Psychologists Offer Important Support to the Bariatric Treatment Team
Some bariatric surgeons require a preoperative psychological evaluation of all surgery candidates in order to screen for significant psychopathology and to prepare candidates for the many lifestyle changes expected after surgery. Other surgeons reserve the psychological evaluation only for candidates who have a positive psychiatric history. Still others cite the rationale that neither the evaluation nor a psychological test is a reliable predictor of long-term outcome. While debate continues over the value of the preoperative psychological evaluation, bariatric surgery practitioners are clear on one point: bariatric surgery—together with medical follow-up and behavioral aftercare—is the most effective clinical intervention available to manage morbid obesity.1, 2
This article offers an understanding of the preoperative psychological evaluation and how this evaluation can be useful after surgery, from information gathered from William M. Rupp, MD and Lana I. Boutacoff, PhD, LP, in St. Paul, Minnesota.
Patient Selection and Education
Dr. Rupp is a bariatric surgeon and Medical Director of the Obesity Surgery Program at St. Paul Surgeons, Ltd. He is also a member of the American Society for Bariatric Surgery. Dr. Boutacoff provides preoperative psychological evaluations for bariatric surgery candidates referred by Rupp and by other surgeons in the Minneapolis/St. Paul metropolitan area. She is a licensed psychologist in private practice and an Associate Member of the American Society for Bariatric Surgery. With 19 years of experience, Boutacoff now dedicates her practice to working with patients who are planning to undergo a bariatric surgical procedure as well as treating patients who are adapting to their procedure.
Rupp acknowledges that a competently executed psychological evaluation frees his time to attend to his work as a surgeon. “Patients who have been evaluated by Dr. Boutacoff have more realistic expectations of this surgery. They have a better understanding of their strengths and weaknesses, what they need to do, and what to expect after surgery,” says Rupp. He sees the psychologist as an important adjunct to a treatment team not only for diagnosing psychopathology, but also for providing educational information in a format that is conducive to the patient’s personality and learning style.
“Objective data from a psychometrically-sound test are helpful in supporting clinical findings and in making treatment recommendations.”
Over the years, Boutacoff has developed a protocol for conducting the psychological evaluation for bariatric surgery candidates. This protocol, she explains, is a psychoeducational treatment module that incorporates assessment with education and skills training. It includes a semi-structured clinical interview that is more akin to the biopsychosocial assessment paradigm, than to the traditional psychiatric or psychological assessment.
This brief treatment module is designed to screen for psychopathology as well as for attitudes and behaviors known to complicate postoperative adjustment. The presurgery psychological evaluation is designed also to prepare the candidate for surgery and to propose alternative or concomitant treatment options, if indicated. Boutacoff encourages interested readers to review a recent article in Obesity Surgery by Glinski3 that addresses psychological factors important to the preoperative evaluation.
The Psychoeducational Treatment Module contains four essential elements:
1. Standard Psychological/Psychiatric Assessment. The psychologist obtains the standard history and assesses the candidate's:
- emotional stability,
- ability to comprehend the risk of surgery and to give informed consent,
- emotional resilience to withstand surgical trauma and to cope with the many stressors and adjustments associated with the lifestyle changes after surgery, and
- motivation and commitment to comply with long-term aftercare, to learn new skills, and to adhere to a healthy lifestyle program that includes making wise self-care choices and setting limits.
Boutacoff emphasizes the importance of conducting a thorough assessment of mood and mental status. The empirical data suggest that undiagnosed or poorly managed anxiety and/or depression may result in weight regain within the first five postoperative years. For this reason, mood stabilization both before and after surgery increases the likelihood of sustained weight loss and of maximizing the health benefits of surgical intervention.
For Boutacoff, psychological testing is essential to this assessment process. She finds the MMPI®-2 test to be especially helpful in providing information for making inferences about the source of a candidate’s psychological distress (whether physically-based or emotionally-based) and about the source of a candidate’s mood disturbance.
2. Objective Psychological Test Data. Objective data from a psychometrically-sound test are helpful in supporting clinical findings and in making treatment recommendations. Boutacoff notes that the empirical literature documents clearly that test-based psychological assessments are not only useful, but also economically justified when conducted by a well-trained and qualified psychologist.4 A well-trained and qualified psychologist interprets the tests competently and within the context of bariatric surgery patients, presents the findings in a manner that is meaningful to the surgeon, and addresses the issues relevant to the surgery candidate.
Boutacoff adds that she uses these objective data as a baseline measure of the patient’s emotional status. Baseline data—whether medical or psychological—provide the treatment team with information for implementing cost-effective intervention after surgery.
