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Journal of Human Stress Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vzhs20
Liaison Psychiatry on a Coronary Care Unit Richard H. Rahe M.D. Commander, Medical Corps, USNR
a
a
Stress Medicine Division , Naval Health Research Center , San Diego, CA, 92152, USA Published online: 09 Jul 2010.
To cite this article: Richard H. Rahe M.D. Commander, Medical Corps, USNR (1975) Liaison Psychiatry on a Coronary Care Unit, Journal of Human Stress, 1:1, 13-21, DOI: 10.1080/0097840X.1975.9940400 To link to this article: http://dx.doi.org/10.1080/0097840X.1975.9940400
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is
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expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
LIAISON PSYCHIATRY ON A CORONARY CARE UNIT*
Downloaded by [Radboud Universiteit Nijmegen] at 05:20 03 December 2014
RICHARD H. RAHE, M.D.,** Commander, Medical Corps, USNR
This paper presents several of the author’s experiences as a liaison psychiatrist on corona y care units. Technological and pharmacological advancements over the past decade have made major contributions toward reducing the psychological stress of patients admitted to these units. The psychiatrist’s main liaison role is in assisting with patient education and rehabilitation efsorts. Examples are given of a patient education program and reasons f o r systematic evaluations j o r such programs. The psychiatrist also can aid in patient rehabilitation eflorts cam’ed out in the outpatient clinic. Results are given from an experimental program of group therapy as an adjunct to the treatment of post-myocardial infarction patients. Finally, two case histories are briefly presented which exemplij) subjects’ serum uric acid and serum cholesterol variability associated with psychological stresses encountered during their hospitalizations .following a myocardial infarction. The conventional role of a psychiatrist as a consultant to medicine in the general hospital is one in which he races from one end of the hospital to the other to see patients in some type of crisis. Frequently he sees a patient only once, obtaining lit*Report NO. 75- 7 , supported by the Bureau of Medicine and Surgery, Department of the Navy, under Research Work Unit MR000.01. Opinions are those ofthe author and are not to be construed as necessarily reflecting the official view or endorsement of the Department of the Navy. **Head, Stress Medicine Division, Naval Health Research Center, San Diego, CA 92152
March, 1975
tle to no follow-up information concerning how his recommendations have fared. Often the psychiatrist is not overly interested in his consultation duties, nor is he particularly knowledgeable about the medical (or surgical) environment into which he is called to see patients. A remedy for this unsatisfactory situation, for both the psychiatrist consultant and for the services requesting his consultation, is the advent of what has come to be called liaison psychiatry. A liaison psychiatrist chooses one of several hospital areas in which to “specialize.” The areas commonly chosen are those of highly developed medical or surgical technology, such as coronary care units, intensive (surgical) care units, renal dialysis centers, burn units and rehabilitation services. In these areas of highly sophisticated medical technology, the patients’ human needs frequently are ignored. Once the psychiatrist has chosen a particular hospital area in which to work, he rapidly develops skill in interviewing and therapeutic techniques from his repeated exposure to a restricted range of patient illnesses. The following is a presentation of observations and research efforts I have made over the past decade as a liaison psychiatrist on coronary care units (CCUs). I shall try to illustrate the rewarding nature of this experience in contrast to that of the conventional psychiatric consultant role. Although my liaison efforts have chiefly been on CCUs, many of the followingobservations and research Journal of Human Stress 13
LIAISON PSYCHIATRY ON A CORONARY CARE UNIT
Downloaded by [Radboud Universiteit Nijmegen] at 05:20 03 December 2014
activities a r e applicable to other specialized treatment areas in the general hospital.
