1
CHAPTER ONE
ORIENTATION, MOTIVATION AND AIM
“A disease experience may be seen as representing problems in one's personal
style of coping and in one's cultural and family context. It reflects multiple
causes, physiological, psychological and cultural.”
Bauer and Rudolph (1975).
1.1
ORIENTATION AND MOTIVATION
Irritable Bowel Syndrome (which will be referred to as IBS hereafter) could well be
classified as the doctor's dilemma. It is a disorder which is centuries old and yet little
light has been shed on the successful treatment of this symptom complex. IBS
symptoms are expressed in various forms. More common are those located in the
mid to lower abdominal tract which include chronic or severe abdominal pain,
abdominal distension, altered bowel habit (diarrhoea, constipation or a mixed stool
pattern) and a passage of mucus (Drossman, 1994). Less common are symptoms
within the upper gastrointestinal tract which could include epigastric pain, dyspepsia,
nausea and heartburn. Seemingly unrelated symptoms such as backache, dyspareunia
or bladder irritability have also been positively correlated with IBS. Psychosocial
factors such as depression and anxiety have been strongly associated with IBS and
this together with the absence of a pathological indication further fuels the diagnostic
dilemma. The incidence of psychiatric illness found in IBS health care seekers
ranges between 70% to 90%, with depression and anxiety predominating (Liss,
Alpers & Woodruff, 1973; Lydiard, Laraia, Howell & Ballenger, 1986; Svedlund,
Sjodin, Dotevall & Gillberg, 1984; Young, Alpers, Norland & Woodruff, 1976).
Historically, science, medicine and psychology have been deeply entrenched in
dualistic presuppositions of man, many of which still exist today (Broom, 1997).
Many psycho logical syndromes with a psychological component and no known
2
cause, such as IBS, have experienced dualistic treatment approaches, which have
often denied the complex interactions between mind, body and soul, between people
and their environments. They may be represented as opposing poles on a see-saw,
with "medicalisation" and the reducing of a suffering human being to a sick organ on
the one end and "psychiatrisation" or the forgetting of the physical body on the other
(Devroede, 1994; Stuart, Pretorius, Stanley, Rossouw, Nel, Dolan & Bush, 1998,
1999).
It is the author's belief that individuals need to be viewed holistically in terms of
their integrated mind, body and soul. This view includes interactive perspectives on
the individual's personal development through time, her particular system of
meaning, her physiological, somatic, emotional, cognitive and behavioural aspects,
her personality, the systems and eco-systems in which she functions and the
particular context from which she has evolved.
A review of the literature indicates that IBS is multifaceted and that the subject's
perception of the disorder may be more important than the symptom itself
(Devroede, 1994; Drossman, 1994). Furthermore, the incidence of IBS is estimated
to affect 8% to 15% of the population and accounts for 13% to 52% of all new
gastroenterology referrals (Whitehead & Schuster, 1985).
In essence, the problematic IBS treatment approach of the past has fragmented the
whole person into mind or body and has disconnected her from her context. It is
therefore imperative to treat the whole person in context and adopt a unified
multidisciplinary approach in order to facilitate therapeutic outcomes.
With the high incidence of IBS in the population and the extremely high association
of depression and anxiety in that group there is an overwhelming need for costeffective treatment strategies to be researched. To date little research has been
conducted in groups although many researchers have advocated the need for it
(Drossman & Thompson, 1992; Els, Gagiano, Grundling, van Zyl & Joubert, 1995).
3
1.2
AIM OF THIS STUDY
The specific aim of the present research is to ascertain the value of a holistic group
therapeutic intervention for subjects with severe IBS who also suffer from moderate
to severe depression and anxiety. This aim can be operationalised as follows: this
study aims to establish if there are statistically significant differences between the
pre-test and post-test scores regarding the IBS Severity Index, depression and
anxiety in a group of white female IBS subjects who participated in a holistic group
therapy intervention versus the control group who received no therapeutic
intervention.
1.3
OUTLINE OF THE STUDY
Chapter One serves to orientate the reader in terms of the motivation and aim of the
present study. Chapters Two and Three lay the theoretical foundation for the study.
In Chapter Two an overview of IBS, depression and anxiety is presented. IBS is
discussed in terms of its definition, epidemiology, etiology and diagnosis.
Depression and anxiety are discussed in terms of their definition, incidence and
etiology as well as a synopsis of the similarities and differences in IBS, depression
and anxiety.
Chapter Three reviews the literature in terms of the therapeutic interventions of IBS
subjects both individually and within the group context. This includes biological
interventions, with emphasis on pharmacotherapy for pain-predominant IBS,
diarrhoea-predominant IBS and constipation-predominant IBS. Psychological
interventions include reviewing insight-oriented psychotherapy, hypnotherapy,
cognitive behavioural therapy and group psychotherapy. This is necessary as a
foundation for the proposal of a holistic metamodel for counselling. In order to
construct a group metamodel for the purposes of this study, an individual model was
initially developed and elaborated on for group intervention. It is with this as a
framework that IBS, depression and anxiety are viewed.
4
In Chapter Four, the empirical investigation is discussed. The research design,
methodology, recruitment of subjects, measuring instruments and hypotheses for the
sample and description of the subjects are also presented. The proposed method for
statistical analysis of the data will be given at the end of Chapter Four. The holistic
short-term group therapy intervention that was conducted as well as the
philosophical assumptions underpinning such an intervention are discussed.
In
Chapter Five, the results of the study are presented. Evaluations are made in terms of
strengths and limitations of the study in Chapter Six, and finally, recommendations
for future research are also discussed and the relevant conclusions drawn.
5
CHAPTER TWO
TOWARDS AN UNDERSTANDING OF IRRITABLE BOWEL SYNDROME,
DEPRESSION AND ANXIETY
"I'm in tears most days and it's so bad when I get up and continues through the
day and night. I get very frightened of going to work and sitting all day with so
much congestion and pain and nowhere to alleviate it. People don't believe
when you try to tell them how degrading IBS is."
Sheila (in Dancey & Backhouse, 1993).
2.1
INTRODUCTION
Chapter Two presents a theoretical review of IBS, depression and anxiety in terms of
their definition, epidemiology, etiology, incidence and diagnosis. Factors
highlighting the similarities and differences between IBS, depression and anxiety are
explicated. Emphasis is also given to a unifying multidisciplinary approach where
the subject is viewed as a whole person residing and interacting within a given
context. The psychologist is seen as a key player within this multidisciplinary team.
This chapter is the theoretical foundation for the short-term holistic group
intervention model presented in Chapter Four.
2.2
DEFINING IRRITABLE BOWEL SYNDROME
2.2.1
Functional gastrointestinal disorders
The lack of a unifying theory of irritable bowel syndrome has perhaps been the most
formidable barrier to an understanding of the illness (Stuart, Pretorius et al., 1998,
1999).
The movement towards a more integrated approach where psychosocial
factors are considered, has given rise to the emergence of functional gastrointestinal
disorders where a variable combination of chronic or recurrent gastrointestinal
6
symptoms are not explained by structural or biochemical abnormalities (Farthing,
1995).
2.2.2
Functional bowel disorders
Functional bowel disorders are those where symptoms pertain to the middle or lower
intestinal tract and include abdominal pain, distension and disordered defecation
(Farthing, 1995). Irritable bowel syndrome is, therefore, a functional bowel disorder
because of its persistent and chronic nature, accompanied by features of disordered
defecation and distension (Drossman & Thompson, 1992; Kellow, Langeluddecke,
Eckersley, Jones & Tennant, 1992). Alpers (1983) suggests that the pattern of
symptoms may flare up periodically, but it does not deteriorate to a more severe
form of the disease.
2.2.3
Irritable bowel syndrome
For the purposes of this study, IBS may be defined as a syndrome which embraces
not only the clinician’s signs of the disorder, but also the subject’s experience of the
illness (Stuart, Pretorius et al., 1998, 1999). The subject’s experience of illness
primarily focuses on the mid and lower gastrointestinal tract where common
symptoms of abdominal pain, bloating, flatulence and disordered defecation – either
diarrhoea, constipation or both, occurs. As Kellow et al. (1992) describe, IBS may
be chronic or persistent and may flare up episodically, varying in frequency and
severity. Upper gastrointestinal symptoms such as dyspepsia, nausea, and heartburn
are also found, as are non-gastrointestinal symptoms such as migraine, non-cardiac
chest pain and fatigue. Due to the integration between mind, body and soul, the
clinician needs to be aware of seemingly unrelated symptoms such as dyspareunia,
bladder irritability or urinary frequency and referred colonic pain to the back or
thigh. It is also essential that strong psychosocial correlates such as depression,
anxiety and stress be evaluated in viewing the subject holistically. In section 2.3.2 a
working definition of IBS will be discussed.
7
2.3
GLOBAL TRENDS IN THE EPIDEMIOLOGY OF IRRITABLE
BOWEL SYNDROME
In western developed countries, the incidence of IBS in the adult population is
approximately one fifth (Drossman & Thompson, 1992), with more than half the IBS
sufferers not consulting physicians (Thompson, 1984). For those who seek health
care, IBS comprises 13%-52% of all new gastroenterology referrals (Walker, RoyByrne, Katon, Li, Amos & Jiranek, 1990).
Current statistics are therefore
underestimated and skewed.
The onset of IBS is generally in late adolescence (Walker et al., 1990) and it seldom
occurs after 60. The disorder is prominently found in white women who are 35
years of age and younger (Drossman, Thompson & Whitehead, 1992; Els et al.,
1995).
Socio-cultural variations have become evident, as found in Sri Lanka and India,
where only 20-30% of IBS subjects are women (Thompson, 1984), whereas in
Europe and America, women are twice as likely as men to have IBS and account for
three quarters of the subjects seeking consultations.
In a South African study
conducted by Segal and Walker (1984), a low incidence of IBS was found in rural
black South Africa, but the syndrome found to be more prevalent in urban black
South Africa. There has been a dearth of both epidemiological studies and local
statistics in South Africa.
Irrespective of the demographics of IBS, the cost of IBS to the nation and the
individual is immense. Farthing (1995) estimates that IBS is responsible for 2.4 –
3.5 million visits to physicians in the U.S.A. each year with 2.2 million prescriptions
being issued. Els et al. (1995, p. 1368) state that its morbidity is responsible for
considerable absenteeism from work, as it is “second only to the common cold."
8
The enigmatic nature of IBS makes its positive diagnosis a very difficult task, but a
number of important criteria can certainly influence this process markedly. These
will be considered in turn.
2.3.1
A unifying clinical approach
The clinician-subject relationship has been found to be a strong predictor of outcome
in the IBS diagnosis and treatment (Devroede, 1994; Els et al., 1995; Thompson,
1984). As IBS may be viewed as a disorder of the whole person where multisystem
complaints are encountered, personnel or clinicians from multidisciplines need to
adopt a unifying approach in order to facilitate the diagnostic and treatment
outcomes.
Devroede (1994) emphasises the importance of “staying” with the subject’s story –
their experience or perception of the disorder. In essence a relationship built on trust,
tolerance, and a non-judgemental attitude where one “tunes- into” the subject’s
phenomenological context, are important elements in the equation for accessing the
subject’s world.
Not only is one going to be intuitively observant and aware of the subjects’ stories,
but also of their non-verbal cues which hint at mind, body and soul issues. Devroede
(1994) believes that the body speaks a la nguage to which the clinician is often deaf.
Devroede (1994, p.108) suggests that one needs to use the analogy of a “camcorder
with a heart”, feeding back to the subject their sad eyes or their phoney smiles. As
most relationships are transferential, the subject needs to “project-at-will”, while the
clinician moves to a meta- level position, distancing herself in mind in order to assess
the subject’s situation.
9
2.3.2
Working definition of IBS – a symptom-based diagnosis
There have been numerous attemp ts to develop a single, unifying, and diagnostic
system for IBS, but all approaches have had shortcomings and limitations
(Drossman, 1994). In 1988, led by Professor Aldo Torsoli at the International
Congress on Gastroenterology, a working committee put together the Rome Criteria
for a symptoms-based diagnosis of IBS (Drossman, 1994). The working definition of
IBS is therefore related to this set of criteria.
According to the 1988 Rome Criteria, Thompson (1984) postulates that in order to
diagnose IBS, subjects must have abdominal pain or discomfort for 3 months
consecutively, that is
(i) relieved with defecation;
(ii) associated with a change in the consistency of stool, and two or more of the
following on at least 25% of occasions or days:
(iii) altered stool frequency;
(iv) altered stool form (lumpy and hard, or loose and watery);
(v) altered stool passage (straining and urgency or feeling of incomplete
evacuation);
(vi) passage of mucus, and
(vii) bloating or feeling of abdominal distension.
It has been argued that this working definition is too restrictive and that pain need
not be present provided the other criteria are (Farthing 1995; Lynn & Friedman
1993). This debate continues.
Not only does one need to be able to identify and recognise the above symptoms, but
their severity also needs to be taken into account. Drossman et al. (1992)
distinguishes between mild, moderate and severe symptoms.
•
Mild symptoms are those in which the subjects have no functional impairment
nor are they psychologically disturbed. Health care seeking behaviour would
10
occasionally be sought for reassurance or education regarding the implication of
their symptoms.
•
Moderate symptoms are experienced by a smaller number of subjects whose
intermittent absenteeism from work is reported. These subjects closely associate
a trigger event for the recent onset of symptoms, e.g. stress, diet or being away
from home. They are slightly more psychologically impaired than the former
group.
•
Severe symptoms often occur in subjects having a diagnosis of comorbid anxiety,
depression and somatisation. Drossman and Thompson (1992) emphasise a
history of abuse combined with an abnormal reaction to illness. These subjects
constantly seek reassurance regarding the disease, insist on unnecessary, invasive
and excessive diagnostic measures, deny the psychological components of their
disorder and place full responsibility on the doctor for an unrealistic cure. It is
felt that these subjects are often unresponsive to most forms of treatment whether
it be psychological or pharmacological intervention (Guthrie, Creed, Dawson &
Tomenson, 1991).
A further point for debate is the omission of psychological or psychiatric criteria in
the working definition.
It is the author’s contention that commonly occurring
psychological or psychiatric criteria such as stress, depression or anxiety be included
in the working definition of irritable bowel syndrome. In a telephone conversation
with Dr Drossman (1998, April) the issue was discussed and he reiterated that
psycho logical criteria had been considered, but were rejected by the majority of the
Rome Working Team, led by Professor Aldo Torsoli, primarily for financial reasons.
He argued that owing to the large number of psychological factors, many of the
gastroenterology subjects would have been referred to psychiatrists who were not
adequately trained in gastroenterology to treat the “pure irritable bowel syndrome
symptoms.” It was rather felt that gastroenterologists could more easily acquire the
skills to treat the psychological criteria. Hence the paradigm shift to a more holistic,
biopsychosocial hypothesis.
11
Lastly, the working definition proposes that an IBS diagnosis is formulated when
unusual signs and symptoms are identified and where specific testing procedures
may be required to exclude other major pathology, for example inflammatory bowel
disease or a malignancy.
Kellow, Cook, Heap and Steadman (1995) list such
alarming symptoms, such as rectal bleeding, steatorrhea (loose, foul, bulky floating
stool), weight loss, fever, recent onset of symptoms, and anaemia, as occurring in
subjects of 40 years of age or older. Recent studies (Drossman & Thompson, 1992;
Kellow et al., 1995) have shown that in the past subjects have been overinvestigated. Drossman and Thompson (1992) and Kellow et al. (1995) stress that
usually an adequate history and some simple routine investigations will suffice in the
making of a diagnosis, except where alarming symptoms prevail.
These
investigations could include the following:
•
Sigmoidoscopy;
•
Stool microscopy;
•
A full blood count and erythrocyte sedimentation rate (ESR);
•
A differential diagnosis.
Sigmoidoscopy: In this procedure a sigmoidoscope is inserted into the rectum as far
as the sigmoid flexure. This provides information on the colonic structure as well as
its contents, that is, the sigmoid colon may be in spasm, there may be evidence of an
inflammatory process or there may be a mass.
The stool pattern can also be
assessed, that is steatorrhoea (fatty, bulky, stool as in malabsorption), diarrhoea,
pellet shaped stool often with copious mucus or well- formed stool. According to
Coremans, Dapoigny, Muller- lissner, Pace, Smout, Stockbrugger and Whorewell
(1995) this can usually be done in the gastroenterologist’s consulting room without a
general anaesthetic and therefore it is less risky and less costly than a colonoscopy.
Stool microscopy: This should be done on subjects with diarrhoea to determine the
presence of infection or inflammation (Kellow et al., 1995). Other stool tests which
12
are seldom done to exclude Giardiasis (Drossman, 1994), a parasitic infection, could
include occult blood, leucocytes, ova and parasites.
A full blood count (FBC) and an erythrocyte sedimentation rate (ESR) are done
routinely to exclude an inflammatory or malignant process.
A differential diagnosis: Drossman et al. (1992) and Kellow et al. (1995) describe
important disorders to consider in a differential diagnosis of IBS. These include:
•
carcinoma of the colon;
•
inflammatory bowel disease;
•
malabsorption (e.g. coeliac disease).
2.4
ETIOLOGY AND EXPLANATORY MODELS OF IRRITABLE
BOWEL SYNDROME
It is well documented that gastrointestinal (GI) motility, to be subsequently referred
to as GI motility, is associated with GI symptoms such as gastroenteritis, vomiting,
diarrhoea and abdominal pain. Furthermore, Drossman (1994) describes how normal
subjects, when exposed to stress, be it emotional or environmental, exhibit increased
motility of the GI tract. How does one then discern the difference between a normal
colonic response versus a functional gastrointestinal disorder?
Historically, early research models describe IBS in terms of the then current dualistic
biomedical model, where symptoms were identified and directly explained in terms
of a disease process. A specific treatment would then be applied in a logical cause
and effect rationale (Kety, in Engel, 1977). This approach lost favour when the
simplest notion of mind, body and soul as separate entities proved to be ineffectual
in explaining the multicausal, complex process that today is recognised as residing
within the IBS subjects and their specific context. Drossman (1994) gives an
example of this as he describes how in the functional gastrointestinal disorders,
13
stressors precipitate an exaggerated gut motility response when compared to normal
subjects, but importantly that this increased motility is only partially correlated to
symptoms. Similarly, increased gut contractility was often not experienced when
pain was reported and conversely, an increase in gut motility did not always result in
pain. Furthermore, a lack of identifiable pathology on examinations seemed to
discount the subjects’ symptoms, which left them disillusioned and misunderstood –
believing it’s “all in the mind”.
In challenging the biomedical model, with its emphasis on the biological, as opposed
to psychological or social influences, the current biopsychosocial model
acknowledges and embraces all the domains of biological, psychological and social
influences which are all operative in a multicausal, complex web of interaction.
These vary idiosyncratically.
Researchers embracing the biopsychosocial model recognise that an individual may
present with an existing biological vulnerability or predisposition which, when
placed into the context of certain psychosocial modifiers, may elicit certain
symptoms or illness behaviours. Drossman (1994) refers to this complex outcome as
the individual’s “Health Related Quality of Life – HRQOL”. It still remains unclear
as to whether IBS represents normal perception of abnormal function or abnormal
perception of normal function.
The biological and psychosocial modifiers will be briefly discussed, bearing in mind
that the interactions between them are nonlinear, multifactorial and are likely to
change with time. The biological factors which still need to be mentioned may
include the specific subject's disordered gut motility, her particular central nervous
system dysfunction, a lower sensory threshold or supersensitive intestines as well as
possible abnormalities in the brain- gut axis (Drossman et al., 1992; Els et al.,1995).
The latter includes chemical imbalances, for example with regard to the
neurotransmitters and their dysregulation in the autonomic innervation of the gut –
the so-called brain- gut axis (Drossman et al., 1992; Els et al., 1995).
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Drossman (1994) discusses three broad categories of psychosocial modifiers in
subjects with functional gastrointestinal disorder. Firstly, it has been found that
psychological stress exacerbates gastrointestinal symptoms, but this is intensified in
IBS sufferers (Walker et al., 1990). Secondly, psychological disturbances modify the
experience of illness by increasing illness and health care seeking behaviours
(Drossman, 1994). Stressful life events often occur in tandem or precipitate IBS and
these frequently determine whether IBS symptoms will be reported or not.
Antonovsky (1979) hypothesised that if a person, or group of people, perceived life
to be predictable, logical and consistent, then the person, or group of people, will
develop resistant resource characteristics to enable them to largely combat the stress.
Social support is a key factor in this process. Antonovsky (1979) comments that
many people exposed to significant stressors do not become ill. IBS sufferers who
report their illness seem to lack these resistant resource characteristics. It is well
accepted that psychologically disturbed IBS sufferers will seek help far more readily
than IBS sufferers who are “psychologically healthy” (Drossman, 1994). Lammert
and Ratner (1986) use a different explanatory model to describe psychosocial
modifiers in IBS. They discuss an object-relations developmental perspective on
IBS, hypothesising that IBS is a psychophysiological symptom that compensates for
an ego deficit and operates as a defence against separation and annihilation anxiety.
