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Moving on: the BodyMind Approach
TM
for medically unexplained symptoms
Helen Payne and Susan D.M. Brooks
Abstract
Purpose –The purpose of this paper is to summarise a practice-based evidence from an analysis of
outcomes from a county-wide pilot study of a specialised primary care clinic employing an original approach
for patients with medically unexplained symptoms (MUS). Conditions with persistent bodily symptoms for
which tests and scans come back negative are termed MUS. Patients are generic, high health-utilising and for
most there is no effective current treatment pathway. The solution is a proven service based on proof of
concept, cost-effectiveness and market research studies together with practice-based evidence from early
adopters. The research was transferred from a university into a real-world primary care clinical service which
has been delivering in two clinical commissioning groups in a large county in England.
Design/methodology/approach –Clinical data calculated as reliable change from the various clinics were
aggregated as practice-based evidence pre- and post-intervention via standardised measurements on
anxiety, depression, symptom distress, functioning/activity, and wellbeing. It is not a research paper.
Findings –At post-course the following percentages of people report reliable improvement when compared
to pre-course: reductions in symptom distress 63 per cent (39/62), anxiety 42 per cent (13/31) and
depression 35 per cent (11/31); increases in activity levels 58 per cent (18/31) and wellbeing 55 per cent
(17/31) and 70 per cent felt that they had enough help to go forward resulting in the self-management of their
symptoms which decreases the need to visit the GP or hospital.
Research limitations/implications –Without a full clinical trial the outcomes must be interpreted with
caution. There may be a possible Hawthorne or observer effect.
Practical implications –Despite the small numbers who received this intervention, preliminary observations
suggest it might offer a feasible alternative for many patients with MUS who reject, or try and find unsatisfying,
cognitive behaviour therapy.
Social implications –Many patients suffering MUS feel isolated and that they are the only one for whom
their doctor cannot find an organic cause for their condition. The facilitated group has a beneficial effect on
this problem, for example they feel a sense of belonging and sharing of their story.
Originality/value –The BodyMind Approach is an original intervention mirroring the new wave of research in
neuroscience and philosophy which prides embodiment perspectives over solely cognitive ones preferred in
the “talking”therapies. There is a sea change in thinking about processes and models for supporting people
with mental ill-health where the need to include the lived body experience is paramount to transformation.
Keywords Primary care, Embodiment, Practice-based evidence, Medically unexplained symptoms,
The BodyMind Approach
Paper type Research paper
Introduction
Medically unexplained symptoms (MUS) or, more recently, somatic symptom disorder (SSD)
is a long-term condition and global problem with very high health utilisation resulting in large
costs and wastage. The patients account for an estimated 15-30 per cent of primary care
consultations (Kirmayer et al., 2004) and doctors report that these can be among the
most challenging. Other studies in primary care show 19-50 per cent of visits are for MUS (Barsky
and Borus, 1995; Preveler et al.,1997;Reidet al., 2002). Furthermore, MUS account for more than
20 per cent of outpatient activity among frequent attenders (Reid et al., 2001) mainly in neurology,
gastroenterology, rheumatology, cardiology and gynaecology (Hamilton et al., 1996;
Received 23 October 2016
Revised 18 January 2017
Accepted 1 March 2017
Helen Payne is a Professor of
Psychotherapy at the School of
Education, University of
Hertfordshire, Hatfield, UK.
Susan D.M. Brooks is based
at Pathways2Wellbeing,
Hitchin, UK.
DOI 10.1108/JPMH-10-2016-0052 VOL. 16 NO. 2 2017, pp. 1-9, © Emerald Publishing Limited, ISSN 1746-5729
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Kooiman et al., 2000; Nimnuan et al., 2001; Burton, 2003; Jackson et al., 2006). MUS is the fourth
most costly population in the UK primary care and the most costly diagnostic category of outpatients.
In 2008, it costs more than £3.1 billion rising to £18 billion if quality of life, benefits and absence from
work are included (Bermingham et al.,2010).The“American Diagnostic and Statistical Manual of
Mental Disorders 5”(American Psychiatric Association, 2013) introduced a replacement term for
MUS, SSD. The new criteria have been criticised (Mayou, 2014; Rief and Martin, 2014); consequently
this paper sticks with the term MUS.
There is a wide range of symptoms falling into MUS such as fibromyalgia, IBS, chronic fatigue,
chronic pain, numbness, headache, insomnia, skin conditions, respiratory difficulties, etc.
