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"The biopsychosocial approach: a note of caution" George Davey Smith (2005/2006)

out2lunch

Senior Member
Messages
204
Not sure I can entirely agree with this. Certainly CBT is not a treatment that will improve ME/CFS somatic symptoms, whether it is 'good' CBT or 'bad' CBT. To improve our health we need medical treatment, not psychology.

However, some people with ME/CFS don't naturally develop the coping skills they need in order to function with a disabling chronic disease. Those people might benefit from the type of CBT that helps the patient learn to live with extremely difficult situations. There are (sometimes) ways to deal with tragedy that can help you get through it. Good CBT can help you face reality and move on with life.

CBT makes not one iota of difference to somatic symptoms, nor does every patient need it. Plenty of patients manage to cope without therapy, just like some people cope with divorce without therapy, but others benefit from some counseling. CBT should never be considered a treatment for ME/CFS, nor should it be recommended for all patients any more than it is recommended for every cancer or MS patient.

That said, I wouldn't put a penny of donated or government money towards 'good' CBT until we have reliable, well-accepted medical treatments available to all patients. It's a matter of priorities.

As for BPS theories -- total BS. They have no solid evidence to support them and should be tossed into the pseudoscience trash bin.
While I agree with many of us not possessing adequate coping skills in dealing with long-term chronic illnesses such as ours, I wouldn't necessarily refer to this training as CBT. I've had CBT in the past, and the primary foundation of the therapy was the underlying belief that my emotional problems fueled my physical symptoms and were the result of my faulty outlook and subsequent reactions to events occurring in my daily life interacting with others.

Learning coping mechanisms for living with chronic fatigue or pain never assumes the symptoms stem from poor coping mechanisms. As a chronic disease patient, you're handed a mental guidebook to use when life overwhelms you. The professional atmosphere of such a therapy environment is positive and uplifting, rather than negative and judgmental. Big, big difference.

As for BPS... rubbish just about covers it.

BPS doesn't even qualify as manure given its propensity to kill living organisms rather than help them bloom. :p
 

SOC

Senior Member
Messages
7,849
While I agree with many of us not possessing adequate coping skills in dealing with long-term chronic illnesses such as ours, I wouldn't necessarily refer to this training as CBT. I've had CBT in the past, and the primary foundation of the therapy was the underlying belief that my emotional problems fueled my physical symptoms and were the result of my faulty outlook and subsequent reactions to events occurring in my daily life interacting with others.

Learning coping mechanisms for living with chronic fatigue or pain never assumes the symptoms stem from poor coping mechanisms. As a chronic disease patient, you're handed a mental guidebook to use when life overwhelms you. The professional atmosphere of such a therapy environment is positive and uplifting, rather than negative and judgmental. Big, big difference.

As for BPS... rubbish just about covers it.

BPS doesn't even qualify as manure given its propensity to kill living organisms rather than help them bloom. :p
I agree that the so-called CBT that involves telling people they are not really ill, to ignore their symptoms, and that their thinking is causing somatic symptoms is complete and utter rubbish. This type of CBT seems to be prevalent in the UK and possibly the Netherlands. It's part of the BPS school of thinking more than an inherent feature of CBT.

There is CBT, the original CBT before it was subverted by the BPS school, that does not support denying the patients' experience. It has some validity in the area of teaching coping skills and helping modify self-defeating thought processes ("I'm a failure." "If I'm not married, I have no future.") This is the type of CBT that is predominant in the US and other parts of the world.

Cognitive behavioral therapy (also known by its abbreviation, CBT) is a short-term, goal-oriented psychotherapy treatment that takes a hands-on, practical approach to problem-solving. Its goal is to change patterns of thinking or behavior that are behind people’s difficulties, and so change the way they feel. It is used to help treat a wide range of issues in a person’s life, from sleeping difficulties or relationship problems, to drug and alcohol abuse or anxiety and depression. CBT works by changing people’s attitudes and their behavior by focusing on the thoughts, images, beliefs and attitudes that we hold (our cognitive processes) and how this relates to the way we behave, as a way of dealing with emotional problems.
http://psychcentral.com/lib/in-depth-cognitive-behavioral-therapy/
Notice no inherent implication of psychosomatic illness. That delightful subversion is the work of the BPS school who hijacked CBT in the UK, just as they hijacked ME, to serve their own personal goals.

