Part a) for cognitive skills programmes

              (a)    Outline how cognitive skills programmes can be used as a treatment for offenders

After a guilty verdict, offender may be given numerous sentences which may punish them for their actions, or attempt to rehabilitate them – or both. One way in which an offender may be rehabilitated is through the use of treatment programmes, such as cognitive skills programmes.

Cognitive skills programmes refer to the cognitive approach’s explanation of turning to crime that criminals have distorted cognitions that cause their offending, such as denial of responsibility, optimistic fantasies of anti-social behaviour, poor moral development, and having tendencies to incorrectly attribute actions to hostile intent (Yochelson and Samenow, Palmer and Hollin).

Two examples of cognitive skills programmes offered to offenders are reasoning and rehabilitation therapy, and enhanced thinking skills. Reasoning and rehabilitation therapy targets moral development, and attempts to encourage the offender to take a social perspective on their behaviour, in the hope that this will discourage them to offend if they understand the effects their actions have on others and how to think more morally. Enhanced thinking skills programmes target aspects of cognition such as self-control, and aim to boost pro-social behaviour by teaching interpersonal communication skills.

One study which looked at how cognitive skills programmes can be used as a treatment for offenders is through Friendship et al, which compared the recidivism rates of those on cognitive skills programmes such as ETS, to those who had not been part of such programme. 670 male offenders who had taken ETS or reasoning and rehabilitation therapy were thus compared to 1801 offenders who hadn’t, and the results showed that reconviction rates were 14% lower in the therapy group. This equated to 21000 crimes prevented, based on the researchers’ estimates.

Thus, cognitive skills programmes can be used to treat offenders by improving the different aspects of cognition thought to be responsible for offending, such as interpersonal skills, moral development and self-control.   

Methods of health promotion

Healthy Living: explaining health behaviours

METHODS OF HEALTH PROMOTION

·         MEDIA CAMPAIGNS: Keating et al.

·         LEGISLATION: Wakefield et al.

·         FEAR AROUSAL: Janis and Feshbeck

METHOD: MEDIA CAMPAIGNS

The phrase “media campaigns” refers to various forms of media, which are used to communicate and interact with a range of audiences. There are many forms of media, but typically health campaigns tend to use print media, such as pamphlets, electronic media, such as television and radio, and new-age media, such as social networking. Media campaigns are a prominent method of health promotion as there is a wide range of diversity and accessibility; most households in the West own a television set, and almost everywhere has access to newspapers or the Internet. Health media campaigns can be on various health behaviours, including sexual health and drug use. Health media campaigns are broadly based on the Yale Model of Persuasion from 1953, which describes how for a campaign to be successful, it must consider the communicator of the message, the communication of the message, and the target audience. The health belief model, which roughly fits this but is more complex, is also often used heavily in media campaigns, such as in the TV adverts for Change4Life and Hands-Only CPR.

EVALUATION: MEDIA CAMPAIGNS

Mass media campaigns are a practical method of health promotion in that they can reach a large population in a relatively short amount of time. However, they require access to some resources that people don’t have, can be avoided or ignored, and may not be seen by the full target population, which reduces the effectiveness. Media campaigns are time effective, but not really cost effective, and only reach a certain demographic – so many forms will be needed. It is also important to remember that improved knowledge doesn’t necessarily mean improved behaviour, and particularly stressful campaigns may cause people to switch off from the message.

STUDY: KEATING et al.

Keating et al. conducted a study which aimed to assess the successfulness of the mass-media campaign VISION on reproductive health and HIV/AIDS prevention. A sample of 3278 participants aged between 15 and 49, from various ethnic and economic groups in Nigeria was used. Verbal informed consent was given, and then participants were asked various questions from a questionnaire on sexual health, with 3 critical fixed choice (yes/no) questions: one on talking with a partner about preventing AIDS, one on whether using a condom reduced the chances of getting AIDS, and finally one on whether they used a condom on their last sexual encounter. Chi square and regression analysis was used on the results. It was found that media campaigns were more accessible by males, with females being more exposed to the information from clinics. Exposure to VISION was high, and this appeared to be associated with positive responses to the first two questions; however appeared to have no effect on the third question. It was therefore concluded that different media campaigns reached different people, but whilst campaigns were successful in giving information, this did not seem to directly lead to behavioural changes, and thus media campaigns should also look at giving practical information on how to do certain health behaviours (such as obtaining a condom).

EVALUATION: KEATING et al.

The study used stratified sampling to improve the representativeness of the sample, which was important in Nigeria for ethnic balance. The sample was also large, but ethnocentric to Nigeria. The study was ethical in that verbal informed consent was given, however the questions were quite personal and this may have caused embarrassment or psychological harm. The questionnaire appears to have highlighted the important points about the success of media campaigns rather efficiently; however it would have been more useful if reasons why condoms had not been used had been included in the self-report – a pilot study could have shown this. The study is useful in that it shows that information is not all that is required for a behavioural change, which is something that could be generalized or investigated further for other health behaviours. The study is also useful as it shows the effectiveness of media campaigns varies by population.

METHOD: LEGISLATION

Legislation refers to law making processes, and this is a method of health promotion as laws can be implemented to change health behaviours, by promoting and enforcing positive health behaviours, whilst banning unhealthy behaviours. Certain behaviours that have been made illegal are smoking in public places and smoking if under 18 (rather than 16), whilst behaviours that have been made compulsory in a legal manner include wearing a seatbelt.

EVALUATION: LEGISLATION

Legislation raises the issue of freewill versus determinism, and the ethical nature of forcing or banning certain behaviours. To what extent is it ethical or right to ban dangerous health behaviours, or to enforce improved health behaviours? Some would argue that the legislation against smoking in public places is denying people human rights, such as freedom of movement, whilst others would suggest smoking itself is so dangerous that it should be completely banned. In addition to this, whilst legislation is far reaching and supposed to be enforced equally wherever it applies, obedience is somewhat optional. In areas such as Greece, where there is the same smoking ban as in the UK, people still tend to smoke in public places due to the fact the authorities don’t fully enforce it. Legislation is only effective if people listen to it and abide by the laws.

STUDY: WAKEFIELD et al.

