Gut Check: Laurie Keefer, PhD, on Gut-Directed Hypnotherapy

Dr Laurie Keefer joins Dr Brian Lacy to discuss brain-gut behavioral therapies, including hypnotherapy, and how they can help patients effectively cope with the chronic symptoms of digestive disorders as well as depression and anxiety.

Brian Lacy, MD, is a professor of medicine at Mayo Clinic-Florida in Jacksonville, Florida. Laurie Keefer, PhD, is associate professor of medicine and psychiatry and the director for Psychobehavioral Research within the Division of Gastroenterology at the Icahn School of Medicine at Mt. Sinai in New York City.

TRANSCRIPT:

Welcome to Gut Check, a podcast from the Gastroenterology Learning Network. My name is Brian Lacy. I'm a professor of medicine at the Mayo Clinic in Jacksonville, FLaurieda, and I am absolutely delighted to be speaking today to Dr. Laurie Keefer, professor of medicine and psychiatry at Mount Sinai in New York City. Our topic today is one that is of great interest to providers of nearly every specialty and to patients as well—gut directed hypnotherapy. Laurie, thank you for joining this podcast today.

Let's begin simply in order to set the stage for our listeners. Brain gut behavioral therapies are used to treat a number of highly prevalent disorders of gut brain interactions such as irritable bowel syndrome or IBS and functional dyspepsia, FP. But brain gut behavior therapy is a really kind of a big broad umbrella term. What types of therapy are considered a brain gut behavior therapy or maybe what we'll call BGBT?

Dr Keefer:

Great question, and thank you again for inviting me to talk about this topic. As you know, I'm very passionate about all things gastro-psychology, but sure. So brain gut behavior therapies are really a class of therapies. They're clinician-administered, they're brief, their skills-based interventions. and their goal is really designed to facilitate coping with the chronic symptoms of our digestive disorders, irritable bowel syndrome, functional dyspepsia, et cetera. Most of the brain gut behavior therapies are actually adapted from really powerful behavior therapies used for a lot of other psychological disorders, anxiety and depression, chronic pain. So I like to think of them as a class of therapies that we've really mastered in the psychology space, but have come back and personalized specifically to things affecting to the gut.

Dr Lacy:

I like that as a great teaching point for our listeners in that this is not something brand new. There's a lot of data behind this that's been successful in other areas and maybe we've just fine tuned things a little bit to make it work. So in our field, so Laurie, before we discuss hypnotherapy in detail, can you tell our listeners how these therapies might work? Do these techniques work on the brain gut access?

Dr Keefer:

Absolutely. So that's the exciting part about them. So they have been personalized. There's been an explosion of science in this area, neuroscience, cognitive science, behavioral intervention science, over the last couple decades that really make us feel pretty confident in saying that these brain-gut behavior therapies focus on key and importantly modifiable factors that affect how our brain interprets symptoms coming from the gut, that brain-gut connection. So a lot of our therapies are gut-based, right? A lot of the medications are, these are really kind of hitting it from the brain perspective. So if you think about some of the mechanisms that we know drive GI symptoms, things like acute and chronic stress, autonomic nervous system arousal, that false alarm of fight or flight responses, that's a target of brain-gut behavior therapies because we know that that affects the way the brain and gut communicate— fear of GI symptoms, avoidance of situations where somebody might have a GI symptom, avoidance of foods, avoidance of going out in public because a bathroom's not available. Sort of the superstitious avoidance almost that people will develop initially as a normal reaction to having a GI symptom, but then eventually becomes problematic.

So again, that brain-gut connection, fear, symptoms, pain, amplification of pain signal. So we know that people with disorders of gut-brain interaction tend to interpret pain at the level of their limbic system and the emotional centers of the brain; they feel emotionally upset about it. They catastrophize their ability to down-regulate those sensations is impaired. And so those are things, again, we can teach skills, we can teach strategies. And then I think I guess— 1, 2, 3, the fourth one is hypervigilance, right? So that I always say it's like that background app tracking your location. It's always scanning your body for cues that there might be a symptom arising or being overly aware of sensations that we always experience. But when you have that dysregulation in the gut-brain axis, you're kind of having those false alarms throughout the day. So I would say those are the 4 main targets of our brain-gut behavior therapies, and as you can tell, they're really focused specifically on the way symptoms are experienced. So symptoms at the level of the gut, how they're experienced at the level of the brain. Our job is to interrupt that process.

