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ContinuingEdCourses.Net d/b/a SocialWorkCoursesOnline.com is approved by the California Board of Behavioral Sciences (CA-BBS) to offer continuing education for MFCCs (MFTs) and LCSWs. CA-BBS provider #3311. ContinuingEdCourses.Net d/b/a SocialWorkCoursesOnline.com is approved by the Ohio Counselor, Social Worker, & Marriage and Family Therapist Board (OH-CSWMFT) to offer continuing education for counselors, social workers, and MFTs. OH-CSWMFT provider #RST080501 & #RCX010801.
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This is an intermediate level course. After taking this course, mental health professionals will be able to:
Chapter 1: The psychoneuroimmunology of surgery
Chapter 2: Conceptual models of surgery preparation
Chapter 3: Preparing for surgery: cognitive-behavioral interventions
Chapter 4: Preparing for surgery: psychosocial interventions
Chapter 5: The business of surgery preparation: adding it to your practice
This course will introduce the clinician to the field of psychological preparation for surgery. This course is an overview and summary of the literature in this area over the past 30 years and including the findings of over 200 studies. The course will outline a surgery preparation program based upon this empirical research that can be used with patients/clients and is applicable to any type of elective (non-emergency) surgery. The course will also discuss how surgery preparation can be added to one’s practice.
In chapter one, an overview of the field of psychoneuroimmunology will be presented. This information provides an understanding as to why preparation for surgery can result in such positive outcomes as improved wound healing, a decreased need for pain medications, less time in the hospital, fewer complications, and a an enhanced surgical outcome overall.
In chapter two, conceptual models of surgery preparation are discussed. The chapter reviews various interventions including information and education, cognitive-behavioral approaches such as relaxation training and imagery, empowerment and self-efficacy, and the biopsychosocial model.
In chapter three, cognitive-behavioral surgery preparation will be reviewed. These techniques include cognitive restructuring, relaxation training, and imagery. The chapter will also review findings in the areas of helping the patient understand and remember medical information, gathering information about the surgery, avoiding medical errors in the hospital, and tailoring the surgery preparation program to the patient’s coping style.
In chapter four, psychosocial interventions for surgery preparation will be outlined. These include such things as effective doctor-patient communication, assertiveness training, preparing family and friends, spiritual issues, and postoperative pain control.
Chapter five is a brief overview of ideas for integrating surgery preparation into one’s practice. These “tips” include such topics as targeting specific types of surgery, working with a surgical group practice, and offering the program at a local hospital as well as billing and reimbursement issues.
Much of the material in this course is based upon the book, Preparing for Surgery: A Mind-Body Approach to Enhance Healing and Recovery (Deardorff and Reeves, 1997; New Harbinger Press). The book is designed as a self-guided patient workbook, but might also be used as a clinician guide for surgery preparation.
I am happy to respond to questions or comments about the strategies presented in this course. You may contact me here. You may purchase my book by clicking on Preparing for Surgery: A Mind-Body Approach to Enhance Healing and Recovery.
From an evolutionary perspective, it was critical for an organism to be able to respond adaptively to environmental threats to increase the chances of survival. In mammals, these physical responses include changes that increase the delivery of oxygen and glucose to the heart and the large skeletal muscles. This reaction allows for a “fight or flight” response. An immune system reaction to a stressful situation is also adaptive since fighting or fleeing in response to a threat carries the risk of injury and subsequent infection. As such, stress-induced changes in the immune system that facilitate wound repair and help fight off infection would certainly be advantageous (See Segerstrom and Miller, 2004 for a review).
Modern humans are rarely faced with the kind of threats experienced by our ancestors such as being chased by a large, hungry animal. Even so, human physiological responses continue to reflect the demands of those early threatening environments (Segerstrom and Miller, 2004). Psychological threats that do not require a physical response (e.g. fight or flight) such as facing an academic exam, sitting in traffic, getting ready for a major surgery, or going through a divorce, still elicit physical changes (e.g. increased blood pressure, muscle tension) along with an immune system response. If these physical changes continue over the long term, they can have a deleterious effect on one’s health.
The field of psychoneuroimmunology (PNI) investigates the psychological modulation of immune function. As presented by Kiecolt-Glaser et al. (2002), there are two milestones in the PNI field. First, Solomon et al. (1964) coined the term “psychoneuroimmunology.” Second, Ader and Cohen (1975) demonstrated that classical conditioning of immune function was possible. As discussed by Kiecolt-Glaser, McGuire, Robles, & Glaser (2002), the field of PNI has rapidly expanded over the past three decades and “…psychological modulation of immune function is now a well-established phenomenon…” (Kiecolt-Glaser et al., 2002, p. 15). Psychological stress has been linked with a broad array of adverse health outcomes such as heightened risk for upper respirator infection, accelerated progression of coronary artery disease, exacerbation of autoimmune disorders, and poorer outcome to surgery (See Miller, Cohen, & Ritchey, 2002; Block, Gatchel, Deardorff, & Guyer, 2003 for a review).
A recent extensive review of the PNI literature along with analysis has provided more support for the stress-immune function link. In their study, “Psychological stress and the human immune system: a meta-analytic study of 30 years of inquiry,” Segerstrom and Miller (2004) completed a meta-analysis of more than 300 studies describing the relationship between psychological stress and immune function. The analyses supported the conclusion that stressful experiences alter features of the immune system and confer vulnerability to adverse medical outcomes that are either mediated by, or resisted by, the immune system. For readers interested in further resources in PNI, the following references are suggested: Benjamini, Coico, & Sunshine (2000) and Rabin (1999).
Until recently, researchers faced a “black box” problem when trying to investigate how presurgical variables influenced post-surgical outcomes since the intricate, inner-workings of a surgical patient’s various body systems could not be adequately measured. Thus, most of the research was correlational in nature and the psychophysiological links between pre-surgical variables (and interventions) and postoperative outcomes could only be speculated. With the emergence of the field of psychoneuroimmunology (PNI), investigators are now able to investigate the inner workings of the “black box” and identify how presurgical variables impact the body to affect wound healing and postoperative outcome. The science of PNI basically focuses on the connections between the central nervous system (“mind”) and the immune system (“body”) (Hafen, Karren, Frandsen & Smith, 1996).
Kiecolt-Glaser, Page, Marucha, MacCallum, & Glaser (1998) have developed an excellent biobehavioral conceptual model that takes into account the various psychological variables that could influence the immune system, wound healing and, subsequently, short term postoperative recovery. A brief overview of the components of this conceptual model follows:
Next, the PNI model developed by Kiecolt-Glaser et al. (1998, 2002) is discussed in detail with a review of background research literature in this area. It is important to have an understanding of these bio-behavioral pathways since this model establishes a firm rationale in support of psychological preparation for surgery. Thus, the clinician can be confident that the preparation for surgery procedures are inducing actual physical changes in the patient to enhance surgical outcome. Discussing these issues with the patient presurgically provides an explanatory model that will help increase his motivation and compliance with active participation in a preparation for surgery program. Finally, the PNI area of research relative to wound healing can help convince surgeons that preparation for surgery interventions are indeed valuable from a physical, psychological, and behavioral standpoint.
Prior to exploring the details of the bio-behavioral healing model, overviews of the immune and neuroendocrine systems, as well as mechanisms of wound healing, will be reviewed. To appreciate the research findings in the area PNI and surgery, it is important to have some understanding of these important body systems. More detailed information about the immune and neuroendocrine systems can be found elsewhere (Benjamini, Coico, & Sunshine, 2000; Cohen & Herbert, 1996; Kiecolt-Glaser & Glaser, 1995; O’Leary, 1990; Page, 1996; Rabin, 1999; Spence, 1982).
The immune system is the body’s primary defense against attackers, both from within the body and from without. According to Kiecolt-Glaser and Glaser (1992), the immune system has two primary functions: to distinguish between “self” and “non-self,” and then to inactivate, destroy, or eliminate foreign substances that are identified as not naturally part of the body (“non-self”).
The immune system contains organs that are found throughout the body. These are generally termed the “lymphoid” organs because they are involved with the development and deployment of lymphocytes (small white blood cells that modulate the immune system response). Lymphoid organs include bone marrow, the thymus, the lymph nodes, the spleen, the tonsils, the appendix, and lymphoid tissue in the small intestine known as Peyer’s patches.
The bone marrow produces cells that will eventually become lymphocytes. There are two major types of lymphocytes, T-lymphocytes and B-lymphocytes. B-lymphocytes (so named because they were first discovered in a chicken gland called the bursa) develop outside the thymus. The B-lymphocytes or B-cells produce circulating antibodies. Antibodies are proteins (belonging to a family of proteins called immunoglobulins) that attack bacteria, viruses, and other foreign invaders (called antigens). Each specific antibody matches a specific invading antigen. The antibodies can inactivate the antigens making them incapable of causing disease. Antibodies “fit” specific antigens commonly described “as a key fits a lock.” Each antibody will attack only a single kind of antigen, and each B-lymphocyte produces only one kind of antibody.
The other major class of lymphocytes is the T-lymphocytes or T-cells. Some of the cells produced in the bone marrow termed “stem” cells migrate to the thymus, an organ that lies high up just beneath the breastbone. These stem cells multiply in the thymus and develop into T-cells (their name is derived from the fact that they develop in the thymus gland). T-cells do not secrete antibodies, but are essential for antibody production.
There are several different groups of T-cells and these have different functions. “Helper” T-cells stimulate B-lymphocytes to produce antibodies as well as “turn on” other T-cells. “Suppressor” T-cells “turn off” the helper T-cells when an adequate amount of antibodies has been produced. Helper and suppressor T-cells communicate with each other by producing chemical messengers such as interferons and interleukins. In a healthy person, the helper/suppressor cell ratio should be in balance. Patients with immunodeficiency diseases have low ratios (too few helper cells relative to suppressor cells) while people with autoimmune diseases have high ratios.
There are other groups of T-cells as well, and these have different functions. Cytotoxic (literally “cell-killing”) T-cells, along with blood cells termed natural killer (NK) cells, patrol the body constantly searching for hazardous abnormal cells. Once these cells are discovered, the cytotoxic T-cells attach themselves and release toxic chemicals to destroy them. In a process that is similar to antibodies, each cytotoxic T-cell is designed to attack a specific target. Thus, there are cytotoxic T-cells that are specific for cancer cells, for cells that have been infected by viruses, and for transplanted tissue and organs. The activity of cytotoxic T-cells is one reason why immunosuppressant medication must be given as part of organ transplantation procedures. The NK cells are called “natural” because they will go into action without prior stimulation by a specific antigen. Normal cells are generally resistant to NK cell activity; however, tumor cells and cells infected with a virus are susceptible. Therefore, the NK cell is thought to play a critical role in the immune system’s response to cancer. In contrast to cytotoxic T-cells, NK cells attack a broad range of targets including tumor cells and a variety of infectious microbes.
Other important components of the immune system include the macrophages and monocytes, which are cells that act as scavengers (or phagocytes). These cells envelop and destroy microorganisms and other antigenic particles within the body. Monocytes circulate in the blood and macrophages are within the body tissues. Granulocytes are phagocytes that are also capable of destroying invaders. These chemicals contribute to the inflammatory response and are also responsible for allergy symptoms.
Surgical stress can affect the neuroendocrine system and, thereby, influence wound healing. The endocrine system is composed of various glands located in different places throughout the body. The major endocrine glands include the pineal, pituitary, thyroid, parathyroids, thymus, adrenals, pancreas, ovaries, and testes. The pituitary gland is considered the “master gland” since its hormones regulate several other endocrine glands and affect a number of body activities. The nervous and endocrine systems are intimately related (hence the term “neuroendocrine”).
One function of the endocrine system is to secrete hormones when the body is under stress. Hormones can be thought of as “chemical messengers” that influence organs in the body (target organs). Two main hormone groups are utilized by the body to deal with stress and are released in response to it – the catecholamines and the corticosteroids. There are two different types of catecholamines – adrenaline (or epinephrine) and norepinephrine. The catecholamines cause significant physical changes such as rapid heartbeat, constriction of blood vessels, hyperventilation, and blood thickening with more rapid coagulation. This has been termed the “fight or flight response” and, basically, prepares the body for a physically threatening situation. This is an adaptive response when one is being chased by a tiger or running from a fire. Unfortunately, this physical stress reaction is unhealthy when it is in response to a non-physically threatening situation (emotional stress) and/or is sustained over a longer period of time (such as facing surgery or chronic anxiety). When catecholamine levels are too high – such as in chronic stress – the result can be a variety of medical problems such as muscle tremors, diabetes, heart attack, and stroke. In addition, unhealthily elevated catecholamine levels significantly suppress the immune response resulting in an increased susceptibility to infection and delayed wound healing.
Corticosteroids are the other major hormone group that is secreted in response to stress. Corticosteroids include cortisone and cortisol. Similar to the catecholamines, increased levels of corticosteroids are adaptive in response to a physical threat but may be unhealthy under other circumstances. For example (Hafen et al., 1996):
The effects of elevated cortisol over a longer term may also create a myriad of physical problems such as (Hafen et al., 1996; McEwen, 1990):
Beyond the acute stress of the surgery process, a surgical patient who has been under chronic stress is likely to be at even greater risk for slower wound healing, postoperative complications, and a longer than normal recovery period.
As discussed by Hubner, Brauchle, Smola, Madlener, Fassler, & Werner (1996), wound repair progresses through several stages:
Of course, any type of surgery produces a wound and the body will respond by initiating this healing process. The initial stage of wound healing is an inflammatory response. The inflammatory response is important for its contribution to pain, immunity, and the beginning of wound healing. Tissue damage caused by the surgical procedure results in a local release of substances (such as substance P, bradykinin, serotonin, calcitonin, prostaglandins, and histamine, among others) that result in the inflammatory response characterized by vasoconstriction, blood coagulation, increased capillary permeability, and sensitization of peripheral afferent nerve fibers resulting in allodynia and hyperalgesia (Page, 1996; Van De Kerkhof, Van Bergen, Spruijt & Kuiper, 1994; Woolf, 1994). Through a variety of mechanisms (see Kiecolt-Glaser, 1998 for a review), other physical responses also occur including local (Schweizer, Feige, Fontana, Muller, & Dinar, 1988) and systemic hyperalgesia, as well as flu-like symptoms (Watkins, Goehler, Relton, Tartaglia, Silbert, Martin, & Maier, 1994; 1995). The flu-like symptoms, such as fever and malaise, are due to activation of the hepatic vagus or the central nervous system (Page, 1996, Watkins et al, 1994; 1995). The hyperalgesia is due to the sensitization of nociceptive fibers that decrease the threshold necessary to initiate impulse transmission (Woolf, 1994). In other words, the surgical patient is physically more susceptible to painful stimuli (i.e. everything hurts more).
The wound repair process, as described by Hubner et al. (1996), results in the migration of phagocytes to the damaged site and this begins the process of cell recruitment and replication necessary for tissue regeneration and capillary regrowth. A patient’s immune function plays a critical role early in the wound healing process. Certain cytokines are essential to protect the person from infection and prepare the injured tissue for repair and remodeling (Lowry, 1993). As Hubner et al. (1996) point out, success in the later stages of wound repair is highly dependent on initial events.
Stress has been found to impact immune (Glaser & Kiecolt-Glaser, 1994; Herbert & Cohen, 1993; Segerstrom & Miller, 2004) and neuroendocrine function which, in turn, has an impact on wound healing (Kiecolt-Glaser et al., 1998; 2002). As discussed previously, immune function plays a critical role in the early stages of tissue damage repair. In addition to other variables, the tissue-damaging component of surgery has been shown to induce immune and neuroendocrine changes (see Page, 1996 for review). For instance, immune suppression during surgery is evidenced by suppression of natural killer cell activity (NKCA) (Pollock, Lotzova, & Stanford, 1991), lymphocyte proliferation responses, and changes in lymphocyte populations (Tonnessen, Brinklov, Christensen, Olesen, & Madsen, 1987). In general, stress suppresses the immune system’s ability to maintain natural killer cells and lymphocytes. Stress has been shown to increase the number of circulating white blood cells, but decrease the number of circulating B-cells, T-cells, helper T-cells, suppressor T-cells, cytotoxic T-cells, and large granular lymphocytes (Goliszek, 1987; Hafen et al., 1996). All of these factors make a person more susceptible to infection and disease while slowing the wound healing process.
The stress of surgery also affects the neuroendocrine system. Stress-related changes in the hypothalamic-pituitary-adrenal (HPA) axis can have important consequences for the wound healing process. For instance, elevations in glucocorticoids can temporarily suppress pro-inflammatory cytokines that are essential to the early stages of wound healing by protecting a person from infection and preparing the injured tissue for repair (Kiecolt-Glaser et al., 1998; 2002).
Another neuroendocrine factor in wound healing is the action of growth hormone (GH). Much of a person’s daily GH release has been found to occur during deep sleep (Veldhuis & Iranmanesh, 1996). Although acute stressors have been found to result in temporary increases in GH (Kiecolt-Glaser, Malarkey, Cacioppo, & Glaser, 1994), more chronic stress that disrupts the sleep cycle can lessen GH secretion. This is important since GH has been found to be a factor in enhancing wound healing (Veldhuis & Iranmanesh, 1996). GH is a macrophage activator (Zwilling, 1994) and is important for improved protection from infection after tissue damage.
There have been a great many studies done, both animal and human, that have documented the effects of stress on wound healing, the mechanisms of which have been discussed previously. In a series of nicely designed studies, a group of family members who provided care for a relative with Alzheimer’s disease was studied and compared with a well-matched control group (Kiecolt-Glaser et al., 1994, 1998; 2002; Kiecolt-Glaser, Glaser, Gravenstein, Malarkey, & Sheridan, 1996; Kiecolt-Glaser, Dura, Speicher, Trask, & Glaser, 1991). The caregiver group was assumed to be under more chronic stressful conditions. The results demonstrated that the caregivers had poorer immune function. In one of the studies directly related to wound healing, a small standardized wound (removal of a small piece of skin from the inner arm below the elbow) was made. The healing process was carefully monitored for the caregiver and the control groups. Consistent with differences in immune function, it was found that the caregiver group took an average of nine days or longer than controls to heal completely. Photographic data of the wound size demonstrated that the largest differences occurred early in the healing process. Thus, it appears that the early stages of wound repair were most significantly impacted by immune system deficiencies (for a complete discussion of this issue, see Kiecolt-Glaser et. al., 1995; 1998). It should be noted that the caregiver and control groups were matched on all other relevant variables.
In a subsequent study using an animal model, a group of mice was divided into a stress group (placed in restraints) and a non-stressed group. A standardized punch biopsy wound was created and the healing process monitored. It was found that the stressed mice healed an average of 27% more slowly than the control group (Padgett, Marucha, & Sheridan, 1998). Again, it appeared that major differences occurred early in the wound healing process. Based upon assessment of serum corticosterone across the two groups, this may have been the result of a disruption of the neuroendocrine homeostasis that modulates wound healing.
In another study, biopsy scalpel wounds were created in the hard palate of 11 volunteer dental students during their summer vacation and then again during their first major examination (Marucha, Kiecolt-Glaser, & Favagehi, 1998). The investigators were able to establish a rate of healing for each individual by measuring the size of the wound initially and at the point of final healing. This rate of healing was measured at the two time periods: first, during the summer vacation and, subsequently, during the high stress examination period. The healing rate during the high stress period was 10.91 days versus 7.82 days during vacation. Thus, wounds placed three days before a major test healed an average of 40% more slowly than during summer vacation. Beyond looking at group data, the authors note that this slower pattern of healing during stress was uniform across all participants. Certain measures of immune function were also investigated during the course of the study. It was found that there was a 71% decline in certain immune cell indices from the low stress assay period to the high stress assay (see Marucha et al., 1998 for details). This study extended previous research in demonstrating that delays in wound healing can occur in response to acute stressors (the examination) similar to what was found in groups who are chronically distressed (Alzheimer’s caregivers).
