Support Versus Therapy: Have You Got It Right?

by Julie M. Janeway, BBA, MSA, JD; and Karen Sparks, BBA, MBEd

INTRODUCTION
With regard to the provision of bariatric support group services, there exists a debate as to whether support groups are appropriate forums for group therapy and counseling, or are better utilized as a place for patients to find support, information, skills, techniques, advocacy, and help. Many of the behaviorists and social science members of the bariatric industry believe that bariatric patients are best served by running support groups as group therapy events. This article seeks to endorse the position that support groups are not appropriate for therapy and mental health counseling, and that the underlying premise that all bariatric patients are in need of such therapy and counseling is flawed.

DISCUSSION
To begin, it is helpful to examine the simple definitions of the two words support and therapy.

Support: To promote the interests or cause of; to advocate; to assist or help; to maintain.1
Therapy: An agency (as treatment) designed to deal with a bodily disorder or to bring about social adjustment as with psychotherapy.1

It is plain to see that both of these terms can apply to the bariatric support group setting, but which is more appropriate to achieving the success of the patient’s long-term weight loss goals and lifestyle changes? Much of the answer lies in the nature of the bariatric patient in general. Bariatric patients, whether they are surgical treatment patients or patients undergoing any other manner of weight loss or weight management treatment modality, are arguably the most complex and multifaceted patient population alive.

These patients come to the medical profession with years and lifetimes of emotional abuse, rejection, marginalization, ridicule, harassment, sometimes physical and/or sexual abuse, and a host of other injuries to their psyches that run particularly deep.2 They have suffered significant negative experiences in their emotional, intellectual, spiritual, physical, medical, legal, social, cultural, financial, educational, career, and personal lives that have left them feeling, in many cases, as if they are less than acceptable as human beings. Yet they manage to survive, in some instances to thrive, and in most cases presenting for treatment wishing to change and improve their situations. Their lived experiences and mindsets are so diverse, so intertwined, and so complex that nothing short of addressing the entire needs of the person will do to advance them toward success in this one life-changing endeavor.

The medical profession has basically accepted that a multidisciplinary approach is needed to help patients find success with weight loss.3 We employ a variety of methods to deal with varying aspects of lifestyle change, including medical, nutritional, behavioral, psychological, motivational, and physical activity. These aspects are addressed through the structured portion of the weight loss process, but tend to taper off as the clinical part of the program declines or terminates. Why should only the psychological aspect continue through the support group function? Do not all the aspects of the patient’s self need attention?

The answer to these questions may be found in a concept that comes from interpersonal relations, called the total person approach.4 The total person approach realizes that one must deal with the whole person, not just a particular set of characteristics or qualities possessed by that individual or a particular issue or portion of a person’s very complex life. People play many roles throughout their lives, and indeed, throughout each day. Support group members are more than just weight loss surgery patients, or laparoscopic adjustable gastric band patients, or medically managed weight loss patients. They are parents, daughters, engineers, teachers, choir members, students, and more. When they attend support group, they will not completely discard all these other roles or the issues that accompany them.

Similarly, they bring all of their personal aspects with them as well: Emotional, intellectual, spiritual, physical, medical, legal, social, cultural, financial, educational, career, and personal lives. Should attention be given only to their psychological or emotional aspects on an ongoing basis? Do all patients need ongoing attention for their emotional and/or psychological issues, or are they often resolved through attention paid to other aspects of their personal selves, or through private counseling? These authors contend that all aspects need ongoing attention at support groups, and that any patient requiring psychological attention for their unresolved issues can seek treatment in a capacity ancillary to the support group setting.

The support group setting is by nature a group environment. Group environments have their own behavior patterns, and therefore require management and direction.5,6 The management and direction applied in the group setting generally takes one of three possible forms: Leadership, facilitation, or a combination of the two.

Leadership in the group setting is recognized as the ability to influence the actions of others, helping others to work toward a goal, and motivating others to do things they would not ordinarily do.7,8

Conversely, facilitation is defined as the ability to take an active part in the group process without having decision-making authority, create a comfortable atmosphere for participation, and when possible or practical, to provide additional relevant information and resources for the group.9,10 Group facilitation is a process in which a person is acceptable to all members of the group, is substantively neutral, has no decision-making authority, intervenes to help improve the way the group discusses issues, identifies and solves problems, and makes decisions in order to increase the group’s effectiveness. Therefore, the essential role of a facilitator is to enable a group to focus its skills and energy on the tasks it is charged to carry out.11

If a support group concentrates only on providing therapy for psychological issues, then the therapist becomes a facilitator by the definition provided above. The group’s tasks center around instructing individuals how to effectively deal with their own psychological and emotional difficulties, as well as helping the group become effective at dealing with the group therapy process itself. The tasks are essentially limited to two aspects.