Dr Lacy:

I like all of what you said to such an amazing degree, but I like the idea of how symptoms are experienced because they're experienced differently in different patients. And I like this whole concept of behaviors that are modifiable, how all these things are going to work to modify this maladaptive behavior for many patients. So Laurie hypnotherapy is kind of an interesting history. We don't want to spend half an hour talking about the history of hypnotherapy, but can you tell us a little bit about the history of hypnotherapy and then when it first came into vogue and how it was initially viewed by the medical community? I think there's still some myths and misconceptions out there.

Dr Keefer:

Absolutely. So I mean we actually first have documented in history hypnosis from the 1770s. That was sort of the theory of mesmerism, animal magnetism, and you could sort of use all these fancy techniques to kind of get people into an altered conscious state. Fun fact in American history, Ben Franklin was actually commissioned here in the late 1700s to go over to Europe and investigate scientifically whether mesmerism or animal magnetism was a real phenomenon and whether we needed all those fancy tools. He concluded that yes, the state of consciousness was real, but all the fancy techniques, the batons and the wands and the potions were not necessary. And that's when it got incorporated into medical management. So we started using hypnosis for surgical procedures. They found that people died less on the table if they were hypnotized first. Really, I mean, this has gone on for hundreds of years at this point. I think it lost a little bit of its power when we discovered ways to anesthetize people that didn't involve hypnosis like everything else. The other interesting thing is hypnosis used to be used to suppress acid in the esophagus before PPIs came out. And now obviously we have a quicker fix for that. But I always like to point that out that there's a lot of data and anecdotal experiences with hypnosis long before it became something for brain gut behavior therapy.

Dr Lacy:

So I know that a lot of providers when they speak to patients about this, hear about some of these myths and misconceptions, and it's kind of fascinating that Ben Franklin was really an early myth buster, but could you maybe just tell us a few of these myths that might help educate our listeners so they could communicate that to patients or to other people?

Dr Keefer:

Yes. I think that it's really important actually for the doctors to address those myths upfront. I think one of the most common concerns that patients have is that they're going to lose control or that the therapist is somehow going to insert thoughts or ideas that they don't want. And that's where you start to get into, maybe it's against my religion or maybe it's something that I am not comfortable with in terms of my views and beliefs. So it's really important upfront to talk to patients about this is a voluntary state, this is a state you choose to go into, you can come out of at any point in time. All it requires is you to be open-minded and there's really no mind control here. And unlike what you see, if you've been to Las Vegas and you see the hypnotist up on stage sort of calling on people in the audience to cluck like a chicken or do other kinds of crazy things, those are the same. They're trained to pick the people that are likely to do that if they even had a couple sips of beer. So these are voluntary behaviors in people who are just very willing to participate.

The other thing I think that is a very common myth is that you have to be hypnotizable. So a lot of patients will say, I don't think I'm, that's not going to work for me. I'm way too controlling to have that happen. But the good news is our data shows that hypnotizability is not a predictor of outcomes. So all of our hypnosis studies that show the benefits of gut directed hypnotherapy do not suggest that patients need to be hypnotizable or not. That really doesn't seem to make a huge difference. So everyone can theoretically benefit from the therapy. And then I guess the one other myth I would say is that a lot of times people think that some of our behavioral therapies are incompatible with hypnosis, right? If I'm here to learn skills and really focus on my conscious mind, why would I do a therapy that's about the subconscious? But again, in brain gut behavior therapies, we're targeting arousal, we're targeting beliefs at the level of the brain, and sometimes we need that subconscious access to be able to really kind of break through that.

