Surgical Patients Need Us: Psychological

Preparation Improves Outcomes

by William W. Deardorff, Ph.D., ABPP

copyright 2007 by William W. Deardorff, Ph.D., ABPP. All rights reserved.

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Preparation For Surgery: Conceptual Models

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:

informative preparations
pre-operative education
cognitive behavioral approaches
empowerment and self-efficacy
individual and social self regulation
biopsychosocial

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.
Informative Preparations
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.
Individualized information

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 informationavoiders 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 patients coping style (informationseeking 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 patients 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
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).
Cognitive-Behavioral Approaches
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 patients
thoughts about the surgery will determine the amount of emotional and physical

stress experienced. Thus, changing a patients 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 individuals self-talk. Turk (2002) has summarized the five
assumptions that characterize the cognitive behavioral treatment approach:
1. People are active processors of information rather than passive reactors
to environmental contingencies.
2. A persons thoughts can influence affective and physiological arousal,
both of which may serve as impetus for behavior. In addition, affect,
physiological arousal and behavior can influence ones thoughts.
3. Behavior is reciprocally determined by both the environment and the
individual.
4. If an individual has learned maladaptive cognitive, affective, and
behavioral patterns, then treatment should be focused on changing these
patterns with intervention across all dimensions (cognitive, affective,
physiological, and behavioral).
5. Just as a person in instrumental in developing and maintaining
maladaptive patterns, the individual must take an active role in changing
these responses.
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.
Self-efficacy and Empowerment
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

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). Selfefficacy 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 individuals
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 individuals 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 selfefficacy (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).

Empowerment

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.
Individual and Social Self-regulation
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.
Individual 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 patients problem representation has objective and subjective
elements. The objective problem representation includes the patients 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 patients 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
Table 2-5: Patients Main Worries about Surgery

Whether the operation will be a success

How long it will be before there is a return to normal function
Feeling unwell after the surgery
Being away from home
How ones children will cope
How ones spouse will cope
Dying during the operation
What is physically wrong
Pain after the operation
Being unconscious
Family worrying
Doctors explaining the procedure
Waking up during the operation
Fear that the surgeon will make a mistake during the operation

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 patients 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 realitybased 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. Preoperatively, 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 patients 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 selfregulation. 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):
1. The immediate physical danger represented by the surgery itself that
includes such things as the threat of general anesthesia, the incision,
resection, reconstruction, catheterization, and immediate postoperative
complications.
2. The aftereffects of undergoing these procedures, including such things as
pain, discomfort, disorientation, fatigue, and a reduced capacity for
physical activity and ambulation. These are essentially the subjective and
functional effects of the surgery itself on the patient. These threats begin
just after surgery (the middle of phase II) and decrease through phases III
and IV.
3. The patients potential inability to enact valued social roles including such
things as engaging in family, occupational, and leisure activities. The
threat to social roles begins in phase III and increases through phase IV.
4. The long-term management of a possibly chronic medical condition. Longterm management issues might include such things as the need to diet,
exercise, take medications, and undergo follow-up visits. This threat
occurs in phase IV.
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.
Social self-regulation

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 patients 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. Taskfocused 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 selfregulation 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 patients
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 patients 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 patients 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 patients 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 patients 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 partners evaluation of the patients coping efforts
can either enhance or impede this ongoing process.
A patients 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 patients 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 patients and partners 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 patients 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 patients and partners 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, genderidentity, 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 roleloss 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 patients 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 patients 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 patients recovery in many ways. It
can lead to negative behaviors such as being overly aggressive in encouraging
the patients recovery, slowing the patients 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 underinvolvement and over-involvement depending upon interactions with patient
behavior.
Consistency between the patients and partners 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 patients family, friend,
coworkers, healthcare professional, and others, as appropriate. The model also
underscores the importance of considering a patients social relationships as a
target of intervention for surgery preparation.

