For some, the thought of having a face-to-face meeting with a psychologist can be more frightening than the surgery. "Is this guy going to find out that I really am a little crazy? What if I don't answer all the questions right? Does that mean I won't be a candidate for the surgery?" Nearly everyone has the same concerns, and they are almost always baseless.
The reason for the psychological evaluation is to help establish the best strategy to help you achieve achievement. It is very evident that obesity is closely tied to how we perceive ourselves and our surroundings. There are certainly some causes of obesity that have their very roots in our psyche, and conversely, the presence of obesity often has profound effects on our psychological well-being. The purpose of the psychological assessment is to establish within reasonable probability if you are adequately motivated and capable of making the behavioral changes needed to be successful. The only way to answer these questions is through an assessment by a trained psychologist.
The evaluation is typically in the form of a personal interview, during which you will be asked a number of questions that will probe into who you are and what motivates you to do what you do. Despite what you may think, there are no trick questions. If you simply answer all of the questions as honestly as possible you will sail through without any trouble. The objective is to find out who you are, not who you think you are or who you would like to be. There is no point in attempting to convey to psychologists what you believe they want to hear because they are trained to recognize incomplete answers, half-truths, and nontruths. Even if you are successful in disguising your true self, the only person that is potentially harmed is you.
Many psychologist use a written test in addition to a personal interview to determine more precisely the personality traits of the patient. This is still somewhat of an inexact science, but there are some clear patterns of thought and basic beliefs that can be accurately identified through this type of evaluation. Testing can provide a wealth of information, but the
first question that the psychologist is trying to answer is this: Does the individual have sufficient personal insight to accept the fact that their past behavior is what led to their weight problem? If so, do they recognize the need to change their behavior patterns and are they capable of making the necessary changes?
These sound like pretty simple questions, right? Unfortunately, there is no single test or series of questions that can ensure an accurate assessment. In large part that is because many people tend to be less than honest with themselves when it comes to evaluating their own behavior. Getting the best correct responses frequently entails asking questions in a number of ways, so don't be shocked if it seems like the questions are repetitious. The objective is to get as clear a psychological picture as possible in an effort to determine whether the adjustable gastric band program is likely to yield the best results for you.
What to Look for When Testing AGB Patients Psychologically
Steven Greer, Ph.D.
When I was brought in initially to run psychological testing on potential band patients for Dr. Sewell, our only source for information was Scandinavian healthcare data. One thing we didn't take into account is how different those systems are. No one in Scandinavia is ineligible for coverage, but there may be very long wait times for care. As a consequence, the Scandinavians used their experience to predict who would fail with the band.
We were warned about certain problems to watch out for, such as severe mental illness, major depression, compulsive people, drug or alcohol dependency, and less self-directed persons. Oddly enough, they stated nothing regarding eating problems.
So we got a "cannon" of a testing instrument, the MMPI-2, a test that takes on the average an hour and a half to complete, in order to screen for a
vast array of psychological issues. We wanted to be very careful about screening.
What we didn't take into account was that in Scandinavia, people aren't paying for any part of their band treatment, so the doctors get absolutely anyone and everyone. We, on the other hand, had to charge several hundred dollars for the testing, which is usually not covered by insurance. What we found is that we didn't see the types of psychological disorders the Scandinavians were describing.
We were given numbers that one out of six people would fail our psychological screening. But what we found was that only 3 percent of the first 100 people we tested ended up having any of the problems we were screening for. People who are truly depressed or addicted recognized it, and they weren't about to pay several hundred dollars to be tested just to be turned down. So, inadvertently, we developed our own screening.
A full 50 percent of the patients coming in to be tested didn't have insurance that covered bariatric surgery. And what we know from other research on self-pay medical patients is that people who pay a significant amount for any kind of medical procedure tend to do better than people who pay nothing. The literature suggests that people are more motivated and more involved when they have a significant financial investment. That's what we were seeing consistently: highly motivated, sophisticated people.
We also know that people who have a religious or spiritual faith, who feel they have an internal source of strength and health, do better in any health category, from cancer to dealing with death. And that also came out in the testing.
The bottom line was that we were seeing hardly any of the things we were warned about. And it came out that some of the things, such as major depression, weren't as much of an issue with the band as we'd been told. Later research in Australia among people who were given a band even though they suffered from major depression, showed they did fine. The
depressed people lagged behind others a little in their weight loss, but they didn't show up significantly different than people who weren't depressed.
