Linda Berg-Cross, PhD

Continuing Education Information

Psychologists are trained to be an integral part of the health care system. The APA division of health psychology (38) boasts 3,023 members and affiliates (APA, 2005). There are more than 75 APA approved internships which have a major rotation in behavioral health with over 50% of the interns’ time devoted to health psychology activities, and more than 30 postdoctoral positions where students can receive advanced training in health psychology. The American Board of Professional Psychology (ABPP) and the National Register of Health Service Providers in Psychology both recognize the specialty area of clinical health psychology. The Bureau of Health Services Training Programs funds clinical psychology programs within the same federal training programs used for medical schools. Both disciplines are seen as preparing professionals to reduce health disparities, promote health, and provide disease management. The future is clear for those wearing the proper lenses: we have gained admission to the health industry, and now we are expected to come up with disease prevention strategies, more effective methods for changing life styles, and more effective treatments for chronic illness.

While health psychology will dominate the 21st century of clinical practice, the field has been developing since the late 1970s. More than 30 years ago, Joe Matarazzo, Ph.D., shaped the role boundaries of the specialty with the following definition:

A clinical health psychologist applies, in professional practice, the specific educational, scientific, and professional contributions of the discipline of psychology to the promotion and maintenance of health; the prevention, treatment, and rehabilitation of illness, injury and disability; the identification of etiologic and diagnostic correlates of health, illness and related dysfunction, and the analysis and improvement of the health care system and health policy formation (1980, p 815).

If this sounds like a tall order, it is. Once we looked to the medical profession to prevent and heal; now we are called upon to do the same. We are assuming a critical role on the health team. Other health care professionals are slowly embracing the model that successful patient care requires the integration of traditional medicine and psychological practice. As experts in behavior, we have become the missing piece in holistic care.

Most of the professional media has focused on the role that health psychologists play in prescribing medications for mental health problems (Hall, 2005). The idea propelling prescription privileges for psychologists is that as we practice within our traditional competency domains treating issues like anger, anxiety, depression, cognitive confusion and distortions, we need to have access to pharmaceutical interventions that also treat these behavioral problems. As a profession, we do not want to outsource an aspect of client care that, with appropriate training, we can assess, implement and monitor with equal or greater competence than other health professionals. Just like the dentist who prescribes for tooth pain, and the nurse practitioner who prescribes for infections, so the psychologist should be able to prescribe for emotional/cognitive distress.

This article, however, is focused on another playing field. We focus on the health psychologist’s role in helping to treat primary medical problems – specifically hypertension. This paradigm shift involves psychologists fulfilling a collaborative role in medical settings. In the past, if some biological indicator were amiss and there was no disabling psychological distress, there would seem to be no reason to go to a psychologist. Now, the cumulative research showing the interconnectedness of the bio-psycho-social systems has taken root in the psyche of the general public. Many now realize that if there are biological indicators that something is amiss, physical assessments and interventions are to be paired with psychological and interpersonal assessments and interventions.

Of course, currently the overwhelming majority of referrals to psychologists from family practitioners, internists, and psychiatrists are for the treatment of depression, anger, anxiety and interpersonal problems. But increasingly, psychologists are developing targeted behavioral health sub-specialties so effective that collaborative care will become the norm. Hypertension may become the poster child of such collaboration.

What is Hypertension and Why is it Important? 

Hypertension isn’t easy to diagnose because blood pressure is highly volatile, and individuals experience a wide range of blood pressure (BP) readings throughout the day. (Table 1 lists the current guidelines used to diagnose hypertension.) However, any one reading could be very misleading. For example, compared to relaxing, work meetings result in an average 20/15 mm Hg rise in systolic and diastolic blood pressure (McGowan, 2001). So what you are doing right before your BP reading can greatly influence the reading that you obtain. For that reason, most physicians use three separate BP readings over different times of the day before they diagnose hypertensive disease, unless the reading is in the Stage II category - in which case treatment may be initiated at once. Ambulatory blood pressure readings, where measurements are taken periodically over a 24 hour period while a person is doing normal routines, is the most reliable way to assess hypertension. In this procedure a small computerized monitor with an occluding cuff is worn for at least 24 hours with periodic readings taken across a range of daily activities and sleep cycles.
This points out that it is important to document that a patient actually has hypertension before treating a person for hypertension. Note that blood pressure readings are highest in the morning and lowest when sleeping. Evening blood pressure readings appear most predictive of cardiovascular morbidity and mortality (Blumenthal et. al., 2002).

