Abstract and Introduction
Abstract
Background: Individual hypnotherapy (IH) is a recognised treatment for irritable bowel syndrome (IBS). However, it is not widely available to patients due to its resource-intensive nature, lack of adequately trained therapists, and scepticism about hypnosis. Non-individualised hypnotherapy approaches, such as group and self-help hypnotherapy, could maximise existing therapist resources by treating more patients at the same time, thus widening patient access to treatment without incurring additional expenditure.
Aims: To investigate the research literature for non-individualised approaches to hypnotherapy for IBS and to determine their effectiveness for reducing symptom severity and/or providing adequate relief.
Methods: A literature review of published peer-reviewed studies was conducted. Quantitative research was selected to determine the effectiveness of the interventions.
Results: Ten studies were eligible for inclusion. Three delivered group hypnotherapy, three integrated hypnosis within a group concept, and four utilised a self-help home hypnotherapy treatment using audio recordings. Both group hypnotherapy for adults and the self-help home hypnotherapy treatment for children were effective interventions that may be non-inferior to IH for patients with mild-to-moderate symptoms. Treatment benefits were long-lasting. The evidence for the integrative group concept and home treatment for adults was less compelling.
Conclusions: Group hypnotherapy for adults, and self-help hypnotherapy for children, may be cost-effective treatments that can widen access for patients with milder IBS in primary care settings. Further research is needed to determine the effectiveness of group hypnotherapy for patients with severe, refractory IBS.
Introduction
Irritable bowel syndrome (IBS) is a chronic disorder of gut-brain interaction (DBGI) and is characterised by recurrent abdominal pain that may be related to defaecation and associated with changes in stool frequency and/or form.[1,2] Worldwide prevalence has been estimated to affect between 3.5% and 10.1% of the population using Rome III[3] diagnostic criteria and 1.5%-4.6% using the more restrictive Rome IV[2] criteria.[4–6] Prevalence is more common in women than men.[4–6] Often debilitating, IBS can adversely impact the quality of life[5,7,8] and psychological wellbeing.[5,9]
IBS is a complex disorder that is better understood using the biopsychosocial model.[2] Despite advancements in understanding, the disorder remains difficult to diagnose and clinically manage.[10] To navigate this complexity, a practical framework for the diagnosis and clinical management of IBS was recently published by the British Society of Gastroenterology (BSG).[11] First-line treatments include regular exercise, dietary advice, Loperamide for the management of diarrhoea and certain antispasmodics for relief of global symptoms and abdominal pain. Second-line treatments include tricyclic antidepressants, selective serotonin reuptake inhibitors and various drugs for managing the symptoms of either diarrhoea or constipation. Psychological therapies, specifically IBS-specific cognitive behavioural therapy and gut-directed hypnotherapy (GDH) are recommended if symptoms do not improve after 12 months. Patients may be referred for psychological treatment earlier if they prefer and if it is available locally. The American College of Gastroenterology also recommends these same psychological therapies for the treatment of global IBS symptoms, declaring them as low-risk treatments with long-term benefits.[12] This review will focus on GDH as a treatment option.
Hypnotherapy for IBS
Medical hypnosis dates back to ancient times and has been simultaneously praised and criticised over the centuries.[13] In recent decades, hypnotherapy has sought to establish itself as an evidence-based practice and has been used successfully as an adjunctive therapy with many medical conditions, including pain,[14] headaches and migraines,[15] depression,[16] anxiety and stress-related disorders[17] and asthma.[18]
Hypnotherapy was first documented in 1984 as an effective treatment for refractory IBS by Whorwell et al[19] In their randomised control trial (RCT) of 30 patients, highly significant improvements were reported in the hypnotherapy group for all bowel symptoms and well-being, compared with the control group who received psychotherapy and a placebo. The RCT was conducted in the UK using a hypnotherapy protocol known as GDH developed by Whorwell and his team. GDH uses suggestions for relaxation, improved self-confidence and increased well-being, and also teaches the patient to influence the way the brain and gut communicates to control and normalise their gut function.[20] It is uncertain how hypnotherapy does this, however, it is speculated that GDH works by activating parts of the brain responsible for subconscious imagination and creativity, cognition and attention, and by influencing psychological and physiological mechanisms that are outside of conscious control.[21] Unlike other interventions which only treat one symptom, hypnotherapy can improve many of the global symptoms of IBS.[22]
