Surgical Patients Need Us: Psychological Preparation Improves Outcomes

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

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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 Consequent Emotions Fear Anxiety and Hopelessness

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.

I cant handle this surgery. I hate Fear and Anxiety the hospital. My family is going to leave me. I should be better by now. The surgery didnt work. I should never have allowed this to happen. Depression and Hopelessness 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 Consequent Emotions Disputing Thoughts Evaluation

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

Fear

I can strengthen my body after surgery. There Less Fear and are techniques I more confidence can use to help with the pain. I will strive to become as functional as More sense of possible. No control one can predict the future I can get through this. I can look forward to discharge and recovery. My family will help me especially if I help myself.

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

I cant handle this surgery. I hate the hospital. My family is going to leave me. I should be better by now.

Fear and Anxiety

Less Anxiety, less hospital stress

Depression

More feelings of comfort/support Less Hopelessness, more

I will continue Hopelessness to work on getting better.

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. There is nothing I can do Helplessness during the surgery and recovery. What if the surgery doesnt work? I bet it wont. I can participate in my own recovery.

More Optimism

More Confidence

Anger

No one can predict the future.

Less Anger and more control

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 Metabolism Blood Pressure Heart Rate Rate of Breathing Blood Flowing to the Muscles of The Arm and Legs Muscle Tension Slow Brain Waves Stress Response Increases Increases Increases Increases Increases Increases Decreases 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. Relaxation Response Decreases Decreases Decreases Decreases Stable Decreases Increases

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.

17. Ask a family member or friend to be there with you and to be your advocate (someone who can help you get things done and speak up for you if you cant). 18. Know that more is not always better. 19. If you have a test, dont assume that no news is good news. 20. Learn about your condition and treatment by asking your doctor and nurse, and by using other reliable sources. 20 Tips to Help Prevent Medical Errors. Patient Fact Sheet. AHRQ Publication No. 00-PO38, February 2000. Agency for Healthcare Research and Quality, Rockville, MD. Due to the frequency of medical errors, the Agency for Healthcare Research and Quality (AHRQ) has developed 20 tips to help prevent medical errors. Table 4-1 summarizes these suggestions. Many of these recommendations will be included as part of the following section and should be provided to patients as part of a surgery preparation program.
Providing Healthcare Professionals with Accurate Medical Information.

As discussed in chapter three, it is important for patients to gather appropriate information regarding their surgical experience. Equally as critical is making sure that healthcare professionals have accurate information about a patients medical history and other variables that might influence the surgical experience. Since many different doctors and healthcare professionals might be involved in the surgery process, having patients complete a medical fact sheet as part of a surgery preparation program will help avoid treatment errors and give the patient an increased sense of control. An example of a medical fact sheet can be found in Deardorff & Reeves (1997). The need for this type of medical data form is becoming more and more critical given changes in the healthcare system that place much more responsibility on the patient. Medical errors are unfortunately more common than the general public realizes and patients can play an active role in preventing them. Provision of information, as well as the information gathering process discussed in chapter three, is consistent with all of the preparation for surgery models.

Assertiveness Training and the Surgery Preparation Program

Consistent with several models of surgery preparation (e.g. biopsychosocial, selfefficacy, and empowerment, social self-regulation), assertiveness skills are essential for a patient to implement many of the preparation for surgery recommendations. Being appropriately assertive can help surgery patients obtain the necessary information preoperatively as well as protecting them from medical errors. The following section will present a brief outline of assertiveness training

and skills. The reader is referred to other sources for more detailed information (Alberti & Emmons, 1974; Bourne, 1995; Bower & Bower, 1991; Deardorff & Reeves, 1997; McKay, Davis & Fanning, 1983). There are four types of communication styles:
Nonassertive or Submissive

