BMJ: Chronic fatigue syndrome and Long Covid, moving beyond the controversy, 2021, Newman

Some psychotherapy is like that, like psychodynamic psychotherapy, but the CBT kind tends to try to be more scientific and medical. It's not clear to me how well it suceeds at that

 

Whatever the initial intentions were when CBT first became a thing, I fear it's now a confusing mess.

To be more medical and scientific then one would assume that involves very clear ideas about who gets what type, methodology and so forth.

In the hands of the BPS (& perhaps others I am unaware of) neither the patient nor their referring GP really have much idea what they're letting themselves in for.

Will CBT be supportive, aimed at helping to adjust to new circumstances or directive, seems to be based on the phobia model, addresses problematic thoughts and behaviour & may even have a GET component built in?

Then if it's individualised and different therapists have free reign to do their own thing this opens patients up to being forced through repeated rounds of therapy with no guarantee of outcome. For example, I've heard reports that the likes of PDW in his role as Chief Medical Officer to an insurance company have attempted to refuse claimants because they've had the wrong sort of therapy, not the sort his team deliver.

 

All this talk of individualised treatment makes me wonder.

As far as I know - & I may not be right in this - one of the reasons NICE were set up was to regulate not only efficacy & cost effectiveness of treat but also treatment safety.

If I am correct in my recall, part of this was in reaction to doctors having what might be considered slightly too much free reign. An extreme example of this was Harold Shipman who despatched a number of patients before their time.

New changes within the structure meant greater oversight on doctors' referrals and ability to prescribe.

One example I have fallen foul of is prescription of Circadin (melatonin). My GP wanted to prescribe it, thanks to trying it on a private prescription we know it's helpful for me and I don't seem to suffer any side effects. However my GP was not allowed to prescribe it on the NHS solely because I was too young.

If GPs aren't permitted to make judgement calls then why should this particular branch of medicine be given free reign?

If treatment is so individualized that two different clinicians would recommend completely different treatments to the same patient for the same health problems then how is it possible for NICE or Public Health England to assess whether it works, is cost effective & safe.

It flies in the face of all the changes that have taken place within our healthcare system over the last decade or so.

Edit spelling

 

It would seem we're going to have to get a grip on exactly what is meant by 'individualised' therapy. If that's even possible since the people banging on about it may be speaking in vague terms.

It would be good to understand if most other medical treatment can be considered to have an individualised component (my uneducated thought is that it does). So they may be blowing smoke by saying this when they mean nothing more than what is already normal practice for most of medicine.

In cancer for example there is standard treatment but also choices to make within that treatment (with the proviso that the patient has accepted to undergo some sort of standard therapy)

Maybe I'm confused about what is meant here in the first place and would be glad to be corrected but this 'individualised' bit just seems to be a distraction of sorts from the fact that there is underlying it a basic premise and standard treatment concept.

More research is required.

 

As usual, the main issue is language. "Individualized" to what exactly? It's not according to need, or evidence, or physiology, certainly not symptoms or disability. Or anything relevant to the patient. The simple truth is that what's individualized is the therapist's opinions and beliefs. They bring their own individual perception and apply it regardless of the context. They have their own program and scripts.

All of this treatment is "individualized" the way a candle has its wax painted and mixed. It may look different while unused, but in the end all it does is burn wax from a wick. The flame is the same color, temperature and everything else. And it burns and melts just the same whether it's red or green. A plain white candle will burn exactly the same as a Spongebob Squarepants-themed candle. And if you don't even put a wick inside, all it is is a stick of wax, not even a real candle. It won't even burn.

Basically: distinctions without a difference. It's all BS misdirection the same way some products are sold. When everyone has a "VIP" treatment, no one actually does. And that's a terrible feature anyway. Nothing useful is meant to be individualized this way, it simply cannot scale.

 

Yup. Every psychic séance is "individualized". So is every Feng-Shui, uh, assessment, I guess? And horoscopes, of course. Means nothing.

Meanwhile vaccines aren't individualized and that's a good thing because imagine how it would go otherwise trying to vaccinate a whole population while having to hum and haa about every case being different.

There's a reason we mass produce stuff, better stuff than has ever been produced by artisan hands. Because individualizing everything is simply not a desirable goal. Imagine a restaurant trying to prepare every meal from scratch with zero preparation. Would go out of business within a month. But the monopoly status of medicine allows it to fail endlessly because it can't run out of business. This is a known problem that frankly has a few toes in the tragedy of the commons.

