What works in the treatment of medically unexplained physical symptoms? The psychotherapist perspective

Re-visiting professional ethics in psychotherapy: Reflections on the use of talking therapies as a supportive adjunct for myalgic encephalomyelitis / chronic fatigue syndrome and ‘medically unexplained symptoms’

“…Given afore-mentioned national clinical guidance recognising the lack of clinically proven therapies as previously mentioned [8,9] and burgeoning body of research on biological abnormalities in ME/CFS [55], practitioners who persist in presenting CBT or any psychotherapeutic modality as a 'cure' or means to 'recovery' will find themselves at odds with best practice. We suggest that attempting to persuade patients of psychological aetiology, or indeed of psychological maintaining factors [25,26,28] is not only inconsistent with the evidence base but also with the ethical requirement for professional competence.…”

“…Patient appreciation of honesty regarding limitations of psychotherapy is further supported by qualitative research [23] and is consonant with medical practice research on MUS indicating that some patients value practitioner humility [56]. However, patient survey data and qualitative research suggest that these ethical standards are not always met, with some therapists insisting on a psychological causation model, and attempting to persuade patients to adopt such a model, despite lack of evidential support [15,16,28]. In a similar vein, patient reports of clinical claims that therapy can be 'curative' for people with ME/CFS [15], would appear exceedingly lacking in humility given lack of evidential support: I was told that my illness could be cured by positively thinking that I was not ill and I should use meditation and stress/anxiety relieving techniques to control my symptoms and carry on with work and normal activities as much as possible.…”

“…Searching across PsycINFO, PsycARTICLES and MEDLINE databases demonstrated limited output. We thus broadened our search to the still limited body of research that exists on this topic in the field of MUS, resulting in a small data corpus: research depicting the experiences of psychotherapy from the perspective of people with ME/CFS [19,23,24] and people with MUS [7], and research capturing the attitudes and behaviours of psychotherapists toward people with MUS [25][26][27][28]. Additionally, we drew upon patient survey data reporting the experiences of people with ME/CFS undergoing CBT and hybrid forms of therapy in the UK [15,16].…”

“…Among examples of judicious use of professional authority, flexibility of psychotherapists vis-à-vis certain therapeutic boundaries (in particular, willingness to change appointments due to a patient's health flare-up) have been reported and are positively received by patients [15]. On the other hand, ethically questionable management of power dynamics can be discerned in patients' reports of feeling pressured into therapy [15,16] and in a broader tendency for psychotherapists to use 'reattribution' within the MUS arena [28]. Reattribution is a technique of encouraging the patient to shift from physical illness attributions to (at least partially) psychological attributions; this technique features in many psychotherapeutic approaches to ME/CFS and MUS, whether explicitly identified as such [25,26,28].…”

“…On the other hand, ethically questionable management of power dynamics can be discerned in patients' reports of feeling pressured into therapy [15,16] and in a broader tendency for psychotherapists to use 'reattribution' within the MUS arena [28]. Reattribution is a technique of encouraging the patient to shift from physical illness attributions to (at least partially) psychological attributions; this technique features in many psychotherapeutic approaches to ME/CFS and MUS, whether explicitly identified as such [25,26,28]. Given the lack of evidential support for psychological aetiology or maintenance in ME/CFS and MUS, this technique, and relevant disclosures, also bear relevance for patient autonomy.…”