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. 

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.

Lack of control (physiological measures)

The NHS has reported that one of the major causes of stress is feeling overwhelmed by a situation and thus feeling out of control.

It's important to recognise the applications of this explanation, because control is a part of so many activities relating to stress, including work, life events, and hassles. It also suggests why people with physical illnesses such as cancer feel more stressed, and why we get stressed when we're not sure what's going on. 

One study which looked at lack of control as a cause of stress was Geer and Maisel. The study was a laboratory experiment using a sample of 60 students, who were made to look at photographs of dead car crash victims. 

The sample was split into three conditions, each with a varying amount of control. Group 1 were told the timings of the photographs so they knew when they'd appear and disappear, and they were also told how to get rid of the photographs from the screen. Group 2 knew the timings only, and Group 3 were unaware of timings and how to stop the photographs remaining on-screen. 

Stress response was measured physiologically by two measures: an ECG machine measuring heart rate (though this measurement was discarded) and through galvanic skin response, which is essentially the change in your skin's ability to conduct electricity due to an emotional response, such as fear or stress.

Group 1 had the lowest stress according to the GSR, and Group 3 had the highest, suggesting that lack of control can increase stress, and that control over your environment could help to reduce stress. 

Hassles as a cause of stress (self-report measures)

Holmes and Rahe's Social Readjustment Rating Scale recognises the importance of life events in causing stress, and it is well-documented that major life events such as getting married, moving house or starting a new job are stressors. 

However, the effects of daily hassles on stress are often ignored. Hassles are minor irritating inconveniences that occur on a daily basis, such as losing keys, getting stuck in traffic, or the water running cold halfway through your shower. Hassles are individual to each person, because we're not all bothered by the same things. 

Psychologists believe that if you are subject to an overwhelming number of hassles, and these are not balanced by uplifts (little things that cheer you up, like listening to your favourite song or finding money in your jeans' pocket), then you're more likely to feel stressed. And, the more hassles, the more stress you'll feel. 

One study which looked into whether hassles and uplifts or life events were better indicators of stress was Kanner et al. It was a longitudinal study whereby 100 Californians were asked to record (self-report) their daily hassles and uplifts for nine months. At the end of ten months, they were asked to complete the Holmes and Rahe SRRS to measure their life events. 

Psychological stress response was measured by the Bradburn Morale Scale and the Hopkins' Symptom Checklist.

The findings suggested that hassles and uplifts more significantly correlated with stress response and thus were a better predictor of stress. Other findings included that for women, both hassles and uplifts correlated positively with life events, but for men, hassles correlated positively with life events whereas uplifts correlated negatively with life events. 

Work-related stress (Combined approach)

Work-related stress is generally caused by when the pressures or demands of a job are not suited to the employee. The daily pressures of work can consist of a lot of stressors, including responsibility, meeting deadlines, long hours, repetitiveness and lack of control. High stress can lead to both poor mental and physical health and can lead to heart problems and depression if a high stress response is maintained for a considerable length of time. 

Stress at work also costs businesses billions of pounds per year and is a common reason for sick leave from work. Thus, it's important that work as a cause of stress is considered.

One study which looked at work as a cause of stress was Johansson's Swedish Sawmill study. It was a quasi-experiment in a field setting which compared the stress experienced by maintenance workers and piece workers.

The first part of the sample was 14 "finishers", who completed piece work. The work was repetitive, mechanised, socially isolated, complex and pressured, and so this group was given the category of "high risk". Also in the sample were 10 maintenance workers, who were deemed as "low risk" workers; they worked as technicians or cleaners. 

Psychological and physiological measures were taken from the participants. Psychological measures included self-reported mood and wellbeing, as well as nicotine consumption, whilst physiological measures consisted of urine sample and body temperature checks. These measures were taken at various intervals throughout the day.

The results showed that the adrenaline levels of the high risk workers was 2x their baseline reading, and that this increased throughout the day, whilst the low risk workers had adrenaline 1.5x their baseline reading, and this dropped throughout the day. Thus, physiological measures suggested stress was more pronounced in the finishing group. Self-report measures showed similar findings; the finishers reported being more irritable, and having lower well-being.

