Busting 8 common myths in gastropsych for patients, providers
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The field of psychogastroenterology has grown tremendously over the years and includes mental health providers who specialize in working with patients with GI concerns.
More gastroenterologists and patients recognize the relationship between psychosocial factors and GI conditions. Yet, despite growing recognition of the field, misinformation persists. My job today is to bust common gastropsych myths so that medical providers can refer patients with confidence and help their patients learn about gastropsych treatment.
Myth 1: Insurance does not cover seeing a gastropsych provider.
Good news: Many insurance companies cover gastropsych services with the use of mental health or health and behavior codes for billing (Keefer L, et al). Patients should check with their insurance company regarding whether the provider they would like to see is in network and ask about coverage for mental health services. Some therapists do not accept insurance and offer out-of-pocket services, while others offer sliding scale/low-cost options.
The Rome Gastropsych group has a directory of professionals specializing in GI behavioral health treatment and you can search by insurance.
Myth 2: If I refer my patients to a gastropsych provider, they will think I’m implying the symptoms are “in their head”.
It is important for GI providers to give their patients comprehensive psychoeducation about their GI diagnosis and reason for referral to decrease the likelihood of this happening. This is especially important for patients with disorders of gut-brain interaction (DGBIs) and for patients whose medical testing is within normal limits.
Providing psychoeducation and introducing the gastropsych provider early on as a member of the patient’s interdisciplinary team (Keefer L, et al) may help with decreasing the stigma of seeing a gastropsych provider. Validating the patient’s experience is important. Many of the brain-gut therapies, such as cognitive behavioral therapy (CBT) and medical hypnosis can help improve patients’ symptoms (Keefer L, et al).
Myth 3: I want to refer my patient to gastropsych. The sooner I put the referral in, the better, right?
In an ideal situation, patients have completed the medical workup and providers have communicated the GI diagnosis prior to being referred to a gastropsych provider; however, this may not always be possible.
Making a GI diagnosis prior to referring can not only help the patient understand their diagnosis, but also informs treatment planning in GI behavioral health. Introducing the gastropsych provider as a member of the patient’s interdisciplinary team may be helpful; but be strategic about when you plan to place the gastropsych referral.
Myth 4: Providers should tell their patients that they are referring them for “CBT” or “hypnotherapy”.
It is essential for medical providers to provide education about the reason for a gastropsych referral; however, recommending a specific type of brain-gut therapy (CBT, medical hypnosis) may be less helpful.
Medical hypnosis and CBT may not be the best treatment options for every patient. For example, medical hypnosis is not appropriate for patients with active posttraumatic stress disorder symptoms. Instead of recommending a specific treatment, consider telling the patient that they are being referred for an evaluation with a gastropsych provider who will offer them individualized treatment recommendations.
Myth 5: Mental health professionals specializing in GI can replace general mental health treatment.
GI behavioral health treatment is short-term and focused on treating the GI condition or concerns related to the GI condition. General mental health treatment can be helpful for anxiety, depression, trauma and eating disorders.
It’s also a common misconception that patients will be talking a lot about their childhood in mental health treatment, though most brain-gut therapies like CBT, acceptance and commitment therapy and medical hypnosis focus on present day concerns. It is common for patients to see a general mental health professional to work on concerns unrelated to their GI condition while concurrently seeing a gastropsych provider (Keefer L, et al).
Myth 6: Patients need to be in significant mental health distress or have a mental health diagnosis to see a gastropsych provider.
Though gastropsych providers do help patients with anxiety and depression related to their GI diagnosis, patients do not need to be significant mental health distress to place a referral.
GI behavioral health treatment can help with treating the GI symptoms directly through improving the brain-gut relationship (Keefer L, et al). Patients may learn coping skills and stress management techniques to better manage their GI symptoms. In addition, if a patient has significant mental health symptoms, a referral to a general mental health therapist may be more appropriate than referring to GI behavioral health (Keefer L, et al).
Myth 7: Medical hypnosis is like stage hypnosis and will involve looking at a watch, losing control and quacking like a duck.
Medical hypnosis for GI symptoms is very different from stage hypnosis and how the media portrays hypnosis, so forget the image of the swinging watch. Patients sometimes worry about losing control during medical hypnosis sessions or being asked to do something that is uncomfortable (Lynn SJ, et al); however, patients have control over the gut-specific language they receive.
Medical hypnosis for many DGBIs can be helpful in decreasing symptoms, such as abdominal pain, non-cardiac chest pain, bloating, urgency, globus as well as improving GI motility (Palsson OS). Gut-specific suggestions are tailored toward the patient’s symptoms. Patients have described medical hypnosis as feeling similar to meditation, with experiencing heaviness and warmth in the body. After trying medical hypnosis for the first time, many patients find the exercise relaxing.
