Therapy for IBS: How I try to help.
I enjoy my work. In reality, I hardly think of it as work. It is more like reading a novel or seeing a play; a privileged access to the lives of my patients, the opportunity to connect and understand how what happens affects both them, both in their mind and their body, and use that to try to help them feel better.
There is not really a pathway for what I do. I sort of fell into it after a career which combined clinical experience as a gastroenterologist with research in nutrition and physiology. I never wanted to be tied down to a particular doctrine, I liked working across academic boundaries, but as I reached the age of 50, I felt somewhat shouldered by colleagues into ever more narrow strands of research. I needed a new challenge. So when the Centre for Psychotherapeutic Studies at the University of Sheffield advertised for students to enrol in its Master’s Course in Psychoanalytical Psychotherapy, I applied and to my delight, was accepted. This new venture gave me a whole different perspective on illness, especially those long term conditions, like IBS, that have no obvious medical explanation.
My current practice is predominantly psychotherapeutic, but I use my background in gastroenterology, physiology and nutrition as well as recent insights into neuroscience and trauma to understand the person with the illness. I consider myself a generalist. In that regard, I see my role as a ‘therapist’ for people, who suffer with IBS, as rather like a traditional GP. I try to embrace not only the science but also the context of the illness, observing how what happens in a person’s life can affect their symptoms as well as how being ill affects how they feel. I recognise not only the restrictions that illness imposes on people’s lives but also the anxieties, fears, frustrations and grievances of being ill. And I try to understand the meaning of the illness, both physical and metaphorical in order to help each of my patients find their own path to wellness.
What I do and how I do it is not really a conscious process. I don’t follow a set protocol. The method differs according to what my patients bring to a session. I believe that therapists, whatever their modality, need to be flexible and adaptable.
Being a therapist for IBS requires an attitude of mind that is very different from when I was a doctor. Then I tended to treat the body as a machine that was defective; a mechanical problem to solve. And I told patients what to do and had little time to listen. Now I recognise illness as a consequence of what happens to a person and the way they lead their lives, as expressed through the workings of the body, including the myriad organisms it is host to. My work is a blend of emotional capacity and technique; it involves listening, understanding the context, making connections. I am more interested in what the illness might represent from the perspective of a person’s life history. I try to understand why my patients feel and think the way they do and help them work out how they might modify this. It is a fascinating journey. I am always adapting to and learning from my patients. I no longer feel I need to hide behind my metaphorical ‘white coat’, though being able to talk about the pathology of their illness as well as the emotional content can impart a certain medical authenticity.
There is no ‘cure’ for IBS, though most people do get better in time. Treatment is more about guided self help. I sense that my patients need a blend of information, understanding, support and a little gentle guidance. Information is the easy bit. Understanding comes with listening, especially to what is not being said. Support is largely about holding or ‘containing’ the emotion of illness; the frustration, fear, shame, hopelessness and helplessness, while offering the kind of consistent, non judgemental relationship, they may not have previously experienced. Guidance largely takes the form of course correction or confirmation, a nudge that is so gentle as to leave people feeling it was their idea anyway. People are more likely to adopt a certain change if that is congruent with their own feelings and they feel they have permission to do it. In the quiet of my consulting room, patients usually know what to do; they just need a little help to find it.
Many of my patients tell me they wish to be treated like everyone else, not discriminated by their illness. Just because a person is ill doesn’t make them any less a person. Nevertheless, their illness marks them out as different. The fact that they need special toilet arrangements, have to be on a special diet and take particular medications defines them. I try to hold both realities in mind while helping them recover the person they can be.
I have learnt to tune in to the feelings I am experiencing when I am with each of my patients. Sometimes, I feel so overcome by exhaustion that I find it hard to stay awake. Then when the next patient comes in the air may suddenly seem electric with passion. On those occasions I often need to try to modulate the interaction to try to achieve a more thoughtful engagement. Emotion is always passed on, stimulating the same feeling in another person. I often pick up other feelings; perhaps a sense of hopelessness, or irritation, or reproach. These feelings inform me of how my patient may be feeling. Upon those occasions, it may be helpful to comment, offering ‘a verbal shape to the nameless dread’.
The work requires a degree of compassion. Life experience has ground down some of the more arrogant edges of my personality, making it easier to connect with my patients’ lives, neither intruding not controlling, nor indeed shielding them from the more difficult aspects of their own behaviour. I do not judge, but I try to use the memories of my own struggles with relationships to understand what they might be going through. I never tell my patients what to do, but try to set the scene that facilitates their own conclusions.
In my psychotherapy training I was taught to reveal nothing of my own life. Therapists, my tutors told me, should be abstinent; a blank screen upon which patients can project their phantasies. While I understand the reasoning, I do not entirely agree with the advice. My patients tell me they dislike abstinence. It may be seen as defensive and can promote fear and resentment, which inhibits communication. The therapist should not be wary of revealing that he or she is a real person. Disclosing a shared interest, even a common experience of illness can facilitate projection, leading to greater insight, trust and understanding. Research into the effectiveness of psychotherapy has shown that the different modalities of therapy have roughly equivalent outcomes; the most important factor in a successful therapy is the nature of the engagement between therapist and client. Much the same has been said about the doctor patient relationship.
Psychotherapy can be like flying with the patient in a light aircraft through dense cloud. Neither the therapist nor the patient knows where they are heading and then suddenly something happens and the sky clears. Therapists have to live with not knowing. It is not an easy way to travel; there is always the temptation to seize the control column and occasionally that may even be necessary. There is no right way to do it, although there may be a few wrong ways. Nevertheless, mistakes, as long as they are well meant, are always opportunities to learn.
The work is no quick fix, but given time, my patients do seem to get better.
The Sensitive Gut 