Preparing For Weight Loss Surgery

Preparing for
Weight Loss Surgery:

Therapist Guide
Robin F. Apple
James Lock
Rebecka Peebles
OXFORD UNIVERSITY PRESS
Preparing for Weight Loss Surgery
--
David H. Barlow, PhD

Anne Marie Albano, PhD
Jack M. Gorman, MD
Peter E. Nathan, PhD
Bonnie Spring, PhD
Paul Salkovskis, PhD
G. Terence Wilson, PhD
John R. Weisz, PhD
Preparing for
Weight Loss Surgery
T h e r a p i s t
G u i d e
Robin F. Apple James Lock Rebecka Peebles
1
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Apple, Robin F. (Robin Faye)
Preparing for weight loss surgery : therapist guide / Robin F. Apple,
James Lock, and Rebecka Peebles.
p. cm.(Treatments that work)
Includes bibliographical references.
ISBN- ----; ---- (pbk.)
ISBN ---; --- (pbk.)
. ObesitySurgery. . Weight loss. I. Lock, James.
II. Peebles, Rebecka. III. Title. IV. Series.
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About TreatmentsThatWork
Stunning developments in health care have taken place over the last several years, but many of our widely accepted interventions and strategies
in mental health and behavioral medicine have been brought into question by research evidence as not only lacking benet but, perhaps, inducing harm. Other strategies have been proven eective using the best current standards of evidence, resulting in broad-based recommendations
to make these practices more available to the public. Several recent developments are behind this revolution. First, we have arrived at a much
deeper understanding of pathology, both psychological and physical, which
has led to the development of new, more precisely targeted interventions.
Second, our research methodologies have improved substantially, such
that we have reduced threats to internal and external validity, making the
outcomes more directly applicable to clinical situations. Third, governments around the world and health care systems and policymakers have
decided that the quality of care should improve, that it should be evidence based, and that it is in the publics interest to ensure that this happens (Barlow, ; Institute of Medicine, ).
Of course, the major stumbling block for clinicians everywhere is the accessibility of newly developed evidence-based psychological interventions. Workshops and books can go only so far in acquainting responsible
and conscientious practitioners with the latest behavioral health care practices and their applicability to individual patients. This new series, TreatmentsThatWork, is devoted to communicating these exciting new interventions to clinicians on the front lines of practice.
The manuals and workbooks in this series contain step-by-step detailed
procedures for assessing and treating specic problems and diagnoses.
But this series also goes beyond the books and manuals by providing an-
cillary materials that will approximate the supervisory process in assisting

practitioners in the implementation of these procedures in their practice.
In our emerging health care system, the growing consensus is that evidencebased practice oers the most responsible course of action for the health
professional. All behavioral health care clinicians deeply desire to provide the best possible care for their patients. In this series, our aim is to
close the dissemination and information gap and make that possible.
This therapist guide and companion workbook for clients addresses psychological and behavioral aspects of weight loss surgery for the morbidly
obese. This approach has been shown to be highly eective as a treatment
of last resort for substantially obese individuals who are subject to the
dramatically increased risk factors to health associated with this condition. And indeed, the rapid growth of obesity in North America, and
much of the developed world, has been referred to by most health care
professionals as an epidemic. Illnesses and conditions exacerbated by
obesity cover all of the major organs and functional systems within the
body, including the development of cancer in various organs. The occurrence of most of these obesity-related conditions, particularly type II
diabetes, is rising dramatically. But these surgical procedures are not
without risks, as has been detailed in the scientic literature as well as the
popular press. Thus, most surgeons and health care professionals insist
on accompanying psychological treatment to prepare patients for surgery and to assist them in complying with their post-operative routine.
The patient who is not properly prepared for surgery or does not understand the surgical procedures will be bitterly disappointed and likely
noncompliant following surgery. Similarly, the patient who does not
comply with the recommended post-surgery regimen will fail to maintain any weight loss and will put themselves at further physical risk.
The approaches detailed in this treatment program explain the nature of
morbid obesity, then go on to describe, in a very user-friendly manner,
the most up-to-date procedures for dealing with attitude, emotional,
and behavioral factors associated with successfully transitioning to a very
dierent lifestyle.
David H. Barlow, Editor-in-Chief,
TreatmentsThatWork
Boston, Massachusetts
vi
Contents
Chapter
Introductory Information for Therapists
Chapter
Understanding Your Patients Eating Behavior
Chapter
Helping Your Patient Keep Track of

His or Her Eating
Chapter
Educating Your Patient About Weighing Behaviors
Chapter
Pleasurable Alternative Activities
Chapter
Challenging Eating Situations:

People, Places, and Foods
Chapter
Teaching Your Patient About Problem Solving

and Cognitive Restructuring
Chapter
Working With Your Patient on Body Image Issues
Chapter
Congratulations! Your Patient Is on the Way

to the O.R.
Chapter
What Happens After Surgery?

References
About the Authors
This page intentionally left blank
Preparing for Weight Loss Surgery
Chapter 1
Introductory Information for Therapists
Background Information and Purpose of This Program

Obesity has quickly become an American epidemic. Patients suering
from signicant overweight often have to contend with a lifetime of signicant co-morbidities, social stigma, and lower quality of life. Many approaches have been tried to combat obesity and its multiple co-morbid
medical illnesses, including pharmacotherapy, psychotherapy, diet, exercise, and other lifestyle change. Weight loss surgery has been used as a
modality for many years but has been increasingly recognized as a durable
tool for weight management over the last decade. Because the success of
traditional diet programs and other therapies has been sporadic and usually
short term, and recent literature has shown signicantly more weight
loss sustained over time in patients who undergo surgery, patients have
been approaching their health care teams about the option of surgery
and asking to learn more.
Table 1.1 oers a detailed description of the dierent types of weight
loss surgery procedures.
Research Support for CBT and Changing Eating Behaviors

Although systematic research has yet to be conducted on the specic
utility of psychotherapy for patients undergoing weight loss surgery, there
is a substantial body of research on related conditions (bulimia nervosa
and binge eating disorder) that suggests cognitive behavioral therapy
(CBT ) may be useful.
Table 1.1 Surgical Procedures

Name of Procedure
Restrictive
Procedures
Restrictive
Malabsorptive
Description
Vertical Banded
Gastroplasty (VBG)
In this procedure, the stomach is divided by a line of

staples to produce a new gastric pouch, much smaller
only about an ounce in size. The outlet of the new pouch
is similarly small, extending about mm in diameter. This outlet empties into a section of old, larger stomach, which then empties as it used to into the small intestine. The surgeon usually reinforces the outlet with mesh
or GORE-TEX to reinforce it. The VBG may be performed with an open incision or laparoscopically.
Siliastic Ring Vertical

Gastroplasty
A variant of the gastroplasty described above. Here, the

stomach is again divided by a row of staples to produce a
small gastric pouch. In this procedure, the new, smaller
outlet of the new gastric pouch is reinforced by a silicone
band to produce a narrow exit into the old section of
stomach, as detailed above.
Laparoscopic Adjustable
Silicone Gastric
Banding (LASGB)
This is a newer surgery, known as the LAP-BAND, approved by the U.S. Food and Drug Administration
in . It is only performed laparoscopically, as its name
implies. Here, a new gastric pouch is formed with staples, as with the gastroplasty, but the band surrounding
the outlet from the new pouch into the old part of the
stomach is adjustable. This is achieved because the band
is connected to a reservoir that is implanted under the
skin. The surgeon can then inject saline (saltwater) into
the reservoir, or remove it from the reservoir, in an outpatient oce setting. This means that your surgeon can
then tighten or loosen the band, adjusting the size of the
gastric outlet.
Roux-en-Y Gastric
Bypass (RYGB)
The RYGB is the procedure most commonly performed

and accepted. It involves creating a small ( 13 oz) gastric pouch by either separating or stapling the stomach.
This pouch then drains via a narrow passageway to the
middle part of the small intestine, the jejunum. This
bypasses the duodenum, which food would normally
traverse before arriving at the jejunum. The older portion
of stomach then goes unused and maintains its normal
connection to the duodenum and the rst half of the
jejunum. This end of the jejunum is then attached to a
new small intestine created by the procedure above.
This creates the Y referred to in the name of the procedure. This redirection of the small intestine creates a
malabsorptive component to the procedure, in
Name of Procedure
Description
addition to the restrictive gastric pouch. RYGB may be
performed with an open incision or laparoscopically.
Biliopancreatic Diversion
(BPD)
This surgery is considered more technically dicult

and is less commonly performed. It involves a gastrectomy that is considered subtotal, meaning that it leaves
a much larger gastric pouch compared with the other options described above. The small intestine is divided at
the level of the ileum (the third and nal portion of the
small intestine), and then the ileum is connected directly
to this midsize gastric pouch. The remaining part of the
small intestine is then attached to the ileum as well. This
procedure thereby bypasses part of the stomach and the
entire duodenum and jejunum, leaving only a small section of small intestine for absorption.
Biliopancreatic Diversion
with Duodenal Switch
(BPDDS)
BPDDS is a variation of the BPD that preserves the rst

portion of the duodenum, the rst section of the
small intestine.
Jejunoileal Bypass
This surgery bypasses large portions of the small intestine; it is no longer recommended in the United States
and Europe due to an unacceptably high rate of complications and mortality.
Aaron Becks seminal work on CBT for depression was modied by Fairburn and colleagues for use with patients with bulimia nervosa (BN)
(Fairburn, ). CBT has been tested in numerous controlled studies
and has been found to be the most eective psychotherapeutic approach
to the treatment of BN. CBT has been found more eective than delayed
treatment, nondirective therapy, pill placebo, manualized psychodynamic
therapy (supportive-expressive), stress management, and antidepressant
treatment. Becks work has since been further modied for use with patients who compulsively overeat or binge, such as many of those who
have developed obesity.
The main focus of CBT, when working with overweight or obese individuals, is to address the negative thoughts that cause and maintain the
behaviors associated with being overweight. Interventions are designed
to combat these cognitive distortions in order to produce lasting change.

In addition, more generally, CBT has been used to help with depressed
mood, anxiety problems, and low self-esteem, all of which are common
to obese patients, as well as to those contemplating surgery or recovering from it.
In the last few years, increasing interest in treating a subset of BN patients who binge eat but do not purge (binge eating disorder or BED)
has arisen. It appears that despite considerable symptomatic overlap in
terms of both behavior (binge eating) and psychological concerns (low
self-esteem and weight and shape concerns) there is a growing consensus that they are a distinct diagnosis. The most eective treatments for
BED are similar to those eective for BN, particularly CBT. Generally
CBT has the most evidence to support its use, and CBT-based self-help
manuals may be even more eective in those suering from BED compared to those with BN (Hay et al., ).
Although patients with BN and BED dier from typical bariatric surgery candidates, there is convergence in some important areas that supports the use of therapeutic treatments such as CBT to help with similar problems among bariatric surgery candidates. Problems such as binge
eating, dissatisfaction with body shape and weight, and issues concerning control over eating are examples of common concerns. In addition,
depressed mood and anxiety, as well as low self-esteem, are common in
many patients considering bariatric surgery or recovering from it. Thus,
it appears reasonable to extrapolate from the current database of systematic research for eating disorders, anxiety, and depression to the population of patients seeking bariatric surgery. In addition, it is unlikely that
systematic research in the specic area of psychological treatments for
bariatric surgery will be forthcoming soon. The current manual is therefore an extension of the existing research in a novel area based on its utility for related concerns for which there is an extensive database.
Working With the Pre-Operative Patient

Recent media reports about surgical success stories may make many patients unrealistic about their goals or the ease of surgery as a choice. A
lot of patients arent prepared for the radical changes they need to make
to their lifestyle and eating habits post-operatively in order to ensure they

reap the maximum benets of their surgery. Making a commitment to
eat healthfully and nutritiously and to exercise regularly is the key to
guaranteeing long-term success. Sustaining weight loss after undergoing
bariatric surgery of any type requires that the patient adhere to a strict
diet while following the very specic recommendations of his or her
primary care physician, dietician, surgeon, and other members of the
team. Without the patients strong level of commitment to a future as
a thinner and healthier person, the probability of the surgery leading to
permanent weight loss maintenance is limited.
The program outlined in this guide will help you teach your pre-operative
patients the skills required to adapt to the lifestyle and dietary changes
that are necessary in order for them to sustain weight loss after surgery.
Based on CBT techniques as described above, the program incorporates
basic cognitive restructuring and problem-solving skills to help your patients change their negative thoughts about food, eating, their bodies,
and themselves. Through this program they will develop a more thorough understanding of all aspects of their past and current problems
with food and weight. It will also help your patients establish a regular
pattern of eating, teach them about self-care and how to replace their
negative eating habits with other, more pleasurable activities, and assume
a lifestyle consistent with long-term weight loss maintenance.
Use of the Workbook

The corresponding patient workbook will aid you in delivering this
CBT-based treatment to your pre-operative patients. It is organized by
skill (e.g., monitoring and recording eating habits, establishing a schedule for weighing-in, replacing eating with alternative, pleasurable activities, etc.) and correlates directly to this therapist guide. You may spend
as many sessions covering each skill as necessary. The workbook contains
user-friendly and interactive exercises, forms, work sheets, and checklists
that your patient will complete either in-session or as homework as a
way to reinforce these skills. All of these documents can be photocopied
from the workbook or downloaded from the TreatmentsThatWork Web
site at http://www.oup.com/us/ttw so that your patient is able to extend
the therapeutic experience outside of the oce.
Chapter 2
Understanding Your Patients Eating Behavior
(Corresponds to chapter of the workbook)
Materials Needed
Figure .. The Cognitive Behavioral Model of Overeating
Outline
Teach patient about the cognitive behavioral (CBT ) model for understanding the development of weight and eating issues
Personalize the CBT model based on patients experiences
Help patient understand the way in which weight loss surgery is likely
to aect these issues
If your patient is obese, that means that he has been overeating in one
way or another (e.g., taking in more calories than the body needs and
storing the excess as increased body weight or body fat.) It might surprise
your patient, as you discuss the contributions to his weight problem, to
nd out that there are dierent forms of overeatingand that he might
engage in some, but not others. It is important to help your patient identify the types of overeating problems that she or he has, so that appropriate interventions can be developed. As you discuss the following section with your patient, you can help him identify the types of overeating
behaviors that she or he might engage in most frequently and help the
patient to understand the various contributions to these behaviors, as
well as ways to stop.
Types of Overeating
You will want to educate your patient about dierent types of overeating.
Overeating can come in various shapes and sizes. For example, there can
be binge eating episodes, e.g., typically quite large and out of control
eating episodes in which a sizable quantity of food is consumed in a
short period of time and in a manner that is considered to be quite different from an average persons eating experience. A binge episode is one
that usually leads to a feeling of being uncomfortably full or stued.
On the other hand, overeating can sometimes take the form of grazing
throughout the day, e.g., taking in relatively small amounts of food frequently between standard snack and meal times, usually in response to
cravings, boredom or other emotions, or the mere availability of food.
For some individuals, overeating episodes are followed by a strong resolve
to eat less, under-eat, starve for a few days, exercise more, or in extreme
cases, to purge the excess food. Those who follow episodes of overeating
with purging (or extreme or compulsive exercise or starving) on a regular basis are classied as having bulimia nervosa as opposed to binge
eating disorder. Most individuals who eventually become obese have
not been engaging in regular, successful purging; if they had, it is much
less likely that they would be as overweight as they are. On the other
hand, if your patient has been purging regularly (but has still managed
to become obese) it is probably wise to encourage the patient to delay
surgery until the purging behaviors are fully resolved.
Once you help your patient to understand the specic nature of the
overeating habits, you can help him t these into a larger model based
on cognitive behavioral theory that takes into account other aspects of
lifestyle and current circumstances. As you discuss this model with your
patient, keep in mind that your goal is to help the patient better understand the interrelationships between eating behaviors and weight, other
factors in his personal history, and the current situations, thoughts, and
feelings that he encounters.
An Illustration of the Cognitive Behavioral Model of Overeating

You will want to spend considerable time educating your patient about
the CBT model of overeating and later helping draw out a form of the
model that reects the patients unique experiences. The CBT model of
overeating and overweight links the overvaluation of thinness in our culture; pressure and intentions or attempts to diet; resulting feelings of
deprivation, loss of control, and overeating (sometimes compounded by
factors of low mood, conicts with others, feelings of fatness, etc.); overeating (whether by grazing, compulsive overeating, or binge eating); loss
of clear hunger and fullness cues; weight gain; increasingly negative emo-
WEIGHT GAIN AND OBESITY
CULTURAL
FACTORS/WORRIES
ABOUT HEALTH ALL LEAD
TO ATTEMPTS TO DIET
MOODS, CONFLICTS,
STRESSORS
LOSS OF CONTROL,
OVEREATING
MOMENTARY PLEASURE
FROM FOOD
FEELINGS OF SHAME, GUILT,

REGRET, FAILURE,
DEPRESSION
Figure 2.1
The Cognitive Behavioral Model of Overeating
tions (from all kinds of sources: negative view of the self, interpersonal
conicts, specic failure experiences); and resignation/giving up, as well
as increasingly turning to food as a primary source of gratication.
The Cognitive Behavioral Model of Overeating

