BPS Models, Recovery, and Epistemic Trust in ME/CFS
1 Bakken et al. 2026 — Making Recovery Conceivable (HCP BPS Perspectives)
Full Citation:: Bakken AK, Mengshoel AM, Synnes O. Making recovery conceivable: perspectives from healthcare professionals using psychologically and behaviourally informed approaches to chronic fatigue syndrome. International Journal of Qualitative Studies on Health and Well-being. 2026;21(1):2745089. (Bakken, Mengshoel, and Synnes 2026) DOI:: 10.1080/17482631.2026.2745089 PMID:: 42853299 Article Type:: Qualitative reflexive thematic analysis (2 focus groups + 3 individual interviews; n=16 HCPs, 5 professions; Norwegian specialist care) Key Findings::
- Four themes: (1) meeting patients in a "no-man's-land" — validation and separating the patient's experience from a proposed explanation; (2) offering a new explanatory "map" (biopsychosocial) with two orientations, one centred on stress/overload/regulation and one on maladaptive-learning/predictive-processing; (3) navigating by the map — graded exposure, gradual re-engagement, "retraining the brain"; (4) maintaining trust in a contested field.
- HCPs viewed the value of the "map" as orientation for change, not causal resolution; embodied improvement (not explanation alone) was the pivotal trust-builder ("the proof of the pudding is in the eating").
- Trust was experienced as fragile: competing narratives ("recovery isn't possible"), patient-organisation criticism, and anticipated future biological findings made some HCPs feel insecure about their legitimacy.
- HCPs with personal CFS-recovery experience were described as "living proof" and unusually credible.Conclusion:: For this purposively selected group of HCPs, therapeutic change rests on an interplay of explanatory framework, its application in practice, the trusting relationship, and the patient’s embodied experience of improvement — not on any single explanation or technique. Limitations:: Purposive sample of HCPs who already endorse psychobehavioural approaches (selection bias); patients described may be unusually receptive; no patient-side data on non-improvers or deterioration; single-country (Norwegian specialist) context; does not test effectiveness. ME/CFS Relevance:: Primary source — the HCP-side operationalisation of the BPS “map”, epistemic trust, and the trust-balancing act in a contested field. Complements the patient/critical side already in ch42/ch46. Certainty Assessment::
- *Quality:* Medium (rigorous, reflexive qualitative analysis)
- *Sample:* n=16 HCPs (small, purposive)
- *Replication:* Single study
- *Score:* 0.35 (raw; population 1.00 → discounted 0.35)2 Knoop et al. 2007 — Is Full Recovery Possible After CBT for CFS?
Full Citation:: Knoop H, Bleijenberg G, Gielissen MFM, van der Meer JWM, White PD. Is a full recovery possible after cognitive behavioural therapy for chronic fatigue syndrome? Psychotherapy and Psychosomatics. 2007;76(3):171–176. (Knoop et al. 2007) DOI:: 10.1159/000099844 PMID:: 17426416 Article Type:: Prospective treatment cohort (secondary outcome analysis) Key Findings::
- After CBT, 69% of n=96 CFS patients no longer met CDC (Fukuda) CFS criteria.
- Full recovery (most comprehensive definition) was achieved by 23%; recovery rate varied with the criteria applied.
- Fewer patients with a comorbid medical condition recovered.Conclusion:: Significant improvement after CBT is probable and full recovery is possible but uncommon; sharing this may raise expectations without false hope. Limitations:: Single-centre cohort; no untreated comparator; recovery definition contested (see (Devendorf et al. 2019)); n=96. ME/CFS Relevance:: F1 anchor — grounds the “recovery is conceivable” premise with a quantified recovery rate (23%) that both supports and bounds it. Certainty Assessment::
- *Quality:* Medium (cohort)
- *Sample:* n=96
- *Replication:* Single study
- *Score:* 0.50 (raw; population 1.00 → discounted 0.50)3 Ingman et al. 2022 — Systematic Review of RCT Prognosis After CBT/GET for CFS
Full Citation:: Ingman T, Smakowski A, Goldsmith K, Chalder T. A systematic literature review of randomized controlled trials evaluating prognosis following treatment for adults with chronic fatigue syndrome. Psychological Medicine. 2022;52(14):2917–2929. (Ingman et al. 2022) DOI:: 10.1017/S0033291722002471 PMID:: 36059125 Article Type:: Systematic review (PROSPERO CRD42018086002) Key Findings::
- 15 RCT publications, 1990 participants (1988–2021). After CBT, 44% self-rated better and 11% worse at short-to-medium term; after GET, 43% better and 14% worse; outcomes 8–26% more favourable than control conditions.
