Part One: Foundations in critical health psychology

Part One explores foundations in critical health psychology. People working in health psychology are involved in multiple activities that aim to support health and wellbeing. These activities include helping people to maintain health, prevent illness, or have better treatment experiences or outcomes. They also do broader work focused on improving healthcare systems and health policies. To do this work well, people working in health psychology need to know about specific theories or approaches in health and to reflect on the broader ideas shaping their thinking and practice. We often take these broader ideas for granted, but questions about how we conceptualise a person, what counts as knowledge, or what constitutes equitable health outcomes can have surprisingly varied answers.

Part One of the book unpacks these ideas, introducing you to a wealth of deep thinking about what it means to be a person and what kind of knowledges we might be working with. We cover some big conceptual approaches in health psychology:

• Māori ways of understanding people and their health
• Western traditions of conceptualising the person – including:
  • the biopsychosocial approach in mainstream psychology
  • phenomenologically informed work in psychology that focuses on individual interpretation and experience
  • narrative approaches that highlight the role of the stories in people’s sense making
  • social constructionist and discursive approaches that conceptualise both people and knowledge as produced within their social context and through relations of power
  • more-than-human theories that emphases the co-constituted, dynamic nature of the material and discursive world.^[1]

We use the first four chapters to outline these frameworks, first focusing on Indigenous Māori health, with each subsequent chapter using a different health issue—coronary heart disease, cancer, and weight. Read as a whole, the chapters give you insights into some of the health and illness topics addressed in health psychology, with a particular focus on dominant health issues: cardiovascular diseases are a leading cause of illness and death worldwide; cancers are the second leading cause of death globally; and weight is often treated as a proxy for health and a key focus in healthy lifestyle advice—despite being discredited by many researchers (Calogero et al., 2019; World Health Organization, 2021; World Health Organization, n.d.). As noted in the introduction to the book, we argue that Indigenous knowledge should be part of foundational learning for critical health psychology, and writing from the context of Aotearoa New Zealand, for us that means foregrounding te ao Māori as it pertains to health. We finish Part One with two chapters focusing on the experience of illness and of treatment, respectively. These chapters show how the ideas that we have introduced you to in the earlier chapters can be applied to better understand personal experiences of health, illness, and treatment.

Throughout Part One, we connect our discussion to the critical health psychology pou discussed in the introduction to our book: valuing theoretical and conceptual thinking; challenging taken–for–granted understandings; paying attention to issues of power and equity; moving beyond individualistic psychology; and considering knowledge as produced in context. The chapters engage with all the pou, but read as a whole, they especially speak to the centrality of the social context in shaping knowledge and experience. Specifically, they evidence the way people’s individual experiences of health and illness are produced in, and through, interpersonal relationships, personal and family histories, social norms, cultural perspectives, wider discourses, politics, economics, and the materiality of technologies, buildings, bodies, and parts of bodies.

The chapters in Part One lay out substantial foundational thinking that underpins the wide range of work represented in the term “critical health psychology”. We have sought to cover this substantial ground in an accessible and interesting way. Our rationale for unpacking these concepts is to give you agency. We all carry with us taken-for-granted ideas that then shape how we think about the world and how we act in it. When we start to explicitly learn about different conceptual approaches, and the perspectives they offer, we can be more choiceful in our thinking.

The metaphor of a map might be useful here. Just like conceptual approaches, different maps offer us different, and only ever partial, ways of interpreting the world. For example, a geologist’s map can tell you about types of rock, while a travel map gives information about roads. Both offer different representations of the same land, and depending on context, one may be more, or less, useful to you. Importantly, having more than one map increases our capacities for action, because now we have more than one way to explore and engage with the territory. Similarly, different conceptual approaches can expand our possibilities of thought, and thus practice, in relation to health psychology.

The chapters in Part One of the book therefore offer multiple conceptual maps to make sense of key issues of concern for health psychology. We hope they will provide you with strong foundations for the work you are doing now, and with tools for the work you might do in the future. As such, our aim is to offer you a toolbox of analytical concepts, so that whether you are writing essays, researching a topic, designing a research project, deciding on a treatment plan, or writing policy for business, NGOs or government, you are empowered to consider the needs of that particular piece of work, and can choose the approach that will best allow you to meet those needs. The aims of Part One thus align with how the French philosopher Michel Foucault described his work:

I would like my books to be a kind of tool-box which others can rummage through to find a tool which they can use however they wish in their own area (Foucault, 1974, p. 523-4).

Overview of chapters

Chapter 1.1 Hauora addresses the questions, “How do Māori worldviews and experiences inform their conceptualisations of health?” and “How can critical health psychology engage appropriately with Māori knowledges and perspectives?” It explores Māori worldviews and knowledges and how these shape Māori understandings of people, and their health and wellbeing. The importance of historical and socio-political context is highlighted, including key events in the history of Aotearoa New Zealand, and their impacts for Māori health. The chapter finishes with a review of Māori models of health and dimensions of wellbeing and their application and relevance for contemporary health psychology.

