"We're going to calm your brain down, and we're going to calm your gut down.”
Three years ago, the only foods that 61-year-old Janet Westfall could eat were cottage cheese, rice cereal, pretzels, and egg whites.
She’d had Irritable Bowel Syndrome (IBS) for more than 20 years, and her symptoms were steadily getting worse. She couldn’t eat any fruits, vegetables, or meats. Those four bland, off-white foods were it.
“You can just imagine what that did to me,” she tells me. “Malnutrition, severe weight loss, immune system compromise. The best way to describe what would happen if I had anything else, without getting into too much disgusting detail, was: Imagine having a very bad stomach and intestinal flu, where you think you're going to die, and you kind of hope that you do.”
Westfall went to multiple doctors and gastroenterologists at the best hospitals in Chicago, near the suburb where she lives. After a battery of tests they would always say to her that they didn’t find anything wrong.
IBS is a functional disorder, which means that while the body’s function is impaired, its structure is unchanged. Functional disorders come back with normal x-rays, endoscopies, and blood tests, even as a person is suffering horrible symptoms. If Westfall ate food that was hot or warm, it could lead to a flare up. A mouthful of tea, or just plain hot water, could cause a reaction.
Last fall, Westfall was in the hospital on an IV, unable to keep any food down. She thought to herself, where am I going with this? What’s going to happen to me? Then she remembered that she had seen a segment on NBC about Laurie Keefer, a gastroenterologist at Mt. Sinai Hospital in New York who was treating patients with IBS with hypnotherapy. Keefer had said it was helpful in people who couldn’t find relief anywhere else.
“I thought, ‘Well, that sounds like me,’” Westfall remembers. ““Would I have gone ahead and tried hypnosis if other, more normal things were working? I don't know.”
IBS affects about 10 to 15 percent of the population and is one of the most common conditions a gastroenterologist will see. And yet it has an image problem, with a lingering perception that it’s more of nuisance than a real illness, and caused purely by psychological issues.
Peter Whorwell, a gastroenterologist at the University of Manchester, has been treating IBS for more than 35 years. He says that in the 1970s, when he was a medical student, he was told that people with IBS were oversensitive females, and shouldn’t be taken too seriously. But when he started to see IBS patients, he saw how serious it could be.
People with IBS have intense pain, bloating, stomach distension (in some cases, adding nearly five inches to their abdomens), and bouts of alternating diarrhea and constipation. Many also have an “exaggerated gastrocolonic reflex,” which means immediately after eating, there is an “urgent need to empty the bowels,” Whorwell says. Patients are scared of eating anything or leaving their houses because it feels like a permanent stomach flu. At the other end of the extreme, some people with IBS won’t have a bowel movement for days or weeks.
It’s now known that IBS is caused by multiple factors, one being a dysfunction of the nervous system. The brain and the gut constantly communicate with each other; it’s how, for example, your stomach tells your brain that it’s hungry. If that communication becomes overactivated, the brain overreacts and over-feels normal digestive changes and processes, leading to the plethora of nasty symptoms.
“The guts interfere with life so much, don’t they?” Whorwell muses. “If you've got a bit of angina, all you have to do is walk a bit slower, but if you're shitting yourself all day long... 58 percent of our patients are fecally incontinent on a regular basis. A third of them are suicidal. Just about every clinic, one patient will say to me, ‘I feel suicidal.’”
When Whorwell first diagnoses someone with IBS, he’ll try the traditional options: low fiber, some version of a low FODMAP diet (which limits short-chain carbohydrates found in a wide variety of fruits and vegetables), anti-spasm drugs, and either laxatives or anti-diarrheals, depending on which issue the person has. But if none of that works, Whorwell will turn to another form of treatment, one that he’s been validating and promoting since he first used it in the 1980s: gut-directed hypnotherapy.
Hypnosis dates back to an Austrian doctor named Franz Mesmer, who we get the word “mesmerize” from. He incorrectly believed that there was a fluid called “animal magnetism” that made people sick when it was blocked in the body. By waving his hands over a person he could cure them by getting their fluid moving again.
When Scottish physician James Braid saw a mesmerist show, he thought there might be something to it. Not in the fluid, but he saw that people could be put into a trance-like state by asking them to focus intently. He dubbed it “neurohypnosis,” and the concept of hypnosis was born.