Figure . illustrates the vicious cycle of overeating followed by subsequent attempts of various types to control eating that applies even to
those who are overweight and for that reason deemed failures at being
restrictors. You will want to discuss the model and the rationale for the
model at length with your patient.
The CBT model of overeating, as described above, suggests that there
are specic links between certain eating behaviors, attitudes, feelings,
and weight. For example, in our culture as a whole, most people tend to
value, if not overvalue, thinness or even in some cases, extreme thinness.
The pressure to eat less felt by those who are overweight who also place
signicant value on thinness can be overwhelming and at times lead exactly to the behavior that is most unwelcome: that of overeating. For
some, overeating in the short term is quite pleasurable and therefore momentarily combats the stress and depression that can accompany the experience of being overweight or obese. In some instances, eating has become the primary tool for gratication and pleasure that an overweight
individual has learned to use to soothe himself in the event of negative
emotions or problem situations.
Typically after a brief period of pleasure, however, overeating can lead to
negative feelings and thoughts about oneself and an overidentication
with the experience of failure, at least with respect to eating and weight
control. While massive eorts to diet and exercise, even unsuccessfully
(e.g., sometimes just hypervigilance or emotional energy about these areas
or simple good intentions without a lot of productive action), can follow bouts of overeating, this extreme eort might lead to feelings of
stress and deprivation (even if the actual amount of food consumed and
physical exertion through exercise remains about the same). Your patients eorts to diet might leave him feeling as if he isnt allowed to eat
to satisfaction or doesnt have the right to eat the foods that he likes. Frequently, these feelings can trigger episodes of overeating no matter what
10
their source (e.g., actual, successful dieting and weight loss or intentions
to diet that fall short of the goal of actually cutting back).
In addition to the experience of deprivation, other aspects of a persons
life might contribute to a lowered threshold for overeating. For example,
general stress, intense emotions of other types (low mood, euphoria, anxiety, grief ), conicts with others, and a distorted sense of hunger and fullness from a history of overeating and purging can create a situation in
which it is impossible to clearly discern hunger and fullness cues.
Finally, there are often historical factors associated with overeating and
becoming overweight. These might include: the early experience of being
teased and labeled fat; having been forced to diet as a young child; retreating into overeating and weight gain to avoid certain challenges associated with growing up; or attempting to cope with trauma of one
type or another. In adulthood, overweight and overeating can often be
associated with pregnancy, raising children, becoming more sedentary
after starting to work again (or leaving a job), or having been forced to
give up certain sports or physical activities due to medical conditions or
injuries. For some, excessive weight gain might be associated with excessive alcohol intake, eating more due to drinking less, or discontinuing
either smoking or stimulant drugs.
You will want to spend a considerable amount of time talking with your
patient about all of the aspects of his life, past and present, that have
played a role in his having become overweight, so that ample time can
be spent understanding and working through the issues.
Your patient will be using the blank space that is provided in his workbook to draw out a version of the CBT model that best ts his own experience. An example is shown below in Figure .. During sessions in
which you discuss the CBT model, you might help the patient start linking it to his experiences by thinking about and noting a few of the relevant factors in his growing up years (that he is aware of ) or any other aspects of his history that have aected his eating behaviors and his weight
over time. Then you might want to encourage your patient to write in
more detail about his particular experiences as they relate to the various
aspects of the CBT model, as presented in the following exercise. Following this exercise, you will be discussing with your patient the speci-
11
It seems that overweight and depression run in my family. So I was

overweight from a fairly young age. The problem seemed to get worse over
time. As I became an adolescent and looks started to be more important, I
retreated somewhat socially and started to eat as a way to make myself feel
better. Obviously, this made the weight problem worse . . . It has been hard
ever since. Even though I have dieted a number of times, none of the weight
losses that I have accomplished have stuck for more than a few months.
Then when I started to have kids my weight just got higher and higher . . .
until the point where it seemed futile to try to do anything about it. Although
I exercised in the past, with increasing weight it has been more and more
difficult to move around, and for that reason I havent done much exercise at
all in the past couple of years, again making the weight problem even worse.
So the surgery seems to be my only solution at this point.
Family history of weight problems and depression
Increasing weight led to decreasing physical activity and more weight
gain
When I dieted I would feel deprived and then eat more as a result . . .
Eating to feel better e.g., to get over social isolation and depression
Diets didnt work anymore and frustration led to more eating and weight
gain and lower mood.
Also stress of any type has usually triggered some overeating.
Figure 2.2
Sample of Patients CBT Model
12
c emotional, cognitive, and behavioral eects of problems with weight

and overeating.
The Effects of Overeating: Emotional, Cognitive, and Behavioral

For many people, overeatingwhether triggered by available food; cravings; negative emotions such as depression, anger, or boredom; conicts
with other people; or a desire to distract oneself by creating a new
focus for negative energycan lead to a variety of dierent outcomes.
As stated in the section above, it can be gratifying or uplifting in one way
or another. For example, it can provide a form of pleasure when there
are few pleasures available; it can distract from dicult thoughts or feelings about any number of problem situationsin a sense it shifts the
focus from one problem to another; it can provide a method for acting
out or breaking the rules for someone who otherwise is quite compliant and sensitive to doing only what is right.
No matter what causes an episode of overeating, in response to its occurrence, in many cases one feels not only an urge or desire to restrict intake, but also usually a whole host of negative emotions, thoughts, beliefs, and behaviors about oneself in relation to having overeaten, which
develop fairly soon after the episode, even if the eating episode was on
some level gratifying. These thoughts and beliefs might take the form of
I am never going to lose weight, I am the only person who engages in
this behavior, or even more negatively I am a fat pig or I am a loser.
These thoughts and beliefs can generate an array of negative feelings.
Some of these may include: sadness, self-disgust, anger at oneself and
others for having gotten into the situation in which overeating occurred,
despair, and resolve not to do it again and a commitment to start dieting or restricting intake on some level as soon as possible after the overeating episode is completed. For some people, overeating in the form of
continuous grazing and consuming excessively large meals and snacks
might not trigger so many extreme reactions but rather strengthen or ignite a sense of resignation and inevitability of future overeating and continued weight gain. In many cases, the negative thoughts, feelings, and
beliefs also lead to compromised behaviors such as not getting out socially to see friends, feeling too full to do other tasks, whether chores or
13
recreational activities, or even additional overeating that may be an attempt to further escape from the bad feelings.
Gastric Bypass Surgery and the CBT Model

Since the experience of weight loss surgery will change your patients relationship to food quite dramatically, the issues discussed above need to
be considered in a dierent light. Mostly, weight loss surgery will help
your patient better manage his reactions to both hunger and fullness
(satiety). Specically, after weight loss surgery of any type, your patient
can expect to feel hungry less frequently and less intensely than before
(for those who do actually experience hungersome obese people do
not). Also it will take much less food to ll your patient up once he does
start to eat after becoming hungry. And your patients method of eating,
which will involve taking very small bites of food, chewing them very
well, and eating very, very slowly, will also increase the likelihood that he
will feel full on much less food. Also, your patient will be given information about which foods to include in his diet and which to avoid, as
well as strategies for alternating his intake of foods and liquids.
While, ultimately, the goal of weight loss surgery is to reduce your patients hunger level so that he can make wiser and less impulsive decisions about food, this surgery benet can also come with certain costs.
These might include the experience of deprivation that can accompany
regular dieting when certain foods in certain quantities are restricted or
the experience of being left without tools if your patient has used food
as a primary means for coping with problem emotions and situations.
Without replacing food with other positive and well-practiced tools for
coping, any individual who is even enthusiastically attempting to restrict
intake by choice can be left feeling unsettled, frustrated, deprived, or out
of control. These feelings can lead to urges to overeat. Solutions for the
problem of being left without tools will be discussed in a later chapter.
You will discuss with your patient the reality that even after weight loss
surgerywhich by now he should understand is no magical cure
overeating can happen, in one form or another. For example, your patient might nd himself unintentionally experimenting with creative
strategies for overeating. These might include: frequent ingestion of
14
small quantities of indulgence foods that are not ideal, such as very small
amounts of sweets, candy, or peanut butter, or taking in increasingly
larger quantities of food, particularly once the new stomach pouch
stretches some. He may deliberately overeat certain foods that are no
longer digestible because of the particular type of surgery he had (e.g.,
fats after the duodenal switch procedure) and come to rely on the malabsorption syndrome, or dumping, as a method of purging the excess
calories.
Despite the surgerys assistance in controlling your patients eating, at
least some of the fundamental features of the CBT model will still apply
to his struggle to manage his intake. In your therapy sessions, you will
want to determine those areas that might prove to be high-risk. For example, while your patient might not feel physically hungry after surgery
in the same manner as before, he might still struggle with physical and
psychological cravings for particular types of foods or for food in general. Associated with these cravings may be emotions of frustration, loss,
sadness, or even despair. He may feel that he will never be able to consume any of these foods again or that he will always struggle with intense
cravings. While the use of words like always and never signies that your
patient may have been triggered into a cognitive lapse that involves
clearly problematic and unhelpful thoughts, these errors in thinking can
be addressed and modied using cognitive restructuring procedures (see
chapter ). By the same token though, no matter how skillfully you might
address the problematic thoughts with your patient, it is equally important to help him get his behaviors onboard so that he doesnt inadvertently contribute to any of the problems noted above.
Similarly, it is important to address any problem emotions your patient
might notice in association with his surgery. In some cases, losing a signicant amount of weight even after weight loss surgery can lead to the
experience of excessive hunger, cravings, and eventual overeating, as the
body struggles to reestablish its former set point. Also, in some cases,
negative emotions can accompany even desirable, radical weight loss and
can lead to a pattern of emotional eating.
As you discuss your patients personalized version of the CBT model and
work hard to understand all of the issues involved, you will be able to
more clearly help your patient ascertain the areas that need the most re-
15
habilitative work prior to surgery. No matter what, it is likely that one

or more of the following chapters will help your patient address the issues that are most troubling.
Homework
Read about and review the CBT model for understanding eating and
weight issues.
Create a personalized version of the CBT model and discuss this with
your therapist.
Review the implications of weight loss surgery on the CBT formulation.
16
Chapter 3
Helping Your Patient Keep Track

of His or Her Eating
Materials Needed
Form: Food Record
Outline
Explain to patient the rationale for establishing a regular pattern of
eating
Teach patient to establish a regular pattern of eating
Introduce patient to food records
Teach patient a method for keeping track of eating using food records
The CBT model of overeating explains the interrelationships between
eating, thoughts, emotions, weight gain, and other behaviors and situations, and purports that the rst steps toward making changes in this
vicious cycle need to be taken at a behavioral level. For example, a key
component in your patient overcoming her problem eating habits or attitudes involves her making a commitment to gathering more data about
her eating behaviors by keeping some form of eating record. Another key
factor involves her willingness to establish a regular pattern of eating, including keeping to a schedule of healthy, balanced, and not overly indulgent nor overly stingy meals and snacks to interrupt any problematic
cycles of overeating followed by compensatory under-eating. You will
want to discuss both of these principles and the following rationale in
more detail with your patient in the sessions that deal with these issues.
17
You will want to sell your patient on the CBT belief that the prescription of a healthy, regular pattern of eating can disrupt the strength of the
links in the model of problematic eating. Helping your patient to disentangle these links and clean up her eating patterns by eating on a
regular but modiable schedule can help her free up her eating behaviors from inappropriate inuences (those that arent related to hunger or
fullness). In this way your patient can slowly achieve healthier eating behaviors and associated attitudes. In many cases, too, this plan for regular eating can help your patient slowly work toward her weight goals, since
the pattern can help her combat any episodes of impulsive overeating.
The Importance of a Regular Pattern of Eating

The treatment of choice for problematic overeating behaviors that occur
in response to triggers of any type has been the prescription of a regular
and healthy pattern of eating (such as three meals and two snacks a day).
Obviously the specics of the planned eating pattern (e.g., the exact
contents and quantities) will dier from individual to individual and
will also depend upon the exact nature of the surgery that your patient
is planning to have and the recommendations of her particular surgery
center. By and large, though, these recommendations will include the
suggestion to consume three small meals and two or three small snacks
a day (or ve or six small meals) that are eaten not fewer than about
hours apart and not more than about hours apart. The rationale behind
this recommendation is that by eating in response to a exible but predetermined schedule, nonessential and inappropriate food and eating
cues such as those described above (e.g., emotions, cravings, the availability of food, and various interactions with people) will be washed out
over time. As you will explain to your patient, the belief is that this mechanical style of eating by the clock will gradually become more automatic and natural, and increasingly will correspond to the ebb and ow
of hunger and satiety signals as these are progressively retrained through
adherence to the schedule. In this way, over time, eating will be initiated
appropriately albeit somewhat exibly at meal and snack times, approximating the pattern that your patient will need to adopt post-operatively.
18
Your patient will obviously learn a lot about nutrition pre- and post-op
from her dietician. However, you will also discuss the importance of eating nutritionally dense meals and snacks after surgery with your patient
during the sessions focused on establishing a regular pattern of eating.
At the same time, you will talk to your patient about the fact that in addition to super-nutritious food and correct eating and uid intake patterns, healthy eating (in both the physical and psychological sense) must
also involve some allowances for certain small treats that are at least
somewhat indulgent. This will help stop problem cravings and deprivations that lead to out of control episodes of overeating (to the extent that
that is possible after weight loss surgery). As you will review time and
again with your patient, the essential tool for getting eating behaviors that
have gone awry back on track is a normalized relationship with food.
If your patient has had particular diculties making a commitment to
eating by the clock, suggest that she try hard to gure out in advance
just about when, just about what, just about how much, and just about
where each meal and snack will take place. Furthermore, she will get the
most mileage out of this type of exercise if she sketches out these plans
in some sort of draft or meal plan, either in a journal or an actual food
record. Working in this way on a regular basis will represent a very substantial step toward her liberating her eating habits from inappropriate
inuences not really connected to physical hunger.
Using Food Records

The rst step in helping your patient try to understand more about her
eating patterns and associated thoughts and feelings, and the contexts or
situations in which she struggles with these, involves learning to record
all of her behaviors in journal form, using what is commonly known as
a food log or food record that provides details beyond the sketching a plan in advance noted above. Explain to your patient that the food
record is all about gathering data so that she wont have to rely on her
memory alone to understand the details of her eating patterns, all that
contributes to them, and how her weight is aected by the current patterns and any changes to them. Inform your patient that when she completes food records, she also has created a written record of her eating be-
19
havior that can be discussed in detail with you during sessions. You can
talk with your patient about her prior experiences, if any, with food
records and any associated thoughts and feelings that she has about food
records based on those experiences.
Your patient might be quite skeptical about food records if she has
worked with them before, perhaps in a structured diet program, while
meeting with a dietician for consultation, or in some type of behavior
therapy. Her reaction might be this is not going to workit never did
before! Or she might feel as if keeping food records is all about being
controlled by her therapist or dietician. No matter what, all of these
sentiments need to be explored in your sessions with her. Forewarn your
patient that to succeed with this program she will need to transcend her
tendency toward skepticism and trust that this experience with food
records can be dierent, that is, that she can productively and therapeutically use these records to her advantage, rather than feel as if she is
completing an assignment for someone else. Assure your patient that
regularly completing food records in the context of this particular CBT
therapy will be a dierent experience than any she has had before, if she
uses them as recommended in the program. Remind her that if she
wants to really succeed with her food records, the best way for her to proceed is to make a commitment to recording her food intake (all meals,
snacks, binges, or grazing episodes and uid intake) as close to the time
of eating as possible. Any delay in her recording can lead to inaccuracies
and even more importantly, the experience of disconnect between her
eating and what she will later record in her food records. Remind her
that she should raise any questions about the food records with you.
A sample completed food record is included in Figure .. A blank copy
for your patients use is available in the workbook. Your patient may photocopy the blank record from the workbook or download multiple
copies at the TreatmentsThatWork Web site at http://www.oup.com/
us/ttw.
Encourage your patient to use the food records daily and to make her entries as close as possible to the time that she is eating. She can also use
the records to plan her eating patterns and specic snacks and meals in
advance, and then cross-check to ensure that she has followed through
on her plan. Either way, educate your patient that if done correctly, the
20
Food Record
Amount of Food and
Liquid/Description
Meal, Snack,
Binge, Graze?
Purge
Y/N
Thoughts, Feelings,
Situation/Context
Time
Place
8:00 a.m.
Standing
in kitchen
1 corn dog with bun,