Self-help book authors such as Anderson and Sherman (2013) and Hanscom (2012) recognise
the unconscious aspects of medically unexplained pain. Others acknowledge the effects on
symptoms of childhood trauma and illness in adulthood (Nakazawa, 2015). Some suggest
expressive writing to nurture health and wellbeing (Pennebaker and Smyth, 2016), and unlearning
the nerve pathways causing the pain (Schechter, 2014; Schubinar, 2016).
There is pain relief medication and cognitive behaviour therapy (CBT) which is effective for IBS,
fibromyalgia and chronic fatigue (but not when compared to enhanced care). CBT has been
found to be no more effective than routine care for generic MUS (Sumathipala et al., 2008).
In a later study a group CBT approach (Schröder et al., 2012) was found to be effective with
generic MUS conditions. Less than 10 per cent of sufferers receive antidepressant treatment or
accept psychological therapy leaving the majority having to “learn to live with it”as is often said to
them (Hamilton et al., 1996; Hansen et al., 2001; Fink et al., 2002; Mangwana et al., 2009).
Peabody (1927) was one of the first physicians to comment that patients with MUS prefer to
remain in primary care than to go to a psychiatrist and be seen as a “nervous”(p. 881) case
suffering subsequent stigma.
As a result of this situation, the stigma of psychological therapies, the complexity of the patient
and their explanatory model being physical, there is limited doctor and patient choice.
Consequently, after noticing this large population with generic symptoms without support or hope
for change a spin-out clinic from within a university was founded, based on research studies
conducted at that university (e.g. Fordham and Payne, 2009; Payne et al., 2009; Payne and Stott,
2010; Payne and Brooks, 2016; Payne, 2017). It is a service based on biopsychosocial and recovery
models, designed specifically for people with MUS, some of whom have fearful attachment.
Delivered as a sort of pre-therapy, it starts at where the patient is, i.e., with their bodily distress.
The patient’s relationship with the symptom is worked with by using an embodied approach
integrated from the arts, mindfulness and methods derived from dance movement psychotherapy.
The BodyMind Approach
TM
(TBMA)
Direct neural connections run through the brain stem and spinal cord to the body. Every cell in the
body is linked into the nervous system and so can be sensed and felt in the body (Fogal, 2012).
“When people feel emotional pain, the same areas of the brain get activated as when people feel
physical pain: the anterior insula and the anterior cingulate cortex”(Fogal, 2012, p. 1; see also
Eisenberger et al., 2003).
Symptoms can be seen as feelings (some of which may represent unsatisfied needs) which need
expression and to make sense.
MUS may be the result of a lack of emotional regulation (Gross, 2002) as a way of coping, initially.
The goal of this treatment is to help patients learn more effective ways of coping without having to
resort to chronic MUS, leading to better emotional regulation.
TBMA focuses on the bodily distress using, e.g., distancing techniques from the arts. TBMA
helps to disentangle the unconscious solutions people find unbearable yet which appear to
defend against their conscious awareness of strong unwanted feelings (often emanating
from early childhood) such as non-conscious trauma (Sass, 2000). The symptoms become a
sort of distraction yet at the same time seem to reflect the intensity of the unconscious feelings.
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These feelings, combined with accumulated life stresses (most of which we are aware of) serve to
lay the ground for the symptoms to appear as the last straw. The body expresses in the end.
Some patients make connections between physical and psychological processes and begin to
manage their symptoms, which sometimes disappear.
The MUS Clinic uses an innovative research-informed group work methodology termed TBMA
that works from the dynamic body to the mind, bottom-up. The emphasis is on the process of the
body-mind and thus the interaction between the corporal and inter-corporeal relationships of
the knowing body. The knowledge base for this is recent neuroscience research (Gallese, 2011;
Shore, 2012) integrating body-mind as in complementary pairs (Kelso and Engstrom, 2006),
physical health complementing mental health or “soma–psycho”. It has a focus on the changing
and always embodied the present moment (bodymindfulness) which allows for the experiential
sensation of the symptom to be addressed. TBMA works directly at the site where much of the
distress and damage occurs, the lived body. By helping patients to accept and learn from their
symptom they become empowered to feel less restricted in their lives despite the symptom,
learning to live well with the symptom/s.
