Counseling Bariatric Surgery Patients

By Dan Orzech
Social Work Today
Vol. 5 No. 6 P. 24

More and more obese Americans are going under the knife to lose weight. Bariatric surgery—the medical
term for weight-loss surgery—is growing dramatically in popularity in the United States as increasing
numbers of people struggle to lose large amounts of weight.
Surgically shrinking the size of your stomach will definitely make you lose weight. But according to social
workers, doctors, and others who work with people who are significantly overweight, bariatric surgery
alone will not necessarily enable people to keep the weight off.
Nor will it necessarily make them happy. “We see a lot of clients who believe that all of their problems are
based on their weight, and that once they lose weight, their quality of life is going to improve,” says Julie
Latimer-Spears, LCSW, team leader of the obesity program at Resources for Living, an Austin, TX-based
behavioral wellness organization that works with weight-loss patients. “It’s a common misconception that
this is a magic bullet, that if they get the surgery everything is going to be better.”
While weight-loss surgery has been around for nearly 50 years, it only began to be accepted by the medical
mainstream in the late 1990s. Until then, says John Pilcher, MD, FACS, a bariatric surgeon in San Antonio
who does more than 150 weight-loss surgeries per year, “it was kind of like black magic.” Today, it’s a
well-accepted medical procedure.
The psychosocial issues surrounding the surgery, however, have not received the same amount of attention
as the medical aspects. “The emotional support issues and psychological aspects of the surgery have been
recognized,” says Pilcher, “but they haven’t been well addressed. There’s decent research on the surgical
techniques today, but there’s very little on the mental health aspects.”
An Epidemic of Obesity
The past 20 years have seen what the Centers for Disease Control and Prevention (CDC) call “a dramatic
increase” in obesity—what many health officials are starting to call an obesity epidemic. CDC research,
according to the nonprofit American Obesity Association, has found that some 9 million Americans, or
4.7% of the population, are morbidly obese. That’s jumped from 2.9% of the population in 1994.
Morbid obesity, also called clinically severe or extreme obesity, is defined as having a body mass index of
40 or more, which typically translates to 100 pounds or more of excess body weight. That much extra
weight increases the risk of a host of medical problems, including type 2 diabetes, breast, prostate and
colon cancer, gallbladder problems, sleep apnea, stroke, and heart disease.
In a society obsessed with being thin, people who are severely overweight are often socially stigmatized
and subject to discrimination in the workplace or school.
As surgeons have gained experience with techniques such as gastric bypass, which uses surgical staples to
shrink the stomach, or gastric banding, where the stomach is surrounded by a plastic band, and laparoscopic
surgery has minimized the size of the incision, more and more morbidly obese people have turned to
surgery to help them lose weight.
The number of weight-loss operations has grown dramatically, from roughly 18,000 per year a decade ago
to more than 170,000 today, according to the American Society for Bariatric Surgery.
The well-publicized bariatric surgery experiences of celebrities, such as singer Carnie Wilson and New
York City TV personality Al Roker have also helped make the procedure more popular.
But many weight-loss patients, according to experts in the field, are not prepared for the amount of work
involved in the process of losing weight after surgery, or for the changes that it may bring to their lives.
With gastric bypass—the most common surgical procedure—for example, “your stomach goes from the
size of a fist, to a little bit larger than a grape,” says Mary Beth Chalk, chief operating officer at Resources
for Living. “So your meals can never exceed 3 ounces at a sitting—the amount in one of those small plastic
containers of water with the peel-off top that the airlines give you. That means you have to eat six to eight
times a day.”
The surgery also bypasses part of the small intestine. “The purpose of the small intestine is to absorb
nutrition,” says Chalk, “so these patients face an ongoing challenge with getting the nutrients they need,
and they have to pay close attention to their nutritional supplement program.”
The result, says Chalk, is that “in short order, they have fairly complex lifestyle issues that they have to
manage.”
Losing Half Your Weight
That’s not all they have to contend with. “Bariatric surgery patients find themselves having to deal with the
sea change that happens in their life as they lose half of their weight, or half of themselves,” says Pilcher.
“Their whole relationship with food changes, as do their relationships with spouses or partners, their
family, and their coworkers.”
In the first year after surgery, Pilcher says, patients often find themselves “trying to figure out who this new
and different person is that they see in the mirror. Adjusting their self-image is not easy. They know they’re
wearing different clothes, and the number on the scale is different but, if they close their eyes, patients tell
us that they still picture themselves as fat.”
The divorce rate after weight-loss surgery is extremely high, according to Pilcher. So is the rate of job
change.
That’s not always a bad thing. Morbidly obese people, subject to a lifetime of discrimination, often come to
feel helpless and accept situations others would not, says Pilcher. “Many patients, through the weight loss,
become empowered to get themselves out of situations—work or marriage—that were bad,” he says.
Not everyone is affected in the same way, however. “If a patient in a long-term marriage was a normal
weight when the marriage began,” Pilcher says, “that marriage is probably in pretty good shape to
withstand the changes following surgery. If the patient was heavy at the time the marriage or the
relationship began, however, there’s an 80% to 85% chance that that relationship is going to break up
within two years of surgery.