1 hot dog with bun,
mustard, ketchup,
cheese with both
1 glass orange juice
Breakfast
Just a typical morning
10:30
Work
at desk
1 package Hostess
Ho Hos from
vending machine
Snack
My usual snack
11:30
Friends
Desk
handful of M&Ms
Grazing a bit
They were there,

so I ate them.
In car,
3 tacos, a burrito, and
drive-thru a large Coke
Taco Bell
Lunch
At least I didnt
have dessert.
3 p.m.
At desk
glass water, handful

peanuts
Snack
I am trying to be
good with the
water.
6 p.m.
In kitchen
preparing
dinner
several slices cheese

and 610 Ritz
crackers
Just snacking
while I cook
dinner
I will try to eat less

at dinner.
6:30
Kitchen
table with
family
plate of spaghetti with Dinner

meat sauce, salad with
ranch dressing, 3
pieces garlic bread
with butter, slice apple
pie, 1 glass 2% milk
12:30 p.m.
I made it so I wanted
to enjoy it.
Figure 3.1
Sample Completed Food Record
food record can be an invaluable addition to her self-care plan around

food. Go through the various features of the food record with your patient, noting that there are places on the record to indicate the time that
she is eating, the amount and contents of the food and liquid consumed,
and whether or not she considered the eating episode to be a meal or a
snack, to be pro-plan or anti-plan, and what the situation or context
was surrounding that particular eating episode. Where was she? Who
was around? What was she thinking? What was she feeling?
21
Your patients keeping an ongoing record of her eating in this way (including the situation/context column) will make it possible for her, in
the context of her therapy with you, as well as any consultation sessions
with the dietician and surgeon, to really understand all of the eating and
other behaviors and thoughts that are contributing to and perpetuating
her eating problems, as well as the exact nature of the problems. Without records, and left to rely only on a memory of what happened with
food (given that eating tends to be an activity during which many people
space out, disassociate, or simply forget exactly what they were doing),
it is highly likely that your patients recollection of her eating will be incomplete and inaccurate.
Discuss with your patient that in many respects, the whole point of food
records has to do with the idea of connection, that is, that she stays
connected to her own eorts to regularize her eating. Remind her that
the food record can help her track her progress on a meal-by-snack basis,
thus providing reinforcement and motivation to stay on track each and
every step of the way. Along the same lines, the record can also serve as
a tool of intervention when she is at risk for lapsing into a nondesirable
eating behavior. Every time she is able to examine completed portions of
her food record and note the number of success experiences that she has
had, she can ease herself back into the groove when she might have
been tempted to feel negatively about her progress and throw in the
towel. Discuss with your patient the fact that when she uses her food
record as a tool of motivation and intervention, she will be taking full
advantage of the methodology. Of course, her food records will also be
helpful in providing an accurate record for you. Remind her, however,
that food records are really most powerful when used to make day-today choices about each and every meal, snack, (and glass of water) that
she decides to consume.
Working With Adolescents

If your patient is a teenager, there are some important factors that aect
his or her ability to establish a healthy routine for eating. The teenager
may not control either the foods that are in the home or the times that
the family eats. So, it is important that you work with your patients par-
22
ents, and to a certain extent the entire family, to promote their understanding and acceptance to change things. This will likely require that
you meet with parents together with your patient to discuss how a structured eating program can be undertaken at their home. This involves
identication of very specic obstaclesnot eating meals at regular times,
parents not preparing meals, fast food as the main or common meal type,
and so on. Each of these will need to be addressed and solutions identied.
Sometimes this will involve asking parents to shop with their teenager
for a period of time in order to make sure the right foods are available.
Sometimes teenagers dont like to keep food records. There is enough
homework already, and keeping track of what they eat seems like a waste
of time. However, it is important to try to overcome these hesitations.
You will learn a lot about what and how they eat that will be essential to
therapy. When you are rst getting started, you and your patient will
likely complete food records in-session to give her the idea and to show
her how they can be useful. Sometimes, you may ask parents to remind
their teenagers to complete the food records. Over time, these food records
will also be helpful when your teenage patient meets with his or her doctors to illustrate how they have changed eating patterns and food choices.
This will help demonstrate their commitment to lifestyle changes needed
to support weight loss after bariatric surgery.
Homework
Review the rationale for maintaining a regular pattern of eating and
discuss this with your therapist.
Read and review the rationale for keeping food records and discuss this
with your therapist.
Review the instructions for use of food records.
In your therapy session, set appropriate goals for the number of days
you will record your eating during the next week.
23
Chapter 4
Educating Your Patient About

Weighing Behaviors
Materials Needed
Weight Graph
Appearance and Weight Compliments Log
Outline
Educate patient about the rationale for and method of regular weighing
Teach patient about the importance of other means for checking on
and measuring his body weight, size, shape, and general appearance
Help patient understand the link between healthfully monitoring his
body size and keeping track of other healthy attitudes and behaviors
A Regular Pattern of Weighing

Most likely, your patient has discussed with you, as well as with his surgeon and dietician, and possibly with his internist, a regimen for weighing
himself regularly before weight loss surgery that makes sense. As your
patient prepares for his surgery, it can be helpful for him to weigh in
weekly with one of his doctors, so that changes in his weight in either
direction can be observed on a regular basis before too much time passes.
In this way, any necessary modications (e.g., increasing or decreasing
intake or activity) can be made as needed. In some cases, because your
patient might still require a special scale for weighing (most likely if his
weight is still pounds or above), it might actually be impossible for
25
him to weigh at home and therefore necessary for him to use a doctors scale
to get an accurate reading of his weight until it drops into a lower range.
The rationale for regular or weekly weighing is easy to understand, and
your patient has probably experienced certain thoughts and feelings
about weighing himself (or being weighed by someone else) that will support the rationale. For example, for many people with weight and eating
problems, weighing themselves has over time become fraught with an
incredible amount of stress and pressure, perfectionism, self-doubt and
self-blame, anger directed inward and outward, and a number of other
perceptions and feelings (some positive, when the numbers were going
in the right direction). Typically, these issues and complexities in relation
to weighing have developed over time in response to your patient having made a number of ultimately unsuccessful dieting eorts (as evidenced by the patients decision to undergo weight loss surgery). As a result of this level of sensitivity that your patient carries about his weight,
including potentially becoming too upset in response to unwanted weight
gain and too excited in response to weight loss, he has become overinvested in what will be revealed about him by the numbers in any particular instance of weighing. And most likely that has led to the development of certain patterns in the way that he weighs himself, which you
will be discussing in detail during the sessions devoted to this topic. For
example, you will want to spend some time educating your patient about
common patterns in weighing among those with eating and weight concerns. Some people who are highly vigilant and reactive to the numbers
on the scale, and who use the numbers to dene crucial aspects of themselves such as their self-worth or lovability, may check the scale daily or
even more frequently (if this is possible given their weight) to ensure
that the numbers have changed, or havent changed, or in any case to get
a sense of what the numbers are saying about them. Others might
avoid the scale altogether to avoid the emotional impact that the numbers are likely to have.
The Risks of Weighing Too Frequently

This pattern of weighing (less likely for obese individuals than patterns
of avoidance) is problematic because it allows people to overreact (e.g.,
cognitively, emotionally, behaviorally) to very minute changes in their
26
weight that virtually have no meaning at all. Shifts of one or more pounds
in either direction that might reect sodium or uid intake changes from
the day or days before can cause fairly exaggerated responses in these
scale-sensitive individuals of either self-denigration or elation. Both
responses are inappropriate given the predictable and meaningless nature of those types of weight changes, which are most likely to be temporary and not indicative of actual fat or lean body mass.
Avoiding the Scale

On the other side of the continuum is the problem of weighing too infrequentlyor even avoiding the scale altogether. Some people with
weight and eating issues have had such negative or emotionally powerful experiences with the scale that they feel unable to tolerate any relationship at all with the numbers and therefore avoid the scale at all costs.
In some cases, even at physicians oces, these individuals might ask to
stand backward on the scale and request that the health care professional
who is weighing them not even comment on the numbers. While this
pattern of scale avoidance might in fact spare an individual with this type
of extreme sensitivity from some short-term unpleasantness or overly
strong emotional reactions, it can, on the other hand, collude with their
perceived need to distance from the scale. Maintaining this type of distant or avoidant stance can contribute quite a lot to a person unknowingly allowing their weight to change in the undesired direction (e.g.,
weight gain in the obese population). This happens easily due to the
absence of a feedback loop, that is, no source of reasonable feedback
about what is happening with the persons weight over time in response
to the various eating habits that have been sustained since the last weighin (which in some cases involving highly avoidant people might have
been years ago).
It is important to inform your patient that avoiding the scale for too long
can lead to an actual fear or phobia of the scale or the experience of
weighing-in, which is not unlike other types of phobias (e.g., a fear of
heights). In these instances, not only is the fear of weighing incredible,
but the pressure to avoid is extremely powerful, too, and as time goes on
without the person normalizing contact with the scale or the experi-
27
ence of weighing-in, the numbers take on an even more exaggerated

level of importance to the point where they become even more extreme
in their power to determine how the person feels about himself. As you
discuss the patterns of weighing with your patient, you can explore the
various meanings attached to his pattern of using the scale. Typically, a
pattern of too-frequent weighing suggests extreme anxiety and some
magical ideas about controlling the outcomes through hypervigilant
checking, while a pattern of avoidance suggests that the numbers on the
scale have come to mean something to the person that extends way beyond the domain of eating and weight control and has huge implications for his emotions and self-concept.
No matter what the particulars of the pattern your patient might be engaging inone of overly frequent weighing or avoidance of the scale
these relationships to weighing are problematic in that they suggest an
overly strong emotional attachment to the numbers. This type of attachment interferes not only with your patient developing a straightforward
and healthy pattern of tracking weight changes as they relate to eating
but also with his maintaining an appropriate and unembellished relationship between his weight and his sense of self (e.g., worthiness, lovability, value, etc.).
Corrective Strategies: Weekly Weighing and Other Measurements

As you and your patient will discuss, one helpful strategy to address
problem patterns of weighing is to prescribe a pattern of weighing-in on
a regular and preplanned basis, such as once a week on a specic day, at
a specic time. Weighing regularly in this manner also is the best method
for obtaining accurate comparison data week to week, particularly as
changes in eatingalong the lines of weight loss dietingand possibly
activity patterns are made. This strategy can work for those who have
been weighing too frequently, by cutting into the overweighing pattern in a very deliberate way. For example, once the day and time for
weighing are selected, and the weekly weigh-in has taken place, the scale
can be deemed o-limits either by encouraging the patient to put it into
a closet or other hard-to-reach place or by limiting access to it by taking
out the batteries or hanging a sign or do not cross rope as a reminder
28
and a motivator to stay away from the scale until the designated weighin time rolls around again. Alternatively, if the excessive weighing has
been done in some other setting, problem solving and motivational exercises (e.g., analyzing costs and benets) pertaining to limiting access
to that scale or limiting visits to that place only to the weigh-in day can
help. In addition, relaxation, distraction, and cognitive-restructuring methods might be useful in addressing problem mood states such as anxiety
or despondence that might occur when your patient has contact with the
scale (or is denied contact with it, as the case may be). (These methods,
discussed in detail in chapters and , can be introduced here if necessary; just encourage the patient to also skip ahead to the appropriate
place in the workbook.)
The strategy of committing to a specic day and time for weighing-in
also applies to those who have been scale avoiders. For those individuals, it may be necessary to either purchase an appropriate scale for the
home or identify an alternative location (such as the doctors oce)
where the scale can be easily accessed once a week on a specic day and
at a specic time. For this group, weekly weighing might also warrant
supplementation with CBT tools such as problem-solving strategies, relaxation techniques (to combat anxiety that occurs before, during, and
possibly even after the weigh-in), and cognitive restructuring exercises to
combat any extreme or distorted thoughts that accompany the sight of
the numbers.
Explain to your patient that using a variety of measures related to weight
can be helpful, in part to take the onus and importance o of the numbers on the scale. Use of a weekly weight chart can help your patient
maintain a visual image of his progress toward weight loss before surgery
(as well as after). In your sessions, you can help your patient design a
weight graph using the blank graph included in chapter of the workbook, in a form that will be maximally helpful to him. Your patient may
photocopy the graph from the workbook or download multiple copies
at the TreatmentsThatWork Web site at http://www.oup.com/us/ttw.
In addition to the weight graph, a number of other indices of body size
and shape can be useful in providing information about how the patients body is changing, without relying on the scale. These include the
obvious: tting into certain pieces of clothing or certain chairs (whether
29
at home, at work, in a movie theater, or on an airplane), measuring various parts of the body by using a tape measure or recording body composition (e.g., percentages of lean body mass and fat) by undergoing a
battery of tests that can determine this, and paying attention to an indirect measure of weight loss by noting increased stamina in doing any
number of physical activities, including formal physical exercise (such as
walking, biking, and the like) and incidentals such as walking up the
stairs. It can be quite helpful for your patient to record some of the
data over time, as well as his perceptions of all of these changes in his
body by using a log similar to the food records. You can also encourage
your patient to think about keeping a record of compliments received
pertaining to his weight loss, which can be particularly helpful and inspiring. You can discuss some of the following areas in detail with your
patient.
How Your Patients Clothes Fit

Another very simple and easy way for your patient to gure out whether
or not hes on a weight loss trajectory is to try on various items of clothing to determine their t. If they are becoming more and more loose, he
is losing weight; if they are becoming tighter, he is gaining weight.
How the Furniture Fits Your Patient

This is another very simple way for your patient to track changes in his
body over time. It is important to remind your patient to notice that he
is much more easily tting into chairs and other furniture that proved
difcult for him in the past.
Taking Measurements
Another option that might appeal to your patient for tracking bodily
changes separately from the scale involves using a tape measure to measure various parts of his body (the obvious choices being waist, hips,
30
chest, upper arms, thighs, calves, etc.). This method can be effective in
offering additional information about the changes your patients body is
undergoing, as long as he measures fairly accurately. It can be difcult to
always get the correct or exact same spot, so your patient might have
to practice or ask for some assistance from a signicant other or possibly
his personal trainer, if he has one, if the results of the measurements
seem off in any way.
Changes in Body Composition: Percentages of Fat and Lean Body Mass

These days, it is not difcult to nd scales that measure body fat (although the accuracy of some of these might be questionable), and your
patient might already have access to one of these scales. A more accurate
determination of body composition would be an evaluation at a health
club, gym, or medical center that offers such testing using calipers, underwater weighing, or other even more sophisticated techniques. Finally, your
patients surgeon, dietician, or internist might also have access to the
most state-of-the-art techniques for tracking body composition over time
as your patient loses weight. You might encourage your patient to think
of the body composition measurement as a fun type of measurement
to obtain before and after his surgery.
Food Records
Remind your patient that food records, discussed in the previous chapter, ultimately will describe everything that he needs to know about which
direction his weight will be heading in the near future. For instance, if
your patient is maintaining a caloric intake or food plan that is providing less energy than his bodily needs require, he will lose weight, and if
he is taking in more calories than he is expending, he will be on a weight
gain trajectory. By focusing on completing daily food records and examining actual behaviors, including the food intake and the output of exercise and any other physical activity, your patient will feel more empowered by recognizing that behavior has an actual impact on the outcome.
31
Ease in Moving Around

Your patient might want to keep track of general activities, such as either how long he is able to engage in a certain activity, such as walking
at the mall, around the block, or on the treadmill, or swimming laps (or
walking laps) in the pool, etc. Your patient might alternatively want to
rate his level of exertion while doing an activity, which will provide yet
another helpful measure of how his weight loss and level of conditioning is progressing.
Compliments
You will be talking at length with your patient, at various stages of the
treatment, about his response to compliments about his weight loss. Obviously, when losing weight, your patient may be, on the one hand, uncomfortable to be noticed more than before or to be on the receiving
end of a lot of compliments about weight loss, particularly when there
is a lot to lose and when there may be a lot of thoughts and emotions of
a complicated nature tied up in the issue of his weight. But explain to
your patient that often it is these external sources of feedback (not unlike the scale, to some extent) that can help a person work through distortions he might have in his perceptions of his weight. Obviously, these
should not be relied on as the only source of pride-generating thoughts
and feelings; in the end, your patients view of himself should serve as
his own primary source of enthusiastic feedback. However, in a pinch
or a low spot, others reactions can help bridge the gap from feeling low
to feeling better.
Remind your patient that, on the other hand, an absence of compliments about weight loss does not have to mean much because in our culture of sensitivity to weight issues, some people may be reluctant to say
much of anything at all about a persons weight loss for a very long time
(until it is very obvious and visible) for fear of intruding or oending.
Your patient should remember not to let the absence of compliments get
him down as one can never know what is going on for another person
in terms of them perceiving, but not commenting on, the transformation that is taking place. Also, your patient might nd that he can expe-
32
rience a range of reactions to others compliments about his weight, from

feeling proud and grateful for the acknowledgement to feeling shy, overly
exposed, intruded upon, or even skeptical at times about what is being
said (this is common when a person does not yet feel their weight loss in
the way others see it). Help your patient gure out strategies he might
like to consider for responding to compliments and questions about his
weight loss that might come up simultaneously. Remind your patient
that there is never any obligation to fully explain anything to anyone
about how the weight loss was achieved; the fact that he had weight loss
surgery can be something that he decides to keep to himself. You can let
your patient know that an explanation that can suce in many dierent
situations is I made a commitment to eat healthy and exercise more and
that is how I lost weight! The reality is that those behaviors will be the
ones that best predict the long-term success of weight loss surgery and
are also the optimal result when an individual is compliant with all of
the recommendations made relative to the surgery.
A compliment log in your patients workbook provides space to document the dates and types of compliments received from others regarding his weight as it decreases over time. A sample lled-out Appearance
and Weight Compliments Log is shown below in Figure .. (In a later
chapter, there will be a broader discussion of body image issues that also
includes some assessment of others responses to your patients changing
appearance.)
Whatever combination of approaches your patient decides to use to measure body changes as he loses weight before surgery, it is important for
My Appearance and Weight Compliments Log