In their perspective, IBS seems to arise out of a combination of a biological
vulnerability and an arrested ego structure occurring in infancy, where control issues
of eating and elimination develop. Coupled with this, communication deficits are
postulated to result from inadequate neuronal development and as a result internal
tensions become somaticised. The infant’s needs are inadequately met and a learned
pattern of behaviour is set up. Lammert and Ratner (1986) explain this modification
of the illness experience in terms of existential issues which arise in chronic physical
illness – isolation, alienation, meaninglessness and the lack of trust, not only in the
future but also in one’s own physical limitations. The third psychosocial modifier –
chronic illness - has significant psychological and social ramifications (Drossman,
1994) and takes the form of frequent medical visits, generalised somatic complaints
and the exaggerated or abnormal concern with minor illness. It is plausible to
15
speculate that certain personality factors contribute to the development and
maintenance of certain illnesses where the personality – health relationship
represents the ideal interface for the study of the mind, body and soul link (Stuart,
Pretorius et al., 1998, 1999). Yalom (1970) highlights how these existential issues of
personal responsibility and choice give rise to further anxiety which in turn fuels
somatic symptomatology. A vicious cycle ensues.
Recent research (Stuart & Stanley, 1999), explored health behaviour and personality
from a salutogenic perspective (Strumpfer, 1990), which focuses on the maintenance
and enhancement of health and wellness over and above the prevention and
treatment of illness. The NEO – Personality inventory which measures neuroticism,
extraversion, openness to experience, agreeableness and conscientiousness was used
in conjunction with the Vickers Health Behaviour Checklist (Stuart & Stanley,
1999). This research showed IBS subjects attaining a highly significant score on the
neuroticism dimension. This means being more vigilant about bodily changes, being
more likely to interpret unusual sensations as signs of illness and more likely to
worry about possible diseases. Furthermore, the IBS group also scored statistically
significantly lower on the extraversion dimension which suggests these subjects
prefer doing things alone or in small groups, avoid large, noisy gatherings and tend
to be quiet and reserved in social interactions. Emotional inhibition combined with
high neuroticism suggests reliance on a neurotic style of coping, characterised by
avoidant or passive reactions where emotions tend to be suppressed and the self is
blamed. IBS subjects also seem more conservative in behaviour, preferring the
familiar to the novel. A low openness to experience suggests that IBS subjects would
find change difficult. It is possible that this, in turn, has a negative effect on their
daily health behaviours. Consistent with these findings, a number of studies have
also shown high neuroticism and introversion scores in subjects with IBS (Esler &
Goulston, 1973; Langeluddecke, 1985; Latimer, 1981; Palmer, Stonehill, Crisp,
Waller & Misiewicz, 1974).
16
Chronic illness, therefore, has psychological and social consequences that affect the
IBS sufferer's overall well being, quality of life and her daily functioning. Whilst the
etiology of psychosocial factors is poorly understood, it is integral in assessing a
person’s adaptation and adjustment to a functional gastrointestinal disorder.
In the light of the above discussion, many IBS issues remain unresolved, partly due
to the practical limitations of research praxis and partly due to the enigmatic nature
of the disorder. There has however been a paradigm shift in terms of the IBS
subjects’ credibility and the legitimising of their symptoms. This needs to be further
extended to the realm of psychopathology where depression and anxiety are factored
into the IBS equation.
2.5
INCIDENCE OF COMORBID PSYCHIATRIC ILLNESS IN IBS
SUBJECTS
Correlations between psychiatric illness and IBS health-care seekers has been well
researched. More specifically, 70% to 90% of IBS subjects are said to have
diagnosable psychiatric problems with depression and anxiety predominating (Liss
et al., 1973; Lydiard et al., 1986; Masand, Kaplan, Gupta, Bhandry, Nasra, Kline &
Margo, 1995; Svedlund et al., 1984; Young et al., 1976).
Svedlund et al. (1984) in their study, attempted to measure the incidence and impact
of psychological symptoms on IBS before assigning a treatment programme. They
found that 98% of the IBS sample reported anxiety, with 70% of the subjects
experiencing a mild comorbid depression. They thus associated IBS with these
affective disorders. Subsequently much research has been conducted that disputes
these mild depressive symptoms (Kellow et al., 1992; Masand et al., 1995;
Swiatkowski & Rybakowski, 1993). Later South African evidence in support of
major depression in IBS subjects can be found in research by Els et al. (1995) who
reported major depression in 38% of their IBS subjects. They also reported 60% of
their subjects as presenting with anxiety syndromes and an overall 71% of subjects
17
had either anxiety and/or depressive symptoms. Endorsing this, Wilson (1997)
reported a higher incidence of depressive symptoms in the IBS subjects studied
(85.4%), with almost half of these (36.6%) exhibiting major depression. In the same
study, 81.3% of the subjects reported elevated levels of general anxiety, with 46.2%
of subjects manifesting clinically significant anxiety levels.
Conversely, Masand et al. (1995) discuss how Major Depressive Disorder may well
meet the criteria for IBS. In their study, 27% of Major Depressive Disorder subjects
had functional bowel disorder as opposed to 2.5% of the control group. In a similar
vein, Lydiard et al. (1986) highlight how common GI symptoms are in subjects with
Panic Disorder. These symptoms occur so frequently that IBS is now a criterion for
the diagnosis of Panic Disorder in DSM IV-R (Kaplan, Sadock & Grebb, 1994).
It is of utmost importance that each member of the multidisciplinary team becomes
vigilant to overt and covert signs of depression and anxiety in the IBS subjects in
order to facilitate holistic intervention. A definition of terms will follow as well as a
brief discussion relating to the similarities and differences of various factors in
depression, anxiety and IBS. The latter will be presented in sections 2.6 - 2.9.
2.6
MOOD DISORDERS
Important mood disorders to consider in association with IBS are Major Depressive
Disorder, Dysthymia and to a lesser extent, Double Depression and Atypical
Depression (Keller, 1996).
2.6.1
Major Depressive Disorder
DSM IV-R in Kaplan et al. (1994) classifies a Major Depressive Disorder as a
change from previous functioning with at least two weeks of depressed mood, with a
loss of interest and accompanied by four additional symptoms of depression. These
symptoms include altered appetite, weight change, sleep or psychomotor activity,
18
anhedonia, lethargy, feelings of worthlessness or guilt, poor concentration or
decision- making skills and suicidal ideation or death ruminations.
A quick, useful, reliable and valid assessment tool that can be applied in any setting
by any member of the multidisciplinary team is the Montgomery and Asberg (1979)
depression rating scale. This is a ten- item scale which reflects core depressive signs
and symptoms. If two or more of these symptoms are present continuously for two
or more weeks, the subject is classified as depressed (Montgomery & Asberg, 1979).
The scale is also very sensitive to treatment effects and, therefore, is a reliable
measure of change (Montgomery & Asberg, 1979). The item checklist is as follows:
1.
Apparent sadness;
2.
Reported sadness;
3.
Inner tension;
4.
Reduced sleep;
5.
Reduced appetite;
6.
Concentration difficulties;
7.
Lassitude;
8.
Inability to feel;
9.
Pessimistic thoughts;
10. Suicidal thoughts.
For a more specific rating of the severity, please refer to the above publications.
2.6.2
Dysthymia
Dysthymia, according to Kaplan et al. (1994), implies a temperamental dysphoria –
an innate tendency to be depressed. Dysthymia needs to be differentiated from Major
Depressive Disorder, as it is a chronic and less severe form of depression. The
incidence, which has been apparent for two years or longer, is much lower, occurring
19
in 3-5% of the general population. It is more common in unmarried women and
young people, and frequently coexists with Major Depressive Disorder, Anxiety
Disorder and substance abuse. Its etiology is similar to Major Depressive Disorder
except that the patient’s cortisol levels are not necessarily raised.
Far less likely to occur is the double depression which Keller (1996, p.10) describes
as “a Major Depressive Disorder superimposed on Dysthymia.” Atypical
Depression, as discussed by Dr Les Koopowitz (1995, p.4), consultant psychiatrist at
the Tara Moross Centre, is a “recurrent brief depression where symptoms are similar
to Major Depressive Disorder but have a shorter duration of less than two weeks.”
Seasonal Mood Disorders include seasonal mood variations, which are often
correlated to the lack of visible sunlight – typically, winter depression (Keller,
1996). Bipolar I and II will not be discussed here as they are not typically associated
with IBS. Although the above disorders need to be excluded in an IBS diagnosis,
Major Depressive Disorder or Dysthymia occur more frequently.
2.7
ANXIETY BASED DISORDERS
Everyone at times experiences vague feelings of apprehension, palpitations, or mild
stomach or gut discomfort. Kaplan et al. (1994) describe this as “normal anxiety”.
Anxiety serves to alert one to the potential of an internal or external stressor –
thereby reducing its likelihood (Kaplan et al., 1994). Whether an event is perceived
as stressful or not, depends on the person’s resources, their support systems, their
coping mechanisms and their psychological defences. Anxiety may also be
distinguished from fear as anxiety is of a longer, more chronic duration and occurs in
response to an unknown threat. Pathological anxiety or an anxiety-based disorder is
characterised by marked distress or impairment in social, occupational or academic
functioning (Sten & Bouwer, in Allwood & Gagiano, 1997). Studies on anxiety in
IBS have also focused on State-anxiety versus Trait-anxiety. Spielberger (1966)
defines State-anxiety as a transitory state of emotional arousal which, he believes
varies in intensity and fluctuates with time. Trait-anxiety, (Spielberger, 1966), is
20
defined as an acquired behavioural tendency predisposing the individual to perceive
a wide range of objectively non-threatening situations as dangerous. Spielberger
(1966) ascertains that the resultant responses are often disproportionate to the real
danger. An observation to make here is that the psychological term “stress”, which
Lazarus (1969, p.198) defines as an external circumstance that makes unusual or
extraordinary demands upon an individual, may often, in practice, be used
synonymously with the term “anxiety”.
Compared with anxiety in the normal population, state-anxiety in IBS subjects has
consistently been found to be high (Feigtner et al. in Langeluddecke, 1985; Latimer,
Sarna, Campbell, Latimer, Waterfall & Daniel, 1981; Palmer et al., 1974). Esler and
Goulston (1973) comment on how diarrhoea – predominant IBS subjects are far
more anxious than subjects who have other GI disorders – which are not specifically
IBS related. Furthermore, Hillman et al. (in Langeluddecke, 1985) were able to show
a positive correlation between severity of anxiety symptoms and severity of GI
symptoms.
2.7.1
Generalised Anxiety Disorder
Generalised Anxiety Disorder is characterised by excessive anxiety or worry, on
most days for 6 months or more. There is no apparent stressor. Somatic symptoms of
restlessness, early fatigue, poor concentration and irritability may prevail.
2.7.2
Panic Disorder
Panic Disorder is characterised by panic attacks – discrete periods of intense fear or
discomfort. Accompanying the attack are autonomic symptoms such as palpitations,
tachycardia, trembling, dyspnoea (shortness of breath), choking, sweating, nausea,
dizziness, hot flushes and a fear of death. These symptoms may mimic a heart attack
and the subject begins to develop anticipatory anxiety for subsequent attacks. Kaplan
et al. (1994) as well as Stein and Bouwer (in Allwood & Gagiano, 1997) believe
21
there to be some evidence of early separation anxiety in the patient with Panic
Disorder. This may be aggravated in later life by a recent separation, which then
fuels the disorder.
Lydiard et al. (1986) in their study on whether Panic Disorder presents as IBS, state
that there is such a frequent overlap of GI symptoms and anxiety disorders, that they
suggest that some IBS patients actually have a primary anxiety disorder such as a
panic-related disorder.
2.8
COMBINED DEPRESSION / ANXIETY SYNDROMES.
A number of grey areas in the diagnosis of depression and anxiety need to be
mentioned and excluded.
•
Adjustment disorder with anxiety – this can be differentiated from Generalised
Anxiety Disorder in that the former is due to an identifiable stressor or trigger,
which does not persist once the stressor has been removed.
•
Depressive symptoms may also present as part of an anxiety disorder – not
otherwise specified – N.O.S. (Kaplan et al., 1994).
Keller (1996) describes how in the 1980’s, depression and anxiety were regarded as
pure and separate syndromes. This belief has undergone a paradigm shift.
Depression is associated with anxiety symptoms in 67% of cases and in 33% of
these, panic attacks occur. Depression, he believes, occurs in 40% of subjects who
are primarily anxious and in 33% of those with Panic Disorder.
The effect of a Combined Anxiety and Depressive Syndrome on the subjects is that
they become more ill and more chronically impaired. The average time of recovery
for depression with anxiety, according to Keller (1996), is 6 months as opposed to 3
months without anxiety. Comorbid anxiety according to Keller (1996) is the rule
rather than the exception. The lifetime probability of depression is approximately
15% and that of anxiety 25%.
22
In an interesting study, Walker et al. (1990) sought to compare the incidence of
psychiatric illness in IBS subjects as opposed to the organically impaired Irritable
Bowel Disorder subjects, referred to as IBD. He concluded that 61% of the IBS
subjects had a history of lifetime depression, versus 16% of the IBD subjects.
Furthermore, 21% of IBS subjects had current depression as opposed to 5% of the
IBD subjects. A lifetime diagnosis of anxiety was made in only 11% of IBD subjects
versus 54% of IBS subjects. Panic Disorder was found to be in 29% of IBS subjects
versus none in the IBD group. This suggests that functional gastrointestinal disorders
are far more likely to have a comorbid psychiatric illness than the organically
disordered GI subjects. A similar study was later conducted by Walker, Gelfand,
Gelfand and Katon (1995) whose results corroborated the above findings.
2.9
FACTORS ASSOCIATED WITH MOOD DISORDERS,
ANXIETY BASED DISORDERS AND IBS
Various factors associated with Mood disorders with particular reference to Major
Depressive Disorder, Anxiety based disorders with particular emphasis on
Generalised Anxiety Disorder and IBS will be discussed. Similarities, differences
and areas of integration will be explicated.
2.9.1
Incidence of Major Depressive Disorder, Generalised Anxiety
Disorder and IBS
In a recent European survey, the prevalence of depression was found to be 17% with
Major Depressive Disorder accounting for 6.9% of depression and the other 10.1%
consisting of Atypical Minor Depression or depressive symptoms (SAMJ, 1998).
Depression is usually more common in females than in men (in a ratio of 2:1) and
occurs most often at a rate of 8.2% in the age groups 45-54. The second highest
incidence of depression was with the age group 24 or younger at a rate of 6.8%. The
incidence dropped to 4.6% in those aged 75 or older (SAMJ, 1998).
23
The incidence of IBS most commonly occurs in the 20-35 age group. There is
therefore less overlap with depressive symptoms than might have been expected.
Unfortunately, the incidence of IBS in non-western society has not been adequately
researched, so accurate assessment of incidences in many non-western populations
cannot be made. Similarly, more research is required that compares IBS, depression
and anxiety across social classes.
Hirshfield and Cross (in Munoz, 1987) discuss how marital status affects the
incidence of depression. Married men show the least depressive symptoms whereas
divorced, widowed and separated men show the highest rates. The incidence has also
been shown to be high in separated women. There are currently no statistical indices
of the effect of marital status on Generalised Anxiety Disorder and IBS.
2.9.2
Etiology
2.9.2.1
Onset of symptoms
There is no clear trigger or stimulus for Major Depressive Disorder, Generalised
Anxiety Disorder or IBS. The only exception to this is Adjustment Disorder where a
clear stressor is generally evident. There is much dispute about the onset of IBS,
depression and anxiety. The chicken and the egg dilemma pertains here.
Young et al. (1976) in a study of psychiatric symptoms in IBS subjects versus a
control group found that 55% of the IBS group reported psychiatric symptoms
before IBS symptoms, 20% reported simultaneous onset of psychiatric and
gastrointestinal symptoms and 25% reported psychiatric symptoms following GI
symptoms. This has been an area of much research in the last 20 years with little
clarity regarding pathways and mechanisms linking psychosocial factors to disease
and illness. (Chaudhary & Truelove, 1962; Dancey & Backhouse, 1993; Ford,
Muller, Eastwood & Eastwood, 1987; Gwee, Graham, McKendrick, Marshall,
Collins & Read, 1995; Kumar, Pfeffer & Wingate, 1990; Latimer et al., 1981; Lynn
& Friedman, 1993; Whitehead & Schuster, 1985).
24
What has been recently acknowledged is the biopsychosocial hypothesis (Drossman,
1994) that has led to the adoption of a multifactorial approach. The role of
psychosocial modifiers in the experience of illness, the exacerbation of gastric
functions and the perception of chronic illness with its subsequent sequelae, has
already been discussed (please refer to section 2.4).
2.9.2.2
Genetic factors
It is thought that genetics plays a role in Major Depressive Disorder, Generalised
Anxiety Disorder and IBS. In Major Depressive Disorder, twin studies, and more
specifically adoption studies, do seem to point towards a genetic inheritance. Family
history, however, is not always indicative of an individual developing Major
Depressive Disorder as some members may develop the disorder and others not
(Roberts, in Munoz, 1987). It is likely, though, that a positive family history of
depression will substantially increase the risk of a manifestation of depression.
Family studies have also linked Generalised Anxiety Disorder with genetic
components as has IBS. In IBS, however, it is very difficult to disentangle
predisposing factors and psychosocial modifiers as they link up with one another in
complex ways and change with time.
2.9.2.3
Endocrine abnormalities
In
Major
both
Depressive
Disorder
and
Generalised
Anxiety
Disorder,
hyperthyroidism and hypothyroidism may mask the disorder. Cortisol levels may
also be raised in Major Depressive Disorder, but not in Dysthymia. Drossman (1994)
describes how in IBS there seems to be a dysregulation of intestinal motor, sensory
and central nervous system activity – the so-called brain-gut axis. In this way, vision,
smell, emotions or thoughts can affect GI sensation, motility and secretion.
25
2.9.2.4
Neuroanatomical structures
The neuroanatomy included in Major Depressive Disorder and Generalised Anxiety
Disorder includes the limbic system and the ventricles. Other structures involved in
Major Depressive Disorder are the basal ganglia while the frontal cortex, occiput and
brainstem are linked to Generalised Anxiety Disorder.
2.9.2.5
Neurotransmitters
Major Depressive Disorder, Generalised Anxiety Disorder and IBS are all affected
by serotonin levels. Major Depressive Disorder and IBS are associated with an
undersupply of serotonin, while Generalised Anxiety Disorder is associated with an
oversupply of serotonin and noradrenalin. However, Gaba aminobutyric acid
(GABA) is undersupplied in Generalised Anxiety Disorder.
2.9.2.6
Personality traits
Avoidant personality traits are common to Major Depressive Disorder, Generalised
Anxiety Disorder and IBS as these individuals experience a high degree of intra- and
inter-personal conflict. Compulsive and hysterical traits are also linked to Major
Depressive Disorder, while negativistic traits are associated with Generalised
Anxiety Disorder. Esler and Goulston (1973), as well as a recent study by Stuart and
Stanley (1999), have shown that introversion and risk aversion is common with IBS
patients.
2.9.2.7
Cognitions
The major cognitions in Major Depressive Disorder, according to Kaplan et al.
(1994), are those of loss and failure where the individual has negative emotions
about himself or herself, the world and the future. This is referred to as Beck’s
Cognitive Triad (in Toner, Garfinkel, Jeejeebhoy, Scher, Shulhan & Di Gasbarro,
26
1990). In Generalised Anxiety Disorder, cognitions centre around the loss of control,
an overestimated threat or threats and underestimated coping resources.
Cognitions in IBS patients may often centre around not being able to say “no” to
demands. Fourie (1993) understands this in terms of difficulty in setting boundaries.
Day (1999) highlights the correlation between IBS and a negative self-esteem, while
Dancey and Backhouse (1993) recognise themes of fear, anger, frustration,
resentment, alienation, loss of dignity and loss of self- respect in IBS subjects. 16%
of IBS subjects suffer from incontinence which means needing to be near a toilet
within twenty seconds. This need places severe limitations and restrictions on the
individual and strips the individual of a sense of control (Dancey & Backhouse,
1993).
