Muddle in the Middle: Psyche and Soma on an Institutional Level within the NHS
Mark Nevin researches which modality NHS Liaison Psychiatrists recommend for patients with psychosomatic illness
Over the past two decades there have been advances within neuroscience which suggest that the dualistic concepts of ‘mind’ and ‘body’ are outdated and obsolete. Body psychotherapist, Nick Totton claims that they are being replaced by the idea of what he calls ‘Wholism’.1 He says there is ‘an increasing groundswell of belief in our culture that the splitting of body and mind is both non-sensical and damaging’, and that ‘Descartes was wrong’, we ‘do not exist because [we] think, but because [we are] embodied’.2 Researcher and psychotherapist Maggie Turp goes further and suggests that what Totton describes as a groundswell of belief is ‘something approaching a consensus’.3 But how does this new understanding influence our thinking about psychosomatic illness and how is it represented on an institutional level within our health service?
It has been estimated that only 15 percent of patients presenting for the first time at their GP will have symptoms that are caused by physical pathology. Wijeratne (2007) points out that anxiety and depression are present in at least one third of patients, but they are more likely to complain of somatic symptoms like tiredness, insomnia and anorexia.4 He puts this down not only to a denial of psychological factors, but to the stigma of mental illness and a common belief that a physical illness will be taken more seriously by the doctor than an emotional problem. Likewise, patients experiencing panic attacks commonly present in A&E complaining of shortness of breath or chest pain due to autonomic arousal.5 On surgical wards, non-specific abdominal pain (NSAP), (abdominal pain without any organic cause) is the most common abdominal presentation and in a year, an estimated 33,000 negative laparotomies, which many of these patients undergo, are performed at a cost of around £30 million to the health service. In the US it is estimated that excessive health care use due to somatisation costs the American health care system a staggering $100 billion annually. 6
The doctor driven by a need to act and a fear of ‘missing something’ is in danger of unwittingly colluding with the patient’s psychosomatic defence by the prescription of medication or referral on to specialists for further medical investigations. Referral on to psychological therapy can be extremely difficult because of the patient’s firm conviction that their suffering is purely a physical matter. The mediator between general medicine and psychological therapy is the liaison psychiatrist (LP) and an important part of the LP’s training is to develop the skills necessary to gain the patient’s trust.
In the UK there are currently 360 psychiatrists who list liaison as a speciality on the register at The Faculty of Liaison Psychiatry at the Royal College of Psychiatry. In my research I was interested to know how common it is for a patient presenting with somatic symptoms to be referred on to psychotherapy by LPs. I conducted a survey with 291 psychiatrists and focused on questions about CBT and psychodynamic psychotherapy referrals. I chose these two methods of psychotherapy for their obvious contrasting foci – learning through therapy as opposed to relational therapy, respectively.
I asked the following three questions and provided box ticking choices for replies:
- How many times in the past 12 months have you referred a patient presenting with somatic symptoms for Psychodynamic Psychotherapy?
- I would make more referrals but I am limited by the availability of Psychodynamic Psychotherapy in my trust/area. (yes or no)
- How many times in the past 12 months have you referred a patient presenting with somatic symptoms for Cognitive Behavioural Therapy (CBT)?
- I would make more referrals but I am limited by the availability of Cognitive Behavioural Therapy (CBT) in my trust/area. (yes or no)
- How many times in the past 12 months have you referred a patient presenting with somatic symptoms for any other kind of psychological therapy? (please specify)
- I would make more referrals but I am limited by the availability of other kinds of psychological therapies in my trust/area. (yes or no)
- In the final section of the survey I asked respondents to write brief comments about availability, relevance, usefulness or funding of psychological therapies for somatic illness. I received many different opinions.
From my results there seemed to be a reluctance to refer patients to psychotherapy of any kind in any area in the UK, and some of the reasons for this are suggested in the comments. Of those who did refer, there was a seven times greater chance that they would use CBT than psychodynamic psychotherapy. Only in London was there any difference, with a slightly greater number of referrals to psychotherapy. Nationally, fewer than half indicated that they would refer more to psychotherapy if availability were greater, but a little more than half said that they wouldn’t. For referrals to CBT, nearly 60% said they would refer more frequently if it were available and more than half said they would make more referrals overall if that was made possible by their trusts. Among other concerns was a question about adequate training for somatised symptoms and some LPs admitted to failure in their own confidence that their patients would engage in therapy.
In the third part of the survey I asked respondents to specify which kind of other psychological therapies they would consider using for referrals. Figure 1 shows the preferences.
[table id=1 /]
Figure 1. Types of therapy preferred if available
It is obvious from Figure 1 that, given the choice, the LPs would make more referrals and opt for less evidence-based therapies for patients with somatised disorders. It is reflected in their comments that they are aware of but restricted by their health trust’s decisions over use of funds and, perhaps, confidence in therapies other than evidence-based.
In the comments section, those LPs who chose to send patients to CBT over longer term psychotherapy showed some agreement with the health trust’s decision; they stated that this was because it was evidence-based. They also felt that CBT worked well with somatic disorders and was more appropriate for patients fearful of deeper work. On another note, some LPs raised the issue of training, stating that they felt it was inadequate for patients with somatic disorders and one respondent added that, ‘it would be good to have a local register of expertise’.
A lack of funding and long waiting lists (one respondent mentioned a waiting list of 18 months) were also mentioned as concerns which worked against referrals for psychodynamic psychotherapy and some respondents commented on the difficulty in rationalizing the responsibility for these patients; medical or mental health teams?
