best practices for counseling in cardiac rehabilitation settings

Journal of Counseling & Development ■ Winter2008 ■ Volume86 111©2008bytheAmericanCounselingAssociation.Allrightsreserved.

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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 As-sociation statistics indicate that, of the U.S. population, more than 60 million Americans live with some form of cardiovas-cular 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 train-ing, 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 coun-selors 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 as-sociated with recovery. A brief review is then given of those psychological factors that have been shown to influence re-covery 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 im-pacts. 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 specifi-cally to implications for counseling practice.

Heart Disease as Traumatic ExposureThe experience of heart disease constitutes a traumatic event. Heart patients typically face a number of extremely stress-ful 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 char-acteristics 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.,

Alia I. Sheikh,DepartmentofClinicalPsychology,NewcastleUniversity;Sylvia A. Marotta,DepartmentofCounseling/HumanandOrganizationalStudies,TheGeorgeWashingtonUniversity.CorrespondenceconcerningthisarticleshouldbeaddressedtoAliaI.Sheikh,DepartmentofClinicalPsychology,RidleyBuilding,NewcastleUniversity,NewcastleuponTyne,NE1�RU,UnitedKingdom(e-mail:a.i.sheikh@ncl.ac.uk).

Best Practices for Counseling in Cardiac Rehabilitation Settings Alia I. Sheikh and Sylvia A. Marotta

HeartdiseaseistheleadingcauseofdeathintheUnitedStatesandcanaffectindividualsofallages,gender,ethnic-ity,andsocioeconomicstatus.Thisarticlereviewstheresearchonpsychosocialinterventionsincardiacrehabilitationprogramsanddiscussestheevolvingsetofbestpracticesforcounselorsworkinginanewsettingwithpeoplewhohaveexperiencedthetraumaofcardiacdisease.Recommendationsforbestpracticesforcounselorswhoworkinthisemergingareaareprovided,includingrecommendationsforfacilitatingposttraumaticgrowth.

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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 pos-sible 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 emo-tional 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 neverthe-less 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 adjust-ment, 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 acceptance of limitations may paradoxically enhance a sense of predictability. Despite the finding that many individuals who survived a heart attack experienced depression, Johnson noted that some individuals were able to make sense out of their experiences and to look to the future with a positive attitude. Indeed, this form of meaning making facilitates adjustment and improves coping.

Review of Psychological Factors in Recovery From MI

Table 1 describes the most consistently reported psychosocial variables in the literature to be associated with physical and psychological recovery after an MI. The most commonly cited variables are social support, appraisals and coping, and the presence of depression.

Social support has long been recognized as a crucial fac-tor influencing psychological and physical health, both in the general population (House, Landis, & Umberson, 1988)

TABLE 1

Summary of Research on Psychological Variables Affecting Recovery From Myocardial Infarction

Psychosocial Variable

Socialsupport

Appraisalsandcoping

Depression

Berkmanetal.(1992),Brummettetal.(2001),Houseetal.(1988)

Afflecketal.(198�),Carveretal.(1992),Eversonetal.(1996),Sheikh(200�),Tedeschi&Calhoun(1996)

Frasure-Smithetal.(1999),Ruoetal.(200�)

Source Study Characteristics Outcomes

Historyofillness,includingheartdisease,surgery,mortality(N=62�)

Life-threateningillness,onelongi-tudinaldesign(N=2,82�)

Majorcardiacevents(N=1,�1�)

Socialisolationlinkedtopoorsurvival;supportnetworklinkedtobetteradjustmentfollowingsugery;positivelinkbetweenavailabilityofsupportandincreasedfunction

Reconsideringvaluesandprioritiesresultsinbetterhealth;protec-tivefactoragainstrecurrence;increaseduseofcopingstrategiesinstillshope

Riskfactorforincreasedmorbidityandmortality;influencesqualityoflifeandoverallhealth

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and in individuals coping with illness, especially those with a history of heart disease (e.g., Berkman & Orth-Gomer, 1996). Studies in this area confirm the deleterious effects on health from poor social support. For example, social isolation has been associated with poor survival in patients with MI (Brum-mett et al., 2001). Low levels of emotional support increase the risk of death even after controlling for disease severity, comorbidity, and various sociodemographic variables (Berk-man, Leo-Summers, & Horwitz, 1992).