Some patients report that they cannot feel their bodies, i.e. body sensations are only
experienced as fatigue or pain for example (Payne, 2015; Payne and Brooks, 2016; Payne,
2017). Experiences such as muscular tension, the quickening of the heartbeat or minimal
breathing in the upper chest become habituated as medical symptoms. Many patients have
overwhelming concerns about their somatic wellbeing, but are frequently unable to connect this
to their current or past situations. TBMA enables patients to be curious, exploring their
symptoms safely leading to meaning-making and sometimes connections with life experience,
e.g., trauma/attachment issues/family illness, etc.
The TBMA model reassures patients that their symptoms are real, diffusing the emotional charge,
and helping patients feel understood and believed. The non-judgmental, non-stigmatising,
non-medical, accepting group culture assists patients in letting go of the tendency to convince
others of the legitimacy of their symptoms.
By addressing the lived body experience whereby emotion, felt-body experience, cognition,
action, and perception are unified, change in self-experience, emotions and behaviour is possible
and resilience promoted.
TBMA integrates embodied practices with mindfulness, and behaviour change strategies to offer
a distinctly flexible and versatile intervention appealing to the whole person, i.e., the cognitive,
physical/kinaesthetic, sensory, social and emotional aspects. Consequently, it can reach a wide
range of patients with differing symptoms in one group. By directing kind attention and
mindfulness to the body and its connection to the self, practices in TBMA meet the basis of the
symptom distress to change the subjective relationship with the symptom/body. The facilitated
group setting promotes social responsiveness (combating isolation), and the group interactive
practices encourage attention towards the bodily mediated emotions of others and their impact
on the self. Action plans, to be embedded over the subsequent six months, are arrived at through
the learning to live well experiences noted by participants in the weekly journals they complete.
In order to replicate this approach it requires specific training of qualified psychotherapists
experienced in adult group work in mental health and adherence to a manual. It cannot be simply
incorporated into any practice.
Practice-based outcomes
The MUS Clinic is committed to a high standard of empirical evaluation, including repeated
assessment and evaluations of outcomes and an understanding of the connections between
processes of change, the unconscious and functional behavioural principles. Outcomes from
clinics delivered so far have been collated as a comparative analysis of pre- to post-course
completion. This is an analysis of data from six commissioned courses framed within the MUS
Clinic. In all, 95 per cent (37/39) of patients completed the 12 ×2 hourly session courses and the
number completing the post-course data collection was 31/39 (80 per cent).
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It is possible that the missing 20 per cent of data are from people who improved less. If so, the
results reported here would appear less favourable. Recovery from MUS is most common in
the first six months so amongst criteria for inclusion stipulated that symptoms had to have been
present for at least six months prior to referral. Hence, these patients should be termed “chronic”
and unlikely to demonstrate improvement without any specialised intervention.
The standardised measurement tools used
■PHQ-9 for depression.
■Generalised Anxiety Disorder (GAD7) for anxiety.
■Measure Your own Medical Outcome Profile2 (MYMOP2) for wellbeing, activity, and symptom
severity.
■Global Assessment of Functioning (GAF) for overall functioning.
The PHQ-9 and GAD7 were included as part of the metrics because anxiety and depression are
frequently co-occurring conditions albeit mostly at mild or moderate levels. This means that
although some patients demonstrate reliable improvement on depression scores and some on
anxiety many do not. Some will demonstrate reliable improvement on one or other but not
necessarily both. Therefore, it makes sense to count reliable change in either depression or
anxiety as reliable improvement for MUS patients.
Reliable change
The calculation for outcomes on the standardised measurement tools refers to “reliable change”in
terms of “reliable improvement”or “reliable deterioration”using guidance on depression and anxiety
from the Increasing Access to Psychological Therapy (IAPT) year 1 audit (Gyani et al., 2013) as cited in
Clark and Oates (2014). This means that a change of six or more points is required in an individual’s
score to qualify on the PHQ-9 and of four or more on the GAD7 (see Table I). This is important because
“reliable change”exceeds the measurement error of the scale used and thus represents “real change”,
i.e., patient improvement/benefit from attending the course. However, it is important to appreciate that
the IAPT data refers to patients whose primary condition is anxiety or depression rather than MUS with
co-occurring anxiety or depression, and hence are probably not the most relevant comparative
measures. However, measurements of symptom distress are probably the most relevant to use in
relation to determining improvement for MUS patients since this is their major concern.
PHQ-9 and GAD7
MYMOP2. MYMOP2 comprises the following:
1. an overall profile consisting of two symptoms chosen by the patient combined with general
wellbeing and levels of activity;
2. a measure of symptom severity;
3. a measure of the symptom’s impact on activity; and
4. a measure of wellbeing.
