How Patients and Clinicians Make Meaning of Physical Suffering in Mental Health Evaluations

Abstract

Clinicians in community mental health settings frequently evaluate individuals suffering from physical health problems. How patients make meaning of such “comorbidity” can affect mental health in ways that may be influenced by cultural expectations and by the responses of clinicians, with implications for delivering culturally sensitive care. A sample of 30 adult mental health intakes exemplifying physical illness assessment was identified from a larger study of patient-provider communication. The recordings of patient-provider interactions were coded using an information checklist containing twenty-one physical illness items. Intakes were analyzed for themes of meaning making by patients and responses by clinicians. Post-diagnostic interviews with these patients and clinicians were analyzed in similar fashion. Clinicians facilitated disclosures of physical suffering to varying degrees and formulated them in the context of the culture of mental health services. Patients discussed their perceptions of what was at stake in their experience of physical illness: existential loss, embodiment, and limits on the capacity to work and on their sense of agency. The experiences of physical illness, mental health difficulties, and social stressors were described as mutually reinforcing. In mental health intakes, patients attributed meaning to the negative effects of physical health problems in relation to mental health functioning and social stressors. Decreased capacity to work was a particularly salient concern. The complexity of these patient-provider interactions may best be captured by a sociosomatic formulation that addresses the meaning of physical and mental illness in relation to social stressors.

Introduction

Co-morbid physical and mental illnesses are common among patients treated in safety-net mental health settings, which serve disadvantaged patients who are often uninsured or have public insurance (Dickey, Normand, Weiss, Drake, & Azeni, 2002; Gaston, 1997; Hall, 2010; Jones et al., 2004). The burden of physical illness predicts a greater likelihood of both psychiatric disorder and significant functional impairment (Kroenke et al., 1994). There is robust national U.S. data suggesting mental and physical illness have additive, and modestly synergistic, effects on disability (Scott et al., 2009). The burden of co-morbidity is particularly damaging to social functioning (Mauksch et al., 2001) and increases visits to primary care and specialist services (Watson, Baird, Hosel, & Peveler, 2009).

With such overlap, mental health clinicians must understand how to address psychological and social suffering in the context of physical illness. In mental health intakes, we have previously noted that physical health issues are volunteered by patients with relatively high frequency (Carson, Katz, Gao, & Alegria, 2010). How patients make meaning of these issues may therefore be a useful area for mental health clinicians to assess in terms of the impact on mental health and functional impairment. The suffering associated with chronic medical conditions may be highly relevant to patients in mental health treatment, but research is needed to clarify in what ways physical illness matters to patients seeking mental health services and how it is responded to and legitimated by mental health clinicians. Any consideration of physical suffering by clinicians must contend with the other priorities of intake providers described in our prior research (Alegria et al., 2008), including clarifying the presenting complaint and relevant symptoms, formulating a diagnosis and treatment plan, developing trust and rapport, and completing electronic billing, documentation and collateral communication.

Kirmayer (2008) has written of the “cultural malleability” of physical symptoms, noting that “the translation of physiological processes into sensory experience and their subsequent verbal report is deeply embedded in cultural systems of meaning” (p. 319). A report of physical illness in a psychiatric intake provides important information about the patient’s embodied experience, as a clue to how socio-cultural factors shape the patient’s illness experience. The implication for equitable mental health services is that presentations of physical illness in mental health intakes may represent suffering that is not just physical but social, and thus benefits from a “sociosomatic” formulation accounting for the relationships between body, mind, and social context (N. Ware & Kleinman, 1992). Qualitative methods are well-suited to this kind of inquiry into symptom meaning because they can identify key, revelatory moments in patients’ language and interactions in which meaning is co-created with clinicians (Katz & Shotter, 1996).

