Post on 19-Mar-2016
description
22 Review Bariatric Times • September 2012
INTRODUCTIONAchieving and maintaining weight
loss after bariatric surgery requires
significant behavioral change.
Further, bariatric surgery patients are
often confronted with a myriad of
psychosocial changes following
surgery. Cognitive behavioral therapy
(CBT) groups have promise for
assisting patients in implementing
dietary and medical
recommendations, helping with
psychosocial adjustment to bariatric
surgery, and possibly minimizing
certain post-surgical medical
complications.
It is important to note that CBT
groups are distinct from bariatric
surgery support groups. Bariatric
surgery support groups vary widely in
that they can be patient-led or
provider-led and can range from
highly structured meetings to free-
flowing discussions. At our clinic, in
addition to CBT groups, we have
monthly support groups that are led
by the multidisciplinary staff and
typically include an hour of
presentation on topics pertinent to
bariatric surgery, which may include
a facilitated discussion followed by
open time for patients to interact.
Support groups provide patients with
education about surgery, social
reinforcement for positive behaviors
and weight loss success, and advice
and problem-solving assistance. While
support groups are currently offered
at most, if not all, bariatric surgery
programs, CBT groups are not,
though they can offer much to our
patients and our practices. Whereas
CBT interventions are presently not
as widespread as support groups,
some bariatric surgery programs
require CBT interventions prior to
surgery. Furthermore, several CBT
programs for behavioral weight loss
are currently being tested for their
effects on post-surgical outcomes.
PRE-OPERATIVE CONCERNS:PREPARATION FOR SURGERY
CBT groups conducted
preoperatively can help patients
prepare for surgery both
psychologically and behaviorally. In
preoperative groups, CBT therapists
teach patients relaxation exercises,
such as imagery and deep breathing,
to assist with managing potential
presurgery anxiety or postoperative
pain or nausea. A preoperative group
also allows for a discussion of the
importance of avoiding a high-fat,
energy-dense diet prior to surgery,
which reinforces the surgical team’s
preoperative recommendations.
Furthermore, preoperative groups
provide patients with the opportunity
to discuss their potential fears and
concerns regarding their upcoming
surgery. Discussing this with other
group members allows patients’ own
concerns to be normalized. It also
provides the therapist an opportunity
to dispel some myths that the patient
may have regarding surgery, and to
help the patient use cognitive
strategies to cope with anxiety-
provoking thoughts.
POSTOPERATIVE CONCERNS:ADHERENCE AND WEIGHT LOSS
Individuals who are undergoing
bariatric surgery are asked to make
numerous lifestyle changes, including
consuming smaller, more frequent
meals, avoiding foods that may limit
weight loss or contribute to digestion
problems, taking vitamins multiple
times per day, and increasing physical
activity. For many patients, meeting
these recommendations requires
dramatic changes from their
presurgical lifestyle, and some
patients struggle to follow these
recommendations. A substantial
number of bariatric surgery patients
report that they are not adherent
with the postbariatric surgery dietary
and physical activity
recommendations.1,2 Thomas et al1
found that only five percent of
postoperative patients eat five or
more meals per day, 15 percent
consume adequate amount of liquids,
and 24 percent meet exercise
recommendations.1 Nonadherence to
these behavioral recommendations is
associated with poor weight loss
outcomes.2–4 The impact of
nonadherence may be significant: an
estimated 15 to 20 percent of
bariatric patients do not achieve 50-
percent excess weight loss(EWL),5
and weight regain is not uncommon
after the first year post-surgery.6,7
Furthermore, nonadherence can lead
to postoperative complications (e.g.,
dehydration, plugging, excessive
vomiting).40
CBT may be beneficial in
improving medical, dietary, and
fitness adherence among bariatric
surgery patients. CBT is a
therapeutic modality that is goal-
directed, collaborative, and time-
limited. CBT has a strong base of
empirical evidence for numerous
psychological disorders, such as
depression, anxiety disorders, and
substance abuse disorders.8 CBT has
also been used to help patients with
chronic medical conditions, such as
chronic pain, diabetes, and asthma,
improve their psychosocial
functioning, and learn disease
specific-management skills.9 The
approach of CBT to weight
management has a strong research
basis demonstrating significant
The Benefits ofCognitiveBehavioral Groupsfor BariatricSurgery Patientsby MEGAN A. McVAY, PhD, and KELLI E. FRIEDMAN, PhD
Bariatric Times. 2012;9(9):22–28
ABSTRACTGroup cognitive behavioral therapy has many benefits for bariatric surgery patients andthe clinical practice. Group therapy, a standard modality of treatment in behavioral health,allows helpful interaction between patients and is guided by a mental health professional.It is also an effective use of staff resources. Cognitive behavioral therapy groups canassist both pre- and postoperative bariatric patients. Preoperatively, groups may helppatients prepare both psychologically and behaviorally for the many changes associatedwith surgery. Postoperative groups may help patients by improving adherence to lifestylechange recommendations, thereby increasing weight loss and maintenance, as well aspotentially reducing postoperative medical complications, such as dehydration, plugging,and vitamin deficiencies. Additionally, cognitive behavioral therapy groups can helppatients adjust to the psychosocial changes that can accompany bariatric surgery.Cognitive behavioral therapy groups can help reduce the risk of patients developing rare,but serious, psychiatric concerns that may occur after bariatric surgery through earlydetection and referral to appropriate treatment sources. Cognitive behavioral therapygroups for nonsurgical weight loss have demonstrated the value of these techniques forassisting individuals in making diet and fitness related behavior change, and recentstudies of cognitive behavioral therapy groups for bariatric surgery patients have shown abeneficial effect for these interventions. We suggest that cognitive behavioral therapygroups be conducted by licensed mental health professionals with experience in bothcognitive behavioral therapy and bariatric surgery. When planning cognitive behavioraltherapy groups for bariatric patients, practitioners should consider factors that willincrease group attendance and consider inviting patients to attend groups during periodsof greatest potential vulnerability.
