Psychological Interventions in the Management of Arthritis

1. Psychological Interventions in the Management of Arthritis Frank McDonald Consultation-Liaison Psychologist The Townsville Hospital www.fmcdonald.com April 4 2003

2. Overview • Psychological challenges of arthritis • Psychological interventions • Your professions’ & your personal input • Self-management strategies • Specific psychological strategies • Resources & references

3. Psychological challenges • Anxiety of facing an incurable disease. May change life expectancy. Initial “What’s going to happen to me?” reaction • Arbitrary nature & course of disease – unpredictable / can come & go • Pain - ranging from minor to incapacitating • Restricted activities – limitations imposed on simple things used to do

4. Psychological challenges • Altered self-esteem / sense of self. We like to feel in control of our selves / health. When disease strikes everyone feels some loss here. We dislike dependency • Sexuality affected – impaired abilities & concerns about attractiveness • Dealing with pain, stress, sadness & possible depression, anger & frustration

5. Psychological challenges • A chief side-effect of RA is sense of helplessness over inability to control the disease and the pain it causes1,2 • Isolation: at home, socially & on the job • So problem is not just disease (biomedical aspects) – but pressure to cope • Everyone with chronic illness suffers psychologically – degree depends on number & intensity of challenges faced

6. Psychological interventions • How can we help patients meet these psychological needs? • 3 levels: • your professional & personal input • encouraging & supporting self-management • specific psychological strategies shown to alleviate condition & associated problems

7. Psych Interventions: Professional & Personal input • Professional contributions can significantly improve patients’ psychological state: • Patients sense of control & esteem can be heightened by progress & improvements with physical therapy, exercise, occupational therapy & medications

8. Psych Interventions: Professional & Personal input • Patients benefit from attentions of concerted professional team approach e.g. primary care physicians & nurse educators • Appreciate being able to discuss & manage their various concerns with appropriate range of specialists

9. Psych Interventions: Professional & Personal input • Personal contributions also can significantly improve patients’ psychological state • Patients do better with professionals whom they say: • “generally are able to empathise & communicate a sense of how difficult things must be” • “are willing to listen & my answer questions without judging me – allowing me to be more informed & knowledgeable about my illness”

10. Psych Interventions: Professional & Personal input • “see me as a whole person - not a disease. They see me not just from the perspective of their profession” • “enquire about common problem areas associated with my illness & so might ask ‘This illness may affect the things you feel you are capable of doing & in turn your self-esteem. How are going in that area?’ ”

11. Psych Interventions: Professional & Personal input • “are willing to bring up issues I may be reluctant to – like sexuality or the anger / ‘ why me ? stuff ’ I was half-denying” • “give a sense of hope to recently diagnosed pts about the promise of new therapies & treatments. They understand the importance of conveying a positive attitude”

12. Psych Interventions: Professional & Personal input • “enquire about degree of support & understanding from partner, family, friends or boss” • “refer to other professionals, like psychiatrists or psychologists, when they do not have the time or skills to get into things - without implying ‘you’re not coping with this as well as you should’ ”

13. Psych Interventions: Self-management strategies • Patients who adopt a self-management approach, to augment professional management, fare better with their condition3 • Subjective experiences like degree of suffering/emotional components of pain diminish

14. Psych Interventions: Self-management strategies • Self-management skills can include: • Self-education. Learning as much as possible about condition. Becoming ‘expert’ at understanding & managing pain e.g. appropriate use of medication • Adopting an internal locus of control attitude. Open, experimental & “I control me” not “it (pain) or they (doctors) …” attitude • Extending coping/self-care skills: Balancing relaxation (mental, physical, behavioural skills) with activity (↑ pacing + ↑ movement + ↑ occupation)

15. Psych Interventions: Self-management strategies • Following slide graphically illustrates the important place of self-management3 • Higher-level treatments tend to be less effective if there are problems at lower levels

17. Psych Interventions: General Psychological Strategies • Broad aims: • Assessment of full range of relevant variables (most important step in management of chronic conditions) • Reducing stress - seems to exacerbate the disease. Immune system appears to be link between stress & its aggravation. RA pts immune systems more sensitive to stress than comparison groups4,5,6,7,8 e.g. reducing stress from disturbances in personal relationships. Several investigations suggest this form may contribute to development of disease9,10 and / or its course11,12

18. Psych Interventions: General Psychological Strategies • Providing a range of cognitive-behavioural strategies directed to: • Pain-coping skills8 e.g. relaxation training • Coping with symptoms of disease8 e.g. ‘self-talk therapy’ • Increasing ‘self-efficacy’ (opposite of helplessness) & optimism13 • Reducing cognitive distortions that canaggravate depression & other emotional responses to arthritis14 • Relapse prevention to preserve behavioural & attitudinal gains15

19. Psych Interventions: General Psychological Strategies • Results of a meta-analysis published in June 2002 Arthritis & Rheumatism (pp. 291-302)16supplementshow psychological therapies can have significant positive effect on several aspects of RA • Specifically: • levels of pain • feelings of helplessness • ability to function • depression • coping (largest & most consistent finding) • joint tenderness – last 3 most enduring (>8.5 months)

20. Psych Interventions: Specific Psychological Strategies • As yet do not know which therapies or combinations work to produce above results • Studies meeting quality inclusion criteria for meta-analysis trialled these & other treatments: • Relaxation training • Progressive muscle relaxation • EMG & Thermal Biofeedback + Autogenic training • Stress Management (within support group framework) • Cognitive therapy (modifying attitudes & beliefs) • Social Support sessions with family & friends + active listening by leaders

21. Psych Interventions: Specific Psychological Strategies • ROM Dance Program (Tai Chi, relaxation, biofeedback, stress discussions) • Guided imagery • ‘Disclosure therapy’ writing/talking about most stressful or traumatic life events • Non-directive/client-centred group therapy • Information • Active coping • Coping with depression • Rational thinking (e.g. ‘decatastrophising’)

22. Psych Interventions: Specific Psychological Strategies • Improving communication with health care professionals • Attention re-focussing (stimuli outside body, on to activity) • Dissociation (self-hypnosis/meditation) / relabelling • Self-encouragement • Communication skills training/assertiveness training • Self-efficacy enhancement • Groups for maintenance of treatment gains

23. Psych Interventions: Specific Psychological Strategies • Other strategies incorporated in other arthritis programs and as suggested by general chronic pain literature17 : • Increasing either mastery or pleasure activities to at least one per day to counter self-esteem & mood problems • Problem-solving (anti-worry) strategies • Teaching principles of activity pacing • Increasing appropriate movement – walking, swimming, physio exercises • Teaching significant others to reinforce positive pain behaviour (e.g. self-massage) & ignore negative (e.g. groaning++) ~~

24. Resources and References • www.fmcdonald.com for a copy of this presentation & related material • e.g. on pain management (self-management guidelines, activity pacing principles & diaries), sleep enhancement, activity scheduling for depression, adjustment to chronic illness advice & stress management booklets • http://www.arthritis.org.au for information, services & links • References available from author