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 apparentâ€”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 Kingâ€™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 Parianteâ€™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 Sharpeâ€™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 Parianteâ€™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 patientsâ€™ symptoms are â€œrealâ€ and should be taken seriously. But he undermines that message by suggesting that patients with ME/CFSâ€”or CFS/ME, as he calls itâ€”reject psychologically oriented interventions because they donâ€™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 crapâ€”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 â€œvery lowâ€ quality and the rest of â€œlowâ€ 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 Parianteâ€™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.
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. Hereâ€™s a brief description from his website: â€œPrior 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.â€
Iâ€™d be hard-pressed to comment authoritatively on Dr Salisburyâ€™s discoveries about wave-breaking and whitecaps and air-sea exchange. But I agree with every point in his letter to The Guardian. Iâ€™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 â€“ with its emphasis on the roles of thoughts and behaviour, rather than pathology â€“ is one of the reasons why long Covid patients are now facing such limited options in clinics.
Dr Dominic Salisbury
Lytham St Annes, Lancashire