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 DOI: 10.1177/1359105309359542

2010 15: 915 originally published online 7 May 2010J Health PsycholSvein Bergvik, Tore Sørlie and Rolf Wynn

Coronary Artery Bypass Graft SurgeryApproach and Avoidance Coping and Regulatory Focus in Patients Having

  

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915

Approach andAvoidance Copingand RegulatoryFocus in PatientsHaving CoronaryArtery Bypass GraftSurgery

SVEIN BERGVIK, TORE SØRLIE, &ROLF WYNNUniversity of Tromsø & University Hospital of NorthernNorway, Norway

Abstract

Coronary artery bypass graft (CABG)surgery is stressful, and the patient’scoping affects recovery and outcome.The aim of the study was to identifypatients’ thoughts and concerns, andexplore the relevance ofapproach/avoidant coping andRegulatory Focus Theory (RFT). Ninepatients were interviewed, using aninterpretative phenomenologicalapproach. The patients made use ofvarious avoidant (e.g. neglectingsymptoms, delaying help-seeking,avoiding thoughts) and approachstrategies (e.g. persistent search forthe diagnosis, mental preparation forsurgery). RFT versusapproach/avoidant coping isdiscussed. RFT may contribute to ourunderstanding of motivationalcognitions in patients’ coping withillness and treatment.

Journal of Health PsychologyCopyright © 2010 SAGE PublicationsLos Angeles, London, New Delhi,Singapore and Washington DCwww.sagepublications.comVol 15(6) 915–924DOI: 10.1177/1359105309359542

ACKNOWLEDGEMENTS . This work was supported by a grant from theNorth Norwegian Regional Health Authority (Helse Nord RHF).

COMPETING INTERESTS : None declared.

ADDRESS . Correspondence should be directed to:ROLF WYNN, Psychiatric Research Centre of Northern Norway, UniversityHospital of Northern Norway, N-9291 Tromsø, Norway. [Tel. +47 77669506; email: rolf.wynn@unn.no]

Keywords

� chronic illness� clinical health psychology� coping� coronary artery disease� Interpretative PhenomenologicalAnalysis

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Introduction

CORONARY artery disease (CAD) is among themajor causes for hospitalization and death inEurope (Allender et al., 2008), and treatment mayinclude invasive procedures such as percutaneouscoronary interventions (PCI) and coronary arterybypass graft (CABG) surgery. At the hospital,patients find examinations to be stressful, and theyfeel lack of control over the events and decisionsabout their treatment (Doering, McGuire, &Rourke, 2002; Gardner, Elliott, Gill, Griffin, &Crawford, 2005; Ivarsson, Larsson, & Sjoberg,2004). The prevalence of anxiety and depressionamong CAD patients has been reported to be two tothree times the rate of the general population, thatis, as high as 30 per cent or more (Barefoot et al.,1996; Carney, Freedland, Sheline, & Weiss, 1997;Carney et al., 1987). Furthermore, anxiety anddepression are strong and independent predictors ofnegative outcomes such as death and higher rates ofhospitalization in patients with heart failure(Rutledge, Reis, Linke, Greenberg, & Mills, 2006).Individuals may differ in how active or passive

their approaches are in their problem-focused (suchas seeking information or help and initiating lifestylechanges) and emotion-focused coping strategies (e.g.strategies for managing the fear and anxiety associ-ated with illness, treatment and treatment situation)when dealing with stress (Carver, Scheier, &Weintraub, 1989; Finset, Steine, Haugli, Steen, &Lærum, 2002; Lazarus & Folkman, 1984; Sørlie &Sexton, 2001b; van Elderen, Maes, & Dusseldorp,1999). This has important clinical implications, asavoidance, denial and inhibition strategies tend tohave negative long-term effects on emotional well-being in CAD patients (van Elderen et al., 1999).In a self-regulation perspective (Carver &

