Development of metaphors to explain cognitive behavioural principles for patients with medically unexplained symptoms in Sri Lanka

Background: Medically unexplained symptoms (MUS) are common in primary care across cultures, accounting for high consultations with multiple providers and unnecessary investigations. Cognitive behavioural therapy (CBT) is efficacious for MUS and reduces physical symptoms, psychological distress and disability. Two intervention trials by the author and his group remain the only reported trials from the developing world. Material: A treatment package was designed by modifying a CBT model. The modifications were innovative use of locally relevant appropriate language and strategies that were simple enough while conforming to the CBT principles. The aim was to convey the principles of CBT to people using simple techniques – using metaphor. These are described in the paper as generic metaphors that could be used to explain the CBT principles and specific ones for patients with MUS. Discussion: Metaphor is an effective clinical tool. The author’s clinical experience and patients’ feedback suggest that these metaphors are helpful in conveying the CBT principles to patients. To develop metaphors appealing to the client and effective clinically, carrying out qualitative research among patients’ explanatory model is an important prerequisite. The generic and MUS-specific metaphors reported here should be tried in other cultural and clinical settings and evaluated. Further systematic work including qualitative work for consensus evaluation among CBT experts as well as opinion on user-friendliness of these techniques tested among CBT practitioners will be needed.