Hypnosis gets a bad rap because of flamboyant stage shows, or stories of therapists using it to “regress” their patients to past lives. But perhaps the main reason why it’s not completely recognized by the medical community is we’re still not sure how it works.
But in the past two decades, studies have started to suggest that measurable changes are going on in the brain during hypnosis. In one, from 2000, David Spiegel and collaborators from Stanford Medicine showed participants grids that were either in color or grayscale. In a hypnotized group, the scientists suggested to participants that the color grid was black and white, and the black and white grid was in color. As Jo Marchant writes about the study in her book, Cure: A Journey into the Science of Mind over Body, “in people who were hypnotized, the part of the brain that processes color vision changed when they received [the] instruction. It became less active when he told them that a color grid they were looking at was black and white, and more active when he told them a black and white grid was in color.”
Because the gut is tied to the brain, hypnotherapy seemed to Whorwell like a potential option for treating IBS. But the first thing Whorwell wants me to know about his gut-directed hypnotherapy is that “we're not taking over your mind,” he says. “We are teaching you to control your condition, so you will control it rather than it controlling you. That's what we're going to end up with: You in control of the condition. We're going to calm your brain down, and we're going to calm your gut down.”
One of his most common visual tools is a river. If someone suffers from constipation, he’ll suggest they picture a river floating slowly along, and then imagine it flowing faster. Or, if diarrhea is the issue, he’ll tell them to imagine the water slowing down. If someone is bloated, they might imagine a balloon being deflated. For pain, he’s had patients place their hand on their stomachs, feel the warmth, and associate this with pain control.
Whorwell’s first study in 1984 was on 30 patients with IBS. Half received seven 30-minute sessions of his gut-focused hypnosis, while the others got regular supportive therapy and a placebo medication. Those in hypnotherapy showed a significant improvement in abdominal pain, abdominal bloating, and bowel dysfunction compared to the placebo group. And the effects seem to last. In 204 patients who had received hypnotherapy, 83 percent of those who responded to the treatment were still well one to five years later. Sixty-three percent of them didn’t need any more medication, and in those who were still taking medications, 62 percent of them were taking them less often.
Whorwell’s latest study, from 2015, looked at 1,000 patients with hard-to-treat IBS, an undeniably respectable sample size, and determined that hypnosis had helped 76 percent of them reduce their symptom severity by at least half. All together, he now has more than two dozen papers that have found that hypnotherapy can help people’s symptoms of IBS.
About a week ago, I lay down comfortably on my couch as an April rainstorm fell outside my window. I was video-chatting with Laurie Keefer, a GI Health Psychologist from Mount Sinai, who was going to do a gut-directed hypnotherapy session on me. I don’t have IBS, but I don’t have the most stable GI system either; I regularly suffer from pretty severe acid reflux and bloating. I was curious if one session would have any affect on me at all.
Keefer would be using a completely scripted IBS hypnotherapy treatment on me. It was written in 1994 by Olafur S. Palsson, a Professor of Medicine at University of North Carolina at Chapel Hill who wrote a completely scripted IBS hypnotherapy treatment with William Whitehead. It was based on Whorwell’s research, so that doctors anywhere could use it. It’s referred to as the North Carolina Protocol (Whorwell’s is called The Manchester Protocol).
Palsson says he felt it important to standardize the hypnosis because most gastroenterologists have little experience with it, and vice versa: most practicing hypnotists don’t have experience with gastroenterology.
It’s seven sessions, written word for word, around 30 to 40 minutes each, so that every patient gets exactly the same thing. Like with Whorwell’s hypnosis treatment, multiple studies have shown that this script can result in a majority of people ending up with at least a 50 percent reduction in symptoms. This success rate is more impressive, Palsson tells me, when you consider that these are patients for whom every other treatment option has failed. There are now close to 600 therapists using it in the US.
I ask Palsson if he thinks hypnosis as a cure for IBS perpetuates the old stereotype that IBS is a purely psychological disease. “I think that is absolutely incorrect,” he says. “We have only started to learn how closely the brain and the gut are interconnected. In the past, people thought of the brain and the gastrointestinal tract as two independent organ systems. But the brain participates very actively every moment of the day in controlling the functioning of the gastrointestinal tract. Hypnosis works by helping normalize the brain's control.”
Palsson tells me that the hypnosis isn’t just making a person feel better mentally, and perhaps cope better—it’s actually making changes in the body.
