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Abstract This article outlines the need for a critical health psychology and how this approach was originally formulated as a challenge to mainstream health psychology. Critical health psychology articulates the need for a more reflexive approach – one that is able to analyse the complex moral, emotional, ethical and political issues underpinning peoples’ experiences of health and illness. This article discusses how critics have responded to the development of critical health psychology, to debates regarding what actually constitutes a critical approach, and finally, to how critical approaches might be refined in future research. It is just about possible to know, in fact, just about everything that can be known about the psychopathology of schizophrenia or schizophrenia as a disease without being able to understand one schizophrenic. Such data are ways of not understanding him. To look and listen to a patient and see ‘signs’ of schizophrenia (as a ‘disease’) and to look and listen to him simply as a human being are to see and hear in radically different ways ... (Laing, 1965, 33) When the physician finds that he is not taking the needed time for ‘reflective meditation’ upon the meaning of his job ... when he finds he is using laboratory tests and X-Ray studies instead of in-depth interviews ... It is at these times that he must ask himself whether the values of efficiency and productivity have not in fact gained the upper hand, submerging other important medical and human values ... Has productivity become a goal in itself? (Hilfiker, 1985, 144) Both of these quotes resonated with me when I first began the process of reflecting on health psychology, a process that eventually culminated in the publication of my book, Rethinking Health Psychology (Crossley, 2000). As an academic psychologist, analysing the ‘data’ produced by an umpteenth ‘respondent’, I began to realise that I had become far too adept at reaching for the safety of a ‘battery’ of pretested measures and statistical packages. Even in my more qualitatively oriented research, allegedly more open and humanistic, the search for ‘discourses’, ‘narrative themes’ and ‘conversation analytic devices’, in the pursuit of yet another peer-reviewed publication, had begun to take over. In short, I was beginning to lose sight of the fact 22 Critical Health Psychology © 2007 The Author Social and Personality Psychology Compass 2/1 (2008): 21–33, 10.1111/j.1751-9004.2007.00041.x Journal Compilation © 2007 Blackwell Publishing Ltd that I was dealing with real people, telling me about their real problems, in the context of their often very difficult lives. I had forgotten why I started doing research in psychology in the first place. Consequently, I needed to back to seeing people as people, not merely as sources of data. But it was not just me, I realised. It was the whole way in which my training as an academic psychologist had geared me up to looking at the world. It was at that point that I began to realise that the whole health psychology ‘enterprise’ needed to be questioned, and new ways of ‘looking and listening’, in Laing’s terms, needed to be developed. Quite simply, the dominant theories and methods of health psychology provided a far too simplistic response to the messy reality of human lives, a reality made more messy by disease and illness – the standard fare of medicine and its allied disciplines. Critical Health Psychology Critical health psychology defines ‘mainstream’ health psychology as the dominant approach propounded within central health psychology textbooks, and taught in universities. This approach relies heavily on a ‘discourse of scientific progress’ and has two main aims. The first is to predict health- and illness-related behaviour through the development and testing of theories. The second, related aim, is to ‘control’, manage or change behaviour through the application of such theories. More fundamentally underpinning this whole approach is the ‘biopsychosocial’ model, a theoretical approach that assumes reciprocal and dynamic interactions between different levels of the human ‘system’, from the biochemical to the psychological, to the sociocultural. One of the central premises of a critical health psychological approach is an appreciation of the inadequacy of mainstream health psychology’s appropriation of the ‘biopsychosocial’ model. Most health psychology textbooks pay lip service to this model but as Cooper, Stevenson, & Hale (1996, 4) point out, it is often presented as a ‘multiple, rather than integrated, explanatory framework’ in which ‘biological, social and psychological factors co-exist in a seemingly fragmented way’. This means that the biopsychosocial model ‘merely reflects the simultaneous juxtaposition of a range of explanatory perspectives and not the integrated theoretical model that its status implies’ (Cooper et al., 19964). In order to illustrate the way in which health psychology’s appropriation of the ‘biopsychosocial model’ has influenced its study and practice, critical