2.9.2.8
Psychosocial factors
It has been hypothesised that Major Depressive Disorder, Generalised Anxiety
Disorder and IBS could all result from an interaction of faulty ego development and
insecure attachment in early childhood (Lammert & Ratner, 1986). Furthermore,
Carson, Butcher and Coleman (1988), discuss the stress diathesis model of
depression where an individual’s vulnerability may become exposed in the face of
the significant stressor. An important mediating factor here is social support which
can counteract the effects of depression (Sue, Sue & Sue, 1994). Similarly the
biopsychosocial model of IBS explains the role of psychosocial modifiers and social
support in the face of significant life events, which could impact on whether the IBS
subject is going to develop into a chronic IBS subject or a non-subject (Drossman,
1994). With regards to Generalised Anxiety Disorder, Edelman (1992) discusses the
behaviourist theory, believing that anxiety is a conditioned response to a specific
environmental stimulus. Lastly, the existentialist’s view is that the individual’s
anxiety may be as a result of facing a possible “nothingness”. This helps the
individual break away from his inauthentic self which isolates man from man and
man from God (Van Vuuren, 1991).
27
2.10
CONCLUSION
Based on the available studies, there seems to be a strong correlation between
psychopathology and IBS health care seekers. More specifically, the most commonly
occurring psychiatric disorders with IBS appear to be depression and its comorbid
anxiety. Perhaps the awareness, recognition, and adequate treatment of these
coexisting psychiatric disorders and maladaptive illness behaviours will assist in the
accurate elucidation of physiological features of IBS (Walker et al., 1990).
28
CHAPTER THREE
TREATMENT OF IBS WITHIN INDIVIDUAL AND GROUP CONTEXTS
“ We must constantly remind ourselves that the patient in front of us is real, not
a product of the scientific discoveries made up to now, and does not have time
to wait for the discoveries to be made in the future. We must thus switch from
an attitude based on ‘scientific content’ to one of ‘scientific method’: the latter is
a way to learn to think what we see, rather than see what we think.”
Devroede (1994)
3.1
INTRODUCTION
The management and treatment of IBS poses a special challenge to caregivers based
on its unpredictable and unremitting course, its biological and symptomatic
heterogeneity and its strong concomitance with psychopathology (Drossman &
Thompson, 1992). The onset of this condition is often associa ted with traumatic
events similar to those that precipitate depression. Similarly, the maintenance and/or
exacerbation of this disorder has been linked to persistent anxiety symptoms which
Fowlie, Eastwood and Ford (1992) found to be exaggerated after a five year period.
Subjects who improved, did so because their anxiety ratings decreased. Depression,
however, behaves differently as it seems to be a consequence of adverse life events
and be more important in the onset and intercurrent fluctuations in perceived distress
and illness behaviour (Fowlie et al., 1992). This stresses the need for treatment and
management strategies to incorporate psychological aspects.
Historically, psychology has been predominantly absent in the treatment equation as
dualistic treatment approaches with their basis in either mind or body were
implemented in a piece-meal fashion, rendering inconsistent, non-comparable and
ambiguous results. Psychology has lacked a theoretical rationale for the treatment of
29
the IBS symptom complex and has located itself somewhere between these two
poles – mind and body.
Furthermore, the lack of a coherent theory of IBS has influenced research
methodologies. Biased or skewed samples and limited control over all variables have
acted to limit the generalisability of psychological treatments (Drossman &
Thompson, 1992). New research trends indicate the need for methodological
diversity and the embracing of the qualitative along with the quantitative.
Therapeutic interventions appear to have been utilised in a haphazard fashion. The
complex interaction between mind and body, between person and environment, has
largely been ignored. There was no place to view the subject holistically.
Consequently, the move towards more holistic, integrated, multi-component
treatments has generated a critical awareness of the integral role of psychological
processes. This has led to an uncertainty as to whether irritable bowel syndrome is
just a matter of learned illness behaviour and a way of somatising about problems, or
whether it is truly a 21 st century mind disorder? (Stuart, Pretorius et al., 1999).
Recent researchers have proposed a more comprehensive and individualised
approach to understanding IBS that incorporates multicomponent treatments
(Drossman, 1989; Drossman & Thompson, 1992). This is seemingly a more
favourable approach as it includes a blend of psychotherapy, psycho-education,
relaxation and medical intervention (Drossman et al., 1992).
The rationale for the multicomponent intervention seems to have its roots in a few
areas. Firstly, it became a useful resource when first- line medical treatment proved
unsuccessful. Secondly, a “shot-gun” approach to psychotherapy seemed more
feasible when it was difficult to assess what intervention would be most effective for
which subject. Additionally, the shift to a biopsychosocial focus (Drossman, 1989)
in the management of the IBS symptom complex created the theoretical platform
30
required for the legitimising of the multicomponent perspective. Various therapeutic
interventions will now be considered.
3.2
INTERVENTIONS WITH INDIVIDUALS
3.2.1
Medical interventions
The very act of a medical practitioner diagnosing the subject as having IBS acts as
an “intervention” in itself (Devroede, 1994). This allows the subject to make sense
of their undesirable, intrusive symptoms and reduces their anxiety.
Many subjects, due to the recurrent waxing and waning pattern of the symptom
complex, have a deep fear of an underlying carcinoma. The diagnosis therefore
serves as a huge relief in coming to terms with the chronic disorder. Symptoms are
often alleviated and the subject gains a sense of internalised control.
The placebo effect is further proof of this “intervention” with an efficacy of 54% 84% (Blanchard, Schwarz, Suls, Gerardi, Scharff, Greene, Taylor, Berreman &
Malamood, 1992; Goulston in Langeluddecke, 1985; Neff & Blanchard in Bennett,
1989). Long-term efficacy of symptom reduction on placebo has not been
demonstrated, but six- month follow up has been positive. This reiterates the
intricacies in understanding and treating the symptom complex and underscores the
need for the inclusion of psychological interventions.
Most of the standard medical treatment in the past three decades has intervened in
addressing the severity and type of IBS symptoms (Drossman & Thompson, 1992;
Thompson, 1984). Symptom severity is classified as mild, moderate or severe
(Drossman & Thompson, 1992). Subjects with mild or infrequent symptoms have
little functional improvement or psychological disturbance. Treatment includes
reassurance and achieving a healthier lifestyle. Subjects with moderate symptoms
experience more psychological distress and therefore require in addition, specific
pharmacotherapy and psychotherapy. Those with severe or intractable symptoms are
31
usually resistant to psychotherapy or pharmacotherapy directed at the gut. The
predominant symptom cluster types based on subjects’ subjective feelings may be
classified into three major groups, namely:
a)
pain – predominant IBS ;
b) diarrhoea – predominant IBS, and
c)
constipation – predominant IBS.
Interventions addressing these three clusters include the use of:
i) Psychotropic or mood altering drugs which have been found to have a marked
effect for all three symptom groups (Klein, 1988).
ii) Anti-depressants for pain - predominant IBS (Aronoff, Wagner & Spangler in
Drossman & Thompson, 1992; Eberhard, Van Knorring, Milsson, Sunqist, Bjorling
in Tura & Tura, 1990). Els et al., (1995) referred to the gut as the “little brain” due to
its high concentration of neurons and neurotransmitters (in particular, serotonin).
Further research is required regarding the use of psychoactive drugs with their local
and central pain-blocking function. Furthermore, due to the high prevalence of a
comorbid depression and anxiety with IBS, a Serotonin Specific Reuptake Inhibitor
(SSRI) may be the drug of choice if moderate to severe IBS symptoms disrupt the
person’s daily functioning. New studies are being conducted with selective opioids
utilising their pain relieving functions while excluding their hypnotic or sleep
inducing properties. It is postulated that their action here is primarily directed at gut
receptors which result in a decrease in gut pain (Klein, 1988).
iii) Antidiarrhoeal agents (for exa mple Loperamide) which slow gut transit time
seem to be most effective for this group (Klein, 1988).
iv) Lastly, constipation – predominant IBS is most effectively treated with drugs
which modify subjects’ perception. Dietary fibre remains the stalwart treatment over
32
the last half-century as it is safe, cheap, regulates gut function and can also mediate a
placebo response. It is a long-term option for mild to moderate IBS with constipation
(Heaton, 1985; Mitchell & Drossman, 1987).
3.2.2
Psychological interventions
Many studies have revealed that IBS health care seekers are more psychologically
disturbed than the general population (Blanchard, Schwarz & Radnitz, 1987;
Drossman et al., 1992; Langeluddecke, 1985) and hence research has focused on
incorporating various forms of psychotherapy in the hope of alleviating symptoms.
Psychological interventions have been aimed at individuals and at groups and
include insight-oriented psychotherapy, hypnotherapy, behaviour therapy and group
psychotherapy.
Creed and Guthrie (1989) discuss the rationale for psychotherapy as a treatment
modality for IBS as it seeks to relieve symptoms by addressing various unconscious
conflicts in the subject and thereby helping them re-establish a sense of emotional
equilibrium. Hopefully, along with a decrease in IBS symptoms, there would be a
decrease in depression and anxiety. Devroede (1994) hypothesises that IBS subjects
have symptoms instead of emotions. (Please refer to section 2.3.1).
3.2.2.1
Insight-oriented psychotherapy
Hislop (1980) conducted an uncontrolled study of brief insight-oriented
psychotherapy in 52 IBS subjects. Therapy lasting between one and four hours
sought to link recent life events with the onset of IBS symptoms. The major focus
was on the subject’s emotional catharsis. Hislop (1980) discusses how the subject,
when confronting her emotions, became overtly distressed, but that IBS symptoms
subsequently decreased. 17% of the subjects experienced moderate relief, 22% of the
subjects experienced little change in bowel symptoms and the rest were
asymptomatic or had mild persistence of IBS symptoms.
33
Langeluddecke (1985) as well as Creed and Guthrie (1989) commented on Hislop's
(1980) outcome results. Subjects who were unable to express emotion were those
who fared least. Another criticism was that this selected group cannot be generalised
to the typical IBS subject reporting to a gastroenterologist, as the majority of these
IBS subjects accepted an emotional basis for their IBS at the outset.
Svedlund et al. (1984) conducted a much larger controlled study comparing IBS
subjects in medical therapy versus those receiving medical therapy plus
psychotherapy. Subjects excluded in this research were severe IBS cases, those with
concomitant mental disorders and those with previous abdominal surgery. A control
group received the standard medication comprising bulk forming agents, and where
necessary antacids, mild tranquillisers and anticholinergic drugs were prescribed.
Beside this, the psychotherapy group received 10 ho urs of individual insightoriented psychotherapy aimed at modifying maladaptive behaviour and seeking new
solutions to problems. Therapy was conducted by two experienced psychotherapists
who rated subjects' responses before and after treatment. Creed and Guthrie (1989)
state that this was a major weakness of this study as subjects' ratings should have
been assessed by an independent gastroenterologist.
The results of this study showed that the psychotherapy group improved
significantly over the control group in abdominal pain and bowel dysfunction.
Differences were further pronounced one year later as the psychotherapy group
continued to improve versus a slight deterioration in the medication-only group.
Svedlund et al. (1984) attributes this difference to the effect of psychotherapy where
an intense therapeutic relationship was established. Creed and Guthrie (1989)
dispute this as a simple linear-reductionistic explanation for the differences between
the groups. They believe a more complex interaction of factors may have occurred
such as a reduction in anxiety and depression or new insight related to the interaction
of stress and IBS. It could also have been attributed to the awareness of, and
resolution of, personal conflicts.
34
Methodological flaws in this study include the admission of IBS subjects who had
symptomatology for one month only. This is a short duration when compared with
chronic IBS subjects who may have long standing emotional issues and limits its
generalisability. Furthermore, the control group and the therapeutic group were not
comparable at the outset in terms of somatic symptoms or level of anxiety
(Langeluddecke, 1985).
Guthrie et al. (1991) conducted a similar study but attempted to address previous
methodological flaws. This included an independent assessor (a gastroenterologist
who rated the subjects before and after while remaining blind to the trial group) and
a couple of refractory subjects (that is subjects who have not responded to a variety
of other forms of treatment). In this study the control group was offered supportive
psychotherapy which included emotional catharsis and a heightened awareness of
their symptoms.
The results of this study were promising as 64% of the refractory IBS subjects
improved significantly and furthermore maintained this at one year follow up.
Dynamic psychotherapy has been shown to be superior to the control group (Guthrie
et al., 1991).
3.2.2.2
Hypnotherapy
Whorewell, Prior and Faragher (1984), experienced hypnotherapists but not trained
in any psychotherapy, randomly allocated 30 refractory IBS subjects to two groups,
the first being hypnotherapy alone and the second supportive “psychotherapy”. Both
involved seven half- hour treatments over a period of three months. Hypnotherapy
included general relaxation, the use of a pre-recorded daily autohypnosis tape and a
technique which led the subject to believe they achieved control over intestinal
motility (Whorewell et al., 1984). “Psychotherapy” focused on the awareness and
discussion of symptoms and exploring interactive emotional problems and stressful
life events. Findings revealed that the IBS symptoms of abdominal pain, bowel habit
35
and abdominal bloatedness significantly improved for the hypnotherapy group as
opposed to the psychotherapy group. Comparison with the study of Svedlund et al.
(1984) cannot be made as the researchers were not trained psychotherapists. The
value this study offers is the comparison of hypnotherapy versus previous medical
treatments which were unsuccessful. Perhaps because their medication had failed,
this self-selected group of IBS subjects were motivated to receive this type of
treatment. Whorewell et al. (1984) further substantiated these findings in 30
refractory IBS patients who underwent hypnotherapy or supportive psychotherapy.
There was greater improvement in IBS subjects receiving hypnotherapy than
supportive psychotherapy. Furthermore, they found hypnotherapy to be less effective
in subjects over 50 years of age, those with atypical IBS or those with severe
psychological symptoms. Quite clearly there is a differentiation regarding the
efficacy of hypnotherapy in IBS subjects.
Hypnotherapy also needs long term follow up after therapy has been discontinued so
as to rule out the effect of therapeutic transference (Devroede, 1994). Furthermore,
hypnotherapy does not seem effective in constipated IBS subjects (Guthrie et al.,
1991) who possibly require much deeper and longer therapy (Devroede, 1994).
3.2.2.3
Behavioural therapy - biofeedback
Drossman (1989) emphasises the importance of incorporating a behavioural
component in the treatment of IBS as it offers the subjects non- invasive, costeffective coping strategies over psychological or physical symptoms (Creed &
Guthrie, 1989).
Biofeedback techniques in behaviour therapy are used in patients with chronic,
idiopathic constipation or anismus. Denis (1994) describes all phases of this
technique as learning to relax the pelvic floor muscles during straining at stool
instead of contracting them. Biofeedback techniques have been criticised for not
36
considering important preceding life events such as sexual abuse which preceded
anismus and therefore a holistic approach is required in further research.
Devroede (1994), in discussing biofeedback, states that many variables are at work
simultaneously, and relate to a composite interaction of the personalities involved
and the techniques utilised. Devroede (1994, p113) sites a comment from one of the
pioneers of pelvic floor dysfunction, Chantal Rossignol (no reference cited) who said
“They speak about their body when we would like them to express their emotions,
but they tell us their life story and release their emotions when we work on their
body.”
Devroede (1994) suggests that when people have been hurt physically through
torture, rape or violence they seem to dissociate. It is this dissociative defence
mechanism that Devroede (1994) believes makes them look for a response from
physical therapy as opposed to psychological therapy. This needs to be incorporated
in therapeutic praxis.
Devroede (1994) warns that if this dissociation, which is related to biofeedback, is
related to hypnosis, the therapist needs to be aware of the constant danger of
symptom displacement. Symptoms may then present as migraine headaches, lower
back pain, sexual impotence or heart arrhythmias.
Bennett and Wilkinson (1985) in a controlled study of first time IBS clinic
attendees, compared the efficacy of either an eight week relaxation training
programme or an eight week trial of Fibergel, Motival and Mebevrine – a medical
prescription by Ritchie and Truelove (1980). They found that IBS symptom
reduction was comparable in the two groups but that behaviour therapy was more
effective in those subjects with high anxiety. One flaw in this study is that these
subjects were first time attendees and as Creed and Guthrie (1989) believe, may have
responded to any first line of treatment. The selected sample was also small –
consisting of only 24 subjects, and has limited generalisability.
37
3.2.2.4
Cognitive Behavioural Therapy
Cognitive Behavioural Therapy involves identifying stressors, recognising thoughts
that increase distress and learning new ways of coping with the stress by
restructuring the subjects’ thoughts. The studies of Beck, Persons and Miechenbaum
(in Greene & Blanchard, 1994) were amalgamated to form Greene and Blanchard’s
(1994) cognitive therapy for IBS subjects. Their intervention aimed at activating
three change mechanisms: firstly, rational self analysis where subjects explored
idiosyncratic beliefs and fears and linked these to their cognitive, affective and
behavioural components of their IBS; secondly, decentering where subjects gained
distance from their own self- talk and began “owning” their automatic thoughts and
thirdly, experiential disconfirmation in which subjects challenged their maladaptive
beliefs and learned to experience themselves in different ways. Their results showed
that 80% of the therapy group showed significant improvement, which held up well
at three months, versus 10% improvement of the monitoring group.
Blanchard et al. (1987), Blanchard, et al. (1992) and Neff and Blanchard (1987)
reported numerous research studies which evaluated a multi-component cognitivebehavioural therapy treatment programme consisting of a) cognitive stress coping
techniques; b) progressive relaxation; c) thermal biofeedback and d) education about
the hypothesised stress and IBS relationship. Their results showed that treatment was
effective in 60% of subjects whose IBS symptoms were reduced by almost half.
Furthermore, this reduction in IBS symptomatology was maintained four years later.
It appears as if resistant cases may include high levels of trait anxiety which often
leads to a poor resolution of symptoms and results in subjects becoming chronic
clinic attendees (Kingham & Dawson in Creed & Guthrie, 1989).
3.3
INTERVENTIONS WITH GROUPS
To date, there is seemingly little IBS research which has been conducted in groups.
Group psychotherapy is generally used for subjects as a means to share common
38
problems, to develop a sense of belonging, to observe others’ behaviours and follow
through on the consequences of their choices and furthermore to offer a sense of
support during self exploration and change (Posthuma, 1996; Yalom, 1970).
Wise, Cooper and Ahmed (1982) conducted group psychotherapy on 20 subjects and
included a blend of IBS education, group psychotherapy, which aimed at identifying
and formulating strategies for life stressors, and progressive relaxation. Groups were
held once a week for approximately one and a half hours over a duration of six
weeks. Results showed that there was little improvement in IBS symptoms but the
study accepted severe, refractory IBS subjects who had not responded to other
treatments. Furthermore, those subjects with high anxiety felt they had little control
of their illness and feared the embarrassment of incontinence. These subjects had a
history of more frequent hospitalisations, utilised enemas more readily and generally
were more dissatisfied with their sex lives (Wise et al., 1982).
Creed and Guthrie (1989) conducted a study with a small number of IBS subjects
who had mild anxiety. They adopted Wise et al’s (1982) relaxation techniques and
found that subjects who could identify their stressors and who could subsequently
learn to relax, gained a sense of internalised control. This study has been critiqued
for its small sample size which limits the generalisability of its findings.
Lammert and Ratner (1986) conducted a pilot group consisting of eight members
who had been self-selected from a group of 290 IBS sufferers referred from the
American Digestive Disease Society (ADDS). Sixty gastroenterologists served as
referral sources. The group participants were all white, their ages ranged from 31 to
83 and on average had IBS for 20 years, with a range from 3 to 47 years. Lammert
and Ratner (1986) described how the subjects varied considerably in social and
personal functioning. Group content focused on educating the subjects about IBS
and explored its impact on their lives while providing support. Problem solving
strategies were brainstormed which allowed subjects to view their coping strategies
and subsequently they became less dependent and more self-sufficient. Lastly,
39
practical techniques for managing pain and stress were discussed. Outcome of the
research was measured by the subjects’ own evaluations, their physicians’
assessments and an evaluation by the group leader.
The subject’s outcome of the research showed that 75% of subjects reported a
positive change in attitude towards IBS. 50% reported some reduction in the
symptoms while 33% reported a significant increase in symptoms. It was also stated
that physician-referred subjects were lower in adaptive functioning than those who
were self-referred. The maladaptive functioning of these members in the group was
also noted by the therapists.
In essence, the leaders’ clinical evaluation of the process focused on increased
awareness of internal emotional states and increased expression of feelings which
evolved as members identified with and learned from others. Most individuals
became, to a varying degree, more aware of their own feelings and also realised that
their IBS may not be cured, that it is a debilitating syndrome but that they can learn
coping strategies to deal with it for significant periods, with a greater sense of
personal control.
Lastly, group psychotherapy is strongly recommended by a number of researchers.
Drossman and Thompson (1992) feel that group psychotherapy is indicated in
subjects who experience interpersonal conflicts and who have limited financial
resources. Similarly, Els et al., (1995) also recommends group psychotherapy for
IBS subjects in their study which explored the relationship between IBS and
psychiatric illness. They believe therapeutic groups consisting of six – eight IBS
subjects could offer the patients much needed education on IBS and its pathogenesis,
diet, lifestyle and exercise. The group context would offer more specialised
psychotherapy and only a few subjects would need psychotropic medication. This
group they saw as being led by a psychiatrist.