Facilitators, by their very definition, are not there to empower group members, to role model for them, or to act as an example or success story. In fact, facilitators are not supposed to bring much of themselves to the situation at all, and that leaves out some of the collective patient and facilitator’s lived experiences. Additionally, it can harm the affiliation and trust that are so important to the relationship between members and their facilitator/leader.

On the other hand, if a support group solely employs leadership methods according to the definition provided, then the group would be resigned to following the vision and goals of the leader, rather than establishing its own vision and goals to serve the congruent interests of the membership. If leadership principles are employed exclusively, then group members would look to the support group leader to provide them with answers, motivation, empowerment, information, boundaries, decisions, and other leadership attributes when both appropriate and inappropriate. Group members would not develop the skills necessary to find those attributes within themselves.

From the two simple definitions stated previously, we can see that good support group leaders embody the traits of both a leader and a facilitator. It then becomes clear that both leadership and facilitation skills must be appropriately used in context to really effectuate a successful support group, thus precluding the traditional group therapy approach to providing support group services. These authors definitively state that a good support group leader must be both, and must know when it is appropriate to take on more of one role than the other, and in doing so group therapy is effectively inappropriate.

For example, it is the leadership function that helps the group set goals and establish its vision pursuant to its own group dynamics. Group dynamics, or more specifically group process, refers to the patterns of interactions that emerge as groups develop.6 Group success depends on the process group members use to interact with each other, not solely on the interaction with the leader or the ability to follow the instructions of the leader.6,8

Each group must determine its own vision and goals. A group functioning solely as an emotional therapeutic entity has predetermined goals and vision. The tasks remain static and rigidly defined. The management of change is strictly limited to each member’s individual emotional and psychological issues, thus excluding dealing with the change that is occurring in a myriad of additional areas within each member’s life.

Similarly, the barriers and resistance to change that are being experienced by each group member will only receive attention pertinent to the aspects at issue in the support-group-as-therapy setting. An appropriately educated and prepared support group leader that is employing a combination facilitative/leadership approach in addressing the multifaceted issues that members experience will be able to assist the members in realizing successful methods and techniques of overcoming various barriers and types of resistance in a variety of areas in their respective lives. The appropriately trained leader will understand when the group and individuals within the group need to be led, trained, educated, motivated, praised, and celebrated, or when they require advocacy, and will also know when facilitation is required to let the group attempt to explore and solve the issues that come before it.

Appropriately trained support group leaders are prepared to teach the necessary skills for lifestyle change. They should also be properly trained by qualified and credentialed individuals, however, to learn to effectively motivate, celebrate, educate, innovate, and advocate. These are not skills generally possessed by individuals at the level necessary for support group leadership. At present, no actual credentialed or accredited certification exists for the training and preparation of support group leaders. Those claiming to be certified support group leaders hold no more credibility or authority than one claiming to be a life coach or a nutritionist. These terms are unaccredited as well, and no particular educational or academic theory, practice, or training exists for career preparation for individuals claiming this expertise.

Leaders need to be taught more than how to deliver a pre-packaged lesson plan meant for the lowest common denominator education level. They must be taught to utilize and model proper communication techniques, to understand and effectuate group dynamics and behaviors, to effect programs and outreach, and to manage risk and administration.

Leaders must facilitate growth and progression, and must respect the norms and roles of the group. They must also respect the intelligence of the individuals in the group, and understand the proper use of various learning styles to reach those who do not learn by more mainstream methods. Leaders must be prepared to think critically and provide structure and direction for the group, but to also let it evolve and grow at its natural pace. Leaders must not stagnate the group or define its parameters if it is to seek its own purpose and success.

In short, effective leaders must be equal parts confidante, educator, nutritionist, friend, leader, motivator, advocate, innovator, provocationist, mentor, facilitator, administrator, guide, and nudge, all within the appropriate confines of the law and regulatory limitations. They must incubate the group’s inherent direction and growth, all the while remembering that the dynamic nature of the group and its members will constantly renew and morph as new members join and others advance.

