Relationship Skills and Heart Disease:
A New Frontier

Martin Sullivan, MD
Cardiologist at Duke University

Plenary Presentation
Coalition for Marriage, Family and Couple's Education (CMFCE)
1997 Conference in Washington, D.C.

(Dr. Sullivan is speaking)

What is a cardiologist doing at a conference on psychoeducation?

As a physician, my role is to find the most effective therapies for my patients. As a cardiologist, data is emerging very clearly that if we can find ways to involve patients with coronary artery disease in lifestyle intervention programs that involve low fat diets, exercise, and a strong psychosocial overlay that reduces their psychosocial risk factors and gets them in a position where they can grasp a lifestyle education program, we can have a huge impact on our number one disease in the country. It is my idea that in the future, standard therapy in patients with coronary artery disease, will involve a psychoeducational program that involves not only lifestyle therapy, but also a psychoeducational program that teaches people about relationship skills, taking care of themselves and about taking care of the people around them.

The idea that coronary artery disease is important and is caused by risk factors and lifestyle is getting around. Coronary artery disease is, as you know, the number one illness. 48% of people in the United States die from coronary artery disease. We designed a number of high tech interventions that can have important impacts on patients with coronary artery disease, in terms of survival.

New Zealand Study

(Across 20 years)

Event Free Survival after Bypass
before Age 40

The question: What was the 20 year event free survival in this study? Zero.

Coronary artery disease is a chronic illness. Once you get coronary artery disease, interventional procedures will reduce symptoms from the blockage, but these procedures do not stop the disease. That's why I say it's a disease of education and lifestyle; and what we are doing with high tech therapy is effective, but in a certain sense, it is palliative therapy.

Cartoon with "Jumbo, block your mate size" cereal box on a table so that partners do not have to look at one another.

What does coronary artery disease have to do with relationship skills? I think it has a lot to do with that because when we look at the risk factors for coronary artery disease and the psychosocial risk factors, many studies have shown that they are very strong. I think that it is no accident that we have an epidemic in this country of divorce and dissatisfaction in marital relationships and also an epidemic in coronary artery disease. The risk factors that we know that are important are:

  • social isolation
  • sleep disorder and depression
  • hostility
  • repression of emotion
  • work stress
  • loss of meaning
  • low affiliation/high power

It is interesting when we talk about social isolation. There was an interesting interview with Mother Theresa when she was traveling in Europe. Someone asked her, "What is the worst disease that you have seen?". They were thinking that this woman had been to India and she was going to talk about Cholera, or leprosy, or AIDS. She thought for a moment and she looked at the press and said, "loneliness and isolation in the West."

When you look at risk factors for coronary artery disease, these are standard risk factors - like males with sex hypertension. They have about a 1.67 ratio. Depression 4.14, dysphoria 2.06 and being divorced or separated doubles your risk of coronary artery disease.

Odds Ratio for MI

Male sex 1.70

Hypertension 1.67

Depression 4.14

Dysphoria 2.06

Divorce/Separation 2.00

We know that unmarried patients with coronary artery disease have a threshold increase in mortality if they do not have a close confidant/partner (work from Redford Williams JAMA 1992 267, 520-524).

How do we treat coronary artery disease?

cartoon (Patient comes in and doctor says:)

"Frankly, I see nothing wrong with you that $1/4 Million of medical care cannot help."

We are changing that now and starting to look at more cost effective ways of treating patients. One of those ways is to look at lifestyle interventions that actually cause some reversal of coronary artery disease. Some of the important trials that did this - the Heidelberg trial and the trial by Dean Ornish, the "Lifestyle, Heart Trial," - documented that patients who undergo this, about 40, 50 or 60% get actual reversal of the process of atherosclerosis. You improve myocardial profusion, the amount of blood flow that goes through to the heart, and you have 50 to 60% reduction in events. I read that literature and it didn't take long for this to sink in. I got it.

cartoon (of two babies in stroller, one baby hitting the other baby over the head with a giant blow-up hammer)

"I was finally hit over the head with the data."

This is the way we should be doing it. So with that, we designed the Healing the Heart Program at the Duke Center for Living which is a 60 thousand square foot rehabilitation facility and retreat on the Duke University campus. We see about 400 to 500 patients per year who come with lifestyle issues and chronic illness. And this is a two week intensive retreat intervention in which lifestyle counselors follow the people for a year by telephone. We teach people how to eat a low fat diet, maintain an aerobic exercise program and we have a strong psychosocial program. We also examine their medical issues.


Two-week intensive retreat

Lifestyle counselor/case manager-follow up for one year :

Diet - 15% calories from fat

Maintain aerobic exercise

Psychosocial - treat depression, hostility, address isolation

Lipids - maintain LDL cholesterol at less than 100 mg/dl

Some of the things that we do psychosocially in the program involve looking at EMOTIONAL LITERACY.


Psychosocial Interventions in Healing the Heart

*Emotional Literacy

*Childhood Scripts

*Body Awareness

*New Priorities

*Coping Styles

*Spiritual Coping

*Naming Fears

*Building Trust and Loving Kindness

Ruth Quillian, a psychologist, has been instrumental in developing this program. Emotional literacy is something we really need to have to protect ourselves from heart disease, and it is also something we need to have to have good relationships. And they go hand in hand. The other thing we work with is body awareness and stress, the fight or flight response. It occurs during marital interaction during stress with type A behavior. That physiological fight or flight is what we believe causes or facilitates getting more blockages in the coronary arteries.