with death. Of great interest is the recent finding that “denial” of illness by postMI patients is associated with lower morbidity rates than seen for “non-denier~.”~ During his first interviews with postOrientation MI patients the psychiatrist will become The liaison psychiatrist must learn (or apprised of several inconveniences reacquaint himself with) the complicated patients experience in the CCU. Many technical equipment and diagnostic routines, for example, are timed for the procedures carried out in the CCU. One convenience of the staff (such as daily of the best places to initiate his learning weighings at 5:OO A.M.) rather than for is on early morning rounds, which the convenience of patients. Reasons for present an ideal opportunity for the daily blood draws or for changes in psychiatrist to meet with the full CCU medication schedule may not be given to staff, to become acquainted with newly the patient. Individuals previously acadmitted patients and, eventually, to ofciistomed to efficiency and explanation fer suggestions regarding psychological from others find the CCU a particularly aspects of the care of cardiac patients. frustrating environment. As the psychiatrist becomes famliliar with patients on the CCU, he will soon Inpatient Care understand t h a t patient-staff interactions often are influenced greatly by When CCUs first were instituted in the how the patient perceives his illness. general hospital 10 to 15 years ago, a few Patients with myocardial infarction (MI) beds along with a great deal of electronic have been described by several authors as cardiac monitoring equipment were showing a remarkable capacity for rnini- crowded into an out-of-the-way corner of mizing, repressing and even denying the a medical ward. Two to four patients ofsignificance and limitations of their ill- ten shared the same room, and the ness.’-4 Such patients often are labelled proximity of the patients and staff made “uncooperative” by the nurses. since they the problems of one quickly apparent to resist following orders, they will not the other. Cardiac emergencies were a remain at bed rest during the early stages frenzy of activity, constantly reminding of their illness, and they may even wish to patients of the potential lethality of their carry on their usual business and per- d i ~ e a s e . ~Patients’ psychological sonal transactions while on the unit. Fur- problems in adjustment to the CCU have thermore, as most patients in the CCU all but disappeared in the relatively are males in their forties and fifties, (daily spacious and modern CCUs of today, in receiving close physical care from young, which patients frequently have private physically attractive nurses, sexual ten- moms and are relatively isolated from sions can lead to patient-nurse problems. emergency medical procedures required by other occupants. In addition, patients As the psychiatrist begins to understand the patient’s point of view, often he will currently spend fewer days on the CCU see that rather than being uncooperative, prior to transfer to the ward. Perhaps the patients may be making attempts at self- most important factor in reducing sufficiency. Overt flirtations with nurses psychological problems of acute cardiac may serve to repress disturbing thoughts, patients has been the recent trend in such as contemplations of a recent brush which cardiologists prescribe relatively 14
Journal of Human Stress
March, 1975
Downloaded by [Radboud Universiteit Nijmegen] at 05:20 03 December 2014
RAHE high doses of tranquilizing medications; CCU patients spend their two to three days on the unit in a state of drowsiness very close to sleep. These patients oftentimes are amnesic concerning their entire CCU stay when interviewed later on the ward. Today’s liaison psychiatrist normally meets with post-MI patients after they have stabilized medically and are ready for transfer to the ward. The psychiatrist frequently discovers that these post-MI patients have little knowledge of their disease. At this point the liaison psychiatrist may find that it’s good “psychotherapy” to be able to give direct and readily understood answers to patients’ “medical” concerns. For example, patients may wish an explanation, in lay terms, of “what is a heart attack?” They may express concern over blood draws, emergency oxygen equipment, enforced bedrest, and so forth. Even though the patient’s medical doctors, as well as the nursing staff, previously may have provided much of this information, it is not uncommon for patients to have failed to remember and/or to assimilate what they had been told. Patient Education
To systematically assist patients to understand their disease and rehabilitation goals at the University Hospital, University of California at Los Angeles, cardiologists, nurses, dieticians and I composed a coronary heart disease (CHD) teaching booklet. This booklet was written in lay language, outlining the pathophysiology of a myocardial infarction, emergency (CCU) care, potentially harmful effects of diet and cigarette smoking, reasons and suggestions for a gradual resumption of physical activity following a MI, psychological factors reportedly associated with CHD. and
March, 1975
some of the problems patients might anticipate upon their return home and to work following hospital discharge. The advantages of our CHD booklet, in terms of patient education, were several: Patients received a consistent, systematized presentation of basic information helpful for their optimal rehabilitation. They could study the booklet at their own pace. The booklet encouraged patient-staff interactions in terms of stimulating questions, from patients and staff, to clarify and assess comprehension of the material. The booklet also was given to the patient’s spouse or to a near relative, for hidher educational needs. 0 The booklet emphasized that several, rather than just one or two, physical and psychological adjustments were desirable following a MI. Inpatient Research We wished to assess the effectiveness of our CHD booklet. To accomplish such an evaluation, a CHD Teaching Evaluation Form was composed.6 Questions posed in a “true or false” format queried patients regarding what a “heart attack” is, the reasons for various CCU emergency equipment, potentially harmful dietary and smoking habits, resumption of physical activity following MI, psychological factors associated with CHD, and problems related to returning home and to work following hospitalization. Patients were first given the questionnaire immediately prior to their receiving our CHD booklet - around the third hospital day. Their questionnaire scores for this administration gave us an
Journal of Human Stress 15
Downloaded by [Radboud Universiteit Nijmegen] at 05:20 03 December 2014
LIAISON PSYCHIATRY ON A CORONARY CARE UNIT estimate as to how much knowledge they had had in these several areas before receiving the booklet. They were readministered the questionnaire shortly prior to hospital discharge - around the 14th to 18th hospital day. Their responses on this second administration of the questionnaire helped us to evaluate how much they had learned throughout their two weeks on the CCU and ward. Areas in the questionnaire in which patients did not demonstrate significant learning were reevaluated subsequently for alterations in our teaching approach. Several changes then were made in our teaching program. As examples, the dietician was invited to the ward to hold occasional meetings with patients and their spouses; a research nurse and a liaison psychiatric resident instiituted weekly patient-spouse group therapy discussions; and a follow-up clinic was begun to which all discharged patients returned for periodic checks on their understanding and compliance with their rehabilitation schedules.