Therapy as a method for support group programming does not embrace the multifold requirements of the patients it purports to serve. Group members in need of more intensive emotional support or who begin disclosing unwanted or troubling personal issues are best assisted by helping them locate a trained professional through the provision of a list of resources from which to choose.

Lists of appropriate resources may extend beyond the psychological and can include legal, insurance, medical, exercise, nutrition, or a variety of other related resources. With all due respect and deference to our esteemed colleagues in the social sciences, and with a tip of the hat in appreciation for their valuable and necessary work, we conclude that practices must guard zealously against the tendency for support groups to devolve into group therapy sessions. It does not serve the patients well, and may actually create barriers and resistance rather than overcome them.

References
1. Merriam–Webster, A. Webster’s New Collegiate Dictionary. Ninth Edition. Springfield, MA; Merriam–Webster, Inc., 1986;1186–223.
2. Janeway J, Sparks K, Baker R. The REAL Skinny on Weight Loss Surgery: An Indispensable Guide to What You Can
REALLY Expect! 2nd Edition. Onondaga, MI; Little Victories Press, 2005;32.
3. 2004 ASBS Consensus Conference Statement. American Society for Bariatric Surgery. Available at: www.asbs.org/html/pdf/2004_asbs_consensus_conference_statement.pdf. Accessed April 1, 2007; ASBP Bariatric Practice Guidelines. 2007. American Society for Bariatric Physicians. Available at: www.asbp.org/about_asbp.php?page_id=65. Accessed: April 1, 2007.
4. Knapp M, Daly J, eds. Handbook of Interpersonal Communication. Third Edition. Thousand Oaks, CA; SAGE Publications, 2002;212.
5. Ringer M. Group Action: The Dynamics of Groups in Therapeutic, Educational, and Corporate Settings (International Library of Group Analysis). Philadelphia, PA; Jessica Kingsley Publishing, 2002;28.
6. Forsyth DR. Group Dynamics. Pacific Grove, CA; Brooks/Cole Publishing Company, 1990;4,42.
7. Maxwell, JC. The 360o Leader. Nashville, TN; Nelson Business, 2005;115.
8. Hughes RL, Ginnett RC, Curphy GJ. Leadership: Enhancing the Lessons of Experience. New York, NY; McGraw–Hill Irwin, 2002;9,107.
9. Schuman S. Creating a Culture of Collaboration: The International Association of Facilitators Handbook. J–B International Association of Facilitators. San Francisco, CA; Jossey–Bass, 2006;14.
10. Schuman S. The International Association of Facilitators Handbook of Group Facilitation: Best Practices from the Leading Organization in Facilitation. J–B International Association of Facilitators. San Francisco, CA; Jossey–Bass, 2005;12.
11. Process Expertise for Group Facilitation. State University of New York at Albany 2007. Available at: www.albany.edu/cpr/gf. Accessed March 30, 2007.

Additional References
1. Greene JO, Burleson BR, eds. Handbook of Communication and Social Interaction Skills. Mahwah, NJ; L. Erlbaum Associates, 2003.
2. Whitmore J. Coaching for Performance. Third Edition. Boston, MA; Nicholas Brealey Publishing, 2002.
3. Maxwell JC. The 21 Indispensable Qualities of a Leader: Becoming the Person Others Will Want to Follow. Nashville, TN; Nelson Business, 1999.
4. Wlodkowski RJ, Ginsberg MB. Diversity & Motivation: Culturally Responsive Teaching. San Francisco, CA; Jossey–Bass, 1995.
5. Branden N. The Power of Self Esteem. New York, NY; Barnes and Noble Books, 1992.
6. Relationship Centered Health Care. Relationship Centered Health Care 2007. Available at: www.relationshipcenteredhc.com/leadership.php. Accessed March 30, 2007.
7. Leadership theory and practice. Legacee Management Systems Inc., 2007. Available at: www.legacee.com/Info/Leadership/Motivation.html. Accessed March 30, 2007.
8. Facilitation. Resource Masters of Change 2007. Available at: www.mastersofchange.com/facilitation.htm. Accessed March 30, 2007.
9. Process Expertise for Group Facilitation. State University of New York at Albany 2007. Available at: www.albany.edu/cpr/gf. Accessed March 30, 2007.

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