Therapist Effects and the Impact of Early Therapeutic Alliance on Symptomatic Outcome in Chronic Fatigue Syndrome.

Lucy P Goldsmith,Richard P Bentall,Alison J Wearden,Graham Dunn,Shôn W Lewis

doi:10.1371/journal.pone.0144623

Abstract

Few studies have examined therapist effects and therapeutic alliance (TA) in treatments for chronic fatigue syndrome (CFS). Therapist effects are the differences in outcomes achieved by different therapists. TA is the quality of the bond and level of agreement regarding the goals and tasks of therapy. Prior research suffers the methodological problem that the allocation of therapist was not randomized, meaning therapist effects may be confounded with selection effects. We used data from a randomized controlled treatment trial of 296 people with CFS. The trial compared pragmatic rehabilitation (PR), a nurse led, home based self-help treatment, a counselling-based treatment called supportive listening (SL), with general practitioner treatment as usual. Therapist allocation was randomized. Primary outcome measures, fatigue and physical functioning were assessed blind to treatment allocation. TA was measured in the PR and SL arms. Regression models allowing for interactions were used to examine relationships between (i) therapist and therapeutic alliance, and (ii) therapist and average treatment effect (the difference in mean outcomes between different treatment conditions). We found no therapist effects. We found no relationship between TA and the average treatment effect of a therapist. One therapist formed stronger alliances when delivering PR compared to when delivering SL (effect size 0.76, SE 0.33, 95% CI 0.11 to 1.41). In these therapies for CFS, TA does not influence symptomatic outcome. The lack of significant therapist effects on outcome may result from the trial’s rigorous quality control, or random therapist allocation, eliminating selection effects. Further research is needed. Trial Registration: ISRCTN74156610

Highlights

Chronic Fatigue Syndrome (CFS), known as myalgic encephalomyelitis or encephalopathy (ME), is characterised by severe, disabling fatigue which affects both physical and mental functioning [1]
As previously reported [5] the 95 patients randomized to pragmatic rehabilitation had a mean age of 43.47 years, and 78% were female
The 101 patients randomised to supportive listening had a mean age of 45.13 years and 79% were female

Summary

Introduction

Chronic Fatigue Syndrome (CFS), known as myalgic encephalomyelitis or encephalopathy (ME), is characterised by severe, disabling fatigue which affects both physical and mental functioning [1]. The most effective treatments for CFS are cognitive behaviour therapy (CBT) and graded exercise therapy (GET) delivered by expert therapists [2,3,4]. An approach which combines elements of CBT and GET, delivered by trained general nurses was effective in improving fatigue over an 18-week treatment period but effects attenuated over one year follow up [5]. A reduction in fear related avoidance of activity has been shown to mediate the effects of both CBT and GET on fatigue[7], as has a decrease in focusing on symptoms[8,9,10] and an increased sense of control over fatigue[9]. Wearden and Emsley [11] showed that reduction in fatigue after pragmatic rehabilitation was mediated by changes in cognitive and behavioural responses to fatigue, namely reductions in catastrophizing and self-reported activity limitation. A limitation of prior work on mediators of change is that potential confounding between purported mediators and outcome has not been addressed, meaning that the purported mediators may merely correlate with, rather than cause the improvement in outcome [12]

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Results

Discussion

Conclusion