Hypertension, defined by an elevation in blood pressure, has profound health impacts. Hypertension is a major risk factor for coronary artery disease (CAD), disabling strokes, fatal heart attacks, congestive heart failure, chronic renal diseases, and impaired vision. Compared to individuals with normal blood pressure, individuals with hypertension are four times more likely to develop CAD and seven times as likely to suffer a stroke. Indeed, 80% of cardiovascular disease is preventable. Appropriate treatment has been shown to save many lives. Large meta-analyses suggest a 38% reduction in strokes among patients treated with anti-hypertension medications (Collins et. al. 1990). Since every year 500,000 Americans have a first stroke and approximately 20% die within thirty days, the anti-hypertensive medication is enormously beneficial. More than 50 million Americans have blood pressure readings that are not in the normal range (one out of four adults). One third of hypertensive people don’t even know that they have it. Of the two thirds who have been diagnosed, only about half are currently getting treatment. Most startling is that only half of the people getting treatment have their blood pressure under control (Aram et. al., 2003). Whether it be by medication or lifestyle changes, reductions in blood pressure dramatically reduces the incidence of strokes, heart attacks and kidney problems. Considering the prevalence and severity of the problem, there is room for innovative treatment and collaboration with internists and family practitioners.

What follows is an overview of health disparities in hypertension, followed by a brief description of some of the evidence-based research supporting the effectiveness of psychological interventions in the treatment of hypertension. This is followed by a description of the treatment delivery model under development at Howard University that seeks to reduce health disparities in hypertension by providing evidence-based, culturally relevant behavioral health interventions.

Diversity and Hypertension 

Across all US ethnic groups, the three biggest killers are heart disease (28.5%), cancer (22.9%) and stroke (6.7%) (Kochanek et. al., 2004). Two of the three major killers, heart disease and stroke, have hypertension as a significant contributing precursor.
Still, within these diseases there are a number of health disparities based on ethnicity. African Americans, Native Americans, and Hispanic Americans bear a disproportionate burden of disease, injury, and premature death. Much of this is due to the economic disadvantages associated with being a minority in the United States. For example, blacks, to a large extent, and Hispanics, to a lesser extent, are more likely than whites to be without health insurance, to not have flu shots and other vaccines, to miss out on early prenatal care, and to not engage in regular moderate physical exercise (Center for Disease Control, 2005).

Environmental issues such as stress, racism, and communities that discourage healthy lifestyles add significantly to the problems. However, there are cultural values as well that may account for some of the differences. For example, Hispanics tend to be more resistant than other ethnic groups in terms of shifting away from unhealthy eating habits.

The disparities in hypertension are somewhat concordant with the disparities found in other diseases. Blacks tend to have higher rates of hypertension that develop at an earlier age and are less likely to be diagnosed and treated for the condition. Indeed, cardiovascular disease and stroke, both of which are fueled by hypertension, account for 37% of all deaths in African Americans (American Heart Association, 2004). Compared to whites, they are 20% more likely to die of heart disease, 33% more likely to die of strokes, and 1.5 times as likely as non-Hispanic whites to have high blood pressure (Massachusetts Department of Public Health, 2001). Hispanics and non-Hispanic whites show similar patterns of hypertension (Shetterly, 1994). The disparities for stroke are even more startling. African American adults are 50% more likely than non-Hispanic whites to have a stroke and 50% more likely to die of a stroke. They are also more likely to become disabled and have difficulty with activities of daily living than non-Hispanic whites.

