Version 4 05.01.

2022

CBT for Chronic Fatigue:

Therapist Manual
PAEDIATRIC ME/CFS TEAM, ROYAL UNITED HOSPITAL, BATH, UK

Starbuck, J., Loades, M.E., & Chapple, K. | 2022

Table of Contents
General CBT Principles .............................................................................................................4
Introducing CBT to Patients & Families...............................................................................6
CBT for ME/CFS ........................................................................................................................ 7
Acknowledging that fatigue is real ................................................................................... 7
Adjustment to a ME/CFS diagnosis, building acceptance and engaging in treatment .. 7
Exploring beliefs about illness and recovery .................................................................... 7
Finding new ways of managing symptoms e.g. pain or disrupted sleep .........................8
Re-building self-confidence and enjoyment of activities ................................................8
Learning to manage setbacks............................................................................................8
Working with fatigued patients ........................................................................................9
What is ME/CFS?: Psychoeducation about ME/CFS ............................................................. 10
Definitions and diagnosis ............................................................................................... 10
Onset and maintenance of ME/CFS ................................................................................ 11
Recovery in ME/CFS......................................................................................................... 11
Assessment ............................................................................................................................... 13
Diagnostic Assessment..................................................................................................... 13
CBT Assessment ............................................................................................................... 13
Formulation – Our road map ..................................................................................................15
Formulations in CBT for ME/CFS ................................................................................... 16
Goals - what do we want to achieve together? ...................................................................... 18
Examples of goals ............................................................................................................ 19
Components of Treatment ..................................................................................................... 20
Sleep..................................................................................................................................... 20
How much sleep/sleep restriction .................................................................................. 20
Timing of sleep .................................................................................................................21
Daytime rests/naps...........................................................................................................21
Sleep Hygiene ...................................................................................................................21
Energy management ........................................................................................................... 22
The boom and bust cycle ................................................................................................ 22

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 Categorising activities ..................................................................................................... 23
Calculating the Activity baseline .................................................................................... 24
Increasing the activity baseline ...................................................................................... 24
Activity Scheduling – valued activities ........................................................................... 25
De-Regulating .................................................................................................................. 25
Energy management with younger ME/CFS patients .................................................... 26
Cognitive work: thoughts that are unhelpful..................................................................... 28
More helpful ways of thinking ........................................................................................ 29
Managing feelings ............................................................................................................... 33
The foundations: Emotional literacy and emotional regulation ................................... 33
Calm Breathing ................................................................................................................ 34
Relaxing place imagery.................................................................................................... 34
Muscle Relaxation ........................................................................................................... 35
Grounding Techniques.................................................................................................... 35
School and ME/CFS ................................................................................................................ 36
Energy Management and time in school ........................................................................ 36
Supporting a young person with ME/CFS in school ...................................................... 36
Extra support available.................................................................................................... 37
When a child cannot attend school................................................................................ 38
The social side of ME/CFS and school attendance ........................................................ 38
The emotional side: school-related anxiety or stress ..................................................... 39
Supporting younger children with ME/CFS in school ...................................................40
What can get in the way of making changes?........................................................................ 41
Motivational interviewing .................................................................................................. 41
Problem solving................................................................................................................... 42
Adapting CBT for ME/CFS when there are concurrent Mental Health Problems ...............44
Anxiety .................................................................................................................................44
Additional CBT techniques which may be helpful ........................................................44
Treating anxiety in younger ME/CFS patients ...............................................................46
Depression ...........................................................................................................................48

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 Additional CBT techniques which may be helpful ........................................................48
When more help for mental health problems is needed.................................................. 49
Relapse Prevention and Managing Setbacks ..........................................................................51

Note: This manual is not intended to be prescriptive. It aims to summarise current

practice, which is individualized for each young person depending on their needs,
formulation, developmental stage, interests and context. Individual therapists also have
their own styles and preferences, so this is intended to be used flexibly but with fidelity.
We also include links to some of our own resources and information sources, as well as
some of other reputable organisations.

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General CBT Principles
The updated NICE guidelines (2021) recommend that Psychological therapy be available
for supporting people with Chronic Fatigue Syndrome/ME (ME/CFS). The primary
therapy that has been used and researched is Cognitive Behaviour Therapy (CBT). CBT is
offered to young people with ME/CFS with the aims of improving wellbeing and quality of
life, learning to manage symptoms, and reducing distress associated with having a chronic
illness.

CBT recognizes that thoughts, feelings, behaviours and physiology interact with each
other. This understanding can be helpful in identifying ‘unhelpful’ links between these
factors and in building new ‘helpful’ links. For example helping a patient to understand
and respond to their symptoms or experiences differently, can help improve their felt
sense of wellbeing and quality of life.

CBT takes a non-judgemental, supportive approach to understanding a person’s

experience and in helping to bring about positive change. It recognizes that whilst some
patterns or links may be commonly seen in certain health conditions, each person’s
experience is unique and it is essential to be sensitive to individual experience and also
symptom fluctuation over time.

The core features of CBT are:

- Based on theory – CBT is based on testable models of links between thoughts-

feelings-behaviour which inform how and where to make changes, based on
evidence.

- Collaborative partnership – Young people are empowered to be active within the

therapeutic relationship. Rather than assuming that the therapist is the expert who
will ‘do’ things to ‘fix’ the problem, the therapist and young person both bring
expertise to the table. The therapist knows the CBT principles for building
recovery from ME/CFS and what works generally, and the young person knows
themselves and their lives. Through a collaborative partnership, they bring this
expertise together to find what works to overcome problems for that young person
at that time.

- Scientist-discoverer – The work of CBT is about testing out different ways of

thinking and doing, and about assessing how things change as a result. It is about
actively learning from experience. The evidence for and against thoughts may be
weighed up, and behavioural experiments may be carried out to test whether
beliefs are true or whether there may be other ways of looking at things. Together
the therapist and young person set out to find new information about the young

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 person and their experiences, with the overall aim of helping that young person to
make positive changes and to feel better.

- Here-and-now- CBT focuses on the present. It aims to address problems in the

here-and-now, and to change ways of interacting with the world going forwards.
This does not mean it completely ignores the past; the past is explored where it is
relevant to what is happening now. But it is particularly helpful for the young
person to be empowered in setting and working towards goals in the present and
future.

- Time-limited – CBT is a relatively brief therapy, and typically lasts for ≤ 16 sessions.
The aim is to develop skills which the young person can continue to use beyond
the end of therapy, and even to come back to later down the line, if they need.
Therefore, rather than the therapeutic relationship being the vehicle for change (as
in some other therapeutic modalities), the skills learned are the vehicle for change.
The therapeutic relationship is considered to be necessary but not sufficient for
change.

- Structured – The process of CBT begins with an assessment. Following this, a

shared understanding (formulation) of the problem is developed with the young
person which includes identifying how thoughts-feelings-behaviours (and how
they interconnect) are keeping the problem going. The therapist works with the
young person to develop skills to manage thoughts, and to respond in more
helpful ways. Progress and change are evaluated using rating scales, and goals set
at the outset are regularly reviewed. Each session is also structured, starting with a
check-in, then agreeing together a shared agenda (key things to talk about in that
session), covering these items with reference to the goals and formulation, and use
of periodic summaries (by both the young person/therapist) to consolidate
learning and check for understanding,

CBT is based on the work of Aaron Beck and his daughter, Judith Beck (see Cognitive
Therapy: The Basics and Beyond).

The main differences in the delivery of CBT when working with young people and families
(compared to when delivering the therapy with adults) are:
 Parents are more likely to be involved (as facilitators/co-therapists/co-clients).
 Greater use of creative methods
 Adaptation to developmental level, including developing emotional literacy, and
considering level of cognitive ability, where needed.

See Stallard’s Think Good Feel Good and Fuggle, Dunsmuir & Curry’s CBT with Children,
Young People and Families for more detailed descriptions.

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INTRODUCING CBT TO PATIENTS & FAMILIES
CBT typically begins by explaining what CBT is and what it will involve to a young person
and their family, known as ‘socialising’ to the model. This enables the young person to
decide whether they would like to use CBT to support them. See information sheets:

- https://www.ruh.nhs.uk/patients/services/clinical_depts/paediatric_cfs_me/docu
ments/PCFS007_CBT.pdf
- Stallard’s Think Good Feel Good & Clinicians’ Guide to Think Good Feel Good.

The key messages are:

- Cognitive Behavioural Therapy (CBT) can be helpful for young people with
ME/CFS.
- CBT looks at the links between the way you think, how you feel and what you do.
- It helps by creating new ways of managing difficult thoughts and feelings.
- CBT involves a series of one-to-one sessions with a specialist healthcare
professional trained in mental health, e.g. a psychologist, who works under clinical
supervision of another healthcare professional with expertise in the relevant
area(s).
- CBT is typically delivered in 1hour (maximum) sessions with the young person,
which take place either weekly or every other week depending on clinic availability
and what is most appropriate for the young person.
- After an assessment session, the therapist and patient will commonly plan a block
of sessions (e.g. 6) after which a review is held. The review helps to track the
progress of treatment more formally in relation to the patient’s goals, and to
consider whether (or how many) further sessions are needed.
- CBT is time-limited and a young person may have on average something like 12-15
CBT sessions. CBT aims to develop tools for the young person to use even beyond
the end of the work together.

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CBT for ME/CFS
What follows in the subsequent sections is a detailed description of the components of
CBT for ME/CFS. As a preface to this, here are some ways in which CBT for ME/CFS may
be different to CBT more broadly.

Acknowledging that fatigue is real

It is important to acknowledge with the young person that the fatigue is real. ME/CFS
unfortunately carries with it a history of being misunderstood (and even sometimes
disbelieved); even today’s patients are affected by this. They might report a sense of others
suggesting it isn’t real, or that (and this is a terrible phrase) it is “all in their head”. The
challenges of an invisible illness can be multiple, complex, and highly distressing. The
therapist has a key role here in acknowledging that the fatigue is very much a real and
present experience, and that whilst there may not be a medical ‘cure’ it is possible to use
non-pharmacological methods such as behavioural and psychological strategies to
helpfully bring about change and improvement in symptom management, daily
functioning and quality of life. This is an important and subtle distinction to address with
the young person and those supporting them.

Adjustment to a ME/CFS diagnosis, building acceptance and engaging in

treatment
Young people, and their families, can react to a diagnosis of ME/CFS in different ways. For
some the diagnosis comes as a huge relief, after a period of uncertainty. As ME/CFS is
diagnosed by excluding other possible explanations for fatigue, a young person may have
had a long journey to reaching a diagnosis. This can lead to a great sense of confusion,
uncertainty and frustration for the young person and their family. In addition to this,
families often report a sense of not being understood (or worse: not believed) by others
around them that something is wrong. ME/CFS is one of many invisible illnesses and it
can pose great challenges for the sufferer in this way.

CBT can therefore be particularly important here for supporting the young person, and
their family, to process the new diagnosis. It also helps to build a shared understanding
together of the aims and goals of CBT treatment within the recovery journey. Adjustment,
acceptance, and engagement are key processes of therapy which must be considered and
explored at the outset of therapy but are also likely to recur later on as the therapeutic
work progresses.

Exploring beliefs about illness and recovery

It is particularly important in CBT for ME/CFS to give the young person space to recognize
and become familiar with their thoughts and beliefs about ME/CFS. Many young people
might not have voiced (or even consciously accessed) these prior to starting therapy. Some
young people can need encouragement and even permission to open these conversations.

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The therapist plays a key role in normalizing and validating any such feelings that the
young person may present.

Curiously exploring the thoughts or beliefs that significant others hold about illness and
recovery can be particularly helpful too. This can include friends, family, and perhaps even
others who have a caring or supportive role such as school staff. The recovery journey in
ME/CFS is certainly not something done by the young person alone but with support of
the therapist and the wider, multi-layered systems around them. Therefore, eliciting and
exploring all beliefs held within these systems is crucial. It might be for example that a
parent feels helpless or doubtful about the prospect of the young person’s recovery; this is
really important to explore and address.

