Therapists often believe that psychosocial factors play a causal role in the etiology of psychosomatic syndromes, such as psoriasis, stomach ulcers, fibromyalgia, chronic fatigue, bowel syndrome or migraines. But for decades, all attempts at confirming such causation seem to have failed. It is possible to explain this disappointment using functional dysphonia as an example.

Functional dysphonia (FD) is characterized by hoarseness and/or reduced voice strength and/or disturbing laryngeal sensations, occurring in the absence of a structural or a neurobiological abnormality. In the search for psychosocial causes of FD, hundreds of results have been found—many with positive findings concerning psychosocial differences between patients with FD and controls without dysphonia. These results are largely formulated as characteristics of personality or psychopathology. But knowledge of isolated psychological adjectives that describe a person at a certain point in time is hardly sufficient for understanding a patient’s life situation. The complex of problems that truly bring distress to the patient only becomes comprehensible when recognized in the context of the time frames of his or her development (Fig. 1.).

Fig. 1 Psychodiagnostic at different points in time
– attachment styles = e. g. «secure», «ambivalent» or «anxious-avoidant»
– personality traits = e.g. «extraversion» or «openness to experiences»
– coping strategies = e.g. «appraisal-focused» or emetion-focused
– psychopathology = e.g. «depression» or «obsessive disorder»
– conflict in family/job = e.g. «overprotection» or «mobbing»

The history lines through the time frames (e.g., at t¹ = 3 years, t² = 16 years, t³ = present) allow the meanings of the characteristics in the individual frames to be understood. But this subjective, idiographic approach has rarely been accepted as a means for reaching valuable conclusions, so most experts assert to this very day: “the etiology of FD is still unclear,” or “the pathogenic mechanisms are still far from being understood.” Why is this?

The answer is to be found in the contemporary dominance of Evidence Based Medicine. EBM is based on calculability—that is, on the processing of quantitative data. It is, however, unable to process qualitative, idiographic data. Therefore, EBM judges the findings of studies that provide soft and subjective data to be “of little or no evidence,” and thus to be untrustworthy. For instance, in their review of the effects of FD therapies, Ruotsalainen and his team searched seven databases and found 5,937 papers on the treatment of FD. But after the elimination of EBM-incompatible studies only seven papers remained for their meta-analysis. So thousands of partially valued studies were declared to provide “minimal evidence” and became ignored.

This is one reason for which physicians—in addition to other health experts, such as speech, physical, and occupational therapists or social workers—hesitate to use systematically psychosomatic insights in their daily work. They fall victim to the belief that the psychosocial background that they often experience as causal to their patient’s suffering cannot be verified and has to be distrusted.

A second reason for the therapist’s hesitation is the fact that, in such cases where they might fully accept the meaning of the psychosocial background they would have to refer their patients to a psychotherapist. They think that they—as responsible professionals—should, themselves, never try to apply techniques similar to psychotherapy, as these are reserved for fully trained psychotherapists. This is, however, not cogent. Of course, patients with major psychopathological problems must be allocated to a psychotherapist or a psychiatrist. But most patients with psychosomatic syndromes are afflicted with only minor psychopathological problems. Moreover, all therapists always use interventions similar to psychotherapeutic approaches. They use mindful listening, they praise or inquire critically, they reflect feelings and they reinterpret thoughts. They cannot and do not want to prevent this. In the manner of the famous quote by Paul Watzlawick, we must say: “It is not possible to act therapeutically without acting psychotherapeutically.” For good or ill, it must be added. Thus, it is in fact better when therapists enlarge and deepen their psychosocial understanding and skills than it is to pretend that they never influence the feelings, thoughts or behavior of their patients.

Nonetheless, a strict requirement for therapists adopting a psychosocial focus in their work is regular participation in supervision guided by a psychotherapist.

Jürg Kollbrunner
Division of Phoniatrics, Department of Otorhinolaryngology, Head Neck Surgery
University of Bern, Switzerland
 

Publication

Encouragement to Increase the Use of Psychosocial Skills in the Diagnosis and Therapy of Patients With Functional Dysphonia.
Kollbrunner J, Seifert E.
J Voice. 2016 Jan 5

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