approaches have examined a whole range of substantive topics covered in mainstream health psychology textbooks (e.g. ‘healthy and unhealthy behaviours’, pain, disease, death and bereavement) and showed how their investigation remains heavily reliant on theoretical models that consist of an amalgamation of multiple hypothetical constructs related to ‘biological’, ‘social’ and ‘psychological’ variables. © 2007 The Author Social and Personality Psychology Compass 2/1 (2008): 21–33, 10.1111/j.1751-9004.2007.00041.x Journal Compilation © 2007 Blackwell Publishing Ltd Critical Health Psychology 23 For instance, in the investigation of ‘health-related behaviours’ (e.g. eating, drinking, smoking, drug-using, sexual behaviour), theoretical models such as the health belief model’, ‘protection motivation theory’, the theory of reasoned action’ and the health action process approach, are routinely utilised. Their main aim is to delineate predictive factors contributing towards behaviour, with an underlying assumption that ‘psycho-’ or ‘subjective’ dimensions of behaviour can be routinely quantified by using questionnaire measures such as ‘perceived susceptibility’, ‘perceived severity’, ‘perceived costs’ and ‘perceived barriers’. Likewise in the investigation of disease and illness. Here, the psychoneuro- immunological (PNI) model is dominant, a model presupposing complex interrelationships between biological and psychological functioning. Investigating diseases such as cancer and HIV/AIDS, initiation, progression and potential survival are modelled as result of interactions between psychosocial processes and activities of nervous, endocrine and immune systems. Questionnaire measures such as the ‘Illness Perception Questionnaire’, ‘Psychosocial Adjustment to Illness Scale’, ‘Mental Adjustment to Cancer Scale’, the ‘Coping Orientations to Problems Experienced Scale’ and ‘Profile of Mood States’, have been developed to take account of psychosocial factors involved in disease processes. All of these measures and scales are part of mainstream health psychology’s attempt to assess the ‘subjective’ element of human behaviour and to specify the nature of the third term, the ‘psycho-’ dimension forming part of the ‘biopsychosocial’ model. They comprise an attempt to ‘streamline’ psychosocial measures, to ensure that they are comparable with biomedical variables and can therefore be used in the process of statistical analysis and modelling. They attempt to capture the complexities of experience by using increasingly sophisticated scaling techniques. Critical health psychology has served to raise an essential question in relation to these aims: ‘Is something essential being lost in the attempt to quantify subjective experiences in this way?’ Let me try to illustrate by taking an example of health-related behaviour. Some years ago, as part of a study of people living and coping with HIV, I interviewed a woman whose partner was HIV positive – Sara. At the time, Sara was not aware of her own HIV-positive status. Gary, her partner, was a haemophiliac and had contracted HIV in the early 1990s due to contaminated blood products. When I interviewed Sara, she had been going out with Gary for about a year. When we started to talk about ‘safer sex’, she made it crystal clear to me that ‘she knew all about the ins and outs of safer sex’ and all of the ways in which HIV could potentially be transmitted. At the same time, however, she told me about a number of occasions recently when she had actually asked Gary not to use a condom when they had sex. I must have expressed some surprise, or dismay, because she suddenly launched into a whole tirade against me as a ‘health professional’: 24 Critical Health Psychology © 2007 The Author Social and Personality Psychology Compass 2/1 (2008): 21–33, 10.1111/j.1751-9004.2007.00041.x Journal Compilation © 2007 Blackwell Publishing Ltd It’s alright you lot sitting there repeating the same old message about safe sex. You’ve got no idea. Of course, I ‘know’ the risks. But I don’t care. I really don’t. It’s not because I’m stupid, or irrational, or unable to see the consequences of what might happen. It’s far more than that. Gary has been through such shit, such absolute shit, that I feel it’s the least I can do to show him how much I love him – to show him how much I care. It’s not that I’m some sentimental or emotional fool either. It’s so much more than that. I can’t really express it. It’s just so incredibly important. A kind of moral stance, if you like. To say, look, there are higher values in this world than just ‘keeping safe’. To show him how I value him over and above all the trite messages that we’re bombarded with. After all, they weren’t too bothered about risks when they infected him with dirty blood, were they? Mainstream health psychology, working with a standardised model such as the health belief model, would assign Sara to a category. As she appears to express little desire to control her risk of exposure to HIV infection, she would probably be categorised as ‘low’ on the ‘perceived