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

Cheshire

Cheshire

Senior Member (Voting Rights)


Objective: Despite the growing evidence of physiological and cellular abnormalities in myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS), there has been a strong impetus to tackle the illness utilizing a biopsychosocial model. However, many sufferers of this disabling condition report distress and dissatisfaction following medical encounters. This review seeks to account for this discord.

Methods: A narrative review methodology is employed to synthesize the evidence for potential iatrogenesis.

Results: We identify seven potential modalities of iatrogenesis or harm reported by patients:

  1. difficulties in reaching an acceptable diagnosis;

  2. misdiagnosis, including of other medical and psychological conditions;

  3. difficulties in accessing the sick role, medical care and social support;

  4. high levels of patient dissatisfaction with the quality of medical care;

  5. negative responses to controversial therapies (cognitive behavioral therapy and graded exercise therapy);

  6. challenges to the patient narrative and experience;

  7. psychological harm (individual and collective distress).
Conclusion: The biopsychosocial framework currently applied to ME/CFS is too narrow in focus and fails to adequately incorporate the patient narrative. Misdiagnosis, conflict, and harm are observable outcomes where doctors’ and patients’ perspectives remain incongruent. Biopsychosocial practices should be scrutinized for potential harms. Clinicians should consider adopting alternative patient-centred approaches.

  • Implications for rehabilitation
  • Patients with ME/CFS may report or experience one or more of the modalities of harms and distress identified in this review.

  • It is important health and rehabilitation professionals seek to avoid and minimize harms when treating or assisting ME/CFS patients.

  • There are conflicting models of ME/CFS; we highlight two divergent models, a biopsychosocial model and a biomedical model that is preferred by patients.

  • The ‘biopsychosocial framework’ applied in clinical practice promotes treatments such as cognitive behavioral therapy and exercise therapy, however, the evidence for their success is contested and many patients reject the notion their illness is perpetuated by dysfunctional beliefs, personality traits, or behaviors.

  • Health professionals may avoid conflict and harm causation in ME/CFS by adopting more concordant ‘patient-centred’ approaches that give greater prominence to the patient narrative and experience of illness.
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https://www.tandfonline.com/doi/abs/10.1080/09638288.2018.1481149?journalCode=idre20
 
Does anybody have access to the paper? [Edit 2018/07/06: full text now available:
https://www.tandfonline.com/doi/full/10.1080/09638288.2018.1481149?scroll=top&needAccess=true]

I find the abstract very promising.

I am a bit worried about this, though:

"There are conflicting models of ME/CFS; we highlight two divergent models, a biopsychosocial model and a biomedical model that is preferred by patients"
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Yes, I too reject the BPS model, but would not reject an BPS apporach per se, if it weren't presented as a "model", especially a model of causation how it is commonly applied to ME.

I wouldn't reject a biopsychosocial approach of my illness, though, when the 3 columns of the model would be addressed appropriately, i.e. the P part being probably, and formemost the S part being strongly affected by the chronic disability caused by the B part, and not the other way round.

Don't know if an BPS approach like this exists at all in the medical world, but would be interested whether there exist patients' narratives similiar to this idea.

Also am curious to know if the analyzed narratives in the paper included the rare cases of encounters with supportive doctors or whether the "preferred model" is only articulated as a desire? (not because I am obsessed with positivity, but to demonstrate that it actually is possible for doctors to do no additional harm.)

(Edited for clarity.)
 
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Keith Geraghty's papers are usually very good. My problem is often the 'academic speak' he has to write them in to get them published.

I'm having trouble getting my head around some of what this abstract is actually saying. For example I have no idea what 'difficulties accessing the sick role' means.

And some parts could be read as saying we don't like the BPS approach because it implies ME is psychological. I do wish academics were allowed to spell it out more bluntly: We don't like it because it's ineffective and harmful.

I know it's unfair to niggle, but so many people just read abstracts, and you could be left with a confused picture from this.

I expect the paper itself is very good. I trust Keith Geraghty to know what he's talking about.
 
The paper is much better than the abstract and should be of use in the forth-coming NICE review. It clearly shows that patients are experiencing and reporting harm as a result of the BPS model.

The term 'bio-psycho-social model' can be interpreted so many ways, most of which seem perfectly sensible, progressive and so very hard to argue against. But, as Keith points out, the BPS model for CFS, is in fact narrow, prescriptive and dismissive of patients' experiences.

I wonder if we should not accept the view of the Wessely school as being appropriately termed a BPS model. Rather, it is a Psychosomatic model or a Dysfunctional Beliefs and Behaviours model. Perhaps if we called it what it actually is, the harm that flows from it would be easier to see.

edit for a typo
 
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Hutan said:
The term 'bio-psycho-social model' can be interpreted so many ways, most of which seem perfectly sensible, progressive and so very hard to argue against. But, as Keith points out, the BPS model for CFS, is in fact narrow, prescriptive and dismissive of patients' experiences.

