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Somatization: From Biomedical to Sociocultural

Posted By Wendy Bradley, Thursday, November 15, 2012

One of the biggest challenges in any health care setting is how to manage somatic symptom disorders. Studies show that one third to one half of all visits to primary care have no identifiable primary cause. These visits cost the US health system over 100 Billion annually due to overuse. Presenting concerns often have components of some sort of pain or a check for some odd symptom.

Often the most frustrating aspect of this condition is the presentation in clinic. These encounters often include:

  • High levels of dissatisfaction and overall distress,
  • Vague and dramatic reporting of medical history,
  • Reactions to psychosocial distress with physical symptoms,
  • Frequent moves from complaining of one symptom to another,
  • Seeking care from multiple providers, failing to keep appointments,
  • Denying psychological influences and referrals to therapy,and
  • Disappointment and frustration when nothing is found.

A fundamental attribution to this dilemma is the overarching perception of what ‘health’ is. "The ‘usual’ medical system and patient expectations have evolved into an ‘evidence based’ system for the physical body where if the right tests are ordered, the right diagnosis made, and the right medications prescribed, health will follow” (Eby, 2011).

Southcentral Foundation logo

As Southcentral Foundation is owned and operated by the Alaska Native people the idea of ‘health’ (mental, emotional, spiritual and physical) is centered on the idea of long- term, trusting, personal relationships.

Through listening to our patients and examining our own behavior we have discovered that we have reinforced the idea that it is the health care team’s responsibility to ‘fix it’. This has become a set up for both providers and patients---as both have difficulty tolerating ambiguity because of this expectation. As long as we make the focus about "physical solutions” to these complex issues we will continue to prescribe new medications, take more tests and make referrals to specialty clinics to find out what is ‘wrong’ with them. We will continue to be frustrated with the patient for not listening to us. As long as we are working harder to ‘fix’ them, we leave no space for them to take responsibility of their own health and begin to learn how to manage the symptom or the distress surrounding the symptom.

As Southcentral Foundation (SCF) is owned and operated by the Alaska Native people the idea of ‘health’ (mental, emotional, spiritual and physical) is centered on the idea of long- term, trusting, personal relationships. This philosophy has created the foundation for how we approach our patients that visit our system the most and have unexplained somatic symptoms. Instead of seeing those patients as a "problem to be solved” we focus on working with that patient to determine the "context” that a condition is occurring in. The focus moves away from trying to figure out the symptom to supporting the patient in learning how to manage the distress the symptom is causing. This approach has resulted in us taking a step back and assessing the entire picture of health

We have been practicing full integration for over 8 years in a level 3 medical home model and it has taken time for this philosophical shift about what ‘health’ is to take place, for both ourselves and our patients. We have learned that managing those patients with somatic symptom disorders cannot fall on the integrated behavioral health consultant alone. Care becomes fractured and teams respond out of frustration and a sense of helplessness. We had to move towards a seamless approach that involved our entire management and clinical staff to use a very different and expanded skill set from the ‘usual’ medical practice.

In response, we designed a process that the main emphasis is on how we communicate and work towards a relationship built on shared responsibility. Teams needed to learn how to effectively manage "dilemmas” (when there is no known medical diagnosis to treat or when what the customer wants what can’t be done safely or is necessary) and move away from trying to "solve the problem”. We provide skills and tools that allow teams to truly engage customer-owners while staying objective. We challenge them to look at what they bring into the exam room that influences outcomes (i.e. countertransference, frustration). We intentionally train and coach teams to listen to and acknowledge the ‘fears’ behind the patient visit and have honest conversations about what is happening. They then use encouragement and questions to support the patient and family to develop a plan on how to manage the condition or distress.

We continually encourage teams to have conversations that encourage health ownership. We found that we needed to spend time discussing expectations. Conversations revolve around who is responsible for what and which parts of ‘health’ the team can support and which part the patient will need to make choices about. It also means having intentional discussions about all factors that impact health and what outcomes are possible. Though the behavioral health consultant is still heavily involved, the entire team practices and reinforces the same approach.

Ultimately, we know that while this approach may not ‘fix’ the dilemma of somatic symptom disorders, we can alter the way ‘usual’ medical care is delivered thus expanding the range of opportunity and options that can influence health outcomes. Through placing our emphasis on the whole person, putting the physical, behavioral, emotional and spiritual back together rather than pulling them apart and our continued engagement in long term, trusting, personal relationships with our patients, we can offer the space for health and wellness to happen.

 

Wendy Bradley LPC is clinical improvement advisor at Southcentral Foundation in Alaska. She developed and provided clinical oversight to behavior health integration in primary care--the program has been successfully established for the past 8 years.

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Comments on this post...

Randall Reitz says...
Posted Wednesday, December 12, 2012
Wendy, a colleague forwarded me SC Foundation's orientation checklist for BHC's. I found it to be a fantastic hands-on document. My only concern would be how to complete the entire checklist with a large BHC staff.

Are you involved with orienting BHC's? If so, does my concern have merit?

Thanks, Randall
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