1203 GROUP THERAPIES FOR RHEUMATOID ARTHRITIS A Controlled Study of Two Approaches GORDON D. STRAUSS, JANE SINDEN SPIEGEL, MARCIA DANIELS, TIMOTHY SPIEGEL, JOHN LANDSVERK, PETER ROY-BYRNE, CAROLE EDELSTEIN, JOHANNA EHLHARDT, ROBERTA FALKE, LEE HINDIN, and LES ZACKLER An important unanswered question about rheumatoid arthritis (RA) is how the patient s psychological or emotional state relates to disease activity and functional status. No controlled studies of psychotherapeutic interventions in RA have been reported. To test the hypothesis that a psychosocial intervention would lead to improvement in functional status or disease activity, 57 RA patients were randomly assigned to 1 of 3 groups, which received: 1) conventional group psychotherapy; 2) group assertionhelaxation training; or 3) no treatment (control group). Patient and physician questionnaires collected at baseline, immediately after the interventions, and 12 months after baseline provided outcome data on functional status, social and psychological adaptation, psychological symptoms, and disease activity. There were few outcome measures for which either treatment resulted in significantly higher scores From the Department of Psychiatry and Biobehavioral Sciences and the Department of Medicine, University of California at Los Angeles. Gordon D. Strauss, MD: Assistant Professor of Psychiatry; Jane Sinden Spiegel, MD, MPH: Assistant Professor of Medicine; Marcia Daniels, MD: Assistant Professor of Psychiatry; Timothy Spiegel, MD, MPH: Assistant Professor of Medicine; John Landsverk, PhD: Assistant Research Sociologist, Department of Psychiatry and Biobehavioral Sciences; Peter Roy-Byrne, MD: Senior Staff Fellow, Biological Psychiatry Branch, National Institute of Mental Health, NIH, Bethesda, Maryland; Carole Edelstein, MD: Assistant Clinical Professor, Department of Psychiatry and Biobehavioral Sciences; Johanna Ehlhardt, RN: UCLA Neuropsychiatric Institute; Roberta Falke: UCLA Department of Psychology; Lee Hindin, MD: Clinical Instructor, Department of Psychiatry, New Jersey Medical School, New Brunswick; Les Zackler, MD: Assistant Clinical Professor, Department of Psychiatry and Biobehavioral Sciences. Address reprint requests to Gordon D. Strauss, MD, 760 Westwood Plaza, Los Angeles, CA 90024. Submitted for publication July 19, 1984; accepted in revised form May 26, 1986. than were seen in controls, though more improvement did occur among patients who received conventional group psychotherapy. Rheumatoid arthritis (RA) affects over four million Americans and is responsible for costs of several billion dollars each year in disability, lost income, and loss of function (1-3). Numerous reports document the emotional and psychological aspects of RA, which include depression, anxiety, irritability, social withdrawal, and dependent and/or compliant personality traits (4-8). However, the relation of psychological or emotional state to disease activity, functional status, and disability is not well understood. One approach to clarification of these relationships is to use interventions which could be expected to most directly affect mood and other psychological states. If changes in disease activity, functional status, or disability do not occur (assuming changes in the rest of RA treatment are minimized or controlled for), this would suggest that RA and the impairment from RA are independent of the course of the associated depression and anxiety. The symptoms of depression or anxiety may still require treatment, but their improvement would not be expected to lead to improvements in RA disease activity or functional status. Studies of other illnesses have shown beneficial changes when psychotherapy is added to routine medical care. Conte and Karasu reviewed 13 well-designed controlled studies of patients with cardiovascular disease, peptic ulcer, ulcerative colitis, and asthma (9). Eight of these studies document greater physiologic improvement in patients who received group (or individual) therapy than in patients who received medical management alone. Until 1981 (9), there were no Arthritis and Rheumatism, Vol. 29, No. 10 (October 1986)
1204 STRAUSS ET AL reports of controlled studies of psychosocial interventions for RA patients. The few controlled studies which have since appeared (10-12) have been quite small, of brief duration, and have emphasized patient education rather than a psychotherapeutic approach. We therefore designed a randomized, controlled trial of two types of group psychotherapy for RA patients: conventional group psychotherapy and group assertionh-elaxation training. Group, rather than individual, psychotherapy was chosen because of its more efficient use of therapist lime, the resulting decreased costs (a realworld concern but not an issue here since the patients studied were not charged), and because it provided less variability in the nature of the intervention (i.e., more patients exposed to the same therapists). We used two different types of groups in order to