Most of our clients come to us for help with relationship difficulties, work-related stress, persistent anxiety, chronic depression or other well-researched and commonly encountered challenges. Most of us feel that our education and experiences have effectively prepared us to deal with these conditions. Armed with a time-tested array of evidence-based strategies, we confidently set out to help our clients work toward productive relationships, satisfying work experiences and greater equanimity.
But in talking to other counselors, I have found that many of them feel ill equipped to help clients who present with more physically based concerns that are interfering with their quality of life. What about clients who are frequently late to work or don’t feel they can go out with friends because they never know when they will need to find a bathroom immediately? What about the 25-year-old client who has a little-known condition called gastroparesis? How would you help her balance the need to puree or blend all of her food with her desire for an active dating and social life?
The previous examples illustrate a cluster of disorders known as functional gastrointestinal disorders, or FGIDs. These are problems marked by persistent, recurring symptoms — such as gas, bloating or loose stools — that result from abnormal function of the gastrointestinal (GI) tract without any underlying physiological problem such as a growth or hormone imbalances.
How can counselors help? There are several ways.
Clarify and validate: Many clients with FGIDs are sent to a therapist by their medical practitioners when medication, procedural or surgical treatment options have not helped or are not indicated for their condition. The unspoken message is, “I, as your doctor, cannot find anything medically wrong with you, so it must be in your head.” The subtle — or sometimes not-so-subtle — implication is that this person has stomach troubles because she or he is so stressed out and overwhelmed by life.
Medical professionals do not often educate patients about the nature of FGIDs or point out the existence of evidence-based psychological treatments that may help them manage the condition. Mental health professionals, on the other hand, have a different view. Psychologist Barbara Bradley Bolen, author of the book Breaking the Bonds of Irritable Bowel Syndrome, writes, “Despite the prevalence of IBS [irritable bowel syndrome], most people feel fairly alone in their suffering. The effort to cover up symptoms and the corresponding feelings of shame and embarrassment can serve to further exacerbate those very symptoms and the discomfort that goes along with them.”
To help clients over these difficult feelings of doubt, counselors can work to validate and normalize clients’ symptoms and experiences, educate them about the nature of FGIDs and suggest strategies to help alleviate their suffering. I have had clients who have broken down in tears of relief during our first session, happy that they have finally found someone who understands what they are going through and who is prepared to offer workable solutions to ease their distress and misery.
Acknowledge the mind-body aspect: In their groundbreaking book Trust Your Gut, physician Gregory Plotnikoff and health psychologist Mark Weisberg write about the new science of psychoneuroimmunology, the study of mind-body interactions. Their work reflects a growing recognition in recent years among medical experts of the interconnectedness of the body and mind. They write, “We approach the treatment of gut issues from the premise that the mind and body are all part of an integrated system. … The most surprising insight is that our brain does not distinguish between what is physical and what is psychological. It creates the same neurohormonal responses either way. This new perspective allows a completely different way of looking at the problems of gastric distress. More important, it makes it possible to find new solutions.”
Many clients and, unfortunately, many medical professionals, think only in a linear and one-dimensional way about FGIDs. Here is a common line of advice offered by doctors: “First, try medication. Then add fiber or a fiber supplement. If that doesn’t work, go to a dietician so she or he can ‘fix the problem’ by providing a regimen of food restrictions.” The flaw in this approach is that a functional disorder always has both physical and psychological components.
In addition to being a licensed clinical professional counselor, I am a clinical nutritionist. In that role, I help patients with supplement or dietary recommendations that may be indicated for their FGIDs. When wearing my counselor hat, however, I have seen firsthand how some clients with FGIDs feel embarrassed about being encouraged to seek out a mental health professional for what they perceive to be a physical problem. Therefore, it is important to help clients understand that FGIDs, like many other health problems, are multifaceted and must be approached from various angles, including the angle of mental health. By looking at the problem in this way, clients ideally will come to understand that the mental health professional may be only part of the solution and that their nutritionist, physician and perhaps other team members might have roles to play as well. In the great majority of cases, a team approach is most effective.
That said, counselors who are trained in empathic listening and who practice Carl Rogers’ unconditional positive regard can be hugely beneficial to clients with FGIDs. Many of these clients have been talked down to, lectured at and even blamed for their gastro distress. Many have been told it is all in their head and that they are simply too stressed or overwhelmed. Many have felt attacked or accused by family members, friends, colleagues or health professionals. A counselor who is paying attention with compassion, seeking to understand the person’s discomfort and attempting to connect both emotionally and cognitively with the distressed client can be a wonderful catalyst, providing the healing space needed to help the client begin to get well.
Teach self-monitoring skills: Within the therapeutic relationship, the counselor can provide information to help destigmatize the FGID, which reaffirms for the client that it is perfectly normal to feel stressed about symptoms that seem unresponsive to medical treatment. Additionally, counselors can play an important role in helping clients establish an effective and personalized style of self-monitoring that will aid them in developing more insight and objectivity related to their condition. This is valuable in helping clients identify factors that increase or decrease their symptoms. Self-monitoring in this way can be analogous to using worksheets or logs to help a client with depression or anxiety. Margaret Wehrenberg, in her book The 10 Best-Ever Depression Management Techniques, recommends identifying triggers as the first technique to use with clients who are struggling with depression. A similar approach, applied in the context of the steps mentioned previously, may be appropriate for FGIDs.