Finding new ways of managing symptoms e.g. pain or disrupted sleep

CBT provides a range of methods or skills for managing symptoms. These might be quite
practical and familiar (e.g. learning good sleep hygiene methods), or perhaps newer to the
young person (e.g. physical relaxation methods and controlled breathing exercises). It is
about giving the young person new ways of coping with and responding to their
symptoms. CBT creates the opportunity to bring about behavioural change through
cognitive and behavioural methods. For example, the therapist can support the young
person to conduct cost-benefit analyses of a current behaviour and use this to consider the
benefits of new or different behavioural responses to their symptoms. The young person is
gently guided to consider new ideas and to try new things out, in an ‘experimental’
approach. The aim here is always about helping the young person to move towards their
own therapeutic goals for recovery.

Re-building self-confidence and enjoyment of activities

As a young person progresses through treatment it is possible to shift focus not just to the
rebuilding of activities themselves but also to the enjoyment of them. CBT for ME/CFS can
give the young person opportunities to explore why activities are important to them, and
to reflect on themes such as their sense of self and identity. As a young person returns to
old favoured activities (or indeed begins new ones) it is important to scaffold the re-
building of their self-confidence; something which is likely to have taken several knocks
during the course of their illness.

Learning to manage setbacks

CBT for ME/CFS has a central focus of building a young person’s skills in recognising,
understanding, and managing their symptoms and experiences. These skills are key in
each stage of the recovery process, including the management of flare-ups (temporary
recurrence or worsening of symptoms) or other setbacks during the recovery journey. It is
important to discuss the possibility of flare-ups and for the young person to feel clear on
which skills and strategies they would employ from their toolkit if needing to. In this way

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the young person can finish CBT sessions armed with knowing what to do later down the
line if symptoms recurred or worsened after therapy had ended.

Working with fatigued patients

Using CBT with young people who are struggling with fatigue is likely to require
adaptations to CBT practices to account for the symptoms of ME/CFS, particularly
concentration and ‘brain fog’. This may include:

- Keeping sessions shorter

- Taking breaks during sessions
- Repeating material/revising key concepts more often
- Providing written material to supplement in session discussion
- Keeping key concepts and written material simple
- Capturing the key points of each session by writing these down (ideally, getting
the young person to do this)
- Offer some sessions by videoconference, particularly if the young person lives a
considerable distance from the clinic location as travelling can be particularly
tiring
- Including parents more to aid the retention of information and to enable them to
provide reminders in between sessions.
- Remember that symptoms are variable, so what a young person can do on one day
may be different from another.

Note, at the end of this manual, we have included a general guide about treatment
sequencing in behavioural approaches, CBT for ME/CFS and CBT for ME/CFS with co-
morbid anxiety and/or depressive symptoms. This guide is not intended to be prescriptive.

Establishing Informed Consent

The new NICE guidelines for ME/CFS highlights the need to provide the young person
and family with information about the benefits and risks of any intervention for ME/CFS
and collaboratively discuss their recovery goals, so they can give informed consent about
whether to engage with the intervention. This is at the heart of all Psychological therapy
and CBT is certainly a collaborative approach led by the patient’s goals. There are a few
risks/disadvantages of undertaking CBT:

1. A patient will need to see a therapist regularly for an intervention to be effective.

Usually this involves weekly/fortnightly appointments. While measures (noted
above) can be taken to reduce the impact of the sessions on a young person’s
fatigue, in order to benefit and take part in the therapy they need to be able to
spend time talking to a therapist and this will take up energy. Sessions can be quite
emotive at times, particularly if difficult emotions are being discussed, which can

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 lead to additional energy expenditure and potentially feeling more fatigued
following the sessions. To be most effective, young people are often asked to
complete tasks in between sessions to consolidate and explore the points they have
learnt from the session, again requiring a certain degree of energy. This should be
monitored throughout sessions and if causing a problem for the young person,
discuss whether now is the right time for the intervention.
2. During CBT a patient may explore more challenging emotions and painful feelings,
and this may lead to them becoming upset, crying or feeling angry. This may be
more prevalent at the beginning of therapy.
3. CBT involves effort and commitment from the young person and they need to be
engaged and willing to take part in the therapy.
4. CBT mainly focuses on the individual and their own agency in managing or
changing their thoughts, feelings and behaviours. It does not address wider
problems that might be present in systems or families that might also be having an
impact on the young person.
5. If a young person raises concerns in therapy about their broader mental health or
safeguarding concerns then this may lead to onward referrals to other services
whom can support the young person and family. While the clinician is offering
psychological therapy to a young person, they may not be able to offer support for
all problems encountered.

What is ME/CFS?: Psychoeducation about ME/CFS

Definitions and diagnosis
Chronic Fatigue Syndrome (CFS), sometimes referred to as Myalgic Encephal0myelitis
(ME), is a health condition characterized by extreme tiredness. Like other syndromes,
ME/CFS has core symptoms, which must be present for a diagnosis to be made. It can also
include a number of other symptoms which not everyone with ME/CFS will have, or has to
differing extents. This means that there is individual variation in how ME/CFS presents.

To be diagnosed with ME/CFS a young person would need to meet the following four key
criteria:

• Persistent fatigue, that is not life-long but has been ongoing for at least 3 months.
• The fatigue is not just due to exertion (instead, it is there in the background a lot
of the time) and is not substantially improved by resting.
• Post-exertional malaise; the fatigue is worsened after increased activity. This can
show itself 1-2 days after the busy time and can take a few days to recover from.
• Fatigue that is severe enough to significantly disrupt all areas of daily life e.g. going
to school, hobbies or clubs, time with friends or family, etc.

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In addition, some other symptoms of ME/CFS include sleep disturbance, muscle and joint
pain, headaches and sore throats, cognitive dysfunction (including attention, processing
and memory difficulties), dizziness, nausea, and heart palpitations, amongst others. Some
young people may also experience increased sensory sensitivity e.g. to touch, noise, or
light. A substantial minority of young people with ME/CFS also experience problems with
mood and anxiety. This may be due to feelings of sadness, worry, or frustration about their
illness and its impact, amongst other things.

Onset and maintenance of ME/CFS

ME/CFS is complex and we do not always know what causes or triggers it. Often, young
people with ME/CFS will report a history of having an acute illness (e.g. a bad virus, or
glandular fever), and a sense that they never really recovered afterwards. For others, the
trigger could have been a highly stressful or traumatic event, however this is less common
and less well understood.

Whereas the trigger or onset of ME/CFS can be unclear, we know more about what can
keep ME/CFS going. The evidence points towards behavioural maintenance factors
(activity patterns, sleep) and cognitive maintenance factors (thoughts and beliefs about
fatigue). And this is where we can helpfully apply evidence-based treatments, including
CBT, to enable the young person to make changes and work towards recovery from their
fatigue. There is no medicine or ‘cure’ for ME/CFS. Instead, treatments use largely
behavioural methods to bring about changes and improvements, e.g. starting with
regulating sleeping patterns and activity levels. This will be explained later in this manual.

Recovery in ME/CFS
There is no cure for ME/CFS at present and no pharmacological treatment. However the
good news is that recovery rates from ME/CFS in young people are good. A Dutch study
looking at recovery found that approximately 85% of young people were recovered
(absence of severe fatigue) at 1 year after starting active ME/CFS treatment (internet based
CBT for fatigue). This data can be compared to a 27% recovery rate for those who were not
in active treatment, after 1 year (see Nijhof, S. L., Bleijenberg, G., Uiterwaal, C. S., Kimpen,
J. L., & van de Putte, E. M. (2012). Effectiveness of internet-based cognitive behavioural
treatment for adolescents with chronic fatigue syndrome (FITNET): a randomised
controlled trial. The Lancet, 379(9824), 1412-1418).

This data shows us a few things:

1. The recovery journey takes a matter of months, or a year, or perhaps longer. It is

not something completed in weeks.
2. It suggests that many young people with ME/CFS will be recovered after 1 year of
CBT.

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 3. But this will not be the case for everyone; for some, the journey may be slightly
over 1 year but also for some it could be significantly longer.
4. Even without active treatment, there is some natural recovery in young people
with ME/CFS, but CBT can speed up this process.

Much less is known about treatments for those who are most severely affected by ME/CFS.

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Assessment
Diagnostic Assessment
The diagnostic assessment of ME/CFS is generally conducted either by community
paediatricians or highly trained clinicians working in specialist ME/CFS services, including
Doctors and Clinical Psychologists, amongst others. Diagnosis involves several sources of
information which are collated and synthesized. Patients with a queried ME/CFS
presentation are required to have a set of screening blood tests completed, in line with
NICE treatment guidelines for ME/CFS, prior to assessment. These blood tests are to rule
out any other underlying health difficulties which could be relevant.

The diagnostic assessment interview includes taking a thorough medical and

developmental history, and asking about the current symptom presentation, including
considering the results of blood tests. A symptom checklist may be used to structure this.
It can be informative to gather information on the family and wider family health history
too. A good biopsychosocial assessment in ME/CFS would aim to build a picture of all
aspects of the child’s functioning at present, including sleeping patterns, school
attendance, engagement in hobbies or social activities, diet, mental health, and any other
pertinent information presented by the family. All possible alternative explanations for
fatigue need to be explored before a diagnostic conclusion can be reached.

The assessment process is helpfully supported by use of questionnaires, typically

completed by the young person prior to the diagnostic assessment in clinic. At a basic
level these questionnaires aim to assess current levels of fatigue and its impact on
functioning, as well as screening of mental health difficulties (anxiety and depression).
Other, more detailed psychological measures can be also conducted e.g. assessing
cognitive and behavioural responses to fatigue, or the extent of general negative thinking
patterns.

Note that where mental health problems like anxiety or depression are the primary
problem that explains the fatigue, a diagnosis of ME/CFS would not be made. However, a
young person may have mental health problems AND ME/CFS, where the fatigue meets
the diagnostic criteria for ME/CFS and is not fully explained by the mental health
problem(s) alone.

CBT Assessment
At the first CBT session, a more detailed exploration of thoughts, feelings, behaviours and
physical symptoms, and the links between these, is likely to be explored. This will feed
into the initial formulation. It is also likely to include an exploration of the key problems,
which may form a ‘problem list’. A more detailed consideration of mood and anxiety,
particularly where there are indications that this might be part of the picture, may also be
undertaken. Assessment is likely to be iterative and ongoing, and may be revisited as
therapy progresses.

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Questionnaires that may be useful for aiding assessment and for progress tracking during
therapy are:

Focus Questionnaire No of items Clinical cut-off/scoring

Fatigue Chalder 11 Items scored as 0 (less than usual) to 3 (much more
Fatigue than usual). 7 items pertain to physical fatigue and 4
Questionnaire to mental fatigue. Higher scores indicate greater
fatigue. Scores of ≥19 indicate clinically significant
fatigue
Physical SF36 Physical 10 Items scored as 0 (yes, a lot)/5 (yes, a little) /10 (not
functioning Functioning at all).
(disability) Subscale 0-100 (where 100 is better functioning).
Anxiety and Revised 10 items Child and parent versions. Each item is scored 0
Depression Children’s depression (never) to 3 (always). Higher scores indicate greater
Anxiety and 37 items anxiety psychopathology.
Depression (separated into RCADS-depression >14-15 likely indicates probable
Scale – GAD, Social depression, and RCADS-anxiety (total) > 37-38 likely
(RCADS) Anxiety, Panic, indicates a likely Anxiety Disorder.
OCD and
Separation
Anxiety)
Cognitive Cognitive and 18 items (also a For the cognitive items, 0 = strongly disagree, 4 =
and Behavioural 40-item version) strongly agree. Higher scores indicate more unhelpful
behavioural Responses to Subscales: beliefs about symptoms. For the behavioural items, 0
responses Symptoms (symptom = never, 4 = all the time. Higher scores indicate more
to fatigue Questionnaire focusing, fear unhelpful responses to symptoms.
(CBRQ) avoidance,
embarrassment
avoidance,
catastrophizing,
damage beliefs,
all-or-nothing
behaviour,
avoidance/rest).
General Children’s 16 (5 subscales: Each item presents a scenario and a distorted
negative Negative (underestimation thought. Respondents are required to indicate how
thinking Cognitive of coping ability, similar their thinking would be to the given thought
patterns Errors personalising on a 5-point scale from ‘not at all like I would think’
Questionnaire without (1) and ‘almost exactly like I would think’ (5). Higher
(CNCEQ-R) mindreading, scores indicate more negative thinking patterns.
mindreading,
selective
abstraction,
overgeneralizing)
Note: this is not intended to be a definitive list. These are examples which have been used
in adolescents with ME/CFS, but others may be more clinically useful in a particular case.
Idiosyncratic measures such as 0-10 or 0-100 rating scales may also be useful and may be
more appropriate to decrease the burden of filling in extensive measures.