Dr Lacy:

I like that, and especially the point that this is not mind control. We are not inserting thoughts, and that's really critical to communicate to patients and to providers. So thinking about hypnotherapy, can you explain exactly how you perform this in your patients? What do you really do?

Dr Keefer:

So it's actually a pretty standardized technique. It's kind of disappointing. I think a lot of patients will say, I don't think I was actually hypnotized. But really there's 4 stages. So the first stage is that orienting the person to being present in the moment and kind of concentrating and getting in the mindset. So that's called induction, and we can do that by having people close their eyes. We can have them stare at something. It's the old fashioned, 'you're getting sleepy.' Then the second phase is the deepening, where we really work on physical relaxation, getting the body to be as comfortable as possible so that you can open your mind to suggestions. And this is really important, particularly in disorders of gut-brain interaction where we know that the body is the source of a lot of discomfort and pain. So we really spend a lot of time on that part of really kind of getting the person into that physical comfort.

Stage 3 is where the magic happens. So if you think of stage 1 and 2 of the IV going into the arm of a person, the dose of the medication is what happens in stage 3. That is the gut specific imagery, and that is the gut specific suggestions. So if I were to say, hey, Dr. Lacy, you're smart and people like you, that would not affect your GI tract. You might feel good after the hypnotic suggestion, but there would be no reason to think that that would affect your GI tract. So instead I'm going to say things like in situations where you might've previously felt pain or discomfort, now you feel a sense of calm and confidence. Those are the suggestions. That's the active ingredient that we're really trying to go after in the hypnotic state, and this is what makes hypnosis gut directed hypnotherapy different from meditation or other forms of relaxation because there's this key ingredient in stage 3. And then stage 4 is just the alerting people back into that normal state. I've seen patients who are doctors and go off to their clinic afterwards, they're able to function. There's no sort of long-term effects of having been in a hypnotic trance, and so we sort of get people back to that normal state.

Dr Lacy:

So that last point is such a great teaching point too, because I think some patients say, well, I'll be kind of out of it or in a fog for a while, I won't be able to function. But that's really not true at all, is it?

Dr Keefer:

That's not true at all. Right. This is a very, about 15 to 20 minutes of intense concentration and suggestion, and then if anything, you feel refreshed and ready to roll for the rest of your day.

Dr Lacy:

Wonderful. So recognizing that everybody's different and patients respond to hypnotherapy differently, how many sessions do patients typically require? And you've already kind of mentioned how long the typical session lasts.

Dr Keefer:

So we have a couple standardized protocols for which the evidence is sort of based on. So one is the North Carolina protocol, which is 7 sessions over a 12-week period. The other is the Manchester protocol out of the UK, which is about 12 sessions over a 12-to-16-week period. So we know that that's sort of where the majority of people fall. I would say though, in my clinical practice, what I usually tell patients is that let's give it four visits. You're going to practice a little bit in between because you can tell when someone's practiced, that's how much deeper they get in the session. And usually in as little as 4 sessions, people are starting to notice benefits. And for a lot of patients that's all they need. Other people are like, 4 sessions is good. I'd like to do a couple more. I rarely do more than 6 or 7.

Dr Lacy:

Laurie, I just want to come back on that one little point there. So could you also say that if somebody at 4 weeks just has had zero response, it's not worth continuing?

Dr Keefer:

Usually I would shift gears at that point. Yep. I would do the normal troubleshooting. So are they practicing? Are they resisting? Maybe they have some myths or misconceptions that I failed to identify. Maybe it's making them more uncomfortable. Sometimes people's increased focus on their bodies is not helpful and we need to do some cognitive work instead. And again, this is, I mean, going back to my first point, which is these are clinician-administered for a reason because they do require that collaboration between the patient and the clinician to really make sure we're targeting the right things and the person's having the right experience.

Dr Lacy:

I like that. Kind of like anything else we do with either a diet or medicine, you ask, is this the right plan for that patient or did we just not give it enough time or do we need to pivot a little bit and maybe fine tune, right.