see whether assertion/relaxation training, which is briefer as well as more structured and focused than conventional group psychotherapy, would achieve as much or even more than the more traditional approach. The well-established curative factors (13) in group psychotherapy could be expected to have a positive effect on psychological adaptation and symptoms generally, and upon self-esteem, resentment, and depression specifically. We hypothesized that assertion training would be particularly useful for imparting a greater sense of mastery or control to patients who may react to their illness with passivity. We further hypothesized that relaxation training would contribute to decreased perception of pain through decreased muscle tension and a simple form of autohypnosis. The null hypothesis for the study as a whole was that changes in disease activity or functional status would be no greater among patients in either experimental group than in control patients. PATIENTS AND METHODS RA patients followed in the rheumatology clinics at the UCLA Medical Center were invited by mail and by posted notices to participate in this study. Requirements for participation included classic or definite RA by American Rheumatism Association criteria (14), the ability to speak English, outpatient status, and sufficient ambulatory function (including wheelchair) to attend a weekly group at the medical center. Fifty-seven patients agreed to participate. After they gave informed consent, patients were randomly assigned to 1 of 3 groups: a conventional psychotherapy group, meeting weekly for 6 months (n = 20); a group receiving assertion/relaxation training conducted weekly for 3 months (n = 17); or a control group (no treatment) (n = 20). Conventional group psychotherapy emphasized mutual support through sharing of experiences and emotions related to RA (13). Pairs of senior psychiatric residents with previous group psychotherapy experience led each of the 2 psychotherapy groups. Sessions were unstructured, though the therapists did attempt to facilitate the expression and discussion of RA-related issues. Assertion/relaxation training utilized a behavioral approach with role-playing of assertive behavior (15). Patients also were taught relaxation exercises and were given audiotapes for home practice of relaxation methods (16). Compared with the conventional psychotherapy sessions, these sessions were more structured. Senior clinicians provided supervision for the leaders of each type of group. A patient self-report questionnaire, a patient satisfaction questionnaire, and a questionnaire completed by each patient s rheumatologist were the data sources for this study. The self-report questionnaire included 91 items about physical, social,--and psychological function taken from several published and previously tested instruments, including the Arthritis Impact Measurement Scales (AIMS) (17), the Rand Health Insurance Study Scales for Mental and Physical Health (18,19), the Rathus Assertive Behavior Scale (20), the Rosenberg Self-Esteem Scale (21), the Hostility,Inventory (22), and Wright s Human Service Scale and Handicap Problems Inventory (23,24). Items selected from the AIMS and Rand instruments, as well as questions about RA medications and demographic characteristics, had been used in a previous study of inpatient rehabilitation in RA (25). Related questions were combined to form scales which we grouped into 4 aggregate outcome measures: functional status, social adaptation, psychological adaptation, and psychological symptoms. The aggregate outcome measure scores were calculated by assigning each component scale a maximum contribution of 1.0. For example, an individual s functional status aggregate outcome score could be between 0 and 4; the mobility component would depend on the proportion of the maximum mobility scale score achieved. The patient satisfaction questionnaire asked whether the group interventions were helpful or harmful and in what ways. The physician questionnaire asked about the patient s overall disease activity at the most recent visit. Patient self-report and physician questionnaire data were collected at baseline, at the conclusion of each group intervention, and again 1 year after baseline for all patients. These data also were collected from patients in conventional group psychotherapy after 3 months, so that the incremental value, if any, of the 6 months of therapy might be determined. Patient satisfaction questionnaires were completed only at the end of each intervention. Differences among the 3 groups at baseline were examined for statistical significance by chi-square and by unbalanced analysis of variance. After baseline, data on patients who dropped out of either group intervention were not included in the analyses. Change in the 4 aggregate outcome measures was assessed by two methods: 1) repeated measures analysis of variance, and 2) analysis of covariance with the outcome means adjusted for differences between the groups at baseline.