In this paper we aim to identify common themes related to the meaning of physical symptoms for patients in the transcripts of intakes and post-diagnostic interviews with mental health patients and providers. We analyze these themes in the context of listening to and privileging “what is at stake” for patients who endure physical, mental, and social suffering (Katz & Alegria, 2009; Kleinman, 2006). This may be useful for clinicians to assess because the meanings that patients make of physical illness affect their success in crucial social roles, such as how and when patients return to work after periods of injury or disability (Coutu, Baril, Durand, Côté, & Cadieux, 2011; Coutu et al., 2010). We used qualitative methods to investigate how patients discuss physical health problems during initial mental health intakes, how these issues are responded to and understood by clinicians, and what attributions patients give to these illnesses. We here discuss the implications of these attributions for mental health assessment in safety-net health care settings.

Methods

Sample

Qualitative data come from the Patient Provider Encounter Study (PPES), conducted in the greater Boston area of Massachusetts, whose methods have been described in prior publications (Alegria et al., 2008; Carson et al., 2010). Here we report on physical illness discussions from the video recordings of a series of mental health intake sessions and audio-recorded post-diagnostic research interviews. The study was described to patients as an effort to improve the quality of the initial meeting with providers. Research staff recruited patients upon presentation to the intake meeting. Patients were not included if there was acute suicidality, psychosis, or need for interpreter services. Capacity to consent was evaluated in all potential participants (Zayas, Cabassa, & Perez, 2005) and institutional review board approval was obtained at each clinic before data collection.

Patients were often recruited from safety-net clinics serving mainly uninsured or publicly insured individuals (Gaston, 1997; Hall, 2010). Patients had often been referred by their primary care clinicians in the same health system, who could read the evaluations in the shared electronic medical record. The intakes were usually 60 minutes duration and aimed to establish a working diagnosis, formulation, and treatment plan. We did not collect data on subsequent treatment and cannot determine whether patients continued in treatment with their intake clinician, although reference was often made to follow-up visits in the recorded interviews.

Both patients and clinicians reported socio-demographic information. Patients also provided information on perceived physical health (using the summary score from the 12-item Short-Form Health Survey measure, SF-12) (J. Ware, Kosinski, & Keller, 1996) and clinicians reported their discipline and years of experience. Sociodemographic information on the full sample of 129 patients is available in a prior publication (Alegria et al., 2008).

Procedures

Clinicians participated up to five times (with different patients) to increase sample diversity and were encouraged to interview as they normally would. Research assistants were not present during intake recordings. After the intakes, patients and clinicians each completed research measures and separate, semi-structured, post-diagnostic interviews in English or Spanish with research assistants. These interviews, each approximately thirty minutes long, assessed perceptions of the presenting complaint and therapeutic rapport. Patients were further asked about the influence of sociocultural factors on their mental health concerns and help-seeking behaviors. Clinicians were also asked about how sociocultural factors may have affected the patient’s chief complaint and the treatment plan. A senior consultant in qualitative research (second author) provided interview training and supervision to research assistants.

Coding of Interviews.

To code intake videos, a team of eight study clinicians developed an “information checklist” to assess DSM-IV criteria for axis I disorders, psychosocial variables, and 21 common physical illnesses (Table 1) derived from the National Latino and Asian American Study interview (Alegría et al., 2004). Checklist data were available for 120 intake sessions due to poor video quality (eight intakes) and the lack of assessment (one intake). Overall agreement among checklist coders was 86%–87% for the last video coded and agreement for items discussed by patients and clinicians was 66%–73%.

Table 1.

List of physical illnesses from information checklist

1. Arthritis

2. Asthma

3. Cancer

4. Chronic physical pain

5. Diabetes

6. Epilepsy or seizures

7. General problems with physical health

8. Heart attack

9. Heart disease

10. Height/growth

11. Hepatitis C

12. High blood pressure

13. HIV infection or AIDS

14. Injury

15. Other chronic lung disease

16. Physical illness

17. Seasonal allergies or hay fever

18. Severe headaches

19. Stroke

20. Tuberculosis

21. Ulcer

Selection of Sample for Qualitative Analysis.

