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5th Apr 2014 from TwitLonger

#mecfs A CBT Model of Understanding disappearing Google Books

Biopsychosocial Medicine

An integrated approach to understanding illness

Edited by Peter White

http://ukcatalogue.oup.com/product/9780198530343.do

Biopsychosocial Medicine: An Integrated Approach to Understanding ...

http://books.google.co.uk/books?id=chwtWAt76JoC&pg=PA1&lpg=PA1&dq=biopsychosocial+medicine&source=bl&ots=KT1ELHRYzm&sig=LNbTek5zUie2JI_868zcR4O68sE&hl=en&sa=X&ei=1EU_U4CSD8mp7Qa26YHwCA&ved=0CJIBEOgBMAw

https://twitter.com/maxwhd/status/452089762136879104

[ ... ]


This book attempts to answer these questions.

It arose out of a two day con­ference held at the Novartis Foundation, in London, on the last day of October and the first day in November 2002.

Because the biopsychosocial approach is better established in psychiatry and healthcare for medically unexplained symptoms, we concentrated on examining the relevance of the biopsychoso­cial approach to chronic medical diseases.

The conference was a joint venture between the Novartis Foundation and One Health.

One Health is a not-for-profit company that was established in order to promote a system of healthcare based on the biopsychosocial model of ill-health.

The conference was co-organized by Dr. Greg Bock, Deputy Director of the Novartis Foundation, and myself, ably assisted by staff at Novartis.

Twenty eight international experts in the field were invited (see the list of contributors).

Twelve talks were given followed by an equal time spent in discussion.

This book includes those talks, edited and updated since the conference in order to incorporate the latest relevant research findings in the field.

The discussions and some of the presentations were audiotaped and transcribed by Jamie Cooke.

The discussions have only been edited for the sake of clarity, since I wanted to keep them as close as possible to the original discussions, in order to keep them as spontaneous as they were on the day.

Professor Peter White, Chairman of One Health December 2004

https://www.duedil.com/director/906430392/peter-denton-white


Dr Peter Denton White is British and was born in 1952. The first directorship we have on file for them was in 1999 at Added Value Advisory Services Limited. Their newest directorship was with One Health where they held the position of "Medical practitioner". The company was established 31 Jan 2002 . Peter has held 2 directorships, 1 of which are currently active, and 1 are previous.

Related Directors

Officer with / at

Professor Trudie Chalder One Health
Dr Brian James Marien One Health
Professor Christopher John Main One Health
Prof Robert John Preston Lewin One Health
Ms Caroline White Added Value Advisory Services Limited

http://positivegroup.org/who-we-are/

Advisory Board

Our multidisciplinary Advisory Team provides the latest expert knowledge and scientific advances from relevant disciplines including: cognitive and behavioural psychology, neuroscience, clinical and health psychology, fitness and exercise, nutritional medicine, executive coaching, leadership and change management.

Dr Brian Marien
MB BS DCH DRCOG MSc (Psychol) MRCGP

Professor Trudie Chalder
PhD MSc SRN RMN Cert in Beh Psychotherapy

Professor Tom Sensky
BSc PhD MB BS FRCPsych

Professor Paul Brown

http://www2.nphs.wales.nhs.uk:8080/PHWPapersDocs.nsf/%28$All%29/82FBCA831638266D80257C1D0040C3AD/$File/28%2015%20Declaration%20of%20Interest%20-%20Public%20Health%20Wales%20Board%20v1.pdf?OpenElement

Public Health Wales

Declarations of Interest

Interests Professor Mansel Aylward

Advisor: Atos Healthcare Ltd Clinical Governance Committe

https://www.gov.uk/government/organisations/independent-medical-expert-group/about/membership


The Independent Medical Expert Group advises the Minister for Defence Personnel, Welfare and Veterans on medical and scientific aspects of Armed Forces Compensation Scheme (AFCS) and related matters.