They have tracked people’s bowel movements, by counting how many diarrhea and constipation episodes there are out of total bathroom visits, and found them to reduce over the course of the treatment. Pain sensitivity can be tested by inserting a balloon into a person’s back end (yup) and inflating it until they report feeling pain. People with IBS can tolerate less than half of what healthy people can—but after they have hypnotherapy they can stand just as much as others.
“The bowels are handling waste material differently and the consistency of the stools are changing over time,” Palsson says. “Yes, that's the result of a psychological treatment. But it shows that we're not just changing the way you feel about your problem. We are actually changing the way the gastrointestinal tract is handling its everyday function.”
Most importantly, a person does not have to believe in hypnotherapy for it to be effective. “I have had patients who specifically do not believe that it's going to do anything,” Palsson says. “And it still works great. All I care about and need is for them to give this a fair chance, listen to my words, and imagine to their best ability the things that I talk about."
There’s been a recent push to move the hypnosis online—and perform it via telemedicine—something Keefer tells me is going to be transformative. There aren’t that many practitioners available, even with the scripted protocol. This way she can treat people who wouldn’t be able to commute to her office. And people can experience the hypnotherapy at home, where they’re more likely to be relaxed. They can lie on their bed, in their pajamas, in their own space, not an unfamiliar doctor’s office where the commute itself and proximity to a bathroom might cause additional stress.
Keefer directed me to do some deep breathing, picture a tranquil beach setting, and then began to tell me reassuringly about how calm and undisturbed my gastrointestinal tract was going to feel that day. Her voice is light and calming, and she speaks slowly with long pauses to allow me to really visualize the beach I am supposed to be on. It reminds me a bit of various guided meditation apps I’ve used to help me fall asleep. I didn’t lose consciousness or feel out of control, but the time did seem to pass more quickly—30 minutes felt more like ten. Oddly, as I try to remember the session a couple of days later, I find my recall of the experience fuzzy, like it belonged more to my subconscious than my conscious memory. I don’t know if this means I was truly “hypnotized” or not. I have a feeling I was, and thought I wasn’t—because it didn’t fit the theatrical stereotypes of what hypnosis should feel or look like.
Keefer is currently collecting data to compare the tele-sessions versus in-person visits. But anecdotally, she tells me, it seems as if it’s just as effective as seeing a hypnotherapist in person.
I see the appeal. By the end of my session, my mug of tea was still steaming on the table next to me. If I had had to commute 45 minutes in the wind and rain, I would not have been as in the zone. “I have patients who try to come in on their lunch hour,” Keefer says. “There's nothing worse than trying to relax on your lunch hour and then going back to work.”
By the fourth session is when Keefer says people start to feel an improvement in their symptoms. It’s not dramatic, like waking up one morning and feeling 100 percent better. It’s more like being out at dinner and starting to feel discomfort, then having it settle and not escalate further. When my session was over, I felt really, really good. Did it miraculously cure my bloating or acid reflux? Nah. But this isn’t a magic pill: Like Keefer says, it’s a strategy.
After experiencing it myself, I’m still left wondering: how exactly does it work? I’m not a hypnosis skeptic—I think it’s a treatment that’s been showing intriguing promise in all sorts of areas, like chronic pain, and I feel it addresses a mind-body connection that we sometimes overlook. But it seems deceptively simple. How does lying down and listening to Keefer tell me I won’t have any stomach upset today—after picturing myself on the beach—make an effect?
Keefer says that there are different triggers that first lead to IBS, from infection to food poisoning to extreme stress. “People with IBS, for whatever reason, don't have the ability to dampen the signals from the gut, and so they experience even the most normal benign sensations as if they are painful or threatening,” she says. “We call that visceral hypersensitivity, meaning there was some damage or issue at one point in your gut and that even after that cleared up, the signals and the nerves that send signals to the brain are not doing so efficiently.”
What the hypnosis is doing, she thinks, is training your brain to ignore—or at least pay less attention—to the signals coming from the gut, which it may have been over-attending to during a period like an infection. Once your brain unlearns that habit, it can stay that way.
Whorwell notes that theories are mostly speculative at the moment. There are some preliminary studies that show that certain areas of the brain, like the anterior cingulate cortex, are more reactive in IBS patients than healthy controls. Hypnosis has also been suggested to affect that part of the brain, which is associated with where the emotional content of pain is processed.
