critique levelled against health psychol-
socially defined, but what it means to be treated ogy is not only that it responds late to
and, make a good recovery’ (2000, p. 302). conditions, but also that it addresses individuals
The chosen method of helping is not only and not societal structures. The proactive
determined by the best available scientific approach that centres on individuals at risk is
evidence; but it is also mediated by the meaning incapable of reducing incidence, or the number
of the condition negotiated among patient and of new cases of a problem. As Wilkinson noted:
multiple professionals. Thus, for example, a
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JOURNAL OF HEALTH PSYCHOLOGY 8(2)

Sometimes it is a matter of providing motivating factor for the hard work they invest
screening and early treatment, other times of in their various therapies. Notwithstanding the
trying to change some aspect of lifestyle, but commitment and dedication of most rehabili-
always it is a matter of providing some service tation professionals and the vital work that they
or intervention. This applies not just to health, do with patients, the elevated value attributed to
but also to studies of a wide range of social, physical independence in such settings should
psychological, developmental and edu- be questioned. Occupational and physical
cational problems. What happens is that the therapists work with their patients towards
original source of the problem in society is left enhancing the latter’s ability to carry out inde-
unchanged (and probably unknown) while pendently activities of daily living. Whereas
expensive new services are proposed to cater most people would prefer to be as independent
for the individuals most affected. Each new as they can in self-care, needing assistance, even
problem leads to a demand for additional with the most intimate tasks of daily living, is not
resources for services to try to put right the tantamount to losing autonomy and control.
damage which continues to be done. Because Deconstructing such words as independence
the underlying flaw in the system is not put and autonomy from a disability rights-perspec-
right, it gives rise to a continuous flow, both of tive, can have a profoundly empowering effect
people who have suffered as a result, and of on the lives of individuals with severe physical
demands for special services to meet their impairments. This is exemplified by the follow-
needs. (1996: p. 21) ing quotation by a disability rights activist:
We believe fundamentally that all individuals
Critical practice Opportunities for helping
have the right to live independently in the
are present at the individual, group/organization
community regardless of their disability. But
and community/societal levels. At each level, we
it is important to note the sense in which we
propose to use a partnership model. A partner-
use the term ‘independence’, because it is
ship ensures that clients and all other pro-
crucial to everything we are saying. We do not
fessionals are heard. Furthermore, it implies
use the term ‘independent’ to mean someone
that decision-making power will be shared, and
who can do everything for themselves, (sic)
that the wishes of medical patients will be given
but to indicate someone who has taken
proper priority.
control of their life and is choosing how that
We consider here the case of patients in a
life is led . . . it can be applied to the most
rehabilitation hospital, following serious acci-
severely disabled person who lives in the
dents, strokes or exacerbation of pre-existing
community and organizes all the help or ‘care’
conditions such as Multiple Sclerosis. Following
they need as part of a freely chosen lifestyle.
the initial phase when one is simply grateful to
The most important factor is not the amount
be alive, the reality of decreased mobility and
of physical tasks a person can perform, but the
difficulties with various aspects of daily living,
amount of control they have over their every-
often sets in. Sometimes it is a temporary
day routine. The degree of disability does not
condition that is expected to improve with time
determine the amount of independence
and physical therapy, other cases may require
achieved. (Brisenden, 1998, pp. 26–27)
adjustment to a permanent change in status,
whereas in some situations, further decline in We are not suggesting here that occupational
health and physical functioning is to be and physical therapists should cease to help
expected. Notwithstanding these important people restore physical abilities and promote
differences, affected individuals often become unaided functioning. Rather, it is the unques-
psychologically vulnerable. tioned assumption that physical independence
The overarching goal of rehabilitation should be attained at all costs, with which we
settings is to enable individuals to return to take issue.
previous levels of functioning, resume roles and If a person does not find meaning in prepar-
re-integrate into society with as little disruption ing breakfast for herself, a task that may take
as possible. Undoubtedly, this is a desired her 45 minutes and drain her of energy that may
outcome for most patients, and serves as a major already be in short supply, perhaps another
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PRILLELTENSKY & PRILLELTENSKY: CRITICAL HEALTH PSYCHOLOGY

person could do it for her in five minutes. A council on the subject (Prilleltensky, Nelson, &
rehabilitation patient in a setting we worked in Sanchez Valdes, 2000). These are examples of
jokingly spoke of the routines he goes through linkages between personal risk factors and their
in order to appease his treating therapists who societal origins. We have to make these connec-
decided that he should participate in ‘breakfast tions for the benefit of people who are at risk
group’. A stroke had left this man with signifi- today and for the benefit of those who will be at
cant physical impairments, while his cognitive risk tomorrow if corporations continue to infect
functioning remained relatively intact. While it the public with toxic products. As critical health
was very clear to him that he would not be psychologists we have to ask ourselves whether
attending to his own breakfast at home given the we want to support the status quo by treating its
time and energy that this required of him, he felt victims, or whether we want to join with them to
it necessary to be a ‘good patient’, thereby challenge noxious consumerism.
