Psychotherapy for the troubled and irritable bowel.
The Nature and the Meaning of Gut Symptoms
If we have an injury or infection, nerve impulses from the affected part alert the brain to the damage and instigate appropriate reactions. But the pain or other sensations that we feel exist not in the body, but in the brain and the reactions are instigated by the brain. After all, pain can be experienced in a limb that is no longer there and abolished by hypnosis or drugs that act on the brain.
In IBS, there is usually no obvious injury to the gut. Instead, there is often an increased sensitivity, but that, of course, is detected by the brain and referred to the gut, where it may induce such gut reactions as diarrhoea, abdominal distension or constipation. If follows that the same reactions can be evoked in the brain by anything that reminds a person of the context of a previous gut illness. This might be a particular food that was eaten, a location, the person you might have had a devastating argument with. Similarly the meaning of the current situation may be translated into symptoms that represent it. For example feelings of disgust may provoke nausea, diarrhoea may represent a lack of emotional control caused by anger or severe anxiety, constipation – a fear of letting things out. Food allergy/intolerance is common in IBS may not always have a biological explanation; it may instead provide an explanation and solution to an extreme state of bodily insecurity. This would explain why the food, to which a person is ‘allergic’ may have particular significance.
Symptoms ‘induced by association’ are more likely to occur when one has not been able to process what has happened. For one of my patients, his abdominal rumblings betrayed his guilty secrets. For others, constipation may represent the fear of letting the emotion out. But the meaning of such symptoms are not stereotypical; they depend on the individual and the context.
Trauma is written into the script of embodiment. When something has happened that cannot be acknowledged and talked about, it is often projected into the body and expressed as symptoms. So our bodies may be thought of as vehicles through which we express our encoded feelings about what has happened. These could be something as familiar as laughter or crying, work, exercise, conflict and, of course, illness.
‘Focussing on her symptoms, she remained alone with her fears. She was hypervigilant, scrutinising her bodily feelings for clues, all too aware of the injustices of the medical system, the tyrannies of investigations, the dangers of invasive treatments. She could not acknowledge that her body was expressing her fears. Instead her unexplained illness had become not only the source of her anxiety, but also a palpable focus for resolution. Why couldn’t they cure her? Why did the treatments not work? And so, she maintained the never-ending quest for a medical solution for all the insecurities that were lodged in her body.’
In such situations, psychotherapy may create the environment whereby gut feelings and reactions to what has happened can be brought to mind, understood, worked through and resolved.
The Role of Psychotherapy
Most contemporary training programmes in psychotherapy offer instruction in brief, ‘empirically validated’ therapies that consist of highly specific techniques and address discrete diagnostic categories, such as depression, eating disorder, panic attacks, addictions or phobias. This technical focus loses sight of the importance of the unique relationship between the therapist and their client. Nevertheless, psychotherapeutic research has consistently shown that the quality of the therapeutic relationship is the most important factor determining recovery.
It is usually the fractures in our personal relationships that upset us, affecting how we see ourselves in relation to others and bringing up existential issues that may be difficult to acknowledge and deal with. These include guilt, shame, anxiety about death, loneliness, loss of meaning, loss of agency and control, confusions over identity and never feeling good enough. These are the sorts of issues that may achieve representation through gut symptoms. As Friedrich Nietzsche once declared, ‘all prejudices come from the gut’. These are the kind of issues that are so often played out in the consulting room, where they can be examined and worked through. They may be rekindled by particular events, but resolution often involves identifying the nature of what has happened and working to come to terms with the theme of what has happened.
The Way I do it.
I was trained in a psychoanalytical model, though the way I practice might be better described as existential – concerned with a person’s concept of who they are, anxiety about death, the loss of loved ones, how to live a meaningful life, coping with ageing, isolation, freedom and authenticity. This is more about meaning than behaviour or process. I do not employ any particular technique; I try to engage my whole personality and training with that of my patient and let myself experience where they are.
In our first meeting, I let my clients tell their story often without interruption, paying particular attention to what was happening when the illness first started and why was that so important to them, what situations make the illness worse and what makes it better, and what their illness seems to represent. I give their story my full attention. I am curious and not judgemental, though I may at times, like Lieutenant Columbo, note any inconsistencies or omissions.
I pay particular attention to their posture or body language or development of symptoms during the session. For example, in the silences, I may hear a loud rumble from my patient’s tummy, and enquire ‘what does you tummy think about it?’ Or when she crosses her legs and moves her ankle up and down, I might ask what her ankle is saying. Freud once said that ‘dreams are the royal road to the unconscious’. The same might apply to bodily symptoms. There is never one interpretation for symptoms, just like there is never one interpretation to dreams. It all depends on the individual.
I also pay attention to the feelings my client’s presence and story evoke in me. For example, I have often noticed how when one patient comes in, I feel so alert and electric I am fizzing with emotion, but when another sits down and starts talking, I find myself falling asleep. And so I wonder what I am picking up. Susie Orbach once said that in therapy, there is no such thing as a body; only the interaction between one body and another.
Being in therapy offers people the opportunity to be heard and understood without fear of criticism or ridicule. With that in mind, I try to promote a trusting therapeutic relationship that allows us to see things in a different way and arrive at a more realistic meaning. This requires the creation of an environment that fosters confidence; a safe haven with secure boundaries, but not so comfortable that it allows a drift into complacency. I focus on what my patient says and only occasionally mention my own experience when I feel this might deepen the relationship.
People often ask how many sessions they will need and for how long. I hedge: it takes time to create a trusting relationship and this will vary from client to client. Therapy can never be formulaic. I prefer to work on a weekly basis in the beginning, but my clients often negotiate longer gaps between sessions as they find their own time and space to think. My experience is that as we engage, their gut symptoms retreat into the background as we grapple with the real issues. Understanding may be enhanced if the symptoms occur and can be examined and resolved in the here and now context of our relationship.
I find it helpful to have worked in gastroenterology, physiology, nutrition and arrived at psychotherapy in my late forties. This means that I can talk the different therapeutic languages and more easily translate between mechanisms and meanings.
A Way Forward.
Finally, it has been estimated that upwards of 50% of medical illnesses are medically unexplained, holistic in nature and related at least in part to the meaning of what has happened. IBS, I believe, is a prime example. This does not mean that all people with IBS need to see therapists. That can never be a practical solution, but I would urge the directors of educational programmes for dietitians, doctors, physiotherapists and nurses to include some understanding on how the vicissitudes of life can make people ill and how they might apply that alongside their particular treatment modalities to help their clients get better. At the same time, I would seek to encourage patients to see their illness in the light of their own personal experience, to share this with the people they trust and find the solution that seems right for them.
The Sensitive Gut 
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