Chapter 1.2 What do we mean by “people”? builds on Chapter 1.1 by considering three approaches from Western traditions that offer different ways to address this question. These approaches are (1) the biopsychosocial approach and associated health psychology models of psychological processes; (2) phenomenologically informed psychology, which focuses on individual interpretations of their lived experience; and (3) social constructionist approaches that conceptualise the person as produced through, and thus inseparable from, their context. Coronary heart disease provides a running theme to show the similarities and differences of these approaches when applied to the same health condition.

Chapter 1.3: What do we know? addresses the question, “What kind of knowledge do people working in health psychology produce and use?” We consider five approaches that conceptualise knowledge differently. These are (1) the objectivist science of mainstream psychology, (2) phenomenologically informed psychology, (3) social constructionism, (4) more-than-human theoretical approaches, and (5) Kaupapa Māori research. We engage with each of these systematically, exploring how they conceptualise what we can know, and our methods for knowing it. Using cancer as our health topic that threads throughout the chapter, each section has a research example to give you a sense of how these ideas are put into practice.

Chapter 1.4 Equity and power asks, “How do our concepts of health shape possibilities for in/equitable health outcomes?” It starts by distinguishing between equity and equality before introducing poststructuralism, a social constructionist aligned approach that centres relationships between power, meaning making, and psychology. We then introduce “healthism”, an individualist orientation to health, and evaluate how it shapes people’s sense of self and possibilities for equitable health care. We finish with some of the ways we might work with, challenge, or destabilise healthism. Within each section, we thread through examples relating to health and weight, since weight is often treated as a proxy for health.

Chapter 1.5 Experiencing illness asks, “How do people experience illness?” It starts by considering the elements that shape people’s experience of illness, showing the importance of the social context. We then introduce the concept of “illness narratives” to show how stories help people make sense of illness. We follow this with a discussion on “biographical disruption”, a term that describes how the onset of illness can profoundly interrupt a person’s sense of self and relations with others, requiring them to craft new stories about themselves. We finish with the limits of biographical disruption as a concept by discussing how social and economic factors shape illness expectations and thus the narratives people tell about their illness.

Chapter 1.6 Experiencing treatment asks, “How do people experience treatment?” It starts by considering the elements that shape people’s experience of treatment, showing how treatment experiences are not purely individual, but shaped by complex, intersecting psycho-socio-material elements. In highlighting the importance of these multiple elements, the chapter demonstrates treatment experiences as complex and embedded in power relations. Returning to more-than-human theory, introduced in Chapter 1.3, it discusses the “assemblage” as a conceptual framework for understanding the interplay between these multiple elements and tool for evaluating treatment.

Combined, these chapters cover a lot. Depending on your background, some or all of these ideas may be new to you. Our aim is to take you through these ideas in an accessible and interesting way – to be a companion as you explore the different conceptual approaches on offer. Even so, learning new ways of thinking can be difficult because there is nothing to “hook” onto in relation to ideas you already hold. We can think of this in terms of lovely knowledge versus difficult knowledge (Lather, 2007). Lovely knowledge adds to what you already know. It is “lovely” because it does not significantly push or challenge you, which means that you remain in your comfort zone. But lovely knowledge is unlikely to develop you very deeply, and comfort zones can get boring after a while. So, the challenge is to face difficult knowledge – the ideas that unsettle or do not fit easily within an existing framework. One way to do this is to recognise those feelings if they happen, and understand they are part of a learning journey. It is also useful to know that the more time you spend with difficult knowledge, the more it becomes part of your thinking—to eventually become lovely knowledge.

There is an expression in te reo Māori, a whakatauākī attributed to the late Professor James Te Wharehuia Milroy, that orients to the moment just before something important happens, a sense of fear, but also of an anticipated action to come—”Tūwhitia te hopo, mairangatia te angitū!” (The essence of this whakatauākī is, “Feel the fear and do it anyway”.^[2])

Taken together, the chapters in Part One of this book offer a comprehensive overview of conceptual approaches that students, researchers, and practitioners can use when seeking to understand how the social context shapes personal experiences of health, illness, and treatment.

References

Calogero, R. M., Tylka, T. L., Mensinger, J. L., Meadows, A., & Daníelsdóttir, S. (2019). Recognizing the fundamental right to be fat: A weight-inclusive approach to size acceptance and healing from sizeism. Women & Therapy, 42(1–2), 22–44. https://doi.org/10.1080/02703149.2018.1524067

Foucault, M. (1974). Prisons et asiles dans le mécanisme du pouvoir. In Dits et écrits (Vol. II). Gallimard.

Lather, P. (2007). Getting lost: Feminist efforts toward a double(d) science. University of New York Press.

World Health Organization. (2021). Cardiovascular diseases. https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)

World Health Organization. (n.d.). Cancer. https://www.who.int/health-topics/cancer#tab=tab_1