- Two-thirds of studies moderate quality, the remainder weak; most outcomes self-reported.Conclusion:: There is some support for positive effects of CBT/GET at short-to-medium term, though this requires further investigation given inconsistent prior reviews and heterogeneity. Limitations:: Clinical heterogeneity; self-report outcomes; findings may not generalise to severe CFS; moderate/weak study quality. ME/CFS Relevance:: F1 anchor — the most recent synthesis of the CBT/GET evidence base, and it explicitly notes the “worse” tail (11–14%) that feeds the F2 harm framing. Certainty Assessment::
- *Quality:* Moderate (systematic review of weak-to-moderate RCTs)
- *Sample:* 1990 participants across 15 RCTs
- *Replication:* Synthesis
- *Score:* 0.60 (raw; population 1.00 → discounted 0.60)4 Ingman et al. 2025 — Recovery From CFS: Reflexive Thematic Analysis (Patient Side)
Full Citation:: Ingman T, Chalder T, Lawrence V. Recovery from chronic fatigue syndrome: a reflexive thematic analysis of experiences of people before, during and after treatment. International Journal of Qualitative Studies on Health and Well-being. 2025;20(1):2595829. (Ingman, Chalder, and Lawrence 2025) DOI:: 10.1080/17482631.2025.2595829 PMID:: 41347569 Article Type:: Qualitative reflexive thematic analysis Key Findings::
- Explored how people with CFS receiving CBT understand recovery before, during and after treatment, and how treatment reshapes that understanding.
- Recovery is contested and variably operationalised; treatment experience itself shifts how recovery is viewed.Conclusion:: Patient-side accounts of recovery co-evolve with treatment, informing what “making recovery conceivable” means from the patient perspective. Limitations:: Qualitative; treatment-linked sample; single UK CBT context; no measure of who recovers vs who does not. ME/CFS Relevance:: F1/F4 bridge — the patient-side complement to (Bakken, Mengshoel, and Synnes 2026)’s HCP-side account. Certainty Assessment::
- *Quality:* Medium (qualitative)
- *Sample:* Qualitative sample (n unspecified here)
- *Replication:* Single study
- *Score:* 0.40 (raw; population 1.00 → discounted 0.40)5 Geraghty & Blease 2019 — BPS Model: Review of Patient Harm and Distress
Full Citation:: Geraghty KJ, Blease C. Myalgic encephalomyelitis/chronic fatigue syndrome and the biopsychosocial model: a review of patient harm and distress in the medical encounter. Disability and Rehabilitation. 2019;41(25):3092–3102. (Geraghty and Blease 2019) DOI:: 10.1080/09638288.2018.1481149 PMID:: 29929450 Article Type:: Narrative review Key Findings::
- Identifies seven modalities of potential iatrogenesis under the BPS model: diagnostic difficulty; misdiagnosis; impaired sick-role/social-support access; dissatisfaction with care; negative responses to CBT/GET; challenge to the patient narrative; and psychological (individual and collective) harm.
- Documents two divergent models — BPS and a patient-preferred biomedical model — and notes many patients reject the premise that their illness is perpetuated by beliefs, personality, or behaviour.Conclusion:: The BPS framework applied to ME/CFS is too narrow and can cause harm; clinicians should adopt more concordant, patient-centred approaches that foreground the patient narrative. Limitations:: Narrative (non-systematic) review; patient-reported harm; cannot establish causal link from BPS model to harm. ME/CFS Relevance:: F2 anchor — the canonical patient-harm counterweight to the BPS “map” the Bakken HCPs deploy; already central to the psychologisation critique stream. Certainty Assessment::
- *Quality:* Medium (well-cited narrative review)
- *Sample:* N/A (review)
- *Replication:* Independent corroboration (e.g. [@Thoma2023PsychosomaticHarmful], [@Cooper2025PacingVsGET])
- *Score:* 0.50 (raw; population 1.00 → discounted 0.50)6 Thoma et al. 2023 — Psychosomatic View Inconsistent With Evidence and Harmful
Full Citation:: Thoma M, Froehlich L, Hattesohl DBR, Quante S, Jason LA, Scheibenbogen C. Why the psychosomatic view on myalgic encephalomyelitis/chronic fatigue syndrome is inconsistent with current evidence and harmful to patients. Medicina (Kaunas). 2024;60(1):83. (Thoma et al. 2023) DOI:: 10.3390/medicina60010083 PMID:: 38256344 Article Type:: Narrative position review Key Findings::
- ME/CFS has been ICD-classified as neurological since 1969; numerous studies document organic abnormalities, and most researchers classify it as organic.