We were still concerned. We identified alcoholism and eating disorders as major issues for potential patients because they endanger the band, which was one of our main concerns. Damage to the esophagus can be a result of either of those addiction disorders, but is most prevalent with an eating problem. With the band, we want people to avoid vomiting because that can throw the band out of place and create problems such as band slippage and erosion, most of which have to be corrected surgically by either repositioning or removing the band.
After the first couple of years, we realized that we didn't need such a comprehensive psychological test. So we switched to tests that take 15 to 20 minutes to complete, including how patients manage their health and a very basic profile of distress.
What we found is that the vast majority of patients who had a weight problem serious enough for them to consider band surgery fell into two categories. One group had a high degree of sociability and gregariousness. They are outgoing and engaging. Since a lot of socializing is done around food, that made sense. These people generally feel confident, some were a little overconfident, and most were independent. The combination of sociability and overconfidence tends to lend itself toward being overweight. Because they believe they can take life by the horns and deal with things later, these people frequently disregard their own internal controls. They're the kinds of people who will overeat now, thinking they'll eat less either later in the day or maybe on another day.
The second group were very rule-governed, responsible people who want to do all the right things. These people tend to hide their emotions from themselves and from others, are overcontrolled, and sacrifice their own personal interests for those around them. We often refer to these folks as "pleasers." Of this group, the majority were women by nearly three to one. This kind of personality makes for a lot of quiet, "subterranean" needs that food is a handy way to satisfy.
So the majority of what we see in our psychological testing is two personality groups: one group is self-indulgent, the kind of people who think they'll fix it later. And the other has unmet needs and uses food as a substitute for basic gratification that is missing.
We have certainly seen some minor depression, discouragement, demoralization, and restriction of activity caused by the limitations overweight people have. We've often heard complaints to go with these symptoms, such as they couldn't climb three flights of stairs, couldn't play with their kids or grandkids, and couldn't fit very well into an airplane seat. But we practically never observed severe psychotic disorders.
What we have found is that attention deficit hyperactivity disorder (ADHD) is a problem for someone who has a band. ADHD is an impulse control problem, and untreated it can potentially lead to problems adjusting to the band.
Bulimia is another issue that we were concerned about. Bulimia is almost always accompanied by a history of sexual abuse, and statistically one out of every eight women has experienced significant, recurrent sexual abuse. If someone is bingeing and purging a few of times a week and attempting to hide it from others, or if they have ADHD, those challenges need to be treated with before they really receive a band.
Noncompliant personality types, who are fiercely independent and autonomous, were something else we looked for. Those are characteristics that tend to lead to overeating to begin with, but these people can also be medically noncompliant, meaning that they have a tendency to be unwilling to submit themselves to medical authority or follow a program. Self-indulgent persons tend to give themselves license not to follow the guidelines put in place by a medical authority, such as their doctor. So we hope to identify these tendencies so that we can provide extra support. These types tend to hit a bump in the road and not make progress for several months to a year. When that happens, the medical staff can find it very frustrating if they're not prepared to handle someone in this position.
So what we have found in psychological testing of potential band patients is different from what we were warned about by Scandinavian data, perhaps because our healthcare system is different. What we now look for are disorders that pertain to either poor impulse control, such as ADHD, or addictions, such as drinking or bulimia. And when we uncover indications of these conditions, which hasn't been common, we suggest the patient to seek therapy for those disorders before trying band surgery.
Checklist: Problem Areas We Look for in Psychological Testing with Potential Band Patients.
Untreated ADHD
✓
Alcoholism
✓
Bulimia
✓
Severe emotional distress.
✓
Checklist: Psychological Factors that Are Helpful in Living with a Band.
Some significant financial commitment toward the band procedure. ✓Research shows that patients having a degree of financial responsibility do better in any medical procedure, and the band is no exception.
Religious or spiritual faith. Again, research shows that people who ✓hold these beliefs tend to do better in terms of their health, especially when facing challenging medical situations.
Medical compliance. People who are committed to following their ✓doctor's advice and the band program do better.
The Dietitian's Assessment
Weight loss is the clear objective, but it is equally important that each patient maintain adequate nutrition as they lose. Most of us give little thought to the actual nutritional value of the foods we eat, and even if we do think about nutrition, we are often misinformed as to what our requirements are and which foods are best. Your evaluation with a qualified and registered dietitian is likely to be the most significant one before surgery. It will involve an extensive dietary history, including not only what you eat but also when, where, and why. This information provides vital insight as to which eating practices have been most responsible for the development of obesity in the first place.