In the present study, the authors identified 30 intakes out of the total 129 that exemplified physical illness assessment. These were analyzed for how patients made meaning of their physical problems in social context both during intakes and in separate “post-diagnostic” interviews immediately following the intakes. To ensure a sample with significant physical complaints, we selected patients that endorsed at least three physical illnesses on the Information Checklist as well as problems due to physical health at least “most of the time” on the SF-12 (J. Ware et al., 1996). We used these selection criteria because the total number of medical diagnoses is often used as a measure of co-morbidity (Chwastiak et al., 2006; Jones et al., 2004). The psychosomatics literature suggests that the endorsement of at least three physical symptoms (which admittedly may indicate the presence of one or more physical illnesses) is correlated with depressive, anxiety, and substance use disorders, as well as service use and psychological distress (Escobar et al., 2010). We included all Black patients with Axis III diagnoses due to low sample size and to ensure a culturally diverse sample.

Qualitative Analysis.

The first author transcribed any discussions of physical illness in the intake and post-diagnostic interviews of patients and clinicians that were selected for qualitative analysis. This close reading allowed for a thorough understanding of the data prior to formal coding. An initial group of intake and post-diagnostic transcripts from 15 participants was then read and coded independently by the first and second authors, and compared for divergent and convergent themes (Braun & Clarke, 2006). Close reading of these transcripts revealed categories and themes related to physical illness meanings, formalized in an NVivo 7 codebook (Ryan & Bernard, 2003). The authors had regular meetings to discuss the literature reviewed in the above introduction, and this process informed the identification of semantic and latent codes. Agreement between qualitative coders was ensured by systematic comparison of our separate codings, noting recurring themes, and using disagreements to revise the codebook. This iterative process moved the analysis towards saturation of common themes and elaboration and refinement of new codes. Transcripts from the remaining participants were coded using this codebook. The post-diagnostic interviews presented additional resources to triangulate understandings of how clinicians and patients integrated physical problems into their organization and their experience of the intake, respectively. The naturalistic methods used in this study did not directly assess how patients experience the impact of physical illness on their lives, and thus thematic analysis of related content in intakes and post-diagnostic interviews was used as the closest, though indirect, approximation of such meanings.

Results

Using the approach described above, we obtained a sample of 30 patients, yielding equal numbers of women and men. Thirteen were White (of 50 total White patients), nine were Black (all Black patients were included), and eight were Latino (of 64 total Latino patients). These proportions broadly reflect trends in the overall sample, where White patients endorsed a higher average number of physical problems than Latinos (1.9 versus 1.5). The most common Axis I diagnoses were depression, anxiety, and substance use disorders. The most common physical health conditions listed on Axis III included chronic pain (11 diagnoses), hepatitis C (7), hypertension (5), sleep apnea (4), asthma (3), headaches (4), and injury (3). Clinicians were social workers in 11 cases, psychiatrists in ten, psychologists in five, and nurse practitioners in four.

Qualitative analyses of data gathered from this culturally diverse sample suggest that patients speak of their experience of physical illness in terms of what is at stake for them in their lives. We noted themes of existential loss and embodiment of a fragmentation affecting their lives due to illness. Patients were often concerned about losing their capacity to work, which affected their engagement in mental health services and imposed limits on their sense of agency, or the ability to act in the world. These themes are not meant to be read as distinct; rather, issues of physical illness were seen as interacting with mental health and social agency. We first examine clinician responses to the articulated experience of patients against the background of the clinicians’ culture of medicine. This serves as an important context for understanding how complex inter-relationships of physical and mental suffering are offered and elicited.

