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.

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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