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Formulation – Our road map
The formulation can be thought of as the shared understanding of the problem and what
is keeping it going. It may also include the shared understanding of how the problem
started.

Most typically, the formulation describes the links between aspects of thinking, feeling
and doing. In the paediatric setting, it most likely also includes physical symptoms. A
relatively basic formulation is Padesky’s hot cross bun, as seen below. The multiple and
bidirectional arrows demonstrate that all of these elements interact with each other and
can make each other worse. Understanding these links is crucial for trying to reduce
unhelpful cycles and to bring about new, helpful cycles between thoughts, feelings,
behaviour, and fatigue.

The formulation is constantly evolving. It guides intervention by highlighting what needs

to change for things to be different. Whilst we often can’t change the situation, or our
feelings directly, by making changes in thinking and doing, the feedback loops lead to
changes in feelings. In paediatric settings, the emphasis is often on living the best life you
can alongside physical symptoms, rather than necessarily seeking to change the physical
symptoms themselves directly.

There are more specific formulation templates that can be used for specific problems (e.g.
social anxiety disorder) or completely idiosyncratic approaches may be worked on
together in therapy. Www.psychologytools.com and www.getselfhelp.co.uk are good
sources of printable worksheets of a variety of models.

The therapist may develop a more detailed formulation of the problem than is necessarily
shared with the young person/family, particularly for patients with complex presentations
where to share the formulation in its entirety could be overwhelming or confusing.
Ideally, the formulation should be as detailed but as simple as possible (parsimony). The

PAGE 15
therapist can use any additional (more complex) formulations to sensitively guide their
thinking during the therapy and in supervision, and may draw on some parts of it as
therapy continues.

Formulations in CBT for ME/CFS

A key task in CBT for ME/CFS is to build a shared understanding (formulation) of the
young person’s experiences, symptoms and situation. It is a way of looking at what is
going on for them, and how their thoughts, feelings and behaviour connect with each
other, and with their fatigue. It also helps to highlight areas which may be particularly
important to work on during CBT sessions.

To illustrate, here are some examples of some of the common thoughts-behaviours-fatigue

links, for a young person with ME/CFS.

A young person with ME/CFS may be prone to focus on their physical symptoms. If aware
of feeling particularly tired or in pain, a young person is likely to be cautious and behave
differently e.g. reduce their activity level. This may mean not going into school, resting
more, or even sleeping more. As an unhelpful consequence, this reduced activity level can
lead to increased disability and worsened fear about reinstating activities, making it
harder for the young person to then resume activities. It is important to notice these sorts
of links carefully and sensitively.

Similarly, young people with ME/CFS may be extra aware of symptoms or feelings in their
body and more likely to detect small changes in how they physically feel. If a young person
then interprets these feelings as ‘bad’, they may ‘blame’ activity as the cause of these
symptoms. As a result, they may find themselves reducing their activity level or engaging
in other precautionary “safety behaviours” in an attempt to prevent their fatigue from
worsening, which can in fact cause them further difficulties and build barriers in reaching
their goals.

Another challenge for young people with ME/CFS can be the role of thoughts and their
influence on behaviour. A young person who has been unwell for some time may have
reduced self-efficacy or be hyper-sensitive to the perceived opinions or reactions of others.
Young people with ME/CFS can feel a great pressure to do their best, or a sense of needing
to be seen to do well, in the context of having lost physical strength or perhaps not doing
as well at school as they used to, for example. These thoughts and worries too can lead to
the young person finding it hard to re-increase activities and becoming somewhat stuck.
Aiming for perfection is very daunting. This reduced activity level combined with
increased anxiety can worsen fatigue itself and the ‘stuck’ circle can continue.

PAGE 16
 FATIGUE

Focus on / awareness
BEHAVIOUR of symptoms of fatigue BODILY SENSATIONS

Reduce activity level Fatigue increases

Cautious to increase Increased pain / other

activity ME/CFS symptoms

FEELINGS THOUGHTS

Worry Wish to avoid increasing activity

level
Hopelessness
Believe that activity causes fatigue
Sadness
Interpret bodily sensations as bad
Pressure (internal) to do more
Focus on symptoms

In these ways, it is hugely important to help the young person recognize the links between
their own thoughts, feelings, behaviour, and symptoms of fatigue. Having a better
understanding of how these things connect enables the young person, with the support of
their therapist, to identify areas to work on in CBT sessions. This might be about setting
activity-related goals or working on managing particular thoughts or feelings; in this way
CBT for ME/CFS can encompass a range of key skills and learning.

The formulation(s) are continually reviewed and adapted as treatment progresses. It is

important to come back to the formulation during treatment and consider what changes
have occurred so far; updating the formulation and revising the patient’s next goals to
focus on. It is an iterative process, of looking back at the formulation and goals.

PAGE 17
Goals - what do we want to achieve together?
After completing the assessment and formulation stages in CBT, it is important to
establish the young person’s goals for their treatment and recovery journey. Goals can be
identified early within assessment but often become clearer, and more specific, through
formulation. Similarly, goals can continue to be reviewed and revised throughout the
whole of the treatment.

It is crucial to set goals for the young person’s recovery, at the outset of treatment
because:

1. It gives the young person a clear message that they are now in the great position of
being able to work towards recovery. They have a diagnosis; a name for their
symptoms and experiences, and with that comes a treatment to bring about
improvement and recovery.
2. It helps the young person to now look forwards with optimism.
3. It helps both the young person and the therapist to track progress during therapy.
As with other complex illnesses, it can be hard for the young person to notice
positive change and improvement. This is particularly the case when the ultimate
goals for full recovery can feel like a long way away for the young person. Use of
measurable goals helps the young person to track steps towards them, however
small.
4. Having goals also helps the young person and therapist together to recognize
when the goals have been achieved and therefore when the time has come to
appropriately end therapy.

We usually try to set goals that are SMART:

- Specific
- Measurable
- Achievable
- Realistic
- Time-limited.

Goal based outcome sheets can be helpful - https://www.corc.uk.net/outcome-experience-

measures/goal-based-outcomes/

Regular progress reviews include a review of these goals, usually at least every 6th session,
and may also include completing other questionnaires to track symptoms and
functioning.

PAGE 18
Examples of goals
Each young person’s goals will be different and unique to them. However, there are often
common themes that arise, when young people with ME/CFS are asked what they would
like to work towards within their recovery journey. Here are some examples:

• School:
o To be able to manage 3 hours in school every day by the end of term (shorter-
term goal)
o To be able to return to school full-time by the end of the school year (longer-
term goal)
o To complete my GCSE exams next year in 8 subjects (longer-term goal)
• Social (friends / families)
o To text my friend Sarah once a week (shorter-term goal)
o To go to my cousin’s birthday party in a month (shorter-term goal)
o To be able to have a sleepover for my 16th birthday next Spring (longer-term
goal)
o To spend one hour with my family every evening rather than be in my room.
• Hobbies / other activities
o To restart my yoga stretches for 10 minutes, once per week (shorter-term goal)
o To get back to competing with my swimming team by next summer (longer-
term goal)
o To restart helping out at Brownies for 1 hour every Tuesday

PAGE 19
Components of Treatment
SLEEP
Sleep is generally one of the first treatment targets for ME/CFS. This is because it is very
common for sleep patterns and/or timings to have become dysregulated for young people
with ME/CFS. It might be that the young person has begun a pattern of having long naps
each day due to their fatigue. Others can drift into a pattern of getting up late in the
mornings, and as a result find it hard to feel tired at bedtime and so end up falling asleep
very late or even in the early hours of the morning. At the most extreme end of this, young
people with ME/CFS can become nocturnal. Whatever the precise pattern, it is commonly
seen in clinic for there to be at least some change or disruption to the ‘normal’ sleeping
pattern that might have been in place prior to ME/CFS.

Addressing sleep early on (if not first) in treatment is important both for reinstating more
adaptive sleeping patterns and improving quality of sleep for the young person, and also
boosting their chances of being able to cognitively engage in the fairly demanding
therapeutic process of CBT for ME/CFS.

Therapeutic work on improving sleep includes advice about sleep restriction to the
appropriate amount for their age, anchored sleep and wake up times, appropriate use of
rests (but not naps) during the day, and good sleep hygiene.

The following bullet points summarise key guidance on sleep to be shared with the young
person and their family. It is important to share this psychoeducation to give the rationale
for making changes to sleeping patterns. This section of treatment can feel quite
information-heavy and so it is a challenge for clinicians to try and keep some elements of
Socratic discussion which enable the young person to draw on their own knowledge and
experience, as per usual CBT practice.

How much sleep/sleep restriction

- This varies for each person.
- For general guidance, see
www.nhs.uk/Livewell/Childrenssleep/Pages/howmuchsleep.aspx.
- There is an optimum amount of sleep. Importantly, sleeping more than needed
will compound tiredness because it reduces the sleep quality.
- We recommend trying to stick as close to the recommended sleep as possible.
- Trying to stop tiredness in ME/CFS by sleeping more usually makes things worse.
- So, the key points are:
o You need to sleep no more than your friends
o At first you will feel much worse, because you will be having less sleep –
after a couple of weeks you should be sleeping better at night and most
young people start to feel better.

PAGE 20
Timing of sleep
- Day/night reversal is common in young people with ME/CFS.
- Treat it like jet lag:
o Wake up 30 to 60 minutes earlier each day until you’re waking up between
7am and 8am
o The most important thing to set is your wake-up time, which should be
anchored. It is important that your brain gets the right stimulation to tell it
if it is day or night. Try to stay awake during the day so that you see
daylight – this helps the brain get into the correct day/night routine.

Daytime rests/naps
- Different types of rest: Most rest doesn’t involve sleeping and can include sitting
quietly or zoning out whilst listening to restful music or a relaxation CD. If
possible, this should not happen in your bedroom.
- If you really need a sleep, make sure it is less than 30 minutes, before 3pm and in a
light room with the curtains open. This is to stop you going into deep sleep, as this
could damage your nighttime sleep.

Sleep Hygiene
- Sleep routine/wind-down - This helps your brain get ready for sleep by giving it
lots of signals to go to sleep.
o E.g. warm bath, warm drink (milk is helpful, but not hot chocolate as it is a
stimulant).
o Don’t do things just before bed that send confusing signals and stimulate
your brain, such as TV, computer games and certain books (e.g. scary
ones).
o Try to do the same thing every evening – your brain will learn to start
getting ready to sleep.
o Some people find lavender oil helps, or listening to gentle music.
o Avoid anything with caffeine in the afternoon – caffeine is a stimulant and
is found in coffee, tea and soft drinks such as Coca Cola, Red Bull, Pepsi
and in chocolate.
- What if I can’t get to sleep? Wait 20 minutes and then get up, go out of the
bedroom and perhaps get yourself a drink. Avoid tossing and turning. When you
do this you may need to repeat it a few times but after a few days you should find
yourself getting off to sleep easier. You could also try some relaxation exercises
(see later section on this).
This advice is summarized in the Sleep and Relaxation Leaflet
https://www.ruh.nhs.uk/patients/services/clinical_depts/paediatric_cfs_me/documents/P
CFS004_Sleep_Relaxation.pdf

PAGE 21
ENERGY MANAGEMENT
Energy Management is a key part of treatment for ME/CFS and can be delivered separately
or within CBT for fatigue. The essential elements of it are the regulation, monitoring and
often gradual increase of activity levels, in line with the individual’s own health, abilities
and goals.

