Therapists in Search of a Treatment Model: Adapting a Cognitive Behavioral Therapy Model for Eating Disorders to a Bariatric Surgery Population

by Merle C. Goldberg, LCSW; and Heidi M. Limbrunner, PsyD

Merle Goldberg is in private practice in Silver Spring, Maryland, and is co-author of Weight Loss Surgery: Is It Right For You and My Thin Excuse: Understanding, Recognizing and Overcoming Eating Disorders. Heidi M. Limbrunner, PsyD, is with Southeast Psychological Services in Charlotte, North Carolina.

Introduction

A topic of increasing interest in the literature is the incidence of eating disorders in our bariatric population, both pre- and postoperatively, and how these eating disorders impact long-term treatment success. Studies vary widely in their findings on preoperative incidence of eating disorders in this population. For instance, Adami, et al.,[1] in 1995 suggested that 68 percent of candidates for bariatric surgery may have binge eating disorder (BED). In evaluating the prevalence of disordered eating in a bariatric population, Saunders[2] reports 33.3 percent with severe BED, but over 50 percent binging or grazing at least two times a week accompanied by a high level of depression. Vander Wal[3] in 2003 reported a rarer study on the incidence of bulimia preoperatively and stated that 20 percent of the patients she evaluated for laparoscopic adjustable gastric banding surgery had a diagnosis of bulimia and 11–37 percent had a diagnosis of BED.

Postoperatively, a number of studies have indicated that BED (recurrent episodes of eating large amounts of food, in a discrete period of time, accompanied by a sense of loss of control) continues to persist, contributing to lessened weight loss and often increased weight regain.[4-6] In addition, BED problems may lead to stretching of the pouch, breaking the band, causing the band to migrate, or creating an obstruction. Kalarchian,[4] in a longitudinal study, found that 46 percent of her patients self-reported recurrent loss of control over eating at long-term follow-up. Pekkarian[7] reported a mean weight gain in bingers of 50 percent and non-bingers of 24 percent of excess weight. On the other hand less frequently reported are the studies like the one by Latner, et al.,[8] at the University of Canterbury, New Zealand, that showed an incidence of 48 percent BED preoperatively and zero percent postoperatively. Saunders describes a more common eating problem that often goes unrecognized and untreated—compulsive eating, including a pattern of binge eating and a pattern of grazing.[9]

These are only some of the studies and yet we must ask ourselves—Why the enormous discrepancy in results? Does it have to do with study size, the measuring tools, geography, patient income, racial or ethnic discrepancies, or a host of other variables of which we are not aware? Perhaps some of the initial answer may lie, again, in the observational data in our clinical practices. Mike, a patient writes, “My weight problem has been a battle since age 5. I have always fought the battle winning temporary victories until the age of 55. I have tried Weight Watchers, the rice diet, high protein, low carb, amphetamines, thyroid pills, Phen-phen, Prozac, liquid protein, fasts, acupuncture, Overeaters Anonymous, and so many medically supervised programs that they have faded from my weary memory. I now throw in the towel. I am done with the good fight.” Along the way, when he felt frustrated, defeated, and desperate, Mike, in yet another desperate effort to lose weight, looked for the answer to weight loss in bulimia and anorexia and was ultimately diagnosed with an eating disorder. Many of our other patients have also struggled with what was diagnosed as an eating disorder. Some have received inpatient as well as outpatient treatment for a disorder. Most commonly reported is BED, but we are also seeing night-eating syndrome (NES), as well as some chewing and spitting, in clinical practice. Periods of starvation are seen, with many of the symptoms of anorexia, but is this anorexia in the classic sense? Perhaps worth considering is that after years of struggle with morbid obesity, with the frustration, pain, and desperation we see in patients like Mike, our patients simply habituate to disordered eating behaviors and with this habituation comes the loss of so many of the clearer hallmarks by which we diagnose and identify eating disorders. Therefore, we are left to wonder whether some of the discrepancy we see in the studies above may be due to the fact that by the time we see the bariatric surgery patient for preoperative evaluation, the disordered eating has morphed into an ongoing frustrating pattern of yo-yo dieting, with multiple failures, and thus becomes a challenge to diagnose.