The other notable disparity in the world of hypertension and its consequences lies in gender. There is a stereotype that men have more hypertension than women. But the data indicate a more complex difference. Recent studies using the 24-hour ambulatory blood pressure monitoring have shown that blood pressure is higher in men than in pre-menopausal women at similar ages. This would be expected since men are at greater risk for cardiovascular and renal disease than are age-matched, pre-menopausal women. After menopause, however, blood pressure increases in women to levels even higher than in men. Hormone replacement therapy does not significantly reduce blood pressure in postmenopausal women, suggesting that the loss of estrogens may not be the only component involved in the higher blood pressure in women after menopause (Reckelhoff, 2001).

More surprising is that more women than men die of stroke (61% of all deaths from stroke are among women). And at older ages, women who have heart attacks are more likely than men to die from them within a few weeks (38% of women dying within a year compared to 25% of men). If we examine all the US deaths in 2000 from heart disease and stroke, it is women who represent 53.5% of all cardiac related deaths. While it is important for women to realize their equal or greater risk for developing hypertension, what women really need is more psychoeducation about the absolute risk level they have for developing hypertension and its related cardiac and stroke problems. Women fear dying of breast cancer, yet only one in 29 women dies of breast cancer. Contrast this with the 1 out of every 2.4 women who die of heart disease, stroke and other cardiovascular diseases. Or forget the death statistics; just knowing that one out of every five women will get some form of cardiovascular disease should rouse the preventative health interests of all females (American Heart Association, 2003).

Subtle but important racial differences also exist in response to anti-hypertensive medication. While African Americans tend to respond very well to diuretics, in part because they are more likely to be salt sensitive, they respond less favorably to beta blockers and angiotensin-converting enzymes (ACE) inhibitors than do whites, although they still show a clinically significant response. Hispanic Americans appear to be equally responsive to all medication classes, perhaps because the group called “Hispanic” in research is so diluted with multiple racial groups that any effects that exist cancel each other out. Hispanics are defined by the federal government as persons of Cuban, Mexican, Puerto Rican, South or Central-American, or other Spanish culture or origin, regardless of race. Because all drug types do work on all ethnic groups, albeit with different levels of effectiveness, many researchers do not believe that ethnicity is an accurate criterion for predicting poor response to any one class of hypertensive medication (DeQuattro, 1996).
Treatment of the Hypertensive Patient

Since the causes of hypertension are multi-determined, a number of interventions, pharmaceutical, behavioral, and dietary, have been demonstrated to be effective in lowering both systolic and diastolic blood pressure. Table 2 outlines the most popular dietary program used to control hypertension - the DASH Diet. Table 3 gives a representative sampling of what types of reductions in blood pressure can be expected from various types of behavioral and dietary interventions.

The recommended algorithm for the treatment of hypertension prescribes lifestyle only interventions for the initial treatment approach of blood pressure readings in the high normal range (130-139/85-89). For stage 1 and stage 2 hypertension, lifestyle modifications are recommended in conjunction with anti-hypertensive medication (Seventh Report of the Joint National Committee of Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, 2005). Usually, the recommended lifestyle modifications include the following: weight reduction, dietary changes, physical activity, smoking cessation, stress reduction and reduction of alcohol intake. Those with higher blood pressure readings need aggressive medication management to be the primary focus until lower readings have been achieved.

Why do only 25% of people with hypertension successfully control it with medication? The other 75% of people with high blood pressure are under-medicated, non responsive to medication, non-compliant with medication, or unaware of their condition. Unfortunately, sufficient motivation to initiate or maintain lifestyle changes is rarely aroused by the doctor telling the patient to diet and exercise. Patients end up receiving only medication and no treatment around prescribed lifestyle modifications. There is dire need for psychologists to intervene in this deadly condition.
Psychologists have been developing models for working with a number of medical conditions besides hypertension. Most notably, many researchers are involved in building treatment models for diabetes, asthma, HIV/AIDs, arthritis, and cancer. The content of most successful disease management programs include the following (O’Donohue, Nayor, and Cummings, 2005).