The underlying mechanisms by which a lack of social support is linked to poor survival in patients with MI remain unclear. It is possible that isolation affects mortality through its associations with demographic measures (e.g., older age, lower socioeconomic status) or through its influence on psychological functioning (e.g., Brummett et al., 2001). Moreover, isolated individuals tend to experience more psychological distress and lower levels of motivation to seek medical care, thereby exerting a negative impact on survival. Thus, social isolation may operate directly or indirectly to influence health outcomes in this population.

Along with social support factors, there is also evidence to suggest that appraisals of the experience of life-threatening illness can have powerful influences on psychological and physical recovery. When individuals reassess their value sys-tems and avoid blaming others following MI, their long-term health outcomes improve. This appraisal process can lead to what has been referred to in the literature as posttraumaticgrowth (Tedeschi & Calhoun, 1996) and has been linked to coping strategies such as problem-focused coping among

patients with MI (e.g., Sheikh, 2004). The finding relating coping strategies to positive recovery has had consistent sup-port in the literature (e.g., Carver, Scheier, & Pozo, 1992). Moreover, a sense of control and establishment of hope have also been found to be beneficial in patients with MI (e.g., Everson et al., 1996).

Major depressive disorder is an important independent risk factor for the occurrence of major cardiac events such as MI in patients with coronary artery disease (e.g., Carney et al., 1988). Frasure-Smith, Lesperance, Juneau, Talajic, and Bourassa (1999) found that patients who were depressed (men and women) were 3 times more likely to die in the year follow-ing their MI as compared with those who were not depressed, regardless of the severity of the initial MI. It is interesting that women were more likely than men to be depressed following an MI, although it remains unclear as to whether this is due to biological or environmental factors. Ruo et al. (2003) found that depressive symptoms were strongly associated with health status outcomes, including physical limitations, quality of life, and overall health in all patients. Therefore, depressive symptoms emerged as being at least as important as cardiac function itself in determining the prognosis of people who experience cardiac events.

Review of Psychosocial Interventions in Cardiac Rehabilitation Programs

Table 2 provides a summary of common interventions to improve cardiac recovery. There have been a number of ad-

TABLE 2

Summary of Research on Psychosocial Interventions in Cardiac Rehabilitation

Type of Treatment

Combinedtreatments:psychoeducation,relaxation,cognitivetherapy,imagingtech-niques,behaviormodification,emotionalsupport,psychodynamicinterpretation

Individualizedcounselingtailoredtopatientneed

Healtheducationandstressmanagement

Cognitive-behavioraltherapytargetingTypeAbehaviors

Cognitiverestructuring,support,behaviorialmanagement

Cognitive-behavioral,behavioralmanage-ment,andhealtheducation

Cognitive-behavioral,socialskills,andsocialnetworkdevelopment

Transcendentalmeditation

Gender-specificskillstraining(women),education,spiritualdevelopment

Lindenetal.(1996),Nunesetal.(198�)

Frasure-Smith&Prince(198�)

Dusseldorpetal.(1999)

Friedmanetal.(1986)

Jones&West(1996)

Cowanetal.(2001)

WritingCommitteefortheENRICHDInvestigators(200�)

Waltonetal.(2002)

Burell&Granlund(2002)

Source Evaluation

Moststudiedtreatmentswerecognitive-behavioralorstressmanagement.Allhadpositiveeffectsonbothphysiologicalandmentalindices.

Reducedmortalityratesby�0%evenwithnotrainingbynurseswhoadministeredtreatment.

Successfullyreducedbehaviorsthatareconsideredriskfactors.

AlteringTypeAbehaviorreducedcardiacmorbidityandmortalityinpost–myocardialinfarctionpatients.

Noimpactonpsychologicaloutcomesorprognosis,attributedtoawash-outeffectbasedongenderdifferences.

Highlightspossibleroleofnonspecifictreat-mentfactorssuchasincreasedattention.

Nodifferenceswhencomparedwithacon-trolgroupreceivingusualcare.

Somepromisebutmoreresearchisneededonthisformofintervention.