The change index required for all of the MYMOP2 scores is ⩾1. For all MYMOP2 measures a
lower score indicates improvement.
Table I To show PHQ-9 and GAD7 reliability
Measure Diagnosis Reliable change index
PHQ-9 Depression ⩾6
GAD7 Generalised anxiety disorders ⩾4
Note: N.B. lower scores indicate improvement
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GAF. Reliable change for GAF requires a “20 per cent increase when calculating an individual’s
score (Dugas and Robichaud, 2007, p. 182). Higher scores show improvement on the GAF scale.
The Participant Experience Form (PEF) (post-course). The PEF gathers feedback from patients
immediately post-course on a variety of aspects of course delivery measures on a Likert scale of
0-5. Hence, it does not require demonstration of reliable improvement as in the clinical measures.
There was a 65 per cent (24/37) response rate for the PEF (Table II).
The initial contact, assessment process, group experience/content, facilitator and overall service
were rated as “satisfactory”to “very satisfactory”(i.e. 4s and 5s).
Other highlights:
■88 per cent (21/24) received a resource list at the exit meeting;
■70 per cent (16/23) felt they had enough help to go forward;
■79 per cent (19/24) would use the service again without hesitation; and
■95 per cent (20/21) would recommend the service to friends and family without hesitation.
With reference to Table III, symptoms affecting work/study reduced in impact. There appears to
have been improvement in patients’felt-capacity to cope with any remaining symptoms generally
and in relation to work after the course compared to their view of their capacity to manage their
symptoms at work before the course began.
Participants reported numerous times how much the course had helped them in understanding
their symptoms; the development of coping strategies and how to manage their MUS.
In all, 75 per cent of patients reported their overall experience of the service as satisfactory or very
satisfactory. With reference to reduced risk and prevention of deterioration this was measured by
assessing the symptom distress levels via MYMOP2. Furthermore, 70 per cent of patients felt
they had enough help to go forward.
Reliable outcomes from clinical measures county wide
Pre- to post-course. Table IV shows the pre-course analysis when compared to post-course for
each of the clinical measures.
With reference to Table IV, PHQ-9 depression shows 35 per cent (11/31) of people demonstrating
reliable improvement with regard to depression and GAD7 anxiety shows 42 per cent (13/31)
of people demonstrating reliable improvement with regard to feelings of anxiety. As some patients
show improvement in depression, some in anxiety and some on both scores it is not possible to
Table II To show participants’satisfaction
Overall service 75% (18/24)
Telephone monitoring 75% (18/24)
Venue 83% (19/23)
Facilitator’s listening skills 100% (23/23)
Overall facilitation 88% (21/24)
Course administration 71% (17/24)
Waiting time to intake meeting 79% (19/24)
Type of treatment 74% (17/23)
Overall experience 75% (18/24)
Table III To show the effect of participants’symptoms on coping
Before course After course
Coping well with symptoms 4% (1/24) 52% (12/23)
Coping well at work 14% (3/22) 50% (11/22)
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simply add these scores to arrive at a percentage improvement as this would result in double
counting. Hence, PHQ-9 and GAD7 improvement on either/or combined gives a figure of 65 per cent
(20/31) of people demonstrating reliable improvement on one or other measure.
There are factors to be taken into account when interpreting reliable change in anxiety and
depression. For example, many patients are medicated for depression and/or anxiety.
Consequently, they do not show major changes in scores for depression. Hence, most MUS
patients in primary care tend to fall into mild to moderate categories for depression and anxiety.
Therefore, these tools (PHQ-9 and GAD7) may not be the most appropriate for this population.
Depression and anxiety is not their presenting problem and not what they appear to be most
concerned about which is their symptom/s.
However, smaller improvements in both anxiety and depression combined with reductions in
symptom distress and improved activity are probably sufficient to contribute to a feeling of
general wellbeing and an ability to self-manage.
The MYMOP2 symptoms give a figure of 63 per cent (39/62) of people reporting reduction in their
symptom distress. Reducing symptom distress is likely to result in consequent improvements in
anxiety and depression. This is in turn may reduce symptom distress still further resulting in an
iterative process, and hence a virtuous circle of general improvement and a sense of wellbeing.