- Persistent psychosomatic attribution drives misdiagnosis, mistreatment, and stigmatisation; physician and public education is urged.Conclusion:: The psychosomatic/BPS attribution of ME/CFS is inconsistent with current evidence and harmful; it must be corrected to protect patient care. Limitations:: Position/opinion review, not a systematic synthesis; advocacy-affiliated authorship (German Association for ME/CFS); no primary data. ME/CFS Relevance:: F2/F3 anchor — the strongest recent biomedical rebuttal to the framing the Bakken HCPs operationalise. Certainty Assessment::
- *Quality:* Medium (review, aligned with prior evidence)
- *Sample:* N/A (review)
- *Replication:* Concordant with biomedical literature
- *Score:* 0.50 (raw; population 1.00 → discounted 0.50)7 Devendorf et al. 2019 — Defining and Measuring Recovery: The Physician Perspective
Full Citation:: Devendorf AR, Jackson CT, Sunnquist M, Jason LA. Defining and measuring recovery from myalgic encephalomyelitis and chronic fatigue syndrome: the physician perspective. Disability and Rehabilitation. 2019;41(2):158–165. (Devendorf et al. 2019) DOI:: 10.1080/09638288.2017.1383518 PMID:: 28982247 Article Type:: Qualitative (semi-structured interviews; deductive thematic analysis) Key Findings::
- n=10 ME/CFS-expert physicians conceptualised recovery as complete symptom remission and return to premorbid functioning (age-adjusted), distinct from "significant improvement" (substantial symptom reduction with functional gains but ongoing coping/treatment).
- Offered recommendations for measuring daily functioning, symptomatology, quality of life, and physical functioning.Conclusion:: Recovery should be operationalised multidimensionally; without a consensus definition, treatment-outcome interpretation remains contested. Limitations:: Small sample (n=10); physician-only perspective; definitional question, not outcome data. ME/CFS Relevance:: F3/F4 anchor — shows that even among sympathetic physicians, “recovery” is narrowly defined (full remission), which tensions with the BPS “recovery conceivable” framing and with the 23% figure in (Knoop et al. 2007). Certainty Assessment::
- *Quality:* Medium (qualitative)
- *Sample:* n=10
- *Replication:* Single study
- *Score:* 0.40 (raw; population 1.00 → discounted 0.40)8 Cross 2026 — Transforming Biomedical Uncertainty: Sociohistorical Origins of ME/CFS
Full Citation:: Cross S. Transforming biomedical uncertainty: the sociohistorical origins of myalgic encephalomyelitis (ME) and chronic fatigue syndrome (CFS). Medical Humanities. 2026. (Cross 2026) DOI:: 10.1136/medhum-2025-013657 PMID:: 42601195 Article Type:: Critical literature/historical analysis (medical texts 1950–1990) Key Findings::
- Traces how ME (UK) and CFS (US) emerged as distinct medical/scientific objects through the regulation of biomedical uncertainty, which systematically obscured certain aspects of illness.
- Argues these transformations underpin the epistemic injustices patients experience and cautions that biomedicine itself can generate ignorance about complex conditions.Conclusion:: The contested, uncertain status of ME/CFS is historically produced, not incidental; this shapes what can be known and is a root of patient epistemic injustice. Limitations:: Historical/archival method, not empirical cohort; single-author interpretation; English-language sources. ME/CFS Relevance:: F3 anchor — explains the sociohistorical substrate of the “contested field” within which the Bakken HCPs must maintain trust. Certainty Assessment::
- *Quality:* Medium (scholarly history)
- *Sample:* N/A (archival)
- *Replication:* Independent of cohort replication
- *Score:* 0.40 (raw; population 0.75 → discounted 0.30)9 Heins et al. 2013 — Therapeutic Relationship in CBT for CFS
Full Citation:: Heins MJ, Knoop H, Bleijenberg G. The role of the therapeutic relationship in cognitive behaviour therapy for chronic fatigue syndrome. Behaviour Research and Therapy. 2013;51(7):368–376. (Heins, Knoop, and Bleijenberg 2013) DOI:: 10.1016/j.brat.2013.02.001 PMID:: 23639303 Article Type:: Prospective cohort (secondary analysis of CBT trial participants) Key Findings::
- Baseline outcome expectations and agreement about therapy content predicted post-treatment fatigue in n=217 CFS patients.
- 25% of post-treatment fatigue variance was jointly explained by outcome expectations, working alliance, and changes in fatigue-perpetuating factors.
