ME/CFS and the biopsychosocial model: a review of patient harm and distress in the medical encounter - Geraghty et al. 2018

https://twitter.com/user/status/1019380900495228928

 

I'm no expert on the biopsychosocial model, but people like Simon Wessely and particularly Peter White are big proponents of it and have recommended restricting access to such payments so I'm not sure one can give the biopsychosocial approach much credit here (not that you explicitly did so but I just thought I would say this). Mansel Aylward is another person who comes to mind with similar views

 

https://twitter.com/user/status/1019384236900577280

 

I mostly agree but I have a worry about this. The current bps euphemism/equivocation dynamic allows a sort of doublethink that patients are severely deluded - causing severe functional impairment via unhelpful beliefs of non-psychogenic causation - but also that it's not that big of a deal because the whole thing can be pretty well addressed via CBT/GET.

If the assertion of delusion were totally out in the open, then as long as that paradigm retained institutional influence coherent action by the state would be to impose some form of institutionalization on (more) patients.

On the other hand, at this point it might all look so ridiculous, or at least distasteful, that it would aid in destruction of the current 'bps' paradigm and construction of a more salutary paradigm.

My agreement is that 'BPS' right now is the Fertile Crescent of euphemism and equivocation, which have no place in the scientific process, period. To me this principle stands with regard to clinical care. One can be tactful and sensitive while being honest and not bullshitting patients. There will be exceptions in compelling situations of psychosis or other intellectual incapacity (although any guardians should be dealt with honestly). This may sound like a lot of wiggle room that can be open for abuse but I think declaring someone insane is itself a pretty grave assertion that forces a medical professional to put a fair amount on the line.

 

hi Tom, the Wessely and White type of BPS (precipitating and perpetuating factors) are one dimension of BPS. From my nursing training and likely from that OT on the ME association website, bio-psycho-social simply means that the whole aspect of the person is cared for, not just the biological needs. It means that while someone is caring for someone newly diagnosed with cancer and giving chemo, you assess for adjustments to new diagnosis, you assess for how the family is adjusting, and you also notice and address issues that may affect this person’s and their families’ capacity in coping and having their needs met.

This is from a nursing perspective.

So there is several dimensions in what is called BPS. In health care professional training, you learn to factor in everything into the continuum of care and I believe this is what Tina may have tried to say. Unfortunately the multi-disciplinary approach is centered towards the psycho-social (with most ofmthe bio stripped away). This is where we are at in Canada.

 

I think you're right. I'm pretty sure Tina was talking about integrated care, which addresses medical, psychological and social needs. As a non-nurse, my best experience of this type of care was my postnatal care, where visiting midwives came to check on my baby's health, but also attended to my mental state and my family support network.

It was great.

But the term BPS has now been so misused of late that it confuses and misleads rather than clarifies. So I think its time to let that particular word go.

 

Having read through this thread I feel a need to stick up for Tina as I think some of the comments have been unfairly harsh to this person who, presumably, is also just trying to make sense of things.

The terminology put forth by the CFS BPS people is very obfuscatory and that can make it difficult for anybody to parse. A biopsychosocial approach to treating CFS would absolutely be fine if by bps you meant the sort of thing @Milo has been kind enough to share. It makes a lot of sense to me in Tina's particular area of rehabilitation where there is a physiological event and then a recovery process that apparently can often be greatly aided by physical therapy - which is a behavioral intervention that people will be intrinsically motivated or practically able to do to varying degrees.

I don't know what her experience is with the disease and treatment has been so I think it's unkind and unproductive to steamroll her for posting an earnest perspective that happens not to line up with the general consensus here.

Yes, I chide. I disagree with basically the entire response but I don't find it unreasonable or in bad faith or otherwise worthy of scorn.

________

Points from Tina's response I'd like to address:

"the fact that most health professionals ignore the “bio” part of the BPS model is not a fault of the model but of its application."

-I don't find this reasoning compelling. Many 'perfect' models go by the wayside for practical reasons. 'From each according to his abilities, to each according to his needs' - theoretically perfect, disastrous in practice, and don't tell me they just didn't execute the plan properly. It may be that the temptation to psychologize is too great and so a paradigm encouraging such will tend to exacerbate this problem. I personally think the historical evidence is for this latter interpretation.

'To suggest we go back to a medical model (used by most NHS GP’s) is throwing the baby out with the bath water. I am sure that most people with CFS/ME recognise that the biomedical cause and effect model is too limited to address the many varied symptoms of any complex long term illness, including ME/CFS.'

-I think the argument against a narrow biomedical approach is a straw man. I can't say whether or not BPS was needed to provide a corrective when Engels first wrote, but it's definitely not now. In any case, at present it seems to be the opposite; everything is overpsychologized, blamed on depression, stress, suppressed memories, conversion disorder, vague existential malaise - with impunity. Even when it comes to things like cancer! - That's totally off the rails! If any corrective is needed it's in the opposite direction.

 

Don’t get me wrong though. It is coming from a nursing perspective. When I visit a doctor, it is because i want my medical issues addressed. I expect medicine, not psychology, not plattitudes such as ‘you have to meditate, healthy mind, healthy body’. From my perspective, family practitioners have no idea what to do and they are not interested in learning. There is no medical home for our disease, which leaves ample room for psycho-social approach and alternative approaches.

As a nurse, I have experienced what a medical specialty does for a disease. Journal clubs, medical conferences, clinical trials, residency and fellowship programs, it all aims at improving the field, and patient outcomes. It makes the physicians experts in their fields and training the younger generation will yield more specialists, some being clinicians, some being researchers.