Educational material about the disease

  • Strategies to increase motivational desire to change
  • Training in how to self monitor the disease
  • Support in making difficult treatment decisions
  • Training in more general self assessment methods
  • Treatment compliance
  • Skills interacting with the health care system
  • Depression, anxiety, and anger
  • Spirituality as a resource
  • Social support as a resource
  • Life style changes such as diet and exercise
  • Relapse prevention
  • Reminders for self care and medication
  • Financial incentives to maintain changed behaviors (e.g. free parking stickers at health clinics, etc.)

At a minimal level, psychologists should be involved in increasing medication compliance and life style modifications among those who are given anti-hypertensive medication and promoting life style changes among those who are in the high normal range of blood pressure readings.
Research has shown that when lifestyle training is a discreet health goal with designated health care professionals involved in guiding the patient’s care in these areas, additional reductions in blood pressure are achieved, beyond the medication only treatment, and can result in such a significant drop in blood pressure that medication doses can be reduced (Shapiro, Hui, Oakley, Pasic & Jammer, 1997). Many discrete behavioral interventions have been researched to assess their effect on individuals with hypertension or high normal blood pressure. The six most important types of life style changes are: dietary changes, smoking cessation, increased exercise, reduced stress and greater problem solving abilities, increased social support and a higher developed spirituality/philosophy of life.

Organized exercise programs have some modest treatment benefit, with reductions in blood pressure of less than 5mm Hg when compared to no organized exercise controls. Salt sensitive individuals will achieve small reductions if they reduce their sodium intake. Similarly, other one shot approaches such as increasing potassium and calcium intake, reducing alcohol consumption, and stress management training will produce small changes in blood pressure (Smith and Glazer, 2004). Blumenthal et. al. (2002) concluded that the single most important life style change is weight loss for individuals who are above optimal weight. Here, clinically significant decreases in blood pressure occur with a 15 to 20 pound weight loss. However, when programs have multiple components (stress reduction, dietary changes, exercise, cognitive restructuring, etc.) the changes are much larger and clinically meaningful (Blumenthal et. al., 2002; Linden and Chambers, 1994). The most popular multiple component programs include psycho-education, stress management, behavior change strategies, home monitoring of BP, and family support of dietary changes (Binstock and Franklin, 1988).

The role of stress in contributing to the development of hypertension has been amply documented in numerous studies (Theorell et. al., 1991). There is research that societal stresses, such as racism, are responsible, in part, for the increased hypertension found among African Americans (Harrell, 2003). Thus, stress at the individual, interpersonal and systemic level all need to be addressed when working with hypertensive clients. The most common stress reduction strategies are relaxation training, guided imagery, meditation, interpersonal psychotherapy, social support, cognitive behavioral therapy and family interventions. As stress levels are addressed, patients have an increased motivation and energy to work on other life style changes.

Some hypertensive clients simply need help in dealing with everyday stressors that impact on their blood pressure. For many others, blood pressure will be a biological problem that co-occurs with a variety of mental health problems. While it is not clear how many people who have hypertension also suffer from a mental health disorder, we do know that nearly one in five primary care patients do have an Axis I disorder. Whether it is anxiety, depression or an alcohol problem, mental health disorders exacerbate physical health problems. Thus, when a patient is referred for hypertension treatment, it is critical to assess his/her mental health so that the treatment program can be tailored to meet both their physical as well as mental health problems.

Researchers and health psychologists are aware that there are a number of factors contributing to hypertension that are not in the control of the client: this includes age, gender, ethnicity, pre-natal factors and genetics, which accounts for about 30% of blood pressure variance. For example, age shows a consistent positive correlation with increasing levels of blood pressure. African Americans are more likely to have hypertension than Caucasians (Blumenthal et. al., 2002). Fetal injury can result in reduced kidney nephrons which impair the ability of the kidney to control hypertension with advancing age (Adair and Cole, 2000). While these uncontrollable factors clearly put individuals in different risk categories, none are uni-dimensional or even multi-dimensional determinants of hypertension. The uncontrollable factors may be the cards we are dealt, but the controllable factors are how we choose to play the cards. Even a crummy hand can be a winner with a focused, strategic player. The five controllable factors discussed above that are within one’s control have been demonstrated to help prevent hypertension from developing and to control the condition as effectively, or more effectively, than medication.