When selecting the appropriate psychological test for a particular bariatric surgery candidate, Boutacoff cautions psychologists to evaluate the appropriateness of the test for the patient. Measures that are designed for non-psychiatric populations or for medical patients are most appropriate for bariatric surgery candidates. MMPI-2 test data demonstrate clearly that this cohort of bariatric surgery candidates is more similar to medical patients (and members of the general population) than to psychiatric patients.
3. Needs Assessment and Skills Training. Boutacoff conducts a needs assessment and provides (or makes the appropriate referral to provide) basic education and skills training to help the candidate prepare for the attitudinal, emotional, physical, and behavioral changes expected after surgery. Specifically, she assesses whether candidates have the set of life skills that will enable them to properly use their tool (i.e., their surgically-altered stomach or “pouch”) when faced with the challenges and adversities of everyday life. This basic skill set includes the ability to:
- Manage stress effectively
- Set clear limits with oneself and with others, and maintain clear boundaries
- Reframe faulty thoughts about food, eating, and oneself
- Engage in basic self-care behavior (viz., eat balanced meals at regular intervals, drink the appropriate fluids, take daily vitamins as directed, pace oneself, and incorporate an adequate amount of sleep and physical activity into each day)
- Understand the basic principles of healthy eating, including the consequences of food deprivation
- Understand the basic principles of habit formation and habit change
- Set realistic expectations for surgery, especially weight expectations that are within a weight range that is both medically and psychologically healthy for that patient
4. Diagnostic Impression, Recommendations, and Treatment Plan. Boutacoff concludes by formulating a recommendation and treatment plan. Rupp finds that the most common recommendation that he receives is one of the following:
- This person is a very good candidate and is in an optimal position to proceed with surgery.
- This person would be a better surgical candidate if he/she takes more time to prepare for surgery and to address the psychological or behavioral objectives recommended in the treatment plan.
- This person is likely to have difficulty after surgery for the following reasons: A referral for additional counseling, psychotherapy, and/or a psychotropic medication evaluation has been initiated.
Rupp emphasizes the importance of writing treatment recommendations that are supported by objective data. According to Rupp, these data are useful for weighing the risks and benefits of surgery as well as for managing the patient postoperatively.
Preoperative Psychosocial Data Are Useful
According to Boutacoff, the clinical utility of the presurgery psychological evaluation gains value as surgeons and allied health clinicians become aware of the behavioral and psychological factors that may interfere with long-term postoperative outcome. She says that this is most evident when a patient requires behavioral or psychiatric intervention after surgery in order to stabilize his/her emotional well-being or to sustain a healthy weight range. Boutacoff notes the baseline psychosocial data are invaluable also when a candidate begins to engage in “symptom substitution” behavior and she needs to determine the origin(s) of this high-risk behavior. When food is no longer readily available to secure a sense of comfort and/or to relieve stress, certain patients may turn to alcohol or illicit substances, while others may turn to excessive shopping and gambling, and still others may engage in sexual indiscretions. A review of the candidate’s psychological profile may shed light on his/her motivation to engage in such high-risk behavior.
Objective and Consistent Results
Why bother with a time-consuming, costly psychological test, especially when it does not predict surgical outcome? The justification, according to Boutacoff, is in the objectivity and consistency of the test results. An objective data-based diagnosis is not tied to a specific psychologist or to that psychologist’s subjective impressions of the patient. In the same way that a lab test or X-ray helps to determine a medical diagnosis, a psychological test helps to clarify the clinical picture, to determine the mental health diagnosis, and to assist in formulating a treatment plan designed to promote the best patient outcome.
Conducting a competent preoperative psychological assessment is deceptively difficult, says Boutacoff. Given that many surgery candidates are strongly motivated to present themselves favorably during the interview, a psychologist cannot be expected to base a diagnostic impression and clinical decisions on subjective data alone. A psychometrically-sound psychological test provides the objective data necessary to help screen for the underreporting of symptoms and/or the inclination to bias the clinical picture.
