THE 5 T'S - LINKING PERSONALITY AND HEALTH - COUTESY OF THE PSYCHOLOGIST

Gareth Hagger-Johnson + Martha C. Pollard-Whiteman-2008- IN THE PSYCHOLOGIST



Evidence that personality traits are
related to health behaviours and
health outcomes is emerging. This
is interesting, but is it important?
How can psychologists and
healthcare professionals apply this
knowledge? Can personality-health
research offer anything practical
that would improve health of the
population?
This article proposes a new
typology, the Five T’s, which are
potential ‘next steps’ for
personality-health research:
targeting, tailoring, training,
treatment and transformation. It is
pertinent to ask what the ultimate
aims of establishing a causal link
between personality and health
might be, and how the Five T’s
might be evaluated in future
research. Getting psychologists ‘on
board’ is an important part of that
future.
The personality traits mostly strongly
related to health behaviours (e.g.
Conscientiousness) could be targeted
in health promotion campaigns.
We know that ‘different types of
individuals may attend to, comprehend,
accept, and retain different types of
messages’ (Caspi et al., 1997, p.1061).
Traits influence all four of these steps
in the processing of health promotion
messages. Sensation seeking
(corresponding approximately to high
Extraversion with low Conscientiousness
in the Big Five) is particularly important,
because it is known to influence risky
health behaviours and interact with
communication media. High sensation
seekers (HSS) require novelty, intensity,
sound, drama, stimulation, suspense, fast
pace, emotionality, complexity, ambiguity,
unconventionality and movement. If a
televised health promotion campaign lacks
these features, HSS will consider it boring
and ignore it. Conversely, low sensation
seekers (LSS) prefer familiar and less
sensational delivery of information.
Does this work in practice? The
targeting campaign ‘SENTAR’ (Palmgreen
et al., 2001) suggests that it might. It
showed that HSS adolescents reduced
their cannabis use after watching targeted,
televised advertisements. Furthermore,
72 per cent of calls to the supporting
telephone hotline were from HSS not LSS.
The principles developed by the
researchers might fruitfully be used with
other traits: (1) pick a trait to target; (2)
conduct focus group research with high
and low scorers; (3) design messages
appropriate to high and low scorers; (4)
place messages in contexts appropriate for
high and low scorers.
A weakness of targeting personality
traits is that any group watching or reading
the message will contain a full range of
individual differences on the trait of
interest. We might define a ‘group’ of HSS,
but without individual assessments it is
difficult to find them. It is often
impractical to create more than two or
three different versions of a campaign, so
studies to date have dichotomised traits
into ‘high’ and ‘low’. However, recent
developments in computer technology
have allowed researchers to take more
variables into account, including
continuous ones, which could allow
messages to be ‘tailored’ to the individual,
rather than targeting groups.
 
Tailoring
Tailored and targeted interventions are
not the same thing, although these terms
read discuss contribute at www.thepsychologist.org.uk 595
personality and health
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Sensation seeking influences risky
health behaviours and interacts with
communication media
596 vol 21 no 7 july 2008
personality and health
have been used interchangeably by some
health promoters (Kreuter & Skinner,
2000). Tailoring interventions are
modified based on the assessment of an
individual rather than an entire segment
of the population. Tailored messages
therefore require individualised
assessments of members of the
population to develop such
communications (Noar et al., 2007).
So perhaps a letter from a clinic could be
modified for someone who scores low on
Conscientiousness (e.g. ‘You might want
to set yourself a reminder about your
appointment next week’).
There are many psychological
measures which can be used in tailored
health promotion. These include
personality, mental ability, reading ability
and cognitive style. Tailored interventions
could take many forms: printed materials
(leaflets, booklets, letters), video or audio
tapes, websites, kiosks, CD-ROMs or other
multimedia programs (Kreuter, 2000).
There is evidence that tailored
messages are more successful than nontailored
or targeted messages at changing
health behaviours. For example, Skinner
et al. (1994) used computer technology to
assemble individualised letters tailored
according to where women were in the
‘stage of readiness’ for mammography: precontemplators,
contemplators, actors or
maintainers. And a recent systematic
review and meta-analysis showed that
printed tailored interventions were more
effective than targeted ones (Noar et al.,
2007). This was particularly true for
studies that tailored the intervention to
health behaviour, demographic variables,
and used a health behaviour change theory
(e.g. stage of change).
Perhaps surprisingly, Noar and
colleagues did not find any studies that
tailored according to personality traits,
highlighting the need for tailoring research
in relation to personality. However several
studies in the review included constructs
that overlap considerably (e.g. self-efficacy,
which is a facet of Conscientiousness).
 