Wakefield et al conducted a cross-sectional study into the effect of restrictions on smoking at home, school and in public places on teenage smoking. A random sample of 17,287 high school students was taken from over 200 schools in the USA – one school in each county of mainland USA. A self-report method of a questionnaire was used to gather demographic data and information on whether adults and siblings at home were smokers, as well as their smoking history and intentions. Participants were then classified into six categories, ranging from non-susceptible non-smokers to established smokers. Further questions asked about restrictions at home and school. Researchers also gathered information on smoking bans and the strength of enforcement. The study found that legal restrictions and enforced bans were significantly associated with not developing an early smoking habit, that home bans were more effective that legal restrictions on taking up smoking, and extensive restrictions on smoking in public places were associated with lower probability of transition between later stages of transition. However, school bans appeared to actually increase the probability of transitions to the last stage. It was concluded that school bans needed to be enforced to actually be effective and that although causality cannot be deduced, their findings are consistent in showing that parental opposition and banning smoking in the home reduces the uptake of smoking amongst teenagers.

EVALUATION: WAKEFIELD et al.

The study used a very large sample, which although was not stratified was random, and so likely to be representative of teenagers across the USA. As the findings are consistent with earlier research, it is likely that the study is reliable; however the use of self-report may reduce this as there is no sure way of checking honesty or accuracy of memory. Social desirability bias may have affected the results. As it was a cross-sectional self-report study, causality cannot be deduced which reduces the usefulness and conclusiveness of the findings; however it is not ethical to do an experiment to determine causality when health is involved. The study highlights that there are complexities within health behaviours, and that there are many factors to consider during health promotion.

METHOD: FEAR AROUSAL

Fear arousal as a method of health promotion refers to using fear and intimidation (usually through strongly emotive media campaigns) to persuade people into doing (or avoiding) certain health-related behaviours. Fear-arousing communication usually features two parts: stressing the severity of the issue using fear, and recommending an action to reduce or eliminate the health risk. The basic underlying assumption is that if the negative consequences of an action are made clear to an individual, they will be more likely to do something to prevent it. A large body of research into fear arousal suggests that high fear campaigns tend to be more successful than low fear campaigns, and this research was guided by the drive reduction model: the idea that fear or emotional tension is a drive to action, and so if a threatening situation is presented, individuals will feel motivated to take action to reduce the threat.  

EVALUATION: FEAR AROUSAL

The major issue with fear arousal is the ethical considerations it raises. Causing someone to feel fear goes against protection from harm, and actually causes psychological harm, which is against BPS ethical guidelines. Aside from this, although it is arguable that fear is a basic human emotion and as such fear arousal is applicable to everyone, people feel and respond to fear differently so fear arousal is unlikely to be effective for large populations. For example, whilst a graphic advert showing the damage smoking does to your body may cause some people to not take up smoking, smokers may ignore or avoid the messages due to it being too emotional and distressing to watch. Fear arousal appears to go against the Yale model, which outlines how too much emotion will not deliver a message successfully, so this is a worthwhile evaluative point. It is reductionist in the way that it is assumed fear arousal will automatically result in a change in behaviour – what about social factors such as the desirability or social pressure to conform to certain lifestyles, or self-efficacy issues such as thinking they cannot do it, and nobody they know would be able to.

STUDY: JANIS AND FESHBECK

Janis and Feshbeck conducted a cross-sectional study to investigate the consequences on emotions and behaviour of fear appeals in communication. A 9^th grade freshman class at a US high school was used as the sample; they had a mean age of 15 years. Janis and Feshbeck used a laboratory experiment, which investigated how the strength of fear arousing material presented in a lecture affected the emotional and behavioural changes in dental practices. An independent measures design was used, with four conditions: strong fear appeal, moderate fear appeal, minimal fear arousal, and the control group. A questionnaire was used before the lecture and afterwards. The strong fear arousal was generally received positively in terms of interest and necessity, but also had higher levels of dislike and unpleasantness. It showed a net increase in positive dental hygiene of 8%, whilst the moderate group had 22% increase, and the minimal fear group showed 36% change. The researchers concluded that fear appeals can be helpful in changing health behaviours, however it is necessary for the level of fear arousal to be appropriate for the appropriate target audience, and that (in teenagers) minimal fear is likely to be more successful.

EVALUATION: JANIS AND FESHBECK

The sample was very limited in that it was small, ethnocentric and age-biased; therefore it is unlikely that the findings could accurately be generalized much further than other American high school students. However, it is useful in that it highlights how high fear arousal does not always result in higher behavioural changes. The use of questionnaires allowed experiences to be relayed; however this raises the issue of internal validity due to the possibility of demand characteristics, dishonesty and social desirability bias.  The use of and findings from the control group however did improve the likelihood that it was the independent variable of fear arousal causing the behavioural changes. The other main issue with this study is the ethics, as children were exposed to material that they knew would be distressing and was intended to cause psychological harm, and whilst it was to try to improve dental hygiene behaviours, the ends here do not justify the means.

Model answer part b) for health promotion

b. Assess the effectiveness of methods of health promotion (15)

When assessing the effectiveness of methods of health promotion, it is first necessary to define effectiveness, and then discuss ways in which effectiveness can be measured. A commonly accepted definition of effectiveness is the degree to which objectives are achieved and targeted problems are solved. Health promotion in terms of media campaigns and fear arousal tend to be based on the Yale model, which describes how for an attempt to be effective, the communication (message), communicator (how the message is given) and audience (keeping in mind the population that is being targeted) must all be considered. Methods of health promotion can be measured in terms of whether they are effective in real life and who they are effective for, as well as time and cost effectiveness.