KEYWORDSCognitive behavioral therapy, therapy groups, bariatric surgery, weight loss
23ReviewBariatric Times • September 2012
weight loss and reductions in medical
comorbidities in individuals with
obesity.10,11 As surgical and
nonsurgical weight loss involve many
similar behavioral change
recommendations (e.g., increased
physical activity, smaller portion
sizes), CBT programs designed for
bariatric surgery patients share
several commonalities with
behavioral weight loss interventions.
CBT for bariatric surgery typically
builds upon standard nonsurgical
CBT weight loss approaches by
addressing the many issues that are
unique to bariatric surgery.
While the techniques utilized
within CBT can vary depending on
the specific problems or symptoms
being treated, CBT generally involves
cognitive strategies that identify and
change cognitions that negatively
influence mood, and incorporate
behavioral strategies that draw upon
learning theory principles. Regarding
cognitive strategies, trained
therapists help patients identify
cognitions that are negatively
impacting their function, and then
help patients critically examine the
accuracy and/or helpfulness of these
thoughts. These techniques can help
patients learn strategies for
improving their adherence to
postbariatric surgery
recommendations. For example, a
post-bariatric surgery patient in a
CBT group who reports difficulty
with physical activity can be assisted
in identifying thoughts that interfere
with motivation to exercise. The goal
is to help the patient become aware
of thoughts that are impacting the
ability to be active (e.g., “Unless I
exercise for an hour per day, there is
no point in exercising at all.”). A CBT
therapist can assist in examining the
validity and the helpfulness of this
thought. The therapist can also
identify this thought as an example of
“all-or-none thinking,” and discuss
how this pattern of thinking may lead
to negative outcomes, such as
nonadherence to the physical activity
recommendations. To help the
patient restructure this thought, the
CBT therapist may ask the patient
probing questions. The therapist
could ask if exercising for 10 minutes
might actually have benefit, and may
inquire if it would be easier to get
motivated for a 10-minute workout or
a 60-minute workout. By
understanding the role of thoughts in
influencing behavior and affect and
learning how to challenge and
restructure unhelpful or inaccurate
thoughts, patients may improve their
ability to make behavior changes
following CBT.
The behavioral component of
CBT facilitates change through the
use of learning theory principles,
including reinforcement, classical
conditioning, and stimulus control. If
a post-bariatric surgery patient is
having difficulty eating with the
recommended frequency, the CBT
therapist might offer a number of
suggestions based on these learning
principles. A therapist might help the
patient develop a plan to reward him
or herself (e.g., utilizing a non-food
reward) after completing a certain
number of days of meeting his or her
meal frequency goal. A therapist
might also suggest that the patient
structure his or her environment to
increase the likelihood of eating five
meals per day. For example, the
patient might be encouraged to set
reminder alarms, to recruit family
members to assist in remembering
when to eat, and to keep easily
accessible, pre-planned, healthy food
at work and in the car. Consistent
with a cognitive and behavioral
framework, self-monitoring,
relaxation training, and problem-
solving skills are other strategies
utilized by CBT therapists working
with bariatric patients.
The previously discussed
strategies can help patients consume
a diet consistent with
recommendations and engage in
more physical activity, thus
contributing to greater weight loss.
However, the effects of CBT groups
on weight loss may be hypothesized
to be greatest with regard to long-
term outcomes. Some evidence
suggests that psychosocial factors are
not strongly related to weight loss in
the first year after surgery but are
more influential longer-term.12 In fact,
there is evidence that the strategies
described previously may be
particularly beneficial in producing
24 Review Bariatric Times • September 2012
optimal weight loss maintenance in
the years following the first
postoperative year.12 Specifically, a
study by Lanyon et al12 found that
weight change over the period from 1
to 3 years postoperatively was
predicted by behavioral and cognitive
coping skills, informational support,
and expectations of increased self
confidence. Additionally, Lanyon et
al12 found that a reduction in
dysfunctional eating over the first
postoperative year is related to
greater weight loss at three years
postsurgery. As CBT groups target
many of these factors, groups may be
particularly beneficial after the first
postoperative year.