We have several therapists (or former therapists) here at PR, including @Gingergrrl, who have used CBT in their work and didn't feel compelled to deny their patients' illnesses, convince them that they have false illness beliefs, or tell them that their thought process is causing somatic symptoms.

That said, I would not advise any PWME in the UK to consider any type of CBT because of the horrific influence of the BPS school there.
 
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out2lunch

Senior Member
Messages
204
There is CBT, the original CBT before it was subverted by the BPS school. That does not support denying the patients' experience. It has some validity in the area of teaching coping skills and helping modify self-defeating thought processes ("I'm a failure." "If I'm not married, I have no future.") This is the type of CBT that is predominant in the US and other parts of the world.
That is the type of CBT my brother received in the late sixties/early seventies in the US. However, it's not the type of CBT I received in the late eighties/early nineties, here in the US, as my health problems exploded.

My version of CBT sounds similar to the UK flavor you face across the pond, which was influenced by a penny-pinching HMO policy. It didn't resemble the classic "Feeling Good" CBT once advocated by David Burns, MD.
 

Kati

Patient in training
Messages
5,497
I agree that the so-called CBT that involves telling people they are not really ill, to ignore their symptoms, and that their thinking is causing somatic symptoms is complete and utter rubbish. This type of CBT seems to be prevalent in the UK and possibly the Netherlands. It's part of the BPS school of thinking more than an inherent feature of CBT.

There is CBT, the original CBT before it was subverted by the BPS school. That does not support denying the patients' experience. It has some validity in the area of teaching coping skills and helping modify self-defeating thought processes ("I'm a failure." "If I'm not married, I have no future.") This is the type of CBT that is predominant in the US and other parts of the world.


http://psychcentral.com/lib/in-depth-cognitive-behavioral-therapy/
Notice no inherent implication of psychosomatic illness. That delightful subversion is the work of the BPS school who hijacked CBT in the UK, just as they hijacked ME, to serve their own personal goals.

We have several therapists (or former therapists) here at PR, including @Gingergrrl, who have used CBT in their work and didn't feel compelled to deny their patients' illnesses, convince them that they have false illness beliefs, or tell them that their thought process is causing somatic symptoms.

That said, I would not advise any PWME in the UK to consider any type of CBT because of the horrific influence of the BPS school there.

The problem in recommending any time of CBT in a world that denies any kind of medical testing is the fact that medical systems expecially socialized health care system will continue to offer CBT only and no testing, no treatments other than CBT.

The influence of Wessely reaches everywhere. Over here our government is saying, well, testing is expensive. Let's not test these people and let's offer these patients CBT so they know how to cope.

The very severe are left behind or are thought to do 'gentle exercises'.
Physcians at the clinic perform medical exams. You know: blood pressure, checking the heart and the lungs. Checking the CBC. Liver and kidney function. Absolutely no viral titers, no nk cell function, nothing that is specific to our illness. If they don't test it, then it doesn't exist. If it doesn't exist, then it must be in your head. Then they discuss what treatment is available. Coping therapy. Soft therapies. Meditation. Gentle exercises. Seeing a naturopath. Acupuncture for pain (absolutely no opioids, at all costs). Doctors get their paycheck. Patients get basically left behind.

Denial of competent medical care is criminal.

And since they have received good reviews on this program, they will continue on this path forever because this is cost effective.

I know @SOC you have access to very good medical care. That should be the start for patients with lifelong illnesses. Patients who have access to most excellent medical care do better than patients who are forced into CBT, the good, the bad and the ugly kind.
 
