Articles: Psychogastroenterology replete with opportunities &
Special considerations articles needed when working with first responders {Below}

Psychogastroenterology replete with opportunities

By Tiffany Taft, Psy.D.
February 5, 2020

For the past 20 years, the role of the clinical psychologist in the manage- ment of chronic digestive disease has evolved into the

newly recognized field of psychogastroenterology. Like other specialties within behavioral medicine, psychogastroenterology focuses on the intersection of chronic medical diseases impacting the digestive system and their subsequent social and emotional impacts.

Research into the brain-gut axis continues to advance rapidly as our understanding of how the brain impacts gut function and vice versa, including the addition of the gut microbiome, identifies unique physiological pathways and patient phenotypes to better classify and treat digestive disease.

While science has quickly progressed, the number of clinicians specializing in this area has lagged behind considerably, creating a dearth of qualified professionals to meet the growing needs of digestive disease patients. As such, opportunities for clinical psychologists to work within the field of psychogastroenterology are immense.

Psychologists within psychogastroenterology treat patients living with chronic digestive diseases such as inflammatory bowel disease (IBD; Crohn’s disease, ulcerative colitis), irritable bowel syndrome (IBS), gastroparesis, celiac disease and gastroesophageal reflux disease (GERD).

There are psychologists embedded within gastroenterology clinics at university-based medical centers across the country, including Mount Sinai in New York, Northwestern University Feinberg School of Medicine, Stanford University and the University of Michigan. Others work within private practices in the community, often servicing overflow patients from the university centers or treating patients from private medical practices.

Most gastroenterologists appreciate the value of psychological services for their patients yet often struggle to connect with proper resources.

A key role psychogastroenterology therapists play in treating refractory symptoms of chronic digestive diseases through evidence-based treatments such as cognitive behavioral therapy and gut-directed hypnotherapy, both having multiple randomized clinical trials supporting their efficacy in several disease groups.

Since psychogastroenterology psychologists have their training foundations in clinical health psychology, they are engaged in similar tasks as those who work with patients with cancer, diabetes or cardiovascular diseases. Most commonly they help with adjustment to a chronic, lifelong disease, teach disease self-management skills, treat comorbid anxiety or depression and help with medical treatment implementation and adherence.

Psychologists in this field also educate physicians on the brain-gut connection and

how it impacts patient outcomes. A particularly important aspect of the work of a

psychogastroenterology psychologist is to de-stigmatize the role of psychological

stress in digestive disease and effectively communicate to patients that while their

brain may be influencing their illnesses, their symptoms are not “all in their heads.”

Unfortunately, stigma can be a barrier to patient engagement in psychogastroenterology

services, but can often be mitigated with proper communication and support.

What types of patients come to a psychogastroenterology practice? Generally, irritable bowel syndrome and other disorders of gut-brain interaction (DGBI; formerly referred to as Functional GI disorders) are the most common referrals.

Irritable bowel syndrome impacts approximately 10 percent to15 percent of the U.S. adult population, making it one of the most common conditions seen in primary care and gastroenterology practices. Pharmacological treatment efficacy for IBS is modest (30 percent to 40 percent) and often targets symptoms versus the underlying mechanisms of the disease.

Conversely, psychological interventions for IBS directly target the dysfunctional brain-gut connection believed to be perpetuating symptoms. As such, 60 percent to70 percent of patients report significant relief from their IBS symptoms after engaging in either CBT-IBS, mindfulness-based stress reduction or gut-directed hypnotherapy.

Due to the success of these interventions in both research and clinical practice, they are now applied across the digestive disease spectrum. For more information on gut-directed hypnotherapy, which requires specialized training to incorporate into practice, visit http://www.ibshypnosis.com/.

Unfortunately, as of 2019, the American Psychological Association does not recognize psychogastroenterology as a specialty. However, the Rome Foundation, a leading international organization dedicated to digestive diseases, established the Rome Psychogastroenterology group in 2018.

If a psychologist is interested in learning more about psychogastroenterology, connecting with the Rome group is the best place to start (https://romegipsych.org). Current gaps in access to psychogastroenterology care leave many patients struggling with chronic digestive disease and underscore the imperative need for more clinical health psychologists to consider psychogastroenterology as a specialty.

