Full text of DOI:10.1207/S15327558IJBM0903_05

INTERNATIONAL JOURNAL OF BEHAVIORAL MEDICINE, 9(3), 228–242
Copyright © 2002, Lawrence Erlbaum Associates, Inc.
Women’s Hearts Need Special Treatment
Gunilla Burell and Brittmarie Granlund
Coronary heart disease (CHD) is the leading cause of death for both men and women
in the Western world. Some studies show that the observed decline in cardiovascular
mortality is not as pronounced among women as among men. There is a growing
awareness that most earlier studies both on primary and secondary risk factors, diag-
nosis, prognosis, and rehabilitation have focused mainly on men. Thus, there is a need
to develop knowledge about women with CHD and to address gender issues in treat-
ment and rehabilitation strategies. Negative affect and emotions increase risk and
may interfere with effective cardiac rehabilitation. Therefore, methods for coping
with emotional stress need to be included in treatment regimens after a coronary
event. The feasibility of a stress management program for women with CHD was as-
sessed in a pilot study. The program consisted of twenty 2-hr group sessions during 1
year, with 5 to 9 participants per group. The pilot study showed that this treatment pro-
gram had a low dropout rate and resulted in improvement in quality of life and reduc-
tion in stress and symptoms. Further work to optimize psychosocial interventions for
women with CHD is needed.
Key words: coronary heart disease (CHD), cardiac rehabilitation, psychosocial intervention,
stress management, gender differences, women
”
Men die—women suffer.” Women in Western countries seek more medical treat-
ment, use more medication, and live longer than men. But they live with greater dis-
ability (Grossi, Soares, & Lundberg, 2000). Cardiovascular disease is the leading
cause of death for women in the Western world. Although there has been a decline
in cardiovascular mortality due to substantial improvements in surgical interven-
Gunilla Burell and Brittmarie Granlund, Department of Behavioral Medicine, Umeå University,
Umeå, Sweden.
This research was funded by the National Board of Health and Welfare in Sweden.
Correspondence concerning this article should be addressed to Gunilla Burell, Department of Behav-
ioral Medicine, Umeå University, S–901 85 Umeå, Sweden.

WOMEN’S HEARTS NEED SPECIAL TREATMENT
229
tions and effective medications (Tunstall-Pedoe et al., 1994), this decline is more
evident among men than women (Peltonen, Lundberg, Huhtasaari, & Asplund,
2
000). There is a growing number of surviving coronary patients living with
chronic illnesses such as heart failure, many of whom are older women. This popu-
lation subgroup has been neglected, relative to younger men. There is a need to im-
prove their care. The purpose of this article is to highlight the need for gender-spe-
cific cardiac rehabilitation programs and to present preliminary data on a pilot
cardiac rehabilitation program for women.
CARDIAC RISK AND REHABILITATION: GENDER GAPS
Cardiac rehabilitation and secondary prevention programs are to a large extent
based on clinical trials of younger male patients. Results have been generalized and
applied to women and elderly patients. They have not generally been evaluated for
effectiveness in women. Optimal treatment is not necessarily the same treatment
for all.
Increasing evidence points to the importance of depression as an independent
risk factor for first and recurrent cardiac events. Numerous studies show that 20%
to 40% of coronary heart disease (CHD) patients exhibit depressive symptoms or
syndromes (Ahearn et al., 1990; Ariyo et al., 2000; Carney, Freedland, Rich, &
Jaffe, 1995; Ferketich, Schwartzbaum, Frid, & Moeschberger, 2000; Ford et al.,
1
998; Frasure-Smith, Lespérance, & Talajic, 1993, 1995; Horsten, Mittleman,
Wamala, Schenck-Gustafsson, & Orth-Gomér, 2000; Ladwig, Roll, Breithardt,
Budde, & Borggrefe, 1994). These studies show that depressive symptoms have an
adverse impact on prognosis both immediately after a cardiac event
(
Frasure-Smith et al., 1993, 1995) as well as several decades after the event (Ford
et al., 1998). Vital exhaustion—a syndrome of unusual fatigue and loss of energy,
increased irritability, and depressive symptoms—has also been demonstrated to
increase risk of MI (Appels, Golombeckm, Gorgels, De Vreede, & van Breukelen,
2
000; Appels & Mulder, 1988) and of recurrent angina pectoris after angioplasty
(
Mendes de Leon, Kop, de Swart, Bar, & Appels, 1996). “Type D personality” was
shown to increase risk of MI (Denollet et al., 1996). This “distress” syndrome en-
tails a cluster of negative affects and social inhibition.