benefits’ of adopting precautionary behaviour relative to the ‘costs’ of maintaining her relationship. But surely, such an attempt at categorisation radically undermines what Sara is trying to say here? Her behaviour, and the rationale behind it, cannot be so easily categorised. One way of interpreting what she is saying is that mainstream health psychology’s theoretical model are far too simplistic and fail to take adequate account of the complexity of the situation Sara is facing. The invalidity of simplistic attempts at quantitative categorisation becomes even more pertinent in the psychological investigation of disease and illness, as researchers exploring how people cope and come to terms with serious illness have shown. For instance, in an autobiographical account of his experience of having suffered a heart attack, Arthur Frank wrote of the moment his doctor called to tell him that his cardiogram showed he had a heart attack: ‘He seemed uncertain of the medical details but I hardly heard him; I was lost in a sense of sudden and profound change. In the moments of that call I became a different person’ (Frank, 1991, 9). Likewise, describing her experience of breast cancer in her autobiography, Mayer wrote of how she felt ‘like an émigré to another, darker country, trying to sort out what my new identity means’. In one moment of discovery, she explained, her life was totally transformed as she ‘entered another world’ and was ‘forced to survive in a hostile new landscape, fraught with dangers’. This world was one in which ‘the ordinary events of my life had abruptly become irrelevant. None of the ingredients of my former identity counted here’ (Mayer, 1994, 23). What ‘tools’ does the mainstream health psychologist have for investigating these kinds of experiences? The need to quantify commonly leads to the application of measures such as the ‘Mental Adjustment to Cancer scale’. And how would such responses be recorded on such as scale? High scorers on ‘anxious preoccupation’ and ‘psychological distress’? Such crass measures merely illustrate further the inadequacy of attempting © 2007 The Author Social and Personality Psychology Compass 2/1 (2008): 21–33, 10.1111/j.1751-9004.2007.00041.x Journal Compilation © 2007 Blackwell Publishing Ltd Critical Health Psychology 25 to feed into the biopsychosocial model by creating psychological data congruent with biomedical data. As critical health psychologists have highlighted, the assumption that experiences of health and illness are amenable to quantitative measurement, experimental manipulation and statistical analysis, may simply be wrong. Such attempts often result in simplistic, frequently banal representations of human experiences which, in reality, are replete with complexity and ambiguity. A Framework for Critical Health Psychology: Rethinking ‘Technical’ Questions as Moral Issues Critical health psychologists have used the work of critical theorists such as Habermas (1973, 1991) in order to question the aims and objectives of mainstream health psychology. Habermas focuses on a critique of ‘instrumental reason’, a form of knowledge that he defines as unique, yet dominant, within modern technological society. Habermas postulates that modern society is based on a damaging confusion of praxis and techne – these are Greek words meaning ‘culture’ and ‘technology’ respectively. Contemporary Western societies tend to be dominated by a collapsing of the cultural and moral dimensions of life into merely technical and instrumental considerations with the implication that advances in technology tend to ‘produce technical recommendations, but they furnish no answer to practical (or moral) questions’ (Habermas, 1973, 254). Accordingly, too many spheres of life become dominated by a practical and instrumental viewpoint that construes problems in terms of means–ends, cost–benefit analyses, and seeks to maximise our control and mastery over events. Although this increases our instrumental prowess, it undermines our ability to evaluate the moral worth of ends and goals. Mainstream health psychology comprises an example par excellence of such dominant ‘instrumental reason’ insofar as it treats issues of health and illness, risk and safety, pain, stress, survival, relationships and death as largely ‘technical’ problems that can be ‘managed’ by various forms of intervention and control. For example, one of the main frequently stated aims of mainstream health psychology, is to promote ‘healthy behaviour’ in order to maintain health and, in the case of already existing disease, to promote healthy behaviours and ways of thinking in order to prolong longevity and survival. One of the ways in which it does this is by targeting beliefs that predict ‘unhealthy’ behaviours – or beliefs that are allegedly related to ‘disease-free’ survival – and attempting to change them accordingly. The very statement of such aims, however, makes clear that they are based on the assumption that concepts of health and unhealth, disease and nondisease, are clear-cut concepts that can be professionally and objectively defined. Perhaps even more problematically, it is simplistically assumed that the technical goals of health psychology (promoting health and survival, ridding the population of disease, pain, and ultimately death?) 