What we need to study is which of the controllable factors are proximal contributors to the development and maintenance of healthy blood pressure levels and which are more distal contributors. We also need to learn the weight of each factor for each individual and how the various factors, controllable and uncontrollable, interact with one another (Myslobosky, 2004). For example, while losing significant weight has an immediate effect on blood pressure levels, we know less about how long it takes for a person who reduces his/her stress level by developing different coping strategies and expectations to see a clinically significant effect (and for which type of individuals that factor is a sufficient or necessary condition for blood pressure reductions).

Medication Compliance and Hypertension

Helping clients achieve medication compliance requires an understanding of the many factors that foster non-compliance including:

a) Unwanted side effects: Each drug class has its own side effect pattern. The two most commonly used classes of medication, diuretics and beta blockers, often cause erectile dysfunction (ED) in men. Among the ACE inhibitors, side effects may include skin rash which at times can be quite serious. A dry hacking cough may necessitate changing to another class of drugs, and alteration in kidney function sometimes require discontinuation of the drug. Drugs in this class include Accupril (quinapril), Aceon (perindopril), Altace (ramipril), Capoten (captopril), Lexxel (enalapril), Lotensin (benazepril), Monopril (fosinopril), Prinivil (lisinopril), Vasotec (enalapril) and Zestril (lisinopril).

Among the alpha blockers, side effects include dizziness, sleepiness, nasal congestion and fatigue or tiredness. Drugs in this category include Cardura (doxazosin mesylate), Hytrin (terazosin HCl), and Minipress (prazosin). Beta blockers cause many of the same side effects as alpha blockers. Beta blockers include Inderal (propanolol), Lopressor (metoprolol), Toprol (metoprolol), Tenormin (atenolol), Zebeta (bisoprolol), and Blocodren (timolol). Helping clients accurately communicate their side effects and concerns to the primary care physician is a vital therapeutic goal.

b) Inability of any one medication to work effectively. The ALLHAT study included 33,357 hypertensive clients with at least one other coronary risk factor across 623 clinics and found that after 5 years, 66% had their hypertension under control. However, 63% of those participants were on at least two different classes of medication (Cushman, W., Ford, C., Cutler, J., Margolis, K., Davis, B. et. al. for the ALLHAT Collaborative Research Group, 2002). Clinicians can help simplify the medication procedures by understanding the client’s routines and schedule.

c) Memory lapses in medication compliance. Many people have trouble remembering to take medication at the prescribed time and filling the prescriptions in a timely manner. Many erroneously assume that if they take the medication occasionally they will be protected. Education plus enlisting the aid of the social support system are often critical in obtaining compliance among patients who are forgetful. It often takes a village to integrate pill taking into the routine activities of daily living. Others are living in denial of the problem since they are not currently experiencing symptoms of distress. Stressing the causes and consequences of hypertension can break through the denial and increase memory for pill taking.

d) Expense. Each medication costs between $9.00 and $50.00 per month. With two hypertensive medications, a person could easily pay $50 to $100 per month for anti-hypertension medications. The high cost of medication means that many people don’t fill their prescriptions regularly or decide to take one pill every three days or more in order to save money. They assume some protection is better than no protection at all. There are a number of programs available to help clients get medications they cannot afford. Some are too proud to sign up for such programs even if they are aware of them. Psychologists can help patients break through their resistance to using corporate or government medication assistance programs. Often clients can afford the medications but feel they are too expensive given other financial commitments. This is often woven into a denial pattern that one actually does not have a disease that needs to be treated and managed.

e) An inability to institute lifestyle changes. Once a patient has decided to take medication, he/she has invested time and money to implement that solution. The recommended lifestyle changes are not stressed as much as medication compliance. Psycho-education helps the person realize that hypertension is a multi-faceted problem and that lifestyle changes are necessary to make the medications work effectively.