It is important to note that Energy Management is an individually tailored, collaborative

treatment approach constructed between the clinician and the young person and their
family. All decisions are reviewed and planned together, in a way which is individually
appropriate for the young person.

Energy management fundamentally recognizes that the activity levels and patterns of a
young person with ME/CFS are important to address. How much activity a young person
does, and how it is spread out across the day or week, can have a direct and significant
impact on their symptoms of fatigue. Typically, before starting treatment a young person
will report highly dysregulated activity levels with great variation in what they do from
day-to-day.

The boom and bust cycle

A known perpetuating factor in ME/CFS is the so-called ‘boom-bust’ cycle. This is where a
young person with ME/CFS will push themselves to do as much as they can on a ‘good
day’ or when they perceive themselves to have more energy. They might even be able to
sustain this high ‘boom’ level of activity for a little while e.g. a few days or more. However,
typically the total amount of activity is higher than they can actually continue to sustain
and so it leads to a flare (or worsening) in symptoms and a crash (or ‘bust’) in activity
levels. For example, a young person may push themselves to be at school for the whole day
on Monday and Tuesday but then experiences significant, increased fatigue and be unable
to get into school for the rest of the week. Or this pattern may play out over longer
timeframes, e.g. getting through the whole school week but then ‘crashing’ at the
weekends, or even managing a half-term but then having a big flare up in symptoms
during the holidays.

We know that neither extreme here (the ‘boom’ nor the ‘bust’ levels of activity) are good
for a young person with ME/CFS and indeed see-sawing between these two states can
keep the fatigue going. Therefore, an important first step in Energy Management is to
establish an appropriate ‘baseline’ for the young person. This means an amount of activity
that they can sustain comfortably every single day and one which does not lead to a
worsening of their symptoms of fatigue.

PAGE 22
Categorising activities
The activity baseline is calculated by using activity diaries to first monitor and categorise
activities. An example of the diary used can be seen at

https://www.ruh.nhs.uk/patients/services/clinical_depts/paediatric_cfs_me/documents/P
CFS022_Activity_Diary.pdf

and the supporting information leaflet at

https://www.ruh.nhs.uk/patients/services/clinical_depts/paediatric_cfs_me/documents/C
FSEnergyManagement.pdf

When completing the diaries, young people can use a colour-code to capture the different
activities they complete. Activities are categorized into colours according to their level of
intensity or demand as follows:

- The most demanding (or fatiguing) activities are coloured as red. These high
energy ‘red’ activities can be one of three things; cognitive activity (e.g. school
work, computer use, reading, watching TV), physical activity (e.g. walking, cycling,
participating in P.E), or emotional (high energy laughter and fun, or also times of
particular anxiety or interpersonal conflict). ‘Red’ activities are by no means bad,
but are those which take the most energy from young people and are those
activities which they self-report they cannot do for very long, compared to some
less-demanding activities.
- The next level of activity (which could be seen as moderate) is coloured as yellow.
These lower-level ‘yellow’ activities are times when they young person is still
engaged in doing something, but not so demanding as the ‘red’ counterparts. For
example, the young person might be playing in a relaxed way with a pet, flicking
through a magazine, doing bits of food preparation or craft activity, or watching
something they have seen before. To the onlooker the young person is engaged in
an activity, but it is not one which requires so much cognitive concentration or
physical or emotional energy.
- The next level of activity (low) is coded as green. This really denotes the absence of
active activity. ‘Green’ time is real relaxation or ‘chill out’ time. It can include lying
down peacefully (as one would before falling asleep at night and on waking in the
morning), or perhaps following simple relaxation, meditation or breathing
exercises. For some it could be having bath or listening to relaxing music. It is a
calm and quiet state with no interaction with others and no real demands being
placed on the young person. Needless to say it is not something that is seen a great
deal in the diaries of young people, when often there is a natural preference for
more active (and interactive) states of being.

Sleep is also important to record on the diaries and this is coloured as blue.

PAGE 23
It is important to note that what is categorized into each kind of activity is individual and
may change at different points of the illness. For example, at the worst point of ME/CFS, a
young person might find getting dressed or combing their hair to be highly demanding of
energy, and would categorize this as ‘red’ activity. However, as they begin to recover, this
may become less demanding and may then be ‘yellow’ or even ‘green’.

Calculating the Activity baseline

After 1 to 2 weeks of tracking activity levels through completing activity diaries (or using
an app), the baseline can be calculated. The baseline is typically the median time spent
doing ‘red’ (high energy) activities each day, when looking at the variation across a couple
of weeks. This baseline (for example it could be 4 hours’ ‘red’ activities per day) then
becomes an aim for the young person; they are asked to now aim for this amount of
activity each day if appropriate, without falling below it on ‘bad’ days nor exceeding it on
‘good days’. The young person will be asked to maintain this level typically for 2 weeks
until the next appointment, and to continue using the diaries to track and record this.
Guidance is given on how to spread out the baseline amount across the day and it is
typically recommended that school activity is no more than half of the baseline (therefore
in this example school or school-work would not exceed 2 hours per day).

Recording activity at home in between appointments is important in helping young

people to notice their patterns of activity and to understand whether they are doing the
same each day or varying their activity. It also helps with gauging whether the baseline has
been set at the correct level. Occasionally it can need some tweaking in the early stages of
activity management.

Increasing the activity baseline

When a young person has managed to sustain the baseline level of activity consistently for
2 weeks, they can then be instructed to increase this by 10-20% every week or two if
appropriate. Therefore, using the above example, a baseline of 4 hours’ ‘red’ activity would
then increase to something in the region of 4 ½ - 5 hours.

The aim is to continue gradually increasing the baseline activity level in this step-wise
fashion if appropriate until the young person can comfortably manage at least 8 hours’
high energy activity per day. At this point the young person will be working towards full-
time school attendance again and will have enough in their allowance to begin reinstating
other activities outside of school. Importantly, at this point the young person will also be
skilled in the process of monitoring and regulating their activity levels and so the need for
this close monitoring within therapy sessions becomes less great.

Throughout the process therapists will discuss problems encountered by patients and
provide possible solutions. Managing setbacks is also discussed (for example, how much

PAGE 24
to reduce school and other activities by, in the context of a worsening in symptoms, and
for how long).

Activity Scheduling – valued activities

Energy management entails a close focus on the key, repeated activities within the young
person’s daily life and weekly pattern. Invariably, school is a big focus both in terms of
time spent but also importance and value attributed to it. Therefore school, and
everything related to attending school whilst recovering from ME/CFS, is an important
topic to be covered within sessions. We have written a separate section with information
pertaining specifically to school.

However, it is important to remember that other activities outside of school are relevant
and very important in the recovery journey for a young person with ME/CFS. Some will
have given up previous hobbies due to their poor health or reduced energy levels, and
others may have fallen out of love with a previous interest due to now doubting their own
abilities or competence. When discussing treatment goals, it is helpful to explore which
activities a young person would like to (re)instate as they re-gain strength and energy
during their recovery journey.

For many young people with ME/CFS, recovery is not about a ‘going back’ to who they
used to be, but a ‘going forwards’ to a new version of themselves whom has been through
what is often reported as an enriching and developing experience, and who has progressed
developmentally too. Young people will commonly report struggles in the journey, of
course, but also a sense that through it they have learnt a great deal about themselves and
what they can cope with, or what is important to them. They often report a sense of
becoming a new person after illness.

In this way it is important to explore valued activities for the young person and to
consider how they can build these into their day and week. As well as exploration of the
activities in question, therapy can helpfully support the young person in considering how
they can best manage their time. CBT for ME/CFS often addresses the need for achieving
balance between times of productivity and times of rest; ‘allowing’ themselves time to
‘switch off’ and enjoy the simple things – whatever that may mean for them. It is not about
being at full capacity all the time.

De-Regulating
Energy management requires close monitoring of activity levels and patterns. As
treatment progresses and the young person can increase their total activity level,
regularity is still encouraged, including regular sleeping patterns and consistent activity
levels across the week. A key process which comes later in energy management (and is
important too in the recovery journey) is what we call deregulating. This is about

PAGE 25
supporting the young person to move away from the strict regularity they have been
keeping and indeed to deliberately bring more ‘natural’ variation back again. For example
in terms of sleep, this could mean a young person returning to having an occasional
sleepover with their friends which would no doubt entail a later and/or shorter nights’
sleep, but also is an event which only happens from time-t0-time. Therefore, the natural,
occasional variation is reintroduced to the pattern of the week or month.

Deregulating is important for many reasons:

1. It may be part of the young person reaching some of their goals for example
attending sleepovers or participating in infrequent events such as the school
sports’ day or attending a big family celebration.
2. It can be a visible marker of having come a long way and achieving particular
milestones.
3. It builds confidence in being more flexible with timings and patterns; helping
them to see that their body can again now cope with variation and that it is not
damaging. Confidence is hugely significant when it comes to reinstating activities
and returning to previous or new, higher, activity levels in the ME/CFS recovery
journey.

Starting the process of deregulating with the support of the therapist helps the young
person to move out of the therapy or treatment mode or towards a sense of ‘normal life’.
This can also help the young person to feel confident in working towards ending sessions
and continuing life beyond therapy.

Energy management with younger ME/CFS patients

Energy management with younger children is invariably more challenging than working
with older children or adolescents. CBT for ME/CFS overall is a demanding treatment
process and requires a reasonable level of emotional literacy, understanding and
recognition of symptoms and experiences, planning ahead, and the cognitive abilities to
communicate these things in treatment. It also requires other key abilities driven by
cognitive development including self-monitoring, self-regulation and inhibitory control. It
is hard for a young child to keep in mind their activity schedule and to stop an activity
early, particularly when they are having fun and their peers can continue taking part.

Therefore, CBT for ME/CFS with younger children needs to bring in extra support, in
order for these young patients to benefit as much as possible. Typically, this means a
greater level of parental involvement and that of other key adults including teachers. The
system around the child must take more ownership for leading and supporting the
treatment process. Therapists must therefore work carefully with these adults and support
networks, and regular joint review meetings can be particularly helpful. As well as shared

PAGE 26
communication, another key aim of working together is to keep the child and their voice
at the centre of the process.

When completing energy management with younger children, creative and visual
methods work well. Pictures can be used to represent activities, when showing a child the
difference between high- and low-energy activities. In terms of using activity diaries, a few
simple changes can be made. When appropriate, parents can complete the diaries on the
young person’s behalf, to the best accuracy possible. It can also really help to employ more
creative methods. Coloured cards, balls, bracelets or marbles can be used to represent the
child’s available activity baseline. The child can be encouraged to ‘trade in’ an item with a
parent each time they complete a high energy activity, helping them to visually track their
allowance. Timers can also be a helpful tool for tracking time limits on activities. Rest
breaks can be planned into the child’s day in advance, to make them more likely to
happen.

Generally, visual tools work best for younger children and so therapists should be creative
in producing these with the young person. Perhaps the child has a name for their fatigue
or imagines it as a monster or a being with a certain shape. The therapist can support the
child in using their own terminology or imagery to track and communicate their
experiences of fatigue. Narrative methods, such as comic book ideas, can also be drawn on
to capture the young person’s experiences. These sorts of tools can then be helpfully
shared with others including school staff, so they too can encourage communication with
the child about their fatigue and activity levels.

A secondary advantage of these creative approaches is to build some sense of ownership of

treatment for the young person at the centre. It can be too easy for CBT for ME/CFS with
young children to fall into another set of ‘rules’ planned by adults (parents, teachers,
doctors etc) that the child must follow. This perceived dynamic can be really hard for the
young person who then might well want to rebel against the process and reject what is
being suggested or asked of them. It can be hard for parents too, who feel like ‘the bad
guy’ and may struggle to follow the treatment recommendations closely due to not
wanting to upset their young child. This will likely affect engagement in treatment and
ultimately can jeopardise the process of recovery. It is important therefore, particularly for
primary school aged children, to have some age-appropriate level of involvement in their
treatment, at every stage possible.

