The ME Association position on CBT, GET and Pacing is made very clear in the summary of the MEA ‘patient evidence’ report on CBT, GET and Pacing:
In particular, in relation to GET, we have stated that NICE should withdraw their recommendation that everyone with mild to moderate ME/CFS should be offered GET.
We also believe that there should not be any further clinical trials of this type of activity management while patient evidence consistently indicates that over 50% of people with ME/CFS (including children and adolescents in the MEA report) report that GET has made their condition worse.
As noted in all the BBC press reports this morning, appropriate management of sleep, pain and activity (in the form of pacing – as was referred to by the young person who was interviewed for the BBC Radio 4 Today programme) are three key aspects of ME/CFS management.
And when done properly, these can all can be important factors in aiding any natural improvement to take place.
But they are not ‘cures’ for ME/CFS and do not help everyone to improve.
SOME PEOPLE DO FIND CBT HELPFUL, BUT…
As noted in the results and recommendations section in the MEA report, some people with ME/CFS do find CBT helpful when it consists of a package that helps people to cope with living with the emotional consequences of a debilitating illness like ME/CFS and includes sensible, pragmatic advice and information on activity, pain and sleep management (as some courses of CBT do).
But we do not believe that CBT, which is based on a flawed model of causation involving abnormal illness beliefs and behaviour, has any role to play in the management of ME/CFS.
And we would not approve of any research involving CBT that wanted to try and support this psychosocial model of causation.
THE UNACCEPTABLE FACE OF ME/CFS NEWS COVERAGE
Finally, to return to the BBC press coverage this morning, whilst it was encouraging to note that while it was being stressed on several occasions that ME/CFS has a biological basis/cause, it was completely unacceptable to then find that news bulletin coverage on BBC Radio 2 was then referring to an illness that caused children to miss school and have mental health problems.
Dr Charles Shepherd
Hon Medical Adviser
CONCLUSIONS AND RECOMMENDATIONS FROM THE MEA REPORT
Cognitive Behavioural Therapy (CBT)
We conclude that CBT in its current delivered form should not be recommended as a primary intervention for people with ME/CFS.
CBT courses based on the model that abnormal beliefs and behaviours are responsible for maintaining the illness, have no role to play in the management of ME/CFS and increase the risk of symptoms becoming worse. The belief of some CBT practitioners that ME/CFS is a psychological illness was the main factor which led to less symptoms improving, less courses being appropriate to needs, more symptoms becoming worse and more courses being seen as inappropriate.
Our results indicate that graded exercise therapy should form no part of any activity management advice employed in the delivery of CBT, as this also led to a negative impact on outcomes.
There is a clear need for better training among practitioners. The data indicates that lack of knowledge and experience had a direct effect on outcomes and remained a key factor, even where courses were held in specialist clinics or elsewhere given by therapists with an ME/CFS specialism.
However, our results did indicate that, when used appropriately, the practical coping component of CBT can have a positive effect in helping some patients come to terms with their diagnosis and adapt their lives to best accommodate it.
CBT was also seen to have a positive effect in helping some patients deal with comorbid issues – anxiety, depression, stress – which may occur at any time for someone with a long-term disabling illness.
An appropriate model of CBT – one that helps patients learn practical coping skills and/or manage co-morbid issues such as those listed above – could be employed, where appropriate, for ME/CFS as it is for other chronic physical illnesses such as multiple sclerosis, Parkinson’s disease, cancer, heart disease, and arthritis and we recommend all patients should have access to such courses as well as access to follow-up courses and/or consultations as and when required.
Graded Exercise Therapy (GET)
We conclude that GET should be withdrawn with immediate effect as a primary intervention for everyone with ME/CFS.
One of the main factors that led to patients reporting that GET was inappropriate was the very nature of GET itself, especially when it was used on the basis that there is no underlying physical cause for their symptoms, and that patients are basically ill because of inactivity and deconditioning.
A significant number of patients had been given advice on exercise and activity management that was judged harmful with symptoms becoming worse or much worse and leading to relapse. And it is worth noting that despite current NICE recommendations, a significant number of severe to very severe patients were recommended GET by practitioners and/or had taken part in GET courses.
The other major factor contributing to worsening symptoms was the incorrect belief held by some practitioners that ME/CFS is a psychological condition leading to erroneous advice that exercise could overcome the illness if only patients would ‘push through’.
We recognise that it is impossible for all treatments for a disease to be free from side-effects, but if GET was a licensed medication, we believe the number of people reporting significant adverse effects would lead to a review of its use by regulatory authorities.
As a physical exercise-based therapy, GET may be of benefit to a sub-group who come under the ME/CFS umbrella and are able to tolerate regular and progressive increases in some form of aerobic activity, irrespective of their symptoms. However, identifying a patient who could come within that sub-group is problematic and not possible at present.
Some patients indicated that they had been on a course which had a gentle approach of graded activity rather than a more robust and structured approach of graded physical exercise. There were some reports that patients were told they should not exercise when they felt too unwell to do so. These led, for some, to an improvement in symptoms or to symptoms remaining unaffected.
However, we conclude that GET cannot be regarded as a safe and effective form of treatment for the majority of people with ME/CFS. The fact that many people, including those who consider themselves severely affected, are being referred to specialist services for an intervention that makes them either worse or much worse is clearly unacceptable and in many cases dangerous.
GET should therefore be withdrawn by NICE and from NHS specialist services as a recommended treatment with immediate effect for everyone who has a diagnosis of ME/CFS. This advice should remain until there are reliable methods for determining which people who come under the ME/CFS umbrella are likely to find that GET is a safe and effective form of management.
Pacing was consistently shown to be the most effective, safe, acceptable and preferred form of activity management for people with ME/CFS and should therefore be a key component of any illness management programme.
For some, improvement may be a slow process so, whilst they may be somewhat better by the end of a course, the improvement is not enough to take them into a better category of severity for some time, perhaps not until they have self-managed their illness for a few years.
The benefit of Pacing may relate to helping people cope and adapt to their illness rather than contributing to a significant improvement in functional status. Learning coping strategies can help make courses more appropriate to needs even if they do not lead to immediate or even longer term improvement in symptoms. Importantly, it can prevent symptoms from becoming worse.
Pacing can be just as applicable to someone who is severely affected, as to someone who is mildly or moderately affected, although additional measures need to be taken to ensure that a person who is severely affected has equal access to services.
As with CBT, there must be better training for practitioners who are to deliver such management courses. Proposed increases in activity, both mental and physical, must be gradual, flexible and individually tailored to a patient’s ability and circumstance and not progressively increased regardless of how the patient is responding and therapists must be taught to recognise that.
All patients should have access to suitable courses, follow-up courses and/or consultations as and when required.
Note: Please see Sections 4 and 5 for our full conclusions and recommendations. Caveats are set out in Section 6.