© Springer International Publishing AG 2017
Josef Niebauer (ed.)Cardiac Rehabilitation Manual10.1007/978-3-319-47738-1_33. Psychological Care of Cardiac Patients
(1)
Department of Psychology, University of Swansea, Singleton Park, Swansea, SA2 8PP, UK
3.1 Introduction
This chapter addresses the impact and rehabilitation needs of patients following diagnosis with acute coronary syndrome (ACS) and how psychologically based interventions may benefit such patients. It considers a range of approaches that can be used with individuals or in group contexts, all of which are targeted at two key goals:
Changing risk behaviours, such as smoking and low levels of exercise
Helping people adjust emotionally to their illness
These goals may be achieved through a variety of means: participation in an exercise programme, for example, may both improve cardiovascular fitness and reduce emotional distress as the individual feels they are gaining control over their illness and life. Likewise, changes in depression or anxiety may improve adherence to medication or exercise regimens. Nevertheless, any interventions can be divided roughly into those that address behavioural change and those that address emotional issues. Accordingly, this chapter will introduce a number of intervention approaches targeted at each outcome. The interventions discussed are not specialist interventions to be used only with a minority of patients. Rather, they, or the principles on which they are based, can usefully be incorporated into any rehabilitation programme. Before addressing these issues, however, the chapter briefly examines the psychological impact an acute coronary event can have on the individual.
3.2 The Impact of Acute Coronary Events
Cardiac events can trigger significant emotional reactions, but surprisingly modest behavioural change, at least in the long term. Hajek et al. [14], for example, found that 6 weeks following a myocardial infarction (MI), 60 % of those who smoked before their MI no longer did so. One year after MI, the percentage of those remaining a non-smoker fell to 37 %. Diet may also change in the short term although, again, old habits may creep back over time. Leslie et al. [23], for example, found that 65 % of participants in their nutritional educational programme were eating five portions of fruit or vegetables a day at its end: a figure that fell to 31 % over the following year. Levels in fitness may change markedly following participation in specific exercise programmes (e.g. [15]). However, the duration of any changes in the absence of continued follow-up is not clear. Lear et al. [22], for example, reported minimal changes from the baseline on measures of leisure time exercise and treadmill performance 1 year following MI despite participants taking part in a general rehabilitation programme.
Of concern also is that even modest behavioural change may be confined to a subgroup of patients. Bennett et al. [3] found that in the 6 months following acute coronary syndrome (ACS), levels of exercise rose only among patients already engaging in meaningful levels of exercise and did not change in those engaging in low levels of exercise. More encouragingly, people with relatively poor diets before the event did show more improvement than those with good diets, although they still did not reach the dietary scores achieved by the latter group at any time. Those with good dietary habits showed no improvement at all.
The psychological consequences of MI may be profound and persistent. Osler et al. [28] reported that 20 % of patients became depressed in the 2 years following the event. Lane et al. [21] found a 31 % prevalence rate of elevated depression scores during hospitalisation. The 4- and 12-month prevalence rates were 38 and 37 %. The same group reported the prevalence of elevated state anxiety to be 26 % in hospital, 42 % at 4-month follow-up and 40 % at the end of 1 year. They also reported high levels of comorbidity between anxiety and depression. Interest in the rates of post-traumatic stress disorder as a consequence of MI has recently increased, with prevalence rates typically being around 8–10 % up to 1 year following infarction (e.g. [5]). Poor emotional outcomes may be predicted by a range of psychosocial factors, including age (younger is worse), gender (female is worse), previous psychiatric history, lacking the availability of a confidant, the experience of ongoing life problems and personality factors including type D personality (e.g. [35, 18]).
Each of these emotional reactions can also influence important outcomes. Depression, and to a lesser extent anxiety, independently predicts re-infarction (e.g. [37]) as well as having a number of emotional and behavioural implications. Depressed and anxious individuals are least likely to attend cardiac rehabilitation classes [20]. Paradoxically, they are more likely to contact doctors and have more readmissions in the year following infarction [35]. Many of these appointments will be due to worry and health concerns rather than cardiac problems. The impact of mood on health behaviour change is modest. Huijbrechts et al. [16] reported that depressed and anxious patients were less likely to have stopped smoking 5 months after their MI than their less distressed counterparts. Bennett et al. [4] reported a modest association between low levels of exercise and depression, but no differences between depressed and nondepressed individuals on measures of smoking, alcohol consumption or diet. Finally, Shemesh et al. [31] found that high levels of PTSD symptoms, but not depression, were significant predictors of non-adherence to aspirin.