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SOC

Senior Member
Messages
7,849
@Kati, @out2lunch, I am not arguing in any way that CBT is a treatment for ME/CFS. It should never be offered as such. I did say so above. :)
Certainly CBT is not a treatment that will improve ME/CFS somatic symptoms, whether it is 'good' CBT or 'bad' CBT. To improve our health we need medical treatment, not psychology.
CBT should never be considered a treatment for ME/CFS, nor should it be recommended for all patients any more than it is recommended for every cancer or MS patient.
My only point is that there is such a thing as good CBT. It's useful for some things. It's not a treatment for ME/CFS, but it may be beneficial to some ME/CFS patients in some circumstances, just like other social services will benefit some of us some of the time. That doesn't make them treatments for the illness.
 

out2lunch

Senior Member
Messages
204
@Kati, @out2lunch, I am not arguing in any way that CBT is a treatment for ME/CFS. It should never be offered as such. I did say so above. :)


My only point is that there is such a thing as good CBT. It's useful for some things. It's not a treatment for ME/CFS, but it may be beneficial to some ME/CFS patients in some circumstances, just like other social services will benefit some of us some of the time. That doesn't make them treatments for the illness.
It seems you've misunderstood me. I know what you're describing. It's just in my experience, that particular form of CBT, the original therapy created by Dr Albert Ellis, is difficult to find these days in managed care settings, or from therapists who accept Medicare.

In my part of the world (San Francisco/Bay Area), less than 15% of psychiatrists accept Medicare, which is what you're stuck with if you're on disability. And the ones who not only take Medicare but who also accept new patients are not experienced nor trained in dealing with patients like us. The "good" form of CBT is difficult to find amongst any practitioners as it is. It's basically impossible to find amongst therapists whom you can afford to work with.
 

Simon

Senior Member
Messages
3,789
Location
Monmouth, UK
The biopsychosocial approach: a note of caution - George Davey Smith​

Summary with comments

[health warning: this talk was published in 2005 and delivered in 2002 so things may have moved on since then]


1: “The more we understand about many diseases, the simpler the models get”

I don’t think I’ve ever come across such an impressive critique of the biopsychosocial model before, and it’s astonishing that this talk from epidemiologist George Davey Smith was delivered way back in 2002.
Epidemiology is the study of the pattern of disease: who gets ill, when, where - and why

The talk was part of a conference titled “Biopsychosocial Medicine: An integrated approach to understanding illness”. And Davey Smith thinks this is the wrong approach – at least when it comes to understanding what causes illness. He argues that much of the evidence is based on spurious associations between illness and psychosocial factors. And that psychosocial treatments for non-psychological illnesses have been disappointing, largely because they are based on false premises. That might ring a bell for mecfs watchers.

Davey Smith agrees that psychosocial factors have important causal roles in mental illness. And they also affect mortality and disease outcomes for other illnesses, he says, through their effects on health-related behaviours such as smoking, drinking and adherence to medical care. But he doubts that psychosocial factors play a direct causal role in most illnesses.

Davey Smith quotes Engel’s seminal 1977 Science paper (pdf) that launched the formal biopsychosocial movement:
Predicated on a systems approach, the biopsychosocial model dispenses with the scientifically archaic principles of dualism and reductionism, and replaces the simple cause and effect explanations of linear causality with reciprocal causal models. Health, disease and disability thus are conceptualized in terms of the relative intactness and functioning of each component system on each hierarchical level. Overall health reflects a high level of intra- and inter-systemic harmony.

Davey Smith isn’t impressed, arguing that instead, “the more we understand about many diseases, the simpler the models get”. He cites the way cholera was viewed in the first half of the 19th century, contrasting “the complex, highly theoretical language of those who opposed the view that diseases like cholera were contagious was contrasted with the crude, reductionist tone of the contagionists”.

He prefers Susan Sontag’s view:
in "Illness as a Metaphor" Sontag said:
Theories that diseases are caused by mental state and can be cured by willpower are always an index of how much is not understood about the physical basis of the disease. The notion that a disease can be explained only by a variety of causes is precisely the characteristic of thinking about diseases where causation is not understood.