Later work in the lab of Spiegel—the Stanford psychiatrist who showed people the color and grayscale grids—has looked closer at brain function. In 2016, they found that in people who were highly hypnotizable, while they were hypnotized there was less activity in the dorsal anterior cingulate, or the “salience network”—how you determine when things in your environment are important. “In hypnosis, you’re so absorbed that you’re not worrying about anything else,” Spiegel said in a Stanford press release.
They saw more connections between the dorsolateral prefrontal cortex and the insula, which Spiegel described as the connection that helps the brain know what’s going on in the rest of the body, and control it. They also saw fewer connections between the dorsolateral prefrontal cortex and the default mode network, which they think translate to a lack of awareness about your own actions.
“During hypnosis, this kind of disassociation between action and reflection allows the person to engage in activities either suggested by a clinician or self-suggested without devoting mental resources to being self-conscious about the activity,” the researchers wrote.
Other groups are showing that a type of cognitive behavioral therapy, or CBT, can help control GI symptoms in as little as ten sessions. The concept here is the same: that the gut is connected to the brain and the brain is connected to the gut; it’s a two-way road. If we can’t make meaningful changes directly to the gut, then turning to the brain might be the next best way to make an impact.
I ask David Poppers, a clinical associate professor of medicine at NYU's gastroenterology division, what he thinks about the use of hypnosis for issues of the gut. Poppers treats a wide variety of gastrointestinal conditions from IBS to gastrointestinal bleeding, inflammatory bowel disease, and more. He has never specifically recommended hypnotherapy to any of his patients.
But that doesn't necessarily mean he's against it. He echoes how important the connection between the stomach and the brain are in these disorders. "Elements of stress—both positive and negative stress—anxiety, lack of sleep, change in one's routine, change in one's diet; all those can affect symptoms," he tells me. "It makes sense that both behavioral [techniques] and medications working at that connection may be effective in some patients."
He says he's read studies on hypnotherapy and found it promising, both in long-term and short-term outcomes. More of his patients have gone through CBT, he says, and those that do seem to have benefit. Though it can be a self-selecting group, he advises: People who are willing to go and seek therapy, or hypnosis, may be more dedicated and ready to commit to those practices. He adds that since he's not an expert, he would want to work with people specially trained in hypnosis before incorporating it into his treatment plan.
Whorwell thinks that people need to change their mindset about hypnosis for us to fully tap into its potential. It’s not a circus trick, but has roots in other accepted practices like meditation, mindfulness, and CBT—it’s just a more focused version. And Palsson things that even if a gastroenterologist isn't an expert, they could still use the script—that why he created it.
Still, Whorwell doesn't want to claim too much too soon. He has some evidence that hypnosis could be effective in inflammatory bowel diseases too, like colitis, and done smaller studies in functional disorders like non-cardiac chest pain, when the esophagus goes into spasms, or functional dyspepsia, and it works there, too.
But he continues to worry that people will say “Whorwell's lost it now; he thinks he can cure anything,’” he tells me. “There are people out there who are like that, so I have to be very careful. You've got to try and change perceptions from the inside rather than the outside. You can't start beating your chest and saying it works and expect people to believe you unless you can prove it with data.”
Whorwell tells his colleagues not to worry if their papers are rejected. He says that his studies have to be better than others because there is a prejudice. “Reviewers see the word hypnosis and their brains switch off,” he says.
When Janet Westfall has a hypnosis session, she doesn’t remember most of the session and after, she feels like a “puddle of jello.”
“What I mean by that is you're as relaxed as a human being can possibly be,” she says.
After her fourth session, she tried adding foods to her diet: baby food made of green beans. To her delight, there was no reaction. She still has good and bad days, but she doesn’t get desperately sick the way she used to. There’s some discomfort, but she doesn’t violently react to food anymore. If she does feel some minor symptoms, she can replicate the hypnosis session herself, by bringing her mind to the imagery that the sessions invoke.
“I can literally think myself out of nausea, or think myself out of cramping,” she says. “I try and go to what that relaxed feeling feels like, and then imagine it flowing down through my body, through my digestive system, through my stomach, through my intestines. I'm not even totally sure what I'm doing, but it's like my brain knows.”
Her last session was at the end of January. She’s now added four foods to her limited food list. It doesn’t sound like much, but for her, it’s revolutionary. “It's going to be a long, slow road back for me,” she says.
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