Ask psychologist Robert Allan, PhD, for an example of a Type-A personality, and he points to his late father. The senior Allan was hostile, insecure and impatient--a textbook case of the kind of personality prone to heart disease. He had his first heart attack at age 46.
"My father had no shortage of free-floating hostility," says Allan, clinical assistant professor of psychology in medicine at the Weill Medical College of Cornell University in New York City. "He was a very Type-A kind of guy."
Fascination with the link between his father's personality and his heart disease inspired Allan to seek a new practice niche. Over the years, Allan's traditional psychotherapy practice has branched out to include cardiac patients. Today Allan, co-editor of "Heart & Mind: The Practice of Cardiac Psychology" (APA, 1996), devotes his practice in large part to helping cardiovascular patients like his father.
Reaching out to cardiac patients
For the last 15 years, Allan has been providing education and individual and group therapy to cardiac patients as co-director of the Coronary Risk Reduction Program at New York Presbyterian Hospital. At any one time, Allan has about 40 to 50 cardiac patients on his caseload.
A big part of Allan's job is simply teaching people about their disease. To accomplish that goal, he conducts educational sessions for patients who are hospitalized following a heart attack, bypass surgery, angioplasty or other cardiovascular problems.
"It's amazing to see how little some people know about coronary disease," he says. "A lot of people come in having had their last cigarette while waiting for the ambulance."
Twice a week Allan gathers inpatients into the hospital's patient lounge. There he reviews risk factors for cardiovascular disease and explains how patients can lessen their risk of further problems.
"One important message I give them is, 'If you have a bad family history, live differently than your family,'" says Allan, who admits that his father's history helps motivate his own stress-reduction program of daily meditation and piano playing.
While some patients need help reducing their risk of further cardiac problems, others need more general psychotherapy. For many, a brush with mortality forces them to reconsider their values.
"If you've had a life-threatening heart attack or come through a cardiac arrest, it puts your life into very bold relief," says Allan. "You begin to wonder what life is all about."
Anger is the No. 1 issue patients face, says Allan, who also runs stress-management groups at the hospital's cardiac rehabilitation centers in Manhattan and Queens.
"The single biggest myth we try to eradicate in our work is that old-fashioned idea that intense anger will consume you if you don't express it," he says, noting that a major study shows that anger can actually trigger heart attacks and sudden death.
Allan teaches patients a two-step strategy for managing their anger safely: Patients learn to avoid explosions of anger and then reframe the situation. Instead of honking and yelling at a driver who cuts you off, Allan tells them, simply identify the situation as one that makes you angry. And instead of seeing yourself as a victim of injustice, consider the situation in a less personal light. Perhaps the other driver is just late for work.
Some groups are comprised of specific types of cardiovascular patients. For example, one of Allan's newest groups targets patients who have received implantable defibrillators. The devices--permanently implanted in patients with potentially life-threatening cardiac arrhythmias--automatically provide a life-saving electrical shock when needed to restore normal heart rhythm.
For this group, the main issue is anxiety. Because patients would die without the device, they often become obsessed with whether it will work when needed. The shocks themselves--which Allan compares to being punched in the chest--can also be traumatic.
"You're basically wearing your mortality in your chest," Allan explains, adding that he teaches patients relaxation techniques and hopes to help them identify signs of impending arrhythmias so they can prepare themselves for shocks.
Because many implantable defibrillator patients are young, self-image can also be a problem. Slightly smaller than a deck of cards, the device is visible under the skin between the shoulder and the chest. This disfigurement can be a serious issue for both men and women, says Allan.
The act of attending a group is itself a kind of therapeutic intervention for many patients, he adds.
"Aside from the content, the groups are also an immensely helpful reminder to patients that they are and remain cardiac patients," he says, adding that only a third of cardiac patients manage to maintain their risk-factor modification programs over the long haul. "It's a pretty undemanding way of being reminded to keep up your healthy habits, especially when you're reminded by the foibles of others."
Collaborating with cardiologists
Convincing the cardiology community of the value of this kind of work hasn't always been easy, admits Allan. When he first decided to move into cardiac psychology in the mid-1980s, he cold-called every cardiologist in Manhattan in search of a collaborator.
"It was and still is a tough sell," says Allan. "It helps that the data on psychosocial factors' role in cardiovascular disease just keep getting better and better." (See article on page 42.)