However, these studies have included only, or mostly, men with CHD. It is
rare that men and women have been analyzed separately and compared with
each other (see, e.g., the review by Brezinska & Kittel, 1995). Thus, the conclu-
sion must be drawn that there is substantial evidence for men that hostility, de-
pression, social isolation, and inability to express feelings and emotions
contribute to increased risk of CHD. It has been inferred that such risk factors
affect women, too. However, there may be other psychosocial risks for women,
of which we have little knowledge so far.

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BURELL AND GRANLUND
CARDIAC RISK AND REHABILITATION IN WOMEN
Psychosocial Risk Factors for an Initial Coronary Event
The Framingham Study (Haynes & Feinleib, 1980) showed that women of lower
socioeconomic status (SES), and who experienced tension, anxiety, suppressed
hostility, lack of vacations, and loneliness, were at increased risk of CHD. House-
wives were at particular risk and being employed outside the home was protective.
However, tension between work demands and personal commitments may increase
risk of CHD (Dixon et al., 1991), especially if a woman’s boss is nonsupportive
(
Eaker, 1989). After adjustment for known risk factors, Dixon et al. (1991) demon-
strated that incidence of CHD was significantly elevated in women who felt that
their professional opportunities had been constrained by personal commitments to
husband and children, and that their family was hurt by their job involvement. This
points to a major gender role-related difference between men and women: Many
women derive self-esteem from relational success and satisfaction, whereas the
male role demands vocational and status success.
Hallstrom et al. (1986), in a prospective study, showed passive dependency,
neuroticism (i.e., anxiety), and major and minor depression predicted angina
pectoris. Findings from a population-based study in Stockholm (The Stockholm
Female Coronary Risk Study) showed that although most women were working
outside the home, the main stressors were not work-related, but associated with
family and marital problems. Both the risk of developing CHD and of suffering a
recurrence were elevated in women with family-related problems. The effect of
these factors was stronger in women who had poor coping abilities, were of lower
SES, were socially isolated, and were depressed. A recent study by Hallman,
Burell, Setterlind, Oden, and Lisspers (2001) showed that women were more sen-
sitive to certain stress-related factors than were men. Psychosocial risk factors that
were stronger predictors of CHD for women were physical stress reactions, emo-
tional stress reactions, burnout, family relationships, and daily hassles.
The profile that emerges of “coronary-prone” women is the experience of wor-
ries, anxiety, depression, exhaustion, burnout, and low self-esteem, in such set-
tings as a lack of perceived support, low status and powerlessness at work, and
considerable family stress. What, then, happens after the woman has had her car-
diac event?
Prognosis After the Cardiac Event
Female patients with CHD are often diagnosed and treated by different clinical
standards than male patients and, in particular, those women with angina pectoris
have often been misunderstood, misinterpreted, and misdiagnosed (Ayanian & Ep-
stein, 1991, 1997). Women have worse prognosis after acute myocardial infarction

WOMEN’S HEARTS NEED SPECIAL TREATMENT
231
(
MI) even when adjusted for clinical covariates (Marrugat, Gil, & Sala, 1999).
Women report greater general morbidity following an MI than men, including
more chronic illness, poorer health, and longer period of reduced activity (for an
overview, see Brezinska & Kittel, 1995).