As pointed out by Kiecolt-Glaser et al. (1998, p. 1209), the results of these studies have “broad implications for surgical recovery.” The combined results from this series of studies demonstrate that surgical patients who have been under chronic stress are at risk for slower wound healing as well as infection due to immunosuppression; further, the short term stress of going through the surgery process, in and of itself, has the potential to hamper wound healing. These findings have special implications for the chronic back pain patient who chooses to undergo spine surgery. That individual’s immune system is confronted not only with the stress of chronic pain, but also with the situational stress of the surgery.
Virtually all surgical procedures are associated with mild to severe postoperative pain. An important area of PNI research is whether pain contributes to neuroendocrine and immune function changes. In animal studies, painful stressors that do not cause tissue damage (such as foot shock and tail shock) have been shown to suppress immune function including NK cell activity, lymphocyte proliferation responses, and specific antibody production (Pezzone, Dohanics, & Rabin, 1994; Liebeskind, 1991). Neuroendocrine changes have also been demonstrated including elevated corticosteriod (Pezzone et al., 1994) and plasma beta-endorphin levels (Sacerdote, Manfredi, Bianchi, & Panerai, 1994).
There are significant neuroendocrine and immune responses to tissue damage (such as surgery), and these have been extensively researched as outlined previously. Beyond the tissue damage, research suggests a connection between the sympathetic nervous system (SNS), the hypothalamic-pituitary-adrenal (HPA) axis, the sympathetic-adrenal-medullary axis (SAM), and the immune system (Keicolt-Glaser et al., 1998; Koltun, Bloomer, Tilberg, Seaton, Ilahi, Rung, Gifford, & Kauffman, 1996; Miller et al., 2002) in response to painful stress such as surgery. SNS and HPA axis activation postoperatively is reflected by elevations in plasma levels of epinephrine, cortisol, and beta-endorphin (Salomaki, Leppaluoto, Laitinen, Vuolteenaho, & Nuutinen, 1993). In addition, immunosuppression during surgery is evidenced by a decrease in NK cell activity (Pollock et al., 1991), lymphocyte proliferation, and changes in the lymphocyte population (Tonnessen, et. Al., 1987).
Although these results cannot firmly verify the role of pain as a factor in neuroendocrine and immune changes in response to surgical stress, there are further findings that support such a conclusion (see Kiecolt-Glaser & Glaser, 1998; Page, 1996 for reviews). Multiple studies have demonstrated that anesthetic techniques used to block transmission of nociceptive impulses locally (Pasqualucci, Contardo, Da Broi, Colo, Terrosu, Donini, Sorrentino, Pasetto, & Bresadola, 1994), at the spinal cord level (Koltun et al., 1996; Salomaki et al, 1993; Tonnessen & Wahlgreen, 1988), or through systemic anesthetic (Anand, Sippel, Aynsley-Green, 1987; Kehlet, 1984) significantly reduces the neuroendocrine or immune response to surgery. Further, at least two prospective studies have found that epidural anesthesia was associated with a significant reduction in the incidence of postoperative infections, suggesting immune function suppression may have been blocked (Cuschieri, Morran, Howie, & McArdle, 1985; Yeager, Glass, Neff, & Brinck-Johnsen, 1987). This would seem to indicate that adequate pain control via the epidural anesthesia resulted in attenuation of the immunosuppressive effect of surgery. In other research approaches to this issue, successfully controlling postoperative pain with systemic opioids has been associated with a reduction in plasma cortisol levels (Moller, Dinesen, Sondergard, Knigge, & Kehlet, 1988), and pain control with narcotic anesthesia has been shown to suppress the hormonal response to surgery (Lacoumenta, Yeo, Burrin, Bloom, Paterson, & Hall; 1987). Taken together, this line of research does suggest that adequate pain control helps attenuate deleterious neuroendocrine and immunological reactions to surgery. Unfortunately, postoperative pain control is commonly inadequate and a preparation for surgery program can help successfully address this problem.
As previously reviewed, several variables affecting the neuroendocrine and immune systems have been investigated as they relate to the final common pathway of wound healing and surgical recovery. These include stress (both acute and chronic), the physical trauma of surgery, and resulting tissue damage, as well as pain. In the following section, the mechanisms by which health behaviors and health status influence wound healing will be explored. One important overall finding to keep in mind is that heightened distress, such as facing a surgery, is associated with an increase in risky behavior across all dimensions, such as alcohol and cigarette use (Steptoe, Wardle, Pollard, Canaan, & Davies, 1996). Many patients faced with a stressful situation will utilize more self-destructive coping techniques. These health habits, as well as the surgery process, interact with health status (such as age and physical deconditioning) to impact healing and recovery.
An impending surgery can be quite stressful for the patient depending on the extent of the operation and the “meaning” the procedure carries with it. For instance, looking forward to a hernia repair is quite different from something like a spinal fusion or coronary artery bypass surgery. Patients who are preparing to undergo a spine operation are often under acute, situational stress associated with the surgery process as well as more chronic stress related to the impact their back pain has had on their lives. As an example, the following scenario is not uncommon in the treatment of spinal disorders.
A patient has a back pain problem that is initially treated conservatively using appropriate interventions (e.g. medications, physical therapy and exercise, epidural blocks). During this time, the patient’s overall level of function may diminish including both work and recreational activities. Once it is determined that the conservative measures will not provide a solution, the surgery option is entertained more seriously. By that time, the patient may be under a variety of psychosocial stressors due to the chronic pain (physical and mental deconditioning as discussed in Gatchel, 1991; 2004).
Patients will occasionally resort to increased alcohol intake as a mechanism for coping with the ongoing stress and/or as a method of self-medicating for pain, sleep, and anxiety. Alcohol has been found to slow wound healing directly due to a slowing of cell migration and deposition of collagen at the wound site (Benveniste & Thut, 1981). There are several other alcohol effects that can influence the body’s ability to heal from a surgery including sleep disruption, increased depression and anxiety, increased smoking behavior due to diminished impulse control, poor nutrition, subclinical cardiac dysfunction, and amplified endocrine changes in response to surgery (Kehlet, 1997; Kiecolt-Glaser et al., 2002; Miller et al., 2002).
As demonstrated in a myriad of studies (see Porter and Hanley, 2001 for a review), smoking (especially chronic) causes a host of problems related to wound healing and surgery outcome. Some researchers have speculated that smoking impairs wound healing after surgery primarily due to a decrease in blood flow to the injured tissues (vasoconstriction) and moderate blood levels of carbon monoxide (Leow and Maibach, 1998; Mosely and Finseth, 1977). In other studies, nicotine has been shown to affect a variety of other bodily functions that relate to wound healing such as a decrease in the proliferation of cells within the extracellular matrix and epithelial regeneration (Sherwin and Gastwirth, 1990). In addition, Jorgensen, Kallehave, Christensen, Siana, & Gottrup (1998) have demonstrated that collagen synthesis was hindered in the wounds of smokers relative to a nonsmoking control group. Collagen is the primary determinant of the flexible strength in a wound that is healing. Silverstein (1992) discussed that smoking diminishes proliferation of fibroblasts and macrophages, causes vasoconstriction that reduces blood flow to the injured tissue, and can inhibit enzyme systems for oxidative metabolism and transport. This decreased availability of nutrients important for wound repair, along with the immune system suppression, results in slowed healing time among smokers along with an increased rate of postoperative infections (Silverstein, 1992).
As previously reviewed, smoking can affect the outcome of virtually any type of major surgery. To review in more detail the potential deleterious effects of smoking on surgical outcomes, the area of spine surgery is certainly applicable. Spine surgery is done fairly frequently in the United States and is most often an elective procedure directed at pain relief. Preparation for spine surgery can enhance outcome; smoking cessation may be one goal of the intervention. There are several studies specifically related to smokers and spine surgery. Some investigators believe that in long-term smokers, the intervertebral discs are malnourished due to the vascular and hematologic changes (Ernst, 1993). It is postulated that tissues such as the vertebra and vertebral disc have a limited blood supply anyway and are not able to compensate for the decrease in blood flow that occurs in chronic smokers. Over time, the diminished delivery of oxygen and nutrients to these spine structures leaves them more vulnerable to injury and less able to heal after a surgery.
Hanley and Shapiro (1989) found that there was a negative impact on the postoperative success of lumbar discectomies to treat severe radiculopathies in patients who were very chronic smokers of 15 years or more. It is also believed that smoking may lead to a higher rate of postoperative wound infections (Calderone, Garland, Capen, & Oster, 1996; Capen, Calderone, Green, 1996). Thalgott, Cotler, Sasso, LaRocca, & Gardner (1991) retrospectively reviewed 32 cases of spinal surgery and found that, in the group of patients who sustained an infection after spinal fusion and instrumentation, 90% were cigarette smokers. Of special importance to the field of spine surgery is the effect of smoking on the healing of bone since this specifically relates to a patient’s recovery from a spinal fusion. Brown, Orme and Richardson (1986) reported that the pseudoarthrosis (non-union) rate for spinal fusion patients approached 40%. This compares with a rate of 8% in nonsmokers in the same study. Carpenter, Dietz, Leung, Hanscom, & Wagner (1996) subsequently found that the rate of repeat spine surgery due to a pseudoarthrosis was significantly less for nonsmokers.
There are a variety of explanations for these results. As discussed earlier, one idea is that smoking causes vasoconstriction that diminishes the blood supply to the area of bone growth. Another theory is that smoking impairs osteoblast function, resulting in defective bone healing (de Vernejoul, Bielakoff, & Herve, 1983). Campanile, Hautmann and Lotti (1998) suggest that that there are a variety of negative effects due to smoking that hamper bone growth including the vasoconstrictive and platelet-activating properties of nicotine, the hypoxia-promoting effects of carbon monoxide, and the inhibition of oxidative metabolism at the cellular level by hydrogen cyanide.
If a spinal fusion is being considered in a patient who smokes, there are no clear guidelines about preoperative cessation of cigarette consumption (Porter & Hanley, 2001). Suggestions range from at least 12 hours before surgery to 60 days. The recommendation for at least 60 days is based upon studies showing a nonsmoker can make 1 cm of bone in two months, but that it takes a smoker an average of three months to make the same amount of bone (Whitesides, Hanley, & Fellrath, 1994). Of course, it is also important that the patient remain abstinent from smoking postoperatively while the fusion is healing. This issue would also be part of surgery preparation.
Physical deconditioning or deactivation syndrome can occur when a patient with a chronic pain problem (e.g. back pain) or physical disability attempts to manage the pain by limiting normal activities, restricting exercise, and/or engaging in extensive bedrest. The deconditioning syndrome can result in a number of unhealthy occurrences affecting virtually every body system including (See Bortz, 1984):
These negative effects have an impact on a person’s ability to heal and recover from a surgery. In addition, healing tissue that is completely immobilized postoperatively tends to become an amorphous, nonfunctional scar with low strength and a vulnerability to re-injury (see Gatchel, 1991; 2004). This is one reason that, in appropriate cases such as orthopedic surgery, surgeons recommend some type of movement on a regular basis beginning very shortly even after a major surgery. Of course, the movement guidelines are designed to facilitate the healing process without putting the surgery results at risk. When done properly, this allows the tissues to heal in a more flexible and strong manner.
As a person gets older, there is an increased risk associated with surgery. As discussed by Segerstrom and Miller (2004), the flexibility of the immune system can be compromised by age and disease. In the area of psychoneuroimmunology, several factors appear to be involved (Kiecolt-Glaser et al., 1998, 2002). First, immune function – in particular, the action of the cellular immune response – diminishes with age (Verhoef, 1990). With this diminished immune response, the older patient is more susceptible to infectious complications. In fact, infection is one of the primary factors for surgical mortality in the elderly (Thomas and Ritchie, 1985).
To further complicate matters, it appears that depression and distress interact more strongly in the elderly person to promote immune system down-regulation. Several studies have demonstrated that older adults show greater immunological impairments in response to stress or depression relative to a younger population (Herbert & Cohen, 1993; Kiecolt-Glaser et. Al., 1996; Segestrom & Miller, 2004). Linn and Jensen (1983) compared older and younger adults on a number of immunological variables prior to elective surgery and postoperatively. It was found that the two groups did not differ immunologically prior to the surgery, but the older group showed more depression of the immune response after surgery relative to the younger group. Of course, older persons are more likely to have other medical problems and these can also influence recovery from a surgery.
The field of PNI seeks to explain how a variety of factors can have negative effects on wound healing and surgery outcome. PNI research can also help explain how psychological preparation for surgery enhances outcomes. The area of PNI research is likely to continue to provide exciting and useful findings in the area of surgery preparation. Having an understanding of this area provides the clinician with a firm rationale for its use that can be presented to both patients and professionals involved in all areas of surgery.
The clinical research literature has extensively documented that psychological preparation for surgery can significantly enhance outcome. Over the past 30 years, more than 200 research studies with thousands of patients investigating psychological preparation for surgery have found the beneficial effects listed in Table 2-1 (see reviews by Contrada, Leventhal, & Anderson, 1994; Deardorff & Reeves, 1997; Devine, 1992; Johnson & Clare, 1993; Johnston & Vogele, 1993; Johnston & Wallace, 1990; Mumford, Schlesinger & Glass, 1982; Prokop, Bradley, Burish, Anderson and Fox, 1991; Suls & Wan, 1989).
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Table 2-1: Beneficial effects of preparation for surgery interventions |
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Two excellent reviews of surgery preparation research are the meta-analytic studies of Johnston and Vogele (1993) and Devine (1992). Johnston and Vogele (1993) identified 38 preparation for surgery outcome studies that met specific design criteria including random assignment. Studies were grouped into type of intervention: procedural intervention, sensory intervention, behavioral instruction, cognitive intervention, relaxation, hypnosis, and emotion-focused intervention. Outcomes were assessed across a number of variables. It was found that “significant benefits can be obtained on all of the major outcome variables that have been explored” (p.252). Outcomes were assessed under eight general categories: negative affect, pain, pain medication, length of stay, recovery, physiological indices, satisfaction, and costs. The authors concluded that, “There is now substantial agreement that psychological preparation for surgery is beneficial to patients” (p. 245).
In two sequential investigations, Devine and Cook (1986) and Devine (1992) completed a meta-analysis on 102 and 191 studies, respectively. Inclusion criteria were an experimental design in which a psychological and/or educational intervention for surgery preparation was completed on adult patients who were to be hospitalized for elective surgery. Outcome measures included such items as length of stay, medical complications, respiratory function tests, and resumption of activities. It was found that patients receiving surgery preparation techniques generally did better than controls on all outcome dimensions.
As reviewed previously, PNI research has shown that the physical stress of surgery is considerable and can cause significant body reactions that may impair healing. As discussed by Horne, Vatmanidis, & Careri (1994), “Invasive medical and surgical procedures can be extremely distressing and can adversely affect the patient’s ability to cope, even when the actual procedures are not a real threat in a medical or biological sense” (p. 5). Thus, even if the surgery has a high probability of a positive outcome, there are often negative individual and social effects. Deleterious physical, emotional, and economic consequences of the surgery are experienced not only by the patient, but also by her family, friends, and work associates (Contrada, Leventhal, and Anderson, 1994). Any treatments that can help address the negative effects of the surgical experience are important to pursue.
In the United States, well over 50 million surgeries are performed each year. Of these, approximately 20 percent are in response to an emergency situation and 80 percent are considered “elective.” An elective surgery is one in which the patient and/or surgeon can choose when and where to complete the operation. Elective surgeries can range from being “optional” such as removing a wart, gastric bypass, most spine surgeries, or cosmetic surgery to “necessary” such as tumor removal, coronary artery bypass, hernia repair, hysterectomy, Caesarean, and some spinal surgeries. Table 2-2 illustrates some of the most common elective surgeries.
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Table 2-2: Common Outpatient and Inpatient Surgeries |
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Abdominal and Lower Back Surgery
Neck Surgery
Female Reproductive System
Male Reproductive System
Cosmetic Surgery
Surgery to the Head
Heart Surgery
Arm and Leg Surgery
Surgery to the Chest
Surgery Inside the Skull
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Psychological preparation for surgery might be appropriate for any elective procedure in which there is time to plan ahead for the intervention. Surgery preparation meets a number of important needs. First, the physical and emotional stress of surgery can negatively impact the outcome; there are a number of psychological interventions that have been shown to alleviate these effects. Second, the health care system is changing in a way that will make the surgery preparation interventions even more important. There is a significant trend towards outpatient surgery, placing much more responsibility on patients and their families to complete pre- and postoperative activities that would have previously been done by the hospital staff. This trend is occurring for all types of surgery, many of which would never have been done on an outpatient basis just a few years ago.
Both the United States and Great Britain (see Contrada et al., 1994; Mitchell, 1997), have seen an increase in the number of outpatient surgeries. For instance, well over half of all surgical procedures in the United States are now performed on an outpatient basis, and this number is rising (for current statistics see Ambulatory Surgery in U.S. Hospitals, 2003). This trend is driven by several factors. In the United States, one of the primary factors has been to reduce skyrocketing healthcare costs. By moving away from the traditional fee-for-service delivery of healthcare, the managed care systems can control inpatient admissions and shift as many procedures as possible to same-day surgery programs. Since approximately three-quarters of all Americans with health insurance are enrolled in some type of health maintenance organization (HMO), this is a formidable group. Beyond reducing costs, other factors fueled this movement towards outpatient surgery. These include technology development, improvements in pain medication and anesthesia, and patient-related factors.
In the past 25 years, multitudes of surgeries have become easier and safer to perform due to technology advances in surgical procedures that result in much less invasiveness. Imaging techniques, such as magnetic resonance imaging (MRI) and computerized tomography (CT) scans, allow a much greater ability to identify problem areas preoperatively, making the surgery process much more efficient. Microscopic techniques have greatly decreased the invasiveness and level of tissue damage during the operation. Other advances that have also decreased the level of invasiveness and/or made the surgery more accurate include the use of lasers, fluoroscopy, and arthroscopic techniques.
In the earlier days of surgery, the use of general anesthesia required that a patient had to stay in the hospital to be carefully monitored for post-anesthesia nausea and vomiting. Advances in general anesthesia over the past several years have decreased risk overall and diminished these types of side effects. Newer, faster-acting agents do not cause vomiting and these current drugs have a much shorter recovery time. In addition, longer acting local anesthetics can be directly injected into the incision sites resulting in improved acute postoperative pain control. Once the patient is discharged from the outpatient surgery center, improvements in pain medications (both oral and other methods of delivery such as the transdermal patch) have made them more effective, safer, and easily monitored on an outpatient basis.
All other things being equal, most patients would choose to undergo an outpatient surgery rather than an inpatient operation since hospital stays can be disruptive in so many ways (being away from family, missing more time at school or work, etc.). When an individual undergoes an outpatient surgery (versus an inpatient admission), there are often several benefits, including a shorter waiting time in terms of getting the surgery scheduled (which means less preoperative anxiety), the ability to recuperate postoperatively at home (which is preferred by most patients), and outpatient surgeries consistently report fewer postoperative infections than inpatient surgeries, likely due to the fact that patients are not exposed to bacteria normally present in the hospital (Benson, 1996; Cohen, 1995).
Even with all the positive aspects of outpatient surgery, there are many potentially negative factors that particularly relate to the issue of preparation for surgery. When undergoing an outpatient surgery, the individual patient and her family must assume a significant portion of the pre-surgical preparation and post-surgical care (Eddy & Coslow, 1991). Information about postoperative activities must be not only understood by the patient, but also fulfilled properly. In the past, much of this was the responsibility of healthcare providers within the hospital setting. This might include such things as medication regimen, physical activity requirements, and restrictions. Two types of surgery that are being done more and more on an outpatient basis are spinal procedures including fusions (single level) and bariatric procedures. Examples of postoperative instructions for these operations can be seen in Tables 2-3 and 2-4. In Table 2-3 postoperative instructions are presented for a spinal fusion (adapted from guidelines available through The North American Spine Society).