In addition to optimizing weight
loss, CBT groups may also reduce
behaviors related to some
complications following surgery. For
example, CBT groups can offer
patients assistance in developing
skills to minimize overeating or eating
nonrecommended foods, which often
lead to vomiting, plugging, and
potentially dehydration. Further, the
group leader may help reduce the
risk for nutritional deficiencies by
assisting the patient in problem
solving through his or her daily
routines and by providing information
about the vitamin recommendations.
Thus, CBT has the potential to assist
patients in identifying risky
behaviors, determining barriers to
behavior change, and problem solving
ways to make the needed changes.
POSTOPERATIVE CONCERNS:
PSYCHOLOGICAL HEALTH AND
PSYCHOSOCIAL FUNCTIONING
For many patients, the goals of
bariatric surgery extend beyond
weight loss and reduction in medical
comorbidities to include
improvements in mental health and
quality of life. In fact, the majority of
bariatric surgery patients do
experience improvements in their
quality of life and psychological
functioning following surgery.13
However, it is not uncommon for
some patients to face psychosocial
struggles post-surgery (e.g., in
regards to body image or social and
romantic relationships).14,15 More
serious issues of depression,
suicidality, and substance abuse
occur in a minority of patients.16,17 In
addition to assisting with lifestyle
change adherence, CBT groups may
also help patients cope with
psychological adjustment to bariatric
surgery, such as those listed
previously, and assist them in
maintaining or achieving quality of
life improvements.
An important issue among many
bariatric surgery patients is body
image. Though an improvement in
body dissatisfaction occurs for most
bariatric patients, the excess skin
that results from massive weight loss
is often of concern and, for some
patients, may cause a significant
amount of distress. Additionally,
many bariatric patients report that,
despite massive weight loss, they
continue to perceive themselves as
being the same size and shape as
they were prior to the surgery. CBT
has successfully been utilized to
address body image problems as part
of eating disorder treatment and as a
standalone treatment18,19 that can be
incorporated into CBT for bariatric
surgery patients to help them
develop a healthier body image. An
example of a CBT strategy for dealing
with poor body image is to encourage
patients to spend more time focusing
on aspects of their appearance that
they appreciate, as well as on
nonappearance-related components
of their self image. Patients might
also be assisted in realistically
exploring how their negative body
image is impacting their ability to
achieve their weight loss goals,
including their motivation for change
(e.g., increased physical activity).
For many patients, bariatric
surgery results in an improvement in
their romantic relationships.15
However, for some patients, struggles
with jealousy, trust, or intimacy may
develop post-surgery.14 In a group
CBT format, relationship changes can
be discussed. The group leader and
other patients can provide validation
and helpful suggestions to each other.
In addition to relationship
struggles, some patients report other
difficult social interactions related to
their weight loss. It is not uncommon
for patients at our clinic to express
frustration with family, friends, or
coworkers who excessively ask about
the patient’s weight loss. Teaching
patients assertiveness skills can help
them better manage these
interactions. Cognitive techniques
can also assist patients in viewing
others’ comments in a different and
perhaps more positive way. Patients
also discuss how they are treated
differently postsurgery. A small group
format is a useful way to examine this
and provide patients with validation
and understanding about weight bias
and how their weight loss may impact
their interactions with others.
While the majority of bariatric
patients report improvements in
mood and psychological functioning
following surgery,13 some bariatric
surgery patients experience
worsening psychiatric symptoms
following surgery.20 For a very small
subset of those patients, suicidality
may increase following surgery, as
suggested by a slight increase in the
rate of suicide in post-bariatric
surgery patients.16,21 A CBT therapist
can help patients learn cognitive and
behavioral strategies for managing
mood, such as restructuring negative
thoughts and planning pleasant
activities. CBT groups also provide
the opportunity to remind patients to
take their psychotropic medications
as prescribed, to monitor for
increased depression and suicidality,
and to make referrals to more
intensive psychological or psychiatric
treatment when needed.
The vast majority of weight loss
surgery patients do not abuse
substances following surgery;
however, there is some evidence that
susceptibility to substance abuse may
increase following bariatric surgery.17
Unfortunately, little is known about
the process whereby bariatric surgery
may place individuals at higher risk
for developing substance abuse
problems. Openly discussing
substance use patterns and risks of
substance abuse after surgery during
group sessions may facilitate earlier
detection and treatment for
substance use.