40
The above discussion has summarised research findings of the treatment of IBS with
individuals and within the group context. What becomes apparent is that subjects
with severe IBS and a moderate to severe depression and anxiety are difficult to
“shift” as they may be chronically impaired in their daily functioning. These subjects
may present with abnormal illness behaviours (Drossman et al., 1992), fear they
have an underlying carcinoma and may frequently be unresponsive to traditional
psychotherapy (Guthrie et al., 1991). Drossman and Thompson (1992) believe these
subjects are the exception rather than the rule and may need brief, regular
appointments with their primary care physician or general practitioner for case
management. What has become evident from current IBS research is that
methodologies and results have been inconsistent and have lacked a holistic
approach. With the high prevalence of IBS in society coupled with its high cost, both
to the individual and to the economy, effective holistic group psychotherapy seems a
logical option which needs further research. This current research study then asks if
a sample of subjects with severe or refractory IBS, combined with a moderate to
severe depression and anxiety could benefit from applying holistic short-term group
psychotherapy or if these subjects may require brief, regular case management as
suggested by Drossman and Thompson (1992) above. Furthermore, if these
refractory cases could benefit from holistic short term group psychotherapy what
implication does this have for the less severe cases of IBS, depression and anxiety?
For the majority of the IBS cases, psychologists are increasingly being consulted
regarding the psychosomatic illnesses. It is felt that the profession of counselling
psychology, which looks to develop wellness, strengths and resources within
individuals, has the potential to make unique contributions to the prevention and
alleviation of IBS suffering. Emphasis would be placed on optimising the subjects
well-being and quality of life as opposed to treating or curing the syndrome, setting
realistic goals, managing concomitant psychiatric syndromes and referring to a
multidisciplinary team for pain management if the pain becomes too disabling.
Working from a holistic, post- modern approach and incorporating the much
neglected emotional dimension along with the cognitive and behavioural
41
dimensions, it is postulated that this will result in effective and creative solutions for
the future (Stuart, Pretorius et al., 1998).
Real progress will be achieved when we can answer the following questions: “What
treatment, by whom, is most effective for this individual with that specific problem
and under which set of circumstances?” (Hatch, 1987).
Bearing this in mind, a holistic individual and group metamodel for the treatment of
severe IBS with its comorbid depression and anxiety will now be discussed.
3.4
TOWARDS A HOLISTIC METAMODEL FOR INDIVIDUAL
AND GROUP COUNSELLING
3.4.1
Motivation for a holistic model
In searching for an answer to Hatch’s (1987) question posed above one turns to the
disciplines of science, medicine and psychology only to find that none of these
disciplines alone has the answer. A brief digression follows as the historical
formation of science, medicine and psychology as disciplines is traced.
Brennan (1998) discusses how the pre- modern epistemology of the Greek
philosophers Plato, Aristotle and Socrates was succeeded by the modern scientific
revolution generated by Copernicus, Galileo, Newton and Einstein. The 1800’s was
a century in which there were substantial advances in biology, chemistry and
physics, and with their implications for the betterment of society, ready justification
for trust in scientific methods was provided (Brennan 1998).
Psychology, having been heavily steeped in religious belief, derived much of its
latter knowledge from science as did the field of medicine. Newtonian physics has
been characterised by reductionism, reducing complex phenomena to its constituent
parts. The aim of this was to understand the simpler parts in isolation, and then reassemble the individual solutions to formulate an answer to the problem, in a linear
42
cause and effect fashion. Empirical observation and logical positivism became the
dominant scientific methodology of the twentieth century (Brennan, 1998).
This mechanistic world view led to issues of alienation and individualism. Dualistic
thinking reduced man to his constituent parts of mind and body and relativism on all
levels prevailed – spiritual, moral and factual. The field of psychology became very
cynical and criticism levelled at the modern philosophy resulted in a further
paradigm shift – the postmodern age. Postmodernism according to Capra (1997)
also developed as a result of major advancements in the field of quantum physics out
of which quantum theory and chaos theory evolved. Capra (1997) highlights how
quantum theory challenged the belief that all physical phenomena could be reduced
to atoms and molecules. Sub-atomic particles have no meaning as isolated entities,
but can only be understood in the context of their interconnections – “the complex
web of relationships between the various parts of a unified whole” (Capra 1997, p.
30). This was accompanied by a general shift in thinking in many other disciplines
whose focus began to reflect the organization of systems. This recent systemic
influence in psychology with its interactive and holistic understanding of an
individua l in reciprocal relationship to others, is largely incompatible with
traditional, linear, reductionist views of man. However, many of the traditional
views remain entrenched.
Medicine and psychology’s dualistic presuppositions still often reinforce the
reductionistic notions of man’s mind and body as separate entities (Please refer to
section 1.1). Bearing the historical background in mind, it is not surprising that
subjects with psychosomatic disorders such as IBS have not been viewed holistically
by the health-care professionals and in turn often present with only a somatic
complaint (or projection) neglecting other aspects of their body, mind, soul and their
given context. Furthermore, the presuppositions one makes as a health-care
professional are often constraining in terms of what one will allow oneself to see in
one’s subject.
43
It is in bearing all of this in mind that the need for a holistic approach to both
individual and group counselling is adopted. In this research programme, both
the individual and the group metamodels were utilised although the primary
emphasis was on group psychotherapy. The individual metamodel was applied
in the problem exploration interview with each subject and after therapy as a
post-assessment tool in terms of how the individual subjectively rated the
success of group therapy against their own personal needs or goals. In addition,
within the group context, individuals will generally interact both on an
interpersonal level and on an intrapersonal level. A description of both the
individual and the group metamodels follow. The holistic individual metamodel
is elaborated on when describing the holistic group metamodel.
3.5
A
HOLISTIC
METAMODEL
FOR
INDIVIDUAL
COUNSELLING
The metaphor of the prism can be utilized by both the therapist and the subject
(please refer to figure 3.1). For the therapist it permits the conceptualisation of the
person as a whole (Broom, 1997) and in the therapeutic context helps the subject
regain the integration of their own body, mind and soul within their specific context.
It is a tool to facilitate a movement within them towards a wider view or a
metaperspective of themselves.
A metamodel, in the present context, is a model which allows one to view the
individual holistically, in an integrated fashion and from many different
perspectives, while acknowledging the blind spots – the information that one is not
seeing. It also infers a second-order therapeutic perspective in which the therapist
“joins” the subject, moving into his world and then out of it, in order to formulate
hypotheses at the theoretical level.
44
45
The personal metamodel depicting the prism dispersing white light into its
constituent rainbow colours, symbolically represents holistic woman, comprising her
body, mind and soul within a given context.
Central to this prism, at the core, is a meaning axis which symbolises the individual's
personal meaning system, her soul or her paradigm. Individual development or the
person’s movement through time is represented by a coil which spirals around the
central meaning axis.
To digress a moment. According to Gordon, Nesser, Pienaar and Walters (1969),
the laws of refracted light were discovered in the early 17th century by Snell and
simplified by Descartes. White light is comprised of seven different colours all of
which have different frequencies. The extent to which the light will be refracted
depends on what frequency the light is. If one holds a prism up to a source of white
light, the white light is refracted into its constituent colours as it passes through the
prism.
The light which has been refracted through the meaning axis breaks up into the
seven colours of the rainbow; red – the somatic projection; orange – the emotional
projection; yellow – the cognitive projection; green – the behavioural projection;
blue – current ego states such as those described in Berne’s (in Stewart & Joines,
1987) Transactional Analysis – (Parent, Adult and Child);
indigo – the
interrelatedness between all systems in the human ecosystem and violet – the
individual’s context, culture and cohort.
Please note: For simplicity each subsystem will be discussed individually.
However, in reality each part of the system, through cybernetic energy, reacts
reciprocally to each other part of the system in recursive feedback loops. Each part
therefore influences and is influenced by the other. This pertains to both the
individual as well as the group metamodels.
46
In discussing this metamodel, attention will be given to the structure of the model for
individual holistic therapy and will attempt at the integration of the content of the
theory.
3.5.1
The use of explanatory and applicatory theories within the holistic
model
3.5.1.1
Explanatory theories
Explanatory theories aid the therapist in analysing the subject’s current scenario, her
development, her physiology, personality, cognitions, emotions and behaviours, ego
states, systems and context from which she has evolved.
Explanatory models or tools the therapist could select in addressing the subject’s
needs could include:
Developmental:
•
Piaget’s theory of cognitive development (Piaget, 1977)
•
Havighurst’s developmental tasks (Havighurst, 1972)
•
Erikson’s psychosocial development (Erikson, 1974)
•
Kohlberg’s theory of moral development (Kohlberg, 1985)
•
Peck’s theory of adult development (for middle and old age,
expanding on Erikson’s theory) (Peck,1968)
•
Hultsch and Deutsch’s (1981) life event framework
Somatic/physiological projection:
•
Genetic predisposition
•
Psychopathology
•
Psychometry
•
Personality theories
•
Neuropsychology
47
Emotional projection:
•
Person Centred theory (Rogers, 1957)
Cognitive projection:
•
Life script (Berne in Stewart & Joines, 1987). Please refer to section 3.5.2.5
•
Self awareness (Pretorius, 1996 – please refer to figure 3.2)
Behavioural projection:
•
Salutogenesis and Fortigenesis (Strumpfer, 1990, 1995)
•
Exercise
•
Diet
Ego states:
•
Ego state theory (Watkins & Watkins, 1997)
Systems:
•
Psycho-social theories
•
Graphic family sculpting (Venter, 1993)
Meaning systems:
•
The subject’s meaning system (embracing their purpose and hope in life) needs
consideration.
Context:
•
Mores, norms, values and cohort also need consideration.
3.5.1.2
Applicatory theories
Applicatory models are subsequently selected depending on the problem exploration
and are determined by whether the helping interventions need to be applied to the
individual (meaning system, somatic projection, emotional projection, cognitive
48
projection and behavioural projection) and/or the greater system/ecosystem in which
she functions (marriage, family and social group). However interventions outside the
field may be required such as dietary modifications or psychopharmacology and then
the subject would need referral.
Applicatory models the author would select to use according to the specific sub ject’s
need could include:
Developmental:
The explanatory model of Erikson’s psychosocial developmental theory can be used
in one applicatory sense as the subject begins to renegotiate specific goals in order to
resolve an unresolved developmental crisis (Erikson, 1974).
Somatic/Physiological Projection:
•
Psychopharmacology (refer subject)
•
Psychoeducation
Meaning System:
•
Logo therapy (Frankl, 1959, 1970)
Emotional Projection:
•
Person-centred therapy (Rogers, 1957)
•
Gestalt therapy (Prochaska & Norcross, 1994)
•
Guided imagery or visualizations (Watkins & Watkins, 1997)
Cognitive Projection:
•
Transactions/analysis (T.A.) (Berne in Stewart & Joines, 1987)
•
Self-acceptance (Pretorius, 1996). Please refer to figure 3.3
Ego states:
•
Ego State therapy (Watkins & Watkins, 1997)
49
Behavioural Projection:
•
Reality therapy (Glasser, 1990)
•
Exercise prescription (Benson in Dientsfrey, 1991)
•
Dietary modifications (refer subject to a dietician)
Systems:
•
Milan systemic (strategic) therapy (Selvini Palazolli, Boscolo,
Cecchin & Prata, 1978)
•
Minuchin’s structural therapy (Minuchin, 1984)
•
Graphic family sculpting (Venter, 1993)
Context:
•
Norms, mores, values within a given context can be applied.
3.5.2
Subsystems
of
the
metamodel
integrating
explanatory
and
applicatory theories
3.5.2.1
Individual development through time as depicted by the coil
The coil represents the subjects developmental history: her current life stage with its
specific developmental tasks (Havighurst in Louw, 1991), and life-events including
normative-age graded events, history graded events and non-normative idiosyncratic
events (Hultsch & Deutsch, 1981). The subject’s history is important to explore
where it may impinge on, or influence her current scenario. Developmental
explanatory models would be most commonly used by the therapist. Factors to
consider could include the subject’s genetic predisposition, the cohort (time and
place) into which she was born, her birth order and her developing personality.
3.5.2.2
The meaning axis (one’s paradigm or soul)
In the model, figure 3.1, light bends through the meaning axis influencing and being
influenced by each subsystem. Issues of meaning may relate to an “existential
50
crisis”. Meaning in life, for Frankl (1970), is not necessarily choosing one’s
environment but having the freedom to choose one’s response to it.
Thomas Moore in his book “Care for the soul” (1992, p4) ascertains that caring for
the soul is not primarily about problem solving. “Its goal is not to make life problem
free, but to give life the depth and value that comes with soulfulness”. If one could
“tap into the soul” of subjects – those with irritable bowel syndrome, depression or
anxiety, one could, according to Moore (1992), find the messages that lie within the
symptoms – the necessary changes requested by depression and anxiety. He believes
we need to “honour symptoms as a voice of the soul” (1992, p.7).
Soul’s power, for Moore (1992), may emerge from failure, depression and loss –
where one finds an unexpected strength. For the subject this is a positive reframing
of loss or pain and however or whatever they wish to believe, their personal
metaphor of meaning needs to respected by the therapist. A personal belief is that the
therapist’s primary task is to listen and not to preach or teach. The following
explanatory models may be used in an existential crisis such as developmental
theories, life-script (Berne in Stewart & Joines, 1987) and psychopharmacology.
Applicatory models could include Self Acceptance (Pretorius, 1996) - Please see
figure 3.3, Person Centred therapy (Rogers, 1957) and Gestalt therapy (Prochaska &
Norcross, 1994).
3.5.2.3
The somatic or physiological projection
The term projection here refers to the outward portrayal of the subsystem and not in
the Gestalt sense (in Prochaska & Norcross, 1994) of disowning a part of self and
placing that on the environment. The prism metaphor helps the somatising IBS
subject regain a sense of who they are, what parts of themselves they have discarded,
what emotions underlie their physical symptoms, and helps them re-connect, if
necessary, with their meaning system or with their broader social systems.
51
In connecting with themselves (Pretorius, 1996) they may wish to uncover an early
or earlier traumatic experience, whe n they may have needed to “split-off” part of
themselves (Berne in Stewart & Joines, 1987). They may need to cathart strong
emotions in order to deal with the emotional pain (Gestalt in Prochaska & Norcross,
1994). They may need to start setting some boundaries, (Minuchin, 1984), may need
to learn to be more assertive (behaviour therapy) and may well need to stop pleasing
the world and start acknowledging their own personal needs.
Personality styles such as neuroticism could serve as an explanatory model,
particularly in IBS, where subjects also elicit emotional inhibition, a more
conservative outlook and more conventional behaviour (Stuart, Pretorius et al.,
1998). Other Explanatory models could include self awareness (Pretorius, 1996)
(please refer to figure 3.2), psychometry, developmental theories and awareness of
the subject’s context.
Depending on the individual subject’s needs, applicatory models could include:
Applicatory models:
•
Transactional analysis
- Accepting different ego states, choosing a
(Berne in Stewart &
different life-script, dealing with conflict,
Joines, 1987)
choosing different communication styles,
Embracing “split off parts” of self.
•
Self acceptance triangle
(Pretorius, 1996)
•
Gestalt psychotherapy
(in Prochaska &
(please refer to figure 3.3 )
- Catharsis and getting in touch with emotions
and unfinished business.
Norcross, 1994)
•
Person centred therapy
- A trusting therapeutic relationship
(Rogers, 1957)
•
Guided imagery or Visualisations (Watkins & Watkins, 1997)
52
•
Behaviour therapy
- Relaxation therapy
- Acquiring and practicing new skills such as
assertiveness and conflict handling
•
Minuchin’s structural
therapy (1984)
3.5.2.4
- Boundary setting
The emotional projection
Emotions for the author, are defined as feelings with a physiological basis such as
fight or flight. There are six basic emotions:- shock, fear, sadness, joy, jealousy and
anger. The latter two are secondary emotions as they are easier to express than the
primary emotion underlying them which is fear.
Emotions serve a protective,
survival and release function.
Candace Pert in her book entitled “Molecules of Emotion” (1997, p.9) has pioneered
research in the field of biophysics and physiology.
She has demonstrated how
neuropeptides and their receptors are the “actual biological underpinnings of one’s
awareness, manifesting themselves as emotions, beliefs and expectations and
profoundly influence how one responds to and experiences the world”.
Pert (1997) proposes that the three classically separated areas of neuroscience,
endocrinology and immunology with their various organs – the brain, the glands, the
spleen, the bone- marrow and the lymph modes, are all interconnected in “a
multidirectional network of communication” linked by the information carriers – the
neuropeptides. It has only recently been discovered that peptide – producing cells
like those in the brain also inhabit the bone marrow – where immune cells develop.
It is with this understanding that Pert (1997) speculates that the mind is the flow of
information as it moves among the cells, organs and systems of the body. This flow
of information occurs mostly at the autonomic or involuntary level of our
physiology.
53
The mind serves to hold the network together, linking and co-ordinating the major
systems and their organs and cells in an intelligently orchestrated symphony of life.
This whole system is referred to as the psychosomatic information network linking
psyche, all nonmaterial aspects such as mind, emotion and soul, to soma, which is
the material world of molecules, cells and organs.
Information networks by definition are mostly unconscious, but Pert (1997) believes
that our conscious mind can also enter the network on cue. An example she cites is
that of a woman in labour, consciously altering her breathing to alleviate pain. Pert’s
(1997) explanation for this conscious modulation of pain by the mind is a result of
peptides flooding the cerebrospinal fluid when one’s breath is held or when one
breathes rapidly.
This restores the body’s homeostasis.
Peptides are often
endorphins – the body’s natural opiates and thus one’s pain is then modulated. Thus
“mind becomes body”.
Lastly Pert (1997) has also demonstrated how conscious intervention of the mind can
positively alter one’s immune system. Pert (1997) cites research by David Spiegel
of Stanford University (no reference given) who has convincingly shown that
expressing emotions like anger and grief can improve survival rates in cancer
patients. The other side of the coin is can negative emotions “cause” cancer?
All emotions expressed, she believes, are healthy emotions, even anger, fear and
sadness. Repressed emotions causes disintegrity in the system and block the flow of
peptides at the cellular level resulting in weakened conditions that can lead to
disease. All honest emotions which are expressed are positive emotions. The key is
to express it in a functional way and let it go.
These findings “dovetail” with the metamodel which strives to integrate soma and
psyche at every level. It also has important therapeutic implications in particular for
the expression of emotions. For the introverted subject, Gestalt techniques may be
threatening, but expression is necessary even if it is in a less formal, less threatening
54
context such as in the quiet of one’s own room or in the “safe place” of one’s
visualizations. The cognitive projection and ego states will be discussed together.
3.5.2.5
The cognitive projection and ego states
Transactional analysis developed by Eric Berne (1964) is both an explanatory model
(personality theory and social interaction model) as well as an applicatory tool
dealing with conflict handling and communication patterns. Berne (1964) and Berne
(in Stewart & Joines, 1987) describe the four life positions: I’m OK- You’re OK;
I’m not OK – You’re OK; I’m not OK - and You’re not OK; I’m OK – and You’re
not OK. Berne (1964) believes all people are equal. The infant begins life generally
from the I’m OK – You’re OK position, but in social interaction may develop a less
favourable position. There are three ego states of parent, adult and child. The parent
represents societal norms, mores and values as well as the introjected parent who can
be nurturing or critical. The parent represents the “musts” – the cognitive demands
which need to be unmasked. The adult represents our conscious thoughts, feelings
and behaviours in the here and now.
The child ego state is unconscious and
represents our thoughts, behaviours and feelings replayed from childhood.
Transactional analysis (Berne,1964) is a theory of communication with ideal
communication between adults being between the two adult ego states. Faulty
communication in adults generally occurs between two adults communicating from a
parent and a child ego state. Within a person, conflict may often arise where the
parental introjections for which we strive, are in conflict with our childish needs.
This leaves the adult ego state in conflict which he consciously is aware of.
Berne’s (1964) theory of child development refers to life-script when a ‘critical
decision’ was made – either that we are acceptable or that we are unacceptable.
Berne (in Stewart & Joines, 1987) discusses how the person will then go out of
his/her way in their lives to prove that their life script is true. The process of self
awareness (Pretorius, 1996) incorporates uncovering and challenging this life-script,
by means of unmasking cognitions and choosing to respond differently.
55
Unmasking Cognitions
Step 1
The subject needs to identify or unmask her cognitions, whether these are conscious
or unconscious. Of particular importance are the subject’s earliest memories. We
all as children experienced on a continuum: total acceptance to total rejection. We
then developed a basic awareness of either acceptance or rejection.
