by Jo Marchant
Her research with children shows that they can voluntarily influence blood flow to change the temperature of their fingertips.6 Although fingertip temperature tends to increase when we’re relaxed, “these children were capable of increasing peripheral temperature way beyond what would be achieved merely from relaxation,” she says.7 “They would create different images. One of them said he was imagining that he was touching the sun.” Olness believes that mental images, so vivid when we are hypnotized, are crucial for influencing the physical body. Perhaps such images activate different parts of the brain than those associated with abstract or rational thought. “But we’re a long way from specifics on that,” she admits.
The finding that hypnotic suggestions can influence body temperature and blood flow has been replicated by other researchers, including Edoardo Casiglia, a cardiologist from the University of Padua in Italy. In one test, he told hypnotized volunteers that he was taking half a pint of blood from their arm. They responded with lowered blood pressure and constricted blood vessels, just as occurred in a second group who actually did give blood.8 In another experiment, he told volunteers that they were sitting in a warm bath. Blood vessels across their whole body dilated as if they were sitting in a real bath; when volunteers were told that their forearm was in warm water, blood vessels dilated just in that forearm.9
In a third study, Casiglia asked volunteers to place their right hand into a bucket of ice-cold water.10 This is an extremely painful task that usually evokes a strong fight-or-flight response, including constricted blood vessels, raised blood pressure and a pounding heart. It is an instinctive reaction; the conventional medical view is that we cannot suppress it voluntarily. Yet hypnotized subjects told that their right arm was insensitive to pain completed the task without any physiological effects.
According to Casiglia, if such effects were better understood they could have a range of potential medical applications. We might use hypnosis to boost blood flow to the brain (protecting against cognitive impairment as we age); to the extremities (to help people with poor circulation in their hands and feet); or even to direct a toxic drug to a particular part of the body. At the moment, this last one “is science fiction,” Casiglia admits, but not completely inconceivable—he says he has recently found that hypnotized volunteers can increase blood supply to their intestines on demand.11
Lab studies from other teams have reported that relaxation suggestions made during hypnosis can influence a variety of immune responses associated with stress, reducing inflammation, for example, in medical students facing exams.12 Meanwhile some small trials have hinted that hypnotherapy may improve autoimmune disorders such as eczema and psoriasis, that it can reduce the duration of upper respiratory infections, and even clear warts.13 The results are mixed, however. Different studies tend to measure different aspects of the immune system, and no consistent picture has emerged. As with hypnosis research as a whole, meta-analyses generally conclude that there is too little high-quality research to draw any strong conclusions about its benefits, or about which techniques work best. To an outsider like me, trawling through the data is a frustrating experience; despite glimpses of exciting potential, it’s a field that mostly feels wishy-washy and obscure.
And then there is hypnotherapy for IBS.
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WHEREAS MANY hypnotherapists delve into people’s childhoods or psychological hang-ups, Whorwell wasn’t interested in fixing his patients’ personal problems. He wanted to target what he saw as the root cause of their misery: the gut.
The brain and the gut are intricately connected, he tells me. There’s constant two-way communication between them, via the hard-wired connections of the autonomic nervous system as well as hormones that circulate through the bloodstream. Signals regarding what’s happening in the gut travel to the brain, which then modulates gut function in response to that information—usually without us being aware of it.
For example, signals from the stomach tell us if we’re hungry and need to eat; if we’re full and need to secrete stomach acid or divert blood flow to aid digestion; or if we have ingested a poison and need to vomit. At the other end of the process, signals from the colon and rectum tell us when we need to poo. We can then either give the go-ahead, or suppress the impulse until a more convenient time.
Most of us have experienced how our state of mind can affect gut function. If we’re uncomfortable with toilet arrangements we might not go for days, whereas when we’re nervous we get butterflies or empty our bowels. “The evolutionary value is that if you are roaming around in the savannah and something is about to eat you, it is good to empty your gut quickly so blood flow to your gut reduces,” says Whorwell. “Then you can put all your blood flow to your muscles so you can run.”