MINDFULNESS PRACTICES IN CBT
GROUPS
It has been suggested that
incorporating mindfulness-based
practices into a CBT group could
prove particularly useful for bariatric
surgery patients. Mindfulness has
been defined as focusing on the
present moment with an attitude of
nonjudgmental acceptance.41,42
Mindfulness therapeutic
approaches are consistent with a
cognitive behavioral framework and
have proven beneficial when
incorporated in standard CBT for
clinical problems, including eating
disorders and obesity.22,23 It has been
suggested that mindfulness practices
may be particularly beneficial for
bariatric patients for several
reasons.24–26 Authors have pointed out
that mindfulness can help patients
become more aware of satiety cues
and internal physical sensations,
skills which are particularly
important in avoiding the discomfort
and risk that can come from
overeating after bariatric surgery.26
Mindfulness can also assist patients
who tend to engage in emotional
eating learn greater acceptance of
their emotions, rather than using
food to avoid negative emotion.25
Additionally, the nonjudgemental
acceptance stance of mindfulness-
based therapy may assist patients in
gaining acceptance with the results of
their surgery, thus helping them
adjust to life after surgery.25
RESEARCH TRIALS OF CBT FOR
BARIATRIC SURGERY PATIENTS
While extensive research
indicates that CBT groups are
beneficial for nonsurgical weight
management and for improving
psychosocial functioning, only
recently have researchers begun to
study the impact of CBT groups on
bariatric surgery patients. One recent
study25 examined the effects of a CBT
group that incorporated mindfulness-
based practices. This CBT protocol
was targeted toward individuals who
engaged in binge eating
postoperatively. Seven post-bariatric
surgery individuals who met criteria
for binge eating disorder and were 2
to 11 months postoperative were
referred by their physician to join the
group. Participants completed 10
weekly, 75-minute group sessions.
Results showed a reduction in binge
eating, an increase in eating self
efficacy, improvements in emotional
regulation, and reduced depressive
symptoms following the program.25
The absence of a control group and
the small sample size make
determining the effects of the group
on weight loss difficult. However, this
study suggests that a CBT
intervention can help improve the
patients’ psychological health and
disordered eating behaviors of
patients with binge eating habits.
These effects may translate into
weight loss or weight maintenance
benefits in the years after bariatric
surgery, though that has yet to be
determined.
Some authors have examined the
value of targeting interventions at
individuals who have not achieved
optimal weight loss benefits from
bariatric surgery. In a study by
Kalarchian et al,27 participants who
were at least three years post-
bariatric surgery and who had lost
less than 50 percent of their excess
body weight were assigned to a six-
month behavioral intervention or to a
control group. Patients in the
behavioral group achieved 5.8
percent EWL compared to 0.9
percent in the control group at 12
months after the intervention. In this
study, it was found that participants
who had more depressive symptoms
and who had experienced less weight
regain prior to entering the study lost
more weight. These results support
the value of CBT groups for
producing weight loss in bariatric
surgery patients who are many years
postoperative. This study also
suggests that patients with more
significant depressive symptoms may
benefit most from CBT groups.
In a study undertaken in
Norway,28 individuals were assigned
to either a control condition or a CBT
group condition. Participants
assigned to the CBT groups
participated in six CBT group
sessions prior to surgery, as well as
postoperative group sessions
occurring six months, one year, and
two years after surgery. These groups
incorporated mindfulness practices in
addition to standard CBT
approaches. Contrary to the authors’
hypotheses, the CBT intervention
was not found to affect the amount of
weight lost or adherence to eating
behaviors or physical activity at one-
year postoperative. Though these
results may initially appear
discouraging, it is important to note
that results were only presented for
the first postoperative year. As
previously discussed, the effects of
CBT groups on weight may be most
25ReviewBariatric Times • September 2012
apparent after the first year
postsurgery. Thus, it may be that in
the study by Lier et al28 the
researchers would have observed
more benefit from CBT groups if the
time point for comparison was
further post surgery.
Individual CBT interventions with
bariatric surgery patients have also
have presented in the literature. In
one study,29 women who underwent
vertical gastric banding between 2005
and 2006 were randomized to two
treatment groups, typical treatment
sessions or individual sessions
focusing on behavioral principles.29
The authors found greater weight
loss in the intervention group at one,
two, and three years post
intervention. They also reported
changes in dietary patterns and
physical activity favoring the
intervention group. While this study
highlights the potential benefit of
individual CBT for bariatric surgery
patients, CBT groups may be able to
provide similar therapeutic benefits
but in a more cost effective and
efficient manner. Further, there is
evidence that group treatment is
more effective for weight loss than
individual treatment in nonsurgical
behavioral treatment.30
These studies, combined with the
strong evidence supporting CBT for
weight loss in nonsurgical patients,
have provided initial evidence that
CBT can be beneficial for bariatric
surgery patients. However, continued
research is needed to study the
impact of CBT groups on weight loss,
particularly when utilized more than
one year after surgery. Additional
research also is needed to determine
the effects of CBT groups on
psychosocial adjustment, quality of
life, and postsurgical medical or
nutritional complications.
Fortunately, clinical trials are
currently underway that may help
shed further light on the impact of
CBT groups on bariatric patients. In a
large trial, Kalarchian et al from the
University of Pittsburgh, Pittsburgh,
Pennsylvania, are randomizing
patients to a control group or to a
six-month behavioral weight loss
lifestyle intervention delivered prior
to bariatric surgery. In addition to
weight outcomes, this study will be
examining the impact on medical
complications and medical care
utilization after surgery. This trial will
help demonstrate the potential value
of group therapy in this population.
