Behavioral science is an area of health care whose time has come, says Edwin B. Fisher Jr., Ph.D.
As a professor of psychology in Arts and Sciences on the Hilltop Campus, Fisher teaches graduate students and undergraduate freshmen that the psychology and biology of health problems are complementary, not mutually exclusive. On the other side of Forest Park -- at the School of Medicine -- Fisher heads the Center for Health Behavior Research as a research professor of medicine in the Division of General Medical Sciences. There, he probes the realm where the physiological and psychological paths of an illness merge. It's a place that sometimes is overlooked and viewed as not real science. For the past 20 years, however, Fisher has been a patient voice for the importance of behavioral science in health.
"Biology and psychology are intrinsically tied," he said. "The understanding of their relationships will grow even deeper and more multifaceted."
Through the center, Fisher works with about 30 collaborators from a range of disciplines, including social work, pediatrics, immunology, cardiology and radiology. Their common thread is to examine the psychosocial aspects of health behavior by exploring such questions as: What motivates people to quit smoking? What role does the family play in supporting a patient who has a chronic illness? How do cultural and social factors influence the course and management of a disease like diabetes? Finding the answers, Fisher said, will become increasingly important.
"Eventually, attention to the psychosocial aspects of any disease will become a normal part of health care," he said. "It's hard, though, because integrating behavioral science into health care involves a shift in perspective."
Why will this field grow in acceptance? Fisher said there are three reasons.
First, solid research has uncovered clear links between health and behavior. For example, smoking is tied to heart disease, and an overweight and sedentary lifestyle can lead to non-insulin-dependent diabetes.
"The medical field sees those ties and realizes that a patient's health improves when his behavior changes. And changing behavior entails some thorny psychological issues," Fisher said.
The second reason is that as baby boomers age, the number of people with chronic diseases will increase dramatically. Most people start getting chronic diseases, such as hypertension and diabetes, around age 50. Managing the diseases usually involves daily behavior and will become increasingly important, Fisher said.
Third, biological breakthroughs are raising some interesting and troublesome psychological issues. Medical advances such as genetic testing pose a mine field for the mind. How do we handle the discovery of disease-causing genes? Should a woman with a high risk for breast cancer test for the gene? If so, what does she do with the results?
"It's nothing new -- behavioral psychology," Fisher said. "It's always been a part of health care, but its recognition is growing immensely."
As a child of the 1960s, Fisher was drawn to psychology as a way to help people. His early research interests focused on self-control -- how people manage behavior in the face of temptation. As he tried to decipher how people are able to resist what they want -- to say "no" to a cookie or a cigarette -- Fisher learned that self-control essentially is about making clever choices. Most people erroneously see self-control as mental stoicism. But dieters who lose weight and smokers who quit acknowledge the temptation and plan around it, Fisher said.
"We all do it," he said. "For example, putting the alarm clock across the room is essentially planning around the temptation to hit the 'off' switch and go back to sleep."
In the course of his work, Fisher has become one of the nation's leading spokespersons on the issue of smoking and smoking cessation. On behalf of the American Lung Association, he has spoken to an array of audiences, has testified before Congress, and has appeared on national television to discuss smoking and how to promote nonsmoking.
"He often has been the lone voice of the behaviorist," said Karen Monaco, the lung association's senior program associate for tobacco control who is based in New York. "We have many physicians and biological scientists advising us on programs and materials, and many times Dr. Fisher's brought a real -- and needed -- perspective on the psychology behind smoking and trying to quit smoking."
Over the years, Fisher's research interests have shifted from self-control to social support and the role it plays in health behavior modification.
Instead of tracking an individual's struggle to lose weight or manage diabetes, Fisher now looks at how society -- from the family to the community -- affects the way a patient manages health. A study he conducted 10 years ago was among the first to look at how men and women might react differently to such social support. That study, and subsequent ones, led Fisher to write a section on gender roles and social support for the forthcoming U.S. surgeon general's report on smoking and health, the third on which Fisher has worked. In the report, Fisher shows that women might be more aware of social support than men. Women also seem more skilled at giving and receiving it. Men, on the other hand, frequently are raised believing that social support is a crutch.
"That autonomy myth is life-threatening. Insisting on autonomy can lead to big problems, especially for older men when they begin having to accept that they need some help," he said.
A recent study by Fisher shows that Nondirective support is more helpful for patients managing chronic illnesses. There is an exception, however. Following an acute episode -- such as surgery -- a patient might benefit from a period of Directive support.
"Consider someone just home from the hospital. At that point, what the patient may need is, 'Don't worry about anything. I've got it all under control,'" Fisher said.
The research findings are important for a growing segment of the population. "Whether it's a nurse, a husband or the child of an aging parent, specific advice on how to be supportive will help them give better care," he said.
What is today the Center for Health Behavior Research was founded in 1977 as the Diabetes Education Center. In 1984, the center expanded to include several projects in the prevention and management of cardiovascular disease, and the name changed accordingly.
The center includes a number of varied research projects. Fisher, Robert C. Strunk, M.D., professor of pediatrics, and other colleagues are developing ways to help low-income African-American families of children with asthma manage the disease better and take advantage of care available to them. Another study is looking at whether peers make effective nutrition counselors among African-American women. An exciting new development in the last year entails working with BJC Health System in Community Health and Wellness Programs.
Many of the center's research projects address health objectives in St. Louis' neediest neighborhoods.
"The positive ramifications are enormous," said George Eberle, president and chief executive officer of Grace Hill Neighborhood Services, a health and social-service agency active in St. Louis for more than 90 years. Grace Hill serves the area's low-income neighborhoods, from Wentzville in St. Charles County to Carondolet in the inner city.
Over the years, the Center for Health Behavior Research has conducted studies on smoking cessation, childhood asthma and weight control within Grace Hill neighborhoods. Many of the studies involve the area's residents as peer counselors or data collectors.
"We've got neighbors performing interventions," Eberle said. "That helps the neighborhood respond to its own problems."
For Fisher, that's the most rewarding aspect of his job. "I'm fortunate to have the opportunity for intellectual fulfillment in a field that helps people," he said.
-- Nancy Mays
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