Referral to the GI Psychologist: IBS-C Roundtable 4

The final expert roundtable session focuses on when patients with IBS-C should be referred to GI psychologists for brain-gut therapy such as gut-directed hypnosis.

Anthony Lembo, MD, is a professor of medicine at the Lerner School of Medicine at Case Western Reserve at Cleveland Clinic in Cleveland, Ohio. Brooks Cash, MD, is a professor of medicine at Texas A &M School of Medicine and the medical director of the Functional Bowel Center at Baylor Scott & White at Baylor University Medical Center in Dallas, Texas. Megan Riehl, PsyD, is a GI psychologist and an associate professor of medicine and the clinical director of the GI Behavioral Health Program at the University of Michigan in Ann Arbor, Michigan.

CLINICAL PRACTICE SUMMARY:

Brain–Gut Behavioral Therapies for IBS (Care Setting: GI Specialty / Behavioral Health Integration, U.S.)

• Ideal referral profile and triage for GI psychology in IBS: Patients with IBS who self-identify as stress-sensitive, note symptom flares with travel or work stress, or recognize stress–symptom links are appropriate for referral to a GI psychologist for consultation. Short-term, goal-directed GI psychology focuses on lifestyle strategies (exercise, diet patterns, sleep hygiene), stress management, and accountability, and is distinct from general mental health care. Patients with active, severe anxiety, depression, or trauma histories should first be referred to a general or trauma-informed mental health provider before GI-specific therapy.

• Evidence-based brain–gut therapies and clinical impact: GI-specific cognitive behavioral therapy (CBT) and gut-directed hypnotherapy are the most widely used brain–gut behavioral therapies, with numbers needed to treat of approximately 3–4, comparing favorably with medications. CBT helps reduce anxiety, modify maladaptive behaviors (e.g., avoidance, fear of eating or leaving home), and rebuild confidence in daily functioning, particularly in IBS with constipation or mixed symptoms.

• Gut-directed hypnotherapy outcomes and access considerations: Gut-directed hypnotherapy uses targeted suggestions to recalibrate brain–gut signal interpretation and promote physiologic relaxation. In IBS, published evidence shows symptom improvement of ~60–80% within ~7 sessions. Access barriers persist due to limited availability of trained GI psychologists, but digital and virtual platforms offering CBT, hypnotherapy, and combined lifestyle interventions are expanding care options.

TRANSCRIPT:

Dr Lembo:

Megan, who should we refer to you? We don't want to just send you the worst, the most difficult patients, most refractive. What should gastroenterologists think about and who's the ideal patient for you?

Dr Riehl:

Well, when you're talking with your patients and they give you the cue that they are a stress sensitive person, they are somebody where before a trip their GI symptoms are perking up or work related, that they have insight that increased stress impacts their symptoms—that's a great patient to send to me. Going back to even lifestyle that as you talked about, Tony, we all should be exercising, we should be eating right the right way. We should be doing all of these things, sometimes a couple sessions with a GI psychologist to help get some lifestyle strategies in place, a plan for that, some accountability, some specific interventions to work on sleep hygiene, to work on stress management, to work on some behavioral eating patterns. My therapy is not meant to be long-term lifelong with patients. So I think even in the language that you're using and making that referral to a GI psychologist, you're helping patients understand this is different from general mental health work.

Certainly if a patient has increased severity in anxiety, depression, trauma history, that is still relevant to their overall health and wellbeing at the present moment, I would suggest making the recommendation of a more general mental health provider or a trauma-informed therapist first before sending them to somebody like myself. Because we're really going to be diving into helping the patient understand how the brain and the gut are intricately connected and how we'll utilize our brain gut behavioral therapies like GI specific cognitive behavioral therapy, which really addresses stress management, avoidant behaviors, especially when it comes to constipation. We think about patients as like you're holding it in. There's a lot of physiological tension there, and how do we help you understand that you're probably living in a way from a body perspective that's uncomfortable. So I'll talk to patients about how you've learned to be comfortable being uncomfortable from a physiological standpoint, and what does it feel like to learn how to reset that brain gut connection, which can have a tremendous outcome in terms of improving your GI symptoms.

Dr Lembo:

So should we tell patients I'd like to send you for hypnotherapy, CBT, or is that just a general referral is better? Do you make the decision and tell us a little about how you do that? Yeah,

Dr Riehl:

That's such an important question because yes, there may be things that your patients haven't shared with you and if you over-promise and they're expecting that when they come and see me, they're getting gut directed hypnosis, but yet I do my full psychological evaluation and behavioral health evaluation and I identify that maybe there are some trauma concerns that we have and that they're not appropriate yet for our types of treatment. I think it can disrupt all of our therapeutic working relationships. So it's best to make that referral as, Megan's on our team, I'm going to give you the referral and she'll do a consult with you and then from there she'll determine what are the best resources and treatment plans for you.

Dr Lembo:

Tell us a little bit about the different treatments. So you have hypnotherapy, cognitive behavioral therapy, and tell us about those and are there others?

Dr Riehl:

Yeah, those are our most probably widely utilized with the most evidence to support their use. So we always like to share our numbers needed to treat for brain-gut. Behavioral therapies are about 3 or 4 comparatively to medications out there; that's pretty superior in most respects. So the majority of patients that are motivated, they're insightful, they're willing to engage in this type of therapy, can get something out of it. So CBT is going to be very good for helping to shift the cognitions around their habits, their experience with managing their GI condition, building confidence, getting them back engaged in their life. So often living with IBS with constipation, life just starts to shrink. You're avoiding things. You're afraid to eat, you're afraid to go. You're afraid to take your medication. You don't know when you're going to have that explosive diarrhea that they fear they may have.

And so working from that anxiety reduction perspective can be really beneficial. I love talking about gut directed hypnosis, so I won't give you too much of a lecture on that, but what I will say is, especially for my patients with constipation, learning to relax into the body and then what makes it hypnosis is that we're using very tailored and targeted suggestions about the calming and soothing and reworking of the way the brain is interpreting signals from the gut, reminding the gut, using our subconscious part of the brain that it knows what to do during the digestive process and for a variety of reasons, we've probably started to overthink and pay too close of attention to what's going on during that digestive process.

Again, gut directed hypnosis has a very large body of literature and research that supports its use for IBS, and within about 7 sessions, we can see improvements of anywhere from 60 to 80% in terms of our patients symptom reduction. So really powerful tools. Access can be limited, so that still can be somewhat of a barrier. But I think some of our excitement in terms of improving access is there are now some digital therapies that can offer things like gut directed hypnosis via an app, which really I think can be really life-changing for many of the practices out there that might not have a live in-person GI psychologist to refer to. But there are also some virtual practices out there that have also increased access to patients directly.

Dr Lembo:

Yeah, it seems like digital health is really taking off not only through the individual platforms for CBT and hypnosis, but there's some of them that combine lifestyle, diet ,and relaxation, stress management, CBT into the app. So more to come on that. I think we're going to have to wrap it up. We're just about out of time, but I want to thank everyone for joining us today. I hope this has been enjoyable, I want to thank my colleagues for joining us as well. It's been a very interesting and enlightening discussion. So thank you so much everyone.

Dr Riehl:

Thanks.