Ideally, health promotion methods need to reach as wide of an audience as possible to be the most effective. Studies such as Keating et al have shown that different audiences receive more information or advice from different sources; in Nigeria, it was found that men tended to get more information from media campaigns, for example radio advertisements on sexual health, whilst women tended to get more advice and support from clinic visits. This suggests that media campaigns may not be effective in reaching a wide audience, and although this may be less true in populations with higher access to the media, such as in the UK. Fear arousal campaigns of course have the same problem as media campaigns, but also have another issue. Although fear is a basic human emotion, so it could be assumed that studies and theories based around fear arousal are nomothetic, people react to fear in different ways, so individual differences may affect the success of fear arousal campaigns. For example, some may turn off an advert on sexual health that they find shocking, or leave an area with a poster showing mouth cancer as a result of smoking, meaning they avoid the campaigns rather than the dangerous health behaviours. Potentially the most effective way of reaching a large population would be legislation, as laws apply to everyone in the country or state and can be enforced by the police, by giving punishments such as fines and imprisonment if laws are not followed. However, obedience to legislation is arguably optional – some choose to deliberately disobey the law, whilst others simply do not consider it and may even not realise they are doing something wrong. Studies such as Wakefield have demonstrated how the existence of a rule itself does very little to change or reduce (smoking) behaviour unless it is heavily enforced in schools, homes and neighbourhoods, and therefore legislation is only most effective within a population if it is strongly enforced there. Thus it can be assumed that health promotion methods probably cannot reach the entire target audience, and that this would be better achieved through a combination of methods.

The real test of effectiveness of a method of health promotion is the extent to which it improves health behaviours or the overall health of people in the real world. It is often assumed that if a message is put across and seen, heard or known of by a large population, then it is effective. However, whilst a method of health promotion that only reaches a small audience is not effective, equally, one which reaches a large audience but doesn’t actually move much of the population to change their behaviour for the better is ineffective. Studies have demonstrated that media campaigns may not really be effective in changing behaviour, for example, Keating’s study showed that whilst more people who had had access to VISION had discussed and knew about the risks of HIV/AIDS, this didn’t appear to correlate with condom use. However, this is not to say media campaigns themselves are ineffective, but goes to suggest that merely information about risks is not enough. Campaigns with practical advice, such as where to get condoms, or how to quit smoking, rather than just arousing fear or providing statistics, are more likely to be the most effective in real life. Research also tends to suggest that in real life, legislation is effective only if properly enforced (Wakefield), and that fear arousal is only successful if used minimally. It can be assumed that methods of health promotion have limited applications, due to there being conditions for them to be effective which cannot always or easily be met for large populations.

Another aspect of effectiveness is the extent to which a method of health promotion is cost and time effective; that is, that the success of the method is more substantial than the time and money it costs to implement. Legislation is cost effective in that it has minimal cost to implement new laws, however, the legislative process can take years, which means it lacks time effectiveness. It is a long term investment which is good as it only needs to happen once, for example the smoking ban only needs to be implemented once, however until the law is in place, other health promotion methods will be needed – which will actually cost. On the other hand, media campaigns often cost a lot of money especially if the communicator is a celebrity; however they usually take a shorter amount of time to produce – so they have a better time effectiveness but are more expensive. Fear arousal campaigns are problematic in this way in that as they usually fall under a media campaign or visits to schools, these lack both time and cost effectiveness – finding the right amount of fear to induce for the target population takes a fair amount of time and research, whilst visits and media campaigns need money to fund. Therefore, methods of health promotion will usually have at least one “effectiveness area” where they are insufficient – cost effectiveness is achieved by reducing time effectiveness, and vice versa.

In conclusion, it would appear that methods of health promotion are most (and only truly) effective when used in conjunction with one another, as various methods are required to appeal to wide target populations, and to be effective both in the long and short term. Legislation is more effective in the long term; however, media campaigns and fear arousal methods are likely to be more effective immediately. 

Theories of Health Belief

Theories of Health Belief

·         HEALTH BELIEF MODEL: Becker, 1978.

·         LOCUS OF CONTROL: Rotter, 1966 OR Wineman, 1980

·         SELF-EFFICACY: Bandura and Adams, 1977

THEORY: HEALTH BELIEF MODEL

The health belief model is a working model that attempts to explain and predict health behaviours by focussing on the attitudes and beliefs of individuals. It was developed in the 1950’s by social psychologists (Hockbaum et al.). The core assumptions of this model is that someone will do a health related action if they believe a negative health condition is avoidable, can be avoided by completing the health related action, and that they feel they will be able to successfully complete the action. The model refers to constructs representing perceived threats and benefits that result in the final decision: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and self-efficacy.

STUDY: BECKER (1978) Compliance with a medical regimen for asthma

Becker conducted a correlational study to test the health belief model on asthma prevention medication. A sample of 111 mothers aged 17 to 54, with asthmatic children aged between 9 months and 17 years, took part in 45 minutes interviews, in which the mothers were asked about compliance, perceptions of susceptibility, seriousness of conditions, interference with education, embarrassment, interference with mother, effectiveness of medication and faith in doctors. Compliance was checked by blood tests of children, taken under the precedent that it was for medical rather than research reasons. Positive correlations were found between compliance and the following factors: susceptibility to attacks, seriousness of condition, interference with own activities, education and marital status. Negative correlations were found between compliance and disruption, inaccessibility to chemists, and complaints. It was concluded that the HBM was accurate in compliance with the medical regimen for asthma.

THEORY: LOCUS OF CONTROL

The locus of control refers to someone’s belief about what causes the good and bad results in their life. The locus of control is a scale from high internal locus of control, the belief that it is the individual is the main cause of their behaviour, actions and situations, to high external locus of control, where the individual will primarily believe that powerful others, fate, or chance strongly determine events, and they are largely out of their control. Those with high internal locus of control will think that they can influence others and their own lives with their actions; they think that their efforts will be successful, and they are active in seeking information – they will blame themselves both for positive and negative outcomes. Alternatively, those at the other end of the scale will often feel stressed out or overwhelmed, and may be prone to laziness, clinical depression or obesity as they believe what will happen, ultimately will happen.  

EVALUATION: this theory has not been strongly supported by later research, especially in terms of eating habits, for example, see Wineman (1980). Therefore, this theory may be limited in its applications and is not wholly nomothetic. This is an overly reductionist theory, which may be why it does not work in terms of complex health behaviours, such as eating habits. It is situational versus dispositional. It largely relies on self-report to gain information in order to determine locus of control, and self-report has issues with internal validity such as dishonesty, memory bias and social desirability.