What is
important for the therapist to remember is that there may be no correlation between
the parents’ perceived intention and the subject’s understanding. This would have to
be investigated, but the subject’s phenomenology – their reality, is what is important.
This acceptance or rejection by others led to our acceptance or rejection of our self
which in turn led to our acceptance or rejection of others. A cycle has been set up.
A positive cycle needs little change, but a negative cycle requires intervention.
Figure 3.2: Explanatory Model - The Acceptance/Rejection Cycle in SelfAwareness (Pretorius, 1996)
Acceptance/Rejection
by others.
Acceptance/Rejection
of others.
Step 2
Acceptance/Rejection
of self.
– Choice
There is a key to this negative cycle – being the choice to accept oneself. Once one
can accept oneself, one can accept others, and in turn be accepted by others.
How does one come to accept oneself?
A self awareness table is a helpful
therapeutic tool. The subject fills in three columns. In the first column will be their
56
positive attributes – the aspects of themselves they can accept. In the second column
are their negative attributes that they need to set goals for and lastly the third column
comprises those negatives that they cannot change, that they need to change their
mind about (Frankl’s freedom of choice.) This is the most active form of change
(Pretorius, 1996).
In reality some strengths are also weaknesses. Sensitivity is an example of this as it
can be both a positive attribute as well as a negative attribute. Unfinished business
needs to be dealt with (utilising for example Gestalt psychotherapy or Personcentred therapy) and goals need to be set and prioritised.
Step 3
Step 3 in this process requires that the subject comes to a place of self acceptance
(Berne in Stewart & Joines, 1987). In order to do this, she must accept her strengths
without feeling superior, she must change those negative attributes which she can,
and lastly those things which she cannot change and therefore needs to change her
mind about, she must accept without feeling inferior or judging herself or others.
Once she can accept herself based on these conditions, she can accept others, accept
one other and ultimately accept the meaning of life. This is depicted in the Self
Acceptance Triangle (Pretorius, 1996).
57
Figure 3.3: Applicatory Model - The Self Acceptance Triangle (Pretorius, 1996)
Accept
Meaning of
Life
Acceptance of
One other
Acceptance of others
Self Acceptance
Depicts a cybernetically energized system.
3.5.2.6
The behavioural projection
Reality therapy
Glasser (1990) focuses on present behaviour, while emphasizing personal
responsibility.
58
Therapists must focus on the “3xR’s”, namely;
•
Reality – what is the contextual reality of the subject and what behaviour is
realistic to expect in that given context?
•
What is right and wrong for this particular subject?
•
The subject needs to take personal responsibility for himself, his choices and their
consequences.
Reality therapy could be both an explanatory model (assessing the subject’s context)
and an applicatory model to correct maladaptive behaviour.
3.5.2.7
Systems
Systemic and ecosystemic theories, according to Prochaska and Norcross (1994) and
Capra (1997), maintain that individuals can only be understood in the social context
in which they function. In order to understand the functioning of a whole organism,
they emphasise the importance of studying the units of the organism in relation to
the whole – in terms of their patterns or processes (Capra, 1997). The whole is
greater than the sum of the parts (Keeney in O’Connor & Lubin, 1984).
The
philosophical assumptions underlying this new epistemology as opposed to the
scientific method, are discussed by Goldberg and Goldberg (1990).
•
Multiple viewpoints exist on what constitutes reality and change (rather than a
single, objective reality).
•
Multiple causality accounts for most events (not simple, linear, causality).
•
The entire unit should be the unit of study (rather than individual changes).
•
The therapist should be searching for systemic connections – patterns and
processes (not explanations based on linear causality).
Jasnoski (in O’Connor & Lubin, 1984) highlights the system’s stabilising and
growth functions in terms of cybernetics. Cybernetics, according to Jasnoski (in
59
O’Connor & Lubin, 1984) refers to the automatic control or feedback mechanisms
that regulate a system usually through exchange of information, energy or matter.
These control processes are termed feedback loops. Positive loops allow the system
flexibility and growth, whereas negative loops maintain the system’s homeostasis.
Optimisation refers to the process whereby people seek optimal environments for
themselves in order for them to optimise their potential, meet their needs and
accomplish their goals.
Lastly, a system will seek equifinality, a teleological
concept which refers to the preferred state toward which a system functions.
The philosophical assumptions underlying the systemic approach can be extended
and hold true for ecosystems. The ecosystemic approach as described by Jasnoski
(in O’Connor and Lubin 1984) describes living systems as open systems –
exchanging information, matter or energy with the environment. The environment is
the context of the individual’s experiences and behaviour.
The “internal
environment” of the subject, for example her physiology, her interpersonal
functioning, her nonverbal (covert) and verbal (overt) behaviours all interchange
energy in a recursive manner with the social environment. Jasnoski (in O’Connor
and Lubin, 1984) delineates this social, external environment on different levels
namely the interpersonal level, the family or small group level, the community level
and the cultural level.
Recursiveness describes how all parts of the system act and react reciprocally to one
another – that is complex causality (Keeney in O’Connor & Lubin, 1984). The
systemic concepts of cybernetics, feedback loops, optimisation and equifinality can
all be applied to the ecosystem.
The ecosystemic approach is of particular
importance when considering the subject with her own world view and from her own
context or phenomenology. It applies to both the individual and group therapeutic
contexts.
60
Systemic therapeutic techniques include:
•
A working hypothesis of the problem within its context.
•
Circular questioning – offers a holistic view of the relationship and pinpoints when
the relationship underwent a paradigm shift.
•
Counter-paradox or positive connotation techniques encourage the continuation of
the symptom and allows the therapist to access the family as a systemic unit
(Boscolo, 1987). It also aids the family in attaining their end goal as there is no
way a family could resist a therapist who told them to continue with their
behaviours they were already engaged in unless they gave up those behaviours.
Furthermore, paradox allows the problem to shift from the identified patient to that
of the family.
Other explanatory and applicatory models here could be Minuchin’s (1984)
structural family therapy (defining the parental subsystem; sibling subsystem;
clarifying or examining new boundaries) and Graphic family sculpting (Venter,
1993). graphic family sculpting (Venter, 1993, p12) may be briefly described as a
"visual spatial metaphor which enables the individual to redefine complex and often
vague family issues in a simple workable form". The technique requires that subjects
are asked to draw their family members on a sheet of paper representing each person
with a circle. significant information is then added to the sketch. often highly
emotionally charged information can be examined in a new light as the emotional
content becomes externalised and the dynamics between individuals becomes more
evident for the subject or subjects and the therapist. This heightened awareness can
enable the subjects to effect the necessary changes within their family relationships.
This has shown to be a powerful and effective diagnostic and therapeutic tool
(Venter, 1993, p12) and therefore it may be utilised as both an explanatory and
applicatory model.
The author would like to briefly introduce quantum physics in this subsystem as it
has relevant applications. From quantum physics, we know that light cannot be
61
broken down into its constituent parts. At the subatomic level light still has a wavelike property and a particle-like property. We choose what we want to focus on. If
we choose to focus on the particle we loose sight of the wave – we can’t see it, but
we know it is there. Similarly, if we loose sight of the particle – we can’t see it, but
we know it is still there.
This has certain important implications:
1.
It is impossible to have a full understanding of reality. It is a changing reality.
2.
This has important ramifications for science and psychology. How can we
confidently make predictions when we have a changing reality?
3.
Due to the fact that we have chosen what we want to focus on we are no longer
objective. We can no longer distance ourselves because of the choice that was
made. This is very different to Newtonian Science with its linear causality,
reductionism and prediction.
4.
Time cannot be measured at this sub-atomic level, because it is unobservable.
Time is linear, reversible and deterministic, but the time-energy uncertainty
principle remains unclear (Capra,1997).
5.
Heisenberg’s uncertainty principle implies a causality and irreversibility. This
contradicts linear causality.
Newtonian Science can still have a place in a consensual reality, but not at the lower
subatomic invisible world.
This is known as the Uncertainty Principle of
Heisenberg (Capra, 1997). It is the author’s perspective that both these approaches
can be utilized. What lessons can we learn from quantum physics in terms of the
subject’s systemic context and/or the therapeutic metamodel? An analogy one could
use from quantum theory is that the whole is much greater than the sum of the parts
(Keeney in O’Connor & Lubin, 1984). So too as with white light, the subject is far
more than the sum of his constituent parts or subsystems and we need to view the
subject holistically. Multiple realities exist in quantum physics, just as they do in the
subject.
Likewise there are multiple truths – not just one truth. This is also
62
applicable for the subject and therefore as a therapist one should get a
metaperspective of the problem. A further application is that of a second-order
perspective. We choose to view the particle or the wave, and our choice ensures we
are part of the observing system – we can no longer be objective. So too in therapy,
the subject and the therapist co-create meaning as their consciousness is being
restructured.
3.5.2.8
Context
This therapeutic subsystem is important to understand as it embraces cohort, culture,
language, values, norms, mores, individualistic orientation or collectivistic
orientation and much more.
A universal psychology, according to Kluckohn (in Ibrahim, 1985) needs, by
definition to be holistic and open to new influence. To be responsive to its context it
must be flexible and sufficiently complex to account for man’s complexity –
whatever the context. An appropriate therapist should be aware of his own possible
cultural prejudices and ideologies and he should be interested in and have some
understanding of his subject’s context. A therapist should always be respectful of
the subject’s individuality, regardless of the context, and should not make
assumptions without deconstructing the information.
Kluckhohn (in Ibrahim, 1985) states that certain existential categories exist
universally with common problems which occur across all nations. Common themes
are:
•
The modality of human nature – “EIGENWELT” (good/bad).
•
The modality of human relationships –
“MITWELT” (individualistic,
collectivistic).
•
The relation of people to nature – “UMWELT” (people-nature orientation harmonious controlling).
•
The temporal focus of human life (time-present, past, future).
63
•
The modality of human activity (doing, being, being- in-becoming).
An ecosystemic stance is of great value with people of diverse cultural backgrounds
as it focuses on patterns and processes rather than on content. Cohort, the specific
time and place in history when one is born, also plays a significant role in
formulating one’s worldview as it assigns certain characteristics to that time frame.
It also needs to be considered in contextual counselling.
3.6
A HOLISTIC METAMODEL FOR GROUP COUNSELLING
Having dealt with the holistic metamodel for individual therapy, consideration needs
to be given as to its applicability within the group setting. The holistic group
metamodel has been developed from the work of Broom (1997), Crafford (1985),
Pretorius (1996) and Yalom (1970).
The group metamodel as depicted in figure 3.4 represents a number of individuals
who cohese (Yalom, 1970) to form a new system, context or family. The individuals
are represented by the three prisms whose light source becomes projected through a
fourth prism. The fourth prism represents the group interaction. The surrounding
refraction of light emitted from the fourth prism, as depicted by the outermost
concentric circle, represents the whole interaction which is much greater than just
the sum of the individual parts. This is represented in figure 3.5 – please refer.
As in the holistic individual metamodel (figure 3.1), much of the group content is
depicted through the various projections as the light becomes refracted through the
meaning axis (figure 3.5). The meaning axis now reflects both the meaning the
group has for the subjects – the hope it embues (Yalom,1970), together with the
existential meaning or meaninglessness which the group members have for life.
64
65
66
However, in group therapy of utmost importance are the group therapeutic factors
which Yalom (1970) describes as the core of the therapeutic process – “the bare
boned mechanisms of change”. These factors are primarily represented in the group
metamodel (figure 3.5) by the coil which depicts group development or group
process with the passage of time. These will be discussed in Chapter Four. Most of
the explanatory and applicatory theories which were discussed in the holistic
individual metamodel (figure 3.1) apply in the holistic group metamodel.
Discussions relating to the individual projections within the group will be
highlighted in Chapter Four where the interaction of the group programme and the
holistic group metamodel are blended into a short-term holistic group intervention.
3.7
CONCLUSION
In this chapter a summary of the treatment of IBS with individuals and within the
group context has been discussed. Furthermore, a holistic metamodel has been
presented which attemp ts to redress problems of past and render creative solutions
for the future. The application of this metamodel to IBS subjects aims at viewing the
whole person in context in terms of her meaning system, her somatic or
physiological projections, her emotional projections, her cognitive and ego state
projections, her behavioural projections and her systemic or contextual projections.
This study attempts to investigate the efficacy of holistic group therapy for subjects
with severe IBS, depression and anxiety based on empirically validated research. In
Chapter Four the empirical investigation is discussed which reiterates the aims of the
study, the practical aspects of the research methodology, such as the recruitment and
selection of subjects, the measuring instruments utilized, the hypotheses which were
formulated, the holistic group intervention which was applied and the statistical
procedures which were adopted.
When part of the system is perturbed there is a shift in the entire system. Capra’s
(1997) “Web of Life” is a metaphor for this and is reflected in this ancient North
American Indian Philosophy…
67
"This we know
All things are connected
Like the blood
Which unites one family
Whatever befalls the earth
Befalls the son and daughter of the earth
Man did not weave the web of life
He is merely a strand in it
Whatever he does to the web
He does to himself"
Ted Perry (in Capra, 1977)
68
CHAPTER FOUR
EMPIRICAL INVESTIGATION
“If you can’t change your fate, change your attitude.”
Amy Tan (1952) – American writer. Source Unknown.
4.1
INTRODUCTION
In the previous chapters, the theoretical foundations have been laid for the present
study. Chapters Two and Three sought to provide a background for, and
understanding of, the complex factors involved in the onset and maintenance of IBS
and its comorbid depression and anxiety. The treatment of subjects with IBS either
individually or in groups was examined in Chapter Three and a holistic metamodel
for individual and group counselling was proposed.
In this chapter the research method for the present study will be explicated. This will
reiterate the research problem, the research question and the aim of the study and
discuss the various practical aspects of the research methodology. This includes the
recruitment and selection of subjects, an overview of the measuring instruments with
their specific psychometric properties, the hypotheses which were formulated, the
group therapy intervention which was conducted and the statistical procedures which
were utilised.
4.2
RESEARCH PROBLEM
As was discussed in Chapter Three, there have been many studies which have
highlighted the effectiveness of diverse therapeutic interventions in the management
of the subject with IBS. However, there have been many restrictions or limitations
which need to be reiterated. Firstly, due to the previous dualistic treatment approach
where mind or body were targeted, psychology was predominantly absent in the
treatment equation. Secondly, a lack of a coherent theory of IBS also influenced
69
research methodologies, where samples were skewed or biased and where there was
limited control over all the variables. Therapeutic interventions were often adopted
haphazardly, as it was difficult to assess which intervention was more effective for
which subject. This served to limit the generalisability of the psychological
treatments (Drossman & Thompson, 1992).
Furthermore, it was only with the shift to a biopsychosocial approach (Drossman,
1989) that a theoretical platform for a multicomponent perspective was legitimised.
There is little evidence, in a search of the international literature, to show that there
has been a fully integrated approach applied to the treatment of subjects with IBS
either individually or in groups. Rather, a “shot-gun” approach to psychotherapy
utilising a few models in combination such as cognitive, behavioural and
hypnotherapy has been adopted. Even Drossman’s (1989) biopsychosocial model
which is most similar to a holistic approach still neglects to view the whole person
interacting dynamically both intrapersonally and interpersonally in their given
context.
There has been a dearth of South African studies with requests for more local data.
A South African study by Dolan (2000) has been the only holistic approach to the
treatment of individuals with
IBS
which
embraced
both
medical
and
psychotherapeutic interventions. To date, there has been no South African nor
overseas literature which has applied or evaluated holistic short-term group
psychotherapeutic intervention in the treatment of IBS and its comorbid depression
and anxiety.
As discussed in section 3.3, there have been strong recommendations for group
psychotherapy in IBS subjects who also have a comorbid anxiety and depression.
With the prevalence so high and the cost to the economy and the individual so great,
effective holistic group psychotherapy seems to be a logical option.
70
4.3
RESEARCH QUESTION
Given the above research problem as well as the theoretical foundation in Chapters
Two and Three, the specific research question for this study is presented as follows:
Are there statistically significant differences in the pre-test versus the post-test
scores in Group 1 (the experimental group) versus Group 2 (the control group)
regarding the Functional Bowel Disorder Severity Index (FBDSI), the depression
scores as indicated on the Personality Assessment Inventory (PAI) and the anxiety
scores as indicated on the PAI? The scores are compared for two groups of adult
female subjects who have severe IBS and moderate to severe depression and anxiety.
The two groups are as follows: Group 1 - the experimental group (N=12) will
receive holistic short-term group psychotherapy and Group 2 - the control group
(N=12) will receive no treatment.
4.4
THE AIM OF THE STUDY
As discussed in section 1.2, the specific aim of the present study is to determine the
effect of the holistic short-term group intervention in the treatment of IBS with its
comorbid depression and anxiety. The intervention is described in section 4.9.
Operationally defined, the aim of the present study is to ascertain whether there are
statistically significant differences in the mean pre-test versus the mean post-test
scores of the three variables. This includes the IBS severity scores as measured on
the Functional Bowel Disorder Severity Index (FBDSI), the depression scores as
measured on the depression scale of the Personality Assessment Inventory (PAI) and
anxiety scores as measured on the anxiety scale of the PAI. The differences are
compared for Group 1 - the experimental group versus Group 2 - the control group
as described in 4.3 above.
71
4.5
RESEARCH DESIGN
This is a between groups experimental design consisting of two groups. Group 1
receives the treatment and Group 2 receives no treatment. It is based on a pre-test,
post-test control group design. The essential feature of this design is that all subjects
are tested before and after the intervention (Kazdin, 1980). The effect of the
intervention is largely reflected in the amount of change from pre-test to post-test.
The degree of change, says De Vos, Shurink and Strydom (1998) is of particular
importance in IBS research.
Kazdin (1980) describes how the pre-test also serves to reduce the within- group
variability so that a more accurate assessment of the intervention is given. However,
the pre-test also allows for individual changes from pre-test to post-test scores. The
researcher can therefore obtain more information than merely the group difference at
a post-test level (Kazdin, 1980).
The design can be illustrated as follows:
Experimental group 1
O1
*
O2
(N=12)
Control group 2
O3
-
O4
(N=12)
O refers to an assessment
* refers to the intervention or treatment
N refers to the number of subjects in each group
Due to the fact that this study incorporated short-term treatment and given that
Yalom’s (1970) principle of homogeneity was adopted, little randomisation was
applied. Discussion of the sample below will highlight the randomisation issues
further.
72
4.6
RECRUITMENT OF THE SUBJECTS
4.6.1
The Sample
The sample for this study which consisted of 24 female adults, was selected from a
pool of approximately 180 adult females who had been positively diagnosed by
either a general practitioner or a gastroenterologist as having severe IBS symptoms.
Referral to the research centre was through the media where subjects were briefed
regarding the study and were invited to be part of the sample group. Other sources of
referral were the subject’s medical doctor, dietician or word of mouth.
Due to the marketing exercise described above, there is little chance that the
obtained sample was truly random (Kerlinger, 1986). Unfortunately, this limits the
generalisability of the findings to all South African population groups. Furthermore,
a self-selected group of health-care seekers (as discussed in Chapter Two) is likely to
have been targeted which also does not represent the wider IBS population
(Drossman, McKee, Sandler, Mitchell, Cramer, Lowman & Burger, 1988).
Generalisation to the white health care seekers in South Africa is probably
appropriate.
4.6.2
Selection Instruments
Four selection instruments were utilised for all subjects within the sample. They are
the Biographical Questionnaire, the IBS Client Questionnaire, the Functional Bowel
Disorder Severity Index (FBDSI) and the Personality Assessment Inventory (PAI).
These questionnaires will now be discussed.
4.6.2.1
The Biographical Questionnaire
The Biographical Questionnaire was compiled by researchers within the research
centre as a means of requesting various personal details including name, address,
73
date of birth, gender, race, marital status, number of children, education
qualifications, occupation or current status of employment, and current monthly
income. Other questions related to the positive family history of emotional or
psychological problems, a history of psychotherapy for those issues and the use of
prescribed medication, drugs, cigarettes and alcohol. Information regarding their
participation in physical exercise was also requested. Based on the information
obtained in this questionnaire, all male subjects were excluded as well as children
younger than 20.
4.6.2.2
The IBS Client Questionnaire
Drossman, Thompson and Talley (in Drossman, 1994) constructed this questionnaire
based on the Rome criteria (please see section 2.3.2) in order to verify a positive IBS
diagnosis. This questionnaire focuses on the nature, frequency and duration of the
subjects’ IBS symptoms. The subject is required to answer questions on the nature of
her IBS symptoms, the consistency of stool, the sense of an incomplete evacuation
and the presence of abdominal fullness, bloating or swelling. The subject is also
requested to note the frequency of her bowel habits in a given week. These criteria
need to be positive in order to have a positive IBS diagnosis. Together with this
client questionnaire, Drossman, Thompson and Talley (in Drossman, 1994)
recommend that all other organic pathology be excluded initially. It was for this
reason that a subject with a positive IBS diagnosis would only be adopted as part of
the sample pool if the doctors’ referral form, which excludes other organic
pathology, had been verified by means of this questionnaire.