Post-MI women are more likely than men to be anxious, dissatisfied with social
support (Frank & Barr-Taylor, 1993), and depressed (Horsten, 2000). Schron,
Pawitan, Shumaker, and Hale (1991) showed that post-MI women were more lim-
ited in social functioning, less satisfied with their current life situations, and re-
ported more emotional and physical stress symptoms than men, regardless of age
and severity of disease.
Psychosocial risk factors increase risk of recurrent CHD. Lack of social support
(
Orth-Gomér, 1998), low SES (Wamala, 1999), and exhaustion (Appels, Falger, &
Schouten, 1993) are important risk factors for recurrence. This array of
psychosocial stressors tends to cluster in certain groups and may dramatically in-
crease the likelihood of poorer health outcomes. For example, women in Stock-
holm who experienced both work and family stress had a five-fold increased risk
for CHD compared to women who did not have either of these experiences
(
Orth-Gomér, 2000). A follow-up of 64 women and 315 men in North Sweden af-
ter coronary artery bypass graft (CABG) surgery (Lerner, 2000) showed that
women were significantly more depressed than men both before and after surgery.
Presurgery they did not differ in anxiety; however, postsurgery women were sig-
nificantly more anxious than men. The overall results showed that the women’s
quality of life was significantly lower than the men’s both before and after CABG
surgery. Thus, distress, feelings of inadequacy, and psychosocial stressors related
to family demands may interfere with recovery and increase the risk for recurrent
CHD.
Rehabilitation
Previous evaluations of gender-mixed programs have revealed that women are less
likely to participate in cardiac rehabilitation programs than men following an MI or
CABG surgery. They show lower attendance rates and greater dropout rates from
such programs (Ades, Waldmann, McCann, & Weaver, 1992; Boogard, 1984;
Conn, Taylor, & Abele, 1991; Downing & Littman, 1994; Haskell, 1994; Schuster
&
Waldron, 1991). Some reasons for the lower participation and attendance in
women may include the physicians’ lack of recommendation or referral to cardiac
rehabilitation, or a dependent spouse at home who may make attendance more dif-
ficult. Because women with CHD are generally working in low status occupations,
they may have difficulties in taking time off from work. However, when women do
participate in cardiac rehabilitation, they have shown to have similar or better im-
provement (Ades et al., 1992; Cannistra, Balady, O’Malley, Weiner, & Ryan,

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BURELL AND GRANLUND
1
992; Toobert, Glasgow, Nettekoven, & Brown, 1998). Data from an ongoing
studyinNorthSwedenfeaturedactivepersonalfollow-upsofmenandwomenafter
their cardiac event (Norrman, 2002). Results indicated that depressed women at-
tended the offered rehabilitation programs to a larger degree than men and
nondepressed women. This suggests the value of active personal follow-up of
women as a way to maximize adherence to these programs.
The first major psychosocial intervention trial for CHD patients was the Recur-
rent Coronary Prevention Project (RCPP), in which Friedman and his coworkers
demonstrated that reductions of the so-called Type A Behavior Pattern led to sig-
nificantly decreased risk of subsequent cardiac morbidity and mortality (Friedman
et al., 1986). It should be noted, however, that over 90% of the participants of the
RCPP were Caucasian men.
Based on the experiences from this intervention, we developed a 1-year
group-based treatment, which was evaluated in a randomized Swedish study
(
Burell et al., 1994), including only men under the age of 65. The results showed
that our treatment format was effective in achieving significant reductions of Type
A behavior. Results were promising enough for us to try a group-based stress man-
agement program with a larger sample of CHD patients (the New Life Trial;
Burell, 1996). Our concept of stress management was broadened to not only in-
clude impatient time-urgent Type A behaviors but also depression, anxiety, and fa-
tigue. In the New Life Trial, 228 male and 37 female patients (mean age 58 years)
who had undergone CABG surgery were invited to participate and were random-
ized to 1-year group treatment or a usual care control condition. Overall, a fol-
low-up of 5 to 6.5 years showed significant reductions of total mortality and
cardiac events for patients who had received group treatment. The number of
women was too small, though, to allow a subgroup analysis.