The Biopsychosocial Model of 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 patients 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 opensystems 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 patients health status, health habits, medical condition, and type of
surgery
the patients psychological status and coping resources
the healthcare professionals involved in the patients treatment and all of
the other subsystems,
family members behavior towards the patient and amongst themselves in
response to the surgery,
the patient and familys interaction with extra-familial systems such as
relatives, friends, and coworkers

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 patients 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).

Summary and Conclusions

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.

Chapter 3: Preparing for Surgery: CognitiveBehavioral Interventions

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 patients
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).
Table 3-1: Assessing the patients understanding of the surgery

What the patient believes is going to happen

The patients beliefs about why he must have the operation and his anticipated
outcome
The patients knowledge about the operation and postoperative recovery
The patients previous experience with the surgical process

The patients understanding about the psychological preparation for surgery

program
Home, work and family information
Some information about the patients motivation for participating in his own
treatment

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.

Individualized versus Prepackaged Programs

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.

Components of Surgery Preparation

Gathering Information
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 patients ability to understand and remember
important medical information, and the doctor-patient relationship.
Coping Style of the Patient

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 patients coping
style. As reviewed in the previous chapter, some patients are informationseekers while others are information-avoiders. For information-seekers, the
general rule is the more information the better. Alternatively, informationavoiders 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 patients coping style relative to information
gathering can be found in Table 3-2. In addition, actual measures that assess an
individuals information-seeking style have been developed (Miller, 1987). Prior to
providing medical information, the patients coping style should be assessed in
some manner.
Table 3-2: Information-Seekers versus Information-Avoiders
Does the patient tend to agree or disagree with the following statements?

Investigating books, magazines, and television programs about medical

conditions and surgeries makes the patient feel more comfortable,
confident and in control.
The patient prefers to gather very specific and detailed information about
her health condition.
Detailed medical information does not bother the patient

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 patients 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 patients 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
patients 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.
Understanding and Remembering Medical Information
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 doctors
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 doctors office).
Table 3-3: Questions patients can ask about their surgery
About the Medical Condition and Surgery
What is wrong with me? What is my diagnosis?
Why do I need the surgery?
How will the surgery improve my condition?
What other treatment options are available and have these been adequately
tried?
What will happen if I don't have the surgery or delay it until a later date? How
long can I delay the surgery if I decide to do so?
What are the risks of the surgery? Do the benefits of the surgery outweigh the
risks?
If the surgery is successful, what results can I expect? If it is not successful (or
only partially successful), then what remaining symptoms can I expect?
Can you describe the surgery to me in simple language?
Do you have a brochure or information sheet that describes the surgery?
How will I feel after the surgery? (in the recovery room, the following day, etc.)
How can I expect to feel each day in the hospital after the surgery? What will I
be able to do, and what should I try to do, each day in the hospital after the
surgery?
What complications might arise after surgery or after being discharged from the

hospital? What is the best way to manage these complications if they arise?
With whom should I discuss these issues?
Will I need assistance at home after I am discharged from the hospital? Should I
arrange for that now? Will I go directly home after discharge or is there the
possibility of going to a rehabilitation or transitional care unit/facility?
Once I go home, what will my level of functioning be and for how long?
Blood Transfusion
Is it possible that I may need a blood transfusion during the surgery? YES NO
Can I give blood in advance in case I need it during the surgery? YES

NO

Where should I go to give blood before my operation? Record below the

address, phone number, and contact person at the blood collection center.
Is there enough time before surgery to give the blood that I may need?
What are the risks in giving and receiving my own blood?
What to do Before the Surgery
What pre-surgical tests or evaluations are necessary? Who will be doing these
and when should they be done?
Should I make sure my family physician knows about the surgery?
Will my family doctor be involved in my postoperative care? Does he or she
need any special medical records?
Do I need to be on a special diet before or after the surgery? If so, can you
explain it in detail?
Will this operation be done on an outpatient or inpatient basis?
In what hospital will the operation be done?
Is the surgery and hospitalization pre-approved by the insurance company?
Hospitalization approval letter received from insurance company?
Number of hospitalization days pre-approved by the insurance company
What if more days are required as recommended by the surgeon? How does one

get approval and who is responsible for that?

