Tuesday, December 15, 2009

Yet more on CBT

Carl Graham asks us whether CBT as a concept has been sufficiently polluted in CFS research and clinical use that it will have to be retired.

My answer is an unqualified "Yes."

The key is the association with ANOTHER questionable concept in psychiatry: "inappropriate illness beliefs."

"Inappropriate illness beliefs" is itself a type of ideology, a type of belief system. It requires the assumption that if there is no APPROVED objective test for a medical condition, then the condition must belong in the domain of psychiatry. In the history of medicine, the reverse has always been the case. Charcot's hysterics were epileptics and victims of third-stage syphillis. Women with hysterical paralysis turned out to have Multiple Sclerosis. "Cold Mother Syndrome" is now called autism.

I have no quarrel with psychiatry as a profession. There is no doubt that the profession of psychiatry has saved patients with such biological disorders as bipolar syndrome and schizophrenia from myths of demons or self-indulgence. And many who would have dropped by the wayside have been saved by the counseling they received from intelligent and caring therapists.

But psychiatry as a profession is also a minefield of confused and inappropriate diagnoses.

It is exceedingly ironic that White, Wessely, Sharpe, and Chalder, the most visible psychiatrists pushing this particular brand of sophistry on the public, always open their presentations (in print or lecture) with the claim that they are breaking down Cartesian mind-body dualism. They then proceed with a dualistic theory as to what is wrong with the patient and how to fix it.

One has to reach back to the "four humors" to find such a thoroughly theory-driven model of how the body works.

Yet article after article is published, the "peer reviewers" apparently losing all their critical reasoning skills. The same research is repeated; the authors all cite each other frequently. The result is the appearance of scholarship with no scholarship.

Here is an example of the excesses to which the theory of "cognitive behaviour therapy" coupled with "inappropriate illness beliefs" has taken us, from the King's College, London, website on CFS for professionals:

http://www.kcl.ac.uk/projects/cfs/health/

"Many clients have built up an infrastructure of support, a coping network, to help them manage their illness. One of my clients had, over the years, established a rota of friends and volunteers, who visited two or three times daily to help her with meals, washing, housework etc. Mostly she was in a wheelchair, and walked only with crutches. She wore a neck-collar to support her head. For her, the road to recovery involved the gradual dropping of each one of these props. To put it in her words, she had to "wean herself of" her network of support, her chair, her crutches, her collar.

"Each new reduction in her dependence was a step into the unknown. This required enormous courage and persistence. Each move back into (her words) 'real life' was potentially that step too far that would send her into relapse. The spectre of the bed and the wheelchair is never far from the mind of many sufferers.

"This weaning is not quick. Two years later we carry on the journey, though her strides are that much firmer and more confident. Therapists used to working with anxiety must acquaint themselves with a far slower pace of change, much less spectacular progress. They must acquire patience, and lower their own unrealistic expectations of speedy recovery. In short, we must fall into pace with the client."

If these psychiatrists are wrong - if so-called "chronic fatigue syndrome" really is caused by biomedical phenomena - and if the vast majority of patients with "CFS" who are confined to wheelchairs are there because of medically verifiable physical limitations, the scenario described on the King's College website is unspeakably cruel. The reader is reminded of scenes from "Elmer Gantry."

As long as that practice remains; as long as patients are grossly mistreated in the name of a false science; as long as insurance companies and government institutions rely on such advice - how can a thinking person take the chance of dignifying such practices by promoting the phrase "cognitive behaviour therapy"?

No matter how well meaning, in the end the author risks having his/her own words used in an act of unspeakable cruelty. Why would you take that chance?

Psychiatry as a profession should be so embarassed by this performance to assign the phrase "Cognitive Behaviour Therapy" to the dustbin of history, along with eugenics and phrenology (the belief that a person's character can be assessed by looking at the shape of his/her head). Do not say it "could" mean something different. A set of rogue psychiatrists has given a fixed meaning to this concept, and it has been applied to extend the suffering of patients with a severe disease. AND THE PROFESSION OF PSYCHIATRY HAS DONE NOTHING TO STOP THIS.

Why the profession itself has not risen up in anger against this false scholarship is, frankly, beyond me. Perhaps it has to do with the patient in the above scenario almost always being a woman. Neurasthenia, like hysteria, has historically been considered a "woman's" disease - attributed by such as Simon Wessely to men only when they fail in the most manly of duties, warfare. Perhaps lingering prejudices against women's internal makeup have provided the loophole through which these clearly absurd ideas have spread unchecked. But neurasthenia does not have the most respectable history. In the nineteenth century, it was paired with hysteria to create the medical view that young women should not be permitted to study science or math in high school (if they were permitted to attend high school at all). Freud's version of "neurasthenia" came from the case of Anna O, whom he concluded secretly wished to have sexual relations with her father as a child. Only the release of Freud's private papers showed the opposite: Anna O herself had come to Freud because her father HAD sexually abused her. After extensive efforts to treat her, the good doctor decided that her claim was too grotesque to be true. Only then did he create the OTHER version of the story - that she had imagined it because she wished it to be so.