Helping to reduce these barriers to medication usage is most critical since, as mentioned above, pharmacological treatments are far more effective if they are coupled with life style modifications. For example, Shapiro et. al. (1997) demonstrated that the addition of a cognitive-behavioral intervention to the standard drug treatment for Stage 1-2 hypertension was far more effective in lowering blood pressure than medication alone and was often successful in reducing the required dosage of medications to adequately control blood pressure. This is very important since the majority of people without life style modifications will need two or more medications to control their blood pressure, thus increasing the likelihood of medication side effects, non-compliance, and increased costs.

Of course, all life style strategies mentioned above should be used with all hypertensive clients who are on medication. The hope is that the medications will work more effectively and dosage can be reduced with successful changes in diet, exercise and stress reduction.
Clearly, some of these services overlap with nurse case management. What makes the health psychologist services unique are the following:

1) Much non-compliance is due to underlying depression and/or anxiety; two conditions for which psychologists have strong evidence based interventions.

2) Psychologists have training and skill in creating a therapeutic alliance, reducing resistance, achieving insight, working at a systemic level with the family and health system, and promoting social support.

3) The treatment delivery model used by psychologists gives ample time to work through the many details required for life style modifications.

A Culturally Relevant Behavioral Health Model for Treating Hypertension

The proposed model is a twelve session, six month treatment program. However, programs up to a year in length are quite likely to be needed in many cases.
The best way to begin a hypertension practice is in collaboration with family practice physicians or internists in your community. Brochures that describe this service can be followed up with letters of introduction. If you have a client who came to therapy for other reasons but has hypertension and wants to work on it, be sure to have the client under the care of a physician throughout your treatment. That means before you begin the hypertension treatment, the client should have a physical and the need for medication should be assessed by the physician. As you treat the client, it is important that he/she keeps scheduled appointments with the physician and that you keep the physician informed of the patient progress.

Confidentiality issues are often tricky. Some clients will want their physician to be aware of the issues discussed in therapy, while others will want a total assurance of confidentiality. Besides getting releases for any progress notes sent to the referring physician, I recommend a) having the client read and approve of the progress notes before they are sent and b) not disclosing any identifying or embarrassing content. For example, a man who is stressed about an extra-marital affair might be said to have “interpersonal stressors;” a woman who is aware of wrongdoing at her office would be described as having “work stressors.” In short, by adhering to Axis IV descriptors noted in the DSM-IV (e.g. problems with primary support group, problems related to social environment, educational problems, occupational problems, housing problems, economic problems, problems with legal system and problems with health or health care system), physicians have enough information to initiate discussion with the patient without revealing information (DSM-IV, 1994).

One potent philosophy guiding the sessions is that nearly all health problems are controlled by a network of multiple factors, any one of which may provoke symptoms in an individual at a particular point in his/her life. For instance, one person may have hypertension due primarily to stress while another person may have hypertension primarily due to diet. Each individual is assumed to be capable of preventing and/or minimizing high blood pressure problems by changing one or a number of lifestyle factors; including behaviors, emotions, cognitions, social networks and nutrition.

Another philosophical tenant guiding the sessions is that cultural relevancy is a potent means of increasing one’s willingness to engage in the business of changing long ingrained, and often powerfully rewarding lifestyles. Telling Mrs. Cohen, a zoftig Jewish woman of 50 with Type II diabetes, that her prized noodle kugel and cheesecake recipes are killing her and her loved ones is not likely to yield a positive therapeutic result. Rather, it is more important to talk about the meaning of evolving rituals in Judaism and recent cooking books that keep the heart and soul of Jewish cooking without all of the salt, fat and cholesterol. Or maybe it would be more culturally relevant with a particular client to discuss what to eat the rest of the week if she is doing heavy cooking on one particular night. Cultural relevancy has many faces but the six essential features are as follows:

  • The ability to effectively communicate the increased risk factors for hypertension, cardiovascular disease and stroke associated with each cultural group to which the client belongs.
  • The ability to effectively communicate the increased resiliency factors, if any, for hypertension, cardiovascular disease and stroke associated with each cultural group to which the client belongs.
  • Awareness of the cultural meanings attached to unhealthy habits and behaviors.
  • An ability of the therapist to embrace and empathize with the cultural values and connections embodied in the behaviors and/or rituals.
  • Reframing the transmission of cultural values as a dynamic process that changes with increasing scientific information.
  • Involving the most important cultural groups to which the client identifies as a form of social support in engaging and maintaining needed behavior changes.