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Table 2-3: Example Post-Discharge Patient Instructions After Spinal Fusion |
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Care of your incision
Activity
When to call the office
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In Table 2-4, postoperative instructions are presented for after a bariatric surgery (adapted from guidelines available through The American Society for Bariatric Surgery).
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Table 2-4: Discharge Teaching after Bariatric Surgery |
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Nutrition
Activity
Wound Care Medications Analgesics
Symptoms to Report
Follow-up visits
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Clearly, some of the postoperative instructions might be difficult for the patient to understand fully, and adequate compliance is often an issue. As will be reviewed, psychological preparation for surgery specifically targets helping patients to understand and follow through on postoperative instructions.
A preparation for surgery program will often involve multiple components such as a variety of cognitive behavioral techniques (e.g., information gathering, cognitive restructuring, various types of relaxation training). In the early research, many studies attempted to parcel out the active components of a surgery preparation program by comparing one technique against another, or a combination of techniques compared with a single approach (Deardorff, 2000; Horne et al, 1994; Prokop et al, 1991). Generally, it has been found that a combination of approaches is more effective when compared to a unilateral intervention. Having some understanding of psychological preparation for surgery conceptual models is important since these guidelines will determine the approaches to individual patient assessment and treatment.
Psychological preparation for surgery programs have been based upon a variety of different “models” including:
As shall be seen, there is a great deal of overlap amongst these models. The list presented here progresses from the least to the most comprehensive interventions. Therefore, the approaches presented at the beginning of the list are generally contained within those near the bottom.
The idea that providing patients with realistic information about their surgery (compared to those less informed) will improve outcome can be traced to Janis (1958; 1971). Subsequent studies have generally demonstrated a positive correlation between preoperative surgical knowledge and postoperative outcome (see Prokop et al, 1991; Shuldham, 1999 for reviews). Studies have identified two different types of information that might be provided – procedural and sensory. Procedural information consists of basic information about the surgery experience including preoperative activities, events that would occur during the hospital stay, and postoperative recommendations. Sensory information has often been added to the procedural information in an attempt to enhance the outcome. Sensory information describes what sensations the patient can expect throughout the surgery experience, including what he will feel, hear, taste and see.
Although the provision of procedural and/or sensory information has usually been found to enhance surgical outcome, this is not a consistent finding. Researchers have speculated that the reason for these inconsistencies may to due to the patients’ individual coping styles in response to a stressor such as impending surgery. Studies have focused on a coping dimension of information-seekers (also called sensitizers, copers, or monitors) versus information-avoiders (also called repressors, avoiders, or blunters). Information-seekers typically respond to a stressful situation by gathering detailed information about it, while information-avoiders will do just the opposite (see Miller, 1987; 1992; Miro & Raich, 1999; Prokop et al, 1991, for reviews).
A number of studies have investigated how a patient’s coping style (information-seeking vs. information-avoiding) affects preparation for surgery (see Miro & Raich, 1999 for a review). It has generally been found that patients do best when the amount and detail of pre-surgical information provided matches their individual coping styles. There is some indication that providing information in a manner that is inconsistent with the patient’s coping style (e.g. providing detailed information to an information-avoider) can actually have deleterious effects (see Prokop et al. 1991 for a review).
Preoperative education is an expansion of the simple information provision approach to surgery preparation. Preoperative education or teaching is defined by Devine and Cook (1986) as providing the patient with health related information, psychosocial support, and the opportunity to learn specific skills in preparation for surgery. Preoperative education programs might include a number of components: provision of information, interactive education done either individually or in groups, inclusion of family members, and teaching of specific skills helpful for recovery. Several meta-analytic reviews have demonstrated the beneficial effects of preoperative education on surgery outcome (Hathaway, 1986; Devine & Cook, 1986; Devine, 1992; Shuldham, 1999).
Depending on the definition used, preoperative education approaches may or may not include cognitive-behavioral (CB) techniques. For the purposes of this discussion, CB approaches will be treated separately and formulated as an expansion of the preoperative education techniques. CB preparation for surgery programs are primarily designed to teach patients self-control strategies that will decrease the stress, anxiety, and pain associated with the surgery experience (see Contrada et al., 1994; Prokop et al., 1991 for a review). CB approaches use a variety of techniques such as cognitive restructuring and deep relaxation training. The cognitive interventions are based upon the premise that a patient’s thoughts about the surgery will determine the amount of emotional and physical stress experienced. Thus, changing a patient’s maladaptive thoughts is one means of reducing stress. Cognitive restructuring is a way of helping patients to identify “unhealthy” or “irrational” thoughts, and combating or substituting these with “coping” or “healthy” thoughts. It is based upon the early work of Ellis (1975), Beck (1979) and Meichenbaum (1977). Cognitive restructuring is also referred to as changing an individual’s “self-talk.” Turk (2002) has summarized the five assumptions that characterize the cognitive behavioral treatment approach:
The behavioral component of CB approaches primarily focuses on teaching patients self-regulating techniques that induce a state of deep relaxation (also termed the “relaxation response”). The specifics of these methods will be reviewed later. Briefly, they include such things as breathing exercises, hypnosis, progressive muscle relaxation, or other techniques to induce a physiological state of deep relaxation. The relaxation response is associated with positive physiological results that can enhance wound healing and surgical outcome. A variety of studies have found CB surgery preparation program can provide numerous positive outcomes, many of which have been discussed previously (See Devine, 1992, Horne, Vatmanidis & Careri, 1994; Johnston & Vogele, 1993, Prokop et al., 1991 for reviews). The details of a cognitive restructuring approach relative to surgery patients will be discussed in the next chapter.
Although extensive research has demonstrated the benefits of preoperative education and CB programs, the psychological mechanisms by which these effects occur are not exactly clear (Pellino, Tluczek, Collins, Trimborn, Norwick, Kies & Broad, 1998; Oetker-Black & Taunton, 1994). The theoretical concept of self-efficacy (and the related idea of empowerment) has been applied to the area of surgical preparation in an effort to explain positive outcomes. These concepts have also guided the expansion of the preoperative education and CB approaches.
Self-efficacy has been researched in the psychological literature for quite some time since originally formulated by Bandura (1977). According to this theory, “expectations of personal efficacy determine whether coping behavior will be initiated, how much effort will be expended, and how long it will be sustained in the face of obstacles and aversive experiences” (Bandura, 1977, p. 191). Self-efficacy is a belief that one can effectively perform a given behavior and that the behavior will result in desired outcomes. Importantly, motivation and perseverance in performing specific behaviors is dependent on the individual’s evaluation her self-efficacy. If the individual does not believe that the behavior can be performed, motivation and perseverance decrease. Thus, self-efficacy mediates the relationship between knowledge and action. In the simplest terms, there are three basic tenants of self-efficacy theory: 1) self-efficacy is situation specific; 2) self-efficacy can be altered through various means such as education, practice, and role modeling; and 3) increased self-efficacy can improve outcomes relative to specific behaviors.
Bandura (1977) postulates that an individual’s self-efficacy for a situation comes from four sources of information. Performance accomplishments are behaviors that the individual has actually performed or practiced. This source of information is the most influential for self-efficacy since it is based on personal mastery experiences. Verbal persuasion occurs when an individual is guided by suggestion into believing that he can perform the activity. Verbal persuasion is usually provided by someone who is perceived as an authority or expert in the area. Vicarious experience, or modeling, is obtained by seeing others similar to oneself perform the activity. Physiological states are information the individual receives from his level of arousal in response to the specific situation. For instance, if you experience a high level of physical arousal (e.g. anxiety) when thinking about a stressful situation you are facing (e.g. the surgery process), then you may be more likely to conclude that your ability to cope with it is low (diminished self-efficacy).
There is a substantial body of research demonstrating that enhancing self-efficacy (e.g. through educational programs) is related to improved health outcomes (See Bandura, 1991; Oetker-Black & Taunton, 1994; Pellino et al., 1998 for reviews). Perceived self-efficacy has specifically been found to improve coping with pain (Pellino & Ward, 1998) and compliance with recommendations after surgery (Bastone & Kerns, 1995; Mahler & Kulik, 1998). It has been hypothesized that many of the benefits of psychological preparation for surgery programs are actually due to the enhanced self-efficacy (Mahler & Kulik, 1998; Oetker-Black & Taunton, 1994; Pellino et al., 1998).
Although patient education programs for surgery have been investigated and implemented for many years, there has been a recent shift from the traditional medical model of patient education to more of an “empowerment” model (Pellino et al., 1998). Early preparation for surgery programs were based upon a traditional medical model, or “disease-based model” in which the healthcare provider is the expert who decides the content, amount and detail of the information that is provided to the patient relative to her surgery. In this model, the provider is the primary decision-maker and problem solver (see Pellino et. Al., 1998 for a review).
The empowerment model of patient education is based on the idea that health educators can assist patients in gaining knowledge, developing skills, and identifying resources relative to the surgery experience. Empowerment has been described as a process of enabling others to take control of their own lives (Pellino et al., 1998). In this process, patients are also taught to actively reassess various issues in an ongoing manner and modify their coping strategy accordingly. Thus, the patient will be taught to take appropriate charge of her own care on a daily basis (Anderson, 1995). In the empowerment approach, the teaching is interactive and the patient helps to determine the content of the surgery preparation program.
The concept of empowerment is closely related to the construct of self-efficacy; the differences are subtle. Self-efficacy is a belief that one can effectively perform a behavior and the behavior will result in the designated outcome. However, someone other than the patient might determine the “designated outcome” or goal. In contrast, empowerment encourages the patient to become an active participant in identifying and choosing healthcare related goals. Once these goals are established, the probability that they will be achieved is increased through enhancing self-efficacy. As portrayed by Pellino et al (1998), empowerment directly influences self-efficacy, which in turn, affects outcome.
The concepts of self-efficacy and empowerment are especially important given the increase in outpatient surgery that makes patients much more responsible for implementing their own preoperative and postoperative care.
As discussed by Contrada et al. (1994), two interrelated sets of theoretical principles derived from research in the areas of psychological stress (Lazarus, 1966; Lazarus & Folkman, 1984), illness cognition (Leventhal & Johnson, 1983) and social support (Cohen, 1988) can provide a conceptual framework for understanding how psychological interventions enhance surgical outcome. These are the principles of individual self-regulation and social self-regulation.
The principle of individual self-regulation involves “cognitive and behavioral activity whereby the patient influences the course of surgical recovery” (Contrada et al, 1994, p. 221). Individual self-regulation is an intra-personal process including cognitive (e.g., appraisal and coping) and emotional (e.g., level of arousal) components. As will be discussed in greater detail later, this coping process occurs in response to many different stressors that occur throughout different phases of the surgery experience and postoperative recovery.
For most patients, surgery is a significant stressor or threat since it is perceived as having the potential for severely negative consequences (Contrada et al., 1994; Lazarus & Folkman, 1984). This is reflected in the content and extent of patients’ worries about the surgery process (see Table 2-5 for a list of common fears; Deardorff & Reeves, 1997; Johnston, 1988). When first informed of the need for an operation, a patient will develop an internal “problem representation” of the surgical stressor. This problem representation defines the dimensions, features, and implications of the threat (or perceived danger) of the impending surgery. A patient’s problem representation has objective and subjective elements. The objective problem representation includes the patient’s perception of the “facts” about the surgery experience such as the mechanics of the operation itself, its effects on physical functioning, the projected recovery time, and behaviors that will be required for postoperative rehabilitation. The subjective problem representation is the patient’s emotional response to his objective problem representation. Subjective problem representation might include worry about being able to cope with the surgery, anxiety over the loss of function, and depression in response to perceived long-term deficits postoperatively
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Table 2-5: Patients’ Main Worries about Surgery |
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The amount of threat experienced by a patient is related not only to his or her appraisal of the danger implications of the surgery, but also how much the threat is buffered “by the perceived availability of personal and social resources to mitigate these dangers” (Contrada et al., 1994, p. 229). When the appraisal of the danger or threat is greater than the buffering resources, the result is a stress response. The self-regulation model has two important postulates related to surgery preparation interventions. First, it is the patient’s formulation of the surgical threat, and not that of the health care professional, that needs to be understood and modified. Second, if the patient can be provided with an accurate mental representation of the surgery experience, then she will have a reality-based framework to guide self-regulation (Contrada et al., 1994; Leventhal, Diefenbach & Leventhal, 1992).
Contrada et al (1994) also reviewed the area of patient coping activities. Coping activities by the patient will be determined by her problem representation of the threat of surgery. Coping involves two different types of individual self-regulation that correspond to the objective and subjective components of the problem representations (how the patient perceives the stress related to the surgery experience). Problem focused coping consists of efforts designed to deal with objective elements of the problem. Relative to surgery, problem-focused coping might include patient behaviors that enhance physical recovery and decrease the probability of complications such as engaging in range of motion exercises, practicing breathing procedures and, ultimately, returning to usual activities of daily living. Later on in the surgery recovery process, problem-focused coping may include resuming social, family, and occupational roles. Emotion focused coping refers to decreasing distress and other subjective responses. Pre-operatively, this might include controlling anticipatory anxiety and distress. Immediately following surgery, this might encompass such things as cognitive behavioral methods to diminish suffering and encourage emotional acceptance of temporary physical and social limitations. A preparation for surgery program should include components that teach patients both problem and emotion focused coping skills.
As the patient proceeds through the surgery experience, the problem representation and coping activity will be modified based upon ongoing appraisal. Appraisal is the process of modifying and updating the problem representation based upon new information from external sources, perceived changes in physical and psychological wellbeing, and evaluation of the effectiveness of coping procedures (Contrada et al., 1994). There are two types of ongoing appraisal – adaptive and outcome. In adaptive appraisal, after the various coping behaviors are completed, the patient assesses their effectiveness and outcome as compared to her own goals. Outcome appraisal is the patient’s evaluation of her progress (usually most salient postoperatively) as influenced by social comparison processes. It is important to note that social psychology research suggests patients will generally compare themselves to other patients who are recovering at a faster rate (termed, “upward comparison”; Contrada et al., 1994; Festinger, 1954).
Although it is possible that this upward comparison could result in the patient emulating successful coping strategies, it seems that negative consequences are more likely. Family members and patients may tend to select unrealistically successful models for social comparison purposes such as those who are younger, have had a less serious surgery, or have a less significant medical history (Taylor 1983). This type of upward comparison has the potential for the patient and family members to set unrealistic criteria for evaluating coping efforts and overall progress. Clinically, this is certainly seen in the area of postoperative spine rehabilitation. It is not uncommon for patients to begin making comparisons once they are released to begin postoperative physical therapy. In the spine rehabilitation setting, there are ample opportunities for this type of upward comparison and the negative effects are not infrequent.
The surgical experience can be divided into different phases, each of which has its own unique challenges and coping issues that will influence individual self-regulation. According to Contrada et al. (1994), the four general phases of the surgery experience include (I) the decision to have the surgery; (II) the preoperative testing, admission to the hospital and surgery; (III) the acute recovery either in the hospital or immediately postoperative at home; and (IV) the longer term postoperative rehabilitation issues. Across these four phases, there are four major issues related to adaptation to the surgical experience (Contrada et. Al., 1994, p.230):
These issues will vary in “relative salience” through the surgery experience. The physical danger and subjective/functional effects dominate during the period immediately surrounding the surgery while social role issues and long-term management issues become increasingly salient after the acute phase of postoperative recovery and over the long term. Each of these issues, within each of these phases, can be addressed as part of a psychological preparation for surgery program.
The interpersonal aspect of self-regulation (“social self-regulation”) comes from the premise that the social context in which the individual functions significantly determines the impact of a life stressor. As discussed by Contrada et al. (1994), social self-regulation involves exchanges between the patient and members of his social network (family, friends, and coworkers). Individual self-regulation is intrapersonal while social self-regulation is interpersonal.
Although a patient’s social network may consist of several levels, the primary support person (spouse, significant other, close family member) is often considered the most important and is investigated frequently in the clinical research. However, these principles might also apply to the larger social network, especially when the patient does not have a support person in the home to help with surgical recovery. Social self-regulation has two main components. Task-focused social self-regulation involves the surgical episodes as a stressor and describes interaction between the patient and caregiver that evolve around the task of understanding and coping with the surgery. Role-focused social self-regulation describes the social roles enacted by the patient and significant other(s).
Similar to the patient, the significant other will also have a set of adaptive goals and these will be interrelated, but different, from those of the patient. Even though both patient and partner will share the goal of optimizing the patient’s recovery from surgery, the task focus will differ for each individual due to their own specific mental representations of the problem. In addition, the partner does not have access to the patient’s internal experience related to the surgery process (e.g. level of pain and discomfort, thoughts about the surgery, worries, etc.). The partner, however, is in a unique position to either enhance or diminish the patient’s overall coping ability. A partner who has an accurate view of the surgery experience will likely help the patient develop a similar representation that will, in turn, aid the patient’s overall coping and achievement of adaptive goals. However, a partner who has inaccurate and unrealistic beliefs will increase the chances that the patient will also adopt a maladaptive view. Examples might include looking towards a surgery as a “cure” when it is not, the belief that the surgery will forever limit certain activities, and discrepancies in beliefs about the postoperative pain experience (as discussed by Contrada et al. (1994).
“In effect, the partner is a mirror in which the patient may see an image that exaggerates, minimizes, or more or less accurately reflects his or her medical status and emotional state. If these reflections bias the patient’s self-appraisal in either direction, before surgery, or at any stage of recovery, there is a risk of negative consequences including over/under-utilization of pain medication, too slow/rapid resumption of daily activities, and non-optimal timing in returning to work.” (p. 240).
An ongoing difference in views may be an obstacle to developing a cooperative approach for coping and can produce interpersonal conflict in other areas of the relationship. In addition, the partner’s evaluation of the patient’s coping efforts can either enhance or impede this ongoing process.
A patient’s partner can provide assistance in a variety of ways including tangible assistance, emotional support, and informational support (See Contrada et al., 1994, for a review). Tangible assistance includes direct efforts to assist the patient such as helping with health behaviors, activities of daily living, and/or work-related endeavors. Emotional support includes any efforts directed at reducing the patient’s worries and elevating his spirits. Informational support is the provision of suggestions that will help the patient cope more effectively with recovery tasks (e.g. pain management, doing prescribed exercises, resuming social roles and function). The manner in which the partner provides these different types of support will either enhance or inhibit recovery. The degree of discrepancy between the patient’s and partner’s mental representations of the problem will determine whether the support provided is appropriate or not. An example might be when the patient is seeking informational support about how to manage an acute pain flare-up and the partner provides emotional support instead. This could actually cause the patient’s situation to worsen by making the lack of ability to control the pain even more salient. The surgery episode has the potential to significantly impact the patient’s and partner’s social roles.
In summary, the surgical patient is often faced with the threat of significant disruption in a number of valued role areas: work function and career, as a parent and spouse, community involvement, recreational activities, gender-identity, and no long being a “well person.” The loss of role function may lead to depression and lowered self-esteem in the patient as well as placing additional strain on the social support systems that are already trying to cope with the surgery process itself. Further, in response to taking care of the surgical patient and responsibilities that he cannot perform, the partner may also experience role-loss such as occupational position, being a parent and/or spouse, community pursuits, and recreational activities. Partners who experience role loss over the long term can also develop their own low self-esteem, anger, depression, and resentment towards the patient for “causing the loss” (Contrada et al., 1994). For a complete and detailed discussion of psychosocial role adjustment see Cohen (1988), Contrada et al. (1994), Coyne and Delong (1986) and Perlin, Mullan, Semple & Skaff (1990).