The RCPP and our own studies thus showed that we had developed a stress
management program that could significantly reduce recurrence in younger male
patients. Powell et al. (1993) showed that the treatment offered in the RCPP had no
benefit in terms of clinical endpoints for women. Predictors of mortality in the
women were arrhythmias on ECG, being divorced, and the lack of a college degree
(
probably a marker of financial stress and lack of power and influence at work) and
not Type A behavior. Because the diagnostic instrument for assessing Type A be-
havior relies on nonverbal behaviors showing intensity of voice, gestures, and
body motions, a fair guess is that absence of such reactions could possibly indicate
depression.
The Montreal Heart Attack Readjustment Trial (M-HART) Study
(
Frasure-Smith et al., 1997) was a randomized controlled trial aimed at relieving
distress, when it occurred, in post-MI male (N = 903) and female (N = 473) pa-
tients. The program included a telephone contact to determine level of stress, and a
home-based nursing intervention to alleviate any stress that was detected. The pro-
gram had no overall effect on cardiac mortality, and only minimal effects on de-

WOMEN’S HEARTS NEED SPECIAL TREATMENT
233
pression and anxiety. For women in the intervention group, though, there was a
higher cardiac and all-cause mortality, compared to control women. The authors’
conclusion was that the results do not warrant the implementation of this type of
psychosocial intervention, because it may possibly be harmful to some women.
The Enhancing Recovery in Coronary Heart Disease (ENRICHD) trial (The
ENRICHD Study Group, 2000) was a randomized controlled trial aimed at reduc-
ing depression and increasing social support in 2,481 post-MI patients, 44 % of
which were women (The ENRICHD Study Group, 2001). The primary outcome
variable was total mortality plus nonfatal MI. The program used Beck cognitive
therapy (Beck, 1995) to reduce depression and improve social support. Patients
were recruited from eight centers across the United States within 28 days of the
MI, and those who scored above a certain criterion of depression and/or low social
support and who were randomized to the intervention were offered a combined
program of individual and group sessions. The groups were gender-mixed. The
overall results showed no survival difference between treatment and usual care pa-
tients (Powell, 2002). The treatment patients reduced depression scores signifi-
cantly more than controls, but the clinical difference was small. Control patients
showed a substantial spontaneous improvement in depression and social support.
A significant Gender × Treatment interaction indicated that the young Caucasian
men did significantly better with this treatment. The women in treatment, how-
ever, did significantly worse than control women in terms of recurrence. Some fac-
tors other than the cognitive treatment could have contributed to this. The men
were younger, had less comorbidity, and were more aggressively treated by their
cardiologists. The women in intervention were older and had more comorbidity,
factors that are known to contribute to increased risk of recurrence (Schneiderman,
2
002). Thus, one should be careful in drawing conclusions about the harmfulness
of this psychosocial treatment for women. But it did not do them any good. It
should be remembered that the clinical population of CHD women is older, shows
more comorbidity, and exhibits more psychological and adjustment problems,
thus this was a representative sample.
Past studies of cardiac rehabilitation in women are not encouraging. New direc-
tions in the treatment of these patients are needed.
WHAT DO WOMEN WITH CORONARY DISEASE NEED?:
CLINICAL OBSERVATIONS
We have had considerable experience observing and working with women who
have experienced coronary events. In the New Life Trial, the treatment groups were
gender-mixed, but there were generally only 1 to 2 women with 5 to 7 men. In terms
of group dynamics, this situation was unfavorable to the women. The women came
across as much less assertive than most of the men, and seemed to withhold their

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BURELL AND GRANLUND
own reactions and opinions. They would be supportive of others—especially of the
men in the group—at the expense of expressing themselves. Thus, ingrained, sub-
missive gender role behaviors were often automatically activated in the presence of
the men, and an important therapeutic target that emerged for women was to im-
prove self-confidence. Thus, there is reason to target low self-esteem and lack of
communication and relational skills in “stress management” training.
