CBT For IBS with Dr. Sula Windgassen

Welcome back to the doctor body mind soul podcast. My name is Dr. Jude. And this is a podcast which explores how we can integrate modern medicine and alternative therapies to help you get the holistic health care that you deserve. I will be speaking to healers and seekers, researchers and authors who will share their experiences and the evidence to help guide us all to Holistic Health. Let's do this. All right, so Dr. Sula Windgassen is a health psychologist and senior cognitive behavioral therapist, mainly working with people who suffer from long term physical symptoms. So sue the welcome.

Hi, thanks for having me.

I mean, you're a psychologist, and yet you're working with lots of physical health conditions like IBS, IBD, pelvic pain, and even UTIs. Can you explain how your work works with our body mind soul connection?

Yeah, absolutely. I guess I mean, it's an area I'm quite passionate about. Because I think when people have ongoing physical health problems, their emphasis, understandably and intuitively is on trying to find the physiological kind of underpinnings, what went wrong, so that you're now experiencing symptoms. But the kind of downfall of this approach is that people expend lots of energy, essentially battling a lot of time with the healthcare system, which often doesn't come up with straightforward answers and straightforward treatment approaches. And the result of this is people get incredibly anxious, incredibly low, it has a huge impact on their life. And so the part that's neglected is the emotional burden of having a long term health condition. And if we think about how that interacts with having the health condition, whatever it might be, we know that there's a huge interaction with how we're feeling emotionally, and how our body is functioning. So just on a very kind of broad level, you know, our central nervous system is fed into by our psychological experiences, whether that's emotions, feeling anxious, feeling unsafe, that's going to cause the secretion of lots of different stress hormones, which then has an impact on how different organ systems are functioning, it's going to have an impact on where our attentional focus is going, which is going to have an impact on you know, how much we experience pain, for example. And we know from things like placebo and no SIBO research, when we are expecting things to work or not work that has a bearing on the actual, you know, physiological outcomes. So to neglect that psychological side is to neglect a fundamental part of, you know, our physical health also.

Wow. So what I really hear you saying is that there is a psychological impact of having the condition, right that you have, and actually our healthcare system makes it harder, which then has an additional impact of having the condition as well. But what you're also really speaking to as well is that, you know, our psychological experience is directly impacting our physiological function. And so there's the mind body connection, both in terms of the disease process itself, and also the impact of having a disease and having a chronic illness. And on top of that, navigating a healthcare system, which is really difficult to navigate. Yeah, yeah, absolutely.

And I guess the way that I work is kind of if we is from a biopsychosocial perspective, so by coming to a health psychologist, you're you're not coming to say, you know, my symptoms are all caused by psychological factors, quote, unquote, you're coming to honor that part of the puzzle, because if we, if we do understand how to be a bit, a complex picture of the biological, you know, the physiological factors involved, and there might be many, which is partly, you know, part of the frustration when trying to find answers for health, it might be that there's a genetic component, there might be, you know, a particular infectious component that was there that's no longer there, or is still there. But, you know, hard to find, you know, there's so many different physiological components within that biological sphere. And then if we also, were talking about what the healthcare system acknowledge that social component, so yeah, the interaction with the healthcare system, how that leaves you feeling how that impacts on your health outcomes. So you know, thinking about diagnostic delays, how does that physiologically impact on the health condition itself, for example, but also the stress that comes with trying to advocate for yourself in a system and how that then, you know, physiologically impacts via the psychological experiences? So I suppose what I'm helping people navigate is the The psychological and social experiences and component of their health condition. And with a view of identifying what those are, and making sense of them, clarifying you know exactly how they're feeding into the physical experience, we can then improve the health experience overall, whether that and that's going to look different for different health issues. So for some health issues, we know that target in some of these aspects can improve symptoms severity and chronic pain in irritable bowel syndrome, even in inflammatory bowel disease, to some degree. For others, it might be that we're alleviating some of the symptom related anxiety and reducing the impairment on functioning, which then will improve the primarily the psychological experience like in multiple sclerosis, for example. So the outcomes are going to look different for different health issues. But what we see no matter what we're targeting, is that this very real interaction that needs to be acknowledged and worked with

one of your specialties, as you've said, is, is IBS. And this is a condition that I see a lot of people present with, actually, what what does your audience need to know sort of right now about IBS and CBT to help them get a quick win.

