Mental Health Preparedness

Bariatric Surgery: Mental Health Preparedness is Important

March 11, 2019

The decision to undergo weight loss surgery offers individuals an opportunity to improve both their physical and emotional well-being. Obesity is a complex, multifactorial disease that has both physical and emotional impacts.  When deciding to undergo surgery, individuals need to be aware of the psychological effects that surgery brings and how to best prepare for a positive and successful post-operative course.

The success of patients' emotional, social, and physical adjustments are achieved through education and understanding of not only the physical changes but also the impact on one's mental health.

Bariatric Surgery Mental Health Preparedness

The following are areas that clinicians most often see impacting patients as they move through their weight loss journey.

BODY IMAGE:  One of the underlying reasons that patients seek weight loss surgery is the result of a negative body image which so many overweight individuals hold true about themselves. The media has bated the hook, and many overweight individuals now hold themselves to an unrealistic standard which for most of us, is not attainable.

Although the literature suggests that individuals who have had weight loss surgery experience an improved overall self-image, it is important for the patient to be aware that both counseling and education can be crucial to post-operative adjustment. It is important that patients set realistic expectations and overall emotional grounding.  It is common that even after extreme weight loss, patients can still look in the mirror and view themselves as overweight.

We recommend that patients save one piece of clothing of meaning to hold up in a mirror to help their minds adjust to their new physical self.

Also, patients can take a photo each month and create a journal as they lose weight. This will provide a visual track of the changes over time. Weight loss can be rapid after surgery, and the psychological internalization of these changes take time to catch up to the physical changes that occur postoperatively.

EXPECTATIONS:  Weight loss surgery patients begin their journey with a result in mind. Patients will have a vision of how they will look, be received, and how life will ultimately feel. The goal of the weight loss surgery team is to help individuals gauge those expectations realistically and help them to have a solid understanding of what the post-operative course will be like.

It is important for patients to know that this is a process that is ever changing both pre and post-operatively. It will take time to adjust to your new life and learn how to navigate the changes you will experience both physically and emotionally.

It is important to monitor how the patient is feeling. Make sure to reach out for help in managing expectations and any issues that may arise with a counselor who can help you navigate the challenges you may face.

Taking the time to reflect on the decision to have surgery is important before starting the journey to weight loss. Support groups can help patients to process and reflect, providing assistance to individuals in the decision-making stage as help to set expectations realistically.

TRANSFER ADDICTION:  Food addiction, eating disorders and disordered eating patterns are all issues that many weight loss surgery patients have to deal with or continue to deal with. For many people, eating has become a way to deal with emotions. When weight loss surgery patients are unable to eat in the way that they are most comfortable and familiar, new maladaptive behaviors can arise.  There is a psychological component to eating that can often drive people to indulge as a way to feel happy, satisfied, loved, less stressed, less lonely, etc.

It is important for patients to know that when food is no longer a place for them to turn to as a way to achieve positive feelings, other focuses can arise that can be just as destructive in an individual's life.

Alcohol, gambling, and excessive shopping are often turned to if the underlying emotional and behavioral problem with food has not been addressed. It is for this reason that a thorough psychosocial screening is done before surgery. This assessment includes a look at a patient's family history of addiction as a potential contributor to the transfer of addiction in a patient's clinical presentation post-operatively.

If indicated, counseling and support groups should be accessed as a way of processing and addressing an individuals emotions and behaviors which resulted in disorder eating patterns to arise. It is through counseling that a patient can gain the skills needed to find alternative behavioral and cognitive strategies for dealing with stress and emotions in a constructive way with positive outcomes.

DEPRESSION AND ANXIETY:  Depression and anxiety are the human conditions that at some point we all experience.  Some level of depression or anxiety may have a little to an extreme impact on daily functioning. Many life circumstances can be challenging such as finances, family, work, illness, etc.

Although depression and anxiety are typically not barriers to a patient being an appropriate candidate for weight loss surgery, like any condition, these need to be managed pre-operatively. Patients need to have demonstrated stability prior to moving forward with surgery.