Attemptedtoaddressdifferencesinhowwomenexperienceamyocardialinfarction;improveddropoutratesofmoretraditionalprograms.

Note.ENRICHD=EnhancingRecoveryinCoronaryHeartDiseasePatients.

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vances in this area in understanding the effectiveness of psy-chosocial interventions that can inform counseling practice. Various studies, including randomized controlled trials and meta-analyses, have found that the most useful interventions for coronary artery disease are drug therapy (anticoagulants, beta-blockers) and rehabilitation regimens (exercise; e.g., Lau et al., 1992; Oldenburg, Perkins, & Andrews, 1985; Oldridge, Guyatt, Fischer, & Rimm, 1988).

In the earliest meta-analysis that evaluated the outcomes of psychosocial interventions on prognosis after an MI, Nunes, Frank, and Kornfeld (1987) concluded that psychological treatments were effective in modifying Type A behavior and in reducing mortality and morbidity. The researchers found that longer and more complex treatments (i.e., package treat-ments rather than a single technique) produced larger effects at a 3-year follow-up.

Although the psychosocial treatments in the studies varied in terms of techniques used and length of treatment, they did share a cognitive-behavioral approach. Additionally, Linden, Stossel, and Maurice (1996) argued that these treatments could be classified together as stress management interventions. The 2,024 patients who received psychosocial treatment showed greater reductions in psychological distress, blood pressure, heart rate, and cholesterol level. Participants in the control group (n = 1,156), who did not receive psychosocial treatment, showed greater mortality and cardiac recurrence rates during the first 2 years of follow-up, supporting the findings of Nunes et al. (1987). Linden et al. concluded that the addition of psychosocial treatments to standard cardiac rehabilitation programs reduced mortality and morbidity, psychological distress, and biological risk factors. It is noteworthy that the benefits were apparent not only for psychosocial end points (e.g., depression and anxiety) but also for reductions in biological risk factors and recurrence of cardiac events. On the basis of these conclusions, Linden et al. recommended the routine inclusion of psychosocial interven-tions within cardiac rehabilitation in addition to drug therapy and exercise regimens.

Controversies still remain regarding the clinical usefulness of psychosocial treatments. This is largely due to the lack of uniformity across studies as to what specific interventions are included for study, the timing and duration of such interven-tions, whether the benefits are distributed equally across all patients, the use of various clinical end points by which to assess the efficacy of interventions, small sample sizes, and the lack of random assignment to groups (e.g., Blumenthal & Emery, 1988). Despite this diversity across studies, it is worth noting that the effects were consistent in showing a positive outcome. Further research is needed to address this specificity question in order to be in a better position to understand the change mechanisms underlying the efficacy of psychological interventions in cardiac rehabilitation.

Arguably, one class of variables that may mediate the positive influence of psychosocial treatments on physical and emotional health may be similar to nonspecific therapy factors

(such as emotional support, establishment of hope, and a sense of control), as is consistent with therapy outcome literature (e.g., Lipsey & Wilson, 1993). Even nonstandardized therapies show promise. Frasure-Smith and Prince (1985) delivered a nonstandardized treatment only when needed and which was provided by nurses without specific training in psychotherapy. It was found that this intervention was successful in reducing mortality rates by 50%. These outcomes were taken to support the benefits of individually tailored rather than standardized treatments, suggesting that it may not be necessary or most cost-efficient to provide all patients with the same intensive treatment protocol. Rather, psychosocial interventions may be individually tailored according to the needs of each patient. Furthermore, in the Recurrent Coronary Prevention Project (Friedman et al., 1986; discussed later), whereas the average length of cognitive-behavioral interventions was 57 hours over 4.5 years, the length of psychosocial education interventions was 19.5 hours. Yet the mortality benefits of both treatments were similar to those found by Frasure-Smith and Prince in their study of individually tailored interventions. However, the less intensive treatment condition did show a propor-tionately smaller treatment benefit. These findings suggest that interventions that are spread over a long time, especially when individually tailored, would lead to the greatest benefits, supporting the conclusions drawn by Oldridge et al. (1988) and by Linden et al. (1996).