STUDY: ROTTER (1966)

Rotter conducted a review article study into internal versus external locus of control. Initially, he used six pieces of research into individual perceptions of ability to control outcomes. Rotter found that the studies’ findings consistently showed that participants who felt they had control over the situation were more likely to show behaviours that would enable them to cope with potential threats than participants who thought that chance or other non-controllable forces determined the effects of their behaviours. In other words, he found that those with an internal locus of control appeared to be more prepared against danger than those with an external locus of control. Rotter concluded that locus of control would affect many behaviours, including health behaviours, as those with an external locus of control were likely to be less pro-active in avoiding health risks. He included in his study research by James et al, which found that male smokers who gave up smoking and did not relapse had a higher locus of control than those who did not quit. However, there wasn’t a significant difference for female smokers.

STUDY: WINEMAN (1980)

Wineman conducted a cognitive study to investigate locus of control, body image and weight loss in a self-selected sample of 116 adult members of Overeaters Anonymous (OA). Most of these were female, all were Caucasian, and they were from a range of social class backgrounds. He conducted a self-report study using retrospective correlation. Three questionnaires were given out: a demographic questionnaire, which featured questions about age, sex and age at onset of obesity; Rotter’s Social Reaction Inventory Scale, 29 forced choice questions measuring internal and external locus of control; and Secord and Jourad’s Body Cathexis Scale, which used five-point Likert scales to measure body satisfaction. The results showed that of the 116 participants, 59% had childhood onset of obesity. Multiple regression analysis was performed at three onset age categories (childhood, adolescence and adult) separately to analyse the relationship between locus of control and weight loss. Locus of control significantly predicted body image in the adult group but there was no correlation between either body image or weight loss in the sample overall. Body image and weight loss correlated in the adolescence group. Males had overall higher body satisfaction and greater weight loss. Wineman concluded that external cues may influence a person’s eating habits specifically yet not be reflected in general locus of control beliefs, and from this she concluded the Rotter scale was not a suitable measure of locus of control with regards to eating habits.

THEORY: SELF-EFFICACY

Self-efficacy refers to a person’s perceptions of their ability in a particular situation. It is at the heart of Bandura’s social cognitive theory, and according to Bandura, someone’s attitudes (including self-efficacy), abilities and cognitive skills comprise what is known as the self-system, which plays a major role in how we perceive different situations, and how we behave in response to these situations. He described self-efficacy as a determinant of how people think, behave and feel (1994), and demonstrated that self-efficacy impacts everything from psychological states to behaviour, to motivation. Self-efficacy is believed to begin in early childhood and evolve throughout life: the four main sources are mastery experiences, social modelling, social persuasion, and psychological responses. People with a strong sense of self-efficacy tend to view challenges as tasks to be mastered, and recover quickly from setbacks and disappointments, whilst people with a weak sense of self-efficacy avoid challenging tasks, quickly lose confidence, and focus on failures.

STUDY: BANDURA AND ADAMS

This study aimed to assess the self-efficacy of patients undergoing systematic desensitisation in relation to their behaviour with previously phobic objects.

It was a controlled quasi-experiment consisting of 10 self-selected patients with snake phobias. There were nine females and one males, aged 19-57 years.

The first part of the procedure was a pre-test assessment: each patient was assessed for avoidance behaviour towards a boa constrictor, then fear arousal was assessed with an oral rating of 1-10 and finally efficacy expectations (how well they thought they will be able to perform different behaviours with the snake). Their fear of snakes was also measured on a scale, along with their own rating on how effectively they would be able to cope.

They then underwent the behavioural therapy of systematic desensitisation: a standard programme was followed where patients were introduced to a series of events involving snakes and each was taught relaxation. These ranged from imagining looking at a picture of a snake to handling a live snake. Post-test assessment: each participant was again measured on behaviours and belief of self-efficacy in coping.

The findings showed higher levels of post-tests self-efficacy were found to correlate with higher levels of interaction with snakes, and thus it was concluded that desensitisation enhanced self-efficacy levels, which in turn led to a belief that the participant was able to cope with the phobic stimulus of a snake.

Adherence to Medical Regimen

Healthy Living: explaining health behaviours

FEATURES OF ADHERENCE TO MEDICAL REGIMES

·         REASONS FOR NON-ADHERENCE: Bulpitt et al. (1988)/Lowe and Raynor (2000)

·         MEASURES OF NON-ADHERENCE: Lustman (2000)/Becker (1978))

·         IMPROVING ADHERENCE USING BEHAVIOURAL MEASURES: Watt et al. (2003)

REASONS FOR NON-ADHERENCE

Adherence to medicines is defined as the extent to which the patients’ action matches the agreed recommendations. Non-adherence can include changing the frequency or dosage of medicines, as well as neglecting to follow agreed actions such as exercise or stopping smoking. Whilst non-adherence can result in deterioration of health and wasted medication, there are various reasons why people don’t adhere to advice they’re given in terms of health. Reasons for non-adherence tend to come under two categories: intentional non-adherence and unintentional non-adherence. Unintentional non-adherence features reasons such as forgetfulness, inability to pay, and confusion, which meant that despite wanting to adhere, they were unable to. Intentional non-adherence occurs when there is a conscious decision not to follow advice, and is best understood in terms of perceptual factors such as believing that the medicine won’t work or is against their ethics (such as a vegan who will not eat meat to improve health), or practical factors, such as the side-effects the medicine produces.

EVALUATION: REASONS FOR NON-ADHERENCE

There are some issues with trying to decipher somebody’s reasons for non-adherence. The most appropriate research method into this is self-report; however social desirability bias, demand characteristics and dishonesty may distort the findings. Non-adherence may also be for a combination of factors, or unique to an individual or group, so finding ways to overcome non-adherence could be quite difficult; however, if it is achieved, the health and money benefits could be beneficial to a lot of people. Another weakness of looking at non-adherence is the validity of the research and theories, as it is difficult to operationalize non-adherence – if somebody takes roughly the right amount of pills, is that adherence? What about if they take them at slightly the wrong time of day? As researchers operationalize adherence differently, research may lack reliability as it cannot be compared and checked with other research. We must be careful when attempting to generalize adherence behaviour, as different illnesses may bring out different attitudes and behaviours in people.