IMEG is an advisory non-departmental public body of the Ministry of Defence.


Dr John Scadding

Honorary Consultant Neurologist at the National Hospital for Neurology and Neurosurgery.


Professor Peter White

Professor of Psychological Medicine at Queen Mary University London and Honorary Consultant in Liaison Psychology at St Bartholomew’s Hospital.



http://ukcatalogue.oup.com/product/9780198530343.do

[...]

Wessely: Cancer patients do not lobby for psychologists because they believe that psychological factors are why they developed cancer in the first place (which is certainly progress given that in previous times there have been scientists who have made those erroneous claims). They do so because they feel that it is safe and permissible to engage with psychological therapies precisely because their doctors do not hold with psychosomatic theories of cancer. Once the physical basis of disease is established, then one can explore the psychological in safety, but not before.

Compare and contrast this with the well known reluctance of sufferers from chronic fatigue syndrome (CFS) to do the same.

Here is a group who are not demanding better access to psychotherapy.

Instead, the principal focus of some activists is the reverse—to reduce and even eliminate all traces of the psychological from the CFS clinic, and even the planet itself if some ultras had their way.

The difference between these CFS sufferers and those with cancer is the former are not confident that the somatic basis of their problems has been established beyond doubt, even if they are convinced that it will in time.

Worse, they suspect, and with good reason, that their doctors are not confident either, and if pushed might well endorse a psychosomatic contribution to ill health.

In these circumstances it would be foolhardy to lobby for better psychiatry, since that would only increase their sense of stigma and rejection.


Wessely: That was a powerful and uncomfortable paper. We should remember a couple of things, though. You presented a strong argument against hubris and accepting fashionable trends, merely because they are fashionable.

There will undoubtedly be many people, including, for example, those who one might call 'CFS activists', who would have loved every word you were saying.

There is a popular and seductive Whiggish 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.

Chalder: I find it refreshing to talk about physiological and behavioural aspects of development in individuals, given that I work in cognitive behav­ioural psychotherapy, where the emphasis today seems to be more on cog­nition.

I was brought up more in the behaviour/physiological paradigm. What is your perspective on how one should intervene and what would be the most powerful intervention?

Chalder: I could see the link instantly.

If you think about how easily con­ditioned we are as babies, this will influence our physiology and behaviour for the rest of our lives.

Rather than starting with middle-class businessmen, we should be starting with babies and children and following them up in order to understand more clearly the link between physiology and behaviour.

Cognition comes much later in one's development. Given that cognition develops so much later, how should we then intervene most powerfully?

White: I want to make a link between rats and humans


Marien: It seems to me that a lot of this boils down to a sort of dualism. We haven't really talked about Descartes.

Aylward: Yesterday we discussed some important issues, but today we have hit on what I think are the crucial issues.

These aspects of the biopsychosocial (BPS) model have had the greatest impact in developing social and welfare policy in the UK.

These techniques are simply described and one can commu­nicate them to our colleagues, and even our politicians, who sometimes find it difficult to grasp these issues.

This sort of work will strongly influence how social policy and rehabilitation will develop over the next year or so.

White: Exercise or activity programmes are the archetypal BPS interventions.

This was shown to us in our trial when we used graded exercise therapy in chronic fatigue syndrome.

We showed that if we improved exercise capacity or performance, there was a closely associated reduction in sub-maximal cardiovascular response to exercise. In other words, there was a physical change—they became fitter.

On the psychological side we found that getting fitter was not associated with feeling better.

The psychological improvement came purely from being exposed to the programme: a behaviour therapy of graded exposure.

Being exposed to the programme was the best predictor of feeling better and it wasn't associated with actually getting fitter.

There are two ways to change beliefs.

You can look at and change beliefs first using cognitive behavioural therapy (CBT), which leads to behaviour changes, which is perhaps is what happened in your programme.