The mechanics of creating change depend on utilizing a graded hierarchy of new behaviors to embrace and unhealthy behaviors to minimize. These are tackled on a step by step basis with the easiest to change items in each hierarchy being successfully changed before more difficult items on the hierarchy are attempted.

Nearly all life style factors are difficult to change so each individual needs to develop his/her own unique graded hierarchy of changes that are relevant to particular social context and personality. At the bottom of the two hierarchies are the changes that would be easiest to implement at this point in time. Items are arranged with increasing emotional weights so at the top of each hierarchy are changes that are too difficult for them to imagine implementing. It is assumed that all life style modifications, even those at the bottom of the hierarchy, take root slowly. Individuals need extensive and repeated reinforced approximations to their new goal behaviors. In order to develop a meaningful hierarchy, clients need both psycho-education about recommended changes and honest discussion about their level of motivation, type of resistances, and possibilities for sabotage in their environment. Once the hierarchy is created, family involvement is essential, as well as the continuing guidance of a therapist.

In the proposed model, the first four sessions are bimonthly; the remaining eight sessions are monthly. The protocol suggested below has not been empirically tested, as of yet, and is presented only to give an idea of the type of program that needs to be assessed for its effectiveness. Excellent programs with research and evaluation projects include Columbia University’s Behavioral Cardiovascular and Hypertension Program and Mount Sinai’s Cardiovascular Institute and Center for Cardiovascular Health (both in New York City).

Session I: A bio-psycho-social assessment guides the first half of the session. The second half of the session is educational. Five areas are covered:

a) what is hypertension?
b) how is it measured?
c) what causes hypertension?
d) what are the controllable and non-controllable risk factors?
e) what lifestyle modifications and medications are available for the treatment of hypertension?

The session concludes with the patient being instructed in how to take blood pressure and record it on a daily basis.

Session II: This session begins by reviewing the BP readings of the previous week. Then the therapist and client begin to explore more deeply which risk factors they believe are contributing to hypertension and which risk factors would be the easiest to modify. The risk factors examined include: tense personality, lack of activity/exercise, poor diet, alcohol consumption, smoking, stress at work, stress at home, lack of emotional support, pressing problems, or emotional problems (depression, anxiety or anger). By the end of the session, the client should choose one life style modification to change.

The therapist should follow a four step procedure each time a new life style modification is introduced: 1) help the client rehearse the new behavior, 2) identify resistance in the environment or internally, 3) identify cues that could sabotage the new behavior, and 4) install cues and rewards for the new behavior. Session II and all remaining sessions end with a blood pressure reading.
Session III: This session is divided into two parts. Part I focuses on relaxation training, guided imagery, progressive relaxation, meditation, or a combination. Part II reviews the behavior change that was attempted. If it was successful and BP readings are still too high, an additional lifestyle modification is added for the next week. Again, the therapist should help the client rehearse the new behavior, identify resistances in the environment or internally, identify cues that could sabotage the new behavior, and install cues and rewards for the new behavior. If the behavior change was not successful and the client feels that you have successfully worked out a plan to insure greater success, give it another week’s try. If the client doesn’t feel he/she would do any better the next week, change the target behavior and follow the procedures for successful implementation discussed above.

Session IV: This is a family session. The client and therapist, together, explain what hypertension is and why it is dangerous. They explain the lifestyle modifications they are trying to make. Family members offer their support, emotionally and practically, and the client is free to ask for help in whatever way needed (e.g. “If we could just keep the ice cream hidden in the back of the freezer, so I don’t see it, that would be a big help”). The last ten minutes of the session the client is seen alone to review the week’s work and take blood pressure. He/she is given the next month to consolidate any gains or increase the ease of the changes instituted before additional tasks are given. No new assignments are given during the family session.

