[edit: I cite this later in this thread: http://forums.phoenixrising.me/index.php?threads/simon-wessely-and-all-in-the-mind.13979/] I just read this thing which has Wessely ask a couple of questions, and sound somewhat concerned about an aspect of his approach to (what he considers to be) psychosomatic conditions and social hysteria which has always seemed a problem to me. The best way of alleviating the problems of social hysteria/psychosomatic conditions is thought to be to encourage what could be considered a dismissive view of them, and to emphasise their psychological nature (sounds familiar). But on an individual level, it's best to maintain a supportive and respectful relationship with patients. There's an inevitable tension there, and Wessely raises that point here (kind of - if one was being uncharitable we could say he was primarily concerned about his customer base). The reply is utterly lacking imo, and I'm not too sure why I'm posting this... perhaps to encourage myself to read the whole thing in more detail later. I sometimes get the impression that Wessely realises that he's on the edge of quackery, and uses his association with the processes of 'science', RCTs, academia, etc to reassure himself that he's not crossed the line. (Although the use of RCTs to justify psychoSOCIAL interventions is somewhat problematic unless you have a few societies to play with). edit: re the benefits of being dismissive. When I was not recovering from glandular fever, and my doctor was telling me the importance of pushing myself to stay as active as possible or I could develop something like chronic fatigue syndrome, I remember being very ignorantly dismissive of the concern: "CFS? Rubbish - I'm not the type."... That was a decade ago.) Edit from 2015: Four years on, and having read much more of Wessely's work, I am feeling increasingly less kindly. Also, I think that his response to PACE and patient's criticism of it reveals a darker side than I had realised was there. www.sjweh.fi/download.php?abstract_id=252&file_nro=1 On the nature and origin of psychosomatic symptoms Lamberg. Well, I don't know whether it relates to "sisu", but I think that "sisu" could be defined as a kind o f stub- born attitude. Would you agree with that? Stenman. Y e s , I have the same opinion that it is a kind o f stubborn optimism that helps you achieve what you are up to; even i f you lose, you have won the second prize. Wessely. Professor Shorter-it is fascinating to hear you talk on psychology, but can I take you back to history? You said two things-first, that you have learned that the essential way of dealing with these problems clinically is to take them seriously, emphasize their genuine nature and so on. That is clinical skill and clinical judgment. But you also said that the way in which these syn- dromes finally go is when the word gets out that they are really "all in the mind" and not to be taken seriously. There is a clear irony and contradiction between what is good clinical practice for the individual, and what you propose would ultimately alter the disease attributions. How are we to resolve this irony? Shorter. I do not see a contradiction here at all. The physi- cian has a whole bag of psychological tricks for dealing with chronic psychosomatic illness, chronic somatization. It is very important not to legitimate these toxic diagnoses, and there is no doubt that multiple chemical sensitivity and chronic fatigue syndrome are toxic diagnoses, because they cause the patients to become fixated upon their symptoms and to dig in even further so that they acquire a sense of hopelessness. Now, you do not have to endorse the patient's illness representations in order to treat the patient in a humane and serious way in the patient-doctor relationship. You do not have to contradict the patient. You can diplomatically slide over the illness attributions in silence, at the same time taking the patient's symptoms seriously in other ways. Wessely. Suppose a transcript of the proceedings here was circulated among a group of patients who believe they have toxic dental amalgam or suffer from multiple chemi- cal sensitivity, it would be clear that the clinicians in this audience would no longer get any patients. Once it was known that they had presumably endorsed the views they had heard at this symposium, that would be the end of their clinical practice. They would no longer be able to do the good things that you have said. So there is a fundamental tension between the public good, and the clinical necessity of treating patients, and it's one that is hard to resolve. Shorter, The tension is between the need to be effective health care educators and the need to have patients. This is clearly a moral choice, and I am sure everybody in this room would opt for the side of the good guys saying, "Our role as physicians is to educate the vast public, which consists of millions and millions of people, that we are dealing with hocum here, rather than to cling to these few extra patients. We have plenty of patients after all who have plenty of other problems".