Outpatient Research
At the U.S. Naval Hospital, San Diego, California. I set up a research experiment to evaluate group therapy as an acljunct to the outpatient management of postMI patients.’ Consecutively discharged post-MI patients were assigned randomly to two groups. Both groups of patients received identical follow-up (clinic schedules and similar pre-discharge counseling regarding diet, physicid activity and cessation of cigarette smoking. One group, however, was additionally provided a series of six, every-other-week, one-and-one-half-hour group therapy sessions which took place over the first three months following hospital discharge. A sampling of some of the 16 Journal of Human Stress
highlights of these group therapy sessions is presented below. It was often the case that during the first or second group therapy sessions, patients performed a “psychological postmortem” on their life experiences over the year or so prior to infarction. Patients appeared to be psychologically ready to inspect their pre-infarction life patterns and to evaluate whether or not they had been pursuing a course of action leading to fulfillment in their life work or, more commonly, trying to obtain unrealistic and ultimately frustrating life goals. Also, at this time, patients were at home and therefore were spending several hours a day with various family members. Interpersonal problems between family members, in many cases previously ignored by the patient due to his preoccupation with work, rose to his attention. Patients’ spouses, too, had to adjust to having their husbands home all day. A common reaction of spouses and children to the patients’ return home was one of overprotection. Group therapy sessions dealt with such issues and. for example, frequently helped a patient to interpret family overprotection as evidence of their concern rather than as a challenge to his manhood. A medical issue frequently raised in group therapy sessions was the area of gradual resumption of physical activity. Immediately post hospitalization patients generally were surprised by their weakness and easy fatigability. Often, previous to their infarctions, they had March, 1975
Downloaded by [Radboud Universiteit Nijmegen] at 05:20 03 December 2014
RAHE maintained physically grueling work patterns. As patients gradually increased their daily walks and achieved some physical endurance, they responded to this increased exercise tolerance with heightened confidence in the recovery of their hearts. Because rushing to meet time deadlines and intolerance of delay had been integral parts of their previous lifestyles, frequently patients started pushing themselves too hard in regard to physical activities. At this point some didactic teaching was in order, including instruction in how to take a pulse rate and discussion about what maximal heart rates were appropriate for various stages in their recovery. When talking of physical activities following a MI, the topic of sexual intercourse following a MI was introduced easily. An understanding of heart rate and blood pressure responses to intercourse helped correct patients’ occasional misconceptions regarding the “strain” of sexual activity on their hearts. Toward the end of the group therapy sessions some patients began to return to work. This was a particularly opportune time to focus our discussions upon previously mentioned work stresses for these patients. For example, if the patient had indicated that habitually he had taken on excessive work or that previously he had placed inordinate emphasis on meeting time deadlines, the inherent frustrations in these work habits were pointed out. Emphasis was placed on modifying these lifelong behaviors, rather than on trying to reverse them. Even with slight to moderate modification of such work patterns, March, 1975
patients often reported notably increased life satisfactions. Both group therapy patients and control group subjects now have been followed for 18 months after MI.8 Their incidence and prevalence rates for angina pectoris, their return to work percentages, their medication usages, and their general life satisfactions currently are being collected. Over the first six months of follow-up, control patients showed a significantly higher hospital readmission rate than that seen for group therapy patients (pa.05). These differences largely were accounted for by the fact that control patients had significantly more rehospitalizations for coronary insufficiency over this period than did group therapy patients (pG.01). Controls continued to experience a significantly higher rehospitalization rate over the next sixmonth interval (p
Journal of Human Stress Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vzhs20
Liaison Psychiatry on a Coronary Care Unit Richard H. Rahe M.D. Commander, Medical Corps, USNR
a
a
Stress Medicine Division , Naval Health Research Center , San Diego, CA, 92152, USA Published online: 09 Jul 2010.
