Gut-directed hypnotherapy and psychological therapy: treatment via the gut-brain axis

Healthy state

Gut and brain are connected through nerves, hormones and immune messengers (see the gut-brain axis). In IBS Irritable bowel syndrome Recurring abdominal pain linked to bowel movements, without tests finding another cause. Today it is understood as a disorder of gut–brain interaction. More in the chapter “The gut-brain axis”, it is mainly the processing of gut signals that is altered: normal stretching or gas is reported as pain, and attention, anxiety and stress turn the volume up further. This is exactly where gut-directed psychological therapies come in. They do not treat "the mind instead of the gut" but the line in between.

Gut-directed hypnotherapy is not stage hypnosis. You stay awake and remain in control. In deep relaxation, the therapist works with images and ideas intended to calm gut activity and pain perception. The best-known approach is the Manchester protocol: originally twelve weekly sessions, plus recordings for practising at home. In an audit of 1000 people treated there, symptoms improved in 76 percent, though without a comparison group.

Hypnosis is a state of focused attention in which one is especially open to mental images. In the Manchester approach, the therapist might paint a picture of a calmly flowing river and place a hand on the belly to provide warmth; at home you practise daily with a recording. Exactly how it works is not fully settled. Discussed are altered pain processing in the brain, less tension and a greater sense of control over the belly. The effect usually builds up over weeks, not in the first session.

Cognitive behavioural therapy (CBT) for IBS is structured training. You learn how stress and the gut interact, recognise patterns such as constant avoidance or checking, practise relaxation and gradually try again things you avoided out of fear of your gut. In the large British ACTIB trial, this was delivered by telephone with a therapist or as a web programme with little support.

Expectations: the goal is rarely complete freedom from symptoms, but noticeably less pain and tension and more calm in dealing with the belly. In the Manchester analysis about one in four people did not respond. This says nothing about the person: if you do not respond, you can try another method or another therapist. Unlike medicines, both approaches have no interactions with drugs.

Disrupted state: causes and effects

Why does a gut problem need treatment via the head? Because pain, worry and tension wind each other up. If you fear the next bout of diarrhoea, you are tense, constantly monitor your gut and avoid situations, and that is exactly what amplifies the signals. This does not mean the symptoms are imagined. They are real, and the therapy acts on a real point in the system. People who had done CBT described initial scepticism in interviews, but then a new understanding of their gut and long-lasting improvement.

The evidence is unusually good for a psychological therapy. A network meta-analysis Meta-analysis An analysis that combines the results of several studies. It is only as good as the studies it includes. of 41 trials and over 4000 people found effects for CBT (face to face, by telephone, online) and for gut-directed hypnotherapy; none was clearly better than another. The authors warn that many trials are biased and the effect is therefore probably somewhat overestimated. Guidelines from the UK and the USA recommend both approaches when diet and medication are not enough.

Some figures: in an Australian trial, gut-directed hypnotherapy worked about as well as the low FODMAP FODMAP Short for fermentable sugars and sugar alcohols that are poorly absorbed in the small intestine, such as fructans, lactose, fructose and sorbitol. More in the chapter “Doing low-FODMAP right” diet over six weeks (72 versus 71 percent clearly improved), the effect lasted six months, and anxiety and mood improved more. In Manchester, in a trial of 448 people, six sessions worked as well as twelve. In ACTIB, telephone CBT was still better than usual care after two years. In Sweden, hypnotherapy worked less well outside specialised centres: who delivers it matters.

How strong is this compared with medicines? A meta-analysis of 53 trials found that low-dose antidepressants and psychological therapies each reduced the number of people whose symptoms did not improve by about a third (relative risk 0.66 for antidepressants, 0.69 for psychological therapies). Relaxation methods, CBT, hypnosis and other therapies worked, each based on at least two trials. The two routes do not exclude each other and can be combined. The studies share the same weakness, though: psychotherapy cannot be blinded.

Apps make hypnotherapy easier to access. In a randomised trial Randomised trial A study in which chance decides who gets the treatment and who does not, for comparison. This makes results particularly reliable. of 240 people, 81 percent reached the main goal with a 42-day hypnotherapy programme (Nerva), compared with 63 percent with a comparison programme without hypnosis. In a Dutch trial of 230 people, however, the app was not as good as a therapist: pain improved in 33 versus 48 percent, and in 22 percent after education alone. After six months, both forms of hypnotherapy were better than education.

Programmes sold under names such as "limbic retraining", DNRS (Dynamic Neural Retraining System) or the Gupta Program, now also called "Amygdala and Insula Retraining", are something quite different. They promise to reprogram a "stuck alarm system in the brain" and target people with chronic fatigue, long COVID, mould or mast cell Mast cells Immune cells beneath the skin and mucous membranes, filled with histamine and other messengers. They raise the alarm in allergies, infections and stress. More in the chapter “Mast cells: alarm cells in the gut, histamine and the disputed MCAS” complaints, often also with gut problems. No controlled study on DNRS was found.

For the Gupta approach there is one small study in fibromyalgia and chronic fatigue in which only 7 of the treated people stayed to the end, and a randomised online study in long COVID with an active comparison group and 100 people, 60 of whom dropped out early; one co-author advises the programme. There is no study on gut symptoms. The courses cost money and their effect has not been independently tested. The difference from gut-directed hypnotherapy lies not in the idea but in the evidence.

Two cautions. First: before starting, warning signs and other conditions should be ruled out medically, so that a treatable cause is not overlooked. Second: in severe mental illness or after trauma, hypnosis should only take place with a professional with relevant experience, not with someone who took a short course. This is caution, not a ban.