Content Warning: discussing some nasty theories surrounding CBT. If you're not in the mood, just skip.
There’s an interesting quote which caught my eye in the York report, which makes it very much more explicit that GET is considered an essential part of CBT for ME than I’ve seen stated anywhere else. My recollection and general impression was that they were always talked about by the BPS cabal as if they were two entirely separate “treatments”.
“A controlled trial of ‘modified CBT’ used a different form of treatment without graded activity, which is normally considered an integral part of CBT.” (My bolding)
I think I can say something about that. I'm researching the earliest years of the Wessely School (which is also why I on here way less than I had previously planned and anticipated when I joined) and its advising of CBT as a treatment. I have been puzzled by how GET is mentioned separate from CBT as it is basically a therapeutic tautology : GET
is the B in CBT, the changing of maladapted behaviour through Operant Conditioning principles, in this case the supposed unwarranted "abnormal illness behaviour" of ME patients. ("Abnormal illnes behaviour" btw. is just a term for hypochondria/hysteria.)
In the theoretical model it is avoidance behaviour that gets in the way of the patients behaving like they should: like they're not ill. The Wessely School treats CFS like hypochondria/hysteria in a new dress. According to Operant Conditioning principles underlying BT and CBT of changing unwanted behaviour in the desired direction, there are 4 types of reïnforcers (Source: "Cognitive Behaviour Therapy for psychiatric problems: a practical guide" by Hawton, Salkovskis, Kirk and Clark, published at the time Hawton and Sharpe started to apply a CBM on ME patients. ME is not specifically mentioned in the book. Hypochondria and hysteria are, as are a lot of descriptions that are very familiar.)
- Presented Positive: wanted behaviour occurs more frequent b/c of positive results. ME theory: gradually doing more means you can do more, you'll notice that you càn do stuff, hoorah!*.
- Omitted Negative: wanted behaviour occurs more frequent b/c the expected negative effect doesn't occur. ME theory: gradually doing more means you'll discover that you won't get symptoms from it.*
- Presented negative: Unwanted behaviour decreases b/c it is followed by an aversive event (punishment.) Applied in CBT's sister therapy, Aversion Therapy with electroshocks (BT) applied to gay and trans people. ME theory: none specifically. I suspect it might have been applied if AT hadn't built such a deserved public bad rep. as being damaging and unethical.
- Omitted Negative: Unwanted behaviour decreases because the reward for it doesn't occur. ME theory: taking away benefits and sympathy from surroundings means there are no cushy treats as an incentive to keep behaving ill.
As you see, graded exercise is the first two reïnforcers of BT. *Of course this all falls to pieces when ME patients unsurprisingly deteriorate from expanding their level of activity beyond their physical limit, so they shoved in some bs about patients failing because they're being too fussy about normal aches and pains after exercise and therefore stop pushing through to the other side , where the magic supposedly
will happen.
See also for example of Sharpe et al, 1992 ("The psychological treatment of patients with functional somatic symptoms: a practical guide")
"Behavioural change is best achieved in a gradual fashion. Sudden changes often produce severe exacerbation of symptoms, avoidance of further efforts and demoraliazation. In order to plan graded increases in activities, a baseline of current behaviour is first established and the discrepancy between desired goals and current functioning identified. The difference can then be broken down into manageable ‘subgoals’ of graded difficulty. The patient is warned that each increase in previously avoided activity is likely to result in a transient increase in symptoms. The behaviour is practised daily until it can be accomplished with ease. Only then is the subgoal increased."
Again a demonstration that graded increase in activity is the Behavioural aspect of CBT.
For the BPS crew, losing GET seems extremely problematic to me, as basically their B falls off. They'd be stuck with CT, and thàt only seemed to work (I have heard that that is contested now too, though no sources or study into it) because in more severe cases BT could be added as a component of the therapy. Besides, with reaffirmation of old research finds regarding e.g. brain hypoperfusion and mitochondrial dysfunction and new ones like dysautomnia-related things, it's kinda hard to claim "I am ill" a false conviction and to base your whole treatment on changing that "belief" with the expectation that that leads to improvement (as that is CT).
I don't know when GET was added as a separate-seeming thing, as I haven't looked into that (so much on my plate, so little spoons, ack!), but for the BPS crew themselves it isn't something separate.
And that concludes another mini lecture. Have an awap day everyone.
And thank you for all your input in this thread, I really enjoyed reading your views and information. (But reading on my phone offline, so no active likes.)