A more recent meta-analysis by Dusseldorp, van Elderen, Maes, Meulmen, and Kraaij (1999) examined effects of psychoeducational programs that included health education and stress management. Outcomes included behavioral (e.g., smoking and exercise) and psychological (depression and anxiety) risk factors. Their results revealed that these pro-grams were associated with significant reductions in cardiac mortality, in recurrence of MI, and in behavioral risk factors. Moreover, it was found that those cardiac rehabilitation pro-grams that successfully altered psychological and behavioral risk factors were more effective in reducing cardiac mortality than programs that were not successful with altering immedi-ate risk factors.

Results from the Recurrent Coronary Prevention Proj-ect (Friedman et al., 1986) also supported the inclusion of psychosocial interventions. In that study, patients with MI were provided one of two types of treatment and were fol-lowed up over several years. The control treatment included counseling and health education. The intervention condition included counseling, plus an additional cognitive-behavioral intervention designed specifically to change Type A behavior patterns. The results showed that, after 4.5 years, the rate of recurrent MI was 21% in the control group and 13% in the Type A intervention group. However, it was noted that, al-though patients in the intervention condition modified typical Type A behaviors (e.g., hostility, time urgency, impatience), they also experienced a reduction in depression and anger and increases in self-efficacy, social support, and general

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well-being. Therefore, the improved health outcomes at fol-low-up may not be entirely attributable to a reduction in Type A behavior, although it is possibly significant that reductions in this particular risk factor also led to reductions in other risk factors, such as depression and social isolation.

Despite the positive findings of these meta-analytic re-views, however, two large randomized trials have failed to demonstrate a significant impact of psychosocial treatment on patients’ psychological symptoms and survival. Jones and West (1996) investigated the impact of a program of psycho-social rehabilitation, which comprised seven 2-hour sessions, delivered by clinical psychologists, involving a combination of psychological therapy (cognitive restructuring), counseling (emotional support), relaxation training, and stress manage-ment training. They found that the program had no impact on either psychological outcomes or prognosis at either the 6-month or 1-year follow-up. Frasure-Smith et al. (1997) also found similar results in a randomized trial involving a program of home-based psychosocial nursing interventions versus usual care. The home-based interventions were indi-vidually tailored and therefore varied in content, frequency, and number of sessions. The results showed that the program was only marginally significant in reducing symptoms of depression and anxiety for men and that it had no impact on psychological symptoms for women. It is possible that one reason for the lack of impact may have been because the in-tervention increased psychological distress in some patients and decreased it in others, yielding an overall nonsignificant result. In a reanalysis of Frasure-Smith et al.’s (1997) data, Cossette, Frasure-Smith, and Lesperance (2001) investigated individual improvement in psychological distress at three different time points: short-term (i.e., after the first and sec-ond home visits) and at 1-year follow-up. It was found that patients’ scores on the General Health Questionnaire (GHQ; Goldberg, 1972) were significantly reduced in the short term, and this outcome was not related to various lifestyle, demo-graphic, and socioeconomic factors and was also unrelated to perceived social support and anger expression. Moreover, successful short-term GHQ outcomes were linked to signifi-cantly less mortality, especially among men. Those patients who showed short-term improvements also tended to maintain these improvements over 1 year, including improvements in psychological symptoms such as anxiety, therefore showing better prognosis than did those with unsuccessful GHQ out-comes. Cossette et al. noted that women were significantly less likely to show short-term improvements in GHQ scores. However, those women who did respond early to psychosocial treatment experienced the same longer term improvements in outcomes as did men. The researchers suggested that their findings highlighted the importance of evaluating short-term improvements once psychosocial interventions are initiated. On the basis of an early assessment of individual responses to treatment, psychosocial programs can then be modified and/or intensified (e.g., referral to specialized mental health

services) for those patients (especially women) who may not show early improvements.