Dr Keefer:

That's right. There's an art to it as a algorithm.

Dr Lacy:

And so thinking about hypnotherapy and disorders of gut brain interaction, we mentioned a few example, but do you think there are some disorders of gut brain interaction or a single disorder that really responds the best or is this really well-versed for all of these?

Dr Keefer:

I think that's a great question. I think when we think through where the evidence is, the science, the randomized controlled trials, those tend to focus on the painful disorders of gut-brain interaction. So irritable bowel syndrome being maybe the most robust data, but also things like functional dyspepsia or gastroesophageal reflux or noncardiac chest pain. And we know that because hypnosis in the brain and pain are all very, very tied together, hypnosis is well tested in painful disorders outside of GI. So I think from a painful perspective, any of our conditions, I've even done it with inflammatory bowel disease pain, I think we can really pretty confidently make a suggestion for that. That said, I use it for a variety of things. Again, these are very customizable interventions. So those suggestions that I use, I've used for motility-based problems, particularly things like constipation. I know we've done a little bit with gastroparesis trying to help things with nausea, anything that has that brain dysregulation, I don't really see a reason why they wouldn't be effective. But we always have to reconcile what would we actually know in our randomized controlled trials versus what we practice.

Dr Lacy:

So let's say you have that patient who does their homework and they're responding well and they're really feeling much better in terms of their brain gut disorder, maybe IBS as an example, what do you tell them about the long-term benefits of hypnotherapy? Is it hours or days or weeks or even longer?

Dr Keefer:

So this is the best part about our brain gut behavior therapies is that unlike medications where you stop taking the medication and you lose the benefit of it, these are skills-based conditions or skills-based interventions. So in hypnosis, for example, there is long-term data up to 6 years posthypnosis where the person did their 7 to 12 sessions of hypnosis in year 1 and didn't do any additional work. And we're still benefiting 6 years later. Now, some patients will come in for boosters, so I might see them for that initial 7-session protocol, and then 2 years later they're like, you know what? I got a wedding coming up. I'm really that the stress is going to cause me to have a little bit of an exacerbation of my condition. I want to do 1 or 2 sessions with you, little bit of a booster. Again, they see the benefit. So it really is a reason to recommend these therapies is that we see the long-term longterm benefits even when the treatment is taken away.

Dr Lacy:

Wow. Really one more thing we should be publicizing because as you mentioned compared to a medicine, you stop the medicine, generally the benefits go away. Now we've got these long lasting benefits really with, it's just phenomenal. So let's think about our patient group and can we identify a patient that is more likely to respond or less likely? Is it that young guy with horrible anxiety that you know is going to respond versus maybe an older woman and without anxiety?

Dr Keefer:

So people surprise you. I think a lot of it comes down to open-mindedness around the hypnosis and the relationship that the clinician has with the patient. So how trusting are they? How much do they believe in the rationale? And like I said before, hypnotizability isn't so much of a important predictor. So you can take people of all different walks of life who are likely to benefit. That said, some people are, we have the luxury of multiple brain gut behavior therapies, right? Hypnosis is one very important one. But some people who have a lot of that anxiety, the self-talk, the cognitions, the avoidance behavior, they may be better suited to a cognitive behavior therapy that really challenges their beliefs. Whereas somebody who doesn't really have those thoughts or avoidance but really has maybe more of the physical somatic complaints, the fatigue, the difficulty sleeping, the low back pain, multiple D GBIs, not just one. Those might be more suited to the hypnosis because of that subconsciousness. So I like to think of it more as the, it is sort of a patient multiplied by what your target is in the intervention that determines whether hypnosis is the right process.

Dr Lacy:

Laurie, I like that a lot. And I want to play off that just a little bit because I was starting to think about patients who should not be referred to hypnotherapy. But one great teaching point is hypnotherapy is just one tool in your toolbox. Maybe it's the first tool, but maybe it's the third or the fifth, so that depends. But is there somebody, you're such an amazing person in this field, is there somebody we should not send to you who shouldn't be sent for hypnotherapy?