What doctors can I expect to see in the hospital and why?
When will I first see my surgeon in the hospital after the surgery?
Will my surgeon be in town and managing my case the entire time I am in the
hospital?
Informed consent
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.
Information Gathering and The Internet
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:

Spine Surgery: North American Spine Society

Bariatric Surgery: American Society for Bariatric Surgery
Organ Transplantation: Government Information
Plastic Surgery: American Society of Plastic Surgeons
Orthopedic Surgery: American Academy of Orthopaedic Surgeons

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 cognitivebehavioral category. The next section will provide a brief overview, along with a
special emphasis on applicability to the surgery patient.

Cognitive Restructuring
Basic Tenets
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:
1. It is not the situation that causes a specific emotional response, but rather
an individuals thoughts or cognitions about the situation.
2. Thoughts influence how we behave including what we choose to do or not
do, and the quality of our performance.
3. Thoughts can be considered behaviors that are susceptible to change.
4. Changing cognitions to be more positive or coping-oriented can influence
the surgical patients coping abilities and, therefore, enhance outcome.
Preparing the Patient for the Cognitive Behavioral Approach

Steps for preparing the pre-surgical patient for the cognitive behavioral approach
include:
1. Dispel the myth that the patient has been referred for surgery preparation
because of any type of weak will or other negative reason.
2. Explain that surgery preparation is commonly done with all patients in
order to normalize the experience.
3. Discuss that psychological preparation for surgery can enhance the
patients outcome and make the entire surgery process proceed much
more smoothly. Review the research on the findings that surgery
preparation will produce actual physical changes that facilitate healing and
recovery.
4. Discuss the rationale behind the various interventions (e.g. cognitive
behavioral, relaxation training).
The more the patient accepts the rationale behind surgery preparation, the more
likely she will embrace and practice the techniques.

Reviewing the Rationale Behind Cognitive Behavioral Techniques

with the Patient
The patient can be told that the cognitive behavioral model (and the method for
changing ones 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.
Self-Talk
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:

Self-talk occurs as specific, discrete messages that often are expressed in

shorthand
Self-talk is highly believable to the person no matter how unhealthy or
irrational it is
Self-talk is experienced as highly spontaneous and difficult to "turn off"
Unhealthy self-talk is often expressed in terms of "should, ought, never,
always and must"
Self-talk is unique to you as an individual

The ABDCE Model

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 Three-Column Technique
The ABCDE model can be utilized in a three- or five-column technique. A threecolumn 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.
Table 3-4: The Three-Column Technique
Activating Event

Beliefs

Preparing for a major My body is weak and fragile. It

surgery after a chronic will never be the same.
disability
My pain is going to get worse
and worse.

Consequent
Emotions
Fear
Anxiety and
Hopelessness

I cant handle this surgery. I hate

Fear and Anxiety
the hospital.
My family is going to leave me.

Depression and
Hopelessness

I should be better by now. The

surgery didnt work. I should
never have allowed this to
happen.

Frustration, Anger,
Guilt, and
Helplessness

If I move the wrong way, Ill do

Helplessness and
myself in. Ill wait until the pain
Fear
is gone, then Ill exercise.
There is nothing I can do during
Helplessness and
the surgery and recovery. Its up
Apathy
to my doctor.
What if the surgery doesnt
work? I bet it wont. Im either
cured or Im not.

Anger and
Hopelessness

I feel worthless. The future looks

Hopelessness
awful.

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 threecolumn 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 threecolumn 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:

Styles of Negative Self-Talk

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).
Catastrophizing
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:

What if I never get better

What if I get worse
What if the surgery doesnt work
What if...

