Patients were obtained from the "heart school", from the outpatient cardiology consultation clinic, and from doctors and other care givers who identified patients who were in need of stress reduction.
The need to be present at all sessions and the evaluation with self administered questionnaires were explained. The relevant questionnaires were distributed, filled out and collected prior to the first session. At the last meeting all questionnaires were distributed again together with an evaluation form, in which the participants could express in their own words how they had experienced the sessions.
All patients were also invited to a personal cardiovascular health check/consultation at two occasions; at the midpoint and at the end of the course.
Recruitment of patients
The intervention groups focusing on cardiac patients were formed in a Stockholm community Hospital. Two criteria for being selected to join a group had to be met:
1) Post AMI, PTCI or CABG, and
2) Self experienced stress problems.
We recruited 21 male and 13 female patients during one year; all aged 70 years or less (mean 55.5 years). All subjects had suffered an acute myocardial infarction (AMI), or undergone CABG or PTCA and also reported high psychosocial stress.
Patients were divided into groups with 5-7 subjects in each group. Four groups consisted of only men and two groups of only women.
The program schedule was planned for 10 original sessions, which were followed by up to ten booster sessions held to enhance practice and skills.
At the first meeting rules were set for the group sessions.
Everything that was said within the group should be considered as strictly confidential and must not be communicated to anyone outside the group. The importance of being a participant and show each other respect, was emphasized.
Each group session lasted for two hours. One of the groups chose to have a short break at the midpoint of the sessions; the others did not. Each session started with coffee and fruit.
The group leader planned and conducted the meetings and divided the time between the group members so that every participant would get an opportunity to speak at each session.
Relaxation exercises to music ended the meetings. The participants were taught techniques for relaxation; most commonly progressive muscle relaxation techniques were used.
Each session focused on a special subject (see below) and was accompanied by relevant home work tasks. At the beginning of the following session the homework from the previous session was reviewed. One such homework task could require that the participant was to observe and record his/her stress behavior-pattern during a whole week.
In one of the exercises the patient was asked to describe a situation which had provoked anger and describe it to the group. The patient's stressful and hostile responses were identified and discussed. Cognitive behavioral strategies were used in an attempt to alter the participant's stressful and angry responses. One strategy, "the Hook", had been specially designed to attenuate irritation and anger. Anger could be triggered by trivial events, for which the exercise was perceived as particularly helpful and repeatedly used. "The Hook" emphasized the opportunity of each individual to make a choice about how to react in a certain situation. The patient was asked to imagine being a fish and to experience the stressor as a "hook". He/she was then given the choice either to "bite", in the sense of getting irritated or angry, or to refrain from biting. Participants were asked to go home and exercise how to avoid "biting the hooks". At the next session they were to report about their experiences.
In another exercise, behavioral strategies for problem-solving were used in situations, which were perceived and described as threatening. The actual problem was observed, discussed and re-formulated by the group and the patient concerned; the other participants were active in giving suggestions to solutions. These were evaluated and judged by the patient who had presented the problem. Typically, the various members of the group offered different approaches to solve the problem. This approach frequently had a positive effect on the well-being and mood of the troubled patient. He/she had several approaches to choose from and could discuss these with the other group members.
It was important, however, to maintain a certain order and discipline during the sessions. Each patient was asked to speak at the order of priority - and the others were expected to listen and be supportive.
Topics discussed at the group sessions
1. Introduction and presentation of group members and their heart condition.
2. Atherosclerosis, coronary risk factors, and psychological consequences in relation to the cardiac event
3. Psychosocial stress and physiological stress reactions
4. Individual assessment of standard coronary risk-factors - and identification of the problem areas of the group
5. Anger and hostility in response to daily stress exposure, problem-solving and cognitive strategies, e.g. the "hook", as described above.
6. Coronary prone stress behavior. Reviewing and testing patients individual stress behavior. A video is used to identify this behavior.
7. Worry, depression, anxieties, low-spiritedness, type D-behavior (depression and social inhibition). Communication training - improving communication skills by passive and active approach.