PAGE 27
COGNITIVE WORK: THOUGHTS THAT ARE UNHELPFUL
It is common, and completely understandable, for young people to have difficult thoughts
about their illness, their situation, or even their chances of making things better. ME/CFS
is a challenging illness in that it often brings about change in many areas of life, such as
reduced time in school, less contact with friends, loss of hobby or extra-curricular
activities due to reduced energy, amongst others. CBT can help here in supporting the
young person to become more familiar with their thinking patterns.

Unhelpful thought are often negative, exaggerated or distorted, to the exclusion of other
positive information, and sometimes ‘all or nothing’ in totality. Perhaps the young person
has some recurring, negative thoughts about certain topics which make it really hard for
them to work towards their goals. Perhaps there are certain things they particularly worry
about, such as going back to school. Whilst these negative thoughts may be grounded in
truth, they are often distorted and useful counter-evidence may be overlooked.

Common unhelpful themes in the thoughts of a young person with ME/CFS may include:

• A focus on symptoms or even looking out for them when they are not present
• Negative interpretation of symptoms, either predicting worsened fatigue and/or
‘blaming’ activity for the presence of symptoms
• Negative view of the self or one’s ability to cope
• Negative predictions about upcoming events or perceived challenges
• A belief of needing to keep struggles to oneself rather than ‘burden’ others
• A wish to present oneself as ‘coping’ and to conceal true thoughts or feelings
• High pressure or standards for oneself

To illustrate these are some examples of specific unhelpful thoughts that a young person
with ME/CFS may present in therapy:

• “It’s my fault I’m ill”

• “No-one understands me, there’s no point talking about it”
• “When will I have another flare?”
• “I’m a burden on my family”
• “Maybe I can just hide it and pretend it’s all ok”
• “I’ve got to do the best I can at school; it’s all I’ve got”
• “If I don’t do my best, people will think I’m a failure”
• “I’m no good at anything anymore”
• “Everyone else can cope fine – why can’t I?”
• “People are talking about me all of the time”
• “If people see me out during the school day they’ll judge me for not being in
school”

PAGE 28
 • “I won’t be able to cope with my exams because of my fatigue”

Key cognitive tasks therefore include helping the young person to recognize unhelpful
thoughts and negative thinking patterns, to notice the effects of these thoughts, and
ultimately to learn more helpful ways of thinking.

Some examples of common, helpful cognitive strategies can be found in the below:

• Paul Stallard’s ‘Think Good Feel Good’ books

• https://www.psychologytools.com/resource/unhelpful-thinking-styles/
• https://www.psychologytools.com/resource/prompts-for-challenging-negative-
thinking/
• https://www.psychologytools.com/resource/simple-thought-challenging-record/

More helpful ways of thinking

Once the unhelpful thoughts and themes have been identified, the young person and
therapist together can then use common CBT cognitive strategies for exploring and
evaluating these thoughts. The following techniques and themes are particularly helpful:

Evidence for and against

This is a central cognitive strategy for working on negative thoughts in CBT for ME/CFS.
The main idea is to identify negative thoughts, consider how valid these are, and to come
up with more realistic or helpful alternatives.

The young person may hold a strong, negative belief about what could happen in a
pending situation. For example they may believe that on returning to school, “I will be so
exhausted that I won’t be able to cope and everyone will notice and comment”. There are
various metaphors which can be used to guide the young person through considering the
evidence for and against their thought. For example, the court case metaphor: The
therapist here guides the young person to act like a judge in court; to consider evidence
for and against the thought, and to come to a conclusion.

In this example, evidence for the thought could include “my fatigue is always worse at
school” or “people have commented before” and evidence against could include “I’m much
better now than I was before” and “my friends are really supportive and wouldn’t say
anything mean”. After considering this sort of ‘evidence’, (many more pieces of ‘evidence’
are normally encouraged) the young person is then supported to generate a more realistic
or rational alternative to the original thought. In this example, the young person may
postulate: “I’m much better than I was before and I will be fine. Even if I do feel tired I can
have a break and my friends will be supportive.”

PAGE 29
Positive evidence: positive self-talk, self-compassion, and positive data logs
In the face of often negative or distorted thoughts, positive self-talk can be a powerful
cognitive strategy for supporting behavioural change, increasing confidence and self-
efficacy, and lifting mood. A young person completing CBT for ME/CFS can be
encouraged to notice and collate positive ‘evidence’ of their achievements and capabilities,
and to use this as an encouraging reminder in challenging times. For example, a young
person who is feeling particularly anxious could remind themselves of recent
achievements which they might not have previously thought possible, back when their
fatigue was at its worst. The therapist can encourage the creation of a positive data log for
capturing this important information. This can also help to boost self-efficacy.

It is particularly important for the young person to be kind to themselves and encourage
themselves forwards, rather than the (somewhat common) pattern of easily noticing
‘failure’ or struggles. When struggling with difficult thoughts and feelings it is too easy for
the brain to generate unkind thoughts or focus. Self-kindness and self-compassion can be
helpfully explored and encouraged within sessions. It is often a somewhat challenging
(and unfamiliar) practice for young people, and so must be explored with sensitivity.
Young people with ME/CFS can be encouraged to notice the positives and at the same
time acknowledge that they are in a tough situation but are working hard to try and make
things better. It is not about being overly positive or dismissive of struggles, but about
being kind to themselves.

Another helpful form of positive self-talk is to shift to an approach of focusing on what has
been achieved, as opposed to what hasn’t. This could be in many areas that inherently
include gradual progress, for example with shifting sleep patterns, amount of schoolwork
or revision completed so far, or progress towards therapeutic goals. Focusing on, and
appreciating, progress made so far is a much better incentive for further therapeutic
progress compared to allowing the mind to focus on what is yet to be done. Staring at a
long ‘to-do list’ is daunting and can halt therapeutic progress. The young person can
helpfully be encouraged to remind themselves of their progress.

Positive/coping imagery
Alongside the more verbal strategies for managing unhelpful thoughts can be the
successful use of imagery. Imagery is a powerful method for connecting with emotion and
soothing difficult feelings. Positive or coping imagery could include use of imagining a
favourite or safe place, to boost positive feelings. The young person can transport
themselves mentally, no matter where they are, and use the image for comfort and
encouragement. Or perhaps imagining success ahead of time, for example the young
person can picture themselves standing up and giving their presentation at school,
successfully, in a similar way to use of imagined rehearsal.

PAGE 30
Surveys
This technique can be particularly helpful when a young person has thoughts about how
others may think or behave, or indeed makes predictions about others’ experiences. These
predictions typically compare the young person with ME/CFS negatively, relative to their
peers. In addition to using some of the strategies above, surveys can be used to actively
challenge and ‘test out’ a young person’s cognitions.

The young person and therapist together will generate a survey to ask others’ opinions on
the most pertinent questions to be explored. The survey is then given out (typically to the
young person’s peers, although this can vary) and the collected responses are explored in
therapy and discussed, often bringing unexpected information or new perspectives for the
young person. There is great therapeutic value in seeking and becoming aware of others’
perspectives, particularly in relation to things like anxiety. Surveys conducted with peers
can often be really effective in helping to shift a young person’s cognitions; there is
something powerful about seeking information from a peer group that is also a neutral
third-party, outside of the therapy room.

Behavioural experiments
Behavioural ‘experiments’ are a way of setting out to test a theory or hypothesis, through a
scientific approach. The idea is to choose a particular thought or cognition of the young
person’s, which is predictive in nature, and to test it out with curiosity. This can be a
highly effective in bringing about cognitive change as the young person is encouraged to
pose a question and to then go and find out the answer. They play an active role in seeking
out the new information, which has inherently a slightly different feel to the more ‘purely’
cognitive discussions held with the therapist in some other cognitive techniques.

An experiment is carefully designed between the young person and therapist to test a
measurable and specific prediction. The currently held expectations are laid out, and the
method of testing them is planned. The young person is encouraged to attend to, and
record, what actually happens in the experimental situation. This information is then
discussed back together with the therapist and is used to consider whether it supported,
or disproved/disputed the original prediction. In a similar way to surveys, gathering new
information in this way helps to weaken previously held negative predictions and to build
a bank of new, perhaps more rational information.

Mindfulness
Mindfulness can be described as a ‘third-wave’ psychological or therapeutic approach
which some might see as a stand-alone therapy or others might place within part of wider
therapies, cultural practices, or religions. It is something that has grown hugely in
understanding and popularity in recent times. In referring to mindfulness here we are

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thinking simply about the basic idea of helping the young person moving from a ‘doing’
mode to a ‘being’ mode.

Being ‘mindful’ is about allowing the mind to focus fully on what the person is currently
experiencing, in a helpful way. Allowing the young person to focus just on what they are
doing in that moment; not other things that they may need to do soon, or other things
they may be worrying about. Nor focusing on symptoms or predicting how the day may go
e.g. based on how their night’s sleep was. But just to focus on the specific task or
experience at that time.

It is about focusing on the present moment (often to the exclusion of other thoughts or
worries attached to other time-points) and engaging in the present, fully. This can also
help with breaking tasks into steps. For example, if a young person is worried about going
into school, perhaps they can first focus on having breakfast mindfully – focus on what it
tastes like! Then focus on brushing their hair and getting dressed. Then focus on the
music that’s playing in the car on the way to school; and so on, moving through the
morning routine. Before they know it, the young person is at school and can become
immersed in the rhythm of the day without feeling worried about it.

There are many examples available of ‘mindful’ activities. Here are some initial ones for
familiarization:

- Finding ways to:

o notice thoughts and to see these as thoughts, not facts
o sit with strong emotions instead of responding automatically to them
- e.g. Leaves on a stream - https://www.mindfulnessmuse.com/wp-
content/uploads/2011/09/Cognitive-Defusion-Exercise-1.pdf
- e.g. for younger children:
o Mindful posing as superman/wonderwoman.
o Spidey-senses – tune in to smell, sight, hearing, taste and touch (like
spiderman)
o Mindful safari – an everyday walk is becomes a safari – spot birds, bugs,
animals – focus all their senses on finding them.
- Further information and examples can be found at
www.getselfhelp.co.uk/mindfulness.

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MANAGING FEELINGS
The behavioural and cognitive elements of CBT for ME/CFS discussed so far aim
ultimately to improve how the young person feels, in a holistic sense. Therefore these
strands of treatment, whilst not focusing directly on managing emotions, can lead to an
improvement in emotional distress. However these strategies can take time, over several
sessions. Therefore it is also important within CBT for ME/CFS to explicitly focus on direct
strategies for managing difficult feelings in the moment. Accessible, simple methods for
managing feelings when they arise are highly valuable in this work.

As with many elements of CBT, it is common for the young person to want to jump to the
‘how to do it’ part of the process, whereas the therapist must first carefully support an
exploration of the ‘why do we need to do it?’ and also establishing ‘what do we need to
do?’.

The foundations: Emotional literacy and emotional regulation

The first step in learning to manage emotions is a check-in of the young person’s
emotional literacy. How familiar are they with identifying emotions? Do they notice when
experiencing different feelings? Can they use words to describe them? These steps, which
may seem simple at first glance, can in fact be new and challenging for some young
people, especially those who are younger or for developmental (or other) reasons are less
well-versed in emotional literacy. Helpful prompts can be used to assess and establish
emotional literacy, including use of pictures and pairing typical bodily sensations (e.g.
shakiness, tummy pain etc) to common emotions.

As well as assessing emotional literacy, preparatory work for building strategies in

emotional regulation also entails a fair bit of psychoeducation. It can be helpful to explain
the role of physiological symptoms within emotions, and how they interrelate. For
example, the ‘fight or flight’ response, which underpins many body-emotion links
including (but not limited to) those within anxiety or panic. If the young person can
understand why they feel certain physical symptoms, they can make better sense of then
applying the strategies below for controlling the symptoms.

A lot of these strategies have been developed into mobile phone ‘apps’ and other audio
versions. These can be greatly helpful in therapy for introducing the methods and making
them even more accessible for young people, particularly for practicing them further at
home. Some great examples can be found on the apps Mindshift, SAM, and Chill Panda,
amongst others.

