The role of the therapeutic relationship in cognitive behaviour therapy for chronic fatigue syndrome

[Dolphin]

The role of the therapeutic relationship in cognitive behaviour therapy for chronic fatigue syndrome.

Behav Res Ther. 2013 Jul;51(7):368-76. doi: 10.1016/j.brat.2013.02.001. Epub 2013 Apr 9.

Heins MJ, Knoop H, Bleijenberg G.

Source
Expert Centre for Chronic Fatigue, Radboud University Nijmegen Medical Centre, 4628, PO Box 9101, 6500 HB Nijmegen, The Netherlands. m.heins@nkcv.umcn.nl

Abstract*

Cognitive behaviour therapy (CBT) for chronic fatigue syndrome (CFS) can reduce fatigue and impairment.

Recently, it was found that changes in fatigue-perpetuating factors, i.e. focusing on symptoms, control over fatigue, perceived activity and physical functioning, are associated with and explain up to half of the variance in fatigue during CBT for CFS.

The therapy relationship, e.g. outcome expectations and working alliance, may also contribute to treatment outcome.

We aimed to examine the role of the therapy relationship in CBT and determine whether it exerts its effect independently of changes in fatigue-perpetuating factors.

We used a cohort of 217 CFS patients in which the pattern of change in fatigue-perpetuating factors was examined previously.

Fatigue, therapy relationship and fatigue-perpetuating factors were measured at the start of therapy, three times during CBT and at the end of therapy.

Baseline outcome expectations and agreement about the content of therapy predicted post therapy fatigue.

A large part of the variance in post-treatment fatigue (25%) was jointly explained by outcome expectations, working alliance and changes in fatigue-perpetuating factors.

From this, we conclude that positive outcome expectations and task agreement seem to facilitate changes in fatigue-perpetuating factors during CBT for CFS.

It is therefore important to establish a positive therapy relationship early in therapy.

PMID: 23639303 [PubMed - in process]

*I gave each sentence its own paragraph

 

[Dolphin]

I found it hard to motivate myself to concentrate on this and think through all the statistics (along with alternative explanations) given it was all just about changes in fatigue: changes in self-reported fatigue could be due to a whole host of factors incl. wish to feel better for oneself, wish to feel better for the therapist, etc. as well as any possible "real" improvement.

So anyway, I don't think I have any major points to make on this study but will point a few observations/quotes, for what they are worth.

From introduction:

Cognitive behaviour therapy (CBT) for CFS can effectively reduce fatigue and impairment (Castell, Kazantzis, & Moss-Morris, 2011; Chambers, Bagnall, Hempel, & Forbes, 2006; Price, Mitchell, Tidy, & Hunot, 2008). Even full recovery, defined as no longer being severely fatigued, being able to resume all activities, and having a perception of health and fatigue that is similar to healthy persons, is possible for a subgroup of patients (Knoop, Bleijenberg, Gielissen, van der Meer, & White, 2007).

Knoop, H., Bleijenberg, G., Gielissen, M. F., van der Meer, J. W., & White, P. D. (2007).
Is a full recovery possible after cognitive behavioural therapy for chronic fatigue
syndrome? Psychotherapy and Psychosomatics, 76, 171e176.

The Knoop et al (2007) paper didn't show that the patient was able to resume all activities. It was just a collection of self-report measures e.g. SF-36 PF>=80.

---

Recently, Wiborg, Knoop, Prins & Bleijenberg (2011); Wiborg, Knoop, Frank & Bleijenberg (2012); Wiborg, Knoop, stulemeijer et al. (2010) used mediation analyses of previous randomised controlled trials (RCTs) to test whether 1) CBT indeed leads to a change in these fatigue-perpetuating factors and 2) whether this change was related to the reduction in fatigue. Their studies showed that changes in focusing on symptoms and sense of control over fatigue indeed mediate the change in fatigue during CBT for CFS (Wiborg, Knoop, et al., 2012; Wiborg, et al. 2011). However, it is not the actual change in physical activity, but the perceived increase in activity that mediates the decrease in fatigue (Wiborg, Knoop, et al., 2012; Wiborg, Knoop, Stulemeijer, Prins, & Bleijenberg, 2010).

Alarm bells should perhaps be ringing in lots of minds when one sees sentences like this.

 

[Dolphin]

Entry criteria: Fukuda et al (1994) CFS criteria,

Severe fatigue was defined as a score of 35 on the Checklist Individual Strength (CIS), subscale fatigue severity (Vercoulen et al., 1994), and severe functional impairment was defined as a total score 700 on the Sickness Impact Profile (SIP) (Bergner, Bobbitt, Pollard, Martin, & Gilson, 1976; Jacobs, Luttik, Touw-Otten, & de Melker, 1990; Knoop et al., 2007; Pollard, Bobbitt, Bergner, Martin, & Gilson, 1976).