The other way is rather than using 'C-BT', using instead 'B-CT': changing the behaviour first, which then changes the cognition.

We also found on the programme that social function improved as well.

The social side is that people on these programmes are getting out of the home and meeting people.

Lewin: Thirty years of research in cardiac rehabilitation shows that exercise programmes alone, although they restored function to the heart, had prac­tically no effect on return to work, anxiety, and depression.

It is a very seduc­tive idea, but in reality it doesn't work.

There is no long-term effect in terms of hard outcomes.


Aylward: This is largely because many of the studies have not actually included return to work as an outcome measure.


Lewin: They abandoned it deliberately because they weren't able to influence it.

White: There are two possible explanations. Perhaps there is a differ­ential effect in different diseases.

So, exposure is needed to the particularly avoided behaviour, which is exercise or physical activity in chronic fatigue syn­drome and perceived stressful activities in heart disease.

Or perhaps we need to look carefully at how an intervention programme is delivered for each disease.

Lewin: You may have delivered the exercise programme in a far more psy­chological way, with more understanding on the patients' part.

But purely physical exercise programmes do not have very much effect.

Wessely: The highly successful BM] trial of exercise was a CBT trial.

White: It was educational, telling people why exercise gets people better and then giving the exercise.

Wessely: We are talking about barriers. Michael Von Korff, you showed a very convincing relationship between fear avoidance and disability.

If I was one of my patients who saw that data, I would immediately say that is right and the reason would be because this is true.

That's the way it is.

I would say I avoid activity because if I don't, this is what happens.

This is the reality: I am more disabled because I am more sick.

This is the huge barrier that we haven't considered.

The people we see just don't believe us.

Wessely: We accept that. This is what we do in treatment programmes.

But we also know that even getting patients to see us is a challenge because of their fear-avoidance beliefs.

Sharpe: In relation to this, I'd like to get the word iatrogenesis on the table; doctors do cause harm by their psychological interventions as well as by their medical ones.

People often do not get consistent messages from their various medical attendants.

In fact, in the UK at least, there are substantial numbers of doctors and others who give people exactly the opposite advice, in terms of this evidence, that is, to rest.

When Simon Wessely is trying to tell his patients one thing, they can read something entirely different on the Internet or see someone else who will tell him or her exactly the opposite.

That inconsistency of apparently authoritative information is an important part of the problem.

White: I would like to make one point about the biology of placebos, which should help us to think about whether we go with either the psychosocial or bio­medical model.

Either would be a mistake, particularly when we are dealing with chronic disabling conditions.

The model is biopsychosocial and we mustn't lose the biology.

One example from the biology of placebos is a recent study showing that functional brain scans of placebo responders have changes in cerebral blood flow not seen in the non-responders.

In other words, here is a good example of how the psychological mind can affect the physical brain; we are back to the brain as the organ of the mind.

We have come full circle back to the BPS model.

Sharpe: I just wonder whether something has been lost in this 'broad-brush' pic­ture that portrays the general public as psychologists. Are there not others who are biologists and who don't want psychological issues raised? They might be expected to prefer narrowly focused biomedicine. Can you see this in your data?

[ ... If you read the popular press, it is all psychological]

Wessely: I absolutely disagree.

In the field we work in, the alternative views on chronic fatigue syndrome (CFS) are unbelievably reductionist.

Furnham: That may be an exception. Is there any other area where that is the case?

Wessely: There is a group of people who consult alternative practitioners because they want the most biological explanations about allergies, toxicities, and so on.

They see them in a political framework: it is all the fault of govern­ments and industry. But in those models there is no room for any psychosocial element.

Marien: Isn't that because they can't have a medical label? If you ask cardiac patients what they believe is the major cause of their heart disease they say stress, whereas if you as a CFS patient they'll seek a biological explanation.

This could be because they feel we are rejecting them as a group of people when they want a medical label.