Scheier, 2001; Leventhal, Brissette, & Leventhal,2003), CAD patients may regulate their actions inways aimed at attaining or avoiding goals (e.g.avoiding pain or relapse, retaining leisure activitiesand returning to work). Self-regulation operates byan approach motivation for positive (desired) goalsand an avoidance motivation for negative (unde-sired) goals (Carver & Scheier, 2001). Similar ideasare presented in Regulatory Focus Theory (RFT)(Higgins, 1997), which holds that individuals differin their sensitivity to the absence or presence of pos-itive versus negative outcomes, and that these sensi-tivities represent two different basic principles (i.e. apromotion versus a prevention focus) in people’s

motivation to act. However, RFT goes beyond the(approaching or avoiding) behaviour, emphasizingthe motivational cognitions behind the behaviour.Drawing on literature focusing on healthy sub-

jects, we believe that RFT is relevant to patients’coping and to their recovery from CAD. First, adopt-ing a promotion or a prevention focus will generatedifferent strategies. A promotion focus on hopes andaccomplishments generates approach and eagernessstrategies, emphasizing the pursuit of positive idealsand goals. A prevention focus on safety and respon-sibilities generates avoidance and vigilance strategiestowards undesired end-states, emphasizing theavoidance of losses and the fulfillment of obliga-tions. Second, empirical evidence suggests thatchoosing either a prevention or a promotion focuswill have different implications with regard to cogni-tive, emotional and behavioural factors that havebeen found to be associated with well-being and clin-ical outcomes in CAD patients (Brockner & Higgins,2001; Higgins, 1997). A promotion focus is associ-ated with openness towards change, a high tolerancefor failure and a tendency to take risks (Crowe &Higgins, 1997; Liberman, Molden, Idson, & Higgins,2001). A prevention focus is associated with scepti-cism to change, preference for stability, a low toler-ance for failure and a tendency to avoid risks (Crowe& Higgins, 1997; Liberman et al., 2001).Furthermore, a promotion focus tends to generateemotions along a cheerful—disappointed dimension,while a prevention focus tends to generate emotionsalong a calm–agitated/anxious dimension (Brockner& Higgins, 2001; Higgins, 1997). The preventionfocus mechanisms have some similarities with thepersonality dimension of neuroticism, associatedwith higher levels of self-reported illness (Horner,1996), disengagement, denial (Penley & Tomaka,2002) and passive coping strategies (Sørlie &Sexton, 2001a). The promotion focus mechanismshave similarities to openness and extraversion, whichare associated with active coping strategies such asgoal orientation and seeking social support (Sørlie etal., 2001a), lower levels of anxiety (Knoll,Rieckmann, & Schwarzer, 2005) and a more flexible,imaginative and intellectually curious copingapproach (Watson & Hubbard, 1996).In sum, we suggest that motivational cognitions

such as approach and avoidance motivation andRFT may explain some of the psychological mech-anisms involved in patients’ coping with illness andtreatment. To our knowledge, RFT has not previ-ously been applied to studies of CAD patients.

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Aims

The main aim of the study was to identify thethoughts and concerns patients had regarding theirCABG experience and to provide a thematicaccount of the interviews. In addition, we wanted toexamine if their thoughts and concerns beneficiallycould be understood in light of RFT.

Material and methods

The departmentThe study took place at the Department of Thoracicand Vascular Surgery at the University Hospital ofNorthern Norway (UNN). This unit serves a popu-lation of 460,000, and treats around 1500 inpatientsper year, including 600 CABG patients.

Recruitment of participantsPatients were recruited at the hospital the first days fol-lowing surgery. Those considered by the Head Nurseto be too sick were excluded. Four patients refused andtwo were excluded (not Norwegian or English speak-ers). Six interviews were cancelled because the patientwas subjected to acute re-surgery, transferred or dis-charged before the interview could take place.

ParticipantsNine patients, seven men and two women, partici-pated (see Table 1). Three arrived at the emergencyunit following an acute myocardial infarction (MI)and six were pre-scheduled for surgery due to seri-ous angina. Eight had CABG surgery, one had aheart valve replacement and one had both. Sevenwere first time diagnosed with CAD. All nine weremarried. Six were retired, while three were work-ing at the time they became ill. Six were regularsmokers.