In catastrophic thinking, the dire predictions are not based on facts but rather
pessimistic beliefs.
Filtering

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:

There is nothing that will help my situation

This situation is awful
Everything in my life is rotten due to this condition
Nobody really cares
I cant stand it
The doctors and surgeons have nothing to offer
I've tried everything and nothing has helped at all

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 persons 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.
Black and White Thinking
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:

I'm either cured or I'm not

I either have pain or I don't
The surgery either works or it doesn't
This doctor is either good or bad
My family is supportive or theyre not

This type of thinking undermines any small steps towards improvement, severely
limits one's options, and filters out any positive aspects of a situation.
Overgeneralization
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:

With this pain Ill never be able to have any fun

People don't want to be around me
My wife told me to try to do something about the pain. She must be ready
to leave me
I will always be sad
I will never be able to get beyond this medical problem

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.
Mind Reading
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:

I know my wife thinks I'm less of a man due to my condition

I know my husband thinks I'm exaggerating my pain
My doctor doesn't really think I'll get better even though she tells me I will
They're not telling me everything about my problem

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
patients 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.
Shoulds
"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:

I should be getting better

I should never have allowed this to happen
I should have known not to have had that procedure (or surgery)
My employer should have protected me
I should be tougher
My family should be more helpful

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).
Blaming
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 ones 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:

My boss is to blame for my injury. If

They should have mopped up that water I slipped on. It's all their fault
That guy who hit me owes me everything for the pain I'm suffering
I'm to blame for this lousy medical problem

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, Its 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.

Challenging Negative Self Talk and Thought Re-Framing

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:

What is the evidence for that conclusion?

Is this statement always true?
What is the evidence for that conclusion being false?

Among all possibilities, is this belief the healthiest one to adopt?

Am I looking at the entire picture?
Am I being fully objective?

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.
Avoid negatives
When having patients write positive coping statements, teach them to avoid
using negatives. For instance, instead of saying, I cant 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.
Keep coping thoughts in the present tense
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.
Keep coping thoughts in the first person
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.
Make coping thoughts believable
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 persons 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 cant wait to have surgery. Im 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.

Coping Self-Talk
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:
Catastrophizing
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.

No one can predict the future

If Im going to engage in What ifs, I might as well choose healthy ones
If I believe in myself, Ill be able to handle any situation including this
surgery

Filtering
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 cant stand it.

I can handle this situation (surgery)

Ive develop a number of resources to make this surgery turn as positive
as possible
I am doing this surgery for the positive reasons of
Im looking forward to getting beyond the surgery and beginning to heal
and recover
Ive had the surgery and now I can focus on getting better

Black and White Thinking

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.

I am making progress in the following areas

My ultimate goal is _____ and Im moving towards it in the following
ways...

Overgeneralizing
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.

Ive been able to get through a lot of situations and Ill get through this one
Just because my last hospitalization was unpleasant doesnt mean this
one has to be

Mind Reading
Nobody can read another persons 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 doesnt like me based simply on mind reading. Remind
patients that nobody can read another persons mind and it is important to check
it out.

I cant be sure about what he thinks unless I check it out

I need to act based on the facts, not on what I assume

Shoulds
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 patients 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?

I do not have to be perfect

Forget the shoulds, oughts, and musts
I am doing the best I can
I am doing what I can to get better and I will reward myself for that

Blaming

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.

They are doing the best they can

I did the best I could
From now on, I will

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.
Table 3-5: The Five-Column Technique
Activating
Event

Beliefs

Preparing for
a major
My body is
surgery after
weak and
a chronic
fragile.
disability

Consequent
Emotions

Disputing
Thoughts

Fear

I can strengthen
my body after
surgery. There Less Fear and
are techniques I more confidence
can use to help
with the pain.

Evaluation

My pain is
going to get Anxiety and
worse and
Hopelessness
worse.

I will strive to
become as
functional as
More sense of
possible. No
control
one can predict
the future

I cant
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.