This is behavior characterized by giving in to another persons preferences while discounting your own rights and needs. If an individual engages in this behavior, the people around him may not even be aware that the patient is being nonassertive or submissive because the individuals needs are never expressed. Of course, surgical patients who engage in submissive behavior are more likely to be the victims of the mistakes of others around them. Aggressive Communication This is a communication style in which the patient expresses her wants and desires in a hostile or attacking manner. This behavior is often done in conjunction with being insensitive to the rights and feelings of others around her. Coercion and intimidation may be part of the aggressive communication style. Typically, aggressive communication increases the level of conflict in any situation. Aggressive behavior as part of a surgery preparation program is likely to result in either healthcare professionals withdrawing from the patient (being passive-aggressive) or counterattacking in a similarly aggressive manner. Either situation is likely to lead to deleterious effects relative to surgery outcome. Passive-Aggressive Behavior Passive-aggressive behavior is a way of expressing anger in a passive manner. This is often seen in pain problems in which the original injury is the result of a work-related or other accident. In these cases, the patient is often angry with the employer or other party who is perceived as having caused the injury. The patient will then either consciously or unconsciously use the pain behaviors to get back at the perceived perpetrator. Often, patients engaging in passiveaggressive communication have no insight into their behavior. Unfortunately, the patient is the one that is likely to sustain the most negative outcome. Assertive Communication The last of the four communication styles is assertive communication. An individual who uses assertive communication is able to express her wants and/or desires while respecting the right of others. It involves communicating in a simple and direct fashion without attacking, manipulating, or discounting those around you (Alberti & Emmons, 1974; Bourne, 1995; Bower & Bower, 1991; Deardorff & Reeves, 1997). As discussed by Deardorff and Reeves (1997), communicating in an assertive fashion allows you to express your needs and desires while keeping those around you comfortable and non-defensive (page 175). Assertive

communication is characterized by the following and should be taught as part of surgery preparation: Use Assertive Nonverbal Behavior. Body language can communicate a great deal beyond what a patient expresses verbally. Assertive behavior includes staying calm, establishing eye contact, and maintaining an open posture. Alternatively, nonassertive behavior includes such things as looking down at the floor while communicating, avoiding eye contact, speaking softly, and turning slightly away from the person with whom one is talking. A component of assertiveness training related to surgery preparation would involve teaching the patient nonverbal assertiveness skills. Keep Requests Simple. An effective assertive request is most often delivered in a simple, direct, and straightforward fashion. This might include asking for only one thing at a time in an easy to understand format. Be Specific. Being specific involves helping the patient determine wants, needs, and feelings are so that he can be very concrete in expressing them to healthcare professionals or other individuals within his psychosocial environment. This is the difference between saying I would like to get more help from your office staff regarding my surgery, versus I would appreciate your office staff helping me with the following issues regarding my surgery: insurance preapproval, scheduling my blood donation, and giving me information about postoperative pain control. The latter request is specific, direct, and nonaggressive. Teach Patients to Use I Statements. Assertive communication often begins with I statements. These would be things like: I need to I would appreciate it if I would like to Teaching patients to use I statements in their communication is one of the primary components of assertiveness training. Patients should also be taught to avoid you statements, since these often sound threatening and put the other person on the defensive. Address Request to Behaviors and Not Personalities. It is important to teach patients to address their request to behaviors of another person rather than personality features. For instance, if a surgery patient needs help with housework postoperatively, it is preferable to say, I would like you take over the heavy household chores while I am recovering from my surgery rather than I know you tend to be careless about housekeeping, but would you help me with

the chores while I am recovering from my surgery. This guideline also applies to requesting behaviors while in the hospital. Teach Patients Not To Apologize For Their Requests. Another component of assertiveness training is teaching patients not to apologize for their requests. Patients who tend to be more submissive or nonassertive will often make requests in an apologetic manner. They might make a request in the form of, I am really sorry to have to ask, but is it possible for you to help me prepare for my surgery. This type of request has a low probability of being acknowledged, and communicates that the person making the request does not really feel deserving or have the right to ask. Learning To Say No. Learning to say no is an important assertiveness skill to teach patients going through surgery. This will help the patient set important limits on the demands of family, friends, work, and others. More submissive and nonassertive individuals have trouble saying no since they feel guilty. Teaching patients to set appropriate limits is extremely important especially during the postoperative recovery phase when pacing is essential for enhanced recovery from many types of major surgery. The Broken Record Technique. The Broken Record Technique is an effective assertiveness tool that patients can utilize easily. It simply involves repeatedly making a request or saying no until the patients communication is acknowledged. For those just learning assertiveness skills, there may be a tendency to make a request and then back down if any resistance is encountered. Or, the patient might try to come up with more and more reasons why her request is justified. In this latter process, every time the patient expresses another reason for the request, it becomes weaker and weaker as if she is trying desperately to convince the other person that the request has merit. The Broken Record Technique can help patients feel comfortable making their request and then following through. An example might be a postoperative surgery patient who wants to make sure his doctor washes her hands before examining him: Patient: I would appreciate it if you would wash your hands before Doctor: Dont worry about it. It will be fine. I really am in a hurry. Patient: I understand youre in a hurry, but I would like you to wash your hands Doctor: You really need not be concerned. I just need to take a quick look. Patient: I still would like you to wash your hands.

