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Dear Editor, As a psychologist/archivist who trained in behaviour therapy, I’d like to try and clear up some of the confusion surrounding CBT. Both Bruce Campbell (Nov/Dec 1998) and Emily Murphey (Mar/Apr 1999) were correct when they noted that CBT is a helpful treatment where illness is complicated by dysfunctional beliefs. As Murphey indicated, it’s one of many tools used with medically ill individuals whose irrational cognitions undermine coping and increase distress. What both Campbell and Murphey did not acknowledge, however, is that most of their medical colleagues do not advocate CBT as an optional extra, but as the basis of treatment. In other words, it’s not perceived as a therapy for those who require it, but as an essential part of rehabilitation (cf. Franklin’s letter Jan/Feb 1999). The view that CBT is appropriate for every person with CFS is based on a theory proposed by British psychiatrists. To cut a long story short, this suggests that fatigue may be triggered by a virus, but that it is largely perpetuated by dysfunctional beliefs. For instance, it is claimed that all patients attribute the exhaustion and weakness to a disease for which the treatment is the avoidance of activity*. Since the psychiatrists consider fatigue to be the result of deconditioning, sufferers are encouraged to increase their activity levels at a predetermined rate. If they are really ill, they can stay at the same level for a while, but they should not reduce what they do, let alone stop. This particular form of therapy is called ‘graded exercise’. In my opinion, it’s unfair to dismiss the patients’ lack of enthusiasm for CBT as a sign of ignorance and prejudice. Regular readers of the Chronicle know about the limitations of the CBT theory, for instance, through the articles by Jason and Friedberg. They’ll also be aware of the controlled trials which did not find CBT to be effective, and about the dangers of exercising beyond fatigue. Unfortunately, a lot of doctors do not have such balanced information. If you read the medical journals, you’ll notice that most accounts of CFS include highly uncritical assessments of CBT, often focusing on the few studies which support its use but downplaying or ignoring those which don’t. In other words, there may be some inaccurate beliefs about CBT, but these are not just limited to patients! I would also like to challenge Campbell’s description of his treatment as a type of CBT. In my view, his multi-dimensional approach has more in common with the self-management programmes advocated for cancer, than with the CBT-based treatment described by Sharpe and Deale. Moreover, it should be noted that CBT is not the same as supportive counselling, nor a general term for teaching patients coping skills. To refer to CBT in connection with the latter pathologizes what are often normal and understandable reactions to a difficult situation. It also fails to distinguish between inadequate coping efforts due to a lack of knowledge, and those resulting from disordered thinking because of misleading information or psychological morbidity. Finally, I noticed a reference to graded exercise ‘as tolerated’ in the Readers’ Survey. What does that refer to? ‘Graded’ implies that exercise should be timed according to a predetermined plan, not the presence of fatigue. In other words, the aim is to increase what you can tolerate, so when the going gets tough, the idea is to keep going. Determining activity levels according to symptoms is usually described in the literature as gentle activity within limits, paced activity or pacing. I’ve summarised the arguments for and against CBT and graded exercise in more detail elsewhere. With best wishes, Ellen Goudsmit PhD C.Psychol. Editor, ME and CFS Capita Selecta Quarterly
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