Examining the psychology of practitioners, institutions and structures:

Abstract

‘Medically unexplained symptoms’ (MUS), through the lens of the biopsychosocial model, are understood in mainstream psy disciplines and related literature as a primarily psychosocial phenomenon perpetuated by ‘dysfunctional’ psychology on the part of people labelled with such. Biopsychosocial discourse and practice in this field, underpinned by little empirical foundation and lacking theoretical coherency, are associated with harms sustained by people labelled with MUS. Yet, little attention is paid to the psychology of social actors and institutions whose practice and policy derives from biopsychosocial theorising, or whose vested interests (re)produce such theorising. This article contends that lack of reflexivity among psy practitioners and other social actors on individual, institutional and structural levels furthers biopsychosocial hegemony and contributes to harms. Non-reflexive behaviour on the part of practitioners within clinical and ‘therapeutic’ encounters and on the part of social actors within institutions and broader power structures is examined, and possible psychological underpinnings of non-reflexivity are explored. Notably, the concept of gain, drawn from dominant discourse around MUS, is applied broadly to explore what might be gained from eschewing reflexivity and from adhering to biopsychosocial narratives. Implications for practice, supervision, training and research are discussed, notably highlighting a need for critical reflexivity in all domains.

Re-visiting professional ethics in psychotherapy: Reflections on the use of talking therapies as a supportive adjunct for myalgic encephalomyelitis / chronic fatigue syndrome and ‘medically unexplained symptoms’

“…Such findings, along with perceived lack of empathy being cited as a barrier in therapy [15,19], suggest that more emphasis should be placed upon practitioner relational qualities during training. This is especially important given the apparent disjunction between practitioners' perceived and actual delivery of compassionate and empathic care [17,26,27].…”

“…Moreover, since patient survey data and secondary analyses suggest that CBT therapists who conceptualise ME/CFS as a physical illness are more likely to help patients when compared to therapists ascribe to psychological models [15,40], practitioner insistence on psychological attributions could be construed as problematic from the perspective of responsibility to do good (beneficence) and to do no harm (non-maleficence). In view of such findings, calls for greater epistemic humility among psychotherapists in the arena of ME/CFS and MUS [17] should be supported. Patients with ME/CFS and MUS report an appreciation of the knowledge base of practitioners: feeling understood appears to arise at the intersection of relational or 'personal moral' qualities [32] and clinical knowledge of the health condition: it was really nice to feel that um I was being treated by expert professionals who understood the condition and were sympathetic to it and were really committed to helping […] " [23], p.4…”

“…It meant I wasn't doing this on my own" [7] p.9. Nevertheless, the individual burden of responsibility for progress in in the case of ME/CFS and MUS often appears to be shouldered by patients [17,45]; there is also evidence that this can be the case when practitioners believe themselves to work in collaborative ways [26,27].…”

“…A final consideration is that patients do not always feel they can raise concerns with their practitioner [15]; this is even more likely when practitioners place responsibility on patients for improvement or 'recovery' [20]. Professional candour extends beyond responding appropriately to patient complaint or negative feedback; practitioners must also be able to initiate discussions with patients when the practitioner believes that practice has fallen short of ethical standards [32,33] This requires a high level of critical self-awareness alongside humility; calls for greater reflexivity among psychotherapists working with people with ME/CFS and MUS [17] should thus be heeded.…”

“…This raises the question of how psychotherapists can safely support people with ME/CFS and, more broadly, people labelled with MUS. Whilst literature from a diversity of theoretical and practice perspectives has attempted to answer that question [12,13,[17][18][19], much of the focus has been on the evidence base of these therapies for ME/CFS, and MUS, or the adequacy of informed consent processes [20][21][22]. Our focus is both broader and more rudimentary, and is concerned with how professional psychotherapy ethics intersects with current practices around administering care to people with MUS, including ME/CFS.…”