STUDY: BULPITT et al. (1988)

Bulpitt et al. conducted a review article study on non-adherence to taking medication to regulate high blood pressure (hypertension). Various pieces of research were looked at to identify problems with taking drugs for high blood pressure. Both physical and psychological side effects were looked at, including problems at work and the effects on physical wellbeing. The study found that anti-hypertension medication had many side effects including sleepiness, dizziness, impotence, and weakened cognitive functioning. Curb et al.’s study that 8% of males discontinued treatment due to sexual problems, whilst the medical research council found that 15% withdrew due to side effects. It was concluded that when side effects outweighed the benefits of treating a mainly asymptomatic problem such as hypertension, there is less likelihood of the patients adhering to their treatment.

EVALUATION: BULPITT et al. (1988)

The problem with using the methodology of a review article is that it looks at dated research, which may lack temporal validity. On the other hand, this enables the researcher to look at patterns and see if attitudes towards medication and adherence change over time, which may be more useful. The use of various pieces of research allows for cross-referencing and increased reliability and generalizability of the findings. As both physical and psychological side effects were investigated, this study appears to be more holistic in its approach. It is not known, however, the depth or validity of the research that was looked at, and the review article appears to be fairly brief.

STUDY: LOWE AND RAYNOR (2000)

Another study into reasons for non-adherence is Lowe and Raynor (2000). The research was conducted on a random sample of 161 patients aged 65 years and older. The mean age of the sample was 76 years, and the mean number of medicines prescribed was 4. The cognitive study used a self-report method, whereby participants were visited and interviewed at home using a structured questionnaire. They were asked questions on which medicines they took, the dosage they take and the frequency dosages are taken. The results showed a discrepancy in 53% of cases. In 28 out of 86 cases, this was due to administrative error, 3 cases were due to confusion and the remaining cases were due to a rational decision by the patient.  92 medicines in all were involved, of which 51 were no longer being taken, 19 dosages had been adjusted and 22 frequencies were adjusted. The reasons given by the sample included side-effects, believing the drugs did not work, and adjustment to fit daily routine. The conclusion was that contrary to popular belief, very few of the elderly who do not adhere to medical regimen are actually confused about it: most make a rational decision by weighing up the costs and benefits, and their non-adherence tends to mostly be intentional. It was deemed “concerning” that patients did not communicate their decisions with their doctor, and that so many administrative errors had been made by the doctors.

EVALUATION: LOWE AND RAYNOR (2000)

The sample was fairly limited in that it looked at a vulnerable, age-biased group (the elderly), however as it was random it is likely that the sample is representative of elderly people. The use of a vulnerable sample however raises ethical issues as they may have felt pressured into giving consent, or not felt that they could have withdrawn from the study. The use of a self-report method is effective in that it enabled participants to recall what they had done and give attitudes, however self-report brings issues of internal validity due to dishonesty, demand characteristics and social desirability bias. As the report was asking for certain amounts of retrospective data, forgetfulness may also have been an issue. The use of a structured questionnaire boosts the reliability of the study, as does comparing the results from the study with medical records. This is a very useful study as it provides reasons for intentional non-adherence, and shows that the common belief about the elderly being confused about medication is somewhat fabricated. It also demonstrated the need for doctors’ surgeries to check for administrative errors, and that communication is lapse between doctors and patients in terms of non-adherence.

MEASURES OF NON-ADHERENCE

There are various ways in which it has been proposed that adherence can be measured: using self-report, looking at the therapeutic outcome (did the patient get better?), asking the doctor, counting pills and bottles, mechanical methods (such as the track cap) and biochemical tests (such as blood and urine tests). As none of these methods are without their faults, methodological triangulation appears to be the most appropriate and accurate way of measuring (non-)adherence.

EVALUATION: MEASURES OF NON-ADHERENCE

Each method of measuring adherence has strengths and weaknesses. Using self-report allows attitudes to be given and is most convenient, but may lack internal validity. Asking the doctor means that social desirability bias wouldn’t be an issue, however patients may have lied to their doctors about their level of adherence. Counting pills and bottles may appear to show what has been taken, but someone may have removed pills and not taken them, or taken more than their recommended dosage one day then nothing the next. It is also an invasion of privacy to check this. Mechanical methods are expensive but can be useful in conjunction with self-report or biochemical tests, and biochemical tests mean that dishonesty isn’t an issue, but they are expensive, time consuming and only show adherence at one point in time, so may be misleading. 

STUDY: LUSTMAN (2000)

Lustman’s study looked into using physiological measures of assessing adherence to medication and the treatment of depression in diabetics. The aim of the study was to assess the effectiveness of fluoxetine as treatment for depression in diabetics. A self-selected sample of 60 diabetic volunteers with depression was involved in a laboratory experiment, using a double blind technique. All were screened for depression and randomly assigned to two groups (the group who would take the drug, and one who would take the placebo). Participants were given daily doses of the medication for 8 weeks, and then re-assessed for depression and their adherence to their medical regimen through measuring blood sugar levels. The results showed that reduction of depression was significantly greater in the experimental group than the control group, and that these patients also had nearer normal blood sugar levels, which indicated improved adherence. The conclusion from this research is that physiological tests were an effective method of measuring adherence, and that reduced depression may improve adherence in diabetic patients. 

EVALUATION: LUSTMAN (2000)

Whilst the use of a laboratory experiment, double blind design and control group should improve the internal validity of the study due to removal of certain confounding variables (such as self-fulfilling prophecy), the use of an independent measures design (which introduces participant variables) balances this out. The participants may simply have gotten better at adherence and felt better within themselves; it may have had very little to do with the drug, however the control group did show that it was not the placebo or Hawthorne effect. The study is useful as it provides another reason for non-adherence, a way of measuring non-adherence, and suggests a way to improve adherence. The extent to which the results can be generalized is limited due to the small, biased sample.