Clinician-patient interaction

As patients told complex stories of co-morbid illness and loss of the capacity to work, clinicians responded in ways that either foreclosed or allowed elaboration of patient suffering. These interactions demonstrate how patient expression and meaning making are influenced by the clinician’s willingness to engage. One example involved an African American man with substance abuse, depression, diabetes, hepatitis C, and extensive chronic pain who noted, “normally, I worked all my life, so it gets to the point where I can’t stand up on my feet all day so I can’t work.” He later reported, “I have so many things going on I didn’t even report the back pain.” The patient then described difficulties having his primary care provider address his pain control. The mental health clinician seemed to foreclose this discussion of pain by transitioning abruptly to another topic with the question, “Any allergies?” The clinician’s approach may be efficient, but may come at the cost of missing the extent of the patient’s pain, and its meaningful impact on the patient’s functioning.

In a second case where work was discussed, we noted the contrast between the patient’s experience of physical illness and social dysfunction and what was at stake for the clinician against the background of biomedical culture. At the outset of this Spanish-language interview, a Latina patient described the logic of her suffering,

“I am not good for anything. I can’t work because I have a problem in my back and my knee. I don’t really know what I am good for.”

When the clinician asked to what the patient attributed her depression, she said, “especially the problem of not being able to work…, like when I started to cry without knowing why, I was still working. I wasn’t working like I was before because I had to switch jobs and change hours because of the problem of back pain and the knee and of this arm.” She described a progression of chronic pain that interfered with her ability to work, leading to a cascade of downstream economic consequences, depression, and anxiety.

The post-diagnostic interview with this Latina patient’s clinician illustrates the tensions that clinicians encounter when assessing the meaning of physical illness for patients during intakes. In contrast to the patient’s direct complaint of suffering and work troubles, the clinician first identified the patient’s reason for coming in as “sort of vague…, symptoms of depression and anxiety, co-morbidly.” The shift in focus from strict diagnosis to broader issues of meaning occured secondarily, as the clinician formulates the case:

“what it meant for her to have this pain, how disabling it has been to her… Even at home she can’t work, she can’t go and relate to other people…. So she can’t support herself. And so, like little by little, she feels that this point, this chronic pain has limited her life and right now she feels that it has completely interrupted and she feels worthless.”

This constellation of presenting symptoms presented a challenge to the clinician, described as follows: “maybe she wants to tell me a little bit about the social implications of her disease. And I had to make sure that she was meeting criteria for depression.” This quote exemplifies the conflict clinicians may experience between needing to provide a required DSM-IV diagnosis and gauging relevant social suffering. The clinician eventually formulated the patient’s presentation as, “if she can’t work because she has pain, then there’s nothing she can do, so she feels like she has no worth.” The clinician pointed to a dilemma in formulating a causal relationship between physical and psychological symptoms: “I wonder if the pain is due to the depression… or if it’s a cause of the depression. Like what comes first, because it’s different, you know? Like you have to treat the pain, but in a different sort of way.” In clarification, she said, “knowing that there is some lumbar disc degeneration and that she’s been trying to do something about it… tells me a lot about how I’m going to be able to help her…, how depression’s secondary to the illness, and not the other way around.” The clinician ultimately chose a diagnosis of Major Depressive Disorder with “a rule out of Mood Disorder Secondary to Medical Condition.” This clinician’s thought process exemplifies how physical suffering is weighed against other priorities of the intake, such as establishing a diagnosis with a causal explanation. The social consequences (unemployment) seemed to hold less etiological priority for the clinician, which may have had consequences for continued engagement and later treatment of both depression and chronic pain.

Experience of Physical Illness

Existential Loss.

During mental health intakes, patients framed their experience of physical illness as profound loss across domains of health, relationships, and employment. A White patient described how his long treatment for cancer coincided with the loss of a relationship and a steep decline in his mood. He noted,

“I just felt so kind of ripped off by the whole situation…. I just have such a sense of unfairness about the way this has all played out and, you know, it was, it could have been done so differently, with the right sort of understanding.”