During the surgical recovery process, the partner is likely to relinquish or modify various normal responsibilities and assume the caregiver role. For a variety of reasons (See Contrada et al., 1994; Coyne & DeLongis, 1986), the caregiver may become under- or over-involved in the patient’s recovery, either of which can have negative consequences. Caregiver under-involvement is due to the partner adopting a set of “goals” that are less than what is appropriate and required. This will prevent the partner from facilitating the patient’s recovery, requiring the patient to draw more on the support of others or on individual efforts. Caregiver over-involvement also results from the partner having a set of inappropriate goals based upon his own mental representation of the problem. Caregiver over-involvement can impede the patient’s recovery in many ways. It can lead to negative behaviors such as being overly aggressive in encouraging the patient’s recovery, slowing the patient’s resumption of activity by continuing to complete these responsibilities, and reinforcing the “sick role” by inappropriate nurturing. Further, a well-intended but overzealous caregiver can be perceived as intrusive, controlling, and critical which may strain the patient-partner relationship (Contrada et al., 1994). In some cases, a negative cycle situation may develop in which the partner/caregiver alternates between under-involvement and over-involvement depending upon interactions with patient behavior.
Consistency between the patient’s and partner’s mental representations of the surgical problem and efforts towards concordant adaptive goals is a critical element in recovery. Social self-regulation expands the concepts of surgery preparation beyond the individual to include the patient’s family, friend, coworkers, healthcare professional, and others, as appropriate. The model also underscores the importance of considering a patient’s social relationships as a target of intervention for surgery preparation.
As with many medical treatment programs, there has been a move from the strictly medical model to a biopsychosocial model over the past several years. A biopsychosocial model takes into account not only the physical aspects of the medical problem and surgery, but also the patient’s individual psychological make-up, coping resources, and social issues.
Any physical problem and treatment (such as surgery) can be conceptualized from a biopsychosocial perspective (Engel, 1977). Biopsychosocial concepts related to pain began with the formulation that the pain experience is impacted by higher order processes in the brain (Chapman, Nakamura & Flores, 1999; Melzack and Casey, 1968; Melzack and Wall, 1965; 1982; Sternbach, 1966). This conceptual model requires an investigation and understanding of the biological, psychological, and family-social factors influences related to the problem. The biopsychosocial approach can be thought of using an “open-systems” model of relationships that contains multiple feedback loops. (See Figure 2-1)
For example, interactions can occur in an almost endless number of ways among the following influences on surgical outcome:
The open system model describes how changes in any of the subsystems (e.g. the relationship between the patient and partner) may reverberate within all systems (e.g. the patient’s own health status, the emotional status and behavior of family members, etc.).
Figure 2-1. The biopsychosocial conceptual model of
the surgery experience. Adapted from Chapman et al. (1999, p. 43).
A biopsychosocial model of surgery preparation dictates that all aspects of the surgery and recovery experience are appropriate targets for intervention. The open mode of systems and subsystems also shows that any subsystem has the potential to exert a negative influence on the entire surgical recovery if appropriate intervention is not provided. For example, a surgery patient may successfully complete and utilize a surgery preparation program that focuses on cognitive-behavioral techniques (an intra-personal treatment focus) only to be faced with recovering in a family systems environment that is non-supportive, dysfunctional, and unhealthy. If the surgery preparation program does not assess the family environment and intervene as appropriate, the CB techniques will likely be doomed to fail (as would any other program that “missed” an important source of intervention and preparation).
Psychological preparation for surgery models have been developed using a variety of surgical experiences. As such, they can easily be adjusted to take into account the different coping and recovery challenges (cognitive, emotional, and physical), as well as the individual and family issues, presented in the case of any particular surgery. It is important for the clinician to be aware of the various surgery preparation models to successful designed treatment intervention for specific cases. In the next two chapters, a variety of surgery preparation components will be reviewed. These techniques, most often combined into a surgery preparation treatment package, are based upon the surgery preparation conceptual models discussed in this chapter.
The first part of a preparation for surgery intervention should include assessment of the patient. Having an understanding of common patient fears and worries (as presented in Table 2-5 in the previous chapter) can help guide the patient assessment (Johnson, 1988; Trousdale, McGrory, Berry, Becker & Harmsen, 1999). In addition, it is important to obtain an initial evaluation of the patient’s understanding of the surgery and related issues. This initial assessment can be completed by obtaining answers to the areas listed in Table 3-1 (Block, 1996; Deardorff and Reeves, 1997; Horne, et. Al., 1994).
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Table 3-1: Assessing the patient’s understanding of the surgery |
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These are very general categories of patient assessment. The preparation for surgery intervention actually represents a process of ongoing assessment and adjustment of intervention strategies, as dictated by the biopsychosocial model. Other important areas of assessment will be discussed under the various treatment components.
Just as there are many conceptual models of psychological preparation for surgery interventions, there are also a variety of methods for developing these types of programs. Differences occur across programs both in the structure (e.g., individualized, group, or a combination thereof) and in content or specific components (e.g., cognitive behavioral, relaxation training, music therapy). Surgery preparation programs that are individualized involve the patient working with a healthcare professional one-on-one (e.g., psychologist, social worker, nurse, health educator). In this approach, the preparation program is completely individualized and can be constantly modified and customized based upon patient issues that are presented. Although this can be a very effective approach, it is often not feasible due to cost, time constraints, and staff resources. Therefore, most surgery preparation programs offer a blend of individualized and group treatment with pre-formatted structured components. No research studies could be located that have investigated whether one approach works better than another does (e.g. individual vs. group).
Common psychological preparation for surgery program components that fall under the general category of cognitive-behavioral interventions will be reviewed. These might also be termed “individual self-regulation” approaches as discussed in the previous chapter. These are techniques that are implemented by the individual and directly target internal processes such as thoughts, emotions, and physiological status. The following chapter will review psychosocial interventions or those that might be term “social self-regulation.”
One of the core components of any psychological preparation for surgery program is helping patients gather relevant information about the surgery process. The information gathering is impacted by several factors including the coping style of the patient, the patient’s ability to understand and remember important medical information, and the doctor-patient relationship.
Information-seekers versus information-avoiders
The provision of information regarding surgery details has generally been found to enhance surgical outcome but this result is impacted by the patient’s coping style. As reviewed in the previous chapter, some patients are information-seekers while others are information-avoiders. For information-seekers, the general rule is “the more information the better.” Alternatively, information-avoiders do much better with only general information about the surgery experience and may even do worse if too much detail is provided. A very simple set of questions to assess a patient’s coping style relative to information gathering can be found in Table 3-2. In addition, actual measures that assess an individual’s information-seeking style have been developed (Miller, 1987). Prior to providing medical information, the patient’s coping style should be assessed in some manner.
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Table 3-2: Information-Seekers versus Information-Avoiders |
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Does the patient tend to agree or disagree with the following statements?
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Early research in surgery preparation demonstrated that patients who possessed accurate information about their surgery did better overall. Realistic information allowed patients to develop accurate expectations and coping strategies.
Later research showed that the provision of information was best tempered by the coping style of the patient. Patients who tend to agree with the above statements are “information-seekers” and do better with more specific and detailed information. Those who disagree with the above statements do better with very general information. The patient’s coping style relative to information gathering should be assessed in the early stages of surgery preparation and the intervention designed accordingly.
External locus of control and self-efficacy
In a recent study, the effects of patients’ external health locus of control (EHLC) and self-efficacy (SE) on surgery preparation for surgery outcomes were studied in a group of patients facing coronary artery bypass graft surgery (CABG) (Shelley & Pakenham, 2007). As discussed by Shelley and Pakenham (2007), and reviewed in this course, two general strategies have been used to improve surgical outcomes – information instruction and cognitive coping. The authors were interested in how a patient’s coping style might affect the successfulness of surgery preparation. EHLC refers to “the belief that outcomes in ambiguous health-related situations, such as CABG, are the result of powerful others, including doctors, other care providers, family and friends” (Shelley & Pakenham, p. 184). EHLC has been found to be a predictor of outcomes to CABG; lower levels of EHLC were associated with improved health outcomes. SE refers to the patient’s confidence in her ability to behave in ways that will lead to desired outcomes. Studies have related SE to improved patient participation in health care. Given these findings, Shelly and Pakenham (2007) hypothesized that patients who were “matched” on SE and EHLC (high on both, or low on both) would show improved outcomes in response to a surgery preparation program. Conversely, the researchers hypothesized the “unmatched” patients (one high and the other low) would be better off with standard care (no surgery preparation). The results are complicated but generally supported the hypothesis.
This study, and others to be reviewed later, underscores the importance of matching the surgery preparation program to the coping style of the patient. If a patient is an information-avoider with high EHLC (believes outcome is in the hands of the doctors) and low SE (low confidence that his own behavior can impact the treatment outcome), doing an intensive preparation for surgery program with a high level of education has a great likelihood of actually making the patient more distressed about the surgery.
Research has consistently demonstrated that surgical patients are dissatisfied with the amount of preoperative information that they receive (see Deardorff & Reeves, 1997; Pizzi, Goldfarb, & Nash, 2001; Webber, 1990 for reviews). In addition, even if information is provided, several problems have been found including the “readability” of the written information, patients’ level of understanding, and their recall for medical information.
Although the situation has improved somewhat since the Webber (1990) review, surgical consent forms often contain highly detailed information written at a level that is far beyond that which most patients can understand (Pizzi et al., 2001). Generally, it has been found that surgical informed consent documents are written at the level of a scientific journal or specialized academic magazine. Clearly, this is beyond the readability capacity of most laypersons facing a surgery. As concluded by Webber (1990), “in summary, written materials are desired and appreciated by patients; however, more attention needs to be given to producing them at a reading level appropriate to their intended audience” (page 1095). Possibly due to their frustration in attempts to understand the information, it has been found that about 40% or less of patients actually read surgical informed consent forms carefully (Deardorff & Reeves, 1997).
As an example of the “readability” problems, Christopher, Foti, Roy-Bujnowski & Appelbaum (2007) completed a review of 154 clinical mental health research studies that utilized informed consent forms. All forms were assessed using several standard “readability” formulas. The overall mean readability scores for the informed consent forms ranged from grades 12 to 14.5. In addition, the higher the risk of the study, the higher the mean readability score of the forms.
A review of medical informed consent studies reached similar conclusions (Pizzi et al., 2001). The results of the National Assessment of Adult Literacy survey in 2003 (http://nces.ed.gov/NAAL) are now being analyzed and published. Part of the 2003 survey included a measure of health literacy defined as, “the ability to use literacy skills to read and understand written health-related information encountered in everyday life.” Although it is beyond the scope of this discussion to define the complex classification system used in the survey, 75 million Americans are estimated to possess Basic and Below Basic health literacy skills with 114 million at the Intermediate level and only 12 million at the Proficient level. It is very unlikely that Americans with Basic or Below Basic health literacy (and probably the vast majority in the Intermediate group) would be able to read and comprehend most informed consent forms since they are written at a 12 to 15 years of education readability level (See Pizzi et al., 2001 for a review). Research findings in this area present serious problems for the practitioner in obtaining informed consent. Given these findings, one critical aspect of surgery preparation is to help the patient understand the operation and facilitate the informed consent process.
In addition to the readability of patient education materials, research has indicated that patients generally remember very little of the information presented to them regarding their surgery and this is true whether the information is provided in written or verbal form (see Deardorff, 1986; Ferguson, 1993; Shuldman, 1999; Webber, 1990 for reviews). This memory problem may be due to the nature of the information being presented, the fact that surgery patients are quite distracted due to the entire surgical experience process, or some other issues. Thus, although highly understandable and appropriate information may be provided to surgery patients, they may not recall this information.
It is not surprising that patients are often dissatisfied with the doctor-patient relationship and are reluctant to request information from surgeons, family doctors, or other healthcare professionals involved in the pre-surgical process. As part of a surgery preparation program, it is important to teach patients how to ask questions and where to go for answers. In the following chapter, simple assertiveness training techniques are reviewed; these will often be used in psychological preparation for surgery interventions. In addition, patients can be informed that they can get information from many sources, not just the doctor’s office (although that is the best place to start). Other sources might include the hospital, the library, governmental agencies such as the National Institute of Health (NIH), and the Internet.
In order to help surgery patients with the information gathering process, a variety of questions have been established as part of a more self-guided preparation for surgery program (See Table 3-3, adapted from Deardorff and Reeves, 1997). Patients can be taught to get these questions answered preoperatively as necessary for their particular surgery and from the appropriate information source (which may not always be the doctor’s office).
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Table 3-3: Questions patients can ask about their surgery |
About the Medical Condition and Surgery
Blood Transfusion
What to do Before the Surgery
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Inadequate informed consent has been the basis for successful lawsuits in surgery. Patients have made the case that if they had adequate informed consent, they would have not undergone the elective surgery or would have chosen some other treatment option (See Benton, 2001; Benzel and Benton, 2001). These cases were made even though the usual consent forms had been signed by the patients. As concluded by Benzel and Benton (2001, p. 33), “One of the main problems with the consent process is that it is just that – a process. Usually, it does not take place only during the final counseling of the patient regarding risks, benefits and alternative of an operation. To one degree or another, it takes place during each physician-patient encounter that precedes an operation.” Making sure a patient acquires accurate and understandable medical information is important to all areas of surgery practice and is part of the surgery preparation process.
With the explosion of the use of the Internet and medically-related websites, it is important to address this issue specifically with patients. The Internet can be a powerful tool in terms of medical information gathering related to any surgery. However, a strong caveat is in order relative to this information resource. There is a great deal of misinformation being promulgated through this media. In encouraging patients to gather information about their surgery, there need to be warnings about this issue. They should also be encouraged to review the type of information that they are gathering from the Internet with the healthcare professional managing the surgery preparation intervention.
Incorrect information can have deleterious effects on surgery outcome since the patient might develop unrealistic and inaccurate expectations. According to the self and social regulation models, patients would then “act” on this incorrect information. Judicious use of the Internet for information gathering is appropriate. In some cases (especially with information-seekers), it may be appropriate to discourage Internet access for the purposes of gathering surgical information. This might be appropriate when a patient becomes almost obsessed with gathering information about surgical options from different sources and viewpoints. The multiple conflicting messages, similar to getting five or ten surgical opinions, can reach a point of information “chaos” for the patient. Alternatively, patients might be guided to websites that are known to contain accurate information. Most of the Websites that are associated with University Medical Centers (e.g. ending in “.edu”), are maintained by governmental institutions (e.g. through the National Institute of Health, ending in “.gov”), or are associated with a professional organization (ending in “.org”) can be trusted as reliable sources of information. Also, those of professional organizations related to surgery are generally reputable and the information can be trusted. Examples include:
Cognitive techniques used in the preparation for surgery generally revolve around cognitive restructuring techniques. In addition, cognitive-behavioral interventions usually include some type of deep relaxation training. For the purposes of this discussion, we will also place hypnosis under the cognitive-behavioral category. The next section will provide a brief overview, along with a special emphasis on applicability to the surgery patient.
The philosophy of cognitive restructuring is guided by observations that were made in the very remote past. For instance, William Shakespeare in Hamlet stated, “there is nothing either good or bad, but thinking makes it so.” Ages before the time of Shakespeare, in the first century, the philosopher Epictetus stated, “Men feel disturbed not by things, but by the views which they take of them.” These principles have recently been rediscovered and refined (Beck, 1979; Ellis, 1975; Meichenbaum, 1977). Several basic tenets guide the cognitive restructuring approach:
Steps for preparing the pre-surgical patient for the cognitive behavioral approach include:
The more the patient accepts the rationale behind surgery preparation, the more likely she will embrace and practice the techniques.
The patient can be told that the cognitive behavioral model (and the method for changing one’s thoughts) has been termed the “ABCDE” model and can be a very useful tool in dealing with chronic pain. The specifics of the ABCDE model will be discussed shortly, but it is important for the patient to have an understanding of how thoughts and emotions operate. This was reviewed previously in terms that are more technical; the following presents a manner in which these concepts can be presented to patients.
We would all agree that we constantly have thoughts and images going through our head related to evaluating the world around us. In addition, we are constantly evaluating the sensations that are going on inside of us as well. These thoughts have been termed “automatic” thoughts because they often occur involuntarily, almost out of our awareness. Automatic thoughts have the characteristics of being very fast, virtually unconscious, and highly believable. As we shall see shortly, automatic thoughts have great power over our emotions and behaviors. At first, the nature of the automatic thoughts may not be readily apparent even though it is influencing your emotions and your body's health.
Many of the cognitive researchers have observed that individuals under stress have a tendency to engage in negative automatic thoughts. Negative automatic thoughts, or “self-talk,” have the following characteristics:
Facing a surgery can be a particularly stressful event, easily resulting in a cascade of negative automatic thoughts. Based on these findings, the ABCDE model was adapted to surgery preparation. The ABCDE model can be explained to the patient in the following manner:
A is the Activating Event or Antecedent Event, which is simply the event to which you are responding. This could be an outside event, such as sitting in a traffic jam, or an internal event, such as a severe pain.
B is your automatic thought or Belief about the activating event. For instance, your belief about being in the traffic jam might be, "Oh no, this is awful. I will never make the meeting in time. I should have left earlier." Alternatively, your belief might be "There's nothing I can do about this traffic jam. I'll take this time to listen to the radio and be as relaxed as possible. I'll leave earlier in the future."
In this traffic example, the first set of thoughts are negative automatic thoughts and the second set of thoughts are coping or rational thoughts. The difference in the makeup of these thoughts can certainly be seen and will be discussed more fully in a later section.
C is the Consequent Emotion that results from the automatic thoughts. Most people think that A causes C, but in reality, B causes C. A person's emotional response to a situation is caused by his beliefs about the situation and not by the situation itself.
D is the Disputing Thoughts that are used to change automatic negative thoughts. These are used to help change the way a person thinks about stressful situations from a negative standpoint to a coping standpoint. In working with patients on doing this exercise, we like to term this process the power of realistic thinking.
E is the Evaluation, using the disputing thoughts to challenge the negative automatic thoughts. This process will be discussed further.
The following simple examples will help the patient understand just how the ABCDE model operates.
EXAMPLE 1
Activating Event: You experience a mild increase in your heart rate and feel "uncomfortable and jittery."
Belief: I'm having a heart attack!!!
Consequent Emotion: Fear, anxiety, panic.
Resulting Behavior: Call doctor or go to emergency room.
In this situation, the symptoms are being interpreted as a possible heart attack. The subsequent emotions and behavior follow from this belief. Suppose an alternative belief was that, "I just drank four cups of coffee and the caffeine is causing the symptoms." With this explanation, the emotions and resulting behavior would be entirely different.
EXAMPLE 2
Activating Event: You hear a noise at the bedroom window in the middle of the night.
Belief: There is an intruder trying to get in.
Consequent Emotion: Fear, panic.
Resulting Behavior: Call police, hide, and grab a weapon.
Again, in this example, the emotions and behavior follow from the belief that there is danger. Alternatively, if the belief was that the noise was caused by the wind blowing a tree branch against the window, the emotional response and behaviors would be entirely different. It should be noted that in each of these examples, the situations prompting the beliefs are exactly the same. The only difference is how the information is interpreted by the person in terms of beliefs. These beliefs are what caused the emotional response and behavior, not the situation itself!
These examples illustrate how our thoughts influence our emotions and behavior. But how can use this information to help with surgery preparation? This is done through the use of the "three-column" and the "five-column" techniques. The power in using this approach comes from changing the negative automatic thoughts to "realistic, coping, and nurturing" thoughts. By changing the thoughts about the surgery experience, the patient can change her emotional responses and behaviors throughout the process.
The ABCDE model can be utilized in a three- or five-column technique. A three-column worksheet can be seen in Table 3-4. This allows the patient to begin to carefully identify negative automatic thoughts. Once this is mastered, the technique is expanded to a five-column technique to be reviewed subsequently.
