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"It's Totally Turned Around the Way I Think": The Patient Perspective of Cognitive Behavioural Therapy for Fatigue In Rheumatoid Arthritis

Dures, E; Kitchen, K; Almeida, C; Ambler, N; Cliss, A; Hammond, A; Knops, B


E Dures

K Kitchen

C Almeida

N Ambler

A Cliss

B Knops


Background/Purpose: RA fatigue is a common, overwhelming symptom caused by interacting clinical and psychosocial factors. Cognitive behavioural therapy (CBT) addresses links between thoughts, feelings and behaviours and uses cognitive restructuring to help patients make behaviour changes. In a randomised controlled trial, group CBT for RA fatigue reduced fatigue impact and severity and improved perceived coping, mood and quality of life. A nested qualitative study explored the nature of the processes and outcomes of the programme from the patient perspective.
Method: After the end of each programme, a focus group with participants was run by researchers not involved in programme delivery (10 groups, 38 patients). Transcripts were analysed using a hybrid (inductive & deductive) thematic approach. Initial codes were generated, depicting patterns across the dataset, and combined to form themes. Analysis was by an independent researcher with a subset analysed by a research team member and patient partner.
Result: 3 overarching themes were identified
“They made us work it out ourselves” (how the programme facilitated change). Patients spontaneously highlighted key elements of CBT as critical, including guided discovery and personal goal-setting (“we own our own plans and they’ve not been foisted on us”), peer support (“I think we all learnt something from each other”) and steering by tutors (“they had to throw the ball into the court for us to pick it and what they have also had to do is stop us going off at a tangent”). Metaphors were memorable (“the picture [assertiveness] sort of stuck in my mind of this little submissive guy in the middle which was me and I thought a lot about that and I’m not like that at all now”). Fatigue itself was a barrier for some (“it was very tiring”).
“Taking a different route” (the nature of changes). Cognitive changes included accepting RA fatigue (“you’re never going to get back to optimum health because optimum health is actually a myth”). Emotional changes included being less volatile (“I was quite fiery but I’ve calmed down”) and less fearful (“I’m not so scared of it [fatigue] now”). Greater self-efficacy and enhanced problem solving (“you analyse these things and then you can turn them around and make them work differently”) led to perceived behaviour change and success (“I am managing my fatigue rather than the fatigue managing my life”).
“My life has changed so much it's unbelievable” (benefits beyond fatigue). Patients re-engaged in previously abandoned activities, (“I got my life back again, you know it's nice, I enjoy myself”), with greater social participation (“I have turned outwards rather than inwards”), improved relationships (“how I am with my family, that has brought us quite a lot closer together”) and being more active (“I actually feel more confident to try more things now”).
Conclusion: Patients highlighted that CBT elements were key to making behaviour change, suggesting information alone would have been insufficient. Despite the focus on fatigue, benefits extended into wider life issues. Further research should examine whether this is due to the far-reaching impact of fatigue on daily life or the application of CB approaches to those issues.


Dures, E., Kitchen, K., Almeida, C., Ambler, N., Cliss, A., Hammond, A., & Knops, B. (2011). "It's Totally Turned Around the Way I Think": The Patient Perspective of Cognitive Behavioural Therapy for Fatigue In Rheumatoid Arthritis. Arthritis Care and Research, 63(10),

Journal Article Type Conference Paper
Conference Name Annual Scientific Meeting of the American College of Rheumatology and Association of Rheumatology Health Professionals 2011
Conference Location United States
Publication Date 2011-09
Deposit Date Oct 23, 2023
Journal Arthritis & Rheumatism-arthritis Care & Research
Print ISSN 2151-464X
Publisher Wiley
Peer Reviewed Peer Reviewed
Volume 63
Issue 10