This chapter looks at some psychological and behavioural ways to deal with some of the symptoms of IBS. In Chapter 1 we outlined how the brain and gut interact via the brain–gut axis (BGA; we’ll explore this again in more detail in Chapter 9). Feeling like you have little control over your body and experiencing unpredictable embarrassing symptoms can cause a great deal of stress and anxiety. You may not have felt anxious or worried before your IBS started but now, like many invisible illnesses, the consequences of IBS may have resulted in a vicious cycle whereby feelings of loss of control feed back into the BGA and worsen symptoms. The types of therapies outlined in this chapter help to deal with the heightened feedback loop within the BGA, so tackling this should help to reduce IBS symptoms. Hence these types of therapies can be important additions to your treatment package.
Clinical hypnosis, or hypnotherapy, is an increasingly common and well-evidenced type of therapeutic technique used in many conditions, including asthma, headaches and migraine, chronic pain in cancer patients and IBS. In fact, hypnotherapy is one of the most researched types of treatment for managing the symptoms of IBS at present.
A modern-day clinical hypnotist or hypnotherapist aims to bring about a state of suggestibility, known as a ‘hypnotic state’, by using exercises that induce deep relaxation. The idea of a hypnotic state may sound a bit strange and unnatural, but it is simply an altered state of awareness, a bit like daydreaming. For instance, have you ever been doing an everyday activity, such as having a shower, but because you have been thinking about something else (perhaps work that you need to do) you can’t remember if you’ve washed your hair? You then check your hair and you have indeed washed it but simply don’t remember as your awareness was somewhere else. Hence, altered awareness is a daily occurrence and causes us no significant problems at all.
Within hypnotherapy, the therapist will help you to reach a hypnotic state wherein the mind is more open to the process of change. The therapist will then make suggestions that can help with a range of issues, including the symptoms of IBS. There are two main methods for using hypnotherapeutic techniques in IBS; these are called the ‘Manchester Approach’ and the ‘North Carolina Protocol’, which have been researched and shown to be effective.
The Manchester Approach was the first type of hypnotherapy to be properly studied and reported on in the medical and scientific community. Professor Peter Whorwell and his colleagues at the University of Manchester published their seminal paper in the esteemed journal the Lancet in 1984, which showed that patients who had been treated with hypnotherapy had much better outcomes in terms of abdominal pain, abdominal distension, bowel habit and general well-being in comparison to patients treated with psychotherapy. These beneficial changes were seen to last when the patients were tested again three months after the therapies finished34.
Over the years, Professor Whorwell and colleagues have further developed this technique into what is now known as the Manchester Approach. With this method, the therapist will first take a detailed personal and medical history, talk the patient through reasons why they may have IBS symptoms and how the therapy work and also reassure the patient throughout. This protocol now consists of 12 sessions, although when Professor Whorwell first started with this technique it was only seven35.
After the patient history has been taken and the method explained, the first couple of sessions are used to allow patients to get used to the process of hypnotherapy. A hypnotic state is reached by progressive physical relaxation (tensing and relaxing muscles sequentially throughout the body from the toes to the fingers) and exercises such as repeating the word ‘calm’ on the out breath. General exercises to increase well-being are used also – for example, metaphors that bring to mind a sense of calm and relaxation, such as sinking into a soft cushion or cloud, being on holiday somewhere in the warm sunshine or the gentle rocking of a tethered boat.
Next come the ‘gut-directed’ sessions. These start in the same way as the general hypnotherapy sessions, by inducing a hypnotic state, but the exercises focus on the gut. For instance, a patient will be asked to create a picture in his/her mind of his/her gut when symptoms of IBS are flaring and then be directed by the therapist to calm it. This needn’t be a literal image and could be something like a roller-coaster where the feelings of urgency are symbolised by the breakneck speed and twists and turns of the ride which, through the hypnotherapy, will metamorphose into a quiet, sedate country drive. Other types of gut-directed exercises include patients placing their hand on their abdomen and using the feeling of warmth as a sense of control over the stomach and its goings-on.
