Vitality Training - a group-based intervention for persons with rheumatic diseases : Experiences, methodological aspects and clinical effects

Background: Chronic rheumatic diseases are painful conditions which are not entirely controllable and can place high emotional demands on individuals. Increasing evidence has shown that emotion regulation in terms of actively processing and expressing disease-related emotions are likely to promote positive adjustment in patients with chronic diseases. The Emotional Approach Coping Scale (EAC) measures active attempts to acknowledge, understand, and express emotions. Although tested in other clinical samples, the EAC has not been validated for patients with rheumatic diseases. This study evaluated the data quality, internal consistency reliability, validity and responsiveness of the Norwegian version of the EAC for this group of patients. Methods: 220 patients with different rheumatic diseases were included in a cross-sectional study in which data quality and internal consistency were assessed. Construct validity was assessed through comparisons with the Brief Approach/Avoidance Coping Questionnaire (BACQ) and the General Health Questionnaire (GHQ-20). Responsiveness was tested in a longitudinal pretestposttest study of two different coping interventions, the Vitality Training Program (VTP) and a SelfManagement Program (SMP). Results: The EAC had low levels of missing data. Results from principal component analysis supported two subscales, Emotional Expression and Emotional Processing, which had high Cronbach's alphas of 0.90 and 0.92, respectively. The EAC had correlations with approach-oriented items in the BACQ in the range 0.17-0.50. The EAC Expression scale had a significant negative correlation with the GHQ-20 of -0.13. As hypothesized, participation in the VTP significantly improved EAC scores, indicating responsiveness to change. Conclusion: The EAC is an acceptable and valid instrument for measuring emotional processing and expression in patients with rheumatic diseases. The EAC scales were responsive to change in an intervention designed to promote emotion regulation. The instrument has not yet been tested for test-retest reliability, which is recommended in future studies. Published: 3 September 2009 BMC Musculoskeletal Disorders 2009, 10:107 doi:10.1186/1471-2474-10-107 Received: 25 February 2009 Accepted: 3 September 2009 This article is available from: http://www.biomedcentral. com/1471-2474/10/107 © 2009 Zangi et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. BMC Musculoskeletal Disorders 2009, 10:107 http://www.biomedcentral. com/1471-2474/10/107 Page 2 of 9 (page number not for citation purposes) Background Chronic rheumatic diseases often have an important impact on physical, as well as psychological and social aspects of patients' lives. Such long-term stressors that have uncontrollable elements can place great emotional demands on the individual. Research has documented a high degree of depression, anxiety and psychological distress in patients with rheumatoid arthritis (RA) and other rheumatic diseases [1-6]. There are individual differences in how patients cope with various symptoms and adjust to the burden of the disease. In early stages of the disease emotional distress is associated with levels of pain and fatigue, functional status, disease impact on daily life, life events and perceived social support [1,7]. The effect of disease-related factors on psychological distress seems to decrease [3,8] and personality characteristics and individual coping resources appear to become more important predictors over time [7,9]. Various self-management interventions have been developed to improve patients' ability to cope with the complexity of symptoms related to their rheumatic disease [10-12]. There is a growing consensus that emotion regulation, in terms of acknowledging and dealing with negative emotions associated with chronic illness, can contribute to adjustment [13,14]. However, few interventions explicitly address patients' emotional response to their disease [9,15]. The Vitality Training Program (VTP) is a Norwegian group intervention [16], which has a special focus on awareness of and reflection upon one's own emotions, thoughts and bodily experiences. It has produced a reduction in psychological distress and increased emotional well-being in a randomized, controlled trial in persons with chronic musculoskeletal pain [17] and in a one-year follow-up of a non-controlled study for patients with inflammatory rheumatic diseases [18]. The results shall be further evaluated in a randomized, controlled trial. However, following a search of the literature, no acceptable instrument to measure intervention-related change in patients' coping strategies related to emotional awareness was found. The coping literature makes a distinction between problem-focused and emotion-focused coping strategies [1921]. Problem-focused coping includes direct efforts to alter the demands on the person, whereas emotionfocused coping includes efforts to regulate emotions associated with stressful situations. Research based on earlier published coping scales has found that use of emotionfocused coping strategies is often associated with psychological distress and maladjustment [13,20,22]. However, there is increasing research on the adaptive nature of acknowledging, processing, and expressing one's emotions. An ability to approach one's and others' emotions is seen as crucial to healthy intraand interpersonal functioning [13-15,23]. This view has also received empirical support through studies on emotional disclosure interventions [24-29]. Major problems have been identified in the existing conceptualization and measurement of emotion-focused coping [13,20,22]. Diverse coping methods, such as approach-oriented (e.g. seeking social support) and avoidance-oriented (e.g. denial) strategies, have been assessed with emotion-focused coping items, some of which are inversely correlated. Emotion-focused coping scales have also included items related to emotional distress and negative emotions (e.g. angry, upset, blame myself). Hence, these earlier measures of emotion-focused coping were confounded by aspects of psychological health. Stanton et al [22] developed a construct of emotional approach coping which does not include distress-related items. Based on this construct, the Emotional Approach Coping Scale (EAC) is comprised of two factors [22]: Emotional Processing, which includes active attempts to acknowledge, explore meanings and come to an understanding of one's emotions; and Emotional Expression, which includes active verbal and/or nonverbal attempts to communicate or symbolize one's emotional experience. The EAC has been tested in clinical samples [13], including patients with chronic myofascial pain [29]. These studies show that emotional approach coping is inversely related to psychological distress and can predict better adjustment and less pain and depression over time [13,22,29]. The aim of this study was to evaluate the Norwegian version of the EAC in patients with rheumatic diseases. More specifically, the instrument was tested for data quality, internal consistency reliability and construct validity in a cross-sectional study. Responsiveness to change was assessed using longitudinal data from a pretest-posttest study that included patients recruited from two different coping interventions, the VTP and an inpatient Self-Management Program (SMP). Methods Data collection Recruitment of three different groups of patients took place in 2007 and all received self-completed questionnaires. For the cross-sectional study, 118 consecutive patients (group 1) who had a confirmed rheumatological diagnosis and who attended regular consultations at rheumatology inpatient, outpatient or day hospital clinics, were recruited. Questionnaires were given to patients by rheumatology nurses at a single data collection point. For the pretest-posttest study, 49 patients (group 2) attending four VTP groups and 103 patients (group 3) attending five diagnosis-specific SMP courses were recruited. Group 2 were given questionnaires by facilitators immediately BMC Musculoskeletal Disorders 2009, 10:107 http://www.biomedcentral. com/1471-2474/10/107 Page 3 of 9 (page number not for citation purposes) before the first VTP session and were mailed questionnaires after the last session. Group 3 were given the questionnaires by a nurse at the beginning of the first day of the SMP and at the end of the last day of the course. Baseline data from group 2 and 3 and all data from group 1 were used in the cross-sectional study. Inclusion criteria were adults with confirmed rheumatological diagnosis in the consecutive sample (group 1) and confirmed rheumatological diagnosis of at least six months duration and age over 20 years in the two coping interventions (group 2 and 3). All patients received written and oral information regarding the study, and informed consent was obtained from all patients before entering the study. Group 1 patients were free to either fill out the questionnaire or not; questionnaires were sent back anonymously. This survey was regarded as a component of quality assurance and hence ethical approval was not required. The pretest-posttest study samples participated in two evaluation studies, which both were approved by the Regional Committee for Medical Ethics. Interventions The VTP aims at helping patients to become more aware of their internal and external resources in order to cope with their current life situation. Processing, acknowledging, and expressing one's emotions are central elements. Through participation-based teaching and counselling methods, as well as awareness and relaxation training, patients learn to accept their thoughts, feelings and bodily experiences as th