Interviews and analysisThe interviews were performed by the first author,were about one hour long and took place in a consul-tation room at the ward the first week followingsurgery. They were tape-recorded and transcribed.The interviews and analysis were inspired byInterpretative Phenomenological Analysis (IPA)(Smith & Osborn, 2008). Following IPA, researchersaim to understand aspects of individual experience.At the same time, researchers drawing on IPA makeevident that their own background, understanding andinterpretation must influence the analysis (Kay,Davies, Gamsu, & Jarman, 2009; Smith, 1996). In theinterviews, an open-ended questioning style wasused, focusing on the patients’ thoughts and concerns,and following up on the patients’ responses. Whilethe patients were encouraged to talk freely about theirexperiences, some open questions (How did youexperience your chest pain?What were your thoughtswhen you were admitted?) were posed to helppatients when needed to facilitate disclosure. Some ofthese open questions were prepared in advance, draw-ing on prior literature as well as on clinical experi-ence. Other questions emerged as the interviewsprogressed. Topics highlighted by patients in priorinterviews were introduced to patients in the follow-ing interviews. The transcribed interviews were readand discussed by the authors. Topics identified asimportant to the patients were highlighted, with par-ticular sensitivity to emotional reactions, hopes, con-cerns and their motivation and strategies used whenfacing these experiences. The highlighted sentenceswere extracted from the text, listed in groups of top-ics and clustered into super-ordinate themes. Eachtheme was compared with the rest of the data andother themes and described as shown below. In addi-tion, we examined how the patients’ experiences andconcerns could be understood in light of relevant the-ories, particularly theories of approach and avoidancecoping and Regulatory Focus Theory.

Formal approvalThe study was approved by the Regional MedicalEthics Committee, the Norwegian Social Science DataServices and by the Head of the Surgical Department.All patients signed an informed consent form.

Results

Following the analysis, the patients’ main thoughtsand concerns were grouped into four generalthemes: Ignoring pain or asking for help; Waiting in

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Table 1. Overview of participants

Patient Sex Approx age Treatment

A Male 60s CABGB Male 60s CABG + valve

surgeryC Male 70s CABGD Male 60s CABGE Female 60s CABGF Female 40s CABGG Male 70s CABGH Male 70s Valve surgeryI Male 60s CABG

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hospital; Fearing and preparing for surgery; andWorrying and looking forward to going home.

Ignoring pain or asking for helpThe patients expressed in various ways a need toavoid, repress and escape the painful and frighteningaspects of the illness in their reactions to the firstsymptoms. One patient had repeatedly ignored thesymptoms and postponed seeking help, even whenhe knew that it was angina and symptoms of CAD:

I had a terrible pain in the chest and down thearm that morning. I decided to just lie down for awhile. This had to pass, as everything else. I hadseveral times felt this sting in the chest and downthe arm previously. My daughter had told me thatthis could be angina. When I got the pain thatmorning, she called an ambulance. (Patient A)

Until that morning, the avoiding and postponingmay have been perceived as successful strategies.However, this morning it did not work that way. Asimilar approach was described by a female patient.She told about having chest pain in the spring aboutone year prior to the surgery:

I thought that it would pass, but it only got worseand worse. Then I got a terrible cold too, oh myhow ill I was! I was so ill that I thought I wasgoing to die. But I probably had an infarctionwithout understanding that the pain was frommy heart, the doctors tell me now. But I didn’tconsult my GP about these troubles untilJanuary (about eight months later). (Patient E)

Another patient had a CAD diagnosis, and evenhad had a prior MI episode, but ignored the recur-ring symptoms of CAD for several years. The GPhad recommended surgery, but the patient hadrefused. As a dedicated amateur fisherman he wasnot too keen having the season for salmon fishingruined by surgery. He did not tell his wife about theincreasing angina pain. A newMI episode, this timewith cardiac arrest, gave him no choice but surgery.In the hospital bed, in the high season for salmonfishing, he regretted his avoidance strategies andgave the following advice to future patients: ‘I rec-ommend all who have these problems, to seek helpin time, and not wait too long!’ (Patient G).Similar postponing and avoidance strategies fol-

lowed by regret and feelings of guilt stated as con-tra-factual thinking were found in several patientstories. Other patients were active and help-seeking.One of them had gradually felt short of breath, andcalled his GP and asked for a ‘check-up’. He took

the necessary actions and seemed convinced that itcould be solved. He expected a short stay at the hos-pital and that he would be able to return home andgo back to work soon (Patient B). Another malepatient presented a similar story:

