Psychological Treatments in Functional Gastrointestinal Disorders

A Primer for the Gastroenterologist

Olafur S. Palsson; William E. Whitehead

Disclosures

Clin Gastroenterol Hepatol. 2012;11(3):208-216. 

In This Article

How to Best Ensure Effective Referral for Psychological Treatment

Referral of an FGID patient for psychological treatment is often a delicate matter. Patients generally consult a gastroenterologist with the expectation of being investigated and treated for organic disease. They may be unaware of the influences of emotions and the brain on gastrointestinal functioning and may not see psychological treatment as relevant to their gastrointestinal problems. Any suggestion of such treatment is easily misunderstood as indicating that their gut symptoms are a mere psychiatric problem. For good probability of success, psychological referral therefore requires tact, correct timing, good doctor-patient communication, ensuring that the patient clearly understands the rationale for referral, and also considerable effort on the part of the doctor or clinic staff to manage the referral. The following steps can help to ensure high probability of successful referral.

Introduce the Role of Psychological Influences and Psychological Treatment Early With Functional Gastrointestinal Disorders Patients

When a psychological referral is mentioned for the first time after a course of medical treatment has failed to produce satisfactory results, the patient is more likely to interpret this as the physician giving up on finding the cause or treatment for the gastrointestinal symptoms. Conversely, if psychological treatment has been a part of the picture the patient has of management of the disorder from the beginning, it may instead seem like the logical next step in treatment efforts. This early introduction of the brain-gut relationship and psychological treatment in the disorder can be in the form of a brochure given at the end of the first visit, as well as incorporated in education of the patient when the diagnosis is verbally explained.

Reassure the Patient That the Correct Diagnosis Has Been Made

Patients who think that they may have an organic disease and have little confidence in their functional gastrointestinal diagnosis are unlikely to be accepting of referral for psychological therapy, because they are likely to see it as inappropriate and even a reckless distraction from pursuing the "real" cause of their symptoms. Thorough explanation of the disorder and the reasons for confidence in the diagnosis, coupled with reassurance that it is highly unlikely that alternative dangerous medical problems can account for the symptoms, is advisable before referral for psychological treatment is discussed.

Establish a Firm Therapeutic Alliance

If the physician makes clear that he or she is committed to working with the patient to pursue whatever means are possible to achieve the best symptom reduction and quality-oflife enhancement and discusses the different options for this purpose with the patient as a partner in that endeavor, this sets the stage for discussing psychological treatment as a logical part of overall symptom management.

Explain Thoroughly the Rationale for the Psychological Treatment

As emphasized by Drossman et al[3] in the American Gastroenterological Association technical review on IBS, explaining to FGID patients the rationale for referral for psychological treatment is crucial. It may be the single most important factor for a referral to work. This explanation should first of all include why psychological treatment is likely to help. For that purpose, explanation of the brain-gut axis and the way the brain down-regulates or amplifies pain perception and gut activity is essential. One should also explain that this control is tuned by both strong emotions and stress, and that psychological treatment can use that same mind-body relationship to neutralize symptoms and the impact of emotions. Because the effects of stress and the gut are apparent to the patient from his or her own experience, examples such as nausea, butterflies in the stomach, or lump in the throat in response to strong emotions can help illustrate this discussion. Second, the fact that numerous studies show that psychological treatments improve outcomes for patients with FGID compared with medical treatment alone should be discussed, especially the evidence for the particular therapy being proposed.

Identify Suitable Local Service Providers

There is great advantage to identifying one or more suitable therapists for referral in the community and learning which therapies they can provide that are appropriate for FGIDs before referral is discussed with the patient. Relying on the patients' initiative to find an appropriate therapist is unlikely to succeed, because their understanding of what is required may be limited. Taking the trouble to find suitable local therapists and learn about their services can pay off handsomely, because a good provider can be used again and again for referrals. If the gastroenterologist already knows what type of psychological treatment will be used and can describe how it works in general terms, this is more credible to the patient and can facilitate follow-through. Appropriate therapists are generally clinicians who are experienced in treating physical health problems, and preferably gastrointestinal disorders, with psychological methods. In general, mental health providers who list health psychology or behavioral medicine as their focus of practice are likely candidates for referral. For finding therapists who provide particular types of psychological services most suitable for FGIDs, consulting online resources for therapist referrals can also be helpful. Useful Web sites for finding therapists in any part of the United States include http://www.abct.org and http://academyofct.org for CBT, http://www.asch.net and http://www.ibshypnosis.com for hypnosis, and http://www.bcia.org for pelvic floor biofeedback. Physicians practicing in small towns or rural areas may not be able to find providers of these psychological services locally but should consider locating providers in the nearest major urban center, because patients may be willing to travel some distance for a short course of such specialized treatment.

Communicate With the Psychological Services Provider

Many gastrointestinal patients will not be able to effectively convey the goals of referral for their FGID problem to the psychological services provider. It can therefore be greatly advantageous to provide the patient with a referral letter explaining the rationale and expectations for the referral. The letter should make clear that what is being sought is a brief course of adjunctive therapy, and it should be clearly stated whether the desired principal goal of the referral is to treat affective symptoms or the gastrointestinal symptoms. It can also be very helpful to request a written report back from the therapist if treatment does not seem appropriate or if therapy response is poor, so that other options can be selected instead, and to encourage the provider to telephone about coordinating psychological treatment with ongoing medical treatment.

Place Emphasis on Continuation of Gastrointestinal Care

Emphasizing both to the patient at the time of referral and in the referral letter to the therapist that the gastroenterologist will continue to manage the overall gastrointestinal care of the patient can reassure patients who have anxieties that he or she is not being "dumped" and give the therapist a better understanding of the context for his or her work with the patient. Encouraging the patient to schedule a return gastrointestinal visit at the end of the course of psychological treatment to assess progress and decide on next steps if needed will further reinforce this sense of continuation of care and strengthen the doctor-patient therapeutic alliance.

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