Thursday, September 12, 2013

A Randomized Controlled Trial of Internal Family Systems-based Psychotherapy for Rheumatoid Arthritis


In a first-of-its-kind "Proof-of-Concept" study, a group of therapists (including IFS founder Richard Schwartz) implemented Internal Family Systems therapy with people who have rheumatoid arthritis. Participants (N=39, 40 controls) were assessed every three months for the length of the study (9 months) and then one year later. They were assessed for self-assessed joint pain (RA Disease Activity Index joint score), Short Form-12 physical function score, visual analog scale for overall pain, and mental health status (Beck Depression Inventory, and State Trait Anxiety Inventory).

The results demonstrated post-treatment improvements for the IFS group (more than the control group) in overall pain [mean treatment effects –14.9 (29.1 SD); p = 0.04], and physical function [14.6 (25.3); p = 0.04]. Post-treatment improvements were still present one year later in self-assessed joint pain [–0.6 (1.1); p = 0.04], self-compassion [1.8 (2.8); p = 0.01], and depressive symptoms [–3.2 (5.0); p =0.01].

These are promising results that demonstrate a psychotherapeutic intervention for auto-immune disorders may be ad effective (or more so) than pharmacological interventions, which tend to have serious and somethings disastrous side effects.

The article is being offered Open Access by the Journal of Rheumatology.


Full Citation:
Shadick, NA, Sowell, NF, Frits, ML, Hoffman, SM, et al. (2013, Aug 15). A Randomized Controlled Trial of an Internal Family Systems-based Psychotherapeutic Intervention on Outcomes in Rheumatoid Arthritis: A Proof-of-Concept Study. Journal of Rheumatology, 40(9), 11 pgs. doi:10.3899/jrheum.121465 Clinical Trials.gov identifier: NCT00869349. 


A Randomized Controlled Trial of an Internal Family Systems-based Psychotherapeutic Intervention on Outcomes in Rheumatoid Arthritis: A Proof-of-Concept Study


Nancy A. Shadick, Nancy F. Sowell, Michelle L. Frits, Suzanne M. Hoffman, Shelley A. Hartz, Fran D. Booth, Martha Sweezy, Patricia R. Rogers, Rina L. Dubin, Joan C. Atkinson, Amy L. Friedman, Fernando Augusto, Christine K. Iannaccone, Anne H. Fossel, Gillian Quinn, Jing Cui, Elena Losina, and Richard C. Schwartz 



ABSTRACT


Objective
 

To conduct a proof-of-concept randomized trial of an Internal Family Systems (IFS)
psychotherapeutic intervention on rheumatoid arthritis (RA) disease activity and psychological status.


Methods
 

Patients with RA were randomized to either an IFS group for 9 months (n = 39) or an education (control) group (n = 40) that received mailed materials on RA symptoms and management. The groups were evaluated every 3 months until intervention end and 1 year later. Self-assessed joint pain (RA Disease Activity Index joint score), Short Form-12 physical function score, visual analog scale for overall pain and mental health status (Beck Depression Inventory, and State Trait Anxiety Inventory) were assessed. The 28-joint Disease Activity Score-C-reactive Protein 4 was determined by rheumatologists blinded to group assignment. Treatment effects were estimated by between-group differences, and mixed model repeated measures compared trends between study arms at 9 months and 1 year after intervention end.
 

Results

Of 79 participants randomized, 68 completed the study assessments and 82% of the IFS group completed the protocol. Posttreatment improvements favoring the IFS group  occurred in overall pain [mean treatment effects –14.9 (29.1 SD); p = 0.04], and physical function [14.6 (25.3); p = 0.04]. Posttreatment improvements were sustained 1 year later in self-assessed joint pain [–0.6 (1.1); p = 0.04], self-compassion [1.8 (2.8); p = 0.01], and depressive symptoms [–3.2 (5.0); p =0.01]. There were no sustained improvements in anxiety, self-efficacy, or disease activity.
 

Conclusion
 

An IFS-based intervention is feasible and acceptable to patients with RA and may complement medical management of the disease. Future efficacy trials are warranted.


Despite effective pharmacotherapy, many individuals with rheumatoid arthritis (RA) suffer ongoing pain and disability. Living with RA can lead to depression, anxiety, isolation, an overall impaired quality of life [1,2], and increased healthcare resource use [3]. Psychotherapeutic interventions that improve disease activity, pain-related symptoms, and psychological function would be helpful to patients living with this disease.
 
A number of psychobehavioral interventions have been shown to be effective in improving coping efficacy and other outcomes in patients with RA [4-11]. Cognitive behavioral interventions, in particular, have reduced pain, joint inflammation, physical disability, and depression [5,6,9,10]. The improvements are variable according to the type of intervention, tend to be most effective in newly diagnosed patients, and have limited sustainability [6,9]. For example, effect sizes (ES) for pain and disability in 2 metaanalyses of psychological interventions for RA were modest [12,13]. Also, joint inflammation and swelling were reduced by several interventions, but these results were mostly seen in patients with illness of shorter duration [13]. In a Cochrane review assessing the effectiveness of educational programs for RA, there were positive effects on disability, joint counts, patient global assessments, psychological status, and depression, but the improvements were short-lived [14]. A sustainable intervention that affects disease activity in individuals with longer-term illness could improve patients’ lives. 
The Internal Family Systems (IFS) model is a rapidly emerging individual psychotherapeutic modality developed by Schwartz [15] that teaches patients to attend to and interact with their internal experience mindfully. The model actively recruits self-compassion toward an individual’s parts, conceptualized as subpersonalities that are manifested by strong feelings, judgments, or physical sensations. By fostering an internal dialogue with polarized thinking, IFS reduces emotional intensity and dysregulation; elements that have been shown to increase pain perception [16] and disease activity in RA [4,17]. IFS also uses nonjudgmental noticing and active mindfulness.  Mindfulness-based interventions have been helpful in a number of painful conditions including RA [4,7,18]. To date, more than 2200 therapists worldwide have been trained in the IFS modality [19]. This technique is increasingly being used as adjunctive therapy for certain medical conditions, with anecdotal benefit reported in migraines, back pain, and multiple sclerosis. To our knowledge, our study is the first to evaluate the IFS model’s feasibility, acceptability, and potential efficacy in a randomized trial.
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