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4 AR´s Tests at the End of Psychotherapy

4 AR´s Tests at the End of Psychotherapy

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Psychotherapy for Cardiac Patients: Selection of Clinical Cases. Part I


Fig. 18.7 Six drawings test

results for AR one year after

beginning psychotherapy:


personality. This time, instead of a small, whole-body puppet-like drawing, the

male figure drawing only included the head (Fig. 18.8) as did his drawing of a

female (Fig. 18.9). At first glance, the absence of the body could be seen as a

negative, but both faces are very expressive and they are no longer like little

puppets. These two drawings could correspond to an expansion of his consciousness, and his increased capacity for personal introspection, and potentially to

improved relations with his wife. The family drawing revealed a clear change in

the family dynamics (Fig. 18.10), with the father and mother at the center, a child on

each side, and all holding hands, providing evidence of renewed and much superior

levels of communication.

For his present situation, AR drew a sunny landscape with a blue (instead of a

black) river, a tree, and a full sun, all positive symbols of personal health and

harmony (Fig. 18.11). Note especially how the sun is complete now, suggesting

restored communication between the patient’s Ego and In-Self.

For his future purpose/situation drawing, AR drew a beautiful seascape

(Fig. 18.12). The sea is blue, but, strangely, the sky is cloudy and the sun broken

by clouds. This image may indicate some doubt about AR’s future evolution,


A. Roncella

Fig. 18.8 Six-drawings test

results for AR one year after

beginning psychotherapy:

Same-sex figure. In the

original test the same-sex

figure was smaller, but in the

center of the sheet

Fig. 18.9 Six-drawings test

results for AR one year after

beginning psychotherapy:

Opposite-sex figure. In the

original test the opposite-sex

figure was smaller, but in the

center of the sheet

Fig. 18.10 Six-drawings test

results for AR one year after

beginning psychotherapy:

Family. In the original test the

family figure was smaller, but

in the center of the sheet

appearing to depict future problems. Note, however, that AR had received only a

short course of psychotherapy which, in my opinion, though efficacious, might only

affect short-term improvements. To maintain personal physical and psychological

equilibrium, it is advisable for each patient to thereafter partake of at least a brief

course of psychological counseling on a yearly basis.


Psychotherapy for Cardiac Patients: Selection of Clinical Cases. Part I


Fig. 18.11 Six-drawings test results for AR one year after beginning psychotherapy: Present



Medical and Cardiac Follow-up at 5 Years

Over the 5-year follow-up period, AR had no further cardiovascular events or new

comorbidities. At the 1-year follow-up evaluation, he exhibited complete recovery

of left ventricular function, the ejection fraction having increased from 40 % at

baseline to 60 %.


The Future

Surely psychotherapy is neither divination nor magic. Nonetheless, looking at AR’s

last 6DT drawing, one might wonder what lies ahead for him. AR was not

scheduled for further cardiac monitoring after completion of 5 years of follow-up,

nor did he ask for monitoring within the hospital’s Department of Cardiovascular

Disease, where he had been treated and followed. The tenth year after the first acute

myocardial infarction, he was admitted to our department for a second acute

myocardial infarction, this time without ST elevation (NSTEMI). Coronary angiography, performed urgently, revealed patency of the stent that had been implanted

in the left anterior coronary artery. However, there was critical stenosis in the


A. Roncella

Fig. 18.12 Six-drawings test results for AR one year after beginning psychotherapy: Future life

purpose or situation

second part of the right coronary artery. Consequently, a PCI was performed on the

right coronary artery, during which a drug-eluting stent was implanted.

When I met with AR during his most recent hospitalization, I asked questions to

determine his lifestyle over the last 5 years. He mentioned having completed a

cardiovascular prevention program and having regular cardiac monitoring visits.

His cholesterol and triglycerides were in the normal range and his arterial pressure

was well controlled. He had not continued any psychological counseling after the

study, because he believed that he had resolved all of his personal problems. It was

not possible to further investigate this patient’s personal situation at that time, so it

is impossible to propose any hypotheses.

Outside of experienced psychotherapists, most would be surprised to discover as

unconscious may speak about the whole situation of a human being, also if

consciousness is not always able to grasp the psychobiological connections,

which are preparing a new event in life, happy or sad, physical or psychological.

Helping people to bring their unconscious drives to a conscious level can aid them

to restore happiness and harmony in their life. The example presented in this

chapter is clear evidence of this.


Psychotherapy for Cardiac Patients: Selection of Clinical Cases. Part I




Our life is in continuous flux as we move from day to day and situation to situation.

This requires our continuous ability to adapt in many complex ways, thereby

influencing our physical health, psychological equilibrium, affectivity, social

relationships, work commitments, physical environment, etc.