Though bariatric surgery support
groups differ from CBT groups in
important ways, the existence of
some common elements suggests that
it may be instructive to examine the
impact of these groups on bariatric
surgery outcomes. A few studies have
examined the effects of attendance of
bariatric surgery support groups on
weight loss. Frequency of support
group attendance has been shown to
predict weight loss in several
studies.31–33 One study33 showed that
12 months post-bariatric surgery,
individuals who attended five or more
monthly support group meetings lost
55.5 percent of excess weight,
compared to 47.1 percent of excess
weight loss in those who attended
less than five groups. While the
results are promising, these studies
involve individuals self selected into
support groups, and it may be that
these are patients who are more
adherent with treatment
recommendations in general.
POTENTIAL BENEFITS TO
SURGICAL PRACTICES
It is our perspective that CBT
groups benefit not only the bariatric
surgery patient, but also the surgical
practice as a whole. Bariatric team
members are often approached by
patients with issues, such as
psychosocial distress, difficulty with
adherence, or mood problems. These
professionals may have minimal
training in addressing such concerns,
as well as limited time. In a clinic that
offers CBT groups, patients have an
opportunity to address these issues
during the groups thereby reducing
the need for these topics to be
addressed during the medical and
nutrition follow-up appointments.
STRUCTURING CBT GROUPS
Trained practitioners considering
implementing CBT groups in their
bariatric surgery practice may have
questions regarding aspects of the
delivery of CBT groups, such as the
optimal “dosage” of intervention, the
frequency and timing of CBT groups,
26 Review Bariatric Times • September 2012
and the selection of appropriate
patients for CBT groups. Currently,
there is no standard protocol for
cognitive behavioral intervention pre-
or post-weight loss surgery. Our
recommendations are based on the
existing literature (i.e., largely from
nonsurgical populations) and clinical
observations from our practice (Table
1).
Regarding the scheduling of
groups, clinicians should consider
strategies to maximize group
attendance. Historically, at our clinic,
an effort is made to schedule
patients’ groups on the same day as
their medical follow-up appointments
to reduce travel burden. Patients are
invited to attend therapy groups that
meet 1 to 2 weeks preoperatively and
postoperatively at three weeks, three
months, six months, and one year
after surgery. This structure was
chosen largely to be consistent with
the existing schedule for medical
follow-up appointments. By
scheduling patients’ medical and CBT
group appointments together,
patients may be more likely to
attend. At our clinic, attendance
rates at CBT postoperative groups
are generally high. Recent data
collected on patients who underwent
Roux-en-Y gastric bypass (RYGB)
between 2009 to 2010 showed that
59.8 percent of participants attended
three out of four of our postoperative
CBT sessions. Attendance rates
decreased with length of time since
surgery; however, 47.2 percent of
patients attended group sessions at
one year postoperative. In addition to
scheduling these sessions in
conjunction with medical
appointments, we also highlight the
benefit of these groups to patients
from the beginning of the application
process (e.g., at the informational
seminar) and encourage all patients
to attend. In fact, some patients have
commented that they sought out our
program because of the intensive
preoperative preparation and
postoperative care, including the CBT
groups. We believe it is of great
importance that the entire surgical
team stresses the usefulness of
attending these groups. Patients
often look to their surgeons for
advice on their postoperative
treatment plan, and when the
surgeons are supportive of behavioral
treatments, it seems more likely that
patients will be willing to participate
in groups.
Though the optimal frequency of
the groups has not yet been
empirically determined, research
from the behavioral weight loss
literature can be instructive. This
literature has demonstrated that
more intensive patient contact is
associated with greater weight
loss.34,35 However, we recognize that
balancing the effectiveness of
increased patient contact with
patients’ interest in attendance and
clinical resources is necessary.
An additional question that can
be asked is “Who should attend CBT
groups?” Historically, all patients who
have surgery at our clinic were
recommended to attend CBT groups.
We believe that the skills taught
during these groups and the
interaction with a small number of
other pre- and postoperative patients
can be of value to every individual
undergoing bariatric surgery.
However, other approaches can be
imagined. For example, some
clinicians may consider offering a
standard group as well as a more
intensive CBT group option for
patients who have experienced
slower than expected weight loss in
the first six months or reach an
earlier than expected weight loss
plateau. Additionally, patients who
experience significant weight regain
in the years after surgery could be
targeted for a specialized
intervention. Indeed, some clinics
have developed programs that focus
on addressing inadequate weight loss
and eating disorders.25,27 Individuals
who are having difficulty adjusting to
psychosocial changes also may be
targeted for interventions. Given
evidence that depressive and anxiety
disorders are common in bariatric
surgery patients and that individuals
with these conditions may lose less
weight and may be less likely to reap
the mental health benefits of
surgery,37 offering patients with these
psychiatric conditions a CBT program
that is more intensive and focuses
more extensively on mood and
anxiety management might be
beneficial. CBT groups may provide
the opportunity to identify patients
for individual assistance or create
tailored group interventions for those
patients who develop more serious
psychological symptoms. Recently,
there has been a published
manuscript outlining a group
intervention for individuals who have
substance-related issues.36 Overall, in
addition to providing support and
skills for all patients, CBT groups
may also provide the opportunity to
identify patients for individual
assistance or create tailored group
interventions for those patients who
develop more serious psychological
symptoms.