The final, but equally important, part of the Manchester Approach involves sessions that focus on reducing the fear and avoidance of situations that people with IBS might find difficult, such as a crowded train journey. Here, the therapist guides the patient through such a situation, but his/her symptoms are not triggered; rather, the gut remains calm, under control and not of concern.
At the end of the therapy patients are given a recording of the sessions so that the gut-directed hypnotherapy exercises can be practised at home. Hypnotherapy is like any other skill and so it must be practised to work well; patients are generally encouraged to use the tools taught to them on a daily basis. For details of how to find a hypnotherapist please see the end of this section (page 94).
The North Carolina Protocol was developed by the clinical psychologists Drs Olafur Palsson and William Whitehead at the University of North Carolina at Chapel Hill, USA. This method differs somewhat from the Manchester Approach as it has standardised scripts that therapists work from, thus each patient receives the same information regardless of which therapist they consult. By developing a standard treatment ‘package’ Drs Palsson and Whitehead have simplified its delivery, making it easier to train therapists throughout the USA and beyond. This has also made researching the protocol easier as researchers know that every patient receives exactly the same input.
Patients have seven 45-minute sessions of clinical hypnosis over 12 weeks. The sessions are arranged in treatment modules that can be interchanged, depending on the patient’s needs. Within these modules are five separate therapeutic components:
Therapists using the North Carolina Protocol have a set of tools that include a number of techniques. Eye fixation induction is one technique where the therapist will ask patients to fix their gaze on a set point, for instance the ceiling or the hypnotherapist’s pen. This staring will tire the eyes and the therapist will also suggest that the patient’s eyelids are becoming heavier and heavier so that eventually they close – once this occurs the patient is believed to be in a ‘hypnotic state’ or ‘trance’. Next, the therapist will deepen the hypnotic state by guided systematic physical relaxation, or relaxation using scenes and imagery. Here, therapeutic suggestions can be made as the mind should be more open to change. The final process is trance termination, where the hypnotherapist gently and gradually brings the patient out of the hypnotic state, often by counting and giving suggestions of returning to full awareness. Dr Palsson and his team have carried out a number of research studies that show that this method of hypnotherapy, designed specifically for people with IBS, is beneficial – more than 80% of people in the research studies saw improvements in their condition following the treatment36.
‘Contrary to common belief, under hypnosis, the client is actually given back control of unwanted thoughts and behaviours. The so-called hypnotic “trance” is in reality just an enhanced state of concentration and relaxation.’
Ian Jackson, hypnotherapist
‘Hypnosis’, ‘altered awareness’, ‘trance’, etc may sound a little odd; however, it’s important to bear in mind that you are still in control of your body and mind when engaging in hypnotherapy and if you do feel uncomfortable at any time, you can ask the therapist to stop and she will end the treatment. But most people enjoy the experience of deep relaxation, although you don’t have to be relaxed to get the benefits of clinical hypnosis. Some people say they feel a sense of floating, whilst others may feel that their bodies are very heavy.
The type of hypnotherapy used to treat IBS doesn’t involve the in-depth exploration of secrets or trauma – modern day gut-directed hypnotherapy is nothing like the Freudian idea of therapy. However, as IBS can feel like an embarrassing illness you may feel a little awkward when discussing symptoms and sensations; remember that a trained therapist will be entirely used to this and will not judge you in any way.