Research using Monkeys

(Given fatty diets and also introduced to psychosocial stresses, Monkeys who had type A behavior developed coronary blockages - twice as many Monkeys as those without type A behavior.)

We have integrated some of the work that Lori Gordon has done with PAIRS - the coping styles in looking at how people respond to stress and what their communication styles are. We look at naming fears, childhood scripts, and what people have learned early on about what their potential is. We talk about new priorities. Who are you really? What is it in your life that makes you important? Are you only your job? Or do you have a larger definition to your life? We also talk about spiritual coping mechanisms. Because they are faced with a life threatening illness, in order to really address what's going on we have expanded to look at how people look at life and death issues. How they look at much larger issues in their life. And the last thing we look at is building trust and loving kindness.

One-year follow-up data on 30 consecutive patients who went through the program shows that there is significant improvement in their stress management practices from less than 1/2 hour per week to greater than 1 and 1/2 hour per week on skills such as meditation and using communication skills. Their Percent of Calories from fat goes down to about 18% and aerobic exercise goes up.


So that the average number of episodes per week has decreased from approximately six to approximately one per week, a significant improvement in symptoms.

About 25% of those referred to the program, someone had looked at their angiograms and had said, "Well , maybe you need to have an intervention...". Only 25% of those people at two years follow up have actually gone on to need an invasive intervention. So what we've shown by this is that we can reduce symptoms and can reduce the need for hospital-based procedures.

We've also looked a little at psycho-social issues, the feelings of anger. There is a significant reduction in that. Feelings of self-esteem - there is a statistically significant increase in self esteem. Now these latter two are important because we know that depression is a strong predictor of death in patients with MI. This is a study conducted by Nancy Frazier Smith showing that patients with coronary artery disease, who are depressed have a six-fold increase in mortality over patients who are not depressed, after they have an MI. More ammunition for looking at psycho-social factors in these patients.

(Dr. Sullivan turns presentation over to the staff psychologist Ruth Quillian who presents more information about type A behavior and social isolation as a circular system of reinforcement to work hard and remain isolated.)


(iceberg theory that medical interventions for patients are only the tip of the iceberg)

iceberg.jpg (14056 bytes)


Coping Styles

Childhood Scripts

Cultural Values

Core Values

Is IT worth it?

Is there a larger meaning?

(Dr. Sullivan presents again)

If I can go back to the (iceberg) model, one of the things I've started to get a grasp about with medical education is that we have taken patients with various illnesses and have put them into medical education programs with variable success. One of the things this iceberg tells us is that individuals must have a core value, a reason. They must find something to make it worth it to protect themselves, some larger meaning. Victor Fraenkel was in concentration camps in World War II and when he survived that experience someone asked him what was it that separated the survivors from those who did not survive? And what was the difference? He said "If you give people a why, they can find the how." If people don't really have a why that they should change their behavior, they are really not going to do it, regardless how much education you are going to give them. Because they are really in the precontemplation phase about making those changes.


(picture of colleague dressed up in clown costume)

Dr. Bowser White (a colleague at Duke) is important in the retreat (at Duke's Healing the Heart Program). He is portraying "scared guy." In the retreat process, one of the things we look at identifying is the scared guy and someone else's scared guy. Because if we can do that, it give us a chance for healing the scared guy or scared gal. And it's really because of the scared guy or gal that causes the type A behavior of hostility and anger that puts patients at risk for coronary artery disease. We do this through multimodal interdisciplinary intervention.

When we look at our society and how we order our world...As in a medicine wheel of native Americans...a way to make sense of the world, it has all the directions of and all of the content of that person's world.


Native American Medicine Wheel

nativemedicinewheellow400.GIF (5408 bytes)

The world of the NORTH was the adult world of logic and information, what you needed to know to function in the adult world. The needs to get by as an adult.

The area of EAST was an area where the eagle was the totem animal, and it was an area of art, spirituality and larger definitions of self -- very important in the native culture.

In the SOUTH was the child's world of emotions and relationships.

And in the WEST was renewal, change and death. And if you'll notice, they are all the same size circles, because they have the same significance in this (the native) culture.


.........nativecircle.JPG (3007 bytes)

(Disproportional Native American Medicine Wheel)

And I think this is what has happened in this culture with most people. They have a huge circle for logic and information and the other areas are really small and under utilized.

One of the things we do is, we connect people with these other areas, and through that it is much easier for them to cope with a chronic illness. Because, if you are really focused on your external adult world and you have an illness which disables you from working in that adult world, that's really depressing and a pretty hard way to cope. When you talk about medicine and larger meanings, I look at the story of Henri Matisse, one of the greatest painters of the 19th and 20th century. When he got into later age, he developed arthritis and poor eyesight and instead of hanging it up, he found a way to cope with his illness which brought the world incredible beauty. As physicians and health care providers our goal is to facilitate people working with illness or working with a difficult situation, to help them find a way to create their masterpiece. He found a way to express essence. I think that's one thing we have in common between medicine and psychoeducation in relationships.

(close of presentation)

Click here to go to Medical Pairs a program which integrates the Sullivan/Ornish wisdom with
the PAIRS marriage education skills program.  

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