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Hypnosis for Irritable Bowel Syndrome - IBS Study
You can visit his website at ibshypnosis.com International Journal of Clinical and Experimental Hypnosis, 54(1): 51-64, 2006 Copyright © International Journal of Clinical and Experimental Hypnosis ISSN: 0020-7144 print / 1744-5183 online DOI: 10.1080/00207140500322933 STANDARDIZED HYPNOSIS TREATMENT FOR IRRITABLE BOWEL SYNDROME: The North Carolina Protocol OLAFUR S. PALSSON University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA Abstract: The North Carolina protocol is a seven-session hypnosis- treatment approach for irritable bowel syndrome that is unique in that the entire course of treatment is designed for verbatim delivery. The protocol has been tested in two published research studies and found to benefit more than 80% of patients. This article describes the development, content, and testing of the protocol, and how it is used in clinical practice. BACKGROUND In 1994, I began a 2-year postdoctoral fellowship in behavioral medicine at the University of North Carolina at Chapel Hill under Dr. William Whitehead, who had spent much of his research career investigating the psychophysiology of irritable bowel syndrome (IBS). Two years earlier, I had completed my doctoral dissertation research in clinical psychology, testing a scripted hypnosis protocol that I had designed to treat chronic stress problems (Palsson, 1993). That study had shown that a scripted course of hypnosis treatment delivered verbatim to a group of individuals could have very substantial beneficial psychological and physiological effects. I therefore had considerable interest in continuing work on developing standardized hypnosis interventions for physical problems. At the time I began my postdoctoral fellowship, a number of reports from England had been published indicating that hypnosis was a highly promising therapy for IBS and seemed to be more effective than anything else for severe and treatment-refractory cases. As we began our work together, Dr. Whitehead and I quickly developed a common interest in designing and empirically testing a fully scripted hypnosis intervention for IBS. We chose this highly standardized approach both for the sake of scientific rigor, because we wanted to investigate how Manuscript submitted November 19, 2004; final revision accepted January 16, 2005. 1Address correspondence to Olafur S. Palsson, Psy.D., Division of Digestive Diseases, CB#7080, Room 1105C Bioinformatics Bldg., University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7080, USA. E-mail: opalsson@med.unc.edu 51 The treatment achieves its benefits and using the exact same treatment with all patients was highly desirable for that purpose, and to make wide generalization of the treatment easier if it proved to be clinically effective. THE CONTENTS AND STRUCTURE OF THE PROTOCOL In consultation with Dr. Whitehead and based on the literature on the psychological aspects of IBS, as well as my past experience from my doctoral research and work with chronic pain patients, I wrote a seven-session hypnosis protocol designed to address the problem of IBS and a shorter session script for an audio recording for patients to use daily at home between clinic sessions. We chose a seven-session therapy format and a biweekly administration schedule to emulate previously published work on successful hypnosis treatment for IBS (Whorwell, Prior, & Faragher, 1984). The nature of the protocol we created was partly dictated by the requirement that it had to be usable without customization with all patients, regardless of their ability to visualize, their pace of hypnotic response, or their need for direct instruction. For this reason, the language of the scripts is very directive, and the style and structure of the sessions are more formal and detailed than might be necessary for many patients. The basic nature and sequence of content in the protocol’s sessions is fairly uniform, consisting of (a) eye-fixation induction, (b) trance- deepening associated with counting and imagined gradual movement down to a different level (going down stairs, going down in an elevator, sinking down on a cloud), (c) guided, systematic physical relaxation, (d) a “therapeutic scene” experienced vividly in multiple senses to enhance dissociation, further facilitate relaxation, and for use as a metaphor for inner comfort and calm (this therapeutic scene is absent in the first session), (e) therapeutic suggestions aimed at changing IBS symptoms and gastrointestinal functioning, and finally (f) trance termination. To illustrate the structure and language of the sessions, the complete script of Session 2 of the protocol (except for the induction) is provided in Appendix 1. All of these session elements are familiar to anybody who practices hypnosis. However, three aspects of the protocol structure that are perhaps not that common should be pointed out here. One is the fact that the protocol was specifically designed to be “modular.” We wanted to be able to easily replace the IBS-specific suggestions with different test suggestions without having to rewrite the entire sessions each time, in case the protocol did not seem to adequately impact IBS symptoms in our early testing. For this reason, all the therapeutic suggestions are found in one circumscribed part of each session, in an “intervention module” in the middle of each session script. Second, the intervention module follows extensive deepening, suggested dissociation, and engagement of the patient in vivid multisensory imagery. This was done with the aim of ensuring that the patients were generally in the most receptive state possible when the therapeutic suggestions were delivered. Third, the therapeutic suggestions in the protocol are typically explicitly tied to the therapeutic scenes that precede them to enhance the impact of