Date
Source
Positive Comments
10/31
man on street
you look beautiful
11/10
friend
youre really looking great
Figure 4.1
Sample Appearance and Weight Compliments Log
33
him to make a commitment to use at least a few of the assessment tools

on a weekly basis and write about them in a log similar to his food
record. This will allow him to review the changes over time, rather than
rely on his memory of them. Some of the more complicated methods
such as measuring body parts you might encourage your patient to do
just once a month, to increase accuracy and decrease overreactions to
disappointing results.
Homework
Find a place where you can weigh in regularly.
Begin to document your weight on the weight log.
Read and think about the other issues presented in this chapter.
Begin to make entries in your appearance and weight compliments log.
34
Chapter 5
Pleasurable Alternative Activities
Materials Needed
List of Pleasurable Alternative Activities
Sleep Enhancement Strategies
Meaningful Roles and Activities Checklist
Outline
Educate patient about the importance of including pleasurable alternative behaviors (e.g., those that dont involve food and eating) in her life
on a regular basis
Help patient establish a list of various types of these activities that can
be used in dierent situations
Enhance patients understanding of the issues of self-care in general and
facilitate patients improving various aspects of her self-care regimen
When Eating Has Been the Pleasure of Choice

Your patient might note that eating has become over time a primary form
of relaxation, pleasure, and enjoyment that always seems to be available
and literally at her ngertips. She might recognize that during certain
periods of time she has lapsed into a pattern of overeating to give her
pleasure because she has literally lost touch with other interesting, creative, fun, and active endeavors that she might have engaged in with enthusiasm in the past. Perhaps your patient began not only to avoid cer-
35
tain activities but also to avoid people and social situations in general,
due to shame or embarrassment about her weight.
In addition, your patient might have experienced certain emotions that
triggered an eating episode that may or may not have been primarily related to her weight, including depression, anxiety, or uctuating mood
states, that might have lifted temporarily when she ate something. As
you will discuss with your patient in the sessions that address this chapter, food can briey and to some extent enhance mood by slightly changing brain chemistry in the direction that certain antidepressants do.
Sometimes, even intense, positive emotions might trigger your patients
urge to eat, since eating can provide a form of distraction and serve as an
anesthetic by calming and soothing a person in response to any form
of arousal.
On the other hand, your patient might believe that she is simply a person who loves to eat and might attribute any or all overeating behaviors that happen (instead of other forms of recreation) to a fondness for
food. This view of food and eating might stem in part from your patients experiences as part of a certain cultural or ethnic community,
family, or social group whose relationships revolved to a great extent
around the experience of eating. Your patient might also ascribe to the
view of herself as someone who, in spite of eating a lot much of the
time, never really gets to the point of feeling full after a meal. Your patient might experience hunger or strong cravings for food despite knowing in her head that her appetite for eating is not reective of a real
need for more food. There are also some people who ultimately end up
overeating because food takes over or lls in a void where some other
type of substance abuse has left o. Your patient might be someone who
fought hard to withdraw from addictions to other substances, such as alcohol or drugs, only to nd that whatever was driving her to use these
substances resurfacedwith a vengeancein the form of appetite, cravings, and motivation for food and eating. Finally, since many of those
who have struggled with weight and eating issues are in so many other
areas of their lives model citizens, overeating might have represented
one of the only opportunities for your patient to rebel or do exactly
what she wanted without allowing others to control or dictate her actions and without very extreme consequences (aside from obesity and all
that accompanies it).
36
Why Does Eating Food Feel So Good?

In any case, while your patient might be extremely frustrated about her
weight and her relationship to food and eating, it is likely that food by
this time is also strongly associated with her experiencing a form of easy
pleasureto the point that few if any alternatives may feel quite as
good, even if she pushes herself to give other options a try. (And, truthfully, it may be that no other activity will ever feel quite as good, or as
simple as food has, at least for some time, no matter how hard your patient tries. It is helpful to predict this dilemma to her and discuss it at
length.) Nevertheless, in order to aggressively combat weight and eating
problems, your patient must stay focused on the importance of replacing her relationship with food with other pleasurable and meaningful activities that dont involve food. As you discuss these issues with your
patient, make it clear that the reality is that turning to pleasurable alternative activities other than food will have to become part of her lifestyle
and her coping repertoire, even if initially or for some extended period
of time, they dont feel particularly great or do the trick in the way that
food has. Remind your patient that with time, practice, and experimentation these activities will become more and more like second nature,
in the same way that her new and healthier eating habits and exercise
routines will become more automatic over time. Reassure your patient
that although it might feel quite dicult to turn away from food as the
primary source of pleasure and comfort, these alternative and pleasurable activities will not only be available to her in a pinch when she feels
that she is at risk for overeating for any reasonin need of some quick
tools that can help her cope without giving in to the urges to eatthey
will also serve to enrich her life away from food in every sense.
Physical Activities May Be Best

As you will discuss with your patient, many people combating food problems report that in their initial eorts to nd other activities to replace
the comfort, stimulation, distraction, and so on that accompanied eating,
activities that involve physical movement seem to be more eective than
those that are sedentary in nature. Why would this be so? Usually, when
people are motivated to eat, it is to nd some method for stimulating
37
themselves, whether to rev up, calm down, or numb out. After all, eating is
itself a physical activity that has a variety of eects on all aspects of the body,
from the brain on down. It makes sense then that to replace eating as the
source of the stimulation, other physical activities would work best, certainly better than stationary activities such as watching TV at home (which
by all accounts can be linked to a pattern of overeating and weight gain).
As you will discuss with your patient, the following general categories of
pleasurable activities, as well as certain specic activities, are known to
be helpful as replacements to eating.
Pleasurable Activities
Taking a hot shower or bubble bath

Going for a walk or participating in some other type of exercise
Getting a manicure
Giving yourself a facial
Working in the garden
Engaging in sexual relations
Going shopping (but not for food!)
Activities That Are Incompatible With Eating

In addition to requiring some energy output, most of the activities listed
above are physically impossible to do while eating (or at least would
make eating dicult). When trying out some new forms of pleasurable
activities, your patient must not allow them to become paired with eating cues. That means not eating while she is engaged in the activity. The
reason for this is that once a given activity includes eating, it can send a
signal to your patient that she should be eating every time she participates in the particular activity. For example, if she has been one to go to
a lot of drive-through restaurants, she might notice a desire to drive by
and pick up something to eat whether or not she is hungry, every time
she is in the vicinity. Similarly, if there is a certain vending machine at
work from which your patient buys a snack every afternoon at .., she
38
might nd it quite dicult, if not impossible, to pass by without purchasing anything.
Getting Out of the House

While it will not always be possible for your patient to leave home to do
something distracting and pleasurable to avoid overeating, often it is helpful to do so if she is feeling tempted to overeat particularly while at home
alone with stocks of tempting foods (or even not-so-tempting foods). Going
out might even involve your patient making the decision to get something (moderately portioned) to eat as a compromise position as she
considers the various options that she has. While this involves giving in
to the urge to eat on some level, still, this decision would be much better
than your patient running the risk of overindulging at home where there
may be large amounts of food and no particular controls (such as the
presence of others or a limited supply of food) in place. Keep in mind
that every time your patient experiences a success in preventing herself
from engaging in an unnecessary overeating episode, she decreases the
strength of the pull to eat for reasons other than appropriate hunger as
she simultaneously strengthens her skill set for choosing more healthy alternative behaviors when she is tempted to inappropriately use food.
Realistic and Manageable Activities

As you help your patient to brainstorm about alternative forms of pleasure other than eating, it is important that she learns to do so in a way
that is realisticthat is, that she comes up with activities that she can
actually aord, and do easily, in a variety of problem situations (e.g.,
such as at night at home alone, during the middle of a work day, on a
weekend, or rst thing in the morningwhenever it is that she feels at
risk for overusing food). For example, remind your patient that while it
is nice to think about getting together with friends for a walk or an outing of some sort, people are not always available when we want them to
be and dont always want to do what we want them to do at the times
when we are available. While it is probably benecial for your patient to
include some social activities on her list, as well as a range of activities
39
she can do alone, she wouldnt want to include only pleasurable alternatives that rely on others company. Given that others are frequently unavailable, this might leave your patient feeling frustrated and disappointed,
and with those emotions onboard, possibly more inclined to turn to
food for comfort.
Big Ticket Activities

While some major activities such as traveling or redecorating should be
included on your patients list for special circumstances, these are best reserved as global lifestyle enhancers rather than in the moment strategies that can help her stay away from food. Similarly, if your patient lives
in a cold climate, certain activities such as outdoor tennis or golng,
while nice in theory, and wonderful in the summer months, are not really possible during the winter months. Still, there would be nothing
wrong with your patient listing these activities as distant or far o
possibilities to be used to enhance her lifestyle when feasible or at some
designated point in time.
Discuss with your patient the importance of staying open to the individuality of her own list of interests and activities. There are no set answers about what types of activities should be relaxing for any individual. The important idea here is to create a list of or things that she
loves (or likes) to do that can help her to feel calmer, more at peace, relaxed, fullled, gratied, proud, and so on. The list might include some
of the bigger ticket items that might interest her such as traveling to
distant locations, signing up for a course on an interesting topic, redecorating a certain room in her house or apartment, or writing a short story
or book. The list should also include several in the moment forms of
pleasure that can be used in a pinch when your patient is feeling a rather
immediate need to alter her mood state (or simply nding herself with
free time) without access to many of the other more serious endeavors.
While the list will of course be individually tailored to her needs and interests, it might include the types of activities that are available to her,
for example, in the middle of the day or at night, when no one else is
around, without generating great expense. These could be reading a fun
magazine or book; taking a hot bath or shower; doing her own facial,
40
manicure, or pedicure (or if available, getting these done professionally);

taking a walk around the block; engaging in breathing, progressive muscle
relaxation, or imagery exercises (where one envisions oneself taking part
in a pleasurable scene of one type or another), and so on. These relaxation
and stress management activities should be thought of as pleasurable alternatives that can be used at times when, in the past, your patients
coping skills and options were not as great (meaning, for example, that
she might have too readily turned to food and eating to solve whatever
mood challenges she faced at that time).
For those patients who might have had any type of substance abuse or
alcohol problem (or cigarette smoking, for that matter) in the years prior
to their consideration of weight loss surgery, creating a list of alternative
pleasurable activities for relaxation is even more important.
Ask your patient to create a list of pleasurable alternative activities. A
sample list is shown below in Figure ..
List of Pleasurable Alternative Activities

. Taking a hot bath
. Reading a magazine
. Chatting in eating disorder chat room on Internet
. Calling a friend
. Walking around the block
. Doing a jigsaw puzzle
. Origami
. Writing in my journal
. Reading a book
. Doing a home manicure
Figure 5.1
Sample List of Pleasurable Alternative Activities
41
Basic Self-Care
In addition to thinking about pleasurable alternative activities, your patient should also thoughtfully consider and address several areas of basic
self-care (in addition to improving her relationship with food) as she prepares for gastric bypass surgery. You will discuss with your patient the
basic concept of self-care and all that it means given the challenge of
weight loss and the upcoming surgery (e.g., she may have been asked to
lose some weight before her surgery). These include your patients sleep;
physical exercise; alcohol, caeine, and drug use; social and meaningful
activities; relaxation and stress management; and of course evolving eating patterns.
A list of basic self-care tools is included in your patients workbook.
While taking charge of eating behaviors might appear to be your patients most pressing or essential self-care component to work on in
preparation for surgery, it may also be the most challenging due to the
basic complexity of her relationship with food and eating. Thus, these
other areas that might appear supercially to be easier or more straightforward are important to work on simultaneously as she tries to make
modications in her eating, since the latter might go slowly and benet
from these other lifestyle changes. In making changes in these core selfcare behaviors, your patient will not only notice the benets directly but
also will begin to experience the type of mastery and success experience
that happens when she sees herself following through with these goals
on a regular basis. It is likely that this feeling of mastery will generalize
to the way that your patient handles eating issues and all of the other issues related to preparation for the surgery.
Sleep
Starting with sleep, it is important that your patient is trying as hard as
possible to get solid hours of sleep a night, if there is any way to do so.
The exact number of hours that she is able to sleep will depend on her
prior sleep patterns and overall history with sleep, as well as her current
lifestyle and any past lifestyle issues that might have aected the way that
she relates to sleep (e.g., a history of nightmares, trauma, or night-eating
42
syndrome). Whether she is at all close to or far from the ideal of hours
a night, it is important to help your patient keep the following ideas
about sleep hygiene in mind, as you attempt to help her get her sleep
patterns back on track.
Sleep Hygiene Strategies
First, many professionals in the area of sleep strongly recommend that a

person try to establish a regular bedtime and wake time. Just like with
food patterns, your patient should attempt to set her body clock to know
just about when she is expecting herself to settle down into sleep and just
about when she will expect to arise from sleep. And similar to planning
a regular schedule of eating, it is also important for her sleep patterns
that she decide on a regular place to sleep. For some, this may sound
both obvious and simplistic. However, there are many people, particularly among those who suer from sleep problems, who dont make the
commitment or the eort to nd their way to their own bed many
nights, instead opting to fall asleep in front of the TV in the family
room. In terms of the regular schedule for sleeping, in reviewing her
typical sleep patterns in recent weeks or months, your patient might decide on or .. generally as her bedtime and or .. as her wakeup time.
Once these ideals are set, the patient should then attempt to establish a
routine for bedtime and wake time that enables her to achieve her goals
as straightforwardly as possible. This might mean setting the alarm clock
to the time she would like to get up and including a repeat function on
the clock so that she doesnt let herself o the hook by hitting the snooze
button and going back to sleep. Similarly, with respect to bedtime, sustaining a regular pattern, if that is a new routine for the person working
on her sleep, will probably involve establishing a series of wind down behaviors and habits that will enable the patient to feel de-stressed, relaxed,
and sleepy when the actual bedtime approaches. These might include
watching TV or reading (best if done in a room other than the bedroom), taking a warm bath, having a small snack (that is healthy and appropriate), doing mild stretching exercises, or engaging in relaxing visual
imagery of some type.
43
Often, it is best for the person working to improve her sleep to actually
get into bed only after she has become sleepy, not simply because she
feels tired. In terms of recommendations for exercise as it relates to sleep,
it has been thought that exercising no fewer than hours before bedtime
works best. Also, consistent with the goals of good health and good selfcare, regular exercise can often serve as a method for decreasing stress
and tension in general and therefore is thought of as an aid to good sleep
for most people. Once your patient practices these concepts, she will
understand and recognize the dierence between how she is approaching sleep (and responding to sleep opportunities) now as compared to
before.
A list of sleep enhancement suggestions is included in the patient workbook. This list can also be downloaded from the TreatmentsThatWork
Web site at http://www.oup.com/us/ttw.
Physical Activity and Exercise

