Bariatric Times

DEC 2017

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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10 Original Research Bariatric Times • December 2017 surgery," but were familiar with the term "weight loss surgery." Likewise, some participants were m ore familiar with specific types of surgery and discussed specific procedures when asked if they were familiar with bariatric surgery. During the interviews, p articipants were asked about what specific bariatric surgical procedures they were aware of and specifically were asked to list each procedure that they could recall. When asked about surgical procedures, 11 out of 15 therapists were able to name at least one surgical procedure, with laparascopic banding (N=9) and the R oux-en-Y gastric bypass (RYGB) (N=6) being the two most reported procedures. In the study, three participants reported being familiar with the "vertical sleeve gastrectomy" procedure. While being interviewed, two participants reported that they were not able to name any bariatric surgery procedures. Further, three participants discussed cosmetic surgical procedures. For example, when asked to list bariatric surgical procedures, Grace stated, "tummy tuck," and Destiny and Nicole replied "liposuction." During the interview process, participants were asked if they learned about weight loss surgery within the context of individual, couple, and family relationships during their graduate training program. Researchers found that one participant (Brian) reported that he learned about weight loss surgery as a process that clients might transition through, with the remaining 14 therapists reporting that they did not discuss weight loss surgery within the context of relational systems during their graduate training. Participants were also asked if they had any training or exposure to assessments for screening patients with obesity prior to weight loss surgery. During the study, four of the participants reported that they either had exposure to assessments or were specifically trained in assessments regarding screening patients for bariatric surgery, with 11 participants reporting not having any exposure or experience. During the interview process, the four individuals who reported having exposure to or experience with clinical assessments communicated that their experience either came from having a clinical internship in a medical setting or came after obtaining employment post- graduation. T heme 2: Theoretical frameworks. The following excerpt from an interview illustrated the second theme that emerged during the study, theoretical frameworks. " The post-modern approach challenges the larger narratives that are out there that are often internalized by people, whether it be a physical illness or obesity." -Ryan The research team determined "theoretical frameworks" to be the second theme that emerged from t he study. During the interviews, 14 of the 15 participants mentioned a post-modern theory that they have used or would imagine using with a bariatric surgery patient. Out of those 14 participants, nine specifically mentioned narrative therapy. The narrative therapy approach focuses on empowering the client to re-author his or her life story. Nicole specifically said that narrative therapy could be used to "encourage hope" but most other clients listed it because it was their theory of choice. Eight of those 14 participants mentioned solution- focused therapy [some of those same participants (n=4) also listed narrative therapy]. Vela listed narrative and solution-focused theories because those are two main theories used at her hospital. She explained that a lot of the time (therapy) has to be brief because they do not see the clients on a regular basis. They only see the patients while they are at the hospital when they have had complications with their surgeries. In this case, the preference for the post-modern theories was for convenience and utility because the patients are only at the location for a limited time period. Destiny and Brian specifically mentioned the "miracle question" as an intervention of the solution- focused method. Both participants sought to bring the future into the forefront of the conversation, and thus highlight potential strategies that the patient can use to get there. Ryan gave the most descriptive answer about why he would choose the solution-focused approach, stating: "I think solution-focused would work well with a client with obesity because it looks at a client's own strengths, empowering the client, and looking for exceptions—times w hen they are being successful. This also involves looking at a client's self-agency and their own capabilities." -Ryan C ognitive behavioral therapy (CBT) was mentioned by five participants, and although there were fewer individuals that listed the post-modern approaches, they were the most specific about interventions. John and Grace said that they would focus on changing negative thoughts, Cindy would focus on cognitive restructuring and r eframing, and Varnes and Wadell would journal to help notice and change thoughts. Theme 3: Perceptions of clinical treatment. The following excerpt from an interview illustrated the third theme that emerged during the study: perceptions of clinical treatment. "I think obesity is tied to something mental. I feel that it is a secondary symptom of something else. I think that before the weight loss there may be fear of having the surgery. Afterwards, I feel that there will be physical things that they will have to deal with, and then they will have to deal with the secondary feelings that come up. Some people think that they just feel bad because of the weight, but then they lose the weight and still feel bad about themselves." -Lionel The research team determined "perceptions of clinical treatment" as the third theme that emerged in the study. During interviews, participants made it clear that they (n=10) deemed support and psychoeducation to the client and their family as extremely imperative pre- and post-surgery. Participants mentioned the importance of teaching family and couple skills to patients or "clients" to help them communicate effectively so that they can be emotionally supportive to one another. Participants also stated that it was important that the entire family system attempt to create healthy eating habits pre- and post-surgery. Two participants verbalized that it is essential that patients and family members engage in support groups. Further, three participants mentioned a plethora of mental health issues that they viewed as related to bariatric s urgery patients, such as eating disorders, depression, body dysmorphia, and anxiety. Three participants also mentioned that financial stress related to how the s urgery is paid for and perhaps the required time off from work might impact patients. Clinicians working from a holistic and multidisciplinary approach with medical professionals and nutritionists were seen as important by all participants. Participants felt it was necessary for medical and other health professionals to be e mpathetic and understand the mental health aspects of bariatric surgery, before, during, and after the procedure. Participants also communicated that it is important f or mental health professionals to be involved in screening for secondary or comorbid diagnoses. For example, during the interview process, Destiny stated the f ollowing: "My bias is that medical professionals see only the medical aspect of it and not see the mental health aspect to it. So, I would want to shed light for medical professionals on the mental health aspect." In addition, another participant conveyed a similar message and discussed the importance of medical professionals understanding clinical dimensions of bariatric surgery. When interviewed, Waddell stated the following: "It is important to remind medical professionals that 93 percent of the way we communicate is nonverbal and the other seven percent is what we let come out of our mouths. I think it is very important to remind medical professionals that we need to be empathetic." -Waddell During the interviews, another key area of focus that participants cited was the lack of education the client has about the bariatric surgery process, including before and after surgery. Many of the clients are unaware of the healthy changes they need to make in their lifestyle and eating patterns. Participant Leila addressed a multi- generational phenomenon that might exist. She stated: "A lot of times, I have noticed in couples and families a multigenerational pattern. There is not a lot out there on healthy habits and healthy eating, and families may have an unhealthy relationship with food in their household, putting "Participants felt it was necessary for medical and other health professionals to be empathetic and understand the mental health aspects of bariatric surgery, before, during, and after the procedure."

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