26 Critical Health Psychology © 2007 The Author Social and Personality Psychology Compass 2/1 (2008): 21–33, 10.1111/j.1751-9004.2007.00041.x Journal Compilation © 2007 Blackwell Publishing Ltd are desirable. Such a focus, as Habermas predicted, although increasing instrumental and technical prowess, fails to engage with the moral questions associated with the worth of such goals. As critical health psychologists have argued, engagement with such issues constitutes a central task of a more thoughtful health psychology. Mainstream health psychology fails to address the ‘reflective’ and meaningful manner in which human beings typically respond to health and illness. The quotes cited earlier were purposely selected to make this point. One woman gets angry at the notion that she is supposed to be concerned with safe sex when her partner is dying before her. She claims it is important for here to have unsafe sex in order to assert the value of his life. Others write about the way in which their illnesses have had a massive and total impact on their lives, forcing them to see the world and themselves in a radically different light. These are not minor issues. All of them relate to the vital importance of issues of values and morality and to the way in which people discuss and debate the moral value of their lives and actions. Critical health psychology has posed the vital question: should health psychologists be bypassing such essential features of human existence? Is the reduction of such considerations to narrowly defined ‘data’, not just invalid, but also unethical? Are health psychologists guilty of objectifying and depersonalising patients in the same way as medicine has been accused of ? And if this is the case, is this not far less justifiable in psychology, a discipline allegedly devoted to the investigation of mind and subjectivity? In an uncritical attempt to emulate the natural sciences, has health psychology failed to get to grips with the characteristic nature of its subject matter – subjectivity, meaning and reflexivity with specific application to issues of health and illness? In summary, critical health psychology has raised the concern that mainstream health psychology seems to have largely bypassed a consideration of many of the complex moral, emotional and ethical issues that lay at the very heart of peoples’ experiences of health and illness. It has done this through the use of methods that encourage reductionism and the objectification of experiences into simplistic coding devices that facilitate the testing of particular theories and models. It should be noted that such critique is not confined to the use of quantitative techniques. As Chamberlain (2000) and Stam (2000) have argued, the unthinking use of qualitative methods can undoubtedly create results which are as bland, obvious and reductionist as the more conventional application of quantitative measures. Qualitative methods are not a panacea for resolving these problems (see also Chamberlain; Stam, 2000). Defending Mainstream Health Psychology In defence of mainstream health psychology, some critics have argued that, although it is true that the agenda for mainstream health psychology is © 2007 The Author Social and Personality Psychology Compass 2/1 (2008): 21–33, 10.1111/j.1751-9004.2007.00041.x Journal Compilation © 2007 Blackwell Publishing Ltd Critical Health Psychology 27 conservative, there are good pragmatic reasons for this (Nicholson, 2001, 257). For instance, Nicholson argues that the profession has had to try and establish itself within the National Health Service and has had some success in doing so by selling itself as a ‘para-’ medical profession. Also within academia, if health psychologists are training medical or allied health professionals, this role ‘(arguably) demands a conventional emphasis’ (Nicholson, 2001, 257). As Yardley (1997, 5) similarly points out, one major advantage of the mainstream health psychology approach is that it has enabled psychological research to win acceptance from medical clinicians and researchers who are familiar with the language and procedures of quantitative investigation. But this is precisely the point of critical health psychology. As health psychologists, should we meekly accept that this role demands a conventional emphasis? Is it ethical to teach health psychology in this way? Just as an example, in the course of my career I have taught health psychology to medical and dental students. During the course of so doing, when setting examination questions, I have been required to set multiple choice questions, or questions that require a true or false answer. But this way of teaching encourages students to believe that there are simple factually based answers to psychological questions, when, in fact, the vast majority of psychological issues are entirely open to moral