The relative effectiveness of
offering groups prior to surgery, after
surgery, or at both time points is an
important issue. The most vulnerable
times for bariatric surgery patients
may be the most valuable time to
have a psychological intervention.
For example, right before surgery
patients often report increased
anxiety. CBT groups could be used to
help patients cope with this anxiety
and to prepare for the many changes
in the early post-surgery weeks. CBT
may be helpful at three and six
months postoperatively for patients
who are already deviating from the
postsurgical lifestyle changes at those
times. Another sensitive time point
for patients may be at 12 to 18
months postoperative, as this is the
time when weight loss slows or stops
and some patients begin regaining
weight.43 Patients’ interest in CBT
groups at different time points should
also be considered.
One study38 examined differences
in group attendance between pre-
and postoperative patients who were
offered group therapy and found that
those patients referred to a
behavioral intervention prior to
surgery were less likely to attend
than patients referred
postoperatively. CBT groups may be
valuable for patients who are many
years postoperative. As described
previously, Kalarchian et al27 had
good results with a behavioral
therapy group for individuals who
had undergone surgery three or more
years prior to participating in the
group.
The qualifications and
experiences of CBT group leaders are
also important. Group leaders should
be licensed mental health providers
who have training and experience
working with both CBT and bariatric
surgery populations. Our clinic has
employed doctoral level clinical
psychologists trained in CBT to
conduct the majority of pre-operative
psychological evaluations and also
lead the pre- and postoperative
groups. This approach facilitates the
development of an ongoing
relationship between therapist and
the patients.
It may also be helpful to identify
those patients who are less inclined
to attend CBT groups so that
strategies can be developed to
increase their likelihood of attending.
A recent study39 found that those
bariatric surgery patients with social
phobia and avoidant personality
disorder were significantly less likely
to attend group counseling sessions
after bariatric surgery. Further
research is needed to determine the
characteristics that may impact
attendance at CBT groups and the
strategies that maximize involvement
of all patients before and after
surgery.
CONCLUSION
Individuals deciding to have
bariatric surgery are typically seeking
weight loss, improved health, and a
TABLE 1. Example of techniques that may be utilized in CBT groups for bariatric surgery patients
TIME POINT APPROACHES UTILIZED IN CBT GROUPS
PRE-OPERATIVE
Provide opportunity to discuss and normalize potential anxiety andother emotions surrounding impending surgery
Teach relaxation exercises and cognitive coping strategies tomanage potential anxiety regarding surgery itself and post-operative lifestyle changes.
Provide psychoeducational information about surgery and likelyemotional and lifestyle changes that occur peri-operatively
Provide information on common peri-operative experiences (i.e.,level of pain, eating-related urges that may occur during the liquiddiet phase).
Review dietary changes required immediately post-operatively;discuss potential challenges to following these guidelines.
POST-OPERATIVE
Approaches to improve weight loss outcomes and minimizecomplications
• Identify and modify negative cognitions interfering withadherence to physical activity, diet, and medication/vitamins.
• Use learning theory principles to help patient adhere to lifestylechange goals (i.e., set rewards for adherence, modifyenvironmental stimuli)
Approaches to increase quality of life and psychosocialoutcomes
• Focus on improving body image (i.e., encourage patients to focuson body parts they appreciate; challenge overvaluation of body sizeor shape).
• Provide support and guidance surrounding possible relationshipchanges following surgery and massive weight loss.
• Teach cognitive and behavioral mood management strategies.
• Make referrals to more intensive treatment for mood orsubstance difficulties, as needed.
28 Review Bariatric Times • September 2012
greater quality of life. CBT groups
can assist with these goals as well as
help the surgical practice. CBT
groups can help patients adhere to
the many behavioral changes that are
required after weight loss surgery,
which has the potential of increasing
weight loss and minimizing weight
regain. Additionally, these groups
may be able to contribute to reducing
the frequency of certain postsurgical
complications, such as nutritional
deficiencies, plugging, recurrent
vomiting, and dehydration. Bariatric
surgery can result in changes in self
image, relationships, and mood.
Group CBT may help patients adjust
to the normal psychosocial changes
that occur after bariatric surgery. For
most patients, the speed at which
they lose weight is almost astounding
and having the support of a trained
therapist and other patients during
this time can be helpful. A small
minority of patients may experience
more serious psychosocial difficulties
after surgery, such as increased
depression, suicidality, or substance
abuse, and CBT groups provide the
opportunity for assisting those
patients who develop these more
serious psychological symptoms. We
also believe that groups are beneficial
to the surgical practice. They allow
treatment of several patients at once
and can help streamline patient care.
