COMMENTARY. Medical Family Therapy with Somaticizing Patients: The Co-Creation of Therapeutic Stories (original) (raw)

Medical family therapy is a systems approach to psychotherapy with patients and families experiencing a medical illness, trauma, or disability (McDaniel, Hepworth, & Doherty, 1992). This approach assumes that no biomedical event occurs without psychosocial repercussions, and that no psychosocial event occurs without some biological feature. Nowhere is this more evident than in the treatment of somatizing patients and their families. These patients, who carry one of the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses of Somatoform Disorder, are people with difficult life situations who present not with anxiety, depression, or relationship problems but with numerous physical symptoms. Some of these patients have a medical illness; for others no disease process can be identified. In either case, they are somatically fixated (Van Eijk et al., 1983). The language they use to construct their problems, their solutions, their identities, their relationships, and their lives is a language of the body. Rather than using emotional language to express emotional distress, they use somatic language to describe all difficulties, whether physical or emotional. These patients typically experience multiple power struggles with helping professionalsboth physicians and psychotherapistswho insist they use emotional language to express their distress. Here is an example of the kind of exchange common with these patients: Mrs. Thomas: I can barely get out of bed in the morning. My back aches. My head is throbbing. And I can't eat because my throat is closed up. I finally get going to do the chores to keep the farm running. Then I fall back into bed exhausted by lunchtime. I wonder if I have a tumor, my head hurts so badly. Is this possible? Therapist: I understand that you are exhausted and very uncomfortable today, Mrs. Thomas. I know your physician does not currently believe you have a tumor, but you should discuss any new symptoms with her. She mentioned to me that your husband works very hard every day and expects you to do the same. Can you tell me some more about your marriage? Mrs. Thomas: Of course we both work hard. What does my back pain have to do with my husband? Leave him out of this! Farming is extremely difficult work, day after day, and someone has to keep it going. I had to be hospitalized a year ago because my back was killing me. I had surgery on a disc in my back. It's never really been right since. I haven't been able to work like I did before, so naturally my husband gets frustrated. Do you think that new medicine that's in the paper today might help me? 1 In this complex situation, the therapist was pushing an agenda and a language that was vastly different than that of the patient. No matter how accurate the hypothesis that marital problems might be intensifying the stress and pain for this patient, the timing and manner in which it was communicated resulted in little information for the therapist, further somatization by the patient, and threatened polarization of the positions of both patient and therapist. The art of medical family therapy with somatizing patients and families involves collaborative negotiation and co-creation of therapeutic stories that are mutually acceptable to the patient, the family, the therapist, and the medical director.