Can metaphors usefully represent underlying CBT principles for Medically Unexplained Symptoms (MUS), and how acceptable are such generic and MUS specific metaphors to patients and practitioners?

‘Medically unexplained symptoms’ (or MUS) is a term used by doctors when patients present with symptoms which may be difficult to understand, where repeated investigations are negative, and which do not have a clear explanation in terms of a demonstrable physical cause. This term includes conditions such as Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME), chronic pelvic pain, fibromyalgia, facial pain and non-cardiac chest pain. Patients who have a diagnosed physical condition can also experience MUS.

MUS are thought to account for a fifth of consultations in general practice, half of new referrals to out-patient clinics, and increase the risk of patients seeking emergency care. There are a few treatments known to be effective in managing patients with MUS (such as cognitive behavioural therapy, CBT), but availability is limited due to lack of appropriately trained practitioners (doctors and psychological therapists), and unacceptability of the label of ‘mental health’ and mental health services to people with MUS.

Prof Sumithapala has completed two studies in Sri Lanka showing that CBT informed by metaphors can be helpful for patients with MUS. A metaphor is an analogy, using one scenario to explain another, and analogies can be used to explain the principles of CBT in a simple way. Metaphors can be quite powerful. For example, the metaphor ‘a rubber ball in the water’ can illustrate how worrying thoughts can keep surfacing and how the person suffering needs to keep suppressing the thought to stop it returning. So, in working with a patient, instead of talking about ‘automatic negative thoughts’ the practitioner can use the metaphor of ‘a rubber ball in the water’ to convey the message. We aim to determine whether metaphors to explain CBT principles and to help patients understand and manage their symptoms are acceptable to practitioners and patients in the UK. We will do this using a series of focus groups with patients and practitioners.