Before psychologist Andrea Bradford, PhD, joined the gastroenterology section at Baylor College of Medicine in Houston, most of the patients in their specialty clinics there weren't getting the psychological care they needed. The patients weren't always comfortable bringing up psychological or behavioral issues, and the physicians found it difficult to find psychologists with knowledge of digestive disorders. Even when providers did refer patients to psychologists in the community, often patients wouldn't make an appointment, says Hashem B. El-Serag, MD, MPH, chief of the gastroenterology and hepatology section at Baylor.
That began to change once Bradford joined the clinic in 2016. She works with about a dozen gastroenterologists to care for patients with functional bowel disorders, inflammatory bowel disease, esophageal reflux disorders, bowel cancer and other gastrointestinal problems that can cause anxiety, depression, even sexual dysfunction.
"We are promoting the concept of digestive wellness, which, in addition to traditional medical care for the digestive system, encompasses a focus on diet and nutrition and mental and psychological well-being," says El-Serag, who hired a dietician at the same time he hired Bradford. Most chronic digestive disorders are associated with stress and poor coping mechanisms, El-Serag explains. "At a minimum," he says, "psychological stress worsens the quality of life for patients with digestive disorders and reduces the effects of medical therapy." In some cases, he adds, psychological factors may be responsible for the disorders in the first place.
Only half a dozen gastroenterology clinics in the United States have a full-time psychologist on their treatment teams, El-Serag says.
When the clinic's physicians identify patients with depression or anxiety, they refer them to Bradford for treatment. They also refer patients with stress or behaviors that are exacerbating gastrointestinal symptoms.
If Bradford discovers that mental illness is a patient's primary problem, she typically refers him or her to another psychologist for treatment. "However, often the mental illness—depression, for example—is closely related to the course of the disorder," she says.
Bradford prepared for her job by earning her clinical psychology doctorate at the University of Texas at Austin, did a postdoctoral fellowship in Baylor's department of family and community medicine, and completed additional training through Northwestern University's gastroenterology clinic.
Psychological treatment usually does not affect the gastrointestinal disorder itself, she says.What it does is change the way patients think about and respond to their symptoms, which can help them manage their pain and reduce visits to the clinic or emergency room. "It's about making these symptoms much more tolerable to people and allowing them to live their lives without excessive interference," she says.
Research supports two main types of psychological treatment for gastrointestinal patients: cognitive-behavioral therapy and hypnosis, says Bradford. While she's now getting hypnosis training, she is already using cognitive-behavioral therapy.
Take people with irritable bowel syndrome, whose fear of not reaching a bathroom in time can be intense. "People sometimes put their lives on hold," says Bradford. "Some become so limited in their activities or even their willingness to leave their houses that it becomes not just a gastrointestinal disorder but a behavioral disorder." Six to eight sessions of cognitive-behavioral therapy can help patients stop exaggerating their symptoms, return to their normal activities and overcome their isolation, says Bradford.
Bradford can also help patients make dietary and other lifestyle changes to help soothe their symptoms. "The dietician is the point person for telling people how and what to eat," says Bradford. "If there are psychological barriers to following those recommendations, I can step in." Mindful eating interventions, for example, can help patients adhere to the smaller, more frequent meals the dietician often suggests. Bradford also helps patients cut back on alcohol, which can exacerbate symptoms.
Other patients need help with sexual problems caused by their disorders. For some, inflammation can make sex uncomfortable or painful. Others are simply embarrassed by their symptoms. "Most people don't think of bowel urgency as compatible with feeling sexy," Bradford points out.
Bradford also assists patients with cancer, whether it's helping those in treatment learn to cope with often-disabling side effects or helping long-term survivors adjust to new limitations.
Because she's located in the same clinic as the gastroenterologists, Bradford can educate them about how to interpret psychological symptoms they may see in their patients. When one of the physicians referred a patient to Bradford for anxiety treatment, for example, her assessment revealed that it was actually something else that was causing the woman's symptoms to flare up: relationship problems.
"If I hadn't been involved in that patient's care, the physician may have just prescribed a higher dose of psychotropic medication," says Bradford, who referred the woman to marital therapy. "By identifying the underlying contributing factors, we could get that person into more appropriate treatment for her distress."
While the clinic has just begun collecting data on how having Bradford on the team is affecting patient outcomes, resource utilization and financial performance, says El-Serag, "the initial experience has been quite positive."
Beginning in January 2015, each issue of the Monitor on Psychology profiles a psychologist in an integrated care setting.