The Doctor-Patient Relationship

Part of preparing for surgery is teaching patients how to work effectively with their doctors, including their surgeon. According to empowerment theory, patients and healthcare professionals work in a partnership in the patients overall care. Any preparation for surgery program should have a component that teaches patients how to interact effectively with their healthcare team. Effective interaction allows for efficient gathering of information, accurate communication of needs, improved patient satisfaction, and enhanced outcome overall. The social self-regulation model of surgery preparation suggests that interactions between the patient and caregiver will primarily be task-focus. As such, the primary goal is for the patient to obtain necessary information and guidance throughout the surgical experience. As discussed previously, there is often discordance between the surgeons and patients perceptions and goals. Ineffective physician-patient communication can compromise compliance, health status, and patient satisfaction (Temple, Toews, Fidler, Lockyer, Taenzer, & Parboosingh, 1998; Stewart, 1995). Levinson and Chaumeton (1999) investigated communication between surgeons and patients during the course of routine office visits. There was a mix of general and orthopedic surgeons in the study. The average office visit was 13 minutes long, and surgeons talked more than patients did. The typical surgical consultation consisted of relatively high amounts of patient education and counseling. Consultations had a narrow biomedical focus with little discussion of psychologic aspects of patient problems. Surgeons infrequently expressed empathy towards patients and social conversation was brief. The authors make the point that the results are consistent with the work of physicians in this setting because they often see patients referred to them for a surgical intervention (page 132). It might be argued that it is not the role of the surgeon to address emotional and/or psychosocial issues. Even so, the importance of these findings for a surgery preparation program is to give the patient appropriate expectations regarding visits with his surgeon. Patients should expect that the office visit will be relatively brief, that a great deal of information will be provided, and that the emotional/psychosocial issues will not be addressed. If patients go in with expectations that are different from these, there will be a high likelihood of dissatisfaction with the visit and overall care. Beyond giving patients appropriate expectations about interactions with their surgeon, the preparation for surgery program can teach them how to work effectively with all members of their healthcare treatment team. The following recommendations are adapted from Deardorff and Reeves (1997) and Ferguson (1993).
Help Patients Plan Their Doctor Visit In Advance

An important component of a preparation for surgery program is gathering information. Patients should be taught to develop a list of questions and concerns to address with their surgeon during the office visits. These should be very specific and not overwhelming in terms of scope and length (a patient who

develops a list of 100 questions will be extremely frustrated when only two or three of them are addressed during the office visit). Therefore, helping patients to be realistic about the number of questions that they want answered during the course of an office visit is important.
Teach Patients To Be Assertive

Teaching patients basic assertiveness skills, as discussed previously, can very much enhance their overall surgery experience as well as their outcome. These skills can be useful in terms of gathering information during office visits, as well as getting other needs and concerns addressed. Once again, patients should be taught to be reasonable in using the assertiveness skills. If patients go overboard, or are seen as aggressive and overly demanding by their healthcare team, the healthcare provider will often react in a passive-aggressive manner without even realizing it. Of course, this sets up a very negative interaction that will likely have deleterious effects on surgery outcome.
Help Patients Direct Their Questions To The Appropriate Person

Healthcare professionals will often take for granted that patients have an understanding of the medical system. Generally, this is not the case, and patients will often be confused about information resources. Thus, the patient may attempt to obtain information from their surgeon when the most appropriate person might be a physicians assistant, nurse, or some other individual. Of course, this inaccurate patient expectation would likely to lead to dissatisfaction.
Remind Patients to Bring Someone Else To Doctor Visits

Having patients bring someone else to their doctor visits can be important in many ways. Patients are often quite nervous and preoccupied during the course of a visit with their surgeon. Under these circumstances, they are likely to miss the opportunity to ask important questions, as well as not remembering medical information that they are given. As discussed by Ferguson (1993) and Deardorff and Reeves, (1997), bringing another individual to the doctors appointment can help calm the patient, make sure that various concerns are addressed, and help the patient with medical information recall.

Surgery Preparation and Psychosocial Environments

Addressing the psychosocial environment as part of a surgery preparation program might include helping the patient with such things as important personal relationships (family, friends, coworkers) and spiritual concerns as they impact the surgical experience. Family and friends