the suggestions. For example, in Session 3, after the patient is induced to vividly imagine resting inside a warm and comfortable mountain cabin with thick protective log walls on a stormy winter night, lying on a big, soft bed close to a crackling, cozy fire in the fireplace and experiencing the concomitant sounds, smells, textures, temperature, colors, etc., this imagery is directly linked to the suggested bowel-symptom changes: Relaxing inside a warm, safe, comfortable mountain cabin like this, nothing can disturb your comfort. The thick walls protect you from all discomfort. Even though the storm is howling outside, you can barely notice it in the safe comfort of the log cabin. In the same way, you are protected more and more every day from pain and discomfort in your stomach and bowels. You are becoming less and less sensitive to discomfort or pain until nothing can upset or irritate your intestines anymore. More and more it feels like your intestines are protected from all discomfort, like nothing can upset them, just like you are protected from the winter storms when you are resting inside the mountain cabin. No matter how strong they blow outside, the thick protective walls keep you warm, comfortable, and safe. You can feel comfortable and relaxed inside. Perfectly comfortable and relaxed inside. The intervention strategies we selected in our protocol were multifaceted. They contained five therapeutic elements that I thought might be useful in addressing IBS as I understood the disorder. These were as follows: 1. Changing attention focus to decrease symptom experience. The protocol contains many direct and indirect suggestions for the patients to automatically pay ever less attention to their symptoms. Example: “You pay less and less attention to unpleasant feelings inside you every day, as your sensitivity to bowel pain and discomfort steadily fades away and disappears.” 2. Altering perceptual experience of the symptoms, by suggesting decreased symptom intensity and frequency or a positive change in the quality of bowel sensations. Examples: “And even if you feel discomfort inside, you will most likely notice that it is surprisingly weak, much milder than before . . .” and “In situations where you might have experienced bowel discomfort or pain before, you will probably be surprised to realize that you only feel pleasant, warm, soothing sensations.” 3. Suggestions of overall increased sense of health and comfort. Example: “You become more comfortable and healthy every day, undisturbed and peaceful inside like this beautiful secluded garden.” 4. Suggestions for the intestines to become immune to irritation or upsetting life events. Example: “Gradually it will begin to feel more and more like nothing can upset or irritate your intestines anymore.” 5. Suggestions and imagery to encourage normal and healthy bowel functioning. Example: “You will probably notice after you leave here today that your intestines are more and more functioning with a healthy, steady, comfortable rhythm that does not cause you problems, a healthy natural rhythm that does not disturb your comfort.” Once we had written the protocol, we first conducted preliminary testing of it on two of our coworkers and polished the scripts to ensure that they could be routinely administered without problems. We then invited a couple of patients with severe IBS to receive treatment with the protocol. As soon as we were satisfied that we were seeing good initial evidence of therapeutic impact in these first patients, we began our first formal hypnosis study. RESEARCH ON THE EFFECTS OF THE PROTOCOL The aims of the first study were to quantify how effective our newly constructed protocol was in improving IBS symptoms and psychological well-being and, assuming that it would have a significant impact on bowel symptoms, to test our hypotheses of the physiological mechanism of action. Regarding the latter, we focused on two physiological parameters that we thought would likely be altered by hypnosis and might mediate improvement in bowel symptoms. These were visceral pain sensitivity in the bowel and smooth muscle tone in the bowel wall. Both of these variables were measured in the study with computer-controlled balloon inflation tests inside the lumen of the rectum. We also wanted to see if pain-specific suggestions affected change in visceral pain thresholds or clinical pain, so we divided our patient sample randomly into two subgroups and omitted any verbal suggestions of pain changes in the treatment of one group. Eighteen patients with chronic symptoms that had been unresponsive to standard medical treatment were treated in the study. The results, which have been described in detail elsewhere (Palsson, Turner, Johnson, Burnett, & Whitehead, 2002) were both pleasing and somewhat perplexing. The protocol clearly had substantial impact on the clinical symptoms of IBS. All but 1 of the 18 patients were judged to be improved after treatment. All IBS symptoms measured-abdominal pain, bloating, and bowel functioning abnormalities (hard or watery stools)-were markedly improved after the treatment course, as shown in the top half of Figure 1. Symptoms of anxiety and somatization Figure 1. Effects of the North Carolina Protocol on Bowel Symptoms of IBS Patients in Two Studies. were also greatly reduced after treatment, as seen in Figure 2. On the other hand, the physiological parameters tested (bowel pain thresholds and smooth muscle tone) were entirely unchanged after treatment, making it clear that these aspects of bowel physiology had no role in mediating the therapeutic effect. We were also surprised to find that the subgroup that had not received any pain-specific therapeutic suggestions showed equal therapeutic gain, including equivalent reduction in clinical abdominal pain, compared to the group receiving the full, unedited protocol. We completed this first