Tuesday, December 15, 2009

More on CBT

I have noted over an extended period references in discussions on ME/CFS
treatment about what CBT is and how, based on that, it could not be
applicable to treating a biologically based disorder except to assist
with comorbidities such as anxiety or depression.

I agree that, based on typical descriptions, it makes little sense to
expect a CBT based approach would be of benefit in a medical condition.
It appears this way, however, because the definition being used does not
fully describe what is being done by many who work with CBT based
approaches in behavioural medicine practice. Of course CBT can be used
to assist with comorbidities, but it can also be deployed directly as a
part of treatment for a chronic disease where there are components of
pain, fatigue, inflammation and mood change and sleep disruption
implicated in the disease process.

The CBT used in psychoneuroimmunological interventions is not limited to
changing 'irrational beliefs'. For instance there are demonstrated
changes in inflammatory cytokine production related to reduced
threat-based responding. CBT is currently being applied to treating
inflammatory bowel disease for this reason. Guided imagery used to
facilitate sensory-motor neural reprocessing in an affected body part is
demonstrating benefit in CRPS related pain problems. There are a host of
similar examples where CBT is used to address things other than beliefs.

The view that all those involved in CBT based treatments accept the idea
that irrational thinking has lead to a somataform disorder in a patient
who has a chronic disease is entirely unfortunate. There is little
support for a mind-body split in any area of health. The idea that
problems are either entirely physical or psychological cannot endure any
sustained scrutiny. For instance, there is evidence that a pathogen
initiated cytokine response can be exacerbated and maintained by
psychological factors (eg; Brydon, et al. (2009) Brain, Behavior, and
Immunity, 23, 217-224). Clearly, this demonstrates that having ongoing
symptoms following an infection is not evidence of a somataform disorder
but of an extended sickness response. A number of the issues that can
exacerbate and maintain a sickness response are absolutely susceptible
to behavioural interventions. None of this requires that a patient had
any kind of psychological or psychiatric disorder.

Lastly, and most importantly, there is no need for medical and
behavioural interventions to compete. The best possible benefit to
patients will be served by collaborative multidisciplinary treatment
approaches which address the complexity of the presenting disease
processes.  It is essential to improved treatment that both health
professionals and patients are encouraged to abandon dualistic
perspectives which result in the politicising of health care. This is
important for the management of health disorders generally and for
chronic health problems in particular.

Best regards,

Carl Graham
Clinical Psychologist
 





3 comments:

Spam said...

What a load of defensive, postmodern psychobabble soapbox crap.

Has anyone who has psychoneuroimmunological-perpetuated immune dysfunction ever died of such immune dysfunction? And has anyone who was terminally ill from genuine disease, ever been saved by changing their "threat based responses"?

The answer of course is no in both casees. Studies on survival rates in cancer show that CBT has zero effect; in other words it is useless against serious organic disease and only possibly useful for faulty behaviour/thinking (e.g. cancer patients who still smoke). Yet this lie is baldly repeated, treating patients like 'shrooms.

The tub thumping denialism of the classical model of disease (which still exists for many diseases whether the psychs like it or not) and pushing the envelope of the "biopsychosocial" is only further evidence that psychs want to have their cake and eat it and will refuse to have any rational *remit* put to their expertise -- no wonder they are trying to abolish psychosomatic classification in the DMS. The market is unlimited!

PS. what's with having to have an account to make a blog comment?

Spam said...

"It appears this way, however, because the definition being used does not fully describe what is being done by many who work with CBT based approaches in behavioural medicine practice."

And where is the PROOF that this "good CBT" officially exists anywhere other than in a few maverick clinics? Where are the studies, the guidelines, even the CBT web sites which describe it?

"part of treatment for a chronic disease where there are components of pain, fatigue, inflammation and mood change and sleep disruption implicated in the disease process."

