Preparing for Weight Loss Surgery: Therapist Guide (Treatments That Work)

Preparing for Weight Loss Surgery: Therapist Guide

Robin F. Apple James Lock Rebecka Peebles

OXFORD UNIVERSITY PRESS

Preparing for Weight Loss Surgery

-- David H. Barlow, PhD    Anne Marie Albano, PhD Jack M. Gorman, MD Peter E. Nathan, PhD Bonnie Spring, PhD Paul Salkovskis, PhD G. Terence Wilson, PhD John R. Weisz, PhD

Preparing for Weight Loss Surgery T h e r a p i s t

G u i d e

Robin F. Apple • James Lock • Rebecka Peebles

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1 Oxford University Press, Inc., publishes works that further Oxford University’s objective of excellence in research, scholarship, and education. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam

Copyright ©  by Oxford University Press, Inc. Published by Oxford University Press, Inc.  Madison Avenue, New York, New York  www.oup.com Oxford is a registered trademark of Oxford University Press All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Oxford University Press. Library of Congress Cataloging-in-Publication Data Apple, Robin F. (Robin Faye) Preparing for weight loss surgery : therapist guide / Robin F. Apple, James Lock, and Rebecka Peebles. p. cm.—(Treatments that work) Includes bibliographical references. ISBN- ----; ---- (pbk.) ISBN ---; --- (pbk.) . Obesity—Surgery. . Weight loss. I. Lock, James. II. Peebles, Rebecka. III. Title. IV. Series. RD.A  .'3—dc 

         Printed in the United States of America on acid-free paper

About TreatmentsThatWork™

Stunning developments in health care have taken place over the last several years, but many of our widely accepted interventions and strategies in mental health and behavioral medicine have been brought into question by research evidence as not only lacking benefit but, perhaps, inducing harm. Other strategies have been proven effective using the best current standards of evidence, resulting in broad-based recommendations to make these practices more available to the public. Several recent developments are behind this revolution. First, we have arrived at a much deeper understanding of pathology, both psychological and physical, which has led to the development of new, more precisely targeted interventions. Second, our research methodologies have improved substantially, such that we have reduced threats to internal and external validity, making the outcomes more directly applicable to clinical situations. Third, governments around the world and health care systems and policymakers have decided that the quality of care should improve, that it should be evidence based, and that it is in the public’s interest to ensure that this happens (Barlow, ; Institute of Medicine, ). Of course, the major stumbling block for clinicians everywhere is the accessibility of newly developed evidence-based psychological interventions. Workshops and books can go only so far in acquainting responsible and conscientious practitioners with the latest behavioral health care practices and their applicability to individual patients. This new series, TreatmentsThatWork™, is devoted to communicating these exciting new interventions to clinicians on the front lines of practice. The manuals and workbooks in this series contain step-by-step detailed procedures for assessing and treating specific problems and diagnoses. But this series also goes beyond the books and manuals by providing an-

cillary materials that will approximate the supervisory process in assisting practitioners in the implementation of these procedures in their practice. In our emerging health care system, the growing consensus is that evidencebased practice offers the most responsible course of action for the health professional. All behavioral health care clinicians deeply desire to provide the best possible care for their patients. In this series, our aim is to close the dissemination and information gap and make that possible. This therapist guide and companion workbook for clients addresses psychological and behavioral aspects of weight loss surgery for the morbidly obese. This approach has been shown to be highly effective as a treatment of last resort for substantially obese individuals who are subject to the dramatically increased risk factors to health associated with this condition. And indeed, the rapid growth of obesity in North America, and much of the developed world, has been referred to by most health care professionals as an “epidemic.” Illnesses and conditions exacerbated by obesity cover all of the major organs and functional systems within the body, including the development of cancer in various organs. The occurrence of most of these obesity-related conditions, particularly type II diabetes, is rising dramatically. But these surgical procedures are not without risks, as has been detailed in the scientific literature as well as the popular press. Thus, most surgeons and health care professionals insist on accompanying psychological treatment to prepare patients for surgery and to assist them in complying with their post-operative routine. The patient who is not properly prepared for surgery or does not understand the surgical procedures will be bitterly disappointed and likely noncompliant following surgery. Similarly, the patient who does not comply with the recommended post-surgery regimen will fail to maintain any weight loss and will put themselves at further physical risk. The approaches detailed in this treatment program explain the nature of morbid obesity, then go on to describe, in a very user-friendly manner, the most up-to-date procedures for dealing with attitude, emotional, and behavioral factors associated with successfully transitioning to a very different lifestyle. David H. Barlow, Editor-in-Chief, TreatmentsThatWork™ Boston, Massachusetts

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Contents

Chapter 

Introductory Information for Therapists 

Chapter 

Understanding Your Patient’s Eating Behavior 

Chapter 

Helping Your Patient Keep Track of His or Her Eating 

Chapter 

Educating Your Patient About Weighing Behaviors 

Chapter 

Pleasurable Alternative Activities

Chapter 

Challenging Eating Situations: People, Places, and Foods 

Chapter 

Teaching Your Patient About Problem Solving and Cognitive Restructuring 

Chapter 

Working With Your Patient on Body Image Issues 

Chapter 

Congratulations! Your Patient Is on the Way to the O.R. 

Chapter 

What Happens After Surgery?  References  About the Authors 



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Preparing for Weight Loss Surgery

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Chapter 1

Introductory Information for Therapists

Background Information and Purpose of This Program Obesity has quickly become an American epidemic. Patients suffering from significant overweight often have to contend with a lifetime of significant co-morbidities, social stigma, and lower quality of life. Many approaches have been tried to combat obesity and its multiple co-morbid medical illnesses, including pharmacotherapy, psychotherapy, diet, exercise, and other lifestyle change. Weight loss surgery has been used as a modality for many years but has been increasingly recognized as a durable tool for weight management over the last decade. Because the success of traditional diet programs and other therapies has been sporadic and usually short term, and recent literature has shown significantly more weight loss sustained over time in patients who undergo surgery, patients have been approaching their health care teams about the option of surgery and asking to learn more. Table 1.1 offers a detailed description of the different types of weight loss surgery procedures.

Research Support for CBT and Changing Eating Behaviors Although systematic research has yet to be conducted on the specific utility of psychotherapy for patients undergoing weight loss surgery, there is a substantial body of research on related conditions (bulimia nervosa and binge eating disorder) that suggests cognitive behavioral therapy (CBT ) may be useful.

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Table 1.1 Surgical Procedures Name of Procedure Restrictive Procedures

Restrictive Malabsorptive

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Description

Vertical Banded Gastroplasty (VBG)

In this procedure, the stomach is divided by a line of staples to produce a new gastric pouch, much smaller— only about an ounce in size. The outlet of the new pouch is similarly small, extending about – mm in diameter. This outlet empties into a section of old, larger stomach, which then empties as it used to into the small intestine. The surgeon usually reinforces the outlet with mesh or GORE-TEX to reinforce it. The VBG may be performed with an open incision or laparoscopically.

Siliastic Ring Vertical Gastroplasty

A variant of the gastroplasty described above. Here, the stomach is again divided by a row of staples to produce a small gastric pouch. In this procedure, the new, smaller outlet of the new gastric pouch is reinforced by a silicone band to produce a narrow exit into the old section of stomach, as detailed above.

Laparoscopic Adjustable Silicone Gastric Banding (LASGB)

This is a newer surgery, known as the LAP-BAND, approved by the U.S. Food and Drug Administration in . It is only performed laparoscopically, as its name implies. Here, a new gastric pouch is formed with staples, as with the gastroplasty, but the band surrounding the outlet from the new pouch into the old part of the stomach is adjustable. This is achieved because the band is connected to a reservoir that is implanted under the skin. The surgeon can then inject saline (saltwater) into the reservoir, or remove it from the reservoir, in an outpatient office setting. This means that your surgeon can then tighten or loosen the band, adjusting the size of the gastric outlet.

Roux-en-Y Gastric Bypass (RYGB)

The RYGB is the procedure most commonly performed and accepted. It involves creating a small ( 1⁄3 – oz) gastric pouch by either separating or stapling the stomach. This pouch then drains via a narrow passageway to the middle part of the small intestine, the jejunum. This bypasses the duodenum, which food would normally traverse before arriving at the jejunum. The older portion of stomach then goes unused and maintains its normal connection to the duodenum and the first half of the jejunum. This end of the jejunum is then attached to a “new” small intestine created by the procedure above. This creates the Y referred to in the name of the procedure. This redirection of the small intestine creates a malabsorptive component to the procedure, in

Name of Procedure

Description addition to the restrictive gastric pouch. RYGB may be performed with an open incision or laparoscopically.

Biliopancreatic Diversion (BPD)

This surgery is considered more technically difficult and is less commonly performed. It involves a gastrectomy that is considered “subtotal,” meaning that it leaves a much larger gastric pouch compared with the other options described above. The small intestine is divided at the level of the ileum (the third and final portion of the small intestine), and then the ileum is connected directly to this midsize gastric pouch. The remaining part of the small intestine is then attached to the ileum as well. This procedure thereby bypasses part of the stomach and the entire duodenum and jejunum, leaving only a small section of small intestine for absorption.

Biliopancreatic Diversion with Duodenal Switch (BPDDS)

BPDDS is a variation of the BPD that preserves the first portion of the duodenum, the first section of the small intestine.

Jejunoileal Bypass

This surgery bypasses large portions of the small intestine; it is no longer recommended in the United States and Europe due to an unacceptably high rate of complications and mortality.

Aaron Beck’s seminal work on CBT for depression was modified by Fairburn and colleagues for use with patients with bulimia nervosa (BN) (Fairburn, ). CBT has been tested in numerous controlled studies and has been found to be the most effective psychotherapeutic approach to the treatment of BN. CBT has been found more effective than delayed treatment, nondirective therapy, pill placebo, manualized psychodynamic therapy (supportive-expressive), stress management, and antidepressant treatment. Beck’s work has since been further modified for use with patients who compulsively overeat or binge, such as many of those who have developed obesity. The main focus of CBT, when working with overweight or obese individuals, is to address the negative thoughts that cause and maintain the behaviors associated with being overweight. Interventions are designed

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to combat these cognitive distortions in order to produce lasting change. In addition, more generally, CBT has been used to help with depressed mood, anxiety problems, and low self-esteem, all of which are common to obese patients, as well as to those contemplating surgery or recovering from it. In the last few years, increasing interest in treating a subset of BN patients who binge eat but do not purge (binge eating disorder or BED) has arisen. It appears that despite considerable symptomatic overlap in terms of both behavior (binge eating) and psychological concerns (low self-esteem and weight and shape concerns) there is a growing consensus that they are a distinct diagnosis. The most effective treatments for BED are similar to those effective for BN, particularly CBT. Generally CBT has the most evidence to support its use, and CBT-based self-help manuals may be even more effective in those suffering from BED compared to those with BN (Hay et al., ). Although patients with BN and BED differ from typical bariatric surgery candidates, there is convergence in some important areas that supports the use of therapeutic treatments such as CBT to help with similar problems among bariatric surgery candidates. Problems such as binge eating, dissatisfaction with body shape and weight, and issues concerning control over eating are examples of common concerns. In addition, depressed mood and anxiety, as well as low self-esteem, are common in many patients considering bariatric surgery or recovering from it. Thus, it appears reasonable to extrapolate from the current database of systematic research for eating disorders, anxiety, and depression to the population of patients seeking bariatric surgery. In addition, it is unlikely that systematic research in the specific area of psychological treatments for bariatric surgery will be forthcoming soon. The current manual is therefore an extension of the existing research in a novel area based on its utility for related concerns for which there is an extensive database.

Working With the Pre-Operative Patient Recent media reports about surgical success stories may make many patients unrealistic about their goals or the “ease” of surgery as a choice. A lot of patients aren’t prepared for the radical changes they need to make

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to their lifestyle and eating habits post-operatively in order to ensure they reap the maximum benefits of their surgery. Making a commitment to eat healthfully and nutritiously and to exercise regularly is the key to guaranteeing long-term success. Sustaining weight loss after undergoing bariatric surgery of any type requires that the patient adhere to a strict diet while following the very specific recommendations of his or her primary care physician, dietician, surgeon, and other members of the “team.” Without the patient’s strong level of commitment to a future as a thinner and healthier person, the probability of the surgery leading to permanent weight loss maintenance is limited. The program outlined in this guide will help you teach your pre-operative patients the skills required to adapt to the lifestyle and dietary changes that are necessary in order for them to sustain weight loss after surgery. Based on CBT techniques as described above, the program incorporates basic cognitive restructuring and problem-solving skills to help your patients change their negative thoughts about food, eating, their bodies, and themselves. Through this program they will develop a more thorough understanding of all aspects of their past and current problems with food and weight. It will also help your patients establish a regular pattern of eating, teach them about self-care and how to replace their negative eating habits with other, more pleasurable activities, and assume a lifestyle consistent with long-term weight loss maintenance.

Use of the Workbook The corresponding patient workbook will aid you in delivering this CBT-based treatment to your pre-operative patients. It is organized by skill (e.g., monitoring and recording eating habits, establishing a schedule for weighing-in, replacing eating with alternative, pleasurable activities, etc.) and correlates directly to this therapist guide. You may spend as many sessions covering each skill as necessary. The workbook contains user-friendly and interactive exercises, forms, work sheets, and checklists that your patient will complete either in-session or as homework as a way to reinforce these skills. All of these documents can be photocopied from the workbook or downloaded from the TreatmentsThatWork™ Web site at http://www.oup.com/us/ttw so that your patient is able to extend the therapeutic experience outside of the office.

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Chapter 2

Understanding Your Patient’s Eating Behavior

(Corresponds to chapter  of the workbook)

Materials Needed ■ Figure .. The Cognitive Behavioral Model of Overeating

Outline ■ Teach patient about the cognitive behavioral (CBT ) model for understanding the development of weight and eating issues ■ Personalize the CBT model based on patient’s experiences ■ Help patient understand the way in which weight loss surgery is likely to affect these issues If your patient is obese, that means that he has been overeating in one way or another (e.g., taking in more calories than the body needs and storing the excess as increased body weight or body fat.) It might surprise your patient, as you discuss the contributions to his weight problem, to find out that there are different forms of overeating—and that he might engage in some, but not others. It is important to help your patient identify the types of overeating problems that she or he has, so that appropriate interventions can be developed. As you discuss the following section with your patient, you can help him identify the types of overeating behaviors that she or he might engage in most frequently and help the patient to understand the various contributions to these behaviors, as well as ways to stop.

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Types of Overeating You will want to educate your patient about different types of overeating. Overeating can come in various shapes and sizes. For example, there can be binge eating episodes, e.g., typically quite large and out of control eating episodes in which a sizable quantity of food is consumed in a short period of time and in a manner that is considered to be quite different from an average person’s eating experience. A binge episode is one that usually leads to a feeling of being uncomfortably full or “stuffed.” On the other hand, overeating can sometimes take the form of “grazing” throughout the day, e.g., taking in relatively small amounts of food frequently between standard snack and meal times, usually in response to cravings, boredom or other emotions, or the mere availability of food. For some individuals, overeating episodes are followed by a strong resolve to eat less, under-eat, starve for a few days, exercise more, or in extreme cases, to purge the excess food. Those who follow episodes of overeating with purging (or extreme or compulsive exercise or starving) on a regular basis are classified as having “bulimia nervosa” as opposed to “binge eating disorder.” Most individuals who eventually become obese have not been engaging in regular, successful purging; if they had, it is much less likely that they would be as overweight as they are. On the other hand, if your patient has been purging regularly (but has still managed to become obese) it is probably wise to encourage the patient to delay surgery until the purging behaviors are fully resolved. Once you help your patient to understand the specific nature of the overeating habits, you can help him fit these into a larger model based on cognitive behavioral theory that takes into account other aspects of lifestyle and current circumstances. As you discuss this model with your patient, keep in mind that your goal is to help the patient better understand the interrelationships between eating behaviors and weight, other factors in his personal history, and the current situations, thoughts, and feelings that he encounters.

An Illustration of the Cognitive Behavioral Model of Overeating You will want to spend considerable time educating your patient about the CBT model of overeating and later helping draw out a form of the

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model that reflects the patient’s unique experiences. The CBT model of overeating and overweight links the overvaluation of thinness in our culture; pressure and intentions or attempts to diet; resulting feelings of deprivation, loss of control, and overeating (sometimes compounded by factors of low mood, conflicts with others, feelings of “fatness,” etc.); overeating (whether by grazing, compulsive overeating, or binge eating); loss of clear hunger and fullness cues; weight gain; increasingly negative emo-

WEIGHT GAIN AND OBESITY

CULTURAL FACTORS/WORRIES ABOUT HEALTH ALL LEAD TO ATTEMPTS TO DIET

MOODS, CONFLICTS, STRESSORS

LOSS OF CONTROL, OVEREATING

MOMENTARY PLEASURE FROM FOOD

FEELINGS OF SHAME, GUILT, REGRET, FAILURE, DEPRESSION

Figure 2.1

The Cognitive Behavioral Model of Overeating

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tions (from all kinds of sources: negative view of the self, interpersonal conflicts, specific failure experiences); and resignation/giving up, as well as increasingly turning to food as a primary source of gratification.

The Cognitive Behavioral Model of Overeating Figure . illustrates the vicious cycle of overeating followed by subsequent attempts of various types to control eating that applies even to those who are overweight and for that reason deemed “failures” at being restrictors. You will want to discuss the model and the rationale for the model at length with your patient. The CBT model of overeating, as described above, suggests that there are specific links between certain eating behaviors, attitudes, feelings, and weight. For example, in our culture as a whole, most people tend to value, if not overvalue, thinness or even in some cases, extreme thinness. The pressure to eat less felt by those who are overweight who also place significant value on thinness can be overwhelming and at times lead exactly to the behavior that is most unwelcome: that of overeating. For some, overeating in the short term is quite pleasurable and therefore momentarily combats the stress and depression that can accompany the experience of being overweight or obese. In some instances, eating has become the primary tool for gratification and pleasure that an overweight individual has learned to use to soothe himself in the event of negative emotions or problem situations. Typically after a brief period of pleasure, however, overeating can lead to negative feelings and thoughts about oneself and an overidentification with the experience of failure, at least with respect to eating and weight control. While massive efforts to diet and exercise, even unsuccessfully (e.g., sometimes just hypervigilance or emotional energy about these areas or simple “good intentions” without a lot of productive action), can follow bouts of overeating, this extreme effort might lead to feelings of stress and deprivation (even if the actual amount of food consumed and physical exertion through exercise remains about the same). Your patient’s efforts to diet might leave him feeling as if he isn’t “allowed” to eat to satisfaction or doesn’t have the right to eat the foods that he likes. Frequently, these feelings can trigger episodes of overeating no matter what

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their source (e.g., actual, successful dieting and weight loss or intentions to diet that fall short of the goal of actually cutting back). In addition to the experience of deprivation, other aspects of a person’s life might contribute to a lowered threshold for overeating. For example, general stress, intense emotions of other types (low mood, euphoria, anxiety, grief ), conflicts with others, and a distorted sense of hunger and fullness from a history of overeating and purging can create a situation in which it is impossible to clearly discern hunger and fullness cues. Finally, there are often historical factors associated with overeating and becoming overweight. These might include: the early experience of being teased and labeled fat; having been forced to diet as a young child; retreating into overeating and weight gain to avoid certain challenges associated with growing up; or attempting to cope with trauma of one type or another. In adulthood, overweight and overeating can often be associated with pregnancy, raising children, becoming more sedentary after starting to work again (or leaving a job), or having been forced to give up certain sports or physical activities due to medical conditions or injuries. For some, excessive weight gain might be associated with excessive alcohol intake, eating more due to drinking less, or discontinuing either smoking or stimulant drugs. You will want to spend a considerable amount of time talking with your patient about all of the aspects of his life, past and present, that have played a role in his having become overweight, so that ample time can be spent understanding and working through the issues. Your patient will be using the blank space that is provided in his workbook to draw out a version of the CBT model that best fits his own experience. An example is shown below in Figure .. During sessions in which you discuss the CBT model, you might help the patient start linking it to his experiences by thinking about and noting a few of the relevant factors in his growing up years (that he is aware of ) or any other aspects of his history that have affected his eating behaviors and his weight over time. Then you might want to encourage your patient to write in more detail about his particular experiences as they relate to the various aspects of the CBT model, as presented in the following exercise. Following this exercise, you will be discussing with your patient the speci-

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It seems that overweight and depression run in my family. So I was overweight from a fairly young age. The problem seemed to get worse over time. As I became an adolescent and looks started to be more important, I retreated somewhat socially and started to eat as a way to make myself feel better. Obviously, this made the weight problem worse . . . It has been hard ever since. Even though I have dieted a number of times, none of the weight losses that I have accomplished have “stuck” for more than a few months. Then when I started to have kids my weight just got higher and higher . . . until the point where it seemed futile to try to do anything about it. Although I exercised in the past, with increasing weight it has been more and more difficult to move around, and for that reason I haven’t done much exercise at all in the past couple of years, again making the weight problem even worse. So the surgery seems to be my only solution at this point. Family history of weight problems and depression Increasing weight led to decreasing physical activity and more weight gain When I dieted I would feel deprived and then eat more as a result . . . Eating to feel better – e.g., to get over social isolation and depression Diets didn’t work anymore and frustration led to more eating and weight gain and lower mood. Also stress of any type has usually triggered some overeating.

Figure 2.2

Sample of Patient’s CBT Model

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fic emotional, cognitive, and behavioral effects of problems with weight and overeating.