I took action quite soon. It was really for myback pains that I consulted the doctor. I had hadterrible back pain for a long time. Then I men-tioned it to him. I understood that somethingwas wrong, but I didn’t think that it was so bad.(Patient I)

One of the women had taken a comparableapproach. She had contacted her GP as soon as shehad the first symptoms, but her symptoms weremisdiagnosed as anxiety-related stomach pains fol-lowing a stressful work-related experience. Sheconsulted her GP and several specialists over thenext six months: ‘I believe I’m quite persistentwhen trying to figure out things, and I wasn’t satis-fied. I wanted to do something about it’ (Patient F).She even had suggested that it might be CAD.However, she did not blame the GP. The search forthe diagnosis was a joint effort of the GP and her-self: ‘We agreed, the GP and I that it had to be apsychosomatic history related to the incident atwork. So that was what we went for, the GP and I’(Patient F).In retrospect, she was grateful that her illness

eventually had been identified and treated correctly.She knew that symptoms of CAD may differbetween women and men, and that women moreoften are misdiagnosed. Her story illustrates howpatients may take an active approach regarding theirillness, and the importance of patient–providerinteraction on treatment satisfaction.

Waiting in hospitalChallenges of adjusting to the hospital routineswere brought up by all patients. Waiting was a dom-inant patient activity at the ward, and patientsdescribed various strategies to cope with waiting.One explained how he used inactivity as a deliber-ate coping strategy: ‘I have to bring myself into astate of drowsiness to kill time. You lie down, try-ing to sleep—or dream yourself away somewhere,to make time pass by’ (Patient A).The patients described how waiting promoted

inactivity and pacified them. The routines, organi-zation and even the architecture of the wardseemed to increase patient inactivity. They foundthe ward designed for patients to stay in their bed,

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and arrangements for patient activities were limitedto reading newspapers or watching television. Thisinactive waiting frustrated them and drained theirenergy. Those motivated to take a more active role,felt restrained and prevented from doing so withinthe hospital setting: ‘The most difficult is the wait-ing—because you’re not able to do anything—noth-ing! The days become very long. It is terriblyexhausting. I believe it’s more exhausting to donothing, than to do something’ (Patient A).They acknowledged that some waiting was

inevitable, but found the hospital situation to behighly unpredictable, and that it undermined anddisrupted their efforts to prepare for the treatment:‘It was uncertain when I could talk to the surgeon.Suddenly one evening the doctor was here, and Ihad to be ready when he was. I know why, but I’msure it could be made more predictable’ (Patient F).Another patient had had a similar experience. A

scheduled consultation with a cardiologist wasdelayed, and he had to wait two to three hours with-out being given any information: ‘It’s understand-able of course, but one just sits there and you don’tknow if you can go out and get the paper or if youhave to sit there. I miss being given information,that bit wasn’t so good’ (Patient C). The pacifyingand unpredictable situation generated negativeemotional reactions, such as annoyance, disappoint-ment, sadness, feeling self-pity and vulnerable andbeing frightened. However, all patients were eagerto praise the nursing staff as supportive andempathic. This gratefulness and appreciation mayreflect the patients’ vulnerability and their depen-dency on the nursing staff. One patient describedquite clearly his helplessness: ‘The worst aboutlying in bed like this is that you need help to get up,help to lie down, and help with everything. Youfeel—how helpless you are’ (Patient D).

Fearing and preparing for surgeryClinging to the hope that surgery would not be nec-essary, some felt dejected and in despair when theyrealized that they ultimately were going to havesurgery. One patient described similar reactionswhen his surgery was postponed: ‘When I wasrejected, I went straight down. I felt sorry formyself, and I wanted to cry’ (Patient A).Information about impending surgery and post-

ponements influenced their emotional reactions.Being postponed due to the priority of other emer-gency patients was perceived as positive for one ofthe patients:

It was a disappointment, having prepared one-self, and then it was postponed. But I could han-dle that, because I knew that these things canhappen, that emergency cases have to go first. Iwasn’t that ill. I could wait, and it was a releaseto do it. I wasn’t depressed by it, because I was-n’t that ill. (Patient B)