debate and discussion. Of what use to medical students is this kind of simplistic psychological approach? How compliant should health psychologists be in this process? This is precisely the question critical health psychology has attempted to address. Yes, health psychology has become increasingly acceptable within medicine, but at what cost? A similar ethical/moral question arises in relation to the development of health-related applications and interventions. Of course, as Nicholson (2001, 257) points out, mainstream approaches lend themselves more easily to the development of applications and interventions – that is indeed one of the reasons why they are used more frequently. But what kind of argument is this? Is this just the pursuit of intervention for interventions sake, a way of promoting the profession? To what extent are such interventions complicit in perpetuating the objectification and depersonalisation experienced by many people in health care? Is this simply another manifestation of a collapsing of the cultural and moral dimensions of life into merely techincal and instrumental considerations? (Habermas, 1973). Moving from the Process of Rethinking Health Psychology towards the Development of a ‘Truly’ Critical Health Psychology A critical psychological approach has been defined as one that challenges many of the theories and practices common in mainstream psychology. There are many different types of critical psychology but they began mainly 28 Critical Health Psychology © 2007 The Author Social and Personality Psychology Compass 2/1 (2008): 21–33, 10.1111/j.1751-9004.2007.00041.x Journal Compilation © 2007 Blackwell Publishing Ltd to gain ascendance in social psychology over 20 years ago (see Gergen, 1985; Henriques, Hollway, Urwin, Couze, & Walkerdine, 1984; Potter & Wetherell, 1987). The influence of critical psychology has now infiltrated most areas of psychology (see Fox & Prilleltensky, 1997). Critical approaches in different areas of psychology vary widely in their aim and scope but one of their defining features is the attempt to question the status quo of psychology and alter it in fundamental ways (Fox & Prilleltensky, 1997, 3). Accordingly, from a critical psychological perspective, it has been argued that psychology ‘too often settles for too little’ (Fox & Prilleltensky, 1997, 3) and in doing so ‘restricts the imagination’ and ‘hinders efforts to create a better society’ (Prilleltensky & Fox, 1997, 14). Committed to making explicit the values lying behind psychological research, critical psychologists argue that mainstream psychology feeds into individualistic ideologies prevalent in contemporary Western societies, actively preventing and exacerbating the failure to achieve social justice, self-determination and participation, caring and compassion, health, and human diversity (Prilleltensky & Fox, 1997, 8). It is these values that guide the pursuit of a critical psychology. Attempts to expand the imagination and to develop a more in-depth, caring and compassionate approach to the psychological understanding of health and illness have been at the heart of new, emergent approaches within health psychology. This is perhaps not surprising given that, as a relatively new discipline, health psychology has drawn heavily on mainstream social and clinical psychology, both of which have been influenced by critical thinking in recent years. Under the remit of such critical approaches, I would include Radley’s (1993, 1994, 1997) ‘cultural’ approach towards the study of health and illness that attempts to counter the ‘individualistic’ bent of mainstream psychology. Recent developments in narrative psychology (see Crossley, 2000; Frank, 1995; Kleinman, 1988) are also consistent with a critical health psychology agenda. And postmodernist approaches, drawing mainly on sociological work, are also important (Fox, 1993). In addition, the First International Conference on Critical and Qualitative Approaches to Health Psychology, was held in 1999, in St. John’s, Newfoundland. This conference resulted in a special issue of the Journal of Health Psychology, entitled ‘Reconstructing Health Psychology’ (Murray, 2000). Since then, a series of further international conferences have been held, a Critical Health Psychology Network, and an International Society of Critical Health Psychology has been formed to promote the development and dissemination of ‘the’ critical approach (Marks, 2002). Debate has continued, with the Journal of Health Psychology’s publication of another special issue devoted to defining and articulating the critical health psychology agenda in 2006. These more recent debates have been concerned to add further definition to the question what actually constitutes a critical approach to health psychology, and where such an approach should aim to be going in the © 2007 The Author Social and Personality Psychology Compass 2/1 (2008): 21–33, 10.1111/j.1751-9004.2007.00041.x Journal Compilation © 2007 Blackwell Publishing Ltd Critical Health Psychology 29 future. An earlier version of some of these