The Effects of Overeating: Emotional, Cognitive, and Behavioral For many people, overeating—whether triggered by available food; cravings; negative emotions such as depression, anger, or boredom; conflicts with other people; or a desire to distract oneself by “creating” a new focus for negative energy—can lead to a variety of different outcomes. As stated in the section above, it can be gratifying or uplifting in one way or another. For example, it can provide a form of pleasure when there are few pleasures available; it can distract from difficult thoughts or feelings about any number of problem situations—in a sense it shifts the focus from one problem to another; it can provide a method for acting out or “breaking the rules” for someone who otherwise is quite compliant and sensitive to doing only “what is right.” No matter what causes an episode of overeating, in response to its occurrence, in many cases one feels not only an urge or desire to restrict intake, but also usually a whole host of negative emotions, thoughts, beliefs, and behaviors about oneself in relation to having overeaten, which develop fairly soon after the episode, even if the eating episode was on some level gratifying. These thoughts and beliefs might take the form of “I am never going to lose weight,” “I am the only person who engages in this behavior,” or even more negatively “I am a fat pig” or “I am a loser.” These thoughts and beliefs can generate an array of negative feelings. Some of these may include: sadness, self-disgust, anger at oneself and others for having gotten into the situation in which overeating occurred, despair, and resolve “not to do it again” and a commitment to start dieting or restricting intake on some level as soon as possible after the overeating episode is completed. For some people, overeating in the form of continuous grazing and consuming excessively large meals and snacks might not trigger so many extreme reactions but rather strengthen or ignite a sense of resignation and inevitability of future overeating and continued weight gain. In many cases, the negative thoughts, feelings, and beliefs also lead to compromised behaviors such as not getting out socially to see friends, feeling too full to do other tasks, whether chores or

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recreational activities, or even additional overeating that may be an attempt to further escape from the bad feelings.

Gastric Bypass Surgery and the CBT Model Since the experience of weight loss surgery will change your patient’s relationship to food quite dramatically, the issues discussed above need to be considered in a different light. Mostly, weight loss surgery will help your patient better manage his reactions to both hunger and fullness (satiety). Specifically, after weight loss surgery of any type, your patient can expect to feel hungry less frequently and less intensely than before (for those who do actually experience hunger—some obese people do not). Also it will take much less food to fill your patient up once he does start to eat after becoming hungry. And your patient’s method of eating, which will involve taking very small bites of food, chewing them very well, and eating very, very slowly, will also increase the likelihood that he will feel full on much less food. Also, your patient will be given information about which foods to include in his diet and which to avoid, as well as strategies for alternating his intake of foods and liquids. While, ultimately, the goal of weight loss surgery is to reduce your patient’s hunger level so that he can make wiser and less impulsive decisions about food, this surgery “benefit” can also come with certain costs. These might include the experience of deprivation that can accompany regular dieting when certain foods in certain quantities are restricted or the experience of being “left without tools” if your patient has used food as a primary means for coping with problem emotions and situations. Without replacing food with other positive and well-practiced tools for coping, any individual who is even enthusiastically attempting to restrict intake by choice can be left feeling unsettled, frustrated, deprived, or out of control. These feelings can lead to urges to overeat. Solutions for the problem of being “left without tools” will be discussed in a later chapter. You will discuss with your patient the reality that even after weight loss surgery—which by now he should understand is no magical cure— overeating can happen, in one form or another. For example, your patient might find himself unintentionally experimenting with creative strategies for overeating. These might include: frequent ingestion of

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small quantities of indulgence foods that are not ideal, such as very small amounts of sweets, candy, or peanut butter, or taking in increasingly larger quantities of food, particularly once the new stomach pouch stretches some. He may deliberately overeat certain foods that are no longer digestible because of the particular type of surgery he had (e.g., fats after the duodenal switch procedure) and come to rely on the malabsorption syndrome, or “dumping,” as a method of purging the excess calories. Despite the surgery’s “assistance” in controlling your patient’s eating, at least some of the fundamental features of the CBT model will still apply to his struggle to manage his intake. In your therapy sessions, you will want to determine those areas that might prove to be high-risk. For example, while your patient might not feel physically hungry after surgery in the same manner as before, he might still struggle with physical and psychological cravings for particular types of foods or for food in general. Associated with these cravings may be emotions of frustration, loss, sadness, or even despair. He may feel that he will never be able to consume any of these foods again or that he will always struggle with intense cravings. While the use of words like always and never signifies that your patient may have been triggered into a cognitive lapse that involves clearly problematic and unhelpful thoughts, these errors in thinking can be addressed and modified using cognitive restructuring procedures (see chapter ). By the same token though, no matter how skillfully you might address the problematic thoughts with your patient, it is equally important to help him “get his behaviors onboard” so that he doesn’t inadvertently contribute to any of the problems noted above. Similarly, it is important to address any problem emotions your patient might notice in association with his surgery. In some cases, losing a significant amount of weight even after weight loss surgery can lead to the experience of excessive hunger, cravings, and eventual overeating, as the body struggles to reestablish its former “set point.” Also, in some cases, negative emotions can accompany even desirable, radical weight loss and can lead to a pattern of emotional eating. As you discuss your patient’s personalized version of the CBT model and work hard to understand all of the issues involved, you will be able to more clearly help your patient ascertain the areas that need the most re-

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habilitative work prior to surgery. No matter what, it is likely that one or more of the following chapters will help your patient address the issues that are most troubling.

Homework ■ Read about and review the CBT model for understanding eating and weight issues. ■ Create a personalized version of the CBT model and discuss this with your therapist. ■ Review the implications of weight loss surgery on the CBT formulation.

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Chapter 3

Helping Your Patient Keep Track of His or Her Eating (Corresponds to chapter  of the workbook)

Materials Needed ■ Form: Food Record

Outline ■ Explain to patient the rationale for establishing a regular pattern of eating ■ Teach patient to establish a regular pattern of eating ■ Introduce patient to food records ■ Teach patient a method for keeping track of eating using food records The CBT model of overeating explains the interrelationships between eating, thoughts, emotions, weight gain, and other behaviors and situations, and purports that the first steps toward making changes in this vicious cycle need to be taken at a behavioral level. For example, a key component in your patient overcoming her problem eating habits or attitudes involves her making a commitment to gathering more data about her eating behaviors by keeping some form of eating record. Another key factor involves her willingness to establish a regular pattern of eating, including keeping to a schedule of healthy, balanced, and not overly indulgent nor overly stingy meals and snacks to interrupt any problematic cycles of overeating followed by compensatory under-eating. You will want to discuss both of these principles and the following rationale in more detail with your patient in the sessions that deal with these issues.

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You will want to “sell” your patient on the CBT belief that the prescription of a healthy, regular pattern of eating can disrupt the strength of the links in the model of problematic eating. Helping your patient to disentangle these links and “clean up” her eating patterns by eating on a regular but modifiable schedule can help her free up her eating behaviors from inappropriate influences (those that aren’t related to hunger or fullness). In this way your patient can slowly achieve healthier eating behaviors and associated attitudes. In many cases, too, this plan for regular eating can help your patient slowly work toward her weight goals, since the pattern can help her combat any episodes of impulsive overeating.

The Importance of a Regular Pattern of Eating The treatment of choice for problematic overeating behaviors that occur in response to triggers of any type has been the prescription of a regular and healthy pattern of eating (such as three meals and two snacks a day). Obviously the specifics of the planned eating pattern (e.g., the exact contents and quantities) will differ from individual to individual and will also depend upon the exact nature of the surgery that your patient is planning to have and the recommendations of her particular surgery center. By and large, though, these recommendations will include the suggestion to consume three small meals and two or three small snacks a day (or five or six small meals) that are eaten not fewer than about  hours apart and not more than about  hours apart. The rationale behind this recommendation is that by eating in response to a flexible but predetermined schedule, nonessential and inappropriate food and eating “cues” such as those described above (e.g., emotions, cravings, the availability of food, and various interactions with people) will be washed out over time. As you will explain to your patient, the belief is that this mechanical style of eating “by the clock” will gradually become more automatic and natural, and increasingly will correspond to the ebb and flow of hunger and satiety signals as these are progressively “retrained” through adherence to the schedule. In this way, over time, eating will be initiated appropriately albeit somewhat flexibly at meal and snack times, approximating the pattern that your patient will need to adopt post-operatively.

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Your patient will obviously learn a lot about nutrition pre- and post-op from her dietician. However, you will also discuss the importance of eating nutritionally dense meals and snacks after surgery with your patient during the sessions focused on establishing a regular pattern of eating. At the same time, you will talk to your patient about the fact that in addition to super-nutritious food and correct eating and fluid intake patterns, healthy eating (in both the physical and psychological sense) must also involve some allowances for certain “small treats” that are at least somewhat indulgent. This will help stop problem cravings and deprivations that lead to out of control episodes of overeating (to the extent that that is possible after weight loss surgery). As you will review time and again with your patient, the essential tool for getting eating behaviors that have gone awry back on track is a “normalized” relationship with food. If your patient has had particular difficulties making a commitment to “eating by the clock,” suggest that she try hard to figure out in advance just about when, just about what, just about how much, and just about where each meal and snack will take place. Furthermore, she will get the most mileage out of this type of exercise if she sketches out these plans in some sort of “draft” or meal plan, either in a journal or an actual food record. Working in this way on a regular basis will represent a very substantial step toward her liberating her eating habits from inappropriate influences not really connected to physical hunger.

Using Food Records The first step in helping your patient try to understand more about her eating patterns and associated thoughts and feelings, and the contexts or situations in which she struggles with these, involves learning to record all of her behaviors in journal form, using what is commonly known as a “food log” or “food record” that provides details beyond the “sketching a plan in advance” noted above. Explain to your patient that the food record is all about gathering data so that she won’t have to rely on her memory alone to understand the details of her eating patterns, all that contributes to them, and how her weight is affected by the current patterns and any changes to them. Inform your patient that when she completes food records, she also has created a written record of her eating be-

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havior that can be discussed in detail with you during sessions. You can talk with your patient about her prior experiences, if any, with food records and any associated thoughts and feelings that she has about food records based on those experiences. Your patient might be quite skeptical about food records if she has worked with them before, perhaps in a structured diet program, while meeting with a dietician for consultation, or in some type of behavior therapy. Her reaction might be “this is not going to work—it never did before!” Or she might feel as if keeping food records is all about “being controlled” by her therapist or dietician. No matter what, all of these sentiments need to be explored in your sessions with her. Forewarn your patient that to succeed with this program she will need to transcend her tendency toward skepticism and trust that this experience with food records can be different, that is, that she can productively and therapeutically use these records to her advantage, rather than feel as if she is completing an assignment for someone else. Assure your patient that regularly completing food records in the context of this particular CBT therapy will be a different experience than any she has had before, if she uses them as recommended in the program. Remind her that if she wants to really succeed with her food records, the best way for her to proceed is to make a commitment to recording her food intake (all meals, snacks, binges, or grazing episodes and fluid intake) as close to the time of eating as possible. Any delay in her recording can lead to inaccuracies and even more importantly, the experience of “disconnect” between her eating and what she will later record in her food records. Remind her that she should raise any questions about the food records with you. A sample completed food record is included in Figure .. A blank copy for your patient’s use is available in the workbook. Your patient may photocopy the blank record from the workbook or download multiple copies at the TreatmentsThatWork™ Web site at http://www.oup.com/ us/ttw. Encourage your patient to use the food records daily and to make her entries as close as possible to the time that she is eating. She can also use the records to plan her eating patterns and specific snacks and meals in advance, and then cross-check to ensure that she has followed through on her plan. Either way, educate your patient that if done correctly, the

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Food Record Amount of Food and Liquid/Description

Meal, Snack, Binge, Graze?

Purge Y/N

Thoughts, Feelings, Situation/Context

Time

Place

8:00 a.m.

Standing in kitchen

1 corn dog with bun, 1 hot dog with bun, mustard, ketchup, cheese with both 1 glass orange juice

Breakfast

Just a typical morning

10:30

Work – at desk

1 package Hostess Ho Hos from vending machine

Snack

My usual snack

11:30

Friend’s Desk

handful of M&Ms

Grazing a bit

They were there, so I ate them.

In car, 3 tacos, a burrito, and drive-thru a large Coke Taco Bell

Lunch

At least I didn’t have dessert.

3 p.m.

At desk

glass water, handful peanuts

Snack

I am trying to be “good” with the water.

6 p.m.

In kitchen preparing dinner

several slices cheese and 6–10 Ritz crackers

Just snacking while I cook dinner

I will try to eat less at dinner.

6:30

Kitchen table with family

plate of spaghetti with Dinner meat sauce, salad with ranch dressing, 3 pieces garlic bread with butter, slice apple pie, 1 glass 2% milk

12:30 p.m.

I made it so I wanted to enjoy it.

Figure 3.1

Sample Completed Food Record

food record can be an invaluable addition to her self-care plan around food. Go through the various features of the food record with your patient, noting that there are places on the record to indicate the time that she is eating, the amount and contents of the food and liquid consumed, and whether or not she considered the eating episode to be a meal or a snack, to be “pro-plan” or “anti-plan,” and what the situation or context was surrounding that particular eating episode. Where was she? Who was around? What was she thinking? What was she feeling?

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Your patient’s keeping an ongoing record of her eating in this way (including the situation/context column) will make it possible for her, in the context of her therapy with you, as well as any consultation sessions with the dietician and surgeon, to really understand all of the eating and other behaviors and thoughts that are contributing to and perpetuating her eating problems, as well as the exact nature of the problems. Without records, and left to rely only on a memory of what happened with food (given that eating tends to be an activity during which many people “space out,” disassociate, or simply forget exactly what they were doing), it is highly likely that your patient’s recollection of her eating will be incomplete and inaccurate. Discuss with your patient that in many respects, the whole point of food records has to do with the idea of “connection,” that is, that she stays connected to her own efforts to regularize her eating. Remind her that the food record can help her track her progress on a meal-by-snack basis, thus providing reinforcement and motivation to “stay on track” each and every step of the way. Along the same lines, the record can also serve as a tool of intervention when she is at risk for lapsing into a nondesirable eating behavior. Every time she is able to examine completed portions of her food record and note the number of success experiences that she has had, she can ease herself back into “the groove” when she might have been tempted to feel negatively about her progress and “throw in the towel.” Discuss with your patient the fact that when she uses her food record as a tool of motivation and intervention, she will be taking full advantage of the methodology. Of course, her food records will also be helpful in providing an accurate record for you. Remind her, however, that food records are really most powerful when used to make day-today choices about each and every meal, snack, (and glass of water) that she decides to consume.

Working With Adolescents If your patient is a teenager, there are some important factors that affect his or her ability to establish a healthy routine for eating. The teenager may not control either the foods that are in the home or the times that the family eats. So, it is important that you work with your patient’s par-

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ents, and to a certain extent the entire family, to promote their understanding and acceptance to change things. This will likely require that you meet with parents together with your patient to discuss how a structured eating program can be undertaken at their home. This involves identification of very specific obstacles—not eating meals at regular times, parents not preparing meals, fast food as the main or common meal type, and so on. Each of these will need to be addressed and solutions identified. Sometimes this will involve asking parents to shop with their teenager for a period of time in order to make sure the right foods are available. Sometimes teenagers don’t like to keep food records. There is enough homework already, and keeping track of what they eat seems like a waste of time. However, it is important to try to overcome these hesitations. You will learn a lot about what and how they eat that will be essential to therapy. When you are first getting started, you and your patient will likely complete food records in-session to give her the idea and to show her how they can be useful. Sometimes, you may ask parents to remind their teenagers to complete the food records. Over time, these food records will also be helpful when your teenage patient meets with his or her doctors to illustrate how they have changed eating patterns and food choices. This will help demonstrate their commitment to lifestyle changes needed to support weight loss after bariatric surgery.

Homework ■ Review the rationale for maintaining a regular pattern of eating and discuss this with your therapist. ■ Read and review the rationale for keeping food records and discuss this with your therapist. ■ Review the instructions for use of food records. ■ In your therapy session, set appropriate goals for the number of days you will record your eating during the next week.

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Chapter 4

Educating Your Patient About Weighing Behaviors (Corresponds to chapter  of the workbook)

Materials Needed ■ Weight Graph ■ Appearance and Weight Compliments Log

Outline ■ Educate patient about the rationale for and method of regular weighing ■ Teach patient about the importance of other means for checking on and measuring his body weight, size, shape, and general appearance ■ Help patient understand the link between healthfully monitoring his body size and keeping track of other healthy attitudes and behaviors

A Regular Pattern of Weighing Most likely, your patient has discussed with you, as well as with his surgeon and dietician, and possibly with his internist, a regimen for weighing himself regularly before weight loss surgery that makes sense. As your patient prepares for his surgery, it can be helpful for him to weigh in weekly with one of his doctors, so that changes in his weight in either direction can be observed on a regular basis before too much time passes. In this way, any necessary modifications (e.g., increasing or decreasing intake or activity) can be made as needed. In some cases, because your patient might still require a special scale for weighing (most likely if his weight is still  pounds or above), it might actually be impossible for

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him to weigh at home and therefore necessary for him to use a doctor’s scale to get an accurate reading of his weight until it drops into a lower range. The rationale for regular or weekly weighing is easy to understand, and your patient has probably experienced certain thoughts and feelings about weighing himself (or being weighed by someone else) that will support the rationale. For example, for many people with weight and eating problems, weighing themselves has over time become fraught with an incredible amount of stress and pressure, perfectionism, self-doubt and self-blame, anger directed inward and outward, and a number of other perceptions and feelings (some positive, when the numbers were going in the right direction). Typically, these issues and complexities in relation to weighing have developed over time in response to your patient having made a number of ultimately unsuccessful dieting efforts (as evidenced by the patient’s decision to undergo weight loss surgery). As a result of this level of sensitivity that your patient carries about his weight, including potentially becoming too upset in response to unwanted weight gain and too excited in response to weight loss, he has become overinvested in what will be revealed about him by “the numbers” in any particular instance of weighing. And most likely that has led to the development of certain patterns in the way that he weighs himself, which you will be discussing in detail during the sessions devoted to this topic. For example, you will want to spend some time educating your patient about common patterns in weighing among those with eating and weight concerns. Some people who are highly vigilant and reactive to the numbers on the scale, and who use the numbers to define crucial aspects of themselves such as their self-worth or lovability, may check the scale daily or even more frequently (if this is possible given their weight) to ensure that the numbers have changed, or haven’t changed, or in any case to get a sense of “what the numbers are saying” about them. Others might avoid the scale altogether to avoid the emotional impact that the numbers are likely to have.

The Risks of Weighing Too Frequently This pattern of weighing (less likely for obese individuals than patterns of avoidance) is problematic because it allows people to overreact (e.g., cognitively, emotionally, behaviorally) to very minute changes in their

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weight that virtually have no meaning at all. Shifts of one or more pounds in either direction that might reflect sodium or fluid intake changes from the day or days before can cause fairly exaggerated responses in these “scale-sensitive” individuals of either self-denigration or elation. Both responses are inappropriate given the predictable and meaningless nature of those types of weight changes, which are most likely to be temporary and not indicative of actual fat or lean body mass.

Avoiding the Scale On the other side of the continuum is the problem of weighing too infrequently—or even avoiding the scale altogether. Some people with weight and eating issues have had such negative or emotionally powerful experiences with the scale that they feel unable to tolerate any relationship at all with “the numbers” and therefore avoid the scale at all costs. In some cases, even at physicians’ offices, these individuals might ask to stand backward on the scale and request that the health care professional who is weighing them not even comment on the numbers. While this pattern of scale avoidance might in fact spare an individual with this type of extreme sensitivity from some short-term unpleasantness or overly strong emotional reactions, it can, on the other hand, collude with their perceived need to “distance” from the scale. Maintaining this type of distant or avoidant stance can contribute quite a lot to a person unknowingly “allowing” their weight to change in the undesired direction (e.g., weight gain in the obese population). This happens easily due to the absence of a feedback loop, that is, no source of reasonable feedback about what is happening with the person’s weight over time in response to the various eating habits that have been sustained since the last weighin (which in some cases involving “highly avoidant” people might have been years ago). It is important to inform your patient that avoiding the scale for too long can lead to an actual fear or phobia of the scale or the experience of weighing-in, which is not unlike other types of phobias (e.g., a fear of heights). In these instances, not only is the fear of weighing incredible, but the pressure to avoid is extremely powerful, too, and as time goes on without the person “normalizing” contact with the scale or the experi-

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ence of weighing-in, the numbers take on an even more exaggerated level of importance to the point where they become even more extreme in their power to determine how the person feels about himself. As you discuss the patterns of weighing with your patient, you can explore the various meanings attached to his pattern of using the scale. Typically, a pattern of too-frequent weighing suggests extreme anxiety and some “magical” ideas about controlling the outcomes through hypervigilant checking, while a pattern of avoidance suggests that the numbers on the scale have come to mean something to the person that extends way beyond the domain of eating and weight control and has huge implications for his emotions and self-concept. No matter what the particulars of the pattern your patient might be engaging in—one of overly frequent weighing or avoidance of the scale— these relationships to weighing are problematic in that they suggest an overly strong emotional attachment to the numbers. This type of attachment interferes not only with your patient developing a straightforward and healthy pattern of tracking weight changes as they relate to eating but also with his maintaining an appropriate and unembellished relationship between his weight and his sense of self (e.g., worthiness, lovability, value, etc.).