So I think first of all, understanding irritable bowel syndrome as a bio psychosocial condition. So there's been so many research papers studies done now that really establish it as a bio psychosocial condition. And what that means is, there will be, you know, the physiological component, which again, can look different for different people. For some people. IBS might have started after a bout of gastroenteritis for some people, it might have been after an extended period of traveling, whether you know, their diet, their routine results, you know, topsy turvy, but usually what we find is, there is an interaction, again, at the onset, where the symptoms start for whatever reason, whatever physiological reasons. And then there is also the psychological experience of those symptoms, whether that's you know, stress, because you have to miss work or worry about what the symptoms are complex diagnostic processes, and then there's the social experience. And again, just thinking about bowel symptoms, there's a lot of taboo, particularly, you know, in the UK, around kind of toileting, and then that might feed into fear of symptoms, embarrassment, there might be, yeah, financial repercussions if you are having to take time off work. So working with IBS, using cognitive behavioral therapy is to understand IBS as his bio psychosocial condition. So the first thing that we start with to get quick wins is more of the behavioral stuff. And usually, what I find really commonly is people have made, again, intuitive connections between things that they've eaten and their symptoms. But the, the process by which they've done this might be slightly incorrect and faulty. So for example, if you've eaten a piece of cheese, and then 10 minutes later, you're having symptoms, it's probably not to do with that cheese, but just the process of your digestive system being fired up, for example, because you've eaten, and so we can misinterpret that as Oh, cheese is bad, or gonna cause the symptoms, we can get fearful around food, and that can quickly generalize out. And so that fear around food can massively play into, into IBS symptoms itself. So one of the first things that we do in in the CBT protocol is get a bit of a broader understanding of, of what things are involved in symptom maintenance. And so we look at not the specific foods, but when you're eating, what times of day, what does that look like over the course of a week, and what meal size you're having. So, you know, small, medium, or large say, and we also look at, you know, how that corresponds with symptoms. So you might be more prone to diarrhea or constipation, and then you know, your your measure of pain or abdominal discomfort. And then we also measure stress. So we look at these kind of four to five different variables, create scores, and we see how those things relate to each other. And usually, what I find for most people, is they're not eating as regularly as they think they're eating, they're often skipping meals in the face of having symptoms. And what we know is skipping meals, avoiding eating, or massively reducing portion size can have a big impact just on the basic regulation of how our guts working if we think about it, like, you know, a creature of habit. It just wants to be trained, when can I when can I expect foods, and then it will kind of establish a sense of regularity around that. Of course, that's not the only factor. But that's the biggest quick When that I find with most clients is just getting a bit more regulation in their eating pattern and making it more regular and trying to stop skipping and avoiding foods when they're having symptoms, reduce it down or find something that's going to be a bit more, you know, palatable, whether that's yoga and a dry piece of toast or whatever it might be, but don't stop eating. And over, you know, even within a week, I find with some of my clients, they see massive differences just on that basis, and then we can work on other stuff. So that would be my go to first thing that I would suggest,

oh, that's so interesting. That's interesting. You can really, I can really imagine the associations we make because we're also hyper vigilant at that time. And you have an IPS CBT groups that you hold, can you walk us through the the approach of your program and how that all works?

