Therapists in Search of a Treatment Model: Adapting a Cognitive Behavioral Therapy Model for Eating Disorders to a Bariatric Surgery Population, Part 2

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
In our previous article in the November/December issue of Bariatric Times, we reviewed the rationale for using a cognitive behavioral model (CBT) traditionally used for eating disorder treatment for the bariatric surgery population. In this issue, we will further discuss in detail the topics and goals for each of the CBT groups (Table 1. Finally, we will review future considerations in the continued use of this model.

Creating social support—The buddy system
For so many of our patients, as their weight has increased, their world has narrowed. Shame and guilt about their weight, as well as increasing comorbidities that make participation in many of their past activities difficult, have exacerbated the problem. For long-term success in weight loss surgery, we feel that social support is an essential element.1 For many of our patients, this social support has become limited.

Even though it is short-term and highly structured, inherent in the CBT group process are many of the same elements that have made our longer-term psychodynamic psychotherapy groups such powerful agents of change. Very briefly, the element of universality is key. For many of our patients, obesity has ruled their lives for as long as they can remember. At the time they enter the surgeon’s office, they may indeed feel very alone and that no one understands. For the first time in a very small and highly structured group setting, the elements of universality and acceptance create a safe, supportive atmosphere where new social and emotional learning can take place.

Creating an atmosphere of trust, safety, and more rapid group cohesion becomes important. Therefore we begin a “buddy” system at the end of the first session. Members choose another member to maintain contact with throughout the week. The task of the “buddy” is to talk and listen, to help group members stay on track with their program and the weekly homework, and to provide support, encouragement, and new creative ideas. After the second session, a permanent buddy is chosen. Frequent weekly phone contacts or e-mail contacts are encouraged. The group confidentiality rule is strictly enforced, and members are not allowed to talk about any of the other group members during these contacts. For many of our patients, it has been easier to begin by developing trust in one other group member and then extending this trust to the group as a whole. Other benefits include not only encouragement and creative ideas, but also a sense of altruism and of being of help to another person, that has greatly enhanced some of the members’ self esteem. The friendships formed in the buddy relationship have often extended far beyond group termination and have aided in later difficult periods, including difficulties with weight maintenance.

Clarifications and Considerations
In Table 1, our CBT model for postoperative bariatric surgery patients is given. The model is broken down into eight individual groups. Group 1 is begun by a series of structured, non-threatening, warm-up techniques to establish more rapid group cohesion and the initial sense of trust and safety essential to our patients. Each group member has a chance to briefly speak and, through these exercises, introduce themselves. Clear structure is necessary so that the lines between CBT and psychodynamic therapy are not crossed and too much self-revealing does not take place at this early group stage. The concept of primary goals is explained, and each group member sets initial primary goals. Other group members may help in setting these goals and offering initial thoughts and encouragement in how to begin movement toward the goals. From the very beginning, through this initial structuring, a sense of universality, as mentioned earlier, as well as social learning and altruism have begun to take place. This allows a level of safety and trust that makes the next step, food charting, easier. More didactic work centers on learning about the CBT model and learning thought logs. Patients practice thought logs in the group and then work on their logs throughout the week. Homework includes thought logs, food charts, taking a step toward primary goals, and staying in touch with one’s buddy.

In Group 2, initial emphasis is on homework. Members begin by sharing progress during the week and specifically any progress toward primary goals. The emphasis is a positive and supportive one. We reinforce that this may be a new way of thinking at first but that it will become easier. The importance of homework is emphasized, and the group members are urged to work with their buddies between sessions if they need help. A focus is on thought logs, and the concept of automatic thoughts is introduced. For some of the group members this may be very informative, and they may also be surprised how many of the other group members have shared their previously “unacceptable,” demeaning, and self-destructive thoughts. The group begins to become more cohesive. Games and exercises are introduced to emphasize and anchor points. Permanent buddies are chosen, and as we emphasize picking buddies based on connections felt through dialogue, we try to avoid members experiencing feelings of rejection they had become accustomed to when they were morbidly obese.

Group 3 continues to focus on food logs, thought logs, and primary goals. Thought logs are more complete at this stage and begin to chart progress in identifying not only negative thoughts but also stressful, triggering situations. Patients have begun to try to change thoughts, experiencing more positive feelings and some changed behaviors. Many of the group members have begun to feel more in control and experience progress. They have also begun to more significantly connect with their buddies. They describe beginning to “get” the model. Cognitive distortions are focused on including all-or-nothing thinking, personalization, catastrophizing, labeling, and overgeneralization. Targeted exercises and worksheets solidify the concepts. More extensive thought logs are begun, seeking thinking errors and challenging existing thoughts.

Group 4 focuses on training in behavior chains. Emphasis on food logs has begun to move away from center stage as patients begin to internalize their new “food awareness” and they automatically make more changes. By the Group 4 stage, increasing trust has been established with their buddies, and they are more likely to call between sessions if problems emerge. This is the beginning of the social support that will prove to be essential long after the group ends. Behavior chain analysis is taught. This is one of the more complex skills and begins the transition from emphasis on thoughts and feelings to behavioral change. Clients choose a target behavior to change (often at this stage related to food noncompliance), emphasizing through the chain not only the thoughts and feelings that lead up to the behavior, but also identifying alternative strategies for change.