Corrective Strategies: Weekly Weighing and Other Measurements As you and your patient will discuss, one helpful strategy to address problem patterns of weighing is to prescribe a pattern of weighing-in on a regular and preplanned basis, such as once a week on a specific day, at a specific time. Weighing regularly in this manner also is the best method for obtaining accurate comparison data week to week, particularly as changes in eating—along the lines of weight loss dieting—and possibly activity patterns are made. This strategy can work for those who have been weighing too frequently, by “cutting into” the overweighing pattern in a very deliberate way. For example, once the day and time for weighing are selected, and the weekly weigh-in has taken place, the scale can be deemed off-limits either by encouraging the patient to put it into a closet or other hard-to-reach place or by limiting access to it by taking out the batteries or hanging a sign or “do not cross” rope as a reminder

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and a motivator to stay away from the scale until the designated weighin time rolls around again. Alternatively, if the excessive weighing has been done in some other setting, problem solving and motivational exercises (e.g., analyzing costs and benefits) pertaining to limiting access to that scale or limiting visits to that place only to the “weigh-in day” can help. In addition, relaxation, distraction, and cognitive-restructuring methods might be useful in addressing problem mood states such as anxiety or despondence that might occur when your patient has contact with the scale (or is denied contact with it, as the case may be). (These methods, discussed in detail in chapters  and , can be introduced here if necessary; just encourage the patient to also skip ahead to the appropriate place in the workbook.) The strategy of committing to a specific day and time for weighing-in also applies to those who have been “scale avoiders.” For those individuals, it may be necessary to either purchase an appropriate scale for the home or identify an alternative location (such as the doctor’s office) where the scale can be easily accessed once a week on a specific day and at a specific time. For this group, weekly weighing might also warrant supplementation with CBT tools such as problem-solving strategies, relaxation techniques (to combat anxiety that occurs before, during, and possibly even after the weigh-in), and cognitive restructuring exercises to combat any extreme or distorted thoughts that accompany the sight of “the numbers.” Explain to your patient that using a variety of measures related to weight can be helpful, in part to take the onus and importance off of the numbers on the scale. Use of a weekly weight chart can help your patient maintain a visual image of his progress toward weight loss before surgery (as well as after). In your sessions, you can help your patient design a weight graph using the blank graph included in chapter  of the workbook, in a form that will be maximally helpful to him. Your patient may photocopy the graph from the workbook or download multiple copies at the TreatmentsThatWork™ Web site at http://www.oup.com/us/ttw. In addition to the weight graph, a number of other indices of body size and shape can be useful in providing information about how the patient’s body is changing, without relying on the scale. These include the obvious: fitting into certain pieces of clothing or certain chairs (whether

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at home, at work, in a movie theater, or on an airplane), measuring various parts of the body by using a tape measure or recording body composition (e.g., percentages of lean body mass and fat) by undergoing a battery of tests that can determine this, and paying attention to an indirect measure of weight loss by noting increased stamina in doing any number of physical activities, including formal physical exercise (such as walking, biking, and the like) and incidentals such as walking up the stairs. It can be quite helpful for your patient to record some of the “data” over time, as well as his perceptions of all of these changes in his body by using a log similar to the food records. You can also encourage your patient to think about keeping a record of compliments received pertaining to his weight loss, which can be particularly helpful and inspiring. You can discuss some of the following areas in detail with your patient.

How Your Patient’s Clothes Fit Another very simple and easy way for your patient to figure out whether or not he’s on a weight loss trajectory is to try on various items of clothing to determine their fit. If they are becoming more and more loose, he is losing weight; if they are becoming tighter, he is gaining weight.

How the Furniture Fits Your Patient This is another very simple way for your patient to track changes in his body over time. It is important to remind your patient to notice that he is much more easily fitting into chairs and other furniture that proved difficult for him in the past.

Taking Measurements Another option that might appeal to your patient for tracking bodily changes separately from the scale involves using a tape measure to measure various parts of his body (the obvious choices being waist, hips,

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chest, upper arms, thighs, calves, etc.). This method can be effective in offering additional information about the changes your patient’s body is undergoing, as long as he measures fairly accurately. It can be difficult to always get the correct or exact same “spot,” so your patient might have to practice or ask for some assistance from a significant other or possibly his personal trainer, if he has one, if the results of the measurements seem “off ” in any way.

Changes in Body Composition: Percentages of Fat and Lean Body Mass These days, it is not difficult to find scales that measure body fat (although the accuracy of some of these might be questionable), and your patient might already have access to one of these scales. A more accurate determination of body composition would be an evaluation at a health club, gym, or medical center that offers such testing using calipers, underwater weighing, or other even more sophisticated techniques. Finally, your patient’s surgeon, dietician, or internist might also have access to the most state-of-the-art techniques for tracking body composition over time as your patient loses weight. You might encourage your patient to think of the body composition measurement as a “fun” type of measurement to obtain before and after his surgery.

Food Records Remind your patient that food records, discussed in the previous chapter, ultimately will describe everything that he needs to know about which direction his weight will be heading in the near future. For instance, if your patient is maintaining a caloric intake or food plan that is providing less energy than his bodily needs require, he will lose weight, and if he is taking in more calories than he is expending, he will be on a weight gain trajectory. By focusing on completing daily food records and examining actual behaviors, including the food intake and the output of exercise and any other physical activity, your patient will feel more empowered by recognizing that behavior has an actual impact on the outcome.

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Ease in Moving Around Your patient might want to keep track of general activities, such as either how long he is able to engage in a certain activity, such as walking at the mall, around the block, or on the treadmill, or swimming laps (or walking laps) in the pool, etc. Your patient might alternatively want to rate his level of exertion while doing an activity, which will provide yet another helpful measure of how his weight loss and level of conditioning is progressing.

Compliments You will be talking at length with your patient, at various stages of the treatment, about his response to compliments about his weight loss. Obviously, when losing weight, your patient may be, on the one hand, uncomfortable to “be noticed” more than before or to be on the receiving end of a lot of compliments about weight loss, particularly when there is a lot to lose and when there may be a lot of thoughts and emotions of a complicated nature tied up in the issue of his weight. But explain to your patient that often it is these external sources of feedback (not unlike the scale, to some extent) that can help a person work through distortions he might have in his perceptions of his weight. Obviously, these should not be relied on as the only source of pride-generating thoughts and feelings; in the end, your patient’s view of himself should serve as his own primary source of enthusiastic feedback. However, in a “pinch” or a low spot, others’ reactions can help bridge the gap from feeling low to feeling better. Remind your patient that, on the other hand, an absence of compliments about weight loss does not have to mean much because in our culture of sensitivity to weight issues, some people may be reluctant to say much of anything at all about a person’s weight loss for a very long time (until it is very obvious and visible) for fear of intruding or offending. Your patient should remember not to let the absence of compliments get him down as one can never know what is going on for another person in terms of them perceiving, but not commenting on, the transformation that is taking place. Also, your patient might find that he can expe-

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rience a range of reactions to others’ compliments about his weight, from feeling proud and grateful for the acknowledgement to feeling shy, overly exposed, intruded upon, or even skeptical at times about what is being said (this is common when a person does not yet feel their weight loss in the way others see it). Help your patient figure out strategies he might like to consider for responding to compliments and questions about his weight loss that might come up simultaneously. Remind your patient that there is never any obligation to fully explain anything to anyone about how the weight loss was achieved; the fact that he had weight loss surgery can be something that he decides to keep to himself. You can let your patient know that an explanation that can suffice in many different situations is “I made a commitment to eat healthy and exercise more and that is how I lost weight!” The reality is that those behaviors will be the ones that best predict the long-term success of weight loss surgery and are also the optimal result when an individual is compliant with all of the recommendations made relative to the surgery. A compliment log in your patient’s workbook provides space to document the dates and types of compliments received from others regarding his weight as it decreases over time. A sample filled-out Appearance and Weight Compliments Log is shown below in Figure .. (In a later chapter, there will be a broader discussion of body image issues that also includes some assessment of others’ responses to your patient’s changing appearance.) Whatever combination of approaches your patient decides to use to measure body changes as he loses weight before surgery, it is important for

My Appearance and Weight Compliments Log Date

Source

Positive Comments

10/31

man on street

“you look beautiful”

11/10

friend

“you’re really looking great”

Figure 4.1

Sample Appearance and Weight Compliments Log

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him to make a commitment to use at least a few of the assessment tools on a weekly basis and write about them in a log similar to his food record. This will allow him to review the changes over time, rather than rely on his memory of them. Some of the more complicated methods such as measuring body parts you might encourage your patient to do just once a month, to increase accuracy and decrease overreactions to disappointing results.

Homework ■ Find a place where you can weigh in regularly. ■ Begin to document your weight on the weight log. ■ Read and think about the other issues presented in this chapter. ■ Begin to make entries in your appearance and weight compliments log.

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Chapter 5

Pleasurable Alternative Activities

(Corresponds to chapter  of the workbook)

Materials Needed ■ List of Pleasurable Alternative Activities ■ Sleep Enhancement Strategies ■ Meaningful Roles and Activities Checklist

Outline ■ Educate patient about the importance of including pleasurable alternative behaviors (e.g., those that don’t involve food and eating) in her life on a regular basis ■ Help patient establish a list of various types of these activities that can be used in different situations ■ Enhance patient’s understanding of the issues of self-care in general and facilitate patient’s improving various aspects of her self-care regimen

When Eating Has Been the “Pleasure of Choice” Your patient might note that eating has become over time a primary form of relaxation, pleasure, and enjoyment that always seems to be available and literally at her fingertips. She might recognize that during certain periods of time she has lapsed into a pattern of overeating to give her pleasure because she has literally lost touch with other interesting, creative, fun, and active endeavors that she might have engaged in with enthusiasm in the past. Perhaps your patient began not only to avoid cer-

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tain activities but also to avoid people and social situations in general, due to shame or embarrassment about her weight. In addition, your patient might have experienced certain emotions that triggered an eating episode that may or may not have been primarily related to her weight, including depression, anxiety, or fluctuating mood states, that might have lifted temporarily when she ate something. As you will discuss with your patient in the sessions that address this chapter, food can briefly and to some extent enhance mood by slightly changing brain chemistry in the direction that certain antidepressants do. Sometimes, even intense, positive emotions might trigger your patient’s urge to eat, since eating can provide a form of distraction and serve as an “anesthetic” by calming and soothing a person in response to any form of arousal. On the other hand, your patient might believe that she is simply a person who “loves to eat” and might attribute any or all overeating behaviors that happen (instead of other forms of recreation) to a fondness for food. This view of food and eating might stem in part from your patient’s experiences as part of a certain cultural or ethnic community, family, or social group whose relationships revolved to a great extent around the experience of eating. Your patient might also ascribe to the view of herself as someone who, in spite of eating a lot much of the time, never really gets to the point of feeling full after a meal. Your patient might experience hunger or strong cravings for food despite knowing “in her head” that her appetite for eating is not reflective of a real need for more food. There are also some people who ultimately end up overeating because food “takes over” or fills in a void where some other type of substance abuse has left off. Your patient might be someone who fought hard to withdraw from addictions to other substances, such as alcohol or drugs, only to find that whatever was driving her to use these substances resurfaced—with a vengeance—in the form of appetite, cravings, and motivation for food and eating. Finally, since many of those who have struggled with weight and eating issues are in so many other areas of their lives “model citizens,” overeating might have represented one of the only opportunities for your patient to “rebel” or do exactly what she wanted without allowing others to control or dictate her actions and without very extreme consequences (aside from obesity and all that accompanies it).

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Why Does Eating Food Feel So Good? In any case, while your patient might be extremely frustrated about her weight and her relationship to food and eating, it is likely that food by this time is also strongly associated with her experiencing a form of “easy pleasure”—to the point that few if any alternatives may feel quite as good, even if she pushes herself to give other options a try. (And, truthfully, it may be that no other activity will ever feel quite as good, or as simple as food has, at least for some time, no matter how hard your patient tries. It is helpful to predict this dilemma to her and discuss it at length.) Nevertheless, in order to aggressively combat weight and eating problems, your patient must stay focused on the importance of replacing her relationship with food with other pleasurable and meaningful activities that don’t involve food. As you discuss these issues with your patient, make it clear that the reality is that turning to pleasurable alternative activities other than food will have to become part of her lifestyle and her coping repertoire, even if initially or for some extended period of time, they don’t feel particularly great or “do the trick” in the way that food has. Remind your patient that with time, practice, and experimentation these activities will become more and more like second nature, in the same way that her new and healthier eating habits and exercise routines will become more automatic over time. Reassure your patient that although it might feel quite difficult to turn away from food as the primary source of pleasure and comfort, these alternative and pleasurable activities will not only be available to her in a “pinch” when she feels that she is at risk for overeating for any reason—in need of some quick tools that can help her cope without giving in to the urges to eat—they will also serve to enrich her “life away from food” in every sense.

Physical Activities May Be Best As you will discuss with your patient, many people combating food problems report that in their initial efforts to find other activities to replace the comfort, stimulation, distraction, and so on that accompanied eating, activities that involve physical movement seem to be more effective than those that are sedentary in nature. Why would this be so? Usually, when people are motivated to eat, it is to find some method for stimulating

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themselves, whether to rev up, calm down, or numb out. After all, eating is itself a physical activity that has a variety of effects on all aspects of the body, from the brain on down. It makes sense then that to replace eating as the source of the stimulation, other physical activities would work best, certainly better than stationary activities such as watching TV at home (which by all accounts can be linked to a pattern of overeating and weight gain). As you will discuss with your patient, the following general categories of pleasurable activities, as well as certain specific activities, are known to be helpful as replacements to eating. Pleasurable Activities

■ Taking a hot shower or bubble bath ■ Going for a walk or participating in some other type of exercise ■ Getting a manicure ■ Giving yourself a facial ■ Working in the garden ■ Engaging in sexual relations ■ Going shopping (but not for food!)

Activities That Are Incompatible With Eating In addition to requiring some energy output, most of the activities listed above are physically impossible to do while eating (or at least would make eating difficult). When trying out some new forms of pleasurable activities, your patient must not allow them to become paired with eating cues. That means not eating while she is engaged in the activity. The reason for this is that once a given activity includes eating, it can send a signal to your patient that she should be eating every time she participates in the particular activity. For example, if she has been one to go to a lot of drive-through restaurants, she might notice a desire to “drive by and pick up something to eat” whether or not she is hungry, every time she is in the vicinity. Similarly, if there is a certain vending machine at work from which your patient buys a snack every afternoon at  .., she

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might find it quite difficult, if not impossible, to pass by without purchasing anything.

Getting Out of the House While it will not always be possible for your patient to leave home to do something distracting and pleasurable to avoid overeating, often it is helpful to do so if she is feeling tempted to overeat particularly while at home alone with stocks of tempting foods (or even not-so-tempting foods). Going out might even involve your patient making the decision to get something (moderately portioned) to eat as a compromise position as she considers the various options that she has. While this involves “giving in” to the urge to eat on some level, still, this decision would be much better than your patient running the risk of overindulging at home where there may be large amounts of food and no particular “controls” (such as the presence of others or a limited supply of food) in place. Keep in mind that every time your patient experiences a success in preventing herself from engaging in an unnecessary overeating episode, she decreases the strength of the “pull” to eat for reasons other than appropriate hunger as she simultaneously strengthens her skill set for choosing more healthy alternative behaviors when she is tempted to inappropriately use food.

Realistic and Manageable Activities As you help your patient to brainstorm about alternative forms of pleasure other than eating, it is important that she learns to do so in a way that is realistic—that is, that she comes up with activities that she can actually afford, and do easily, in a variety of problem situations (e.g., such as at night at home alone, during the middle of a work day, on a weekend, or first thing in the morning—whenever it is that she feels at risk for overusing food). For example, remind your patient that while it is nice to think about getting together with friends for a walk or an outing of some sort, people are not always available when we want them to be and don’t always want to do what we want them to do at the times when we are available. While it is probably beneficial for your patient to include some social activities on her list, as well as a range of activities

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she can do alone, she wouldn’t want to include only pleasurable alternatives that rely on others’ company. Given that others are frequently unavailable, this might leave your patient feeling frustrated and disappointed, and with those emotions onboard, possibly more inclined to turn to food for comfort.

“Big Ticket” Activities While some major activities such as traveling or redecorating should be included on your patient’s list for special circumstances, these are best reserved as global lifestyle enhancers rather than “in the moment” strategies that can help her stay away from food. Similarly, if your patient lives in a cold climate, certain activities such as outdoor tennis or golfing, while nice in theory, and wonderful in the summer months, are not really possible during the winter months. Still, there would be nothing wrong with your patient listing these activities as “distant” or “far off ” possibilities to be used to enhance her lifestyle when feasible or at some designated point in time. Discuss with your patient the importance of staying open to the individuality of her own list of interests and activities. There are no set answers about what types of activities should be relaxing for any individual. The important idea here is to create a list of  or  things that she loves (or likes) to do that can help her to feel calmer, more at peace, relaxed, fulfilled, gratified, proud, and so on. The list might include some of the “bigger ticket” items that might interest her such as traveling to distant locations, signing up for a course on an interesting topic, redecorating a certain room in her house or apartment, or writing a short story or book. The list should also include several “in the moment” forms of pleasure that can be used in a pinch when your patient is feeling a rather immediate need to alter her mood state (or simply finding herself with free time) without access to many of the other “more serious” endeavors. While the list will of course be individually tailored to her needs and interests, it might include the types of activities that are available to her, for example, in the middle of the day or at night, when no one else is around, without generating great expense. These could be reading a fun magazine or book; taking a hot bath or shower; doing her own facial,

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manicure, or pedicure (or if available, getting these done professionally); taking a walk around the block; engaging in breathing, progressive muscle relaxation, or imagery exercises (where one envisions oneself taking part in a pleasurable scene of one type or another), and so on. These relaxation and stress management activities should be thought of as “pleasurable alternatives” that can be used at times when, in the past, your patient’s coping skills and options were not as great (meaning, for example, that she might have too readily turned to food and eating to solve whatever mood challenges she faced at that time). For those patients who might have had any type of substance abuse or alcohol problem (or cigarette smoking, for that matter) in the years prior to their consideration of weight loss surgery, creating a list of alternative pleasurable activities for relaxation is even more important. Ask your patient to create a list of pleasurable alternative activities. A sample list is shown below in Figure ..

List of Pleasurable Alternative Activities . Taking a hot bath . Reading a magazine . Chatting in eating disorder chat room on Internet . Calling a friend . Walking around the block . Doing a jigsaw puzzle . Origami . Writing in my journal . Reading a book . Doing a home manicure Figure 5.1

Sample List of Pleasurable Alternative Activities

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Basic Self-Care In addition to thinking about pleasurable alternative activities, your patient should also thoughtfully consider and address several areas of basic self-care (in addition to improving her relationship with food) as she prepares for gastric bypass surgery. You will discuss with your patient the basic concept of self-care and all that it means given the challenge of weight loss and the upcoming surgery (e.g., she may have been asked to lose some weight before her surgery). These include your patient’s sleep; physical exercise; alcohol, caffeine, and drug use; social and meaningful activities; relaxation and stress management; and of course evolving eating patterns. A list of basic self-care tools is included in your patient’s workbook. While taking charge of eating behaviors might appear to be your patient’s most pressing or essential self-care component to work on in preparation for surgery, it may also be the most challenging due to the basic complexity of her relationship with food and eating. Thus, these other areas that might appear superficially to be easier or more straightforward are important to work on simultaneously as she tries to make modifications in her eating, since the latter might go slowly and benefit from these other lifestyle changes. In making changes in these core selfcare behaviors, your patient will not only notice the benefits directly but also will begin to experience the type of mastery and success experience that happens when she sees herself following through with these goals on a regular basis. It is likely that this feeling of mastery will generalize to the way that your patient handles eating issues and all of the other issues related to preparation for the surgery.

Sleep Starting with sleep, it is important that your patient is trying as hard as possible to get  solid hours of sleep a night, if there is any way to do so. The exact number of hours that she is able to sleep will depend on her prior sleep patterns and overall history with sleep, as well as her current lifestyle and any past lifestyle issues that might have affected the way that she relates to sleep (e.g., a history of nightmares, trauma, or night-eating

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syndrome). Whether she is at all close to or far from the ideal of  hours a night, it is important to help your patient keep the following ideas about sleep hygiene in mind, as you attempt to help her get her sleep patterns back on track.

Sleep Hygiene Strategies

First, many professionals in the area of sleep strongly recommend that a person try to establish a regular bedtime and wake time. Just like with food patterns, your patient should attempt to set her body clock to know just about when she is expecting herself to settle down into sleep and just about when she will expect to arise from sleep. And similar to planning a regular schedule of eating, it is also important for her sleep patterns that she decide on a regular place to sleep. For some, this may sound both obvious and simplistic. However, there are many people, particularly among those who suffer from sleep problems, who don’t make the “commitment” or the effort to find their way to their own bed many nights, instead opting to fall asleep in front of the TV in the family room. In terms of the regular schedule for sleeping, in reviewing her typical sleep patterns in recent weeks or months, your patient might decide on  or  .. generally as her bedtime and  or  .. as her wakeup time. Once these ideals are set, the patient should then attempt to establish a routine for bedtime and wake time that enables her to achieve her goals as straightforwardly as possible. This might mean setting the alarm clock to the time she would like to get up and including a repeat function on the clock so that she doesn’t let herself off the hook by hitting the snooze button and going back to sleep. Similarly, with respect to bedtime, sustaining a regular pattern, if that is a new routine for the person working on her sleep, will probably involve establishing a series of wind down behaviors and habits that will enable the patient to feel de-stressed, relaxed, and sleepy when the actual bedtime approaches. These might include watching TV or reading (best if done in a room other than the bedroom), taking a warm bath, having a small snack (that is healthy and appropriate), doing mild stretching exercises, or engaging in relaxing visual imagery of some type.

