CBT for a Case of Mixed Irritable Bowel Syndrome and Inflammatory Bowel Disease
By Allen R. Miller, PhD
Irritable Bowel Syndrome (IBS) and Inflammatory Bowel Disease (IBD) had implications for Ann’s life that she never anticipated. After learning that her penchant for eating fatty foods and smoking cigarettes exacerbated her symptoms and discomfort, she started to make lifestyle changes, hoping to ameliorate the severity of her physical symptoms and the associated depression she experienced. Almost constant feelings of bloating, alternating constipation and diarrhea, fatigue resulting from sleep disruption, and other IBS and IBD symptoms made it impossible to maintain her daily routine. The lifestyle changes and medications helped, but the discomfort and disruption to her life became so great that she eventually had surgery.
Though Ann’s physical symptoms were diminished following surgery, they were not resolved, and her depression worsened. Her surgeon informed her that problems with her small intestine were improved, but her colon still had considerable inflammation, and additional surgery might be necessary. Adding to what Ann had already been through, she began to think that her efforts were useless and that she had no hope for recovery and living a normal life. Recognizing her worsening mood and fearing the impact it would have on Ann’s strength and recovery, her surgeon referred her for cognitive behavior therapy (CBT).
Ann was receptive to the therapy referral, even if she didn’t recognize a connection between her physical condition and her mood. During her initial CBT sessions, she related a history of emotional abuse as a child. She also reported several long-term relationships characterized by emotional and sexual abuse. After being told repeatedly as a child that she was worthless and would never amount to anything, Ann eventually came to believe that it was true. Ann’s core belief of worthlessness provided a foundation for thoughts and assumptions that defined her lifestyle. To Ann, having no worth meant that she was lesser than other people and undeserving of having her needs met. Others’ wants and needs always took precedence over her own. She believed she should only have something she wanted if everyone else was taken care of first. She was in constant search of ways to please others in order to earn their appreciation. Associated with Ann’s beliefs were feelings of stress and worry about whether or not she could satisfy other people’s needs. She soothed herself by consuming tasty, unhealthy foods and smoking cigarettes.
Changing her belief about herself became a life-altering event for Ann. After starting to think of herself as being like other people, she permitted herself to think about what she wanted from life and worked on becoming more assertive in pursuing her wants and needs.
As her CBT therapy progressed, Ann recognized the connection among her thoughts, feelings and behaviors and was motivated to make further changes. She could easily recall times when she experienced flare-ups in her symptoms following the receipt of bad news, dissatisfaction from others, and even when she thought about doing things for herself.
Ann’s core belief of worthlessness permeated all aspects of her life. Since she had already started to make dietary changes and reduce her smoking, she opted to start working on her beliefs. We proceeded to evaluate her belief that she had no worth. She offered the fact that she had IBS and IBD, was overweight, still smoked, did not always satisfy other people’s needs, and had never pursued anything she valued as her as proof of her worthlessness. A more difficult part of the belief evaluation was having her identify things about herself that did not support her belief of worthlessness. She struggled to describe herself as a reliable and competent employee, a person with a good sense of humor and pleasant demeanor, and a person who had significant musical talent playing the flute. An aside worth noting here is that her current and past partners, who were very possessive, did not allow her to pursue her musical interests. In keeping with her belief that others’ wants and needs were more important than her own, she had not challenged their restrictions.
With great effort on her part, Ann accepted that she did have characteristics that indicated worth. Acknowledging positive characteristics about herself led her to reconstruct her beliefs. Having positive characteristics is inconsistent with being worthless, so Ann resolved the dilemma by developing an alternative core belief that recognized that there were items that supported her belief of worthlessness and items that did not support her belief. She settled on, “I have strengths and weaknesses, just like most other people.”
Changing her belief about herself became a life-altering event for Ann. After starting to think of herself as being like other people, she permitted herself to think about what she wanted from life and worked on becoming more assertive in pursuing her wants and needs. She worked with her therapist to use relaxation techniques and replace anger– at not having her needs met– with hope for the future. She made major changes in her life. Ann allowed herself to consider her own wants and needs when juxtaposed with those of others. She ended her abusive relationship and started seeing other people who treated her better. She renewed her love for playing the flute. Eventually, she left her unrewarding job and supported herself by playing with orchestras and smaller bands. Ann did not need to have the second surgery that her surgeon had predicted. She recognized the connection between her body and her mind!