In IBS patients, however, the communication between brain and gut goes haywire. Chronic stress, for example, can lead to persistent diarrhea, vomiting, or painful gut contractions. This can create a vicious cycle in which people worry about their symptoms, making the problem even worse. “The pain comes, then the anxiety comes,” says Emma, the 21-year-old who visited Whorwell’s clinic with her mother. “I know how it works, but I just can’t break the cycle.”
After his training in hypnotherapy, Whorwell believed that the technique might reduce that stress and anxiety, helping patients not to overreact to signals from the gut. But he also hoped to influence gut function directly. To do this, he gave patients a tutorial on how the gut works, then during hypnosis asked them to visualize a calmer, trouble-free digestion process over which they had control. A popular method was to imagine the gut as a river. Someone with constipation might conjure a surging waterfall, whereas a diarrhea patient might prefer boats on a slow-moving canal.
To survive his foray into hypnotherapy with his reputation intact, Whorwell knew he would have to document his results in robust scientific trials. He published the first one in 1984. It was a randomized trial of 30 people, who received 12 weekly sessions of either gut-focused hypnotherapy or psychotherapy (which involved discussing stress and emotional problems that might be contributing to their symptoms).14 These were desperate patients who had suffered from severe IBS for years, with no relief from conventional treatment. He asked them to score their bowel function on a 21-point scale, with higher scores denoting worse symptoms. The psychotherapy group started with an average score of 13 and were no better three months later. The hypnotherapy group started the trial on 17, and finished it on 1.
That’s when a tentative experiment became a life’s calling. Determined to drag hypnosis kicking and screaming into scientific acceptance, Whorwell has since set up a dedicated hypnotherapy unit at Wythenshawe Hospital, which now has six therapists, and has built up an impressive body of evidence supporting his technique.
Gut-focused hypnotherapy doesn’t help everyone. Emma has been through the course, for example, and still suffers terribly. But over multiple trials and audits, Whorwell has shown that hypnotherapy helps 70–80% of patients for whom all other treatments have failed.15 Other symptoms such as headaches and fatigue are eased as well as gut-related ones, and after hypnotherapy patients make fewer visits to doctors and consultants—not just for their IBS, but for everything. Small trials suggest that the approach is helpful for other functional gastrointestinal disorders too, including functional dyspepsia and non-cardiac chest pain,16 and it may even help patients with more serious autoimmune disorders such as Crohn’s disease and ulcerative colitis, in which the immune system attacks the gut lining.17
For IBS at least, the benefits seem to last long-term—when Whorwell followed more than 200 IBS patients who had responded to hypnotherapy for up to five years, 81% of them stayed well, and in fact most of them continued to improve.18 This lasting effect, and the fact that in trials patients receiving hypnotherapy improve significantly more than those in control groups, suggests that it isn’t simply working as a placebo.
Although IBS patients can experience dramatic placebo effects, as we saw in cha
pter two, these are often temporary. Whorwell notes, for example, that when his patients have surgery they often feel better at first, but then relapse. By contrast, he believes that hypnotherapy helps to change patterns of thinking about their gut in order to ease symptoms for good. He gives patients CDs of their sessions, so they can keep practicing at home as long as they need to.
Whorwell’s studies also help to show that the therapy does more than reduce stress. In IBS patients, the gut lining is over-sensitive to pain, something you can measure by putting a balloon up someone’s bottom and inflating it until they say it hurts. Healthy people feel pain at a pressure of around 40 mm Hg; IBS patients don’t usually get to half that. Hypnotherapy seems to correct that hypersensitivity. When Whorwell tested them after a course of treatment, they were back into the normal range.19
And crucially, when patients are hypnotized, they are able to influence the speed at which the stomach empties its contents into the small intestine (measured using real-time ultrasound imaging),20 as well as the rate at which the colon contracts.21 As with Olness and Casiglia’s experiments on blood flow, these are not things we are supposed to be able to do at will.
