@Barry
I sort of see three 'levels' of failure with PACE/BPS as applied to ME and other things bucketed into MUS/Functional/Psychosomatic
-I'd classify what you've shown in your post as the widest 'Philosophical' defect, which is that the whole BPS paradigm presupposes itself in order to generate evidence in its favor. Feeding into this is that it is set up to be unfalsifiable. It sets up that the only way for it to effectively fail is to appear so implausible in light of generally accepted interpretations of reality that it appears absurd; unfortunately, psychosomaticism is a centuries-old fetish in medicine and by default sounds plausible to probably most people.
You're saying that this amounts to a lack of 'probable cause' or 'reasonable suspicion', to use legal/law enforcement terms. I think this is somewhat the case but that's not really the punchline here. For me, the punchline regarding the issues at hand for us is the insight into the theoretical structure which any serious scientist and policymaker ought to find quite suspicious once enlightened as to its nature, and thus subsequently begin to look at it critically and, frankly, take offense to it. Fortunately, I think we are seeing this happening to a promising degree.
There are even broader lessons here for all scientific thought and even the necessarily speculative theorizations of the humanities. I mean, it really isn't even scientific thinking and is more on the intellectually lazy end of the humanities that piles bullshit on bullshit to build a dogma, attract zealots, and demonize detractors. It's disturbing... well, actually it's just plain fucked up, that this sort of trash can so easily enjoy a prominent and celebrated status in medicine and science.
-The next 'level' is more where probable cause comes in. I think of this as the 'Procedural' defects. It starts with the idea that
@Jonathan Edwards shared a while back that, (if I can remember accurately,) even on the most charitable reading, the magnitude of the effect size in PACE or other such trials is so small (and overlapping in the individual study arms (?)) that, in real life, CBT/GET practitioners could not possibly have discerned them, i.e. if they perceived reality dispassionately they would never have had 'probable cause' to think they were worth investigating because their experience would have said otherwise.
The good thing though is that this has taught us all another valuable lesson! Clinicians do not perceive reality dispassionately - actually they are prone to wildly inaccurate assessments. Or more formally, you can't put any scientific stake in claims of 'clinical experience'; if it's actually worth anything, it will prove out in a convincing trial without much trouble.
And, actually, I think 'probable cause' is not really the definitive angle here when you think about it. Rituximab was trialed based on 'clinical experience' and with no actual 'theory' behind it, for instance. Or, nobody knows why ECT is so effective in many cases of severe depression, and it frankly doesn't even sound plausible, but it works. Which is to say, I'm not in principle upset that 'psychological' therapies were trialed, even though it came from doltish theory and, in retrospect, preposterously inaccurate interpretation of past experience.
It's more what came after, in the actual execution of the trial - telling patients that CBT or GET was already known to be effective, sending out propaganda pamphlets, compelling patients to 'push through', changing outcome measures/thresholds, etc. Many of the sorts of things uncovered by enterprising patients and pursued by David T . That's where the real 'miscarriage of justice' begins to take shape for me. It's sort of like if police raid your house on dubious - but not quite unforgivably so - suspicion, find nothing relevant,
and then beat you up, plant narcotics, weapons, a dead body, shoot your pets, and then sue you for emotional distress. This is the BPS brigade.
-The last level is the 'Interpretive' defects - all the stuff we always talk about regarding evidence. This is where the real problem continues. As we have discussed ad nauseam, they are hopeless for reasons that circle back to the 'Philosophical' defect. Fortunately they managed to (a) produce evidence that contradicts their theory in probable the most direct way possible (i.e. patients beliefs 'improve' on questionnaire but objective measures do not improve); less fortunately, they (b) did the lightning trial, which highlights the naked absurdity of the whole approach for all to see.
Anyway that's my thoughts for the day.
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