The next self-care behavior to discuss with your patient is exercise. For
most people, of course, the ideal of moderate, regular exercise is the obvious recommendation. It is important to remember that your patients
exercise goals and needs, and even the way that she denes moderate exercise, depends upon her level of tness and conditioning and the advice
and recommendations of her medical team. They might have certain
concerns or qualications based on her weight, specic physical issues or
problems, and her general health and tness. For example, if she is extremely obese, has serious medical issues, has diculty even walking very
small distances such as from the car into a building or around the block,
or has not moved much for years, she may need to take it very slowly. It
might be too dicult for her to jump into any type of regular routine,
even a standard one involving minutes of walking three times a
week. The last thing you want to do is encourage your patient to push
too hard, to the point where the exercise she is doing is extremely uncomfortable. This will make it less likely for her to get back to it in any
form and possibly even dangerous to her health. If your patient is in a
very de-conditioned state, it might be enough for her to try to walk in
place for minutes at a time a few times a week, either indoors or out-
44
doors. She can also try to do the same minutes of walking around the
block (no hills though). Keep in mind, also, that your patient might
consider activities such as gardening, window-shopping, or playing with
her kids in the parkall of these count toward her exercise goals even
if she does not consciously dene these activities as formal exercise. Obviously, any up and active time burns more calories than sedentary
time spent sitting or lying down. In addition, incidental day-to-day activities such as your patient parking her car farther from the door or taking the stairs more frequently instead of the elevator can add up to several more minutes of exercise a day. Over time, this equates to a few
more hours of exercise per week or month.
For some individuals, especially those who may have some lower body
pain, stiness, or other limitations, such as those imposed by prior joint
replacements, it may be important to modify the physical activity recommendations so that water exercise becomes the primary activity of
choice rather than walking. Even walking, which has a lower impact
compared to other activities, might aggravate pain or stiness or other
pre-existing musculoskeletal problems aecting the lower body, if overdone. Also, general stretching activities, progressive muscle relaxation,
and breathing training can be considered a part of your patients exercise
routine, as a warm-up or a cool-down activity. You should encourage
your patient to discuss any new exercise routine with her medical team
to make sure that it is within the guidelines of what they are suggesting.
No matter what, creating a regular schedule and routine for exercise, in
a fashion that is similar to her eorts to regulate eating and sleeping behaviors, will help your patient to stay focused and committed to her exercise goals. Keeping an exercise log or journal along with a food record
(or separately if that seems better) can also be helpful.
Caffeine Intake
Probably your patient is not accustomed to thinking of caeine as a potential substance to overuse or abuse. But excessive intake of caeine can
play a role in a persons experience of anxiety, stress, and tension and can
also contribute to the kinds of intense feeling states that can trigger episodes of overeating. While there are no very specic guidelines or absolutes
45
pertaining to caeine intake, it is a good idea to encourage your patient

to try to limit herself to no more than a couple of caeinated beverages
a day. In terms of coee, tea, and soda drinks (although most surgeons
specify that one is not supposed to drink manyor anycarbonated
beverages following weight loss surgery), your patient needs to limit herself to about two - to -ounce servings of coee and possibly one additional caeinated beverage per day. Mostly, the downside of drinking
a lot of coee is that it can give a person the jitters and a sense of incredibly overwhelming anxiety, urgency, or in some cases panic. These
are all feeling states that for some of your patients might have been
quelled with food, alcohol, or other nonoptimal tools for coping in the
past. Also, caeine can in the short term dampen appetite while in the
long term actually stimulate appetite by causing metabolism to speed up
enough that a person is left hungrier than they should be based on their
intake. One additional issue with caeine intake, particularly when it
comes from coee, and instant coee more than percolated coee, is
that of gastrointestinal distress, in some cases diarrhea and gastric upset
or heartburn.
Alcohol
Many weight loss surgery programs advise that patients drink no alcohol for at least the rst year after surgery and thereafterwhile a small
indulgence on occasion might be acceptablelimit their alcohol intake
as much as possible. The reasons for this are manifold. First, alcohol,
while providing a lot of calories ( calories per ounces of wine and
calories for a standard -ounce serving of beer) provides no nutrition otherwise. The ingestion of these calories will contribute obviously
to the overall calorie intake without providing the necessary proteins that
are needed to keep the body healthy. (Yes, alcohol will provide carbohydrates similar to sugars but in a form that contributes nothing else nutritionally.) Second, the intake of alcohol can be disinhibiting in the
sense that following consumption of alcohol, people typically are less
thoughtful, clear, and committed to exercising good judgment than they
would have been without any alcohol in their system. (Encourage your
patient to think back to times, if any, that she might have been under
46
the inuence of alcohol and to recall possible compromises in her behavior or thought processes based in part on her alcohol consumption.)
This lack of stellar judgment can specically aect the way a person relates to foodthat is, it can disrupt the usual controls that have kept
eating in check while the patient was dieting to lose weight before weight
loss surgery (and after). Remind your patient that she wont want alcohol to get in the way of her using her head in all matters, including
those of food intake. Finally, alcohol is a substance, as is food, and in
that way it can appear at times to be a useful and productive tool for selfregulationthat is, regulating intense emotions, longer-standing problem moods, or other bouts of uninvited intensity of one type or another. But, while alcohol can appear to have the short-term eect of
modulating your patients emotions, it is far from a productive solution.
If used for this purpose over time, alcohol can begin to parallel or mimic
other problematic tools for coping, such as food, used in the past. Obviously, most individuals who have contended with eating and weight
concerns have at times relied on food to inappropriately provide a selfsoothing and gratifying component when they need to cope with some
form of stress. Rather than replacing food with another substance such
as alcohol, which can be overused or abused and which for some can
become addictive or habitual, using other strategies such as talking to
friends and loved ones, or a therapist, or engaging in meaningful hobbies or work to move through the problem times are more preferable.
After all, replacing one addiction with another is not a worthwhile goal!
If you feel that alcohol has become a problem for your patient, you need
to address it with her and recommend additional professional help focused
on the substance abuse issues as soon as possible. Encourage her to consider
attending Alcoholics Anonymous (AA) meetings, which have an excellent reputation as a forum for working through substance abuse issues.
Illicit Drugs
Much of the above discussion of alcohol also applies to the use of illicit
drugs. In the case of drugs (particularly cocaine, amphetamines, any injected drugs, heroin, etc.), it is imperative that your patient seek expert
help if she has experienced any level of use, not just use that has reached
47
a problematic proportion in her life. Whereas with alcohol a little really can be acceptable (once the surgeon has cleared your patient for this),
such as a small drink for a special occasion or celebration, no amount of
illicit drug use is at all acceptable. Even the use of large amounts of marijuana is problematic and will need to be at least addressed by a substance
abuse expert, if not also treated by that person. If your patient had a past
history of use of any drugs, it was discussed in detail during the psychological evaluation that she may already have had (or is now preparing for) as part of her pre-op series of evaluations. To be accepted as a
weight loss surgery candidate, she has to report that she has been clean
and sober for at least years. For those patients who used in the past, use
at this time would represent a form of lapse or relapse that would signal
the possibility of an ongoing use pattern developing once again. Whether
this is the situation for your patient, or she is a new user of drugs, the issues discussed above with respect to alcohol would apply. In any case, no
matter what the source, this would require some form of intervention as
soon as possible. Stated as simply as possible: there is no room for illicit
drug use before or after weight loss surgery.
Socializing and Social Support

While there are obviously no hard and fast rules about what an adequate
social support network could or should look like, the experience of your
patient having people in her lifewho care about her and who she cares
aboutcant be overemphasized. Whether these people include a signicant other, family members, friends, or an assortment of all of the
above, staying connected to other people in intimate waysmeaning,
through reciprocal conversation, shared activities, fun times and hard
timesthe existence of important others in ones life has been linked to
decreased stress and disease states and to an overall sense of health and
well-being. As someone who has been dealing with a very signicant
weight problem for some time, your patient may (or may not) have let
her social life lapse into near nonexistencee.g., where there are few
people and few meaningful contexts in which she engages with them. If
this has happened to herout of sheer exhaustion or inertia related to
her physical state, social anxiety, lack of opportunity, or on some level, a
perceived lack of interest in relationships (that may reect other emo-
48
tional issues such as depression or low self-esteem or a sense of resignation

and giving up)it is time to help her change all of that and restimulate her social life.
One of the most straightforward and obvious ways for your patient to
start this process is to take advantage of the network of people to which
she is exposed through her involvement in one or more ongoing pre- and
post-op weight loss surgery support groups. As a starting point, at the
very least, a therapeutic group experience can help her retool her conversational skills, her feelings of safety around personal self-disclosure,
her sense of understanding and empathy for others circumstances, and
her level of condence that others will listen to her and take her issues
and needs seriously. Your patient might hear about other opportunities
that are social in nature from her weight loss surgery support group. For
example, if a group member volunteers at a communal garden, and gardening (or volunteer work) has been of interest to your patient, she
might be able to make use of the group connection to get started pursuing those areas of interest.
Also, it may be that friendships that begin in the group might extend far
beyond the group experience to include recreational get-togethers and
activities that involve your patient and one or more other people. Again,
the idea here is to help your patient take steps to begin to socialize, if this
has been an issue for her, starting with her weight loss surgery support
group, in order to get some practice rebuilding her network by socializing with members of that group, but not to limit herself in any way from
reaching far beyond the social experiences provided by the group.
On the other hand, if your patient is someone who has been diligently
maintaining a social life, exposing herself to an array of people and situations that create opportunities for forming meaningful connections, the
message you would give your patient here is one of simply continuing
what she is doing and possibly extending it someif she is feeling a
need for more meaningful social stimulation than what she has already
been part of. To either deepen her existing relationships, expand upon
those that are currently active, or create entirely new relationships will
involve taking some risksthat is, extending herself beyond her usual
comfort zone. While risk taking is never easy, it remains one of the essentials for changing ones life and creating something new, similar to
49
what your patient has decided to do in pursuing gastric bypass surgery

as an option to solve her problems with weight.
Considerations for Teens

For teenagers, social activities are in part structured by school and related
activities. Like many adults, adolescents may feel that they will be rejected or teased by peer groups. However, usually they have a few close
friends that they feel they can really trust. It is important for you to encourage your patient to keep those close friends while also beginning to
reach out occasionally for new friends. Some of the best ways to encourage them to nd new possible friends is through after-school activities or through youth groups associated with religious practices. The reason this is the case is that there are likely to be similar interests among
members of these groups that can make the initial stages of making friends
easier. Many times teenagers struggling with obesity have retreated to
their families out of fear of humiliation or actual harassment. Although
it may be dicult, one of your goals in your work with adolescent patients should be to identify reasonable ways to work on new friendships.
Building new friendships will not mean that there is no longer a need for
family, but it may mean that your adolescent patient will feel less dependent on them. For most adolescents, this is a good thing.
Meaningful Activities and Role Competence

During the period of time in which your patient has been anticipating
and planning for surgery, and possibly even for some of the time that she
was struggling with obesity and secondary hassles and limitations to
her life due to that, she might have disengaged from not only people and
social activities but also from meaningful roles and activities that she
otherwise might have taken on enthusiastically. For example, perhaps
your patient decided to withdraw from certain recreational activities that
she enjoyed and added value to, such as performing in a choir or other
musical group; having an active role on a bowling, softball, or other athletic team; or taking on a leadership role at work, within a religious organization she is a part of, or in a volunteer capacity involving children,
50
Meaningful Roles and ActivitiesNow and Plans for the Future

Now
Plan to Get Started Soon
being a mom
going back to school
working at my job
starting to do an exercise class
having good friends
attending church
more involvement in support group
Figure 5.2
Sample Meaningful Roles and Activities checklist
animals, or any other cause she might believe in. Since self-esteem and
self-concept reects the number of eggs in a persons basket (or the diversity of a persons meaningful roles and involvements with people and
activities), it is important that you help your patient begin the process
of rebuilding this part of her life, if she has allowed it to dissipate over
the time that she has been dealing with obesity, eating issues, weight loss
surgery, and any other health concerns.

Adolescents are rst beginning to explore what things they would like to
do and nd meaningful. They might nd participation in a youth group,
volunteer organization, or extracurricular activity works well for exploring what interests and excites them. For many, however, schoolwork and
preparing for college and work may be the main focus. You may nd that
helping them to increase their dedication to efforts that will lead to college or a career will help them focus on the other aspects of their lives
that relate to changing eating and health-promoting behaviors as well.
Have your patient complete the Meaningful Roles and Activities checklist in the workbook, in order to identify some of the meaningful activities and competent roles that she has in place now and that she would
like to work toward reinstating at some point in the near future. A sample
checklist is shown in Figure 5.2.
51
Homework
Review all sections of the chapter and discuss these with your therapist
Create your list of pleasurable alternative activities.
Choose at least one of the activities to do in a situation in which you
feel at risk for overeating.
Pick two or three of the basic self-care areas to start working on.
52
Chapter 6
Challenging Eating Situations:

People, Places, and Foods
(Corresponds to chapter in the workbook)
Materials Needed
Places to Eat Inventory
List of Correct Places to Eat
Problem-Solving Strategies for Handling Challenging Eating Situations
Comments and Reactions Log
Outline
Help patient identify the situations, people, places, and foods that are
most challenging for him as he increasingly takes charge of his eating
and weight problem
Assist patient in identifying the alternative situations, people, places,
and foods that contribute to his forming and maintaining healthy eating behaviors and attitudes
Encourage patient to become aware of and list certain foods that have
been most challenging for him as well as a method for becoming more
comfortable with these foods
The struggle for your patient to gain control over eating and to ultimately nd a way to eat that facilitates slow but steady weight loss presurgery involves many dierent factors. Obviously your patients choice
of foods and portionsof both good and bad and healthy or indulgent foods, and so onwill likely have the most pronounced impact
on his weight, along with of course the degree of output (e.g., physi-
53
cal activity such as planned exercise and unintentional movement such

as taking the stairs, parking farther away, etc.) that he is able to t into
his schedule. Believe it or not, active choices that your patient can make
about the settings in which he eats and the people that join him in those
settings can also play a major role in contributing to the quality of his
eating behavior in any one instance. In the sessions with your patient,
you will help him to identify the changes that he needs to make in these
areas to be more successful in the struggle to lose weight.
Stimulus Control
You will teach your patient that when it comes to eating, certain settings
are more appropriate than others. Obviously the kitchen, dining room,
picnic table, and breakfast nook are areas in which eating should regularly happen; these places are already steeped in eating cues, and probably most people are conditioned to want to eat something when they sit
down in these settings, particularly at mealtime. On the other hand,
places like the couch (especially when it is positioned in front of the
TV), the bedroom, the bathtub, the work desk, in front of the computer, and the car are not typical locations for eating. They only become
paired with eating cues if, over time, one regularly begins eating when
in these settings (e.g., when watching TV, sitting in bed reading, taking
a bath, driving, etc.) You will want to underscore to your patient that
once these unnatural eating situations become linked with food, it can
be very dicult to disentangle them from those strong eating cues. For
example, if nearly every time your patient sits down to watch TV he begins to eat something, to refrain from eating while watching TV will
seem incredibly dicult if not impossible.
You and your patient might share a laugh and think that it is rather incredulous that others might actually eat while in bed, in the bathtub, or
in other hard to envision settings, but eating in these places actually does
occur. Furthermore, it complicates things a lot when that individual nally makes an attempt to purify his eating environments by trying to
limit eating to appropriate settings, when eating has spilled over into so
many environments in this way. It is important to spend some time discussing with your patient the powerful feedback loops that get set up
54
when specic situations and gratifying behaviors are paired. Initially,

your patient will think that it just doesnt feel right when rst trying
to limit eating to certain settings. Thus, the more quickly you can help
your patient fully understand the issue of stimulus control and begin
to get a grip on itthat is, limiting the number of automatic, situational associations to food and pairing eating only with appropriate
places, times, and situationsthe easier it will be for him to take charge
of his eating behavior.
The rst place to start is to help your patient take an inventory, rst just
verbally and then later in written form, of all of the places in which he
currently eats or drinks something on a fairly regular basis. You might
want to help jog his memory here as some of these behaviors can become
so automatic or unconscious that he might not even realize that he is eating in situations or places in which he ideally shouldnt, for example, regularly drinking coee drinks and eating pastries in the car on the way to
work or snacking on peanuts or chips at his desk during the work day.
The Places to Eat Inventory can be found in chapter of the workbook or
downloaded from the TreatmentsThatWork Web site at http://www.oup
.com/us/ttw. Ask your patient to list all of the current nonoptimal eating environments that have become associated with food cues. The areas
have been categorized into home, work, and other to help jog your
patients memory about what he is doing in the various settings in which
he spends time. Encourage your patient to simply check either the yes
or no column for each area listed, and note any additional non-eating
places in which he may be eating if these other areas or situations havent
been included.
After your patient completes the process of taking an inventory of these
inappropriate places to eat, he should give himself credit by acknowledging the ways in which he is also eating correctly and in all the right
places by opting for the kitchen or dining room table, among other appropriate sites. Instruct your patient to make a list of the proper eating
settings that he is utilizing on a regular basis. The List of Correct Places
to Eat form can be found in chapter of the patient workbook or downloaded from the TreatmentsThatWork Web site at http://www.oup
.com/us/ttw.
55
You might have noticed, together with your patient, that the word table
was used throughout nearly the entire List of Correct Places to Eat form
(with nook or bar used in its absence). What the word table implies for
most people is that eating takes place while sitting down not standing.
Explain to your patient that eating while standing is another nonoptimal
eating situation that can contribute to his eating in a manner that tends
to be correlated with overeating rather than with eating in moderation.
Discuss with your patient the reality that when people are seated, particularly over a meal, they are much more likely to be relaxed and at ease
and, for those reasons, more inclined to take their time. On the other
hand, while standing, most people are more likely to feel less relaxed and
more in a hurry, as if they are on the run. Standing can equate to a style
of eating that is neither calm nor relaxed but, rather, harried, as in swallowing large gulps of not well-chewed food that is neither really tasted
nor enjoyed. Far dierent from the relaxed image of someone sitting at
a table, nicely set with place mat, linen napkins, candles, and owers, is
the image of someone grabbing and gulping whatever is available while
standing in front of the open refrigerator. Since it is known that satiety
or fullness kicks in about minutes after one has started eating, the
slower and more relaxed the pace, the more inclined a person is to reach
the state of fullness before too many calories have been consumed.
As your patient will read in his workbook, one of the principal benets
of any type of weight loss surgery is that it will facilitate a more rapid experience of satiety or fullness once a person begins to eat. This is due in
part to the small volume of food that the new stomach is able to
handle, as well as the full sensation that can be a side eect of eating too
much, too quickly, which can be both extremely uncomfortable and in
some cases dangerous, leading to vomiting or dumping syndrome.
Given that weight gain postweight loss surgery can happen in certain
cases, it will still be essential for your patient to learn, practice, and master all of the techniques that are typically associated with weight loss and
weight loss maintenance by modifying his behavior.
On this list of behavior modication techniques that your patient should
practice and rehearse are both of the issues discussed above: choosing the
appropriate settings and sitting down while also slowing down. Your patient will also train himself to consume very small quantities of food. It
will be extremely helpful for him to purchase small-size plates and cups
56
that make the food look more substantial rather than appearing minute.
Part of your patients behavioral regimen required after surgery will be
that of allowing himself adequate time for his meals and snacks ( minutes or more), to ensure that satiety or fullness sets in and also to practice relaxation while eating. To make this even more likely to happen, it
is important to recommend that your patient begin to plan his meals
and snacks in advance, in a much more diligent way than before, to ensure that all of the above strategies are in place and also to make it more
likely that the principles of adequate nutrition and such will be upheld.
To help your patient keep track of his progress in working through these
issues, it might be useful for him to complete the Places to Eat Inventory and List of Correct Places to Eat forms now and then again in about
six months.
Social Inuences: Eating With the Right People in the Right Places
Your patient might nd that handling certain types of challenging eating situations, such as eating at someones home, out at a restaurant with
a group of people, at a party, or at a work function, can be dicult when
following any type of stringent diet and perhaps even more dicult as
he prepares for weight loss surgery and readies himself for the type of
eating he will have to do after the surgery. Your patient might report that
it can even be a challenge in some instances to maintain an ongoing eating relationship with his family members and signicant others when
radical changes in his eating behaviors have taken place.
Some of the challenge depends on the specics of the situation your patient is in; for instance, handling a buet meal comes with certain advantages (an individual can choose his own foods) and disadvantages
(there is potential to eat much more than what would typically be served)
as compared to a set, sit-down meal. Similarly, having an intimate meal
with a small group of friends at a friends home presents dierent obstacles
than going to a restaurant with the same group of friends. Traveling to a
foreign country will present yet another set of challenges. No matter
what the circumstance, there will be times when your patient will have
to confront eating situations that push the envelope for himin the
sense that he will be forced to be focused on his eating plan and dietary
57
needs and, given the options, also somewhat exible in his choices. This
balance between your patients maintaining his focus and staying exible
will ultimately prove invaluable in his long-term weight loss and weight
loss maintenance eorts. To that end, you can remind him that it can be
helpful whenever he is anticipating a challenging eating situation to do
some problem solving in one of your therapy sessions and also in written form, as shown in Figure 6.1, to address and work through the challenges of the particular situation.