Returning to cholera, Davey Smith points out that many psychosocial factors were linked to cholera, but they didn’t cause it. [Miserable people were more at risk, because people who lived in insanitary conditions where cholera was rife were more likely to be miserable.] In a modern-day example, he points out that many psychosocial factors are associated with lung cancer through their association with smoking. But take away cigarettes, and the same psychosocial factors will not result in lung cancer.

[Cholera may be an old example for Davey Smith to choose, but it will have resonated with the audience because John Snow’s work on an outbreak of cholera in London in 1854 helped found the modern science of epidemiology. Not only did Snow’s careful statistical work on cholera cases help map the outbreak to the Broad Street water pump, but he used an experiment too. Snow persuaded the local council to remove the handle of the suspect Broad Street pump, forcing residents to get water from other sources. The outbreak stopped. The importance of experimental evidence to back up theories based simply on association is one of the main themes of Davey Smith’s talk.]

Continued below…
 
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Simon

Senior Member
Messages
3,789
Location
Monmouth, UK
...continued
2: Cautionary Tales – Peptic ulcers

The heart of Davey Smith’s case is highlighting how often in general associations between ‘risk’ factors and disease are spurious, and how the biopsychosocial movement had some major examples of this. He implies they should be much more careful in future about claiming psychosocial causes for poorly-understood illnesses.

Exhibit A is the famous case of peptic ulcers, long argued to be caused by stress until Barry Marshall showed them to be mostly caused by a bacterium, Heliobacter Pylori, work that won him a Nobel Prize. The other principal causes of peptic ulcers are now thought to be smoking and anti-inflammatory pain killers such as aspirin – but not stress.

Davey Smith points out that epidemiological work repeatedly fingered stress, including one seemingly well-designed study that gave an Odds Ratio of 20 for ‘life events’ for men as a ‘risk’ factor for peptic ulcers. He suggests the false results was because those who reported symptoms of peptic ulcers were also tended to over-report problems in other aspects of their lives; such reporting bias is a big problem in epidemiological work.

He highlighted another study that found peptic ulcers were more common among those who came from large families. Now this would be interpreted as evidence for transmission of infection (hygiene can be harder to maintain and disease can spread more easily with lots of young children living together). Instead, because of the prevailing belief in a biopsychosocial-like model, it was taken as evidence of psychosocial factors were at play and taken as “yet more ‘proof’ of the pre-eminent role of stress in peptic ulcer.” Other evidence from Birth cohorts that indicated infection in early life was instead interpreted as more support for the prevailing stress theory.

Some people at the time argued against this mind-set, says Davey Smith, including one Richard Asher: ‘It is now fashionable to put forward mental causes for those illnesses where physical causes have not yet been found, such as peptic ulcer’. Asher gave a colleague an article to read about peptic ulcer and its cause by psychological stress and asked, ‘Do you think that's a fair account of what people think?' The colleague replied, ‘Well, it's a bit stilted language, but yes, it’s a perfectly fair account’. Asher replied. ‘Actually, it was written in 1850 about general paralysis of the insane. And I merely substituted peptic ulcer for general paralysis of the insane’. Which just highlights how long this has been an issue in medicine.

Davey Smith doesn’t hold back in his criticism of the peptic ulcer debacle, pointing out how psychological treatments were claimed to be the answer but well-designed trials showed no benefit, including one that concluded that:
our study demonstrates a need for humility about the degree to which psychological interventions can effect powerful biological processes and impact on patient's lives

And Davey Smith argues that the focus on psychosocial theories actually held back progress:
All the pieces fitted together, including the identification of a bacterium, by the 1950s [bacteria were first associated with peptic ulcers in the late 19th century; first reports of successful antibiotic treatments came in the 1940s]. But the answer that could have led to an effective treatment of the disease was missed because of a particular model—essentially the biopsychosocial model—and the mindset that it generated.