The answer to this is quite simply, yes. A large number of research studies have demonstrated that hypnotherapy is safe and doesn’t have the same type of side effects that some medications can have. Nevertheless, as with any other type of treatment or therapy, it is important that you find a practitioner who is appropriately trained. In the UK, hypnotherapy isn’t a regulated profession so there aren’t laws regarding the minimum level of qualifications and training that a person needs to have to call themselves a ‘hypnotherapist’. This can make it difficult for patients to find the best therapist but there are professional bodies that ‘self-regulate’ in the UK. These organisations do have a set of standards that practitioners need to meet to be held on their lists and registers. There are quite a few of these self-regulatory bodies in the UK at present and it is a matter of opinion if one is better than another. Therefore, if you’re looking for a hypnotherapist there’s a very useful search tool on the Hypnotherapy Directory website (http://www.hypnotherapy-directory.org.uk/adv-search.html). Within this advanced search tool you can select ‘Member of a professional body’ which will only give you the results for therapists who have been vetted by a professional organisation. There is more information regarding the professional bodies that self-regulate hypnotherapy and also more general information on this type of treatment on the website.
Your GP may be able to refer you for hypnotherapy as the National Institute for Health and Care Excellence (NICE) recommends this as a treatment for IBS. But if you’ve found your GP to be less than supportive or the services are not offered by the NHS in your area, you might want to contact private practitioners yourself. If you do, it is worth asking some questions in addition to checking their qualifications and registrations with professional bodies, such as:
You may want to approach a few different therapists and see if you feel you like them after speaking on the phone, before making a booking.
Cognitive behavioural therapy, or CBT, is a talking therapy that has been researched in a wide range of conditions, from depression and anxiety disorders to chronic pain and fatigue in cancer patients. This type of treatment is very structured with a problem-focused approach, as opposed to other forms of talking therapies that are more exploratory (e.g. psychotherapy). CBT is most commonly delivered by a trained and qualified therapist, but there are now many self-help books on the technique.
CBT works by helping you think closely about your thoughts and feelings and seeing how these influence your behaviour, which in turn loops back to how we feel and think about situations and experiences. It may seem obvious that our thoughts (‘cognitions’) affect our behaviours and vice versa, but we can all get caught in vicious circles. Over-thinking and ruminating on events, the future and even bodily sensations can impact on our hypothalamus–pituitary–adrenal (HPA) axis, and as we’ve seen in Chapter 1 (page 13), the HPA axis and brain–gut axis (BGA) link our digestive systems to our brains/cognitions/feelings (more about this in Chapter 9).
Although there are no standardised protocols for CBT in IBS, like the methods mentioned previously within hypnotherapy, there are common components that most CBT therapists will use with someone who has IBS. These are:
In a CBT session, the therapist will work through some exercises that challenge your thoughts and beliefs. You will most likely be given some ‘homework’ to do between sessions as well as it can take time and practice to change the way we think.
CBT requires quite a lot of work on the part of the patient; it is an active therapy rather than a passive treatment, such as taking medicines. You’ll be asked to record your thoughts and feelings as well as your symptoms to see if you can identify links between them. Then you may be asked to try activities or foods that you felt were damaging or triggers for symptom flares and monitor what happens in order to identify and then change your reactions, which should help to dampen down the stress response and disengage an over-active HPA and BGA function.
Like hypnotherapy, IBS-specific CBT has been studied by many different research groups in numerous countries. Early studies showed promising results; for instance in a study with 20 IBS patients who either had intensive individual CBT or were asked to monitor their GI symptoms, 80% of the people who received CBT had improvements in their conditions whereas only 10% of those who symptom-monitored did37. Other studies compared CBT with standard medical care and similar benefits of CBT were found. However, these types of comparison groups weren’t particularly similar as patients allocated CBT clearly had more time with practitioners and care than those who were not assigned to this group. Therefore, further studies split the patients into groups who received CBT and an intervention that gave people the same amount of human interaction, in this case a self-help support group. CBT still seemed a good option as 67% of people in this group said they had a reduction in GI symptoms, whereas only 31% of those in the self-help support group saw their symptoms improve. (There was also a symptom-monitoring group in which 10% of people reported a decline in symptoms.)38 Further studies have shown more mixed results but overall it does seem that CBT can help to deal with some of the symptoms of IBS and also the anxiety and depression that can come with having an unpredictable and embarrassing illness39.
