A modo de conclusión: ¿es maravilloso ser joven?

As I have discussed previously, the research participants‟ concept of psychology reflected the prevalent attitude amongst my patient population in general and those referred for somatic symptoms specifically: in a medical environment they found it challenging to negotiate effectively from their initial expectations of a physical diagnosis to one which incorporated explanations of psychological and emotional genesis. My participants‟ were not unique in this. Research indicates that there is frequently a mismatch between expectations and outcome for low-income patients initially encountering psychological services both here in South Africa (S. Swartz,

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2007, 2015) and internationally (Fels Smyth et al., 2006). Explanations for the difficulty appear to vary according to the particular situation. With my participants, the confusion was two-fold: firstly, most of my patients have had no prior exposure to psychology which created fear, suspicion and confusion. Secondly these difficulties of negotiation and understanding were further complicated by the physical nature of their presenting symptoms and the entrenched belief that they required medical management – in the form of medication or tangible procedures such as scans, X-rays, even operations.

However, some participants challenged the stereotype in a very positive way. Rivka had reacted with the same resentment as other participants about the suggestion that her pain was being discounted or that she was “crazy”. However, she was able to successfully negotiate to a position where she was able to consider and finally accept the possibility of an underlying psychological origin. She had no previous experience of psychology and her knowledge of the discipline was vague, but remarkably insightful. When I asked what she thought a psychologist could do to help her, she replied, “Maybe if I could speak to somebody, or may it, its (.1) how do they say? (.1) The „small brain‟? Maybe there‟s something wrong there?” I asked for her to elaborate on what she meant when she used the term “small brain” and she replied, “Almost like your (.1) um (.2) you‟ve got your that, that, I‟m telling you now there‟s nothing wrong with me, but deep down, there, there is something that bothers me, but I just can‟t put my finger on it.” I asked if she was referring to the subconscious, and she replied in the affirmative, “The subconscious, that‟s it! Ja! The small one.”

Rivka was also the participant who provided an interesting distinction between “worry”, which she saw related to things that could be rectified or at least dealt with, “like problems at home, kids that‟s worrying me, their school, work, um, baby,” and “stress” which was generated by issues that might be difficult or impossible to resolve, “Like my husband! (.2) Sometimes like I said, when I‟m at work, but I‟m not at work, I‟m at home! When I‟m home (.2) I‟m at work . . . That‟s what I can’t fix sometimes.” By making this connection, she reported that she felt less helpless in the face of her life circumstances. She would change what she could, and be tolerant of those issues which at present appeared insoluble. For Rivka, as well as several other participants who continued in therapy, the use of such cognitive behavioural therapy

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(CBT) interventions as progressive muscle relaxation appeared to facilitate both the acknowledgement of stress as a contributing factor to their physical symptoms, as well as a way of managing problematic aspects of their lives more effectively. L. Smith et al. (2012) validate the usefulness of such concrete psychological interventions within low-income individuals.

As a corollary, outside of patients with medically unexplained symptoms, Fels Smyth et al. (2006) describe the psychological challenges faced by poor women encountering the mental health system and traditional psychological approaches. They discuss the shame and self-denigration that might be generated as a consequence of inappropriate interventions which appear to position the blame internally. While internal processes are of importance, many of the stress-generating factors associated with poverty are external and outside of the control of the women (L. Smith et al., 2012). For those of the participants who continued beyond the initial interview, the initial feelings of incomprehension, even resistance, became modified by explorations of externally generated stress as contributing factors to their physical symptoms, while at the same time the use of overt self-management techniques, such as those used with Rivka, which provided a sense of collaboration and autonomy in managing their life circumstances.