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Calm Breathing
The breath is a hugely powerful entity. It is a fundamental yet completely accessible part
of how our bodies work and is closely connected with both the mind and body. Various
emotional states can lead to changes in breathing patterns and it is a fantastically simple
but effective strategy therefore to learn how to control or alter the breath.

One example (and there are many to choose from) is a simple controlled breathing
exercise. The basic idea is to bring focus on the breathing. This can be done anywhere and
a great advantage is that onlookers won’t even notice what you are doing. When using this
method, the young person learns to slowly draw in a deep breath, hold it for 5 seconds and
then very slowly let it out. As you breathe, they can also say to themselves “Relax!” Doing
this a few times will help the young person to feel calmer.

A similar idea is called square breathing where, in a similar way to the above, the young
person is encouraged to focus on their breathing. This time they hold the image of a
square in their mind. When taking the in-breath, the young person can imagine going up
the left-hand vertical side of the square. They then hold their breath for a moment,
imagining moving along the horizontal. The out-breath goes with the image of descending
the right-hand vertical side and holding the breath travels back along the bottom
horizontal side of the square.

The aim in both of these methods is to bring focus to the breath, indirectly also likely
slowing it down and simultaneously moving focus away from other, less helpful things
such as negative thoughts or physical feelings of anxiety. It is very hard for the mind and
body to feel both anxious/agitated and calm at the same time.

Relaxing place imagery

As mentioned briefly earlier, imagery can be a powerful and effective method for bringing
change in how people feel in the moment. It can be applied to feelings of anxiety, fear, low
mood, and many others. In CBT for ME/CFS, imagery can be used to help manage physical
feelings of the illness (e.g. fatigue itself, or pain, amongst others) as well as emotional
experiences such as frustration or anxiety.

The young person can be prompted with a script, for example: “Think about a special
place that you find restful. Think about your dream place. It could be somewhere you have
been, or a pretend place. Imagine a picture of it and make the picture as real as you can.
Think about: the noise of the waves crashing on the beach or the sound of the wind
blowing in the trees, or the smell of the sea or the scent of pine forests, or perhaps the
warm sun shining on your face or the wind blowing in your hair.” As with the other
strategies above, the use of imagery here aims to shift the young person’s physical and
emotional experiences in the moment from that of discomfort or suffering to a more
comfortable and calm place.

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Muscle Relaxation
Building on the physiological links between the mind and body as discussed above under
‘calm breathing’, physical relaxation methods are used to explicitly relax the muscles of
the body itself. This can be highly effective and helpful for managing both physical
discomfort and emotional difficulty. The aim of physical relaxation methods such as
progressive muscle relaxation exercises, is to bring a new focus to the physical experience
in the moment and thereby bring improvement or change in emotions. An example
simple script to use with a young person could be: “When we are tense or worried, our
muscles become tight. Practice tensing and relaxing different groups of muscles. Enjoy the
feeling of being completely relaxed.” Again, many Apps have accessible audios for
progressive muscle relaxation exercises and young people with ME/CFS can be
encouraged to try these exercises within their daily routine such as before going to bed.

Grounding Techniques
Grounding techniques are a set of strategies for helping the young person to reconnect
with their immediate surroundings. This is used across many different psychological
disciplines and for many different difficulties, including dissociation, trauma and
flashbacks. In CBT for ME/CFS, grounding techniques can be particularly helpful for
enabling the young person to reconnect with their immediate, physical surroundings; to
the exclusion of focusing on symptoms of fatigue, or on thoughts or worries stemming
from their fatigue. It is in some ways similar to mindfulness, but doesn’t require the young
person to be doing anything, rather just bringing a focus to their physical being. The aim is
that this present, physical focus allows a sense of comfort and security.

One example of a beautifully simple yet effective grounding technique is to use 5-4-3-2-1:

- Encourage the young person to tune into their senses, and notice:
o 5 things you can see
o 4 things you can touch around you
o 3 things you can hear
o 2 things you can smell
o 1 thing you can taste

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School and ME/CFS
School is such a big part of life for children and young people. School is discussed at every
stage of CBT for ME/CFS as it is a hugely relevant and important part of the picture. It is
therefore important for healthcare professionals and education providers to ensure good
communication between themselves, with families’ consent, in order to best support the
needs of the young person with ME/CFS as they work through treatment. Regular reviews
and joint meetings can be particularly helpful.

This section aims to outline some of the key considerations about school, when working
with young people who have ME/CFS.

Energy Management and time in school

School time must be calculated within the energy management element of treatment.
Typically, when young people with ME/CFS are engaged in treatment they will be
encouraged to reduce their school attendance and begin some form of reduced timetable
plan if they have not already done so. This is part of the wider process (discussed earlier)
of moving from a boom-bust pattern of activity to a more sustained, manageable one. For
example, attending school every day just for 2 hours is better than attending for the full
day on Monday and Tuesday, and then needing the rest of the week off due to increased
fatigue. Once the young person can manage the new reduced timetable consistently, it is
reviewed and gradually increased (in line with overall, gradual increases in activity level),
working back towards full-time attendance.

School time (meaning time in school, any school work completed at home through home
tuition or other means, and also homework or revision) should equate to no more than
roughly half of the young person’s activity baseline. This is particularly important when
the young person is earlier on in treatment and/or has a relatively low baseline. For
example, a young person with a baseline of 4 hours’ high energy activity per day should do
no more than 2 hours per day of school-related activity. This is important in ensuring
there is enough high energy activity time left for other activities outside of school.

Supporting a young person with ME/CFS in school

Clinicians working with young people with ME/CFS can make recommendations for
teachers and school staff. It is often helpful to discuss these with school staff in order to
boost a collaborative approach between services and to address any queries.

• Rest breaks
o Rest breaks away from the classroom and learning can be effective;
something like 10 minutes per school hour tends to be enough.
o Ideally these regular rest breaks are away from the classroom environment
and in a quiet place.

PAGE 36
 o It can be particularly helpful for younger children if these are scheduled
into the daily timetable.
o ‘Time out’ (or ‘medical’) cards – These can be used to enable older pupils to
indicate to teachers those times when they feel they need a break, and to
access it without having to draw particular attention during the lesson.

• Concentration
o Concentration is often impaired for young people with ME/CFS and it can
be helpful to work in chunks of no more than 30-45 minutes; severely
affected students may only be able to sustain concentration for 15 – 20
minutes.
o Students often have increased sensitivity to everyday sounds and are likely
to be more easily distracted in the classroom environment.
o Students may experience ‘brain fog’ i.e. difficulty processing information –
it can be helpful to provide written instructions and memory aids.

• Exams
o Young people with ME/CFS benefit from being allowed to sit exams in a
room on their own, or with few other students.
o They should be allowed to get up and move around for timed rest breaks.
o We would also advise that they are allowed 25% extra time in exams.
o Some young people also benefit from access to a laptop, a scribe, or a
reader in exams depending on their needs.

Further related guidance can be found at the following websites:

https://www.ruh.nhs.uk/patients/services/clinical_depts/paediatric_cfs_me/documents/P
CFS011_Info_for_Schools_and_Colleges.pdf

https://www.ruh.nhs.uk/patients/services/clinical_depts/paediatric_cfs_me/documents/P
CFS019_Learning_Challenges.pdf

https://www.wellatschool.org/chronic-fatigue-syndrome

Extra support available

Some young people may need a greater, more individualized level of support in school due
to their ME/CFS and associated health needs. There are various assessments and support
plans which can be completed for a young person, particularly if their needs are more
complex. These can include Individual Healthcare Plans (IHP) or an Education and
HealthCare Plan (EHCP), amongst others. Schools are the best placed to apply for such

PAGE 37
assessments and plans, given their familiarization with both the young person and also the
remit of the different forms of support. Healthcare professionals can play a role in
providing supporting information from the clinical side, when requested by schools or
families, as well as signposting families to helpful information sources.

The following websites provide a good starting point for further information:

https://www.wellatschool.org/resources

http://medicalconditionsatschool.org.uk/

When a child cannot attend school

If a young person struggles to attend school due to the extent of their ME/CFS and its
associated challenges (e.g. severity of other ME/CFS symptoms, or associated anxiety,
amongst others), it is appropriate to consider alternative methods of accessing their
education. A common alternative is to work with the local Hospital Education and
Reintegration Service (or similarly named service). These services offer home tuition,
online education options, and sometimes the option to attend schooling at a smaller,
specialist unit often called a Hospital School. The exact provision available of course varies
between counties and depends on what the service has available at that time, as well as
what is deemed most appropriate for the educational needs of the young person in
question.

The young person’s mainstream school can refer pupils to the appropriate local alternative
education provider, and are highly experienced in doing so. Medical teams and ME/CFS
clinicians can often help the process by writing a letter of support to accompany the
school’s referral, or sometimes completing the referral form direct. Medical and healthcare
professionals can also help to inform the process by giving approximate recommendations
for example of how much schooling the young person can currently manage, based on
their activity levels and current health.

The social side of ME/CFS and school attendance

Young people with the illness can feel different from their peers; socially isolated, left out,
and can struggle with the sense of peers not understanding their situation. Patients in our
clinic often recount unthinking comments from friends, generally made with good
intentions, but often with damaging emotional impact. For example “you’re so lucky you
get to go home early”, or “I get tired too”, or “I wish I didn’t have to do homework”. Young
people with ME/CFS have to navigate these such social-emotional challenges within
school, on top of their fatigue management. It can be hard work. Some young people may
think about ways of helpfully sharing information about ME/CFS with their friends, class
or even year group, in order to boost understanding of the illness.

PAGE 38
Attending school on a reduced timetable clearly has the potential for social consequences
for children and young people with ME/CFS. It is already hard to feel different from peers,
and potentially to feel ‘left out’ due to not being able to do as much as them. But the very
practical reality of not having as much time with friends in school can be really hard.

For this reason, it is important to ensure that children and young people who are on a
reduced timetable of some sort can keep some contact with their friends. For example, if
in school for 2 hours per day, this could include a lesson and some non-lesson time such
as break, lunch or tutor time. Attending school isn’t just about the educational aspects
and so, ideally, a reduced plan should try to include as many of the elements held within a
fuller school day as is possible.

Unfortunately, it can be the case that ME/CFS can disrupt school attendance for anything
between 6 months and a few years. As we know from epidemiological research there is a
peak in ME/CFS prevalence within adolescence – an already complex developmental
period. It is possible to suggest that less time in school during childhood and/or
adolescence can have an impact on the development of social skills and related areas
including problem-solving skills, self-confidence, and assertiveness, amongst others.

Another important consideration to keep in mind are the key transition stages held within
the school years including moving from primary to secondary school, the major exam
years, and other key points such as end of year performances, school trips, competitions,
or formal events. The impact of missing such events can be hard emotionally for children
and young people with ME/CFS. Thought should always be given to how at least some
participation can be kept.

The emotional side: school-related anxiety or stress

Children and young people with ME/CFS can experience increased anxiety; notably this
tends to be increased separation anxiety in younger children and both social anxiety and
generalised anxiety in adolescents. After a prolonged absence, returning to school can be
anxiety provoking. Therefore, it is important for education and healthcare teams to keep
an awareness of the young person’s emotional state and to consider how best to support
and alleviate anxiety where possible. CBT for ME/CFS can offer a great deal for managing
anxiety within the illness; this will be covered in more detail in a later section.

Stress is another important consideration. For a young person who has had to reduce their
school-time, perhaps give up hobbies and cut down on things they used to enjoy, school
can suddenly seem a much bigger focus. Particularly as re-building time in school is often
a key goal for CBT treatment. It becomes a tangible measure of progress and young people
with ME/CFS can all too easily feel pressure (often internally driven) to therefore do their
best. School might move from being an ordinary part of life pre-illness to a very central
focus during illness where very high standards ‘must’ be achieved. This can play out

PAGE 39
during key times of stress such as exams, but can also underpin general and ongoing
worries. It is helpful to explore these issues within CBT for ME/CFS.