With such a history, I would think psychiatrists would be doubly careful to police their profession for such misguided theories.

We are not talking about something hidden away in a corner. The CBT/GET pushers and proponents of "biopsychosocial" medicine have been unusually prolific - often publishing more than one paper on the basis of a single study. They cite each other frequently, so they would show up on the citation index as highly regarded, too. Highly regarded by themselves alone, perhaps, but the citation index does not make these distinctions. It simplies counts the citations - the more, the better, no matter why.

Do you really expect bureaucrats to make the fine distinctions between one form of CBT and another? They do not, as a rule, and the money is behind the cruel version. Children and young people have been taken from their families and placed in foster homes or psychiatric institutions on the beliefs bolstered by proponents of CBT and GET. It has taken its time getting to the United States, but with the help of Emory's psychiatry department and Reeves' "empiric [sic]" questionnaires, the U.S. has finally arrived at a purely psychiatric view of CFS.

As long as psychiatry refuses to clamp down on the con artists of Cogitive Behaviour Therapy and "CFS/ME" as they sometimes call it, a thinking professional should run, not walk, from their terminology. The dangers are too great: the risk lies in legitimizing an inherently illegitimate activity.

Has CBT as a concept been sufficiently polluted in CFS research and clinical use that it will have to be retired?

My answer is an unqualified "Yes."


Mary M. Schweitzer, Ph.D.

* * *
15 years ago, Dr. David Bell noted that fully half of the people originally diagnosed with hypochondria or "all in your head" were eventually diagnosed with a very real physical disease that matched the symptoms they'd complained about all along.

I was told in 1988 that I did have a very real illness, for which there was no blood test yet, but I was ahead of the technological curve, and had to wait for medical science to catch up to prove it. With the first MRI machine in the Tahoe area, Peterson/Cheney found brain lesions similar to those in MS; this information was ignored by those who wanted to blame the problem on "depressed menopausal women". Five years ago, I had a C-Reactive Protein test, which shows inflammation/infection, can verify that a person has a virus without needing to identify which one; the "off the charts" results still were not enough to convince some people that I'm physically ill, not faking. Now we have XMRV, and I'm sure there are still those who are going to deny that this is good enough evidence that patients have a physical disease, not a psychiatric flaw.

It's taken 21 years since my initial diagnosis for technology to prove that I wasn't lying, I wasn't faking, I wasn't malingering ... there really is a virus behind my problems.

Unfortunately, a study has shown that it takes 17 years -- a full generation -- for research findings to become common medical practice. So just because we, as patients, know about XMRV, that does not mean that the average doctor knows (or cares to learn); expect it to be 2026 when more doctors than not recognize CFS as a retrovirus to be treated accordingly. Say it takes 5 years from now to determine that Drug X is the best treatment -- that puts it at 2031 (almost 50 years after the Tahoe and Lyndonville epidemics!) -- before most doctors are prescribing Drug X.

I hope that Hillary Johnson has it in her to write a sequel to "Osler's Web", talking about the horrors that patients have undergone since the end of the original book, and what roadblocks are put up to the acceptance of the notion that CFS=XMRV.






1 comment:

Joanne said...

Such an excellent and informative post. I like to follow ME/CFS developments as this was my original diagnosis until it was found to be Lyme Disease.
There are so many parralels with these two illnesses and some patients may indeed have both how many of the sickest Lyme patients also have XMRV or visa versa.

However my reason for commenting is that the President of ILADS Robert Bransfield a psychiatrist presented at the LDA conference last year and what he had to say should be of interest to all Psychiatrists and also ME/CFS as well as Lyme patients. He is not the only Psychiatrist at the forefront of Lyme Disease research and developments.Dr Brian Fallon being another one. What a pity more don't follow their example.

http://www.lymediseaseaction.org.uk/conf2008/bransfieldneuro.pdf

Conclusion
• Chronic infections and immune reactions
contribute to causing mental illness.
• Diagnosing and treating Lyme/tick-borne
diseases and other infections and immune
reactions from them are new treatment
opportunities for mental illness.
• Since interaction between infections, the
immune and nervous systems can cause
mental illness, greater interaction is
needed between infectious disease
physicians, immunologists and practicing
psychiatrists to more effectively treat
mental illness.
and
http://www.lymediseaseaction.org.uk/conf2008/bransfieldchronic.pdf
From Controversy to Collaboration
• Psychoimmunologists don’t have to be convinced
that infections cause immune dysfunction that in
turn causes mental disorders. Some don’t
understand brain physiology and need to listen
more attentively to psychoimmunologists.
• Since interaction between the immune and
nervous systems can cause mental illness, greater
interaction is needed between immunologists and
practicing psychiatrists.
• It is time to stop fighting each other and direct all
our efforts towards fighting these diseases instead