avoiding conflict, which may be more trouble
than it is worth. This man was willing to play the
Interventions for group and
game and had maintained his sense of humour
organizational wellness
in the process. However, making such decisions
on behalf of patients is what truly robs people of Typical expectations Work with groups and
dignity and control over their lives. organizations can also be reactive or proactive.
Proactive interventions with individuals have Health psychologists can work with patients in
to address the societal sources of smoking, support groups or exercise programmes, and
drinking, binging and sitting for too long. To they can assist worksites to improve the social
begin addressing the societal causes of disease it climate and reduce stress and conflict. Many
is important to politicize community members. health psychologists assist organizations to
It can be empowering for a young woman with improve the health of their employees through
an eating disorder to understand and take action lifestyle changes and exercise.
against the media. Lyons (2000) asserts that
media representations of health and illness have Critical formulation In the meso context of
been surprisingly overlooked by health psychol- hospitals, clinics and work settings, power and
ogists. She makes a cogent argument for a control affect health in significant ways as well.
critical analysis of media images. In addition to In the Whitehall studies, Marmot and his
affecting people’s beliefs and understanding of colleagues followed the health of thousands of
health and illness, media images can influence British civil servants for three decades (Marmot,
people’s attitudes towards certain sub-groups of 1999; Marmot, Siegrist, Theorell, & Feeney,
the population, as well as mediating individuals’ 1999). The participants were all middle class
own lived experience of illness. She further people who enjoyed relative affluence. Al-
reminds us that ‘examinations of what is not though all of them could be considered middle
represented in the media are also extremely class, the 25-year follow-up study showed that
beneficial’ (2000, p. 356), referring to the those in lower positions had a four times higher
preponderance of images of young female mortality rate than those in administrative
bodies versus the invisibility of disabled bodies, positions. There was a clear correlation between
aging bodies, etc. level of control over the work environment and
Feminists use anger towards societal oppres- several measures of disease, with those lower on
sion in empowering ways (Riger, 2000). So do the scale of control experiencing poorer health.
narrative therapists and advocates of just When participants were divided into four
therapy (Community Mental Health Project, employment grades, there was a distinct and
1998). There is a need to connect corporate gradual escalation in health from the lower
agendas with personal suffering. In a smoking grade to the higher grade. As Marmot noted:
prevention programme with children and young
people we discussed at length the commercial There are abundant data showing a link
roots of addictions. Children in the programme between poverty and ill health. These results
protested in shopping malls against tobacco from Whitehall have influenced us in coming
companies and made a presentation to city to the view that inequality is also important.
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The problem of inequality in health is not psychologist has the difficult job of discerning
confined to the poorest members of society whether an intervention will benefit workers
but runs right across the social spectrum. In unequivocally or only temporarily, and whether
Whitehall the social gradient was seen not the net effect of the programme is not worker
only for total mortality, but for all the major appeasement.
causes of death, including coronary heart
disease and stroke. (1999, p. 12) Critical practice We consider possible inter-
ventions in hospital and work settings in turn.
Studies conducted by Marmot and others Because of the prescribed scripts that patients
suggest that the work environment affects and doctors are expected to follow in a total
health through three psychological mechanisms. institution like a hospital, we regard both of
The first relates to levels of demand and control, these groups as sites for action. Of course not all
whereby higher demands and lower levels of patients and professionals engage in stereotypi-
control affect health negatively. The second cal roles of sick and helper, but the evidence is
mechanism refers to the effort–reward imbal- such that people in hospitals often behave in
ance and the third to the level of social support hierarchical and constraining ways. Hence, at the
(Marmot et al., 1999). group/organizational level we recommend inter-
From a critical psychology perspective, we see ventions to improve communication between
that the amount of power experienced by professionals and patients. Research suggests
workers is directly related to health and mortal- that communication between practitioners and
ity. How this power is attained, and how it may patients is often faulty. A study by Beckman and
be challenged and redistributed is a key concern Frankel (1983) confirms this claim. In a sample
for critical psychologists. The struggle to distrib- of 74 office visits, only 23 per cent of the patients
ute power and control equitably within hospitals had a chance to finish their explanations of
and work settings defines a key job for the concerns. Doctors were found to interrupt
critical health psychologist. patients in 69 per cent of the visits. On average,
Hospitals and work settings are laden with doctors interrupted patients after they had
power conflicts. It would be a mistake to inter- spoken for only 18 seconds. In another study,
vene in these types of organizations without West (1983) reported that patient-initiated ques-
considering the effects of the political environ- tions were discouraged. Out of a total of 773
ment. Unless the health psychologist recognizes questions asked in 21 medical encounters, only 9
the political role that he or she might be fulfill- per cent of the questions were initiated by
ing, undesirable consequences may ensue. Inter- patients. The use of jargon, patronizing attitudes
ventions to improve the working climate may and patient anxiety contribute to miscommuni-
mask underlying conflict, to the direct benefit of cation between doctors and patients.