One of the most important variables in terms of enhancing postoperative recovery from surgery may be the patients family environment. As discussed under the conceptual model of social self-regulation, it is important for the patient and her family to have similar adaptive goals. In addition, according to social selfregulation theory, the family can help enhance the patients surgical outcome by providing tangible assistance, as well as emotional and informational support. A preparation for surgery program should contain a component of working with the family of the patient prior to the surgery. There is evidence that including the patients family in the preparation for surgery will enhance results versus intervening with the patient alone (see Raliegh, Lepczyk & Rowley, 1990). Most of the concepts of surgery preparation that have been discussed as interventions for the patient can also be applied to family members. This would include such things as information gathering, cognitive issues, and interacting with the medical system. It is important for family members to have appropriate and realistic expectations regarding the course of the patients recovery from surgery. If they expect too much, or too little, the patient is less likely to do well. Preparing the home environment for the postoperative recovery period can also be an important focus of a preparation for surgery program. This might include organizing the actual living space of the patient for surgery recovery, obtaining any necessary assistive devices beforehand, and arranging home healthcare if necessary. Assessing and intervening in the social system is especially important in the case of a patient with a chronic pain problem that is being addressed by the surgery (e.g. back pain, neck pain, etc.). Most chronic pain patients have a partner in pain as described by Engel (1959); Szazs (1968) and Waddell (1998), also termed this an associate victim (Halmosh & Israeli, 1984; Waddell, 1998). There is usually one main partner who provides most of the social support, although other members of the patients family and friends will assist. As Waddell describes it, Chronic pain patients and their partners play active, mutually supporting roles, and the pain may become a major focus in their whole relationship. Their whole social milieu may become pervaded by pain and disability, medical values and health care. Chronic pain and caring may become almost full-time careers, with both partners equally committed. In extreme cases, this may actually provide a more satisfying emotional relationship for both of them (1998; p. 208-209). In this case, there may be a great cost for the patient to give up the chronic pain even if the surgery is technically a success. These issues are usually identified as part of the pre-surgical evaluation. If the patient is going to have surgery, and these issues are present, they must be successfully addressed as part of a surgery preparation program. If they are not, the surgery is likely to be a technical success but a clinical failure. An example of this might be the chronic back pain patient who has been disabled for years and is fully ensconced in the sick role. If

psychosocial issues are not addressed prior to surgery (such as becoming more independent), the spinal fusion may be technically perfect but the patient will show no change in postoperative pain complaints, level of disability, and other concerns. Work and coworkers One of the most valued social roles for an individual is her work. Work provides such values as (Waddell, 1998):

Income Activity Occupies and structures our time Creativity/mastery Social Interaction Sense of Identity Sense of Purpose

Given the pervasive importance of work values, this is another important area of surgery preparation. Surgery patients will often have significant concerns related to how the operation will affect their work abilities. This might include such issues as how long will they be disabled from work due to the surgery process, how will they survive financially, and will they ever be able to return to full-time and unrestricted work. Any surgery preparation program should be sure that these issues are addressed with patients. Patients can be helped to develop strategies to deal with the work and financial issues in the most effective manner possible. Unfortunately, many surgery patients are so concerned and distracted by the surgery approaching that they forget to deal with the work and financial issues until it is too late. When this happens, usually postoperatively, it can create an extreme level of stress that negatively impacts the patients ability to recover. Spiritual Issues Aside from preparing the family system for a patients operation, the individuals spiritual issues are also rarely addressed by the medical system, including the surgery experience. For instance, a review of over 1,000 articles in primary care physician journals revealed that only 11 studies (1.1 percent) examined religious considerations. In another review, it was found that, in the last 200 years, only about 200 studies out of hundreds of thousands of English medical journal articles, investigated some aspect of spiritual faith. Benson (1996) concludes that these findings show just how taboo the topic of God has become in the recent history of Western medicine. Even though Western medicine rarely incorporates spirituality as part of the treatment and healing process, it is often an important part of the patients life. According to a Gallup poll, conducted in 1990, 95 percent of Americans say they

believe in God, and 76 percent say they pray on a regular basis. In addition, spiritual beliefs have been found to correlate with health benefit, including surgery outcome (see Deardorff & Reeves, 1997; Larson, 1993; Levin, 1994; Matthews, Larson, & Barry, 1994; Oxman, Freeman, & Manheimer, 1995; Pressman, Lyons, Larson, & Strain, 1990 for more detailed reviews of this issue). Some of the more interesting results are:

Levin (1994) reviewed hundreds of epidemiological studies and concluded that belief in God lowers death rates and increases health. In a study completed at Dartmouth Medical School, it was found that, of 232 patients who had undergone elective open-heart surgery for either coronary artery or aortic valve disease, the "very" religious were three times more likely to recover than those who were not (Oxman, Freeman, & Manheimer, 1995). In a study of hospitalized male patients, 20% reported that religion is "the most important thing that keeps me going" and almost 50% rated religion as very helpful in coping with their illness (Larson, 1993). Religious coping helped these men to be significantly less depressed. It has been found in various research studies that church attenders have nearly one-half the risk of heart attack and lower blood pressure, even after taking into account the effects of smoking and socioeconomic status (see Larson, 1993; Matthews, Larson, & Barry, 1994 for reviews). Of 300 studies on spirituality in scientific journals, the National Institute for Health Care Research found nearly three-fourths showed that religion had a positive effect on health (Larson, 1993). Pressman, Lyons, Larson, & Strain, (1990) studied 30 elderly women recovering from surgical corrections of their broken hips to determine relationships between religious beliefs and health. At comparable time periods postoperatively, those with strong religious beliefs were able to walk significantly further and were less likely to be depressed than those who had no religious beliefs.