CBT is a very popular treatment at present for many illnesses; this has led to researchers and medics developing novel ways to make this therapy available to more people. One such method that has been studied by researchers is group CBT which has the obvious benefit of reducing costs and potentially making it easier for healthcare providers to fund. A large study of 210 patients either had CBT or ‘psychoeducational support’ in a group of three to six people for 10 weeks. (Each session was 90 minutes long.) There was also a symptom-monitoring group to act as a comparison. If you’re wondering what psychoeducational support means, in this study the group of patients given this treatment had a number of therapist-led discussions on IBS-related topics such as diet, food sensitivities, types of diagnostic tests and interactions with doctors. The key here was that the patients were encouraged to talk about their experiences with others who had the same condition and no standard therapeutic exercises took place, hence it was a bit like a support group but with specific areas of conversation. Interestingly, the researchers found improvements in peoples’ IBS symptoms in both the CBT group and psychoeducational support groups, but not the symptom-monitoring group40. This is noteworthy in a couple of ways – first, that group CBT seems to be effective and so is yet another option for IBS patients, and, secondly, that simply discussing problems and illness experiences appears to help manage IBS symptoms. In Chapter 2 we touched on the effects of the hormone oxytocin in the context of supportive relationships, and how this can reduce the stress response and benefit our BGA/HPA systems, so it’s possible that support groups, even without any traditional therapeutic exercises, could be a therapy in themselves (see Chapter 7 for more on support groups).
Self-help CBT has also been investigated. There are lots of books on CBT available now and some specifically for people with IBS. Therefore, researchers interested in IBS, and particularly using CBT to treat IBS, conducted a scientific evaluation of a self-help book41. Although the number of people in this study was small (28 in total), it was found that after reading the self-help book and using the advice given, general GI symptoms declined, abdominal pain was reduced and perceptions of health and well-being improved42. Of course this was only a small study but it does illustrate the potential benefits of self-help books.
There are a variety of professionals that may be trained in CBT – clinical and counselling psychologists, counsellors, CBT therapists, to name a few. Psychologists, whether from a clinical, counselling or health background, are trained to a high level and should have ‘chartered status’ with the British Psychological Society (BPS). The BPS is a representative body for psychologists in the UK. To become a chartered psychologist an individual needs to have completed a minimum of six years’ education and training on BPS-recognised courses to doctorate standard. To find a chartered psychologist in your area who offers CBT you can use the BPS’s directory (http://www.bps.org.uk/bpslegacy/dcp). Make sure you type in ‘CBT’ in the ‘Additional Information’ tab at the bottom of the page and you should receive a number of psychologists in your local area who offer this therapy. Once you’ve done this it is worth also checking that the psychologist is a ‘practitioner psychologist’, which means she has trained specifically to deliver therapy rather than, or in addition to, conducting research or work in other fields, such as policy-making.
Practitioner psychologists are regulated by the Health and Care Professions Council (HCPC; http://www.hcpc-uk.org.uk). The HCPC defines certain criteria in terms of professional skills, education and behaviour in order to protect members of the public. For instance, if a practitioner doesn’t meet the HCPC’s standards it can prevent her from practising. Patients can make complaints about psychologists to the HCPC, which will act upon the information. It’s exactly the same sort of body as the General Medical Council that regulates doctors, so there is an avenue of recourse if anything should go awry within therapy. The title ‘practitioner psychologist’ is protected by law and anyone using this label without being registered with the HCPC can be prosecuted. You can check if someone is registered with the HCPC by searching his/her last name or registration number if you have it (http://www.hcpc-uk.org/check/). But remember, this is only for ‘practitioner psychologists’ – if someone someone simply says they’re a therapist they probably won’t be a member of the HCPC and potentially won’t have been through the rigorous training that the HCPC requires.