The staff had explained that they had to give prior-ity to the most critical patients and that this patientwas in a more critical condition than he was. Thismade him reconsider his own situation as not beingthe worst. It also enhanced his trust in the medicalstaff. Several patients highlighted the importance ofbeing mentally prepared for surgery: ‘You becomeso tuned into it, that this is something that you’regoing to take part in and go through with. You buildup a certain resistance against that anything shouldgo wrong’ (Patient A).Those who stressed the importance of mental

preparation also expressed high self-efficacy beliefs,that they could influence their illness and outcomeby their own thoughts and actions: ‘It makes a dif-ference because you are going to deal with this in anexcellent way. If you don’t mentally prepare, youbecome terribly down, and soon start to feel thateverything works against you’ (Patient A).Another patient had similar thoughts expressed

as positive thinking: ‘I have focused my thoughtson the surgery and to have the strength to it. All thetime, only mobilized positive, and very little onwhat’s negative’ (Patient B).A different patient described his thoughts possi-

bly more in line with a prevention focus. Hefocused on the implications of losing courage: ‘Youmust keep your courage no matter how dark itseems. Because then you’re soon finished. I tellyou, then you hit rock bottom’ (Patient H).However, some patients found mental prepara-

tion difficult to apply. This was particularly true forthe emergency patients, as they had limited time toadjust to the illness and the hospital setting andmentally prepare for the surgery. Some of thepatients did not think about mental preparation atall. Rather than mobilizing their own resources,their strategy was to avoid any thoughts about thesurgery, and trust the surgeons: ‘When I realizedthat I had to have surgery, I just disengaged from it.I said to the surgeons: I leave it all up to you. Icouldn’t do anything anyway, that would make anydifference’ (Patient E).Reflecting on the details about the surgery can

be overwhelming, and some expressed an explicit

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strategy to avoid and push away these thoughts:‘The best is to think as little as possible. I’ve triedto keep myself occupied with other things, tried toput away the thoughts, always push them ahead ofme. I believe that is important’ (Patient I). He feltthat this was the best way to take care of both him-self and his wife: ‘I’ve managed very well with this.You can ask my wife. She hasn’t noticed me beingworried or anything. I haven’t showed that I havebeen particularly nervous or anything like that. Shethinks I’ve been brave’ (Patient I).

Worrying and looking forward togoing homeThe future was another important topic for thepatients. Their worries included how to handle med-ications and clean the surgery wound and how to beable to perform practical tasks in the house whenreturning home. Some expressed fears of doing some-thing wrong that could harm the wound, they werecautious and careful to avoid that and requested moreinformation from the staff: ‘I’m worried about doingsomething wrong, because I didn’t ask enough aboutwhat to do and not to do. I must be cautious not todestroy anything’ (Patient E).Worries of relapse were also a concern. One of

them explained how he tried to avoid any thoughtsabout the risk of relapse: ‘You can’t think about therisk of new events. You’ll become nervous if youstart thinking like that. I’m only so relieved that I’mthrough with this’ (Patient I). Worries and avoidingstrategies seemed to be followed by low self-efficacy beliefs. Some patients talked about theirillness in terms of destiny. They could not do any-thing about it anyway. What happened would hap-pen. Some had doubts whether they would be ableto make the recommended lifestyle changes such asquitting smoking and changing their diets. Onestated a general disbelief on this topic: ‘I believethat these things may last only until you’re out (ofhospital). Then you just return to old habits. Tochange your way of living—I believe that’s a verydifficult thing to do’ (Patient D).All of the patients were looking forward to

returning home. Some focused on what they appre-ciated in daily life, such as being with their grand-children, working in the garden and hiking andfishing trips: ‘We walk about five to 10 kilometresevery day. That’s good for us, old ladies. I don’tthink I would recover that fast if I wasn’t so physi-cally active’ (Patient E). They focused on thepositive experience of these activities. They also

expressed high self-efficacy beliefs; they were opti-mistic about their future abilities to perform andachieve the goals they set themselves. One of themexplained it like this: ‘It’s important that I get outand start to take my strolls, that I gradually increasethe length of my walks. I have done this before,after having an eye operation’ (Patient F). Someeven characterized their illness as something posi-tive, as it made them aware of what they had and thepositive side of life. As one said it: ‘If this turns outwell, it means that I have got a new chance in life,and that is a gift’ (Patient D).