As can be seen from the above findings, religious and spiritual beliefs form a vital part of the way a majority of people view and cope with life, as well as being associated with health benefits. The following summarizes what these beliefs can provide relative to enhancing surgery outcome: A sense of meaning and purpose. Spiritual beliefs can give an individual a sense of meaning and purpose that help him rise above or cope more effectively with the stress related to surgery. Setting healthy priorities. Spirituality provides a framework to set priorities and place stressors in perspective. This can help the individual maintain a sense of inner security and safety relative to the surgery experience through having a connection with God. This feeling of connection with the ultimate Power causes surgical and other stressors to be placed in a healthy perspective.

Comfort in the face of illness and crises. Spiritual beliefs can give the individual great comfort in the face of a health crisis, such as going through a major surgery. Security, safety, and peace of mine. A sense of security, safety, and peace of mind is especially important when approaching major life stressors such as surgery. Through spiritual beliefs, this sense can be fostered by the patient knowing that her higher power is close by. Peace of mind is developed through "letting go" and "turning over" ones anxiety and fear associated with the surgical procedure and recovery process. Self-confidence. Self-confidence is often enhanced in individuals with spiritual beliefs since they feel that they were created by God, making them lovable and worthy of respect. Guidance. The surgical patient with spiritual beliefs will often feel a sense of guidance due the relationship with God. Since God is "all knowing, the individual believes that God can be drawn upon for wisdom when asking for guidance. A preparation for surgery program may or may not specifically include a spiritual component. However, it is important for the healthcare professional completing the program with patients to be aware of these issues. The spiritual component should at least be acknowledged and patients should be specifically allowed (and encouraged) to discuss this aspect of their lives relative to the surgery. If spirituality is important to an individual patient, she can be helped to use those beliefs as part of surgery preparation in a variety of ways such as developing coping self-talk statements and incorporating prayer into deep relaxation exercise; this can greatly enhance the commitment to practice (see Deardorff & Reeves, 1997; Benson, 1996 for a discussion of these issues). In addition, patients can also be helped in facilitating appropriate psychosocial spiritual support relative to their surgery and postoperative recovery whether it is from their church, synagogue, family members, friends, or some other network.

Postoperative Pain Control

Postoperative pain control is one of the primary concerns of surgery patients yet research has indicated that it is frequently not well controlled. As discussed in chapter one, psychoneuroimmunology research has demonstrated that pain leads to negative bodily responses that can impede wound healing, suppress immune system function, and delay recovery from surgery. Therefore, a critical component of a preparation for surgery program is to help the patient ensure that adequate postoperative pain control will be achieved. One would think that the healthcare system would be expert at providing adequate pain control after surgery, but this is not the case. In fact, many studies have found that postoperative pain control is grossly inadequate, even though this need not be

the case (American Pain Society, 2001; Peebles & Schneiderman, 1991; Warfield & Kahn, 1995). The area of pain control is placed under the category of social self-regulation since the patient will need to interact with a variety of other systems (e.g. doctors, nurses, family members) to ensure that adequate postoperative pain control takes place. Although many hospitals have established pain services that specifically manage postoperative pain in the hospital setting, the following discussion will assume that this may or may not be available to the patient. Excellent information about pain control issues can also be found at a number of websites such as www.ampainsoc.org, www.iasp-pain.org, www.painmed.org, www.painfoundation.org, and www.paincare.org. Acute Pain Management Guidelines, Hospital Standards for Pain Control, and The Pain Care Bill of Rights. According to the American Pain Foundation (2001a), pain is a major healthcare crisis as evidenced by the statistics that over 50 million Americans suffer from chronic pain and another 25 million experience acute pain as a result of injury or surgery. Recognition of the widespread inadequacy of acute pain control prompted Congress, through the Agency for Health Care Policy and Research (AHCPR), to commission a multidisciplinary panel of experts to develop guidelines for the management of acute postoperative pain. This led to the publication and distribution of the Practice Guidelines for Acute Pain Management (AHCPR, 1992). Other professional groups also published acute pain treatment guidelines at that time (American Pain Society, 1992; International Association for the Study of Pain, Ready & Edwards, 1992). The specific problem of acute pain management in hospitals was addressed shortly thereafter. Recently, the Joint Commission of Accreditation of Healthcare Organizations (JCAHO) established new standards for the assessment and management of pain in accredited hospitals and other health care settings (JCAHO, 2000). These standards require that JCAHO-accredited hospitals maintain specific functions and activities related to pain assessment and management for patients. These are summarized as follows (Chapman, 2000):

Recognize the right of patients to appropriate pain assessment and management. Screen for pain in a variety of ways, document the results, and perform regular follow-up assessments. Ensure that the staff is competent in pain assessment and management. Establish policies and procedures related to support appropriate use of pain medications. Educate patients and their families about pain management. Address patient needs for pain management as part of discharge planning.

