The acceptability and appropriateness of metaphors to explain cognitive behaviour therapy principles for people with medically unexplained symptoms (MUS): a qualitative study

Talk Code: 
Tom Kingstone
Professor Carolyn Chew-Graham, Dr Heather Burroughs, Dr Marta Buszewicz, Dr Tom Shepherd, Professor Athula Sumathipala
Author institutions: 
Research Institute for Primary Care and Health Sciences at Keele University, South Staffordshire and Shropshire NHS Healthcare Foundation Trust, University College London


Medically Unexplained Symptoms (MUS) include persistent pain, discomfort, fatigue and other somatic symptoms with no identifiable physical cause despite adequate examination. MUS accounts for between 20-40% of new consultations in UK primary care. The understanding and management of people with MUS is suboptimal, which can have adverse impacts on patients and their families, as well as healthcare practitioners. Evidence suggests cognitive behaviour therapy (CBT) may provide an effective treatment for people with MUS and is highlighted in the NHS positive practice guide (2014). However, access to CBT is restricted by a lack of formal CBT training among primary healthcare practitioners and reluctance from patients to accept psychological therapy for physical symptoms. Metaphors have been used to support the delivery of a CBT-intervention for MUS in trials conducted in Sri Lanka. The aim of this study was to explore the acceptability of metaphors to explain CBT principles for people with MUS and those who manage their care in a UK setting.


One-to-one qualitative interviews and focus groups were conducted with a diverse range of healthcare practitioners (HCPs) from both primary and specialist care [General Practitioners (GPs), Psychiatrists, Psychologists, and Psychological Wellbeing Practitioners (PWPs)] and people with MUS. Interviews took place at Keele University or at the participant’s place of work (for HCPs), were digitally recorded and transcribed with consent. Interviews explored understanding of MUS, current management and presented ten metaphors for discussion. Thematic analysis of participant experiences/management of MUS was conducted by the research team, led by the first author, using principles of constant comparison. Also, content analysis of data relevant to each of the 10 metaphors was conducted.


Interviews were completed with 21 HCPs: 7 Psychiatrists, 6 GPs, 5 Psychologists, and 3 PWPs. Three people with MUS were interviewed. Recruitment challenges are described. The following key themes were identified: stigma, inadequacy of the bio-medical model, neglect of emotional dimension, tortuous diagnostic process, complex treatment pathways, and barriers to accessing care. All participants provided views on the metaphors and agreed on the acceptability of metaphors to support the understanding of CBT principles; however, not all the metaphors suggested were considered appropriate by all participants.


The perspectives of different HCPs helps explain the barriers to accessing care and the complexity of the treatment pathway for people with MUS. The acceptability of using metaphors, which may be employed by all HCPs, may enable GPs to better support people with MUS. Our findings will inform development of a specific intervention using metaphors to explain CBT principles which could be used by GPs and PWPs (specifically high-intensity workers) working with people with MUS.

Submitted by: 
Tom Kingstone
Funding acknowledgement: 
This paper summarises independent research funded by the National Institute for Health Research School for Primary Care Research (grant no. 254). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.