IMPROVING ADHERENCE USING BEHAVIOURAL MEASURES

Sometimes, non-adherence to medical regimen is not particularly serious, as sometimes symptoms and illnesses clear up by themselves. However, non-adherence can prove fatal, and it is these cases which require health psychology to combat non-adherence. Potentially the most useful psychological standpoint in terms of a perspective or approach to non-adherence is the behavioural perspective, as it is a practical and nomothetic viewpoint. Some appropriate behaviourist techniques in combatting non-adherence include direct reinforcements (positive reinforcement), modelling (imitation – this could be from a support group, for example), and contingency contracts (whereby the patient negotiates with the health worker concerning goals and rewards for achievements).

EVALUATION: IMPROVING ADHERENCE USING BEHAVIOURAL MEASURES

The main issue with attempts to improve adherence is that the method used depends on the approach that the problem is explained in terms of, and this will often mean methods are reductionist – this makes them simple to understand and easy to apply to different contexts, but is also likely to be overly simplistic in an area of behaviour which is fairly complex. Combined methods are therefore most likely to be effective. Cultural differences also complicate things; different cultures view medicine and illness differently, so it is likely that findings and theories from one culture cannot be generalized to different cultures. Individual differences should also be a consideration: people differ individually to what they will adhere to and their reasons behind it based on their individual differences. For example, women have been shown to visit doctors more quickly after becoming ill than men. The focus of improving behavioural measures on behaviourism is reductionist in that behaviourism ignores freewill, context and individual differences such as religion.

STUDY: WATT et al. (2003)

Previous research had suggested that non-adherence in children with asthma could be due to boredom, apathy and forgetfulness. This study aimed to see if using a Funhaler instead of a regular inhaler could improve children’s adherence to taking asthma medication. 32 asthmatic children with a mean age of 3.2 years, who had been prescribed drugs taken via an inhaler, were involved in the study. Parental consent was gained, as the children were too young to give informed consent. The method was a field experiment using a repeated measures design, assessed through self-report. The independent variable was whether the child used the inhaler or Funhaler, and the dependent variable was the level of adherence to taking their asthma medication. For the first week, children used regular inhalers, and in the second week the Funhaler was used – a device which incorporates features to distract the child from the drug delivery and reinforces the use of the Funhaler, such as a spinner and a whistle which work best when the deep breathing required for effective drug delivery is used. After each week, the parents completed a questionnaire on adherence. The results were that 38% more parents reported higher adherence in the children when using the Funhaler, and thus it was concluded that making a medical regimen fun can improve adherence in children.

EVALUATION: WATT et al. (2003)

The main issue with this study in terms of methodology is that it was conducted over a fairly short time span. Whilst adherence may have improved with the use of the Funhaler, this may have been due to novelty which could have worn off fairly quickly after the initial week’s use, as behaviourist research has found that constant reinforcement is less rewarding that partial reinforcement. This study is useful because it tested uptake of the medication through both self-report from the parents and through calculating the volume of air in the Funhaler, and thus the amount of medication absorbed by the child. The Funhaler is widely available to asthmatic children, and may well be a lifesaver as it can help to control asthma. However, making medication regimen fun may only work for very young children, and for medication taking through an inhaler rather than orally or through injection, so the findings are unlikely to be able to be generalised, reducing how useful it is.

General points on evaluation of adherence: adherence can be affected by a wide range of patient beliefs, so a holistic approach is desirable. Ethics are potentially an issue due to the samples, and in Becker, the lack of parental consent. Physiological measures of adherence are most reliable, whilst self-report studies have questionable validity. 

Past paper questions (June 2012)

Happy Thursday guys! Hope your revision is going well; here's some past paper questions from last year's paper to keep you going. I'll be doing these over the next day and a half, so if you've got a query, leave a comment!

Forensic Psychology

1. TURNING TO CRIME       
(a) Describe how social cognition can explain criminal behaviour (10) (b) Evaluate the validity of research into cognitive explanations of criminal behaviour (15)

2. MAKING A CASE
(a) Describe how top-down typology is used to create a profile (10) (b) Assess the usefulness of qualitative and quantitative data when creating a profile (15)

4.  AFTER A GUILTY VERDICT      
(a) How can probation serve as an alternative to imprisonment? (10)(b) Evaluate limitations of research into alternatives to imprisonment (15)


Health and Clinical Psychology6.  STRESS 
(a) Describe self-report as a method of measuring stress (10) (b) Compare different measures of stress (15)

7.   DYSFUNCTIONAL BEHAVIOUR    
(a) How has dysfunctional behaviour been defined? (10) (b) To what extent may diagnoses of dysfunctional behaviour be considered ethnocentric? (15)

8.   DISORDERS    
(a) Outline a cognitive behavioural therapy as a treatment for one disorder (10) (b) Assess the effectiveness of treatments of one disorder (15)

Validity - What you need to know

What is Validity?
Validity refers to the extent to which a measure is measuring what it intends to, or in other words, it refers to extent to which it reflects the reality that it claims to represent. The first definition is more relevant to internal validity, whilst the latter helps to explain external validity.

How many types of validity are there? 
In short, loads. But out of ones that you should know at A-level, there's two categories, and a couple of types under each heading.

Internal validity: the extent to which a measure or test is measuring what it intends to. There are typically thought to be three main types:

1. Face validity - validity at face value, the simplest form. It's basically what gets affected by confounding and extraneous variables and lack of control over these factors. 

2. Construct validity - is the IV or DV appropriate for the concept being investigated? For concepts such as stress, this is a major issue. How do you define stress? And how can it be properly measured if there's no standard definition? One study which is relevant from the clinical psychology bit is Lewinson's study on positive reinforcements and depression - can you really measure depression levels on a depression adjective checklist? 

3. Concurrent (criterion) validity - do other relevant measures get the same result as yours? For example, if you're intending to measure intelligence through a new method, do the IQ scores or school performances of your participants correlate with the results you're getting?

External validity: the extent to which a measure or findings reflect the reality that it claims to represent. Again, there are 3 main types:

1. Ecological validity - refers to how realistic the task and environment is. If your task is similar to the real life behaviour it's attempting to measure, it's going to have high ecological validity.

2. Population validity - refers to how relevant the population is. If you're attempting to generalise your findings to all eyewitnesses, for example, you should ideally have a wide variety of real-life witnesses, who vary in age, gender, occupation, intelligence, ethnicity, etc.