It is our belief that CBT groups are a
valuable component to a
comprehensive approach to surgical
weight loss.
REFERENCES
1. Thomas JG, Bond DS, Ryder BA, et
al. Ecological momentary
assessment of recommended
postoperative eating and activity
behaviors. Surg Obes Relat Dis.
2011;7(2):206–212.
2. Sarwer DB, Wadden TA, Moore RH,
et al. Preoperative eating behavior,
postoperative dietary adherence,
and weight loss after gastric bypass
surgery. Surg Obes Relat Dis.
2008;4(5):640–646.
3. Edwards C. Success habits of long-
term gastric bypass patients. Obes
Surg. 1999;9(1):80–82.
4. Evans RK, Bond DS, Wolfe LG, et
al. Participation in 150 min/wk of
moderate or higher intensity
physical activity yields greater
weight loss after gastric bypass
surgery. Surg Obes Relat Dis.
2007;3(5):526–530.
5. Maggard MA, Shugarman LR,
Suttorp M, et al. Meta-analysis:
surgical treatment of obesity. Ann
Intern Med. 2005;142(7):547–559.
6. Magro DO, Geloneze B, Delfini R, et
al. Long-term weight regain after
gastric bypass: a 5-year prospective
study. Obes Surg.
2008;18(6):648–651.
7. Christou NV, Look D, MacLean LD.
Weight gain after short-and long-
limb gastric bypass in patients
followed for longer than 10 years.
Ann Surg. 2006;244(5):734.
8. Butler AC, Chapman JE, Forman
EM, Beck AT. The empirical status
of cognitive-behavioral therapy: A
review of meta-analyses. Clin
Psychol Rev. 2006;26(1):17–31.
9. Morley S, Eccleston C, Williams A.
Systematic review and meta-
analysis of randomized controlled
trials of cognitive behaviour
therapy and behaviour therapy for
chronic pain in adults, excluding
headache. Pain. 1999;80(1):1–14.
10. Svetkey L, Stevens V, Brantley P, et
al. Comparison of strategies for
sustaining weight loss: the weight
loss maintenance randomized
controlled trial. JAMA.
2008;299(10):1139–1148.
11. Wing R. Behavioral Weight Control.
In: Wadden T, Stunkard A, eds.
Handbook of Obesity Treatment.
New York: Guilford Press;
2004:301–316.
12. Lanyon RI, Maxwell BM, Kraft AJ.
Prediction of long-term outcome
after gastric bypass surgery. Obes
Surg. 2009;19(4):439–445.
13. Burgmer R, Petersen I, Burgmer M,
et al. Psychological outcome two
years after restrictive bariatric
surgery. Obes Surg.
2007;17(6):785–791.
14. Applegate KL, Friedman KE. The
impact of weight loss surgery on
romantic relationships. Bariatr
Nurs Surg Patient Care.
2008;3(2):135–141.
15. Kinzl J, Traweger C, Trefalt E, Biebl
W. Psychosocial consequences of
weight loss following gastric
banding for morbid obesity. Obes
Surg. 2003;13(1):105–110.
16. Tindle H, Omalu B, Courcoulas A,
et al. Risk of suicide after long-term
follow-up from bariatric surgery.
Am J Med.
2010;123(11):1036–1042.
17. Saules KK, Wiedemann A, Ivezaj V,
et al. Bariatric surgery history
among substance abuse treatment
patients: prevalence and associated
features. Surg Obes Relat Dis.
2010;6(6):615–621.
18. Jarry JL, Ip K. The effectiveness of
stand-alone cognitive-behavioural
therapy for body image: A meta-
analysis. Body Image.
2005;2(4):317–331.
19. Rosen JC. Body image assessment
and treatment in controlled studies
of eating disorders. Int J Eat
Disord. 1996;20(4):331–343.
20. Larsen F. Psychosocial function
before and after gastric banding
surgery for morbid obesity. A
prospective psychiatric study. Acta
Psychiatr Scand Suppl.
1990;359:1–57.
21. Adams T, Gress R, Smith S, et al.
Long-term mortality after gastric
bypass surgery. N Engl J Med.
2007;357(8):753–761.
22. Dalen J, Smith BW, Shelley BM et
al. Pilot study: Mindful Eating and
Living (MEAL): Weight, eating
behavior, and psychological
outcomes associated with a
mindfulness-based intervention for
people with obesity. Complement
Ther Med. 2010;18(6):260–264.
23. Forman EM, Butryn ML, Hoffman
KL, Herbert JD. An open trial of an
acceptance-based behavioral
intervention for weight loss. Cogn
Behav Pract. 2009;16(2):223–235.