The protocol of CBT for CFS used in this study (Bleijenberg et al., 2003; Knoop & Bleijenberg, 2010) consists of approximately 12 sessions during 6 months. First of all, illness attributions are discussed with the patient, bearing in mind that a somatic cause for the symptoms has not been found in previous medical examination. The way through which thoughts and behaviour can lead to the persistence of symptoms is explained and the patient formulates his or her goals of therapy. These goals usually include the resumption of work, hobbies and other activities that imply recovery for the patient. Recovery is named as the maximal attainable goal of therapy, although patients are told that not every patient will reach this goal. After the formulation of treatment goals, bedtimes are regulated to stop disruption of the circadian rhythm.

It is a bit more than not every patient recovers; very few recovers following CBT would be more accurate.

(continues)

Next, patients are taught how to recognise and challenge nonaccepting and catastrophising thoughts in response to fatigue that may hamper adequate coping. They also learn to redirect their attention from the fatigue to activities and their environment. Patients who are relatively physically active (i.e. bursts of activity followed by inactivity) first start dividing their activity evenly throughout the day. Patients who have a low level of physical activity start immediately with the next part of the treatment, in which patients gradually increase their level of physical activity, mostly by walking or cycling. Dysfunctional illness beliefs, such as the thought that even moderate levels of activity are harmful, are challenged during this period. Once patients have increased their level of physical activity, they start to realise their treatment goals in the same way. At the end of treatment they are encouraged to stop labelling themselves as a CFS patient. All participating therapists were thoroughly trained in the protocol of CBT for CFS and received frequent intervision and supervision to ensure fidelity to the treatment protocol.

It is very questionnable whether such a clear subdivision can be accurately made.
e.g.

http://www.sciencedirect.com/science/article/pii/S0022399913001918

Journal of Psychosomatic Research

Volume 75, Issue 3, September 2013, Pages 249–254

Differences in physical functioning between relatively active and passive patients with Chronic Fatigue Syndrome

Desirée C.W.M. Vos-Vromansa, , ,
Ivan P.J. Huijnenb, ,
Albère J.A. Kökec, ,
Henk A.M. Seelenb, c, ,
J. André Knottnerusd, ,
Rob J.E.M. Smeetsb, c,

[..]
Conclusions

A clear difference in actual and perceived physical functioning between relatively active and passive patients with CFS as judged by their therapists could not be found. Future research is needed to form a consensus on how to categorize subgroups of patients with CFS.

 

[Dolphin]

Contrary to our expectations, most patients with CFS have positive outcome expectations when starting CBT. Therapists generally expect a very positive outcome of CBT. White et al. found considerably lower outcome expectations of patients in their randomised controlled trial on CBT for CFS than in the present study (White et al., 2011). This may be because patients who participated in their trial could not choose which treatment they would start. Participants in our trial all accepted a referral for CBT and among those referred, they may have been those most motivated and confident about CBT.

Also:

Another limitation of our study is that patients who were less motivated for CBT and had less positive outcome expectations and working alliance may not have participated in our study. This may have led to a selection bias and may limit generalisability of our study results.

I thought this was a somewhat interesting point/admission: perhaps those who do CBT at Nijmegen may not be fully representative of patients.

---

The bond with the therapist did not predict treatment outcome. This may be due to the nature of the symptoms. Patients with somatic symptoms may have a more mechanical vision on therapy than patients with e.g. depression or anxiety. They may feel that the therapist is merely someone explaining the treatment and that the bond with the therapist therefore is less important.

This seems plausible.

---

We did not measure patient participation within the session, but we measured patients’ homework compliance. At the first measurement, 10% of the patients and 15% of the therapists stated that patients had never or only seldom done their homework, which increased to 11% and 25%, respectively, at the second interim measurement. This indicates that patients were relatively adherent. However, numbers were too low to compare treatment outcome between those adherent and non-adherent to therapy.

We rarely get such information so thought I'd post. However, this is far from saying all the others were fully compliant.

 

[Dolphin]

Therapists' effect info:

It is possible that working alliance was higher for those patients working with therapists who more competently used thought evaluation techniques. We did not directly measure therapists’ competence or adherence to the protocol, but the multilevel analysis indicated almost no variation in treatment outcome between therapists. The same was found by Cella, Stahl, Reme, & Chalder, (2011). Wiborg, Knoop, Wensing, et al. (2012) did find differences in outcome between therapists. Their study was conducted in three secondary care centres in which CBT for CFS was being implemented. The centre in which therapists worked explained a part of the therapist effect. Both our study and that of Cella et al. were conducted in one highly specialised tertiary care centre, and all therapists participating in our study had been thoroughly trained in the protocol of CBT for CFS and received frequent intervision and supervision. This will probably have limited the differences between therapists and the way they performed CBT.

------

Conclusions
Expectations of recovery and agreement about the content of treatment contribute to actual treatment outcome. This study enhances the understanding of the process of change during CBT for CFS as it shows that these factors do not have a direct positive effect on post-treatment fatigue, but seem to facilitate cognitive changes during CBT for CFS.