3. Temporal validity - refers to how relevant the time period is in affecting the findings. e.g. A study on attitudes conducted decades ago cannot be expected to have temporal validity due to how quickly attitudes shift in society. 


All of these essentially link back to generalisability, usefulness and applicability to real life situations, so it's a really useful issue to get your head around, and worth mentioning if you can.

Reliability of Measures of Stress (Part B)

June 2011 - (b) Assess the reliability of methods of measuring stress (15)

Firstly, define the key terms in your introduction and outline the methods. You might also want to list some of the issues surrounding reliability.

"Stress is the body's response to when physical or perceived demands on an individual do not match their perceived or actual abilities to deal with a situation. It can manifest itself both physiologically and psychologically, and thus the most common approaches to measuring stress are physiological measures such as GSR, and self-report measures such as the Holmes and Rahe SRRS. However, the reliability of these measures is questionable, because of the changeable nature of stress, issues surrounding bias and standardisation, and confounding variables which mean that measures of stress may not always produce consistent results when the measure is replicated."

There's a lot of ways you could tackle the main body, such as doing one paragraph on internal reliability and one on external reliability, or going through different issues, but I prefer to go through measure by measure, and assessing each one's reliability. For example:

"One prominent measure of stress is the self-report method, which involves asking individuals to record either their stressors, such as their hassles and uplifts, or stress responses, as in the Bradburn Morale Scale. Whilst self-report appears to be an appropriate measures of psychological stress responses as it asks them about how they feel and what has bothered them, it is affected by many confounding variables that mean it's often not reliable. For example, two people may actually have the same number of hassles and uplifts, but individual differences such as the extent to which dishonesty, their mood, their memory, social desirability bias or interpretation affects their responses may result in them self-reporting different numbers of hassles. Thus, the measure may lack both internal and external reliability as well as internal validity for this reason. However, not all self-report methods lack reliability, and those with checklists or which ask closed questions may give more consistent results. For example, Holmes and Rahe's Social Readjustment Rating Scale (SRRS) involves a checklist, which is standardised and consists of the same life events. There is very little interpretation involved in answering the checklists which removes this confounding variable, and as stressors are listed in front of the individuals, poor memory is also less likely to affect the results. Thus, the measure is likely consistent over time, but may still have poor internal reliability due to the impact of mood and bias. Self-report measures are therefore variable in their reliability."

This paragraph includes examples, and a number of factors affecting reliability including standardisation, mood and subjectivitiy. It gives both strengths and weaknesses of the measure, thus fulfilling the "assess" part of the question, too. The result of my answer would consist of:

>> an assessment of physiological measures. I'd include objectivity as a strength, and that it's less affected by the user, but then say it's reliability is damaged by the fact that everybody experiences stress differently - some get headaches, some get muscle tension, others have increased heart rates, some do not experience it very much in terms of biology but their concentration lapses, etc. Also, different factors affect the physiological measures, such as in Geer and Maisel's study, GSR may not have merely measured stress response but other emotional responses, such as fear arousal or shock, and that heart rates as a measure can be affected by general health condition and exercise as well as weight, fitness, etc. 

>>briefly mention combined approach as seen in Johansson. Likely to share strengths and weaknesses of both, but may cancel out the influence of individual differences in terms of stress responses. 

>>Conclusion: both are replicable and thus should have external reliability, though stress is variable and thus the extent to which any measure can be considered to be consistent is questionable as it relies on a large number of variables to be controlled. 

The problems with diagnosing dysfunctional behaviour (and a great audio podcast on abnormality)

Here is an absolutely brilliant audio podcast from Todd Daniels, entitled "What is Normal?" He's a psychologist from the US, and he's got 50 audio podcasts on a range of issues. He explains things with plenty of examples, and I think it's definitely worth checking out. It's a little lengthy though, so here are some of the main issues:

Dysfunctional behaviour is a tricky term to define. Here's a working definition generally used by the psychology community:

It is behaviour which is deviant, maladaptive, and personally distressing. 

It fits pretty well with Rosenhan and Seligman's definition, too. Statistical infrequency, deviation from ideal mental health and deviation from social norms all links to the characteristic of "deviant", and failure to function adequately comes under both "maladaptive" and "personally distressing".

So, it seems like a great definition. But, there are limitations.

Not all behaviours considered dysfunctional have all three characteristics - so can they be defined as dysfunctional or abnormal? Sometimes. Smoking is an addiction, but unlike most addictions, it's not really considered dysfunctional, even though it's maladaptive and most find it personally distressing. On the other hand, depression is considered dysfunctional, even though it's likely more people suffer from depression than get addicted to cigarettes.

So, a major problem with diagnosing dysfunctional behaviour is not only defining it, but knowing how many characteristics of the definition behaviour has to exhibit to be labelled as dysfunctional.

Another problem is subjectivity, which leads to both poor validity and poor reliability. Whilst the DSM attempts to standardise diagnoses, the person who's diagnosing the disorder has room for subjectivity. For example, the DSM criteria for a phobia states that in order to be diagnosed, the fear of the object or situation must be "excessive". But, what's excessive? It changes according to the person. If the psychologist also fears the object, they might think there's a higher threshold for excessive than somebody who doesn't understand or share the same fear. So, a lot of diagnoses are actually based on bias of other people. Definitions also suffer from this weakness, as seen in the "observer discomfort" criterion for failure to function inadequately. Thus, there is unlikely to be uniformity in diagnoses, which leads to poor internal validity due to the confounding variable of bias, as well as poor reliability due to the individual differences of clinicians. 

Ethnocentrism is also an issue, related to this. Depending on our own culture, we may or may not perceive a behaviour to be abnormal. For example, if a man were to wear clothes such as dresses, or skirts, this in many Western cultures could be labelled as both deviant, and causing observer discomfort. It's statistically infrequent, and deviates from social norms. However, in Scotland for example, men wear kilts, which are essentially skirts. And, in the LGBT community, it wouldn't be considered abnormal. So, there's a fair amount of ethnocentrism within diagnoses. It's a fairly similar point to subjectivity, but you can extend it to points such as the fact that diagnoses cannot be generalised externally due to lacking population validity in other communities. They're also likely to lack temporal validity, due to the changing nature of cultures. Furthermore, it's arguable that the concept of dysfunctional behaviour lacks construct validity, as it's difficult to define. And thus, is it really nomothetic? 

