Treating Somatization: A Cognitive-Behavioral Approach

The book Treating Somatization, by Robert L. Woolfolk and Lesley A. Allen, is another installment in the application of cognitive-behavioral therapy techniques to address problems that the psychopharmacologic revolution has failed to eliminate. The book reviews the social and psychological history that has led to classifying the experience of chronic, unexplained, polysymptomatic physical complaints as mental illnesses. Chapters 4 through 9 take the reader somewhat laboriously through therapy from assessment to termination. The appendices include a ten-session treatment manual, the results of the authors' controlled clinical trial evaluating this therapy, two instruments used for the assessment of symptoms and their severity, instructions for abbreviated progressive muscle relaxation, and ten questions to help patients examine their thoughts.

The recommended interventions are those one would expect in any cognitive-behavioral treatment: relaxation training, increasing activities, and moderating the emotions and thoughts of "catastrophic thinkers." The authors attend to the special empathy needed for treating people with somatization disorders. On the other hand, the authors have altered their treatment approach to be consistent with more recently developed cognitive-behavioral therapy treatment models that place more emphasis on emotional processing than the traditional models of the 1960s. They have modified the name of their treatment to "affective cognitive-behavioral therapy" to underscore the added deficits of people with somatizing disorders. The authors' experiences have led them to the understanding that these patients are disconnected from the experiences that need to be accessed to find and modify dysfunctional cognitions. This situation requires that therapy "involves a constant tacking between emotions and cognitions."

One controversial aspect of this book is the inclusion of irritable bowel syndrome, chronic fatigue syndrome, and fibromyalgia as part of the continuum of somatization disorders. These diagnoses have provided health care professionals and patients with a way to circumvent the treacherous territory of characterizing symptoms as psychosomatic. Providing a "real" diagnosis may be on some level a relief to both the provider and the patient. However, it also permits the treater to avoid recommending therapies, like those in this book, that may be more likely to relieve distress rather than simply giving it a name.

The main weakness of this book is that it tries to be both practical and academic. The practical aspects of the book, which include delineating a therapy and providing examples and tools, are overshadowed by the almost obsessive attention to rigorous scholarly discourse. Because this is a treatment that would be most readily applied by experienced cognitive-behavioral therapists, this level of detail and repetition seems unnecessary. On the other hand, the environment in which this therapy would provide its greatest benefit is a multidisciplinary primary care or pain management setting. Highly skilled therapists with the recommended "training both in cognitive-behavioral therapy and experiential psychotherapy, at least five years' experience in conducting psychotherapy, and exposure to most forms of adult psychopathology" will be few and far between in medical milieus.

The success of Treating Somatization is in elucidating the complexities of the emotional and cognitive experience of people with somatization disorders. It also provides hope that the techniques of a treatment model that is growing more and more familiar can help not only the patients but also the often-frustrated clinicians faced with the challenge of helping people with an unexplained disorder.