[In the case of mecfs, in the UK particularly, the medical establishment’s acceptance of a biopsychosocial model made it harder to get funding for biomedical research, and perhaps more importantly discouraged researchers from pursuing the biomedical challenge.]

continued…
 
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Simon

Senior Member
Messages
3,789
Location
Monmouth, UK
...continued
3: Cautionary tales - Heart disease and bias (and the importance of objective measures)

Davey Smith gave plenty of examples of the problems with epidemiological evidence for biomedical work too, including the striking case of β-carotene, which is converted in the body to Vitamin A and had been repeatedly linked to heart disease. People with higher levels of β-carotene consistently have lower rates of heart disease. So β-carotene prevents heart disease? It turns out not: studies found that taking β-carotene over up to 13 years led to a small but statistically significant increase in heart disease.

It may well be that people with higher levels of β-carotene have them as a result of a healthy diet, and that the diet, not the β-carotene protects against heart disease. The point is the risk of ‘confounding’ in observational studies, where you are measuring a ‘bystander’ that just happens to be associated with the real cause of an illness (the real cause ‘confounds’ the study results). The answer, says Davey Smith, is to use experimental approaches to back up – or refute - the observational findings. HRT is another case in point: again it was linked with protection against heart disease in observational studies, again randomised controlled trials showed no benefit.

[diagram showing the problem of confounding, in this case how the link between coffee and cancer was actually down to the association of coffee-drinking with smoking, where the smoking caused cancer]


upload_2015-7-13_16-6-50.png

Another telling example is the link between car ownership and heart disease. Originally, car-ownership status was measured as part of the huge ‘Whitehall’ epidemiological study, with researchers suspecting car ownership would be associated with less exercise and so a risk factor for heart disease. By the time the data was collected, researchers (including Davey Smith) realised that car ownership was a marker for social class and this drove health risk (through, for example, behaviours such as promptly seeking treatment).

Car ownership turned out to ‘protect’ against heart disease, but again the problem is confounding, where car ownership is simply a marker for the real factor linked to disease. Davey Smith argues that many psychosocial factors suffer from the same confounding problem as car ownership:
If we randomized people to car ownership, would this reduce their coronary heart disease mortality? Probably not. But if, rather than asking people about car ownership, we had asked them about other socially patterned factors—for example, many of the stress measures we have heard about at this meeting—we would get exactly the same finding.

Such confounding explains why health advice has changed so much over the years – on salt and polyunsaturated fats amongst others – as early observational data suggesting a causal role for dietary changes wasn’t backed up by experimental evidence.

On to the final example, one of the Crown Jewels of the biopsychosocial model: the link between stress and heart disease. A series of studies had shown that higher levels of stress are linked with higher rates of heart disease – more specifically of angina (chest pains). However, when researchers instead focused on objective markers of disease (electrocardiogram abnormalities and death from heart attack), the association was no longer statistically significant. It seems stressed people are more likely to report chest pains, but not more likely to have heart disease.

And the evidence of psychosocial interventions reducing heart disease is similarly weak, according to the evidence reviewed by Davey Smith.

continued…
 
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Bob

Senior Member
Messages
16,455
Location
England (south coast)
Encore, encore!
Seconded. Thanks @Simon. Very interesting.

I love the bit about the 1850 document re "general paralysis of the insane". It would be interesting to get that document and substitute "general paralysis of the insane" with "ME/CFS" to see how it reads compared to the current psycho-social BS.

Some people at the time argued against this mind-set, says Davey Smith, including one Richard Asher: ‘It is now fashionable to put forward mental causes for those illnesses where physical causes have not yet been found, such as peptic ulcer’. Asher gave a colleague an article to read about peptic ulcer and its cause by psychological stress and asked, ‘Do you think that's a fair account of what people think?' The colleague replied, ‘Well, it's a bit stilted language, but yes, it’s a perfectly fair account’. Asher replied. ‘Actually, it was written in 1850 about general paralysis of the insane. And I merely substituted peptic ulcer for general paralysis of the insane’. Which just highlights how long this has been an issue in medicine.
 

Simon

Senior Member
Messages
3,789
Location
Monmouth, UK
...continued

4. Discussion: "I want to get the right answers”

As you might imagine at a conference organised for biopsychosocial enthusiasts, there was a lively discussion following Davey Smith’s talk.