If these symptoms are the the RESULT of serious, severe disease you're going to find it hard to treat them with CBT! Most severely ill ME/CFS patients find that "sleep hygeine" has no effect or makes them worse.

"The CBT used in psychoneuroimmunological interventions is not limited to changing 'irrational beliefs'. "

Nevertheless that's how it works; it's about changing behaviour. The clue is in the acronym.

"CBT is currently being applied to treating inflammatory bowel disease for this reason."

I very much doubt that. The people I know with IBD were glad to finally get a proper diagnosis and get onto proper medical treatment and get away from the derisory CBT crap they'd been offered until then. Who are all these people with IBD who'd choose CBT over appropriate medical treatment? Yet there's no official drug treatment for ME/CFS whatsoever.

"Guided imagery used to facilitate sensory-motor neural reprocessing in an affected body part is
demonstrating benefit in CRPS related pain problems. There are a host of similar examples where CBT is used to address things other than beliefs."

The vast majority of CBT doesn't use guided imagery but does work with irrational beliefs.Graham seems to want it to be whatever he says it is. Carruthers et al (2003) are clear that paient-centered therapists should not abuse the term "CBT".

"The view .. is entirely unfortunate."

Well please hurry up and tell that to White, Reeves, Barsky, Prins, governments, policy makers, GPs, social workers instead of lecturing us.

"There is little support for a mind-body split in any area of health."

Nonsense, it's still the predominant model of diseases other than the self-inflicted "biopsychosocial" ones (eg. meningitis vs. obesity).

"For instance, there is evidence that a pathogen initiated cytokine response can be exacerbated and maintained by psychological factors"

Maybe but ME is not maintained by psychological factors. No doubt the findings in the above study were trivial. It seems people with MS, AIDS are still reliant on immune drugs rather than CBT therapists: how unfortunate!

"Clearly, this demonstrates that having ongoing symptoms following an infection is not evidence of a somataform disorder but of an extended sickness response."

Nonsense reasoning. You've just claimed to demonstrate that psychology produces somatic responses, but choose to euphemise the result to suite your agenda.

A number of the issues that can exacerbate and maintain a sickness response are absolutely susceptible to behavioural interventions. None of this requires that a patient had any kind of psychological or psychiatric disorder.

It's almost like a satire of itself, isn't it? "You're head can make you sicker, keep you sick, but it's not a head problem"

"Lastly, and most importantly, there is no need for medical and behavioural interventions to compete."

Two words: research funding. Two more words: clinical posts.

As Dr Byron Hyde says, psychs should not be allowed to deal with these patients.

http://preview.tinyurl.com/y89tgb8

CFS Facts said...

"Most severely ill ME/CFS patients find that "sleep hygeine" has no effect"

Absolutely! The people who blame it on my current "sleep when tired" schedule entirely miss the point that when I relapsed, I was still working. I went to bed at the same time every night and got up at the same time every morning and didn't have the opportunity to nap because I was at work. My sleep hygiene was essentially perfect, but I didn't fall asleep till 5 or 6 AM due to the pain.

For a couple of years after relapsing, I still maintained the habit of going to bed and getting up on the schedule required for work, regardless of whether I'd had one hour of sleep or eight. And got progressively sicker because most nights, it was closer to the one hour.

Eventually, I resigned myself to the reality that I was not likely to ever go back to working in an office, so "gave myself permission" to go to bed whenever I was tired -- no more forcing myself to try to stay awake till 11 PM, nor frustrating myself lying there staring at the ceiling for endless hours -- and get up whenever I was done sleeping -- no more forcing myself out of bed after 15 minutes of sleep because the clock said it was time to get up -- and my health has improved dramatically because I'm now getting enough sleep for my body to heal.

I did finally get sleeping pills, and then pain pills, which have been a big help, too. If I'd gotten them years ago, I would've been back to work in a matter of months, but the doctors were too busy attributing everything to psychiatric causes to bother looking for a physical cause for the pain that was keeping me awake.