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This case study examines how naturopathic doctor Kim Bretz challenged a complex patient to try a simple plan of gut-directed hypnotherapy rather than a dietary intervention to address her gut-brain interaction disorder.
Case study overview
- For patients who’ve tried ‘everything’, Kim believes presenting gut-directed hypnotherapy as a non-negotiable part of her IBS management plans increases their buy-in and likelihood of completing the six-week program.
- Engaging a patient’s family in the IBS management process can positively impact their chance of success, and their support can be invaluable.
- Kim didn’t implement a dietary intervention as there was no evidence that anything had worked in the past for this patient and her restrictive eating habits were only making things worse.
Patient history
“Most of my patients are like Samantha*—they’re very committed as they feel desperate,” Kim said. “Often how it goes is they’ve seen an MD, a naturopath, a specialist, and they’re stuck. That’s when they’re sent my way.”
Samantha was referred to Kim by another doctor seeking help for her intolerable levels of pain after eating.
“She would be doubled over with painful cramping. She also had gas, bloating, and felt exhausted after eating. And she would regularly experience different symptoms, moving between loose stools and constipation.
“As a mother in her mid-30s who ran her own business, Samantha led an incredibly busy lifestyle. She’d been wondering if she could keep it all going at work as her gut problems greatly impacted her quality of life.
“She’d had fatigue and urgency issues since her teens, but it just kept escalating. She told me the previous five years were bad, but over the past two years she questioned whether she could keep going at all.”
Assessing symptoms
By the time Samantha met with Kim, she’d already undergone many tests and had met with a range of healthcare practitioners to no avail.
“Samantha was such an intense case,” Kim recalls. “She had no upper GI pain, but she did experience nausea when the pain was high enough. Testing found trapped pockets of gas on her distal colon, and she was able to massage herself to get it moving a little bit. But it was just total discomfort and pretty awful for her.
“She also did SIBO testing, which came back negative; she tried two colonoscopies and two upper GI series; she was negative for celiac disease; she had a normal CT and an X-ray to look at the trapped gas; she was H-Pylori negative; and she has a pending MRI.
“She would go to the emergency room to see if they could help, and she saw a gastroenterologist who ran every test possible. Her family doctor was supportive but said, ‘I don’t know what we can do anymore’ when she felt like she’d run out of options.”
Samantha had also tried a wide range of dietary interventions to target her pain.
“In the past, she had tried to follow a low FODMAP diet, then a low histamine diet. She tried cutting out all grains and then cut out carbs as much as possible. She did experience benefits here and there from changing her diet, but it was unstable and she wasn’t getting better consistently.”
Addressing anxiety
When they first met, Samantha’s anxiety immediately caught Kim’s attention and she saw how everything spiraled in her mind.
“Just about anything to do with food and eating was traumatic for her. She worried about how she would make it to her office, get through a work meeting, and handle the kids at home. She said, ‘I don’t know what to feed them and feed me’. She worried about what would happen if she didn’t get better and we couldn’t figure it out.
“The other thing that stood out to me is that she told me her husband thought she was totally focused on her gut symptoms too. When it came time for me to devise a plan for her, her husband’s comments really helped her take my advice on board, as we were both telling her the same thing, and she could see that it was all swirling around her.”
Once Samantha understood more fully how her stress and anxiety contributed to her symptoms, Kim said, “All of this energy you’ve spent worrying could be better put towards focusing on your gut-brain miscommunication.”
Implementing a plan
Kim’s first step was taking Samantha through a detailed explanation about disorders of the gut-brain interaction, believing a thorough education about their condition secures buy-in from her patients.
“I always reassure them, ‘It’s not in your head’, and I tell them we’re going to look at the whole critical abnormality going on.”
Kim’s plan was simple for Samantha. “I said, ‘Just try Nerva’. That was it. I actually can’t believe she agreed to this, looking back. But if I thought something else could make her brain happy, I’d have implemented it!
“I opted to not recommend any kind of dietary intervention. Almost every food was potentially a problem for her, and nothing she’d tried before was consistently proving helpful.
“Instead, how I explained it was, ‘It’s like you’re ‘feeling’ everything you’re not meant to feel, like your digestion’. We set her goal as being able to introduce more foods back into her life, especially when there was no proof they’d been a problem for her and restrictions were only making things worse.
“She still had doubts, and she brought up the idea that maybe it really was SIBO and thought she should test again for this. She wondered if antibiotics like Rifaximin would help and thought something might be wrong with her pancreas too.