Discussion

Four themes emerged during the analysis; Ignoringpain or asking for help; Waiting in hospital; Fearingand preparing for surgery; and Worrying and look-ing forward to going home. The patients made thepoint that suffering from CAD and being subjectedto CABG was perceived as stressful. However, theydiffered in how they handled this stress. Whilesome of the patients told about how they coped byavoiding (ignoring pain, postponing help-seeking),other patients were more actively help-seeking.Avoidance coping is considered one of the mostcommon ways of dealing with stress (Folkman &Lazarus, 1988; Suls & Fletcher, 1985). However,whether avoidant strategies are beneficial or harm-ful in dealing with stress is unclear. Some studieshave found that avoidance strategies such as denial,self-distraction, repressing of emotions, self-blameand fatalism are associated with depression,reduced quality of life and delayed recovery (Brink,Karlson, & Hallberg, 2002; Klein, Turvey, & Pies,2007). Other studies have found that repressivecoping such as minimizing negative thoughts andemotions and even denial of illness can be success-ful strategies as they divert attention to more posi-tive thoughts, and thus contribute to increasedwell-being, and reduced anxiety and stress (Brink etal., 2002; Ginzburg, Solomon, & Bleich, 2002;Havik & Mæland, 1988; van Elderen et al., 1999).Possible explanations for these diverse findings

could be variations in type of avoidant behaviourand the timing of when it is acted out. Carver et al.(1989) differentiated between mental disengage-ment (activities that distract and take one’s mind offthe problem) and behavioural disengagement(reducing efforts or giving up to attain goals or todeal with the stressor). We found that some of thepatients deliberately avoided thoughts about the

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illness and the surgery, as they felt that thesethoughts increased their worries and anxiety. Thus,mental disengagement may be beneficial as an emo-tion-focused strategy regulating the emotional reac-tions in the highly stressful situation prior to andduring hospitalization. Ignoring the symptoms anddelaying help-seeking are examples of maladaptivebehavioural disengagement strategies used by someof our patients. These strategies resulted in a break-down of the self-regulatory system, and the patientsfailed to react to changes and take the necessaryactions (Brashers, Goldsmith, & Hsieh, 2002).Patients also used behavioural disengagementstrategies such as passively waiting, walking rest-lessly in the corridors and dozing off on the bedduring day-time, to cope with the unpredictablehospital setting. The hospital setting and routinesseemed to promote and stimulate behavioural dis-engagement rather than active engagement, and thismade the patients feel helpless. Such associationsbetween behavioural disengagement and helpless-ness were also suggested by Carver et al. (1989).Review studies conclude that avoidant coping

may have short-term positive effects, while thelong-term effects tend to be negative with reducedquality of life, increased depression and a poorrecovery pattern (Klein et al., 2007; van Elderenet al., 1999). Thus, we may assume that it wouldbe more beneficial for the long-term recoveryif avoidant strategies gradually were replacedwith approach and attention-oriented strategies.However, as the patients in our study only wereinterviewed at the hospital, we have no informationabout what they thought later.Some of the patients described how they used

various approach strategies to identify the illness,adapt to the hospital, prepare for surgery and focuson positive goals in the future. Using such strate-gies may reflect a need for information and control(Breemhaar, van den Borne, & Mullen, 1996;Dunckley, Ellard, Quinn, & Barlow, 2007).Inaccurate beliefs about the illness and treatmentand the overestimating of risks are frequent amongCAD patients, and associated with increased anxi-ety (Broadbent et al., 2006). Meeting the patients’needs for information is a major challenge in healthcare. Vigilant information-seeking behaviour mayhelp the patient to get treatment in time, but is alsoassociated with sustained high anxiety and arousal(Miller, Brody, & Summerton, 1988), more com-plications and increased postoperative hospitalstays (Cohen & Lazarus, 1973). We found that

many of the patients experienced high levels ofstress and anxiety, and showed a high tendency touse both active and passive coping strategies.Feeling a loss of control is also frequent duringhospitalization, and associated with anxiety(Schroder & Schwarzer, 2005). Thus, the persistentsearch for a diagnosis, the urge for predictabilityand the focus on mental preparation in the patientsmay reflect anxiety and a need for control in afrightening and stressful situation. Whether vigi-lant strategies are adaptive or not, patients foundsuch strategies to be inconsistent with the hospitalenvironment, which seemed to reinforce patientpassivity and dependency rather than mastery ofone’s environment (Cohen & Lazarus, 1973; Sørlie& Sexton, 2001a).We found some indications of the patients’ regu-