8. Every day conflict situations. The patients are introduced to examples of conflict situations and asked to deal with them. True examples from the patients' daily lives are used along with fiction.
9. Positive and negative emotions. An exercise-book with daily, concrete cognitive exercises is started and maintained throughout the course.
10. Daily practice of relaxed behavior. Walking slowly, choosing the longest queue in the grocery store, driving in the right lane without unnecessary passing in the left lane, keep smiling at other people. The patients are expected to report back about the results to the group.
11. Patterns/roles of life, roles of social relations, strong and weak "legs" to stand on - "legs" symbolized for example "mother", "daughter", "professional pride" etc. Patients were asked to focus on their strong legs.
12. Stress and personality. Describing one's strengths in the working situation, and how this strength becomes visible within professional life. Exercises to increase one's understanding how other people function and think to recognize different strengths. To some details are more important; to others the whole context is of greater significance. This can cause conflicts both at work but privately. If a person ends up in the "wrong" professional place, e.g. is forced to deal with detailed questions, although his/her talent is more appropriate for global tasks, stress and "burn-out" may be the result.
13. Defining one's own life-situation; "How is my situation now?", "How would I like it to be?", "How do I divide my time between work, leisure, friends and family?", "How would I like this distribution of time to be?", "How much time do I get for myself?", and "What is a good balance between these different life domains?"
14 - 20. Maintenance of knowledge and skills by repetition and practice.
Health related Quality of life
To measure the health related global life quality, the "ladder of life" was used. This is a ladder with ten steps, the lowest one illustrating the worst state of life and the highest illustrating the best. The subjects were first asked to rate their present health related quality of life, then to estimate what it was like a year ago and last, what it would be like a year from now. This measure was based on our experience with patients and developed in the early phases of the Stockholm Female Coronary Risk Study [7
Sense of Coherence
The Sense of Coherence (SOC) scale was used to estimate the ability to master and cope with stressors. It describes the extent to which a person feels in tune with society around him/her and feels incorporated in a benevolent setting and system [10
]. Examples of questions are "Do you have a feeling that you have been treated wrongly?" "Has it happened that people you trust have disappointed you?". Response alternatives go from 1 to 7 with a maximum score of 91 points and a minimum of 13 points. A higher SOC score corresponds to better coping capacity of the patient.
Anxiety and Depression
To assess subjects anxiety and depression symptoms, the Hospital Anxiety and Depression scale (HADS) [11
] was used. The scale is divided into two subscales, anxiety and depression, and both consist of seven questions. All questions were scored 0,1,2,3, resulting in a maximum of 23 points and minimum of 0 on each of the scales.
Daily life stresses
A patient with coronary prone behavior is competitive, impatient, aggressive and in a hurry. Such a person also has a desire to achieve recognition, another highly estimated quality in modern society. To measure these stresses the "every day stress scale" was used [12
]. This scale is closely related to the early Type A assessments. The Stress questionnaire consists of 20 statements, such as "I get irritated by other drivers" and "I compete with myself and others". A four point Likert scale is used, with high scores corresponding to high stress. The scale has a maximum score of 80 points and a minimum of 20 points.
Depressed mood and social inhibition/type D behavior
A person with Type D personality tends to worry, to feel tense and unhappy. He/she often gets irritated and seldom sees the bright side of life. He/she is also socially and emotionally inhibited with relative social isolation as a consequence. The Type-D scale 16 (DS16) [13
] was used in its short form (DS 14). Examples of statements are "I am often in a bad mood" and "I am often irritated". Five response alternatives are used and scored from 0 - 4, with a maximum score of 56 points and a minimum of 0 points. The higher score corresponds to more Type D personality.
Information about marital status, number of children, smoking and other health habits, type of work, and employment status was obtained through interview. A self reported history of obesity, diabetes, hypertension, hyperlipidemia, family history, diagnosis, and medication was collected.
To determine statistically significant effects, paired t-tests were used to compare mean scale scores before and after the intervention. SAS (Software Analytics Systems) version 8.02 was used for analyses.