Under a heading ‘Long-Covid: interventions not proven’ the May issue of The Psychologist publishes a letter (see below) I wrote with Joan Crawford. The same issue contains an interview with Jo Daniels, the newly appointed Chair of the Scientific Committee of the British Association for Behavioural and Cognitive Psychotherapy (BABCP) outlining her mission to apply CBT to all long-term conditions (LTC). This despite a paucity of evidence that CBT protocols matched to a specific LTC make any unique contribution. She proclaims “It is now commonly accepted that CBT ‘works’ to a greater or lesser extent for most physical health conditions”, this is grist to the mill for the expansionism of the Improving Access to Psychological Therapies (IAPT) service. But contrary voices do not get a hearing in BABCP, echoes of Russia.
‘The underlying message of Dr Siddaway’s article ”We need to talk about Long-Covid” in the March 2022 issue of the Psychologist is that there is or will be an added value from psychological intervention for those affected by Long-Covid i.e Covid of more than 3 months duration. But the Scottish verdict ‘not-proven’ seems appropriate.
There can be no doubt that offering emotional support to people like Grace, cited in the article, is an important resource for anyone suffering from a long-term medical condition. But there is a distinction between the provision of emotional support (travelling alongside) and delivering a psychological intervention (fixing). The latter is inevitably more costly, requiring more highly trained staff and therefore less likely to be available. Is it a proper use of scarce psychological resources to offer psychological treatments to those with Long-Covid?
Clearly if a person with Long-Covid suffers from an additional disorder such as PTSD or depression a case can be readily made for addressing the comorbid disorder. But the effectiveness of this treatment, in such circumstances, remains to be demonstrated. There are no randomised controlled trials of the psychological treatments of Long Covid plus or minus comorbid disorders. Thus, the evidence for the efficacy of treatment must be currently regarded as weak.
Siddaway suggests that it is possible to extrapolate from studies of chronic fatigue syndrome and pain and apply the strategies to Long-Covid. But there are significant problems with this: a) it assumes Long-Covid is in the same domain as CFS and pain, but arguably, there is little evidence that this is a homogenous category b) the evidence base for the efficacy of psychological treatment for CFS Is problematic if objective indices of outcome are insisted upon c) the evidence base for psychological treatments for CFS and pain, such as it is, is for protocols and not for the components of the interventions, such as pacing or distraction. Using strategies out of context is problematic.
Siddaway appeals to a biopsychosocial model to justify psychological intervention for Long- Covid, despite any evidence that mood and coping strategies make a significant difference to the physical symptoms of Long-Covid. The proposed model ” the complexity of Long-Covid” is not capable of falsification, any factor e.g a hostile working environment, could be proposed to be pivotal in the development of Long Covid, but not ruled out. As such it is not a model.
It serves the interests of the powerholders of psychological therapies to transmute the physical disorders into candidates for psychological intervention. An extending of Empires. This is not to say that psychological intervention may not sometimes be helpful in the context of a long-term medical condition but unless the population is clearly specified clients will be failed by inappropriate treatments and services exhausted.
6 replies on “Psychologising Long-Covid and Anything Else”
“ delivering psychological intervention = fixing”. This premise has long been substituted with the far more realistic concept of “ psychological flexibility/ resilience “. Process- based CBT ( e. g., ACT) has produced strong and convincing empirical evidence not just for beneficial outcomes but – more importantly- for the six hitherto identified psychological processes underlying these outcomes. As an empirically supported, trans diagnostic intervention it is absolutely valid to extrapolate efficacy for long Covid related distress and behavioural problems on the basis of its efficacy for other long- term, bio- medical treatment resistant conditions such as chronic pain.
I totally disagree, processes are not seen as a sufficiently reliable outcome measure in any of the randomised controlled trials. The methodologyical rigour of the ACT trials is significantly less than the standard CBT trials see Ost’s work in 2008, he thought ACT should not be regarded as an Evidence Supported Treatment. The NICE review of CBT for chronic pain was far from a ringing endorsement. There is an absence of independent blind assessors in the health related CBT studies and there is a conflict of interest in that the developers of the protocols are marking their own homework.
I wanted to thank you for this excellent post (and article in the Psychologist) that highlights the difficulties that can arise when a CBT model is super-imposed on ME/CFS. My wife and I have both worked as clinical psychologists since 1990 and regularly made use of CBT techniques in its many different forms throughout our careers.
However, as you explain so well, there are important differences in how these ideas are used in work with people with clearly identified mental health needs, and when used with people diagnosed with ME/CFS.
We are especially aware of this because our daughter was diagnosed with ME as a 15-year-old and was ill for 8 to 9 years.
There are so many things I could say about the inappropriate application of CBT to ME, but I think I need to confine myself to just two
First, you were absolutely right to describe how people tend to confuse walking alongside and intervening. It is as if, in the absence of a widely agreed physical cause for ME then this must mean that it is a psychological illness instead. In fact, strong evidence is emerging to implicate aspects of cellular functioning in the maintenance of symptoms including problems in the uptake of oxygen and failures of the immune system. While CBT therapists sometimes claim that they are agnostic about the causes of ME, this is being disingenuous: there are clear messages (usually implicit, sometimes explicit) that associate physical symptoms with cognitive errors.
Second, as you say, the empirical evidence for CBT is ‘problematic’ – notably the misinterpretations and misrepresentations of evidence from the PACE trial (do see the brilliant work of Tom Kindlon, who has himself lived with ME for many years – e.g., https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-018-0218-3?fbclid=IwAR2T2nDlW6YtdD4a1eThe8p_iEiGQvngoMSZDoEmBeGrHd5wr8EY1fbMqAg). Even worse has been the way in which proponents of psychological interventions typically ignore the ample evidence that many patients believe they were harmed by inappropriate applications of CBT derived therapies.
You are also spot on to identify the Imperial tendencies of the powerholders, seeking to extend the CBT Empire by seeking out new territories to plant their flag.
In general, I am proud to be a psychologist and feel privileged to have been able to have a career working alongside many good, clever, thoughtful and kind people. But over the last ten years or more as I have seen the harm that psychologists can cause when they stop being either thoughtful or reflective so I have also begun to feel ashamed of my profession.
I couldn’t agree more thanks so much Richard
Peculiar Lancet Psych article spends half a page puffing the author before getting down to the ‘psychiatric sequelae’ of the title:
“The third study, published in PLOS Medicine,
studied more than 270 000 patients and found that over one in three had
one or more features of long-COVID (such as fatigue, pain, or brain
fog) recorded between 3 and 6 months after a diagnosis of COVID-19. This
was significantly higher than after influenza. The risk of long-COVID
features was higher in patients who had more severe COVID-19 illness,
and slightly higher among females. White and non-White patients were
equally affected. “We plan to extend our work to look at longer-term
follow up, as well as to see whether the effects of the virus are
evolving over time, in relation to change in dominance of differing
variants”, explains Harrison.”
There’s no escape from the psych lobby’s territorialism, it seems.