Where Mental Health Meets Gastrointestinal Health

While doctor after doctor looked for a definitive diagnosis and solution, Knoepfle managed his symptoms the best he could. He avoided situations with seemingly problematic foods, or sometimes intentionally ate them because the day or two after an episode often offered a reprieve.

But over the years these challenges haven’t just taxed him physically. They have disrupted his life and isolated him from friends and family. Knoepfle’s attempts at symptom management were largely trial and error, often focused on eliminating various foods and trying to minimize stress.

Knoepfle isn’t alone in this experience living with chronic gastrointestinal challenges. For many patients like him, the disruption to life and lifestyle can be just as difficult as the physical pain and procedures. “It is so hard to see him get down on himself—he beats himself up because he can’t do certain things with me or the kids. He hates not knowing if he will be well enough,” says his wife, Jenny. “I really worried about his anxiety and depression caused by his GI issues.”

Resources and therapies to support patients like Knoepfle have been few and far between. But that could soon change, thanks to a burgeoning program at Dartmouth Health’s Dartmouth Hitchcock Medical Center
(DHMC) that addresses the mental and behavioral health aspects of chronic gastrointestinal conditions alongside medical treatments.

The new initiative, called the Gastrointestinal (GI) Behavioral Health Program, is led by clinical psychologist Jessica Salwen-Deremer, PhD, director of behavioral medicine at the Walter and Carole Young Center for Digestive Health and assistant professor of psychiatry and of medicine at Geisel School of Medicine, who Knoepfle has been working with for nearly eight years. Salwen-Deremer specializes in providing targeted mental health care to help GI patients navigate life with chronic, stigmatized health challenges, as well as behavioral health therapies that complement clinical care and improve patient outcomes.

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“She was the first therapist I had ever seen that understood GI issues,” Knoepfle says. “The mental impact of a chronic GI condition can be devastating, but at the same time, it is more within my control than my physical issues. Finding my therapist and putting in the work has given me tools to help me cope and live my life as fully as I can. She has been a life-saver in the truest sense of the word.”

Now with philanthropic support from LilaPants, a Knoepfle family business, Salwen-Deremer is building on her individual clinical work through the new program, developing a model for delivering this kind of care to patients around the country.

Expanding Access to Care

In her clinical practice, Salwen-Deremer had long felt there was more she could do for GI patients. “There’s a very limited number of GI psychologists in the country, and there’s a lot of patient need,” she says. She would try to see more patients by offering them just a few sessions. But it was long-term treatment that they really needed, and waitlists were still growing. By the time patients were seen, their symptoms had gotten worse, making treatment more difficult.

Three years ago, Salwen-Deremer said to herself, “Enough is enough,” and began developing group therapy approaches for GI patients.

She started by providing directed hypnotherapy in a virtual group therapy setting. This would retrain GI patients’ brains so that when their guts were doing normal, healthy things, like digesting food, their minds didn’t respond to the gurgling, for example, as if it was the same as the pain caused by their chronic conditions. Later, she launched more groups to provide other kinds of therapies and skill-building guidance, with the help of trainees embedded in her service at DHMC. In 2022, Salwen-Deremer received an award from the Susan and Richard Levy Health Care Delivery Incubator to formally develop and establish the GI Behavioral Health Program at DHMC, devising innovative workflows, content, and delivery mechanisms that improve access to care on a larger scale.

“That helped us with a lot of growth, and so it’s just been this steady improvement and increase of the ways that we can help people and the number of providers that we have,” she says.

Now, not only is Salwen-Deremer embedded in DHMC’s GI department, she is also accompanied by another full-time faculty member, a postdoctoral fellow, and an intern.

The program approaches patients with three different kinds of treatment: primary, complementary, and supportive. Primary treatment tackles the physical GI symptoms, using interventions like cognitive behavioral therapy (CBT) or gut-directed hypnotherapy to disrupt the gut-brain connection that normally primes the body for activities like eating and excreting. Complementary treatment targets psychological challenges that interfere with a patient’s ability to manage their disease, such as treating them for panic attacks that they might have whenever they set foot in a hospital. And supportive treatment addresses the complexities of living with a chronic disease, helping patients lead “a life you care about in the context of unpredictable pain or symptoms,” Salwen-Deremer explains. Most sessions are conducted virtually, expanding the reach of the program and allowing patients like Maryland-based Knoepfle to participate.

Paying it Forward

For Knoepfle, this kind of care is as vital as his medical care. Salwen-Deremer, he says, has been a critical part of his ability to navigate the tougher days. She helps Knoepfle strategize and prepare mentally ahead of difficult surgeries with long recovery times and holds him accountable for skill-building. And now, through the GI Behavioral Health Program, she encourages him to participate in group sessions, where he has tried new therapies and connected with others in similar situations.

“It can help make it a little more normal to realize, hey, I’m not the only one dealing with this,” Knoepfle says. “Even if they have a different diagnosis, they’re still struggling” with similar challenges and can talk about how it affects family, friends, and the ability to live a fulfilling life.

The gift from Knoepfle family business LilaPants is supporting the program expanding its therapeutic offerings, training more clinicians like Salwen-Deremer in GI psychology, streamlining access to the program, and supporting patients who may not be covered by insurance.

“If our donations can help anybody who is struggling, they’re worth their weight in gold,” Knoepfle says.

With this expanded support, Salwen-Deremer has already begun conducting trainings around the country about delivering behavioral health care to GI patients. “This is a very specialized subfield where we’re working with the direct GI condition and GI symptoms, and it takes a lot of additional training as a provider,” she says.

“We’re certainly leading the charge,” Salwen-Deremer adds, saying that she aims to deliver therapy and training that can be replicated or adapted to circumstances beyond other academic medical systems. “I don’t want to just be a model for how people in other ivory towers can operate. That’s good, but it also means that we’re only reaching the patients who have access to that type of care” due to insurance, location, or other factors.

Listen to Dr. Salwen-Deremer talk about how she is building new care models for patients with irritable bowel syndrome:

To learn more about the Gastrointestinal Behavioral Health Program, contact Matthew Hall at 603-653-0723 or Matthew.R.Hall@hitchcock.org.