Group 5 focuses on motivation for change. Primary goals as well as weight and health goals are stressed. Barriers to long-term change are discussed. Emphasis then shifts to the positive, and the other structured group exercises are lively and fun. Group members serve as “cheerleaders” and are very supportive. Social learning is important, and the power of group to help surmount barriers and impart hope is key. Some of the creative charting is presented in a form that can later be hung on the refrigerator or other visible place as a constant long-term reminder.

Groups 6 and 7 are the groups patients call “dessert.” We feel that for our patients building self esteem is key. A short didactic component focuses on “what is self esteem”—how to develop more positive self esteem and what stands in the way. A series of group exercises are again lively and fun. Affirmation books, which are written in by other group members in this and subsequent meetings, are begun. Patients usually leave this group thoughtful but very energized and motivated. These exercises lead into the next group where distress tolerance skills are taught. Again, in Group 7 the emphasis is positive even though the content of the material is serious. Self-soothing and distraction skills are taught. Extensive handouts are distributed to help develop and then practice these skills. Self-soothing bags are created in the group and throughout the week are filled with new and different non-food-related objects to bring to the final group.

The final group, Group 8, is always somewhat sad. Members have bonded and most feel that the group process has flown by. Any final questions on food or thought logs or any of the other skills are answered. Positive changes, including progress toward food, weight goals, and primary goals, are shared. Self-soothing bags are shared and members frequently bring in small objects to place in the self-soothing bags of others. We also bring in something small to add to each bag. Affirmations are a focus, with a set of activities centering on them. As focus then moves toward the future, relapse prevention is emphasized and techniques for relapse prevention are taught. Goodbyes and endings complete the group as members focus on the future.

Future Directions
The adaptation of this model for use with a bariatric surgery population is still in its preliminary stages and has been in use for approximately one year. As stated earlier, in searching for a model, we looked for one that was effective, replicable, cost and time efficient, able to be modified for a variety of treatment settings (many of our patients come from a long distance for the procedure), user friendly, and “worked.” To date we are pleased with the promise it is showing.

Many of our patients have shown reluctance to engage in any form of psychotherapy in the past. Therefore, one of the most important aspects of the model for us was that it was user friendly. To date, the dropout rate is approximately 12 percent with primary reason cited for drop-out being distance to travel for group.

After each group is completed, patients are excited about the results, including not only greater understanding, but also increased support and new friendships, a greater sense of control, new learning and a wide range of new tools to maintain long-term health, increased self esteem and confidence, and often surprising movement toward new primary goals and weight goals. As each group ends, patients are eager to tell their friends and other support group members about their positive reactions. The results have been wait lists as each new series begins.

We have outlined how a therapist with the appropriate training can use this model for a bariatric population. This model can be replicated with brief training by any experienced psychotherapist. Knowledge of CBT and of group process is extremely useful. We are in the beginning stages of collecting data. We are hoping to continue our efforts in collecting data and look forward to expanding data collection to other sites. To date we have been limiting participation to postoperative patients and, in particular, patients who are experiencing difficulties. We have worked with both gastric bypass patients and laparoscopic adjustable gastric band patients and to date have kept the groups separate. We are aware of the additional need for preoperative interventions and will soon begin preoperative groups.

Currently, this CBT model is in group format. However, for those that do not succeed with a group format, it may be interesting to further investigate the use of this module on an individual basis.

A final note—CBT is not intensive psychotherapy. As the groups progress and trust is developed, more and more material will emerge. For some of our patients, this is the first time they have shared powerful thoughts, feelings, and events. It is important to listen and support as the material emerges but to contain the content and remain “on track,” keeping in mind the distinction between a psychodynamic group and CBT group.

In brief, psychodynamic therapy emphasizes the importance of past events, with heavy emphasis on childhood experiences and the unconscious, to explain current behaviors and psychological disturbances. CBT views behaviors as a results of a person’s interpretation of the event (thought) with more emphasis on the “here and now.” While CBT views past experiences, such as those in childhood, as potentially important, psychodynamic theory views these as more imperative to the understanding of current functioning. Additionally, psychodynamic therapy tends to be long-term, lasting six months or longer; however, CBT, tends to be more short-term with therapy typically lasting less than six months. Currently, CBT is viewed as the treatment of choice for most eating disorders (with the exception of adolescent eating disorders), anxiety, and depressive disorders.

One of our groups chose to continue for a number of months as a more intensive psychotherapy group. In the other groups, some of the members chose to continue with individual treatment. It is therefore important to not only keep in mind the distinction between psychodynamic and CBT groups, but be willing to adapt to the needs of different groups and individuals.

References
1. Cooper Zafra, Fairburn Christopher G, Hawker Deborah M. Cognitive-Behavioral Treatment of Obesity. New York: Guilford Press, 2003.

Category: Commentary, Past Articles