By David Tuller, DrPH
Earlier today, I posted a blog about the decision by the Royal College of General Practice to remove from its site a training program called METRIC, which promoted the GET/CBT approach. I then sent the following letter to Carolyn Chew-Graham, a professor of general practice research at Keele University in Staffordshire and the main author of the training program.
Dear Professor Chew-Grahamâ€”
I was interested to see that the Royal College of General Practitioners has taken down the METRIC training module, which promoted GET and CBT for treating what it called CFS/ME. (Earlier today, I posted this blog about METRIC’s removal on Virology Blog, a site hosted by Vincent Racaniello, Columbia University’s Higgins Professor of Microbiology. I have cc’d Professor Racaniello here.)
From what I gather, this step was taken because the draft of the new NICE clinical guidelines has repudiated this approach, relying on an assessment that rated the evidence from dozens of studies as of “low” or â€œvery lowâ€ quality. The METRIC site itself states that “the course is currently offline while being reviewed to be in accordance with new NICE guidelines.”
As the lead author of METRIC, you have been a strong advocate of the biopsychosocial approach to ME/CFS and its theoretical foundation of dysfunctional illness beliefs and progressive deconditioning. However, in your recent remarks during the Royal Society of Medicine’s long-Covid webinar, you appeared to endorse â€œpacingâ€ as perhaps the most appropriate response to the profound exhaustion experienced by so many patients after an acute bout of Covid-19. From what I understand, this appreciation of pacing emerged from your qualitative research among “long-haulers.”
Of course, in some or many cases, this profound exhaustion and other long-Covid symptoms would justify a diagnosis of ME/CFS. Yet the GET/CBT treatment paradigm dismisses pacing as an ineffective and undesirable strategy through which patients maintain a hypothesized “sick role” and therefore receive purported emotional and psychological benefits.
This contradiction raises some questions:
Do you agree with the decision to remove the METRIC program? Do you agree with NICEâ€™s assessment that the evidence for GET and CBT is uniformly of â€œlowâ€™ or â€œvery lowâ€™ quality? Do you also agree that GET and CBT are not indicated for long-Covid patients whose symptoms are similar to those that characterize ME/CFS? Should ME/CFS and long-Covid patients who pursue a pacing strategy be presumed to be seeking emotional and psychological benefits by maintaining their illness and preserving their “sick role”?
You have also been a strong proponent of expanding the Improving Access to Psychological Therapies program to patients diagnosed with so-called “medically unexplained symptoms,” or MUS. As you know, IAPT identifies CFS/ME as an MUS.
If you agree with NICE that the biopsychosocial approach is not indicated for ME/CFS, do you believe CFS/ME should be removed from the IAPT’s MUS expansion? Do you still believe that biopsychosocial interventions are indicated for people with IBS and other conditions identified as MUS under IAPT?
In sum, the long-Covid phenomenon appears to have led to a shift in your thinking about the relative value in post-viral syndromes of pacing versus the GET/CBT approach, and now a GET/CBT training module you wrote has been taken down. Given these developments and your prominent role in this domain of medicine, it would be helpful if you could clarify your current position on treatments for ME/CFS.
If this position has in fact changed, do you feel an obligation to acknowledge that you and your colleagues were wrong, and/or to apologize to ME/CFS patients who have been inappropriately prescribed biopsychosocial interventions as curative treatments? Since ME/CFS patients experience post-exertional malaise (or post-exertional symptom exacerbation, as it is called in the NICE draft), are you concerned that some or many might have suffered harm from the GET/CBT approach that has dominated clinical care for the past thirty years?
I would be happy to post any response on Virology Blog.
David Tuller, DrPH
Senior Fellow in Public Health and Journalism
Center for Global Public Health
School of Public Health
University of California, Berkeley