Ontopsychological psychotherapy might be considered a method that helps

people to develop more complete awareness about their personal state, by learning

how to interpret the continuous communication of their unconscious. This provides

them with additional information in any situation and a greater capacity to cope

with life’s nonstop complexities. Our unconscious may guide us to seek out the best

solution for each specific context. Continuously understanding and following the

indications of our “unconscious intelligence” requires long-life learning and



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controlled, short-term psychotherapy in acute myocardial infarction (STEP-IN-AMI) trial.

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Psychotherapy for Cardiac Patients:

Selection of Clinical Cases. Part II


Marinella Sommaruga and Antonia Pierobon

Symptoms of illness and distress, plus your feelings about

them, can be viewed as messengers coming to tell you

something important about your body or about your mind.

Jon Kabat-Zinn (Jon Kabat-Zinn (1990) Full Catastrophe

Living: Using the Wisdom of Your Body and Mind to Face

Stress, Pain, and Illness)



Our model of psychotherapy covers a process of assessment, intervention, and

follow-up, as mentioned in Chap. 11 and 22 and Fig. 22.1).

During the assessment process, after the first interview, the psychologist decides

if any psychometric screening (Appendix 1) or further psycho-diagnostic evaluation is necessary. Then he/she chooses the specific tailored intervention for that

particular patient.

The context of psychotherapy is cardiac rehabilitation, which entails

individualized physical training, nutrition monitoring, psychological assessment,

and psychotherapeutic interventions, as indicated (Appendix 2) [1–3].

Psychosocial screening reliably identifies the problematic macro-categories,

especially if they are characterized by behavioral indicators, which facilitate detection. The psychological approach appears more suitable for better specifying

M. Sommaruga, PsyD (*)

Clinical Psychology and Social Support Unit, Salvatore Maugeri Foundation, Care and Research

Institute, Via Camaldoli 64, 20138 Milan, Italy

e-mail: marinella.sommaruga@fsm.it

A. Pierobon, PsyD

Psychology Unit, Salvatore Maugeri Foundation, Care and Research Institute, Via per

Montescano, 27040 Pavia, Italy

e-mail: antonia.pierobon@fsm.it

# Springer International Publishing Switzerland 2016

A. Roncella, C. Pristipino (eds.), Psychotherapy for Ischemic Heart Disease,

DOI 10.1007/978-3-319-33214-7_19



M. Sommaruga and A. Pierobon

macro-category characteristics, and for detecting less overt but still critical aspects

of distress, thereby providing advice for and therapeutic management of any

psychopathology. This may facilitate synergistic teamwork to address common

priorities that respect both the point of view of the patient and clinical-rehabilitation


Each of the following two sections describes a typical clinical case involving a

patient with ischemic heart disease treated in the cardiac rehabilitation ward.


Clinical Case 1: Mr. F. (Anxiety and Family Problems)

Mr. F. was a married sixty-one-year-old man with two adult married sons. He was

working as a plumber with a demanding, high-paced time schedule and heavy

workload. He had presented to the unit one year earlier for regular follow-up

after a myocardial infarction. The patient was of normal weight (BMI ¼ 23), but

tended toward being hyperglycemic on a noncontrolled diet (fasting serum

glucose ¼ 120 mg/dl). Both his total and LDL cholesterol levels were elevated

(total cholesterol ¼ 230 mg/dl; LDL cholesterol ¼ 150 mg/dl).

During psychosocial screening, performed during the first outpatient visit and

involving the following tests—PCS, ASiHD, and HADS (described in Appendix

1)—the need for a full psychological interview became apparent. In fact, according

to his Hospital Anxiety and Depression Scale (HADS) scores, Mr. F. suffered from

high-level anxiety (HAD anxiety score: 14/21) and was near the threshold for

borderline depression (7/21). Moreover, according to his ASiHD responses, a low

level of perceived self-efficacy in behavioral adherence was evident, even though

he appeared to have an appropriate level of illness perception and knowledge (see

Fig. 19.1) [4–6].

During the psychological interview, the patient confirmed the low levels of

adherence detected during screening. He admitted to not taking his medication

punctually, not engaging in adequate physical exercise, not regularly following

dietary prescriptions, and not being able to suitably manage stressful situations,

despite his current heavy workloads. He expressed good knowledge of the cardiovascular risks that his severe lack of adherence to medication and lifestyle change

recommendations subjected him to, and made no attempts to either minimize or

deny his wrongful behavior. His high anxiety level appeared not to be a personality

trait, but a conditioned reaction to family difficulties.

During the psychological intervention, Mr. F. claimed that he was “forced to

work” as a result of debts contracted by his two sons and that, if it was not for his

sense of duty, he would stop working and live on his annuities and other economic

returns. However, he also strongly defended his moral responsibility to help his

sons, even if both of them were adults and the resulting workload for him was

beyond the safe limits of his clinical condition. His stress was worsened further by

his deteriorating relationship with his sons, as well as their apparent ingratitude. It

often happened that Mr. F. skipped meals to see clients, and this caused him to alter

the timing of his drug doses. And even though Mr. F. appeared to be quite aware

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