Myth 8: Patients will need to be in gastropsych treatment for years.
Gastropsych treatment uses a short-term treatment model, consisting of approximately 4-9 sessions. Treatment is short due to being focused on treating the GI condition, improving quality of life, learning coping skills and/or managing anxiety, stress or depression related to the GI condition (Keefer L, et al). Some gastropsych providers may help patients with concerns unrelated to the GI condition, though others will encourage patients to work on additional concerns with a general mental health professional.
References:
- Keefer L, et al. Gastroenterology. 2021;doi:10.1053/j.gastro.2021.09.015.
- Lynn SJ, et al. Psychol Conscious. 2022;doi:10.1037/cns0000257.
- Palsson OS. Am J Clin Hypn. 2015;doi:10.1080/00029157.2015.1039114.
For more information:
Jessica P. Naftaly, PhD, is a licensed clinical psychologist and clinical lecturer in the division of gastroenterology and hepatology at the University of Michigan, Michigan Medicine. All opinions expressed by Naftaly are her own and do not necessarily reflect the opinions of her employer.
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Stephen E. Lupe, PsyD
The understanding that the gut, mind and whole person are interconnected is growing and, with this, a greater need for interdisciplinary care is evolving. The more education that exists that makes it easier for providers to refer patients and patients to schedule for services, the more success will be achieved in improving health and managing gastrointestinal conditions. This article did a fantastic job highlighting many common misperceptions that can be barriers to care and providing realities behind the myths.
As a provider, I have heard many of these myths, and we address them frequently. For instance, the myth that services are not covered. In my clinical practice, we have created a letter that not only lets patients know they will be seen in a multidisciplinary clinic, but it also directs patients to verify that their insurance companies cover psychological and nutritional services. In my experience, psychological services — both in-person and virtual — are usually covered, but we always direct patients to double check with their insurance providers.
Another myth that is frequently addressed by our clinic is that seeing a psychologist means that the patient’s symptoms are “in their head.” Highlighting this myth is especially helpful, because the human body is a very complex place. Everything is connected to everything, and more and more we are finding that the things a person goes through physically change their physical health, functioning and well-being.
On top of this, our bodies learn and have reactions to sensations and symptoms inside our bodies. Because of that interconnectedness, we can use behavioral and psychological interventions that change the physical functioning of our body. An example of that is diaphragmatic breathing, which helps the nervous system move from a “fight or flight state” to a “rest and digest” state. The effect of that breathing practice then changes the physical functioning of our body, including our digestive system. This does not mean that symptoms are in a patient’s “head,” but that we can utilize what we know about the nervous system and its functioning to help the body move to a place where symptoms may reduce.
As for myth No. 3, it is often helpful to have a diagnosis prior to seeing a patient, although this is not a requirement. Many times, this will assist in directing treatment and allow for education about the condition and how GI psychology could assist with the person’s concerns. A GI psychology provider will tailor the treatment to the person.
This also covers the next myth that people should be told they are being referred for cognitive behavior therapy or hypnotherapy. Providers will assess the needs of a patient and decide which treatments they are competent to provide, and which treatments may help the person they are treating. This is a highly individualized service that needs to be provided by an expert.
The next two myths require a caveat be made: While it is true that a GI psychology provider focuses on short-term GI specific treatment, it is not uncommon to also work with someone for underlying anxiety or depression symptoms. Not only is it very difficult at this time to access adequate therapeutic and psychiatric services in the United States, but as Dr. Naftaly pointed out, many times these conditions exacerbate GI conditions and affect the course of a disease.
Often a GI psychologist will work with a “traditional” mental health provider to provide comprehensive services, but strict adherence to this model is becoming more difficult with “traditional” mental health services being in high demand to a point where wait times to see a provider can be long. The challenge of meeting the demand for service and length of care is, unfortunately, a reality.
That said, while treatment will often require long-term care, short-term services can — and often do — help as well. Many of the skills learned in treatment with a GI psychology provider are transferable to other life difficulties and often reducing symptoms of “co-occurring” psychological difficulty is a goal for treatment.
As stated above, this article provides insightful information that will be helpful for providers and patients alike. The more education that can be provided on psychogastroenterological services and the more these services can be normalized, the more we will forward the view that people are whole, interconnected organisms living in a context. That understanding is growing within the field of medicine, which will allow us to work together to maximize health and treat people as whole persons.
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