management. Surely reducing stress is a meri- While we advocate for assertiveness and
torious cause, but diverting attention away from communication training, we should remain
the root causes of that stress hinders the cause sceptical of the potential for such interventions
of health. As we can see, the health psychologist to make lasting changes. The origins of patriar-
is caught in a bind, much like the organizational chal mentality in medical settings are profound
psychologist who is asked to improve working and may not be undone by workshops on
conditions. On one hand, research clearly communication. Lupton cautions that:
suggests that reduced stress is good for health.
But on the other hand, superficial attempts to To assume that the majority of patients, given
alleviate conflict may divert attention from appropriate training in communication com-
more fundamental roots of discomfort. petencies, will have equal authority in the
Marmot and colleagues (1999) clearly showed doctor–patient relationship is to ignore the
that lack of control at work is related to structural and symbolic dimensions of this
increased levels of illness. Launching initiatives relationship. Although there is limited oppor-
that restore employee control across the board tunity for patients to assert their agency, the
is a good health intervention for as long as it is whole nature of the doctor–patient relation-
not temporary or superficial. The health ship and the healing process rests on the
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unequal power balance and asymmetry of for women in 21 years. This dramatic increase
knowledge between patient and doctor. took place between the years 1965 and 1986.
(1994, p. 59) Japanese people experience the highest life
expectancy in the world, near 80 years, in large
It is clear that more fundamental changes in the
part because in that period of time they became
medical establishment will have to occur to
the advanced society with the narrowest income
democratize the patient–doctor relationship.
differences. Communities with higher levels of
Work towards that goal, however, does not
social cohesion and narrow gaps between rich
invalidate the need to empower patients while
and poor produce better health outcomes than
they are the subject of medical investigations
wealthier societies with higher levels of social
and interventions.
disintegration.
The health psychologist can also intervene in
When probability of death between ages 15
work settings. Solidarity among workers is very
and 60 is compared between richer and poorer
important. It is a source of social support and
countries, the former have outcomes that are
even empowerment. Not all aggression in the
about three times better than the latter. Reasons
workplace comes from above. Horizontal
for death include infections, perinatal, nutri-
violence is quite prevalent (Keashley, 1998).
tional, maternal, cardiovascular, cancer, respira-
Programmes that address workplace bullying
tory disease and other external causes (see
and that build cohesion among workers can
Marmot, 1999, p. 6). Lack of shelter and sanita-
have substantial health benefits. By linking
tion are major causes of killing disease around
health with solidarity we are politicizing well-
the world. Feuerstein (1997) reports that
ness and supporting cohesion among workers.
between 1988 and 1991, in 34 of the 47 least
We touched here on hospital and workplace
developed countries, only 46 per cent of the
actions. Table 2 mentions other possible inter-
population had access to safe water. The
ventions with groups and organizations. We
atrocious effects of poverty on health have been
move now to consider tasks at the community
documented extensively. They remind us that
and societal levels.
health is not only the effect of health care but of
living conditions.
Interventions for community
Within countries, the poor, the unemployed,
and societal wellness
refugees, single parents, ethnic minorities and
Typical expectations Psychologists partici- the homeless have much lower rates of health
pate in health promotion campaigns through than more advantaged groups. This applies not
research, education and intervention. They may only to poor countries, but to rich countries as
facilitate the dissemination of information well. Homeless people in western countries, for
through regional health authorities or contri- example, are 34 times more likely to kill them-
bute to the development of public policy. selves than the general population, 150 times
more likely to be fatally assaulted and 25 times
Critical formulations The macro economic more likely to die in any period of time than the
and psychosocial environment where we live people who ignore them on the streets (Shaw,
have direct repercussions for health and quality Dorling, & Smith, 1999). There is no question
of life. Consider the following examples that the macro environment influences health in
provided by Wilkinson (1996). A child born and potent ways.