“I listened to all of it and explained why more testing probably wouldn’t be beneficial for her. I didn’t think it was her pancreas, but I knew she had a family history of Type 1 diabetes and I told her we could run a fecal elastase test to see if she’s not making enzymes.
“I said this because I knew she might feel like Nerva wasn’t enough. I wanted to reassure her that we can set this test up for her after she has given the six-week gut-directed hypnotherapy program a go. I also offered to set her up with a glucose SIBO test after the six weeks if it still wasn’t enough.
“I opted to share the list of what we could do if Nerva didn’t work and broke down the time period of the plan for her as I felt like it would give Samantha some level of control over what’s happening.
“Fortunately, she was pretty agreeable to just starting with gut-directed hypnotherapy.”
Positive progress
After Samantha met with Kim, she spoke to her husband about Kim’s recommendations and started Nerva the next day.
“It was a very fast turnaround! But she had a strong buy-in and was very committed from the start.
“She was happy to share that her pain went away in the first week, which we understood was likely a placebo effect. The only slight setback was she still felt nauseated at the start of the program, but this was not an uncommon symptom for her.”
Samantha was consistent and determined. She listened to Nerva every day and its positive impact on her overall quality of life was soon evident.
“Not only was she doing better, but she started eating more again too, which was just the biggest thing for her.
"I saw her six weeks later and was happy to hear she was eating with her family again and was able to have pizza with her kids. She was also eating culturally specific foods she had been avoiding, and she returned to a plant-focused diet—she wasn’t a vegetarian, but this was still important to her.
“She has since told me she still experiences bloating that comes and goes. And she knows it’s mostly because she reintroduced carbonated drinks into her diet. But what matters the most is she’s not panicking about it and recognizes everyone experiences bloating and gas.
“She’s also introduced diaphragmatic breathing and yoga into her routine. I work with a yoga instructor through my clinic, and she shared videos with Samantha focused on movement around the midsection to help with her discomfort.”
Routine adherence
While gut-directed hypnotherapy research confirms that adherence to a six-week program of daily hypnotherapy is challenging for many, Samantha didn’t experience any problems sticking to the Nerva program, mostly thanks to Kim creating such a strong buy-in through education.
“As a clinician, I’m getting better at helping all of my patients with adherence by learning how to better explain gut-directed hypnotherapy so they understand the thinking behind it.
"Just this week, I had a male patient say to me, ‘When you first told me about Nerva and gut-directed hypnotherapy, I thought it sounded so stupid. But it’s been life-changing for me.’
“Samantha, however, has a controlling Type A personality, and she said to me, ‘If someone told me to do a carbohydrate-specific diet, I did a carbohydrate-specific diet. If they said eat 20 grams of carbs a day, that’s what I did.’ So, the compliance with Samantha was there for sure, which I wouldn’t see in all of my patients.
“What also helped was the support she received from her husband and family. He backed her up and encouraged her along, which was great for her. With her demanding career, her husband had been the one holding up the back end of her life, so he really needed her to get better. It was incredibly helpful how supportive he was.”
Patient learnings
From Kim’s time working with Samantha, she’s since realized that she needs to make gut-directed hypnotherapy a more significant focus in her consultations and IBS management plans.
“In the past, I’ve had it as a backup, and I’d say, ‘We can try gut-directed hypnotherapy if this other stuff doesn’t work.’ Not all of my patients were as extreme a case as Samantha, but now I tend to bring up Nerva much earlier in our consultations, especially for the patients who’ve already tried everything.
"I’m trying to communicate with patients that it’s less of a negotiable strategy and make it the primary intervention to secure buy-in to my proposed plan.
“The critical abnormality with the disorder of the gut-brain interaction is the miswiring and miscommunication that’s going on. So, I tell patients, ‘We can take away foods and do all sorts of other treatments and tests and it might contribute to you feeling better in the short-term, but this is a long-term goal. And if you don’t get it sorted now, you’re just dragging it out longer.’
“To be honest, I didn’t expect to get such a good outcome from Samantha. She went from telling me, ‘I’m doubled over in pain, I’m eating almost nothing, and I can’t keep going’, to ‘This works, I feel amazing’. I just wasn’t expecting that magnitude of positive benefits. If I had my time over with her, I wouldn’t do anything differently.”
Dr. Kim Bretz is a practicing naturopathic doctor focusing on gut health for over 20 years. She is an advocate for education, leading continuing education in gut health for many healthcare professionals, and is adjunct faculty at the University of Waterloo, Pharmacy School in Ontario, Canada.
*Name changed. As we share real stories from real people, stock images have been used to ensure we protect the privacy of our users.