Thus, it was concluded that work which is repetitive, mechanised and paid per piece may be more stressful than work which is paid per hour and is less pressured. 

Studies to use for "Causes of Stress" and "Measuring Stress"

The number of studies is one of the more daunting aspects of A2 psychology.

Some areas, though, allow you to use the same study for different areas, which can make quite a big difference to you. A couple less studies gives you more time to revise the rest, so it could be pretty useful. 

One area you can do this for is Stress. The causes of stress (work, hassles and lack of control)  studies obviously measure stress, so you can use these studies and their measuring technique for the second part of the subtopic.

Here's the studies I use:

Johansson (work as well as combined approach)
Kanner et al (hassles/life events as well as self-report measures)
Geer and Maisel (lack of control and physiological measures)

Gender biases in DIAGNOSING DYSFUNCTIONAL BEHAVIOUR

The DSM-IV (soon to be DSM-V) and ICD-10 are intended to make diagnoses as valid and reliable as possible. But there's still only 50% agreement between clinicians in diagnoses, which suggests that subjectivity plays a significant part in diagnoses.

Thus far, we've seen from Rosenhan and Seligman that diagnosing dysfunctional behaviour is fairly subjective and ethnocentric. 

But diagnoses of disorders can also be affected by gender. Gender biases in diagnoses leads to poor reliability and validity, and could actually be life-threatening if someone is treated for the wrong disorder; and even if it wasn't, prescribing medication or therapy for a misdiagnosis is not desirable. 

One piece of research into gender bias is Ford and Widiger (1989). They aimed to find out if clinical psychologists were gender stereotyping when it came to diagnosing certain disorders, namely histrionic personality disorder and anti-social personality disorder.

Histrionic personality disorder (HPD) is a personality disorder which is characterised by seductive, manipulative behaviour, shallow expression of emotions and attention-seeking. For this reason, it's often stereotyped as a "female" disorder as it fits in with common stereotypes of women. Anti-social personality disorder (ASPD) is characterised by aggressive behaviour and impulsivity, and thus is often stereotyped as a "male" disorder. N.B both genders can have either personality disorder.

A sample of 266 clinical psychologists made diagnoses based on the information given to them, thus it was an experiment using self-report measures. The IV was the gender of the patient, and the DV was the diagnosis given. 

Participants were given anonymous case studies with the only detail being gender and were asked to identify the disorder. The case studies documented cases of HPD, ASPD, and patients with symptoms from the two disorders in an equal mix. 

ASPD was correctly documented in males considerably more than with females (42% to 15%), and the reverse was found in HPD as females were correctly diagnosed with HPD considerably more often than males (76% to 44%). This suggested that clinical psychologists, even with considerable clinical experience, gender stereotype certain disorders, and also that males were perhaps taken more seriously rather than being judged negatively for their gender, as they were misdiagnosed less often. 

Usefulness

Like many of the issues and key terms in psychology, we know the gist of this term but it's one that is pretty hard to answer in an exam situation. What does it mean, and what points can we make on usefulness?

Usefulness refers to whether a piece of research or a theory is useful, practical or applicable. A useful piece of research is one that can be accurately generalised to a wide population or the target population and benefit a number of people or causes.

Accurately generalised to a wide population. You can actually split this definition pretty cleanly into three evaluative points: internal validity, external validity (including population and ecological) and to what extent it takes a nomothetic approach. 

Internal validity
It encompasses a number of individual factors, and you'll have to really think about it in terms of the question to know what part is relevant to evaluate. Most of the time, it's either face validity (is it measuring what it intends to measure?) or construct validity (is the definition in the research actually accurate? Often a problem with stress is that it's hard to define stress, and often it's operationalised in a way that isn't truly accurate). If either are poor, a study isn't going to be very useful.

External validity
There are three main types: ecological validity (conducted in a real-life situation, i.e. has mundane realism), population validity (representative, large sample) and temporal validity (whether the research is only really applicable at one time). If any of these are poor, it's not going to be as useful as we would ideally like.

Nomothetic
Nomothetic in psychology refers to a theory which can be assumed to be a general law or principle of behaviour. If it is, it's more likely to be useful. The more "exceptions to the rule" there are, the less it's going to be useful. For example, Loftus et al's theory about weapon focus is pretty nomothetic, as is the theory about hassles causing more stress than life events. Findings from research that aren't nomothetic and can only be applied to a small number of people or situations aren't very useful. 

