Interventions that manipulate how patients report symptoms as a separate form of bias

[Sean]

I offer a free organic disposal service loving home for all unwanted black rice pudding.

 

[FMMM1]

I had the same impression. Haven't looked at it closely but I have a suspicion that the "hard science" Benedetti refers to (his own work presumably) is rather weak.

I haven't seen anything yet that shows the placebo effect isn't simply due to response bias.

I haven't read the study being discussed - here's my "usual" rant!

There's a thread on a study which compared actimetry with self reported questionnaires. Questionnaires overestimate activity/improvement if you like.
Real world scenario:
You work in policy and you are part of a team overseeing a study your Government is funding i.e. to see if intervention X works [think PACE]. Your job is to ensure that you have good quality evidence to present to the Minister so you'd (logically) go for actimetry and quote the relevant study(s) which set out how this method is objective and robust/defensible. Study ends, you write a summary which e.g. says intervention wasn't shown to be effective ---- Minster, on the face of it, has two options - highlight that the available evidence does not support the use of this treatment or say nothing.
Problem is our experience doesn't look anything like that scenario - poor quality studies just keep getting funded by the UK Government.

As for why questionnaires are crap, that seems to be irrelevant --- I think it could be the Hawthorne effect* and that in turn reflects inadequate blinding in studies [raised by Professor Hughes, Galway University, and I guess many others] - but I'm not sure you could ever blind a CBT/GET study effectively. @Simon had a really simple summary - unblinded then use objective outcome indicators, blinded then subjective indicators OK (you have an adequate control group).

Bottom line is if there's a method which works [actimetry] then why consider why the other method doesn't [questionnaires]?
*https://en.wikipedia.org/wiki/Hawthorne_effect


@Keela Too @Caroline Struthers

 

[Mich]

Hi. I've very much enjoyed reading through this forum so far. There are some extremely intelligent and knowledgeable contributors. I'm truly humbled to allowed to voice my meager opinions on the same platform.

Note: some of this is reflective of my spouse's opinions, as I read some of it aloud to them to get their opinion too.

Also: I'm aware of how old this post is, but I decided to start from "the beginning." I've also been reading new posts as they've come in since I joined, and from what I can tell so far, a lot of it's still relevant.

Caveat: I do have some college level education in psychology, and have found CBT and similar modalities to be helpful on occasion (especially REBT--but dicidely not anything bearing traces of Aaron Beck's CBT, with the exception of some of David Burns' stuff). However, for the most part, I would not call myself a proponent of CBT genrerally, despite my dangerous love affair with William James and incongruous fascination with the historical roots of "New Thought." But they way the coporate world glommed on to CBT (and it's cousin during the mindfulness hysteria of the Y210s), and the way Beck just adjusted his bow-tie and with a twinkle of they smiled away through it being co-opted by the business rats, and the ogseqious entrepreneurs and sycophant venture capitalist was such a vomit show.

My spouse, OTH, still denies it has ever done anything for their pain, PEM, or the deep grief and sorrow over mourning the loss of living much beyond the bedroom or our flat; yet, even then, once in a while, they'll begrudgingly admit that REBT has helped them now and then with their "stinkin' thinkin,'" For the most part, though, if it's brought up, they maintains that, "it's a bunch of fucking bullshit."

...."self-efficacy", which we know very well means not trying hard enough but they just pretend they don't mean that, even though we all know they do and so do they.

That's not how Bandura meant it. Do you mean like on self report questionnaires, and in interviews and such? This is an old thread, so maybe it's different now?

@Barry:

So to me the fundamental problem is that CBT and GET are formulated to be bias-inducing treatments, it's their very purpose. So it is hardly surprising they induce bias in the way people think, and to self report with significant bias on their physical illness.

Though no two CBTs were created equal, they're all against any type of bias. They aim to reduce or eliminate bias.

I like this. Or maybe "treatment-induced cognitive bias"

Then why not go for broke and call it iatrogenic bias or maybe even just (a sub-species of) iatrogenesis?

Or we could just call it what it is.....loading the dice. Loaded dice bias?

Except that we'd be committing a stereotyping or caricaturizing fallacy.

...So there are 3 stages:
1. Change your beliefs about your symptoms
2. Change your behaviour by increasing activity
3. Be able to sustain increased activity, and thereby recover back to normal fitness and employment levels.

For my partner, there was also a fourth stage, which involved returning my blank "fear-avoidance, "Questionnaire" to their physio's admin team, and if they asked why they didn't fill it out, being prepared to say, "Because I'm not going to let you use your misunderstanding of Bandura, social learning theory, CBT, etc... as a victim blaming, gaslighting instrument and down-the-road documentation that I'm non-compliant when your PT fails, which it' s about a coin flip that it will." Luckily it only came to getting the office manager to admit I didn't have to have to fill it out to receive treatment simply by asking a her a few times if I had to fill it out.