GROUP THERAPY IN RA 1205 Table 1. Demographic features and baseline disease characteristics of rheumatoid arthritis patients studied* Psychotherapy Assertionirelaxation Control group group (n = 20) group (n = 17) (n = 20) Age (years, mean k SD) 53 +- 16.7 56 2 9.1 53 k 13.0 Female 75 82 85 White Marital status 86 88 50t Married 40 71 65 Never married 20 5 5 Education beyond high school Employment 70 59 55 Employed 40 29 20 Retired due to age 20 29 25 Income >$15,000/year 50 59 53 MD assessment of disease activity Mild 46 18 43 Moderateisevere 46 82 50 Pain (severity/frequency) Mildoccasional 25 29 35 Moderate/often 35 18 15 Severelalways 40 53 50 Medications Aspiridantiinflammatory 85 88 90 Goldantirheumatic 35 53 30 Steroids 25 29 30 C ytotoxic 10 0 15 Difficulty walking 2 blocks Little 35 12 16 Moderateisevere 50 76 68 * Except for age, all values shown are percents. t P < 0.05, chi-square = 6.76, 2 degrees of freedom versus other 2 groups. Table 2. Mean scores on self-report scale, at baseline Scale (maximum possible Psychotherapy group Assertiodrelaxation group score) (n = 20) (n = 17) Functional status Mobility (5) 4.23 4.37 Physical activity (4) 2.20 2.01 Household activity (4) 3.32 3.30 Self-care (4) 3.60 3.74 Social adaptation Social activity (6) 3.92 4.16 Sexual activity (6)* 2.14 3.30 Assertiveness (6) 3.40 3.74 Family life satisfaction (6) 4.13 4.56 Psychological adaptation Self-esteem (5) 3.52 3.55 Locus of control (5) 3.88 3.84 Rejection of sick role (5) 4.22 4.35 Resentment of illness (5) 3.02 2.78 Psychological symptoms Anxiety (6) 3.03 2.73 Depression (6) 2.56 2.37 Pain (6) 4.18 4.14 * P < 0.05, F = 3.25, 2 degrees of freedom among the 3 groups. Control group (n = 20) 3.70 2.00 3.20 3.58 3.60 2.71 3.43 4.17 3.63 3.79 4.40 3.04 2.63 2.25 4.17
STRAUSS ET AL Tabk 3. Outcome measures for treatment and control patients at study entry and at 3 months Score at Unadjusted Adjusted Outcome measure (possible study score at 3 score at 3 range), group (n)* entry months monthst Functional status (0-4) Assertiodrelaxation (11) 3.21 3.27 3.16 Psychotherapy (12) 3.23 3.33 3.20 Controls (19) 2.90 2.90 3.05 Social adaptation (0-4) Asseitiodre~axation (8) 2.63 2.75 2.51 Psychotherapy (9) 2.30 2.41 2.49 Controls (16) 2.31 2.35 2.42 Psychollogical adaptation (0-4) A$sertion/relaxation (10) 3.24 3.29 3.09 Psychotherapy (12) 2.96 2.95 3.04 Controls (20) 3.01 3.00 3.04 Psychological symptoms (0-3) Assertiodrelaxation (11) 1.32 1.41 1.46 Psychotherapy (12) 1.49 1.57 1.46 Controls (20) 1.33 1.47 1.51 * n values vary due to missing responses to items on some scales. t There: were no statistically significant differences between groups on adjusted scores. RESULTS Patient demographics and baseline measures. The majority of patients in the study were middleaged, white, married women (Table 1). Most of the patients had at least some college education. More than half of the patients had moderate to high levels of disease activity reported by their rheumatologist. This was confirmed by difficulty in walking 2 blocks and by frequency of severe pain reported by most patients. Except for a paucity of nonwhite