questions can be found in Nicholson (2001, 258) who argued that, despite the intention to create a radical and critical health psychology that challenged individualistic ideologies and implicit power structures, there was a danger that such approaches were not going far enough. It is not sufficient, she argued, just to listen to, and report the ‘voices’ of peoples’ experiences of health and illness in a respectful and ethical manner. This is just the first step in the pursuit of a truly critical health psychology. The next step is to identify the implicit and explicit power structures shaping respondents’ experiences in the context of the contemporary organization of health care. As Nicholson (2001, 258) argued: Giving a voice is but a small component of the project of qualitative and critical health psychology. Critical health psychologists can use the data to argue the case for structural change and reconceptualisation of ‘the problem’. The respondents whose voices are given a platform can only take their case so far. Indeed, they are unlikely to have the skills to make sense of their experience in a political and social context. Why should they? That is the role of critical health psychologists ... Critical health psychologists have likewise argued that in order to understand the successes and failures of various health interventions to change individual behaviour, it is necessary to incorporate a critique of the corporate ruling of health and illness. Our eating, drinking, smoking, exercising and sexual behaviours are all intextricably linked to economic structure and the specific socioeconomic situations that we find ourselves in (see Crossley, 2001b; Prilleltensky & Prilleltensky, 2003). The increasing move towards a more ‘radical’ agenda in critical health psychology is reflected in contemporary debates. Murray and Poland (2006) argue that although the early ‘landmark’ critical health psychology conference (in 1999) served to highlight a growing frustration with the complacency and barrenness of mainstream health psychology – a discipline that had as its focus human suffering yet seemed to lack the theoretical and methodological approaches to grasp the character of the phenomenon – at that conference, there was no ‘clearly defined alternative programme of research but rather the development of a variety of different critical perspectives’ (Murray & Poland, 2006, 308). Over the last 8 years or so, however, this has changed, as there has been a turn away from interpretive and language based approaches, or what Murray and Poland characterise as ‘light’ versions of social constructionism, towards far more ‘radical’ forms of analysis whose explicit aim is to engage in social action and the ‘struggle for social justice’. The recent articulation of this more ‘radical’ approach has led to further debate regarding the extent to which critical health psychology can contribute to the promotion of public health, global health, justice and equity. The conclusion seems to be that it can, but it needs to ally more closely with other disciplines (mainstream health 30 Critical Health Psychology © 2007 The Author Social and Personality Psychology Compass 2/1 (2008): 21–33, 10.1111/j.1751-9004.2007.00041.x Journal Compilation © 2007 Blackwell Publishing Ltd psychology, public health, law, economics), in order to do so (McClachlan, 2006). The call here is for ‘action’ – a critical health psychology that is ‘not content with merely describing reality, but rather seeks to transform reality. As agents of change critical health psychologists define themselves not as scientist-practitioners but rather as scholar-activists’ (Murray & Poland, 2006, 383). Lee (2006) goes so far as to argue that this moral and political task entails the definition of critical health psychology as an explicitly left-wing endeavour. Some critical health psychologists, however, have argued that it is necessary to sound a large note of caution here. McVittie (2006) and Hepworth (2006) argue that although the left wing aim to ‘side with the interests of the oppressed’ is laudable, it is certainly not intrinsic to a critical health psychology agenda. Indeed, given critical health psychology’s commitment to interpretivism and critique, it is necessary to question the appropriateness of adopting the overarching principles of fairness/justice and links to ‘action’, of any kind, as a goal and primary focus (McVittie, 2006, 375). As McVittie cogently argues, previous research has shown how notions of fairness and justice have to be examined for their effects within micro-contexts. In view of the ‘occasioned’ use of such concepts, researchers’ attempts to ‘introduce libertarian interventions for disadvantaged groups runs the risk of merely substituting one set of restrictive practices for another’ (McVittie, 2006, 375). Given this, the contribution of critical health psychology ‘must surely remain primarily one of critique, whereby it draws attention to the ways in which unfairness and injustice come to be played out in everyday understandings of health, illness