The Treatment Nobody Offered You
Dr. Rick's Picks, Issue 003: one practice, one paper, one product, one person
A weekly read on the gut, the brain, and the wiring in between. One clinical pearl, one paper, one product, one person.
1. Practice
The treatment with some of the best evidence in IBS, and the reason almost nobody is offered it.
Start with the sentence that ends most of these appointments: "there's nothing wrong, it's probably stress." Patients hear an accusation. They hear that the pain is invented, that they are the problem, and that the visit is over.
The anatomy in that sentence is wrong, and getting it right is the most useful thing I can hand you this week.
Your gut is always talking. Stretch, pressure, acid, the ordinary mechanics of a meal moving through, all of it generates signal traveling up to the brain constantly. Almost none of it reaches awareness, because the brain sets the gain. Think of a volume knob sitting between the gut and consciousness. In disorders of gut-brain interaction, the umbrella term Rome V uses for IBS, functional dyspepsia and their relatives, that knob is turned up. Normal signals arrive loud. The pain is entirely real, it is being generated by real nerves carrying real traffic, and the amplification is the pathology.
Which means there are two ends to treat. You can work on the gut, which is what diet and most drugs do. Or you can work on the amplifier.
Gut-directed hypnotherapy is the best-studied way of working on the amplifier, and the name does it no favors. This is not stage hypnosis, and nobody is unconscious or suggestible in the way the word implies. It is a structured protocol, roughly fifteen minutes a day for six to twelve weeks, of focused attention and specific suggestion aimed at gut sensation. Same category as the breathing protocol a cardiac rehab program teaches. Boring, repetitive, and effective.
How effective is the part that surprises people. In a head-to-head trial from Monash, gut-directed hypnotherapy performed about as well as the low FODMAP diet for gastrointestinal symptoms, and better on the psychological measures, with the benefit holding at six months. The low FODMAP diet is the most famous dietary intervention in gastroenterology. Hypnotherapy matched it, without asking anyone to eliminate a food group.
Two honest caveats, because this is where enthusiasm usually outruns the data. You cannot blind a patient to whether they received hypnotherapy, so expectation is baked into these effect sizes in a way it is not for a drug trial with a matching placebo capsule. And the trials are mostly modest in size. This is good evidence for a symptom-based condition. It is not the same grade of evidence as a large cardiovascular endpoint trial, and anyone selling it that way is selling.
So why has almost nobody reading this been offered it?
Not because of the evidence. Because of arithmetic. The clinicians formally trained to deliver these therapies are called GI psychologists, and estimates put the worldwide number in the low hundreds. Millions of patients, a few hundred providers. There is no version of that math where referral is the answer. The treatment is not being withheld out of skepticism. It mostly does not exist within driving distance.
That gap is why Rome V, published this year, did something quietly significant. Its stepwise model for psychosocial care places digital, self-directed brain-gut behavioral therapy at Level 2, sitting between the education a physician gives in the room and the personalized therapy of a specialist you probably cannot find. Not a consolation prize. A recognized tier of care. An app is now a legitimate answer to a real access problem, which brings us to the product pick.
2. Publication
One paper worth reading, in three sentences.
The Rome V biopsychosocial chapter (Elsenbruch et al., Gastroenterology 2026;170:1205-1223) lays out the stepwise model for psychosocial care in DGBI and is the document that formally elevates app-delivered behavioral therapy to a recognized tier. The line I keep returning to is its treatment of resilience, which it describes as the ability to cope with and respond positively to stress, and which it associates with lower symptom severity and better quality of life, with the recommendation that clinicians ask about it early. That is a guideline telling physicians to inquire about a patient's capacity to recover, not just their capacity to hurt, and I think it is the most quietly radical sentence in the chapter.
3. Product
This week's pick: Nerva, an app-delivered gut-directed hypnotherapy program. Unsponsored, no affiliate relationship, and deliberately not a BellyMD product.
Nerva is a self-paced six-week program built on the Monash protocol, the same lineage as the trial above, running about fifteen minutes a day. A randomized trial published last year in the American Journal of Gastroenterology compared it against an active control rather than a do-nothing group, which is the harder and more honest comparison, and found meaningful improvement in symptom severity, abdominal pain and anxiety.
Two things to know before you decide. It is a subscription, so check the current price yourself and treat it like any other recurring cost. And there is a prescription alternative worth asking your physician about: Mahana's program, authorized by the FDA in 2020 as the first prescription digital therapeutic for IBS, delivering cognitive behavioral therapy rather than hypnotherapy on the back of a 558-patient trial. Different technique, same target, and it may be covered when a consumer subscription is not. The two companies have since combined, which is worth knowing so you understand they are not fully independent options.
Neither one is a cure, and neither one is a reason to skip a workup you have not had. What they are is the first genuinely accessible version of a treatment that has been sitting in the literature for thirty years while almost nobody could get to it.
4. Person
One person worth following in this space.
Laurie Keefer, PhD, a clinical health psychologist at the Icahn School of Medicine at Mount Sinai, where she directs psychobehavioral research in the Division of Gastroenterology. She describes herself as a GI psychologist, which is roughly the point, because she is one of the people who built that job into a real thing with a name and a training pathway. She led the Rome Foundation working team report that gave brain-gut behavior therapies their shared vocabulary, and her research program centers on resilience and self-regulation as treatment targets rather than as personality traits you either have or you do not.
If this issue landed, her work is where the field's actual thinking lives, and she is considerably easier to read than most people at her level.
That's the four. See you next week.
Rick
From BellyMD
I build MGB+, a small supplement line for gut-brain support: Clear, Cool, and Calm, each a magnesium and B-vitamin based formula meant to support the gut-brain axis as part of a broader routine. Structure-function support, not a treatment for any disease. If that is relevant to you, it lives at belly-md.com.
If you want to talk through your own gut-brain picture with me directly, I offer a gut-brain consultation (educational, 500 dollars). Details at belly-md.com.
Not medical advice. This newsletter is for education and does not create a physician-patient relationship. Nothing here is a diagnosis or a prescription. Talk to your own physician before starting, stopping, or combining any medication or supplement, including over-the-counter ones.