trial just as I finished my postdoctoral training and accepted a position as director of a behavioral medicine clinic at Eastern Virginia Medical School in Norfolk, Virginia. There I began to use this standardized protocol routinely in my own clinical practice, as it had shown itself to be helpful for most patients. I did, however, want to repeat formal testing of the protocol on a different patient sample to confirm the degree of therapeutic effects that could be expected, since our initial patient sample had been small. I also wished to further pursue the quest for understanding the physiologic basis of the impact of this treatment on bowel symptoms. Figure 2. Effects of the North Carolina Protocol on Psychological Symptoms of IBS Patients in Two Studies. I, therefore, designed and carried out a second study, treating 24 patients with the protocol and using the same main clinical-outcome measures as in our prior study. As in the first study, the patients we enrolled had already failed to benefit from medical management of their IBS. This time, the physiological hypothesis tested was that hypnosis effected its improvement in gastrointestinal functioning via impact on autonomic nervous system activity. This idea was based on indications from several published studies that autonomic dysfunction plays a role in IBS. To assess autonomic-activity changes, we used a well-standardized psychophysiological stress profile procedure to measure surface parameters of autonomic activity (heart rate, systolic and diastolic blood pressure, skin temperature, and skin conductance), as well as skeletal muscle tension (forehead electromyographic recordings) before and after the hypnosis treatment course. As in the previous study, most of the patients (21 out of 24) improved from the treatment, both in bowel symptoms and in psychological symptoms. The posttreatment improvements in IBS symptoms were nearly identical to those of our first study (see Figure 1). This provided a nice confirmation of our assumption that by using an entirely standardized verbal intervention, one can achieve closely replicable clinical effects on IBS in different patient samples. In this second study, we further found that all treatment responders remained improved at 10-month follow-up. However, we found again that the physiological variables we tested did not reflect the substantial changes in bowel symptoms or psychological symptoms. Of all the physiological parameters measured, only finger skin conductance (that is, sweat gland activity) showed a small change after treatment (see Palsson et al., 2002, for further details). In short, the conclusions of our empirical testing of the standardized IBS treatment protocol to date are that it produces highly replicable results that constitute substantial and long-lasting improvement in bowel symptoms for most patients and that this treatment is also associated with improved psychological well-being. On the other hand, it remains unclear in spite of our research through which mechanisms hypnosis achieves its beneficial effects on bowel symptoms. Apart from treating patients in our research studies, I have completed treatment on more than 70 additional patients with this same protocol and have continued to enjoy success with it equivalent to our formal studies. As more and more clinicians have become aware of the protocol and our promising outcome data, we have started sharing the whole treatment protocol at no charge with clinicians nationally and internationally. We now call it the North Carolina Protocol, to distinguish it from the other well-outlined and empirically tested hypnosis approach to IBS, that of the Manchester group in England. Because more therapists are continually adopting our treatment approach, it may be worth outlining here how I have typically utilized the protocol in clinical practice. HOW TREATMENT WITH THE NORTH CAROLINA PROTOCOL IS CONDUCTED The initial visit of an IBS patient presenting for hypnosis treatment consists of a thorough general clinical interview that includes medical and psychological history, discussion of the nature and severity of the current symptoms, and review of past treatments and conclusions of any medical evaluation and tests. I typically want to make sure that the patient has been well evaluated medically and that a firm diagnosis of IBS has already been made. I also use this first visit to establish rapport, educate the patients about IBS as needed, and orient the patient to hypnosis. I make every effort to give the patient a realistic expectation of therapeutic gains. I explain that the treatment offered is not a cure for IBS and that not everybody improves, but the research as well as my own experience indicate that about 4 out of every 5 people benefit from the treatment. I further explain that the patient may or may not feel noticeable improvement right away and that some people only begin to feel markedly better halfway through the treatment course. I give the patient symptom log sheets to record their IBS symptoms daily in detail, and I recommend that the patient keep diet, medications, vitamins, and supplements consistent as much as possible during the treatment course (unless changes are recommended by a physician) to enable us to observe the effects of the intervention without confounding influences. The second visit is generally scheduled at least 2 weeks after the first one to allow a 2-week symptom baseline. I strongly emphasize to the patient to record the bowel symptoms daily in the interval between the first and second visits and to bring the symptom record to the second visit. The scripted treatment course is initiated in the second visit and is optimally conducted approximately biweekly until the entire seven-session sequence is completed. I try to avoid an interval longer than 3 weeks if at all possible, especially in the first half of the treatment