4.6.2.3
The Functional Bowel Disorder Severity Index (FBDSI)
The Functional Bowel Disorder Severity Index (FBDSI) is a standardised scoring
method designed by Drossman, Zhiming, Toner, Diamant, Creed, Thompson, Read
et al. (1995) as a means of assessing both the nature and the severity of functional
bowel disorders which present either in the mid or lower gastrointestinal tract. Due
74
to the fact that IBS has been described by many authors as the epitome of a
functional bowel disorder (please refer to section 2.2.2) the FBDSI was utilised as
both a selection instrument for this study as well as a measuring instrument. This
will now be elaborated on.
The FBDSI is based on a raw score derived from the subject’s weighting of the
following three questions:
•
Assessment of the subject’s pain in terms of a percentage scale, where 0%
represents no pain versus 100% which represents very severe pain;
•
The number of visits to a general practitioner or gastroenterologist for bowel
discomfort in the three previous months; and
•
A diagnosis of functional abdominal pain obtained from the subject with
reference to:
- the frequency of continuous abdominal pain for at least three months.
(This excludes any gynaecological pain).
- interference with daily functioning.
This severity score is the sum of the values (derived from the above questions)
which have been multiplied by a given constant (Drossman et al., 1995). It is this
severity score which has been used to both select subjects for the research sample or
reject them as well as to measure the treatment effect on the IBS variable pre-test
versus post-test (Please refer to sections 4.6.2 and 4.7 for a description of these
instruments). Drossman et al.’s (1995) severity rating is as follows:
Mild IBS symptoms
<36
Moderate IBS symptoms
37-100
Severe IBS symptoms
>111.
The subjects selected for this study all required a severe IBS rating (together with a
moderate to severe depression and anxiety rating – please refer to section 4.6.2.4),
otherwise the subjects were excluded from the study.
75
4.6.2.3.1
Reliability of the FBDSI
Drossman et al. (1995) provide evidence which attests to the reliability of the FBDSI
based on the following findings:
1) Visual analogue scales have been shown to be reliable and responsive in
assessing pain severity (Duncan, Bushnell & Lavigne, 1989; Talley, 1994).
2) A diagnosis of chronic functional abdominal pain, and the frequency of doctor
visits is not likely to change during the time frame (<2 weeks) within which
test-retest reliability is established.
3) Repeating the FBDSI as a measuring instrument in another sample of IBS
subjects assessed the replicability of the scale. The distribution of scores closely
approximated those of the original study, suggesting that the FBDSI can reliably
determine the range of illness in replicated studies (Drossman et al., 1995)
4.6.2.3.2
Validity of the FBDSI
The validity of the FBDSI scale was determined both in terms of face and
convergent validity by means of regression analysis (Drossman et al., 1995). In
terms of face validity, subjects with more severe pain that remains constant and who
frequently consult doctors are likely to be judged as having more severe illness.
Convergent validity was established since the same items repeatedly emerged from
several different types of regression methods. The Kruskal-Wallis test was used to
test construct validity by comparing the FBDSI scores to the degree to which
symptoms interfered with daily activities. The researchers found a significant
association in the predicted direction with a chi-square result of 43.64, with four
degrees of freedom, at the 0.0001 level of significance.
4.6.2.4
The Personality Assessment Inventory
The Personality Assessment Inventory (PAI) was selected as the instrument used in
this study to assess the presence and severity of depression and anxiety in all IBS
76
subjects. The PAI is both a selection and a measuring instrument as subjects in this
study could only be selected on the basis of a positive diagnosis of moderate to
severe depression and anxiety. Furthermore, the subject’s depression and anxiety
was then measured both at the pre-test and at the post-test levels in order to verify
the treatment effects. (Please refer to section 4.7).
Although developed in the United States of America by Morey (1991) and
standardised for use on a westernised population, the PAI was selected as being
suitable for this particular South African sample where the urban population shares
many characteristics with the American people.
4.6.2.4.1
The content of the PAI
The PAI is a self-administered, objective inventory of adult personality, developed
and standardised for use in the clinical assessment of individuals from the age of 18
years. As a clinical instrument, the PAI is designed to screen for the presence of
psychopathology as well as to provide information relevant to clinical diagnosis and
treatment planning. It is not intended to provide a comprehensive assessment of the
domains of normal personality.
The inventory consists of 344 items or statements which are arranged in 22 nonoverlapping scales. The subject is required to determine the extent to which each
statement accurately applies to herself. The possible answers are: false, not at all
true; slightly true; mainly true; and very true. The scales are selected to include
constructs which are most pertinent to a broad-band assessment of mental disorders.
Four of these validity scales are designed to determine the validity of individuals’
responses: eleven are clinical scales that assess the presence of actual clinical
syndromes; five are treatment scales which identify issues which may complicate
treatment and two are interpersonal scales that identify the individual’s particular
style of interaction and characteristics of her environment. In the following
77
discussion, attention will be paid to the depression and anxiety scales only.
Please refer below.
•
The Depression Scale measures clinical features common to depression
including pessimism and negative expectations, and physical signs such as low
energy and disturbances in sleep and eating patterns. The scale comprises the
subscales reflecting three major groups of depression symptomatology:
Cognitive, Affective and Physiological. Cognitive depression refers to those
subjects who report thoughts of worthlessness, hopelessness and personal failure.
Indecisiveness and difficulties in concentration are also likely. Affective
depression refers to those subjects who report sadness, a loss of interest in
normal activities and a loss of pleasure in things that were previously enjoyable.
Physiological depression refers to those subjects who tend to experience and
express depression in somatic form. They report a change in level of physical
functioning, activity and energy. They are likely to show a disturbance in sleep
pattern, a decrease in level of sexual interest and a loss of appetite and/or weight.
The three subscales for Depression are added together for a total score.
A total score of depression (59T or below) reflects a person with few complaints
about unhappiness or distress. Such individuals are typically seen as being stable,
self-confident, active and relaxed. Scores ranging from 60-69T are indicative of
a person who may be unhappy and is sensitive, pessimistic and self-doubting.
Scores at or above 70T suggest prominent dysphoria. With a score in this range,
the respondent is probably despondent much of the time and has withdrawn from
activities that were previously enjoyable. Such individuals may be described as
guilt-ridden, moody and dissatisfied. With scores above 70T, at least one scale is
likely to be elevated and subscale scores should be examined to determine the
typical modality in which the depression is manifest. As scores become elevated
above 80T there is an increasing likelihood of a diagnosis of major depression.
78
Depression scores that are markedly elevated (at or above 96T) will likely have
elevations on all three subscales, often reflecting a diagnosis of major
depression. Individuals scoring in this range are likely to feel hopeless,
discouraged and useless. They are socially withdrawn and feel misunderstood by
others. Typically, there is little energy and motivation to pursue interests.
Suicidal ideation is not uncommon with scores in this range and particular
attention should be given to this.
•
The Anxiety Scale measures clinical features common to the experience of
anxiety, such as ruminative worry, subjective feelings of apprehension and
strain, and physical signs of tension and stress. The scale also comprises three
subscales reflecting three major modalities of the expression of anxiety:
Cognitive, Affective and Physiological. Cognitive anxiety refers to those subjects
who report prominent worry and concern about current issues; these worries are
present to the degree that the ability to concentrate and attend are significantly
compromised. Their acquaintances are likely to comment about their
overconcern regarding issues and events over which they have no control.
Affective anxiety refers to those subjects who report experiencing a great deal of
tension, difficulty in relaxing and the presence of fatigue as a result of highperceived stress. Physiological anxiety refers to those subjects who tend to
experience and express stress in a somatic form. They are likely to manifest
overt physical signs of tension and stress, such as sweaty palms, trembling
hands, complaints of irregular heartbeats and shortness of breath. The three
subscales for Anxiety are added together for a total score.
A total score on anxiety (59T or below) reflects a person with few complaints of
anxiety or tension. Such subjects are typically seen as calm, optimistic and
effective in dealing with stress. Scores ranging from 60-69T are indicative of a
person who may be experiencing some stress and is worried, sensitive and
emotional. Scores at or below 70T suggest significant anxiety and tension. With
a score in this range, the respondent is probably tense much of the time and
79
ruminative about anticipated misfortune. Such individuals may be seen as
highly-strung, nervous, timid and dependent. With scores above 70T, at least one
subscale is likely to be elevated and subscale scores should be examined to
determine the typical modality in which anxiety is expressed. Anxiety scores that
are markedly elevated (at or above 91T) will likely have elevations on all three
subscales, reflecting a generalised impairment associated with anxiety. The
respondent’s life is likely to be seriously constricted; she may not be able to meet
even minimal role expectations without feeling overwhelmed. Mild stressors are
likely precipitate a crisis, and this pattern may present difficulties for
psychotherapy despite the motivating nature of the distress. In most instances,
scores in this range will reflect a diagnosable anxiety disorder.
In conclusion, only subjects with a moderate to severe depression and anxiety
together with a severe IBS score were selected for the sample. Out of a total of
approximately 180 subjects, 24 filled the above criteria. The other subjects were
excluded from this study.
4.6.2.4.2
Administration of the PAI
The PAI is a self-administered test which can be conducted in either individual or
group testing situations. In either instance it is imperative that the testing takes place
in a quiet room free of external interference. In both settings the confidentiality of
responses should be protected. Instructions for completing the test must be carefully
discussed with the subjects ensuring their understanding. This is provided in the test
booklet (Morey, 1991). The importance of answering all relevant items should be
emphasised as well as the necessity for choosing only one response per item. To
answer the relevant questions above, approximately 15 minutes should be allowed.
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4.6.2.4.3
Scoring of the PAI
The first step in scoring the PAI involves counting the number of relevant items that
have been unanswered or to which more than one response has been given. As a
rule, at least 95% of items should be completed before the test may be considered for
scoring.
The answer sheet on which the respondent records his responses is a carbonised
form, the bottom page of which provides item scores ranging from 0-3 for each of
the items. The items are arranged in scales and sub-scales and the scores for each are
totalled and entered in the appropriate area on side B of the profile form. The raw
scores for the sub-scales and scales may be plotted on a profile graph on side B. On
side A of this form the raw scores for each scale are transformed into T-scores which
may also be plotted on the graph.
4.6.2.4.4
Interpretation of the PAI
One of the most noteworthy features of the PAI is the fact that it allows for profiles
of respondents to be compared both to normal and clinical samples. PAI scale and
sub-scale scores are transformed to T-scores in order to provide interpretation
relative to a standardisation sample of 1000 community-based adults and to a
clinical sample of 1246 patients. The T-scores have a mean of 50 and a standard
deviation of 10. Thus, a T-score greater than 50 lies above the mean in comparison
to the scores of subjects in the standardisation sample. Approximately 84% of nonclinical subjects will have T-scores below 60 (one standard deviation above the
mean), while 98% of non-clinical subjects will have T-scores below 70 (two
standard deviations above the mean). This means that a T-score at or above 70
represents a pronounced deviation from the typical responses of adults living in the
community. T-scores provide a meaningful way of determining whether certain
problems are clinically significant since relatively few normal adults will obtain
markedly elevated scores. For the interpretation of anxiety and depression scores
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in this study, T-scores between 0-50 were considered mild; 50-70 moderate; and
70+ severe. The blue profile line on the profile form indicates the scores on subscales and scales which are two standard deviations above the mean established for
the clinical sample. This means that approximately 98% of clinical patients will
obtain scores below this blue line. Scores above this line represent a marked
elevation of scores relative to those of patients in clinical settings.
4.6.2.4.5
Psychometric qualities of the PAI
The reliability of the test refers to the consistency of the measurement provided by
the test. In assessing the reliability of the PAI, the focus was on internal consistency
and test-retest stability. In all studies of the internal consistency reliability of the
PAI, use was made of the coefficient alpha which can be interpreted as an estimate
of the mean of all possible split- half combination of items (Morey, 1991). This
statistic was calculated for the two scales, details of which will not be provided in
this work but are available in the test manual. In order to determine the test-retest
reliability of the PAI scales, the test was administered to each of the two samples of
normal subjects on two different occasions, on average 24 days apart. The
correlations ranged from 0,60-0,94 with the average correlation being 0,85.
Generally the mean scores were very similar indicating that few global changes were
observed over time (Morey, 1991). According to Morey (1991), the process of
establishing the validity of the PAI involved firstly the concurrent administration of
the best available diagnostic indicators to various samples to determine their
convergence with corresponding PAI scales. Secondly, diagnostic judgements
concerning clinical behaviours were examined to determine if the PAI correlates
were consistent with hypothesised relationships. The diagnostic indicators used
included the Minnesota Multiphasic Personality Inventory and the NEO Personality
Inventory (refer to Chapter Two for the latter). It is clear from the available data that
the validity of each sub-scale within the PAI was confirmed.
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4.6.3
Assignment of the Subjects to Groups
Selection of subjects for this study was obtained from a sample pool of
approximately 180 self-selected and doctor-referred IBS subjects. Each subject
underwent an intake interview where an overview of the research aims were
discussed and the subject’s history was taken. During this interview, subjects were
also requested to produce their doctor’s referral letter stating a positive IBS
diagnosis. A second appointment was then scheduled for the subject where the
subject then completed the selection questionnaires for this study, namely the
Biographical Questionnaire, in order to obtain personal information, the IBS Client
Questionnaire, in order to verify a positive IBS diagnosis and the Functional Bowel
Disorder Severity Index (FBDSI), in order to ascertain the severity of IBS.
A further interview was scheduled where each subject was given feedback on her
personal data obtained. If the subject's scores indicated a severe IBS score together
with a moderate to severe depression and anxiety score, the subject was invited to be
part of the holistic short-term group psychotherapy programme. Twenty four
subjects were chosen, 12 for the intervention or experimental group (Group 1),
which, for group therapy purposes, was subdivided into two groups of six, and
12 for the control group, (Group 2), who received no intervention. Only after
the research was completed were the subjects in the control group offered
individual psychotherapy. The subjects in the intervention then had to be
committed to six weekly sessions of psychotherapy, each session lasting one and a
half to two hours, and needed to be able to adapt to the group scenario. Two groups
of six members each were selected for the intervention group, with one group having
its sessions on a Friday and the other on a Saturday. Unfortunately, there were no
black respondents and this is possibly because of the media campaign which
featured predominantly in English and Afrikaans newspapers and magazines.
Unfortunately, this limits the generalisation of these results to certain population
groups in South Africa only. Furthermore, the subject's personality style was taken
into account by the researcher, for example, whether she was dominant, shy,
83
introverted or extroverted. The subject was then placed in the group where it was felt
she would be most comfortable. This is in accordance with Yalom’s (1970) principle
of homogeneity which he believes builds ego strength in short-term psychotherapy.
The subject was then advised by the researcher to enter either the Friday or the
Saturday therapeutic group depending on the factors cited above. The control group
subjects (Group 2 – who received no intervention) were in the meanwhile put on a
waiting list.
4.6.4
Description of the subjects
Biographical information pertaining to the composition of subjects in the
experimental and control groups will be discussed. These variables were not
incorporated into the statistical analysis as depicted in Chapter Five due to the
relatively small numbers of subjects per group. However, a discussion of the
variables follows, as they may be important for future research.
4.6.4.1
Age of subjects
Epidemiological studies have shown that IBS is most prominent in white women 35
years of age or younger (Drossman et al., 1992; Els et al., 1995). The age of the
white women in this stud y, however, was in a slightly older age group, with 35% of
the subjects being 35 years old or younger and 62% of the subjects being between 35
and 59 years of age. Only one subject was over 60 years of age. One reason why an
older group of IBS subjects was sampled was perhaps due to the more senior
population and the older geographical areas which were targeted.
In terms of Group 1 (the experimental group - who received intervention) and Group
2 (the control group - who received no intervention), there was no statistically
significant difference in age (p=0.241 according to Levene’s test for the equality of
variances).
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4.6.4.2
Educational status, Occupation, Employment and Monthly Income
In this study, more than 50% of the subjects had tertiary education and 33% of the
remaining 50%, had at least a matric qualification. In terms of Group 1 (the
experimental group - who received intervention) versus Group 2 (the control group who received no intervention) there were no statistically significant differences in
educational status (p=0.58) according to Pearson’s chi-square test.
In terms of occupational status, 42% of the sample were professionals and a further
37% were in a business position. Here there were statistically significant
differences between the experimental and control groups regarding occupational
status (p=0.05 according to Pearson’s chi-square test). This is significant at the 5%
level. In examining the data, there were two students in the control group who were
technically oriented as opposed to the experimental group where all 12 subjects were
either professionals or in a business position.
There were no statistically significant differences between the experimental and
control groups regarding employment status (p=0.247 according to Pearson’s chisquare test).
46% of the sample received a monthly income of R2000 – R6000 per month. 25%
of the subjects received more than R6000 per month and 30% of the subjects
received less than R2000 per month. There was no statistically significant difference
between the experimental group (Group1 - who received intervention) and the
control group (Group 2 - who received no intervention) regarding monthly income
(p=0.360 according to Pearson’s chi-square test). However, when it is acknowledged
that 71% of the sample receive <R6000 per month and that the average family in this
study had between one and three children, the possibility remains that financial
strain may further exacerbate the subjects’ IBS.
85
The factors cited above could have implications for further stressors associated with
an already busy life-stage, where the woman is raising a family, being a wife and
mother, earning a living and still having to meet career demands. This could reiterate
the role which stress has in the development and/or maintenance of IBS (Drossman
& Thompson, 1992).
4.6.4.3
Number of children
58% of the sample had between one and three children, 8% had more than four
children and 33% of the sample had no children. There were no statistically
significant differences in the experimental and control groups regarding the number
of children (p=0.319 according to Pearson’s chi-square test). There may be a
correlation between the number of children and the presence of IBS but this would
require further research.
4.6.4.4
Family history of psychological problems
According to Fisher’s exact test, the experimental and control groups do not differ
significantly regarding a family history of psychological and emotional problems.
However, 58% of subjects reported that they did have family problems whereas 42%
of the sample denied family issues. This would support Drossman’s (1991) findings
that abnormal illness behaviour may result in a greater tendency to report the
family’s psychological issues.
4.6.4.5
Physical exercise
There was a statistically significant difference between the experimental group
and the control group in terms of physical exercise (p=0.020 according to Fisher’s
Exact test). Two thirds of the members in the control group exercised as opposed to
only one third exercising in the experimental group. One reason for this may be that
although the age differences between the experimental group and control group were
86
not statistically significant, the average age for the experimental group was 42 years
versus 35 years for the control group, and the younger group may exercise more than
the older group. Further research is required to ascertain whether the role of exercise
has any bearing on health-care seeking.
4.6.4.6
Religion
There was no statistically significant difference between the experimental and the
control group regarding the importance of religion (p=0.319 for Pearson’s chi-square
test). 58% of the subjects reported religion being very important in their lives and
33% reported being fairly religious. 8% of sub jects were not religious at all. This
supports Bayne, Stuart and Pretorius’ (1999) findings.
4.7
POST-INTERVENTION TESTING
One month after the intervention had been completed, all 24 subjects were asked to
complete the measuring instruments again in order to ascertain the treatment effect
as indicated by the difference in the pre-test versus the post-test scores.
This included post-tests on:
a)
the FBDSI in order to ascertain the severity of the IBS symptoms after the
intervention;
b) the depression scale of the PAI to ascertain the depression score post
intervention; and
c)
anxiety scale of the PAI to ascertain the anxiety score post intervention.
Furthermore, the 12 subjects who were in the control group were offered six sessions
of individualised holistic psychotherapy after the post-tests were completed.
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4.8
HYPOTHESES
Statistical or null hypotheses propose that no differences between Group 1 (the
experimental group - who received intervention) and Group 2 (the control group who received no intervention) be expected. Research hypotheses or alternative
hypotheses usually indicate the expected outcome of analyses based on literature
findings. Only alternative hypotheses will be stated here in order to avoid tedious
reading. Furthermore, one-tailed or two-tailed hypotheses can be formulated. Onetailed hypotheses are usually used where there are clear indications from the
literature for the direction of expected differences. Two-tailed hypotheses are
formulated when contradictory results are reported in research, that is when clear
differences are not indicated in the literature. In this research two-tailed hypotheses
are formulated given the contradictory research findings with regard to IBS.
For the purposes of this study, hypotheses will be formulated regarding the
following:
i.
Differences in the pre-test scores between Group 1 (the experimental group who received group intervention) versus Group 2 (the control group - who did
not receive intervention) (Hypothesis 1).
ii.