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Often, it is best for the person working to improve her sleep to actually get into bed only after she has become sleepy, not simply because she feels tired. In terms of recommendations for exercise as it relates to sleep, it has been thought that exercising no fewer than  hours before bedtime works best. Also, consistent with the goals of good health and good selfcare, regular exercise can often serve as a method for decreasing stress and tension in general and therefore is thought of as an aid to good sleep for most people. Once your patient practices these concepts, she will understand and recognize the difference between how she is approaching sleep (and responding to sleep opportunities) now as compared to before. A list of sleep enhancement suggestions is included in the patient workbook. This list can also be downloaded from the TreatmentsThatWork™ Web site at http://www.oup.com/us/ttw.

Physical Activity and Exercise The next self-care behavior to discuss with your patient is exercise. For most people, of course, the ideal of moderate, regular exercise is the obvious recommendation. It is important to remember that your patient’s exercise goals and needs, and even the way that she defines moderate exercise, depends upon her level of fitness and conditioning and the advice and recommendations of her medical team. They might have certain concerns or qualifications based on her weight, specific physical issues or problems, and her general health and fitness. For example, if she is extremely obese, has serious medical issues, has difficulty even walking very small distances such as from the car into a building or around the block, or has not moved much for years, she may need to take it very slowly. It might be too difficult for her to jump into any type of regular routine, even a standard one involving – minutes of walking three times a week. The last thing you want to do is encourage your patient to push too hard, to the point where the exercise she is doing is extremely uncomfortable. This will make it less likely for her to get back to it in any form and possibly even dangerous to her health. If your patient is in a very de-conditioned state, it might be enough for her to try to walk in place for  minutes at a time a few times a week, either indoors or out-

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doors. She can also try to do the same  minutes of walking around the block (no hills though). Keep in mind, also, that your patient might consider activities such as gardening, window-shopping, or playing with her kids in the park—all of these count toward her exercise goals even if she does not consciously define these activities as formal exercise. Obviously, any “up and active time” burns more calories than sedentary time spent sitting or lying down. In addition, incidental day-to-day activities such as your patient parking her car farther from the door or taking the stairs more frequently instead of the elevator can add up to several more minutes of exercise a day. Over time, this equates to a few more hours of exercise per week or month. For some individuals, especially those who may have some lower body pain, stiffness, or other limitations, such as those imposed by prior joint replacements, it may be important to modify the physical activity recommendations so that water exercise becomes the primary activity of choice rather than walking. Even walking, which has a lower impact compared to other activities, might aggravate pain or stiffness or other pre-existing musculoskeletal problems affecting the lower body, if overdone. Also, general stretching activities, progressive muscle relaxation, and breathing training can be considered a part of your patient’s exercise routine, as a warm-up or a cool-down activity. You should encourage your patient to discuss any new exercise routine with her medical team to make sure that it is within the guidelines of what they are suggesting. No matter what, creating a regular schedule and routine for exercise, in a fashion that is similar to her efforts to regulate eating and sleeping behaviors, will help your patient to stay focused and committed to her exercise goals. Keeping an exercise log or journal along with a food record (or separately if that seems better) can also be helpful.

Caffeine Intake Probably your patient is not accustomed to thinking of caffeine as a potential substance to overuse or abuse. But excessive intake of caffeine can play a role in a person’s experience of anxiety, stress, and tension and can also contribute to the kinds of intense feeling states that can trigger episodes of overeating. While there are no very specific guidelines or absolutes

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pertaining to caffeine intake, it is a good idea to encourage your patient to try to limit herself to no more than a couple of caffeinated beverages a day. In terms of coffee, tea, and soda drinks (although most surgeons specify that one is not supposed to drink many—or any—carbonated beverages following weight loss surgery), your patient needs to limit herself to about two - to -ounce servings of coffee and possibly one additional caffeinated beverage per day. Mostly, the downside of drinking a lot of coffee is that it can give a person the “jitters” and a sense of incredibly overwhelming anxiety, urgency, or in some cases panic. These are all feeling states that for some of your patients might have been quelled with food, alcohol, or other nonoptimal tools for coping in the past. Also, caffeine can in the short term dampen appetite while in the long term actually stimulate appetite by causing metabolism to speed up enough that a person is left hungrier than they should be based on their intake. One additional issue with caffeine intake, particularly when it comes from coffee, and instant coffee more than percolated coffee, is that of gastrointestinal distress, in some cases diarrhea and gastric upset or heartburn.

Alcohol Many weight loss surgery programs advise that patients drink no alcohol for at least the first year after surgery and thereafter—while a small indulgence on occasion might be acceptable—limit their alcohol intake as much as possible. The reasons for this are manifold. First, alcohol, while providing a lot of calories ( calories per  ounces of wine and  calories for a standard -ounce serving of beer) provides no nutrition otherwise. The ingestion of these calories will contribute obviously to the overall calorie intake without providing the necessary proteins that are needed to keep the body healthy. (Yes, alcohol will provide carbohydrates similar to sugars but in a form that contributes nothing else nutritionally.) Second, the intake of alcohol can be disinhibiting in the sense that following consumption of alcohol, people typically are less thoughtful, clear, and committed to exercising good judgment than they would have been without any alcohol in their system. (Encourage your patient to think back to times, if any, that she might have been under

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the influence of alcohol and to recall possible compromises in her behavior or thought processes based in part on her alcohol consumption.) This lack of stellar judgment can specifically affect the way a person relates to food—that is, it can disrupt the usual “controls” that have kept eating in check while the patient was dieting to lose weight before weight loss surgery (and after). Remind your patient that she won’t want alcohol to get in the way of her “using her head” in all matters, including those of food intake. Finally, alcohol is a substance, as is food, and in that way it can appear at times to be a useful and productive tool for selfregulation—that is, regulating intense emotions, longer-standing problem moods, or other bouts of uninvited “intensity” of one type or another. But, while alcohol can appear to have the short-term effect of modulating your patient’s emotions, it is far from a productive solution. If used for this purpose over time, alcohol can begin to parallel or mimic other problematic tools for coping, such as food, used in the past. Obviously, most individuals who have contended with eating and weight concerns have at times relied on food to inappropriately provide a selfsoothing and gratifying component when they need to cope with some form of stress. Rather than replacing food with another substance such as alcohol, which can be overused or abused and which for some can become addictive or habitual, using other strategies such as talking to friends and loved ones, or a therapist, or engaging in meaningful hobbies or work to move through the problem times are more preferable. After all, replacing one addiction with another is not a worthwhile goal! If you feel that alcohol has become a problem for your patient, you need to address it with her and recommend additional professional help focused on the substance abuse issues as soon as possible. Encourage her to consider attending Alcoholics Anonymous (AA) meetings, which have an excellent reputation as a forum for working through substance abuse issues.

Illicit Drugs Much of the above discussion of alcohol also applies to the use of illicit drugs. In the case of drugs (particularly cocaine, amphetamines, any injected drugs, heroin, etc.), it is imperative that your patient seek expert help if she has experienced any level of use, not just use that has reached

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a problematic proportion in her life. Whereas with alcohol “a little” really can be acceptable (once the surgeon has cleared your patient for this), such as a small drink for a special occasion or celebration, no amount of illicit drug use is at all acceptable. Even the use of large amounts of marijuana is problematic and will need to be at least addressed by a substance abuse expert, if not also treated by that person. If your patient had a past history of use of any drugs, it was discussed in detail during the psychological evaluation that she may already have had (or is now preparing for) as part of her pre-op series of evaluations. To be accepted as a weight loss surgery candidate, she has to report that she has been clean and sober for at least  years. For those patients who used in the past, use at this time would represent a form of lapse or relapse that would signal the possibility of an ongoing use pattern developing once again. Whether this is the situation for your patient, or she is a new user of drugs, the issues discussed above with respect to alcohol would apply. In any case, no matter what the source, this would require some form of intervention as soon as possible. Stated as simply as possible: there is no room for illicit drug use before or after weight loss surgery.

Socializing and Social Support While there are obviously no hard and fast rules about what an adequate social support network could or should look like, the experience of your patient having people in her life—who care about her and who she cares about—can’t be overemphasized. Whether these people include a significant other, family members, friends, or an assortment of all of the above, staying connected to other people in intimate ways—meaning, through reciprocal conversation, shared activities, fun times and hard times—the existence of important others in one’s life has been linked to decreased stress and disease states and to an overall sense of health and well-being. As someone who has been dealing with a very significant weight problem for some time, your patient may (or may not) have let her social life lapse into near nonexistence—e.g., where there are few people and few meaningful contexts in which she engages with them. If this has happened to her—out of sheer exhaustion or inertia related to her physical state, social anxiety, lack of opportunity, or on some level, a perceived lack of interest in relationships (that may reflect other emo-

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tional issues such as depression or low self-esteem or a sense of resignation and “giving up”)—it is time to help her change all of that and restimulate her social life. One of the most straightforward and obvious ways for your patient to start this process is to take advantage of the network of people to which she is exposed through her involvement in one or more ongoing pre- and post-op weight loss surgery support groups. As a starting point, at the very least, a therapeutic group experience can help her retool her conversational skills, her feelings of safety around personal self-disclosure, her sense of understanding and empathy for others’ circumstances, and her level of confidence that others will listen to her and take her issues and needs seriously. Your patient might hear about other opportunities that are social in nature from her weight loss surgery support group. For example, if a group member volunteers at a communal garden, and gardening (or volunteer work) has been of interest to your patient, she might be able to make use of the group connection to get started pursuing those areas of interest. Also, it may be that friendships that begin in the group might extend far beyond the group experience to include recreational get-togethers and activities that involve your patient and one or more other people. Again, the idea here is to help your patient take steps to begin to socialize, if this has been an issue for her, starting with her weight loss surgery support group, in order to get some practice rebuilding her network by socializing with members of that group, but not to limit herself in any way from reaching far beyond the social experiences provided by the group. On the other hand, if your patient is someone who has been diligently maintaining a social life, exposing herself to an array of people and situations that create opportunities for forming meaningful connections, the message you would give your patient here is one of simply continuing what she is doing and possibly extending it some—if she is feeling a need for more meaningful social stimulation than what she has already been part of. To either deepen her existing relationships, expand upon those that are currently active, or create entirely new relationships will involve taking some risks—that is, extending herself beyond her usual comfort zone. While risk taking is never easy, it remains one of the essentials for changing one’s life and creating something new, similar to

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what your patient has decided to do in pursuing gastric bypass surgery as an option to solve her problems with weight.

Considerations for Teens For teenagers, social activities are in part structured by school and related activities. Like many adults, adolescents may feel that they will be rejected or teased by peer groups. However, usually they have a few close friends that they feel they can really trust. It is important for you to encourage your patient to keep those close friends while also beginning to reach out occasionally for new friends. Some of the best ways to encourage them to find new possible friends is through after-school activities or through youth groups associated with religious practices. The reason this is the case is that there are likely to be similar interests among members of these groups that can make the initial stages of making friends easier. Many times teenagers struggling with obesity have retreated to their families out of fear of humiliation or actual harassment. Although it may be difficult, one of your goals in your work with adolescent patients should be to identify reasonable ways to work on new friendships. Building new friendships will not mean that there is no longer a need for family, but it may mean that your adolescent patient will feel less dependent on them. For most adolescents, this is a good thing.

Meaningful Activities and Role Competence During the period of time in which your patient has been anticipating and planning for surgery, and possibly even for some of the time that she was struggling with obesity and secondary “hassles” and limitations to her life due to that, she might have disengaged from not only people and social activities but also from meaningful roles and activities that she otherwise might have taken on enthusiastically. For example, perhaps your patient decided to withdraw from certain recreational activities that she enjoyed and added value to, such as performing in a choir or other musical group; having an active role on a bowling, softball, or other athletic team; or taking on a leadership role at work, within a religious organization she is a part of, or in a volunteer capacity involving children,

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Meaningful Roles and Activities—Now and Plans for the Future Now

Plan to Get Started Soon

being a mom

going back to school

working at my job

starting to do an exercise class

having good friends

attending church more involvement in support group

Figure 5.2

Sample Meaningful Roles and Activities checklist

animals, or any other cause she might believe in. Since self-esteem and self-concept reflects the number of “eggs in a person’s basket” (or the diversity of a person’s meaningful roles and involvements with people and activities), it is important that you help your patient begin the process of rebuilding this part of her life, if she has allowed it to dissipate over the time that she has been dealing with obesity, eating issues, weight loss surgery, and any other health concerns.

Working With Adolescents Adolescents are first beginning to explore what things they would like to do and find meaningful. They might find participation in a youth group, volunteer organization, or extracurricular activity works well for exploring what interests and excites them. For many, however, schoolwork and preparing for college and work may be the main focus. You may find that helping them to increase their dedication to efforts that will lead to college or a career will help them focus on the other aspects of their lives that relate to changing eating and health-promoting behaviors as well. Have your patient complete the Meaningful Roles and Activities checklist in the workbook, in order to identify some of the meaningful activities and “competent roles” that she has in place now and that she would like to work toward reinstating at some point in the near future. A sample checklist is shown in Figure 5.2.

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Homework ■ Review all sections of the chapter and discuss these with your therapist ■ Create your list of pleasurable alternative activities. ■ Choose at least one of the activities to do in a situation in which you feel at risk for overeating. ■ Pick two or three of the basic self-care areas to start working on.

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Chapter 6

Challenging Eating Situations: People, Places, and Foods (Corresponds to chapter  in the workbook)

Materials Needed ■ Places to Eat Inventory ■ List of Correct Places to Eat ■ Problem-Solving Strategies for Handling Challenging Eating Situations ■ Comments and Reactions Log

Outline ■ Help patient identify the situations, people, places, and foods that are most challenging for him as he increasingly takes charge of his eating and weight problem ■ Assist patient in identifying the alternative situations, people, places, and foods that contribute to his forming and maintaining healthy eating behaviors and attitudes ■ Encourage patient to become aware of and list certain foods that have been most challenging for him as well as a method for becoming more comfortable with these foods The struggle for your patient to gain control over eating and to ultimately find a way to eat that facilitates slow but steady weight loss presurgery involves many different factors. Obviously your patient’s choice of foods and portions—of both “good and bad” and “healthy or indulgent” foods, and so on—will likely have the most pronounced impact on his weight, along with of course the degree of “output” (e.g., physi-

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cal activity such as planned exercise and unintentional movement such as taking the stairs, parking farther away, etc.) that he is able to fit into his schedule. Believe it or not, active choices that your patient can make about the settings in which he eats and the people that join him in those settings can also play a major role in contributing to the quality of his eating behavior in any one instance. In the sessions with your patient, you will help him to identify the changes that he needs to make in these areas to be more successful in the struggle to lose weight.

Stimulus Control You will teach your patient that when it comes to eating, certain settings are more appropriate than others. Obviously the kitchen, dining room, picnic table, and breakfast nook are areas in which eating should regularly happen; these places are already steeped in eating cues, and probably most people are conditioned to want to eat something when they sit down in these settings, particularly at mealtime. On the other hand, places like the couch (especially when it is positioned in front of the TV), the bedroom, the bathtub, the work desk, in front of the computer, and the car are not typical locations for eating. They only become paired with “eating cues” if, over time, one regularly begins eating when in these settings (e.g., when watching TV, sitting in bed reading, taking a bath, driving, etc.) You will want to underscore to your patient that once these “unnatural” eating situations become linked with food, it can be very difficult to disentangle them from those strong eating cues. For example, if nearly every time your patient sits down to watch TV he begins to eat something, to refrain from eating while watching TV will seem incredibly difficult if not impossible. You and your patient might share a laugh and think that it is rather incredulous that others might actually eat while in bed, in the bathtub, or in other hard to envision settings, but eating in these places actually does occur. Furthermore, it complicates things a lot when that individual finally makes an attempt to purify his eating environments by trying to limit eating to appropriate settings, when eating has spilled over into so many environments in this way. It is important to spend some time discussing with your patient the powerful feedback loops that get set up

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when specific situations and gratifying behaviors are paired. Initially, your patient will think that “it just doesn’t feel right” when first trying to limit eating to certain settings. Thus, the more quickly you can help your patient fully understand the issue of “stimulus control” and begin to get a grip on it—that is, limiting the number of automatic, situational associations to food and pairing eating only with appropriate places, times, and situations—the easier it will be for him to take charge of his eating behavior. The first place to start is to help your patient take an inventory, first just verbally and then later in written form, of all of the places in which he currently eats or drinks something on a fairly regular basis. You might want to help jog his memory here as some of these behaviors can become so automatic or unconscious that he might not even realize that he is eating in situations or places in which he ideally shouldn’t, for example, regularly drinking coffee drinks and eating pastries in the car on the way to work or snacking on peanuts or chips at his desk during the work day. The Places to Eat Inventory can be found in chapter  of the workbook or downloaded from the TreatmentsThatWork™ Web site at http://www.oup .com/us/ttw. Ask your patient to list all of the current “nonoptimal” eating environments that have become associated with food cues. The areas have been categorized into “home,” “work,” and “other” to help jog your patient’s memory about what he is doing in the various settings in which he spends time. Encourage your patient to simply check either the “yes” or “no” column for each area listed, and note any additional non-eating places in which he may be eating if these other areas or situations haven’t been included. After your patient completes the process of taking an inventory of these inappropriate places to eat, he should give himself credit by acknowledging the ways in which he is also eating correctly and in “all the right places” by opting for the kitchen or dining room table, among other appropriate sites. Instruct your patient to make a list of the proper eating settings that he is utilizing on a regular basis. The List of Correct Places to Eat form can be found in chapter  of the patient workbook or downloaded from the TreatmentsThatWork™ Web site at http://www.oup .com/us/ttw.

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You might have noticed, together with your patient, that the word “table” was used throughout nearly the entire List of Correct Places to Eat form (with nook or bar used in its absence). What the word “table” implies for most people is that eating takes place while sitting down not standing. Explain to your patient that eating while standing is another nonoptimal eating situation that can contribute to his eating in a manner that tends to be correlated with overeating rather than with eating in moderation. Discuss with your patient the reality that when people are seated, particularly over a meal, they are much more likely to be relaxed and at ease and, for those reasons, more inclined to take their time. On the other hand, while standing, most people are more likely to feel less relaxed and more in a hurry, as if they are “on the run.” Standing can equate to a style of eating that is neither calm nor relaxed but, rather, harried, as in swallowing large gulps of not well-chewed food that is neither really tasted nor enjoyed. Far different from the relaxed image of someone sitting at a table, nicely set with place mat, linen napkins, candles, and flowers, is the image of someone grabbing and gulping whatever is available while standing in front of the open refrigerator. Since it is known that satiety or fullness kicks in about  minutes after one has started eating, the slower and more relaxed the pace, the more inclined a person is to reach the state of fullness before too many calories have been consumed. As your patient will read in his workbook, one of the principal benefits of any type of weight loss surgery is that it will facilitate a more rapid experience of satiety or fullness once a person begins to eat. This is due in part to the small volume of food that the “new stomach” is able to handle, as well as the full sensation that can be a side effect of eating too much, too quickly, which can be both extremely uncomfortable and in some cases dangerous, leading to vomiting or “dumping syndrome.” Given that weight gain post–weight loss surgery can happen in certain cases, it will still be essential for your patient to learn, practice, and master all of the techniques that are typically associated with weight loss and weight loss maintenance by modifying his behavior. On this list of behavior modification techniques that your patient should practice and rehearse are both of the issues discussed above: choosing the appropriate settings and sitting down while also slowing down. Your patient will also train himself to consume very small quantities of food. It will be extremely helpful for him to purchase small-size plates and cups

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that make the food look more substantial rather than appearing minute. Part of your patient’s behavioral regimen required after surgery will be that of allowing himself adequate time for his meals and snacks ( minutes or more), to ensure that satiety or fullness sets in and also to practice relaxation while eating. To make this even more likely to happen, it is important to recommend that your patient begin to plan his meals and snacks in advance, in a much more diligent way than before, to ensure that all of the above strategies are in place and also to make it more likely that the principles of adequate nutrition and such will be upheld. To help your patient keep track of his progress in working through these issues, it might be useful for him to complete the Places to Eat Inventory and List of Correct Places to Eat forms now and then again in about six months.

Social Influences: Eating With the Right People in the Right Places Your patient might find that handling certain types of challenging eating situations, such as eating at someone’s home, out at a restaurant with a group of people, at a party, or at a work function, can be difficult when following any type of stringent diet and perhaps even more difficult as he prepares for weight loss surgery and readies himself for the type of eating he will have to do after the surgery. Your patient might report that it can even be a challenge in some instances to maintain an ongoing “eating relationship” with his family members and significant others when radical changes in his eating behaviors have taken place. Some of the challenge depends on the specifics of the situation your patient is in; for instance, handling a buffet meal comes with certain advantages (an individual can choose his own foods) and disadvantages (there is potential to eat much more than what would typically be served) as compared to a set, sit-down meal. Similarly, having an intimate meal with a small group of friends at a friend’s home presents different obstacles than going to a restaurant with the same group of friends. Traveling to a foreign country will present yet another set of challenges. No matter what the circumstance, there will be times when your patient will have to confront eating situations that push the envelope for him—in the sense that he will be forced to be focused on his eating plan and dietary

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needs and, given the options, also somewhat flexible in his choices. This balance between your patient’s maintaining his focus and staying flexible will ultimately prove invaluable in his long-term weight loss and weight loss maintenance efforts. To that end, you can remind him that it can be helpful whenever he is anticipating a challenging eating situation to do some problem solving in one of your therapy sessions and also in written form, as shown in Figure 6.1, to address and work through the challenges of the particular situation.