For some patients, the conversation with the dietician could be a little awkward. The probing questions asked may make you feel a sense of guilt, or even shame. While admitting certain eating habits to someone may be painful, it is a necessary part of the process of developing new habits. Say, for example, you make a habit of eating a whole box of cookies or a large bag of potato chips at one sitting. You know that habit has contributed to your weight problem, and you have vowed many times to stop. But now, when you are asked specific questions, you are embarrassed to admit it, so you simply suppress the information. After all, you know what to do, and you don't need somebody preaching to you about it, right? Well, don't you believe if you really could change your conduct by yourself you would have done it already? The dietician is trained to help you but will be unable to assist you improve your behavior without full information.
You might be tempted to show off how proficient you are at calorie counting or how much you understand about the fundamental food groups during the dietitian's assessment of you. A few patients have indicated that they know all about nutrition and don't really see the value of visiting with a dietician. While your understanding of nutrition may be extensive, each of us tends to be exceptionally terrible at judging our own behavior when it comes to food. So before you blow off this evaluation, recognize this as
your moment to begin genuinely getting the treatment you need to shift the food choices and eating behaviors that helped generate and perpetuate your obesity. Just as with the psychological evaluation, you need to make every effort to answer the dietitian's questions as honestly as you can. To do any less is only cheating yourself.
After the nutritionist has taken your dietary history, he or she will give you a full description of what and how you can expect to consume after the band is implanted. This is a very crucial element of the dietitian's function. You can expect to eat more slowly, take smaller bites, chew your food thoroughly, and avoid drinking liquids during your meals. We have devoted an entire chapter to the subject, but suffice it to say that your success with the AGB program depends on your willingness to make a major commitment to modify your eating behavior.
Grace Ann's Story
I always thought my weight was about the bad habits I was taught as a child. I never could see why my eating anything would protect a baby from starving in another nation. But my granny claimed it would. So I ate everything put in front of me. But when I had my daughter, she completely ruined my plan. I thought I could make her thin by never telling her to clean her plate. It didn't, though. My daughter weighs 300 pounds as an adult. There is little doubt in my view that this weight problem is at least in part inherited.
My cardiac surgeon informed me that I needed to lose weight. At 5-foot-7 and 3/4 inches tall, my highest weight was 292; this was following open heart surgery. At that weight, I was miserable. I couldn't move, my legs were so sore from swelling, and I felt like everything was too tight and cutting off my circulation. But in reality, my skin's extreme stretching was what was preventing my blood from flowing. It looked awful. It was challenging.
Recently my husband and I joined Weight Watchers and paid our money. Then we had a death in the family and a bunch of other stuff going on. At
We each gained 6 pounds by the end of the Weight Watchers period we had committed to.
I ultimately realized I had to try something different. I've just had the band on for three months, and I've only lost 10 pounds. However, I already refused to return. I assumed I'd lose faster, but this is so much simpler than dieting. The biggest benefit of the band for me is just knowing that I can continue to eat this way for the rest of my life. With other weight-loss programs, I'd get so sick of what I was eating and wonder, "Am I supposed to do this all the time?" For instance, I've had one hamburger in the last six weeks despite other regimens forbidding it. Although I didn't finish it all, I probably could have. Now, if I have food on my plate from a restaurant meal, it's okay if I give it to someone else or save it for another meal. Previously, if I ate out and carried food home, I just did it for display and ate it as soon as I returned home.
Another change is that I'm exercising and I have a personal trainer. I've never had the urge to do that before.
I discovered a fill doctor who is only an hour away because I live several hours from my surgeon. The fill doctor and my surgeon's office agreed to cooperate, but there was confusion on the sort of band I had. I've had three fills, but I didn't feel as constrained as I would have liked. Turns out I had a bigger band that the fill doctor knew about. Additionally, my surgeon gave another physician who billed me extra for visiting me in the hospital post-op care. I felt that because I'm a self-pay patient, the problems with my fills and the second doctor cost me more money that wasn't necessary.
I do love the band. It's constantly there. Unlike with diets, I don't fall off the wagon and stay off. I'll lose all the weight I want in a few years if I keep going at this pace. But there isn't a band support group near where I live, and as I previously mentioned, my surgeon is several hours away by car. I'm looking for extra band members who can assist me as a result.