Differences in the post-test scores between Group 1 (the experimental - who
received group intervention) versus Group 2 (the control group - who did not
receive intervention) (Hypothesis 2).
iii. Differences between the pre-test versus the post-test scores of Group1 (the
experimental group - who received group intervention) (Hypothesis 3).
iv. Differences between the pre-test versus the post-test scores of Group 2(the
control group - who did not receive intervention) (Hypothesis 4).
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The four alternative composite hypotheses and their subhypotheses that pertain to
this study follow:
4.8.1
Alternative Composite Hypothesis 1
There are statistically significant differences in the averages of Group 1 (the
experimental group) versus Group 2 (the control group) regarding their pre-test
Functional Bowel Disorder Severity Index (FBDSI), depression and anxiety scores.
Alternative sub-hypothesis1.1
There are statistically significant differences in the averages of Group 1 (the
experimental group) versus Group 2 (the control group) regarding their Irritable
Bowel Syndrome severity scores as measured by the Functional Bowel Disorder
Severity Index (FBDSI).
Alternative sub-hypothesis 1.2
There are statistically significant differences in the averages of Group 1 (the
experimental group) versus Group 2 (the control group) regarding their depression
scores as measured by the depression scale of the Personality Assessment Inventory
(PAI).
Alternative sub-hypothesis 1.3
There are statistically significant differences in the averages of Group 1 (the
experimental group) versus Group 2 (the control group) regarding their anxiety
scores as measured by the anxiety scale of the Personality Assessment Inventory
(PAI).
89
4.8.2
Alternative Composite Hypothesis 2
There are statistically significant differences in the averages of Group 1 (the
experimental group) versus Group 2 (the control group) regarding their post-test
Functional Bowel Disorder Severity Index (FBDSI) scores, depression and anxiety
scores.
Alternative sub-hypothesis 2.1
There are statistically significant differences in the averages of Group 1 (the
experimental group) versus Group 2 (the control group) regarding their post-test
Irritable Bowel Syndrome severity scores as measured by the Functional Bowel
Disorder Severity Index (FBDSI).
Alternative sub-hypothesis 2.2
There are statistically significant differences in the averages of Group 1 (the
experimental group) versus Group 2 (the control group) regarding their depression
scores as measured by the depression scale of the Personality Assessment Inventory
(PAI).
Alternative sub-hypothesis 2.3
There are statistically significant differences in the averages of Group 1 (the
experimental group) versus Group 2 (the control group) regarding their anxiety
scores as measured by the anxiety scale of the Personality Assessment Inventory
(PAI).
90
4.8.3
Alternative Composite Hypothesis 3
There are statistically significant differences in the averages of the pre-tests versus
the post-tests for Group 1 (the experimental group) regarding their Functional
Bowel Disorder Severity Index (FBDSI) scores, depression and anxiety scores.
Alternative sub-hypothesis 3.1
There are statistically significant differences in the averages of the pre-test versus
the post-test scores for Group 1 (the experimental group) regarding their Irritable
Bowel Syndrome severity scores as measured by the Functional Bowel Disorder
Severity Index (FBDSI).
Alternative sub-hypothesis 3.2
There are statistically significant differences in the averages of the pre-test versus
the post-test scores for Group 1 (the experimental group) regarding their depression
scores as measured on the depression scale of the Personality Assessment Inventory
(PAI).
Alternative sub-hypothesis 3.3
There are statistically significant differences in the averages of the pre-test versus
the post-test scores for Group 1 (the experimental group) regarding their anxiety
scores as measured on the anxiety scale of the Personality Assessment Inventory
(PAI).
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4.8.4
Alternative Composite Hypothesis 4
There are statistically significant differences in the averages of the pre-test versus
the post-test for Group 2 (the control group) regarding their Functional Bowel
Disorder Severity Index scores, depression and anxiety scores.
Alternative sub-hypothesis 4.1
There are statistically significant differences in the averages of the pre-test versus
the post-test scores for Group 2 (the control group) regarding their Irritable Bowel
Syndrome severity scores as measured by the Functional Bowel Disorder Severity
Index (FBDSI).
Alternative sub-hypothesis 4.2
There are statistically significant differences in the averages of the pre-test versus
the post-test scores for Group 2 (the control group) regarding their depression scores
as measured on the anxiety scale of the Personality Assessment Inventory (PAI).
Alternative sub-hypothesis 4.3
There are statistically significant differences in the averages of the pre-test versus
the post-test scores for Group 2 (the control group) regarding their anxiety scores as
measured by the anxiety scale of the Personality Assessment Inventory (PAI).
In section 4.8 the hypotheses for the present study were formulated. This will now
be followed by a detailed description of the short-term holistic group intervention
which was conducted.
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4.9
A SHORT-TERM HOLISTIC GROUP INTERVENTION
4.9.1
Introduction
Yalom (1970) relates a story. One day when talking to God, a Rabbi asks God to tell
him about “heaven” and “hell”. But God beckoned to him and said: “I will show you
heaven and hell.” On walking into the first room, the Rabbi found a group of people
sitting on the floor in a circle around a huge pot in which a stew was brewing.
Balancing around the pot were ladles, spoons with extra long handles, and as hard as
they tried, the people couldn’t manage to get the food into their mouths and feed
themselves. “This is hell”, said God. The Rabbi then walked into the second room.
Here the people were also seated around a pot but were eating. They were feeding
each other. And God said, “this is heaven.”
The melting pot is an inclusive metaphor for the group therapy conducted with
subjects having IBS, depression and comorbid anxiety and is symbolic in various
contexts. Firstly, it illustrates the unique contribution that the individual subjects
brought to the groups. The rich exotic flavour of the stew was far greater than the
sum of the condiments. Secondly, it underpins the integrated and holistic therapeutic
approach of attempting to view the whole person in context (Broom, 1997) rather
than as isolated parts or fragments. In this way, it acknowledges the subjects’
specific and intricately woven symptom complex of their own bodies' poetics of
illness! (Moore, 1992). Thirdly, the melting pot is symbolic of the altruistic risk that
the individual members had to take in opening up and reaching out to others
(Posthuma, 1996; Yalom, 1970)), tapping into the very essence of the group. The
innate curative and nurturing power, which the groups offered, served to cohese
(Yalom, 1970) the members in their own unique way.
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4.9.2
Rationale for group therapy intervention
IBS, like most chronic illnesses, tends to instil, support and possibly maintain a self
absorbed life style which is deficient in the sense of belonging experienced through
close relationships (Lammert & Ratner, 1986). Using a group format is an effective
way of re-establishing those links – both interpersonally where issues of
individualisation, intimacy (Lammert & Ratner, 1986) and illness arise, as well as
dealing with intrapersonal issues of an existential meaninglessness, responsibility,
choice and conflict avoidance.
The high prevalence of female subjects with IBS, depression and anxiety combined
with the severe dysfunction which these subjects experience also points to the need
for effective group psychotherapy (Dancey & Backhouse, 1993; Drossman &
Thompson, 1992; Svedlund et al., 1984; Thompson, 1984). Group therapy may be a
more cost-effective form of therapy as a group constitutes between six and eight
subjects with one or two therapists co-ordinating it. Lastly, very little holistic
intervention has been conducted with a dearth of research occurring in South Africa.
It is with this understanding, that this study was undertaken.
4.9.3
Integrating
personal
philosophical
assumptions
and
group
therapeutic factors into the group context
The author’s personal theoretical stance views individuals holistically in terms of
their integrated mind, body and soul (Broom, 1997). This view includes interactive
perspectives of the individual’s personal development through time, her particular
system of meaning, her physiological, somatic, emotional, cognitive and behavioural
aspects, her personality, the systems and eco-systems in which she functions and the
particular context in which she has evolved (Crafford, 1985).
A holistic view allows for metaperspectives of the individual while acknowledging
the blind spots – the information that one is not seeing (Boscolo, 1987). Even more
94
so in the group context, as opposed to individual psychotherapy, multiple views of
self are perceived by others which then become introjected within the individual
(Gomez, 1997). This facilitates a movement within the individual to a
metaperspective of herself allowing her to regain an integration of her own mind,
body and soul. This implies a second order therapeutic or clinical perspective
(Boscolo, 1987), where the therapist “joins” the subject moving into her world and
then out of it to formulate theoretical hypotheses.
In the object relations sense, a therapeutic group recreates a transitional object that
is an initial step in the differentiation of self from others (Lammert & Ratner, 1986).
These bridging characteristics of the group allow the individual to work with her
inner world (Lammert & Ratner, 1986) while being placed in relation to others
(Capra, 1997) within a microcosm of reality (Yalom, 1970).
Initially, the group processes focus on cohesing the group (Yalom, 1970) and
forming attachment bonds until a milieu of confidentiality, support and trust
(Rogers, 1957; 1959) has been established. Brown, Harris and Copeland (in Rush,
1982) describe how the development of attachment, or a confiding, intimate
relationship can protect against depression in the face of life stress.
Once individual boundaries have been set and the individual feels safe, their internal
conflicts may become more evident (Lammert & Ratner, 1986). Then they can begin
dropping their defences, experiencing their internal phenomenological processes and
further forging their own mind, body and soul links.
Catharsis (Yalom, 1970) is of particular importance to the IBS subject who more
often than not is alexithymic (Sifneos, Apfel-Savits & Frankel in Lammert & Ratner,
1986). This implies that the subject may find difficulty in ‘tuning’ into her feelings,
labelling and expressing them. Catharsis in the group context will be done against a
mirror of multiple viewpoints which will serve to both link the members universally
while offering reality testing and interpersonal learning (Yalom, 1970). The
95
therapist or therapists will meanwhile be searching for systemic connections, that is
patterns and processes (Jasnoski in O’Connor & Lubin, 1984), and not seek simple
linear-causal explanations. These observations will then be fed back into the system.
The author’s epistemological assumptions about man and the world were blended
into the ‘exotic flavour of the stew’, in which group therapeutic factors came to play.
Victor Frankl’s (1959, 1970) principles of freedom of will was meaningful in the IBS
group as subjects learned they could choose their attitude towards their illness and
take personal responsibility for the growth and changes that were necessary.
Complexly intertwined in this, is the meaninglessness and existential aloneness
which is associated with chronic illness (Lammert & Ratner, 1986). Once subjects
accepted that there is no ‘cure’ for IBS, they were set free to acquire new coping
mechanisms and skills. Interpersonal learning came into play.
It is the author’s belief that many people who refer themselves for therapy are
seeking change and wholeness (Kopp, 1994). Wholeness is understood in terms of
subjects integrating their various ego states (Watkins & Watkins, 1997) as well as
their cognitive, emotive, behavioural, physiological, meaning and contextual
subsystems (Crafford, 1985).
Interpersonal bonds are shaped and strengthened in the group context as one
becomes an active participative member of this new family. As De Pree (in
Posthuma, 1996, p.51) states so aptly, “to give one’s time doesn’t always mean
giving one’s involvement.” The degree to which the members become involved is
directly related to the degree of attractiveness or hope the group holds for them
(Posthuma, 1996; Yalom, 1970). Therefore it is essential that the group leader
identify the specific group’s needs and by addressing these relevant issues, engage
the members. All parts of this new family act and react complexly and recursively
until a new state of equilibrium is attained. Equilibrium is generally re-established
with, and between members, as conflicts between the various ego states diminish
and where the “family of self is sought” (Watkins & Watkins, 1997, p.96).
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4.9.4
Integrating the short-term group programme within the holistic
group metamodel
The short-term group therapeutic programme is integrated with the holistic
metamodel for group counselling as discussed in section 3.6. (Please refer). Prior to
the group commencing, each subject had to complete a battery of psychometric tests
and had to have an initial personal interview (please see section 4.6). The interview
served to identify the specific subjects’ needs, themes and goals for therapy which
would then be personally re-evaluated post therapy. The subjects were then allotted
to the appropriate group based on their own personal needs or preferences and to the
suitability of their personality style. An overview of the group process and holistic
programme follows where extensive reference will be made to figure 3.5 - the
holistic group metamodel - and the projections which became evident within the
group intervention.
Table 4.1
Week 1
A short-term holistic group intervention
Therapy commenced with ‘setting the scene’ in a general introduction
where rules of the group were established. These included
confidentiality setting, maintaining respect, inviting disclosure,
questions and constructive criticism and where goals for therapy were
negotiated and established (group process and cognitive projection). A
Gestalt Self- Awareness exercise was conducted where members
depicted a) how they perceived themselves and b) how they believed
others perceive them in terms of a t-shirt design (emotional projection).
This introspection was aimed at generating cohesion and making use of
humour (Yalom, 1970). It also encouraged direct contact and
expression of feelings and limited intellectualising of the problem
(Corey, 1996) (group process).
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Week 2
The anatomy, physiology and treatment of IBS, depression and anxiety
were discussed (Rush, 1982) (somatic projection). This was followed
by intense discussions of the subjects’ personal signs and symptoms of
the disorders (Dancey & Backhouse, 1993; Lammert & Ratner, 1986)
(somatic, cognitive and emotional projections). The session ended with
a relaxation and ego strengthening exercise (Watkins & Watkins, 1997)
(behavioural and ego state projections).
Week 3
Self Awareness (Pretorius, 1996) with issues of life-script (Steiner,
1974) and ego states was discussed in the group as a whole and then
the group broke up into pairs to thrash out their personal needs, issues
or goals for therapy (this tapped into the group process, the emotional
and ego state projections and the subjects’ meaning axis).
Week 4
This included the dietician’s lecture as well as feedback,
recommendations and dietary modifications (Dancey & Backhouse,
1993; Drossman et al., 1992) (this addressed the behavioural and
cognitive projections). This generated much group discussion and
further facilitated the group process.
Week 5
The following session was spent looking at the emotions which related
to IBS (Dancey & Backhouse, 1993; Lammert & Ratner, 1986). This
was a cathartic session where there was much support and
understanding as well as learning of new coping skills. An exercise
prescription for IBS, depression and anxiety was shared (Benson in
Dienstfrey, 1991). This accessed the somatic, emotional, cognitive and
behavioural projections and meaning axis.
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Week 6
Principles of conflict handling skills and assertiveness training were
discussed. Assertiveness and anxiety are largely incompatible and by
having learned to assert oneself in stimulus situations that previously
evoked anxiety, members deconditioned the anxiety response (Wolpe
in Prochaska & Norcross, 1994). Group discussion revolved around
difficulties in setting boundaries (Fourie, 1993), and asserting one’s
needs. Time in the session was allocated for queries, questions and
sharing areas of growth or goal formulation. This accessed the group
process as well as the behavioural and cognitive projections. The group
therapy programme terminated with a commitment for a post-test
meeting and interview four weeks later.
Various therapeutic techniques were utilised (as highlighted above) such as
cognitive therapy, gestalt psychotherapy, self-awareness, behavioural therapy, some
limited solution focused therapy and logo therapy. An individual post interview and
feedback session was held with each subject four weeks later where their personal
themes were re-examined (from their own perspective) to subjectively measure their
change and growth.
Furthermore, the post-test IBS severity score, depression score and anxiety score
were run. The subjects had also been asked to keep weekly variations in the
qualitative rating of their IBS symptoms during therapy which was studied for their
own personal use and recorded.
Besides the group content, the process of group therapy facilitated the coconstruction of meanings between all members (Boscolo, 1987) and opened up new
ways of “seeing and doing”. It was learnt that it was acceptable to experience and
discuss their symptoms and emotions. Consequently, in their discussions they began
forging their own mind, body and soul links.
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Consideration will now be given to the statistical analysis of the data that was
obtained from all the subjects both in Group 1(the experimental group who received
the intervention) and Group 2 (the control group who did not receive intervention).
4.10
STATISTICAL ANALYSIS OF DATA
The statistical analyses of data was determined by utilising the t-test for the equality
of means for between groups variance and the paired samples t-test was utilised to
determine the within group variance. The details are as follows:
The t-test was utilised for two analyses. Firstly, the t-test for the equality of means
was utilised in order to determine the between groups variance in terms of the pretest scores for Group 1 (the experimental group – who received intervention) versus
Group 2 (the control group – who received no intervention).
Secondly, the t-test for the equality of means was also used to determine the
between groups variance in terms of their post-test scores for Group 1 (the
experimental group) versus Group 2 (the control group).
The paired samples t- test was also utilised for two analyses. Firstly, the paired
samples t-test was used to determine the within group variance in order to ascertain
whether there was a statistically significant difference regarding the pre- intervention
test scores versus the post- intervention test scores for Group 1 (the experimental
group).
Secondly, the paired samples t-test was also utilised to determine the within group
variance in order to ascertain if there were statistically significant differences in
terms of the pre-test scores versus the post-test scores of Group 2 (the control group
– who received no intervention).
100
4.11
SUMMARY
This chapter has described the empirical investigation of this study, detailing the
subjects who participated, the selection and measuring instruments used, the
hypotheses to be tested, the short-term holistic intervention for the groups
integrating the holistic metamodel that was presented and the statistical analyses of
the data. Chapter Five will present the test results of the study.
101
CHAPTER FIVE
RESULTS
“You may be disappointed if you fail, but you are doomed if you don’t try.”
Anonymous.
In this chapter, the results of the differences between the pre-test versus the post-test
scores are presented. The raw scores were then submitted to the Statistical
Consulting Department of the Rand Afrikaans University, captured on the Excel
computer programme and then analysed. Statistical analysis was conducted utilising
the t-test for the equality of means to determine the between group variance with
reference to Hypothesis 1 and 2. The paired sample t-test was used to determine the
within group variance with reference to Hypothesis 3 and 4. The results of the study
are presented in a tabular format according to the hypotheses formulated in Chapter
Four.
5.1
RESULTS OF ALTERNATIVE COMPOSITE HYPOTHESIS 1
(AND 1.1 – 1.3)
Hypotheses 1 and 1.1 – 1.3 refer to the differences between Group 1 (the
experimental group – who received intervention) and Group 2 (the control group –
who received no intervention) regarding their pre intervention test scores for IBS
severity as measured on the Functional Bowel Disorder Severity Index (FBDSI),
depression scores measured on the depression scale of the Personality Assessment
Inventory (PAI) and anxiety scores as measured on the Personality Assessment
Inventory (PAI). The results of the Alternative Composite Hypotheses 1 and 1.1 –
1.3 are presented below in Table 5.1 followed by an explanation of the Table.
102
Table 5.1
Significance of differences of the mean pre-test FBD Severity Indices, depression scores and anxiety
scores between Group 1 (experimental group, N=12) versus Group 2 (control group, N=12)
Variables
Group 1
N=12
8
Group 2
N=12
SD
8
SD
Levene’s test for
equality of variances
t-test for equality of means
F ratio
Significance
t-test
DF
P value
IBS severity
187.50
45.5781
168.42
26.0435
0.439
0.515
1.259
22
0.221
Depression
69.6667
14.7114
66.2500
18.4101
0.684
0.417
0.502
22
0.620
Anxiety
69.9091
12.2838
66.5000
8.5334
1.805
0.193
0.779
21
0.445
* = Significant at 5% level
** = Significant at 1% level
103
According to Table 5.1 there were no statistically significant differences between
Group 1 (the experimental group) and Group 2 (the control group) regarding the
various pre-intervention test scores.
According to Table 5.1, the p-values for the IBS severity index of Group 1 (the
experimental group) versus the Group 2 (control group) was p=0.221 (not
significant). Similarly, the p-value for depression regarding Group 1 (the
experimental group) versus Group 2 (the control group) was p=0.620 (not
significant). Lastly, the p-value for anxiety for Group 1 (the experimental group) and
Group 2 (the control group) was p=0.445 (not significant).
The alternative composite hypothesis 1 is therefore rejected and the null hypothesis
1 is accepted indicating that there are no statistically significant differences between
the two groups with regard their pre-test scores for IBS severity, depression and
anxiety.
5.2
RESULTS OF ALTERNATIVE COMPOSITE HYPOTHESIS 2
(AND 2.1 – 2.3)
Hypotheses 2 and 2.1 – 2.3 refer to the differences between Group 1 (the
experimental group) and Group 2 (the control group) regarding their post-test scores
for IBS severity, depression and anxiety. The results are shown in the Table below.
104
Table 5.2
Significance of differences of the mean post-test FBD Severity Indices, depression score and
anxiety score between Group 1 (the experimental group, N=12) versus Group 2 (the control
group, N=12)
Variables
Group 1
N=12
8
Group 2
N=12
SD
8
SD
Levene’s test for
equality of variances
t-test for equality of means
F ratio
Significance
t-test
DF
P value
IBS severity
192.25
70.8059
156.00
24.4800
2.380
0.137
1.676
22
0.108
Depression
55.9167
14.0936
65.3333
19.7638
0.666
0.423
-1.344 22
0.193
-2.220 21
*
0.037
Anxiety
56.4167
* = Significant at 5% level
** = Significant at 1% level
9.4336
66.9167
13.3924
2.661
0.117
105
According to Table 5.2 there are no statistically significant differences between the
post-test scores of Group 1 (the experimental group) and Group 2 (the control group)
with regard to their IBS severity score (p=0.108) or their depression score (p=0.193).