Tiffany Taft, Psy,D., is a clinical psychologist specializing in psychogastroenterology. She is the director of psychogastroenterology research at Northwestern University Feinberg School of Medicine in Chicago and owns a group private practice, Oak Park Behavioral Medicine. Her email address is: ttaft@opbmed.com.

Special considerations needed when working with first responders

By Mark Kamena, Ph.D.
February 4, 2020

First responders and their families make up a unique subculture. Therapists have heard countless stories of their difficulties finding competent treatment.

Police and fire responders report that they often overcome a reluctance to seek treatment only to be met with a provider who understands little

about their work and has difficulty handling their trauma.

Psychologists providing treatment and specialized services with their agencies and departments may encounter ethical challenges as well.

A primary mistake therapists make in treating emergency responders is a failure to understand what they do and how they do it. The culture is closed and infused with high levels of distrust, yet treatment requires self-disclosure. Responders may be trained interrogators or simply guarded. Self-disclosure, or transparency, in treatment with responders, is essential. A therapist lacking transparency is seen as unsupportive, paranoid and mistrustful.

They want to be sure that they can trust you with their innermost secrets and won’t have to rescue you. They want to make sure that you can tolerate their critical incidents and pain and not judge them.

One story heard was from a law enforcement officer who had been involved in his third shooting. The therapist asked if he was ready to stop being a “paid killer.” He did not return.

Dual or multiple relationships are the most frequently encountered ethical challenges. The emergency responder world is relatively small and there may be times that the psychologist has a patient attending a training they are conducting.

Encounters occur in the gym, parking lot, bathroom, at weddings, funerals and parties, deathbeds and christenings and AA meetings. There is nothing inherently harmful about these encounters; however, the APA Ethics Code 3.05 cautions to avoid such relationships if it impairs objectivity, competence or effectiveness.

It is best to notify patients of the possibility of such encounters during the explanation of your statement of understanding (informed consent). The question is not whether one should avoid such relationships, rather to anticipate what to do when they occur.

Treating responders while simultaneously interacting with public service agencies

creates a need to establish clear boundaries. For example, a chief may ask how an

employee that you are treating is doing. This may present an opportunity to educate

administrators about the need for confidentiality in treatment. Having a mental

script to anticipate such questions is recommended.

Another issue that frequently comes up is that police and public safety psychologists do not generally conduct both pre-employment psychological or fitness for duty evaluations and also engage in conducting psychotherapy with responders.

Avoiding harm (3.01), cooperation with other professionals (3.09), maintaining confidentiality (4.01) and explaining confidentiality (4.02) are consistently employed in working with this population. We also are guided by principles of beneficence and non-maleficence, safeguarding the welfare and rights of co-workers and keeping an awareness of vicarious or secondary trauma that may occur.

Having integrity, seeking justice and respecting the dignity of those with whom we come in contact includes clarifying roles and responsibilities, upholding standards of conduct and managing conflict between standards and organizational needs while establishing trusting relationships.

Consultation is extremely important to deal with trauma and being able to review one’s work with other experts. We believe that you don’t know what you don’t know. These colleagues may point out omissions or errors that serve as teaching and learning opportunities for all.

Other considerations involve training and specialized education. For example, several states require five years of experience in police and public safety, three of which must be post-doctoral, and 12 hours of continuing education biannually that must be completed in order to be able to provide pre-employment psychological evaluations, according to California Police Officer Standards and Training (frequently referred to as POST requirements.)

Training is available through continuing professional education offered by several organizations: APA section on police and public safety, Academy of Forensic Psychology, International Association of Chiefs of Police psychology services section, Society of Police and Criminal Psychology, American Board of Professional Police and Public Safety Psychology and the American Academy of Police and Public Safety Psychology.

Mark Kamena, Ph.D., ABPP, MBA, MCrim, is co-author of Counseling Cops: What Clinicians Need to Know (Guilford Press, 2013) and co-founder and director of research for the First Responder Support Network Adjunct Faculty at Wright Institute, Berkeley, Calif. His email is: markkamena@comcast.net.