Working With Adolescents For teenagers, eating at school can be challenging. Usually they don’t have as much time at lunch to eat, the choices available are not usually the best, and they often have to put up with a fair amount of immature, loud, and otherwise distracting behavior. Thus the school setting is conducive to quickly eating unhealthy food, in an atmosphere that is not relaxing. However, as it is generally unavoidable, it is worth the effort to try to improve the situation as much as possible. Ways to improve this include encouraging your patient to take lunch with the food he wants and needs, to arrange to meet a friend or two for lunch, and to find as quiet a corner as possible to eat in. In addition to the challenges to eating that come with the territory that your patient is in, the people your patient is with during a given eating situation can either help or hurt when it comes to sticking with his program. There can be people in his life who are more like “coaches” and also those who are more like “saboteurs,” and obviously he will want his team line-up to include more coaches than saboteurs, to the extent that that is possible. No matter what, it can often be helpful for your patient to have at his fingertips a number of catchy and clever explanations and responses, should the curiosity of his dining companions result in their asking a lot of questions about his weight loss, food choices, and the like. In your therapy sessions with your patient, you can engage in some roleplaying exercises in which some of these catchy phrases and clever explanations are tried out.

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Problem-Solving Strategies for Handling Challenging Eating Situations Challenging eating situations: Getting home after work when I head for the fridge and overeat Goal(s) or desired outcome: A reasonable snack after work but not out of control overeating. Thoughts that will help me achieve my goal: I can do this if I set my mind to it. I need to come up with a plan that keeps me out of the kitchen after work. I could write reminders of my goal on the fridge and also go somewhere after work to relax for a few minutes before arriving home and finding myself in the kitchen. All it takes is one step at a time to change. Maybe I can exercise after work to avoid overeating. Behaviors that will help me achieve my goal: Put on workout clothes at work before getting in car. Stop off to get coffee and a small healthy snack on the way home. Meet a friend for a walk (combined with the above two). When I get home, read “reminder” on fridge (to not eat) before doing anything else. And after the fact: Did I achieve my goal?

Yes

x

No

If so, why If not, why not Forgot to bring workout clothes to work and felt bad and guilty about that, as well as tired. Went home and did same old thing of heading to the fridge without thinking. I should have followed my plans above, and then I think I would have achieved my goal. Figure 6.1

Sample Problem-Solving Strategies for Handling Challenging Eating Situations

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Questions and Comments Made to Dieters At some point, discuss with your patient the probability that others eventually will begin to make comments about his weight. Whether or not his friends and significant others know what type of diet he is on as he prepares for his surgery, they will likely begin to notice his weight loss after a given point in time. Your patient will likely find that once people notice his weight loss, questions will automatically follow, such as “How did you lose so much weight?”; “Did you have the surgery?” (fill in the blank with either “stomach stapling,” “gastric bypass,” “weight loss” or other words to describe the surgery); “Why are you eating so slowly?”; “Can you have that?”; “Should you be eating that?”; or “Don’t you think you’ve lost enough weight?” Also there might be observations about why your patient seems to be avoiding certain foods such as carbonated beverages or sweets, or there might be comments based on a thorough or simplistic understanding of the media’s depiction of weight loss surgery and the behavior changes that accompany it. Make sure that you invite your patient to discuss in your sessions all of his reactions to the comments, questions, and so on that are made to him about his weight loss so that at no time do uncomfortable feelings about these “unsolicited” attentions cause him to act out in any way with his eating. In addition to these types of questions and comments, your patient will likely be on the receiving end of statements that are mostly complimentary in tone but that at the same time might feel intrusive, depending on the exact content and the time at which they are made relative to his beginning the process of weight loss. And of course the way any of these comments sound will depend on the source, or who it is that is making the comment, giving the compliment, or registering the criticism and what your patient’s relationship with that person entails. (See earlier chapter on recording weight, which includes a table for keeping track of weight-related compliments.) For example, your patient might acknowledge that it would likely feel much different if a close loved one expressed concerns about how much weight he’s lost or the rapidity of the weight loss, compared to the same sentiments expressed by a mere acquaintance with whom your patient maintains a very superficial relationship. No matter what, it is important to encourage your patient to think about how any of these comments or questions affects him. If necessary, chart

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Comments and Reactions Log What was said, by whom and when: Date

12/2

Comment(s)

“How did you lose so much

Source

Reactions

co-worker

felt intruded on

friend

“Thanks, I have!”

mother

felt irritated—didn’t want to

weight?” 12/15

“You look great! Have you lost weight?”

12/20

“Are you getting too skinny?”

have to reassure her about my weight loss Figure 6.2

Sample Comments and Reactions Log

out the comments along with the specific thoughts, feelings, and behaviors that come up for your patient in reacting to what was said, similar to the techniques that were recommended in the section on compliments. The purpose of this exercise is to help your patient identify those external inputs that lead to unhelpful thoughts, feelings, and behaviors so that he can then challenge them using any of the CBT tools previously described and others that will be introduced later in the manual and discussed with you in sessions. A sample Comments and Reactions Log is shown above in Figure ..

Managing Challenging and “Feared” Foods: Choosing the Right (and Wrong) Foods in Moderation As your patient diets to lose weight before his weight loss surgery (and eventually learns a regimen for healthy eating after), he may notice that there are certain foods that are more tempting than others and even

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some that are still likely to trigger urges to overeat. Your patient may have discussed his relationship to some of these foods with you in session, particularly if he has been a binge eater who has had a problem in the past losing control over particular foods or food groups. For example, many people describe at times having cravings for salty snack foods or alternatively for sweets or chocolate. Sometimes these cravings may occur in relation to physical hunger, while at other times emotions may play a larger role. Occasionally, the mere fact that the food in question is stocked at home or otherwise available might be enough to create the problem cravings. Many of the foods that your patient might now struggle to control at times might actually invoke the feelings of a “lovehate” relationship based on a combination of strong cravings, a strong desire to avoid, and a not-infrequent tendency to give in to the urge to lose control and overeat or binge on these foods, for any number of reasons, typically followed again by a vow to restrict their intake. Instruct your patient that, no matter what, it is important for him to learn both flexibility and mastery over these types of high-risk foods. For example, it might be that your patient is stuck at some point at a celebration or party where only cake and ice cream—two of his most common binge foods—are being served. Whereas in the past he might either have lapsed into a bad bout of binge eating given the presence of these foods, or during a dieting episode eaten nothing at all at the party, only to binge eat on other foods later, ideally you would teach him to flexibly have “some” of these foods in moderation, without duress, in order to stave off either extreme in behavior (e.g., losing control altogether and bingeing or avoiding the perceived problem food for now and overeating later). Alternatively, another solution that you could teach your patient is to plan in advance to bring his own healthy (or acceptable, in his opinion) food to the event, if he is concerned that no appropriate food for him will be served. Encourage your patient to consider bringing his own food when he wants to uphold the option of learning to feel comfortable in avoiding some of his challenging foods altogether, or as much as that is possible, when this may be the most reasonable strategy to follow. For example, when these foods are really threatening to your patient’s health, such as sweets if he is a diabetic or very high-fat foods if he has heart disease, it is best for him to plan and prepare in advance to feel comfortable showing up with his own healthy stash of food.

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For some of your patients, depending on their particular psychological and emotional issues, it might be that avoidance altogether of these certain triggering foods sets up feelings of deprivation and “specific hungers” or cravings that ultimately increase their likelihood for losing control and binge eating when they are exposed to those foods. For example, if your patient is someone who has tended to overeat chocolate in the past but knows at the same time that he “can’t live without it,” it might be necessary to help him think about the concept of incorporating “just a little bit.” Encourage him to experiment with this behavior only at times when he is not vulnerable to overeating or losing control, to ensure that he can maintain a sense of mastery, flexibility, and power in his relationship to chocolate. Once your patient has had surgery, there will likely be certain clear-cut recommendations about foods to stay away from altogether, due to either difficulties with digestion/absorption or the ease with which these foods can lead to weight re-gain. For example, at some surgery centers or among certain groups of surgeons performing specific techniques, there might be recommendations against the intake of sweets for a year or longer (or forever) after weight loss surgery. In those instances, it may be that these foods really do become “off-limits” for your patient and that you should help him learn to start living without them as soon as he reasonably can. In other instances, there may be foods that are not optimal but that are acceptable as indulgences on a once-in-awhile basis. In any case, your patient will need to respect any of the recommendations that his surgeon has made, consistent with the general suggestions about exercising good self-care. With your patient’s permission, it might be helpful to at some point talk directly with his surgeon or dietician (or to review the written materials offered to your patient by the surgery program) in order to read firsthand about the recommendations that have been made to your patient and “translate” and support if and when that is necessary.

Incorporating Feared Foods Exercise As your patient begins to think about the list of foods that he loves/ hates/overeats/avoids, what might work best, in addition to talking about his relationship with these foods in your sessions, is to discuss the im-

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portance of following through on the “feared foods exercise.” This means that your patient should go to a grocery store and create a list of all of these types of challenging foods, walking each and every aisle of the store, so that none of the problem foods are omitted. A Challenging Foods List can be found in chapter  of the patient workbook. Figure 6.3 shows a sample completed Challenging Foods List. Once he accomplishes that, the next step is to categorize the listed foods into four different groups, ranging from how easy to how difficult it would be for him to experiment with eating a small or moderate portion of the food in question—that is, not fully avoiding the food but not overeating the food either. Remind your patient that completion of this exercise should also help him work through eventual urges to overeat even after his surgery, despite the physical limitations that the surgery imposes. You will talk at length with your patient about the realities of weight loss surgery and how “non-foolproof ” a method of weight loss it is, so that he moves forward with no illusions about it. For example, while any of the weight loss surgery procedures will make it much more difficult for your patient to overeat, and much less likely for your patient to want to overeat, the potential is still there, in particular the potential for your patient to want “just a little bit more” and to have “just that little bit.” These tendencies post–weight loss surgery, for individuals to overeat by a little bit now and again, to the point of feeling overly full or stuffed, and then to feel bad about themselves, can heighten their vulnerability to overeating again in the future in part because of these bad feelings. In any case, helping your patient to experiment with his intake of “feared” or challenging foods will be an exercise in mastery and flexibility over food that should generalize quite well after his surgical procedure.

Working With Adolescents For teenagers, it is often helpful to ask parents to help them out with addressing feared foods. Parents can work with you and your patient to establish a list of foods and the situations they want to experiment with. You might decide to start off by asking parents to buy and prepare the food and be there with their child when they try it, but work up gradu-

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Challenging Foods List Group 1 (Easiest)

Group 2

Group 3

Group 4 (Most Difficult)

bread

peanut butter

pizza

any red meat

jam

butter

ice cream

nuts

cheese

any chocolate

cookies

cheeseburgers_

sweet cereal

potato chips

brownies

French fries_

some crackers

pie or cake

donuts

Figure 6.3

Sample Challenging Foods List

ally to more independent experiments. In any case, you should try to use the resource of parents as much as possible to support this type of behavioral experiment.

Once your patient has created the list, you can begin to help him set weekly goals of eating a small amount of one or more of these foods (beginning with the least challenging and slowly working up to the more difficult foods) in settings in which he feels safe (e.g., not vulnerable to overeating because he is not “feeling fat,” “out of control,” or emotionally aroused or distraught in any way and when he is not in a situation in which he is likely to have access to large quantities of the problem food). Once your patient has set up his eating “experiments”—that is, set a goal of trying a certain amount of a challenging food in a planned situation—he should try to make a commitment to following through (except in the event of the presence of any of the vulnerability factors or danger signs for losing control noted above), and he should document his efforts (with a * or some other designation) in his food journal. Ideally, he will be doing such eating experiments up to a couple of times a week and, in so doing, will feel a great sense of liberation over any prior extremes, if these existed, in his relationship with particular foods.

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Homework ■ Read sections of chapter on where eating happens and complete checklist. ■ Take inventory of “people influences” on your eating and note effects of these. ■ Work with your therapist on developing your problem-solving strategies for various eating situations. ■ Create your feared foods list and begin to incorporate some feared foods into your meal plan. ■ If you’re a teenager, talk to your parents about feared foods and how your parents can help.

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Chapter 7

Teaching Your Patient About Problem Solving and Cognitive Restructuring (Corresponds to chapter  in the workbook)

Materials Needed ■ Problem-Solving Exercise ■ List of Common Cognitive Distortions ■ Cognitive-Restructuring Exercise ■ Situational Analysis Method

Outline ■ Help patient learn methods for identifying and working through challenging problems ■ Help patient identify common types of cognitive distortions ■ Teach patient methods for identifying and working through problem thoughts when she becomes aware of thinking in a distorted fashion ■ Teach patient methods that combine problem solving and working through her thoughts so that she can better handle situations that in the past might have led her either to overeat or to use other nonoptimal behaviors to cope with stresses of one type or another When your patient is faced with a dilemma of any type in which eating or overeating might have emerged in the past as the solution (albeit a faulty and temporary one) of choice, in addition to the tools presented earlier (e.g., pleasurable alternative activities), it is important to also help her learn about the option of engaging in formal problem solving. Problem solving is something that many people are able to do naturally and

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automatically, without giving it much, if any, thought at all. It might be something that your patient is also able to do quite easily in many, if not most, situations in which she is not stressed or overtaxed. For example, in a situation in which your patient wakes up on a given morning that is cold and rainy as opposed to warm and sunny, she is probably able to think through her options about what to wear and to easily come up with the solution of wearing warmer clothing and taking a raincoat and an umbrella. If your patient’s problem-solving skills are basically sound, then it is probably only in very stressful or complicated situations that she ends up getting “rattled” and for that reason becoming confused about what she wants or how to go about getting what she wants. It might be that many of those stressful or confusing situations ultimately involve using food to cope in one way or another, either as the only solution that appears at all potentially helpful or as a procrastination, delay, or distraction tool when a solid solution might appear to be too difficult or complicated to proceed with in a straightforward and easy fashion. When eating and food are used in this sense, they likely also serve the purpose of regulating your patient’s mood, in that they modulate the stress she might feel about the problem situation she is facing, as well as the challenge of implementing any of the complex solutions that might be warranted in the situation. For all of those reasons, it is important that you deliberately train your patient in formal problem-solving skills and also encourage her to practice and rehearse these skills as much as possible so that she can internalize them and make them as automatic as possible. When this happens, the process of working through even very complex and stressful problems and solutions will become much easier for her. Start by defining formal problem solving for your patient. Formal problem solving involves the following: identifying the exact problem that needs to be solved in simple terms, brainstorming (without screening) about the possible solutions, evaluating the practicality and probable effectiveness of each solution, choosing one or a combination of these, and following through on the selected solution or combination of solutions. The following sample exercise (Figure 7.1) illustrates the process of problem solving. A blank exercise is included in the patient workbook. You

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Problem-Solving Step . Define the problem in simple terms: I was invited to a friend’s pool party, and I want to go, but I am embarrassed about getting into my bathing suit and hanging around the pool in it with everyone else. Step . Brainstorm about solutions (without screening): I could decide not to go. I could go in regular clothes and not swim at all. I could have my suit on under a cover-up or other clothes and see how I feel once I’m there and make a decision then. I could ask the hostess about the guest list and see how comfortable I will be “exposing myself” to that crowd and then make a decision. Step . Evaluate the practicality and effectiveness of each solution (with either “⫹” or “⫺”): I want to go so not going is not an option (-) I want to have the option of swimming – no swimsuit seems like a cop-out (-) I like going with the option of swimming (+) Maybe I should talk to my friend in advance (+) Step . Choose one or a combination of solutions: I think I will call the hostess, who is a fairly good friend, and describe my dilemma (e.g., sensitivity about my weight) and “feel out” the situation but also go to the party, since I want to socialize, prepared to swim (by bringing my suit or wearing it under clothes) or not, depending on how it feels when I am there. Step . Commit to following through with your behavior: OK, I will be going to the party in some type of cover-up clothing with swimsuit under that; there’s no turning back now! Step . Evaluate the entire problem-solving method: This worked well. I was afraid to go, but wanted to, and figured out a strategy that worked for me by combining a couple of approaches to the problem and some flexible options. Figure 7.1

Sample Problem-Solving exercise

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should encourage your patient to make an effort to practice this method at least a couple of times a week on various problems that she might face and then bring in the completed problem-solving exercises to your sessions so that you can review and discuss them together.

Modifying Problem Thoughts In addition to helping your patient solve certain problems or dilemmas that she might face, there are also exercises that you can introduce and teach to help her identify problem thoughts and then modify them in order to keep them on the right track when she notices herself slipping into distorted ways of thinking. This distorted thinking may lead directly to eating problems or result in other types of emotional distress that can eventually lead to overeating or poor self-care in general. For starters, introduce your patient to the following list of common cognitive distortions that can help to get her started understanding what these errors in thinking are all about. . All-or-nothing thinking: You see things in extremes of black and white. . Overgeneralization: You take one negative event and extrapolate to a much larger pattern. . Magnifying the negative, minimizing the positive: You dismiss positive experiences or data points and deem those unimportant while instead holding fast to all of the negative. . Jumping to conclusions and mind reading: You make negative assumptions and interpretations, even involving others and the future, when there is no actual data to support your position. . Emotional Reasoning: You assume that just because you feel a certain way about a situation, the situation really is that way, rather than understanding that your feelings, while valid, don’t create a reality. . Labeling: You relate to yourself and others with pronounced labels, typically of a negative sort, rather than attributing the cause (of, for example, an error) to a situation or a specific behavior.

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. Personalization: You see yourself as the source or cause of an external event or situation when you are not responsible for it or “it is not about you.” (Burns, ) Once you have helped your patient identify the specific types of “thinking problems” that she is vulnerable to, you will introduce her to a technique called cognitive restructuring. Your patient can use this technique at times when she is troubled by problem thoughts that lead to vicious cycles of negative thoughts, feelings, and behaviors such as the above. An example of the emergence of a problem thought that then interferes with your patient functioning optimally would entail a situation in which she starts to feel self-conscious at a family gathering when she perceives people are watching her to see how much food she is eating because of their concern about her weight. Your patient starts to worry so much about her family members’ perceptions of her that inadvertently she finds herself overeating—simply because of the primary troubling thought that keeps running through her mind: “Everyone is watching me because they think that I weigh too much to be eating so much at this meal.” Your patient realizes later that although there was no actual data to objectively support her perception of her family members’ views of her, she made such a strong internal conclusion about their beliefs that she could not shake the thought from her mind. Ultimately, it was your patient’s own thought that led to a host of problem behaviors on her part (namely, negative feelings toward herself and others, combined with overeating) that could have been avoided if only she had made efforts to actively correct the distorted thoughts and follow a different thought process. It is really quite simple to teach your patient this exercise to challenge a given problem thought. All it involves is leading the patient through the steps involved once the problem thought has been identified. The steps include: writing down the core problem thought on the top of a page and then creating two competing columns of evidence, one called “objective evidence to support the thought” and another called “objective evidence to argue against the thought.” Once your patient has gathered all of the evidence on both sides, she should be able to come to some sort of conclusion that helps her modify the initial problem thought and regain her sense of clarity and calmness regarding the issue that was troubling

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her. Figure 7.2 shows how this exercise can be used to help your patient work through problem thoughts in a productive way, using the example of the family meal introduced above. A blank copy of this exercise is included in the patient workbook. After your patient practices these straightforward problem-solving and problem thoughts exercises a few times and discusses them with you, you might then encourage your patient to try one additional spin on problem solving, which combines both approaches by introducing the situational analysis method. See Figure 7.3. In this method, which can be used either prospectively, as your patient anticipates a certain problem situation, or retrospectively, after she has emerged from a problem situation either successfully or unsuccessfully, you can teach the patient to describe a problem situation that she is facing (or faced), the desired outcome that she wants (or wanted), what thoughts and behaviors she should have (or should have had) in order to achieve the desired outcome, and whether she achieved the outcome that she wanted. If your patient did achieve the outcome she wanted, she should describe which thoughts and behaviors were most helpful, and if not, she should describe how the situation actually turned out (the actual outcome) and which thoughts and behaviors were most problematic in obstructing her from achieving her goal.