Nevertheless, there are other professionals, such as counsellors and psychotherapists, who are trained to deliver CBT. The British Association for Behavioural and Cognitive Psychotherapies (BABCP) also has a register where you can find out if a therapist has completed an accredited CBT course and also locate CBT therapists in your area (http://www.cbtregisteruk.com/Default.aspx). As this register includes other types of professionals who are trained in CBT but are not psychologists, such as doctors, social workers and occupational therapists, you may want to contact the individual or look at her website to see exactly what type of patient she works with. (Unfortunately there isn’t an easy way to search for this on the BABCP website.)
The practice of mindfulness has become increasingly popular in recent years. Mindfulness is a particular form of meditation, stemming from Buddhism but now used in a secular fashion as a way to manage both stress and a number of illnesses, including chronic pain, anxiety and depression, stress in cancer patients and fibromyalgia. There are many different strands of mindfulness, including therapies that merge this technique with CBT (mindfulness-based cognitive therapy or MBCT) and specific stress-targeted strategies (mindfulness-based stress reduction or MBSR). Mindfulness techniques can also be part of a therapy called ‘acceptance and commitment therapy’ (ACT), which is a therapy that helps people to accept what they cannot change whilst equally committing to tackling areas in which quality of life can be improved. The common core of the mindfulness approach in all these therapies is the practice of bringing our attention to the moment, rather than mulling over the past or worrying about the future. A variety of meditative exercises are used to focus attention on the here and now, which we will explore more in Chapter 7 (page 114).
We tend to spend most of our lives on automatic pilot, rarely noticing what’s happening in each moment. But on the flip side we do have the capacity to control our attention and focus on specific aspects of the environment and our internal sensations (such as mentioned previously in the hypnotherapy section). The basic tenet of mindfulness is that by zooming in on the present and becoming active, but non-judgemental, observers we can enrich our lives. This enrichment stems from the development of a greater sense of control over life, rather than the constant reactivity that we can become stuck in if we live too much in the past or future. Like the other treatments in this chapter, mindfulness does not claim to be a ‘cure’ for any condition, but rather it aims to enhance coping with the day-to-day effects of a chronic illness and the stresses that this inevitably places on a person. Also, this technique can help us to view ill health and ‘wellness’ as not mutually exclusive, instead helping us to realise that symptoms and health complaints are a natural part of life and life can still be enjoyable and fulfilling.
Mindfulness exercises can be taught either on a one-to-one basis or in groups. The more structured treatments, such as MBSR, usually consist of eight to 10 weekly 2.5-hour sessions and can be delivered in large groups of up to 30 people at a time. Some courses also have a weekend day session, although there is wide variation in less structured courses. Typical components of MBSR are:
(See Chapter 7 for examples of the above that you can practise at home.)
When using all of these techniques, individuals are instructed to sharpen their focus onto the observation target – this may be their breathing or merely the sensation of sitting on a chair. Numerous cognitions (thoughts) will drift into our minds when we try this – ideas, memories, daydreams, for example. To engage in mindful awareness, it’s essential to note in your mind the nature of the cognition, without assigning any type of judgement or deep evaluation to it. Next, attention should be calmly pulled back to the moment and to the observation target, such as the sensation of your back resting against the chair. It’s quite common to have thoughts that are judgemental in their nature when first practising mindfulness, such as ‘Why on earth am I doing this, it’s ridiculous and not going to help me’; even these types of thought should be noticed without judgement, perhaps simply categorised as ‘a thought’, nothing more, nothing less. Other types of information will pass through your mind, such as a police siren – this can be noted and labelled ‘a noise’ before gently moving your attention back to the mindfulness task. You may have an itch on your nose that can be logged as ‘a physical sensation’ and then, again, attention should be brought back to the mindfulness exercise. The purpose is to help you appreciate that most thoughts, feelings and sensations are transient and we need not become fixed within them.