In another randomized controlled trial by Cowan, Pike, and Budzynski (2001), the risk of cardiovascular mortality was lower at 2 years in a psychosocial therapy group than in the usual care group. In that study, psychosocial therapy provided by nurses consisted of relaxation and biofeedback techniques; cognitive-behavioral therapy for depression, anxiety, and anger and for improving coping strategies; and health education. The usual care group received health education only. Although this study failed to specify which of the three components of psy-chosocial therapy may have contributed to the positive outcomes associated with this intervention, it has been suggested that the increased attention given to patients in the intervention group may also have been a crucial factor in the success of psychoso-cial therapy (Palinkas, 2001), especially given that no statisti-cally significant changes were observed in certain physiological variables (e.g., heart rate variability) and only minor changes in mood. This once again highlights the possible importance of common therapeutic factors in influencing positive outcomes within psychosocial interventions.

A large multicenter, randomized controlled trial, the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD), was conducted to determine whether treating depression and increasing social support immediately after MI would reduce the risk of subsequent mortality and reinfarc-tion (Writing Committee for the ENRICHD Investigators, 2003). Cognitive-behaviorial therapy (supplemented with SSRI [selective serotonin reuptake inhibitor] antidepressant medication) was provided, either at home or at a clinic, for 6 months for 2,481 patients approximately 17 days after an MI, as well as group therapy when feasible. Counseling addressed patients’ specific needs, including behavioral and social skill deficits, cognitive factors that contributed to the perception or maintenance of unsatisfying levels of social support, and social outreach and network development. Unexpectedly, the results revealed that although these psychosocial interventions decreased depression and improved social support more than in the control group (usual care), they did not affect mortality and reinfarction in a follow-up (average of 29 months). In accounting for these results, the researchers proposed the pos-sibility that psychosocial interventions may need to continue for a longer period of time and/or be provided at different time points. Nevertheless, the findings of this study raise questions about the effectiveness of psychosocial interven-tions for patients with MI—in particular, the optimal timing and duration of such interventions.

In terms of other interventions found to be useful within this population, transcendental meditation has been investigated. In a review of meta-analyses and randomized controlled trials investigating the effectiveness of transcendental meditation on cardiac-related morbidity and mortality, Walton et al. (2002) concluded that this intervention can reduce both psychosocial and traditional (e.g., physiological) risk factors that halt or re-

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verse pathophysiological mechanisms that are implicated in the progression of heart disease. For example, they cited studies that show that meditation programs reduced lipids and cholesterol levels, substance abuse, reactivity to stress (e.g., by changing the hypothalamic-pituitary-adrenocortical axis and other hor-monal systems), atherosclerosis, and cardiac-related mortality (after controlling for age and gender). The authors concluded that meditation programs show promise in terms of influencing positive health outcomes among cardiac patients.

In considering the effectiveness of psychosocial interventions, it seems important to consider the unique needs of special popula-tions (e.g., Brezinka & Kittel, 1995). It has been suggested, for example, that women experience their illness differently than men do and that their coping behaviors differ as a result. In Burell and Granlund’s (2002) preliminary report on women’s experiences, it was found that women were more likely to have comorbidity with other diseases, such as cancer, arthritis, and chronic pain. They were also more private about their disease and rarely participated in cardiac rehabilitation programs. Women attempted to avoid involving the families in their concerns because they reported not wanting to burden them, thus removing themselves from support opportunities. Women tended to experience self-esteem issues and family-related stress and felt unable to express their concerns in mixed cardiac rehabilitation groups because of a lack of assertiveness and possible submissive gender role behaviors. Burell and Granlund conducted a pilot study investigating the effectiveness of psychosocial interventions for women. Interven-tions consisted of education, self-monitoring, skills training (e.g., assertiveness), cognitive restructuring, and spiritual development. Their results (after 1 year) indicated that this treatment led to im-provements in quality of life, significant reductions in stress, and low dropout rates. The researchers concluded that when women are offered rehabilitation programs that are tailored to their needs, good adherence and positive outcomes can result.

Implications for PracticeA growing body of research, as previously reviewed, suggests causal relationships between psychosocial interventions and post-MI recovery. The overall evidence suggests that psy-chosocial interventions can enhance patients’ quality of life as well as dramatically improve their physical health. These linkages have potential utility for counselors as they design interventions to improve the prognosis of patients with heart disease. The existing evidence suggests the effectiveness of strategies that focus on factors such as social support, ap-praisals, and coping behaviors and that factor in the role of depressive symptomatology in the post-MI recovery period. This section provides counselors first with a recommendation of strategies for enhancing perceived levels of social support, healthy appraisal, and effective coping. Observations about theoretical approaches and treatment modalities are then dis-tilled from the reviewed literature. A discussion of assessment issues for counselors to consider in working with the depres-

sive aspects of post-MI recovery follows, and, finally, some implications for counselors regarding diversity issues and the delivery of services to this population are provided.