Frequently Used Psychological Tests
1. The MMPI-2™ (Minnesota Multiphasic Personality Inventory-2™) assessment and its version for adolescents (the MMPI-A™) are well-designed and well-validated measures of personality. For the MMPI-2 test, profile frequency data are available for medical patients, for members of the general population (non-clinical patients), as well as for psychiatric patients. The MMPI-2 test is used, for example, to describe and understand the emotional status of various types of medical patients, including those with chronic pain, cardiovascular disease, and general medical conditions.5 Boutacoff administers the MMPI-2 test to bariatric surgery candidates in order to help her make inferences about:
- Level of psychological distress
- Evidence of denial, defensiveness, or emotional immaturity
- Problems with substance abuse, including the risk of misusing prescription narcotics, alcohol or illicit substances after surgery
- Problems with impulse control
- A tendency to somaticize (which increases the potential for increased healthcare costs)
- Negative attitudes toward authority
2. The MCMI-III™ (Millon™ Clinical Multiaxial Inventory) assessment is used extensively in mental health settings as an objective measure of character traits and personality disorders.6 Boutacoff cautions clinicians to use the MCMI-III test judiciously with bariatric surgery patients. The MCMI-III test is designed for psychiatric patients or for patients seeking mental health treatment6 and not for medical patients without psychopathology. Boutacoff explains that she administers the MCMI-III test as an adjunct to the MMPI-2 test, either for the purpose of clarifying high elevations on the MMPI-2 profile or to rule out a personality disorder.
3. The MBMD™ (Millon™ Behavioral Medicine Diagnostic) inventory is an easily administered psychological measure that informs healthcare providers about psychosocial factors that are known empirically to play a role in the course of a patient’s medical illness and its treatment.7 The MBMD test, normed on a general medical population, is designed to provide physicians with psychosocial information about the patient. In addition the test helps provide information about how that patient ispersonally experiencing his/her disease process.7 Boutacoff uses the MBMD inventory to help her gather information about the candidate’s coping style, attitudes toward treatment, strengths, and liabilities.
4. The QOLI® (Quality of Life Inventory) test is a multidimensional construct that is becoming progressively more important in medical decision-making and especially in the care of chronically ill patients. While “Quality of Life” is a relatively easy construct to conceptualize, it is a very difficult construct to assess objectively.
The QOLI test lists 16 “valued areas in life.” Patients rate: (a) how important each one is, and (b) how satisfied they are in each of these areas. Thus, the QOLI test takes into account two dimensions—importance and satisfaction—that are central to Quality of Life theory. The QOLI test takes a few minutes to complete. It helps to measure not only the Health dimension of quality of life, but also several psychosocial dimensions (including Love, Self-Esteem, and Play) that surgeons and allied health professionals believe to be important to bariatric surgery patients.8
For More Information
Professionals in the field of bariatric surgery encourage psychologists and psychiatrists to join their ranks. Working with bariatric surgery patients involves developing an expertise in the psychosocial treatment of morbid obesity as a medical disease (and not as an eating disorder, or as a sign of weakness or loss of willpower). In some cases, the role of the psychologist is to provide education and guidance using established cognitive-behavioral techniques. In other cases, the role of the psychologist is to diagnose, treat, and/or make the necessary psychiatric referral.
The American Society for Bariatric Surgery offers an extremely informative website (http://asmbs.org/). Topics addressed on the website include: the disease of morbid obesity and its treatment with bariatric surgery, upcoming meetings and seminars, and membership to the Society. Psychologists are allied health professionals who are welcome to apply for Associate Membership to the Society. An interested psychiatrist would apply for membership as an Affiliate Physician. The administrative office of the American Society for Bariatric Surgery (ASBS) is located in Gainesville, Florida and can be contacted by telephone (352-331-4900), or by e-mail (email@example.com).
1 National Heart, Lung and Blood Institute. (1998). Executive summary of the clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Archives of Internal Medicine, 158, 1855-1867.
2 Buchwald, H. (1999). Mainstreaming bariatric surgery. Obesity Surgery; 9, 462-470.
3 Glinski, J., Wetzler, S., & Goodman, E. (2001). The psychology of gastric bypass surgery. Obesity Surgery, 11, 581-588.
4 Stedman, J.M., Hatch, J.P., & Schoenfeld, L.S. (2001). The current status of psychological assessment training in graduate and professional schools. Journal of Personality Assessment, 77, 398-407.
5 Graham, J.R. (2000). MMPI-2: Assessing personality and psychopathology. New York: Oxford University Press.
6 Millon, T. (1994). MCMI-III manual. Minneapolis, MN: National Computer Systems, Inc.
7 Millon, T., Antoni, M., Millon, C., Meagher, S., & Grossman, S. (2001). Millon Behavioral Medicine Diagnostic manual. Minneapolis, MN: NCS Pearson, Inc.
8 Mason, E.E. (1998). Quality of Life. IBSR Newsletter, 13, 13-14.
ProFiles, June 2002, revised May 2005 (F52CS)