by Peter Mabbutt, FBAMH
Despite the fact that we live in a health-conscious society, cardiovascular disease is still one of the major causes of premature death. These days we drink too much; we eat too much (of both the wrong and right kinds of food); and smoking is still endemic. Compounding this we are encouraged to lead increasingly sedentary and stressful life styles. All this represents bad news for the heart as these activities place it under increasing strain and could result in the development of cardiovascular disease. If recognized early enough, drugs and a change of life style are all that’s needed to provide an effective route to management and recovery from cardiovascular disease. However, for some the only route to better health will be through surgical intervention.
For anyone facing the prospect of surgical intervention this will be a major event in their life. Despite the fact that the techniques of cardiovascular surgery have advanced immeasurably over recent years, as with all surgical interventions there is a risk of death. It is therefore not surprising that patients faced with surgical intervention go through a whole range of feelings and emotional responses. Research has shown that 60% of patients hospitalized for heart disease experience elevated levels of stress, anxiety and depression. Unfortunately, the heart responds unfavourably to these emotional states, thus placing extra demands on an already damaged cardiovascular system.
Psychology of surgery
For anyone being told that they need to undergo a surgical procedure this will undoubtedly provoke a stressful response that may increase when the surgery is considered to be major or life saving. For many, this can bring on a bereavement reaction as they will experience a whole range of losses: a loss of health; a perceived loss of control over their life; and a possible loss of independence. Also, they are likely to experience guilt over the harm their lifestyle may have caused their body. Compounding this may be an increased awareness of their own mortality as they are going into hospital for an operation that will save their life. Fear is another factor that features, as many patients may be worried that they will not survive the surgery or, alternatively, that they may be damaged mentally or physically in some way by the surgical procedure.
It must be remembered that psychological disturbance also occurs during the post-surgical period. Even when surgery has been successful many patients will enter a period of post-surgical depression. Many factors may be responsible including a continued perception of lost health due to post-anaesthetic nausea, pain, and worry about the healing process. Patients may also experience a profound loss of control over their life. During the early stages of recovery they may be bed-bound and therefore reliant on others for cleaning, feeding and drinking. Compounding this they will experience a loss of privacy with regard to bodily functions, as urine and faecal output need to be monitored immediately after surgery.
Many patients will experience concerns over what they will and won’t be able to do in the future as a result of their heart condition and surgery. Unfounded concerns that they will be unable to engage in the sexual act can lead to psychogenic sexual dysfunction. The belief that they may damage the heart during coitus can lead to performance anxiety with all its consequences
Often patients will exhibit concerns that they will be unable to give up activities proscribed by their medical-care team such as excessive alcohol consumption, smoking and eating certain foods.
If left untreated all these psychological factors could provoke a negative mind-set. Many studies have shown that a patient’s outlook toward upcoming surgery as well as to the post-surgical period can greatly affect recovery outcome. Essentially, patients with a poor outlook may have a poor prognosis (it has also been shown that those patients who are socially isolated and come from the lower-income bracket are also at greater risk post-surgically). However, those patients showing an optimistic outlook recover more rapidly and show an increased survival rate.
Studies have shown that those patients undergoing hypnosis as an integral part of the pre- and post-operative procedure demonstrate an increased rate of recovery and decreased levels of post-surgical infection.
Hypnosis and Surgery
As the patient should be set up for success from the beginning, pseudo orientation in time needs to be included during each session, taking the patient to a time in the future when they have successfully recovered from the operation. It goes without saying that the therapist must ensure that the pseudo-orientated future is realistic and achievable. As well as this, ego boosting should also be included during each session to help the patient create a positive mind-set and to enhance inner resources.
Reframing approaches should not be ignored. It is an undeniable fact that the patient’s lifestyle may have led to the reason they are in hospital at this time. Reframing the situation so that the patient perceives that they are taking control of their future thus ensuring a speedy recovery as well as living a long, healthy and productive life will be of obvious benefit to the therapeutic process.
Induction of Hypnosis
A word needs to be said about the induction process used with cardiovascular patients. Any induction will suffice. However, as part of the therapeutic process it is important to teach the patient how to relax, so progressive relaxation approaches should be the therapist’s primary consideration as this will indirectly provide a format for the patient’s own approach to relaxation.
Dealing with Fear
Many patients will understandably have a fear of the process of surgery and of their stay in hospital. Imagination techniques (a preferable term to visualisation as asking someone to visualize implies that they have to ‘see’ and therefore does not take into account the other modalities of representation) should be used to take them through their hospital experience and beyond: being admitted to hospital; the pre-surgical stay; going to the operating theatre and receiving their pre-medication; undergoing the operation; their time in the recovery room; being taken back to the ward and their post-operative stay; leaving hospital; and making a full recovery.
Presented scenarios should show the patient coping calmly, confidently and with appropriate self-control. Again the therapist needs to be realistic with regard to the outcome. Self-hypnosis should be taught and the patient encouraged to practise these imagination techniques. If the patient has specific fears with regard to their stay in hospital, for example needle phobia, these need to be dealt with as a separate issue.
Life style Issues
Many patients presenting for cardiovascular surgery will be advised to make life style changes. These may include reducing their alcohol intake, stopping smoking or reducing their weight. Here hypnosis takes an obvious role and standard approaches are used. For the patient there is the added incentive of the increased health risk should they not change which will provide a strong motivator that can be used during therapy. Care should be taken, as some may view these lifestyle changes as a short-term adaptation and may subsequently revert to old behaviours once they have recovered (a possible indication that they are experiencing denial with regard to the seriousness of their heart condition).
Stress management should be taught, as stress responses will place an added burden on an already damaged heart. The use of self-hypnosis should be included and encouraged, as the trance state will reduce any stress-induced increase in cardiac activity. It is also known that the trance state will reduce blood pressure (high blood pressure, or hypertension, is a major risk-factor in coronary disease).
In many cases pre-surgical hypnotic intervention will help to prevent post-surgical depression. However, biochemical changes occurring after the use of anaesthetics may result in the patient developing an endogenous depression. This state should be dealt with appropriately.
A positive mental attitude towards the healing process needs to be encouraged. Various approaches can be taken with an emphasis placed on healing the body: asking the patient to imagine the heart healing and becoming more healthy; imagining the wound healing, the tissue and bone knitting together with the minimum of scarification; imagining the body protecting the wound, the immune system guarding the incision and preventing infection.
Pain may be an issue and the full range of pain control techniques should be employed: glove anaesthesia; imagination approaches; control room of the mind; dissociation. The therapist should also help the patient to maintain recommended lifestyle changes.
Some patients develop cardiophobia: an abnormal awareness of their heart beating. This can provide a focus for neuroticism after any heart event or surgical intervention, as the patient may believe that naturally occurring changes in the beating of the heart herald a catastrophic heart event. Consequently they become over-protective towards their cardiovascular system and this may lead to a sedentary lifestyle (that in its own right will be damaging to the heart). Desensitization approaches and reframing should be used.
A word of warning with regard to the use of regression with patients who have experienced a heart event needs to be given. Do not take them back to the event as they may re-experience it with inevitable consequences. If carrying out a diagnostic approach, regressing the patient year by year, avoid the year in which the event occurred for the same reason. If possible regression should be avoided.
Hypnosis can play an important role in cardiovascular surgery by helping to create a positive mental outlook for the surgical patient. This, combined with helping the patient undertake and maintain life style recommendations, can significantly increase the prospects of a full and healthy recovery.