BuildingSocialSupports

Counselors place much emphasis on Rogerian principles (Rogers, 1961) of unconditional positive regard, respect, and facilitating individuals’ natural tendency toward growth. The literature reviewed earlier suggests that nonspecific therapeutic factors embedded in psychosocial interventions (cf. Palinkas, 2001) can have a powerful effect on outcomes. Counselors who attend to rapport building with their clients as a way of establishing an initial treatment support system, and who realize the value of collaboration with the client in treatment goal setting, can restore a sense of efficacy and control during the recovery period following an MI.

Having attended to the process of building and maintaining the working alliance in the initial postmorbid period, counsel-ors can consider ways to promote increasingly wider social support systems for individuals with heart disease. To this end, counselors can also help clients develop the cognitive restruc-turing skills that will help them to perceive those supports that may already be there. They can normalize the introspective process that affects clients with MI while they deal with the acute phase of their illness, but which may unintentionally distance the client from family and friendship networks. The negative conditions that accompany depression and anxiety may also affect the perceived availability of social supports. Counselors who are in case management roles can develop a variety of resource and referral networks. The more varied the network, the more likely it will be that a person recovering from MI might find a support system that is congruent with her or his personality or gender. The literature suggests that individually tailored programs might be more beneficial than a one-size-fits-all approach. This means that the onus is on the counselor to have a sufficient base of resources from which to refer clients. These varied resources should include alter-native medical sites, such as centers that teach mindfulness techniques or meditation to enhance the capacity of clients to manage their recovery behaviors. Behavioral management strategies such as relaxation, breathing exercises, and guided imagery are important elements of treatment planning to ad-dress autonomic system balances that are interrupted by the physiological mechanisms of MIs (Walton et al., 2002).

Counselors can use their knowledge of family systems to promote social supports within nuclear and extended fami-lies, as well as helping clients to navigate the complexities of today’s health care system so that it can be more supportive and less potentially retraumatizing. The literature lends cre-dence to the systemic theoretical approach by encouraging involvement of family members and caregivers in adjunctive treatment settings. Family members may potentially be vicari-ously traumatized by witnessing the struggles of the person with an MI to cope across the trajectory of illness. Counselors

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who schedule adjunctive family sessions would benefit from assessing the potential for vicariously acquired PTSD among the entire system. Additionally, they can incorporate coping skills training into adjunctive family sessions.

TheoreticalApproachesandModalitiestoImproveSelf-Appraisals

The research literature reviewed earlier demonstrates that cognitive-behavioral approaches are efficacious with this population. Treatment is best configured in frequent, short, focused interventions within a longitudinal time frame. This means that over the course of a year, for example, patients and/or their families may be scheduled for six separate courses of therapy, with each course consisting of four to six weekly sessions. In terms of modality, the literature supports either individual or group treatment, with the group setting being more facilitative of building social supports, whereas individual modalities may be more helpful for skill building or reconstruction of dysfunctional self-appraisals. Psychoedu-cational interventions may be much shorter and can even be delivered by paraprofessionals trained by counselors.

The literature on posttraumatic growth (e.g., Affleck, Tennen, Croog, & Levine, 1987; Sheikh, 2004) suggests that appraisals regarding the experience of life-threatening illness may be important in shaping outcomes within this population. Specifically, those individuals who are able to perceive benefits in their struggles show better prognosis than do those who maintain negative appraisals of their situation. Counselors can facilitate meaning making by teaching skills for chang-ing stable and pervasive attributions about illness to more flexible and focal attributions. A client who is able to change from negative self-talk about never recovering, for example, to recognizing how much has already been recovered and how much can still improve decreases risks of future cardiac events and improves depressive symptoms as well. Also, being able to shift focus from blaming the self (e.g., enacting a victim role) and/or blaming others (e.g., medical professionals) can serve to minimize helplessness and anger, both of which represent risk factors for recurrence of MI. Such a shift may also facilitate acceptance and cognitive accommodation of the inevitable physical health changes brought about by the MI, thus allowing for increased motivation and planful action. Finding meaning from this trauma also allows individuals to reconstruct their basic assumptions about self, others, and the world and to re-establish some predictability (e.g., Nolen-Hoeksema & Davis, 2002; Starck, 1983). Counselors can also reinforce changes that are life giving, thereby enhancing clients’ self-esteem and sense of control.

