In the community situation very few patients arrive at the door of psychology displaying attitudes of enthusiasm or the outward appearance of positive anticipation. Seldom does the patient reveal an understanding of the process they are about to engage with. In the years I have been working in community based hospitals and clinics, the patients coming to psychology for the first time can invariably be identified in the waiting room by their expressions of bemusement, irresolution, and occasionally downright fear. Even in circumstances when people have been referred as a consequence of being traumatized in some way, or who recognize that the turmoil of their emotional life or that their personal relationships are awry or destructive, these feelings of apprehension are evident. For the patient with somatization this is further complicated by confusion as to how a mental health practitioner can in any way contribute to the resolution of their physical symptoms. Even in the broader context outside of MUS, stigma and ignorance is seen as a limiting factor in individuals accessing mental health services in South Africa (Hugo, Boshoff, Traut, Zungu-Dirwayi, & Stein, 2003).
On the reverse side of the relationship, the patient with MUS in the community setting presents certain, very particular, challenges to the attending psychologist. Attempting to reconcile patient preoccupation with physical complaints and the expected role of providing emotional and psychological support, can tax the sense of professional focus and competence. With a background as a qualified and registered nursing sister with twenty years of clinical experience, my situation is somewhat different. I am fortunate in being able to understand much of the medical terminology and disease etiology which might obfuscate understanding for the non-medically trained psychologist or counsellor. This has provided me with the opportunity to engage in
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dialogue and debate about symptoms in a more informed way. While increasingly the focus in psychology, particularly community psychology, is to diffuse the power differential between practitioner and patient, with regards to this particular patient group, the authority of “knowing” about physical pathology can be a positive attribute and help in the process of exploration and understanding. While being mindful of the potential to wield inappropriate authority from an expert stance, being able to talk the language of the medical practitioner can add weight to the process of cognitive restructuring, understanding and the challenging of dysfunctional thoughts in these particular patients.
For the professional, having an extended knowledge base may be a useful tool in maintaining credibility. Many patients, irrespective of their socio-economic status, are increasingly looking to technology to obtain information and to substantiate or explore diagnoses. No longer are they necessarily the passive recipients of information. Even amongst the women I have seen in my practice and during my research, who frequently had limited education and were unemployed or never employed, several had used the Internet and/or smart phones to access information to check their perceived conditions. A few used the digital photographic facility on their phones to take pictures of transient symptoms to show the doctors at their next visit in an attempt to validate their concerns. In my interaction with these patients, my ability to be able to talk the language of medicine helped them to negotiate the transition from one discipline to the other. It also gave me, perhaps a spurious, aura of authority which enabled them to accept my corroboration of the doctors‟ diagnosis. Be that as it may, attempting to assist an individual to move from a conviction that their physical symptom augurs a serious disease or disability is not easy. It is one that needs to be executed with enormous sensitivity and an understanding of the real distress associated with the physical condition. This transition is not always possible to facilitate, which is upsetting for both patient and the practitioner.
However, depending on individual circumstances these patients can also respond very positively to therapy. Once the initial hurdles of trepidation and confusion have been overcome, frequently the response is one of enthusiastic engagement. Sigmund Freud‟s term “The talking cure” if often aptly enacted. At times it has almost seemed magical to observe the palliation and resolution which follows disclosure of
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previously unvoiced experiences. In the most graphic demonstration of the power and value of words, a patient who had been sent to me for idiopathic aphonia, told me (in strained whispers) that her husband continually told her to “hou jou bek” (“be quiet”). She had. Literally. As she attended the subsequent sessions, with increasing interest in the process and ability to describe her home dynamic, her voice returned. By the third session she was speaking completely normally. However, despite this dramatic improvement and her increasingly positive attitude towards therapy, this patient was obdurate in her refusal to accept an association between the physical loss of her voice with her husband‟s aggression and his need to silence her. There was a profound need to attribute the loss of her voice to a physical event and causation. She had, a week prior to the development of her symptoms, become drenched in an unexpected downpour of rain while away from home. It certainly was not beyond the realms of possibility that this event was a precipitating factor. However, the reality that months later she had not regained the use of her voice – despite multiple medical interventions – and that it did return shortly after initiating a psychological therapeutic process did nothing to change her mind. Perhaps it is of no real importance in the bigger scheme of things. On presentation she was one of my most hostile and resentful patients. Two years later she continues to attend on a monthly basis – more frequent attendance is impossible because of her dire financial circumstances. She does so “just to talk”. Her home situation and economic status remains suboptimal to say the least, but her symptoms have never resurged. Despite her initial hostility she was able to express her experience of the therapeutic process positively, “I left this room the first time feeling like I was a bird that had been let out of a cage. Just because I could talk to someone.”