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Table 3-4: The Three-Column Technique
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Activating Event |
Beliefs |
Consequent Emotions |
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Preparing for a major surgery after a chronic disability |
My body is weak and fragile. It will never be the same. |
Fear |
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My pain is going to get worse and worse. |
Anxiety and Hopelessness |
|
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I can’t handle this surgery. I hate the hospital. |
Fear and Anxiety |
|
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My family is going to leave me. |
Depression and Hopelessness |
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I should be better by now. The surgery didn’t work. I should never have allowed this to happen. |
Frustration, Anger, Guilt, and Helplessness |
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If I move the wrong way, I’ll do myself in. I’ll wait until the pain is gone, then I’ll exercise. |
Helplessness and Fear |
|
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There is nothing I can do during the surgery and recovery. It’s up to my doctor. |
Helplessness and Apathy |
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What if the surgery doesn’t work? I bet it won’t. I’m either cured or I’m not. |
Anger and Hopelessness |
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I feel worthless. The future looks awful. |
Hopelessness |
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The three columns represent the A, B, and C events discussed previously. It is useful to make several copies of a blank ABC worksheet in order to practice identifying activating events, beliefs, and consequent emotions. The three-column technique is a tool to enables the patient to run the automatic negative thoughts in slow motion. The patient can use the three-column technique to analyze thoughts and feelings whenever a stressful situation presents itself. An activating event can be any stressor, such as pain, a situation, a memory, or an interaction with another person. At first it can be difficult for the patient to "flesh out" the beliefs or automatic negative thoughts about a situation. Automatic negative thoughts often contain such words as should, ought, must, never, and always. As can be seen in the previous examples, phrases with these words are common in negative thinking. It is best to have the patient practice just the three-column technique for a week. In the follow up session, the chart should be reviewed to ensure that the patient understands the concepts and is being compliant with the charting. Any problems can then be resolved early on.
Negative thinking often takes on certain styles or patterns and these are important to identify and discuss with the patient. Briefly, these styles can be summarized as follows:
Over the years, cognitive researchers have identified a variety of “irrational” or negative styles of thinking. Although many of these negative styles have been identified, only the most common as applicable to the surgery patient will be reviewed. For further details regarding negative styles of thinking, the reader is referred to other sources (Beck, 1979; Ellis, 1975; McKay & Fanning, 1991; Meichenbaum, 1977).
Imagining the worst possible scenario and then acting as if that will actually happen characterize this type of negative thinking. It will often include a series of "What if's" such as:
In catastrophic thinking, the dire predictions are not based on facts but rather pessimistic beliefs.
This thinking style involves focusing on only the negative aspects of a situation to the exclusion of any positive elements or options. This type of negative self-talk has also been termed “tunnel vision” since it causes the patient to look at only one element of a situation to the exclusion of everything else. This style will commonly include searching for evidence of "how bad things really are" and discounting any positive or coping focus. Examples include:
Discounting and “Yes-Butting” often characterize this style of negative thinking. No matter what positive option or coping method is suggested, the person engaging in filtering will discount it with a "Yes-But". For instance, a person requires a surgical procedure that will cause a limitation in certain activities while also improving the person’s overall health and quality of life. When this is discussed as being very positive overall, the person retorts, "Yes, but I will have these limitations”. This type of thinking continues to foster helplessness, hopelessness, and depression.
This type of thinking amounts to seeing things either one way or the other, and has also been termed “all-or-nothing” thinking. In this style, there is no middle ground or shades of gray. People and things are either good or bad. Events and situations are either great or horrible. This type of thinking is typified by:
This type of thinking undermines any small steps towards improvement, severely limits one's options, and filters out any positive aspects of a situation.
This is the process of taking one aspect of a situation and applying it to all other situations. It involves generalizing reactions to situations in which such reactions are not appropriate. For instance:
As can be seen, this style of negative self-talk will take one incident and make it apply it to many other situations, resulting in the person reaching an incorrect conclusion. Overgeneralization is often indicated by such key words as all, every, none, never, always, everybody, and nobody.
This negative self-talk "trap" involves making assumptions about what other people are thinking without actually knowing. The person will then act on these assumptions (which are usually erroneous) without checking them out for accuracy. Examples of this would include:
If the patient accepts these assumptions as facts, then her behavior will follow accordingly, and will likely to create a self-fulfilling prophecy. For example, a patient’s spouse might ask, "How do you feel today?" Instead of taking his comment at face value, the patient believes he really means, "Are you still letting that problem bother you?" So the patient responds, "How do think I feel today? The same as always, that's how!" One can easily guess how this scenario would be completed.
"Should" statements are key elements in negative self-talk. In this style of negative self-talk, the patient operates from a list of inflexible and unrealistic rules about their own actions as well as those of others. Examples of such thinking include:
Should thinking also includes terms like ought, must, always, and never. Should thinking is judgmental and often involves an individual measuring his performance against some irrational perfect standard. It has the effect of making the patient feel worthless, useless, and inadequate. When directed at others, it will have the effect of making the patient feel angry and resentful in those relationships. As discussed in the previous chapter, the process of the “upward comparison” phenomenon in social self-regulation is the finding that patients may have a tendency to compare themselves with other patients who are “doing better.” This process might involve “should” irrational thinking (“I should be recovering as fast as he is…”).
In blaming, the person makes something or someone else responsible for a problem or situation. There is some comfort in being able to attach responsibility for one’s suffering to someone else. Unfortunately, blaming can often cause a person to avoid taking responsibility for his own choices and opportunity for improvement. This type of negative thinking is very often seen in cases of industrial injury, automobile accidents, or other such trauma. Examples include:
Blaming as a form of negative self-talk can be focused either externally or internally. Internally focused blaming (self-blame) takes on the form of, “It’s all my fault.” Self-blame is often an excuse for not taking responsibility and can lead to depression, hopelessness, and helplessness. Blaming can be very destructive in keeping the patient from focusing on what needs to be done to get better rather than whom or what is to blame.
As the patient practices identifying negative automatic thoughts, certain patterns will usually emerge. Most often, individuals will tend towards a certain style of negative automatic thinking. This can help identify future types of negative automatic thoughts. Once the negative automatic thoughts are identified, cognitive preparation for surgery involves helping the patient engage in challenging these thoughts as well as thought re-framing. Challenging negative self-talk can be accomplished by training patients to ask themselves the following questions:
Having the patient subject his self-talk to these questions will help identify negative versus positive (or coping) messages. After helping the surgical patient identify and challenge any negative self-talk, it is important to facilitate the process of substituting positive, realistic, or coping self-talk. These coping thoughts can be written down by in the thoughts and feelings diary and then practiced through rehearsal. Bourne (1995) has developed the following rules to help patients write positive coping self-talk statements.
When having patients write positive coping statements, teach them to avoid using negatives. For instance, instead of saying, “I can’t be nervous about going to the hospital,” a patient can say, “I will be confident and calm about going to the hospital.” The first type of statement can be anxiety-producing in and of itself, which will defeat the purpose of the coping thought.
Since most negative self-talk occurs in the here-and-now, it should be countered by coping thoughts that are in the present tense. Instead of a patient saying, “I will be happy when this surgery is over” she might say, “I am happy about _____ right now.” Teaching surgery patients to begin self-statements with, “I am learning to...” and “I can...” is very beneficial for cognitive restructuring.
Whenever possible, have patients keep their thoughts in the first person. This can be done by having patients begin coping thoughts with “I” or by being sure that “I” occurs somewhere in the sentence.
Coping thoughts should be based in reality. This will ensure that the patient will have some belief in his own coping self-talk. As a patient practices the positive self-talk, it becomes more and more believable. A person’s coping thoughts should not be broadly positive, Pollyannaish, and unrealistic; otherwise, the patient will completely discount them as untrue. For instance, the coping thought of “I can’t wait to have surgery. I’m sure I will completely enjoy the entire experience” is unrealistic and not believable. Rather, the thought, “I will be able make the surgery experience as positive as possible, and I will be looking forward to beginning the recovery process” is much more tenable.
Examples of positive or coping self-talk, which can challenge each of the negative styles, follow. These examples can be reviewed with patients to help them understand how the thought reframing process works. Also, see Table 3-5 for an example of how these coping thoughts directly combat negative self-talk:
For catastrophizing, the patient should be reminded that no one can predict the future. Tell the patient that it is probably in his best interest to predict a realistic or positive outcome rather than a catastrophic and “What if…” outcome. Explain to the patient that acting “as if” things will turn out OK is usually the best course of action.
If a patient is filtering out everything except the most negative aspects of a situation, she needs to learn to shift focus. First, teach the patient to redirect her attention to active strategies that can be used to make the situation more manageable. Help the patient look at the situation realistically rather than magnifying the negative aspects. Then, have the patient focus on the positive aspects of the situation. Patients should be encouraged to avoid the negative thought, “I can’t stand it.”
Thinking in Black and White will always set the patient up for disappointment since there will be no allowance for gradual improvement. The first step in changing this thinking is to help the patient identify when he is using absolute words like “all, every, always, never, and none”. The second step is to have the patient focus on how the situation may be changing in gradual steps. Lastly, remind the patient there are always different options, not just the two extremes of black and white.
In overgeneralizing, the patient is taking one element of a situation and applying to everything else. A patient can stop overgeneralizing by being reminded to evaluate each aspect of a situation realistically and independently.
Nobody can read another person’s mind although individuals often have the tendency to act as if it is possible. This causes a person to act and feel towards others based upon inaccurate conclusions. For instance, a patient might think, “I know my doctor doesn’t like me” based simply on “mind reading.” Remind patients that nobody can read another person’s mind and it is important to “check it out.”
If a patient has a propensity towards using the words should, ought, or must, then he is either self-discounting or is judging others by standards that are unrealistic. These types of statements seek to lower a patient’s self-confidence and self-esteem. To help patients evaluate when this is happening, teach them to ask themselves, “Is this standard realistic?”, “Is this standard flexible?” and “Does this standard make my life and situation better?”
If patients are tending towards self-blame, they should be reminded that they tried to make the best choice at the time and can continue to make healthy choices from now on. If they are blaming others, have them assess realistically how they went about making their choices and remind them of what aspects of the situation are in their control and realm of responsibility.
As can be seen from the previous examples, as well as the common surgical patient fears listed in the previous chapter, presurgical automatic negative thoughts are not uncommon and there are specific coping thoughts to address this aspect of surgical preparation.
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Table 3-5: The Five-Column Technique
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|
Activating Event |
Beliefs |
Consequent Emotions |
Disputing Thoughts |
Evaluation |
|
Preparing for a major surgery after a chronic disability |
My body is weak and fragile. |
Fear |
I can strengthen my body after surgery. There are techniques I can use to help with the pain. |
Less Fear and more confidence |
|
My pain is going to get worse and worse. |
Anxiety and Hopelessness |
I will strive to become as functional as possible. No one can predict the future |
More sense of control |
|
|
I can’t handle this surgery. I hate the hospital. |
Fear and Anxiety |
I can get through this. I can look forward to discharge and recovery. |
Less Anxiety, less hospital stress |
|
|
My family is going to leave me. |
Depression |
My family will help me especially if I help myself. |
More feelings of comfort/support |
|
|
I should be better by now. |
Hopelessness |
I will continue to work on getting better. |
Less Hopelessness, more Hopefulness |
|
|
The surgery didn’t work |
Frustration and Anger |
I will begin to move and exercise slowly. |
Less Frustration |
|
|
I should never have allowed this to happen. |
Hopelessness |
I did what I thought was right. |
More Optimism |
|
|
There is nothing I can do during the surgery and recovery. |
Helplessness |
I can participate in my own recovery. |
More Confidence |
|
|
What if the surgery doesn’t work? I bet it won’t. |
Anger |
No one can predict the future. |
Less Anger and more control |
|
|
I’m either cured or I’m not |
Hopelessness |
Small steps will lead to bigger ones. |
More Hopefulness |
|
|
The future looks awful. I feel awful. |
Hopelessness |
There are things I can do to lead a quality life. |
More Hopefulness |
|
Some of the correlates of the stress response that have been found to impede wound healing have been discussed previously. A common component of a preparation for surgery program is teaching patients the relaxation response. It is important to distinguish between the relaxation response and simply “relaxing.” Engaging in an enjoyable and sedentary activity may be relaxing, but this does not necessarily induce what researchers have termed “the relaxation response.” The relaxation response is a specific physiological state that is essentially the opposite of the body’s condition when it is under stress. The relaxation response was first described in the early 1970’s (Benson, 1975). Learning to elicit the relaxation response can only be achieved through regular practice of some type of relaxation exercise. Table 3-6 demonstrates the physiological difference between the stress response and the relaxation response. As can be seen, the relaxation response is directly incompatible with the stress response. Teaching patients to elicit the relaxation response is a powerful tool in preparation for the surgery experience. It is a tool that can be utilized by the patient both pre- and postoperatively It not only helps the patient manage various stressors, but also can help with pain control.
|
Table 3-6: A comparison of the stress response and the relaxation response |
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|
Physiologic State |
Stress Response |
Relaxation Response |
|
Metabolism |
Increases |
Decreases |
|
Blood Pressure |
Increases |
Decreases |
|
Heart Rate |
Increases |
Decreases |
|
Rate of Breathing |
Increases |
Decreases |
|
Blood Flowing to the Muscles of The Arm and Legs |
Increases |
Stable |
|
Muscle Tension |
Increases |
Decreases |
|
Slow Brain Waves |
Decreases |
Increases |
|
Adapted from Dr. Herbert Benson, 1996. |
||
There are many different types of exercises for learning the relaxation response. These include such things as breathing techniques, progressive muscle relaxation, visualization, and meditation. It is beyond the scope of this chapter to review the various types of relaxation exercises and the reader is referred elsewhere for more details (Davis, Eshelman, & McKay, 1995; Deardorff & Reeves, 1997; Goleman & Gurin, 1993). In choosing among the various possibilities that could be used as part of a surgery preparation program, there are a few guidelines to keep in mind. First, there is often not much time to complete a preparation for surgery program prior to the scheduled operation; therefore, the breathing technique should be easy to learn and practice. Second, the breathing exercise should be something that the patient can complete even during the postoperative phase of surgical recovery. For instance, some type of progressive muscle relaxation (in which the patient alternates between tensing certain muscle groups and relaxing) may not be feasible after a major surgery.
One of the most straightforward and simple to learn relaxation exercises is deep breathing. It allows the patient to learn relaxation quickly and easily with a minimum time commitment of daily practice. In addition, the deep breathing exercise can easily be placed on audiotape to help patients with their home practice sessions. An example of a deep breathing exercise for patients follows.
Example of a deep breathing exercise
Cue-controlled relaxation can help make the relaxation response even more useable for the surgery patient. In cue-controlled relaxation, the patient is taught to use a specific “cue” to signal the relaxation response. The relaxation cue could be anything, but is commonly a phrase (saying, “Relax”), a visual reminder, or a muscular signal. A very useable technique discussed by Deardorff and Reeves (1997) involves having the patient simply touch his thumb to his index finger while thinking about relaxing. This type of cue works well especially when the patient is in a situation where using a verbal or visual cue is not possible.
Cue-controlled relaxation is based on classical conditioning principles originally developed by Pavlov. In Pavlov’s original experiment in the early 1900’s, it was found that dogs would salivate in response to a bell or a light if the stimulus had previously been “paired” with the salivation response. Cue-controlled relaxation training works on the same principle. The critical component of cue-controlled relaxation is that the cue must be repeatedly paired with the relaxation response prior to being able to use the technique effectively. Thus, a patient might practice the deep breathing exercises for a week or to the point of being able to reliably elicit the relaxation response. Once the patient has achieved this level of mastery, the relaxation response can be paired to a specific cue. This is done by focusing on completing the cue while in a state of deep relaxation.
Cue-controlled relation is extremely beneficial as part of a preparation for surgery program. This skill can be used for a number of purposes including invoking the relaxation response in almost any situation, to help the patient refocus concentration on relaxing and coping, to help with the cognitive restructuring process, to help manage acute pain, and to help control nausea and vomiting (Deardorff and Reeves, 1997).
It should be explained to patients that learning the relaxation response is similar to acquiring any other skill: it takes practice. It is not uncommon for patients to attain deep relaxation when they do the exercise but have trouble making practicing it a priority. Regular practice is essential to firmly establish the relaxation response as a skill that can be used efficiently at any time. At the beginning of the learning the skill it may take the patient 20 to 30 minutes to achieve deep relaxation whereas, after practicing, it may take only a few deep breaths the accomplish the same result. As discussed by Deardorff and Reeves (1997), the following guidelines will help patients structure their relaxation practice and ensure that the skill is acquired in a timely manner.
Once or twice a day
It is important to have patients practice the breathing exercises once or twice per day. Practicing at least once per day is mandatory in order to learn to elicit the deep relaxation response. As they practices regularly, patients may find that the amount of time required to elicit the relaxation response decreases.
Quiet location
It is important for patients to practice the breathing exercises in a quiet location where they will not be disturbed or distracted. For instance, patients should be told not to allow the phone to ring while practicing or be able to hear outside distracting noises. It can often be useful for patients to use something like a fan or air conditioner to block out outside noise if that is a problem.
Give a five-minute warning
It can be useful to give to have the patient give other family members a five-minute warning when he begins breathing exercises. This can help a patient take care of "loose ends" prior to practicing the deep breathing. For instance, if a patient tends to be worried about a number of things "to do," it can be helpful to have him her make a short list prior to doing the relaxation exercise. This will help the patient be able to focus on the deep relaxation exercise rather than "trying to remember" what "needs" to be done after relaxing.
Practice at regular times
It is important to have patients set up regular practice times, as this will increase the likelihood or followthrough on deep relaxation exercises. These times should be when a patient is most likely to follow through on completing the exercises. The regular practice times should not be when the patient is so tired (for instance, right after a big meal or just prior to bed) that he is likely to fall asleep.
Practice on an empty stomach
As discussed above, practicing deep relaxation after a big meal increases the likelihood that a patient will fall asleep in the middle of trying to relax. In addition, the process of digestion after meals can disrupt deep relaxation. Therefore, it is recommended that patients try to practice on an empty stomach if possible.
Assume a comfortable position
A patient should be in a comfortable position when practicing deep relaxation exercises. A common position is lying flat on one’s back with the legs extended out and arms comfortably at the sides. Depending upon the patient’s medical condition and surgery, this posture may not be possible. In that case, some other position can be used (e.g. knees up with a pillow underneath, sitting, or even standing). If a patient is tired or sleepy, relaxation exercises can be practiced sitting up, as opposed to lying down, to prevent falling asleep.
Loosen clothing
It is useful to have patients loosen any tight clothing and take off such things as shoes, watch, glasses, jewelry, and other constrictive apparel when practicing relaxation. Again, the object is to have the patient be as comfortable as possible while practicing.
Assume a passive attitude
It is important for patients to complete the deep relaxation exercise while adopting an attitude of "allowing" the relaxation response to happen. The patient should not "try" to relax or "control" his body.
Relaxation training is a critical component of a preparation for surgery program. Therefore, it is important to make every effort to ensure that patients practice and master this skill. The previously presented guidelines can help in this regard. However, patients may present other “obstacles” to practicing that will have to be addressed. Some of the more common obstacles to practicing relaxation follow, along with techniques for helping patients overcome these issues.
There is no time to relax
Complaints about not having enough time to practice the relaxation are probably one of the most common obstacles encountered in a preparation for surgery program. In this case, it is important to help the patient prioritize the relaxation practice. This issue is especially salient presurgically since patients sometimes feel “overwhelmed” by the number of issues they have to address prior to the operation. Helping patients schedule a specific time for relaxation practice can help in this regard. In addition, they should be reminded that the relaxation practice session takes less than 30 minutes, and even less time after regular practice.
It is boring
Some patients have trouble completing the relaxation exercises stating that they are “boring.” These patients will typically deal with stress by becoming quite “busy” and, in general, have trouble “being still” as a personality style. When this type of obstacle occurs, it is important to remind the patient that the relaxation response skill is critical to the success of the preparation for surgery program. These patients will often need to be convinced of the “value” of relaxing and not see it as simply wasting time. In more extreme cases, it might be useful to have these patients practice a more “active” type of relaxation exercise. This might include something like imagery or some other similar procedure that requires the patient to “do something” during the relaxation exercise. For patients with this personality style, the act of “doing something” versus being passive may be more appropriate.