BestAssessmentPractices

Given the consistency of findings in the literature about MI being comorbid with post-MI depressions (cf. Frasure-Smith et al., 1999; Ruo et al., 2003), counselors should routinely screen patients with MI for mood changes. Post-MI depres-

sion has been noted to be underdiagnosed in medical popu-lations (Perez-Stable, Miranda, Munoz, & Ying, 1990), and Ziegelstein (2001) further proposed that physicians may be attributing somatic complaints of fatigue and lethargy, for example, to the MI itself and not to a comorbid depression. Counselors can assess for motivational issues related to treat-ment compliance that may be the sequelae of depression and that may interfere with making the necessary lifestyle changes of increasing activity and managing diets. Moreover, clients who are depressed may be less likely to adhere to prescribed medical regimens because these regimens require more energy than they perceive themselves to have. The counselor who is in frequent contact with clients during this period may have more direct contact with patients than their physicians and thus can serve as valuable collaborators with primary care providers in managing compliance with physical and mental health regimens.

An additional benefit of screening for depression is that if counselors use standardized symptom checklists in the screening process, these instruments provide a systematic way to measure how much a patient improves during treatment. Regular use of the Beck Depression Inventory (Beck, Ward, & Mendelson, 1961), for example, at the beginning, middle, and end of each treatment period, provides counselors with a trend analysis for symptom improvement. This practice is consistent with other treatment guidelines, such as for PTSD (Foa, Keane, & Friedman, 2000), where response to treatment is defined as more than a 75% reduction in initial symptom presentation. Moreover, if clients do not respond and the symptom checklists show little or no reduction, counselors can change modalities or add treatment approaches they have not yet tried in order to improve dose/response outcomes.

DiversityIssuesandDeliveryofCounselingServices

Much of what is currently known about responses to psychosocial issues has been derived without regard to potential gender-based differences that may exist. To illustrate, where gender has been factored in (e.g., Burell & Granlund, 2002), it appears that women are less likely than men to participate in cardiac rehabilitation programs following an MI, and when they do participate, they are likely to have poor attendance and higher dropout rates. Coun-selors who work with women in the immediate post-MI period may benefit from careful assessment of needs and availability of the women with whom they work, as they design individualized treatments to enhance supports, appraisals, and coping. Finally, the literature shows that access to treatment can be difficult for minority populations (e.g., Garcia & Marotta, 1997), and counselors may need to consider training paraprofessionals in nonstandard treatment settings, such as senior citizens’ groups, to recognize the need for psychosocial interventions once a per-son has experienced the trauma of an MI. Counselors who work in vocational rehabilitation settings could also be trained in the issues discussed in the present article so that they can improve

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employment for people with a history of MI, thereby contributing to an overall improved quality of life.

Suggestions for Future ResearchThe aforementioned review of randomized controlled trials and meta-analytic studies highlights some of the variables shown to be influential in recovery from MI. However, more research is needed to identify specific types of psychosocial interventions by means of more randomized controlled trials. Moreover, it remains unclear as to which individuals would benefit from what types of treatment, and future studies may evaluate the particular needs of subgroups (e.g., women, lower social economic status) and design and assess specific inter-ventions relevant for those groups. Further research can also address the processes by which improvements occur in order to examine the mechanisms by which psychosocial interventions exert their impacts. In addition to empirical studies, qualitative approaches aimed at phenomenologically examining the sub-jective experiences of patients with MI may enrich the existing body of research by generating new hypotheses that can then be tested empirically. It is hoped that future research examin-ing the factors that contribute to the success of psychosocial interventions would continue to inform counseling practice within cardiac rehabilitation programs.

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