title: "They didn't tell us, they made us work it out ourselves": patient perspectives of a cognitive-behavioral program for rheumatoid arthritis fatigue.
abstract: OBJECTIVE
  Fatigue is an overwhelming rheumatoid arthritis (RA) symptom caused by interacting clinical and psychosocial factors. Cognitive-behavioral therapy (CBT) addresses links between thoughts, feelings, and behaviors and uses cognitive restructuring to facilitate behavior changes. In a randomized controlled trial, a group CBT program for RA fatigue improved fatigue impact, severity, and perceived coping, as well as mood and quality of life. The aim of this study was to explore the patient perspective of the program and the impact of behavior changes.
  
  
  METHODS
  Ten exit focus groups were held (38 patients). Transcripts were analyzed by an independent researcher using a hybrid thematic approach, with a subset analyzed by a team member and patient partner.
  
  
  RESULTS
  Three overarching themes were identified. In "they made us work it out ourselves" (program factors facilitating changes), patients spontaneously identified elements of group CBT as pivotal, including guided discovery, the impact of metaphors, and working as a group. In "feeling much better about yourself and coping much better" (the nature of changes), patients described cognitive changes, including enhanced self-efficacy and problem solving, and emotional changes, including being less volatile and fearful of fatigue. In "my life has changed so much it's unbelievable" (benefits beyond fatigue), patients reengaged in previously abandoned activities, were more active, and enjoyed greater social participation.
  
  
  CONCLUSIONS
  Patients highlighted that CBT elements were key to making behavior changes and that these had far-reaching impacts on their lives. This suggests it could be beneficial in clinical practice to incorporate cognitive-behavioral approaches into patient education programs that aim to enhance self-management.
authors.affiliation: University of the West of England, Bristol, UK. emma2.dures@uwe.ac.uk
authors.forename: E
authors.initials: E
authors.lastname: Dures
authors.forename: K
authors.initials: K
authors.lastname: Kitchen
authors.forename: C
authors.initials: C
authors.lastname: Almeida
authors.forename: N
authors.initials: N
authors.lastname: Ambler
authors.forename: A
authors.initials: A
authors.lastname: Cliss
authors.forename: A
authors.initials: A
authors.lastname: Hammond
authors.forename: B
authors.initials: B
authors.lastname: Knops
authors.forename: M
authors.initials: M
authors.lastname: Morris
authors.forename: A
authors.initials: A
authors.lastname: Swinkels
authors.forename: S
authors.initials: S
authors.lastname: Hewlett
mesh_terms: D000223:Adaptation, Psychological; D000328:Adult; D000368:Aged; D001172:Arthritis, Rheumatoid / Q000150:complications* / Q000523:psychology; D015928:Cognitive Behavioral Therapy; D005221:Fatigue / Q000209:etiology* / Q000523:psychology / Q000628:therapy*; D005260:Female; D017144:Focus Groups; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010353:Patient Education as Topic; D012648:Self Care; D011795:Surveys and Questionnaires; D016896:Treatment Outcome