454 Health Psychology
hypertension, rheumatoid arthritis, and asthma. He believed
that the repressed psychic energy could affect autonomic
nervous system functioning directly, thus altering visceral
functioning. For instance, in the case of an ulcer patient, the
repressed emotions associated with a dependency conflict
would increase the secretion of acid in the stomach, which
would in time affect the stomach lining and ultimately pro-
duce ulcers (Alexander, 1950).
In the United States, the work of Dunbar and her followers
was seriously questioned in the 1950s at the same time that
psychoanalysis was being criticized for its lack of scientific
rigor. However, more scientific psychoanalytic/psychody-
namic theories of psychosomatic illness were subsequently
developed, as reflected in the work Sifneos and Nemiah on
alexithymia (Nemiah, 1973; Sifneos, 1967) and the specific-
attitudes theory developed by Graham and his colleagues
(Graham, 1972; Graham, Stern, & Winokur, 1958). Indeed,
the idea of a relationship between personality and physical ill-
ness is present in current concepts such as Type A behavior
patterns and Type C personality. Moreover, expansion of the
field was fostered by the strengthening of other conceptual
models as well as the development of new ones that would
drive health behavior research.
As noted above, the other early theoretical framework
that contributed to the survival and expansion of the psycho-
somatic movement was psychophysiology, an approach
that provided more objective and scientific foundations for
the development of the field. Edmund Jacobson, a psycholo-
gist and physician who had studied under James and Cannon
at Harvard, examined the role of muscle tension in
relaxation (Jacobson, 1938). He also developed progressive
muscle relaxation, a behavioral intervention that is today
referred to as the aspirin of behavioral medicine. In fact, by
the 1950s the field seemed dominated by a focus on stress
and its relationship to health and bodily functioning. Hans
Selyé (1953), a physiologist, popularized stress as a cause of
illness.
In addition, Harold G. Wolff’s work on the psychology
and physiology of gastric function (Wolf & Wolff, 1947) as
well as his work on migraine, ulcer, colitis, and hypertension
provided careful examination of the physiological changes
associated with conscious emotional states such as anger and
resentment. Wolff’s 1953 book, Stress and Disease,remains
a classic. This psychophysiological approach marked the
growth of experimentation and a departure from the study of
unconscious processes and reliance on methods of clinical
observation. The use of the term psychophysiological disor-
dersalso dates back to Wolff’s work and reflects an effort of
the psychosomatic movement to dissociate itself from
the psychodynamic orientation and move toward a more
cognitive behavioral framework that would characterize
much of the future work on stress and disease.
By the 1950s, the specificity theories based on psychoan-
alytic foundations also had serious competition from systems
approaches. Guze, Matarazzo, and Saslow (1953) published
a description of a biopsychosocial model as a blueprint for
comprehensive medicine, a term more favored in some
circles than the label psychosomatic. This model emphasized
the interrelationships among, and mutually interacting effects
of, multiple biological, psychological, and social processes.
Later work by Engel (1977) and Leigh and Reiser (1980) has
perhaps been more widely cited, but all were very similar
attempts to provide a unitary framework for diagnoses and
treatment of the full spectrum of health problems.
A number of other societies were developed in the mid-
1900s that reflected the expansion of interest in the psycho-
somatic movement: the American Society of Psychosomatic
Dentistry (1948), the Society for Psychosomatic Research in
Great Britain (1960), and the Swiss Society of Psychoso-
matic Medicine (1963).
As interest in stress and disease during the 1960s and
1970s grew, so did interest in coping—which in turn brought
more attention to cognitive and behavioral efforts to manage
stress. It was also recognized that illness was a part of life
that no one could escape, and that illness itself was a stressor
that required coping skills for adaptation. Coping was viewed
as a complex process that included significant cognitive, af-
fective, behavioral, and social components. The development
of the health-belief model also focused attention on cognitive
components in health and disease and fostered the interface
with public health perspectives (Rosenstock, 1966).
Concurrent with developments in stress and coping was
the pioneering work of Neal E. Miller, whose theoretical and
empirical work on the conditioning of physiological pro-
cesses laid the scientific foundation for the development of
biofeedback interventions for specific health problems
(Miller, 1969). The application of operant learning theory to
the management of chronic pain was initiated by Wilbert
Fordyce, whose work became fundamental to the design of
pain and chronic illness management programs for the rest
of the century (Fordyce, 1976).
A serendipitous event occurred in 1974 that was also to
shape future research and practice in the field. Robert Ader,
an experimental psychologist, noticed that some of his ani-
mals died unexpectedly during a conditioning experiment.
Through careful research, he subsequently determined that
those deaths had been the result of a conditioned suppression
of the immune system. As expected, this finding was greeted
with much skepticism in the field, but nevertheless it heralded
the beginning of what Ader called psychoneuroimmunology,