As I have described in the introduction, patients presenting at hospitals with physical symptoms which are found to have no organic basis, provide a particular kind of challenge to both medical and mental health practitioners, particularly in under- resourced settings.
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diagnosis. On the other hand there is often a covert, even acknowledged, irritation with the “time-wasting” potential of these patients. Inherent in this needless waste of medical expertise is the potentially unnecessary and expensive utilization of diagnostic resources.
From the psychologists‟ perspective, particularly working in a community setting, where lack of understanding of the discipline hampers interaction with patients, the individuals referred with MUS are particularly difficult to engage with. Predominant feelings of resentment and anger at having their physical symptoms negated colours their willingness to engage with psychology or psychiatry. This is problematic in providing appropriate mechanisms of psychological assistance to a population which has the potential to benefit from such interventions.
There are psychometric instruments to assess the possibility of malingering or purposeful presentation of fallacious or factitious symptoms (Larrabee, 2003; Lezak, Howieson, & Loring, 2004; Rogers 1997; Young, 2014). There are innumerable chemical, laboratory and imaging tests (X-rays, scans, ultrasound) to explore organic malfunction. However, for the patient who appears to have no conscious motivation of secondary gain, and who is both objectively and subjectively distressed by physical pain or discomfort, there is no clear pathway to connect symptom and pathogenesis. From the patients‟ perspective the entire process is problematic and fraught with opportunities for misunderstanding and alienation. The social exclusion experienced by individuals living in poverty is disabling, disempowering and humiliating and has a knock on effect both backwards and forwards in contributing to maintaining sub- optimal socio-economic circumstances (L. Smith, 2010). In a country such as South Africa, with its history of racial segregation and gender inequality the situation of healthcare management becomes more complex (Benatar, 2013; Lund, 2015). Black and Coloured women are statistically most likely to be poor, diseased, and suffering from such mental health conditions as depression and anxiety (Bean & Moller, 2002; Coovadia et al., 2009) and posttraumatic stress (Guay et al., 2006; Kaminer & Eagle, 2010; Williams et al., 2007). In my experience working in two separate poor communities, the presentation of female patients with psychosomatic symptoms or MUS is notable. However, very little has been written on this subject and virtually nothing from the perspective of the women themselves and how they understand or
29 experience the process.
Research to explore and capture the experience and emotional distress of low-income women who find their physical symptoms discounted, would appear to be of potential value to all three components of the conundrum: the patient, the medical practitioner and the mental health team.
1.6.2. Goals and research questions
Taking into consideration the points made above, and in the context of the phenomenological underpinning of this research project, my preeminent purpose in conducting this research was to access data which made explicit the feelings and experiences of the female participants through their own words and voices (Carel 2011, 2012; Finlay, 2008; Husserl, 1962, 1970; Merleau-Ponty, 1962). Through these participants I hope to highlight not only their own experiences but also those of many patients within the same demographic who are faced with the diagnosis of MUS and who are then referred to mental health services after having had physical symptoms investigated and negated.
Inherent in the lived experiences of these women, is consideration of the extent to which their socio-economic context contributed or supported their particular presentation to the healthcare system. Contextual issues are increasingly taken into consideration when formulating mental health interventions (Sorsdahl, Stein, & Lund, 2012). This is of particular value in the context of my own research. Historically, psychology and psychological and psychiatric theory is grounded in a Western, first world milieu which may not translate well into understanding patients or populations in less advantaged communities and contexts. The experience of a poor, socially and racially disempowered woman with confusing physical symptoms, living in a third world context, has the potential to be different in many ways from that of a women with similarly puzzling symptoms but with greater choice, access to and understanding of the healthcare system.
In the service of achieving these goals my research question was potentially focused on one particular area:
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two geographically separate hospitals, experience the process of attempting to access medical help for physical symptoms but who were then referred to mental health services.
I obtained contextual data regarding the manner in which the medical staff, who encountered these patients, negotiated the investigation and referral, and how they felt about the presenting symptoms and their failure to be organically validated. While I had hoped to include this in my research, the interviews I conducted with the six doctors (four from Hope Hospital and two from Waterstroom Hospital) have not been included. The volume of data generated by my patient participants excluded this possibility. However my interviews with the doctors provided background to the patient interviews and the contextual relationship between the two. I intend reporting specifically on this data elsewhere.
In attempting to answer these questions and achieve the goals inherent in my research I utilized a qualitative research design, with a phenomenological emphasis. I collected data through the use of semi-structured interviews within a clinical setting. I examined the data through the lens of phenomenology. In this way I hoped to provide and describe data rich with the voices of the participants while containing and contextualizing their stories within a particular socio-economic milieu.