Psychology and rehabilitation of patients with CHD

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cope with stressful situations. Kaluza (2000) evaluated an intervention designed to
change the coping profiles of 82 healthy working men and women. The intervention
lasted for 12 weeks and focused on assertiveness, cognitive restructuring, time management, relaxation, physical activities and the scheduling of pleasant activities.
Changes were compared to a control group who received no intervention. The results
showed significant improvements in emotion focused coping and problem focused
coping which were related to the individual’s original coping profiles. In particular,
those who were originally more problem focused became more emotion focused and
those who were more avoidant copers became more problem focused. The authors
suggest that the intervention changed unbalanced coping profiles. In addition, these
changes were related to improvements in aspects of well-being.
Psychology and rehabilitation of patients with CHD
Psychology also plays a role in the rehabilitation of individuals who have been diagnosed
with CHD either in terms of angina, atherosclerosis or who have suffered a heart attack.
Rehabilitation programmes use a range of techniques including health education,
relaxation training and counselling and have been developed to encourage CHD sufferers
to modify their risk factors, such as exercise, type A behaviour, general lifestyle factors
and stress.
Modifying exercise
Most rehabilitation programmes emphasize the restoration of physical functioning
through exercise with the assumption that physical recovery will in turn promote
psychological and social recovery. Meta-analyses of these exercise-based programmes
have suggested that they may have favourable effects on cardiovascular mortality (e.g.
Oldridge et al. 1988). However, such meta-analyses are problematic as there is a trend
towards publishing positive results, thereby influencing the overall picture. In addition,
whether these exercise-based programmes influence risk factors other than exercise,
such as smoking, diet and type A behaviour, is questionable.
Modifying type A behaviour
The recurrent coronary prevention project was developed by Friedman et al. (1986) in
an attempt to modify type A behaviour. This programme was based on the following
questions: Can type A behaviour be modified? If so, can such modification reduce the
chances of a re-occurrence of a heart attack? The study involved 1000 subjects and a
five-year intervention. Subjects had all suffered a heart attack and were allocated to
one of three groups: cardiology counselling, type A behaviour modification or no treatment. Type A behaviour modification involved discussions of the beliefs and values of
type A, discussing methods of reducing work demands, relaxation and education about
changing the cognitive framework of the individuals. At five years, the results showed
that the type A modification group showed a reduced re-occurrence of heart attacks,
suggesting that not only can type A behaviour be modified but that when modified there
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378 HEALTH PSYCHOLOGY
may be a reduction of reinfarction. However, the relationship between type A behaviour
and CHD is still controversial, with recent discussions suggesting that type A may at
times be protective against CHD.
Modifying general lifestyle factors
In addition, rehabilitation programmes have been developed which focus on modifying
other risk factors such as smoking and diet. For example, van Elderen et al. (1994)
developed a health education and counselling programme for patients with cardiovascular disease after hospitalization, with weekly follow-ups by telephone. Thirty CHD
sufferers and their partners were offered the intervention and were compared with a
group of 30 control patients who received standard medical care only. The results
showed that after two months, the patients who had received health education and
counselling reported a greater increase in physical activity and a greater decrease in
unhealthy eating habits. In addition, within those subjects in the experimental condition
(receiving health education and counselling), those whose partners had also participated
in the programme showed greater improvements in their activity and diet and, in
addition, showed a decrease in their smoking behaviour. At 12 months, subjects who had
participated in the health education and counselling programme maintained their
improvement in their eating behaviour. The authors concluded that, although this study
involved only a small number of patients, the results provide some support for including
health education and counselling in rehabilitation programmes. More recently, however, van Elderen and Dusseldorp (2001) reported results from a similar study which
produced more contradictory results. They explored the relative impact of providing
health education, psychological input and standard medical care and physical training to
patients with CHD and their partners after discharge from hospital. Overall, all patients
improved their lifestyle during the first three months and showed extra improvement in
their eating habits over the next nine months. However, by one year follow-up many
patients had increased their smoking again and returned to their sedentary lifestyles.
In terms of the relative effects of the different forms of interventions the results were
more complex than the authors’ earlier work. Although health education and the psychological intervention had an improved impact on eating habits over standard medical care
and physical training, some changes in lifestyle were more pronounced in the patients
who had only received the latter. For example, receiving health education and psychological intervention seemed to make it more difficult to quit a sedentary lifestyle and
receiving health education seemed to make it more difficult to stop smoking. Therefore,
although some work supports the addition of health education and counselling to
rehabilitation programmes, at times this may have a cost.
Modifying stress
Stress management involves teaching individuals about the theories of stress,
encouraging them to be aware of the factors that can trigger stress, and teaching them a
range of strategies to reduce stress, such as ‘self-talk’, relaxation techniques and general
life management approaches, such as time management and problem solving. Stress
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