Since the studies at this point appear to be yielding conflicting results, it might be useful to return to clinical observation as we continue to seek treatment answers. Fabricatore, et al., reported that the principal components analysis in the bariatric population tested yielded the following five factors: Eating in response to negative affect, eating in response to positive affect and social cues, general overeating, and impaired appetite regulation, overeating at early meals, and snacking.[10] Although we may not be clear on the percent of our patients that have a diagnosed eating disorder, what we do know is that a large percent of the patients that enter our offices share characteristics with our eating disorder clients. Many of our bariatric surgery patients suffer from low self esteem, isolation, depression, mood swings, intense body dissatisfaction or distortion, morbid fears of weight gain, periods of restriction (sometimes severe restriction), emotional eating or restricting, the use of food to compensate for negative affect, minimizing food choices, obsessive behaviors, and the use of diuretics and laxatives. Like our eating disordered patients, some judge their day, or indeed the entire quality of their lives, by their weight.

Correlation with our BED patients includes a rare sense of satiety, binge eating, overeating, the presence of behavioral indicators of loss of control, such as trying to eat more rapidly than usual, eating until uncomfortably full, embarrassment at eating large amounts when not hungry, eating alone, and feeling depressed, disgusted, guilty, or markedly distressed after these episodes of non-compliance. It should be noted that postoperatively, what now constitutes large amounts, eating more rapidly, and eating until uncomfortably full will be affected by the restrictive nature of the surgery, and our traditional hallmarks blur even more.

Thus, a percentage of the patients that come to us for bariatric surgery can be clearly diagnosed with eating disorders. For others, the lines become less clear and diagnosis more difficult. Bariatric surgery can perform miracles in changing weight and radically decreasing comorbidities. But as we all know, it is just a tool, and does not change the patient’s mental state. Binge eating and grazing are still possible, particularly with laparoscopic gastric banding surgery, where it is still possible to consume large quantities of soft food and liquid. While our patients can successfully lose weight, they may remain both physically and mentally unhealthy. Many of the psychosocial issues that they struggled with before surgery remain, and they no longer have food to numb or ease the pain. Alternative behaviors to eating, as well as techniques to distract or self soothe, may be limited. Patients feel out of control.

Cross addictions may occur. Many of the issues that have been stuffed under by food may reemerge. After surgery, life will most certainly change, and many of our patients will not have the non-food-related skills to cope.

In brief, both before and after surgery, whether or not a clear eating disorder diagnosis has been made, many of our patients exhibit the same characteristics seen in an eating disorder population. In recent years, increasing emphasis has been placed on the preoperative psychosocial aspects and ability to give informed consent as a means of predicting postoperative compliance. Indeed, the preoperative surgical evaluation has been studied and well refined; however, clear indicators of who will and will not be compliant still do not exist. So the question remains: How do we treat those individuals who are noncompliant after surgery has occurred?

The challenge that remains may require more focus and increasing collaboration on developing treatment models, particularly models that are effective, replicable, cost and time efficient, modifiable for a variety of treatment settings, and proven to yield positive outcomes. In addition, user-friendliness of a model is key. We are finding that many of our patients, for a wide variety of reasons, are reluctant to enter or reenter treatment. For some, psychotherapy is a frightening prospect; for others, psychotherapy offers none of the immediate gratification of food; and others have been not only “diet failures” but also “psychotherapy failures.” Thus, a key component of our program was making it one that the patients not only learned from and valued, but also enjoyed and urged other patients, particularly those in trouble, to attend. We sought a program that was user friendly. In light of the above, in developing our model, we turned to a cognitive behavioral therapy (CBT) protocol that had been successful as a part of an inpatient treatment team for eating disordered patients and might satisfy these criteria.

The Model: CBT for Eating Disorders

For bulimia nervosa, CBT is generally viewed as the treatment of choice.[11] The use of CBT for the treatment of eating disorders was initially manualized by Christopher Fairburn at Oxford in the early 1980s and found to be effective in reducing eating disorder symptoms typically by 50 percent.[14] Smith, et al., found that obese individuals with binge eating reported a reduction of bulimic episodes by 81 percent after participation in a 16-week CBT group.[15] Agras, et al., found that obese individuals with BED maintained a reduction in binge eating one year after CBT treatment.[16] Currently, CBT is viewed as the empirically supported method in the treatment of bulimia nervosa and is suggested for the treatment of anorexia nervosa in adults.