Yeah, absolutely. I mean, the first thing that we do even before this diary is go through some fundamental information, I think about how the guts working and how that interacts with our psychological experience. So you know, lots of people know some basics around, you know, gut function. But I would say the majority of my Well, definitely the majority of the people that I've worked with, haven't been told, so fundamentals about what's going on in their bowels to underpin that IBS symptoms on why it's happening. And if we separate that question of why in terms of, you know, the physical, physiological kind of why what is actually going on in order to cause the symptoms rather than what what's causing the physiological changes, if that makes sense. So just even understanding and being able to trace what's going on in your colon, predominantly, it is your color, and IBS demystifies the symptoms a little bit and also then gives you a basis for increase in a sense of control, because we know the symptoms are happening for these reasons. And we know some of the things that can influence those things. Just like you know, regularity of eating, we also introduced that concept of the brain got access, so how stress whether you know, consciously oh my god, I'm really stressed about this, or just, it's a stressful day, but you're getting through it can then impact on our function. So so that would be the very first step that we would do in order to, you know, set the basis and foundation for everything

else, then I see a lot, or I see a lot of anger or frustration when they're told this is IBS is in your head. Right? So this is a psychological problem. That kind of phrase can be quite damaging.

I completely agree. I think you're quite right, you know, this. In that sense, there's no such thing as in your head, because the body is so interconnected with with thought processes with emotional experiences and whatnot. But yes, to really understand that relationship is important, I think for you to, to get a sense that it's a really, it is a really damaging thing to think I will, you know, the message is, it's all in my head. So it's my fault. So I just need to, you know, sort my head out on my cell phone, not, you know, not be so dramatic, or whatever it is, I've heard all different variations of this. So it kind of puts the blame really on the person experiencing symptoms, but it doesn't give any resolution because they've tried many different things to try and help with this. And I guess, in terms of like, feeling a sense of safety, it makes me feel very unsafe, because it's like, well, I've now received this information that this is something that I'm causing, I don't know how I'm causing it. And I don't know how I can unpause it. So am I just left with this forever. And then you battled with your mind with your body and it feels even more unsafe. And there's a sense that no one else can help me with this. So just thinking about, I keep using this word safe, but I think that's a really helpful way to think about the way this plays out in the body. If you no longer feel safe in your body, then just inherently your central nervous system is picking up threat, threat, threat, threat threat. And, you know, me and my clients have many kind of discussions about this metacognitive process where you notice a thought, oh my God, I've got a symptom, it's gonna get worse stop saying that you're gonna make it worse. Oh my god. I can't stop thinking about any stop thinking about it. And then layers and layers get piled on. And this is really, you know, exacerbated by these messages of it's all in your head. So yeah, I think just helping people. And that's what this CBT for IBS program does. So well, helping people understand you know, how the different parts of working and you know, what's going on in your body. So it's not just you know, quote unquote, all in your head and there are different ways around to working with this, so yeah, that that first step is really fundamental. And that this program that I use was the one we developed for our large randomized control trial, which,

yeah, assess the efficacy of this program CBT for IBS, remotely, over 612 and 24 months, and we found that symptom severity significantly reduced. And this, those results were maintained up to 24 months later. And the feedback that we got from participants in that trial was about the psychoeducation. One of the things that was most regularly talked about was that, you know, why wasn't I told this right? When I got my diagnosis, I feel like things could have been a lot different. And the people in our tribe were people who'd had IBS for like, 10 plus years. And they were in the category of refractory IBS. So they'd at least tried one firstline IBS treatment. But I think the average age, the average duration of symptoms was definitely above five years might have been around eight to 10. I can't quite remember. So people have had it for a long time. And that's, you know, those were their reflections. And, yeah, so I do think that's a real key foundation in any CBT fibers program. And from there just to answer your question to begin with, we do, then, you know, if that's our hypothesis, this is how it's all working, let's collect some data specific to you. Let's see how these relationships are playing out. We use that then to inform a bit of a cycle. So we identify what are some of the key thoughts that come up when you're getting symptoms? What are the key responses that you've got to the symptoms, there might be like avoiding food, like I mentioned earlier, there might be avoiding things more generally, which keeps anxiety going, which keeps symptoms going, there might be lots of safety behaviors like taking Imodium preemptively, which we know further kind of dysregulated gut gut function. So so we're trying to pick out all the different, you know, maintaining factors, thoughts, behaviors, and we lump in emotions with thoughts, because the understanding is the two are interlinked. And the two have a similar effect on on the symptoms themselves. And then we pick our focal point to begin with, with just the behaviors, we make some changes, starting with regulating eating, or reintroducing avoided foods, or increasing particular things like if somebody's got constipation, then it might be increasing fibrous foods, or increasing water intake or something like that. And then from there, we start to tackle activity patterns. So when we were talking about stress there, we were talking about how people can can often report not feeling stressed, but actually, their body's very stressed because they're always on the go. And definitely, that's something I see with people with IBS, commonly, they tend to be really able to just keep going and keep going to keep going. And so that demands a lot of the body. And so one of the goals that we have is about building in breaks, allowing themselves more time just to recuperate, that doesn't have to be sat on a couch watching Netflix, it can be, you know, reading, we spent in you know, enjoyable time with a loved one, it can still be active, quote, unquote, but it needs to be restorative. So it's not just all task oriented, and you know, responsibility oriented. And then then we make a switch from the behavioral part of things to the cognitive to looking at some of these thoughts, looking at how we respond to them, looking at our emotions, as well, and how we process those. And, yeah, we start to pull it all together. So yeah, it's kind of a multifaceted program. But it's, it starts off with the low hanging fruit that can create some physical differences early on.