To cite this article: Richard H. Rahe M.D. Commander, Medical Corps, USNR (1975) Liaison Psychiatry on a Coronary Care Unit, Journal of Human Stress, 1:1, 13-21, DOI: 10.1080/0097840X.1975.9940400 To link to this article: http://dx.doi.org/10.1080/0097840X.1975.9940400
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is
Downloaded by [Radboud Universiteit Nijmegen] at 05:20 03 December 2014
expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
LIAISON PSYCHIATRY ON A CORONARY CARE UNIT*
Downloaded by [Radboud Universiteit Nijmegen] at 05:20 03 December 2014
RICHARD H. RAHE, M.D.,** Commander, Medical Corps, USNR
This paper presents several of the author’s experiences as a liaison psychiatrist on corona y care units. Technological and pharmacological advancements over the past decade have made major contributions toward reducing the psychological stress of patients admitted to these units. The psychiatrist’s main liaison role is in assisting with patient education and rehabilitation efsorts. Examples are given of a patient education program and reasons f o r systematic evaluations j o r such programs. The psychiatrist also can aid in patient rehabilitation eflorts cam’ed out in the outpatient clinic. Results are given from an experimental program of group therapy as an adjunct to the treatment of post-myocardial infarction patients. Finally, two case histories are briefly presented which exemplij) subjects’ serum uric acid and serum cholesterol variability associated with psychological stresses encountered during their hospitalizations .following a myocardial infarction. The conventional role of a psychiatrist as a consultant to medicine in the general hospital is one in which he races from one end of the hospital to the other to see patients in some type of crisis. Frequently he sees a patient only once, obtaining lit*Report NO. 75- 7 , supported by the Bureau of Medicine and Surgery, Department of the Navy, under Research Work Unit MR000.01. Opinions are those ofthe author and are not to be construed as necessarily reflecting the official view or endorsement of the Department of the Navy. **Head, Stress Medicine Division, Naval Health Research Center, San Diego, CA 92152
March, 1975
tle to no follow-up information concerning how his recommendations have fared. Often the psychiatrist is not overly interested in his consultation duties, nor is he particularly knowledgeable about the medical (or surgical) environment into which he is called to see patients. A remedy for this unsatisfactory situation, for both the psychiatrist consultant and for the services requesting his consultation, is the advent of what has come to be called liaison psychiatry. A liaison psychiatrist chooses one of several hospital areas in which to “specialize.” The areas commonly chosen are those of highly developed medical or surgical technology, such as coronary care units, intensive (surgical) care units, renal dialysis centers, burn units and rehabilitation services. In these areas of highly sophisticated medical technology, the patients’ human needs frequently are ignored. Once the psychiatrist has chosen a particular hospital area in which to work, he rapidly develops skill in interviewing and therapeutic techniques from his repeated exposure to a restricted range of patient illnesses. The following is a presentation of observations and research efforts I have made over the past decade as a liaison psychiatrist on coronary care units (CCUs). I shall try to illustrate the rewarding nature of this experience in contrast to that of the conventional psychiatric consultant role. Although my liaison efforts have chiefly been on CCUs, many of the followingobservations and research Journal of Human Stress 13
LIAISON PSYCHIATRY ON A CORONARY CARE UNIT
Downloaded by [Radboud Universiteit Nijmegen] at 05:20 03 December 2014
activities a r e applicable to other specialized treatment areas in the general hospital.