Working With Adolescents Many adolescents (like some adults) are not able to use formal cognitiverestructuring techniques without a lot of therapist assistance. This is the case because cognitive restructuring requires perspective taking, generation of a range of alternatives, and the use of judgment about each option’s viability and value. You will need to help your adolescent patients to use perspective, develop alternatives, and assess alternatives. Therapists experienced with adolescents recognize that they will need to do the groundwork on such efforts, especially at first. Therapists need to avoid “taking over” but will be very active in these processes at the start. Problem solving is commonly used with adolescents when formal cognitive-restructuring strategies are too difficult or rejected. Problem solving is more direct, appeals to the immediate needs of adolescents, requires less in the way of judgment, and is experienced as being very prac-

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Cognitive Restructuring Exercise . Write out the “core” problem thought in simple terms. . Gather up and list objective evidence to support the problem thought. . Do the same for objective evidence that argues against the problem thought. . Come up with a “reasoned conclusion” based on the evidence that will guide you to appropriate and healthy behavior Problem Thought: Everyone is watching me because they think that I weigh too much to be eating so much at this meal. Supportive Evidence: 1. I see more glances coming my way from other people. 2. My daughter said, “Mom, do you really need that?” when I reached for a piece of pie. 3. When my brother saw me, he said, “Wow, it looks like you’ve gained weight, and I thought you were dieting. Are you going to be eating with us?” Disconfirming Evidence: 1. It was kind of a free-for-all at the table – everyone was interacting with everyone about food and other topics, too. 2. People in our family always comment on others’ weight and what others are eating; this is just how it is in our family. 3. Some other family members are overweight, too. 4. I know that I have been watching my weight and that I had deemed this a special meal that I could indulge at a little bit. Given that, I was doing pretty well at this dinner. Reasoned, Evidence-Based Conclusion (that will lead to positive behavior): People may have been watching me (or maybe not), but it really doesn’t matter what they say or think about my weight and eating, because I know that I was doing my best with food at this special meal and that it didn’t ruin my diet. So the last thing I would want to do is overeat because of them and my interpretations of what they were thinking. I will make an even firmer commitment to eat healthfully, for myself, not because of anyone else. Figure 7.2

Sample Cognitive Restructuring Exercise

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Situational Analysis Method Step . Describe the problem situation: I am going to a potluck lunch at work and in the past have always overeaten at these, usually on desserts, because I stand around and chat with people by the dessert table. I don’t want this to happen again. Step . Identify the desired outcome: I want to eat only one plate of food in all, including the main course, side dishes, and dessert. Step . Note helpful “reads” or thoughts that will move me toward my desired outcome: I am committed to not overeating in this situation. I deserve to eat lightly, like everyone else. I want to consume only one plate of food and to be very selective about what I take. Probably the food won’t be that good anyway; it always looks better than it is. Step . List behaviors that will help me achieve my desired outcome: Relax by doing some deep breathing (and deep thinking!) before the luncheon. Go up to the buffet line after a lot of people have already gone through, so that it doesn’t feel like a big rush. Look over the entire array of food first so I can choose wisely. Pick one or two small servings of main courses, side dishes, and small desserts, and remember they have to fit on one plate. Sit down with my plate, far from the buffet table, eat slowly, and talk a lot to people while I’m eating. Don’t get back in line. Step . Assess my outcome: Did I achieve my desired outcome? If so, which thoughts and behaviors were most helpful? Yes! The commitment to the new behaviors made it most easy to achieve what I planned, and relaxing and thinking through the image of what I wanted to do in advance helped a lot. If not, what was the actual outcome, and which thoughts and behaviors got in the way the most? This didn’t happen, but I might have gotten off track and “overstimulated” if I had let myself get caught up in the rush of people initially in line and if I had dived in for a whole bunch of food/desserts first, without surveying the scene, planning to take only what I wanted, and committing to only one plateful. Figure 7.3

Sample Situational Analysis 74

tical. CBT therapists working with adolescents have found that problem solving is more likely to be employed with this age group than formal cognitive restructuring.

Homework ■ Review problem solving, discuss with your therapist, and complete a few examples during the next week or so. ■ Review cognitive restructuring, discuss with your therapist, and complete a few examples during the next week or so. ■ Review the situational analysis method, discuss with your therapist, and complete a few examples during the next week or so.

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Chapter 8

Working With Your Patient on Body Image Issues

(Corresponds to chapter  of the workbook)

Materials Needed ■ Form: My Body Image Perceptions ■ Form: The Ways That I Check My Body ■ Form: My Body Checking Behaviors: How Frequent Are They? ■ Body Image Journal

Outline ■ Teach patient the concept of body image and encourage him to discuss some of the contributions to his body image with you (as they relate to the CBT model) in sessions ■ Increase patient’s awareness of the issue of “body checking” and help him learn to keep frequency counts of these behaviors ■ Educate patient about the links between his body checking behaviors and certain thoughts, feelings, and other behaviors ■ Focus patient on identifying body parts that he appreciates and that have nothing to do with weight and shape, and help him learn to associate these with positive thoughts, feelings, and behaviors ■ Encourage patient’s use of “body image journals,” capturing both the more negative and positive experiences You might find that your patient is somewhat in the dark when it comes to what his body image is all about. He might not understand exactly

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what the term “body image” means, or he might be so resigned to concluding that his body image is defined in full by the fact that he is overweight that he hasn’t explored the concept further. Like with the issues of weighing himself on the scale, he might simply have put his head in the sand when it comes to even thinking about the notion of his body image—thereby avoiding the concept altogether. So one of the first places to start with your patient is with the definitional issues, by exploring in session the question of what is body image? In talking to patients about this complicated notion, often the best and most straightforward place to start is with a definition like this one: that body image is a person’s internalized version of the physical realities of his body. That means, most simply, a combination of how he thinks and feels about his body historically and also at any one point in time, based on the inputs of that particular situation at that particular moment. For example, your patient’s body image might vary somewhat even over the course of a single day, depending on whether or not he has eaten and how much, if he has exercised and how much, or what clothing he happens to be wearing and how it fits. Another example would be that of your patient feeling somewhat slim and in control of his body having eaten relatively little before a large holiday meal, whereas after this type of meal, say Thanksgiving as one example, he might have the contradictory experience of feeling “stuffed,” overly large “fat,” or “bursting at the seams,” particularly if any items of his clothing have started to feel a bit tight after eating. Alternatively, after a long session at the gym, your patient might again feel differently about his body, that is, he may be experiencing himself as relatively strong, thin, and on the road to fitness. You will want to encourage your patient to take a few minutes during the session to jot down a few words in the My Body Image Perceptions form provided in his patient workbook. Figure 8.1 shows a completed sample of this form. He should use this form to characterize his body image in general, as he thinks about it in an ongoing way (e.g., not in response to a large meal, an exercise session, or a diet). It is important to take some time also to allow your patient to reflect in the session on the words that he has written in the workbook. Likely, at least some of these body image–related reactions and perceptions might at times lead to certain emotional reactions, either bad or good, some of which might even trigger episodes of eating or overeating for him, as discussed in earlier

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My Body Image Perceptions I feel that I am fat . . . and I feel that I have been that way my entire life. Mostly I don’t know what it is like to feel really good about or proud of my body. I tend to cover up a lot, at the beach, etc., or even to avoid activities and places where more of my body might show. It is hard for me to think about my body “beyond” the issue of my weight. Although some people compliment me on my hair and my eyes, also, I usually don’t take these into account when I consider my “body image.” Figure 8.1

Sample of My Body Image Perceptions

sections of the manual. It is likely that many of your patient’s experiences throughout his life have contributed to the way that he feels about his body, as described in the earlier section on the CBT model, and you might want to encourage your patient to keep all of those contributions in mind as he works through the various parts of this chapter. It will be important as you help your patient become more and more aware of his thoughts and feelings about his body that you spend time in the sessions devoted to the issue of body image, discussing it in depth, particularly as his weight loss surgery date draws closer. While radical weight loss of the magnitude usually facilitated by the surgery might affect positive change in your patient’s body image, there is no guarantee that weight loss will lead to improved feelings about his body. On occasion, the weight loss only serves to intensify negative feelings about the “whole self ” not just the “bodily self ” that your patient might have been displacing in full onto his body. It is important that you prepare him for that possibility, as well as for the reality that it can take some time before the rapid weight loss facilitated by the surgery actually starts to really “look good” on his body beyond registering in any variety of “interim” ways that might appear somewhat unattractive (e.g., unevenness in weight loss, lumpiness, loose skin, feeling generally “saggy” and out of shape, etc.). It is imperative that at the same time that your patient is losing weight (before his surgery, if that is recommended, as well as after) you encour-

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age him to maintain his focus on the underlying issues of self-image that in the end are most likely the root source of the feelings that he has about his body no matter where his weight ultimately lands after his surgery. In chapter , your patient read about the importance of weighing regularly and obtaining a variety of measures of his body size, shape, and general appearance (including to some extent the comments of others). He learned about regularly assessing his body in order to keep track of where he is on various indices. Probably, with respect to body weight and shape, and possibly also as related to body image, your patient has been informally doing this for some time, although he may have been quite unaware of it. Examples of how certain individuals “keep tabs” on their body (and respond with certain types of thoughts and feelings about what is happening to their body, whether positive or negative) include very common behaviors such as often looking in mirrors, windows, or any reflective surfaces; pinching various areas of the body such as the upper arms, forearms, or thighs; trying on different items of clothing to see how they might fit; and/or sitting in various pieces of furniture to see how the furniture fits them. If your patient is actively and regularly engaging in any of these behaviors, it is quite likely that he has never before given much thought to the notion of how these behaviors affect his subsequent thoughts, feelings, and behaviors. Now is the time to help him start making these links. Helping your patient create these insights is very important, as in many cases, he will come to realize that the “results” (in the form of cognitions, emotions, and behaviors, including decisions about eating) of body checking of this type are only negative. The first place to start is by helping your patient get in touch, over the course of a week or so, with the strategies he is using to keep track of what is happening with his body. Help your patient to first keep a log of the different types of body checking behaviors that he engages in regularly (if any). Then eventually help him add some frequency counts to this data, so that over time he becomes more aware of how often he does what. For example, many people have been quite surprised to realize that they are pinching their upper arm or stomach to “see how fat I am” up to  times a day! Clearly, their weight could not have changed dramatically, if at all, within a day’s time, yet their method for continually checking by pinching themselves provided them some sense of anxiety mastery or the illusion of “staying in control” of any changes that might

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The Ways That I Check My Body Looking in the mirror Trying on multiple pairs of pants each day Pinching the “flab” on my stomach Seeing how much of a certain armchair that I take up Looking at myself in store windows every time I walk by Figure 8.2

Sample of The Ways That I Check My Body

be happening. Realistically and at a distance, it is clear that pinching any part of the body and actual weight gain can in no way be naturally correlated (no amount of checking behavior of any type, be it pinching, trying on multiple pairs of pants, or weighing on the scale can prevent weight gain if a person is overeating). See Figure 8.2 for a sample. Later, after this baseline data is collected, there will be further opportunities in sessions devoted to this material to explore more about your patient’s thoughts, feelings, and behaviors that seem to follow from these “body assessment” experiences. Next, after discussing the above (types of body checking behaviors) with your patient, you will want to encourage him to start keeping “frequency counts” of how many times he is engaging in any of these “body checks” each day. Your patient will be using the chart shown in Figure 8.3 (also found in the patient workbook) to enter his “body checking data” as this becomes available over the next couple of weeks or so. Encourage your patient to simply transfer his list from the exercise above (The Ways That I Check My Body) to the frequency chart and then begin to make tally marks for each of the seven days of the upcoming week, for a grand total for the week per each behavior. Ultimately, you and your patient will discuss the importance of decreasing all types of the excessive checking behavior over time, particularly as you will be helping your patient to note the links between body checking and problem emotions, thoughts, and behaviors. As your patient tracks the frequencies of these behaviors

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My Body Checking Behaviors: How Frequent Are They? Su

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Looking in the mirror

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Trying on more than one pair of pants

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Pinching my upper arm

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Figure 8.3

Sample for My Body Checking Behaviors: How Frequent Are They?

per week, you will be looking to see downward trajectories for each. You will want to reinforce to your patient that this goal of decreasing excessive body checking behaviors doesn’t contradict the earlier message about the importance of weekly weighing sessions and other forms of “checking in” with what’s happening with his body in moderation (e.g., trying on different pieces of clothing and such.). It is just the excessive checking that becomes problematic, just as much as does pure denial—which you can otherwise describe to your patient as “putting your head in the sand.” Next, after you discuss your patient’s “frequency data” with him, you can encourage him to note the thoughts and feelings that seem to come up for him when he “chooses” (after all, it is a choice, to pay attention to or “check” a certain part of the body that might have some symbolic meaning related to one’s overall weight) to focus or dwell on this area or areas. One would surmise that many of the thoughts and feelings would be more negatively toned than positive, given that the presence of body checking often implies anxiety of at least mild or moderate intensity and that the behaviors associated with those thoughts and feelings would run the gamut from avoiding people to avoiding other positive events or experiences to overeating (as but one nonproductive “escape route” from the negative feelings). It might be easiest and most straightforward to encourage your patient to do this in some sort of a journal form or in the Body Image Journal I/Body Checking–Related Thoughts, Feelings, and Behaviors form found in the patient workbook, so that he can write about the issues freely and then have a written document to review with you in the sessions devoted to this material. See Figure 8.4 for a completed sample.

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Just to get your patient started, encourage him to keep in mind the following “equation”: Body Checking ⫽ thoughts, feelings, additional behaviors, and maybe more body checking Once your patient has written down the specific thoughts, feelings, and actions that occur in relation to certain body checking behaviors, he can apply one or more of the cognitive-restructuring, problem-solving, or situational analysis techniques to his experiences. For example, if your patient finds that when he tries on too many pairs of pants or too many shirts in the morning, he starts on a downward spiral of thoughts that goes something like “I am fat, nothing fits anymore, I am going to cancel my lunch time walk with friends,” and so on, and then he stays home alone and overeats, it is clear that he is creating a negative experience for

Body Image Journal I/Body Checking–Related Thoughts, Feelings, and Behaviors When I try on more than one pair of pants, my thoughts start to run like this: “Maybe I am not as fat as I thought,” “Maybe I have gained more weight than I thought,” “Perhaps these are tight because I just washed them,” “I am afraid to get on the scale to just see how much I actually weigh.” The feelings that I end up experiencing are all about anxiety and worry – for example, I end up feeling very, very concerned that I am “off track” in what I think is happening with my weight, especially if I have not weighed for a long time. The anxiety or low mood might stay with me for a day or even more. . . and usually when I am feeling that way, I end up eating more to try to feel better. I realize it is such a vicious circle; I just don’t know how to stop. The same thing used to happen when I would weigh myself many times a day, but fortunately I have stopped that, at least for now. Figure 8.4

Sample of Body Image Journal I/Body-Checking-Related Thoughts, Feelings, and Behaviors

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himself that could be interrupted by learning to try any of the following strategies: ) altering his thought process; ) focusing on the problem situation at hand and identifying a constructive, desired outcome that he can work toward; or ) engaging in some type of problem-solving exercise that will help him identify, at the outset, situations in which he is vulnerable to body checking behaviors that will make him feel bad, think bad, and act badly, too. Another issue often overwhelming to those with obesity is the basic difficulty of validating their right to consider any other aspects of their body or appearance, other than their weight, as important in playing a role in determining their level of attractiveness as a person. Therefore it is essential that you help your patient get in touch with all of the other parts of his body and physical appearance that he might like and value and that might even compensate at times for the way that he feels about his weight and shape, if and when he might get down on himself for carrying more weight than he needs. For example, some people are able to acknowledge that they have very nice hair, hands, eyes, even feet, or a rosy, glowing complexion. Ask your patient to consider if and when he has ever stopped to ponder the physical attributes that make him feel good about his physical self, no matter what is happening with his weight. Whether your patient has done this before or not, encourage him to take some time to jot down a few notes about the physical features that he might also value. See Figure 8.5 for an example.

Working With Adolescents If your patient is a teenager, you might find it very useful to go over these exercises with your patient’s parents. One reason is that sometimes adolescents do not perceive that they are body checking, while outside observers like parents do. In addition, family members might have some things to add to a positive qualities list that adolescents themselves haven’t considered. They may also be able to help you and the adolescent think through some of these issues. It may seem awkward at first to include parents in some sessions, but as you get used to it, you will find you learn a lot of helpful information that will be useful in your therapeutic work with the adolescent.

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Physical Features That I Like (and that have nothing to do with my weight) I like my hair. I was told that I have a nice complexion. I usually get compliments on my hands and manicure. My eyes are a nice color. Figure 8.5

Sample of Physical Features That I Like

Body Image Journal II Appreciated Physical Features: Related Thoughts, Feelings, and Behaviors When I am able to “look beyond” my weight and appreciate the other attractive features that I have – features that I like and that other people have complimented me on – I feel much better about myself as a person and much more likely to treat myself well. What I mean by that is when I am feeling good about who I am physically, I am much less inclined to overeat or to in any way behave in an unhealthy fashion. So the thoughts would be: “There are a lot of aspects of my physical appearance that I like and value.” And the feelings would be some relative sense of peace and contentment. And the behaviors would be acting more like I LIKE myself, e.g., not treating myself poorly. NOT overeating, NOT under-exercising, allowing myself to reach out to friends that I like, etc. Figure 8.6

Sample of Body Image Journal II Appreciated Physical Features: Related Thoughts, Feelings, and Behaviors

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In relation to these non-weight-related body perceptions, it is equally if not even more important to help your patient get in touch with the thoughts, feelings, and other behaviors that result when he focuses on them. For example, if focusing on a “negative” body aspect such as the flab on his stomach reminds him that he is “fat” and sets in motion a spiral of despondence, depression, isolation, and overeating, it should stand to reason that the converse would also be true, that focusing on his full head of hair, nice eyes, or translucent complexion would lead to feelings of well-being, contentedness, and good self-care. In the same way that your patient kept track of the more negatively toned body checking– related thoughts, feelings, and behaviors, he should be encouraged to do the same with these positive experiences in the Body Image Journal II (see Figure 8.6) in his workbook. You will take several weeks in sessions devoted to this material to discuss the issues, and undoubtedly both of you will come back to it time and again as your patient progresses toward surgery. Remind your patient that it will be important at various phases after his surgery to continue to monitor his experiences with body image, including “checking” and other associated behaviors, thoughts, and feelings. This ongoing focus on body image will be important, because as his body changes so rapidly in response to the weight loss, his perceptions of his body will also be expected to fluctuate and become destabilized at times, possibly more during times of stress than when all else is status quo.

Homework ■ Read and discuss the chapter with your therapist. ■ Begin self-assessment of body checking areas and frequency counts. ■ List “appreciated” physical attributes. ■ Start to work on both body image journals, the one reflecting thoughts and feelings after body checking and the one associated with thoughts and feelings about appreciated attributes. ■ If you are a teenager, ask your family to help with these exercises to expand your perspectives and to use them for support.

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Chapter 9

Congratulations! Your Patient Is on the Way to the O.R. (Corresponds to chapter  in the workbook)

Materials Needed ■ Pre-Surgery Planning Journal ■ Exercises to access and clarify feelings about surgery ■ Instructions for breathing, progressive muscle relaxation, and visual imagery

Outline ■ Orient your patient to all of the issues still to be addressed before surgery. ■ Guide your patient in getting in touch with deeper thoughts and feelings about the upcoming surgery. ■ Facilitate your patient’s use of checklists and exercises pertaining to these issues.

Addressing Agenda Items No matter how much time has passed since your patient first began to consider a weight loss surgery procedure, as she gets closer to scheduling her surgery or moves closer to her actual surgery date, you will want to help her create and maintain a written list of the agenda items that need to be attended to before she actually undergoes the procedure, so that all of the agenda items are kept “top of her mind” and none are forgotten.

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Professional Consultations Obviously, one of the most important issues here is that your patient has selected a weight loss surgery program that she is comfortable with and a surgeon who has agreed to work with her and perform the particular weight loss surgery procedure that she is looking for, given the options that are available to her. As part of the process of deciding on a weight loss surgery program and professional “team,” your patient should have obtained a referral from her primary care physician and also communicated with her insurance company to determine the extent to which the array of recommended and required medical visits and treatments associated with her surgery are covered. It is likely that her physicians and the members of the surgical team will have completed and submitted to her insurance company a variety of forms and other paperwork to support her need for the surgery; in some cases, the psychological evaluation will also be requested by a patient’s insurance company. In working with a particular surgeon and surgery center, your patient will have been given a list of pre-operative guidelines, including the requirement for the pre-op session(s) with a mental health professional, dietician, internist, and possibly other medical personnel. And in some instances a significant other or close friend might be asked to accompany your patient to a given meeting.

Follow Through With Recommendations In the context of all of the professional consultations that your patient will take part in, it is likely that several recommendations have been made about what she needs to do to ready herself for surgery. These suggestions might pertain to, for example, starting on a weight loss diet and exercise program or losing a given number of pounds by a certain date, or (separate from a goal of weight loss per se) eliminating or decreasing certain foods from the diet that may be problematic after surgery, adopting a specific eating schedule that is more consistent with what will be required post-operatively, or improving the nutritional quality of the diet. Other suggestions made during the series of evaluations may not be specifically related to weight loss, nutrition, or exercise. These might include participating in a support group comprised of both pre- and post-

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operative weight loss surgery patients that is focused on all types of issues related to the surgery; meeting with a mental health professional one or more times (in addition to the initial consultation) to work on issues of self-care, mood regulation, emotional eating, or other concerns (e.g., consistent with the work you are doing with your patient); starting on a medication or other treatment for any condition that has been diagnosed that warrants an intervention (e.g., using a C-PAP machine to treat sleep apnea); or starting on an antidepressant or mood management medication to improve or stabilize your patient’s emotional state. No matter what the particulars, as your patient’s surgery date (or scheduling of it) draws closer, you should be helping her to “keep tabs” on which consultation sessions have been completed and which are pending, and what she needs to do to ensure that a given meeting gets scheduled. (Programs and individual practitioners may differ in terms of the expectations regarding the “flow” for scheduling, that is, “who contacts whom” to set up appointments and follow-up meetings.) Encourage your patient to use the Pre-Surgery Planning Journal in chapter  of the workbook to help keep track of all aspects of surgery preparation. You might recommend that she start by recording events and “to do” items on a day-by-day basis. Later, she can use the checklist provided in chapter , along with her pre-surgery planning journal, as she gets even closer to the date.

