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J Journal of Counseling
and Development Best
practices for counseling in
cardiac rehabilitation
settings.(Report)
Best practices for counseling
in cardiac rehabilitation
settings.(Report)
Publication: Journal of
Counseling and Development
Publication Date: 01-JAN-08
Author: Sheikh, Alia I. ;
Marotta, Sylvia A.
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COPYRIGHT 2008 American

Counseling Association
Cardiovascular disease is the
leading cause of morbidity and
mortality in the United States,
accounting for almost 50% of
all deaths (American Heart
Association, 2004). These
statistics rank cardiovascular
disease far ahead of cancer,
AIDS, and other diseases as a
cause of death. In terms of the
impact of this disease on those
who survive, the American
Heart Association statistics
indicate that, of the U.S.
population, more than 60
million Americans live with
some form of cardiovascular
disease, and it is critical to
improve the quality of life of
these survivors. These
statistics indicate that the
treatment and management of
coronary heart disease is an
increasingly large part of
health care.

Along with a variety of health

professionals, counselors can
play an important role in the
health care and rehabilitation
of people with a history of
heart disease. The inclusion of
a mental health perspective
within the rehabilitation of
heart patients constitutes a
critical aspect of recovery.
Moreover, counselors, by
virtue of their theoretical
background and training, focus
on enhancing quality of life
among their clients and on
promoting personal growth
and development. Counselors
are in an important position to
provide treatment that is
geared toward cultivating
those factors that facilitate
psychological growth. This
would in turn help to reduce
the recurrence of the disease,
preventing further
complications, as well as
reducing the impact on those
who are affected, including
clients and their caregivers.
Furthermore, facilitating
psychological growth in
patients with a chronic
disease, such as cardiovascular
disease, has implications for
empowering clients to
facilitate their own health care.
For example, it has been
suggested (e.g., Suls &
Fletcher, 1985) that the active
involvement of patients in the
management of their chronic
conditions fosters compliance
and cooperation with their
medical consultants and,
consequently, their recovery
and adjustment.

The purpose of this article is to

review the literature on cardiac
rehabilitation to distill the best
practices for counselors to
consider in working with
people with a history of
cardiac events. The article
begins with a
conceptualization of heart
disease from the patient's
perspective--specifically, its
traumatic characteristics and
the developmental stages
associated with recovery. A
brief review is then given of
those psychological factors
that have been shown to
influence recovery in heart
patients. A more detailed
discussion follows, focusing
on the impacts of psychosocial
interventions within cardiac
rehabilitation programs,
including what is currently
known about a variety of
treatments in terms of their
efficacy and impacts on
recovery, as well as the
possible mechanisms whereby
effective interventions may
exert their positive impacts.
Within this discussion,
questions that remain unclear
about what constitutes an
optimal psychosocial
intervention for patients with
myocardial infarction (MI) are
highlighted. Finally, findings
from this review of studies are
related specifically to
implications for counseling
practice.

* Heart Disease as Traumatic

Exposure

The experience of heart

disease constitutes a traumatic
event. Heart patients typically
face a number of extremely
stressful events during a
relatively short period of time
(e.g., the experience of a heart
attack, then receiving the
diagnosis of a life-threatening
condition, then the experience
of uncertainty involved in
surgery). These adverse
experiences can have a deep
psychological impact.
According to theory (e.g.,
Janoff-Bulman, 1992), trauma
has the potential to threaten
one's sense of meaning in life,
about one's assumptions about
the self and about the world.
Specifically, Janoff-Bulman
and Frieze (1983) claimed that
these assumptions are
fundamental to one's personal
theories. Life-threatening
disease as a trauma, therefore,
challenges assumptions of
personal invulnerability,
meaningfulness in life, and
positive self-regard and, in
doing so, causes stress and
anxiety. An MI can be
experienced as traumatic
because of its unpredictable,
uncontrollable characteristics
and may result in a variety of
cognitive sequelae, including
repetitive intrusive thoughts
that may be sufficient to
warrant a diagnosis of
posttraumatic stress disorder
(PTSD). Researchers have
found prevalence rates of
PTSD in this population to
range from approximately 8%
to 16% (e.g., Doerfler, Pbert,
& DeCosimo, 1994; Kutz,
Shabatai, Solomon, Neumann,
& David, 1994).

Once a person experiences a

heart attack, the person must
cope with a life-threatening
illness. Morse and Johnson
(1991) described four stages in
the process of coping with
life-threatening illness: (a)
uncertainty, a stage during
which patients attempt to
understand their condition and
its severity; (b) disruption,
during which individuals
realize that they are affected
by a serious disease and
experience a crisis that is
characterized by high levels of
stress; (c) striving for
recovery, during which
individuals try to gain control
over their illness with the help
of personal and environmental
resources; and (d) restoration
of well-being, which
represents a stage at which
patients attain a new
equilibrium as a result of
accepting the illness and its
consequences.

To illustrate the model, heart

attacks occur suddenly and
with little warning, leaving
individuals feeling confused
and frightened (uncertainty
stage) and with new physical
and psychological restrictions
(Johnson, 1991). These
individuals typically have little
understanding of heart disease
and its treatment, and this lack
of understanding may
undermine a sense of power
and control, rendering
individuals more reliant on
others for support and, in turn,
challenging a sense of
independence (disruption
stage). Furthermore, a heart
attack may leave the
individual with permanent
heart damage, and acceptance
of this loss constitutes an
important aspect of adjustment
following an MI.

The process of adjustment

after a heart attack occurs in
stages during which
individuals face their own
mortality, make sense out of
the experience, regain control,
and accept the possible
limitations that might occur as
a result of the experience
(Johnson, 1991). This is a
difficult task if the limitations
are perceived to be
insurmountable and if
individuals continue to
experience a loss of control
over their lives. Research
indicates that depressive
symptoms are common after
an MI (e.g., Forrester et al.,
1992).

The experience of surgery is

also disruptive and can be
considered to be a major
stressor. Blacher (1987)
suggested that the heart plays
a special role in human
culture, symbolism, and
expression, in that it is equated
with life and death, love,
emotions, and thought, much
more so than any other human
organ. For the heart patient,
surgery, therefore, represents
an extreme emotional stressor
because of its life-threatening
potential. Moreover, Blacher
reported that although
mortality reports may be less
than 1% in an uncomplicated
coronary procedure, patients
nevertheless feel that they
have a 50-50 chance of
survival. Therefore, patients
typically perceive the
operation as more life-
threatening and dangerous
than it may actually be.

In terms of the role of

depression in postoperative
adjustment, researchers have
reported rates of depression
from 14% to 50% after
coronary artery bypass surgery
(Duits, Boeke,
Duivenvoorden, & Passchier,
1996; Timberlake et al., 1997).
Predictors of depression
among patients following
coronary artery bypass surgery
include preoperative level of
depression and trait anxiety.

In Johnson's (1991) third

stage, striving for recovery,
individuals try to understand
the event: why it occurred,
what impact it has had, and
what significance it has for the
future. Although some aspects
of control cannot be regained,
nevertheless, an...

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