and poverty’. This suggests that ‘action in pursuit of fairness/justice cannot provide a common unifying goal’ (McVittie, 2006, 375). McVittie’s comments reflect the reticence I originally had towards the title ‘critical health psychology’ when I published my book, Rethinking Health Psychology, in 2000. I felt that the label ‘critical health psychology’ bore the risk of plugging into a predefined political agenda that was precisely left wing – with predefined aims and overarching objectives. The immediate call to ‘arms’ and ‘action’ emerging within contemporary critical health psychology smacks, in Habermasian terms, of ‘instrumental reason’ – of domination by a practical, instrumental viewpoint seeking to maximise control and mastery over events, whereas the original intention of a critical approach was to question to the too quick grasp of easy actions and solutions – to open a space for critical questions that had not been raised before – not to jump on the first left-wing ‘action’ bandwagon that came along. But the question remains – how can ‘critical health psychology’ survive if it does not reframe and dedicate itself towards an explicit political objective? As Stam (2006, 386) observes, critical movements rarely last more than a decade or so. Likewise, Flick (2006, 352) comments that critical approaches start as a ‘critical discourse about an established approach or © 2007 The Author Social and Personality Psychology Compass 2/1 (2008): 21–33, 10.1111/j.1751-9004.2007.00041.x Journal Compilation © 2007 Blackwell Publishing Ltd Critical Health Psychology 31 discipline and after a while, criticising is not enough and alternatives have to be developed’. However, critical health psychology has entailed a critique of the professionalisation of health psychology for professionalisation’s sake – and this must include any process of professionalising and promoting critical health psychology. If the role of critique becomes defunct, well, all well and good. A critical health psychology will no longer be needed – in which case it can be allowed to die. It should not be the intention of critical health psychology to promote itself simply in order to perpetuate its own existence. Hepworth (2006, 406) argues that appreciation of the reflexive dimension incorporated within a critical approach towards health psychology is as important as any predefined call to ‘action’ and ‘justice’. The emergence of critical health psychology is: as much about continuing to retain a place that is critical in psychology as it is about actually ‘doing it’. The reflection is not overdone, certainly not overdue and may well always be necessary within the broader politics of being part of psychology and it place in the broader social and health sciences. Indeed, ‘The process of rethinking health psychology involves the injection of a much needed sense of caution, a heavy dose of modesty, and a proper academic skepticism with regard to the limitations of our knowledge’ (Crossley, 2000, 175). In the light of more recent developments, it may be cautionary to add to this sentence – ‘a proper academic skepticism with regard to the limits of our knowledge and action’. To be fair to those advocating a more radical, action-based approach, many continue to underscore the importance of reflective awareness in the research process. For instance, Murray and Poland (2006) end their article by stating: ‘Lest we leave the reader with the impression that critique is to be applied only to others, we underscore the importance of reflexivity in critical research ... that is, an awareness of one’s own social location (class, race, gender) and its implications for how we see the world, how research questions are framed and investigated, the theoretical orientations we bring to our work. We work to make these explicit, just as we encourage others to do the same’. Marks (2002, 16) argued that a ‘critical stance will always need to stand back and look at things at a distance’. It is probably not advisable to try and integrate such an approach within the mainstream because then it will be ‘neutered’. The ‘critical, skeptical approach aims to question the values, underlying assumptions and power relations of academic study and social organisation more generally. Its place will always be on the edge of the mainstream, looking in’ (Marks, 2002, 16). This, perhaps, is a good place to remain. Otherwise, there is a risk that critical health psychology will become drawn into research projects on the terms and agendas set by others, in a desire to avoid isolation at any cost. If this were the case, as critics such as McVittie (Marks, 2002, 375) argue, critical health psychology may very quickly lose its critical edge. 32 Critical Health Psychology © 2007 The Author Social and Personality Psychology Compass 2/1 (2008): 21–33, 10.1111/j.1751-9004.2007.00041.x Journal Compilation © 2007 Blackwell Publishing Ltd Short Biography Professor Michele Crossley is Professor of Health Psychology at Liverpool John Moores University. 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