Table 1.
A list of interventions that have been trialed as psychosocial approaches to pain management for patients with RA, discussed in this review, a brief description, and the level of evidence
| Therapy | Description | Level of evidence and comments |
|---|---|---|
| CBT | CBT aims to identify unhelpful patterns of behavior and attitudes toward RA and to change these. Hence, the behavioral components include strategies to help achieve a balance of rest versus activity, while the cognitive strategies aim to encourage an attitude of realistic optimism toward the illness. CBT includes some or all of the following strategies, including psychoeducation, relaxation, pacing and goal setting, attention diversion, problem solving, assertiveness training, cognitive challenging, and managing high-risk time and relapse. | Level I evidence. Definitely efficacious. Demonstrated both in patients with chronic pain generally and for patients with RA specifically. Dosage of at least six sessions is necessary. |
| Expressive writing | Participants are asked to write about stressful times in their lives as a form of emotional expression. | Level I evidence. Definitely efficacious. One head-to-head trial with CBT found CBT was more effective than expressive writing. |
| Mindfulness | Mindfulness-based intervention teaches patients to adopt a nonjudgmental and observant stance in relation to their experiences. Although there are different variants of mindfulness, they typically include a meditative component. Unlike CBT, mindfulness explicitly encourages participants not to attempt to change, but rather to accept their experiences. | Level II evidence (Level I evidence for chronic pain). Definitely efficacious. One head-to-head trial of CBT compared it to mindfulness, where CBT outperformed mindfulness in the whole sample. However, patients with a history of clinical depression did better with mindfulness. |
| Problem solving | Problem solving is often a component of CBT in the context of pain management, but it can be a stand-alone treatment. Patients are taught to identify problems, brainstorm potential solutions, evaluate each solution, and then implement the solution and review its effect. | No evidence for RA, specifically, but Level II evidence for older patients who have arthritis and a clinical depression. Possibly efficacious. |
| IFS-based psychotherapy | IFS focuses on having patients attend to their experiences in a mindful way and uses self-compassion to encourage dialogue with part of the self. Patients are taught to identify the thoughts and emotions that are associated with pain, fatigue, disability, and deformity and use an internal dialogue to respond to them. | Level II evidence. Possibly efficacious. |
| ACT | ACT shares overlap with both CBT and mindfulness. ACT focuses on accepting internal experiences without judgment and on clarifying values that are important to an individual in order to commit to acting in accordance with one’s values. | No evidence specifically for RA. Level II evidence for chronic pain. Definitely efficacious for chronic pain, unclear for RA. One head-to-head trial of CBT and ACT for chronic pain, no differences between the treatments. |
Notes: The following descriptors are used: Level I evidence: a systematic review or meta-analysis of RCTs is available; Level II: an RCT is available. Definitely efficacious: two or more RCTs from different researchers are available. Possibly efficacious: a single RCT or multiple RCTs from a single group of researchers are available.
Abbreviations: ACT, acceptance-and-commitment therapy; CBT, cognitive behavioral therapy; IFS, internal family systems; RA, rheumatoid arthritis; RCT, randomized controlled trial.