Issues and Debates in Psychology: How to answer "Compare..."

A lot of the part b) questions ask you to "compare" research, methods and theories. It's actually one of the easiest forms of question to answer because you can apply the issues you know best to the question, but it can be pretty daunting to think of them at first. 

Good issues to mention are:

• reductionism/holism
• to what extent do the theories/studies support psychology as a science?
• nomothetic/idiographic
• situational/dispositional
• to what extent are they subjective/objective?
• nature/nurture
• ethics
• application of research
• usefulness
• validity
• reliability
• approach
• determinism/freewill
• research methods

Some people use the GRAVER STANDERS acronym to help them but there's a few extra ones above just for good measure.

Personally, I think the most important ones are reductionism, validity, reliability, usefulness and situational/dispositional because you can apply them to most questions, but it's worth learning them all.

With regards to how to answer compare questions, here's an example:

b. Compare techniques for managing stress [15]

Intro: outline the three main approaches (cognitive, behaviourist and social support)

Main body: compare the approaches on the basis of (for example) whether they take a situational or dispositional approach, how useful they are, and how easily they can be applied. Use evidence from studies to support your arguments, and then evaluate one or two strengths or weaknesses. E.g. social support is situational which may be harder to change and may cause additional stress so may not be appropriate, but cognitive therapy is expensive and requires dedication, but the support offered may help to reduce stress more quickly and thus may be more efficient. Make sure you include similarities and differences and evaluate them on this basis. 

Conclusion: summarize the main points from each paragraph

What is Reliability?

Reliability is probably one of the most difficult concepts to get a handle on that you have to understand at A-level psychology. So I'll ease you in gently.

Reliability refers to the extent to which something is consistent. It does not imply validity, as something may consistently give incorrect measures, though both can be affected by factors such as participant variables, observer bias, subjectivity and standardisation. 

You can be asked to assess reliability of a number of things, most commonly:

- reliability of a measure
- reliability of research
- reliability of a method

There are two main types of reliability: external reliability and internal reliability. Internal reliability refers to the extent to which a measure is consistent within itself whilst external reliability is consistency over time (i.e. it is externally reliable if the measure taken in similar circumstances would produce similar results).

Generally, the factors that affect reliability are:
- the level of control over confounding variables. The higher the control, the less chance there is of inconsistencies over time and thus the more externally reliable it is likely to be
- standardisation. If research into an area tends to use experiments with standardised procedures, or a manual is used, it's more likely that reliability will be high.
- population and ecological validity (research). If a study has poor generalisability due to an ethnocentric or biased sample, or poor mundane realism (as in the case of many lab experiments) findings when applied to real life cannot be expected to be consistent with that of the research.
-subjectivity. If a measure or study relies on subjectivity to give results, as with all qualitative data, self-reports or observations and much research done in cognitive/psychodynamic psychology, it's unlikely to produce consistent results and will probably lack in internal reliability because interpretation becomes a confounding variable and thus may change from measure to measure.

Tips on revising for G543

People revise in different ways, but here are some tried-and-tested methods that have worked for me and may work for you:

The best, most reliable way to revise and to check your progress is to do past papers. Obviously, this step is only applicable once you've learned your studies and theories, but it's the best way to test how much you really know. Start with your notes beside you, and looking every so often to check you're writing the correct material, regardless of how long it takes. Once you've done that a few times with different questions, try to reduce how many times you look at the answers and highlight bits you keep forgetting and focus on learning these. Gradually, you need to be able to write the answers in the time limit (15-20 mins per 15 mark question, and 10 mins for the 10 mark questions) and then check your answers against the mark scheme. 

For those of us who learn by writing it out:

- Flashcards (name of study and topic on one side, details - sample, method, results conclusion and main evaluation points - on the back). Test yourself, or get anyone you can to test you.

- Plan out how you'd answer questions. It's virtually impossible to do EVERY past paper question, and often the most difficult part isn't writing it; it's knowing what to write and being able to think of the points (especially for part b) questions) instantaneously. Bullet point what you would write for each kind of question, such as for validity you could write about internal validity, population validity and ecological validity. 