“It may be that the patient’s partner becomes nervous because the patient becomes more attractive. It may
be that there’s an abusive relationship going on, and the patient won’t tolerate it anymore. Or they might
just decide that there are better options out there.”
The sudden discovery of many new options for relationships can be a challenge for some patients.
“Promiscuity becomes a problem with some people, especially those who were overweight younger,” says
Vickie Norrod, MFT, a marriage and family therapist in New Hampshire who has worked with bariatric
surgery patients. “If they were obese during the years that they should have been developing a sense of
themselves as a male or female and a sexual being, much of that development got sidelined.”
Defining Success
Whether patients get help dealing with these changes can be hit or miss. While there’s a growing awareness
of the importance of the psychosocial aspects of bariatric surgery, says Chalk, “there’s not a lot of
consistency across programs, and there’s not a lot of information out there about what constitutes best
practices.”
Psychiatric evaluations before surgery are common, says Chalk. Beyond that, programs range from no
psychosocial support at all to interventions that begin three to six months prior to surgery and then continue
as much as a year or more of postsurgery support.
At the hospital in San Antonio where Pilcher operates, for example, psychiatric nurses and clinical nurse
specialists provided mental health support for bariatric surgery patients for a period of time. Since those
services were not covered by insurance, however, the hospital eventually reassigned the nurses to other
duties. Now, Pilcher’s patients can attend a variety of support groups—if they pay cash out of pocket. “We
see the need for more support than we currently are able to provide,” Pilcher says.
One reason patients are not getting that support may be the relatively narrow definition of success the
medical community applies in evaluating bariatric surgery.
The generally accepted medical definition of the success of a bariatric operation, according to Pilcher, is
whether a patient loses one half of his or her excess weight and keeps it off for five years. By that
definition, the national success rates for bariatric surgery are in the 80% to 85% range, Pilcher says, “even
without much psychological support.”
From a medical standpoint, it makes sense to call losing 100 or more pounds a success. When you get
people to lose that much weight, says Pilcher, “you’ve made a very substantial lifetime impact on the
medical comorbidities. Diabetes, high blood pressure, sleep apnea, and joint pain all tend to improve
dramatically with 50% excess weight loss.”
But most surgeons, and most patients, would probably agree with Pilcher that this is not a fully adequate
definition of success.
Take a patient who weighed 350 pounds before surgery, for example, and who’s lost 120 pounds thanks to
the operation. If she’s 5’6” and in her mid-40s, her ideal weight may be 150 pounds, says Pilcher, so she’s
lost more than one-half of her 200 pounds of excess weight.
But now, her goals may have changed. “When she weighed 350,” says Pilcher, “she may have told me ‘all I
want to do is get rid of my diabetes medicines.’ And she meant it. But now, she sees a normal self within
reach, but she’s not there. That’s where the psychological support becomes essential.”
That’s because gastric bypass surgery will generally cause patients to lose 100 to 175 pounds in the first 12
to 18 months after surgery, “pretty much no matter what the patient does,” he says.
Getting Help
What happens after that, says Pilcher, “really depends much more on the patient than the surgical
procedure.” To maintain their weight loss, or to continue to lose, patients must make significant changes in
what and how they eat and how much they exercise. For people who have been hundreds of pounds
overweight, that almost inevitably involves significant lifestyle changes, says Susan Crum, LCSW, service
delivery manager, health and wellness division at Resources for Living.
Many people have a tendency to use food to manage stress or deal with feelings such as sadness or
boredom, she says. “A huge piece of the psychosocial work is just acknowledging what you’re using food
for.”
Beginning these lifestyle changes early is key. “The stomach can eventually stretch after surgery, so it’s
important to start working with patients long before the surgery to help them establish these behavior
changes ahead of time,” Crum says. “Most bariatric surgeons like to see some successful weight loss before
they conduct the surgery.”
Making the necessary lifestyle changes around food can involve every arena of patients’ lives, including
how they relate to other people. Dealing with relationships is “a huge piece” of the work that patients must
do after the surgery, according to Norrod. “If the way you relate to your friends is to go out every
Wednesday for dinner, you’re going to have to find other ways to maintain your friendships. And what do
you do if the only way Aunt Mary knows to tell you she loves you is to bring you your favorite pie—and
you have to say, ‘I can’t have that any more?’”
Our culture, says Norrod, “has a huge emphasis on celebration through eating and nurturing through eating.
It’s how you say, ‘I love you, I care for you, you’ll feel better.’”
In the bariatric surgery support groups Norrod has led, “the patients spent a lot of time trying to come up
with their own ideas about how they could celebrate and nurture themselves and each other—in ways that
didn’t involve food,” she says.
The most successful patients in Norrod’s groups were those who were able to make changes in their lives
and who were realistic about the impact of the surgery. They recognized, she says, “that you can go in and
cut out a piece of your body, and it will have an impact on your weight, but the majority of your life is
going to stay the same. You don’t cut out your mother-in-law or your ex-husband or your boss. You don’t
cut out life’s problems.”
— Dan Orzech is a Philadelphia-based freelance writer.