“You can’t just sit there and tell the patient, ‘You’ve got to relax your muscles,’ ” says Whorwell. “But in this hyper-suggestible state, people seem to be able to do things to their body which they can’t necessarily do in the conscious state.”
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IN CRUICKSHANKS’S card-lined office, I ask former flight attendant Nicole how she felt while she was hypnotized. As if she’s floating, she says. “When Pam’s talking, I’m visualizing warm, green-turquoise water. Soothing, sunshine holiday water. I feel like I’m smiling inside.”
And is the hypnotherapy helping her? She struggled to get it at first, she says. But since last week…She pauses, looking at us both, eyes bright like someone with a thrilling secret to share.
“A miracle has happened,” she says. “The bloating and swelling was right up to my breasts. The pain was constant. Now, I’ve no bloating. I’m not taking any pain relief.” She turns to Pam, on the verge of tears. “I want to kiss you! I’ve suffered so long. For me to say I’ve had no pain in one week—it’s wonderful.”
Before Nicole leaves, Cruickshanks asks what her week has been like. “I’ve just got cancer again,” she says, calmly. It’s a tumor on her back. She’s had it before, but now the cancer has returned. “I’m so sorry,” I say, but Nicole shakes her head. “It was caught early,” she says. “I’m fine about it.” Then she points to her stomach. “This is the worst thing. This is the most painful, soul-destroying thing.”
As she stands to go, she gives Cruickshanks a huge hug. Soon there will be one more thank-you card on the wall.
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BACK IN Peter Whorwell’s office after my visit to the hypnotherapy unit, he wants to emphasize that IBS is not all about stress and anxiety. Other factors include genes, diet, gut microbes, the way the brain processes pain and, of course, the gut itself.
Every patient represents a different combination of these factors, he points out. In some cases, like Emma’s pain or Nicole’s bloating, psychology seems to play a large role. In others, like Gina’s constipation, it may not be a significant factor at all.
He thinks Gina’s problems have more to do with repeated abdominal surgery, which can damage the nerves necessary for the gut to function. As well as her hysterectomy, and having her gall bladder removed, “She’s had several rounds of surgery on her bottom,” he says. “No wonder it’s not working properly.”
This is why he insists that hypnotherapy should always be used alongside conventional treatment approaches. Although hypnotherapy might help Gina to manage the stress associated with her symptoms, Whorwell has also recommended powerful muscle relaxants and laxatives, and if they don’t work, a colostomy.
I’m struck by how many patients referred to Whorwell have previously had abdominal surgery—at least seven of the ten patients I’ve met that day. It’s a big factor in IBS, he confirms. If the gut is moved or disturbed during surgery it can become sensitized, and starts sending amplified pain signals to the brain. This is often what triggers IBS in the first place. In other cases gastroenterologists operate in the hope of alleviating patients’ symptoms, only to find that their condition ultimately gets worse.
“Surgeons are programmed to operate,” says Whorwell. “And in a lot of instances they bring about miraculous cures. If you have appendicitis or cholecystitis or a perforated bowel, they’ll save your life.” But when somebody has abdominal pain, their default reaction is to remove something. Unfortunately, this often exacerbates the problem. “It is done for the best reasons in the world,” says Whorwell. “But once you have structurally changed the gut, causing scarring and adhesions, you are not going to be able to hypnotize that away.”
It reminds me of the dilemma faced by patients with chronic fatigue syndrome, who are pushed between CFS being either a biological, incurable disease, or a psychological invention. Are IBS patients too, I ask Whorwell, being caught between the two extremes of body and mind? Some are treated as if their IBS is a purely physical problem, with surgeons cutting out piece after piece of their bowel, while others are told the problem is all in their heads. When what they really need is an approach that treats mind and body together?
Whorwell looks at me for a moment. “Absolutely spot on,” he says.