patients in the intervention groups, there were no statistically significant demographic or disease activity differences between experimental and control groups. On the questionnaire scales, a higher score represented more or a greater degree of the function being assessed. Although most patients did have some problems with functioning, there were no significant differences at baseline between the intervention groups or between each intervention group and controls on most of the scales derived from the patient self-report questionnaire (Table 2). Outcome measures immediately after treatment. Eleven of 17 patients (65%) completed the 3-month assertion/relaxation training. Their adjusted scores after treatment (i.e., analysis of covariance with scores adjusted for differences at baseline) were not significantly higher than those of controls (Table 3). Fourteen of 20 patients (70%) completed the 6-month psychotherapy intervention. Their adjusted scores after 3 months were very close to the scores of the assertionhelaxation group (Table 3); after 6 months, their scores were not significantly different from those of controls on any of the aggregate outcome measures (Table 4). Outcome measures at 1-year followup. One year after baseline, there were no significant differences in the mean adjusted scores for any of the 4 aggregate outcome measures (Table 5). Functional status was the only category in which the adjusted scores of treatment patients were higher than those of controls. (On that measure, the difference between the group psychotherapy patients and the controls approached significance [P < 0.08, F = 3.34, 1 degree of freedom].) Similarly, when the 4 aggregate outcome measures were examined by repeated measures analysis of variance, no significant differences were found between the experimental groups and the controls at baseline, after the interventions, or at 1-year followup. Data from the physician questionnaires did not reflect significant differences in disease activity between any of the groups of patients at 3, 6, or 12 months after baseline. Similarly, patient reports of decreased use of antiinflammatory medications were the same for both experimental group and control group patients. The majority of patients in both experimental groups expressed high levels of satisfaction with their experience, and no patients stated that their group experience had been harmful. Table 4. Outcome measures for treatment and control patients at study entry and at 6 months Score at Unadjusted Adjusted Outcome measure (possible study score at 6 score at 6 range), group (n)* entry months monthst Functional status (0-4) Psychotherapy (14) 3.30 Controls (19) 2.90 Social adaptation (0-4) Psychotherapy (11) 2.36 Controls (15) 2.34 Psychological adaptation (0-4) Psychotherapy (13) 2.98 Controls (20) 3.01 Psychological symptoms (0-3) Psychotherapy (13) 1.46 Controls (20) 1.33 3.40 2.81 2.27 2.38 2.96 3.02 1.43 1.38 3.20 3.01 2.26 2.38 2.98 3.01 1.36 1.42 * n values vary due to missing responses to items on some scales. t There were no statistically significant differences between groups on adjusted scores.