Tailoring is the least researched
application of personality-health research
but it is potentially the most fruitful. If
health promotion can tailor to personality
traits more effectively than targeting
personality traits, then this is a strong
incentive to study the utility of tailoring
to traits for ‘prevention and prediction’
purposes.
 
Training
Although personality traits are largely
stable, there is some
preliminary evidence
that basic (Big Five)
traits might be
modifiable by
psychological
therapies such as
psychotherapy or
cognitive behavioural
therapy. For example, a six-week
programme of psychotherapy, totalling
180 hours of ‘training’, was designed to
treat drug addiction. The aim was to
intervene on basic traits, improving
vocational skills (Conscientiousness),
coping ability (Neuroticism), spiritual
development (Openness to Experience),
and social skills (Extraversion and
Agreeableness). Surprisingly, changes
were observed on all the traits,
particularly Neuroticism, which was
lowered by one half a standard deviation
– a large effect size (Piedmont, 2001).
Traits, then, may not be stable if there is
input from clinicians aimed at changing
them (although the investigators did note
that these changes might have occurred
due to reductions in psychological
distress).
Another recent trial used training to
modify personality traits. The Penn
Resiliency Program (e.g. Gillham et al.,
2006) was designed to cultivate optimistic
traits in children. Optimism corresponds to
Cheerfulness/Positive Emotions in the Big
Five. The programme used cognitive
behavioural therapy to discourage children
from interpreting events as internal, stable
and global (e.g. my fault, always my fault,
in every situation). This explanatory style
is a risk factor for depression and anxiety,
particularly when coupled with
catastrophic beliefs about the future and
the belief that small problems are
insurmountable. Children were
encouraged to identify these styles of
thinking and were taught techniques such
as ‘putting it into perspective’ and ‘one step
at a time’.
The programme provided encouraging
results. Two years after it ended, children
who participated showed fewer depressive
symptoms than controls not
in the programme. Those in
the programme were half as
likely to report symptoms in
the moderate to severe
range, with the prevention
effect growing stronger over
time. A recent follow-up
showed the training reduced
depression, anxiety, and adjustment
disorders (when combined) among highsymptom
participants.
Both of these studies show that it is
possible to cultivate traits that may protect
against illness. However, the possibility
that traits can be changed raises ethical
questions about autonomy and authority –
who should decide?
 