course. I typically treat patients with the exact protocol and use the hypnosis scripts verbatim, except for occasionally making minor adjustments in the inductions to account for varying rates of patient response. On rare occasions, if the patients have unusual symptoms that I believe should also be targeted, I make additions to the therapeutic suggestions of the therapeutic module parts of the scripts (such customizations were not made in our studies). The scripted hypnosis sessions take between 20 and 40 minutes to deliver, so they can easily be accommodated within regular therapy hours with time to spare to address any matters of importance. I avoid, however, carrying out much psychological therapy other than the scripted hypnosis intervention in hypnosis-treatment visits. At the end of the second treatment session, patients receive the hypnosis audio recording for home use. The home practice is an integral part of the treatment, and I strongly emphasize the importance of it with patients. If people report having a hard time using the audio recording daily, I ask them to do their best to use it at least five times a week. Compliance with home practice is generally good. The audiotaped home exercise contains a self-hypnosis type of induction to aid patients in eventually switching to self-hypnosis home practice once they are very familiar with the recorded hypnosis exercise, and I invite them to do so. However, many prefer to continue their home hypnosis practice with the aid of the audio recording throughout the treatment course. In the sixth treatment visit, I ask patients to again start recording their bowel symptoms on the standard diary forms and to bring them to the last session. I generally graph this information after the last hypnosis session and show the patient in graphic form the comparison of their current and pretreatment symptom levels. This is a good way for patients to get an objective picture of their own therapeutic gains and also creates a summary of treatment change to keep in the patient file. Once the seven-session sequence is completed (which typically takes about 3 months), the therapy course is finished and no further treatment for IBS is generally required. However, I have typically offered my patients the opportunity to return for a 3-month follow-up visit as a booster session, because many patients find that helpful. In that visit, I generally repeat one of the sessions from the protocol, allowing patients to pick their favorite session, although I have sometimes created a custom therapeutic scene based on the patients’ requests instead. I have learned over time from these follow-up visits that most patients continue to improve further in their bowel symptoms in the months after completing the standard treatment course. It has been my experience that the occasional patient who does not respond to the standard seven-session treatment sequence typically does not benefit either from additional sessions. I therefore have come to discourage further treatment efforts with hypnosis if there is little or no response. I also do not continue therapy beyond the seven sessions and a single follow-up with patients who have responded well to treatment except in uncommon cases when there seems to be a particular reason to do so (such as to address new or atypical symptoms that might be helped with a focused customized hypnotic intervention). Both my clinical experience and our research data have shown that treatment responders typically remain better for a long time. In a few cases, however, patients have contacted me years after the end of treatment and told me that they are experiencing a relapse (often brought on by unusually stressful life circumstances). In such cases, I have found that the patients can often bring their symptoms back under control if they use their audio exercise again daily for a couple of months. The clinical effects of the North Carolina Protocol need to be further confirmed in larger studies than have been conducted to date, and especially in controlled studies comparing this intervention to other treatments known to have some effectiveness for IBS treatment, such as medications or cognitive-behavioral therapy. In the meantime, the protocol offers advantages that make it an excellent therapy option for patients who do not experience adequate relief of symptoms from standard medical interventions. It provides a brief and fixed course of therapy, it is extremely easy for clinicians to use, it is well received by practically all patients, and the experience to date shows that it can be expected to reliably improve the bowel symptoms of the great majority of IBS patients who have been unresponsive to other treatments. We continue to share the protocol for free with licensed health professionals who wish to use it and have proper training and experience in clinical hypnosis. There are now more than 200 clinicians using the protocol nationwide in the United States, and the numbers of therapists using it and patients benefiting from it continue to grow steadily year by year. OLAFUR S. PALSSON REFERENCES Palsson O. S. 1993 The psychological and psychophysiological effects of stress reduction by means of group hypnosis intervention. Unpublished doctoral dissertation. Virginia Consortium for Professional Psychology. Palsson, O. S., Turner, M. J., Johnson, D. A., Burnett, C. K., & Whitehead, W. E. (2002). Hypnosis treatment for severe irritable bowel syndrome: Investigation of mechanism and effects on symptoms. Digestive Diseases and Sciences, 47, 2605-2614. Whorwell, P. J., Prior, A., & Faragher, E. B. (1984). Controlled trial of hypnotherapy in the treatment of severe refractory irritable-bowel syndrome. Lancet, 2, 1232-1234. If you have any questions about the protocol, you can go to Dr. Palsson's website ibshypnosis.com | |||
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