Aylward: I know you were presenting this with a slightly jovial slant, but the message I got is that most complementary medicine practitioners are being duplicitous at worst and ingenuous at best.

In the same way as we find it difficult to find people to interview who are malingering and practising illness deception, has anyone done any work to look at the reasoning of the beliefs of people who do practise complementary medicine?

From what you said, it seemed that they were using fairground techniques.

Aylward: To reiterate what Simon Wessely said, many of those comple­mentary medicine techniques are not psychosocial.

They allege that they have a specific biological action.

Chalder: Have you done a regression analysis putting all the predictors of outcome in?

Chalder: I was just wondering whether sexual abuse was put into the model.

Chalder: Irritable bowel syndrome does seem to be one of those conditions that appears to respond to almost anything in terms of a placebo response.

Wessely: We have done a cohort study of members of the British armed forces.

When we repeated the same question about traumatic events 2 years later, we found their responses changed according to their current mental state.

The worse they rated their current health, the more adversities they recalled.

Wessely: But we find it in patients with chronic fatigue syndrome and fibro­myalgia as well. It is not specific.

Wessely: The bit where I can see there might be problems is with the actual interventions that your groups are proposing. You are proposing certain inter­ventions and you have a particular view of the world. You mentioned diet and exercise.

But what would happen if your group started to challenge these par­ticular treatment ideologies and, for example, said that they wanted to know how to get more benefits from the state?

They might agree that their problem is fatigue, but they may say that they think the solution is something different.

Wessely: As you turn over your flip charts you are going to come to some bits where some people in the room fundamentally don't agree.

They might say, 'I tried that and it didn't work for me: in fact, it made me worse'.

White: In this final discussion I think would be useful would be to outline the barriers that we have identified so far in our discussions and to explore ways round them.

I think we have agreed that the aetiological work is not imme­diately relevant to the biopsychosocial (BPS) model in the healthcare system at the moment.

It may be in the future.

Therefore what we need to concentrate on pragmatically is the use of the BPS model in healthcare.

We have already identified various barriers: lack of resources of time and money, lack of train­ing, emotional inhibition, and patient engagement inhibition.

It may be useful to discuss possible solutions to these.

Chalder: Rather than start with the physicians, which might be quite a dif­ficult task, we could make a start with youngsters in schools.

My experience is that they are much easier to educate and to treat.

The only barrier is the parents.

Once we have the child or older youngster on our side we are in a very good position. They take up the messages up very quickly.

Wessely: Mansel Aylward, you are involved with policy definitions. What have you heard here that might influence your secretary of state?

Aylward: I have been given a lot of information that reinforces some of the mes­sages that I have passed on to decision makers. I haven't heard anything startlingly new, but I am happy to have my views confirmed.

We have made some significant progress.

We had some great difficulty last year persuading certain people that the way forward in the more effective assessment of disability and its management in people on state benefits lay more with a BPS approach to rehabilitation, job retention, and recovery, than a focus on economic dis­incentives or wielding the stick approach.

There seems to be an antipathy in some parts of Government towards anything that is perceived as fuzzy or nebulous, without a hard evidence base.

If the BPS approach is perceived in this way and is competing for investment with hard policies focusing on bed occu­pancy and delivery of acute services, it is very difficult to get the Department of Health, among others in Government, to favour health-focused interventions and rehabilitation adopting the BPS approach.

But in recent months I'm begin­ning to see a change. The Department for Work and Pensions may now have been persuaded to invest in initiating pilot studies in various areas of the country, in particular involving benefit recipients with back pain and fatigue, to see if all the talk about the BPS approach has any basis in improving outcomes.

Wessely: What made some of the policy makers change their views?


Aylward: Systematic reviews of the literature garnering evidence to support the BPS concept.

Identification of best practices in using BPS approaches that improve function and rates of return to work, particularly in people with dis­ability caused by back pain.