An Introduction to Emotional and Interpersonal Readiness Another set of issues that your patient needs to look at and consider seriously before surgery is that of emotional and interpersonal readiness. What this means is that your patient begins to think about all that the surgery means to her, in relation to certain goals, concerns, and so forth— for example, following through with something she has wanted to do for herself for some time to improve her life, while simultaneously facing the potential for certain risks and negative consequences that are always associated with radical surgery. Remind your patient that many different kinds of emotions might surface as you and she, in your sessions together, begin to take a look at this layer of her experience with the surgery. She might notice feelings of guilt that she is “allowing” herself the

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surgery when she’s not sure she deserves it or anger that she has unfairly had to experience a weight problem to the degree that surgery is required. Likely, both anxiety and sadness, as your patient faces the unknowns of surgery and what lies ahead for her after, will be part of the picture, as well as great enthusiasm and excitement about the outcome and her new life after radical weight loss. All of the feelings will be linked in some way to various aspects of your patient’s changing relationship with food, her body, her sense of herself, and her relationships with other people. As she delves into all of her emotions about the surgery, you will want to help her to stay well aware of the “opposing currents” nature of many of these changes that she is beginning to face. Her relationship with food will change following surgery, for both good and bad, meaning that while she will be “forced” in a sense by the procedure to adopt a more healthy relationship with food, this changed stance will also involve loss, that is, no longer having the option to use food to excess, in an attempt to soothe and comfort herself in response to the difficult emotions or situations that she may face, and no longer having the option of just eating too much for pleasure. Another example of a “mixed bag” of feelings might be the bodily changes that your patient anticipates following her surgery. While weight loss and all that comes with it, such as improved health, mobility, and appearance, is your patient’s goal in following through with weight loss surgery, she won’t be able to predict in advance exactly what the “new, thinner version” will look like or how her body will “hold up” in response to the massive weight loss. Yes, her clothing sizes will eventually decrease and, over time, radically so. But certain other issues might arise in the process of your patient losing her excess weight, for example, an accumulation of excess skin that doesn’t shrink back after weight loss, the possibility of hernia or hair loss, and/or the experience of simply feeling disoriented in a physical person that she no longer recognizes in full. In addition to encouraging your patient to think through all of the feelings that are likely to come up as she progresses through surgery, it is also important to facilitate her thinking in advance about the way that she has communicated to her loved ones, friends, acquaintances, and others all that she wants them to know about what she is and will be going

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through. You might help her focus this discussion within herself by thinking through ways in which she can tell her loved ones and others how they can be helpful to her before, during, and after the procedure. She might also share with them her sense of what they inadvertently might do that would be harmful and not helpful to her process of preparing for and recovering from her surgery, her hopes and fears, should the surgery not go well—or even more remotely, in the event of death related to the surgery—the thoughts and feelings that she would want to share with them in advance. The point here is not to force excessive sentimentality on your patient about what she will be going through emotionally and interpersonally as she undergoes surgery but rather to have her realistically assess what is happening “inside” of her as it relates to the upcoming surgery and based on this what needs to be addressed “on the outside.” Finding the space to do this kind of work well in advance of the surgery makes it much more likely that your patient can work productively on the issues noted above with a clear and level head. The issues raised in the last two sections will be discussed in more detail below.

Exercises to Access and Clarify Feelings About Surgery This section in the workbook provides space for your patient to thoroughly examine and write about her deepest thoughts and feelings about the weight loss surgery that she is about to undergo. As she gets closer to the date of surgery, she might notice that her thoughts and feelings change; thus it will be important for her to keep an ongoing chronicle, in journal form, of “where she is” in relation to surgery.

Deservedness Exercise # in the patient workbook, Why I Am Deserving of Weight Loss Surgery and How It Will Improve My Life, provides an opportunity for your patient to write about why she deserves the surgery, what types of positive changes she is hoping for in undergoing the surgery,

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and all that she has been doing to appropriately care for herself in preparation for it.

Ambivalence and Concern Exercise # in the patient workbook might be more difficult for your patient to do. It gets back to the idea of the “opposing currents” or “mixed bag” of feelings that often come with complicated terrain like radical elective surgery. Specifically, it addresses the “costs” aspect of the “costs and benefits” analysis that your patient completed in one of the early chapters associated with choosing to undergo weight loss surgery. Here, it is important that you encourage your patient to take time to think through and freely express in writing any and all of the fears, concerns, worries, or misgivings she might have about the surgery. Of course these will differ across individuals, but the list might include attention to some of the physical risks associated with undergoing any surgery, or weight loss surgery in particular, including the risk of mortality; general worries about complications and physical discomfort; difficulties with healing; or more “trivial” worries associated with being in the hospital, finances, time away from usual activities, and the like. By the same token, it is also essential that you help your patient get in touch with any subtle or hard-to-access issues of “entitlement” that she might also have about the surgery and her recovery from it. Here, entitlement means assuming a somewhat grandiose attitude that denies any of the negative aspects potentially associated with the procedure or recovery from it. While obviously staying positive is of the utmost importance, not blinding oneself to the potentially negative consequences of the surgery (see section immediately below) is also essential. Without keeping the door open to allow for appreciation of both the positive and the negative (e.g., exercising sound judgment, clear thought processes, constructive problem-solving strategies, effective emotion regulation techniques), your patient will not be appropriately prepared to take herself and her self-care seriously at all stages of the surgical experience: preparation, initial recovery and healing, later recovery, and long-term maintenance of change.

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A Changed Relationship With Food and Eating Exercise # in the patient workbook pertains to your patient’s relationship with food and eating and how these areas of her life specifically will be affected by the surgery. Obviously, it is impossible to understand the extent to which your patient’s relationship with food will be changed by the surgery, until the procedure has been done. But, clearly, her relationship with food and eating will be profoundly and permanently changed (with the exception of lap band surgery, which can be to some extent “reversible”). While individuals become obese for different reasons—some may have a very strong familial predisposition such that, despite basically sound eating and activity patterns, obesity is a foregone conclusion, while others may have had long-standing habits of overeating or binge eating, combined with inactivity, that have caused or amplified the problem— food likely has played a significant role in their lives no matter what the fundamental contributions to their weight problem. This may be for no other reason than the fact that, for good or for bad, the attention to dieting causes one to focus on eating, thereby further amplifying its importance. Once the surgery is done, your patient’s relationship with food will have to be more “deliberate,” careful and mechanical, at least at first, until the newly developed eating habits become second nature. Despite the fact that the net effect of having weight loss surgery should be a decrease in appetite and a speedier route to fullness, considerable thought needs to be given to the experience of eating, to enable compliance with the medically necessary recommendations regarding the timing, contents, and portions of eating episodes and fluid intake. This deems one’s relationship with food anything but spontaneous or reactive (to emotions, hunger signals, cravings, or situational factors). This stands in contrast to what many obese people would acknowledge about their eating before surgery, namely, that mostly their eating was “in response to” some type of triggering agent that often had little to do with hunger or the goal of making eating decisions that were ultimately in their best interest from a health and weight-management standpoint. Food and eating will no longer have the capacity to fulfill a “recreational” purpose for your patient. And in this sense, there will probably be feel-

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ings of sadness, loss, frustration, or even anger, as well as a very strong need to “fill the void” left by the inability and unavailability of food to meet so many of your patient’s needs that might have been addressed by food in the past. In thinking through the earlier section on the “costs” of undergoing the surgery, it is very important to encourage your patient to devote special attention to the altered relationship that she will have with food post-operatively and to think through how this might affect her on multiple levels. After this exploration, the next exercise will help your patient focus on shifting her mind to alternative activities that don’t involve food, that can be at least somewhat pleasurable and gratifying (even if initially they are not as stimulating to her as food has been).

Alternative Pleasures Not Linked to Food Exercise # in the patient workbook, What I Will Do to Fill the Voids Without Eating, is meant to encourage your patient to take some time to get in touch with a range of other emotionally gratifying or meaningful ways to spend her time and energy. Instruct your patient to review chapter  of the workbook, which discusses Pleasurable Alternative Activities. Also, direct her to the breathing, progressive muscle relaxation, and visual imagery techniques in chapter  of her workbook.

Handling “Coaches and Saboteurs” Your patient has probably discovered that her relationships with the people that she is closest to in her life have already begun to change since her decision to undergo weight loss surgery. Similar to others’ responses to any self-care decision that she might have made in her life in the past (e.g., perhaps when she began a diet or started a new educational program, job, or relationship), others’ responses to her decision to undergo the surgery are likely to be quite mixed. It is important that you help your patient determine the stance that she wants to adopt regarding her decision about the surgery and that you also help her think about the members of her support team—who is likely to be a “coach” and who is likely to be a “saboteur.” Instruct your patient to complete Exercise #,

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Handling Internal and External Coaches and Saboteurs, in the patient workbook. In considering the issues of “coach” and “saboteur,” it is also important that you help your patient sort out in advance how she is likely to respond to herself as she observes herself going through the process of preparing for and undergoing surgery. This gets back to the issue of deservedness and also hits upon reactions of anxiety, guilt, self-sabotage, and acting out. Specifically here, you should spend time helping your patient create a mental image of herself progressing through all of the stages associated with her surgery, from pre-op to post, keeping in mind the possibility that while all can go exceptionally well, with your patient emerging from the surgery without complications or setbacks of any kind, it is also possible that one or more problems could occur. In the instance of an initial or later outcome that is not % perfect, it is important that your patient has strategies that enable her to hold onto her earlier commitment to feel deserving and self-caring in all respects regarding her decision to undergo the surgery, no matter what unexpected and untoward complexities might arise. This work will require that your patient get in touch with her deepest thoughts, feelings, and problem-solving strategies as they relate to her goals for the surgery.

Working With Adolescents Obviously, if your patient is a teenager, their parents will be highly involved in all aspects of the pre-surgical and surgical processes. Teenage patients will not be on their own. You will want to make sure that parents understand the work your patient has done pre-surgically with you to make them confident that they will succeed as a family. Parents always worry about their children and will want to protect their child as much as possible from pain and harm. As a therapist, you are expected to be called upon to support the parents during this process, as well as the teenager. However, once they have gone through the pre-surgical processes with their child, they will be a great resource for their child and a great help to you in supporting your patient post-surgically. You should try to identify how particular parents can be specifically helpful—who will be with the patient when, what they need to bring and

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have waiting in the room for the patient, how much and when it is appropriate to bring others (friends and relatives) to visit, and what to say about the surgery to others more generally in keeping with their adolescent’s wishes. You will also want to help educate the parents to the role therapy continues to play post-surgically and garner their support in making sure their child continues to get help during the post-surgical adjustment period.

When Surgery Goes Badly: Preparing for Unlikely Complications Finally, as your patient has become more and more aware of the potential benefits of the surgery, as well as the costs, the issue of mortality (death) from surgery has to be on her mind on some level. While the goal here is not to encourage her to dwell on worries about dying as the result of surgery, it is important that you help her come to terms with the possibility of this, no matter how remote it is, and “make peace” with herself regarding her decision about the surgery and other aspects of her life, as well as with the significant others who are affected by all that happens in her life, including the possibility of losing her as a result of the surgery. The way that your patient handles getting in touch with this material by definition will be quite personal; there is no one way for her to approach preparing herself and her significant others for the remote possibility that she could die as the result of what is in most cases an elective surgical procedure. Nevertheless, the recommendation is that you encourage your patient to take some time to really think through these issues. For example, you might consider recommending that she write a letter to her significant others incorporating all that she would want to say to them, if this were her final opportunity to do so. For example, she might want to incorporate some of the above material regarding her decision to have the surgery, so that significant others fully understand the entirety of her experience. Given the likelihood that all will go well with your patient’s surgery, it is of the utmost importance that she plans for and prepares others to support her in the most helpful ways possible. For example, she might request certain family members or friends to provide transportation to the hospital, to stay while she is undergoing the procedure, and to be pres-

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ent once she wakes up afterward, and so on. She might request assistance in stocking her kitchen with all of the necessary foods and beverages that she will need during the first few post-op weeks. Others might be called upon to visit her while she’s at home, to provide transportation to follow-up visits and other appointments or activities, or to provide emotional assistance should she need that during periods of anxiety or worry before or after the procedure. Your patient’s ability to communicate to her significant others about her emotional state and needs is essential during this planning stage. They can’t know that in addition to feeling very excited about her upcoming surgery, your patient is also highly anxious, worried, or struggling with guilt about “whether or not she deserves it.” If your patient doesn’t let people know what she is experiencing and what she needs from them, they can’t possibly respond. My Weight Loss Surgery Support, Supplies, and Tasks List in chapter  of the patient workbook pertains to this issue of your patient’s relationship with the important people around her.

Homework ■ Complete all exercises in the chapter. ■ Review these in sessions with your therapist.

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Chapter 10 What Happens After Surgery?

(Corresponds to chapter  in the workbook)

Materials Needed ■ My Weight Loss Surgery Support, Supplies, and Tasks List ■ Post-Surgery Journal

Outline ■ Help patient think through the range of challenges he will face at various points after surgery ■ Facilitate patient’s taking charge of as many of these issues as possible in advance of surgery ■ Introduce patient to CBT strategies that he can use should he experience problems following the surgery (and review certain CBT strategies that he has already learned) This chapter discusses what your patient should expect immediately after his surgery and in the first few days and weeks that follow, and it will remind him of the importance of being fully compliant with the recommendations made to him regarding the initial post-operative phase. For example, those recommendations involving dietary intake, the optimal amount of rest and physical activity, and the necessity of being patient, utilizing various supports, normalizing frustrations, and so on in the short term are all important for him to heed in full. In this chapter, you will find strategies that you can use to encourage your patient to work on various written plans of action for situations he might face after surgery; completing these exercises, or at least helping your patient to start

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to think them through now—well before surgery—will enable him to be more thoughtful than he might be otherwise when facing the immediate stress of surgery or the rigors of the recovery period immediately after. Since the focus of your therapy is mainly to prepare your patient for surgery, likely he is reading this chapter of the workbook well in advance of the procedure, and the material presented here will prime him to think about the way he needs to be treating himself, not only before but also after the surgery has been completed. Once your patient has undergone surgery, he deserves to give himself a big congratulations and pat on the back, as he has followed through on an undertaking that was extensive in terms of the mental, physical, financial, social, and logistical challenges involved. In any case, no matter how far along your patient is in the process, or how close he is to the actual surgery date at this point, he deserves to be commended for persevering with his goal and accomplishing what he set his mind to. Hopefully, all will go well with your patient’s procedure. In advance of undergoing surgery, it will be particularly helpful for him to identify those who will be able to care for him at various stages pre- and postoperatively (refer your patient to My Weight Loss Surgery Support, Supplies, and Tasks List in chapter  of his workbook). For example, he should by now have created a very detailed and well-developed list of the individuals who will be available to him and the specific tasks that he would like to assign to them (of course, with their permission and enthusiasm). Your patient will want to know well in advance who will transport him to the surgery, who will stay in the hospital while the procedure is completed, who will be there to visit him in the hospital during the initial hours and up to few days after the procedure (assuming there are no complications), and what he would like various individuals to bring with them or be “on call” to do for him should he have needs of one type or another that arise that could not be predicted in advance. As you help your patient prepare for what will happen after he is discharged from the hospital, he will also want to know exactly who will be there for him in the hours, days, and weeks after the procedure when he is at home recovering. For example, your patient will want to have some sense of who will be there to keep him company, prepare any of the simple

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meals that he needs, and bring those meals and fluid requirements to him if he is having any trouble getting around. At some point before your patient’s surgery, he will want to make a detailed list of all of the food and other supplies that he will need (again, refer your patient to My Weight Loss Surgery Support, Supplies, and Tasks List in chapter  of his workbook) so that either he or one of the members of his support team can be sure to purchase the staples that will have to be on hand in the initial post-op period. Also, there may be special first aid supplies that your patient should have available to address any issues associated with taking care of his healing incision wounds or other issues like that. Your patient might have been prescribed certain vitamins or other medications that need to be picked up and prepared a certain way (possibly crushed, halved, or softened in some cases). And, in addition, it will be extremely important that he restarts, in the appropriate form, possibly changing from pills to liquid, all necessary medications being used pre-op that physicians recommended continuing. Particularly important is your patient restarting any medication related to mood. Helping your patient devise a scheme for keeping track of all of these potential necessities in advance of surgery is essential so that no detail comes as a complete surprise either for him or for any of those who are helping out. Finally, your patient will be required to attend a number of post-operative follow-up visits that are scheduled at various intervals after surgery, depending on the practices of the surgical center, the type of procedure that was done, the initial surgical outcome, and any particulars involving his health status. Since it will be a matter of weeks (depending on the exact nature of the surgery) before your patient can drive, it is also imperative that he lines up members of his support team to transport him to those visits. Obviously, it goes without saying that no follow-up visit should be missed, as it is at these meetings that your patient’s surgeon and members of the team will fully assess his progress given the length of time since his surgery relative to others that they have worked with over time and, after they have made their assessments of your patient’s progress, make any suggestions, adjustments, or interventions that might be necessary. It is at these visits that your patient will also be able to obtain consistent and reliable data about what is happening with his weight, again relative to others who have undergone the same procedure. While your patient

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might be one of the few who has a scale at home that has had the capacity to accurately measure his weight both before surgery and after (following some weight loss), usually the scales at physicians’ offices are more accurate than a typical home scale, and thus your patient will be more likely to get a spot-on reading when he sees his doctor(s) at these regular visits. The exercises included in chapter  of the patient workbook, as well My Post-Surgery Journal (also found in chapter  of the workbook), can help your patient organize the information discussed above, and of course he should know that he can add as many people and tasks beyond  to the list that he wants to. Assuming that the first few days out of the hospital and then at home have gone well, your patient might be quite relieved if not euphoric that he has made it through this very crucial initial stage of healing. Once he becomes aware that the first few days have passed uneventfully, it’s possible that his state of mind might then shift into conjuring up the next set of worries or excited plans that he might have about the surgery that he has just experienced and what he wants to happen in the future relative to that. For example, your patient might become somewhat anxious about either some of his body’s reactions to having undergone surgery and/or some of the bodily changes that have already started to happen (such as continued pain in the site of the wound[s] or changes in his bathroom habits). Perhaps, alternatively, his mind might have already jumped to what the next few stages of healing, recovery, and adjustment will be like. Some people may even feel an initial, somewhat catastrophic reaction of “what have I done to myself ?” that represents a type of “buyer’s remorse.” This type of reaction reflects anxiety about the unpredictability of what is in store and how things will progress or evolve over the next few days, weeks, and months. While some modicum of anxiety might be helpful to motivate an individual to stay on track regarding the magnitude and seriousness of the surgery and the vigilance that self-care following the surgery will entail, too much anxiety can actually have the negative effect of shutting a person down and thereby preventing him from caring for himself optimally following surgery. For example, highly anxious thoughts, also known as catastrophizing, might cause a person to lose sight of the positive aspects

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of the decision to undergo surgery and of all of the improvements in life that await him as he loses weight. Instead, the person may be aware only of pain and exhaustion, stiffness and soreness, and other sensations that might accompany most radical surgeries. Or the person may choose to focus on some of the specific, slightly disorienting changes to the body caused by this surgery, for example, having a distinctly different experience of appetite that requires very extreme changes in eating habits. These imposed physical and behavioral modifications might initially feel very scary and permanent, and thoughts like “it is always going to be like this” might occur along with worries such as “what if the surgery doesn’t work and I don’t lose weight”? Or “what if it wasn’t worth it”? (Refer back to the list of basic cognitive distortions in chapter .)

Managing Anxious Thoughts After Surgery It is very important if and when your patient experiences anxious thoughts after surgery that he stare them in the face, embrace them, and then sensibly “massage” or transform them into thoughts that are much less worrisome and much more constructive. Your patient will know when appropriate and healthy thoughts are onboard because these will be oriented toward keeping him in an optimistic frame of mind, on the right track with respect to tasks associated with solidly recovering and healing after surgery, and focused on his commitment to learning to relate to food and his body in a new and more healthy way. At this juncture, it will be important to review with your patient the cognitive-restructuring exercise introduced in chapter . In addition, at such times of anxiety, when your patient may be secondguessing the decision to have surgery, or when he may actually be feeling some level of “buyer’s remorse” during the post-operative phase, it is very important to help him figure out what other options he may have to quell his anxiety. While his list of pleasurable activities that don’t involve food or eating will obviously be somewhat limited in the early stages after surgery (e.g., he most likely will not be able to take a bath or even a shower, exercise, or drive anywhere), you should both work together to create a short list of appropriate alternatives that includes simple, relaxing, and sedentary activities such as reading, watching TV, surfing the

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Internet, chatting with a friend, and so on. It is very important that your patient learn to overcome any signs of anxiety in this early post-op stage because anxiety can cause him to act out—that is, engage in a behavior that is ultimately not in his best interest given his desire to heal adequately after surgery and get on with the business of serious weight loss.

