By David Tuller, DrPH
On Tuesday (four days ago), The Guardian published an opinion piece from Professor Carmine Pariante titled “Long Covid is very far from ‘all in the mind’–but psychology can still help us to treat it.” The article is the latest from a member of the biopsychosocial ideological brigades to demonstrate what has long been apparent—those who proclaim that others are falling into an unhelpful mind-body dichotomy are using this argument to deflect attention from the failings of research into their favored interventions. Professor Pariante is a psychiatrist based at King’s College London, the home of Professor Trudie Chalder, Professor Sir Simon Wessely, and other leading lights of the biopsychosocial firmament, so he is likely steeped constantly in a brew of self-reaffirming but unwarranted assertions.
Professor Pariante’s piece has been published in the wake of two articles by Guardian columnist George Monbiot. The first column, in January, expressed alarm about the epidemic of Long COVID cases. The second column, published last month, took a sledgehammer to Professor Michael Sharpe’s creative accusation that Monbiot was causing Long COVID just by having written about it in the first place. It was clear from Monbiot’s second column and a detailed Twitter thread that he’d quickly learned a whole lot about the PACE trial disaster.
Professor Pariante’s new piece appears to be part of an ongoing campaign seeking to prevent the unraveling of the biopsychosocial paradigm for ME/CFS–and by extension for Long COVID. As is usual for this group, Professor Pariante reassures us that patients’ symptoms are “real” and should be taken seriously. But he undermines that message by suggesting that patients with ME/CFS—or CFS/ME, as he calls it—reject psychologically oriented interventions because they don’t fully appreciate the relationship between mental and physical health.
Professor Pariante should know better than to parrot such silliness. Perhaps he needs to spend more time listening to patients’ concerns and less to the theoretical blatherings of his fellow campaigners. No one seriously disputes that emotional and psychological states can influence how we experience symptoms and disease. That is a straw-person argument. At issue is the quality of the research behind the claims being made. As has been documented over and over, the research on cognitive behavior therapy and its companion, graded exercise therapy, for ME/CFS is fraught with disqualifying flaws and does not prove what it claims to prove. Patients frown on these interventions because the studies are crap—not because of prejudice against psychiatry or psychological interventions. Rejecting CBT as a treatment for ME/CFS cannot reasonably be construed as a denigration of people with mental illness.
It is long past time for experts like Professor Pariante to drop these specious claims about patients’ motivations and face reality: The PACE trial seems to meet common definitions of research misconduct, and the overall CBT/GET literature is equally unconvincing. In the course of developing the draft of its new ME/CFS guidelines, the National Institute for Health and Care Excellence (NICE) conducted a thorough review and found most of the evidence for the current interventions to be of “very low” quality and the rest of “low” quality.
Presumably Professor Pariante and his colleagues don’t agree, but that’s too bad. Whatever they think, this NICE evidence review is the most authoritative recent assessment. The draft NICE released in November rejected the perspective on ME/CFS treatments that Professor Pariante has just espoused in The Guardian. Hopefully, the final version of the NICE guidelines will adhere closely to that draft, despite ferocious push-back from the biopsychosocialists.
Professor Pariante’s comparison of the use of CBT in the field of cancer to its use in ME/CFS is one frequently invoked by like-minded professionals. Cancer patients are obviously not told they can be cured with CBT, so the comparison is ridiculous, irrational and insulting. Does Professor Pariante think that cancer patients should be satisfied with CBT and that those who want pharmaceutical treatments are too wedded to a bifurcated view of mind and body? What about patients with Crohn’s or Parkinson’s? ME/CFS has nothing to do with Descartes or Cartesian dualism, no matter how often Professor Sharpe, Professor Pariante, and their colleagues opine that these patients are suffering from philosophical confusion over mind-body matters.
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In the meantime, The Guardian this week posted a succinct and spot-on response to Professor Pariante from Dom Salisbury, an ME/CFS patient in Lancashire. Here’s a brief description from his website: “Prior to becoming too ill to maintain a job, I worked in scientific research in the fields of atmospheric and ocean physics. I obtained my PhD from the University of Leeds in 2014, with a thesis investigating the role of ocean wave-breaking and whitecaps on air-sea exchange.”
I’d be hard-pressed to comment authoritatively on Dr Salisbury’s discoveries about wave-breaking and whitecaps and air-sea exchange. But I agree with every point in his letter to The Guardian. I’m reposting it here, with his permission:
In reviewing the possible role of psychology in treating long Covid, Dr Carmine Pariante misrepresents why many ME/chronic fatigue syndrome patients remain sceptical about psychological interventions such as cognitive behavioural therapy (CBT). It is not because we deny the important overlap between mental and physical illness, but rather because these interventions are offered as treatments based on poor-quality evidence of short-term marginal improvements in some patients.
