A Comparative Case Study of the Impact of Psychotherapy on Inflammatory Bowel Disease Patients

To the Editors, Our study was of a patient with Ulcerative Colitis and a patient with Crohn’s Disease drawn from a group of IBD patients who had reported psychosomatic improvement following psychotherapy.1 This group was drawn from attendees at a rural IBD clinic noted previously to have low engagement and low reports of psychological distress.2 Emerging themes identified in this case study were converted into the following therapeutic parameters: (1) increased awareness of and attendance toward psychological symptoms, (2) increased internal psychological focus, (3) increased awareness of the role of psychological processes in improving health, and (4) improved self-care and adaptability to stressors. Our comparative case study sought to identify psychotherapeutic treatment factors relevant to the change in these parameters. Two female patients were selected, both with chronic IBD and similar psychological symptoms and background demographics: UC patient 53 years old, CD patient 54 years old, limited formal education, pre-existing grief/depression, and current external stressors. There were no surgeries or significant changes to medication for either patient. Consented video recording and transcript from a complete session for each patient was obtained from the middle of a 12-session psychotherapy treatment. The psychotherapy used the intensive short-term dynamic psychotherapy (ISTDP) theoretical framework as a basis for assessment and technique.3 This was reviewed by an expert (second author) in the treatment modality used to corroborate or refute the assessment of patient characteristics, identify in the therapist/patient interaction any instances demonstrating therapeutic mechanisms, and identify patient behavioral responses that operated against the therapeutic aims. The UC patient was confirmed as being on the fragile spectrum of ISTDP’s psycho-diagnostic criteria, meaning anxiety could interrupt their cognitive and perceptual function. The CD patient was confirmed as being on the resistant spectrum, meaning anxiety could affect voluntary and smooth muscle but not cognitive perceptual function. Treatment using ISTDP was tailored accordingly with the UC patient receiving Graded-format ISTDP to build anxiety tolerance. Sample interactions are shown in Table 1, demonstrating therapeutic mechanisms and patient responses. Apart from the CD patient not maintaining an internal focus, all therapeutic aims were demonstrated in both patients. Summary of Patient Assessment Treatment and Response With Exemplars aTherapeutic Parameters 1) Increased awareness of and attendance towards psychological symptoms, 2) Increased internal psychological focus, 3) Increased awareness of the role of psychological processes in improving health, 4) Improved self-care and adaptability to stressors. EXEMPLARS OF THERAPEUTIC PARAMETERS Th: Just coming back to your anxiety, you said that you can still feel it a bit here (stomach). Is it more, less than it was? Pt: A lot less. Th: Yeah? Pt: A lot less yeah. Well it used to be in here (moves hand over upper chest and throat). Th: Okay, a bit higher. Pt: All the stress used to be here (motions up and down upper chest and throat). And—and I was told once that it’s because I won’t—I can’t talk about things sometimes…But now it’s just here (motions to stomach). So obviously I’m opening up more (motions between) 1. Th: Yeah. so can you tell me a bit more about that? Because I think we need to go and pay attention to what it is that’s actually occurred here probably, that’s improved that situation. Pt: Oh, just being more honest with myself I suppose. 2. Pt: And I’ve got to concentrate. I want to live for—for a long time…And ah that’s why I really got to look after my health—you know. 3. Th: Your own little exchange…so you offer him affection. Pt: Yeah. Th: And you offer him affirmation that you love him yeah? Pt: Yeah. And I like to listen to him about his work. And even though I don’t—I’ve always, always listened to him about his work um and I know he appreciates it even if I don’t understand some of it. Th: Sure. So you’re a good listener. Pt: Yeah. You know. I—actually I’ve—lately I’ve heard a couple of guys say that he’s a very clever man—you know? Th: But I’ve heard him say—through you—that you are a very clever woman. Pt: Yeah, yeah. 4. Pt: I’ve just got to focus on being—feeling great for myself. Not having to do it for others and that’s the thing. I dress for others and look for others instead of for myself. Th: Sure. Pt: I have a lot lately actually because I’ve always had this thing—put makeup on before you go out. Even it’s only for a couple of hours or an hour, whatever and I still go put this makeup on. But lately I’ve been not wearing it…I’ve just not gone with it. And I just think I don’t care. And—and I’ve just got to—I think I’ve really got to start—start feeling comfortable not doing that…because makeup—I feel it’s like I’m hiding. 