WARNING: Philosophy Alert!
I intend to write a series of blogs giving the flavour of one line of argument in the book I am writing, though I am using many other lines of investigation as well. This is the view from a position of critical rationalism. Using different but well recognized philosophical stances it can be shown that there are major problems with psychogenic explanations of CFS. Over time I hope to discuss other philosophical stances.
DBM: Dysfunctional Belief Model
The primary psychosomatic claim about the cause of CFS, sometimes called the Wessely School, has become synonymous with the claim that patients with CFS have a dysfunctional belief system that drives the illness. This claim is derived from older Freudian claims including claims about hysteria. They put forward the hypothesis that it can be treated with modified forms of CBT and GET. I have come to call this model of CFS the Dysfunctional Belief Model. This is the core philosophical stance underlying their treatments and it has major failings.
Critical Rationalism and Popper
Critical Rationalism is largely derived from the philosophy of science by Karl Popper. It is based on the idea that hypotheses must be testable. If they are testable, they can be found false with the right data, which makes the theory falsifiable: capable of being found false.
The DBM is descended from views held in the psychoanalytic tradition of Sigmund Freud. While Freud's ideas have largely been discredited, they have lived on in the ideas of psychosomatic illness including conversion disorder, somatization and hysteria. Hysteria is an old name that is now in disfavour, though it is still sometimes invoked.
Psychoanalysis was labelled by Karl Popper as non-science. It fails to be falsifiable, and hence fails to be testable. The claim by Popper and others is psychoanalysis relies on self-referential explanations but this is circular reasoning - nowhere does it ground out in objectively verifiable hypotheses or facts. There are so many additional secondary hypotheses that every item of data can be explained by the model, but none of these are testable hypotheses either. They cannot be testable if they cannot be falsified. They can only be subject to the steady accumulation of data intended to verify them.
Edward de Bono would call this a superstition: internally explicable but immune to external criticism or the evidence. Superstitious thinking tends to look like cults: there is often a central dogmatic figure. Once upon a time that was Freud. Of course that criticism can be levelled at Popper too. Its sometimes a subtle argument by authority, which is a recognized logical fallacy. Popper at least has the strength that his arguments are rational and well developed, and not dependent on secondary hypotheses, though they have also been extensively criticized. It is hard to cite argument without refering to authorities though - that is called plagiarism.
The name for this claim about CFS has changed over time, but the core is the same. Our beliefs about our illness drive us to maladaptive behaviour and drive our symptoms. Challenging and correcting these beliefs is the essence of treating or curing us.
Its a pity the evidence does not back their claim, and that very large numbers of us have tried these approaches and failed. I am not going to recite the litany of failure here though, there is so much material on this already out there. Its a pity because a cure would be really really nice. It is wrong, as I will discuss in later blogs, to claim we reject their model because of the stigma of mental illness or conflict with our supposed dysfunctional beliefs.
Popper calls everything that cannot be falsified non-science. He has another name for it, a name which is well known and considered derogatory: pseudoscience. I intend to return to this point in a later blog, but there is an entire section planned for my book on pseudoscience. The DBM fits every established description of pseudoscience I have yet seen, and I have investigated (so far) the primary definitions put forward by the leading philosophers of science.
My Reply to the Popperian View
The DBM is only derivative of psychoanalytic hypotheses. Its nowhere near as well evolved, it lacks the huge raft of secondary protective hypotheses, though I note their number is growing. There are numerous valid complaints about this approach yet they tend to reply with standard phrases and ideas.
These are hard to engage with, hard to refute, largely because they are true in one sense (often a trivial or irrelevant sense) but have so many vague secondary meanings that they cannot be pinned down and discredited except one by one. I have looked at several of the stock replies and they can be discredited by the tactic of identifying and isolating specific or concrete implications from the replies and demonstrating that they are either counter-factual or irrational. This is something I hope to do in detail in my book, but for now I do not wish to expand on this, only to point out it can be done. As they generate new versions of such claims, it is necessary to criticize them one by one - in all their alternative meanings.
Engaging in Wider Scientific Criticism
I think that due to our limitations, both in terms of cognition and material resources, we have failed to properly engage in the wider scientific debate on these issues.