In my view, physicians should really focus on what is most needed which understanding the biology disease through research and developing the field, through seeing patients with ME on a full time basis, and networking with other physicians seeing patients with ME full time. This is what our field needs.

What is not needed is developing programs based on CBT, group therapy, patient education, and calling this ‘medical care’ because it’s not. Imagine offering such program to a group of patients that is struggling to get groceries and get food on the table, and they are expected to attend weekly sessions for months on end? This is happening right now.

 

I see. The one thing I would say is that I see general practitioners/primary care physicians largely as hybrid clerk/technicians, highly trained to be sure but not necessarily scientists per se; only a few will contribute significantly to the scientific understanding of any disease or its treatment (I think).

What I would like to see from them scientifically is to advocate for their patients with ME/CFS or other non-understood conditions by calling for that research, pushing for it, helping to facilitate it. I think this is related to what you're getting at. I have personally found it frustrating that doctors I have encountered seem so frustrated by always encountering 'chronic fatigue' patients yet never seek to learn more or take any proactive action whatsoever.

At the moment though clinically they don't have any more to offer that actually treats the illness than a nurse or anyone else. They need to have the wisdom, humility, and critical thinking to understand this, which leaves them offering... psychosocial support - helping family understand the illness, facilitating access to social services... so the food does get to the table, people are isolated as little as possible, can accomplish as much as allowed by their condition... essentially make things as good or un-bad as possible. That could accurately be called biopsychosocial.

Yes, I've been in the worst way and encouraged to go to CBT and exercise more when all I could do during the day was sit up to eat and go to the bathroom. That is... I don't even have words for that.

 

That is exactly what is needed. Instead of sending the patient home and cash up their check, for once, they could speak up. Their voice can be powerful, if they use it.

It reminds me of when the doctors decided to speak up about the fact that refugee had to pay for health care. They stood up and said no, that it is a public health issue, and that refugees needs access to free health care just like the rest of us.

Our problem remains that we do not die, and after repeated office visits that lead nowhere, the ptient simply gives up going to the doctor. In their eye, the problem is solved - not.

 

I get it. I respect the demands of the job and I wouldn't expect more than a handful of doctors who become highly interested in the topic for some particular reason to spend hours making some sort of large contribution of their effort. At the same time I think it's not too much to do for most to simply register up the hierarchy that there is a big issue here and current measures are not doing well for people. It doesn't take a lot to 'call for research' and even 'pushing' might not entail a ton ('facilitating' would be more of a dedicated effort). Lots of very small positive contributions and nullification of negative contributions could be a huge boon.

 

The whole aspect of a person belongs to that person, they seek medical objective treatment in something like cancer not state appointed assumed authority making presumptions that they need anything else from you unless they ask for services.

I think the notion of good BPS and bad BPS is people lower down the BPS chain of command trying to persuade themselves that its not them its the others at the top who have got the model wrong. Its somewhat like CBT, nobody knows what the bloody hell it is but everyone claims its only them that is getting it right.

Social and disability support can easily be summarised by the treating doctor, the problem is with the BPS model is that many doctors refuse to write supporting letters for such services or simply lie in the letters they do write. This leaves a layer of nonsense pain, fatigue and rehabilitation clinics underneath that have to justify their existence to keep the people there employed. I am not saying they dont do any good logistical support ever, but I think many people who work in such places are just in cognitive dissonance over the value of what they claim to do.

If Medics and scientists did their jobs properly we wouldn't need the dumping ground layers underneath asking people condescending questions like how they feel about their illness and what effects it has on their families.

Judging peoples capacity to cope and judging their family also. One can well imagine how may times this has landed a family of a child with ME for example into a dangerous path.

What gives nurses the authority to do any of that anyway and believe that their own judgements are not based on prejudices or simple interference.

Please don't say, "its in our training".

 

Perhaps one way to look at biopsychosocial care is to not assume what is done in its name is good.

For example, giving or not giving disability payments is considering the social aspect, but it is questionable to say that they are both good.

Similarly considering family supports is a social aspect, but telling family members not to be supportive (as can happen with CFS experts) is not necessarily as helpful as telling them to be supportive

 

Personally I am of the persuasion that any service that claims to have expertise in assessing how someone is coping or uses within its model the belief that they have the right to ask about family members coping or just give themselves the right to "assess" them from the perspective that the service is the expert because they have "trained people", is very dodgy.

I would just tell such people to mind their own business. No doubt that would often get recorded on some risk assessment somewhere as non complient or obstructive.

I really think these notions are what perpetuates the "bad BPS" with the "good" BPSers just propping up the model overall.

If people need help with social support etc they can just ask for it, it shouldn't be assumed that its part of a disease model to be rolled out on everyone.

The notion that part of the service for nursing is to "asses peoples coping and their families, their "adjustments to diagnosis", or how "the family is adjusting" just makes me see the bigger picture of BPS and how certain jobs can be used as feeders to dangerous models.

 

I agree that BPS in ME is for the most part, all wrong because there is a repression of the biological part and because there has been an abuse in P and S.

Anything else than bio-medical will be viewed as suspicious until we have a genuine interest and until patients receive meaningful care.

@large donner I am sorry but you have no understanding of the nursing profession. We are worth so much more than passing the bedpan and make the bed.

 

Do nurses just give themselves the right to do such assessing and who decides "they are doing it correctly"?

I didn't say otherwise I was making the point that common sense connected services should not be claimed to be part of the claimed disease process and how dangerous it is to assume positions over patients claiming that BPS is just misused by some "other" people.