In the post-diagnostic interview, this patient’s clinician noted his “existential angst…, like, not being sure where he’s going.” She linked these existential struggles to chronic depression, loss of a romantic partner, substance abuse, and his cancer. The patient, in his post-diagnostic interview, echoes his clinician’s formulation, saying “I think it just all kind of played in together to create a lot of upheaval for me…. [I’m] trying to get a handle on a lot of stuff and get back to like smooth sailing again.” This patient’s physical illness is seen as having unfairly disrupted most aspects of his life, leaving him feeling buffeted by forces beyond his control and struggling to gain mastery and direction in his life once again.

Others described the effect of physical illness as a loss of self-hood, where their identity as individuals felt subsumed by the sum of the demands of their physical illnesses. A non-Latino White man with a recent severe physical trauma, diabetes, alcohol dependence, and depression noted to his clinician during his intake,

“with all the other meds I take, it seems to be increasing, you know. I feel like it’s running me… the meds, you know, like I’m in pain constantly, especially if I don’t take the meds, and if I’m drinking or something I don’t touch the meds, any of them, pain meds or anything like that, I won’t touch them. I’m kinda worried about it. So I just substitute, instead of taking the meds I’ll just drink, you know? That works.”

Still in the initial interview, the clinician responded, “Well, to a certain extent, doesn’t it,” showing empathy for the patient’s rationale for drinking instead of taking his prescribed medications. The clinician then asked, “So, you’ve been sober for a while. How’s that going?” and supported the patient’s plan to find more appropriate rehabilitation facilities. In the post-diagnostic interview, this patient elaborated on his loss of control related to physical problems, noting “it always seems like I’m rebuilding and have a lot of health problems that just keep popping up and I’m taking all kinds of meds. It’s like I’ve got no control anymore…. It’s like I don’t care.” The above two patients perceived a similar sense of loss of control in the face of mounting physical and mental health problems. In both cases, the clinicians responded to existential hopelessness with a focus on empathy and strength-building.

Embodiment.

Patients often used metaphors of fragmentation or imbalance in reference to their bodies. The above patient evoked a sense of “upheaval” in his life. A non-Latino White patient with hepatitis C related to her clinician, “My liver was really damaged from all the pills that I took and all the drinking I did, all the overdoses. I start falling apart; I’m trying to pick myself back up.” Another White patient summed up his experience of physical and mental illness as, “I feel like my head’s racing around the racetrack and my body’s broken down in the pit stop,” evoking a metaphor of bodily disintegration. He noted, “I’m coming down here trying to get back on track, get my head together, get my health together.” These metaphors draw parallels between bodily integrity and good health, while poor health is reflected in bodies that have lost an essential integrity (Kirmayer, 2008).

Capacity to Work

Engaging with Mental Health Services.

The impact of physical illness on the capacity to function, specifically to work, was prominent in patient decisions about engaging mental health services. An African American patient with sleep problems and a history of depression noted, “I had to stop driving because I had terrible sleep apnea. I was running off the road during the day, I couldn’t get deliveries on time, so I had to quit driving, period.” In the post-diagnostic interview, he noted,

“I used to drive trucks [across the] 48 states when I developed sleep apnea and high blood pressure and increased hypertension, which constituted for me to be fired from a trucking company because of my high blood pressure. So that was the reason, one of the major reasons I pursued to find out more about my health.”

He rated this problem a “ten plus” in terms of severity, noting, “I was getting very in a deep depression. I couldn’t function in the aspect of life.” Thus for this African American patient, chronic physical health problems are a reason for both his unemployment and current depression. In another example, a Latino man with dizziness and memory problems noted, “I’ve been having a problem at work, you know, being [at] the wrong place at the wrong time. So, therefore, my supervisor asked me if I could, you know, see professional help.” In both of these cases, physical problems that were impinging on the capacity to work preceded the presentation for mental health services.

Synergy of mental and physical suffering.