More importantly, perhaps, depression has consistently been associated with delayed or failure to return to work, reduced work hours and low ratings of work or social satisfaction (e.g. [32]). Delay in returning to work has been predicted by greater concerns about health and low social support. Resuming work at a lower activity level than before infarction is associated with older age, higher health concerns and patients’ expectations of lower working capacity (independently of actual capacity). Indeed, patient’s beliefs about their condition, which will be influenced by mood, appear critical in determining their behavioural response to it. Petrie et al. [30], for example, found that attendance at cardiac rehabilitation was significantly related to a stronger belief during admission that the illness could be cured or controlled. Return to work within 6 weeks was significantly predicted by the perception that the illness would last a short time and have less negative consequences. Patients’ belief that their heart disease would have serious consequences was significantly related to later disability in work around the house, recreational activities and social interaction.
Finally, the partners of patients also experience high levels of distress, often greater than that reported by the patient [26]. Such anxieties may be increased by fears for the patient’s health linked to a poor prognosis and non-compliance with treatment or behaviour change programmes [6]. Many wives also appear to inhibit angry or sexual feelings and become overprotective of their husbands [33].
3.3 Changing Risk Behaviour
A key component of any cardiac rehabilitation programme should address behaviour change designed to reduce risk for further disease progression and enhance quality of life. Achieving this goal can best be considered to involve two sets of processes:
Increasing motivation to change
Developing strategies of change
As the evidence reviewed above suggests, not everyone is motivated to change risk behaviours, even after acute events such as an MI. This group of individuals can be particularly challenging to health professionals as they are unlikely to respond to exhortations to change their behaviour, nor are they likely to benefit from interventions designed to show them how to change their behaviour. The best approach to use with such individuals is one that increases their intrinsic motivation to change.
3.3.1 Information Provision
One apparently simple approach to increasing motivation to change involves the provision of information. If individuals are unaware of the advantages of change, they are unlikely to be motivated to attempt to make change. The logic is clear. Unfortunately, while clear information may be of benefit when it is completely novel, does not contradict previous understandings of issues, is highly relevant to the individual and is relatively easy to act on, health-related information rarely meets all these criteria. And even when it does, it may well not impact on behaviour.
Reasons for these failures are complex and involve social, psychological and situational factors. Even relatively simple behavioural changes, such as improvements to diet, may involve quite complex barriers to change including negotiations within families, potential expense and lack of cooking skills. For this reason, a number of specific strategies have been used in attempts to influence motivation to change. One guide to relevant strategies is provided by the UK National Institute for Health and Care Excellence Guidelines on Behavioural Change (NICE 2014). These identify, for example, several ways of framing information through conversation or leaflets and similar outputs in order to increase the motivation of smokers to quit. Key messages should target psychological factors known to influence behaviour and include:
Outcome expectancies: Smoking causes people to die on average 8 years earlier than the average.
Personal relevance: If you were to stop smoking, you could add 6 years to your life and be fitter over that time.
Positive attitude: Life is good and worth living. Better to be fit as you get older than unable to engage in things you would like to do.
Self-efficacy (confidence): You have managed to quit before. With some support there is no reason why you cannot sustain change now.
Descriptive norms: Around 30 % of people of your age have successfully given up smoking.
Subjective norms: Your wife and children will appreciate it if you were to give up smoking.
Personal and moral norms: Smoking is anti-social and you do not want your kids to start smoking.
3.3.2 Motivational Interview
A more formal, technique-based approach to increasing motivation is afforded by the so-called motivational interview [25]. As its name suggests, its goal is to increase an individual’s motivation to consider change – not to show them how to change. If the interview succeeds in motivating change, only then can any intervention proceed to considering ways of achieving that change. The approach is designed to help people to explore and resolve any ambivalence they may have about changing their behaviour. It assumes that when an individual is facing the need to change, they may have beliefs and attitudes that both support and counterchange. Prior to the interview, thoughts that counterchange probably predominate, or else the person would be actively making change. Nevertheless, the goal of the interview is to elicit both sets of beliefs and attitudes and to bring them into sharp focus, perhaps for the first time: ‘I know smoking does damage my health’, ‘I enjoy smoking’, and so on. This is thought to bring the individual to a decision point which is resolved by rejecting one set of beliefs in favour of the other. These may (or may not) favour behavioural change. If an individual decides to change their behaviour, the intervention will then focus on consideration of how to achieve change. If the individual still rejects the possibility of change, they would typically not continue in any programme of behavioural change, although the possibility of future motivational change should not completely preclude such continuation.