People who attend MBSR classes are asked to practise the taught exercises for 45 minutes every day. This is because mindfulness is a skill and like any other skill it needs to be practised for someone to be able to access it when needed – for example, in a stressful situation such as an important meeting where it would be frowned upon to leave the room and use the toilet. Like the other therapies and techniques mentioned in this chapter, it is believed that mindfulness can influence the HPA axis and so help manage the symptoms of IBS by regulating the BGA /HPA function. Research has also shown that mindfulness can positively impact immune function43, which could also benefit people with IBS.
Research into mindfulness techniques for IBS is a new field but it is gaining momentum. In a study of 75 women with IBS, each woman either attended training in mindfulness or a support group for eight weeks, with a final half-day session at the end of the courses. IBS symptoms were reported before and immediately after the mindfulness training and support group sessions, and after a further three months. Right after the courses, IBS symptoms decreased by on average 26% in those who engaged in mindfulness practice and only 6% in the support group. At three months, patients who had been taught mindfulness further improved with an average 38% reduction in symptoms compared with 11% in the support group44. Hence, learning, and using, the mindfulness techniques was more beneficial to the women in this study than social support alone.
Another study that included 90 patients with IBS (this time both men and women) found greater improvements in IBS symptoms following mindfulness training as compared with patients receiving standard treatment; 50% of people using the mindfulness techniques improved compared with 21% of those simply adhering to general advice from their doctors45. Therefore, evidence is gathering to support the use of mindfulness techniques for the management of IBS, although more work needs to be done to gain a comprehensive picture of exactly why mindfulness could help.
If you’d like to try a mindfulness approach, follow the guidance earlier in the chapter for accessing psychologists and counsellors in the previous section but ask specifically if the therapist has been trained in mindfulness techniques – an experienced professional should have a battery of methods she can use for a particular problem or condition and will be able to tailor therapy to your individual needs.
You don’t have to see a therapist face to face, however, to try mindfulness techniques specifically designed for people with IBS. Brjánn Ljótsson and colleagues in Sweden have done a great deal of work on creating and evaluating an online programme that uses mindfulness exercises to help IBS patients accept the condition, rather than control it46. This approach may help people who do not find traditional CBT beneficial, although it does integrate CBT ideas into the mindfulness techniques. The mindfulness exercises included in this online programme were designed specifically to help people with IBS deal with the anxiety that can develop around IBS symptoms and how this anxiousness can lead to avoidance of certain situations or activities. This 10-week programme is divided into five steps, starting with an explanation of the treatment and mindfulness instructions. Steps 2, 3 and 4 build on the first step with a description of the theory behind the programme and continued advice on mindfulness techniques. The fifth and final step involves ‘exposure exercises’, in other words purposely triggering symptoms. This can be done by eating trigger foods, engaging in strenuous physical activity or by entering into a stressful situation. This may sound crazy but the point of this part of the programme is to use the mindfulness strategies when symptoms occur so that you can become less fearful of these situations. By reducing anxiety and avoidance, IBS symptoms can also decrease, which will lead to a better quality of life. Indeed, this is exactly what the researchers found when they compared this programme with an online discussion forum of 86 people where 42% of those who completed the mindfulness training saw improvements in their IBS symptoms47. Anxiety and depression also improved for the people using the mindfulness techniques, as did overall functioning.
This chapter has explored a number of psychological and behavioural techniques that can help people cope with an illness like IBS and potentially dampen the overactive BGA/HPA function that was briefly discussed in Chapter 1 and is looked at in more detail in Chapter 9. Whilst none of these methods claims to be curative, they have been shown in research studies to be beneficial to people with IBS. You may want to try one or more of these techniques alone or in addition to dietary changes and medication as they are not harmful and the potential benefits could indeed spill over to other areas of your life, promoting general well-being and quality of life.
In the following chapter we will outline various techniques that you can try yourself that can also help to reduce stress and worry and deal with the difficulties of living with IBS.