Maintain a pain control improvement plan. Table 4-2: Pain Care Bill of Rights (American Pain Foundation, 2000)

As a person with pain, you have:

The right to have your report of pain taken seriously and to be treated with dignity and respect by doctors, nurses, pharmacists and other healthcare professionals. The right to have your pain thoroughly assessed and promptly treated. The right to be informed by your doctor about what may be causing your pain, possible treatments, and the benefits, risks and costs of each. The right to participate actively in decisions about how to manage your pain. The right to have your pain reassessed regularly and your treatment adjusted if your pain has not been eased. The right to be referred to a pain specialist if your pain persists. The rights to get clear and prompt answers to your questions, take time to make decisions, and refuse a particular type of treatment if you choose.

Although not always required by law, these are the rights you should expect, and if necessary demand, for your pain care. In addition to the new JCAHO standards, the Pain Care Bill of Rights has recently been developed (American Pain Foundation, 2000b; see Table 4-2). The Pain Care Bill of Rights can be given to surgery patients as part of the preparation program. A list of these Rights along with a Pain Action Guide can be downloaded free from the American Pain Foundation website. The topic headings that are covered in the Pain Action Guide can be found in Table 4-3. Table 4-3: Summary of The Pain Care Action Guide How do I talk with my doctor or nurse about pain?

Speak up! Tell your doctor or nurse that youre in pain. Tell your doctor or nurse where it hurts. Describe how much your pain hurts. Describe what makes your pain better or worse. Describe what your pain feels like. Explain how the pain affects your daily life. Tell your doctor or nurse about past treatments for pain.

How can I get the best results possible?

Take control. Set goals. Work with your doctor or nurse to develop a pain management plan. Keep a pain diary. Ask your doctor or nurse about non-drug, non-surgical treatments. Ask your doctor or nurse about ways to relax and cope with pain. If you have questions or concerns, speak up. If you're going to have surgery, ask your doctor for a complete pain management plan beforehand. If youre a patient in a hospital or other facility and youre in pain, speak up. Pace yourself. If youre not satisfied with your pain care, don't give up.

Similar to the Pain Action Guide, but more detailed, Deardorff and Reeves (1997) have developed a pain control plan as part of a surgery preparation program. As part of a surgery preparation program, patients should be encouraged to do the following: Determine if there is a hospital-based surgical pain service Many hospitals have an established surgical pain control service that is responsible for postoperative pain management. Typically, hospitals that have set a high priority on pain relief by committing to having a surgical pain service provide the most effective pain management. If a patients surgeon operates in more than one hospital, and there are no other medical factors related to hospital choice, encourage patients to use the one with the established pain service. In addition, it is important for the surgical patient to have one individual or service in charge of pain control in order to avoid confusion. This guideline applies to the hospitalization episode as well as the post-discharge recovery period. Talk to their doctors about pain control In helping patients develop a pain control plan with their surgeon and surgical team, they should be encouraged to complete the following tasks:

Talk with nurses and doctors about pain control methods that have been either effective or ineffective in the past. Talk with nurses and doctors about any concerns related to pain medicine. Tell doctors and nurses about any allergies to medicines. These should have been recorded on the patients medical fact sheet. Talk with your doctors and nurses about medicines being taken for other health problems.