 

First we had, supposedly, science based medicine. Then we had evidence based medicine. Now we have individualised medicine. Could it be diluted further? I probably shouldn't ask.

It will of course only work properly when there is no residual trace of medicine at all.

 

Individualized treatment is more complex and thus requires even more rigorous methods to assess treatment efficacy. Not less rigorous ones.

It's also untrue that individualized treatment cannot be tested. There is going to be some logic in how a treatment is selected or modified and this can be tested.

 

I'm not sure what progression you are referring to but historically, evidence based medicine was an attempt to overcome 'medicine by authority' with which it has met with some success. However there are some significant failings in EBM thinking and it was these that science based medicine was formulated to address. SBM remains a minority movement and EBM is the dominant philosophy of health care provision.

Individualised medicine is a marketing gambit and political soundbite, based very loosely on the notion that an understanding of genetics can lead to tailoring of treatments precisely to the requirement of the individual.

The Science Based Medicine website is a long established blog which publishes mostly critical and sceptical articles. It says this about EBM:

https://sciencebasedmedicine.org/hello-world/

 

I think @chrisb is right in his history. When I started medicine in 1970 we worked on the basis that we thought we had a scientific understanding of what was wrong with people, at least some of the time, and we guessed what was likely to help most based on the scientific analysis. We did that because there was precious little hard evidence. We also realised that some of the time there was some hard evidence for things for which we had no good scientific explanation, like the efficacy of gold salts in RA. But practice was 'science-based' without capital letters in the sense of being theory based.

Evidence-based medicine, as you say, came along with the idea that we actually need to check with evidence that the theory-based approach works in practice. So it was shown that giving people with acute nephrotic syndrome protein supplementation was a bad idea (which probably should have been obvious theoretically but wasn't to some).

Science Based Medicine with capital letters seems to be a small group of people who think they understand how to do medicine better than everyone else, and probably don't judging by some of the blogs I have seen.

What matters in the end is evidence when it is possible to define your context clearly enough - ideally backed up with lots of theoretical understanding when it comes to flying in the dark when the context is novel.

 

This is a bit bizarre considering most IAPT patients are given the same CBT regardless of their illness and Trudie Chalder said
"The term 'somatic symptom disorder' which is very controversial but I really like it.
I like it because the same model can be applied irrespective of the cause of the
symptom"

https://www.s4me.info/threads/cogni...20-goldstein-chalder.15251/page-4#post-273720

so much for individualised therapy.

 

It is merely the Procrustean variety of individualisation.

 

Yes. I hadn't remembered that. But it's a very good point. A point I think that can be highlighted to demonstrate that they are all over the place in order to protect their turf.

It doesn't matter what the question is or what the problem is their solution is the only thing that matters.

 

I agree that CBT is more practical (and why I found it more helpful than psychotherapy). But while they may borrow the outward forms and language of science, I don't know that it really is. I mean, is yoga science? We might use science to try (though mostly unsuccessfully) to study yoga, but yoga itself is not science. More practical, perhaps, than sitting meditation. But does it really tell us something specific about how the physical laws of nature work? I'm not so sure, nor do I feel confident that CBT does either.

 

from cbtwatch

IAPT’s Rigidity – The Antithesis of Personalised Care

http://www.cbtwatch.com/iapts-rigidity-the-antithesis-of-personalised-care/

 

interesting given what's just happened re the pause of guideline publication
"The course is currently offline while being reviewed to be in accordance with new NICE guidelines.

"
https://elearning.rcgp.org.uk/course/info.php?id=93

 

There are several glimpses that reveal that this was all going according to the process, many institutions were already prepared to follow the new guidelines. To cancel this at the last moment must have taken significant political pressure and, obviously, threats. We have seen Clare Gerada openly declaring her intent to use her influence to trash Cochrane when they were just about to retract the GET review, it's not exactly a secret that these people abuse their power to promote their self-interest.

We need to know the details of what happened, it must have been quite extraordinary and very significant.

 

This article (of which this thread is about, which I'd entirely forgotten about) appeared in a search for something else this afternoon, and it occurred to me that we so often pounce on the bits that we disagree with, but not the parts that are better? This extract from the grey box section stood out:

I was searching for it because I found her video on Managing Fatigue for the Oxford LC clinic (the bit run by Resp Med), and it seemed OK? So I guess I'm glad there are folks working at these clinics who are quietly just getting on trying to do the right thing (if that is the right thing?).

The other reason for the search was the suggestion that Sharpe was still actively involved in the Oxford LC clinic (I thought he'd retired?).