Recent meetings in the form of focus groups of key opinion makers support with authoritative and expert opinion the value of BPS approaches.

There are going to be some developments soon

Wessely. What kind of evidence caused this change?


Aylward: The evidence which has been there all along.

The key aspect has been effectively communicating this evidence in a far more robust and authoritative way.

We also ran a series of workshops where we discussed and evaluated various approaches to facilitate return to work and to address the rising numbers of people in receipt of incapacity benefits.

Some £25 billion per year is being spent on state benefits resting either directly or indirectly on a medical basis.

The prospect of effective interventions that might reduce that expenditure are powerful catalysts for change.

Wessely: I once tried to add up the cost burden of a range of conditions and it comes to more than the gross national product of the entire western world!

Lewin: Yes. The study is looking at the possible cost savings. What would the Government gain if they were to spend more on these areas?

Mitchell: People are pretty limited in viewing government future budgets. They will escalate: that is a fact of life. Therefore, if you are going to add to this bill you won't catch the government's attention, even if you say you have the perfect cure, but that it will cost.

However, if you go to Gordon Brown (UK Chancellor) and say, 'We can prove to you that if we address this issue, we can save £2 billion', then you will have his full attention.

Aylward: That is the approach that has been taken, but not in such a robust fashion.

Fitzpatrick: ... Last night I picked up my e-mails and received a summary produced by the ME (myalgic encephalomyelitis) association of the report to the chief medical officer of that celebrated working group.

This is of interest.

The line from the ME association is that if you as a general practioner (GP) say you are sceptical about the ME label, the chief medical officer has stipulated how this must be dealt with.

This reflects the endorsement at the highest level of policy in the medical sphere of a disease label that is not supported by the evidence—it is a completely irrational formulation.

Aylward: It doesn't follow that all of that report is supported completely by everyone in government service.

The Department of Work and Pensions doesn't necessarily endorse all that is in the working party's report to the Chief Medical Officer at the Department of Health in England.

I am also mindful of the views of those who, as members of that group, distanced themselves from some aspects of the report.


Fitzpatrick: Nonetheless this is the line and it is very much promulgated that GPs should follow this. It is a consensus forged by excluding many of the peo­ple in this room who have been involved in this area.

This illustrates a big problem: the government are linking up with patient activist groups in rela­tion to this very significant area of medical practice to dictate a line of approach which is not actually going to be beneficial to patients.

Wessely: This is a problem that would need five separate conferences to address.

The fact that the response to the possibly non-existent problem in Middlesborough was lifelong counselling indicates that this course is still extremely popular, even if it might not be necessary in those particular instances.

Whereas some of us have worked with patients who are sceptical and frankly hostile to any sniff of psychological or psychosocial interventions, there is a much bigger world where there is sometimes the opposite problem: people are all too keen to make psychological formulations and interventions if only they have the opportunity.

Von Korff: Someone said earlier that research isn't going to carry the day.

Perhaps in the short term this may be true, but if this field doesn't start to do definitive trials and strengthening of the research base, we are dead in the long run.


Wessely: There is no dispute about that.

Some of the evidence doesn't trans­late into policy as quickly as we would like, but without the evidence I am quite sure that there would be no changes.

Evidence alone is not enough.

George Davey Smith wrote a good paper called 'Policy-driven evidence'.

This is when policy changes and people look for evidence to support the change that they have decided to make. Greville Mitchell: I think you should have the last word.


White: With the exception of Chapter 10, this book has been careful to avoid address­ing the issue of medically unexplained ill-health and mental disorders, because the BPS is important in addressing disability and improving quality of life associated with all chronic ill-health, whatever its provenance.

Having stat­ed this, there is an overwhelming amount of evidence for the utility of the BPS approach in both understanding and helping patients with mental ill-health and physical symptoms for which no explanation is apparent.

The latter includes common disorders such as chronic fatigue syndrome, chronic pain disorders, and functional bowel disorders.

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