Carson and his colleagues at Harvard Medical School recently published findings from qualitative interviews in the journal Transcultural Psychiatry highlighting the need for mental health clinicians to explore the meaning of physical symptoms and pain when working with individuals who present with “comorbid” conditions – that is, when they have diagnoses of a mental health condition and physical illness. This is important because comorbid conditions can be “mutually reinforcing” or in other words inextricably linked with each other. Treating them as just information to be gathered to rule out psychiatric diagnoses may be a disservice to treatment planning and may lead to clinicians missing out on “what really matters” to their clients, the researchers concluded.
They describe impetus for this study as follows:
“In mental health intakes, we have previously noted that physical health issues are volunteered by patients with relatively high frequency. How patients make meaning of these issues may therefore be a useful area for mental health clinicians to assess in terms of the impact on mental health and functional impairment. The suffering associated with chronic medical conditions may be highly relevant to patients in mental health treatment, but research is needed to clarify in what ways physical illness matters to patients seeking mental health services and how it is responded to and legitimated by mental health clinicians.”
The researchers analyzed mental health intake conversations between clinicians and clients as well as post-diagnosis sessions that were conducted individually. The individual meetings focused on gathering data related to perceptions about the clients’ presenting concerns and therapeutic rapport. They also asked both clinicians and clients about their understanding of the problems discussed in light of sociocultural factors in the clients’ lives.
From all the conversations that were recorded (n=129), for this analysis, 30 were chosen because those clients endorsed a mental and physical health complaint. The most commonly endorsed physical health problem was chronic pain. Interestingly people like Laurence Kirmayer, who the researchers reference in this paper have written about chronic pain as a metaphor for psychological distress. For example, Kirmayer notes, “The value of pain as a message, as an imperative to withdraw and immobilize the self and also as a social call for care, is strained and tested in the situation of chronic pain.”
The study's results indicate that themes related to physical and mental health were not distinct but rather were related to one another and had an impact on clients’ “sense of agency, or the ability to act in the world.”
This level of analysis highlights that how mental health clinicians respond when clients share their physical health status influences whether or not they get incorporated into the conversation around meaning making of symptoms – that is clinicians differ in their willingness to actively engage in conversations that focus on the meaningful links between physical and mental health. An area of divergence that was observed in clinician versus client understanding of problems was related to etiology or cause of presenting concerns – clients tended to focus more on social consequences like unemployment as causal factors. Also, clients were more concerned about the effects of their problems, especially related to their inability to work rather than the symptoms themselves.
Experience of physical illness
- Existential loss: Clients experienced the effects of physical problems in the areas of health, relationships, and employment. This, in turn, affected their sense of identity and self, especially as the compounding of physical and mental health problems led to feelings of loss of control. In these situations, the usefulness of focusing on empathic listening and client strengths by clinicians was highlighted
- Embodiment: Clients often self-generated metaphors to refer to their bodily experiences. For example, one client said, “I feel like my head’s racing around the racetrack and my body’s broken down in the pit stop,”
Capacity to work
- Engaging with mental health services: For many clients, their decision to seek mental health services was prompted by the experience of their physical problem becoming disruptive of their ability to work, and consequently leading to symptoms of depression.
- Limits on agency: Both clinicians and client identified the constraints physical illness places on their psychosocial health – for example, illness leading to isolation from others in turn leading to depression symptoms. Sometimes structural factors led to a perpetuation of problems, for example in the case of a client finding it difficult to find employment because of a criminal record. Finally, mental health treatment or medications could sometimes interfere with agency or the ability to engage in life tasks like work because of their side effects.
In their discussion, the researchers note that clients often speak of their physical illness, mental health, social functioning and capacity to work as inextricably linked.
“The incapacity to work, in particular, was seen as both a cause and a consequence of poor mental health, making it an important factor to evaluate in the mental health intake.”
They also noted cultural differences in the presentation of physical and mental health symptoms between Latino and White clients. The speculate that this may be because of differing levels of engagement with providers by members of these groups but also because of clinician biases in assessment. This can perpetuate the disparities in healthcare that work against minority clients, and the researchers advocate for sociosomatic formulations of illness as one panacea.
They note that clinicians who may come from cultures of medicine can have competing demands about what to focus on in assessment and may be influenced by inaccurate assumptions about what is important. On the contrary, they conclude “a clinician who elaborates a sociosomatic formulation would inquire about relevant social roles, relationships, and networks, and consider how these might be related to, even productive of, illness within an individual (Kleinman & Becker, 1998). . . . exploring the challenges to identity that result from physical illness may be one way in which patients can feel heard and validated, and become more engaged in their mental health care.”
Carson, N. J., Katz, A. M., & Alegría, M. (2016). How patients and clinicians make meaning of physical suffering in mental health evaluations. Transcultural Psychiatry, 53(5), 595-611. doi:10.1177/1363461516660901 (Abstract)