In this study, they only reported on fatigue (they don't mention any objective measures and although they used the SIP, they didn't report on this), so it's less interesting.

Like lots and lots of the Nijmegen studies, there is no mention of a protocol, so we don't know how much of this is altered from what they might have planned e.g. could they have looked at the SIP results but not reported the results.

 

[Esther12]

Thanks for that D. I understand your lack of enthusiasm. There are things which could be worth thinking about in here... but it could just be spun, or trivial findings. Good of you to pull out those other references too.

Post 3 was a favourite. I really don't see myself in either of those models either, and vaguely remember some doctor getting a bit irritated with me for not fitting into either in the distant past.

 

[wdb]

From this, we conclude that positive outcome expectations and task agreement seem to facilitate changes in fatigue-perpetuating factors during CBT for CFS.

Isn't that exactly what you would expect to see if you studied a placebo.
http://en.wikipedia.org/wiki/Placebo#Expectancy_and_conditioning

 

[Esther12]

Also though, I think that the bond with the therapist would be expected to increase placebo/response bias for talking therapies:

The bond with the therapist did not predict treatment outcome.

Lots of different processes end up being lumped together, and described as a 'placebo effect', so it's difficult to really say.

 

[Valentijn]

Post 3 was a favourite. I really don't see myself in either of those models either, and vaguely remember some doctor getting a bit irritated with me for not fitting into either in the distant past.

I caused a lot of trouble at the Dutch clinic I went to, where they very closely follow the Nijmegen model. At first they assumed I was "active" because I was crashing all the time, then they assumed I was "passive" because an actometer showed I was doing virtually no moderate activities and no intense activities at all

So while the physiotherapist and occupational therapist were trying to get me stable enough to start the GET aspect, the psychologist was suggesting I get pregnant and go for a nice swim and the relaxation therapist was having me tense muscles.

It was a huge stupid mess.

 

[Simon]

Thanks, Dolphin, for reading this so that we don't have to - and esp for giving us the digest.

First of all, illness attributions are discussed with the patient, bearing in mind that a somatic cause for the symptoms has not been found in previous medical examination. The way through which thoughts and behaviour can lead to the persistence of symptoms is explained and the patient formulates his or her goals of therapy.

I don't know why, but I continue to be staggered by the sheer lack of curiousity this reveals on the part of researchers. It would make more sense if there was good evidence that CBT or GET were good, effective therapies - but they are mediocre at best.

Contrast that with people like Stephen Holgate who came fresh to the field from other disciplines and argues that ME/CFS is probably many different illnesses, we need to focus on causal molecular pathways and that now is an exciting time to study the illness as new technologies are emerging that are up to the task. And Ian Lipkin, who led the study ruling out XMRV and promptly stated that he was committed to new research to crack the illness, saying of earlier research looking at B-cells in CFS patiets "we know these people are sick: we don't know why they are sick, but they are". And he explicitly stated that by 'sick' he did not mean psychosomatically ill.

It seems to me that researchers such as Gus Bleijenberg are stuck in the past, and unwilling to consider other explanations that might better explain their findings.

If you got this far, thank you for listening to my rant.

From this, we conclude that positive outcome expectations and task agreement seem to facilitate changes in fatigue-perpetuating factors during CBT for CFS.

Isn't that exactly what you would expect to see if you studied a placebo.
http://en.wikipedia.org/wiki/Placebo#Expectancy_and_conditioning

Yes, though it might be response bias rather than genuine placebo effect. The King of placebo research is a guy called Hrbjartsson who has done massive meta-analyses showing that when you compare placebo vs no treatment (as opposed to placebo vs baseline) the placebo effect is either small or non-existent. They don't seem to like him on the Wikipedia page, but his research is way more robust - and on a much bigger scale - than most placebo studies. His first such study Is the Placebo Powerless? came out in the New England Journal of Medicine, the top medical journal by far.

He found that the strongest placebo effects (though still small) were in psychological research and in studies with self-reported outcomes (there is presumably a high overlap between the two). He also published Placebo effect studies are susceptible to response bias and to other types of biases, discussed here.

 

[biophile]

Valentijn. So your suspicions about their claims were borne from their own practical failures? But that goes against the official party line that patients only disagree because of ideological differences with the enlightened wisdom of CBT/GET!

[their lack of curiosity compared to other researchers who are pressing ahead with biomedical investigations] It seems to me that researchers such as Gus Bleijenberg are stuck in the past, and unwilling to consider other explanations that might better explain their findings.

Yes, it is amazing that the same university which produces the BPS fluffiness on CFS also produces work such as:

Computer Can Read Letters Directly from the Brain

"Aug. 19, 2013 — By analysing MRI images of the brain with an elegant mathematical model, it is possible to reconstruct thoughts more accurately than ever before. In this way, researchers from Radboud University Nijmegen have succeeded in determining which letter a test subject was looking at."

http://www.sciencedaily.com/releases/2013/08/130819141641.htm