In brief, CBT for eating disorders focuses on both the behavior and thoughts that maintain eating disorder symptoms. At the core of bulimia, is a low sense of self esteem and self worth. For a person with bulimia, it is theorized that this poor self esteem results in an overly valued importance of appearance, including weight and shape. Due to this extreme importance of weight, the person diets excessively to control weight to an unrealistic goal. This extreme dieting then leaves a person both physically and emotionally vulnerable to binge eating. Once the individual binge eats, an increase in anxiety over potential weight gain ensues, resulting in purging behavior. Typically feelings of guilt and shame follow and the cycle continues. The goal in CBT is to change those behaviors (dieting, purging, bingeing) and cognitions (importance of weight, low self esteem) that maintain the eating disorder
CBT for bulimia, as defined by Fairburn’s model, is typically conducted on an outpatient basis in 15 to 20 individual therapy sessions. Therapy is typically divided into three stages. In stage one, the rationale of the CBT model is explained, psycho-educational information with regard to weight loss and dieting are discussed, and behavioral strategies to normalize eating are employed. In stage two, problem-solving skills, restructuring thoughts, and methods to challenge the personal importance of body shape and size are addressed. In the third and final stage, relapse preventions strategies are defined, including maintaining a realistic perspective of recovery and identifying how to handle any setbacks.

CBT Group Therapy

Although Fairburn’s module was originally proposed in an individual therapy approach, many clinicians have applied the module to a group format with successful results.[17,18] Using CBT in a group format has the benefit of providing empirically supported treatment in a more cost-effective approach, important for both the patient and the treatment center. In addition to reducing cost, we find that other factors inherent in a group, even short-term groups, can have enormous therapeutic benefit for our patients. For example, many persons who struggle with eating disorders (as well as morbid obesity) feel isolated and believe that no one else can fully understand their experience. In participating in a group, many individuals are able to share similar experiences, which then decreases feelings of isolation. This factor universality creates rapid group cohesion and social support. Additionally, group members are able to provide suggestions to others in the group, often with a unique perspective that is different from the group leader, providing valuable interpersonal learning, imparting of information, social support, imitative learning, and the instillation of hope. Feelings of altruism that emerge from helping others raises self esteem.

While Fairburn’s model consists of 15 to 20 sessions, the group protocol was reduced to an eight-session format, with the group facilitator having the option to extend some modules to an additional session. The length of the group was reduced for several reasons, including cost effectiveness and reducing dropout rate. Often group members have little insurance coverage and pay out-of-pocket for group. It is often more feasible for individuals to pay for eight sessions compared to 15 to 20 sessions. Additionally, by having fewer sessions, the time commitment was shortened, which decreased the likelihood of individuals missing groups and willingness to commit for the eight weeks. Despite the group being reduced in number of sessions, all three modules are covered within the group format. The protocol outlined in this article has been used for treatment in various settings for eating disorders, including inpatient and outpatient settings.

The Protocol

The first three group sessions focus on education of the basic tenets of the CBT module. Teaching the group members the Antecedent-Belief-Consequence (A-B-C) module is key, as the participants in the group begin to understand the link between their thoughts/interpretations and their resulting emotions and actions. Simply put, the Antecedent-Belief-Consequence is a basic component of CBT. For a bariatric client, an example would be walking by a favorite fast food restaurant (Antecedent); having the thought, “I feel deprived of the foods I love” (Belief); deciding to have the food anyway, which results in stomach discomfort (Consequence).

The importance of this tool is emphasized via thought logs and records. Group members are required to keep thought logs throughout the week. Group members are required to produce at least two thought logs; however, surprisingly, most group members bring in several more thought logs. In continuing to emphasize the link between thoughts and feelings/actions, a group module focuses on identifying automatic thoughts. Finally, the importance of challenging thoughts and identifying thinking errors (such as catastrophization) is emphasized.

The group often benefits most through review of thought logs and discussing thoughts that they are often unable to challenge. Often, group members may feel “stuck” when it comes to challenging a particular maladaptive thought. Other group members often will offer advice and suggestions that can assist the other group member in moving forward.

Two groups focus on behavioral management of symptoms through the use of behavioral analysis and distress tolerance skills. Behavioral analysis in the form of behavior chains is used to identify precipitating factors to a targeted behavior (for the bariatric population, this is often non-compliance with diet). Group members work toward identifying their risk factors or triggers to non-compliance and also identify ways to cope with difficult feelings. For example, often group members report becoming triggered when faced with a stressful event at home or work. In group, clients come up with a list of alternative behaviors to participate in, such as knitting, blowing bubbles, or taking a walk. The group members report that coming up with a list and hearing ideas from other group members is invaluable.