24. Bly T, Hammond M, Thomson R,
Bagdade P. Exploring the use of
mindful eating training in the
bariatric population. Bariatric
Times. 2007.
http://bariatrictimes.com/2007/12/1
0/exploring-the-use-of-mindful-
eating-training-in-the-bariatric-
population/. Accessed March 2012.
25. Leahey TM, Crowther JH, Irwin SR.
A cognitive-behavioral mindfulness
group therapy intervention for the
treatment of binge eating in
bariatric surgery patients. Cogn
Behav Pract. 2008;15(4):364–375.
26. Weineland S, Arvidsson D,
Kakoulidis TP, Dahl J. Acceptance
and commitment therapy for
bariatric surgery patients, a pilot
RCT. Obes Res Clin Pract.
2012;6(1):e21–e30.
27. Kalarchian MA, Marcus MD,
Courcoulas AP, et al. Optimizing
long-term weight control after
bariatric surgery: a pilot study.
Surg Obes Relat Dis. 2011. (Epub
ahead of print)
28. Lier HØ, Biringer E, Stubhaug B,
Tangen T. The impact of
preoperative counseling on
postoperative treatment adherence
in bariatric surgery patients: A
randomized controlled trial. Patient
Educ Couns. 2011. (epub ahead of
print)
29. Papalazarou A, Yannakoulia M,
Kavouras SA, et al. Lifestyle
intervention favorably affects
weight loss and maintenance
following obesity surgery. Obesity.
2009;18(7):1348–1353.
30. Renjilian DA, Perri MG, Nezu AM,
et al. Individual versus group
therapy for obesity: Effects of
matching participants to their
treatment preferences. J Consult
Clin Psychol. 2001;69(4):717–721.
31. Kaiser KA, Franks SF, Smith AB.
Positive relationship between
support group attendance and one-
year postoperative weight loss in
gastric banding patients. Surg Obes
Relat Dis. 2011;7(1):89–93.
32. Elakkary E, Elhorr A, Aziz F, et al.
Do support groups play a role in
weight loss after laparoscopic
adjustable gastric banding? Obes
Surg. 2006;16(3):331–334.
33. Song Z, Reinhardt K, Buzdon M,
Liao P. Association between
support group attendance and
weight loss after Roux-en-Y gastric
bypass. Surg Obes Relat Dis.
2008;4(2):100–103.
34. Perri MG, Nezu AM, Patti ET,
McCann KL. Effect of length of
treatment on weight loss. J Consult
Clin Psychol. 1989;57(3):450–452.
35. Baum JG, Clark HB, Sandler J.
Preventing relapse in obesity
through posttreatment
maintenance systems: comparing
the relative efficacy of two levels of
therapist support. J Behav Med.
1991;14(3):287–302.
36. Heinberg L, Ashton K, Coughlin J.
Alcohol and bariatric surgery:
Review and suggested
recommendations for assessment
and management. Surg Obes Relat
Dis. 2012. In press.
37. Kalarchian MA, Marcus MD, Levine
MD, et al. Relationship of
psychiatric disorders to 6-month
outcomes after gastric bypass. Surg
Obes Relat Dis. 2008;4(4):544–549.
38. Leahey TM, Bond DS, Irwin SR, et
al. When is the best time to deliver
behavioral intervention to bariatric
surgery patients: before or after
surgery? Surg Obes Relat Dis.
2009;5(1):99–102.
39. Lier HØ, Biringer E, Stubhaug B, et
al. Psychiatric disorders and
participation in pre-and
postoperative counselling groups in
bariatric surgery patients. Obes
Surg. 2011;21(6):730–737.
40. Sarwer, DB, Dilks, RD, West-Smith,
L. Dietary intake and eating
behavior after bariatric surgery:
threats to weight loss maintenance
and strategies for success. Surg
Obes Relat Dis. 2011;7;644–651.
41. Kabat-Zinn, J. Full Catastrophe
Living: Using the Wisdom of Your
Body and Mind to Face Stress,
Pain, and Illness. New York:
Bantum Dell; 1990.
42. Kabat-Zinn, J. Wherever You Go,
There You Are: Mindfulness
Meditation in Everyday Life. New
York: Hyperion; 1994.
43. Sjöström L, Lindroos AK, Peltonen
M, et al. Lifestyle, diabetes, and
cardiovascular risk factors 10 years
after bariatric surgery. N Engl J
Med. 2004;351:2683–93.
FUNDING: No funding was provided.
DISCLOSURES: The authors report no
conflicts of interest relevant to the content of
this article.
AUTHOR AFFILIATION: Dr. McVay is from
Duke University Medical Center, Department
of Psychiatry, Durham, North Carolina. Dr.
Friedman is from Duke Health System, Duke
Center for Metabolic and Weight Loss
Surgery, Durhan, North Carolina.
ADDRESS FOR
CORRESPONDENCE:
Kelli E. Friedman, Duke
Center for Metabolic and
Weight Loss Surgery, 407
Crutchfield Street, Durham,
NC 27704;Phone: (919)-
470-7000; Fax: (919)-470-7028; E-mail:
Kelli.friedman@duke.edu