Certain cases illustrated a mutual reinforcement of co-morbid physical and mental illness with detrimental effects on the capacity to work. A non-Latino White woman with gastrointestinal inflammation noted,

“I went on disability two years for the depression. I just wasn’t able to function. I developed colitis at the same time. I developed severe anxiety about being able to leave the house because I have problems with incontinence …. I wanted to find… a work-at-home job… so that I could get off of disability ultimately, and still be able to function and hold down a job without having to worry about that issue, but I just went through a whole bunch of stressors at one time. I was having difficulties at work, there were several people being harassed at work, which I was one, and it just, kinda drove me over the edge.”

This patient’s physical, mental, and work difficulties were not discrete events; they were presented as interacting and potentiating each other.

Limits on agency.

A Spanish-language interview with a Latina woman with depression, injury, and chronic pain demonstrated how the loss of agency may be a concern in mental health intakes where physical suffering is prominent. She noted (in translation),

“Anything I start doing, I have to stop because before I used to clean the house, I moved the furniture here and there. Now, I can’t. I feel like as if I were an invalid because I get the pain quickly and I have to stop doing whatever I’m doing.”

In the post-diagnostic interview, the clinician described this patient’s presenting complaint as,

“illness management in dealing with the limitations of her diabetes and chronic pain.… She’s isolated and limited in activity, which kind of results in her limited sense of [a] self-run house and worse dependence on the family.”

The clinician identified psychosocial complications of this patient’s experience of pain, and linked these to the presenting complaint of depression.

In another exchange, an African American woman with depression, hepatitis, and a record of prior legal convictions presented to a psychiatrist for evaluation. He asked about employment and she responded, “No, I’m not working. I had to get on disability.” The clinician commented, “Because it was hard to get a job because of your record,” and the patient responded “Yeah, and so was the depression, you know… couldn’t concentrate right. And I knew my sickness, you know, my liver… And I was still going to the doctor for that.” This patient linked her physical illness and concentration problems to an inability to work, in addition to employment difficulties presented by a criminal record. Had she not continued, the clinician may have inadvertently foreclosed this discussion of what physical illness meant to this patient.

Mental health treatment itself sometimes presented impediments to agency by interfering with work. An African American man noted that his psychiatric medications “make me drowsy, oversleep, miss work, my boss gets mad at me.” In other cases, underemployment and lack of insurance were experienced as stressors and as reasons for seeking mental health services. A Latino patient noted, “I need to find a full-time job…. I would say, yeah, that’s a stressful thing.” At the end of his intake he noted, “I just don’t wanna get sick or anything because I can’t miss work.” These examples are instances where the mutual reinforcement of mental, physical, and social roles is evident.

Similarly, a White man with multiple medical and psychiatric issues noted,

“when I didn’t have any insurance nobody seemed to wanna to talk to you without money or insurance or something to pay for it, so I got a job three years ago making eleven dollars an hour, without health benefits, and [public insurance] told me that was too much money for me to be getting [public insurance] and they cancelled me and here I am three years later trying to get back on the right track.”

This quote exemplifies the overlap in themes of work functioning and loss that, combined, illuminate this particular patient’s deeply felt sense of betrayal by the public health system. In the post-diagnostic interview, he disclosed the meaning of his physical suffering with regard to how he was able to function as a provider for his family:

“I want to be healthy and want to live an average life. I want my kids to grow up and have me around and if I don’t take care of myself physically and mentally and the other way, who’s going to be there for them? I need to take care of myself.”

He expressed this duty in terms of a gendered work role, “Feel like I’m a man. I just need to go to work, pay the bills, and whatever. Everything else should fall through. Why should I need to go see a doctor on a weekly-biweekly basis, and whatever else? I know I’ve got the health issues.” His chronic pain was interpreted as a sign of failure to fulfill this role, “I get extreme muscle cramps and pains of both my legs…. As soon as I try to relax and take time for myself, it seems like I’m getting punished.”