A focus in the group is working on self esteem. As previously mentioned in the Fairburn conceptualization of eating disorders, at the core of an individual is a lowered sense of self. Due to this lower sense of self, there is an increase focus on weight and size. Like those persons with bulimia, we hypothesize that many of bariatric patients with non-compliance concerns also have a lowered sense of self. For this reason, an entire module is devoted to exercises that start the process of improving self worth. This issue is also addressed throughout the group, but a specific focus on this is a must. It is in this module that group members also demonstrate their support for one another by sharing the positive traits they see in their fellow group members.

The final groups focus on relapse prevention and maintaining motivation for recovery. Maintaining motivation throughout the postoperative process can often be difficult. The initial elation of significant weight loss disappears as a person plateaus or begins to regain weight. The focus of motivation is in assisting group members in remembering and identifying their goals in addition to identifying barriers to change. A relapse prevention plan is discussed in the last group, and there is heavy emphasis placed on continuing the CBT techniques once group is ended.

Modifications and Changes: Food charting

In adapting the CBT model for bulimia for use with bariatric surgery patients, three important modifications were made. The first was the use of more extensive food charting. These charts were an important part of the homework and initially were expected to be completed daily. In later groups, the patents were in charge of how often they completed the charting. The charts were shared with the group, providing ongoing accountability. They were initially processed extensively as members learned how to best use all of the columns in the chart. In later groups, patients shared their charts when they felt stuck or when problems, including weight gain or plateaus, emerged. Patients reported that the helpful, non-judgmental attitude of the therapist and other group members allowed them (perhaps for the first time) to view their food intake objectively and with lessened shame and guilt. Some patients initially refused to chart, but by the second and third group, patients reported being surprised that the food charts, which many had completely refused to keep in the past, allowed them to effectively self-monitor, thereby regaining control and improving compliance.

The first column in the chart deals with time food was consumed. Patients learned to space meals, to not skip meals (in particular breakfast), to avoid night eating, and to be more aware of grazing. The second and forth columns indicating hunger before and hunger after eating are among the most important components in the chart. Over 25 years ago, Bruch wrote that overweight children are unable to resist the ever-present temptation of food.[19] Saunders, et al., in a study of 125 patients, found that the mean age of onset of obesity (self reported) in bariatric patients was less than 12 years of age. Bruch called it an abnormal development of hunger awareness and stated that an obese person overeats because he or she does not recognize real hunger, the signal of nutritional need, and does not differentiate it from a variety of other states of discomfort that he or she misinterprets as a need to eat.19 Eating, therefore, lends itself to being misused as a solution for a multitude of conflicts and problems because in obesity, this important body function—the ability to recognize biological hunger—may be experienced in a distorted way. Both the numbers on the chart, showing before and after hunger, as well as the final column charting emotions help our patients to begin to recognize distorted hunger awareness and to differentiate when their need for food is physical and when it is emotional. Many are also aware for the first time of satiety—not only why they are eating, but when they are full and have had enough to be physically satisfied. As the group progresses, numbers begin to change, with patients attempting to eat when they are at a level of 3–4 of hunger and stopping when they are at a level of 7–8. These numbers are somewhat arbitrary but have added to the structure and seem to make our patients feel more in control as they have a set and more concrete goal. In later groups, most of the numbers fall within the desired range, with significant digressions usually linked to emotional states, which are brought to the group to address.

Although much of what appears in the food column is self-explanatory, we have learned a number of things. First and foremost is that, largely due to shame and guilt, as well as for many a lifetime of having food monitored by others, our patients have become masters at deceiving both themselves and others about food intake. Therefore, in regard to food charting, the attitude of the leader and other group members is crucial in providing a non-judgmental environment. It is important to understand that, for these reasons, early resistance for some may be normal, but a Sherlock Holmes curiosity, support, the feeling of universality inherent in the other group members, and a sense of the power of the group in sharing help and ideas for change will usually overcome any initial resistance. Patients report that after a few sessions, they have become much more aware of their food intake and much more comfortable with charting, so that long after the group has ended, they go back to food charting during periods of plateau and weight regain, helping them to again regain control.