Since 1984, the evidence supporting GDH has continued to grow. In 1995 a dedicated National Health Service (NHS) funded hypnotherapy unit was set up in Manchester in the UK to treat patients with IBS.[20]Systematic reviews and meta-analyses have concluded that hypnotherapy is safe[23,24] and superior when compared to control conditions,[23–26] including education and support, proposed as the gold standard of control conditions,[26] and is comparable in efficacy to other psychological therapies for IBS.[26] GDH also provides long-lasting improvements in IBS symptoms.[23,26] An audit of 1000 patients receiving GDH as a one-to-one individual hypnotherapy (IH) treatment,[27] reported 76% achieved the primary outcome of ≥50-points reduction using the IBS Symptom Severity Score (IBS-SSS)[28]—which is a standard measure of treatment effect for IBS clinical trials[29]—indicating highly clinically significant improvements (P < 0.001). Highly significant improvements were also reported in non-colonic symptoms, quality of life and anxiety or depression scores (Ps < 0.001). In the largest RCT[30] of IH to date, with 448 patients to test the non-inferiority of six sessions of IH compared with 12 sessions, clinically significant improvements of ≥50-points reduction were achieved by 78% of patients after 6 sessions and 73.9% after 12 sessions. IH has also been reported to be effective in 65% of patients when delivered at a distance using video consultation.[31]
The Problem
The evidence for hypnotherapy is so convincing that it has been asserted it should be routinely offered to those with IBS.[32] However, GDH is still not widely available.[11,31] In the UK, some NHS Clinical Commissioning Groups do not routinely commission hypnotherapy, with funding requests only considered in exceptional circumstances.[33–35] Consequently, patients who live in these areas are unlikely to be able to access treatment or may have to travel long distances.
The lack of therapists trained in hypnosis is considered part of the problem.[11,22,36] Hypnotherapy should only be practiced by someone with appropriate training.[23]Achievement of the national occupational standards for hypnotherapy as defined by the Complementary and Natural Healthcare Council (CNHC) in the UK, typically takes a minimum of ten months of training and supervised practice.[37] NHS therapists are also required to have a medical or social work background in addition to extensive training in hypnosis and GDH.[27] The requirements for training combined with the labour-intensive nature of hypnotherapy—which usually involves up to 12 individual, face-to-face sessions, each lasting up to an hour—makes hypnotherapy resource-intensive and costly to provide.[38,39] However, this cost should be considered in the context that patients with IBS tend to have more time off work, experience a lower quality of life, use health services more frequently and on average incur more healthcare costs than patients without IBS.[7,40] In England the NHS healthcare expenditure in 2012–2013 for IBS related hospital admissions and associated costs was £95 692 068. Whilst the cost of prescribing laxatives and antispasmodics by GPs was £121 804 929.[41] As the benefits of GDH have been found to last between 2 and 7 years following treatment, with responders using healthcare services less than non-responders,[42] it is possible that investment in GDH may be more cost-effective than usual care in the longer-term and may have beneficial implications for earlier intervention.
For patients experiencing milder IBS symptoms, it has been proposed that group-delivered GDH may be beneficial and may provide a cost-effective and more accessible alternative to individual GDH.[11] It would be interesting to learn whether the evidence supports the use of group GDH or any other non-individualised hypnotherapy approaches.
Unfortunately, many people with IBS are unaware of GDH as a possible treatment option, even though they would be open-minded towards using it.[43,44] This lack of awareness may reflect GPs' and gastroenterologists' reluctance to refer patients with IBS for GDH or other psychological interventions, because of their doubts about the evidence-base.[36,45,46]
Aims and Objectives
This review aims to investigate the research literature for non-individualised approaches to hypnotherapy for IBS and to determine their effectiveness for reducing symptom severity and providing adequate relief. A non-individualised approach would be more cost-effective in terms of time, money and resources. It could also increase patient access to hypnotherapy, improve patient treatment choice and potentially lead to earlier intervention. The objectives of this review are therefore to:
identify the different methods used for delivering non-individualised hypnotherapy;
critically review the evidence to determine its validity and reliability;
make recommendations for the type of additional research that may be needed and the questions that could be addressed to support or refute the body of evidence;
raise awareness of the findings to both clinicians and the public;
identify opportunities and barriers for replicating and implementing effective treatments in practice;
discuss the implications of the findings for hypnotherapists working in private practice.
Aliment Pharmacol Ther. 2021;54(44512):1389-1404. © 2021 Blackwell Publishing