This conclusion is further supported by the data from the overall MYMOP2 measure which shows
55 per cent (17/31) of people reporting improvement. Similarly 55 per cent of people report
improvement in their general wellbeing using the MYMOP2 General Wellbeing Tool. MYMOP2
activity levels show 58 per cent (18/31) of people reporting improvement in activity. In other
words, most patients report important improvements in their perception of their illness helping
them to self-manage conditions and consequently cope better in their daily life.
For the GAF measurement, a 20 per cent increase in pre-treatment scores is required for clinical
significance (Dugas and Robichaud, 2007, p. 182). In this case, 35 per cent (11/31) of patients
demonstrated the 20 per cent required to claim that they had undergone clinically significant
improvement post-intervention.
Conclusion
It must be remembered that this is a small-scale pilot with no control cohort, which would have
enabled a comparison between it and the participants undertaking TBMA to see if any
improvement was likely to be due to the TBMA intervention. Furthermore, there may have been a
placebo effect operating.
There may also have been a Hawthorne or observer effect (Roethlisberger and Dickson, 1939),
that is participants change their behaviour due to the increased attention or observation as a
result of being in a pilot group.
Therefore, there needs to be a randomised controlled trial to validate these outcomes.
Notwithstanding these caveats the outcomes suggest that many people do report important
benefits from attending the TBMA programme.
Table IV To show reliable change pre-course to post-course
Reliable improvement Reliable deterioration No reliable change
PHQ-9 depression 35% (11/31) 3% (1/31) 61% (19/31)
GAF general functioning 35% (11/31) 0% (0/31) 65% (20/31)
Overall profile MYMOP2 55% (17/31) 0% (0/31) 45% (14/31)
GAD7 anxiety 42% (13/31) 3% (1/31) 55% (17/31)
MYMOP2 symptom distress 63% (39/62) 8% (5/62) 29% (18/62)
MYMOP2 general wellbeing 55% (17/31) 19% (6/31) 26% (8/31)
MYMOP2 activity 58% (18/31) 23% (7/31) 19% (6/31)
Either PHQ-9 or GAD7 combined 65% (20/31) 3% (1/31) 32% (10/31)
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Implications for practice could include the following:
■the lived body experience as the focus for all practices, i.e., the subjective body is emphasised;
■employing the sensory experience of the symptom helps patients learn more about
themselves, their symptoms and new coping strategies to live well;
■the importance of the facilitated group format for cultivating a sense of belonging, the
motivation for change, peer support, reduction in isolation and making new and long-lasting
friends; and
■providing opportunities for meaning-making through artistic practices.
There is no other specialist treatment pathway in primary care for this generic MUS primary care
population and this paper highlights the need and potential to support these patients effectively.
A 95 per cent completion rate for a 12-session course is a notable demonstration of the value
experienced by participants. The reliable change outcomes are not inconsequential for a group of
people who have experienced extremely debilitating symptoms for at least six months (and many
for years) prior to treatment. A figure of 35 per cent of people reporting a reduction in their levels of
anxiety and 42 per cent reporting reduced depression is quite a large proportion. It seems
possible that reduced symptom distress may lead to a reduction in anxiety and depression,
which in turn fuels further reduction in symptom distress leading to a virtuous circle of
improvement. The consequent feeling of wellbeing appears to assist patients to self-manage.
Additionally, if the figure of 63 per cent of people reporting reduced symptom distress was
translated into fewer doctor visits, a reduction in secondary care referrals and fewer accident and
emergency visits considerable NHS resources would have been saved from this intervention.
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Further reading
Carney, D.R., Cuddy, A.J.C. and Yap, A.J. (2010), “Power posing: brief nonverbal displays affect
neuroendocrine levels and risk tolerance”,Psychological Science, Vol. 21 No. 10, pp. 1363-68, doi: 10.1177/
0956797610383437.
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Dewey, J. (1988), “Creative democracy –the task before US”, in Boydston, J.A. (Ed.), Experience and Nature,
The Later Works, 1925-1953, 1938-1939 (original work published in 1938), Vol. 13, Southern Illinois
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Koch, S.C. and Fuchs, T. (2008), “Embodied arts therapies”,Arts in Psychotherapy, Vol. 38 No. 4,
pp. 276-80, doi: 10.1016/j.aip.2011.08.007.
Payne, H. (2014), “Patient experience: push past symptom mysteries”,The Health Service Journal, Vol. 124
No. 6390, pp. 26-7.
Corresponding author
Helen Payne can be contacted at: h.l.payne@herts.ac.uk
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