Wow. And also just like massive congratulations for, you know, starting your program doing doing a trial alongside it. That's no and publishing your results. So that's no mean feat.

Well, yeah. Just to clarify that program. So that was when I was doing my PhD. So I was doing that with with a large research group who were amazing. So I learned a lot from them. And I've been since you to the same program going into private practice. Yeah. But thank you.

Yeah, yeah, great, because it's always it's always really it's always so much more robust when we actually looked at these things. And what really stuck out to me as I read a paper recently about endometriosis, which I know that you actually work with as well. But it was just that it was, it was it showed that there was a reduction by half in the pain scores of pelvic pain, just by giving nutritional advice. It wasn't even whether that advice had been implemented, but actually being given something that someone can do like to be able to get control of you know, what is going on is so huge. And that's what I really sort of really hope to be supporting with like the witchy women platform. And Dr. body mind, soul is just really allowing people to learn and become more informed because feeling empowered within your own body and within the healthcare system is more important, I think that we've been given credit for it can have such a huge impact on on the experience of our symptoms, pain being one that's been researched quite extensively.

Yeah. Yeah, there's a health psychology model called the illness perceptions model or common sense model by Leventhal. And it posits that there's, I mean, the original was there was five main domains that have an impact on people's long term conditions, outcomes, or health outcomes, one of them being identity. So the identity that we give the condition, so for example, if someone's got irritable bowel syndrome, they might then experience symptoms, really bowel symptoms, and say, that's part of my IBS, but they also might start lumping in other things like fatigue, or you know, if they feel noisiest one time, and that gets lumped under, oh, it's my IBS. So it's kind of how people develop an understanding of what their condition is what falls into that, then the other one is consequence. So what's the impact of me having this illness? What, you know, how does that affect me? What did it get in the way of? What does it mean? One is duration. So how long is this going to go on for is it going to go on forever, and one is control or Curability. And that's been separated into two. So you know, own ability to control and kind of treat, you know, doctors being able to provide support. And so there's been lots of research looking at that illness perception questionnaire, and what domains influence outcomes. And you know, similar to this interview choices study, we find that increased perceptions of control are associated with better health outcomes, because it is such an important factor.

That's so interesting. And I love that you bring research into support to support that answer. I think that's my desire is to an out and I My wish is that we as doctors are able to empower our patients more because it is so important. So yeah, I think both of both of us share that mission a little bit. Yeah. Well, thank you so much for joining me on this episode. I feel like I've learned so much. I think I've learned a bit more about what the role of a health psychologist actually is. And you've explained and articulated so many lovely concepts that wouldn't really take away. So thank you so much

for being here. Thank you. Thank you for having me.