Supporting younger children with ME/CFS in school

ME/CFS is less common (in terms of diagnosis rates) in children under the age of 12.
However, we know that those younger children with ME/CFS require greater
differentiation and support within school due to their age and earlier stage of
development in key areas including emotional literacy. A young child with ME/CFS is
likely to need a great deal more help in the school environment to manage their physical,
practical and emotional needs in relation to ME/CFS, compared to an older child.

Young children will often struggle particularly with regulating their activity levels. They
are more likely to be driven by impulse and desire, and to overlook what they are being
asked to do within CBT for ME/CFS. For example, a young child will find it hard not to
run around at break time with friends, or to remember to take rest breaks during the day.
Younger children may well be less aware of when they are running out of energy and may
push themselves beyond what they can comfortably manage. It can be helpful therefore
for members of staff to prompt and remind the child about their individualized plan. For
this to be successful, meetings between ME/CFS healthcare professionals, the family, and
school staff are essential and should be regular. Ideally a child would have a clear
personalized timetable for the day which includes pre-determined rest breaks and any
other needs identified by the team. Times of potential high-energy activity (P.E., break
and lunch for example) should be carefully thought through in advance.

In addition, younger children with ME/CFS are more likely to struggle with anxiety, as
well as their understanding and communication of it being more naïve. It can be helpful
for those supporting the child to use age-appropriate supports and prompts for talking
about emotion and opening up these conversations. Some of the best tools are the
simplest, such as a traffic light system of coloured cards, for the child to indicate whether
they are feeling fine, slightly unsure, or when something is wrong.

PAGE 40
What can get in the way of making changes?
Although making behavioural changes to sleep and activity might appear simple, these
can often be very difficult in practice. This can be for a number of reasons:

- When the young person may have been in their current patterns for a long time.
Habits are hard to break, and perhaps too they could feel fearful of moving away
from what they have become used to. Or perhaps the young person may have tried
to change their patterns unsuccessfully before starting CBT and therefore they
have reservations about making change now.
- Systemic factors can make change more challenging for the young person. For
example, in some families a relative or friend may have had ME/CFS and this can
bring prior experience or expectations of what the journey may be for the young
person now in question. Clearly in some cases this could be helpful. But for others,
and particularly when those prior experiences have been hard, this could bring
unhelpful thoughts or beliefs for example about what the young person’s own
recovery journey may be.
- Practical barriers can get in the way. For example, a reduced timetable plan at
school can only really work if the family is able to accommodate the different
drop-off and pick up times, alongside other childcare commitments and parental
working hours. Or perhaps the family work patterns include night-shifts and it is
hard therefore to have the same systemic teamwork in supporting the child’s
sleep-wake plans, as the parent and child may not have the same amount of time
available together during the day.

As can be seen, there can be many reasons why young people can find treatment
challenging and it is important firstly to normalize and acknowledge this with them. CBT
for ME/CFS is a demanding treatment which asks a lot of the patients, including making
several changes in different areas of their lives. Motivational interviewing and problem-
solving can help to identify and overcome these barriers.

MOTIVATIONAL INTERVIEWING
Motivational interviewing is a helpful strategy for improving engagement in, and
adherence to, treatment. This approach recognizes that as humans we can struggle to get
‘on board’ with something. We might have a sense of procrastinating, or avoidance, or
ambivalence about what we want to do. This can be for a number of reasons, including
lack of information or understanding about what’s being asked or required, or perhaps
anxiety about the possibility of trying and getting it wrong. Or many other reasons.

The aim of motivational interviewing within CBT for ME/CFS is to help the young person
make behavioural change particularly when they feel unsure about doing so. The key idea
here is about having a non-judgmental conversation with the young person in therapy,

PAGE 41
exploring where they are now, what they think about that, and where they might like to
be. Motivational interviewing allows space to talk about cognitive dissonance,
ambivalence, fear of change and any other barriers to moving forwards in therapy. It
introduces the idea that change is possible, and helps the young person move towards it.

- Some key steps in motivational interviewing are as follows: Start by listening and
seeking to understand where the young person is at in relation to change
(assessing readiness to change), by use of:
o Open ended questions
o Reflective listening
o Acknowledging the dilemma/struggle
o Clarifying and summarising
o Looking for successes in changing behaviour and building on those
- Exploring the pros and cons of change vs no change (e.g. see
https://www.psychologytools.com/resource/motivation-and-ambivalence/)
- Considering what change would mean for the young person, in relation to working
towards their therapy goals.
- Building the young person’s confidence in making steps towards change.

PROBLEM SOLVING
Problem solving aims to help gently move the young person from a ‘stuck’ position (often
accompanied by a lack of hope or self-efficacy) to one of making an active choice to
improve the given situation. It helps the young person to move through a barrier and to
move forwards in treatment.

Problem solving is done together between the therapist and young person, working
collaboratively through a series of logical steps. Firstly, the current ‘problem’ is identified;
then possible options or solutions are considered, before selecting the best one and
establishing how to act in line with this plan. This process, like many others within CBT
for ME/CFS, aims to ‘skill up’ the young person in thinking through the current situation
and also then applying the same strategy by themselves, both between appointments and
after therapy has ended. It is a useful skill for the young person to have in their ‘toolbox’.

The following example illustrates how problem solving might be used in CBT for ME/CFS:

- Where particular problems have arisen in making behavioural changes (e.g. “I

can’t wake up in the morning because I don’t have an alarm clock”), this presents
an opportunity to build problem solving skills by scaffolding the young person to
work through the following steps:
o Step 1: Specify the problem
o Step 2: Why is this a problem?
o Step 3: What are the possible ways to solve this?

PAGE 42
 o Step 4: Advantages and disadvantages of each possible solution?
o Step 5: Try out the best solution
o Step 6: Check – did it work?

(see https://www.getselfhelp.co.uk/docs/ProblemSolvingWorksheet.pdf for example)

Thinking in these ways with patients can enable them to move from a ‘stuck’ position to
one in which they can see and choose different possible actions, in order to move
forwards. It is an important and empowering process, particularly for this patient group
where it can be common to feel a sense of helplessness or lack of self-efficacy.

By breaking challenges into steps and encouraging a focus on just one step at a time, the
young person can begin to see solutions and ways out of the initial problem. It can often
be helpful to involve parents in these discussions, for a number of reasons, but one being
that the parent can then model some of these problem-solving strategies with the young
person at home in between appointments, if challenges arise.

PAGE 43
Adapting CBT for ME/CFS when there are concurrent Mental
Health Problems
ANXIETY
Anxiety is common in young people with ME/CFS. Anxiety is, itself, an energy sapping
activity. Some young people with ME/CFS will not report any particular worries, or not to
a greater extent than the general population. Others may report some low-level worries
relating to their illness and perhaps attending school, or coping with their symptoms.
These sorts of low-level worries can helpfully and effectively be addressed using the CBT
techniques discussed earlier. We often see reduction in anxiety as the young person moves
towards recovery in the ME/CFS treatment journey.

However, some children and young people with ME/CFS will struggle with anxiety to a
much greater extent. We know from recent research that approximately one-third of
young people with ME/CFS also meet the diagnostic criteria for an anxiety disorder (See
Loades, M.E., Read, R., Smith, L., Higson-Sweeney, N., Laffan, A., Stallard, P., Kessler, D.,
& Crawley, E. (2020). How common are Depression and Anxiety in adolescents with
Chronic Fatigue Syndrome (CFS) and how should we screen for these mental health co-
morbidities? A clinical cohort study. European Child and Adolescent Psychiatry.
doi:10.1007/s00787-020-01646-w).
The most common anxiety disorders are generalized anxiety disorder and social anxiety
disorder. Many young people who meet the criteria for one anxiety disorder diagnosis also
meet the criteria for another anxiety disorder diagnosis and/or depression. Some of these
young people may have had anxiety prior to their ME/CFS and it has since become
compounded or exacerbated. Others report that their anxiety began after their ME/CFS,
and in some instances, this may be because they have (or perceive themselves to have)
fallen behind academically and or socially as a result of ME/CFS. In this situation
resuming normal activities on the journey towards recovery can be anxiety provoking.
Anecdotally in clinic, we commonly see increased symptoms of panic amongst the more
anxious patients, who particularly report physiological anxiety symptoms such as fast
breathing and shakiness. Young people with ME/CFS may be more hypervigilant for
physical symptoms generally, including those which may arise from anxiety. A young
person with ME/CFS may also have had a protracted period of time (prior to diagnosis)
where there was a great focus on trying to understand and identify their symptoms, again
perhaps contributing to a heightened awareness of physiological symptoms. Therefore,
the principles applied to shifting the focus away from symptoms generally may be helpful.

Additional CBT techniques which may be helpful

The core CBT techniques described earlier in this manual such as unhelpful vs. helpful
thinking, and tools for managing feelings, remain relevant and appropriate for those also
struggling with more significant anxiety. They can be adapted and shaped to include a

PAGE 44
greater focus on managing anxiety, and exploring its relationship with ME/CFS. However,
anxiety may hinder treatment progress in several ways, including:

1) Anxiety, which is a high energy activity, gets in the way of activity management
and contributes to ongoing boom and bust patterns
2) Anxiety-driven avoidance gets in the way of resuming normal activities.

Therefore, there are some additional techniques which may be helpful when delivering
CBT for ME/CFS with more anxious children and young people. The formulation should
be used to inform if and when these are utilized.

Gradual exposure / goal hierarchy work

A graded approach to overcoming avoidance and facing feared situations may be helpful
when there is a specific situation (or situations) which particularly provokes anxiety. It
could be something like giving a presentation in school, or talking to someone new at a
youth club. Typically the target behaviour or action will be something of importance to
the young person; something they would love to be able to do, but currently feel unable to
due to their anxiety. The idea here is to break the goal into steps, and to work towards it.

The therapist supports the young person in first generating a list of potential steps; actions
or behaviours which also induce some anxiety, but less so than the target one. They are
then placed in order, starting with the easiest (least anxiety provoking) and working
towards the main goal. The therapist can help the young person to consider any safety
behaviours (precautions) that they are taking, which in their mind prevent the feared
catastrophe. These safety behaviours in fact keep anxiety going as they prevent the young
person from discovering that the feared catastrophe actually does not happen. Therefore
safety behaviours need to be dropped in order for the young person to fully engage in the
anxiety-provoking situation and to see that they can cope. It is also helpful to think about
rewards or anything to help boost the young person’s motivation for trying each step.

Each action or behaviour (or step in the ladder) then provides an opportunity to face an
anxiety-provoking situation, to test out related fears about what might happen, to practice
anxiety management in the moment (e.g. through breathing exercises, or other strategies
as discussed earlier), and to gather new evidence about what actually happened. Each
step, if successful, should increase the young person’s confidence in completing the next,
and anxiety should gradually reduce.

See Stallard, P. (2014). Anxiety: Cognitive behaviour therapy with children and young
people (book) for further information. Useful resources including anxiety ladders can be
found in the final chapter of this book, in Stallard’s Think Good Feel Good book, and at
https://www.psychologytools.com/professional/problems/anxiety/ for instance.

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Worry time (worry postponement)
This strategy brings together many different strands of CBT because it is essentially both a
cognitive and behavioural method which also enables an increased management of
emotions in the moment. Put simply, ‘worry time’ is a method for postponing any worries
to an allocated (delayed) time, typically in the evening or before bed. For example, a
young person may be given the following instruction: “Scan through your mind and see if
there are any busy thoughts or worries. If there are any, write them down and make a note
to deal with them at a specific, dedicated worry time. If something is really bothering you,
plan to talk to someone you trust.”

The idea here is to learn that worries do not have to be dealt with necessarily in the
moment but that it is possible to put them to one side with the plan of addressing them
later. This method is often done jointly with parents, as they can be helpfully involved in
sharing the ‘worry time’ with the young person when the worries are then talked through.
It can be particularly helpful for younger children. The child or young person is
encouraged to write down or record their worry in some way, for discussion later. In the
short term this enables them to free their mind of the worry until the designated time,
and in some ways to learn the ability to ‘sit with’ the emotion.

Often, by the time of the allocated ‘worry time’ the young person may notice feeling less
worried about the issue in question, as time has passed and the intensity of the feelings
may well have reduced. This too is a helpful experience for the young person to notice and
should be picked up on in therapy.

