Cluster randomised controlled trial of training practices in reattribution for medically unexplained symptoms (2007) Richard Morris et al.

F

fivetowns

Established Member (Voting Rights)
Sorry if this has already been posted somewhere already. (I searched and couldn't find anything). I haven't had time to study the full article in much detail, but I thought it might be worth looking at -the results in particular.

Full text here, plus doi
(If any one needs it.)
Abstract


Background
Reattribution is frequently taught to general practitioners (GPs) as a structured consultation that provides a psychological explanation for medically unexplained symptoms.

Aims
To determine if practice-based training of GPs in reattribution changes doctor–patient communication, thereby improving outcomes in patients with medically unexplained symptoms of 3 months' duration.

Method
Cluster randomised controlled trial in 16 practices, 74 GPs and 141 patients with medically unexplained symptoms of 6 hours of reattribution training v. treatment as usual.

Results
With training, the proportion of consultations mostly consistent with reattribution increased (31 v. 2%, P=0.002). Training was associated with decreased quality of life (health thermometer difference −0.9, 95% CI −1.6 to −0.1; P=0.027) with no other effects on patient outcome or health contacts.

Conclusions
Practice-based training in reattribution changed doctor–patient communication without improving outcome of patients with medically unexplained symptoms.
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Just catching up with this one. My goodness, what an irresponsible conclusion - the method doesn't work so we must redouble our efforts to make it work. I agree with everyone else's comments here.

Why didn't they draw the obvious conclusions -
1. the method doesn't work so everyone should stop doing it immediately.
2. the method should never have been used in the first place as it is dishonest and wrong to tell lies to patients to try to make them go away and stop bothering doctors.

I see this was from 2007. Do we know whether reattribution is still used?
I guess I can answer my own question - it's what the PACE CBT was based on - changing illness beliefs and as a result changing behaviour. Look how well that works. :arghh:
 
Afraid my reading capacity for unknown texts is not good today, so I have not yet read the paper. However the language seems familiar. There are papers in 1991 by Goldberg and 1993 by Abbey (both with interest in somatisation) in which they clearly use the term attribution in connection with dysfunctional cognitions and maladaptive behaviours which lie at the heart of the Wessely and Sharpe enterprise, and it is not hard to believe that they consider CBT and GET to be exercises in reattribution.

Apologies if this is already clear.
 
Hi I found this guide sheet about MUS from Royal Society of Psychiatrists from 2011. This is the advice it gives on dealing with MUS patients. It cites the paper in the references. This is what it says about reattribution;
Reattribution training– whilst
appearing to increase GPs confidence
and improve the Dr-Patient relationship,
it is unclear if it improves patient
outcomes.
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Which is a very positive spin on the results. But what's more interesting is the advice they give on dealing with MUS:

Consultation techniques
that help:

Connect
• Listen to the patient – their beliefs
about the cause of their symptoms
and their associated worries – ideas,
concerns and expectations (ICE).41
• Ask open questions and let them tell
their story fully their way: it’s their
experience; their family background;
their worries.
• Go back to the beginning of the
complaint – right back, including
previous health experiences. (“Drain
the symptoms dry”)
• Focus on the impact of symptoms –
how it affects them.
• Acknowledge and validate the
patient’s sense of suffering –
empathy; acknowledge it can be
frightening.
• Watch for signs that you are not
“hearing” the patient; repetition, new
symptoms, amplifying symptoms etc,
and then try a different tack.
• Knowing the patient and the context –
or admitting you don’t know these
things – makes all the difference.

Summarise
• Let the patient recap their view of the
situation.
• Summarise what you think you have
heard – being open about your
uncertainty and willingness to check
your understanding.
• Use the patient’s language to offer
tangible explanations of what is causing
the symptoms; be clear on what is not
wrong and why.
• Indicate how common such symptoms
are.
• Use narrative and metaphor –linking
to the patient’s own experience.
• Offer the opportunity to link physical
with psychosocial.
• Certain ‘word-scripts’ have been shown
to help. See website for examples.
• Show your interest – “I have spent a
lot of time thinking about this.” “I would
really like to learn more about you.”

Hand Over
• Share the action plan – around goals
and functional improvement; suggest
that the patient may monitor his or her
symptoms to observe fluctuation.
• Agree that the goal is to restore
function, as well as minimising
symptoms.
• Develop an individual personal health
plan (similar to ones for other long term
conditions); but not a pre-defined one.
• Reassure about long-term improvement
and reversibility of symptoms, the ability
of the body to recover.
• Introduce the idea that emotions can
aggravate physical symptoms, being
careful not to imply you disbelieve them.
• Believe in patients and their ability to
manage this; encourage them; build
on their strengths.
Click to expand...

It's a lot wordier but very similar to the reattribution techniques listed in the paper. I've quoted them here for comparisons;

Feeling understood
Elicit physical symptoms, psychosocial problems, mood state, beliefs held by patient about their problem, relevant physical examination and investigations

Broadening the agenda
Summarise physical and psychosocial findings. Negotiate these findings with patient

Making the link
Give explanation relating physical symptom to psychosocial problems of lifestyle because of link in time or physiology

Negotiating further treatment
Arrange follow-up or treatment of symptoms, psychosocial problems or mental disorder
Click to expand...
 

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