@Adrian
...it is important for any assessment/review to understand what is being measured...."

In terms of research method and design, I've always struggled with this. If we understand what we're measuring, do we really need to do a trial----especially over already overly replicated trials? When do we move the knowledge our research project has given us from the category of "verifying" to "verified" or "good enough"? IMHO, may of the problems of medical and social science research stem from its base in inductivist methods, especially the hypothetico-deductive form. Inductivsm, despite all the sweeping under the rug/look over there shenanigans it's inspired since your eminent Mr. Hume initially complained about, induction is still one hell of a problem. Someone early mentioned incestuous reasoning or something of that sort? That's not an artifact of inductivsm. It shows our lack of imagination as a cognitive species, and especially of scientist, whether of the citizen or career variety. As one at moments in both worlds, but mostly in latter (especially now), I for one have not spent enough time asking how can we do better when I was saying just look what these idiotic psychologists have done or projects.

@Adrian
....to distinguish between patients' interpretation/perception of their symptoms, and their reporting.....

True. But's let's not forget that this relates to other huge problems in science and epistemology (which involves the limits knowing), and it's why we still have other even bigger problems in these fields, like the pragmatist's rejection the object/subject, fact/value, rational/irrational dualisms Let's also not forget that this very problem brought us Skinner, and there would be no CBT without his contributions. In the case of science, we don't have a pendulum uni-directinally swayng to and fro at a stead rate, but several pendula at different speeds and sizes going all at once.

@Invisible Woman: So even before they participate in a study patients are primed to believe if only they do it right, have faith, recovery will happen.

GOOD CBT therapy ALSO essentially involves learning how to accept and cope with recovery when it does not happen without self blaming.

 

[Jonathan Edwards]

That's not how Bandura meant it.

But how Mr Bandura wanted to mean it is not the issue. It is how it is used.

Though no two CBTs were created equal, they're all against any type of bias. They aim to reduce or eliminate bias.

The creators of CBT may have this belief but the poster is right. CBT is designed to bias. Peter White of the PACE trial actually wrote this in a paper with Hans Knoop - that CBT works as a placebo. If the people who have promoted CBT for ME/CFS believe this is what they are doing then that is what they are doing.

It is not what is usually meant by iatrogenic because we are not talking about causing harm and why use jargon when you can use English?

If we understand what we're measuring, do we really need to do a trial-

Yes, because you need controlled observations even to apply inductive reasoning. Hume was worried that even if you repeatedly observe one thing under one set of conditions and another under another set you cannot deduce causation for sure. If you don't even have another set of conditions to check a negative finding on you have no reason to deduce anything at all.

But's let's not forget that this relates to other huge problems in science and epistemology

It might relate to the sort of armchair semantic debates you mention but in medical science the situation is uniquely bad for psychological interventions - for all the reasons the thread posters have given. I spent my life designing, executing, reviewing and making use of trials. Bisas problems crop up all the time but this is a unique situation where users admit that their treatment is designed to bias yet refuse to admit that there is any bias. The contradiction explicit in White and Knoop's paper shows just how little these people understand about what they are doing. And from what I have seen this is a completely general problem for psychological therapies.

 

[rvallee]

That's not how Bandura meant it. Do you mean like on self report questionnaires, and in interviews and such?

More of a general use of the term in how it's applied to chronic illness some perceive as psychosomatic. There is this widespread idea that, since there is "nothing actually wrong" with us, absence of evidence being used as affirmative evidence, then all we pretty much lack is something that can be lumped into the concept of self-efficacy. This is not about CBT but rather the generic biopsychosocial/psychosomatic models.

This idea that we're just people who "can't cope with modern society" is common in the literature, has been around since before electrification, no less, we should be be able to just do normal stuff, but we don't, because we lack this "self-efficacy". We should be able to "pick ourselves up", but we don't because *gesticulates widly* reasons.

Problem is that in the general area touching the problems medicine hasn't got a handle on, words are routinely twisted to mean something different. It's a big problem because it's used explicitly to hide the true meaning. It takes a long time to accept that this is really how it's done, and it's hard to point at specific examples precisely because deceit is the point.

This is an old thread, so maybe it's different now?

Sadly not. This thread contains a great example of how it plays out, here on the usage of the word 'functional', where it's explicitly admitted that it's a preferred term because more patients think it means the opposite: https://www.s4me.info/threads/diagnostic-labels-in-functional-disorders-2026-novak.48670/post-672279.