- Keep rewriting your notes. This may not work for everyone, but personally I find that if I keep writing out my studies and theories, trying to remember all the details and getting it condensed into the best format I can, then I won't forget it when it comes to the exam.


Visual learners:

- make posters about each topic, sub-topic and study; include pictures, bubble-writing, little symbols, anything you like to make sure you remember it. 

- play Pictionary with the studies! Grab a friend who's taking the same exam, and all you have to do is take it in turns drawing clues about a study and get the other to guess what study it is (bonus points for every detail about the study each of you can recall!). For example, to guess Fisher et al's CIT study you could draw a police officer, Florida (or an American flag), a burglar, a desk, etc. 

- give each study in a section a different colour/font combination, and whenever you revise it  make sure you stick with that combination as colour aids memory and recall. But make sure it's readable!

Other tips on revising:

- Try listening to music. Make a playlist of music you like, but won't get distracted by. This might be classical or instrumental, but I like listening to music with lyrics so long as it's not too loud. When I was doing my Core Studies paper, I made a playlist with one song per study and I'd try to remember everything I can about the study when its song was on. It'd work for this unit too and is a pretty fun way to revise a lot all at once. Just don't spend too long finding a song for the study. Relevant ones work best for me, such as Memories by Panic! at the Disco for Loftus et al's weapon focus study or Old Grey Face by Twin Atlantic for Bruce et al's facial recognition study.

- Move about. This includes physical exercise at least every couple of days (preferably a walk or more everyday), as well as working in different environments. Being cooped up in your room at the desk for hours on end isn't healthy and you'll start to get really bored. Try working in the kitchen one day, the dining room another, your sofa, outside, in the library... literally anywhere for a change of scenery when you're struggling to concentrate.

- Talk to people. I don't find study groups helpful as I prefer independent revision, but when you're struggling, real people are a lot more reassuring and helpful than searching through the internet for hours on end just getting stressed out. Check here for why social support is definitely good for you!

- Try different modes of revising. Revising gets boring; after all, you're looking at the same information for hours on end. So try to make it somewhat interesting by combining visual methods, note-making, flashcards and past paper questions. 

- Make up your own practice questions. This'll get your brain working, help you to practice and even means you can target specific areas of weakness. For example, if you struggle with reliability, write yourself a reliability question on every topic. You never know, it might come up.

- Take breaks. I'm rubbish at this, because I tend to work at something until I'm utterly shattered but so much research has shown our concentration lapses sometime after half an hour of work. I'd suggest working periods of 50 minutes followed by a ten minute break, and then every couple of hours, take an hour break. During your breaks, make sure you get a drink, maybe a snack, and leave your work area. Even just wandering around your living room is better than surfing the internet at the laptop you'll be staring at all afternoon as it'll keep you energised. 


Good luck, let me know if you have any tips for me to add!

MANAGING STRESS: Social support networks [Waxler-Morrison et al.]

Many forms of dysfunctional behaviour are treated in group therapy and support sessions, such as alcoholism, drug addiction and anger management. Some stress management also emphasises the need for social support in coping with stressful situations.

Cohen and Willis argue that there are four types of social support (all of which we need):

1. Instrumental support; practical support such as help with taking care of loved ones or help with getting to where you need to be.

2. Informational support; advice on what to do and how to cope with different situations.

3. Esteem support; emotional support from friends, colleagues, loved ones and others which makes you feel valued, safe, loved and respected. 

4. Social companionship; general interaction with others for its own sake rather than functional relationships such as at work.

Study: Waxler-Morrison et al. 

Waxler-Morrison et al conducted a study on the impact someone's social support networks had on their ability to cope with the stress of and survive cancer. It used a sample of 133 Canadian women under the age of 55 who had been diagnosed with breast cancer. Data was taken from medical records as well as self-report methods (largely questionnaires but also some interviews). The findings suggested six aspects of social support were most closely associated with cancer survival:

1. Marital status (married women who survived tended to report supportive husbands)

2. Support from friends

3. Contact with friends

4. Employment (employed women found this important in coping with cancer as it was a source of information and social support).