No cancer patient is offered psychotherapeutic interventions as treatment; rather, these therapies play a supportive role for patients who require them. In contrast, CBT has been recommended as a first-line treatment for ME/CFS for more than a decade. Indeed, the dominance of the biopsychosocial model of ME/CFS – with its emphasis on the roles of thoughts and behaviour, rather than pathology – is one of the reasons why long Covid patients are now facing such limited options in clinics.
Dr Dominic Salisbury
Lytham St Annes, Lancashire
Comments
11 responses to “In Guardian Column, Professor Pariante Parrots Standard Biopsychosocial Nonsense”
I certainly not predjudiced against mental health support as I am a qualified counsellor who also happens to have m.e – what I am against is CBT used to treat m.e and our negative illness beliefs.
Having studied the many theories of counselling and psychology, what is often left out of these columns is the fact that psychology is developed from a theory, not science.
I think Counselling/Talking Therapy is good in helping a patient who maybe struggling with the grief of losing their health and the issues around who they are now. It is not helpful if it gaslights a patient about their illness or promotes the idea that it will cure them.
I’ve been frustrated by PACE and the negative effect it has on an m.e sufferers life. I was affected by it at a benefit tribunal, where a hostile Dr asked if I’d heard of CBT and GET. It affects the way drs and wider specialists perceive us, in benefit assessments and tribunals, in treatment settings, media and public perception and in the lack of funding research attracts.
PACE and the biopsychosocial brigade know that they benefit professionally and financially from psychologising illness. They are willing to go all out to protect this. It’s rather insidious.
If we all complained to the GMC about this defamation, all the psycho babble would cease in weeks.
“Professor Pariante should know better than to parrot such silliness. Perhaps he needs to spend more time listening to patients’ concerns and less to the theoretical blatherings of his fellow campaigners.”
“Does Professor Pariante think that cancer patients should be satisfied with CBT and that those who want pharmaceutical treatments are too wedded to a bifurcated view of mind and body? What about patients with Crohn’s or Parkinson’s? ”
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I wonder if Pariante does think that with respect to Crohn’s or even Parkinson’s , because it appears that according to Professor Sharpe
-https://www.youtube.com/watch?v=DqDTAHUMnq4 – when it comes to morbidity (rather than mortality) most illnesses aren’t based in disease but are powered instead mainly by mind-body or ‘psycho-somatic’, complexity. So what doesn’t kill you (within days/weeks/months/years – what time frame are we talking about here?) should be treated predominantly with CBT or other psych therapies?
The problem is that many chronically ill patients aren’t getting better with psychological therapies, they’re remaining chronically ill or are getting worse…. and in large numbers….and nobody in medicine seems to care. For example, the evaluation of the Primary Care Psychotherapy Consultation Service (PCPCS) in London that particularly targeted patients with medically unexplained symptoms (MUS) showed that 31% of MUS patients stayed the same or got worse on the Work and Social Adjustment Scale WSAS scale (see -https://opposingmega.wordpress.com/2020/08/19/so-what-if-23-get-worse-2/) with 23% of treated patients getting worse. But this large minority doesn’t matter when some of the most vulnerable people in our society are at risk of their physical health deteriorating?
It seems particularly dangerous to preach to others about mind-body complexity but then to relegate the body – i.e disease – to a minority position as Professor Sharpe appears to do. (Of course, Sharpe’s suggestion that the one is predominant over the other implies that he is drawn to Cartesian dualism himself…..and if it’s all so complex then how can he possibly know that the body – disease – comes second to the mind and takes up a minority position?)
It all comes down to what’s prioritized for patients for both treatment and research, and psychiatry, neuropsychiatry etc appear to have been grabbing the research funding, in the UK at least, by claiming that their treatments are cheap and effective and should therefore be prioritized, but with little regard it seems for what happens to patients as a consequence.
The problem, as I see it, is how do we tell the 70% or whatever that are horses (the bodily-deconditioned/demotivated/anxious or depressed Paul Garners of this world who might benefit from CBT/mental reprogramming and GET) from the 30% or whatever that are zebras (those with more damaging disease who won’t get better and will likely be made biologically worse by GET and suffer the physical neglect and psychosocial harms of a CBT/psych therapy approach).