4. Pt: Well—you know I was always doubting myself but now I don’t -I feel I can make a positive—even coming here today. I left a bit later. I just couldn’t—in the end I just could not rush myself. I just thought nah, I’m going to get there. No rush, I’m not going to worry. Th: Well that’s wonderful. Pt: …and I’ve been doing that a lot lately I’ve noticed. Th: Have you? Pt: Yes, constant you know. Th: Regulating your anxiety. Pt: Yeah. And oh it makes a difference. Th: Yeah. Pt: I even feel better now just talking. Th: Yeah. That’s fantastic. Pt: I already feel a lot better you know. Th: Oh that’s so good. Pt: So I’m clearer in my mind so you’re obviously working for me (laughs). Th: Well you know, you’re working for your best interests. Pt: Yeah. Th: And you—you’re actually basically not allowing yourself—not permitting yourself really, to work off the back of a stressed position. Pt: Yeah. Th: Like you—you’re actually saying “No—you know I deserve better than this.”—You know you’re actually establishing a baseline calmness before you actually do something and building that into your planning as well. Pt: Yeah. Th: Which is wonderful! Pt: It is good for me. 4. Psychodynamic psychotherapy aims to improve anxiety regulation and capacity to verbalize internalized psychological conflict, which gives rise to anxiety and maladaptive defences including somatization. Processing previously unconscious material and the accordant lowering of anxiety may improve IBD symptoms via psychoneuroimmunological pathways.4 Our comparative case study illustrates psychotherapeutic change mechanisms that may mediate this process. Summary of Patient Assessment Treatment and Response With Exemplars aTherapeutic Parameters 1) Increased awareness of and attendance towards psychological symptoms, 2) Increased internal psychological focus, 3) Increased awareness of the role of psychological processes in improving health, 4) Improved self-care and adaptability to stressors. EXEMPLARS OF THERAPEUTIC PARAMETERS Th: Just coming back to your anxiety, you said that you can still feel it a bit here (stomach). Is it more, less than it was? Pt: A lot less. Th: Yeah? Pt: A lot less yeah. Well it used to be in here (moves hand over upper chest and throat). Th: Okay, a bit higher. Pt: All the stress used to be here (motions up and down upper chest and throat). And—and I was told once that it’s because I won’t—I can’t talk about things sometimes…But now it’s just here (motions to stomach). So obviously I’m opening up more (motions between) 1. Th: Yeah. so can you tell me a bit more about that? Because I think we need to go and pay attention to what it is that’s actually occurred here probably, that’s improved that situation. Pt: Oh, just being more honest with myself I suppose. 2. Pt: And I’ve got to concentrate. I want to live for—for a long time…And ah that’s why I really got to look after my health—you know. 3. Th: Your own little exchange…so you offer him affection. Pt: Yeah. Th: And you offer him affirmation that you love him yeah? Pt: Yeah. And I like to listen to him about his work. And even though I don’t—I’ve always, always listened to him about his work um and I know he appreciates it even if I don’t understand some of it. Th: Sure. So you’re a good listener. Pt: Yeah. You know. I—actually I’ve—lately I’ve heard a couple of guys say that he’s a very clever man—you know? Th: But I’ve heard him say—through you—that you are a very clever woman. Pt: Yeah, yeah. 4. Pt: I’ve just got to focus on being—feeling great for myself. Not having to do it for others and that’s the thing. I dress for others and look for others instead of for myself. Th: Sure. Pt: I have a lot lately actually because I’ve always had this thing—put makeup on before you go out. Even it’s only for a couple of hours or an hour, whatever and I still go put this makeup on. But lately I’ve been not wearing it…I’ve just not gone with it. And I just think I don’t care. And—and I’ve just got to—I think I’ve really got to start—start feeling comfortable not doing that…because makeup—I feel it’s like I’m hiding. 4. Pt: Well—you know I was always doubting myself but now I don’t -I feel I can make a positive—even coming here today. I left a bit later. I just couldn’t—in the end I just could not rush myself. I just thought nah, I’m going to get there. No rush, I’m not going to worry. Th: Well that’s wonderful. Pt: …and I’ve been doing that a lot lately I’ve noticed. Th: Have you? Pt: Yes, constant you know. Th: Regulating your anxiety. Pt: Yeah. And oh it makes a difference. Th: Yeah. Pt: I even feel better now just talking. Th: Yeah. That’s fantastic. Pt: I already feel a lot better you know. Th: Oh that’s so good. Pt: So I’m clearer in my mind so you’re obviously working for me (laughs). Th: Well you know, you’re working for your best interests. Pt: Yeah. Th: And you—you’re actually basically not allowing yourself—not permitting yourself really, to work off the back of a stressed position. Pt: Yeah. Th: Like you—you’re actually saying “No—you know I deserve better than this.”—You know you’re actually establishing a baseline calmness before you actually do something and building that into your planning as well. Pt: Yeah. Th: Which is wonderful! Pt: It is good for me. 4. Psychodynamic psychotherapy aims to improve anxiety regulation and capacity to verbalize internalized psychological conflict, which gives rise to anxiety and maladaptive defences including somatization. Processing previously unconscious material and the accordant lowering of anxiety may improve IBD symptoms via psychoneuroimmunological pathways.4 Our comparative case study illustrates psychotherapeutic change mechanisms that may mediate this process. The authors thank Dr Charles Greenfield (Specialist Centre, St John of God Hospital, Geraldton, Western Australia).

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