Building tolerance of uncertainty

Because we can’t see into the future, uncertainty is unavoidable. Tolerance of uncertainty
can be thought of a bit like an allergy. For most people, uncertainty, like pollen, for
instance, provokes mild discomfort at most. For some people though, even a little pollen
(or uncertainty) provokes high levels of discomfort; it provokes high levels of worry and
anxiety. It is particularly typical of those who have Generalised Anxiety Disorder. There
are ways in which a young person can build up their tolerance of uncertainty. Some ideas
can be found here https://www.psychologytools.com/resource/intolerance-of-
uncertainty/

Treating anxiety in younger ME/CFS patients

As with other elements of CBT for ME/CFS, anxiety work with younger children generally
requires slightly different ways of working. This is partly due to the less matured cognitive
and emotional abilities of the younger child. CBT for anxiety with younger children,
outside of ME/CFS treatment specifically, has been found to be most effective when

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delivered with and through the child’s parents. The therapist’s role therefore is to ‘train’
parents in delivering CBT with the child in the home environment. For example, skilling
the parent in helping the child to identify and communicate times of feeling anxious, as
well as facilitating the delivery of key cognitive and behavioural strategies to manage the
anxiety. Another key part of this work can be helping the parent themselves to recognize
any contribution of their own anxiety, and to learn ways of managing it constructively.
Cathy Creswell and Lucy Willets’ ‘Helping your child with fears and worries: a self-help
guide for parents’ (2019) is an excellent resource for further information. There are a
number of self-help guides for anxiety in young children, which again can be ‘delivered’ by
the parents. Examples include:

• ‘What to do when you worry too much: A kids’ guide to overcoming anxiety’ by
Dawn Huebner (for children aged 6-12 years)
• ‘Starving the anxiety gremlin: A cognitive behavioural therapy workbook on anxiety
management for young people’ by Kate Collins-Donnelly (for children aged 10+)

Paul Stallard’s ‘Think good feel good’ resources include ideas for helping young children
with managing anxious thoughts and feelings. Additional tools for anxiety work within
CBT for ME/CFS, may include:

• Body mapping
• Emotion cards
• Idiosyncratic assessment/monitoring tools such as visual rating scales
• Parent only sessions to be considered

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DEPRESSION
Low mood and depression is also common in young people with ME/CFS. This can
compound fatigue because fatigue is a somatic symptom of depression, as are problems
with sleeping, appetite and concentration. Depression is characterized by negative
thinking, hopelessness and anhedonia (lack of interest in and enjoyment of activities)
which can get in the way of engaging in treatment for ME/CFS and being able to live life
to the fullest.

Feeling frustrated and sad about not being able to do the things that a young person wants
to is a reasonable response to having a disabling and prolonged illness. Low mood and
depression are negatively reinforced by not being able to engage in activities which give us
a sense of enjoyment and/or pleasure. For many young people, their mood may improve
as they begin to re-engage in the activities they want to do on the journey towards
recovery from ME/CFS.

However, some children and young people with ME/CFS will struggle with their mood to
a much greater extent. Around one in five young people with ME/CFS also meets the
diagnostic criteria for Depression, and many of these young people will also have
difficulties with anxiety (See Loades, M.E., Read, R., Smith, L., Higson-Sweeney, N., Laffan,
A., Stallard, P., Kessler, D., & Crawley, E. (2020). How common are Depression and
Anxiety in adolescents with Chronic Fatigue Syndrome (CFS) and how should we screen
for these mental health co-morbidities? A clinical cohort study. European Child and
Adolescent Psychiatry. doi:10.1007/s00787-020-01646-w).

Additional CBT techniques which may be helpful

The core CBT techniques described earlier in this manual such as unhelpful vs. helpful
thinking, and tools for managing feelings, remain relevant and appropriate for those also
struggling with more significant mood problems.

Behavioural Activation
Within energy management, an increased focus on doing more valued activities (those
that have meaning for the young person), including activities that bring a sense of
achievement, closeness and enjoyment, could be useful where low mood is evident.
Drawing on the principles of Behavioural Activation Treatment for Depression (BATD)
can be helpful. It is important to help the young person to identify enjoyable activities that
are low energy, so that their activity management baseline does not preclude them from
engaging in mood-boosting activities. With these young people, it might also be
particularly important to focus the available high energy time available on the most
meaningful and mood-boosting activities for the young person rather than those that are
‘important’ but perhaps not mood-boosting.

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See Lejuez, C. W., Hopko, D. R., Acierno, R., Daughters, S. B., & Pagoto, S. L. (2011). Ten
year revision of the brief behavioral activation treatment for depression: revised treatment
manual. Behavior modification, 35(2), 111–161. https://doi.org/10.1177/0145445510390929

General as well as fatigue-specific negative thoughts

Young people with ME/CFS who are also low in mood tend to experience more negative,
distorted thoughts in general as well as unhelpful fatigue-specific thoughts. The cognitive
techniques discussed above for addressing unhelpful thoughts should be more applied
more broadly in those with concurrent mood problems so that general negative thoughts
are also addressed. If these are not addressed, general negative thinking can form a barrier
to making changes that can help with ME/CFS (e.g. thinking ‘Nothing is going to help’
may make a young person less likely to make changes to sleep and activity patterns).

Core Beliefs
Core beliefs are deeply held beliefs about ourselves, other people, or the world. They can
determine how we perceive things and respond to our experiences. Sometimes in CBT for
ME/CFS it may be appropriate (and indeed necessary) to explore the young person’s core
beliefs. This can be particularly helpful if the therapist sees that certain core beliefs are key
to the formulation and, perhaps, inhibiting the young person’s progress throughout
therapy.

See Verduyn, C., Rogers, J., & Wood, A. (2009). Depression: Cognitive behaviour therapy
with children and young people. Routledge for further information and helpful worksheets.

WHEN MORE HELP FOR MENTAL HEALTH PROBLEMS IS NEEDED

There are of course some instances where a young person’s mental health needs become
greater than can be appropriately supported within a ME/CFS service. At these times the
clinician needs to consider whether the young person would be better served by accessing
CBT (or other evidence-based treatment) for their anxiety within a mental health service,
such as CAMHS (Child and Adolescent Mental Health Services).

It is important for this need to be correctly identified, primarily to best support the mental
health of the child or young person, and also to consider most efficient use of specialist
ME/CFS clinicians’ time. There are very few paediatric ME/CFS services in the country and
so it is important to ensure clinicians in this service are able to provide support to children
and young people which they cannot otherwise access elsewhere.

The following points are useful to consider, when deciding where a young person’s mental
health needs are most appropriately supported:

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• Primary issue – What does the young person feel is their main difficulty at the
current time? If mental health related, and not ME/CFS, it could be appropriate to
refer outwards.
• Longevity of the mental health problems – Does the young person feel their
anxiety/mood is long-standing? Is it something they have always struggled with,
and never previously had professional support for it? Are their longer term issues
which may need exploring in a different modality e.g. through Art Therapy or
Family Therapy?
• Maintenance formulation – What is keeping the young person stuck currently
from working towards their ME/CFS goals? Is mental health the main barrier to
progressing with their ME/CFS treatment programme? If so, is the mental health
inter-related to their ME/CFS or is it somehow separate?
• Severity and complexity – There are some mental health problems for which
specialist input is indicated at the outset, including PTSD, and Eating Disorders as
these require management and specialist therapy from appropriately trained
mental health clinicians.
• Risk management – Any young people presenting with significant levels of risk
(e.g. self-harming behaviours and/or suicidal ideation) must be supported within
mental health services.

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Relapse Prevention and Managing Setbacks
Another key stage of CBT for ME/CFS is preparing the young person for how to manage
after the time that active treatment has ended. There are two key processes here; relapse
prevention, and building a therapeutic ‘blueprint’ for managing setbacks if they do occur.

Relapse prevention is about helping the young person know what they need to keep going
with, after therapy has ended, to prevent further fatigue. This does not necessarily mean a
strict monitoring of activity levels, but perhaps keeping going with some elements of the
treatment journey that have been particularly helpful for them. This can often link to
specific events. For example, many young people will come to reflect that stress (such as
that brought about during exam periods) can be unhelpful through disrupting their sleep,
making it harder to concentrate at school, and ultimately impeding their exam
performance. Therefore, the young person can help to prevent future difficulty in this area
by being clear on what helps them to manage or minimize stress if it does arise, before it
can cause more difficulty and potentially lead to increased fatigue. Consideration should
also be given to what the early warning signs would be if difficulties did emerge again.

Having a clear plan of helpful behaviours or actions helps the young person to recall what
has helped them previously. This information is what is held within the therapeutic
blueprint. If the young person’s fatigue does re-increase (following a particular trigger e.g.
illness or cause of stress, for example), the blueprint can be used as a personalized self-
help guide to know how to then best manage this setback. In terms of activity levels, it
might be appropriate for example to temporarily reduce school attendance slightly again,
and to gradually re-build it in the same way as was done before. Having these ideas
planned out in advance gives the young person security in knowing they are skilled to
manage any setbacks if they arise, without needing to return to active treatment with a
therapist.

Of course, there are times when previous patients may be re-referred to a ME/CFS service,
particularly if health or circumstances have changed more significantly for them during
the interim time. But at these times the therapist would keenly take a clear focus on
revisiting previous strategies and exploring with the young person what they can do to
manage; it would not be a case of starting again in full therapy. We might think of this as
having a few ‘top up’ CBT sessions.

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Version 4 05.01.2022

Treatment Sequence for Behavioural Approaches vs CBT-F vs CBT-F with co-morbid anxiety and depression (indicative time frames) - Note: This is a general guide and is not intended
to be used prescriptively. The idiosyncratic formulation would inform in a specific instance.

Behavioural Approaches (e.g. CBT-F CBT-F + depression &/anxiety

Energy/Activity Management, GET)
Assessment & formulation
Assessment Usually 1 90-minute session, and may include filling in questionnaires and collecting information from others (e.g. teachers, especially for primary
school age children)
What is ME/CFS? Psychoeducation Usually covered briefly during the assessment session, with information leaflets to take Also include psychoeducation about mood and
about ME/CFS away, and revisited as needed, particularly at the early stages of treatment. anxiety e.g. fight-flight response
Formulation    including how mood/anxiety link to fatigue
Goal setting Usually covered at the end of the assessment, revisited at the beginning of treatment. Would include goals relevant to mood and anxiety as
Focus on goals related to overcoming fatigue. well as overcoming fatigue.
Treatment sessions
Sleep Sessions 1-2 Sessions 1-2 Sessions 1-2
Setting an activity baseline Sessions 1-6 Sessions 1-3 Sessions 2-5
(GET focuses on physical activity only; Likely to take longer - include consideration of mood
Energy/ Activity management focuses on boosting activities by:
cognitive and social activities too) (1) Identifying low energy enjoyable activities
(2) Making sure that some of high energy time is
spent on fun activities (activity scheduling for
depression).
Gradually increasing activity levels by Session 3 onwards when baseline is Session 3 onwards when baseline is Sessions 3 onwards when baseline is established and
10-20% every 1 -2 weeks as tolerated established and stable established and stable stable
If specific fears and worries identified may need to
use graded hierarchy for exposure to overcome
those fears (e.g. a graded hierarchy of social
situations)
Cognitive work: Thoughts that are  About fatigue specifically – often later in  Broader (i.e. general negative thoughts as well as
unhelpful therapy, particularly if thoughts about fatigue specific) and may be introduced earlier in
fatigue are getting in the way of making therapy
progress.
Managing feelings May introduce relaxation strategies if As soon as needed e.g. where anxiety is a key part of
needed. the problem, relaxation might be introduced early on
Risk management Only if indicated Only if indicated -Throughout-
School and ME/CFS  throughout  throughout  throughout
What can get in the way of making As needed As needed As needed
changes?
Reviewing progress Approx. every 6 sessions Approx. every 6 sessions Approx. every 6 sessions
Relapse prevention & Managing Towards end of therapy
setbacks deregulating
Version 4 05.01.2022