with death. Of great interest is the recent finding that “denial” of illness by postMI patients is associated with lower morbidity rates than seen for “non-denier~.”~ During his first interviews with postOrientation MI patients the psychiatrist will become The liaison psychiatrist must learn (or apprised of several inconveniences reacquaint himself with) the complicated patients experience in the CCU. Many technical equipment and diagnostic routines, for example, are timed for the procedures carried out in the CCU. One convenience of the staff (such as daily of the best places to initiate his learning weighings at 5:OO A.M.) rather than for is on early morning rounds, which the convenience of patients. Reasons for present an ideal opportunity for the daily blood draws or for changes in psychiatrist to meet with the full CCU medication schedule may not be given to staff, to become acquainted with newly the patient. Individuals previously acadmitted patients and, eventually, to ofciistomed to efficiency and explanation fer suggestions regarding psychological from others find the CCU a particularly aspects of the care of cardiac patients. frustrating environment. As the psychiatrist becomes famliliar with patients on the CCU, he will soon Inpatient Care understand t h a t patient-staff interactions often are influenced greatly by When CCUs first were instituted in the how the patient perceives his illness. general hospital 10 to 15 years ago, a few Patients with myocardial infarction (MI) beds along with a great deal of electronic have been described by several authors as cardiac monitoring equipment were showing a remarkable capacity for rnini- crowded into an out-of-the-way corner of mizing, repressing and even denying the a medical ward. Two to four patients ofsignificance and limitations of their ill- ten shared the same room, and the ness.’-4 Such patients often are labelled proximity of the patients and staff made “uncooperative” by the nurses. since they the problems of one quickly apparent to resist following orders, they will not the other. Cardiac emergencies were a remain at bed rest during the early stages frenzy of activity, constantly reminding of their illness, and they may even wish to patients of the potential lethality of their carry on their usual business and per- d i ~ e a s e . ~Patients’ psychological sonal transactions while on the unit. Fur- problems in adjustment to the CCU have thermore, as most patients in the CCU all but disappeared in the relatively are males in their forties and fifties, (daily spacious and modern CCUs of today, in receiving close physical care from young, which patients frequently have private physically attractive nurses, sexual ten- moms and are relatively isolated from sions can lead to patient-nurse problems. emergency medical procedures required by other occupants. In addition, patients As the psychiatrist begins to understand the patient’s point of view, often he will currently spend fewer days on the CCU see that rather than being uncooperative, prior to transfer to the ward. Perhaps the patients may be making attempts at self- most important factor in reducing sufficiency. Overt flirtations with nurses psychological problems of acute cardiac may serve to repress disturbing thoughts, patients has been the recent trend in such as contemplations of a recent brush which cardiologists prescribe relatively 14
Journal of Human Stress
March, 1975
Downloaded by [Radboud Universiteit Nijmegen] at 05:20 03 December 2014
RAHE high doses of tranquilizing medications; CCU patients spend their two to three days on the unit in a state of drowsiness very close to sleep. These patients oftentimes are amnesic concerning their entire CCU stay when interviewed later on the ward. Today’s liaison psychiatrist normally meets with post-MI patients after they have stabilized medically and are ready for transfer to the ward. The psychiatrist frequently discovers that these post-MI patients have little knowledge of their disease. At this point the liaison psychiatrist may find that it’s good “psychotherapy” to be able to give direct and readily understood answers to patients’ “medical” concerns. For example, patients may wish an explanation, in lay terms, of “what is a heart attack?” They may express concern over blood draws, emergency oxygen equipment, enforced bedrest, and so forth. Even though the patient’s medical doctors, as well as the nursing staff, previously may have provided much of this information, it is not uncommon for patients to have failed to remember and/or to assimilate what they had been told. Patient Education
To systematically assist patients to understand their disease and rehabilitation goals at the University Hospital, University of California at Los Angeles, cardiologists, nurses, dieticians and I composed a coronary heart disease (CHD) teaching booklet. This booklet was written in lay language, outlining the pathophysiology of a myocardial infarction, emergency (CCU) care, potentially harmful effects of diet and cigarette smoking, reasons and suggestions for a gradual resumption of physical activity following a MI, psychological factors reportedly associated with CHD. and
March, 1975
some of the problems patients might anticipate upon their return home and to work following hospital discharge. The advantages of our CHD booklet, in terms of patient education, were several: Patients received a consistent, systematized presentation of basic information helpful for their optimal rehabilitation. They could study the booklet at their own pace. The booklet encouraged patient-staff interactions in terms of stimulating questions, from patients and staff, to clarify and assess comprehension of the material. The booklet also was given to the patient’s spouse or to a near relative, for hidher educational needs. 0 The booklet emphasized that several, rather than just one or two, physical and psychological adjustments were desirable following a MI. Inpatient Research We wished to assess the effectiveness of our CHD booklet. To accomplish such an evaluation, a CHD Teaching Evaluation Form was composed.6 Questions posed in a “true or false” format queried patients regarding what a “heart attack” is, the reasons for various CCU emergency equipment, potentially harmful dietary and smoking habits, resumption of physical activity following MI, psychological factors associated with CHD, and problems related to returning home and to work following hospitalization. Patients were first given the questionnaire immediately prior to their receiving our CHD booklet - around the third hospital day. Their questionnaire scores for this administration gave us an
Journal of Human Stress 15
Downloaded by [Radboud Universiteit Nijmegen] at 05:20 03 December 2014
LIAISON PSYCHIATRY ON A CORONARY CARE UNIT estimate as to how much knowledge they had had in these several areas before receiving the booklet. They were readministered the questionnaire shortly prior to hospital discharge - around the 14th to 18th hospital day. Their responses on this second administration of the questionnaire helped us to evaluate how much they had learned throughout their two weeks on the CCU and ward. Areas in the questionnaire in which patients did not demonstrate significant learning were reevaluated subsequently for alterations in our teaching approach. Several changes then were made in our teaching program. As examples, the dietician was invited to the ward to hold occasional meetings with patients and their spouses; a research nurse and a liaison psychiatric resident instiituted weekly patient-spouse group therapy discussions; and a follow-up clinic was begun to which all discharged patients returned for periodic checks on their understanding and compliance with their rehabilitation schedules.