Treatment
Many people temporarily ‘treat’ or modify
their states using drugs such as caffeine
and alcohol. However, the ‘new
neurotechnologies’ have the potential to
make longer-term changes to personality
traits. Widely prescribed psychotropic
medications such as Ritalin and selective
serotonin reuptake inhibitors (SSRIs, e.g.
Prozac and Seroxat) change molecular
events that underlie cognition, emotions,
identity – and perhaps personality. Farah
et al. (2004) noted that changing brains
actually changes people.
Several studies have demonstrated
changes in Neuroticism or Extraversion in
response to SSRIs. For example, Prozac has
been shown to alter scores on Neuroticism
(Du et al., 2002). This is only a
preliminary finding, and we should note
that a baseline measure of personality is
“Treatment is clearly the
most controversial aspect
of personality-health
research”
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(2007). Does tailoring matter?
Psychological Bulletin, 133, 673–693.
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predicts disease progression (CD4
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et al. (2001). Television campaigns and
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Journal of Public Health, 91, 292–296.
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(2004). Personality: Theory and research
(9th edn). Hoboken, NJ: Wiley.
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Skinner, C.S., Strecher, V.J. & Hospers, H.
(1994). Physicians’ recommendations
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messages make a difference?
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often not available, and that lowered
Neuroticism scores could reflect removal
of depressive symptomology (the observed
score might represent a return to normal).
The effect size is about one half a standard
deviation.
Interestingly, this effect size is about
the same effect as that observed during
psychotherapy training (see above). But
not all commentators approve of the
shortcut, arguing that cognitive
enhancements undermine the value and
dignity of hard work and learned selfinsight.
Brock (1998, p.58) argued that
‘altering a fundamental character trait or
psychological feature by a “quick fix” of
“popping a pill” seems to some people too
easy and less admirable than changing that
same trait or feature through hard-earned
insight psychotherapy’.
Many aspects of psychological
functioning are potential targets for
enhancement: memory, mental ability,
mood, appetite, libido, sleep and
personality traits (Farah, 2005). The
Human Rights Act poses new legal and
ethical questions about the rights of
children to refuse treatments (Hagger,
2003) – and by extension, enhancements
(including those not yet brought to
market). Treatment is clearly the most
controversial application of personalityhealth
research. As the use of ‘cosmetic
psychopharmacology’ increases, dialogue
between trait researchers and bioethicists
will be required.
 
Transformation
Personality change (transformation) is
a symptom of many illnesses, such as
multiple sclerosis, dementia, Alzheimer’s,
Parkinson’s or stroke. Personality trait
transformation is different from the other
four T’s in that it is something observed,
rather than something applied.
Trait change has important
implications for patients and their families,
and is a key clinical problem. Changes can
cause distress, and in some cases it is more
distress for caregivers than for patients.
Patients may lack insight into their
personality change, which may result from
what Stone et al. (2004) called ‘emotional
agnosia’. Yet personality change has
received far less attention for
neuropsychologists than emotional
disorders and cognitive impairment.
A key challenge for this application
of personality research is to obtain a
premorbid measure of personality traits,
since these are not usually measured in
medical settings. As a result, we know very
little about how illnesses can change basic
traits. The instruments that are used in
clinical and medical settings tend be those
designed as measures of
psychopathology (e.g.
anxiety and depression) or
as measures of neurological
disorders or brain injury
(Nelson et al., 1998). For
example, the
Neuropsychology Behaviour
and Affect Profile (Nelson et
al., 1989) provides a
premorbid and current
description of personality. It
has been used successfully
with stroke, dementia and
closed head injury patients.
The scales include
Indifference (to one’s
injury), Inappropriateness,
Depression, Mania,
Pragnosis (social/pragmatic
communication style). It
would be fascinating to see
trait researchers collaborate
with specialists observing
personality change after
illness, designing
personality measures that
are both descriptive of basic
traits and are informed by
illness aetiology. Measures
that assess adjustment or
coping after illness will also
be of high value. Neurospecialists
may be reluctant to measure
the Big Five, since it was not designed
with brain structures in mind, but this is
certainly an area ripe for exploration.
Get on board the train
Personality-health researchers often
have trouble persuading their colleagues
in psychology (in health-, clinicaland
neuro-psychology) to ‘get on board
the train’, let alone those working in
other disciplines. We argue that this
is at least partly because the applied
utility of personality for health
improvement initiatives has not been
made clear. The emphasis on showing
that personality is related to health, the
groundwork of personality-health
research, has distracted from a discussion
about the possible applied end-points or
‘destinations’ of this work.
Like the Circle Line on the London
Underground, basic empirical work is
always ongoing and does not necessarily
have a final destination. There are at least
five possible destinations (targeting,
tailoring, training, treatment,
transformation). By pointing out possible
end points for this research, it more likely
that ‘increased collaboration between
personality psychologists and researchers
in fields such as public health,
epidemiology, and sociology’ (Krueger et
al., 2000, p.968) will actually happen.
This dialogue will not only encourage
others to ‘get on board the train’, but will
improve the groundwork. Personality
researchers need to engage with passengers
from other disciplines, to move beyond the
groundwork that traits influence health, to
what can or should be done about it.
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