Laurie Keefer, PhD

Medscape spoke with Laurie Keefer, PhD, associate professor in the departments of medicine and gastroenterology at the Icahn School of Medicine at Mount Sinai in New York City, about the brain-gut connection and its influence on digestive health. We discussed how the use of hypnotherapy can be an effective alternative treatment for patients, one that is backed by scientific evidence and is now being offered at medical centers and via telemedicine throughout the United States. A leader in the development of effective behavioral therapies for gastrointestinal disorders, Dr Keefer's extensive research focuses primarily on gastroesophageal reflux disease (GERD) and other esophageal disorders, irritable bowel syndrome, and inflammatory bowel disease, including Crohn disease and ulcerative colitis.

A Bidirectional Pathway

Medscape: What do we know about how the mind-gut connection influences our health?

Dr Keefer: The pathway between the mind (or the brain) and the gut is bidirectional. A lot of times people forget that. There are a lot of processes that happen symptomatically in the gut that go up to the brain, and vice versa. I think GERD is one of those, where shifts in acid exposure may be perceived by the brain, and so the gut is essentially telling the brain that something is going wrong. When treating patients with brain-gut therapies, I think it helps them to know that while we're working on the brain, we're also taking into account input from the gut.

When treating patients with brain-gut therapies, I think it helps them to know that while we're working on the brain, we're also taking into account input from the gut.

Medscape: Much of the research around hypnotherapy for digestive health has focused on irritable bowel syndrome (IBS). For what other gastrointestinal (GI) conditions has hypnotherapy been shown to be effective?

Dr Keefer: The research is very robust in IBS but then drops off after that. IBS happened to be the test case, partly because it is so common and refractory. For many of us, though, we believe that if hypnosis has been validated and shown to be effective in IBS and we're targeting the same processes, then it should work for other GI conditions. IBS is brain-gut dysregulation. GERD is brain-gut dysregulation. Inflammatory bowel disease (IBD) has an element of brain-gut dysregulation. While we categorize diseases and say that hypnosis hasn't been tested in this disease or that disease, we do know that symptoms of brain-gut dysregulation are improved with hypnosis.

Medscape: In regard to IBD, has any of the research borne out whether hypnotherapy is more effective for ulcerative colitis versus Crohn disease?

Dr Keefer: I believe that there have been only two studies,[1,2] and both are in ulcerative colitis because it is much easier to demonstrate the brain-gut process in ulcerative colitis. Clinically I do not necessarily differentiate, though. I see a lot of patients with Crohn disease who are in remission but have ongoing abdominal pain and bloating or overlap with IBS, and so it brings us back to hypnotherapy.

Medscape: Has hypnotherapy been shown to be effective in both adults and children?

Dr Keefer: Yes, in both. Children are imaginative, so it can be a nice intervention for them. Van Tilburg and colleagues conducted a study[3] in children with abdominal pain using hypnotherapy, and it was shown to be effective. With children, you use different techniques than with adults, because children don't have a long attention span; the approach tends to be more active and conversational. Therefore, you can't necessarily translate the adult literature to the pediatric literature.

Medscape: Can anyone be hypnotized?

Dr Keefer: I think about 20% of patients are not hypnotizable.[4] Even if they're not technically hypnotized, meaning they haven't reached that brain-wave state where they're in and out of consciousness, they're still picking up on the messaging. They're in a relaxed state. I usually tell patients not to worry too much about whether they're hypnotizable. The important thing is that they're open to the experience. One way to be sure you're not going to be hypnotized is to sit there and not let yourself be. Certain patients are really skeptical, or they can't imagine themselves being able to sit still for 20 minutes; for those, I might suggest deep breathing.

Medscape: Is there any truth to depictions of hypnosis as a means of mind control?

Dr Keefer: Medical hypnosis is a voluntary state. It's really a choice. Even if you are hypnotizable, you're still going to respond appropriately to an emergency in your environment. For example, I tell patients, "If a fire alarm were to go off during our session, you'd be ready to evacuate. You're not going to be 'out of it.'" I often describe it as akin to watching a TV show, where you are falling asleep and all of a sudden something happens on the show—like a gunshot goes off—and you are wide awake again. You are under that hypnotic trance.

Moving Beyond Medications for GERD

Medscape: Specific to GERD, given the recent concerns surrounding proton pump inhibitors (PPIs), do you feel that more patients are seeking alternative treatments like hypnotherapy to help with their disease?

Dr Keefer: It's come full circle. There were early studies[5,6] in which the researchers were able to reduce abnormal acid secretion under hypnosis. Then PPIs came out, and it became, "Why would you go through all of that when you could take a pill?" But now, people don't necessarily want to take PPIs, and there is also more interest in the brain-gut component.

In fact, I initially got interested in hypnotherapy for GERD because of PPI nonresponders—that is, patients who are taking double or triple doses of these drugs but are still experiencing symptoms. Why take more of something that doesn't work? We realized that these patients are not responding to PPIs because they don't have abnormal levels of acid; instead, they were feeling their normal levels of acid as if they were abnormal. They had an element of hypersensitivity—a perception problem, if you will. These patients don't need PPIs; acid suppression doesn't work here, nor does doubling or tripling the dose. In IBS, we tell patients that they don't need to feel the presence of food in their stomach. They just do because they're sensitive. It's the same with the esophagus. We tell patients that they're feeling their normal levels of acid. Hypnosis helps target that.

Medscape: For these patients not responding to PPIs, is there resistance on their part to stop medication and undergo hypnosis instead?