Outpatient Research
At the U.S. Naval Hospital, San Diego, California. I set up a research experiment to evaluate group therapy as an acljunct to the outpatient management of postMI patients.’ Consecutively discharged post-MI patients were assigned randomly to two groups. Both groups of patients received identical follow-up (clinic schedules and similar pre-discharge counseling regarding diet, physicid activity and cessation of cigarette smoking. One group, however, was additionally provided a series of six, every-other-week, one-and-one-half-hour group therapy sessions which took place over the first three months following hospital discharge. A sampling of some of the 16 Journal of Human Stress
highlights of these group therapy sessions is presented below. It was often the case that during the first or second group therapy sessions, patients performed a “psychological postmortem” on their life experiences over the year or so prior to infarction. Patients appeared to be psychologically ready to inspect their pre-infarction life patterns and to evaluate whether or not they had been pursuing a course of action leading to fulfillment in their life work or, more commonly, trying to obtain unrealistic and ultimately frustrating life goals. Also, at this time, patients were at home and therefore were spending several hours a day with various family members. Interpersonal problems between family members, in many cases previously ignored by the patient due to his preoccupation with work, rose to his attention. Patients’ spouses, too, had to adjust to having their husbands home all day. A common reaction of spouses and children to the patients’ return home was one of overprotection. Group therapy sessions dealt with such issues and. for example, frequently helped a patient to interpret family overprotection as evidence of their concern rather than as a challenge to his manhood. A medical issue frequently raised in group therapy sessions was the area of gradual resumption of physical activity. Immediately post hospitalization patients generally were surprised by their weakness and easy fatigability. Often, previous to their infarctions, they had March, 1975
Downloaded by [Radboud Universiteit Nijmegen] at 05:20 03 December 2014
RAHE maintained physically grueling work patterns. As patients gradually increased their daily walks and achieved some physical endurance, they responded to this increased exercise tolerance with heightened confidence in the recovery of their hearts. Because rushing to meet time deadlines and intolerance of delay had been integral parts of their previous lifestyles, frequently patients started pushing themselves too hard in regard to physical activities. At this point some didactic teaching was in order, including instruction in how to take a pulse rate and discussion about what maximal heart rates were appropriate for various stages in their recovery. When talking of physical activities following a MI, the topic of sexual intercourse following a MI was introduced easily. An understanding of heart rate and blood pressure responses to intercourse helped correct patients’ occasional misconceptions regarding the “strain” of sexual activity on their hearts. Toward the end of the group therapy sessions some patients began to return to work. This was a particularly opportune time to focus our discussions upon previously mentioned work stresses for these patients. For example, if the patient had indicated that habitually he had taken on excessive work or that previously he had placed inordinate emphasis on meeting time deadlines, the inherent frustrations in these work habits were pointed out. Emphasis was placed on modifying these lifelong behaviors, rather than on trying to reverse them. Even with slight to moderate modification of such work patterns, March, 1975
patients often reported notably increased life satisfactions. Both group therapy patients and control group subjects now have been followed for 18 months after MI.8 Their incidence and prevalence rates for angina pectoris, their return to work percentages, their medication usages, and their general life satisfactions currently are being collected. Over the first six months of follow-up, control patients showed a significantly higher hospital readmission rate than that seen for group therapy patients (pa.05). These differences largely were accounted for by the fact that control patients had significantly more rehospitalizations for coronary insufficiency over this period than did group therapy patients (pG.01). Controls continued to experience a significantly higher rehospitalization rate over the next sixmonth interval (p