Discussion

In this sample of mental health intakes, patients viewed their physical health problems as intimately related to their mental health, social functioning, and, in particular, their capacity for work. The themes of existential loss, embodiment, loss of agency, and reduced capacity to work represent challenges to identity that participants experienced when ill. The incapacity to work in particular was seen as both a cause and a consequence of poor mental health, making it an important factor to evaluate in the mental health intake. Patients described work as an activity and commitment that helped them feel fulfilled and useful, and thus might be said to serve as an organizing principle for wellness. Some possible mediators in this relationship between work and wellness might include the negative effects on daily structure, social contact, self-purpose, social status, and activity (Jahoda, 1981), as identified in research linking unemployment causally to poor mental health (Paul & Moser, 2009). Future research might explore the relative importance of these potential mediators in community mental health settings, where there is a growing move to integrate mental health and primary medical care services.

Further research may explore whether our findings on the importance of work generalize across race/ethnicity and class, although our sample included culturally diverse and disadvantaged individuals from community health settings, many of whom may had immigrated to the United States specifically to work. White patients in this study reported a greater burden of physical illnesses, as reflected in our qualitative sample, and seemed to present more concerns related to existential and embodiment issues. These findings suggest the importance of exploring cultural background, along with immigration, work, and treatment histories, to discern how physical suffering impacts on major areas of meaning for patients.

Some of the more striking examples of existential and embodiment concerns came from non-Latino White patients, who spoke of losing their sense of self amidst the impact of substance abuse, physical illness, and polypharmacy. These examples may suggest larger patterns when considering that Latino patients use health services less, may be more reluctant to take medications (Nam, Chesla, Stotts, Kroon, & Janson, 2011), and are less likely to be asked about substance abuse by their providers (Alegria et al., 2008). Thus, Latinos may experience the consequences of physical suffering differently than patients who address their suffering through more aggressive engagement with health services and medications, and whose providers ask more about the consequences of substance abuse.

In prior research using PPES data, we found that clinicians evaluate physical illness during mental health intakes for several reasons: to assess the contribution of physical conditions or medication side effects to a psychiatric formulation, to encourage patient contact with primary care providers, and to promote physical health care (Carson et al., 2010). With these priorities, clinicians may not readily probe the depth of meaning that patients associate with physical illnesses, given the opportunity. Our results revealed several themes reflecting the ways in which physical suffering might underlie the depression and anxiety that bring individuals to mental health care. In circular fashion, this mental suffering can exacerbate physical suffering, such as chronic pain (Kroenke et al., 2011). Qualitative research can be useful in preparing mental health clinicians to listen for “what really matters” in the inter-related themes of loss and work that emerge in evaluations of physical and mental suffering. Missed opportunities to appreciate what really matters in the interaction between patients and clinicians, as described above, may disrupt healing opportunities for meaning-making. In safety-net mental health settings, the result could be worsening of disparities in quality of care for underserved minority patients.

A useful approach to understanding the process and content of these accounts is what Ware and Kleinman (1992), in research on neurasthenia and chronic fatigue syndrome, described as the sociosomatic formulation. This approach to explaining mental illness links interactions between social relationships or conditions with bodily experience (N. Ware & Kleinman, 1992) and evolved as a complement to the psychosomatic formulation, which locates illness in the interplay of mind and body. This approach is similar to Kirmayer’s (2008) conceptualization of pain as a socially embedded experience in which social and political processes influence the translation of physiological processes (e.g. from physical illness) into symptom reports.

Practically speaking, a clinician who elaborates a sociosomatic formulation would inquire about relevant social roles, relationships, and networks, and consider how these might be related to, even productive of, illness within an individual (Kleinman & Becker, 1998). A relevant guide can be found in the Cultural Formulation Interview in the DSM (American Psychiatric Association, 2013). Many of the participants in this study offered employment-related explanations for the loss of meaning in their lives and related social suffering. They described struggles to support family in the United States or abroad, laboring in an economic system that seems to penalize those who become disabled or who earn just enough to be ineligible for public insurance coverage. A clinician who empathically acknowledges this precarious position and offers employment-oriented supports may therefore find improved engagement in treatment.