For teenagers, eating at school can be challenging. Usually they dont
have as much time at lunch to eat, the choices available are not usually
the best, and they often have to put up with a fair amount of immature,
loud, and otherwise distracting behavior. Thus the school setting is conducive to quickly eating unhealthy food, in an atmosphere that is not relaxing. However, as it is generally unavoidable, it is worth the eort to
try to improve the situation as much as possible. Ways to improve this
include encouraging your patient to take lunch with the food he wants
and needs, to arrange to meet a friend or two for lunch, and to nd as
quiet a corner as possible to eat in.
In addition to the challenges to eating that come with the territory that
your patient is in, the people your patient is with during a given eating
situation can either help or hurt when it comes to sticking with his program. There can be people in his life who are more like coaches and
also those who are more like saboteurs, and obviously he will want his
team line-up to include more coaches than saboteurs, to the extent that
that is possible. No matter what, it can often be helpful for your patient to
have at his ngertips a number of catchy and clever explanations and responses, should the curiosity of his dining companions result in their
asking a lot of questions about his weight loss, food choices, and the like.
In your therapy sessions with your patient, you can engage in some roleplaying exercises in which some of these catchy phrases and clever explanations are tried out.
58
Problem-Solving Strategies for Handling Challenging Eating Situations

Challenging eating situations: Getting home after work when I head for the fridge and
overeat
Goal(s) or desired outcome: A reasonable snack after work but not out of control overeating.
Thoughts that will help me achieve my goal: I can do this if I set my mind to it.
I need to come up with a plan that keeps me out of the kitchen after work.
I could write reminders of my goal on the fridge and also go somewhere after work to
relax for a few minutes before arriving home and finding myself in the kitchen.
All it takes is one step at a time to change.
Maybe I can exercise after work to avoid overeating.
Behaviors that will help me achieve my goal: Put on workout clothes at work before getting in car.
Stop off to get coffee and a small healthy snack on the way home.
Meet a friend for a walk (combined with the above two).
When I get home, read reminder on fridge (to not eat) before doing anything else.
And after the fact:
Did I achieve my goal?
Yes
No
If so, why
If not, why not Forgot to bring workout clothes to work and felt bad and guilty about that, as
well as tired. Went home and did same old thing of heading to the fridge without thinking.
I should have followed my plans above, and then I think I would have achieved my goal.
Figure 6.1
Sample Problem-Solving Strategies for Handling Challenging Eating Situations
59
Questions and Comments Made to Dieters

At some point, discuss with your patient the probability that others
eventually will begin to make comments about his weight. Whether or
not his friends and signicant others know what type of diet he is on as
he prepares for his surgery, they will likely begin to notice his weight loss
after a given point in time. Your patient will likely nd that once people
notice his weight loss, questions will automatically follow, such as How
did you lose so much weight?; Did you have the
surgery?
(ll in the blank with either stomach stapling, gastric bypass, weight
loss or other words to describe the surgery); Why are you eating so
slowly?; Can you have that?; Should you be eating that?; or Dont
you think youve lost enough weight? Also there might be observations
about why your patient seems to be avoiding certain foods such as carbonated beverages or sweets, or there might be comments based on a
thorough or simplistic understanding of the medias depiction of weight
loss surgery and the behavior changes that accompany it. Make sure that
you invite your patient to discuss in your sessions all of his reactions to
the comments, questions, and so on that are made to him about his
weight loss so that at no time do uncomfortable feelings about these unsolicited attentions cause him to act out in any way with his eating.
In addition to these types of questions and comments, your patient will
likely be on the receiving end of statements that are mostly complimentary in tone but that at the same time might feel intrusive, depending on
the exact content and the time at which they are made relative to his beginning the process of weight loss. And of course the way any of these
comments sound will depend on the source, or who it is that is making
the comment, giving the compliment, or registering the criticism and
what your patients relationship with that person entails. (See earlier
chapter on recording weight, which includes a table for keeping track of
weight-related compliments.) For example, your patient might acknowledge that it would likely feel much dierent if a close loved one expressed
concerns about how much weight hes lost or the rapidity of the weight
loss, compared to the same sentiments expressed by a mere acquaintance
with whom your patient maintains a very supercial relationship.
No matter what, it is important to encourage your patient to think about
how any of these comments or questions aects him. If necessary, chart
60
Comments and Reactions Log

What was said, by whom and when:
Date
12/2
Comment(s)
How did you lose so much
Source
Reactions
co-worker
felt intruded on
friend
Thanks, I have!
mother
felt irritateddidnt want to
weight?
12/15
You look great! Have you

lost weight?
12/20
Are you getting too skinny?
have to reassure her about my

weight loss
Figure 6.2
Sample Comments and Reactions Log
out the comments along with the specic thoughts, feelings, and behaviors that come up for your patient in reacting to what was said, similar
to the techniques that were recommended in the section on compliments. The purpose of this exercise is to help your patient identify those
external inputs that lead to unhelpful thoughts, feelings, and behaviors
so that he can then challenge them using any of the CBT tools previously described and others that will be introduced later in the manual
and discussed with you in sessions.
A sample Comments and Reactions Log is shown above in Figure ..
Managing Challenging and Feared Foods: Choosing

the Right (and Wrong) Foods in Moderation
As your patient diets to lose weight before his weight loss surgery (and
eventually learns a regimen for healthy eating after), he may notice that
there are certain foods that are more tempting than others and even
61
some that are still likely to trigger urges to overeat. Your patient may
have discussed his relationship to some of these foods with you in session, particularly if he has been a binge eater who has had a problem in
the past losing control over particular foods or food groups. For example, many people describe at times having cravings for salty snack
foods or alternatively for sweets or chocolate. Sometimes these cravings
may occur in relation to physical hunger, while at other times emotions
may play a larger role. Occasionally, the mere fact that the food in question is stocked at home or otherwise available might be enough to create the problem cravings. Many of the foods that your patient might now
struggle to control at times might actually invoke the feelings of a lovehate relationship based on a combination of strong cravings, a strong
desire to avoid, and a not-infrequent tendency to give in to the urge to
lose control and overeat or binge on these foods, for any number of reasons, typically followed again by a vow to restrict their intake.
Instruct your patient that, no matter what, it is important for him to
learn both exibility and mastery over these types of high-risk foods. For
example, it might be that your patient is stuck at some point at a celebration or party where only cake and ice creamtwo of his most common binge foodsare being served. Whereas in the past he might either have lapsed into a bad bout of binge eating given the presence of
these foods, or during a dieting episode eaten nothing at all at the party,
only to binge eat on other foods later, ideally you would teach him to
exibly have some of these foods in moderation, without duress, in
order to stave o either extreme in behavior (e.g., losing control altogether and bingeing or avoiding the perceived problem food for now and
overeating later). Alternatively, another solution that you could teach
your patient is to plan in advance to bring his own healthy (or acceptable, in his opinion) food to the event, if he is concerned that no appropriate food for him will be served. Encourage your patient to consider bringing his own food when he wants to uphold the option of
learning to feel comfortable in avoiding some of his challenging foods
altogether, or as much as that is possible, when this may be the most
reasonable strategy to follow. For example, when these foods are really
threatening to your patients health, such as sweets if he is a diabetic or
very high-fat foods if he has heart disease, it is best for him to plan and
prepare in advance to feel comfortable showing up with his own
healthy stash of food.
62
For some of your patients, depending on their particular psychological

and emotional issues, it might be that avoidance altogether of these certain triggering foods sets up feelings of deprivation and specic hungers
or cravings that ultimately increase their likelihood for losing control
and binge eating when they are exposed to those foods. For example, if
your patient is someone who has tended to overeat chocolate in the past
but knows at the same time that he cant live without it, it might be
necessary to help him think about the concept of incorporating just a
little bit. Encourage him to experiment with this behavior only at times
when he is not vulnerable to overeating or losing control, to ensure that
he can maintain a sense of mastery, exibility, and power in his relationship to chocolate.
Once your patient has had surgery, there will likely be certain clear-cut
recommendations about foods to stay away from altogether, due to either diculties with digestion/absorption or the ease with which these
foods can lead to weight re-gain. For example, at some surgery centers
or among certain groups of surgeons performing specic techniques,
there might be recommendations against the intake of sweets for a year
or longer (or forever) after weight loss surgery. In those instances, it may
be that these foods really do become o-limits for your patient and
that you should help him learn to start living without them as soon as
he reasonably can. In other instances, there may be foods that are not optimal but that are acceptable as indulgences on a once-in-awhile basis. In
any case, your patient will need to respect any of the recommendations
that his surgeon has made, consistent with the general suggestions about
exercising good self-care. With your patients permission, it might be
helpful to at some point talk directly with his surgeon or dietician (or to
review the written materials oered to your patient by the surgery program) in order to read rsthand about the recommendations that have
been made to your patient and translate and support if and when that
is necessary.
Incorporating Feared Foods Exercise

As your patient begins to think about the list of foods that he loves/
hates/overeats/avoids, what might work best, in addition to talking about
his relationship with these foods in your sessions, is to discuss the im-
63
portance of following through on the feared foods exercise. This means

that your patient should go to a grocery store and create a list of all of
these types of challenging foods, walking each and every aisle of the store,
so that none of the problem foods are omitted. A Challenging Foods
List can be found in chapter of the patient workbook. Figure 6.3
shows a sample completed Challenging Foods List. Once he accomplishes that, the next step is to categorize the listed foods into four dierent groups, ranging from how easy to how dicult it would be for him
to experiment with eating a small or moderate portion of the food in
questionthat is, not fully avoiding the food but not overeating the
food either.
Remind your patient that completion of this exercise should also help
him work through eventual urges to overeat even after his surgery, despite the physical limitations that the surgery imposes. You will talk at
length with your patient about the realities of weight loss surgery and
how non-foolproof a method of weight loss it is, so that he moves forward with no illusions about it. For example, while any of the weight
loss surgery procedures will make it much more dicult for your patient
to overeat, and much less likely for your patient to want to overeat, the
potential is still there, in particular the potential for your patient to want
just a little bit more and to have just that little bit. These tendencies
postweight loss surgery, for individuals to overeat by a little bit now and
again, to the point of feeling overly full or stued, and then to feel bad
about themselves, can heighten their vulnerability to overeating again in
the future in part because of these bad feelings. In any case, helping your
patient to experiment with his intake of feared or challenging foods
will be an exercise in mastery and exibility over food that should generalize quite well after his surgical procedure.

For teenagers, it is often helpful to ask parents to help them out with addressing feared foods. Parents can work with you and your patient to establish a list of foods and the situations they want to experiment with.
You might decide to start o by asking parents to buy and prepare the
food and be there with their child when they try it, but work up gradu-
64
Challenging Foods List

Group 1
(Easiest)
Group 2
Group 3
Group 4
(Most Difcult)
bread
peanut butter
pizza
any red meat
jam
butter
ice cream
nuts
cheese
any chocolate
cookies
cheeseburgers_
sweet cereal
potato chips
brownies
French fries_
some crackers
pie or cake
donuts
Figure 6.3
Sample Challenging Foods List
ally to more independent experiments. In any case, you should try to use
the resource of parents as much as possible to support this type of behavioral experiment.
Once your patient has created the list, you can begin to help him set
weekly goals of eating a small amount of one or more of these foods (beginning with the least challenging and slowly working up to the more
dicult foods) in settings in which he feels safe (e.g., not vulnerable to
overeating because he is not feeling fat, out of control, or emotionally aroused or distraught in any way and when he is not in a situation
in which he is likely to have access to large quantities of the problem
food). Once your patient has set up his eating experimentsthat is,
set a goal of trying a certain amount of a challenging food in a planned
situationhe should try to make a commitment to following through
(except in the event of the presence of any of the vulnerability factors or
danger signs for losing control noted above), and he should document
his eorts (with a * or some other designation) in his food journal. Ideally, he will be doing such eating experiments up to a couple of times a
week and, in so doing, will feel a great sense of liberation over any prior
extremes, if these existed, in his relationship with particular foods.
65
Homework
Read sections of chapter on where eating happens and complete
checklist.
Take inventory of people inuences on your eating and note eects
of these.
Work with your therapist on developing your problem-solving strategies for various eating situations.
Create your feared foods list and begin to incorporate some feared
foods into your meal plan.
If youre a teenager, talk to your parents about feared foods and how
your parents can help.
66
Chapter 7
Teaching Your Patient About Problem Solving

and Cognitive Restructuring
Materials Needed
Problem-Solving Exercise
List of Common Cognitive Distortions
Cognitive-Restructuring Exercise
Situational Analysis Method
Outline
Help patient learn methods for identifying and working through challenging problems
Help patient identify common types of cognitive distortions
Teach patient methods for identifying and working through problem
thoughts when she becomes aware of thinking in a distorted fashion
Teach patient methods that combine problem solving and working
through her thoughts so that she can better handle situations that
in the past might have led her either to overeat or to use other nonoptimal behaviors to cope with stresses of one type or another
When your patient is faced with a dilemma of any type in which eating
or overeating might have emerged in the past as the solution (albeit a
faulty and temporary one) of choice, in addition to the tools presented
earlier (e.g., pleasurable alternative activities), it is important to also help
her learn about the option of engaging in formal problem solving. Problem solving is something that many people are able to do naturally and
67
automatically, without giving it much, if any, thought at all. It might be

something that your patient is also able to do quite easily in many, if not
most, situations in which she is not stressed or overtaxed. For example,
in a situation in which your patient wakes up on a given morning that
is cold and rainy as opposed to warm and sunny, she is probably able to
think through her options about what to wear and to easily come up
with the solution of wearing warmer clothing and taking a raincoat and
an umbrella.
If your patients problem-solving skills are basically sound, then it is probably only in very stressful or complicated situations that she ends up getting rattled and for that reason becoming confused about what she
wants or how to go about getting what she wants. It might be that many
of those stressful or confusing situations ultimately involve using food
to cope in one way or another, either as the only solution that appears at
all potentially helpful or as a procrastination, delay, or distraction tool
when a solid solution might appear to be too dicult or complicated to
proceed with in a straightforward and easy fashion. When eating and
food are used in this sense, they likely also serve the purpose of regulating your patients mood, in that they modulate the stress she might feel
about the problem situation she is facing, as well as the challenge of implementing any of the complex solutions that might be warranted in the
situation.
For all of those reasons, it is important that you deliberately train your
patient in formal problem-solving skills and also encourage her to practice and rehearse these skills as much as possible so that she can internalize them and make them as automatic as possible. When this happens,
the process of working through even very complex and stressful problems and solutions will become much easier for her.
Start by dening formal problem solving for your patient. Formal problem solving involves the following: identifying the exact problem that
needs to be solved in simple terms, brainstorming (without screening)
about the possible solutions, evaluating the practicality and probable eectiveness of each solution, choosing one or a combination of these, and
following through on the selected solution or combination of solutions.
The following sample exercise (Figure 7.1) illustrates the process of problem solving. A blank exercise is included in the patient workbook. You
68
Problem-Solving
Step . Dene the problem in simple terms: I was invited to a friends pool party, and I want
to go, but I am embarrassed about getting into my bathing suit and hanging around the pool in
it with everyone else.
Step . Brainstorm about solutions (without screening): I could decide not to go.
I could go in regular clothes and not swim at all.
I could have my suit on under a cover-up or other clothes and see how I feel once Im
there and make a decision then.
I could ask the hostess about the guest list and see how comfortable I will be exposing
myself to that crowd and then make a decision.
Step . Evaluate the practicality and eectiveness of each solution (with either or ):
I want to go so not going is not an option (-)
I want to have the option of swimming no swimsuit seems like a cop-out (-)
I like going with the option of swimming (+)
Maybe I should talk to my friend in advance (+)
Step . Choose one or a combination of solutions: I think I will call the hostess, who is a
fairly good friend, and describe my dilemma (e.g., sensitivity about my weight) and feel out
the situation but also go to the party, since I want to socialize, prepared to swim (by bringing
my suit or wearing it under clothes) or not, depending on how it feels when I am there.
Step . Commit to following through with your behavior: OK, I will be going to the party in
some type of cover-up clothing with swimsuit under that; theres no turning back now!
Step . Evaluate the entire problem-solving method: This worked well. I was afraid to go,
but wanted to, and figured out a strategy that worked for me by combining a couple of
approaches to the problem and some flexible options.
Figure 7.1
Sample Problem-Solving exercise
69
should encourage your patient to make an eort to practice this method

at least a couple of times a week on various problems that she might face
and then bring in the completed problem-solving exercises to your sessions so that you can review and discuss them together.
Modifying Problem Thoughts