Dr Keefer:

I think we have to be really careful with hypnotherapy because it is a dissociative state. And so anyone that would potentially be harmed from being in a dissociative state really would not be a good candidate. And I like to think of, there are some nuances here, but people who've had significant trauma who maybe are currently still experiencing intrusive memories of their trauma, flashbacks, that type of thing, people who have had sexual trauma, I mean, that's definitely someone that you want to have a conversation with before you engage in a hypnotic trance. And then certain personality conditions, some people are very prone to dissociation, and that can be a not good thing that can increase their anxiety or increase their depression or make them want to engage in self-harm. So anything you're doing, you really don't want to just prescribe it out there to everybody not knowing their history and their background. We talk about this with GIS in general, right? Are we assessing for trauma history? This is so common in our DGBI population that we do have to be somewhat conscious that hypnosis may not be for everybody.

Dr Lacy:

Okay, that's wonderful. So a lot of things we should just be approach. This is a very useful technique. It benefits a huge number of people with long lasting benefits, but just make sure we choose the right person for the right therapy. Everything else we do. So you've mentioned medications a little bit, and we know we use medications, we call them neuromodulators to help these disorders of gut brain interaction. But let's think about maybe that patient with IBS and diarrhea, and they're very fearful about going out in public because they might have an accident, although they never did. You talked about that kind of fear and hypervigilance. Do we say you either get hypnotherapy or you get a medicine, or can we do both together? How do you decide on that?

Dr Keefer:

I like to think of combination therapy because I think these disorders are multifactorial. I mean, it's rare that one pathway drives the experience. So most of our clinical trials with brain gut behavior therapies have been done in combination with medications to treat the IBS or functional ASEP as symptoms. So we're never really tested these as standalone interventions. I mean, I think that they certainly could be in a lot of ways, but for the most part, they've always included standard gut medications. Now with the neuromodulators, particularly like antidepressants, so the SSRIs, the tricyclics, there have been some studies that have shown that there may be equivalents between a brain gut behavior therapy and an antidepressant, for example, particularly in the SSRI space. And we also know that tricyclics and SNRIs can be really helpful, not just for mood and anxiety, but also for pain, sleep, appetite, regulation, and even maybe diarrhea. So I think it's helpful to have people consider doing all of these things as needed. They all have different aspects of intervention, and I would, again, I like to think about the integration of all of our options for our patients, recognizing that no one thing probably drives all of the symptoms of these disorders.

Dr Lacy:

Great teaching point. It's not either A or B, but this combination, this augmentation therapy can be incredibly impactful and useful. So Laurie, this has been just an absolute wonderful discussion, but no surprise to me, thinking as we wind down here, any last comments for our listeners?

Dr Keefer:

No, other than I'd love to highlight that we are obviously access to brain, gut behavior therapies is limited by the number of clinicians. And one of the things that I'm really passionate about is trying to increase the availability of clinicians. Obviously, the more psychologists the better, but we actually have started to do training for nurse practitioners as well, and nurse specialists who might be also on the front lines of seeing these patients have a little bit more time to learn some of the strategies. So I just wanted to point out that there are trainings. We just completed a training through the Rome Foundation that is available on demand, but I always want my GI professionals to know that if they have people in their practices, nurses in particular, who have interest in this area, it's a good way to increase the availability of the services.

Dr Lacy:

Wonderful. So Laurie, again, thank you so much for letting your expertise on this important topic to our listeners on Apple and Spotify and other streaming networks. I'm Brian Lacy, a professor of medicine at the Mayo Clinic in Jacksonville, FLaurieda, and you have been listening to Gut Check a podcast from the Gastroenterology Learning Network. Our guest today was Dr. Laurie Keefer, professor of medicine and psychiatry from Mount Sinai in New York City. I hope you found this just as enjoyable as I did, and I look forward to having you join us for future Gut Check podcasts. Stay well. Okay. Well, I'm smarter right now.