In several instances the participants symptoms were reported to have manifested in close proximity to a stressful or negative life event. This has been supported by some research (Kaminer & Eagle, 2010). Raabia’s presenting symptoms had manifested shortly after her husband had told her he wanted to take a second wife. Throughout both interviews with Raabia she would describe the physical pain as a “stabbing in the back”. She felt betrayed by her husband and unconsciously appeared to recognise the symbolism of her description because almost immediately she would change the adjective to “pressing”. The prevailing uncertainty of her situation permeated both interviews. She was concerned about her marital status – would she end up divorced or not – as well as the financial and social implications. After she had described the process of marital uncertainty she acknowledged that perhaps it had made sense to be referred to psychology (although initially she had said that she had wondered if the referring doctor had thought she was “crazy”). She said she knew there was nothing wrong with her body, “I knew that” and that, “I realised, like I explained, um my

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body couldn‟t handle the stress anymore.” Acknowledgement of the stressful component of her life situation, while it did not ameliorate her physical symptoms, seemed to provide her with a degree of calm and acceptance. During her second interview we conducted a progressive relaxation intervention. Although Raabia was unable to return for a further follow-up, she reported telephonically that ongoing practice of the routine, helped her manage the ongoing stress of her marital relationship.

While not overtly discussed, the concept of reduced resilience emerged with one participant. This particular participant had lived a life defined by chronic stress and the impact of her social circumstances. When we discussed the possible reason for her emerging somatic symptoms she acknowledged that her middle age possibly made her less able to cope. As described in the section on physical explanations in section 4.3.2.1.1., Davina had originally been convinced that the explanation for her internal shaking was an imminent stroke. However, eventually during our second interview, she was beginning to entertain the possibility that the development and maintenance of her internal shaking was related to stress, specifically about her son. When I asked her about stressors in her life she said, “Oooh, I have such a lot of stress!” And she went on to describe the situation when she had to “put out” [evict] her thirty-nine year old son, “He‟s a big man, (.2) he‟s not working, he‟s doing drugs [tik and dagga] and (.4) I just put him out.” She was able to say about the two separate incidents, “I think it, it‟s stress because the, the first time it [the internal shaking] happened (.2) I was also stressing with my son. And the second time!” The situation with her son had been going on for many years as he had started using drugs in his late teens. I asked why she thought it might have become untenable for her now after many years of enduring his behaviour, “I think that (.3) maybe um, that time I was still younger. You see? Now I‟m older now and um (.4) being on my nerves all the time, maybe that affects me now.” Unfortunately, due to her non-attendance at the third session and her failure to respond to messages asking to reschedule, I was never able to follow up on her ongoing understanding of the cause of her physical symptoms.

Another participant, Maryam, while invested in the physical nature of her symptoms, was also able to effect some relief through a basic CBT intervention aimed at reducing stress. She described symptoms which were predominantly concerned with

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pain: up the side of her neck and the pulling of the muscles in that area, “The pain comes from here till in ears, and it like feel tight as I so move, man. Tight and tight my everything is like pulled together,” as well as the peculiar description of the “bowl” in her neck. She was also adamant that she had lost weight – specifically from her face. The pain and alleged weight loss had taken her on a circuitous route of investigation from the local Day Hospital where they did innumerable blood tests such as HIV, TB (tuberculosis) and thyroid function with no positive results. She went to a second clinic with the same result and then she demanded further investigation, “Then I told them, I want to see a doctor that can do a scan to see what is wrong because I can feel here is glands.” She was referred to Hope Hospital where both an X-ray and a CT scan were done and “They also find nothing [sounding disappointed] But the pain is there, the the, the tightness is there, the everything is there but (.3). She didn‟t continue, looking sad and despondent. She offered no explanation for the symptoms but was prepared to consider the possibility that they were related to the stress of her unemployment. At the conclusion of her first interview I decided to do a progressive muscle relaxation exercise with her. She was almost childlike in her expectations of help and I felt that offering her a practical tool would perhaps provide her with the possibility of agency. She engaged with the procedure well, but failed to follow up with the subsequent appointment for us to explore the possible effect on her symptoms.