No place to relax
This obstacle presents itself when the patients complain that they don’t have any quiet place to practice the relaxation exercises on a regular basis. Again, when this issue is explored more thoroughly, it is often related to the patient not making relaxation practice a priority. As discussed by Deardorff and Reeves (1997), the following patient recommendations can be helpful to overcome this obstacle.
- Put the phone on an answering machine and unplug the phone in your bedroom.
- Give your family the "five-minute warning" that you will be unavailable for the next 20 minutes while you practice the exercises.
- Close the door to the room in which you are going to practice and place a "Do Not Disturb" sign on the doorknob.
- During the five-minute warning period, be sure the family demands are placed on hold or managed by another household member.
- If there is not room enough to "get away" from these distractions, you might have to practice when the other people in the household are out of the house.
Hypnosis has been extensively used as a component of preparation for surgery programs (Blankfield, 1991; Lynch, 1999; Kessler and Dane, 1996; Wood and Hirschberg, 1994). In fact, one of the early known uses of hypnosis was as an anesthetic agent with a surgery patient in the United States in 1836 (Wood and Hirschberg, 1994). There are a variety of techniques for hypnotic induction and these will not be reviewed here. Reviews of the literature show that hypnosis training for surgical patients might include a single session or multiple pre-surgical consultations (see Wood and Hirschberg, 1994 for a review). One important finding that has implications for the cost effectiveness of this procedure is that many of the programs consist of audiotaped hypnosis exercises that can be practiced by the patient on her own.
The content of the hypnotic suggestions can be quite variable from inducing simple relaxation to suggestions for enhanced wound healing. Some of the more common hypnotic suggestions used in helping patients cope with the surgical experience can be found elsewhere (Deardorff and Reeves, 1997; Wood and Hirschberg, 1994). Similar to developing the relaxation response, patients must practice the hypnotic exercises prior to using them to manage pre- and postoperative situations. Again, if the patient practices these on a regular basis, the hypnotic state can be induced quite rapidly and in almost any stressful situation related to the surgery.
If hypnosis is part of the preparation for surgery program, misconceptions about hypnosis should be discussed with the patient. Due to common misperceptions, patients are often fearful of term “hypnosis.” Some of these popular erroneous beliefs about hypnosis follow (adapted from Deardorff and Reeves, 1997).
A person is not asleep when under hypnosis. In fact, hypnosis is a state of relaxed attention in which the person is able to hear, speak, move around, and think independently. The brain waves of a hypnotized person are similar to those of someone who is awake; reflexes, such as the knee jerk, which is absent in the sleeping person, are present when hypnotized.
Books, movies, and stage hypnotists have capitalized on perpetuating this myth and it is perhaps the biggest misconception that keeps people from pursuing and benefiting from hypnosis. A patient cannot be hypnotized against his will and once hypnotized, a person cannot be forced or coerced into doing something he finds objectionable or do not want to do.
It is actually more difficult to become hypnotized than it is to slip out of hypnosis. Patients frequently become alert when a hypnotherapist stops talking, inadvertently says something inconsistent with the person’s beliefs, leaves the room, or is otherwise distracted. If left alone when hypnotized, most people reorient, alert themselves, and awaken naturally.
When hypnotized, a person is aware of everything that happens both during and after hypnosis, unless he wants to accept and follow specific suggestions for amnesia. Thus, secrets cannot be forced from a person who is unwilling to divulge them.
Some people are more responsive than others to hypnosis, but nearly everyone can achieve some level of hypnosis and can benefit from it with practice. Obstacles to hypnosis include trying too hard, fears or misconceptions about hypnosis, and unconscious desires to hang on to troublesome symptoms. A licensed psychologist, physician, or dentist experienced in hypnosis can help a person overcome these stumbling blocks.
Imagery, visualization, distraction, and humor are powerful techniques that can form an integral part of the preparation for surgery program. Imagery is thought to be one of the basic ways in which the mind stores information in the unconscious. In fact, imagery techniques for physical healing date back many hundreds of years. From a very early time, it has been known that the thoughts and images that come from our imaginations can have very real physiological consequences. In fact, sometimes our brains cannot differentiate whether we are experiencing something that is really occurring or whether it is simply an image coming from our imagination (e.g. dreaming). The rationale for imagery in surgery preparation can be explained to the patient in the following manner:
There are many examples of images affecting our physical state in day-to-day life. Think about the last time you watched a scary movie. During the course of the movie, you may have noticed your heartbeat increasing, your palms becoming sweaty, your breathing accelerating, and your respiration increasing. All of these very real physical responses occurred to something that was not real. The movie was simply activating your imagination and your body responded.
Another example of our bodies responding to our imagination is dreams. When we experience a nightmare, we will have a physical reaction as if it was actually happening. Also, a dream about a very pleasant time may invoke very strong physical and emotional reactions. Another example of our imaginations evoking a physical response is a dream that has a sexual content.
The above observations demonstrate that our imaginations are, in fact, a normal way of thinking. The power of our imaginations has been utilized in a variety of areas in health care. Specifically, using the ability to imagine can have very positive effects, such as:
This is the use of imagery as a relaxation technique. It is most often done after the initial deep relaxation state is achieved through the breathing exercises discussed in the previous section.
Many imagery exercises are designed to activate the body’s natural ability to heal itself. This might include such images as white blood cells attacking and dissolving germs or injured tissues receiving the valuable nutrients from increased blood flow.
Imagery can help the patient remove herself from the experience of pain while it is occurring. Using the imagery techniques, a patient can mentally “go to another place” to decrease the perception of pain and discomfort. In addition, there are specific images for reducing the experience of pain more directly such as turning the volume down on the pain or changing the color of an imaginary “ball of pain” to something less intense.
Sleep disturbances are not uncommon when a patient is anticipating surgery, when she is in unfamiliar hospital surroundings, or is recovering at home after surgery. Imagery can be very helpful for promoting sleep. Often this imagery will involve a “passive” technique in which the patient will imagine his or her body feeling the physical sensation of relaxing (e.g. “warm and heavy”).
This type of imagery will involve such things as imagining the muscles “unwinding” like the knots in a twisted rope, a “ball of tension” in the body that dissipates with exhaling, or one’s muscles becoming more “smooth” and loose.
This type of imagery is very effective when a patient is undergoing an unpleasant medical procedure that causes discomfort or pain. Guided imagery, in which the patient “guides” her imagination through a sequence of events such as walking on the beach or down a forest path, is particularly powerful in this purpose.
As can be seen from these examples, there are many ways in which imagery can be used for health issues, including the surgery process. The imagery discussed subsequently will focus on its use specifically for surgical issues and healing.
The following are guidelines for developing an effective imagery exercise. It is important to remind the patient that imagery is a natural process and she is always in complete control.
Recording an imagery exercise on audiotape can help a great deal in terms of the patient’s regular practice and making the imagery experience as powerful as possible. The clinician can record an imagery exercise during the course of surgery preparation exercise, or some patients prefer to make their own. Using a tape recording can also be a good technique for developing the deep relaxation response through the breathing exercises discussed in the previous section.
It is best to develop an image with which the patient is quite familiar. Generally, people have an easier time conjuring up all aspects of the image if it is something that they have actually experienced in the past. For instance, a patient may choose a beach or forest scene, which is a place that they have visited (and, of course, had a pleasurable time). There are standard imagery exercises, some of which are presented in the following section. These can be modified to fit with the patient’s own personal experiences. The use of images developed from the patient's memories and experiences does not have to contain the entire memory. The patient can draw from bits and pieces of different memories in order to form a complete image.
It is most powerful if the patient utilizes all five senses (sight, sound, touch, smell, and taste) in developing the image. For instance, in a beach scene for relaxation, the image should include the view of the ocean and beach, the smell of the salty sea air, the sounds of sea gulls and the waves, the salty taste of the ocean air, and the feel of bare feet walking on the warm sand.
The old adage that “one person’s feast is another person’s poison” applies to imagery as well. Imagery is a very personal and individualized experience. It is important to be sure that the patient’s imagery is pleasing to her (and not as defined by the clinician).
As an example of the importance of individualized images, consider the standard relaxation image called "The Beach Scene." While this may be relaxing to most people, other people may find it quite distressing. I was very much reminded of this while leading a group relaxation/imagery exercise with a colleague. We chose the beach scene as a standard image to have the group develop. At the end of the exercise, we asked the group members to comment on their experience with the image. Although most everyone found it very relaxing and pleasant, one woman felt it was quite distressing and anxiety producing. She discussed that she absolutely “hated” going to the beach. For her, going to the beach meant not being able to find a place to park, suffering through sunburn, eating sandwiches with sand and ants in them, and listening to the radio with bad reception. There was no part of the beach scene that she found relaxing.
This example underscores that structured imagery exercises such as the beach scene serve only as examples from which you can develop the patient’s own personalized image.
Sometimes it can be difficult to focus immediately on an entire image at one time. In trying to create the total image at once, the patient may find it stressful if he is unable to do so adequately. This is especially the case when a person is trying to use the imagery in attempting to manage a stressful situation. It has been discovered that it can be useful to "sneak up on the image" as suggested by Margo McCaffrey, R.N.
In order to avoid becoming frustrated in creating the scene, sneaking up on the image simply involves constructing it slowly. For example, if you are using a forest scene as your chosen image, you can begin by imagining that you are at home preparing to go to the forest, or that you are on the drive to the forest. You can imagine driving to the trailhead, getting out of the car, and slowly walking into the beautiful mountain scene, which is your final goal image. Using this technique of sneaking up on the image helps ensure that the imagery is relaxing and that you adopt an attitude of "letting it happen," rather than trying too hard.
It is best only to try to imagine one total image at a time. Trying to maintain several images at once is stressful and usually does not accomplish the goal of imagery.
Using a deep relaxation exercise, prior to doing the imagery can greatly facilitate the use of imagery. Although not required, it is highly recommended approaching an imagery exercise in this fashion. This process includes choosing one of the breathing exercises as discussed previously. Have the patient practice with the breathing exercise until he is skilled at eliciting the deep relaxation response. Once this is mastered, the patient can then add an imagery exercise as suggested in this section. Each session of deep relaxation and imagery should total about ten to twenty minutes. All of the guidelines for practicing the relaxation exercises also apply to the imagery experience.
It is important to regularly practice imagery in order to develop the skill. This is the same as developing any other skill such as riding a bike or playing a sport. The ability to create a mental image utilizing all of the five senses may be difficult at first but it does improve with practice. Therefore, if your images are not vivid initially, don’t worry about it. As you practice, you will notice more details coming into focus, along with feeling as if you are actually in the image more and more. As discussed above, making a tape recording of your image can facilitate practice sessions.
It is important to develop a technique to end your image rather than stopping it abruptly. One of the most common side effects of using imagery is a slight sense of drowsiness afterwards. This can be avoided by using a technique for ending the image. One of the most common methods is to count silently from one to five. Then, on the last count, you inhale deeply, open your eyes, and say to yourself, "I feel alert and relaxed." Another example of an ending statement is as follows:
In a moment, you will notice becoming more alert, refreshed, and awake. As I count from one to five, I would like you to become more awake, renewed, and energized. When I get to five, you can open your eyes, feeling refreshed. One…gradually becoming more alert…Two…becoming more and more awake…Three…beginning to slowly move your fingers, hands, and arms…Four...almost back to an alert state...you can now begin to move your toes, feet, and legs...and...Five...opening your eyes and finding yourself fully awake, alert, renewed, and refreshed.
After completing an imagery exercise, the patient should get up slowly due to the risk of orthostatic hypotension.
The patient can get the beneficial effects of imagery even if the image does not have a great amount of detail or is not particularly vivid. As discussed above, the more the patient practices, the more likely the details of the images will emerge and the patient will notice a sense of actually being there. It is not helpful for the patient to judge his performance, or to make this in any way stressful.
As part of the imagery exercise, the patient can incorporate affirmations or prayers as he desires. For instance, affirmations such as, "I am letting go," "I am at peace," and "All of the tension is flowing from my body" are common for relaxation and imagery training.
The following imagery exercises are given as examples and are fairly standard, having been developed over a number of years. In these examples, it can be seen how the guidelines for developing imagery as discussed previously have been utilized. These examples can be used with patients, or more individualized and personal ones can be developed. As described earlier, it is most beneficial to customize the image to the patient’s own individual experience. In the examples, the series of dots represent places where the clinical should pause in order to develop a nice, slow pace to the exercise.
The standard image exercises that will be presented are called:
For all of the following exercises, it is assumed that the patient will have already completed a breathing exercise to elicit the relaxation response. If a tape is made for patient use, put the breathing exercises at the beginning of the tape and then incorporate the imagery sequence after the breathing exercises. It is also important to end the image as discussed previously. In the first example, all of these phases (breathing exercise, imagery, ending the imagery) are presented.
As you feel ready, allow your eyes to slowly close…Take in a full, deep breath through your nose, allowing your lungs to fill completely. Let the air go all the way in, breathing down into the bottom of your lungs. Notice the cool sensation in your nose as the air rushes in…Then, breath out through your mouth while slightly pursing your lips…Notice that the air you exhale is warm and moist....Release all of the air in your lungs as you exhale completely…Slowly repeat this cycle several times…Breathing in through your nose and out through your mouth…Remember, there is nothing else to think about except becoming completely and deeply relaxed…
[Pause 3 to 5 minutes here for the breathing]
You may have noticed the healthy breathing exercise has already helped you become quite relaxed…As you allow yourself to relax more and more fully, begin to focus your attention on your fingers and hands…As you mentally focus your attention on your fingers and hands, I would like you to notice the sensations that are coming from that part of your body…You may notice your hands resting on another part of your body or elsewhere…Simply focus on the sensations coming from your fingers and hands…Imagine what it would feel like for your hands and fingers to become more and more relaxed…Let go of any excess tension you may feel in your fingers or hands.
As you continue to relax and breath peacefully, slowly move your mental attention to the sensations coming from your forearms and upper arms…As your fingers and hands continue to relax, allow that feeling of relaxation to move into your forearms and upper arms…You might notice your hands or arms feeling warm or heavy as they relax…Or you may notice them feeling cool and light…Simply focus on what the relaxation response feels like for you.
As your arms continue to relax with every breath, allow the feeling of relaxation to move into your head, neck, and shoulders…Notice what it would be like for your forehead to relax completely…Allow the muscles around your eyes to relax…As you relax the muscles of your jaw you may notice that your lips separate slightly…Allow your shoulders to relax completely…Mentally scan these parts of your body, and imagine letting go of any tension that you notice...Just allow the wave of relaxation to extend throughout your arms and upper body.
When you are ready, focus your attention on the sensations coming from your stomach and back...Again, notice the relaxation response move slowly down your body as you let go of any tension in your stomach and back…Imagine what it would be like for all of the muscles in your stomach and back to unwind and loosen up completely…It is as if you are inhaling relaxing and exhaling tension with every breath…There is nothing else for you to focus on right now except enjoying the feelings of relaxation throughout your upper body.
As you continue to enjoy those feelings of relaxation, imagine the pleasurable sensation moving into your upper legs…Allow the relaxation response to move further and further down your body…Nothing else to focus on except enjoying the relaxation response. When you are ready, allow the relaxation response to move further down into your ankles, feet, and all the way to your toes. Notice how the relaxation spreads throughout all the muscles of your legs and feet. Again, you may notice your entire body becoming heavier and heavier, or lighter and lighter. You may also notice a tingling sensation as part of the relaxation response…These are all normal feelings as part of relaxing…Simply focus on what the relaxation sensation feels like for you…You may also notice a warming sensation or, perhaps, a cooling sensation. Enjoy the sensation of your entire body being deeply relaxed. As you relax further, take a few moments to enjoy the sensation of relaxation…
[Pause here for 1 or 2 minutes]
In a moment, you will notice becoming more alert, refreshed, and awake. Even so, remember you can call upon the relaxation response at any time you like throughout the day…Simply take a deep breath and tell yourself to “relax” as you exhale…This will recall the relaxation sensation…
As I count from one to five, I would like you to become more awake, renewed, and energized. When I get to five, you can open your eyes, feeling refreshed. One…gradually becoming more alert…Two...becoming more and more awake…Three…beginning to slowly move your fingers, hands, and arms…Four...almost back to an alert state...you can now begin to move your toes, feet, and legs…and...Five...opening your eyes and finding yourself fully awake, alert, renewed, and refreshed.
It is about five in the afternoon on a midsummer day…You are walking along a shady path that opens up to a very beautiful and expansive beach...As you walk from the path onto the sandy beach, you notice that it is virtually deserted...The beach extends off in both directions farther than you can see...The sun has not yet begun to set, but it is getting very low on the horizon…The sun is a deep and golden yellow, the sky full and a brilliant blue, and the sand is a glistening white in the sunlight…As you walk on the sand in your bare feet, you notice it rubbing between your toes…The sand is warm and comfortable...You notice the taste and smell of the salt in the ocean air…There is the residue of salt deposited on your lips from the ocean spray…You can slightly taste its presence...You can hear the roaring sound of the surf as it rhythmically comes in and washes out from the shore…You hear the far-off cry of a sea‑gull as you continue to walk along the beach…You notice yourself becoming more and more relaxed as you continue walking down the beach...You realize that you have nothing else to think about except enjoying this moment...You feel the warm sea breeze blowing against your face, as well as the warmth of the sun on your body...You feel more and more content as you enjoy the surroundings of this beautiful beach...As you continue to walk, you notice a place where it would be quite comfortable to simply sit down and relax against a sand dune…As you sit, you are look out over the beach, the waves, and the sun on the horizon...The sun has started to set, causing the sky to turn many colors including scarlet, pink, gold, orange, amber, and crimson. You allow yourself to settle deeply into the comfortable sand dune as you enjoy the sun's reflection off the water. The sand forms perfectly to your body as you settle in…As you sit, you allow yourself to relax more and more. You find yourself relaxed, peaceful, and content.
Continue to breathe comfortably and slowly, feeling your body relax more and more each time you breathe out…If you wish, the next time you breathe in, imagine that your breath goes to that part of your body in which you are experiencing pain or discomfort…Imagine your inhaling brings with it valuable oxygen and nutrients your body needs...Your deep breath also brings with it a sense of calm and comfort…As you slowly exhale, you might imagine that just a bit of the pain and discomfort is exhaled along with your breathing out…As you exhale some of this pain and discomfort, the tissues left behind seem to be more relaxed, healthy, and comfortable…This reduction in pain may be only slightly noticeable at first, but it seems to become more and more powerful with each breath…Each time you breath in, imagine the air flowing to that area of pain and discomfort…It brings with it a sensation of health and comfort…Then, each time you breathe out the air, notice the area of pain and discomfort becoming smaller and smaller…As you breathe out, you are exhaling discomfort and pain…Breathe in the relaxation and breathe out the pain.
As you continue to relax, focus once again on your breathing. Notice how you are slowly breathing in…Feel the air going into your lungs...Notice your lungs filling completely with air as you inhale…Then, notice the air rushing out of your lungs and mouth as you exhale…Enjoy the experience as you become more and more relaxed each time you inhale and exhale...As you continue to relax, you may begin to imagine a ball of white light forming in the area of your chest and lungs...This is a ball of healing energy…It may not be particularly clear or distinct and that is perfectly fine…Whatever its shape and texture, simply notice what your ball of healing energy looks like...Focus for a few seconds on this ball of healing energy in your chest area…When you feel ready, you may begin to notice this ball of white healing energy move to an area of your body which is feeling pain or discomfort…Notice the ball of healing energy moving slowly to that part of your body…Imagine that ball of healing energy settling in that part of your body...As it settles there, imagine it helping the tissues becoming more and more healthy…Imagine the white ball of healing energy bringing with it valuable nutrients and healing power...As the power of the healing ball of energy begins to work, you might notice a warming or cooling sensation in that part of your body…You might also notice a slight tingling sensation...Simply focus on what the healing experience feels like for you as the healing ball of energy begins to work…As you exhale, you might notice the ball of energy moving away from your body, taking with it toxins, tension, and injured tissue...Each time you inhale, imagine the ball of healing energy going to your area of discomfort with its healing energies...Each time you exhale, notice the ball of energy move away, taking with it some of the pain, discomfort, and tissue damage...When you breathe in, it bring with it takes valuable relaxation and healing power...Each time you breathe out, it removes discomfort, pain, and toxins.