Perhaps the most enthusiastic supporter of cardiac psychology is Allan's colleague Jeffrey Fisher, MD, clinical associate professor of medicine at Weill Medical College. Fisher often refers patients to Allan and other mental health professionals. That makes him an unusual cardiologist, he admits.
Fisher, who double-majored in biology and psychology as an undergraduate, says many of his fellow cardiologists ignore the role emotions play in illness and recovery.
"There are a number of high-powered groups doing high-powered studies, but their data just aren't trickling down to the trenches," he says. "The average physician isn't intervening when a patient comes into the office with angina and a wife who says he put his fist through the door the other day. They just shrug their shoulders."
Patients as well as physicians can fall prey to the societal stigma still associated with seeking mental health treatment. Many of Fisher's patients, for example, refuse to follow his advice and see psychologists or other mental health professionals for their anxiety and depression. They prefer that Fisher treat their problems, and he does--with medication.
To Fisher, patients' reluctance to seek psychological care means they're not getting the best treatment they can. Instead of treating cardiovascular disease from a strictly medical perspective, he says, cardiologists should work with psychologists to address both psychological and physical issues.
Fisher points to one of his patients as an example of how powerful such interdisciplinary collaborations can be. The patient had had bypass surgery even though her only risk factor was high blood pressure. After the surgery, she revealed almost casually that she had suffered enormous disruption growing up in World War II-era Germany. Fisher urged her to see a psychologist. When she finally addressed her lingering anger in therapy, her previously uncontrollable blood pressure dropped.
Cases like that helped convince Fisher of the importance of psychologists in cardiac care.
"Psychologists should be involved in all aspects of medicine, whether they're helping people deal with stress or helping them comply with treatment regimens," says Fisher. "We need to realize that the mind is a huge part of our well-being."
To participate as partners with cardiologists, says Allan, psychologists need to be able to speak their language. That's why "Heart & Mind" includes a chapter offering a "whirlwind tour" of cardiology to mental health professionals.
"You need to be able to speak to cardiologists in 'cardiologese,'" says Allan. "When cardiologists refer patients to me, they talk about patients' 'ejection fractions' or what kind of lesions they have. They talk to me as if I'm a fellow physician."
Learning that language required extensive training, says Allan. His education began in 1981 with an informal visit to the San Francisco office of cardiologist Meyer Friedman, MD--the father of research on Type-A behavior. By coincidence, a nurse Allan knew happened to refer his first cardiac patient to him soon after he returned from his trip.
Soon Allan had contacted cardiologist Stephen Scheidt, MD, professor of clinical medicine and director of cardiology training at Cornell University Medical College, whose name had come up over and over again during Allan's cold calls to cardiologists. The collaboration they formed eventually led to Scheidt becoming the co-founder of the Coronary Risk Reduction Program and the co-editor of "Heart & Mind."
Scheidt invited Allan to go on rounds at the hospital and sit in with his patients for a year. When Allan noticed that patients seemed anxious or upset, he invited them next door for a conversation. Today most of his referrals come from physicians and nurses.
Now Allan travels around the country advising others how to start their own programs. For psychologists interested in moving into the field, he says, the best way to start is getting trained by a cardiologist in a university-based hospital. They should also get included as part of the group of fellows and residents who make rounds on cardiac floors. Allan recommends asking the chief of cardiology for training opportunities.
"That's the way to get your foot in the door," he says.
Prospects are bright for psychologists with this kind of training, says Allan--especially if studies continue to produce promising data. After all, he points out, cardiovascular disease is still the nation's No. 1 killer. And the area has proven lucrative for the handful of psychologists who practice cardiac psychology full-time, he says.
Allan says he has never had a problem convincing insurers to pay for his services. Allan helps ensure problem-free reimbursement by providing insurers with the data linking psychosocial factors with heart attacks and other cardiac events. "They're not used to having hard data presented to them," he says. "They don't argue."
Of course, psychologists aren't the only ones who benefit. For Scheidt, patients are the ultimate beneficiary of collaboration between psychology and cardiology.
"Every physician knows instinctively of the enormous influence that the psyche has on patients' well-being and functioning," he and Allan write in the introduction to their book. "The opportunity presented by collaboration between cardiology and psychology in day-to-day work in a hospital...must be taken to improve practitioners' ability to heal patients."
Rebecca A. Clay is a writer in Washington, D.C.