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YOU’D THINK that with all he has achieved, Whorwell might be feeling pretty pleased about his career choice. He has developed a highly effective therapy, and helped thousands of patients whom other doctors had given up on. Teams around the world are carrying out randomized controlled trials into gut-focused hypnotherapy, also with positive—if not always quite so dramatic—results,22 and a recent systematic review concluded that the treatment is effective and long-lasting.23
Thanks to evidence like this, the U.K.’s National Institute for Health and Clinical Excellence (NICE), which approves medical treatments for use by the National Health Service (NHS), now recommends hypnotherapy for IBS where conventional treatments have failed. This is one of the only complementary therapies backed by NICE, and its only recommendation of hypnotherapy for a physical condition.
But Whorwell doesn’t seem happy. Actually he seems quite disappointed. Because despite those trials, and that NICE recommendation, many of the administrative bodies responsible for funding treatment in the U.K. still refuse to support it, while the NHS website advises patients that research studies into hypnotherapy for IBS “do not provide any strong evidence for its effectiveness.”24
According to Whorwell, one problem is that hypnotherapy isn’t amenable to the strict trial designs that were developed for testing drugs. Before recommending a particular therapy, advocates of evidence-based medicine look for double-blind trials, where neither the patient nor their doctor knows whether they are receiving the real treatment or the fake one. This makes sense when testing drugs, in order to rule out that they aren’t simply triggering a placebo effect.
But you can’t hypnotize someone—or be hypnotized—without knowing. So reviewers or funders may look at the data on hypnotherapy for IBS, see that there are no double-blind trials and conclude that the evidence for it is poor. “It’s nonsense,” says Whorwell. And while it makes sense to blind patients in a drug trial, in order to separate the chemical action of the drug from any psychological effects, it misses the point when testing therapies such as hypnosis, when patients’ beliefs and expectations are integral to how they work.
Whorwell argues that reviewers should be willing to accept evidence from a broader range of trial designs that are appropriate for testing a mind–body therapy but are still as close as possible to the gold standard. For example, researchers can carry out a single-blind trial, in which hypnotherapy is tested against a suitable control group and patients’ symptoms are independently assessed by a researcher who doesn’t know which treatment patients have received.
Jeremy Howick, an epidemiologist and philosopher of science at the Center for Evidence-Based Medicine in Oxford, agrees that carrying out double-blind trials can be difficult or impossible for mind–body therapies, but points out that this is a problem for some conventional therapies too, such as surgery or physiotherapy. He suggests that in such cases it makes sense to forget the placebo group altogether and instead compare a therapy against other treatments that are known to be effective. “If you have a health problem, what you want to know is what’s the best treatment from all these alternatives?” he says. “That’s what patients care about.”25
A deeper problem may be that hypnotherapy is very unfashionable in most scientific and medical circles, and still carries those connotations of quackery. Proponents complain that there is very little funding available for research into hypnosis, even compared to other mind–body therapies such as meditation,26 and little interest in studying how it might help patients. “The majority of health care professionals just don’t think that it’s necessary or important,” says hypnosis researcher Karen Olness.
Over the years, Whorwell has attempted to expand his hypnotherapy model beyond gastrointestinal disorders. He says he has approached specialists in a wide variety of fields from eczema to cancer, thinking that the technique might at least help patients to manage the pain and anxiety associated with their conditions. All turned him down, including one who told him: “I don’t think what you are doing could possibly help any of our patients.”
“There is tremendous prejudice against hypnosis,” Whorwell concludes. “Medicine has become terribly technical. We’re wedded to drugs, scans, all this high-tech stuff. Something as simple and mundane as hypnosis can’t be seen as being any good.” Embracing hypnotherapy would require rethinking not just trial design, he says, but how to do medicine. “The standard medical model of treatment is take a history, give them a drug, send them away, if the drug doesn’t work, give them another drug and so on. This is a different model where you throw away the prescription pad, you throw away the desk, you throw away everything and you are the thing that either makes them better or not.”