These discussions of physical suffering can help mental health clinicians clarify “what matters” for patients (Katz & Alegria, 2009; Kleinman, 2006). Qualitative research among individuals recovering from schizophrenia reports that patients place a high value on employment in terms of personal meaning and promoting recovery (Dunn, Wewiorski, & Rogers, 2008). The current study extends these findings to individuals with less severe mental problems (anxiety, depression, substance abuse) and co-morbid physical illness. Mental health clinicians who effectively discern the meaning of patients’ physical health problems may identify a need for vocational support or rehabilitation in addition to psychotherapy or psychopharmacology.

Patients who speak poignantly of physical problems and their consequences on work function are calling attention to health issues for which they experience a need for care. These patients with chronic co-morbid conditions, who are disproportionately racial/ethnic minority and lower income individuals, bring a complexity to mental health treatment that requires particular attentiveness from clinicians. However, there are many other competing demands on the clinician’s attention, as discussed above. The impact of these demands may mean that clinicians must make decisions about which concerns to prioritize, and may fall back on prior assumptions about what matters in order to save time. These assumptions might be influenced by the clinician’s past clinical experiences and by the patient’s social and cultural background. Research on bias in healthcare suggests these assumptions may be inaccurate (Pronin, 2007).

Katz and Alegria (2009) have written of the active listening that allows clinicians to hear the voice of the patient and track shift of assumptions in the clinician-patient interaction (Katz & Alegria, 2009). Such active listening may improve patient-provider communication in community mental health settings (Street Jr, Gordon, & Haidet, 2007; van Ryn & Burke, 2000). For example, identifying and acknowledging patient representations of pain may be key to improvements in psychosocial functioning (Coutu et al., 2010). Similarly, exploring the challenges to identity that result from physical illness may be one way in which patients can feel heard and validated, and become more engaged in their mental health care.

Biographical Notes

Nicholas Carson, MDCM, is a Clinical Research Associate at the Health Equity Research Lab and Center for Multicultural Mental Health Research at the Cambridge Health Alliance (CHA), where he has been interested in understanding patient-provider communication in community mental health settings. He is also Medical Director of Child and Adolescent Outpatient Psychiatry Services at CHA and an Instructor in the Department of Psychiatry at Harvard Medical School. His research aims to identify cultural disparities in mental health services, including medication use, and test novel interventions to improve the quality of mental health care.

Arlene Katz, EdD, is a lecturer in the Department of Global Health and Social Medicine where she mentors in the MMSc Global Health Delivery program and teaches cross-cultural care in the residency program of the Department of Medicine, Cambridge Health Alliance. Her main research interests include the culture of medicine, qualitative methods in multicultural mental health, disparities in vulnerable populations, newborn health and social change, and ageism and stereotyping. Dr. Katz is also interested in mental health in primary care, the moral dimensions of care, social suffering, accompaniment, care giving, and the experience of illness, social poetics, and narratives of clinical care, the ethics of informed consent, and hearing the voices of the community in care, research, and environment.

Margarita Alegría, PhD, is the Director of the Disparities Research Unit in the Department of Medicine at the Massachusetts General Hospital. She is a Professor of Psychology in the Department of Psychiatry at Harvard Medical School. Dr. Alegría researches mental health services for cultural minority groups in the United States. She is currently the Principal Investigator on research grants from the National Institute on Aging, the National Institute of Mental Health, the National Institute of Drug Abuse, and the Patient-Centered Outcomes Research Institute. Her published works focus on mental health services research, conceptual, and methodological issues with minority populations, risk behaviors, and disparities in service delivery.