I wonder if we should not accept the view of the Wessely school as being appropriately termed a BPS model. Rather, it is a Psychosomatic model or a Dysfunctional Beliefs and Behaviours model. Perhaps if we called it what it actually is, the harm that flows from it would be easier to see.
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I'm with you. It's hard to argue against because it's unobjectionable at first glance. It sounds to the uninitiated like a perspective (even though it says model - it's not) that tries to provide a corrective to purported overly-narrow 'biomedical' views of illness and approaches to treatment. Other than that it doesn't really make specific assertions. But the quote provided from Moss-Morris -
It is unlikely that CFS can be understood through one etiological [mechanism]. Rather it is a complex illness....CFS is precipitated by life events and/or viral illness in vulnerable individuals, such as those who are genetically predisposed, prone to distress, high achievement, and over or under activity. [There is a] self-perpetuating cycle where physiological changes, illness beliefs, reduced and inconsistent activity, sleep disturbance, medical uncertainty and lack of guidance interact to maintain symptoms.
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is full of very arguable (but irresponsibly unsubstantiated...) assertions. When Sharpe twitters something like 'bps is widely accepted stop bitching' he's hiding these sorts of assertions behind something unobjectionable and - I like your word choice - 'progressive'. To me, BPS for ME/CFS really is just a euphemism for psychogenic. I would call it the psychogenic model. Or psycho-perpetuated.

On the other hand I'm not sure what good BPS does in other diseases. If it's only used mischievously, it needn't be saved and enough people are pretty capable of understanding the euphemism if it's explained.
 
Maybe now that people are more open and supportive of people who have mental illnesses it could be that needing to look at everything through BPS lense to “make sure the psychological factors are considered” can be pushed back on as outdated and have gone too far in psychologising everything if people have health issues they should be taken seriously whatever type of health problems they are. Look at each person as an individual and work with them on their actual issues.
 
Hutan said:
I wonder if we should not accept the view of the Wessely school as being appropriately termed a BPS model. Rather, it is a Psychosomatic model or a Dysfunctional Beliefs and Behaviours model. Perhaps if we called it what it actually is, the harm that flows from it would be easier to see.
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"Psychosomatic" is a word that should be avoided, as advocates of this approach have rebranded it so that it merely refers to the psychological component of any disease.

"Dysfunctional Beliefs and Behaviours Model" is good. And gets around that whole psychology vs/ physical thing.
 
Woolie said:
"Psychosomatic" is a word that should be avoided, as advocates of this approach have rebranded it so that it merely refers to the psychological component of any disease.

"Dysfunctional Beliefs and Behaviours Model" is good. And gets around that whole psychology vs/ physical thing.
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It doesn’t matter how beautiful the words are. They are aimed at denying people from competent medical care. ‘Holistic’ is currently being used instead of bio-psycho-social. It caters to the current demand, and it fools people to believe they are receiving good care.
 
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Milo said:
It doesn’t matter how beautiful the words are. They are aimed at denying people from competent medical care. ‘Holistic’ is currently being used instead of bio-psycho-social. It caters to the current demand, amd it fools people to believe they are receiving good care.
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Perhaps I should clarify.

I was commenting on what words are most effective to use when critiquing these ideas. And 'psychosomatic' isn't an effective word, because it is commonly used nowadays to refer to the role that a person's mental state plays in any illness. Using it therefore diverts any points you make into endless arguments about mind-body relations and cartesian dualism, and away from the real problem - which is the idea that PwMEs have the delusional belief that they're ill.
 
Trish said:
For example I have no idea what 'difficulties accessing the sick role' means.
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I tripped up over that phrase as well. It makes me feel uncomfortable. My immediate reaction to the word "role" is that it is connected with acting i.e. someone is pretending to be ill.

Despite my first impressions I can guess what it means (I think) i.e. a person who is ill needs space and time to be ill. Getting that person to wade through appointments and interviews while being severely ill is simply torture.
 
Arnie Pye said:
I tripped up over that phrase as well. It makes me feel uncomfortable. My immediate reaction to the word "role" is that it is connected with acting i.e. someone is pretending to be ill.

Despite my first impressions I can guess what it means (I think) i.e. a person who is ill needs space and time to be ill. Getting that person to wade through appointments and interviews while being severely ill is simply torture.
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It means time to be ill, but also things like accessing benefits and support, if I'm understanding it properly.
 
MSEsperanza said:
Yes, I too reject the BPS model, but would not reject an BPS apporach per se, if it weren't presented as a "model", especially a model of causation how it is commonly applied to ME.
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Biopsychosocial approaches are very specific. They distinguish between disease, which is what goes wrong in the body and illness, which is the behaviour that comes from that. A behaviour can be changed by using psychological therapies. It has no place in medicine as it is a political tool rather than anything meant to help the patient.

A holistic approach, in the sense of taking a person's whole life into account can help a patient (someone with young children may need more help after an operation than someone who can rest) but that is not what this is at all.

One of it's main premises is that work makes people healthy so getting people back to work is a good thing. This has been used as the basis for the UK's government to bring down and restrict benefits alongside the reasoning that benefits "encourage" people to remain ill. If they had their way there would be no benefits for sick people for the most compassionate of reasons!

I am not very good at explaining my thoughts but going right back to the earliest days of BPS it was a whole theory of health and never a consideration of biological, psychological and social concerns around a patient. I could believe that some people practise it in a compassionate manner, but they are taught that pushing patients is helping them.

The thinking has permeated much of medicine and social work with universally dire results for sick people. It is now being rolled out for MUS and functional neurological disorders directly from the "model" for CFS by citing the successes they have achieved in that disease which is one of the reasons they can't admit to any failings. It promises lots and lots of savings for government but it will only help people despite itself.
 
I know Keith Geraghty is very good, and not looked at the whole paper yet so this may just be a context issue.

"There are conflicting models of ME/CFS; we highlight two divergent models, a biopsychosocial model and a biomedical model that is preferred by patients." [My bold]

The biomedical model is surely also favoured by a lot of scientists also?

Edit: Corrected misspelling of Keith's name :oops:
 
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