Another participant, who initially had also been preoccupied with the possibility of major illness, was able to move to a place of being able to link the advent of the symptoms to stress – specifically episodes of acrimony with her family. Kamila described the particular situation, “It‟s almost like someone was choking me [actually puts her hands around her own throat] it‟s almost like my family is choking me!” In fact, she was one of the few participants who could exactly identify the precipitating event, “I found out my son was tattooed out.” The significance of this was initially lost on me, but later she explained that the specific wording of the tattoo indicated membership of one of the Cape Flats most notorious gangs. Despite his history of drug abuse, she had felt that, “I thought there was something maybe I could do about it.” But the tattoo and associated gang membership was a final indication that he was lost to her. Her symptoms started immediately afterwards. The poignancy of her description of her symptoms, “Um, it‟s almost like a stabbing pain, someone is

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stabbing me with a knife continuously . . . in my heart,” together with the choking feelings seemed to be directly related to her sadness regarding the breakdown in her relationship with her children and husband. Kamila was one of the participants who continued in therapy, and with her both CBT interventions and explorations of interpsychic processes facilitated a shift in her perceptions and management of her physical symptoms.

The relationship between poverty and mental health has been well documented, particularly in the way it impacts most significantly on women (Belle & Doucet, 2003; Pearce, 1978; L. Smith et al., 2012). While much of the literature focuses on such psychological sequelae as depression (Belle & Doucet, 2003; Dukas, 2009; Kessler et al., 2005) there is some evidence for the development of somatic symptoms as a consequence of adverse economic conditions (Allaz & Cedraschi, 2015; Burns, 2015). One participant particularly illustrated this symptom configuration. Angela had a pre-existing diagnosis of depression and a history of suicide ideation and attempt. Her physical symptoms however had developed and intensified as her financial situation deteriorated. Her mother had been supportive, but then lost her job. Angela had ended her relationship with the father of her child and he had subsequently withdrawn financial support. At the stage at which I first saw her, Angela was struggling to feed herself and her child. Her symptoms had worsened from pain and shaking on the one side of her face to a general body palsy, which at one stage had resulted in hospitalisation at Hope Hospital and her mobility reduced to using a wheel chair, “It used to be my face only. But now, it was as my whole side, and then my leg. I would feel that this one is (.1) heavier than this one [pointing first to left, then right leg] . . . The second day it became the same, the third day, fourth day then I started even worse (.1). I started getting this needles. These needles and my face would be like a nervous, I‟m a nervous person. Would shake, shake, shake!” I asked her what she thought the symptoms could indicate, “I noticed when it happens, it happens when I‟m think or stressing or (.1) something bothered me.” At the end of her first interview Angela was able to walk back unaided to her ward. During the second interview I asked her how she understood it, “I think that (.) I have to put my body in a position whereby I (.1) relax my body, I relax my mind [sounding dreamy]. You know?” She went on to describe incidents where her she had shown a capacity to

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manage problematic situations and relationships more calmly with a consequent reduction in her symptoms.

Angela was unfortunately unable to attend a third session due to the positive event of obtaining employment, so we were unable to explore this connection more fully. However, our telephonic conversation after she had begun working was characterised by a voice that sounded clear, concise and without the slow and monotonous tone that had prevailed in her sessions. She also described a reduction in her somatic symptoms. The opportunity to have explored this with Angela would have been an interesting addendum to my research, but was unfortunately not possible.

One of the benefits of having interviewed two participants, who had previously been patients with somatic symptom disorder, was the opportunity to obtain a longitudinal impression of the evolution of somatic symptomology and understanding following intervention. For Nambitha, whom I had last seen approximately two years before, continued to have the occasional symptoms (chest pain) but she reported that the process of identifying the underlying stress had enabled her to manage, “Like I know now, that when I‟m hurting, why am I hurting and how does it feel to hurt. Let it make me to, it make me to identify [the underlying cause or stress] . . . But what it is that is stressing me is my family.” Joy, who provided the second of my retrospective interviews, was one of the participants who had initially been concerned about cancer underlying her symptoms of pain. However in hindsight she reported that she could now entertain the possibility that her inability to express feelings had been a contributory factor, “I think that the problem that uh, I‟m not open with my feelings, ja. (.2) Even if I‟m angry with something, I (.2) keep it inside, ja.”