“Does the doctor think I’m Crazy?”: Stories of low-income Cape Town women receiving a diagnosis of somatic symptom disorder and their subsequent referral to psychological services

Cowlin, Avril Moira (2015-12)

Thesis (PhD)--Stellenbosch University, 2015

Thesis

ENGLISH ABSTRACT : Within the health system there is a group of patients who appear destined to remain at the borderline between medicine and mental health. They fail to fit into either discipline with any degree of comfort and so, to some extent, become marginalised by both. The presenting symptoms of these patients fall under the general rubric of “medically unexplained symptoms” (MUS), “medically unexplained physical symptoms” (MUPS), or “somatic symptoms disorder”. The physical manifestation of symptoms which have no known underlying organic cause creates confusion for the medical practitioner. Conversely, patients with apparent medical pathology superficially may appear to lie outside of the ambit and expertise of mental health. The fear and uncertainty which is ubiquitously generated by illness and pain, appears to be complicated and exacerbated in patients with MUS. I attempted to explore the meaning and experience of these conditions “fraught with uncertainty” in the context of twenty female participants and their lives. As poor women of colour in South Africa, a country with a racialised and gender-weighted discriminatory history, these participants represent marginalisation on many fronts: socio-politically, economically, and medically – and who by their presence challenge the status quo of rendering them invisible. This study explored and described the way in which this specific cohort of patients experienced and understood their medical management and subsequent referral to psychology. To this end, over a period of a year, I interviewed two groups of low-income women who presented to the state hospital system at two separate district level hospitals with unexplained physical symptoms. Ultimately, after varying periods of investigation these women were referred to psychological services in the respective hospitals. I adopted a qualitative research approach, with an emphasis on foregrounding of the experiences of the women. I wished to obtain the rich and layered narratives of the women and their sense of identity within hospital and wider context. All the participants I interviewed had been referred to me as a psychologist by the medical officers after no organic aetiology for their symptoms had been evidenced. While qualitative research frequently relies on the semi-structured interview, my research was particular in that it was conducted in circumstances which necessitated the accommodation of both clinical and research components. The aspect of maintaining the dual role became an important component of consideration and negotiation. This requirement impacted on the interview process. In this particular setting a formal clinical interview initiated the research process to accommodate the possibility of participants progressing to therapy. Conclusions: Poor communication and misunderstanding of the role and function of psychology provide impediments to effective use of both medical and mental health services in low-income communities. Where knowledge is facilitated and patient participation encouraged the positive outcomes of referral to psychological services may possibly increase. Collaboration between mental and medical practitioners with patients with medically unexplained symptoms has the potential to alleviate distress and improve respectful and more effective management of these vulnerable and marginalised patients.

AFRIKAANSE OPSOMMING : In die gesondheidstelsel is daar 'n groep pasiënte wat hulleself op die grens tussen gesondheid en geestesgesondheid bevind. Hierdie pasiënte pas nie gemaklik in een van die bogenoemde velde nie en word dan, tot „n mate, deur albei gemarginaliseer. Die simptome van die pasiënte val onder die breë sambreel van “medies onverklaarbare simptome” (MOS), “medies onverklaarbare fisiese simptome” (MOFS) of “somatiese simptoomsteurnis.” Die verskyning van fisiese simptome wat geen bekende, verklaarbare organiese oorsaak het nie, verwar die mediese praktisyn. Daarenteen mag pasiënte met oënskynlike mediese patologie weer voorkom asof hulle buite die kennissfeer van die geestesgesondheidswerker val. In die geval van MOS-pasiënte blyk dit dat die vrees en onsekerheid, wat deur alle siekte en pyn veroorsaak word, erger en meer gekompliseerd is. Hierdie studie het probeer om die betekenis en ervaring van hierdie toestande "belaai met onsekerheid" in die konteks van twintig vroulike deelnemers se lewens te verken. As arm vroue van kleur in Suid-Afrika, 'n land met 'n rasgedrewe en gender-ongelyke diskriminerende geskiedenis, verteenwoordig hierdie deelnemers marginalisasie op verskeie vlakke: sosio-polities, ekonomies en medies. Boonop daag die teenwoordigheid van hierdie vroue ook die status quo uit wat hulle gereeld onsigbaar maak. Hierdie studie ondersoek en beskryf die manier waarop hierdie spesifieke groep pasiënte die bestuur van hulle gesondheid en die daaropvolgende verwysing na sielkundiges ervaar en verstaan het. Oor „n tydperk van „n jaar is daar met twee groepe lae-inkomste vroue wat staatshospitale besoek het, onderhoude gevoer. Die deelnemers aan hierdie studie het twee verskillende distriksvlakhospitale met hul onverklaarbare fisiese simptome besoek. Mettertyd, na verskillende periodes van ondersoek, is hierdie vroue na sielkundige dienste in die onderskeie hospitale verwys. Die navorsing is kwalitatief benader met die klem om die ervaringe van die vroue op die voorgrond te plaas. Daar is gepoog om die ryk en gelaaide narratiewe van die vroue en hulle gevoel van identiteit te bekom. Al die deelnemers met wie daar onderhoude gevoer is, is na die navorser verwys vir sielkundige behandeling nadat mediese personeel geen biologiese etiologie vir hulle simptome kon vind nie. Kwalitatiewe navorsing maak meestal van semi-gestruktureerde onderhoude gebruik, maar in die geval van hierdie navorsing was kliniese en navorsingskomponente van pas. Die handhawing van die dubbele rol as sielkundige en navorser moes goed bestuur word en het die onderhoudvoering beïnvloed. Die navorsingsproses is geïnisieer deur „n formele kliniese onderhoud om die moontlikheid te akkommodeer dat deelnemers aan die studie dalk later ook tot terapie kon oorgaan. Gevolgtrekking: Swak kommunikasie en „n misverstaan/wanbegrip van die rol en funksie van sielkunde verhinder die effektiewe gebruik van mediese-en geestesgesondheidsdienste in lae-inkomste gemeenskappe. Die positiewe uitkomstes wat voortvloei wanneer daar na sielkundige dienste verwys word, kan verhoog as kennis gedeel en pasiënte se deelname aangemoedig word. Samewerking tussen geestesgesondheidswerkers en mediese praktisyns - wanneer daar met MOS-pasiënte gewerk word - het die potensiaal om angs van hierdie kwesbare en gemarginaliseerde pasiënte te verlig en respekvolle en effektiewe bestuur van hulle toestande te verbeter.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/97836
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