GROUP THERAPY IN RA 1207 Table 5. Outcome measures for treatment and control patients at study entry and at 12 months Score at Unadjusted Adjusted Outcome measure (possible study score at 12 score at 12 range), group (n)* entry months monthst Functional status (0-4) Assertiodrelaxation (1 1) Psychotherapy (1 3) Controls (19) Social adaptation (0-4) Assertiodrelaxation (8) Psychotherapy (1 1) Controls (16) Psychological adaptation (0-4) Assertiodrelaxation (10) Psychotherapy (12) Controls (19) Psychological symptoms (0-3) Assertiodrelaxation (1 1) Psychotherapy (13) Controls (20) 3.21 3.30 3.29 3.46 2.90 2.88 2.63 2.52 2.31 2.38 2.36 2.45 3.24 3.24 2.96 2.92 2.99 3.04 1.32 1.34 1.48 1.49 1.33 1.41 3.20 3.32 3.04 2.35 2.41 2.52 3.04 3.00 3.09 1.39 1.38 1.46 * n values vary due to missing responses to items on some scales. t There were no statistically significant differences between groups on adjusted scores. DISCUSSION Group psychotherapeutic interventions have been reported to be a useful adjunct to medical treatment in chronic and acute illness since 1905, when Dr. Joseph Pratt began educational and inspirational groups for his tuberculosis patients (26). More recently, group interventions have been tried with patients with chronic or fatal diseases such as diabetes (27), multiple sclerosis (28), and cystic fibrosis (29). There is also descriptive literature about various group approaches for patients with arthritis (30,3 1). However, until 1981 there were no controlled studies of group treatments for RA patients, and we are not aware of any other controlled studies of primarily psychotherapeutic group interventions. In a controlled trial of conventional supportive group psychotherapy or assertivenesshelaxation training for RA patients, we were unable to demonstrate significant improvements in self-reported functional status, social or psychological adaptation, psychological symptoms, or disease activity. Our findings must be interpreted with caution and within the context of our methodology and statistical analysis. The lack of positive results could have been influenced by attrition, level of therapist experience, compliance, and sample size. There were 6 patients who dropped out of each experimental group; their scores were not significantly different at baseline from those who completed the group treatments. The therapists, though supervised and experienced, were still in training; it is possible that more experienced therapists might have made a difference in outcome. In the assertionh-elaxation group, compliance with homework assignments was quite variable. Our sample size, while larger than those in previous studies, was still quite small; this increases the possibility of a Type I1 statistical error (failure to find differences that actually may exist). The failure to detect changes in disease activity or in psychological symptoms or adaptation is consistent with the findings of the few other published controlled studies of group interventions in RA. Kaplan and Kozin conducted a controlled study of 12 weeks of client centered group counseling for 11 women with RA (10). Patients who had group counseling did have an improved self-image, but did not have less disease activity or depression than patients who had only an educational session. Similarly, Potts and Brandt conducted a controlled study of education support groups for patients with RA which involved 19 patients and a similar number of controls (12). Patients met 4 times at weekly intervals, and were encouraged to bring family members with them. Patients self-reports were used to assess knowledge of RA, ability to cope, compliance, and family relationships. While significant increases in patients knowledge about their disease occurred, groups had little effect on patients ability to cope with arthritis or on their compliance with prescribed treatment. These previous studies used interventions which were quite brief, ranging from a few weeks to a few months. In our study, interventions were of differing durations, and we found more changes associated with the group therapy that lasted longer. Given the chronic nature of RA, it perhaps should not be surprising that interventions of 3 months (or less) had little measurable impact (32). Further research might address this issue in two ways: group interventions lasting a year or longer, or short-to-intermediate length (3-6-month) groups for newly diagnosed patients who have not yet spent years coping with and reacting to their illness. Perhaps most surprising was not the absence of significant improvement in functional status, social or psychological adaptation, or RA disease activity, but rather the lack of any differential impact on psychological symptoms: depression, anxiety, and pain. The interventions appeared to have only a small effect on psychological symptoms. It is possible that our mea-