A few commented on the suitability and need for psychodynamic psychotherapy under certain conditions; availability in the NHS, the nature of the relationships between stressor and symptom and if it is appropriate for the relevant disorder. Other themes included issues such as the complexity of patients presenting with medically unexplainable symptoms (MUS) and the need for thorough assessment and one comment expressed a possible failure of assessors to fully understand the nature of somatisation.
When we consider the high incidence of patients presenting at their GP with MUS, it would seem that there are remarkably few referrals for somatising patients to psychotherapy, whether it be psychodynamic, CBT or other kinds, especially when one considers that this survey was conducted among the very people supposedly responsible for this job. Of course, most patients’ entry point into the healthcare system is via their GP, with ‘the diagnosis of the GP decisively influenc[ing] the subsequent treatment’ 7 and Brian Broom (1997) suggests that,
‘The impact of the [LP] service is small because generally it only serves patients referred by the somatically preoccupied physician or surgeon. There is great irony in this. The somatically preoccupied are allowed to circumscribe the purview of the mind-oriented when it comes to exploring mind-body connection’. 8
He also criticizes ‘soma-preoccupied psychiatry’ and the trend for ‘abandoning the psyche to embrace the soma in the form of its brain and its biology’. 9
To conclude, Jeremy Holmes suggests that the NHS is in a ‘crisis of values, in which the personal aspect of medicine competes with, rather than complements medical technology’.10 Like the individual somatiser, the institutional body of the NHS seems to struggle with the abstract and wants concrete evidence and ‘treatment’, a pill, an operation or a therapy that performs like one, but ‘mind’ and ‘body’ are abstractions and, ‘To treat these abstractions as concrete realities is to fall into what Whitehead (1926) called “the fallacy of misplaced concreteness.” ’11 The psychodynamically informed therapist, ‘ …knows that the psychosomatic symptom, when unravelled …[is] perfectly legible in the languages of metaphor, pun and symbol.’ 12
While the challenge for psychotherapy is to enlarge a credible evidence base that can speak a language comprehensible to medicine, the NHS might do well to observe how the German health service, under the influence of Michael Balint’s legacy, attempts to implicate something like Balint’s ‘Patient-centred Medicine’, 13 which considers attention to a patient’s emotions as a routine part of a doctor’s work, because, in the words of McWhinney et al (1997),
To attend to the emotions only in certain kinds of illness, or only after diagnostic testing is negative, perpetuates the prevailing dualistic distinction between mental and physical illness. All significant illness is a disturbance at multiple levels, from the molecular to the personal and social. This implies that some of the skills that are at present considered “psychiatric” will need to be more general in all clinicians, especially those working in primary care, where so much general undifferentiated illness is seen. 14
If there is to be progress it depends upon communication between the fields of psychotherapy and general medicine, the difficulty is in mutual comprehension that allows fruitful communication and engenders mutual respect.
Mark Nevin works at Camden Psychological Services which is the combined Psychodynamic Psychotherapy departments of the Royal Free Hospital and UCH. In this article, Mark Nevin discusses the results of his research carried out in 2008 about the choices made by NHS psychiatrists to psychotherapy referrals for patients with psychosomatic illnesses. This work is part of the research he carried out for his MA dissertation.
Barsky A J, Orav E J, Bates D W, (2005), Arch Gen Psychiatry; 62:903-910. in Kroenke, (2007), Efficacy of Treatment for Somatoform Disorders: A Review of Randomized Controlled Trials. Psychosom. Med. 2007;69:881-888.p. 881.
Bass, C and Murphy M (1996) ‘Somatisation, Somatoform Disorders and Factitious Illness’ in Guthrie, Elspeth & Creed, Francis, (eds.), (1996), Seminars in Liaison Psychiatry, London, Gaskell, pp. 103 – 156 p. 114.
Broom, Brian, (2007), Meaning-full Disease, London, Karnac Books, pp. 15 -25 p. 43
Hafner, S & Petzold, E-R, (2007) ‘The Role of Primary Care Practitioners in Psychosocial Care in Germany’ in The Permanente Journal, Winter 2007/volume11 No. 1 pp 52-55.
Holmes, J, (1994) Controversies in Management Psychotherapy – a luxury the NHS cannot afford? More expensive not to treat. British Medical Journal 1994;309:1070-1071, retrieved in May 2008 from http://bmj.bmjjournals.com/cgi/content/short/309/6961/1070.
Totton, N, (2003) Body Psychotherapy: An Introduction, Maidenhead, Open University Press, pp. 22 – 52. pp. 88 – 115. p29.
Turp, M, (2006) Hidden Self Harm: Narratives From Psychotherapy, Gateshead, Athenaeum Press, pp. 9 – 19, pp. 23 -37, pp. 53 -66, pp. 187 – 207. p198.Whitehead A N, (1926), in McWhinney, Ian R., Epstein, Ronald M., Freeman, Tom R., (1997) An Introduction to Rethinking Somatization, retrieved in June 2008 from <http://www.uwo.ca/fammed/ian/somatization.htm>.
Wijeratne, C. (2006) ‘How to Treat Functional Somotaform Disorders’, retrieved in May 2008 from <www.theaustralian, doctor.com.au> .
Young, R M., (1990) The Mind-Body Problem, in R. C. Olby et al. (eds). Companion to the History of Modern Science. Routledge, 1990, pp. 702-11, retrieved in June 2008 from http://www.human-nature.com/rmyoung/papers/pap102h.html