We see the Wessely School, but it is based on the the ideas of Sigmund Freud and so inherits many of the criticisms. It is established within the current philosophy of the Biopsychosocial model yet fails to live up the that model. There is a claim the DBM is evidence based, but I am in the process of showing this claim is spurious. At some point I might look at writing a blog on the Cochrane review on CFS treatments.
There is so much debate and information against these views in the wider science. I encourage every advocate, every patient who is fed up with DBM claims, to look beyond ME and CFS and see what others are saying. Psychosomatic medicine is dying. Its being overshadowed by other branches of psychiatry. In a century they have failed to find substantive evidence of biomarkers that support their models, and yet I think its impossible to make their claims and be consistent with evidence and to not acknowledge that such biomarkers must exist if psychosomatic theory is correct. Vague claims relating to mind-body Cartesian dualism do not change this conclusion. This is a field of medicine that appears to be either stagnant or degenerating. Paying lip service to the BPS model has not done much to revive it that I can see.
I am not bothered with calling psychosomatic medicine by its more modern label changes, at least just yet. Its not substantially different - the names just keep changing because the old names are associated with a litany of failure and dubious reputation. People know to avoid the old hypotheses, so they change the name in the hope of catching the unwary. Its spin over substance.
Progress on My Book
A working title for my book is The Dysfunctional Belief Model of CFS, with a subtitle Embracing the Null Hypothesis. It looks like being nine chapters with numerous appendicies, and threatens to blow out to many hundreds of pages (possibly over a thousand) even before I count references. It has become clear that I will not ever be able to do an exhaustive analysis - that would be a life's work by a healthy person, and probably require an institute with many experts in different fields. What I can do however is establish multiple frameworks of analysis and establish common themes of error in the DBM and how it is promoted. My goal is to expose, in detail, how irrational these claims are.
There will also be a long series of critical questions arising from this. If some of these can be sufficiently substantiated by the evidence this may lead to formal complaints to oversight and regulatory bodies involved in medicine and medical research.
My best estimate is that writing the first draft of this book will take 2-5 years. Two years presumes I can regain the health I had briefly in January, five years if not. Five years might not be nearly enough however, I will have to see. Maybe I will release my writing in stages: part one for the problem, part two addressing possible solutions. I will have to see about that.
Currently I am only writing a few pages a day at best, none at worst, and the background reading is probably less than 20 pages a day. At this rate, for a thousand page book, we are talking maybe 500 days just to write the first draft, and thats after I have done sufficient analysis. It also presumes I can sustain writing at least two pages a day, and that is doubtful as the book advances and the complexity increases. On the other hand this project has some momentum. Things might advance faster once I can establish a workable writing process.
The good news is that I am at the stage where every morning I wake up with the idea for several new sections and arguments for my book. In fact I have trouble making notes about them before I forget them. The muse is fleeting. I wake up with whole paragraphs written in my head, but by the time I walk to my desk I often only remember one thing - whatever I was thinking of last. This blog was what I woke up with this morning.
In the meantime I hope the debate intensifies. There are so many things wrong with the model that it is easy to poke holes in it, its just that doing so requires casting a very broad net and a whole lot of sustained effort. This is not easy for very sick people with underdeveloped advocacy organization and a fractured community. Its not easy when the wider medical community and political institutions fail to care.
With any luck you will all debunk DBM before I finish, and I can stop spending years writing this stuff. Alternatively I hope the evidence from the Phase 3 clinical trials of Rituximab is so strong that it will severely discredit the DBM.
However, sad as it is to say, I think even if most of us are cured by Rituximab the DBM will just change its secondary hypotheses and go on, this time targeting a modified subset of the idiopathic fatigue population. That is why I think the problems with the model need to be engaged with - by the wider medical profession, research scientists, philosophers, statisticians and by the people with the biggest vested interest: patients.
My blog on verificationism is being reworked at the moment. I hope to get it out there soon.
The Dysfunctional Belief Model, Karl Popper, and my Book
Blog entry posted by alex3619, Apr 20, 2012.
About the Author
I am a long term ME patient with many complications. While I have pushed research advocacy since 1993, I become political around 2009. My current project is a book called "Embracing the Null Hypothesis". The hypothesis that is unsubstantiated is the idea that CFS is due to dysfunctional beliefs.