This document discusses the potential role of a health psychologist in the Parkinson's service at Western General Hospital in Edinburgh. It provides an overview of the Parkinson's service and notes two key health behaviors - medication adherence and physical activity - that impact patient outcomes. The document argues that a health psychologist could address these issues by introducing theory-based interventions, like motivational interviewing and cognitive behavioral therapy, to increase medication adherence and physical activity. A health psychologist could also provide training to nurses on these interventions and theories of health behavior.

1. Health Psychology in the Parkinson’s Service, is there a
role to be filled: Executive Summary.
Alison Morrow

2. Overview of the Service
Parkinson’s is a progressive neurological disorder that affects approximately 1 in 500 people
(Parkinson’s, 2015). The Parkinson’s Service within the Western General Hospital,
Edinburgh, consists of three Lead Nurses who deliver care to patients through a combination
of clinics, home visits and telephone calls. The Nurses work with patients throughout their
whole Parkinson’s journey, beginning at the original diagnosis through to management of
symptoms and medication. As Parkinson’s motor and non-motor symptoms have the ability
to cause patients to struggle with daily life, treatment requires input from a number of Health
Professionals. There are a variety of treatment options, and the Nurses collaborate with
patients as their condition progresses to relieve symptoms and hopefully increase patient’s
quality of life.
Health Care Context
Similarly to other chronic conditions, the service requires input from a number of health
professionals, including Occupational Therapists, Speech and Language Therapists and
Physiotherapists. However, they do not yet have their own multi-disciplinary team. Access to
these specialists can be difficult, particularly for younger patients as they cannot be referred
to the Assessment and Rehabilitation Centre (as it is dedicated to those over 65 years of
age), however the Nurses have developed contacts in order for younger patients to be
assessed by the necessary professionals. This raises concerns such as patients’ waiting
times and understanding of the condition.
Parkinson’s UK is utilised by the service to provide additional social support as well as the
aim to alleviate or improve symptoms. Service users do not have to be experiencing
particular symptoms to attend specific classes, however, for example, singing classes look to
help service user’s project and control their voice if they are having difficulties with speech
and swallowing, and dance classes aim to target stiffness by including a variety of stretching
and relaxation techniques.
Due to the input from a variety of teams, it is essential for all health professionals to foster
positive relationships with each other, as well as with patients and their carers within the
service, to ensure that patients receive the best care and outcomes. Particularly due to the
nature of Parkinson’s, Nurses are required to work collaboratively with patients to establish
the best route of care. They have to highlight restrictions of medication and therapies to
ensure patients do not have unrealistic expectations as this has the potential to highlight
barriers to successful relationships (Fentiman, 2007). This is particularly prevalent in the
Parkinson’s service as the effectiveness of medication for Parkinson’s disease varies from
patient to patient and it is essential for patients to understand this. Additionally, after
medication has begun or is adjusted, patients have to be aware that the medication will not
“cure” their Parkinson’s disease.
It is therefore vital to for health professionals to develop a positive and trusting relationship
with patients to influence the exchange of information regarding medication beliefs and
expectations. An exchange of information between the patient and clinician is necessary
and crucial to ensure they have a shared perception (Duffy, Gordon & Whelan et al., 2004)
by highlighting and modifying detrimental beliefs.