Prior to implementing the cognitive-behavioral (CB) component of surgery preparation, the patient should be carefully assessed for such things as beliefs about the surgery, knowledge about the surgery process, the patient’s personality style, and psychosocial information. The CB intervention is designed and individualized based upon the initial assessment. The CB program might include information gathering, cognitive restructuring, relaxation training, and cue-controlled relaxation. The CB intervention relies upon regular patient practice in between individual or group program sessions; this should be emphasized throughout the program.
Both the biopsychosocial and the social self-regulation models of surgery preparation include an emphasis on interpersonal influences on surgery preparation. The previous chapter focused primarily on individual self-regulation or intra-personal techniques that can be used for enhancing surgical outcome. This section will focus on helping the patient with surgery preparation within a social context.
Communication issues between the surgical patient and those involved in her medical care are of the utmost importance and can significantly impact surgical outcome. As previously reviewed, information gathering is a critical component to any preparation for surgery program. In an ideal world, patients could attain accurate and understandable information from their healthcare providers as well as other sources. Unfortunately, research indicates that this is simply not the case. Consider the following statistics (See Deardorff & Reeves, 1997 for more details):
Effective communication between doctor and patient has been found to enhance patient recall of information, compliance with treatment recommendations, satisfaction with care, psychologic well-being, and overall treatment outcomes (see Levinson & Chaumeton, 1999; Stewart, 1995 for a review). Certainly, research indicates that patient concerns about obtaining appropriate information are not unfounded. For instance, it has been found that general practice physicians and surgeons spend an average of between 7 and 13 minutes per patient visit. In addition, it is likely that a patient will be interrupted by their doctor within the first 18 seconds of their explanation of symptoms (Beckman & Frankel, 1984). However, the entire doctor-patient communication problem cannot be placed with the physicians. There are research findings that suggest that patients share some of the responsibility for not getting what they need from their healthcare providers. For instance, Kaplan and Greenfield (1989) determined that the average patient asked fewer than four questions in a 15-minute visit with the doctor. In addition, one of the more frequently asked questions was, “Will you validate my parking?”
Unfortunately, medical errors are more common than is generally realized by the patient population (See Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact, a Report to the President). Medical errors range from mistakes in hospital meals to blatant surgical mistakes (See the Agency for Healthcare Research and Quality report, “Medical Errors: The Scope of the Problem.” Fact sheet, Publication No. AHRQ 00-P037).
One of the more common mistakes in the hospital is medication error (Leape, Bates, Cullen et al, 1995). The Journal Of The American Medical Association estimates that doctor- or hospital-related mistakes could be at least partially responsible for 180,000 deaths annually (Leape, 1994). A recent 2006 report (“Preventing Medication Errors,” available from the National Academies Press) by the Institute of Medicine found that medication errors are surprisingly common.
Probably two of the most important medical errors for a patient to monitor during an inpatient stay are medication interaction and infection. The hospital setting is one of the most likely and most risky places to get infected. According to the Centers for Disease Control and Prevention, approximately 5-10% of hospitalized patients pick up an infection; this translates to 1.75 and 3.5 million cases per year (see Benson, 1996; Cohen, 1995). CDC officials estimate that failure to follow standardized infection control practices causes at least one-third of hospital-acquired infections. These procedures include such simple tasks as healthcare professionals washing their hands prior to performing any type of physical contact with the patient. In a comprehensive review of 37 studies on hand washing, it was found that doctors and nurses typically wash their hands only 40% of the time prior to physical contact with the patient (Griffin, 1996). Unfortunately, the hospital setting is the one place where the patient is more prone to be infected with an antibiotic resistant bacteria, or “super bug” (Cohen, 1995).
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Table 4-1: Patient handout for avoiding medical errors |
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20 Tips to Help Prevent Medical Errors. Patient Fact Sheet. AHRQ Publication No. 00-PO38, February 2000. Agency for Healthcare Research and Quality, Rockville, MD. |
Due to the frequency of medical errors, the Agency for Healthcare Research and Quality (AHRQ) has developed “20 tips to help prevent medical errors.” Table 4-1 summarizes these suggestions. Many of these recommendations will be included as part of the following section and should be provided to patients as part of a surgery preparation program.
As discussed in chapter three, it is important for patients to gather appropriate information regarding their surgical experience. Equally as critical is making sure that healthcare professionals have accurate information about a patient’s medical history and other variables that might influence the surgical experience. Since many different doctors and healthcare professionals might be involved in the surgery process, having patients complete a “medical fact sheet” as part of a surgery preparation program will help avoid treatment “errors” and give the patient an increased sense of control. An example of a medical fact sheet can be found in Deardorff & Reeves (1997).
The need for this type of medical data form is becoming more and more critical given changes in the healthcare system that place much more responsibility on the patient. Medical errors are unfortunately more common than the general public realizes and patients can play an active role in preventing them. Provision of information, as well as the information gathering process discussed in chapter three, is consistent with all of the preparation for surgery models.
Consistent with several models of surgery preparation (e.g. biopsychosocial, self-efficacy, and empowerment, social self-regulation), assertiveness skills are essential for a patient to implement many of the preparation for surgery recommendations. Being appropriately assertive can help surgery patients obtain the necessary information preoperatively as well as protecting them from medical errors. The following section will present a brief outline of assertiveness training and skills. The reader is referred to other sources for more detailed information (Alberti & Emmons, 1974; Bourne, 1995; Bower & Bower, 1991; Deardorff & Reeves, 1997; McKay, Davis & Fanning, 1983). There are four types of communication styles:
This is behavior characterized by “giving in” to another person’s preferences while discounting your own rights and needs. If an individual engages in this behavior, the people around him may not even be aware that the patient is being nonassertive or submissive because the individual’s needs are never expressed. Of course, surgical patients who engage in submissive behavior are more likely to be the victims of the mistakes of others around them.
This is a communication style in which the patient expresses her wants and desires in a hostile or attacking manner. This behavior is often done in conjunction with being insensitive to the rights and feelings of others around her. Coercion and intimidation may be part of the aggressive communication style. Typically, aggressive communication increases the level of conflict in any situation. Aggressive behavior as part of a surgery preparation program is likely to result in either healthcare professionals withdrawing from the patient (being passive-aggressive) or counterattacking in a similarly aggressive manner. Either situation is likely to lead to deleterious effects relative to surgery outcome.
Passive-aggressive behavior is a way of expressing anger in a passive manner. This is often seen in pain problems in which the original injury is the result of a work-related or other accident. In these cases, the patient is often angry with the employer or other party who is perceived as having “caused” the injury. The patient will then – either consciously or unconsciously – use the pain behaviors to “get back at” the perceived perpetrator. Often, patients engaging in passive-aggressive communication have no insight into their behavior. Unfortunately, the patient is the one that is likely to sustain the most negative outcome.
The last of the four communication styles is assertive communication. An individual who uses assertive communication is able to express her wants and/or desires while respecting the right of others. It involves communicating in a simple and direct fashion without attacking, manipulating, or discounting those around you (Alberti & Emmons, 1974; Bourne, 1995; Bower & Bower, 1991; Deardorff & Reeves, 1997). As discussed by Deardorff and Reeves (1997), “communicating in an assertive fashion allows you to express your needs and desires while keeping those around you comfortable and non-defensive” (page 175). Assertive communication is characterized by the following and should be taught as part of surgery preparation:
Use Assertive Nonverbal Behavior. Body language can communicate a great deal beyond what a patient expresses verbally. Assertive behavior includes staying calm, establishing eye contact, and maintaining an open posture. Alternatively, nonassertive behavior includes such things as looking down at the floor while communicating, avoiding eye contact, speaking softly, and turning slightly away from the person with whom one is talking. A component of assertiveness training related to surgery preparation would involve teaching the patient nonverbal assertiveness skills.
Keep Requests Simple. An effective assertive request is most often delivered in a simple, direct, and straightforward fashion. This might include asking for only one thing at a time in an easy to understand format.
Be Specific. Being specific involves helping the patient determine wants, needs, and feelings are so that he can be very concrete in expressing them to healthcare professionals or other individuals within his psychosocial environment. This is the difference between saying “I would like to get more help from your office staff regarding my surgery,” versus “I would appreciate your office staff helping me with the following issues regarding my surgery: insurance pre-approval, scheduling my blood donation, and giving me information about postoperative pain control.” The latter request is specific, direct, and non-aggressive.
Teach Patients to Use “I” Statements. Assertive communication often begins with “I” statements. These would be things like:
I need to…
I would appreciate it if…
I would like to…
Teaching patients to use “I” statements in their communication is one of the primary components of assertiveness training. Patients should also be taught to avoid “you” statements, since these often sound threatening and put the other person on the defensive.
Address Request to Behaviors and Not Personalities. It is important to teach patients to address their request to behaviors of another person rather than “personality features.” For instance, if a surgery patient needs help with housework postoperatively, it is preferable to say, “I would like you take over the heavy household chores while I am recovering from my surgery” rather than “I know you tend to be careless about housekeeping, but would you help me with the chores while I am recovering from my surgery.” This guideline also applies to requesting behaviors while in the hospital.
Teach Patients Not To Apologize For Their Requests. Another component of assertiveness training is teaching patients not to apologize for their requests. Patients who tend to be more submissive or nonassertive will often make requests in an apologetic manner. They might make a request in the form of, “I am really sorry to have to ask, but is it possible for you to help me prepare for my surgery.” This type of request has a low probability of being acknowledged, and communicates that the person making the request does not really feel deserving or have the right to ask.
Learning To Say “No”. Learning to say “no” is an important assertiveness skill to teach patients going through surgery. This will help the patient set important limits on the demands of family, friends, work, and others. More submissive and nonassertive individuals have trouble saying no since they feel “guilty.” Teaching patients to set appropriate limits is extremely important especially during the postoperative recovery phase when “pacing” is essential for enhanced recovery from many types of major surgery.
The “Broken Record” Technique. The Broken Record Technique is an effective assertiveness tool that patients can utilize easily. It simply involves repeatedly making a request or saying “no” until the patient’s communication is acknowledged. For those just learning assertiveness skills, there may be a tendency to make a request and then “back down” if any resistance is encountered. Or, the patient might try to come up with more and more reasons why her request is justified. In this latter process, every time the patient expresses another reason for the request, it becomes weaker and weaker as if she is trying desperately to convince the other person that the request has merit. The Broken Record Technique can help patients feel comfortable making their request and then following through. An example might be a postoperative surgery patient who wants to make sure his doctor washes her hands before examining him:
Patient: “I would appreciate it if you would wash your hands before…”
Doctor: “Don’t worry about it. It will be fine. I really am in a hurry.”
Patient: “I understand you’re in a hurry, but I would like you to wash your hands…”
Doctor: “You really need not be concerned. I just need to take a quick look.”
Patient: “I still would like you to wash your hands.”
Part of preparing for surgery is teaching patients how to work effectively with their doctors, including their surgeon. According to empowerment theory, patients and healthcare professionals work in a “partnership” in the patient’s overall care. Any preparation for surgery program should have a component that teaches patients how to interact effectively with their healthcare team. Effective interaction allows for efficient gathering of information, accurate communication of needs, improved patient satisfaction, and enhanced outcome overall. The social self-regulation model of surgery preparation suggests that interactions between the patient and caregiver will primarily be “task-focus.” As such, the primary goal is for the patient to obtain necessary information and guidance throughout the surgical experience. As discussed previously, there is often discordance between the surgeon’s and patient’s perceptions and goals. Ineffective physician-patient communication can compromise compliance, health status, and patient satisfaction (Temple, Toews, Fidler, Lockyer, Taenzer, & Parboosingh, 1998; Stewart, 1995).
Levinson and Chaumeton (1999) investigated communication between surgeons and patients during the course of routine office visits. There was a mix of general and orthopedic surgeons in the study. The average office visit was 13 minutes long, and surgeons talked more than patients did. The typical surgical consultation consisted of “relatively high amounts of patient education and counseling.” Consultations had a narrow biomedical focus with little discussion of psychologic aspects of patient problems. Surgeons infrequently expressed empathy towards patients and social conversation was brief. The authors make the point that the results are “consistent with the work of physicians in this setting because they often see patients referred to them for a surgical intervention” (page 132). It might be argued that it is not the role of the surgeon to address emotional and/or psychosocial issues. Even so, the importance of these findings for a surgery preparation program is to give the patient appropriate expectations regarding visits with his surgeon. Patients should expect that the office visit will be relatively brief, that a great deal of information will be provided, and that the emotional/psychosocial issues will not be addressed. If patients go in with expectations that are different from these, there will be a high likelihood of dissatisfaction with the visit and overall care.
Beyond giving patients appropriate expectations about interactions with their surgeon, the preparation for surgery program can teach them how to work effectively with all members of their healthcare treatment team. The following recommendations are adapted from Deardorff and Reeves (1997) and Ferguson (1993).
An important component of a preparation for surgery program is gathering information. Patients should be taught to develop a list of questions and concerns to address with their surgeon during the office visits. These should be very specific and not overwhelming in terms of scope and length (a patient who develops a list of 100 questions will be extremely frustrated when only two or three of them are addressed during the office visit). Therefore, helping patients to be realistic about the number of questions that they want answered during the course of an office visit is important.
Teaching patients basic assertiveness skills, as discussed previously, can very much enhance their overall surgery experience as well as their outcome. These skills can be useful in terms of gathering information during office visits, as well as getting other needs and concerns addressed. Once again, patients should be taught to be reasonable in using the assertiveness skills. If patients “go overboard,” or are seen as aggressive and overly demanding by their healthcare team, the healthcare provider will often react in a passive-aggressive manner without even realizing it. Of course, this sets up a very negative interaction that will likely have deleterious effects on surgery outcome.
Healthcare professionals will often take for granted that patients have an understanding of the medical system. Generally, this is not the case, and patients will often be confused about information resources. Thus, the patient may attempt to obtain information from their surgeon when the most appropriate person might be a physician’s assistant, nurse, or some other individual. Of course, this inaccurate patient expectation would likely to lead to dissatisfaction.
Having patients bring someone else to their doctor visits can be important in many ways. Patients are often quite nervous and preoccupied during the course of a visit with their surgeon. Under these circumstances, they are likely to miss the opportunity to ask important questions, as well as not remembering medical information that they are given. As discussed by Ferguson (1993) and Deardorff and Reeves, (1997), bringing another individual to the doctor’s appointment can help calm the patient, make sure that various concerns are addressed, and help the patient with medical information recall.
Addressing the psychosocial environment as part of a surgery preparation program might include helping the patient with such things as important personal relationships (family, friends, coworkers) and spiritual concerns as they impact the surgical experience.
One of the most important variables in terms of enhancing postoperative recovery from surgery may be the patient’s family environment. As discussed under the conceptual model of social self-regulation, it is important for the patient and her family to have similar adaptive goals. In addition, according to social self-regulation theory, the family can help enhance the patient’s surgical outcome by providing tangible assistance, as well as emotional and informational support.
A preparation for surgery program should contain a component of working with the family of the patient prior to the surgery. There is evidence that including the patient’s family in the preparation for surgery will enhance results versus intervening with the patient alone (see Raliegh, Lepczyk & Rowley, 1990). Most of the concepts of surgery preparation that have been discussed as interventions for the patient can also be applied to family members. This would include such things as information gathering, cognitive issues, and interacting with the medical system. It is important for family members to have appropriate and realistic expectations regarding the course of the patient’s recovery from surgery. If they expect too much, or too little, the patient is less likely to do well. Preparing the home environment for the postoperative recovery period can also be an important focus of a preparation for surgery program. This might include organizing the actual living space of the patient for surgery recovery, obtaining any necessary assistive devices beforehand, and arranging home healthcare if necessary.
Assessing and intervening in the social system is especially important in the case of a patient with a chronic pain problem that is being addressed by the surgery (e.g. back pain, neck pain, etc.). Most chronic pain patients have a “partner in pain” as described by Engel (1959); Szazs (1968) and Waddell (1998), also termed this an “associate victim” (Halmosh & Israeli, 1984; Waddell, 1998). There is usually one main partner who provides most of the “social support,” although other members of the patient’s family and friends will assist. As Waddell describes it,
“Chronic pain patients and their partners play active, mutually supporting roles, and the pain may become a major focus in their whole relationship. Their whole social milieu may become pervaded by pain and disability, medical values and health care. Chronic pain and caring may become almost full-time careers, with both partners equally committed. In extreme cases, this may actually provide a more satisfying emotional relationship for both of them” (1998; p. 208-209).
In this case, there may be a great “cost” for the patient to give up the chronic pain even if the surgery is technically a success. These issues are usually identified as part of the pre-surgical evaluation. If the patient is going to have surgery, and these issues are present, they must be successfully addressed as part of a surgery preparation program. If they are not, the surgery is likely to be a technical success but a clinical failure. An example of this might be the chronic back pain patient who has been disabled for years and is fully ensconced in the sick role. If psychosocial issues are not addressed prior to surgery (such as becoming more independent), the spinal fusion may be technically “perfect” but the patient will show no change in postoperative pain complaints, level of disability, and other concerns.
One of the most valued social roles for an individual is her work. Work provides such values as (Waddell, 1998):
Given the pervasive importance of work values, this is another important area of surgery preparation. Surgery patients will often have significant concerns related to how the operation will affect their work abilities. This might include such issues as how long will they be disabled from work due to the surgery process, how will they survive financially, and will they ever be able to return to full-time and unrestricted work. Any surgery preparation program should be sure that these issues are addressed with patients. Patients can be helped to develop strategies to deal with the work and financial issues in the most effective manner possible. Unfortunately, many surgery patients are so concerned and distracted by the surgery approaching that they forget to deal with the work and financial issues until it is too late. When this happens, usually postoperatively, it can create an extreme level of stress that negatively impacts the patient’s ability to recover.
Aside from preparing the family system for a patient’s operation, the individual’s spiritual issues are also rarely addressed by the medical system, including the surgery experience. For instance, a review of over 1,000 articles in primary care physician journals revealed that only 11 studies (1.1 percent) examined religious considerations. In another review, it was found that, in the last 200 years, only about 200 studies out of hundreds of thousands of English medical journal articles, investigated some aspect of spiritual faith. Benson (1996) concludes that these findings show just how “taboo” the topic of God has become in the recent history of Western medicine.
Even though Western medicine rarely incorporates spirituality as part of the treatment and healing process, it is often an important part of the patient’s life. According to a Gallup poll, conducted in 1990, 95 percent of Americans say they believe in God, and 76 percent say they pray on a regular basis. In addition, spiritual beliefs have been found to correlate with health benefit, including surgery outcome (see Deardorff & Reeves, 1997; Larson, 1993; Levin, 1994; Matthews, Larson, & Barry, 1994; Oxman, Freeman, & Manheimer, 1995; Pressman, Lyons, Larson, & Strain, 1990 for more detailed reviews of this issue). Some of the more interesting results are:
As can be seen from the above findings, religious and spiritual beliefs form a vital part of the way a majority of people view and cope with life, as well as being associated with health benefits. The following summarizes what these beliefs can provide relative to enhancing surgery outcome:
A sense of meaning and purpose. Spiritual beliefs can give an individual a sense of meaning and purpose that help him “rise above” or cope more effectively with the stress related to surgery.
