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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