In addition to helping your patient solve certain problems or dilemmas
that she might face, there are also exercises that you can introduce and
teach to help her identify problem thoughts and then modify them in
order to keep them on the right track when she notices herself slipping
into distorted ways of thinking. This distorted thinking may lead directly
to eating problems or result in other types of emotional distress that can
eventually lead to overeating or poor self-care in general.
For starters, introduce your patient to the following list of common
cognitive distortions that can help to get her started understanding what
these errors in thinking are all about.
. All-or-nothing thinking: You see things in extremes of black and
white.
. Overgeneralization: You take one negative event and extrapolate
to a much larger pattern.
. Magnifying the negative, minimizing the positive: You dismiss
positive experiences or data points and deem those unimportant
while instead holding fast to all of the negative.
. Jumping to conclusions and mind reading: You make negative
assumptions and interpretations, even involving others and the
future, when there is no actual data to support your position.
. Emotional Reasoning: You assume that just because you feel a
certain way about a situation, the situation really is that way,
rather than understanding that your feelings, while valid, dont
create a reality.
. Labeling: You relate to yourself and others with pronounced labels, typically of a negative sort, rather than attributing the cause
(of, for example, an error) to a situation or a specic behavior.
70
. Personalization: You see yourself as the source or cause of an external event or situation when you are not responsible for it or it
is not about you. (Burns, )
Once you have helped your patient identify the specic types of thinking problems that she is vulnerable to, you will introduce her to a technique called cognitive restructuring. Your patient can use this technique
at times when she is troubled by problem thoughts that lead to vicious
cycles of negative thoughts, feelings, and behaviors such as the above.
An example of the emergence of a problem thought that then interferes
with your patient functioning optimally would entail a situation in which
she starts to feel self-conscious at a family gathering when she perceives
people are watching her to see how much food she is eating because of
their concern about her weight. Your patient starts to worry so much
about her family members perceptions of her that inadvertently she nds
herself overeatingsimply because of the primary troubling thought
that keeps running through her mind: Everyone is watching me because they think that I weigh too much to be eating so much at this
meal. Your patient realizes later that although there was no actual data
to objectively support her perception of her family members views of
her, she made such a strong internal conclusion about their beliefs that
she could not shake the thought from her mind. Ultimately, it was your
patients own thought that led to a host of problem behaviors on her part
(namely, negative feelings toward herself and others, combined with
overeating) that could have been avoided if only she had made eorts to
actively correct the distorted thoughts and follow a dierent thought
process.
It is really quite simple to teach your patient this exercise to challenge a
given problem thought. All it involves is leading the patient through the
steps involved once the problem thought has been identied. The steps
include: writing down the core problem thought on the top of a page
and then creating two competing columns of evidence, one called objective evidence to support the thought and another called objective
evidence to argue against the thought. Once your patient has gathered
all of the evidence on both sides, she should be able to come to some sort
of conclusion that helps her modify the initial problem thought and regain
her sense of clarity and calmness regarding the issue that was troubling
71
her. Figure 7.2 shows how this exercise can be used to help your patient
work through problem thoughts in a productive way, using the example
of the family meal introduced above. A blank copy of this exercise is included in the patient workbook.
After your patient practices these straightforward problem-solving and
problem thoughts exercises a few times and discusses them with you,
you might then encourage your patient to try one additional spin on
problem solving, which combines both approaches by introducing the
situational analysis method. See Figure 7.3. In this method, which can be
used either prospectively, as your patient anticipates a certain problem situation, or retrospectively, after she has emerged from a problem situation
either successfully or unsuccessfully, you can teach the patient to describe
a problem situation that she is facing (or faced), the desired outcome that
she wants (or wanted), what thoughts and behaviors she should have (or
should have had) in order to achieve the desired outcome, and whether
she achieved the outcome that she wanted. If your patient did achieve the
outcome she wanted, she should describe which thoughts and behaviors
were most helpful, and if not, she should describe how the situation actually turned out (the actual outcome) and which thoughts and behaviors were most problematic in obstructing her from achieving her goal.

Many adolescents (like some adults) are not able to use formal cognitiverestructuring techniques without a lot of therapist assistance. This is the
case because cognitive restructuring requires perspective taking, generation of a range of alternatives, and the use of judgment about each options viability and value. You will need to help your adolescent patients to
use perspective, develop alternatives, and assess alternatives. Therapists
experienced with adolescents recognize that they will need to do the
groundwork on such eorts, especially at rst. Therapists need to avoid
taking over but will be very active in these processes at the start.
Problem solving is commonly used with adolescents when formal
cognitive-restructuring strategies are too dicult or rejected. Problem
solving is more direct, appeals to the immediate needs of adolescents, requires less in the way of judgment, and is experienced as being very prac-
72
Cognitive Restructuring Exercise

. Write out the core problem thought in simple terms.
. Gather up and list objective evidence to support the problem thought.
. Do the same for objective evidence that argues against the problem thought.
. Come up with a reasoned conclusion based on the evidence that will guide you to appropriate and healthy behavior
Problem Thought:
Everyone is watching me because they think that I weigh too much to be eating so much
at this meal.
Supportive Evidence:
1. I see more glances coming my way from other people.
2. My daughter said, Mom, do you really need that? when I reached for a piece of pie.
3. When my brother saw me, he said, Wow, it looks like youve gained weight, and I
thought you were dieting. Are you going to be eating with us?
Disconrming Evidence:
1. It was kind of a free-for-all at the table everyone was interacting with everyone
about food and other topics, too.
2. People in our family always comment on others weight and what others are eating; this
is just how it is in our family.
3. Some other family members are overweight, too.
4. I know that I have been watching my weight and that I had deemed this a special
meal that I could indulge at a little bit. Given that, I was doing pretty well at this dinner.
Reasoned, Evidence-Based Conclusion (that will lead to positive behavior):
People may have been watching me (or maybe not), but it really doesnt matter what they
say or think about my weight and eating, because I know that I was doing my best with
food at this special meal and that it didnt ruin my diet. So the last thing I would want to
do is overeat because of them and my interpretations of what they were thinking. I will
make an even firmer commitment to eat healthfully, for myself, not because of anyone else.
Figure 7.2
Sample Cognitive Restructuring Exercise
73
Situational Analysis Method

Step . Describe the problem situation:
I am going to a potluck lunch at work and in the past have always overeaten at these,
usually on desserts, because I stand around and chat with people by the dessert table. I dont
want this to happen again.
Step . Identify the desired outcome:
I want to eat only one plate of food in all, including the main course, side dishes, and dessert.
Step . Note helpful reads or thoughts that will move me toward my desired outcome:
I am committed to not overeating in this situation.
I deserve to eat lightly, like everyone else.
I want to consume only one plate of food and to be very selective about what I take.
Probably the food wont be that good anyway; it always looks better than it is.
Step . List behaviors that will help me achieve my desired outcome:
Relax by doing some deep breathing (and deep thinking!) before the luncheon.
Go up to the buffet line after a lot of people have already gone through, so that it doesnt
feel like a big rush.
Look over the entire array of food first so I can choose wisely.
Pick one or two small servings of main courses, side dishes, and small desserts, and
remember they have to fit on one plate.
Sit down with my plate, far from the buffet table, eat slowly, and talk a lot to people
while Im eating.
Dont get back in line.
Step . Assess my outcome:
Did I achieve my desired outcome? If so, which thoughts and behaviors were most helpful?
Yes! The commitment to the new behaviors made it most easy to achieve what I planned,
and relaxing and thinking through the image of what I wanted to do in advance helped a lot.
If not, what was the actual outcome, and which thoughts and behaviors got in the way the
most?
This didnt happen, but I might have gotten off track and overstimulated if I had let
myself get caught up in the rush of people initially in line and if I had dived in for a whole
bunch of food/desserts first, without surveying the scene, planning to take only what I
wanted, and committing to only one plateful.
Figure 7.3
Sample Situational Analysis

74
tical. CBT therapists working with adolescents have found that problem
solving is more likely to be employed with this age group than formal
cognitive restructuring.
Homework
Review problem solving, discuss with your therapist, and complete a
few examples during the next week or so.
Review cognitive restructuring, discuss with your therapist, and complete a few examples during the next week or so.
Review the situational analysis method, discuss with your therapist,
and complete a few examples during the next week or so.
75
Chapter 8
Working With Your Patient on Body Image Issues
Materials Needed
Form: My Body Image Perceptions
Form: The Ways That I Check My Body
Form: My Body Checking Behaviors: How Frequent Are They?
Body Image Journal
Outline
Teach patient the concept of body image and encourage him to discuss
some of the contributions to his body image with you (as they relate to
the CBT model) in sessions
Increase patients awareness of the issue of body checking and help
him learn to keep frequency counts of these behaviors
Educate patient about the links between his body checking behaviors
and certain thoughts, feelings, and other behaviors
Focus patient on identifying body parts that he appreciates and that
have nothing to do with weight and shape, and help him learn to associate these with positive thoughts, feelings, and behaviors
Encourage patients use of body image journals, capturing both the
more negative and positive experiences
You might nd that your patient is somewhat in the dark when it comes
to what his body image is all about. He might not understand exactly
77
what the term body image means, or he might be so resigned to concluding that his body image is dened in full by the fact that he is overweight that he hasnt explored the concept further. Like with the issues
of weighing himself on the scale, he might simply have put his head in
the sand when it comes to even thinking about the notion of his body
imagethereby avoiding the concept altogether.
So one of the rst places to start with your patient is with the denitional issues, by exploring in session the question of what is body image?
In talking to patients about this complicated notion, often the best and
most straightforward place to start is with a denition like this one: that
body image is a persons internalized version of the physical realities of
his body. That means, most simply, a combination of how he thinks and
feels about his body historically and also at any one point in time, based
on the inputs of that particular situation at that particular moment. For
example, your patients body image might vary somewhat even over the
course of a single day, depending on whether or not he has eaten and
how much, if he has exercised and how much, or what clothing he happens to be wearing and how it ts. Another example would be that of
your patient feeling somewhat slim and in control of his body having
eaten relatively little before a large holiday meal, whereas after this type
of meal, say Thanksgiving as one example, he might have the contradictory experience of feeling stued, overly large fat, or bursting at the
seams, particularly if any items of his clothing have started to feel a bit
tight after eating. Alternatively, after a long session at the gym, your patient might again feel dierently about his body, that is, he may be experiencing himself as relatively strong, thin, and on the road to tness.
You will want to encourage your patient to take a few minutes during
the session to jot down a few words in the My Body Image Perceptions
form provided in his patient workbook. Figure 8.1 shows a completed
sample of this form. He should use this form to characterize his body
image in general, as he thinks about it in an ongoing way (e.g., not in response to a large meal, an exercise session, or a diet). It is important to
take some time also to allow your patient to reect in the session on the
words that he has written in the workbook. Likely, at least some of these
body imagerelated reactions and perceptions might at times lead to certain emotional reactions, either bad or good, some of which might even
trigger episodes of eating or overeating for him, as discussed in earlier
78
My Body Image Perceptions

I feel that I am fat . . . and I feel that I have been that way my entire life. Mostly I dont
know what it is like to feel really good about or proud of my body. I tend to cover up a lot,
at the beach, etc., or even to avoid activities and places where more of my body might
show. It is hard for me to think about my body beyond the issue of my weight. Although
some people compliment me on my hair and my eyes, also, I usually dont take these into
account when I consider my body image.
Figure 8.1
Sample of My Body Image Perceptions
sections of the manual. It is likely that many of your patients experiences

throughout his life have contributed to the way that he feels about his
body, as described in the earlier section on the CBT model, and you might
want to encourage your patient to keep all of those contributions in mind
as he works through the various parts of this chapter.
It will be important as you help your patient become more and more
aware of his thoughts and feelings about his body that you spend time
in the sessions devoted to the issue of body image, discussing it in depth,
particularly as his weight loss surgery date draws closer. While radical
weight loss of the magnitude usually facilitated by the surgery might aect
positive change in your patients body image, there is no guarantee that
weight loss will lead to improved feelings about his body. On occasion,
the weight loss only serves to intensify negative feelings about the whole
self not just the bodily self that your patient might have been displacing in full onto his body. It is important that you prepare him for
that possibility, as well as for the reality that it can take some time before
the rapid weight loss facilitated by the surgery actually starts to really
look good on his body beyond registering in any variety of interim
ways that might appear somewhat unattractive (e.g., unevenness in weight
loss, lumpiness, loose skin, feeling generally saggy and out of shape, etc.).
It is imperative that at the same time that your patient is losing weight
(before his surgery, if that is recommended, as well as after) you encour-
79
age him to maintain his focus on the underlying issues of self-image that
in the end are most likely the root source of the feelings that he has about
his body no matter where his weight ultimately lands after his surgery.
In chapter , your patient read about the importance of weighing regularly and obtaining a variety of measures of his body size, shape, and
general appearance (including to some extent the comments of others).
He learned about regularly assessing his body in order to keep track of
where he is on various indices. Probably, with respect to body weight and
shape, and possibly also as related to body image, your patient has been
informally doing this for some time, although he may have been quite
unaware of it. Examples of how certain individuals keep tabs on their
body (and respond with certain types of thoughts and feelings about what
is happening to their body, whether positive or negative) include very
common behaviors such as often looking in mirrors, windows, or any reective surfaces; pinching various areas of the body such as the upper
arms, forearms, or thighs; trying on dierent items of clothing to see
how they might t; and/or sitting in various pieces of furniture to see
how the furniture ts them. If your patient is actively and regularly engaging in any of these behaviors, it is quite likely that he has never before given much thought to the notion of how these behaviors aect his
subsequent thoughts, feelings, and behaviors. Now is the time to help
him start making these links. Helping your patient create these insights
is very important, as in many cases, he will come to realize that the results (in the form of cognitions, emotions, and behaviors, including decisions about eating) of body checking of this type are only negative.
The rst place to start is by helping your patient get in touch, over the
course of a week or so, with the strategies he is using to keep track of
what is happening with his body. Help your patient to rst keep a log of
the dierent types of body checking behaviors that he engages in regularly (if any). Then eventually help him add some frequency counts to
this data, so that over time he becomes more aware of how often he does
what. For example, many people have been quite surprised to realize that
they are pinching their upper arm or stomach to see how fat I am up
to times a day! Clearly, their weight could not have changed dramatically, if at all, within a days time, yet their method for continually
checking by pinching themselves provided them some sense of anxiety
mastery or the illusion of staying in control of any changes that might
80
The Ways That I Check My Body

Looking in the mirror
Trying on multiple pairs of pants each day
Pinching the flab on my stomach
Seeing how much of a certain armchair that I take up
Looking at myself in store windows every time I walk by
Figure 8.2
Sample of The Ways That I Check My Body
be happening. Realistically and at a distance, it is clear that pinching any

part of the body and actual weight gain can in no way be naturally correlated (no amount of checking behavior of any type, be it pinching,
trying on multiple pairs of pants, or weighing on the scale can prevent
weight gain if a person is overeating). See Figure 8.2 for a sample. Later,
after this baseline data is collected, there will be further opportunities in
sessions devoted to this material to explore more about your patients
thoughts, feelings, and behaviors that seem to follow from these body
assessment experiences.
Next, after discussing the above (types of body checking behaviors) with
your patient, you will want to encourage him to start keeping frequency
counts of how many times he is engaging in any of these body checks
each day. Your patient will be using the chart shown in Figure 8.3 (also
found in the patient workbook) to enter his body checking data as this
becomes available over the next couple of weeks or so. Encourage your
patient to simply transfer his list from the exercise above (The Ways
That I Check My Body) to the frequency chart and then begin to make
tally marks for each of the seven days of the upcoming week, for a grand
total for the week per each behavior. Ultimately, you and your patient
will discuss the importance of decreasing all types of the excessive checking behavior over time, particularly as you will be helping your patient
to note the links between body checking and problem emotions, thoughts,
and behaviors. As your patient tracks the frequencies of these behaviors
81
My Body Checking Behaviors: How Frequent Are They?

