The Extended Reattribution and Management Model - for treating somatisation - Fink et al, 2004 - Functional disorders, CFS

[Esther12]

Moved from this thread:
Facts and Myths about Chronic Fatigue Syndrome, 2022, Per Fink et al. (Danish Medical Journal article)

This post has been split into 3 parts for easier reading
________________

A bit OT, but I was just looking at this 2004-ish presentation from Fink: https://web.archive.org/web/2007030...h.dk:80/cl_psych/term/TERM-UK/term-dias02.pdf

Someone had pointed out some bits like "Finally, these pts. really can be a right pain and you may need a time-out resulting in an
admission or referral of the pt. This is quite legitimate, but you should always acknowledge that this is the actual reason for admission/referral", and "It is crucial that you resist the temptation to correct the patient, no matter
how crazy the patient sounds."

There was a lot of troubling stuff in there, but also some bits that I thought was better than I expected, and that I agreed with. It was 120 pages long, and these were the quotes I pulled out for my own interest, in case they're of value to anyone else.

"When we have discussed the contents of this course, we have been talking
much about tools. A tool, which is nearly always effective regarding ’heart
sink patients’ is: [picture of hammer]"

"The kind of tools we will be working with for the next 2 days are primarily
”elements in the dialogue”. We are hoping to teach you some magic words
and sentences during this course. In addition to this we will go over some
standard questionnaires used a a diagnostic aid. This will be at the second
evening meeting.

(In the bubble it says in Finnish:
”I sometimes see symptoms like these in people under stress. I wonder if
this could have happened in your case?")"

"The model we will be using is named the TERM-model. It is an extention of The Reattribution Model, developed by
Linda Gask in Manchester. For several years she has educated GPs in this model."

"As to no. 1, the important thing is that the patient feels understood."

"Definition of Somatization and Somatization and
Functional Disorders

Conditions where the patient
experiences or worries about physical
symptoms and attributes them to
somatic disease, but no adequate
organic or pathophysological basis for
the symptoms can be found.
Fink et al 1999"

"In 1989 Kroenke & Mangelsdorff registered the primary reason for the visits
of 1000 patients in a medical out-patients’ clinic in USA.
They found these 10 symptoms to the most frequent (READ ALOUD).
It is noticeable how often (or rarely) the GPs found an organic cause for the
complaints - that is marked with red.
Only in 12-13% of the cases they found an organic or pathophysiological
explanation for the symptoms.
In other words, it is rather the exception than the rule that we find an organic
cause for a physical symptom (repeat if necessary)."

"The difference between facultative somatising patients and genuine somatizing patients is that facultative
somatizing patients accept the correct diagnosis when it is made, whereas it is impossible or difficult to
convince a genuine somatizing patient that s/he doesn’t have a somatic disorder.
A patient with anxiety will say ”yes, it’s good that nothing serious is wrong with my heart doctor, but what
do we do about my anxiety?"

"Peter Salmon and co-workers asked a large group of patients in general practice how they had perceived the
GP’s explanation that nothing organic was wrong.
They found 3 typical experiences.
The great majority felt rejected and felt that the GP didn’t tale them seriously.
Another group felt the GP had, what we have called, a Laissez-faire attitude. The GP let matters take their
own course and let the patient control of dialogue and the treatment.
A lot of patients were actually quite pleased with this, but from a therapeutical point of view it is quite
unfortunate.
As an example they mention a pt. who on the internet has found a description of fibromyalgia. The pt. sees
the GP and asks if that is what she has got. The GP says, that he has had the same thought.
The patient therefore wonders why the GP hasn’t told her earlier, why he kept it a secret.
The GP’s credibility and authority will decrease in the eyes of that patient.
Den rigtige måde at gøre det på, og den måde som vi arbejder på at lære på dette kursus, er såkaldt empowerment eller
kvalificerende forklaring, som vi har oversat det til.
The right way to do this, which is also the way we are working on learning on this course, is called
empowerment or qualified explanation.
The aim is to make the patient feel that the GP’s explanation has helped her to a better understanding of her
illness and symptoms, and feels that she herself can do something to get better, and that she can control her
symptoms to some extent.
I say ”explain” the patient, but as I mentioned before, the pt. sees herself as the expert, and it is therefore
crucial that you negotiate with the patient - expert to expert- so to speak in order to make the pt. accept and
understand a link."

"Especially in somatizing patients we have to accept that the health care
system, and we as physicians, to a great extent contribute to the patients
becoming chronically ill."

"The wording ”to overlook something” is an unfortunate one.
It is better to talk about having made a wrong differential diagnosis, and that
of course is unfortunate, just as much as it is to make a wrong diagnosis
between two somatic disorders.
You can rather say that the diagnosis is delayed, and this probably rarely has
any serious consequences for the pt"

"You may encounter the attitude that the pt. is to blame,- that they are given
the examinations and treatments that they have asked for themselves.
This is caused by the lack of understanding of the character of the
psychiatric disorders.
The problem here is that the pt. cannot be made responsible since the
motives are unconscious and irrational."

continued next post

 

[Esther12]

[Slide]:
"Iatrogenic Factors of Somatic Over-Treatment”

! Insufficient knowledge or skills
! The physician’s definition of his own role
! The physician’s modesty
! Fear of loosing control or of ”opening Pandora’s box”
! Fear of dependence
! Lack of time
! Need for time-out"

"Pre- and postgraduately only very little is taught about the treatment of somatizing pts., which
is why a lot of physicians don’t know how to treat pts. with functional disorders."

