Balabanovic Janet, Hayton Philip
London Metropolitan University, UK.
Psychol Psychother. 2020 Jun;93(2):347-366. doi: 10.1111/papt.12213. Epub 2019 Jan 8.
Patients with "medically unexplained symptoms" or "MUS" experience subjectively compelling and distressing somatic symptoms that are not fully explained by underlying physical pathology. Effective treatment of these patients has been impeded by multiple barriers. Problems with patient engagement have been highlighted in the clinical and research literature, yet few exploratory studies have been conducted in this area. This research explores how experienced psychological therapists in a specialist MUS service work to engage these patients.
An in-depth qualitative study was conducted to explore the process of engaging patients with MUS in psychological therapy.
Semi-structured depth interviews were conducted with psychological therapists who work with complex patients with MUS. The therapists interviewed were recruited from an NHS primary care psychological therapy service that specializes in working with this patient group. Data were analysed using grounded theory to develop a model of this process.
The analysis identified how multiple interacting layers of systemic, interpersonal, and intrapsychic disconnections impede engagement. The research introduces a new theoretical framework 'Negotiating disconnection' that conceptualizes the process of engagement in terms of a series of stages, namely 'Drawing in' (negotiating systemic disconnection), 'Meeting' (connecting in the disconnection), and 'Nudging Forward' (cultivating new connections), and illustrates how these are negotiated by therapists.
The model shows that it is critical for therapists to collaborate closely with GPs to engage these patients while also highlighting barriers to doing this, reflecting the complexities of organizational and cultural change. Clinically, the model illustrates the importance of adopting a flexible, pluralistic, and integrative approach that is person-centred and process-led. Doctors and therapists should embrace a holistic, biopsychosocial stance towards MUS and be sensitively attuned to its complex phenomenology.
To engage patients with MUS psychological therapists should be person-centred and process-led rather than theory- or protocol-led. A pluralistic and integrative mindset facilitates this by enhancing clinicians' flexibility. A multidisciplinary approach is essential. Clinicians should embrace a biopsychosocial stance towards MUS and work closely with medical colleagues to help them do the same. Structural and cultural change is needed to tackle this issue effectively.
患有“医学上无法解释的症状”（MUS）的患者会经历主观上令人信服且痛苦的躯体症状，而潜在的身体病理学无法完全解释这些症状。这些患者的有效治疗受到多种障碍的阻碍。患者参与方面的问题在临床和研究文献中已得到强调，但该领域的探索性研究却很少。本研究探讨了在专业MUS服务中经验丰富的心理治疗师如何努力让这些患者参与进来。
进行了一项深入的定性研究，以探索让患有MUS的患者参与心理治疗的过程。
对治疗患有复杂MUS患者的心理治疗师进行了半结构化深度访谈。接受访谈的治疗师来自英国国民医疗服务体系（NHS）的初级保健心理治疗服务机构，该机构专门治疗这一患者群体。使用扎根理论对数据进行分析，以建立该过程的模型。
分析确定了系统、人际和心理内部多重相互作用的脱节层次如何阻碍参与。该研究引入了一个新的理论框架“协商脱节”，该框架根据一系列阶段将参与过程概念化，即“吸引”（协商系统脱节）、“相遇”（在脱节中建立联系）和“推动前进”（培养新联系），并说明了治疗师如何对这些阶段进行协商。
该模型表明，治疗师与全科医生密切合作以让这些患者参与进来至关重要，同时也突出了这样做的障碍，反映了组织和文化变革的复杂性。在临床上，该模型说明了采用以患者为中心、以过程为主导的灵活、多元和综合方法的重要性。医生和治疗师应对MUS采取整体的生物心理社会立场，并敏锐地适应其复杂的现象学。
为了让患有MUS的患者参与进来，心理治疗师应以患者为中心、以过程为主导，而不是以理论或方案为主导。多元和综合的思维方式通过增强临床医生的灵活性来促进这一点。多学科方法至关重要。临床医生应对MUS采取生物心理社会立场，并与医学同事密切合作，帮助他们也这样做。需要进行结构和文化变革以有效解决这个问题。
