WORK IN PROGRESS
ETHICAL PSYCHOTHERAPEUTIC MANAGEMENT OF MEDICALLY UNEXPLAINED SYMPTOMS
With Keith Geraghty, academic chapter
Management of medically unexplained symptoms (MUS) is undergoing a period of change. We see this in the recent breakdown of consensus on mental health management of quintessential medically unexplained conditions (like myalgic encephalomyelitis/chronic fatigue syndrome), and in recent work in bioethics suggesting that the issue of biological versus mental health management of MUS is fundamentally an ethical matter. For these reasons, it’s important to think carefully about ethical aspects of MUS management in psychotherapeutic settings. In Part 1 of this chapter, we show how ambiguity in the term “MUS” leads to routine conflation of diagnostic uncertainty with psychological diagnosis for unexplained symptoms in medical settings. In Part 2, we explore evidence suggesting that substantial harm results from a failure to draw that distinction in medical settings, and we clarify the psychotherapist’s obligations to avoid those harms. In Part 3, we explore the risk for psychological harms when psychotherapists conflate diagnostic uncertainty with psychological diagnosis. Finally, in Part 4 we consider challenges to informed consent in psychotherapy for MUS. We conclude with principles for ethical psychotherapeutic management of MUS.
"WHAT ARE PSYCHOSOMATIC SYMPTOMS, NOW THAT WE'VE REJECTED CARTESIAN DUALISM?"
Psychosomatic symptoms are understood to be very common in medical practice, but it remains unclear what it means to say that symptoms are “psychosomatic” or “functional”. This paper explores that question from a philosophically informed perspective. Based on clarity about property dualism and the difference between brain states and mental states, we can clearly mark three senses in which symptoms are said to be psychosomatic in research and practice: (1) experience of bodily symptoms is primarily caused by psychological distress, (2) experience of bodily symptoms is caused by actual biological pathology that arises room (or is triggered by) psychological distress, (3) experience of bodily symptoms is caused by neurological pathology that may or may not be caused by long-term psychological distress or chronic pain. What we're working with in this area is really not a single idea, but three distinct ways for the mental states to impact bodily health – each demanding a distinct approach to treatment and research. The mind's relation to the body is complex. Success in this area of medicine depends on philosophical clarity.