Dr Keefer: Yes. Half of what we do is to convince the patient that this is a viable alternative, which means that we have to explain what brain-gut therapy is and do so in a way that they don't feel like it's psychosomatic. A lot comes down to the communication, and obviously some clinicians are better at that than others.

What we do have to our advantage is that many physicians treating PPI nonresponders also prescribe antidepressants. We tell patients that antidepressants work on the brain to help improve their comfort level. With hypnosis, we're doing that but without an antidepressant. It's all neuromodulation. It might be a pill (eg, antidepressant) or it might be brain-gut therapy. Our job is to modulate this relationship between the brain and the gut.

Our job is to modulate this relationship between the brain and the gut.

Also, when you're in the hypnotic state, a lot of defenses come down, and the brain does open up to the possibility of controlling symptoms better. That's why we use hypnosis—because it gives that subconscious messaging.

Medscape: Besides hypnosis, can you briefly speak to what other psychological treatments might be effective for gastrointestinal disorders, such as cognitive-behavioral therapy and biofeedback?

Dr Keefer: Psychological interventions for the functional GI disorders are pretty equivalent. We have some newer data that will be coming out soon on cognitive-behavioral therapy, but to my knowledge, no one has compared it against hypnotherapy. If you look at the numbers needed to treat for cognitive-behavioral therapy versus hypnotherapy, they are both in the 2-3 range, so one patient gets better for every two treated, which is reasonable. They certainly look equivalent on paper even though they haven't been tested head to head. I think cognitive-behavioral therapy is a really good treatment as well.

Biofeedback tends to work primarily in patients with pelvic floor or anorectal disorders. In my opinion, there is not enough good data to recommend it for any of the other functional GI disorders. However, a lot of patients come in asking for biofeedback, and I advise them that it is probably not the most constructive strategy of what we have out there.

It really boils down to the patient. If it is more about them just feeling symptoms but not engaging in behavior that is perpetuating their symptoms, then hypnosis is my choice. If there is more of a behavior component to it (eg, avoidance behaviors, self-talk, anxiety), then I am more likely to try cognitive-behavioral therapy. And sometimes it may even be a combination of both—hypnosis and cognitive-behavioral therapy.

Treating Patients and Training Clinicians

Medscape: What types of clinicians typically treat patients with hypnotherapy?

Dr Keefer: The general rule of thumb around providing hypnosis for any condition is that you must know how to treat the condition (eg, GERD, IBS) without the hypnosis. Anyone with a master's degree or above could train to be a hypnotherapist—physicians, nurses and nurse practitioners, psychologists, social workers. I work with gastroenterologists who have been trained.

Medscape: For those clinicians who may want to be able to offer hypnotherapy to patients themselves, what does the training entail?

Dr Keefer: Clinicians should train in basic hypnosis first—for example, through the American Society of Clinical Hypnosis. They can then take workshops or training programs that apply hypnosis specifically to GI disorders. Here they are provided with a scripted protocol. They can read it word for word. They don't have to make up their own suggestions and stories. However, they do need to understand the rationale behind it and what the brain-gut connection is.

We are currently piloting a program wherein we are looking for clinicians who are licensed in each state and trained in the protocol, and can provide hypnotherapy across that state through telemedicine. Hypnotherapy requires a commitment on the part of patients; they are having a session every week or every other week, and telemedicine helps them be compliant.

Medscape: Is providing hypnotherapy via telemedicine versus in person just as effective?

Dr Keefer: We are studying that now, but I would say, anecdotally, yes—it seems to be just as effective. In some ways, patients do better because they can choose where they want to do it. They may be less apprehensive in a home setting. Also, given the stigma that is attached, no one knows if you're doing it from home, and it increases the likelihood that people will follow through with it.

Medscape: What options do clinicians have if they wish to direct patients toward a qualified hypnotherapist?

Dr Keefer: There are two options.

First, http://www.ibshypnosis.com/ is a website hosted by the University of North Carolina and includes a list of all of the providers by state who have access to the IBS and GERD protocols. Even though it says IBS, it includes GERD too.

For those in Illinois, New York, or California, patients can be connected to hypnotherapists for IBS and GERD at metaMe Connect. While we have only these three states now, our goal is to have at least one therapist in every state in the next 2 years, part of that pilot program I mentioned. While the sessions can be done via telemedicine, the provider must be licensed in the state in which the patient resides. Hopefully, in time and with telemedicine becoming more mainstream, that barrier will be lifted.

You can run into problems when hypnosis is applied to everything, no matter what the disorder. It is important to be cautious and seek a qualified provider for patients. Hypnosis is a technique, and much of it is in the development of the suggestions—and we are very specific.

Medscape: What are the clinical implications of hypnotherapy to practicing clinicians? How might they apply it to their patients?

Dr Keefer: Clinicians may be apprehensive about bringing up psychotherapy to a patient because they think the patient may be offended, so one of my main recommendations to clinicians is that they develop an "elevator pitch" around brain-gut therapies for GI disorders. In my experience, the clinicians who are most successful in directing their patients to these treatments are those who have mastered this and can comfortably explain what brain-gut therapy is, and how and why a patient might benefit from it. Even calling it brain-gut therapy as opposed to hypnotherapy or cognitive-behavioral therapy can help, because this way it applies to us treating the patient's GERD or IBS.

The other recommendation is to bring up hypnosis earlier as a possible treatment option. This shows the patient that it is actually part of your medical decision-making, not simply a last resort. When it is brought up later, patients may feel that they are only being given this option because every other treatment has failed them and you don't know what else to do.



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