"Many physicians have experienced that when you start asking about the pt.’s problems, then
you can hardly stop the pt.
You have, so to speak, opened up ”Pandora’s box”. We also call it the Ketchup effect, you tap
and tap at the buttom of the bottle, and suddenly it all comes out at once.
There are some good methods to stop this in an empathic way, and you will hear more about
that during this course."

"Finally, these pts. really can be a right pain and you may need a time-out resulting in an
admission or referral of the pt. This is quite legitimate, but you should always acknowledge
that this is the actual reason for admission/referral."

[slide]:

"Grouping of Patients Presenting with Functional Symptoms

! Acute and subacute functional symptoms
! Chronic somatizing disorders
- Chronic somatizing (poly-/oligo-symptomatic)
- Syndrome diagnoses (generalized rheumatism,
chronic fatigue syndrome)
! Physical symptoms in other mental disorders
(facultative somatizing) e.g. in anxiety and depression
! Worrying about- and aggravation of illness,
and pathological illness behaviour in somatic
disorder"

"In chronic somatization we also include the so-called syndrome diagnoses like
fibromyalgia and chronic fatique syndrome, as these disorders have more similarities than
differences compared to somatoform disorders."

"However, you should be aware that, especially by chronic disorders, is is
rarely a question of either/or, but rather a question of both/and!
The patients can be damaged because if they have gone through many
examinations, and there are different somatic diseases, where is can be hard
to determine whether the symptoms are caused by somatization or a genuine
somatic disease."

"In this exercise we will deal with the first item of the TERM model: To
make the patient feel understood.
Psychologically it is the most important item in the treatment program - that
the patient feels the physician understands him/her and the problem he/she
presents.
Once you have obtained that you have come pretty far, and I’m inclined to
say that it is a precondition in order to offer a satisfactory treatment.
It may seem banal, but very often this it where it goes wrong when dealing
with patients with functional disorders, and the result is that the patient feels
rejected and dissatisfied.
I’m sure you have all met patients with functional disorders complain about
feeling rejected, overseen or misunderstood by family, colleagues and
physicians.
So once you have succeeded in making the patient feel understood, you are
half-way there!"

"People more readily accept their own explanations rather than those other
people try to put on to them."

"Even if it is difficult, it is therefore important not to give premature advice
or explanations.
The art is, through discrete guidance, to make the patient pick up the clue."

Continued next post

 

[Esther12]

[slide]:

"Empathy and Emotional Feedback
" I can hear that this has been hard on you
" I understand you find it unpleasant
" I can see this is unpleasant"

"Often empathy is confused with acceptance.
It is important to remember that this is not the case.
You don’t have to accept the patient’s actions or explanations - just make it
clear that you have understood how difficult it is for the patient –
irrespective of the cause."

"It is crucial that you resist the temptation to correct the patient, no matter
how crazy the patient sounds.
How things really are is not important, the important thing is how the patient
perceives it.
You have to know the patients’ way of thinking to be able to help the
patients change it."

"Somatising patients often have completely unrealistic expectations of
treatment possibilities and what medical science can do, and this could be
one of the reasons why they keep seeing the physician.
They find it har to accept the limits of medical science (which also goes for
some physicians)."

"Throughout many years a widespread misunderstanding has been to avoid
examination of the somatising patient in order not to give the patient a
”secondary gain”.
Forget all about that!
This phenomenon is only relevant in longterm pshycho-therapy .
Besides, a somatising patient has the same right to a proper examination as
any other patient."

"Patients very easily perceive it as if the physician says nothing is wrong with
them.
It is therefore extremely important to acknowledge that the patient’s
symptoms are real and to make it clear to the patient that you believe they
are suffering and find it difficult."

"Here we will mainly focus on the interview techniques: rope-a-dope and empowerment
You need to discuss the cause of the symptoms with the patient, and there is a great risk
that you will face difficult discussions and futile attempts of persuasion.
Avoid this as the patient will always hold the winning cards.
They are so used to discussions, and there is no point in trying to argue - you rarely get
anywhere.
You can avoid this by rolling with resistance, we call this Rope-a-dope. It is an
expression from boxing that comes from the match between Muhammed Ali and
George Foreman in Zaire.
Muhammed Ali let himself be punched again and again, but cought the punches by
blocking, rolled with resistance, and eventually wore out his opponent without getting
hit himself.
When George Foreman was worn out, Mohammed Ali knocked him out."