raised in Harlem has less chances of living to 65 But the body of knowledge compiled by
years old than a baby born in Bangladesh. Also Marmot and Wilkinson (1999) clearly indicates
in the USA, life expectancy is seven years longer that, in addition to economic prosperity,
for whites (76 years) than for African Ameri- equality and social cohesion are also powerful
cans (69 years). In lower social classes, infant determinants of health. Indeed:
mortality in Sweden (500 per 100,000) is less
than half the rate in England (1250 per 100,000). In the developed world, it is not the richest
Because of more egalitarian income distri- countries which have the best health, but the
bution, the life expectancy of Japanese people most egalitarian . . . Looking at a number of
increased by 7.5 years for men and eight years different examples of health egalitarian
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societies, an important characteristic they all health promotion to activities designed to chal-
seem to share is their social cohesion . . . The lenge corporate ruling of health and illness
epidemiological evidence which most clearly (Crossley, 2001a, 2001b). What we watch, eat,
suggests the health benefits of social cohesion drink and breathe have a lot to do with global
comes from studies of the beneficial effects of capitalism, an economic structure that has
social networks on health. (Wilkinson, 1996, proven detrimental to global health (Feuerstein,
pp. 3–5) 1997; Korten, 1995; Marmot & Wilkinson, 1999).
Re-inventing ourselves as advocates, social
As Wilkinson observed, social cohesion is medi-
critics, community leaders and psychologists at
ated by commitment to positive social struc-
the same time is a necessity that may not sit well
tures, which, in turn, is related to social justice.
with health psychologists. However, to remain
Individuals contribute to collective well-being
at the level of reactive or person-centred inter-
when they feel that the collective works for them
ventions is to deny a massive body of evidence
as well. Social cohesion and coherence are
linking social and economic structures to
‘closely related to social justice’ (Wilkinson,
physical and psychological health. Critical
1996, p. 221). The critical psychologist faces a
health psychology is well positioned to break
serious challenge in trying to incorporate these
interdisciplinary barriers and address wellness
lessons into his or her practice. We distill below
in a truly ecological way.
some of the implications for action.

Conclusion
Critical practice Within the reactive and
indicated framework, there is much that needs What health psychologists do mostly is not
to be done to ensure that minorities have necessarily what helps the most. Whereas most
adequate access to health care. ‘A lack of access health psychologists work with individuals
can have deadly consequences’ (Weitz, 1996, already affected or at risk for health problems,
p. 61). Advocacy, lobbying and solidarity evidence suggests that the most promising ways
partnerships are vehicles to pressure govern- to promote overall health is to work with entire
ments to act on behalf of vulnerable popu- communities in a proactive fashion (Kaplan,
lations. Although the formal medical system is 2000; Smedley & Syme, 2000). Critical and
not the only means to health, it is a social community psychologists used to argue that the
resource that needs to be distributed equally focus on the individual is not enough. New infor-
among all. We see this type of political work as mation indicates that working with groups at
integral to the work of critical health and risk is not good enough either. By the time
community psychologists. Feuerstein (1997) groups of people develop symptoms, it is
outlines several strategies for collaborating with extremely difficult to revert unhealthy behav-
the poor for improved health, including financial ioural patterns. Furthermore, most risk
services and credit for the poor. conditions do not reside within the individual
The practice of health promotion at the social but within the social and physical environments.
and community levels is appealing, but only As a result, preventive efforts for people at risk
insofar as it includes a critique of capitalist have proven only minimally effective (Kaplan,
market rules. We link health promotion to a 2000; Wilkinson, 1996). This was the rather
critique of corporate ruling because, otherwise, disappointing result of the largest trial of behav-
we focus on individuals and neglect the societal ioural change ever conducted. The Multiple
and market origins of illness (Kawachi et al., Risk Factor Intervention Trial (MRFIT)
1999; Kim et al., 2000; Korten, 1995). As Lupton ‘attempted to change diet, smoking and exercise
noted, ‘although the health promotion per- among white men identified as being in the
spective relies heavily on a critique of the highest 10 per cent of risk for coronary heart
biomedical model, it fails to challenge the disease. Despite concentrated efforts over six
hegemony of ideologies that deflect the years they only succeeded in making minimal
responsibility of health maintenance from the changes’ (Wilkinson, 1996, p. 64). The impli-
state to the individual’ (1994, p. 57). Therefore, cation of these findings is that risk factors are in
we advocate a combined approach that couples themselves symptoms of more profound causes
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