Many decades ago, doctors would rely on patients coming back as a means of determining which patients with hard to diagnose symptoms were at risk. If the patients kept knocking at the door then there was probably something seriously wrong. But that’s been twisted by the psychs – now if patients keep knocking then they’re called ‘frequent flyers’ and deemed to be somatizers. (This is usually behind patients’ backs of course, with coding applied to boot to stop them getting any future objective opinions.) So the cheapest means of sorting the horses and zebras – GP/hospital attendance and how distressed a patient claims to be – can unfortunately no longer be used to determine how at risk a patient is, since too many doctors now believe that frequent attendance and complaining about symptoms are signs of somatization. Can psych research offer us anything to sort the zebras from the horses? Well probably not much, because so many of us have mental health problems anyway. With a quarter of us suffering some kind of mental health difficulty each year -https://www.mind.org.uk/information-support/types-of-mental-health-problems/statistics-and-facts-about-mental-health/how-common-are-mental-health-problems/ I suspect it would be well nigh impossible to tell whether any identified psych issues were a cause/effect of disease or were there anyway. Any attribution would be bound to be subjective. So what we need are biomarkers to divide those deconditioned horses from the diseased zebras, and guess how we get those – biomedical research.
So I’d say to all those dimwits out there who only look for horses – you need to start looking for (and listening to) the 30% or so that are zebras, and pile money into biomedical research as a matter of priority before millions of people come to serious harm.
CT: sadly many of us have already come to very serious harm, including at the *direct hands* of members who promulgate the Wessely School dogma around ME.
Wrt attendance, there is also the conundrum whereby doctors might presume patients are well because they do not continue to return, & they do so not simply to avoid being labelled as a ‘somatizer’ per se, but because any interventions either fail to help or make the patient worse. I’m sure this accounts for some of the high drop-out rates in BPS -framed so called ‘research’.
Patients are desperate for help but patients also tie themselves up like pretzels trying to work out how to juggle seeing their doctors such that they don’t run in to the ‘frequent flyer’ label as you have outlined above. It’s a crazy, crazy world (ironically) ‘designed’ by the psyches such that patients have to strategize their interface with medics in order to reduce the likelihood of being gaslighted & of being iatrogenically harmed and increase their chance of being taken seriously. If I’d wanted to play such silly games I’d have taken up poker.
Lady Shambles: I’ve no doubt that all of that is true. (I’ve felt like a pretzel too. They’ve engineered a ‘no win’ situation for patients and especially women, their poker game is rigged from the start.)
Do you remember when doctors the world over didn’t believe that gastric ulcers were often caused by H. pilori? I think it’s over 80% of them, by CURRENT science.
Well, that’s where we are right now: the establishment is mobilizing every power it has to block acceptance of ME/CFS as a physical disease – against ALL evidence.
Hope we get out of this maelstrom definitively soon – it’s getting VERY tiring going around in circles yet again.
I thought the Lighting Process was the latest miracle treatment recommended by the Royal Colleges of Psychiatrists / Paediatrics and Child Health isn’t CBT/GET obsolete.
It’s probably worth watching/revisiting Pariante’s presentation to the 2018 CMRC conference in Bristol -https://www.youtube.com/watch?v=Hc1k8GngGJA . If I’m reading this right then Pariante thinks that a treatment solution for ME/CFS may lie in the use of certain antidepressants that can apparently reduce inflammation in the brain of people with depression (with perhaps some knock-on effect on the immune system?) because he perceives a biological similarity between depression sufferers and ME sufferers, even though their cortisol profile seems to be starkly different? Well that was my interpretation.
In the Guardian piece Pariante indicates that he’s not surprised that ME/CFS patients identify either an infection or a serious life event as occurring when their illness began, but do they? Or is this a perception that’s resulted from using overly broad definitions in the past? But, if they do, then given that ME/CFS is so far unexplained, should we bundle these patients up together for research purposes anyway or should we separate them out from the start into 3 groupings – those who can identify an infection as a trigger, those who believe a life event triggered their illness, and those who haven’t a clue what might be behind their disease? I suspect he might say a resounding ‘no’ to that, because we shouldn’t separate mind from body, but by not separating them as potential triggers aren’t we adding to the complexity of the problem? Aren’t there instances where a dualistic approach could be helpful to scientific inquiry? (Surely you don’t have to believe in dualism to use it as a tool? And if we shouldn’t separate mind and body under any circumstances then why do we have psychiatry and psychiatrists at all?)
SK wrote: “I thought the Lighting Process was the latest miracle treatment recommended by the Royal Colleges …”
Yes, that is what people are supposed to think. This shows their marketing dressed in a lab coat is working. No official body has actually recommended LP, but that is irrelevant, because Greed Is Good! trumps truth every time.
The problem with modern medicine, dentistry, and perhaps life itself is that as soon as we solve one problem we create another. I looked up Professor Pariante’s job title and felt distinctly queasy at ‘Consultant Perinatal Psychiatrist’. I thought I needed an antidote to feel well again and I searched out Michel Odent who is 90 and has written some very interesting books including ‘Childbirth in the Age of Plastics’. Odent is saying that the routine use of synthetic oxytocin to speed up the birth process causes unnaturally large amounts of this hormone to enter the baby’s blood stream and hence brains. Nobody knows how this can affect lifetime behaviour.