"To illustrate how to avoid the discussion of the cause, I find this figure of Simon Wessely
very illustrative.
He works with chronic fatigue syndrome.
We don’t know the actual cause for that, but many patients think it is a virus.
You can explain the patient that we don’t know the fundamental cause for CFS, and that there
is no medical treatment for it.
However, there are other ways to get better, no matter what the cause is.
Many rest when they are tired, because they are afraid of getting worse if they are active.
Due to lack of exercise, the muscles become weaker, and the patient may perceive that as a
sign that s/he has become even more ill, and therefore needs even more rest.
The vicious circle goes around.
Explain the patient that no matter what causes the fatigue, we know that it is important they
remain active to avoid a worsening of the condition.
Be aware, that this a good illustration of the either/or way of thinking failing.
The cause in unimportant because we don’t have any causal treatment, but we can do
other things to make the patient feel better."

 

[Sean]

Avoid this as the patient will always hold the winning cards.

News to me.

 

[Snow Leopard]

I say ”explain” the patient, but as I mentioned before, the pt. sees herself as the expert, and it is therefore crucial that you negotiate with the patient - expert to expert- so to speak in order to make the pt. accept and understand a link."

That isn't going to work with us - experts cite high quality evidence and understand methodological limitations and statistics.

You can rather say that the diagnosis is delayed, and this probably rarely has any serious consequences for the patient

Fk off! You mean months or years of loss of employment, quality of life or death in some cases. "rarely serious" just shows what they really think of such patients.

 

[Peter T]

"Somatising patients often have completely unrealistic expectations of treatment possibilities and what medical science can do, and this could be one of the reasons why they keep seeing the physician. They find it har to accept the limits of medical science (which also goes for some physicians)."

Surely in relation to ME it is Fink that is arguing that we have current effective treatments, whereas many patients and most patient organisations are strongly in favour of the current NICE guidelines position that there is no evidenced treatment for the condition, and that current interventions like GET/CBT are potentially harmful.

Do people like Fink genuinely think they have an evidenced research base for their pontificating, or are they so over confident that they believe whatever they say must be true solely because they say it?

People keep seeing their doctor because they continue to be unwell, however many with ME stop seeing their doctor prematurely because their doctors have harmful false beliefs about their condition. Though we lack hard data, it distinctly possible that more people with ME stop seeing their doctor when they should continue, rather than the reverse claimed by Fink.

[corrected typos]

 

[Sean]

We are hoping to teach you some magic words and sentences during this course.

Yeah, that's what we need. Magic words and sentences.

Conditions where the patient experiences or worries about physical symptoms and attributes them to somatic disease, but no adequate organic or pathophysological basis for the symptoms can be found.
Fink et al 1999"

Because there is no such thing as incomplete understanding or insufficient techniques in biomedical medicine.

It is noticeable how often (or rarely) the GPs found an organic cause for the complaints - that is marked with red. Only in 12-13% of the cases they found an organic or pathophysiological explanation for the symptoms. In other words, it is rather the exception than the rule that we find an organic cause for a physical symptom."

Maybe because GPs are not the final word on accurate diagnosis of poorly understood conditions?

"The difference between facultative somatising patients and genuine somatizing patients is that facultative somatizing patients accept the correct diagnosis when it is made, whereas it is impossible or difficult to convince a genuine somatizing patient that s/he doesn’t have a somatic disorder.

You're in denial.
No, I'm not.
See, I told you so.​

"negotiate with the patient - expert to expert- so to speak in order to make the pt. accept and understand a link."

'The patient is wrong and must be made to accept the subjective reality we allocate to them.'

Because only patients are held captive to their subjectivity, ignorance, fallibility, and character flaws. That never happens to a clinician or researcher, especially in psychosomatics.

This just confirms that the whole 'negotiation' 'expert-to-expert' schtick is just a grubby gutless deceit.

"I’m sure you have all met patients with functional disorders complain about feeling rejected, overseen or misunderstood by family, colleagues and physicians."

That's right, the real problem is that patients are reporting that you are doing a shit job of treating them.

"People more readily accept their own explanations rather than those other people try to put on to them."

They really don't do self-awareness, do they.

 

[rvallee]

They really don't do self-awareness, do they.

Literally never. As in, seriously, I have never seen any display of self-awareness in anything I have read or heard from people working in psychosomatic medicine.

Mostly because any level of self-awareness above zero is like the emperor looking down at his underwear. The only level that can maintain the belief system is exactly and precisely zero.

I wish I were exaggerating here but the entire field is at a Mr Bean or Tobias Funke from Arrested development level, it's a level that is supposed to be comical, but is properly ghoulish in the hands of professionals with the power to coerce people and invent an alternative perception of reality.

 

[Sean]

What is really being described in this document is what happens when medicine fucks it up big time, and how they avoid accountability by blaming the patient for it.

 

[DigitalDrifter]

It is therefore extremely important to acknowledge that the patient’s
symptoms are real and to make it clear to the patient that you believe they
are suffering and find it difficult.

Gaslighting.

Here's one I made earlier:

"We're not saying your symptoms aren't real", Uhm yes you are, I suffer from an adverse reaction to exercise and you're telling me the solution is to exercise.

(Normally used after claiming without evidence that my illness is psychological).

They clearly don't believe in consequential progression.