Jeffrey Lackner, a research psychologist at the University of Buffalo Behavioral Medicine Clinic, has written a self-help book called Controlling IBS the Drug-Free Way in which he suggests that clients first track their symptoms in a daily IBS diary. Specifically, he recommends that clients should note when symptoms occur and what triggers them. In addition, he recommends that clients use a daily stress worksheet to write down stressful situations, thoughts related to what was happening during the situation and techniques that were used to cope. He believes it is important for clients to monitor their symptoms for several reasons. “Tracking your symptoms will help you identify more subtle triggers of your symptoms and how you respond to them,” he writes. He then adds, “Monitoring creates a little distance between you and your symptoms so that you can see the big picture more clearly.”
Recommend relaxation training: Another way counselors can support these clients is by introducing, demonstrating and helping to monitor a regular program of relaxation training. Lackner suggests controlled breathing, muscle relaxation and visualization exercises.
Many clients with FGIDs have a chronically activated fight-or-flight stress response. As Lackner writes, “Diaphragmatic breathing … activates the part of the nervous system that puts a brake on the fight-or-flight response. It’s impossible to be physically relaxed and stressed at the same time, so that by controlling your breathing patterns you override the physical part of stress that can aggravate bowel symptoms.”
The authors of Trust Your Gut also include relaxation in their programs and recommend that patients work on getting grounded, a term they define as “being calm, centered, relaxed and focused.”
Offer or recommend hypnosis: Counselors can also assist clients with FGIDs through the use of hypnosis. Clinical psychologist Olafur Palsson, an expert in hypnosis for gastrointestinal disorders, writes, “Clinical hypnosis is a method of inducing and making use of a special mental state where the mind is unusually narrowly and intensely focused and receptive. In such a state, verbal suggestions and imagery can have a greater impact on a person’s physical and mental functioning than otherwise is possible.”
Palsson also states that during the past 15 years, research has shown that hypnosis can influence gastrointestinal functioning in powerful ways and is particularly effective in helping patients with IBS. In a study at the University of Sweden, for example, researchers found a 40 percent reduction in symptoms of IBS and observed long-term relief even for the most severe symptoms. What intrigued the researchers was not only the high percentage of patients who got relief but also the cost-effectiveness of the intervention. The hypnosis sessions took place in a regular health center, so there was no need for patients to attend a specialized treatment center.
Palsson offers an encouraging outlook on hypnosis for gastrointestinal functioning: “This benign and comfortable form of treatment will hopefully become a more popular treatment option for GI patients — especially for those who have not received much relief from standard medical management.”
Offer cognitive behavior therapy: Charles Burnett, nationally known for his work with patients suffering from chronic illness, says, “Cognitive behavioral therapy [CBT] is not a cure for functional gastrointestinal disorders, but the tools and skills developed during therapy can dramatically reduce the stress of coping with a chronic condition.” Importantly, Burnett points out, “CBT helps to shift functional GI symptoms to the background, so patients can experience decreased depression, reduced anxiety and improved quality of life.”
Furthermore, in a 2013 review study published in the World Journal of Gastroenterology, the researchers concluded, “There is increasing evidence for the efficacy of CBT in alleviating the physical and psychological symptoms of IBS, and it has been recommended that it should be considered as a treatment option for the syndrome.”
Note that studies have found not only psychological benefits from CBT but physical ones too. Again, the mind-body connection is paramount. Here’s an example of how this can play out: Many people who suffer from FGIDs worry about finding a bathroom in time to avoid an embarrassing accident in public. CBT can give these clients tools to help lessen their stress, which in turn may ease their actual physical symptoms.
In particular, CBT is often used in cases of IBS — one of the most common forms of FGIDs — because it enables clients to overcome cognitive distortions related to their symptoms. To help clinicians recognize all-or-nothing or absolutistic thinking, Bolen offers the example of a client who maintains the irrational thought that her symptoms are completely unpredictable and unmanageable. Bolen suggests that once this person learns to identify triggers, she will better understand when and how her IBS is likely to manifest, and she will be better equipped to deal with the unpleasant symptoms.
Most counselors are trained in the basic tenets of CBT and should be able to effectively help FGID sufferers with this therapy. In recognition of this, a 2007 review article in Psychosomatics emphasized the “great need” for FGID behavioral specialists.
My hope is that as a result of this article, counselors will feel more confident in helping clients with FGIDs by drawing upon evidence-based therapies ranging from relaxation training to CBT. It is gratifying to know that we possess the knowledge, training and skill to help alleviate the suffering of those coping with this debilitating and frequently misunderstood health condition.
Lauren Mirkin is a licensed clinical professional counselor and licensed dietitian/nutritionist. Contact her at email@example.com.
Letters to the editor: firstname.lastname@example.org