Session V: Sessions V-XI are divided into two parts. In part I, the role of relationships in reducing stress and maintaining behavior changes is discussed. Part II is devoted to the hierarchy of lifestyle changes.

Session VI: In part I of this session, exercise is discussed in greater detail. Part II is devoted to the hierarchy of lifestyle changes.

Session VII: In part I, the role of potassium, sodium, and calcium in the promotion of hypertension are explained. Part II is devoted to the hierarchy of lifestyle changes.

Session VIII: In part I, an existential life review is conducted so that the patient can clarify what is meaningful to him/her, what he/she is responsible for, and how he/she can re-shape the life plan. Part II is devoted to the hierarchy of lifestyle changes.

Session IX: In part I, cognitive behavior therapy is used to help the patient solve some pressing problem in his/her life and the link between what one thinks and how one feels is reinforced. The value of reframing is the underlying focus of this part of the session.

Session X: This session is to further consolidate the gains made and further discuss the role of emotions and the flight/fight response in affecting our biology.

Session XI: This session is to further consolidate the gains made and discuss techniques for relapse prevention.

Session XII: In this session, an evaluation is made of where the patient has come in terms of the referring problem. The lessons from previous sessions are reviewed and issues of maintenance and relapse prevention are discussed. Either the referring physician or you should schedule seasonal check-ins so that the patient can continue to reinforce gains made and work on remaining issues. The goal is to integrate a methodology of life style modification. An outcome assessment should be made during this session.

In summary, clinicians who want to help treat hypertension will find this a challenging and rewarding addition to their practice; fostering close collaboration with primary care physicians, cardiologists, nutritionists, personal trainers, and family support systems.

Table 1: Classification of Blood Pressure for Adults Age 18 and Older


Systolic (mm Hg)

Diastolic (mm Hg)







High Normal






Stage 1



Stage 2



Stage 3



Table 2: Dash Eating Plan

Food Group

Daily Servings (based on 2000 calories a day)


7-8 (1 slice bread)


4-5 (1 medium fruit)


4-5 (1/2 cup cooked vegetable)

Low-fat and dairy

2-3 (8 ounces fat free milk)

Meats, poultry and fish

2 or less (3 ounces meat)

Nuts, seed and legumes

4-5 per week (1/3 cup nuts)

Fats and oils

2-3 (one teaspoon margarine)


5 per week (one tablespoon sugar)

Table 3: Effectiveness of Lifestyle Interventions on Lowering Blood Pressure


Level of

On Medication
Yes or No


BP Systolic

BP Diastolic

Whelton et. al. (1997)



More potassium in diet

3.0 mm HG

2.0 mm HG

Whelton, Chin, Xin & He (2002)




3.8 mm HG

2.5 mm HG

Cutler (1997)



Less salt in diet

5.8 mm HG

2.5 mm HG

Neter et. al. (2003)



Weight loss of 5.1 KG on average

4.44 mm HG

3.57 mm HG

Miller et. al. (2002)



Life Syle (Dash Diet & exercise and low sodium

9.5 mm HG

5.3 mm HG

Conlin et. al. (2000)

NHLBI-sponsored multi-center


Dash Diet

11.0 mm HG

5.5 mm HG

Linden and Chambers (1999)

Meta-analysis (showing largest effect)


One on one cognitive stress management

15.2 mm HG

9.2 mm HG


Linda Berg-Cross received her Ph.D. from Teachers College/ Columbia University and is a Professor of Psychology at Howard University. Dr. Berg-Cross is a member of the National Register Board of Directors.


Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT),
Hypertension guidelines: Seventh Report of the Joint National Committee on the Prevention,
Detection, Evaluation and Treatment of High Blood Pressure,
Public and patient information: Your Guide to Lowering High Blood Pressure,
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