I will continue
Hopelessness to work on
getting better.

Less
Hopelessness,
more

Hopefulness
The surgery Frustration
didnt work and Anger

I will begin to
move and
exercise
slowly.

Less Frustration

I should
I did what I
never have
Hopelessness thought was
allowed this
right.
to happen.

More Optimism

There is
nothing I
can do
Helplessness
during the
surgery and
recovery.

I can
participate in
my own
recovery.

More Confidence

What if the
surgery
doesnt
work? I bet
it wont.

No one can
predict the
future.

Less Anger and

more control

Anger

Im either
Small steps will
More
cured or Im Hopelessness lead to bigger
Hopefulness
not
ones.
There are
The future
things I can do More
looks awful. Hopelessness
to lead a quality Hopefulness
I feel awful.
life.

Relaxation Techniques
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 bodys condition when it is under stress. The relaxation response
was first described in the early 1970s (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
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.
Deep Breathing
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

1. Lie down on your back. Bend your knees and move your feet about eight
inches apart with your toes turned slightly outward. This will help
straighten your spine and keep you comfortable as you practice the
breathing exercise. If you have back pain, you may want to place a pillow
under your knees for extra support.
2. Mentally scan your body for any tension.
3. Place one hand on your abdomen and one hand on your chest.
4. Inhale slowly and deeply through your nose into your abdomen, so that
your hand rises as much as feels comfortable. Your chest should move
only a little and should "follow" your abdomen.
5. When you feel at ease the previous step, you can practice the deep
breathing cycle. In the deep breathing cycle, you should practice inhaling
through your nose while smiling slightly. Once you inhale deeply and
diaphragmatically, exhale through your mouth. This is done by gently
blowing the air out of your lungs and making a "whooshing" sound like the
wind. Doing this will help relax the muscles of your mouth, tongue, and
jaw.
6. Take long slow deep breaths that raise and lower your abdomen. Focus
on the sound and feeling of breathing as you become more and more
relaxed.
7. Continue this deep breathing pattern for 5 or 10 minutes at a time, once or
twice a day. Once you have done this daily for a week, you might like to
extend your deep breathing exercise period to 15 or 20 minutes.
8. At the end of each deep breathing session, take time to once again scan
your body for tension. Compare the tension you feel at the conclusion of
the exercise with that which you were feeling at the beginning of the
exercise.
9. As you become more proficient at deep breathing, you can practice it
anytime during the day in addition to your regularly scheduled sessions.
Simply concentrate on your abdomen moving up and down and the air
moving in and out of your lungs.
10. Once you have learned to use the deep breathing technique to elicit the
relaxation response, you can practice it whenever you feel the need.
Cue-controlled relaxation
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 Pavlovs original experiment in the early 1900s, 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).
Guidelines and Obstacles to Practicing the Relaxation Exercises
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 fiveminute 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 ones back with the legs extended
out and arms comfortably at the sides. Depending upon the patients 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 dont 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
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 presurgical 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).
Hypnosis is a state of deep sleep or unconsciousness
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.
Hypnosis allows someone else to control the patients mind

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.
A hypnotized person might not be able to come out of a trance
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 persons beliefs, leaves the
room, or is otherwise distracted. If left alone when hypnotized, most people
reorient, alert themselves, and awaken naturally.
A hypnotized person will give away secrets
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.
The patient believes that he probably cannot be hypnotized
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.

Visualization, Imagery, Distraction, and Humor

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:

To help achieve a more fully, deep, relaxed state

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.

To enhance physical healing

Many imagery exercises are designed to activate the bodys 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.

To provide a method for pain relief

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.

To help with improving sleep

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).

To promote muscle relaxation and decrease anxiety

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 ones muscles becoming more smooth
and loose.

