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Balabanovic, Janet (2017) Negotiating disconnection : a grounded theory study of therapeutic engagement of patients with "medically unexplained symptoms". Doctoral thesis, London Metropolitan University.
"Medically unexplained symptoms" or "MUS" is a term used to reference a poorly understood phenomenon in which patients experience subjectively compelling and distressing somatic symptoms which are not explained by underlying physical pathology. The literature on MUS is replete with controversy regarding the diagnosis and classification of this problem. A dualistic diagnostic system that seeks to classify disorders as either “physical” or “mental” disenfranchises patients with MUS who are so firmly at the intersection, causing problems that reverberate throughout the system. Effective treatment of MUS has been impeded by a complex array of barriers, including structural problems in the health system, lack of consensus over MUS aetiology, lack of effective therapies, and a shortage of suitably trained therapists. A pluralistic review of the clinical literature highlights that no single, universally accepted, and empirically supported model of MUS currently prevails. Furthermore, issues with patient engagement have been consistently highlighted as a problem. Despite this, few exploratory studies on treatment have been conducted so at present, relatively little is understood about either therapists’ or patients’ experiences of therapy for MUS. This research has used a constructivist grounded theory approach to explore the process of therapeutic engagement based on depth interviews with specialist clinicians who work with the most complex patients with MUS in primary care. Through a process of constant comparison the analysis identified how multiple interacting layers of disconnections (systemic, interpersonal and intra-psychic) impede engagement. The research introduces a new theoretical framework “negotiating disconnection” that conceptualises the process of engagement in terms of a series of stages: “drawing in” (negotiating systemic disconnection), “meeting patients where they’re at” (connecting in the disconnection) and “nudging forward” (cultivating new connections), and illustrates how the different stages of engagement are negotiated by clinicians. The model shows that it is critical for mental health clinicians to engage the medical system and collaborate closely with GPs in order to engage these patients. However, it also points to some of the challenges that may be encountered doing this, reflecting the complexities of organisational and cultural change. At a clinical practitioner level, the model illustrates the importance of adopting a flexible, pluralistic and integrative approach that is person and process-led. The model emphasises the importance of clinicians and doctors, who must both embrace a holistic (biopsychosocial) stance towards MUS and to be sensitively attuned to its complex phenomenology. Implications for service structure, psychological therapy provision, training and future research are discussed, as well as implications for Counselling Psychology.
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