Find out what to expect relative to pain

Previously reviewed research suggests there may be a tendency for surgeons, doctors and other healthcare professionals to minimize discussions about what the patient may feel following the surgery. It is possible that they believe this silence will reduce the patients anxiety and distress, but that is not the case. Patient should obtain answers to the following questions as part of their surgery preparation program. Having this information prior to the pain experience will greatly enhance a patients sense of control, security, and self-efficacy. Will there be much pain after surgery? What will the pain likely feel like? Where will the pain occur? How long is the pain likely to last? How long will it be before I am able to be active? Will there be any side effects to the treatment (such as nausea)? How long will these last? Discuss pain medication options There are many pain management options available to patients. Some of these involve the use of pain medications and others do not. It is important for patients to understand these options prior to surgery. Have patients find out about the different types of pain medication options as well as the mode of delivery (e.g. oral, injection, PCA). This can be provided as a simple informational handout to the surgery patient. Understand time-contingent scheduling and patient-controlled analgesia As most healthcare professionals are aware, there have been two major advances in the way pain medications are scheduled and this has resulted in significant improvements in postoperative control of pain. These are timecontingent scheduling and patient-controlled analgesia. These concepts should be taught to patients as part of a surgery preparation program. Time-contingent scheduling. Time-contingent scheduling involves giving the pain medication at set times, whether or not the pain is severe. Instead of waiting until pain gets worse or breaks through the effect of the pain medicine, the patient is given the medicine at set times during the day to keep the pain under control. Thus, time determines when the medication is delivered rather than the severity of the pain (which is prn or as-needed dosing). By giving medications in this time-contingent manner, a steady-state level of pain medication in the blood can be achieved by adjusting the doses. Time-contingent dosing avoids the

peaks and valleys of pain which are characteristic of as-needed dosing and is one of the most important advances in the effective use of pain medications. It reduces the roller coaster ride characteristic of as-needed scheduling. This type of dosing is commonly used when the patient is in the hospital and should actually be maintained during the acute recovery phase. Patient-Controlled Analgesia (PCA). The second major advancement in medication scheduling and delivery is called Patient-Controlled Analgesia or PCA. This technique involves the use of special medication pump that allows the patient to deliver predetermined amounts of pain medication through a catheter into a vein when a button is pushed. The PCA puts the patient in charge of pain management by allowing increased control over pain medicine delivery. Built-in safety measures prevent the patient from administering too much medication. The results for the patient are immediate because he does not have to wait for the nursing staff to respond to requests for medications. In addition, the PCA can be programmed to deliver medication through the night automatically to insure that pain control is achieved around the clock. PCA is the method of choice for controlling pain following most major surgeries. A great many research studies have found that patients using PCA are much more comfortable, use less pain medication overall, can be discharged from the hospital earlier, and are generally more satisfied with their care (see Carron, 1989; Ferrente, Ostheimer, & Covino, 1990; Warfield & Kahn, 1995; Williams, 1996; 1997 for reviews). Recent research has found that a patients use of the PCA is impacted by psychological variables such as anxiety, fear of pain medication, stoicism, a lack of readiness to take control of the pain, and not wanting to be seen as a complainer (Gil, Ginsberg, Muir, Sykes, & Williams, 1990; Perry, Parker, White, & Clifford, 1994; Wilder-Smith & Schuler, 1992; Williams, 1996; 1997). Talk to the surgeon or anesthesiologist about anesthesia Many advances have been made in anesthesia options; patients should discuss these with the appropriate physician. Many surgery preparation programs recommend that patients meet with their anesthesiologist in advance of the scheduled surgery. This discussion should include the patients previous experience with anesthesia and whether any problems occurred then. Investigate non-medication approaches for pain control There are several non-medication techniques that can be very effective for pain control. Most pain is best treated with a combination of medications and nonmedication approaches. The non-medication approaches listed below are readily available, easy to use, low risk, and inexpensive. Patients can be easily taught about these techniques as part of a surgery preparation program and use them both pre- and postoperatively Even though these techniques are readily

available, they are often not suggested unless a surgery patient makes a specific request. Patient Education. This involves patient instruction on any aspect of surgical recovery that they use to help with pain control. Instruction might include such things as coughing exercises, deep breathing, proper body mechanics, and physical restrictions. Patients given such instruction prior to surgery report less pain, require fewer pain medications, and have shorter hospital stays. Cognitive-Behavioral and Relaxation Techniques: These techniques have been previously reviewed and can help not only with overall surgical recovery and outcome, but also with pain control. Heat and Cold: The application of heat and cold is used to reduce pain sensitivity, reduce muscle spasms, and decrease congestion in an injured area (for example, the site of surgery). The initial application of cold decreases tissue injury response, and later, heat is used to promote clearance of tissue toxins and accumulated fluids. Massage and Exercise: Massage and exercise are used to stretch and regain muscle and tendon length and range of motion. These techniques can be especially important with orthopedic surgeries. Transcutaneous Electrical Nerve Stimulation (TENS): TENS is a technique that can promote pain control and healing. TENS involves placing adhesive pads (electrodes) in specific locations related to the pain following surgery or injury. The electrodes are connected by thin wires to a small pocket-sized battery operated stimulator that produces electrical current that the patient can adjust. The electrical current, which feels like a tingling sensation, is thought to decrease pain by raising the threshold of the nerves in the spinal cord that respond to injury. TENS may also promote healing by reducing inflammation and increasing mobilization following surgery. Learn to stay ahead of the pain The most important thing for patients to remember regarding effective pain management is to stay ahead of the pain. This is done by teaching patients to take pain medications and use non-medication techniques when the pain first begins or before it starts. If the pain escalates and gets out of control, it becomes more and more difficult to bring under control. Inquire about post-discharge pain control Patients who are experiencing pain at the time of discharge from the hospital are generally given oral medications to take with them. These are usually to be taken using a strict time-contingent scheduling with a gradual tapering as pain