The women experienced their disease differently from the men. Despite techni-
cally successful surgery, some women still experienced angina, which, of course,
wasadisappointmenttothem.Morewomenthanmenhadcomorbiditywithvarious
diseases, such as cancer, arthritis, and chronic pain. Their risk factor burden was of-
tengreater,andyettheyoftenhadtowaitlongerforthecorrectassessmentordiagno-
sis. Most strikingly, many of these women were depressed, anxious, bitter, and
frustrated. They did not converse with other people about their disease, and rarely
participatedinactiverehabilitationprograms.Theywouldtrytoavoidinvolvingthe
families in their worries and concerns, because they did not want to “burden” them,
and thus missed obtaining any necessary support. The life areas where they encoun-
tered stress and other problems were quite different from those of the men. Women
experienced a lack of both physical and psychological well-being.
In summary, our clinical observations in the New Life gender-mixed groups
suggested that the psychological and social consequences of suffering an MI or go-
ing through CABG are different for men and women. In the groups, it was some-
times difficult to pay enough attention to the unique problems of the women, such
as low self-esteem, family-related stress, and severe life events. It seems reason-
able that therapeutic efficacy for female patients could be enhanced in single-gen-
der groups. In this setting, problem areas that are shared by many women could be
emphasized, and mutual understanding and support could be maximized.
PILOT RESULTS OF A SKILLS DEVELOPMENT
PROGRAM FOR WOMEN WITH CORONARY DISEASE
The aim of this treatment was to help women develop coping skills to manage ev-
eryday life problems, minimize cardiac symptoms, improve quality of life, and de-
crease the risk of a recurrent event. Therapeutic targets included anger manage-
ment, coping with anxiety and depression, increasing self-assertion and
self-efficacy, improving communication, handling social roles and burdens, cop-
ing with severe life events and grief, and managing medical symptoms.
Before embarking on a randomized clinical trial, we undertook this pilot study
to determine feasibility and effectiveness on psychosocial endpoints. The pilot
study was a treatment-group-only study of 23 women with CHD, with a mean age
of 59 years (range 46–73). The treatment was conducted in groups, the first six of
which took place during a 1-month stay at a wellness center where participants

WOMEN’S HEARTS NEED SPECIAL TREATMENT
235
were enrolled in a program of change in dietary and exercise habits. The stress
management group sessions were added to this pre-existing general program and
then continued in outpatient settings for the remainder of 1 year.
Assessments
Assessments were made before treatment and at the 1-year conclusion of treatment.
Perceived stress was assessed by The Everyday Life Stress Scale, a self-adminis-
tered questionnaire consisting of 20 statements referring to stress reactions in ev-
eryday life situations (Lindahl, Burell, Granlund, & Asplund, in preparation). The
participant responds to each statement on a 4-point scale. Vital exhaustion was
measured by the Maastricht Questionnaire (Appels, Höppener, & Mulder, 1987).
Quality of Life was measured using the Göteborg Quality of Life Inventory
(
Tibblin, Tibblin, Peciva, Kullman, & Svärdsudd et al., 1990), which consists of
twoparts: the Well-Being Scale, which assessesperceived well-being in various ar-
eas of life, and a Symptom Scale.
Description of the Program
Structure. The program consisted of twenty 2-hr sessions over the course of
1
year. Sessions were held weekly for the first 10 weeks. Patients entered the pro-
gram between 3 to 6 months after the acute coronary event. Treatment groups con-
sisted of 5 to 9 participants. Each session agenda covered a specific theme and was
presented using written texts, case illustrations, slides, films, audio and videotapes,
and specific exercises. Participants worked with homework assignments between
sessions. Relaxation was practiced in each session to increase the probability that it
would be applied as a coping technique in everyday situations.
Each group session began with a few minutes of relaxation. Homework assign-
ments were discussed and the group leader and the participants provided feedback.
New themes were introduced using factual information, case illustrations, or other
exercises. Throughout the treatment, social support from the group was utilized to
facilitate therapeutic progress.
Components of the program. There were five key components of the
program:
1.