latory foci in how they described their actions.When ignoring pain and other symptoms, patientsA and E expressed a clear prevention focus whenarguing that their passive avoidance was a strategyto make their negative experiences disappear. Onthe other hand, the amateur fisherman ignored hissymptoms and postponed help-seeking, this wasexpressed as a strategy to gain the positive experi-ence of salmon fishing, which we deem to representa promotion focus. However, all three showed mal-adaptive strategies which resulted in worsening ofthe illness. Those patients who were actively seek-ing help, argued that they knew that something waswrong, but believed that through treatment theycould regain their health. Thus, their help-seekingwas expressed as promotion focus strategies to gaingood health, rather than to avoid illness.Among those preparing for surgery, we also

found a mixture of promotion and prevention foci.Some patients focused on the positive aspects ofgoing through surgery, expressed as a promotionfocus on positive outcomes of the surgery. Othersdescribed their mental preparations as preventionstrategies to avoid or reduce the potential negativeeffects of surgery.Thus, we did find some indications of promotion

and prevention foci strategies in the patients’accounts in these open and unstructured interviews.Whether adopting either a promotion or a preven-tion focus is advantageous remains to be seen.However, following the analysis, we have theimpression that a prevention focus seemed to be fol-lowed by a tendency to express fear and worries.Further research, for instance by means of morestructured interviews, could bring us even closer to

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an understanding of the clinical implications ofadopting either a promotion or a prevention focus.The different emotional implications of failing in

a promotion versus a prevention focus (Brockner &Higgins, 2001; Higgins et al., 2001) have relevancefor patients’ coping. For the promotion focusedpatient, failing to reach desired outcomes such asbeing socially active, engaging in leisure activitiesand returning to work, may generate disappoint-ment and dissatisfaction. On the other hand, forthe prevention focused patient, failing to avoidundesired outcomes such as discomfort and pain,incomprehensible symptoms and loss of control andphysical disabilities, may generate agitation andanxiety. Further studies are needed to explore theimportance of this topic with respect to CADpatients. It has also been suggested that RFT couldexplain some cognitive processes involved indepression, and even that depression can be under-stood as a type of breakdown in the promotionfocus regulatory system (Strauman, 2002). Such apotential relation between RFT and depression rep-resents an impetus for more research exploring theimportance of RFT in CAD patients, as many CADpatients suffer from depression. Moreover, depres-sion is a central predictor of a poor recovery inCAD patients (Rutledge et al., 2006).Some study limitations should be mentioned. As

all patients were interviewed once at the hospitaland only a few days following major heart surgery,a poor general state of health may have influencedwhat they were thinking and feeling. Also, we haveno information about their experiences andthoughts at later stages of their rehabilitationprocesses. A prospective study with a series ofinterviews with the same patients at different stagesof their illnesses and treatments might provideinformation about the processes and changes intheir experiences and ways of coping.In sum, we found that patients’ descriptions

could be understood in terms of approach andavoidant coping. However, we have argued that thepromotion and prevention dimensions of the RFTmay be more useful concepts as they explain themotivational cognitions guiding the coping strate-gies. Patients’ tendency for a prevention orienta-tion seemed to be stimulated and strengthened bythe hospital setting. Those motivated for activeinvolvement in their own treatment process werefrustrated as they experienced that the hospital set-ting favoured and increased passivity and ham-pered active participation.

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SVEIN BERGVIK is a Clinical Psychologist, currentlyworking at the Pain Clinic at the UniversityHospital of Northern Norway and atthe University of Tromsø, Norway. He has a PhDwithin the field of clinical health psychology.

TORE SØRLIE is a Consultant Psychiatrist andProfessor of Psychiatry at the University of

Tromsø. His research is mainly focused on clinicalhealth psychology and cultural psychiatry.

ROLF WYNN is Head of the Psychiatric ResearchCentre of Northern Norway and Professor ofPsychiatry at the University of Tromsø. Clinicalhealth psychology is one of his main researchinterests.

Author biographies

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