5. Social network

6. Total support

A strong social support system was concluded to reduce the stress associated with life-threatening but not necessarily terminal illnesses such as breast cancer, and thus make survival more likely. Though, obviously the most important factor in survival is the diagnosis of the cancer (i.e. how developed the cancer is).

MANAGING STRESS: Behaviourist Approach and biofeedback [Budzynski et al]

The behaviourist approach to psychology assumes that we are all born as a blank slate, and we learn all of our behaviour. It's a very reductionist approach as it is purely on the nurture side of the nature-nurture debate, the situational side of the situational-dispositional debate, and deterministic on the freewill-determinism debate. 

It essentially works on the basis of three concepts: classical conditioning (learning via association), operant conditioning (learning via punishment and reinforcement) and social learning theory (learning via imitation and interaction with others).

In terms of stress management, the behaviourist approach takes the view that as behaviour is learned, you can be taught to manage stress through the same processes. Stress is often dealt with in behavioural therapies through the use of CBT (mentioned in this post on cognitive therapies) or through the use of positive reinforcements. This often involves direct positive reinforcement in terms of improved relaxation and reduced stress combined with feedback from a biodot (which shows you reducing your stress) or a monitor such as a heart rate monitor.

Study: Budzynski et al 

Budzynski et al conducted a study on the role of biofeedback in reducing stress management. It was a field experiment using 18 volunteers who had responded to an advert asking for people with tension headaches. They were split into 3 conditions. Group 1 were taught relaxation techniques during two weekly sessions for eight weeks, during which they had their muscle tension measured by an EMG machine. They were informed about the biofeedback in terms of clicks, (more clicks = more tension) and encouraged to relax. Group 2 had the same relaxation training but didn't know about the biofeedback and were given a false soundtrack of clicks, whilst Group 3 were not trained in the relaxation techniques nor taught about the biofeedback and so acted as a control group. The study showed that Group 1 had the lowest muscle tension, lowest levels of hysteria and depression and the fewest tension headaches by the end of the study, concluding that biofeedback combined with relaxation techniques help to significantly reduce stress-related illness. 

MANAGING STRESS: Cognitive Approach and SIT [Meichenbaum]

The cognitive approach works on the assumption that it is necessary to refer to internal mental processes such as thought, perception and language in order to understand and explain behaviour. 

It would thus view stress as the result of faulty thinking and poor perceptions, and as a form of dysfunctional and maladaptive behaviour which can be improved or cured via cognitive restructuring. This is the fundamental concept behind all forms of cognitive behavioural therapy (CBT).

One form of CBT specifically targeted at coping with stress is Stress Inoculation Therapy (or SIT). It was developed in the 1970s by Meichenbaum, and has three stages which aim to help clients to replace "self-defeating thoughts" which cause stress with more positive ones, which can help to reduce the effect of potential stressors, and thus reduce the overall stress response.

The three stages of SIT are:

1. Conceptualisation - the client and therapist work together to identify the nature of stress, and the therapist educates the client on the general effects of stress to help them understand what stress is and thus how it can be overcome

2. Skills acquisition - the therapist helps to train the client in relevant skills which will aid them to cope with and reduce their stress. This often includes monitoring their own internal dialogue and reassuring themselves that things are okay if not everything goes to plan.

3. Follow through/application - the patient has to apply their skills to real-life situations, and the therapist helps them with this. 

Study: Meichenbaum: comparing SIT to systematic desensitisation and a control group in reducing test anxiety (a major cause of stress)

The study consisted of 21 students aged 17 to 25, who had responded to an advert asking for participants in a study on test anxiety. It was a field experiment, where the IV was the type of therapy (if any) the participant received, and the DV was reduction in test anxiety, which was measured through the use of grade averages and self-reported measures. It was a matched pairs design with three conditions. Group 1 received eight therapy sessions where they were taught to identify stress, learn how to reduce thoughts which increased their stress, monitoring their internal dialogue, etc. Group 2 received the same number of sessions but were given the behavioural therapy of systematic desensitisation, whilst Group 3 were put on a waiting list. Both therapy groups had improved results, but Group 1 (SIT group) performed better in test conditions and had reduced anxiety levels than both other groups, and thus it was concluded that SIT helped to reduce the test-associated stress people felt and enabled them to perform better.