Education: The goals of education can be summarized as developing
knowledge about: basic anatomy and physiology of the cardiovascular system;
manifestations of, and treatment procedures for, CHD; the symptoms and signs
of different types of stress reactions; and the relation between stress and CHD.

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BURELL AND GRANLUND
Homework assignments included booklets about heart and stress and the study
of case illustrations, where the participants can identify their own reactions. Of
relevance would be discussions on risk factors of particular importance for
women, such as anxiety, exhaustion, and marital stress. Each woman was asked
to discuss which of the risk factors were relevant and present when she experi-
enced her cardiac event.
2.
Self-monitoring: The goals of self-monitoring can be summarized as: be-
coming more alert to bodily signals such as muscular tension, heart rate, and pain;
noticing behavioral and cognitive cues; and observing, reflecting, and drawing
conclusions about contingencies of behavior. To increase awareness of one’s own
reactions, case illustrations and audio-visual materials were used and participants
practiced systematic observation of specific behaviors, both in themselves and in
other people. The use of systematic diaries during extended periods of time was
very important. Group processes were used to facilitate disclosure and ensure so-
cial support. Of relevance would be the monitoring of situations involving a need
forassertion(e.g., inrelationtodemandsfromfamilymembersorworkmates). One
example was the woman who had an offer from a female friend to go on a week’s
vacation but did not dare to ask her husband for fear of his refusal. She worried that
it was her total responsibility to care for her disabled son at home.
3
Skills training: The goals of skills training were to reduce negative affect by
learning to express thoughts and emotions directly, honestly, and in a caring man-
ner;and learningtoact, ratherthan merelyreact, to everyday problemsof living. Of
relevance would be practicing to let go of perfection in household chores, asserting
about own needs in the work situation, and communicating to family about finding
recreational time for oneself. The group setting can provide a stage for rehearsing
the specific situation. The group leader makes use of group processes, support, and
modeling, where both the group leader and the other group members become im-
portant role models. A booklet of daily behavioral exercises is used throughout
most of the treatment period. The focus is on stress situations related to managing
the relationship (“say no lovingly”).
The woman in the aforementioned example would need to practice assertive
communication with her husband. In this particular case, the woman never even
mentioned the issue to her husband because of her fear of violent reactions in him.
After having reflected on pros and cons in the group, she decided to decline her
friend’s offer in order not to provoke her husband. She is one of many examples of
the kinds of marital stress that many CHD women encounter, including having to
deal with abuse and severe physical or mental illness in family members. Applying
certain behaviors that seem appropriate (at least to the group leader!) might in some
complex social contexts entail negative consequences. It is important then to agree
onwhatispossibleandfeasibleforthewomantodo,andsometimesthefirststepsto-

WOMEN’S HEARTS NEED SPECIAL TREATMENT
237
ward assertion and self-esteem must be very small and applied with care, persis-
tence, and a long-term perspective.
4.
Cognitive restructuring: The goals of cognitive restructuring can be sum-
marized as the development of self-talk that enhances self-respect and self-esteem;
the ability to cope with the unexpected; tolerance, acceptance, and respect for peo-
ple different from oneself; trust in others; and positive emotions such as joy, enthu-
siasm, curiosity, optimism, and love. The contents are the women’s personal,
day-to-day experiences. Group discussions and sharing of similar experiences fa-
cilitate re-interpretation and alternative attributions. Social support and feedback
from other group members, who may provide different views and attitudes, helps
the participants to adopt alternative ways of thinking.
A relevant example came from one group member who struggled with
anginal pains whenever she cleaned her windows. The group members discussed
various practical solutions, implying that she could let go of her expectation of
doing the work herself. But the woman was resistant and what became obvious
was that not being able to clean her house triggered a loss of self-esteem and
worth. A situation that may at first glance look trivial could then be used to get
at profound issues of re-orientation and finding a new basis for self-esteem. In
women’s groups, self-monitoring very often reveals situations that many men
would regard as trivial, but which often hold a deeper meaning for the woman.