3. Applications of Health Psychology
The biopsychosocial model (Engels, 1977), which underpins Health Psychology, is a
progression of the medical model of health and illness which understands that a patients’
biological and psychological factors, and their social environment all interact and determine
the outcome of one’s condition. Within the Parkinson’s service, there were two distinct health
behaviours, influenced by psychological and social factors, which impacted patient
outcomes, medication adherence and physical activity.
Findings suggests that, despite its benefits, only 10% of Parkinson’s patients take their
medication exactly as required and significant non-adherence occurs in up to 54% of
patients (Grosset, Bone and Grosset, 2005). Intentional non-adherence often occurs when
patients make conscious decisions, which are often dependent upon the patient’s beliefs
regarding the medication or their broader condition, to not take their medication despite its
therapeutic effects and against advice from the Nurse. Leventhal et al’s ., (1980) Self-
Regulation Model suggests that individuals’ coping behaviour, or response, to a health threat
is influenced by their cognitions, beliefs and emotional representations of the illness in
relation to 5 factors; identity/label of the condition, the cause, its consequence on the patient,
its timeline and whether it can be cured/controlled. Patients can therefore have beliefs about
their medication, particularly whether the treatment is necessary, for example will this
“cure/control” my condition, and potential risky side effects (Clifford, Barber, & Horne, 2008).
If patients believe their medication will not help control their symptoms, their illness
representation clashes with the treatment provided by health professionals. Cognitive
Behaviour Therapy could be used to elicit patients’ beliefs, their physical feelings and the
actions they take (non-adherence to medication) as a result of such beliefs. CBT could be
used to help explain how medication adherence can reduce symptoms and consequently
improve health and quality of life (Safren et al., 2009).
Non-intentional non-adherence to medication, such as forgetting, would merit a modest
Implementation Intentions intervention (Gollwitzer, 1999) that requires patients to identify
when and where their medication has to be taken, with the aim of forming habits and
removing the need to rely on memory. Nurses already suggest that medication has to be
taken at specific times of the day, for example with breakfast, lunch and dinner, however as
some Parkinson’s patients have cognitive impairment, which may lead to non-adherence,
concrete plans could be printed and displayed in the home to act as environmental cues.
Once barriers had been identified, coping plans could be introduced if adherence is still not
optimal. This could be simple measures of additional environmental cues throughout the
home to prompt patient’s at specific times of the day.
Although research indicates that physical activity has the ability to improve functional
capacity, health, physical fitness and quality of life (Speelman et al., 2011; Ransmayr, 2011),
the majority of Parkinson’s patients do not meet recommended levels of weekly physical
activity (Skidmore et al., 2008). Using the Theory of Planned Behaviour (Ajzen, 1985) as a
theoretical framework, we can understand why physical activity rates are so low in people
with Parkinson’s. The TPB presumes that a person’s motivations to perform a particular
behaviour, like physical activity, are influenced by peoples’ attitudes and beliefs, surrounding
social norms and perceived control. If patients believe that physical activity will increase their
overall pain and stiffness experience, rather than alleviate symptoms, there are numerous
theory-based interventions that have the potential to modify such maladaptive beliefs.

4. The Transtheoretical Model of Change (Prochaska & DiClemente, 1982) consists of 5
stages; precontemplation, contemplation, preparation, action and maintenance, and
assumes that at each stage of readiness, people are faced with different barriers. It is
suggested that when designing interventions for those who are inactive, people at
precontemplation and contemplation stages, to concentrate on the cognitive aspects of the
behaviour change (Marcus, Bock & Pinto., 1997). An intervention in the service could be
used to identify maladaptive cognitions, such as fear of increasing pain, and then re-
educating patients regarding the benefits of physical activity.
Additionally, the use of Motivational Interviewing (MI) would be a valuable addition to the
service. MI is used to form a collaborative conversation between the patient and clinician in
order to strengthen the patient’s own desire and motivation to change (O’Halloran et al.,
2014). It is used to elicit the patient’s own reasons for change as well as their own ideas to
make this change. As the service consists of a small team of Nurses that patients have
developed strong relationships with, it seems to be the most desirable environment to
introduce this intervention. Using MI in clinics would allow the Nurses to identify patients’
ideas of what they feel is reasonable and achievable in order to increase physical activity,
which may be more beneficial than recommending exercise groups that they have no
interest in.
Professional Issues
Although there is no Health Psychologist currently employed in the service, there is a visible
role that one could fulfil. Health Psychology can be used to promote self-management of
symptoms which is extremely beneficial, particularly when dealing with a chronic,
progressive condition. If a Health Psychologist were to be employed in the service, their role
would be to promote self-management through interventions carried out in clinics. This could
be through using Motivational Interviewing to promote making healthy lifestyle choices,
monitoring and managing symptoms, engaging in activities that promote and protect health
and managing the impact of the condition on physical functioning. Additionally, the Health
Psychologist could train Nurses to use Motivational Interviewing themselves and carry out
theory-based interventions, such as Implementation Intentions and CBT, to increase
medication adherence and physical activity. The Health Psychologist could teach theories to
the team through seminars by focusing on how cognitions and environmental factors impact
and influence health behaviour and the progression and perception of illness. Due to the
importance of medication adherence and physical activity in people with Parkinson’s
(Ransmayr, 2011; Leopold, Polansky and Hurka, 2004), it is imperative for theory-based
interventions to be introduced to the service and it can be assumed that a Health
Psychologist would be the most capable health professional to fulfil this role.
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