12O8 STRAUSS ET AL sures were insufficiently sensitive to changes in mood and pain; though well-calibrated in terms of face validity and reliability, the Rand mental health scales are tioo new to have a well-established record of sensilivity to change (18). While our results cannot support the idea that psychosocial interventions can be specifically useful for patients with RA, the fact that our interventions didn t reduce depression or anxiety significantly leaves open the question of whether an intervention (such as medication) which does reduce depression or anxiety might lead to improved functionall status or decreased disability. This would appear to be another logical path for future research. We hope our results don t lead only to a therapeutic nihilism with regard to psychological interventions in RA. Rimon and Laakso (33) suggest that RA patients can be subdivided into two types: those with a disease that is more genetic, and those with a disease that is less genetic and more influenced by envirlonmental psychosocial changes. It may be that group interventions would be especially effective if focused on this latter group of patients. However, the paucity of improvements in disease activity, social and psychological adaptation, or psychological symptoms does suggest that these programs are only marginally helpful. Finally, this study has shown once again the importance of control groups in studies of psychosocial interventions. Our results emphasize the need for caution in the interpretation of case reports which describe positive outcomes from these types of interventilon. REFERENCES 1. Rodnan GP, McEwen C, Wallace SC (editors): Primer on the Rheumatic Diseases. Seventh edition. New York, Arthritis Foundation, 1973 2. Weiner H: Psychobiology and Human Disease. New York, Elsevier, 1977, p 419 3. Yelin E, Meenan R, Nevitt M, Epstein W: Work disability in rheumatoid arthritis: effects of disease, social, and work factors. Ann Intern Med 93551456, 1980 4. Moldofsky H, Chester WJ: Pain and mood patterns in patients with rheumatoid arthritis. Psychosom Med 32309-3 18, 1970 5. Robinson ET, Hernandez LA, Dick WC: Depression in rheumatoid arthritis. J R Coll Gen Pract 27:423427, 1977 6. Gardiner BM: Psychological aspects of rheumatoid arthiritis. Psychol Med 10: 159-163, 1980 7. Mindham RH, Bagshaw A, James SA, Swannell AJ: Factors associated with the appearance of psychiatric symptoms in rheumatoid arthritis. J Psychosom Res 25:429-435, 1981 8. Udelman HD, Udelman DL: Emotions and rheumatologic disorders. Am J Psychother 35576-587, 1981 9. Conte HR, Karasu TB: Psychotherapy for medically ill patients: review and critique of controlled studies. Psychosomatics 22:285-315, 1981 10. Kaplan S, Kozin F: A controlled study of group counseling in rheumatoid arthritis. J Rheumatol8:91-99, 1981 11. Knudson KG, Spiegel TM, Furst DE: Outpatient educational program for rheumatoid arthritis patients. Patient Couns Health Educ 3:77-82, 1981 12. Potts M, Brandt KD: Analysis of education-support groups for patients with rheumatoid arthritis. Patient Couns Health Educ 4: 161-166, 1982 13. Yalom ID: The Theory and Practice of Group Psychotherapy. Second edition. New York, Basic Books, 1975 14. Ropes MW, Bennett GA, Cobb S, Jacox R, Jessar RA: 1958 revision of diagnostic criteria for rheumatoid arthritis. Bull Rheum Dis 9:175-176, 1958 15. Alberti RE, Emmons ML: Your Perfect Right. San Luis Obispo, CA, Impact Books, 1978, pp 119-145 16. Berstein DA, Berkovec TD: Progressive Relaxation Training: A Manual for the Helping Professions. Champaign, IL, Research Press, 1973, pp 11-55 17. Meenan RF, Gertman PM, Mason JH: Measuring health status in arthritis: the Arthritis Impact Measurement Scales. Arthritis Rheum 23:146-152, 1980 18. Ware JE, Johnston SA, Davies-Avery A, Donald CA: Conceptualization and Measurement of Health for Adults in the Health Insurance Study. Vol. V. Mental Health. Santa Monica, CA, Rand Corporation, R- 1987/5-HEW, 1979 19. Ware JE, Johnston SA, Davies-Avery A, Brook RH: Conceptualization and Measurement of Health for Adults in the Health Insurance Study. Vol. 111. Physical Health. Santa Monica, CA, Rand Corporation, R- 1987/3-HEW, 1979 20. Rathus SA: A 30 item schedule for assessing assertive behavior. Behav Ther 4:398-406, 1973 21. Rosenberg M: Society and the Adolescent Self-Image. Princeton, NJ, Princeton University Press, 1965 22. Buss AH, Durkee A: An inventory for assessing different kinds of hostility. J Consult Psychol 21 :343-349, 1957 23. Wright GN: The Human Service Scale. Madison, WI, Human Service Systems, Inc., 1973 24. Wright GN, Remmers HH: Manual for the Handicap Problems Inventory. Lafayette, IN, Purdue Research Foundation, 1960 25. Spiegel JS, Spiegel TM, Ward NB, Paulus HE, Leake B, Kane KL: Rehabilitation for rheumatoid arthritis pa-
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