A recent post alerted me to the misunderstanding amongst some health
professionals as to the nature of CBT. This is not surprising given that
one would not expect a consultant in immunology or epidemiology to keep up
to date with the developments in a different speciality such as
psychological medicine. I don't read immunology textbooks, nor am I familiar
with the latest drug treatments for CFS. To be a competent specialist, one
does not have the time to venture into other areas. It does mean, however,
that some experts appear to hold views of CBT which can be challenged by any
mental health professional in a court.
CBT is primarily a structured intervention where the primary aim is to help
patients cope with psychological problems. This means that it can be used to
alleviate anxiety and depression in patients with cancer, multiple
sclerosis, diabetes and rheumatoid arthritis. It generally consists of 6-8
sessions lasting one hour if you are treated on the NHS, and the structure
of the sessions means that the patients knows ahead of time what they can
expect. Common elements include setting the agenda, discussing problems
encountered during the previous week, choosing one problem to focus on,
examining various options to deal with that problem and setting 'homework'
for the next week. There is nothing wrong with CBT per se. With regard to
MS, AIDS etc, no one claims that it is a cure for the illness as a whole,
and the only issue is whether CBT is as effective as the newer
The problem with regards to CFS is that there is a mountain of literature,
particularly from the UK, which suggests that CBT can be used to treat the
illness as a whole. This suggests that it is a psychiatric disorder, like
OCD. The CBT for CFS articles describe a reductionistic model where the
assumption is that symptoms are maintained by stress, a fear of activity
(phobic avoidance) and deconditioning. Viruses play no clinically
significant role in the chronic phase. As this old model has been replaced
by a more sophisticated one (cf. Harvey and Wessely), it is likely that the
type of CBT offered to patients will be amended as a result.
Interpretation of the trials is difficult because of the lack of information
on the manuals used. This means that we tend not to know exactly what the
sessions entailed and it is possible that the published trials assessed a
number of different versions of CBT. Depending on the therapist and what he
or she reads, a patient with CFS may be offered a programme focusing on the
psychological problems associated with the illness, and find that subjects
such as possible causes won't even be discussed. However, if the therapist
has only read journals such as the Lancet or BMJ, then beliefs about causes
may be both discussed and challenged. (This is a pointless exercise as
research has shown that changing attributions about causes has little effect
When British journals provide a wider range of expert opinions, the current
obsession with assumptions such as the alleged link with deconditioning,
will cease. However, a dismissal of CBT per se, without recognition of the
specific model which underpins it at the moment, will be easy to challenge
in a court. All one has to do is to note that CBT is a useful way of
identifying sources of, and treating emotional distress, and that trials
have noted its value in people with a variety of conditions, including
cancer, AIDS etc, and that may curtail the discussion.
In my opinion, CBT isn't the problem. The type of CBT is. This is where
integrity comes in. An honest professional will not claim that CBT is being
used to treat MS, cancer etc. That is misleading. It is used to treat the
emotional aspects associated with those diseases. CBT cannot shrink tumours.
It can't remove plaques. However, it can help someone to cope more
effectively with the illness burden and therefore make them feel better.
Most patients however, won't require it.
The aim should be to encourage a more critical analysis of the type of CBT
being offered to patients with CFS. For example, few appear to have noticed
that the NICE guidelines describe two different versions of GET. As fas as
CBT is concerned, I know that the trials also covered different versions.
There appears to be some confusion in the literature about the nature of the
psycho-educative component (do therapists explain the origins of the disease
or the emotional distress etc). It's the manuals we should focus on. Some
may be appropriate and some may not. The central issue is, what is the
evidence supporting the old versions of CBT which aim to treat the illness,
as opposed to the emotional problems resulting from the illness. How many
have shown that their intervention allows the majority to return to their
previous occupations? Global impression of change measures, e.g. asking
patients if they feel better, or worse, means little. If a patient is
treated for nightmares caused by the severity of their illness, they may
well feel very much better. Less fatigued. However, they are far from cured.
Unfortunately, the lack of attention to detail shown by NICE etc means that
the 'confusion', let alone the flaws (limited or inappropriate outcome
measures, lack of stratification etc), have not been adequately addressed.
Attempts to correct factual errors have failed. Rigour is not what it used
Dr. Ellen M. Goudsmit C.Psychol. FBPsS
Health Psychologist (HPC Registered)
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