Dr. Lela Altman is a naturopathic doctor who alleviated symptoms and expanded the ultra-restrictive diet of a complex senior patient with SIBO, drastically improving her quality of life through gut-directed hypnotherapy. This case study details Dr. Altman’s approach over a two-year period.
Case Study Overview
- Patient presented with what appeared to be SIBO and had previously tried a range of dietary interventions.
- Dr. Altman trials every treatment, test, diet, and management plan herself before she recommends anything to a patient. While costly, she says this successfully secures adherence to her treatment plans and builds invaluable trust with her patients, leading to better outcomes.
- Dr. Altman consistently checks in with her patients via messaging. This has helped her patients stay on track and continue following her treatment recommendations in between appointments
- The patient in this case study completed the Nerva program and was highly motivated. Dr. Altman still checked in with her in Week 3 (the halfway point) to ensure she was on track to complete the full six weeks and motivate her to continue following the process, knowing that most patients don’t see positive changes until around Week 4.
Presenting with a 40-year history of pain
Violet* suffered from poor gut health since she visited Nepal in her 40s. Now in her 80s, she met with Dr. Altman to manage her most recent symptoms and hoped to expand her diet beyond the handful of foods she could tolerate. While Dr. Altman initially thought Violet was going to be a straightforward SIBO case, it took two years of trial and error before gut-directed hypnotherapy turned Violet’s life around.
“Violet first came to see me in early 2020. She traveled through Nepal in 1983, and since then, she experienced ongoing diarrhea and abdominal pain.
“Then, two years before we met, she started experiencing problematic bloating, nausea, belching, and gas. She also had fatigue, some intermittent joint pain, and she’d been diagnosed with SIBO.”
Unlike many Nerva patients, anxiety and depression weren’t a significant part of Violet’s presentation to Dr. Altman.
“She’s a pretty even-keeled person and emotionally solid. She was frustrated with her symptoms for sure, but she wasn’t experiencing depression.
“Over the past 40 years, she had seen a range of doctors and a gastroenterologist and had had an endoscopy and a colonoscopy. I wasn’t worried at this point that we were missing something big, and it felt like something more concerning would’ve been caught by now. So, I assumed it would be a straightforward SIBO case—which it absolutely wasn’t.”
Challenging dietary restrictions
Violet’s diet was extremely restrictive after suffering from symptoms for so long, and she had tried a range of dietary therapies and interventions over the years.
“She’d cut out many foods to try to manage her symptoms, including all gluten, dairy, and nightshade fruits and most vegetables. Until she started Nerva, she ate about five foods, that was it, that was what she stuck to consistently.
“Recently, she had a major flare-up, that I managed as a mast cell activation, after eating out at a restaurant. So, it hasn’t been easy for her. Mentally she thought to herself, ‘It is what it is’, but that didn’t mean she liked it.
“It’s particularly hard as she lives in a retirement community and had to arrange for special dinners to be made for her with no dairy and gluten, all of her vegetables had to be steamed with no additives, and no onion or garlic. Everything else she made herself and kept it very simple.”
Implementing a plan
After their first appointment, Dr. Altman spent the next two years trying to help Violet through various approaches.
“At the start I thought it probably is SIBO, and there’s a post-infection autoimmune component there too. So, that was my first approach—I treated her for SIBO. She took antibiotics, probiotics, and herbs, and I got her to try the elemental diet.
“She did some of these things multiple times, but she didn’t get better. She had a bit of relief here and there from diarrhea and abdominal pain, but very little, and that was about it.
“I started thinking it was intestinal fungal overgrowth and treated with statin and antifungals, but still there was no improvement. I moved on to mast cell activation, and she started taking quercetin, which she saw the most improvement from and that worked better than everything else.
“For her diet, she tried both a low FODMAP and histamine diet. She did an ALCAT (Antigen Leukocyte Cellular Antibody Test) to check her food intolerances and to see if something in her already extremely limited diet was triggering her.”
Violet being such a poor responder to all of these approaches was frustrating and disappointing for Dr. Altman, who cares deeply about helping her patients improve their quality of life.
“I was out of ideas,” Dr. Altman admits. “I’m an attending physician at a teaching clinic, and I remember seeing Violet and then telling my students afterward, ‘I don’t have anything left’, which is really saying something! I’d tried all the herbs, combo products, everything.
“That’s when I finally thought of Nerva. Honestly, it felt like I was grasping at straws by this stage but I didn’t know what else to do.”
Responding positively to gut-directed hypnotherapy
Once Violet started Nerva, Dr. Altman felt like she’d finally turned a corner after two years of trial and error, and for Violet, over 40 years of symptoms.
“Lo and behold, she did Nerva paired with a new probiotic and she came back to me and finally told me something was working.
“I checked in with her during Week 3 of the program and she told me she had started reintroducing foods into her diet that she previously couldn’t tolerate and just felt better overall. She said her gas and bloating (her main complaints) had reduced, though she still had some nausea with particular foods.