Setting healthy priorities. Spirituality provides a framework to set priorities and place stressors in perspective. This can help the individual maintain a sense of inner security and safety relative to the surgery experience through having a connection with God. This feeling of connection with the ultimate Power causes surgical and other stressors to be placed in a healthy perspective.
Comfort in the face of illness and crises. Spiritual beliefs can give the individual great comfort in the face of a health crisis, such as going through a major surgery.
Security, safety, and peace of mine. A sense of security, safety, and peace of mind is especially important when approaching major life stressors such as surgery. Through spiritual beliefs, this sense can be fostered by the patient knowing that her higher power is close by. Peace of mind is developed through "letting go" and "turning over" one’s anxiety and fear associated with the surgical procedure and recovery process.
Self-confidence. Self-confidence is often enhanced in individuals with spiritual beliefs since they feel that they were created by God, making them lovable and worthy of respect.
Guidance. The surgical patient with spiritual beliefs will often feel a sense of guidance due the relationship with God. Since God is "all knowing,” the individual believes that God can be drawn upon for wisdom when asking for guidance.
A preparation for surgery program may or may not specifically include a spiritual component. However, it is important for the healthcare professional completing the program with patients to be aware of these issues. The spiritual component should at least be acknowledged and patients should be specifically “allowed” (and encouraged) to discuss this aspect of their lives relative to the surgery. If spirituality is important to an individual patient, she can be helped to use those beliefs as part of surgery preparation in a variety of ways such as developing coping self-talk statements and incorporating prayer into deep relaxation exercise; this can greatly enhance the commitment to practice (see Deardorff & Reeves, 1997; Benson, 1996 for a discussion of these issues). In addition, patients can also be helped in facilitating appropriate psychosocial spiritual support relative to their surgery and postoperative recovery whether it is from their church, synagogue, family members, friends, or some other network.
Postoperative pain control is one of the primary concerns of surgery patients yet research has indicated that it is frequently not well controlled. As discussed in chapter one, psychoneuroimmunology research has demonstrated that pain leads to negative bodily responses that can impede wound healing, suppress immune system function, and delay recovery from surgery. Therefore, a critical component of a preparation for surgery program is to help the patient ensure that adequate postoperative pain control will be achieved. One would think that the healthcare system would be expert at providing adequate pain control after surgery, but this is not the case. In fact, many studies have found that postoperative pain control is grossly inadequate, even though this need not be the case (American Pain Society, 2001; Peebles & Schneiderman, 1991; Warfield & Kahn, 1995).
The area of pain control is placed under the category of social self-regulation since the patient will need to interact with a variety of other systems (e.g. doctors, nurses, family members) to ensure that adequate postoperative pain control takes place. Although many hospitals have established pain services that specifically manage postoperative pain in the hospital setting, the following discussion will assume that this may or may not be available to the patient. Excellent information about pain control issues can also be found at a number of websites such as www.ampainsoc.org, www.iasp-pain.org, www.painmed.org, www.painfoundation.org, and www.paincare.org.
According to the American Pain Foundation (2001a), pain is a “major healthcare crisis” as evidenced by the statistics that over 50 million Americans suffer from chronic pain and another 25 million experience acute pain as a result of injury or surgery. Recognition of the widespread inadequacy of acute pain control prompted Congress, through the Agency for Health Care Policy and Research (AHCPR), to commission a multidisciplinary panel of experts to develop guidelines for the management of acute postoperative pain. This led to the publication and distribution of the Practice Guidelines for Acute Pain Management (AHCPR, 1992). Other professional groups also published acute pain treatment guidelines at that time (American Pain Society, 1992; International Association for the Study of Pain, Ready & Edwards, 1992).
The specific problem of acute pain management in hospitals was addressed shortly thereafter. Recently, the Joint Commission of Accreditation of Healthcare Organizations (JCAHO) established “new” standards for the assessment and management of pain in accredited hospitals and other health care settings (JCAHO, 2000). These standards require that JCAHO-accredited hospitals maintain specific functions and activities related to pain assessment and management for patients. These are summarized as follows (Chapman, 2000):
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Table 4-2: Pain Care Bill of Rights (American Pain Foundation, 2000) |
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As a person with pain, you have:
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Although not always required by law, these are the rights you should expect, and if necessary demand, for your pain care. |
In addition to the new JCAHO standards, the “Pain Care Bill of Rights” has recently been developed (American Pain Foundation, 2000b; see Table 4-2). The Pain Care Bill of Rights can be given to surgery patients as part of the preparation program. A list of these “Rights” along with a Pain Action Guide can be downloaded free from the American Pain Foundation website. The topic headings that are covered in the Pain Action Guide can be found in Table 4-3.
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Table 4-3: Summary of The Pain Care Action Guide |
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How do I talk with my doctor or nurse about pain?
How can I get the best results possible?
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Similar to the Pain Action Guide, but more detailed, Deardorff and Reeves (1997) have developed a pain control plan as part of a surgery preparation program. As part of a surgery preparation program, patients should be encouraged to do the following:
Many hospitals have an established surgical pain control service that is responsible for postoperative pain management. Typically, hospitals that have set a high priority on pain relief by committing to having a surgical pain service provide the most effective pain management. If a patient’s surgeon operates in more than one hospital, and there are no other medical factors related to hospital choice, encourage patients to use the one with the established pain service. In addition, it is important for the surgical patient to have one individual or service in charge of pain control in order to avoid confusion. This guideline applies to the hospitalization episode as well as the post-discharge recovery period.
In helping patients develop a pain control plan with their surgeon and surgical team, they should be encouraged to complete the following tasks:
Previously reviewed research suggests there may be a tendency for surgeons, doctors and other healthcare professionals to minimize discussions about what the patient may feel following the surgery. It is possible that they believe this silence will reduce the patient’s anxiety and distress, but that is not the case. Patient should obtain answers to the following questions as part of their surgery preparation program. Having this information prior to the pain experience will greatly enhance a patient’s sense of control, security, and self-efficacy.
Will there be much pain after surgery?
What will the pain likely feel like?
Where will the pain occur?
How long is the pain likely to last?
How long will it be before I am able to be active?
Will there be any side effects to the treatment (such as nausea)? How long will these last?
There are many pain management options available to patients. Some of these involve the use of pain medications and others do not. It is important for patients to understand these options prior to surgery. Have patients find out about the different types of pain medication options as well as the mode of delivery (e.g. oral, injection, PCA). This can be provided as a simple informational handout to the surgery patient.
As most healthcare professionals are aware, there have been two major advances in the way pain medications are scheduled and this has resulted in significant improvements in postoperative control of pain. These are time-contingent scheduling and patient-controlled analgesia. These concepts should be taught to patients as part of a surgery preparation program.
Time-contingent scheduling. Time-contingent scheduling involves giving the pain medication at set times, whether or not the pain is severe. Instead of waiting until pain gets worse or “breaks through” the effect of the pain medicine, the patient is given the medicine at set times during the day to keep the pain under control. Thus, time determines when the medication is delivered rather than the severity of the pain (which is prn or “as-needed” dosing). By giving medications in this time-contingent manner, a steady-state level of pain medication in the blood can be achieved by adjusting the doses. Time-contingent dosing avoids the “peaks and valleys” of pain which are characteristic of as-needed dosing and is one of the most important advances in the effective use of pain medications. It reduces the roller coaster ride characteristic of as-needed scheduling. This type of dosing is commonly used when the patient is in the hospital and should actually be maintained during the acute recovery phase.
Patient-Controlled Analgesia (PCA). The second major advancement in medication scheduling and delivery is called Patient-Controlled Analgesia or PCA. This technique involves the use of special medication “pump” that allows the patient to deliver predetermined amounts of pain medication through a catheter into a vein when a button is pushed. The PCA puts the patient in charge of pain management by allowing increased control over pain medicine delivery. Built-in safety measures prevent the patient from administering too much medication. The results for the patient are immediate because he does not have to wait for the nursing staff to respond to requests for medications. In addition, the PCA can be programmed to deliver medication through the night automatically to insure that pain control is achieved around the clock.
PCA is the method of choice for controlling pain following most major surgeries. A great many research studies have found that patients using PCA are much more comfortable, use less pain medication overall, can be discharged from the hospital earlier, and are generally more satisfied with their care (see Carron, 1989; Ferrente, Ostheimer, & Covino, 1990; Warfield & Kahn, 1995; Williams, 1996; 1997 for reviews). Recent research has found that a patient’s use of the PCA is impacted by psychological variables such as anxiety, fear of pain medication, stoicism, a lack of “readiness” to take control of the pain, and not wanting to be seen as a “complainer” (Gil, Ginsberg, Muir, Sykes, & Williams, 1990; Perry, Parker, White, & Clifford, 1994; Wilder-Smith & Schuler, 1992; Williams, 1996; 1997).
Many advances have been made in anesthesia options; patients should discuss these with the appropriate physician. Many surgery preparation programs recommend that patients meet with their anesthesiologist in advance of the scheduled surgery. This discussion should include the patient’s previous experience with anesthesia and whether any problems occurred then.
There are several non-medication techniques that can be very effective for pain control. Most pain is best treated with a combination of medications and non-medication approaches. The non-medication approaches listed below are readily available, easy to use, low risk, and inexpensive. Patients can be easily taught about these techniques as part of a surgery preparation program and use them both pre- and postoperatively Even though these techniques are readily available, they are often not suggested unless a surgery patient makes a specific request.
Patient Education. This involves patient instruction on any aspect of surgical recovery that they use to help with pain control. Instruction might include such things as coughing exercises, deep breathing, proper body mechanics, and physical restrictions. Patients given such instruction prior to surgery report less pain, require fewer pain medications, and have shorter hospital stays.
Cognitive-Behavioral and Relaxation Techniques: These techniques have been previously reviewed and can help not only with overall surgical recovery and outcome, but also with pain control.
Heat and Cold: The application of heat and cold is used to reduce pain sensitivity, reduce muscle spasms, and decrease congestion in an injured area (for example, the site of surgery). The initial application of cold decreases tissue injury response, and later, heat is used to promote clearance of tissue toxins and accumulated fluids.
Massage and Exercise: Massage and exercise are used to stretch and regain muscle and tendon length and range of motion. These techniques can be especially important with orthopedic surgeries.
Transcutaneous Electrical Nerve Stimulation (TENS): TENS is a technique that can promote pain control and healing. TENS involves placing adhesive pads (electrodes) in specific locations related to the pain following surgery or injury. The electrodes are connected by thin wires to a small pocket-sized battery operated stimulator that produces electrical current that the patient can adjust. The electrical current, which feels like a tingling sensation, is thought to decrease pain by raising the threshold of the nerves in the spinal cord that respond to injury. TENS may also promote healing by reducing inflammation and increasing mobilization following surgery.
The most important thing for patients to remember regarding effective pain management is to stay ahead of the pain. This is done by teaching patients to take pain medications and use non-medication techniques when the pain first begins or before it starts. If the pain escalates and gets out of control, it becomes more and more difficult to bring under control.
Patients who are experiencing pain at the time of discharge from the hospital are generally given oral medications to take with them. These are usually to be taken using a strict time-contingent scheduling with a gradual tapering as pain subsides. If a patient is taking too much pain medication before the surgery, it may put them at risk for inadequate pain control or side effects following surgery. In this case, part of surgery preparation program might be a time-contingent tapering or modification of pain medications prior to the surgery.
Patients should understand that a large body of research has demonstrated that if pain medication is given for a legitimate reason (e.g. related to surgery), addiction to analgesics is very unlikely (Cleary & Backonja, 1996; Porter, 1980; Portney, 1994; Zenz, Strumpf & Tryba, 1992). The fear of addiction is prevalent among individuals facing surgery and may cause the patient to be reluctant to take appropriate doses of medication for adequate pain control. To ease patient fears, it is important to help them (and healthcare professionals) understand the difference between important pain medication concepts: tolerance, pseudotolerance, physical dependence, addiction, and pseudoaddiction (see American Academy of Pain Medicine, the American Pain Society & American Society of Addiction Medicine, 2001):
Tolerance is a well-known property of all narcotics. It is the need for an increased dosage of a drug to produce the same level of analgesia that previously existed. Tolerance also occurs when a reduced effect is observed with a constant dose. Analgesic tolerance is not always evident during opioid treatment and is not addiction.
Pseudotolerance is the need to increase dosage that is not due to tolerance but due to other factors such as changes in the disease, inadequate pain relief, change in medication, increased physical activity, drug interactions, or lack of compliance. Patient behavior indicative of pseudotolerance may include drug seeking, “clock watching” for dosing, and even illicit drug use in an effort to obtain relief. Pseudotolerance can be distinguished from addiction in that the behaviors resolve once the pain is effectively treated.
Physical Dependence is also a well-known and understood physical process. It is a state of adaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. Physical dependence is not a problem if patients are warned to avoid abrupt discontinuation of the drug, a tapering regimen is used, and opioid antagonist (including agonist-antagonist) drugs are avoided.
Addiction is a psychological dependence on the medication for its psychic effects and is characterized by compulsive use. The medication is sought after and used even when it is not needed for pain relief. Addiction includes both tolerance and dependence as well.
Pseudoaddiction is drug-seeking behavior that seems similar to addiction, but is due to unrelieved pain. The behavior stops once the pain is relieved, often through an increase in pain medication. If the patient complains of unrelieved pain and shows drug-seeking behavior, careful assessment is required to distinguish between addiction and pseudoaddiction.
Patients (and healthcare professionals) often confuse these concepts. Both tolerance and dependence commonly occur in pain medication use and can be readily managed by the physician specializing in this area. Tolerance can be managed by adding other non-addictive medicines that help the narcotics work better and/or by emphasizing non-medication pain control techniques. Dependence is addressed by slowly tapering the pain medication and, as appropriate, adding other medication to control withdrawal symptoms.
Most surgery preparation programs focus primarily on self-regulation techniques. Although these approaches are certainly important, a great deal is missed if the psychosocial factors are not taken into account. A comprehensive surgery preparation program will intervene both for the individual surgery patient and in the social network. Figure 4-1 shows the process of putting together a preparation for surgery program.
In summary, the program begins with assessment of the patient and proceeds to assembling program components, implementing the intervention, and following up to enhance outcome (see Figure 4-1). It is important to emphasize that the preparation for surgery program is extremely flexible and can be adapted to the individual patient’s needs, the program structure (individual, group, or a combination thereof) and/or the time available before the operation. For instance, although the number of possible surgery preparation program components is extensive, not all interventions will be used with every patient. Also, the program can be adjusted to emphasize more of a patient self-guidance focus, if necessary.
A last consideration is follow-up with the patient after the surgery. Surgery
preparation programs often end with the surgery, and this is a mistake. Follow-up
after the surgery is very important in order to increase the probability that
the patient will continue to utilize the surgery preparation and pain management
techniques throughout the postoperative period. Depending upon the situation,
the follow-up treatment might include postoperative visits in the hospital,
outpatient sessions after the patient is discharge and is ambulatory, or simple
telephone calls.
Figure 4-1: Components of a surgery preparation program
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Assess Patient Needs
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Assemble Appropriate Program Components
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Implementation Strategy
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Postoperative Follow-up
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After clinicians become familiar with surgery preparation techniques, they must successfully integrate preparing for surgery into their practice. There are several ways to approach marketing, and given the clinician’s particular situation, one or all of them might be pursued. These ideas include the following:
Probably one of the best and most sure ways of gaining access to surgery patients is within the offices of a group surgery practice. Offering the preparation for surgery program either in a group format or individually within the surgeon's office makes it easier for the patient and the physician, as well as increasing the probability that patients will follow through on the recommendation. When approaching surgeons with this proposal, it is important to be as organized and succinct as possible. Focus on making the process easy to implement within another doctor's office and highlight how the program will benefit the surgeon. A few suggestions include (a) prepare patient pamphlets for the waiting room that describe the program, (b) design referral slips in the form of a prescription pad that the surgeon or assistant can use to make the referral, and (c) make the surgeon a part of the program so that patients see it as being a benefit of the surgery practice.
Adequate space is often an issue in any office. A useful method to address this problem is to use the waiting room of the practice in the evenings to do the preparation for surgery groups. Of course, paying an overhead fee for the use of the space is appropriate. Lastly, the logistics of running the groups should be almost transparent to the surgery practice. The clinician or a designate should handle scheduling, questions about the program, and other program-related issues so that these responsibilities do not fall upon and overburden the surgery practice. Becoming too much of an administrative "hassle" is the death knell of this type of arrangement.
It can be useful to target a certain surgery population for marketing for at least two reasons. First, providing successful preparation for surgery treatment almost always requires that the clinician have knowledge about the specific procedure (e.g., what the procedure involves, amount of time in the hospital, what the postoperative course is usually like, possible complications, what the psychological issues are likely to be). For instance, if you choose spine surgery or bariatric surgery, you should be well versed in the preoperative, peri-operative, and postoperative course of treatment. You will likely spend more time with the patient than many of her physicians and, therefore, will be a valuable source of information.
Second, some surgeries are highly amenable to advanced scheduling, which allows adequate time for the surgery preparation program. Excellent surgeries that are very amenable to surgery preparation programs include scheduled C-sections, most spine surgeries, many heart surgeries, certain organ transplantations, bariatric surgeries, and cosmetic surgeries.
Another marketing method is to arrange with a local hospital to offer a preparation for surgery program. It can be formulated to the hospital administration as being similar to offering child-birthing classes. Hospitals are always looking for ways to stand out in the public eye. Being able to advertise that they offer a unique program such as preparing for surgery is an excellent item that they can use as part of their marketing to the public as well as doctors.
Insurance companies are another area for potential marketing, although this is bound to be the most frustrating and probably least fruitful. Although you can do a dynamite presentation on how referring patients to a preparation for surgery program can benefit the insurer (e.g., increased patient satisfaction, decreased complications, shorter hospital stays, and overall cost-savings), it can be virtually impossible to get beyond the "red tape" to actually implement the idea.
One type of insurance company that might be more amenable to this type of program is an HMO. Most HMOs are a closed system and they are more interested in prevention programs that can save them money over the long-term. If they understand that surgery preparation programs will decrease complications and result in less time in the hospital, they become more excited about the idea.
Depending on a number of factors, practice in this area can often be done outside the constraints of mental health managed care in one of two ways. First, because the program is very amenable to a group format, it can be offered in a structured "class" format rather than as psychological treatment. Patients simply sign up to take the surgery preparation class and pay a fee for the entire class when they register. Under this approach, it would not matter if the clinician were on the managed care panel of any of the class members because the program is not being offered as treatment. It is important to remember that, if the program is offered as a class, it should be done as such for all members of the group. It would not be prudent to have some members of the class participate on an insurance basis (implying treatment) while others are doing it as a "class."
The class method of running the program is probably the best approach because it really decreases the amount of administrative overhead (e.g., patient and insurance billing, getting pre-approvals) and increases patient motivation to attend each meeting, as it is prepaid. Any patient who required individual treatment beyond the groups (for instance, in the case of medical phobias) could be seen on a different basis at another time. Doing the surgery preparation program as a class follows a model similar to the child-birthing classes or a stress management class one might take at a local college or hospital
Second, it is occasionally possible to get approval to provide this treatment under the patient's medical benefits because it directly relates to a surgical intervention. This can be a somewhat long and arduous process requiring pre-certification documentation to be supplied about the program, documenting why it should be considered medical treatment, and a referral letter of medical necessity from the surgeon.
Much of the material in this course is based upon the book, Preparing for Surgery: A Mind-Body Approach to Enhance Healing and Recovery (Deardorff and Reeves, 1997; New Harbinger Press). The book is designed as a self-guided patient workbook, but might also be used as a clinician guide for surgery preparation.
To purchase the book for $17.95 with free shipping and handling, click here to visit the Preparing for Surgery: A Mind-Body Approach to Enhance Healing and Recovery website.
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