To provide a powerful distraction from a stressful medical procedure

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.
Guidelines for Practicing Imagery
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.
Record an imagery exercise

Recording an imagery exercise on audiotape can help a great deal in terms of

the patients 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.
Use an image with which the patient is familiar

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
patients 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.

Use all five senses in developing the 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.
Use an image that is pleasing to the patient

The old adage that one persons feast is another persons poison applies to
imagery as well. Imagery is a very personal and individualized experience. It is
important to be sure that the patients 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 patients own
personalized image.
Sneak up on the 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.
Use one image at a time

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.
Precede the imagery with a relaxation exercise

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.
Practice the Image

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, dont 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.
Develop a technique to end your image

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.
Onegradually becoming more alertTwobecoming more and more
awakeThreebeginning to slowly move your fingers, hands, and

armsFour...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.
Don't worry if the image is not completely vivid

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.
Incorporate affirmations or prayer into the imagery

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.
Standard Imagery Exercises
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 patients 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:

"Passive Muscle Relaxation"

"The Beach Scene"
"Pain Reduction"
"Ball of Healing Energy"

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.

Passive Muscle Relaxation

As you feel ready, allow your eyes to slowly closeTake 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 inThen, breath out through your mouth while
slightly pursing your lipsNotice that the air you exhale is warm and
moist....Release all of the air in your lungs as you exhale completelySlowly
repeat this cycle several timesBreathing in through your nose and out through
your mouthRemember, 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 relaxedAs you allow yourself to relax more and more fully, begin
to focus your attention on your fingers and handsAs 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 bodyYou may notice your hands resting on
another part of your body or elsewhereSimply focus on the sensations coming
from your fingers and handsImagine what it would feel like for your hands and
fingers to become more and more relaxedLet 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 armsAs your
fingers and hands continue to relax, allow that feeling of relaxation to move into
your forearms and upper armsYou might notice your hands or arms feeling
warm or heavy as they relaxOr you may notice them feeling cool and
lightSimply 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 shouldersNotice what it would be like for your
forehead to relax completelyAllow the muscles around your eyes to relaxAs
you relax the muscles of your jaw you may notice that your lips separate
slightlyAllow your shoulders to relax completelyMentally 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 backImagine what
it would be like for all of the muscles in your stomach and back to unwind and
loosen up completelyIt is as if you are inhaling relaxing and exhaling tension
with every breathThere 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 legsAllow the relaxation response to move
further and further down your bodyNothing 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
responseThese are all normal feelings as part of relaxingSimply focus on
what the relaxation sensation feels like for youYou 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 daySimply take a deep breath and tell yourself to relax as you
exhaleThis 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.
Onegradually becoming more alertTwo...becoming more and more
awakeThreebeginning to slowly move your fingers, hands, and
armsFour...almost back to an alert state...you can now begin to move your
toes, feet, and legsand...Five...opening your eyes and finding yourself fully
awake, alert, renewed, and refreshed.
The Beach Scene

It is about five in the afternoon on a midsummer dayYou 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 horizonThe sun is a deep and
golden yellow, the sky full and a brilliant blue, and the sand is a glistening white
in the sunlightAs you walk on the sand in your bare feet, you notice it rubbing
between your toesThe sand is warm and comfortable...You notice the taste
and smell of the salt in the ocean airThere is the residue of salt deposited on
your lips from the ocean sprayYou can slightly taste its presence...You can
hear the roaring sound of the surf as it rhythmically comes in and washes out
from the shoreYou hear the far-off cry of a sea-gull as you continue to walk
along the beachYou 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 duneAs 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 inAs you sit, you allow yourself to relax more and more. You
find yourself relaxed, peaceful, and content.
Breathing out pain