The Chair, Professor Sir Simon Wessely, suggested Davey Smith had presented a popular but simplistic view of medical history:
in which we move implicitly from unknown diseases which are thought to be psychiatric and as we become brighter, better scientists they are finally accepted in the pantheon of real diseases. You should remember that there is an opposite trend as well, which you didn’t mention. You ignored the history of visceral proptosis, floating kidney, autointoxication, or focal sepsis, for example. There are also lots of other things that are seen as very clearly organic and which switch the other way.

@Woolie has pointed out that list of disease that were seen as organic and now are known to be psychological is still under debate.

Davey Smith’s response was focused on the evidence he’s presented: “My main point was about disease aetiology. As a disease epidemiologist I want to get the right answers about this”.

Professor Sir Michael Marmot made a lot of points which struck me as marginal, but he also said:
That’s why in my chapter I spent some time discussing the systematic review of the evidence that actually looked at validated endpoints. Self-reported measures of psychosocial factors predict validated diagnoses of heart disease and mortality

Davey Smith and Marmot are two heavyweight epidemiologists, and collaborators on the Whitehall 2 study: I’ve no idea what accounts for the very different views of the literature on this.

The final comment was from Professor Glyn Elwyn, who suggested the case for causal biopsychosocial factors may be weaker:
You raised very interesting issues about aetiology. We have heard other presentations about interventions. We may have to differentiate in the biopsychosocial model between aetiology, where it is a weaker kind of model and intervention for complex diseases such as back pain, cardiac syndromes, and depression.

Overall, I thought Davey Smith's critique was fascinating as well as highly readable (online), and just wish I'd come across it years ago. I've always been frustrated by the lack of robust intellectual scrutiny of the biopsychosocial model in the research literature but that's exactly what Davey Smith has delivered here.
 
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Graham

Senior Moment
Messages
5,188
Location
Sussex, UK
It's what statisticians call confusion between correlation and causation: there is, for example, in the UK a direct correlation between the number of consonants in the name of a month and the amount of rainfall, but renaming Junnnnne isn't going to open the heavens. In the case of John Snow, doctors were so convinced that miasmas were to blame (the foul stench from industries such as tanning) that they accused him of being in the pocket of the owners of such industries. His statistics were not generally accepted, and it was only when the stench in the Thames from so much sewerage became so bad that Parliament was forced to suspend its activities, and they commissioned Bazalgette to build a proper sewerage system, that Snow's ideas were accepted. It took 16 years.
 
Messages
3,263
I'm still really unclear what George Davey Smith's reason was for resigning from the JHP. I'm also unclear why he was there in the first place. His main research expertise is in another domain entirely.

I see that he has worked with Crawley, but in the one paper I saw that they coauthored, he had clearly had a strong influence on tempering some of the wilder claims. The paper reads as much more sceptical and cautious than the other work of Crawley that I've seen.

I've heard some things from Coyne about the resignation, but some of it sounds more rhetorical than factual. I asked on another thread, and @Jonathan Edwards saw it as a straight up case of Davey Smith supporting the status quo/his cronies rather than the truth.

I was just wondering if anyone had anything further to add?
 
Messages
13,774
I was just wondering if anyone had anything further to add?

Only little things, like Crawley thanking Davey Smith for getting her into research, helping with early proposals, presenting him as a mentor, etc. Her inaugural lecture has some of that?

He signed that open letter complaining about Wessely's critics, along with Crawley and co: http://www.independent.co.uk/voices...-online-postings-2-december-2012-8373777.html

There are enough things like that, along with his failure to speak out against PACE, Crawley and the way critics have been smeared, to make me think he's an arse-hole.
 

daisybell

Senior Member
Messages
1,613
Location
New Zealand
I can only imagine he's been crawlied.....
It's a strange sort of brain-washing, that probably involves flattery and a fair amount of eyelash-batting. Like CBT, with the result that a certain person takes on saintly qualities and has to be defended at all costs. Rational, scientific thought has no place.