“While she was on a new probiotic at the same time she started gut-directed hypnotherapy, she and I still think most of the changes were from Nerva as she’d tried probiotics in the past and didn’t see any improvements.
“She made it all the way through the six weeks, started the Maintenance plan immediately after, and continues to listen to sessions about twice a week.”
Managing patient setbacks
Happily, Violet experienced few setbacks after she began following the Nerva program diligently.
“Unfortunately, she did experience a symptom she described as burning fire mouth that flared up after she went out to eat. It turned out to be a mast cell activation and I treated it with antihistamines. It wasn’t the same GI complaints though.
"Nevertheless, after this setback, she started following the Nerva program again all the way through for the second time.
“Now, I haven’t seen her in months, which is a good sign! Before that, I saw her every few weeks. But I still message her just to check in.”
Achieving program adherence
While asking a patient to commit to daily hypnotherapy for six weeks can be challenging for some, Dr. Altman has successfully managed to keep all of her patients prescribed to Nerva on track through to the end.
“Like most of my patients, Violet had no problem sticking with it. Though I do have one challenging patient who likes to tell me in every appointment how much she doesn’t like Nerva, but at the same time she is still up to Week 5. I haven’t had a problem with anyone else.”
Dr. Altman’s strength as a practitioner who secures strong adherence to her treatment plans stems from her communication practices.
“I think it’s because I am in frequent contact with my patients via messaging. Even though I’m booked out and I might not be able to see a patient for three months, I always encourage my patients to reach out to me via a message if they have any questions or need help with complications that have come up. And then I do something about it.
“I think problems are more likely to come up if I were hands-off and told my patients, ‘Do this for the next three months and we’ll speak after that’. It wouldn’t work as well if that was my approach.
“I just sent Violet a check-in message recently. It was simply, ‘Hi, I haven’t seen you in a few months, how are you doing?’. This sort of communication really keeps them engaged.
“The other way I keep patients like Violet committed to the Nerva program or whatever I’m recommending is I have them decide what to do. I’m never in favor of, ‘I’m the doctor, and here’s what you’re going to do.’ Instead, I phrase it as, ‘We have three options, here’s the pros and cons and financial costs of each, and here’s how long each option is likely to take. What do you want to do?’ It’s always their choice.”
Supporting complex patients
Dr. Altman’s support is in high demand, but as a naturopathic doctor, most of her patients have already seen many clinicians before they come to her.
“I was the 61st doctor one of my patients had tried!”, Dr. Altman said. “I have a long wait list, but my patient population is a desperate population. All of them, including Violet, are complex, and I specialize in that multi-system disease state.
“I still have patients coming to me saying they don’t believe in naturopathic medicine and have told me, ‘I’d never be here seeing you if you weren’t my last choice’. These are the people I usually help the most!
“But I used to work at a hospital and I get a lot of referrals from gastroenterologists. Often they tell me they’ve done all the testing and thrown their hands in the air. They don’t know what’s wrong and nothing they’ve tried has worked—that’s when their patients find me.”
Trialing everything herself
Dr. Altman’s unique approach to patient care extends to trialing every treatment, test, medication, or management plan herself before she recommends or refers it to others.
“I do everything first before I ask a patient to try something, unless it’s a medication I shouldn’t take for my body. But I like to experience it all myself and be able to tell patients what they should expect.
"I admit, it can get expensive—and extreme! Just this week I paid about $1,000 for a cancer screening test that wasn’t covered by insurance because a patient wanted to try it.
“It’s a great way to build trust as patients can say to themselves, ‘Well, if Dr. Altman tried it, it must be safe and effective if she’s telling me to do it too’.
“This means I’ve followed the Nerva program for the full six weeks myself, I’ve taken antibiotics, I’ve followed an elemental diet—anything I’ve asked my patients to do. Though it helps that my specialty areas are about treating conditions I have myself.
“So, walking my patients through Nerva and knowing exactly what I’m recommending has been very helpful. I tell them it’s an app on your phone and explain what it will look like. I say it’s going to take you about 15 minutes, maybe 20, you have to do a bit of reading, and the hypnotherapy scripts will start to repeat. Having done Nerva myself, I can really answer people’s questions, instead of saying, ‘You should try this gut-directed hypnotherapy thing’ and not know anything about it.”
Dr. Lela Altman is a naturopathic physician based in Seattle, USA. She is a Fellow of the American Board of Naturopathic Gastroenterology, a licensed acupuncturist, and an Associate Professor at Bastyr University. She received her Doctorate in Naturopathic Medicine and her Masters of Science in Acupuncture from Bastyr University in 2011. She went on to complete a three-year residency at the Bastyr Center for Natural Health in Naturopathic Primary Care, prior to becoming an adjunct professor and now a full-time Associate Professor at Bastyr University.
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