The group leader must be sensitive to when this is the case, and it would be
counter-therapeutic to step into the role of advice giver.
5.
Spiritual development: The goals for the discussion of spiritual and life val-
ues can be summarized as: creating a balance between work, family, health, plea-
surable activities, and spiritual interests; finding new interests; developing joy, en-
thusiasm, and hope; and accepting and giving love. Spiritual discussions and
exercises are an integrated part of the program, especially the last sessions. The so-
cial support provided by the group becomes an important facilitating mechanism.
In work with women, the issue of—and right to—provide themselves with as much
care and need fulfillment as they give to others is crucial.
RESULTS
The results after 1 year of treatment showed significant reductions of self-rated
stress (p < .001) and vital exhaustion (p < .01) and improvements in quality of
life (p < .05; Table 1).
Attendance was excellent. Once a woman decided to participate in the pro-
gram, she did not drop out. The mean attendance rate was about 80%.

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BURELL AND GRANLUND
TABLE 1
Psychological Variables Before Treatment and at Follow-Up
Pretreatment
Follow-Up
M
SD
M
SD
pa
Everyday life stress
Vital exhaustion
GQL well-being
GQL symptom
26.2
21.8
55.4
13.1
6.9
6.7
14.3
4.9
16.0
15.0
61.3
12.0
8.0
8.0
13.9
6.0
.000
.002
.045
.273
Note. Göteborg Quality of Life Inventory.
a
Wilcoxon Signed Ranks Tests
DISCUSSION
Our program was feasible and attractive and the dropout rate was low. Thus, it
seemed to meet many of the emotional needs of these women. Apparently, when
women with CHD are offered rehabilitation programs that are tailored to their
needs, good adherence can result. Our initial results suggest that quality of life
may improve considerably as well.
Many women were very unhappy when they first came to group sessions. They
often blamed themselves for their disease. In contrast, many of our male patients in
our former trials (Burell, 1996) seemed to cope fairly well. In our experience, such
optimism and eagerness is rare in women with CHD. The women were often worse
off medically and might have justification for worry. Very often they were de-
pressed,anxious,andbitterregardingtheadequacyoftheirmedicaltreatment.They
feltlonelyandhadnoonetotalktoabouttheirsituation.Theydidnotwanttoburden
theirfamilyandfriends.Theydidnotexpectpeoplearoundthemtoaccommodateto
their needs in the new situation and/or had difficulties asserting themselves.
Self-worthandcommunicationwerecoreissuesinthetherapy.Atitsconclusion,
manyparticipantsreportedthattheydevelopedanenhancementoftheirself-esteem.
Many participants expressed what this experience meant to them in the following
ways:“Ifeelcalmer;Irelaxsomuchbetter;Iworryless;Itakeiteasy.Idon’tneedto
finish everything today; I feel hope for the future.”
Itisclearthatthisprogramimprovedpsychosocialfunctioninthewomen. Aswe
continue our study of it, we will determine whether or not these psychosocial
changes translate into improved prognosis.
CONCLUSIONS
We do not yet know how to optimize psychosocial interventions in secondary
prevention for women with CHD. Because of this, we believe that it is time we

WOMEN’S HEARTS NEED SPECIAL TREATMENT
239
start listening to the women themselves and their common experiences. It is time
to start to implement insights into their psychosocial situation after a cardiac
event. Some of what has been tried may have been harmful to a number of
women. Thus, potential interventions must be relevant not only for women’s
bodies, but also their psyches and everyday lives. There is a need to offer treat-
ment that attracts women and enhances adherence to treatment. There is a need
to meet this imminent challenge, as observed by the U.S. Department of Health
and Human Services, National Heart, Lung, and Blood Institute (1995): Further
scientific studies should address the following: Evaluations of the effects of car-
diac rehabilitation exercise training, education, counseling, and behavioral inter-
ventions on special populations. These populations include elderly patients,
women of all ages, patients from different ethnic groups, and those with lower
educational and socio-economic levels. (Recommendations for additional re-
search).
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