In the final column, we have surprisingly found that identifying emotions is very difficult for some of our patients, perhaps in part because food has so long been used to blunt feelings. Therefore, at the first session we provide a humorous chart of funny faces with the emotions printed below. This also serves to reduce judgment and create, from the beginning, a more lighthearted approach to inquiry. Initially many of the emotional states listed include stressed, sad, happy, calm, and anxious. In later groups, a much wider range of emotions are listed. When we move to thought logs in the later groups, patients are urged to refer to this chart. Finally, the patients are asked to chart exercise and water intake. Again, accountability to the group has been motivating. At the bottom of the page is room for notes. We have been surprised that sometimes the notes show powerful feelings that we may not have been aware of through any other means. Some of the patients have asked to add calories and carbohydrates to the chart and we have done so. This is particularly useful, as we have found that for many of the patients, even though they think they are maintaining compliance, high calorie intake is an important factor in weight regain. We do not always add calories and carbohydrates because we have found that simplifying the chart increases compliance.

Primary Goals

Cooper, et al.,[20] describes the establishment of primary goals for long-term weight maintenance as essential. For our patients, weight regain, often after the 12- to 18-month window has passed, has become of enormous concern. Some researchers cite a 30-percent patient weight regain. Although many variables go into this regain, Cooper, et al.[20] working with obese and non-bariatric surgery patients, suggest that weight regain is due to failure to engage in effective weight control behavior, which is a result of two interrelated processes. The first is a progressive decrease in patients’ beliefs that they can control their weight to a worthwhile extent. (Regaining control is one of the most important outcomes of the group.) This may come as a response to the decline in the rate of weight loss experienced after a set period of time. It may also come as a result of realizing that they may never fully reach the weight loss goals that they have dreamed of and with this realization, they believe that other goals set for themselves, particularly the dreams that are attainable once they are “thin,” may never occur as well. This results in frustration, demoralization, and a growing fear that they are increasingly out of control and may fail yet another time.

Our clinical observations strongly agree with Cooper. Clearly, weight regain after surgery is of enormous concern.[20] Although weight regain for our patients may not occur until a later time, frustration with diminishing losses and plateaus is demoralizing. Diminishing losses and plateaus are also reminiscent of the myriad number of weight loss attempts in the past, and for some patients serve as a signal to “give up.” In addition, for so many of our patients weight loss has been a dream for so long that the final result of their efforts may never match the magnitude of the long-term dreams. Therefore, the second modification we have made to the CBT model for bulimia is the establishment of primary, non-weight related goals. Cooper describes these primary goals as non-weight related goals, although to a degree some of the goals she suggests do rely on weight loss and include better health, better appearance, a desire to be more active, and increased self confidence and self respect.[18] These goals are set at the first session and progress is noted at the beginning of each session. “Stuck” times are met with a wide range of group suggestions, encouragement, and often good humor. In the past, some of the group goals have included increased activity, decreased isolation, joining a fantasy baseball team, changing or beginning relationships, joining a club, going back to church, making new friends, being a better mother, controlling temper, enjoying sex, going on a trip overseas, climbing a mountain, running in a mini marathon, making stained glass, and “finding a sugar daddy.”

Now that we have reviewed the rationale for using a cognitive behavioral model traditionally used for eating disorder treatment for the bariatric surgery population, Part 2, which will appear in the upcoming February issue of Bariatric Times, will discuss in detail the topics and goals for each of the CBT groups. Finally, we will review future considerations in the continued use of this model.

References
1. Adami GF, Gandolfo P, Bauer B, Scopinaro N. Binge eating in massively obese patients undergoing bariatric surgery. Int J Eat Disord 1995;17(1);45–50.
2. Saunders R. Binge eating in gastric Bypass patients before surgery. Obes Surg 1999;9(1):72–6.
3. VanderWal M, Jillon S. Bulimia nervosa and laparoscopic adjustable gastric banding. Obesity Reports. NAASO Newsletter, 2003;1(5).
4. Kalarchian M, Marcus M, Wilson G, et al. Eating among gastric bypass patients at long term follow-up. Obes Surg 2002;12:270–5.
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14. Fairburn CG, Cooper Z, Cooper PJ. The clinical features and maintenance of bulimia nervosa. In KD Brownell & JP Foreyt (eds.), Handbook of eating disorders: physiology, psychology and treatment of obesity, anorexia and bulimia (pp.). New York: Basic Books;389–404,1986.
15. Smith P, Markus M, Kayne W. Cognitive-behavioral treatment of obese binge eaters. Int J Eat Disord 1992;12:252–62.
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