Essentially, diagnosing dysfunctional behaviour is complex and often inaccurate. 

All the studies and theories for G543 (the ones I'm using)

Some people have been asking how many studies I've learnt, so I've put them all down here. It's also a bit of a reference point to see whether you're familiar with them or if you need to revise some sections more than others.

Forensic Psychology

Turning to crime

Upbringing - disrupted families [Juby and Farrington], differential association theory (learning from others) [Akers], poverty and disadvantaged neighbourhoods [Wikstrom and Tafel]

Cognition – criminal thinking patterns, [Yochelson and Samenow] moral development, social cognition (attribution) [both use Palmer and Hollin]

Biology – brain dysfunction [Raine], genes and serotonin [Brunner], gender [Daly and Wilson]

Making a case

Interviewing witnesses – recognising faces [Bruce], influencing factors (weapon focus)[Loftus] , cognitive interview [Fisher]

Interviewing suspects – detecting lies [Mann], interrogation techniques [Inbau], false confessions [Gudjonsson]

Creating a profile – top down [Mokros and Alison], bottom up [Copson], case study of John Duffy [Canter]

After a Guilty Verdict

Imprisonment – Planned behaviours [Gillis and Nafekh], depression/suicide risk [Dooley], prison situation and roles [Haney and Zimbardo]

Alternatives to imprisonment – probation [Mair and May], restorative justice [Sherman and Strang], looking death worthy [Eberhardt]

Treatment programmes – cognitive skills [Friendship], anger management [Ireland] and ear acupuncture [Wheatley]

Health and Clinical Psychology

Stress

Causes of stress – work [Johansson], hassles [Kanner], lack of control [Geer and Maisel]

Measures of stress – self report [Kanner], physiological [Geer and Maisel], combined approach [Johansson]

Managing stress – stress inoculation therapy [Meichenbaum], biofeedback [Budzynski], social support [Waxler-Morrison]

Dysfunctional behaviour/Disorders

Diagnosing dysfunctional behaviour – definitions [Rosenhan and Seligman], DSM, gender bias [Ford and Widiger]

Explanations of dysfunctional behaviour/disorders – faulty thinking (cognitive) [Beck], learned/positive reinforcements (behavioural) [Lewinson], serotonin and genes (biological) [Wender]

Treatments of dysfunctional behaviour/disorders – rational emotive therapy (cognitive) [Beck], CBT/behavioural activation (behavioural) [Lewinson], drug therapy (biological) [Karp and Frank]

Note that the two Beck studies and two Lewinson studies are different studies. The explanations one refers to studies where Beck interviewed patients with depression to see what cognitive distortions they shared, and Lewinson looked at positive reinforcements in the lives of depressed participants. In the treatments studies, Beck compares drug therapy and cognitive therapies, whilst Lewinson sees whether a "coping with depression" course coupled with parents being taught how to reinforce good behaviour is studied. 

Biological explanation of depression

Biological explanations of dysfunctional behaviour centres around physiology, and refers to aspects of biology such as genetics and brain functioning. 

The biological explanation of depression specifically refers to two factors: neurotransmitter dysfunction and inherited genes. In terms of neurotransmitter dysfunction, the biological approach would explain that depression is significantly associated with low levels of serotonin, which has been also been associated with many forms of dysfunctional behaviour including excess anger, anxiety, poor social functioning and other mood disorders. Serotonin is believed to have a variety of roles, and affects brain functioning; though it is not known whether depression is caused by serotonin levels, or whether depression causes low serotonin, or if there is another factor causing them both.

In terms of genes, family research - especially twin and adoption studies - has shown there to be a genetic link to depression, and that this suggests some people may carry genes that predispose them to depression and other mood disorders. Thus, depression could be explained in terms of genetic predispositions.

One study which conducted family correlational research into depression was Wender et al. It was an adoption study which looked at whether environment or genetics appeared to be more associated with depression in adopted adults. The study used a sample of 71 adults who had been adopted and who had a mood disorder, and 71 controls with the same mean age who'd also been adopted but did not have a mood disorder. All had been removed from their mothers at a young age. Psychiatric evaluations were conducted of both the biological and adoptive parents to see whether there was a stronger correlation between depression in adopted adults and depression in adopted parents or biological parents. The results showed that there was an eight fold increase in unipolar depression among the biological parents of the adults. In other words, adoptive parents were eight times less likely to have depression, and the biological parents having depression correlated more significantly with depression in the adopted children than the adopted parents having depression. 

Thus mood disorders appear to have a genetic link, and biological psychologists would thus attribute depression to genetics. 

Behaviourist explanation of depression

One explanation of depression is that given by the behaviourist perspective, which assumes that all behaviour, including depression, is learnt. Typically of the behavioural approach, it refers to the two main processes: operant conditioning (learning via punishment and reinforcement) and classical conditioning (learning via association).

Seligman's infamous "learned helplessness" study which showed how dogs can be conditioned not to try to remove themselves from a negative situation demonstrated how operant conditioning could potentially lead to depression. 

One study which illustrates the behaviourist explanation of depression in humans is Lewinson et al (1990). The study aimed to compare the amount of positive reinforcements received by depressed and non-depressed patients. The sample consisted of 30 participants; a selection of these had depression, some had other disorders, and some were not diagnosed with any disorder.

It was thus an independent measures design quasi-experiment. Both the IV (the number of positive reinforcements) and the DV (depression rating) were given via self-report, through a "pleasant events schedule" and a "depression adjective checklist" where participants had to tick the adjectives they felt applied to their mood. 

The results found that there was a significant positive correlation between mood ratings and pleasant activities, however there were individual differences. Thus, it was concluded that positive reinforcement is likely to be one of several factors involved in depression. 

Therefore, the behaviourist explanation of depression is that depression is the result of conditioning and learning, and processes such as positive reinforcement are important influencing factors in the extent to which someone feels depressed.