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Fred Friedberg’s Seven-Step Protocol for Treating CFS & FM

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By Bruce Campbell

If you're looking for practical strategies to improve your quality of life with CFS or FM, you might consider picking up a copy of Fred Friedberg's book Fibromyalgia and Chronic Fatigue Syndrome: Seven Proven Steps to Less Pain and More Energy. Friedberg is a psychologist, researcher and person with CFS (PWC).

His approach is based on the belief that lifestyle change is the treatment of choice for CFS and FM. He writes that while effective medical treatments are yet to be developed, effective treatments of "behavioral, psychological, personality, and stress factors" are available, offered not as cures but as vehicles "to greatly improved quality of life and lessened illness severity."

Describing the shift in his own approach to CFS, he writes that "it took me almost two decades to realize that deliverance from CFS wasn't going to come from outside treatments." He notes the irony that as a psychologist he often mentioned mind-body connections to others, but it took him 18 years to recognize that lifestyle change might work with CFS.

He says that the lifestyle change approach described in the book is effective for a majority of people who use it and he offers a carefully-worded promise: "If you follow the lifestyle and stress reduction recommendations in the book for at least six months -following the recommendations to the letter- you will experience a noticeable improvement in your condition." "Noticeable" means at least 20 percent, he writes.

So what are his seven steps?


Noting that stress is very common among people with CFS and FM, his first step is to adopt a daily relaxation practice. He writes that "relaxation is to CFS and FM what aspirin is to headaches; relaxation can reduce symptoms and dissolve tension." He suggests people start with 10 to 20 minutes twice a day, then later increasing it to 30 minutes twice a day. He gives step-by-step instructions for several techniques.

Improving Sleep

Poor sleep is very common in CFS and FM, and contributes to other symptoms such as fatigue, pain and cognitive problems. The second step focuses on improving sleep through changing sleep habits and practices.

Friedberg's advice on sleep hygiene practices is similar to that of other authorities: have a regular schedule for going to bed and getting up, limit daytime napping, use your bed only for sleep and intimacy, prepare for bed by gradually winding down, have a good mattress and a dark, quiet environment.


Pacing is the heart of every lifestyle change approach and is the third step in this plan. In this book (as in most plans), pacing means reducing overall activity level, breaking activity into units, having shorter activity periods, and keeping a consistent activity level from day to day. Consistent with other authorities, Friedberg advises keeping a log of activity and symptom levels to determine what worsens symptoms.

Lessening Anger

Emotional reactions are a central aspect of CFS and FM. Friedberg devotes steps 4 and 5 to them, beginning with a chapter on anger. One strategy for reducing anger is to adjust expectations. He suggests using a log to record feelings and to ask what thoughts lie behind the feeling.

Often they are unmet expectations. Frustration can be lowered by adjusting expectations. He also suggests that saying self-assertive statements five minutes a day can help produce more realistic expectations. Examples are "I can balance my personal needs with those of others" and "I do not need to completely sacrifice myself for others."

Reducing Worry, Discouragement & Guilt

It is easy to become discouraged and preoccupied with the negative. He advises focusing instead on what you can still do and reducing worry by repeating such statements as "Instead of worrying, I can make a plan about how to deal with my symptoms and my life. This will ease my fears and help me focus on the practical things I can do."

He believes that guilt is often created by "perfectionistic high standards" and advises people lessen guilt by using phrases like "I will do what I can reasonably do and will value this achievement rather than condemning myself for what cannot be done."

Scheduling Pleasant Events

Pleasant experiences are an antidote to the suffering of chronic illness. They can lessen stress and may improve functioning. As a strategy for increasing pleasure, he suggests a three step process: a) make a list of ten low-effort, pleasant activities (for example, taking a bath, sitting in a park, reading an absorbing book, sharing time with a spouse or friend), b) select five items, c) schedule them for the next week.

Getting Support

The last step is to get support from others. The first technique he recommends is to reduce the influence of bad relationships. The example he gives is of someone in a conflicted marriage whose health improved after he and his wife divorced. Another strategy he suggests is asking for help.

People may be reluctant to do this out of a sense of self-sufficiency or because they expect others to recognize their needs. Third, he suggests that if you don't get support from people close to you, you look for help elsewhere, including support groups, therapists (especially those who specialize in chronic illness) and from others who also experience CFS and FM.

Evaluation and Conclusion

Friedberg presents a sensible set of suggestions for using lifestyle change to address important issues faced by people with CFS and FM: stress, sleep problems, emotions, activity level and support. Readers may feel frustrated with the book for several reasons, however.

First, treatment of the seven steps is relatively brief, a total of just 70 pages. Second, those who wish to combine lifestyle change with medical approaches will be disappointed in the book's exclusive focus on lifestyle.

Third, some will feel frustrated at all he didn't discuss and his limited range of strategies. For example, while behavioral treatments for sleep are addressed, there are no recommendations about sleep medications or discussion of fatigue, pain, cognitive problems and other symptoms.

His two stress management approaches are widely recommended, but other sources describe a dozen or more ways to control stress. Loss, a major issue for people with CFS, is given one paragraph.

Nonetheless, the book provides helpful ideas and is a useful reminder that in order to improve, people with CFS have to adopt new practices and use them consistently.