For the weight loss surgery patient, it is important to be aware of any depression or anxiety related symptoms that they may be experiencing while being evaluated for surgery as well as after surgery. Without support and counseling to address emotions that arise, it is not uncommon for patients to find it difficult to make the dietary and activity changes necessary to achieve their goals.

Without effective alternative behavioral and coping strategies, patients will often return to food as a way to find a place of comfort and familiarity and to push down negative emotions.

For this reason, it is important for patients to be aware of how they are feeling, and the potential impact feelings have on the ability to make changes to reach one's goals. Psychological counseling, and in some cases psychiatric medications, are needed to manage any presenting symptoms and will aide instability needed to move forward with surgery.

ALCOHOL:  Alcohol is consumed and influenced by cultural or societal norms. While alcohol is enjoyed by most adults, it presents a risk factor to weight loss surgery patients in several different ways. It is understood by bariatric clinicians that the development of a new onset of alcohol use disorder or of relapsing after a period of control is a possible risk associated with weight loss surgery.

This is both a behavioral and metabolic issue as patients can experience changes with regard to how alcohol is absorbed post-operatively. There is an increased sensitivity to the effects of alcohol: alcohol absorption is accelerated, the effects of alcohol can last in the body longer in the body, it takes longer for the alcohol to be eliminated, and some patients report that they have poor control over their drinking.

In addition, alcohol can create weight gain, liver issues, and potentially alcoholism if abused.

It is important for the weight loss surgery patient to be aware of the ways that alcohol can react in their bodies and be alert to any problems that may arise when drinking alcohol. Counseling and support may be needed to assist a patient if symptoms of abuse or dependency are present.

SUPPORT:  For both the pre and post-operative weight loss surgery patient it is important that they surround themselves with a variety of support options be it family, friends, professionals or fellow patients.

Support is at the core of patient success and whether it is family or a medical team member, one will need to identify a support system during the weight loss journey.

Having a supportive influence in one's life can help if challenges occur and it has been known to improve patient outcomes in relation to overall weight loss. Support groups are a way to engage with others. In a support group, patients are able to share their mutual experiences. When patients attend a support group meeting that is facilitated by a licensed provider, they will be able to ask questions and obtain direction from the professional.

Support groups can be designed as a safe space with more of an open forum or can be topic driven to have a psychoeducational focus. Without exception, there will be times when patients need encouragement, advice and an active listener to process their thoughts and feelings. It is beneficial to have this support system identified by attending an information session, an appointment, or read various literature provided in a patients' workbook. The more that this supported member is aware of the journey both pre and post-operatively, the more engaged they will be in providing the support that is needed.

The Take-Away for Bariatric Surgery Patients

In conclusion, psychological preparation, education, and support will aid in a patient's long-term success. The surgery is the tool for patients to use but the preparation, with the support of the multidisciplinary team, can help patients achieve maintained weight loss.

Many weight loss surgery patients have dieted throughout their lives,  losing and regaining weight. The decision to have surgery is complex in that patients need to have embraced how to develop a healthy long-term relationship with food.

It is essential to take time to prepare for surgery and to be mindful of the appropriate time to have surgery. Surgery cannot be rushed and the time spent selecting an appropriate time in life, where stressors and major life events are managed, will be advantageous long term.

Angela Fenton

ABOUT THE AUTHOR

Angela Fenton, MA, LMHC is Interim Senior Director of Clinical Integration and Director of Operations Center for Specialty Care & Bariatric Surgery Program at Beth Israel Deaconess Medical Center. She received her Dual Masters in Mental Health & Behavioral Medicine from Boston University School of Medicine. She is a member of the American Society for Metabolic and bariatric Surgery and has performed pschological assessment for bariatric surgery patients since 2004.
Sue Walker

ABOUT THE AUTHOR

Sue Walker, LICSW, MSW received her BA from American University in 1986 and her Masters in Social Work at Rutgers University in 1989. Mrs. Walker has spent the last 11 years as the social worker for the Bariatric surgical program at The Beth Israel Deaconess Medical Center in Boston and the last 5 years as the Social Worker for the Bariatric Surgical program in Milton Massachusetts. Mrs. Walker received her LICSW in 1991 and has worked in a variety of Medical institutions throughout New England over the last 30 years.