There was, however, a significant difference in the post-test anxiety score
(p=0.037) at the 5% level of significance between Group 1 (the experimental
group) and Group 2 (the control group). The mean of the post-test anxiety score
for Group 1 (the experimental group) was x=56.4167 versus Group 2 (the control
group) was x=66.9167.
The alternative sub-hypothesis 2.1 is rejected and the null hypothesis 2.1 is accepted
as there are no statistically significant differences in the averages of Group 1 (the
experimental group) and Group 2 (the control group) in terms of their IBS severity
scores. Similarly the alternative sub-hypothesis 2.2 is rejected and a null hypothesis
2.2 is accepted as there are no statistically significant differences in the averages of
Group 1 (the experimental group) and Group 2 (the control group) regarding their
depression scores.
However, alternative sub hypothesis 2.3 is accepted as there are statistically
significant differences in the averages of Group 1 (the experimental group) versus
Group 2 (the control group) regarding their anxiety scores (p=0.037 – significant at
the 5% level). This indicates that there was an improvement in anxiety after the
intervention in Group 1 (the experimental group).
5.3
RESULTS OF ALTERNATIVE COMPOSITE HYPOTHESIS 3
(AND 3.1 – 3.3)
Hypotheses 3 and 3.1 – 3.3 refer to the significance of the differences between the
pre-intervention test scores versus the post- intervention test scores for Group 1 (the
experimental group – who received intervention) regarding the IBS severity,
depression and anxiety.
106
Table 5.3
Significance of differences between the mean pre -test scores versus the mean post-test scores
for Group 1 (the experimental group; N=12) regarding FBD Severity Indices, depression
scores and anxiety scores.
Variables
Pre intervention
scores for Group 1
8
SD
Post intervention
scores for Group 1
8
SD
Pre intervention
minus post
intervention for
Group 1
Mean
Standard
deviation
t-test
DF
P value
IBS severity
187.50
45.5781
192.25
70.8059
-4.7500
95.7754
-0.172
11
0.867
Depression
69.6667
14.7114
55.9167
14.0936
13.7500
11.5611
4.120
11
**
0.002
10
*
0.014
Anxiety
69.9091
* = Significant at 5% level
** = Significant at 1% level
12.2838
57.0909
9.5860
12.8182
14.2044
2.993
107
According to Table 5.3 there are statistically significant differences between the
pre intervention test scores versus the post intervention test scores for Group 1
(experimental group) regarding their depression scores (p=0.002 – significant at the
1 % level; x=69.6667 versus x= 55.9167) and anxiety scores (p=0.014 –
significant at the 5% level; x=69.9091 versus x=57.0909). The post-test scores for
both depression and anxiety were thus lower after the group intervention. There are
no statistically significant differences in the averages of the pre-test versus the posttest for Group 1 (the experimental group) with regard to the IBS severity scores.
Therefore alternative sub hypothesis 3.1 is rejected in favour of a null hypothesis 3.1
as the post intervention average IBS severity score as measured on the FBDSI was
not lowered after the intervention. Alternative sub hypotheses 3.2 and 3.3 are
accepted as there are statistically significant differences in the averages of the pretest versus the post-test scores for Group 1 (the experimental group who received
intervention) regarding their depression and anxiety scores which were lower after
the group intervention.
5.4
RESULTS OF ALTERNATIVE COMPOSITE HYPOTHESIS 4
(AND 4.1 – 4.3)
Hypotheses 4 and 4.1 – 4.3 refer to the significances of the difference in the averages
of the pre-test versus post-test scores for Group 2 (the control group who received no
intervention) regarding their FBD Severity Index scores, depression scores and
anxiety
scores.
The
results
are
shown
in
the
Table
below.
108
Table 5.4
Significance of differences in the averages of the pre-test versus the post-test for Group 2 (the
control group; N=12) regarding their FBD Severity Indices, depression scores and anxiety
score s.
Variables
Pre intervention
scores for Group 2
8
SD
Post intervention
scores for Group 2
8
SD
Pre intervention
minus post
intervention for
Group 2
Mean
Standard
deviation
t
DF
variab
le
P value
IBS severity
168.42
26.0435
156.00
24.4800
12.4167
26.8581
1.601
11
0.138
Depression
66.2500
18.4101
65.3333
19.7638
0.9167
11.5559
0.275
11
0.789
Anxiety
66.5000
8.5334
66.9167
13.3924
-0.4167
11.7895
-1.22
11
0.905
* = Significant at 5% level
** = Significant at 1% level
109
According to Table 5.4 there are no statistically significant differences between
the pre-test versus the post-test scores for Group 2 (control group which received
no group intervention) regarding the IBS severity, depression and anxiety scores.
Therefore, the alternative composite hypothesis 4, as well as alternative composite
hypotheses 4.1 – 4.3, are rejected and the null hypotheses 4 are accepted.
5.5
CONCLUSION
The results presented in this chapter will be discussed in detail in Chapter Six.
In addition, the limitations of the study will be highlighted, the conclusions
drawn and the implications for advocating short-term holistic group intervention
to the wider population will be elucidated.
110
CHAPTER SIX
EVALUATIONS, RECOMMENDATIONS AND CONCLUSIONS
“When everything has its proper place in our mind, body and soul, we are
able to stand in equilibrium with the rest of the world.”
Henri Frédéric Amiel(1821 – 1881)
Swiss philosopher and poet (in Odhams Books, 1969).
6.1
INTRODUCTION
In this chapter, a discussion of the results (which have been tabulated in Chapter
Five) will be presented. This will be followed by an evaluation of the research study
with emphasis given to its limitations and strengths. Recommendations, with their
implications for future research and IBS intervention programmes will be discussed
and conclusions will be drawn.
6.2
DISCUSSION OF RESULTS
The holistic short-term group psychotherapy for subjects with severe IBS and
moderate to severe depression and anxiety was effective in reducing anxiety
statistically significantly. Depression scores were also significantly reduced for the
subjects within the experimental group, while severe IBS symptoms remained
unchanged.
The literature verifies the IBS severity scores remaining unchanged after
intervention. Drossman and Thompson (1992), Guthrie et al. (1991) and Dolan
(2000) state that subjects with intractable or severe IBS symptoms together with a
comorbid depression and anxiety may frequently be unresponsive to traditional
psychotherapy. The percentage of IBS subjects who fall into this category is
approximately 5% (Drossman & Thompson, 1992). Given that both Group 1 and
111
Group 2 had subjects with severe IBS and moderate to severe depression and
anxiety, it is not surprising that these IBS symptoms did not improve over a six week
period. Research has shown that these subjects often present with abnormal illness
behaviours (Drossman & Thompson, 1992) and neurotic traits (Stuart, Pretorius et
al., 1998, 1999). This means that they will generally have symptom constancy,
severe concomitant psychiatric disorders and their activity and daily functioning will
be severely disrupted. They may also be unresponsive to gut-directed
pharmacotherapy (Drossman & Thompson, 1992). In a similar vein, Lammert and
Ratner (1986) found that in their study of a self selected group of IBS subjects, 33%
of the subjects experienced an increase in IBS symptom severity post intervention.
Further speculation about the lack of IBS symptom severity change with intervention
could relate to the type of intervention being implemented. In this research study,
much of the psychoeducation was aimed at helping the subjects gain an
understanding of the anatomical and physiological underpinnings of IBS. With this
education, it is possible that a greater understanding of the syndrome led to a
heightened awareness and therefore a closer monitoring of the symptoms. Research
conducted by Creed and Guthrie (1989) with constipated IBS subjects has shown
that psychotherapy with this particular group of subjects needs to be continued for a
longer duration. A large proportion of this experimental group also reported
constipated patterns. Therefore a research intervention of a longer duration may be
required in order to alter severe IBS symptomatology. Furthermore, in this study,
resistant cases were selected for this sample as previous research offered little
positive outcomes for these subjects. Therefore, if in this study a positive result
could be obtained from this resistant group, it is suggested that less resistant IBS
subjects with a comorbid depression and anxiety could possibly benefit far more
from similar intervention programmes.
Due to the severe nature of IBS and depression in this sample, a longer duration of
psychotherapy with possible referral for psychopharmacotherapy as an adjunct,
would have been advisable. However, the intervention was successful in
112
significantly reducing the depression scores of the experimental subjects. This
contradicts Drossman and Thompsons’ (1992) findings that subjects with intractable
IBS symptoms with a comorbid depression do not usually respond to psychotherapy.
This has important implications for future IBS interventions. Similarly, anxiety was
also improved after the intervention for Group 1 (the experimental group). This also
contradicts Drossman and Thompsons’ (1992) findings that subjects with intractable
IBS and anxiety do not usually respond to psychotherapy.
The post-test scores for Group 2 (the control group who received no intervention)
showed that there was no significant change after being placed on a waiting list for
approximately six weeks. There were no spontaneous recoveries and it is feasible
that non specific factors such as expectancy, anticipation and increased negative
perceptions may have exacerbated negative outcomes.
6.3
EVALUATION OF THE RESEARCH STUDY
Kazdin (1980) and Talley, Owen, Boyce and Paterson (1996) propose a number of
factors that need consideration when assessing the strengths and limitations of a
design. These will now be discussed in the light of the present study.
6.3.1
Limitations of the study
Although every effort was made to ensure this study is methodologically sound,
there are inevitable flaws and shortfalls.
6.3.1.1
Recruitment of subjects and generalisation limitations
Although the subjects in this research project were matched on variables of gender,
age (females below 20 years were excluded), IBS severity, depression and anxiety,
the process of sample selection was rather diverse. The sample consisted of subjects
both referred to the Rand Afrikaans University’s Psychogastroenterology Clinic by
113
gastroenterologists, general practitioners, dieticians or were self- selected by
answering various advertisements in the press or magazines. This limits the
generalisability of these findings as only certain sectors of the population were
targeted according to where the advertisements were placed. Unfortunately, there
were no black respondents which limits these results to white subjects only.
It took approximately eight months and the exclusion of approximately 180
subjects to find 12 subjects who were suited, willing and committed to group
therapy. Another 12 subjects with similar criteria needed to be placed in the
control group on a waiting list. The sample size out of necessity was small but
adequate for research purposes of limited scope such as the present dissertation. This
difficulty in obtaining an adequate sample is not an uncommon finding as Lammert
and Ratner (1986) describe a more difficult scenario. They site having tested 290
IBS subjects in order to obtain a pilot group of eight IBS subjects. This is obviously
a costly and time-consuming exercise. As Yalom (1970) comments, group therapy is
perceived as being cost-effective but in reality it may prove otherwise. Furthermore,
it poses potential history and maturation problems when the control group is
introduced.
6.3.1.2
Randomisation
Bearing the recruitment issues involved in mind, the randomisation of subjects was
impossible. Subjects were, however, matched on gender, age and variables of IBS
symptom severity, depression and anxiety.
6.3.1.3
History and maturation variables
History and maturation variables may have distorted the post-test results of Group 1
(the experimental group) as the recruitment of suitable subjects for the experimental
group took approximately eight months. Recruitment of the control group required
114
less time as subjects were placed on the waiting list for individual therapy and
therefore did not need to be matched according to the most suitable group.
6.3.1.4
Sensitising effect of the pre -test
Sensitisation (Kazdin, 1980) implies that the intervention has its effect due to the
sensitising effect of the pre-test on the subjects. Due to the difficulty in recruiting
subjects, this effect is unlikely to have had much influence as there was a long
duration between recruiting the subjects and the group intervention itself.
6.3.1.5
The placebo effect
This placebo effect is described by Drossman (1996) as the decrease in IBS
symptoms as a result of the subjects’ admission to, or participation in the research
project. This is prior to the intervention. The placebo effect is unlikely in the present
study as IBS symptom severity was uncha nged. However, there was a significant
decrease in Group 1 (the experimental group’s) level of depression and anxiety
which Talley et al. (1996) believe may be due to the raised expectancy effect. An
example of the raised expectancy effect could be the subject’s conviction that the
treatment package would be successful. This can confound the therapeutic results.
6.3.1.6
Double blind experimentation
Psychological research has shown that it is unlikely that complete blinding of
subjects to groups, trial managers and trial evaluators is feasible. A further limitation
in this study is that the trial evaluator was known to the subjects within the
experimental group (Group 1), which limits the validity of the results.
115
6.3.1.7
The Personality Assessment Inventory
Unfortunately the PAI has not been standardised for use in South Africa. The test
was selected due to its applicability within a western society population. However,
due to the specific sample which was selected, the test was highly applicable as
subjects fell into the western society population group. Further research needs to be
conducted with respect to South Africa’s broader “rainbow nation”.
6.3.1.8
Short-term duration of group psychotherapy
A six week group therapy intervention lasting one and a half to two hours per
session per week was adequate for the improvement of depression and anxiety in the
IBS subjects. Fowlie et al. (1992), in their study of IBS, depression and anxiety,
found that if the symptoms of anxiety were reduced, these were often associated
with a reduction in IBS symptomatology. They did not, however, find a reduction in
the depression scores. In this current study the subjects’ IBS severity might also
have decreased if the group therapy had been of a slightly longer duration –
approximately eight to ten weeks with a long term follow up. This is suggested
because three years later the subjects in this study are subjectively finding an
improvement in their IBS symptoms. Furthermore, the benefits that the subjects
received in discussion with each other could have allowed for a few more sessions.
An eight to ten week holistic group intervention would accommodate most needs.
6.3.2
Strengths of the current research
6.3.2.1
Standardised IBS definition
Chapter Two discusses the Rome Criteria from which a standardised and working
definition of IBS was developed. This definition is accepted internationally.
Furthermore, the IBS Client Questionnaire was based on Drossman’s (1994) criteria
116
which provide an adequate IBS definition. This has been a limiting factor in much
other research.
6.3.2.2
Commitment to the intervention
Subjects who were chosen for the group therapy were well prepared and deeply
committed. Most were eager to get some help and gain understanding of the
syndrome.
6.3.2.3
A low drop-out rate
Only one subject dropped out of the experimental group programme after the first
week, as she fell pregnant and as a result felt she could not keep her commitment. A
substitute subject was selected in her place.
6.3.2.4
Appropriate control group
Individuals in the control group were placed on a “waiting list” after which they
could receive six free therapy sessions. Talley et al. (1996) describe this anticipatory
effect as a possible expectancy effect. However, the control group’s pre and post-test
scores were not significantly different therefore it can be assumed that the
expectancy effect was minimal. Kazdin (1980) stresses the importance of a control
group but warns that there may be a high drop-out rate. In the present study there
were no drop-outs in the control group.
6.3.2.5
The similarity of the experimental and control groups’ pre -test
scores
The similarity of the two groups regarding the variables prior to group interventions
strengthens the value of the study (as discussed in section 6.2). This reduces the
within- group variability (Kazdin, 1980) and allows the researcher to make specific
117
statements about the change. In this study, there were no differences in Group 1 (the
experimental group) and Group 2 (the control group) pre-test results.
6.3.2.6
Severe nature of IBS symptoms
The fact that the subjects who were recruited all had severe IBS set the standard for
this therapy at a much higher level. As has been discussed, Guthrie et al. (in
Drossman & Thompson, 1992) state that these “intractable” patients are usually
unresponsive to traditional psychotherapy. This finding has been discredited, as the
present research showed that even with intractable symptoms of IBS, depression and
anxiety there can be significant improvement, even if only in the depression and
anxiety scores. What has been of interest to note is that three years subsequent to the
completion of this study, many of the subjects in question have reported a marked
subjective improvement in their IBS severity. Perhaps this emphasises the need for a
long-term research project of a similar nature.
6.3.2.7
A South African based holistic group intervention
There have been many calls for group psychotherapy for IBS subjects (as discussed
in Chapter Three) and furthermore, this is the first known group therapy for IBS
subjects in South Africa. There is a dire need for further holistic group
psychotherapy for IBS subjects which addresses more than Drossman’s (1994)
biopsychosocial model, as it also taps into the subject’s or groups’ meaning system.
This allows for the forging of mind, body and soul links. Psychotherapy, if
attempting to view the whole person, needs to learn from its mistakes of the past and
embrace the whole person within their given context – intrapersonally and
interpersonally. This implies the need for holistic interventions. Furthermore, an
analysis of IBS across all the racial groups in South Africa is required in order to
facilitate more appropriate interventions for all people.
118
6.2.3.8
Therapeutic observation of the group process
The group process is difficult to evaluate quantitatively. However, some qualitative
observations of the intervention groups were made which will briefly be discussed.
Subjects were eager to be part of the group process as they sought to gain new
understanding of their own symptom complex. The group created an opportunity for
many subjects to cathart their deepest emotions, acknowledging those "split-off"
parts of themselves which had been repressed or shunned for so long. This openness
engendered much tolerance, support and trust between the subjects. New skills were
acquired through vicarious learning (Yalom, 1970) as subjects shared with each
other alternative methods of dealing with similar issues. A deep sense of
interpersonal learning (Yalom, 1970) evolved and as subjects observed others'
disabilities and heard their various obstacles which they had to overcome, they
began wondering if their own issues were really insoluble or whether they could
make different choices. Many humorous anecdotes were shared which often lent a
light- hearted perspective to the issues thus decreasing their anticipatory nxiety
(Frankl, 1970). The group cohesed (Yalom, 1970) and bonded in such a meaningful
way that much of it still exists today, some three years later. This is an example of
the "power" of the group which is difficult to quantify.
6.4
•
RECOMMENDATIONS
Unfortunately the sample that was selected was not representative of the
multicultures in South Africa. Therefore it is recommended that further group
research needs to be conducted within South Africa across multicultural
boundaries in order to be able to generalise the results to the wider community.
•
The benefits which a cohesed IBS group offer each other has been briefly
described above. There is much place for more contact groups of this nature
where mutual understanding, bonding, caring, learning of skills and making new
119
choices can occur. This needs to be developed despite the difficulty in recruiting
homogeneous groups for short to medium term group psychotherapy.
•
In the control group, three out of twelve subjects (or 25%) had learning
disorders. The only known study which broached part of this was Wender and
Kalm (1983) (in Wilson, 1997) who studied Attention Deficit Disorder (ADD) in
IBS subjects. Out of their IBS sample, 27% had ADD. It would be interesting to
research this variable in more detail.
•
Having been in contact with members of Group 1 (the experimental group – who
received intervention) three years later, there seems to be a tendency amongst
more than half of them that their IBS symptoms are less severe and more
manageable than previously described. These perceptions would require further
research.
•
There is a strong belief system in both the experimental and the control groups. It
would be interesting to explore the role of religion and IBS.
6.5
CONCLUSION
This chapter presented a discussion of the results of a short-term holistic group
intervention for the treatment of severe IBS with its comorbid depression and
anxiety. Furthermore, the benefits of the holistic group intervention together with the
limitations and strengths of the research design have been elucidated. The results
have indicated that short-term holistic group intervention is successful in
significantly decreasing the depression and anxiety scores, but not the IBS severity
scores. It is recommended that for refractory cases, the holistic group intervention
programme be extended to eight to ten weeks (with a duration of one and a half to
two hour sessions) as this could possible reduce IBS symptom severity.
120
In addition, when the subjects within the group can feel safe enough to begin
embracing the “split-off” or shadow parts of themselves and tolerate what has to be
faced, together with the range of feelings which erupt around that (Dowrick, 1997),
they can begin “tapping” into their own inner strength. It is then that language,
feelings and the awareness can begin to unmask the somatic symptoms that have
their roots in unspeakable dilemmas (Griffiths & Griffiths, 1994).
Furthermore, a classic psychosomatic disorder such as IBS essentially requires an
interdisciplinary team approach so that the multiple dimensions of the illness can be
holistically addressed. Much of the literature on IBS indicates that although the
general practitioners, gastroenterologists, psychiatrists and dietitians have done most
of the treatment this is gradually changing. Lynch and Zamble’s (1989, p.521)
sentiments are reflected below…
“… patients who are referred by general practitioners, or gastroenterologists, would
likely include the more persistent patients, those who are most annoying and
troublesome, those who have the most severe symptoms, those for whom traditional
medical treatment has failed and those who have more doubtful or difficult
diagnoses.”
It is with this common medical sentiment in mind that this thesis will be
concluded…
Not
only
are
psychologists
increasingly
being
consulted
regarding
the
psychosomatic disorders, but there is a growing consensus among the
multidisciplinary health-care team, that the psychologist is most appropriately placed
at the fulcrum of the client’s mind, body, soul axis (Stuart, Pretorius et al., 1998,
1999).
121
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Bennett, P & Wilkinson, S. (1985). A comparison of psychological and medical
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Berne, E (1964). Games People Play. The Psychology of Human Relationships.
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