Continue to breathe comfortably and slowly, feeling your body relax more and
more each time you breathe outIf 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 discomfortImagine your inhaling brings with it valuable
oxygen and nutrients your body needs...Your deep breath also brings with it a
sense of calm and comfortAs you slowly exhale, you might imagine that just a
bit of the pain and discomfort is exhaled along with your breathing outAs you
exhale some of this pain and discomfort, the tissues left behind seem to be more
relaxed, healthy, and comfortableThis reduction in pain may be only slightly
noticeable at first, but it seems to become more and more powerful with each
breathEach time you breath in, imagine the air flowing to that area of pain and
discomfortIt brings with it a sensation of health and comfortThen, each time
you breathe out the air, notice the area of pain and discomfort becoming smaller
and smallerAs you breathe out, you are exhaling discomfort and painBreathe
in the relaxation and breathe out the pain.
Healing energy

As you continue to relax, focus once again on your breathing. Notice how you are
slowly breathing inFeel the air going into your lungs...Notice your lungs filling
completely with air as you inhaleThen, notice the air rushing out of your lungs
and mouth as you exhaleEnjoy 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 energyIt may not be particularly clear or distinct
and that is perfectly fineWhatever 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 areaWhen 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 discomfortNotice the ball of healing energy moving slowly to
that part of your bodyImagine 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 healthyImagine 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

bodyYou 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
workAs 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.

Summary and Conclusions

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 patients
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.

Chapter 4: Preparing For Surgery: Psychosocial

Interventions
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.

Doctor-Patient Communication Problems and Medical Errors

The Doctor-Patient Communication Gap
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):

A recent survey of consumers by the American Medical Association

indicated that 58% of patients felt their physician did not provide adequate
explanations about their conditions.
69% of patients felt that their physician did not spend enough time with
them.
60% of patients do not read complex consent and hospital forms.
Research has demonstrated only a 30-50% retention for surgical
information in medical patients.
A majority of HMO complaints against physicians involve communication
issues.

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?
Medical Errors

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 hospitalacquired 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).
Table 4-1: Patient handout for avoiding medical errors
1. The single most important way you can help to prevent errors is to be an
active member of your health care team.
2. Make sure that all of your doctors know about everything you are taking.
This includes prescription and over-the-counter medicines, and dietary
supplements such as vitamins and herbs.
3. Make sure your doctor knows about any allergies and adverse reactions
you have had to medicines.
4. When your doctor writes you a prescription, be sure you can read it.
5. Ask for information about your medicines in terms you can understandboth when your medicines are prescribed and when you receive them.
6. When you pick up your medicine from the pharmacy, ask: Is this the
medicine that my doctor prescribed?
7. If you have questions about the directions on your medicine labels, ask.
8. Ask your pharmacist for the best device to measure your liquid
medicine. Also, ask questions if youre not sure how to use it.
9. Ask for written information about the side effects your medicine could
cause.
10. If you have a choice, choose a hospital at which many patients have the
procedure or surgery you need.
11. If you are in the hospital, consider asking all health care workers who
have direct contact with you whether they have washed their hands.
12. When you are being discharged from the hospital, ask your doctor to
explain the treatment plan you will use at home.
13. If you are having surgery, make sure that you, your doctor and your
surgeon all agree and are clear on exactly what will be done.
14. Speak up if you have questions or concerns.
15. Make sure that someone, such as your personal doctor, is in charge of
your care.
16. Make sure that all health professionals involved in your care have
important health information about you.

Figure 4-1: Components of a surgery preparation program

Assess Patient Needs

Information from medical records

Targets of assessment
o Cognitive
o Affective
o Behavioral
o Psychosocial

Assemble Appropriate Program Components

Cognitive Behavioral
o Information Gathering
o Cognitive Restructuring
o Relaxation Exercises/Cue Controlled Relaxation
Psychosocial
o Communication and Assertiveness
o Family, Friends and Work
o Spirituality
o Pain Control Plan

Implementation Strategy

Self-Guided
o Individual
o Group
o Blended

Postoperative Follow-up

Assess implementation of the treatment plan

Encourage patient use of various program skills
Facilitate family involvement, as appropriate
Assess and facilitate medical system postoperative recovery process