Working With Adolescents Post-surgical worries of the parents of teenagers are similar to those of most patients, while an adolescent may feel less worried than many adults. If your patient is a teenager, therefore, you might want to work through some of these exercises not only to help the patient but also his parents, so that you can work together as a team to get on with post-surgical recovery with the minimum amount of worry. You might also review with your patient the exercise on formal problem solving (also found in chapter ) to help him work through additional issues or obstacles as he is recovering. After your patient has had at least a few weeks to adjust to the changes associated with his surgery, he should have a sense of “how he is coming along” in terms of following through with the dietary recommendations appropriate to the specific post-op stage and feeling comfortable with those changes in eating, as well as the actual rate of weight loss. At your patient’s regular follow-up meetings with his physician(s), he should be obtaining feedback about how he is progressing (including documentation of his continuing weight loss) and receiving many forms of encouragement to stay on the right track. These messages should correct any misperceptions that your patient might have been struggling with, regarding how things should be going as opposed to how he is actually doing, as well as any problem behaviors that he has been exhibiting. Within the first few weeks and months after surgery much of your patient’s focus will be on ensuring that he is handling his food and fluid intake correctly, losing weight, healing from the wounds of surgery, and generally staying positive and optimistic about all that he’s been through and all that he is hoping for.

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Mind and Mood At some point within or shortly after the first couple of months post-op, your patient might be ready to shift focus from his body and all of the changes that he is going through physically to his mind and his mood. You might even encourage your patient to begin a process of querying himself as to how he is really feeling—in an emotional sense—to help him get in touch with this more subtle layer of perception (relative to his body) that might have been overlooked in the flurry of activity oriented at keeping his body healthy after the surgery. While there are no established research statistics to date that specify the exact percentage of people who might develop significant, as opposed to mild, mood problems (such as depression or anxiety) at some point after weight loss surgery, there is always the possibility that a mood issue will develop. It makes sense intuitively that this may be particularly true for those individuals for whom mood issues have been present to a moderate or serious level at some point in the past, before they underwent the surgery. On the other hand, some individuals for whom mood issues were not problematic before surgery might also be affected by mood problems after. Again, without actual data to support it, this vulnerability might be more pronounced in those who, prior to surgery, relied on food to a great degree, in the form of binge-eating episodes or other compulsive eating behaviors, to regulate their mood or relied on other substances or alcohol for the same effect. In any case, given the very dramatic changes to the body that happen on multiple levels following the radical weight loss made possible by weight loss surgery, even previously nondepressed and nondistressed individuals might begin to feel some mood changes that are uncomfortable at some point post-operatively. For that reason, you should prepare your patient for this possibility.

Depression It is important to help your patient understand the signs and symptoms of depression and other mood issues, should these start occurring at some point after the surgery. In terms of “sizing up” a depressed mood,

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most likely what your patient would experience would be at least some of the following symptoms: a feeling of sadness, a sense of pessimism that is inconsistent with the positive decisions and changes he has made surrounding the surgery, tearfulness, distractibility, difficulty getting up to greet the day, difficulty performing his usual activities (any that are appropriate for the post-op stage that he is in), and in the worst cases, thoughts or plans pertaining to suicide. Clearly, if such extreme signs of depression—such as your patient having thoughts pertaining to ending his life—are present, both of you would likely already be painfully aware of his depressed mood, without having to do any structured form of “querying.” (On the other hand, there are individuals who are quite skillful at hiding from themselves and others, or denying, any negative feeling states such as depression.) The next steps you and your patient would need to take involve trying to understand all of the contributions to his mood difficulties (both from the biological perspective, possibly seeking a second opinion of a psychiatrist or other M.D. and also from the psychosocial perspective) and then helping him figure out what to do to work through these problems. It would be most important to encourage your patient first, to talk to the team of professionals already involved in his care, such as his surgeon and primary care physician, to consider disclosing his difficulties to trusted significant others so that they would also know what is happening with him, and to think about either increasing the frequency of therapy sessions, adding in (or increasing) support group sessions of one type or another, or encouraging your patient to take part in a regular, structured activity that has been known to make him feel better in the past. Once your patient lets at least one, but hopefully a few, of the doctors he has been working with in on the fact that he has been struggling with his mood, he should rest assured that they will have a number of options at their fingertips for helping him out with respect to his depression (in addition to all of the work the two of you are doing in therapy). They might recommend that your patient start on an antidepressant medication, make a change to a different medication if he has been taking one with limited effectiveness, increase the dose of a medication he is currently taking, or restart a medication that he may have discontinued but had been taking with good results at some point before. In addition to

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discussing medications, at some point you might ask your patient’s spouse, partner, or other family members to join you in one or more therapy sessions or take part in family or couples therapy (separate from the work your patient is doing individually).

Anxiety As with depression, any anxiety problems your patient might be having would first be identified by teaching him to become a good self-observer (while you also observe his mood, thought processes, and behaviors in your sessions, as well as his reports of such happenings outside of sessions). Your patient would likely note the presence of a “stressed,” “strained,” or “fearful” kind of mood, along with the occurrence of persistent worries that feel intrusive and ongoing, as well as muscle tension, “hypervigilance” and possibly even panic attacks, despite his attempts to use the recommended tools of cognitive restructuring, distraction, and relaxation activities and the like. Just as with the occurrence of a depressed mood, the presence of moderate or serious anxiety would warrant that your patient consult with the members of his professional team, disclose to significant others what he is going through, and think through, together with his team, the potential viability of options such as medication, additional psychotherapeutic interventions (e.g., such as an anxiety-management focused group), and so forth. Although to date there is only limited clinical and research data available to support this impression, it appears that the experience of serious anxiety by some individuals at some point postoperatively is more likely to occur in those with a history of anxiety in the past or a history of other difficulties in mood regulation. Because managing these in the past might have been done by nonproductive solutions such as overeating, frank binge eating, or substance use or abuse— tools that are no longer available following gastric bypass surgery—post-op patients might be left feeling particularly uncomfortable and without access to their usual means of soothing or escape from these types of difficult feelings. For that reason, working hard on identifying optimal solutions in your work with your patient is key.

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Problem Eating Another obvious category of potential problems after weight loss surgery involves that of eating. Ideally, after surgery your patient will be following the program (in terms of all of the eating suggestions) in full, that is, eating (and drinking) all that is recommended, at the appropriate times and in the appropriate amounts. In the optimal case, your patient’s following his program in this manner—that is, investing himself fully in “doing the program right”—will yield a “return” that equates to an absence of difficulties or problems. Unfortunately, even in instances in which an individual is doing his best to follow the program to the letter, your patient might experience an eating difficulty of one type or another, of an inadvertent or involuntary nature. For example, not terribly uncommon is a side effect of occasional bouts of vomiting or other gastric upsets in response to eating certain foods, or in rare instances, in response to eating anything at all. Although infrequent in occurrence, this type of vomiting or other gastric incident (e.g., some version of “dumping syndrome” involving diarrhea after eating) might continue beyond a few episodes to become more problematic over time. In more severe cases, there could be a nutritional impact resulting from the too rapid “transmission time” of food, which accumulates over time, either in the form of dehydration in the short term or even some level of malnutrition over the long term due to not enough nutrients regularly being absorbed into the system. There are also obvious and noteworthy physical consequences of repeated vomiting (or diarrhea, for that matter) including soreness or sensitivity in the gut or esophagus (or “lower,” e.g., when going to the bathroom). A psychological impact can also develop over time, after repeated bouts of vomiting or “dumping,” for example, in which the afflicted person might fear eating due to the possibility of one type of problem episode or another happening yet again. Over a period of time, this can develop into a full-blown food phobia that might look like classic anorexia nervosa to some degree, in that the affected person is likely to deny hunger or appetite, may or may not acknowledge a fear of eating, but is motivated primarily by this fear to avoid eating altogether. Clearly, if any of this seems similar to what might be happening with your patient, it is

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imperative that you help stop the progression of this problem as quickly as possible. The best course of action, in the event of what appears to be a food phobia in development, would be to combine a strictly behavioral and CBT approach that includes helping your patient to stay vigilant about his eating patterns and habits, as well as the thoughts and feelings that he is experiencing in response to these. Encouraging him to keep regular food records, on which he can document all of the above, can be quite useful for both of you as you put your heads together to try to understand his eating behaviors and associated attitudes and emotions in full. Also, encouraging your patient to take in feedback that significant others might have based on their observations of his eating patterns might also at times be quite helpful, even though your patient might initially bristle in response to what feels like judgmental control or criticism rather than helpful wisdom that others in his personal life might be able to offer. While others’ constant intrusion in a situation like this is obviously not desirable, when it comes to matters like eating patterns, weight loss, selfcare, and mood states (including anxiety and depression), those around your patient might sometimes see more clearly what is going on than he is able to see for himself.

Binge Eating A related but different problem that might happen for your patient postoperatively is that of the occurrence of overeating or binge-eating episodes, obviously on a smaller scale than what would have taken place prior to the surgery. A pattern of overeating after weight loss surgery can develop slowly or insidiously over time, or it might appear all of a sudden, as if out of nowhere. Again, based on clinical impressions, it appears that those who had problematic binge-eating habits prior to surgery are more at risk for redeveloping the problem after surgery (even if there was a considerable binge-free phase before surgery was attempted) than those who never binged in the past, but so far there is no research data to support this impression in full. In any case, a number of different types of scenarios involving overeating might develop over time in a post-op weight loss surgery patient. For example, in one individual, a

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craving for “just a little bit” of a certain type of food might trigger the beginning of what ultimately becomes an overeating episode, at least overeating from the standpoint of what is ideal in terms of food contents and quantities that are recommended after weight loss surgery (even if this exact eating episode would have been considered perfectly acceptable before surgery). At the point when the eating episode transitions from normal or acceptable to problematic, the person involved might also start producing a number of problematic cognitions that might make it more likely that he ends up eating more in response to this initial bit of overeating rather than stopping himself when he still can. This represents an example of the type of catastrophic thinking described earlier in this chapter and in chapter , which focused on cognitive distortions. For example, your patient entertaining a thought, after consuming a nonoptimal food (either in content or quantity), that goes something like, “Now I’ve gone and blown it! I am ruining my surgery and will never lose weight!” would obviously be more likely to perpetuate additional problematic eating behaviors for your patient than if he curtailed these behaviors at their earliest stages, which he would be more likely to do by exercising more constructive thinking such as, “OK, this was just a small indulgence, and it will be best to quit now, while I am still ahead, with no damage done.”

Cravings Another type of overeating or binge episode that might happen “out of the blue” post-operatively involves an individual developing a strong craving for a particular food. Thinking optimistically and in the direction of good self-care—which can sometimes involve “indulgence in moderation”—your patient might allow himself a treat of some type and then end up having an experience characterized as “my eyes were bigger than my stomach.” What this means is that, in his zeal to take in as much of the “really good indulgence food” that he wants or can consume, he ends up significantly overeating relative to the post–weight loss surgery recommendations. Some in this instance might go on to experience “dumping syndrome” in response, partly depending on the amounts and types of foods that were ingested, that results in stomach upset at minimum and sweating, trembling, diarrhea, and possibly vomiting as

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other potentialities. In this instance, as much as the “dumping syndrome” proves to be a negative reinforcer for overeating, that is, maximizing the distress or negative consequence that results from overeating to the point that many would then be tempted to avoid it at all costs, some may ultimately experience the “dump” as something akin to a purge. When it is seen this way, as a purge that eliminates food from the body, it enables them to feel—even if illogically—that they have in essence rid themselves of the excess food and calories consumed and therefore can do it again if and when they feel like it. (This is the same logic that keeps bulimic individuals tied to their habit of binge eating and purging.) If overeating in this fashion has been a problem for your patient in the past, there may be a greater likelihood that he develops a pattern like this yet again, particularly if he has experienced mood issues related to all stages of the binge and purge cycle (for example, experiencing initial “prebinge” anxiety, followed by a distracted euphoria during and immediately after eating, followed by panic as the reality of what has been consumed sets in, followed by discomfort as awareness returns and satiety registers, followed by more panic pre-purge, followed by calm after purging is completed). In all such instances of chronic and frequent (e.g., more than a few in a week or a few weeks’ time) occurrences of problematic eating of this nature, it is absolutely essential that you and your patient focus very specifically on this problem as soon as possible. In addition, you would also want to encourage your patient to discuss what is happening in his eating patterns (including any purge-like behaviors) with his primary care physician and surgeon, so that they are kept well informed about the problem behavior. Their involvement is particularly important since they know what to look for in terms of any potential physical damage or side effects that can stem from a combination of your patient’s surgery and this type of behavior, and they might also have suggestions about additional personnel that might become involved in your patient’s care if necessary (such as a gastroenterologist). It is also important that you discuss with your patient the option of a psychiatric evaluation in which the likelihood of his benefiting from psychotropic medications, which might help him with both mood and eating issues, can be assessed. No matter what the type of eating problem, always keep in mind for your patient that in addition to his work with the medical professionals that are already part of his team (includ-

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ing you), as well as any weight loss surgery support group meeting that he is already attending, he always has the option of adding to the mix attendance at another type of group meeting (for example, Overeaters Anonymous or another type of support group if this seems appropriate), along with expanding the involvement of significant others in his care.

Alcohol and Drugs Finally, one other cluster of problematic behavior patterns that can occur after any type of stressful life experience such as that of radical surgery is abuse of alcohol or drugs. Again, those with predispositions for this type of problem, based on a family history of substance abuse or more likely their own history of any type of substance abuse occurring even years before undergoing the surgery (as stated earlier in this manual, most programs require that patients are clean and sober for at least five years before going through weight loss surgery), are probably more at risk than others who have had no experiences abusing or developing a dependency on any type of substances. However, in a manner that is similar to the development of the problematic eating behavior, these issues might occur secondary to the existence of an as yet untreated, underlying mood disorder, such as anxiety or depression. Clearly, your patient obtaining speedy and adequate treatment for any mood regulation problems he might be having after surgery likely decreases the probability that he will rely on these other inappropriate strategies—misuse of food, drugs, or alcohol— for managing his mood. However, if you do notice that your patient is engaging in any type of substance abuse problems, whether these are newly developing or resurfacing at any point after surgery, the two of you need to assess the degree of the substance problem and likely seek an evaluation with a substance abuse expert, outside of your therapy sessions. You should also recommend that your patient attend Alcoholics Anonymous (AA) or another appropriate meeting specific to the substance that he is abusing. Remind your patient that you commend him for opening up to you about the nature of the substance abuse problem and reassure him that he should not, under any circumstances, concern himself with problematic thoughts related to feelings that he has “let down” the members of his surgical or medical team or that he has “bro-

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ken the rules” or will be “getting in trouble.” The simple fact of the matter is that your patient is in acute need of professional assistance if he is abusing or dependent upon any type of substance, whether alcohol or drugs, and the sooner you are able to help him obtain the appropriate type of treatment, the better off he will be.

Options for Seeking Help In all of the instances noted above—involving mood, eating, and substance abuse issues—the problems were serious enough to warrant and require specific, expert, individual, professional assistance and, possibly in addition, some form of group therapy or support. Keep in mind, however, that any type of problematic feeling or behavior that your patient is experiencing, no matter how mild, deserves some type of attention and treatment. Hopefully, many of the treatment needs that your patient might experience can be addressed in your therapy work. But at times both of you might reevaluate the course of treatment that you are engaged in together and decide to make some changes, even those requiring that you refer him to someone else. Remind your patient not to keep a “stiff upper lip,” symbolized by thinking along the lines of “unless my problem is severe and includes depression, anxiety, major eating issues, or substance abuse, I should not seek help.” The reality is, even if your patient is doing amazingly well, or moderately well with the exception of a few minor problems, if he wants extra help or assistance, either in the form of some other type of individual psychotherapy (that may or may not include a consultation for medications), couples counseling, group interventions—either AA or OA in addition to his weight loss surgery support group—or any other type of group forum, he should feel that he is healthfully entitled to seek it out. In terms of individual therapy, most important may be the fit between your patient and the individual therapist that he decides to work with (if he makes a change later to work with someone other than you). By the same token, there are several different “schools” of individual therapy that you might educate your patient about, albeit somewhat briefly, so that he knows at least something about what the options are.

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Cognitive Behavioral Therapy Cognitive behavioral therapy (CBT )—which is what your patient has spent most of the time on in the current therapy—in the most basic sense would address the types of thoughts your patient is having along with the behaviors he is exhibiting relative to the issues of weight loss surgery, eating, weight, body shape, mood, self-esteem, cultural pressures to be thin, and other concerns. The sessions would likely be somewhat structured and driven by an agenda that is based on your patient’s and the therapist’s ideas about appropriate goals for the stage of therapy that they are in. In CBT, your patient will often be assigned homework at each session, so that the between session time is like a laboratory in that he is encouraged to experiment on various new perspectives and behaviors the two of you have been talking about in your sessions.

CBT Self-Help Manuals This is a “shorthand” form of CBT therapy based on a written manual, used in conjunction with intermittent and brief (e.g., every other week,  minutes each) therapy sessions that are oriented toward keeping the patient focused on the tasks and issues presented in the book.

Interpersonal Therapy Interpersonal therapy (IPT ) is a less directive approach to treatment, although there is a clearly defined agenda that involves a patient talking about one or a few primary interpersonal problem areas that are integrally related to eating issues and weight concerns. Examples of core interpersonal problems might be navigating a difficult transition, such as that associated with becoming a more assertive person or becoming thin for the first time ever or for the first time in a long time; experiencing conflicts with other people on a very frequent basis; or working through an unresolved grief. In the initial few sessions of IPT, the therapist would help the patient take some time to reflect on his entire social life, the number, quality, and type of relationships he has now and has had in the past, in an attempt to identify the core problem areas that are troubling

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to him. In many cases, it turns out that these same problem areas have also been instrumental to one degree or another in triggering or perpetuating aspects of the patient’s disordered eating behavior and weight problem.

Other Therapies Many other types of therapies exist and are practiced in a form that could potentially be very helpful for someone with eating problems and weight concerns. These days, an extremely popular form of treatment is that of emotion regulation therapy, in which an individual is taught a number of different strategies and tools to embrace, validate, and gradually change any excessive or nonconstructive emotional reactions they may have in response to “charged” or stressful situations of one type or another. In addition, there are several “nonspecific” therapies that may offer support, encouragement, feedback, reality checks, and an opportunity for accountability that can be quite helpful if delivered by the right person, to the right person, in the right circumstance. In any event, given the significance of what your patient has been through, in terms of following through with surgery after a long period of preparation and anticipation, recovery, healing, adjustment, and the like, psychotherapy or counseling, just to have “someone in his court” (in the form of a psychotherapist or counselor) who is supportive, objective, there for him, and hopefully a source of some wisdom and guidance, might be something to strongly consider if he has any interest at all in continuing therapy beyond the work that you two have done together.

Homework ■ Complete the exercises in this section. ■ Take some time to relax! (Use progressive muscle relaxation, breathing exercises, items off your list of alternative activities that don’t involve food, or anything else.)

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About the Authors

Robin F. Apple received her PhD from the University of California–Los Angeles in  and has published articles and chapters in the area of eating disorders. She has also cowritten a patient manual and a therapist guide that utilize cognitive-behavioral therapy (CBT) techniques for treating bulimia nervosa and binge eating disorder. In her current role as associate clinical professor, Department of Psychiatry and Behavioral Sciences, Stanford University, she has completed over  pre-operative evaluations of patients seeking weight loss surgery, has co-led a weight loss surgery support group, and has provided short- and long-term individual therapy for those preparing for and adjusting to their surgery. Apple maintains a varied caseload of patients with eating disorders and other issues, both at Stanford and in her private practice in Palo Alto, California. She consults on weight loss surgery–related research and forensics cases and is actively involved in Stanford’s training program for postdoctoral psychology fellows and psychiatry residents. James Lock, MD, PhD, is associate professor of child psychiatry and pediatrics in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine, where he has taught since . He is board certified in adult, as well as child and adolescent, psychiatry. In the Division of Child Psychiatry and Child Development, he is currently director of the Eating Disorders Program that consists of both inpatient and outpatient treatment facilities. His major research and clinical interests are in psychotherapy research, especially in children and adolescents, specifically for those with eating disorders. In addition, he is interested in the psychosexual development of children and adolescents and related risks for psychopathology. Lock has published over  articles, abstracts, and book chapters. He is the author, along with Daniel le Grange, Stewart Agras, and Christopher Dare, of the only evidence-

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based treatment manual for anorexia nervosa, called Treatment Manual for Anorexia Nervosa: A Family-Based Approach. He has also recently published a book for parents, Help Your Teenager Beat an Eating Disorder. He serves on the editorial panel of many scientific journals especially focused on psychotherapy and eating disorders related to child and adolescent mental health. He has lectured widely in the United States, Europe, and Australia. Lock is the recipient of an National Institute of Mental Health (NIMH) Career Development Award and an NIMH Mid-Career Award, both focused on enhancing psychosocial treatments of eating disorders in children and adolescents. He is the principal investigator at Stanford on a National Institutes of Health–funded multisite trial comparing individual and family approaches to anorexia nervosa in adolescents. Rebecka Peebles, MD, is an instructor in adolescent medicine at the Department of Pediatrics at Stanford University School of Medicine. She completed her training at the Cleveland Clinic Foundation and at Stanford University School of Medicine, and is board certified in pediatrics and in adolescent medicine. She is a member of the Adolescent Bariatric Surgery Board and works in the Eating Disorders Clinic and the Pediatric Weight Clinic at Lucile Packard Children’s Hospital at Stanford. Her major research and clinical interests are in health outcomes of binge eating and purging behaviors, and in better understanding links between eating disorders and obesity. In addition, she has researched the impact of the Internet and pro–eating disorder Web sites on adolescent populations. She is the recipient of multiple awards for teaching and humanistic medicine. She has written on eating disorders and obesity, and frequently lectures on these topics and adolescent health in the community.

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