- Positive expectations and task agreement appeared to facilitate change in fatigue-perpetuating factors.Conclusion:: A positive therapeutic relationship early in CBT facilitates the cognitive/behavioural changes that reduce fatigue. Limitations:: Correlational within-treatment cohort; cannot prove the alliance causes improvement independent of therapy content; single centre. ME/CFS Relevance:: F4 anchor — the only CFS-specific quantitative evidence that the alliance/trust mechanism (the core of Bakken’s theme 4) predicts outcome. Certainty Assessment::
- *Quality:* Medium (cohort)
- *Sample:* n=217
- *Replication:* Single study
- *Score:* 0.55 (raw; population 1.00 → discounted 0.55)10 Bordin 1979 — The Working Alliance (Foundational)
Full Citation:: Bordin ES. The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice. 1979;16(3):252–260. (Bordin 1979) DOI:: 10.1037/h0085885 Article Type:: Theoretical/conceptual (classic) Key Findings::
- Defines the working alliance as agreement on treatment goals and tasks plus a personal bond.
- Generalises the alliance concept beyond psychoanalysis to all change-oriented relationships.Conclusion:: The alliance is a pan-theoretical construct central to therapeutic change. Limitations:: Conceptual, no empirical data; predates modern measurement. ME/CFS Relevance:: F4 foundational citation — the definition Bakken invokes for the therapeutic relationship. Certainty Assessment::
- *Quality:* Foundational concept
- *Sample:* N/A
- *Replication:* Universally adopted
- *Score:* 0.35 (raw; population 0.75 → discounted 0.26)11 Fonagy & Allison 2014 — Mentalizing and Epistemic Trust
Full Citation:: Fonagy P, Allison E. The role of mentalizing and epistemic trust in the therapeutic relationship. Psychotherapy. 2014;51(3):372–380. (Fonagy and Allison 2014) DOI:: 10.1037/a0036505 PMID:: 24773092 Article Type:: Theoretical Key Findings::
- Proposes epistemic trust — the extent to which communicated knowledge is experienced as credible, personally relevant, and applicable — as a central component of effective therapy.
- Links epistemic trust to mentalizing and the therapeutic relationship.Conclusion:: Epistemic trust is a core mechanism through which patients take up and apply new knowledge. Limitations:: Theoretical; no ME/CFS data; concept’s measurement still evolving (see (Fisher, Fonagy, and Zilcha-Mano 2025)). ME/CFS Relevance:: F4 foundational citation — the concept Bakken uses to interpret how embodied improvement makes the HCP’s “map” credible. Certainty Assessment::
- *Quality:* Foundational concept
- *Sample:* N/A
- *Replication:* Broad uptake
- *Score:* 0.35 (raw; population 0.75 → discounted 0.26)12 Flückiger et al. 2018 — Alliance in Adult Psychotherapy: Meta-Analytic Synthesis
Full Citation:: Flückiger C, Del Re AC, Wampold BE, Horvath AO. The alliance in adult psychotherapy: a meta-analytic synthesis. Psychotherapy. 2018;55(4):316–340. (Flückiger et al. 2018) DOI:: 10.1037/pst0000172 PMID:: 29792475 Article Type:: Meta-analysis Key Findings::
- 295 independent studies, >30,000 patients (1978–2017).
- Alliance robustly associated with outcome (r ≈ .28) across orientations and conditions.Conclusion:: The therapeutic alliance is a reliable, moderate predictor of psychotherapy outcome. Limitations:: General psychotherapy population (not ME/CFS); correlational (alliance may partly reflect early improvement). ME/CFS Relevance:: F4 anchor — the large-N evidence base for the alliance mechanism, extrapolated (population-discounted) to CFS where direct evidence is limited to (Heins, Knoop, and Bleijenberg 2013). Certainty Assessment::
- *Quality:* High (meta-analysis)
- *Sample:* >30,000 patients
- *Replication:* Meta-analytic
- *Score:* 0.70 (raw; population 0.75 → discounted 0.53)13 Fisher et al. 2025 — A Panoramic View of Epistemic Trust in Psychotherapy
Full Citation:: Fisher S, Fonagy P, Zilcha-Mano S. More than meets the “I”: a panoramic view of epistemic trust in psychotherapy. Psychopathology. 2025;58(2):80–93. (Fisher, Fonagy, and Zilcha-Mano 2025) DOI:: 10.1159/000541667 PMID:: 39467536 Article Type:: Narrative review Key Findings::
- Reviews whether epistemic trust is an inherent patient characteristic or a catalyst for therapeutic change.
- Notes comprehensive empirical support is still lacking despite clinical significance.Conclusion:: Epistemic trust is a promising but under-validated construct in psychotherapy. Limitations:: Narrative; limited empirical base; general psychotherapy, not ME/CFS. ME/CFS Relevance:: F4 current-synthesis anchor — the epistemic-trust framework Bakken cites, with the caveat that its empirical support is still limited. Certainty Assessment::
- *Quality:* Medium (review)
- *Sample:* N/A (review)
- *Replication:* N/A
- *Score:* 0.40 (raw; population 0.75 → discounted 0.30)