The motivational interview is deliberately non-confrontational. Miller and Rollnick consider the process to be a philosophy of supporting individual change and not attempting to persuade an individual to go against their own wishes. When the intervention was first developed, it was based on exploration of two key issues:
‘What are the good things about your present behaviour?’
‘What are the not so good things about your present behaviour?’
The first question is important as it acknowledges the individual is gaining something from their present behaviour and is intended to reduce the potential for resistance and argument. This process of exploration is not simply a one-question approach. Both the questions above are leads into a wider detailed exploration of these issues. However, once the individual has considered each issue (both for and against change), they are summarised by the health professional in a way that highlights the contradiction between the two sets of issues: ‘So, smoking helps you cope with stress, but it causes trouble at home because your wife doesn’t want you to smoke’. Once this has been fed back to the individual, they are invited to consider how this information makes them feel. Only if they express some interest in change should the interview then go on to consider how to change. More recently, Miller and Rollnick have suggested that patients may be encouraged to consider more actively the benefits of change and how things may be different were change achieved. Other key strategies include:
Expressing empathy through the use of reflective listening: this involves engaging with the individual and trying to see things from their perspective rather than that of a health professional trying to encourage change. This helps develop an alliance between patient and health professional rather than a potentially adversarial relationship.
Avoiding arguments by assuming the individual is responsible for the decision to change: this removes the onus of the health professional to actively persuade. In the end, it is up to the individual whether they change their behaviour, not the health professional.
‘Rolling with resistance’ rather than confronting or opposing it: again, this means avoiding arguments and attempts at direct persuasion.
Supporting beliefs in the ability to change an optimism for change: if the individual is unwilling to contemplate change because they are not sure they can achieve it, then part of the conversation could usefully look for evidence of the person’s ability to change and feed this back to them, to increase their confidence in achieving change.
The motivational approach can be extremely powerful, even where people show high levels of resistance. Take the (true) example of Mr Jones, who had continued smoking despite having had two infarctions and being told that he may require two below-the-knee amputations due to ischaemia in his lower legs if he continued smoking:
Mr Jones:
I know you want me to give up smoking. The doctors have told me that I have to give up, but I’m not going to. I know it’s your job, but you can’t persuade me! It’s the one pleasure that I have, and I’m not giving it up.
Nurse:
OK. OK. I’m not going to try and persuade you to stop smoking. In the end it is your choice. However, I am interested in why you smoke and why you are so firmly against changing despite all the hassle you have had from the doctors. So, what do you get out of smoking?
Mr Jones:
Oh! (looks surprised and relieved and starts talking in a much more non-confrontational manner). Well, I’ve smoked all my life, ever since I was a kid really. It’s difficult to give up something you’ve done for so long. It’s part of my life. In a way, that’s the main thing really – it’s just part of my life. I can’t see life without smoking. It helps me keep calm, and most of my mates are smokers – so it’s part of my social life.
Nurse:
So, it’s difficult to see how to give up and how life would be without smoking….
Mr Jones:
That’s about it, really. I’ve tried to give up in the past and it’s been really difficult. I’ve been back to smoking pretty quickly, so it’s difficult to see myself giving up, even if I wanted to….
Nurse:
Oh, so you’ve tried in the past to quit. What led you to that?
Mr Jones:
Well, I know it really does make my heart bad, and I get out of breath when I smoke. So, it really makes it obvious the harm I’m doing to myself. But it’s one thing to say you want to quit and another to actually do it. And I know I can’t quit, so what’s the point of even trying?
Note at this point that by not challenging or actively trying to persuade Mr Jones, the conversation has shifted from his not wanting to give up to not feeling able to give up – although because of the confrontational way this had been discussed previously, this had not been clear. So, the nurse moves from highlighting the pros and cons of behavioural change and takes this as a cue to look at how and why things have gone wrong before, in the hope that this may lead to consideration of behavioural change:
Nurse:
You say you have tried to stop smoking in the past. How did you set about this?
Mr Jones:
Well, I just tried to do it…. What do you call it? Will power?
Nurse:
How well did that work? Not too good from what you say….
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