subsides. If a patient is taking too much pain medication before the surgery, it may put them at risk for inadequate pain control or side effects following surgery. In this case, part of surgery preparation program might be a time-contingent tapering or modification of pain medications prior to the surgery. Understand key concepts in pain medication management Patients should understand that a large body of research has demonstrated that if pain medication is given for a legitimate reason (e.g. related to surgery), addiction to analgesics is very unlikely (Cleary & Backonja, 1996; Porter, 1980; Portney, 1994; Zenz, Strumpf & Tryba, 1992). The fear of addiction is prevalent among individuals facing surgery and may cause the patient to be reluctant to take appropriate doses of medication for adequate pain control. To ease patient fears, it is important to help them (and healthcare professionals) understand the difference between important pain medication concepts: tolerance, pseudotolerance, physical dependence, addiction, and pseudoaddiction (see American Academy of Pain Medicine, the American Pain Society & American Society of Addiction Medicine, 2001): Tolerance is a well-known property of all narcotics. It is the need for an increased dosage of a drug to produce the same level of analgesia that previously existed. Tolerance also occurs when a reduced effect is observed with a constant dose. Analgesic tolerance is not always evident during opioid treatment and is not addiction. Pseudotolerance is the need to increase dosage that is not due to tolerance but due to other factors such as changes in the disease, inadequate pain relief, change in medication, increased physical activity, drug interactions, or lack of compliance. Patient behavior indicative of pseudotolerance may include drug seeking, clock watching for dosing, and even illicit drug use in an effort to obtain relief. Pseudotolerance can be distinguished from addiction in that the behaviors resolve once the pain is effectively treated. Physical Dependence is also a well-known and understood physical process. It is a state of adaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. Physical dependence is not a problem if patients are warned to avoid abrupt discontinuation of the drug, a tapering regimen is used, and opioid antagonist (including agonist-antagonist) drugs are avoided. Addiction is a psychological dependence on the medication for its psychic effects and is characterized by compulsive use. The medication is sought after and used even when it is not needed for pain relief. Addiction includes both tolerance and dependence as well.

Pseudoaddiction is drug-seeking behavior that seems similar to addiction, but is due to unrelieved pain. The behavior stops once the pain is relieved, often through an increase in pain medication. If the patient complains of unrelieved pain and shows drug-seeking behavior, careful assessment is required to distinguish between addiction and pseudoaddiction. Patients (and healthcare professionals) often confuse these concepts. Both tolerance and dependence commonly occur in pain medication use and can be readily managed by the physician specializing in this area. Tolerance can be managed by adding other non-addictive medicines that help the narcotics work better and/or by emphasizing non-medication pain control techniques. Dependence is addressed by slowly tapering the pain medication and, as appropriate, adding other medication to control withdrawal symptoms.

Putting It All Together

Most surgery preparation programs focus primarily on self-regulation techniques. Although these approaches are certainly important, a great deal is missed if the psychosocial factors are not taken into account. A comprehensive surgery preparation program will intervene both for the individual surgery patient and in the social network. Figure 4-1 shows the process of putting together a preparation for surgery program. In summary, the program begins with assessment of the patient and proceeds to assembling program components, implementing the intervention, and following up to enhance outcome (see Figure 4-1). It is important to emphasize that the preparation for surgery program is extremely flexible and can be adapted to the individual patients needs, the program structure (individual, group, or a combination thereof) and/or the time available before the operation. For instance, although the number of possible surgery preparation program components is extensive, not all interventions will be used with every patient. Also, the program can be adjusted to emphasize more of a patient self-guidance focus, if necessary. A last consideration is follow-up with the patient after the surgery. Surgery preparation programs often end with the surgery, and this is a mistake. Follow-up after the surgery is very important in order to increase the probability that the patient will continue to utilize the surgery preparation and pain management techniques throughout the postoperative period. Depending upon the situation, the follow-up treatment might include postoperative visits in the hospital, outpatient sessions after the patient is discharge and is ambulatory, or simple telephone calls.

Figure 4-1: Components of a surgery preparation program 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