Su
Th
Sa
Looking in the mirror
Trying on more than one pair of pants
Pinching my upper arm
Figure 8.3
Sample for My Body Checking Behaviors: How Frequent Are They?
per week, you will be looking to see downward trajectories for each. You
will want to reinforce to your patient that this goal of decreasing excessive body checking behaviors doesnt contradict the earlier message about
the importance of weekly weighing sessions and other forms of checking in with whats happening with his body in moderation (e.g., trying
on dierent pieces of clothing and such.). It is just the excessive checking
that becomes problematic, just as much as does pure denialwhich you
can otherwise describe to your patient as putting your head in the sand.
Next, after you discuss your patients frequency data with him, you can
encourage him to note the thoughts and feelings that seem to come up
for him when he chooses (after all, it is a choice, to pay attention to or
check a certain part of the body that might have some symbolic meaning related to ones overall weight) to focus or dwell on this area or areas.
One would surmise that many of the thoughts and feelings would be more
negatively toned than positive, given that the presence of body checking
often implies anxiety of at least mild or moderate intensity and that the
behaviors associated with those thoughts and feelings would run the
gamut from avoiding people to avoiding other positive events or experiences to overeating (as but one nonproductive escape route from the
negative feelings). It might be easiest and most straightforward to encourage your patient to do this in some sort of a journal form or in the Body
Image Journal I/Body CheckingRelated Thoughts, Feelings, and Behaviors form found in the patient workbook, so that he can write about the
issues freely and then have a written document to review with you in the
sessions devoted to this material. See Figure 8.4 for a completed sample.
82
Just to get your patient started, encourage him to keep in mind the following equation:
Body Checking thoughts, feelings, additional behaviors,
and maybe more body checking
Once your patient has written down the specic thoughts, feelings, and
actions that occur in relation to certain body checking behaviors, he can
apply one or more of the cognitive-restructuring, problem-solving, or
situational analysis techniques to his experiences. For example, if your
patient nds that when he tries on too many pairs of pants or too many
shirts in the morning, he starts on a downward spiral of thoughts that
goes something like I am fat, nothing ts anymore, I am going to cancel my lunch time walk with friends, and so on, and then he stays home
alone and overeats, it is clear that he is creating a negative experience for
Body Image Journal I/Body CheckingRelated Thoughts, Feelings, and Behaviors

When I try on more than one pair of pants, my thoughts start to run like this: Maybe I am
not as fat as I thought, Maybe I have gained more weight than I thought, Perhaps these
are tight because I just washed them, I am afraid to get on the scale to just see how
much I actually weigh.
The feelings that I end up experiencing are all about anxiety and worry for example, I
end up feeling very, very concerned that I am off track in what I think is happening with
my weight, especially if I have not weighed for a long time. The anxiety or low mood might
stay with me for a day or even more. . . and usually when I am feeling that way, I end up
eating more to try to feel better. I realize it is such a vicious circle; I just dont know how
to stop. The same thing used to happen when I would weigh myself many times a day, but
fortunately I have stopped that, at least for now.
Figure 8.4
Sample of Body Image Journal I/Body-Checking-Related Thoughts, Feelings, and Behaviors
83
himself that could be interrupted by learning to try any of the following

strategies: ) altering his thought process; ) focusing on the problem
situation at hand and identifying a constructive, desired outcome that
he can work toward; or ) engaging in some type of problem-solving exercise that will help him identify, at the outset, situations in which he is
vulnerable to body checking behaviors that will make him feel bad,
think bad, and act badly, too.
Another issue often overwhelming to those with obesity is the basic difculty of validating their right to consider any other aspects of their
body or appearance, other than their weight, as important in playing a
role in determining their level of attractiveness as a person. Therefore it
is essential that you help your patient get in touch with all of the other
parts of his body and physical appearance that he might like and value
and that might even compensate at times for the way that he feels about
his weight and shape, if and when he might get down on himself for carrying more weight than he needs. For example, some people are able to
acknowledge that they have very nice hair, hands, eyes, even feet, or a
rosy, glowing complexion. Ask your patient to consider if and when he
has ever stopped to ponder the physical attributes that make him feel
good about his physical self, no matter what is happening with his
weight. Whether your patient has done this before or not, encourage
him to take some time to jot down a few notes about the physical features that he might also value. See Figure 8.5 for an example.

If your patient is a teenager, you might nd it very useful to go over these
exercises with your patients parents. One reason is that sometimes adolescents do not perceive that they are body checking, while outside observers
like parents do. In addition, family members might have some things to
add to a positive qualities list that adolescents themselves havent considered. They may also be able to help you and the adolescent think through
some of these issues. It may seem awkward at rst to include parents in some
sessions, but as you get used to it, you will nd you learn a lot of helpful information that will be useful in your therapeutic work with the
adolescent.
84
Physical Features That I Like (and that have nothing to do with my weight)
I like my hair.
I was told that I have a nice complexion.
I usually get compliments on my hands and manicure.
My eyes are a nice color.
Figure 8.5
Sample of Physical Features That I Like
Body Image Journal II

Appreciated Physical Features: Related Thoughts, Feelings, and Behaviors
When I am able to look beyond my weight and appreciate the other attractive features
that I have features that I like and that other people have complimented me on I feel
much better about myself as a person and much more likely to treat myself well. What I
mean by that is when I am feeling good about who I am physically, I am much less inclined to
overeat or to in any way behave in an unhealthy fashion.
So the thoughts would be: There are a lot of aspects of my physical appearance that I
like and value.
And the feelings would be some relative sense of peace and contentment.
And the behaviors would be acting more like I LIKE myself, e.g., not treating myself
poorly. NOT overeating, NOT under-exercising, allowing myself to reach out to friends that
I like, etc.
Figure 8.6
Sample of Body Image Journal II

Appreciated Physical Features: Related Thoughts, Feelings, and Behaviors
85
In relation to these non-weight-related body perceptions, it is equally if

not even more important to help your patient get in touch with the
thoughts, feelings, and other behaviors that result when he focuses on
them. For example, if focusing on a negative body aspect such as the
ab on his stomach reminds him that he is fat and sets in motion a spiral of despondence, depression, isolation, and overeating, it should stand
to reason that the converse would also be true, that focusing on his full
head of hair, nice eyes, or translucent complexion would lead to feelings
of well-being, contentedness, and good self-care. In the same way that
your patient kept track of the more negatively toned body checking
related thoughts, feelings, and behaviors, he should be encouraged to do
the same with these positive experiences in the Body Image Journal II
(see Figure 8.6) in his workbook. You will take several weeks in sessions
devoted to this material to discuss the issues, and undoubtedly both of
you will come back to it time and again as your patient progresses toward surgery. Remind your patient that it will be important at various
phases after his surgery to continue to monitor his experiences with
body image, including checking and other associated behaviors,
thoughts, and feelings. This ongoing focus on body image will be important, because as his body changes so rapidly in response to the weight
loss, his perceptions of his body will also be expected to uctuate and become destabilized at times, possibly more during times of stress than
when all else is status quo.
Homework
Read and discuss the chapter with your therapist.
Begin self-assessment of body checking areas and frequency counts.
List appreciated physical attributes.
Start to work on both body image journals, the one reecting thoughts
and feelings after body checking and the one associated with thoughts
and feelings about appreciated attributes.
If you are a teenager, ask your family to help with these exercises to expand your perspectives and to use them for support.
86
Chapter 9
Congratulations! Your Patient

Is on the Way to the O.R.
Materials Needed
Pre-Surgery Planning Journal
Exercises to access and clarify feelings about surgery
Instructions for breathing, progressive muscle relaxation, and visual
imagery
Outline
Orient your patient to all of the issues still to be addressed before
surgery.
Guide your patient in getting in touch with deeper thoughts and
feelings about the upcoming surgery.
Facilitate your patients use of checklists and exercises pertaining to
these issues.
Addressing Agenda Items

No matter how much time has passed since your patient rst began to
consider a weight loss surgery procedure, as she gets closer to scheduling
her surgery or moves closer to her actual surgery date, you will want to
help her create and maintain a written list of the agenda items that need
to be attended to before she actually undergoes the procedure, so that all
of the agenda items are kept top of her mind and none are forgotten.
87
Professional Consultations
Obviously, one of the most important issues here is that your patient has
selected a weight loss surgery program that she is comfortable with and
a surgeon who has agreed to work with her and perform the particular
weight loss surgery procedure that she is looking for, given the options
that are available to her. As part of the process of deciding on a weight
loss surgery program and professional team, your patient should have
obtained a referral from her primary care physician and also communicated with her insurance company to determine the extent to which the
array of recommended and required medical visits and treatments associated with her surgery are covered. It is likely that her physicians and
the members of the surgical team will have completed and submitted to
her insurance company a variety of forms and other paperwork to support her need for the surgery; in some cases, the psychological evaluation
will also be requested by a patients insurance company. In working with
a particular surgeon and surgery center, your patient will have been
given a list of pre-operative guidelines, including the requirement for the
pre-op session(s) with a mental health professional, dietician, internist,
and possibly other medical personnel. And in some instances a signicant other or close friend might be asked to accompany your patient to
a given meeting.
Follow Through With Recommendations

In the context of all of the professional consultations that your patient
will take part in, it is likely that several recommendations have been
made about what she needs to do to ready herself for surgery. These suggestions might pertain to, for example, starting on a weight loss diet and
exercise program or losing a given number of pounds by a certain date,
or (separate from a goal of weight loss per se) eliminating or decreasing
certain foods from the diet that may be problematic after surgery, adopting a specic eating schedule that is more consistent with what will be
required post-operatively, or improving the nutritional quality of the
diet. Other suggestions made during the series of evaluations may not be
specically related to weight loss, nutrition, or exercise. These might include participating in a support group comprised of both pre- and post-
88
operative weight loss surgery patients that is focused on all types of issues related to the surgery; meeting with a mental health professional
one or more times (in addition to the initial consultation) to work on issues of self-care, mood regulation, emotional eating, or other concerns
(e.g., consistent with the work you are doing with your patient); starting on a medication or other treatment for any condition that has been
diagnosed that warrants an intervention (e.g., using a C-PAP machine
to treat sleep apnea); or starting on an antidepressant or mood management medication to improve or stabilize your patients emotional state.
No matter what the particulars, as your patients surgery date (or scheduling of it) draws closer, you should be helping her to keep tabs on
which consultation sessions have been completed and which are pending, and what she needs to do to ensure that a given meeting gets scheduled. (Programs and individual practitioners may dier in terms of the
expectations regarding the ow for scheduling, that is, who contacts
whom to set up appointments and follow-up meetings.) Encourage
your patient to use the Pre-Surgery Planning Journal in chapter of the
workbook to help keep track of all aspects of surgery preparation. You
might recommend that she start by recording events and to do items
on a day-by-day basis. Later, she can use the checklist provided in chapter , along with her pre-surgery planning journal, as she gets even closer
to the date.
An Introduction to Emotional and Interpersonal Readiness

Another set of issues that your patient needs to look at and consider seriously before surgery is that of emotional and interpersonal readiness.
What this means is that your patient begins to think about all that the
surgery means to her, in relation to certain goals, concerns, and so forth
for example, following through with something she has wanted to do for
herself for some time to improve her life, while simultaneously facing
the potential for certain risks and negative consequences that are always
associated with radical surgery. Remind your patient that many dierent
kinds of emotions might surface as you and she, in your sessions together, begin to take a look at this layer of her experience with the surgery. She might notice feelings of guilt that she is allowing herself the
89
surgery when shes not sure she deserves it or anger that she has unfairly
had to experience a weight problem to the degree that surgery is required.
Likely, both anxiety and sadness, as your patient faces the unknowns of
surgery and what lies ahead for her after, will be part of the picture, as
well as great enthusiasm and excitement about the outcome and her new
life after radical weight loss.
All of the feelings will be linked in some way to various aspects of your
patients changing relationship with food, her body, her sense of herself,
and her relationships with other people. As she delves into all of her
emotions about the surgery, you will want to help her to stay well aware
of the opposing currents nature of many of these changes that she is
beginning to face. Her relationship with food will change following surgery, for both good and bad, meaning that while she will be forced in
a sense by the procedure to adopt a more healthy relationship with food,
this changed stance will also involve loss, that is, no longer having the
option to use food to excess, in an attempt to soothe and comfort herself in response to the dicult emotions or situations that she may face,
and no longer having the option of just eating too much for pleasure.
Another example of a mixed bag of feelings might be the bodily changes
that your patient anticipates following her surgery. While weight loss
and all that comes with it, such as improved health, mobility, and appearance, is your patients goal in following through with weight loss surgery,
she wont be able to predict in advance exactly what the new, thinner
version will look like or how her body will hold up in response to the
massive weight loss. Yes, her clothing sizes will eventually decrease and,
over time, radically so. But certain other issues might arise in the process
of your patient losing her excess weight, for example, an accumulation
of excess skin that doesnt shrink back after weight loss, the possibility of
hernia or hair loss, and/or the experience of simply feeling disoriented
in a physical person that she no longer recognizes in full.
In addition to encouraging your patient to think through all of the feelings that are likely to come up as she progresses through surgery, it is also
important to facilitate her thinking in advance about the way that she
has communicated to her loved ones, friends, acquaintances, and others
all that she wants them to know about what she is and will be going
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through. You might help her focus this discussion within herself by
thinking through ways in which she can tell her loved ones and others
how they can be helpful to her before, during, and after the procedure.
She might also share with them her sense of what they inadvertently
might do that would be harmful and not helpful to her process of preparing for and recovering from her surgery, her hopes and fears, should
the surgery not go wellor even more remotely, in the event of death
related to the surgerythe thoughts and feelings that she would want
to share with them in advance.
The point here is not to force excessive sentimentality on your patient
about what she will be going through emotionally and interpersonally as
she undergoes surgery but rather to have her realistically assess what is
happening inside of her as it relates to the upcoming surgery and
based on this what needs to be addressed on the outside. Finding the
space to do this kind of work well in advance of the surgery makes it
much more likely that your patient can work productively on the issues
noted above with a clear and level head. The issues raised in the last two
sections will be discussed in more detail below.
Exercises to Access and Clarify Feelings About Surgery

This section in the workbook provides space for your patient to thoroughly examine and write about her deepest thoughts and feelings about
the weight loss surgery that she is about to undergo. As she gets closer to
the date of surgery, she might notice that her thoughts and feelings
change; thus it will be important for her to keep an ongoing chronicle,
in journal form, of where she is in relation to surgery.
Deservedness
Exercise # in the patient workbook, Why I Am Deserving of Weight
Loss Surgery and How It Will Improve My Life, provides an opportunity for your patient to write about why she deserves the surgery, what
types of positive changes she is hoping for in undergoing the surgery,
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and all that she has been doing to appropriately care for herself in preparation for it.
Ambivalence and Concern

Exercise # in the patient workbook might be more dicult for your patient to do. It gets back to the idea of the opposing currents or mixed
bag of feelings that often come with complicated terrain like radical
elective surgery. Specically, it addresses the costs aspect of the costs
and benets analysis that your patient completed in one of the early
chapters associated with choosing to undergo weight loss surgery. Here,
it is important that you encourage your patient to take time to think
through and freely express in writing any and all of the fears, concerns,
worries, or misgivings she might have about the surgery. Of course these
will dier across individuals, but the list might include attention to some
of the physical risks associated with undergoing any surgery, or weight
loss surgery in particular, including the risk of mortality; general worries
about complications and physical discomfort; diculties with healing;
or more trivial worries associated with being in the hospital, nances,
time away from usual activities, and the like.
By the same token, it is also essential that you help your patient get in
touch with any subtle or hard-to-access issues of entitlement that she
might also have about the surgery and her recovery from it. Here, entitlement means assuming a somewhat grandiose attitude that denies any of
the negative aspects potentially associated with the procedure or recovery from it. While obviously staying positive is of the utmost importance,
not blinding oneself to the potentially negative consequences of the surgery (see section immediately below) is also essential. Without keeping
the door open to allow for appreciation of both the positive and the
negative (e.g., exercising sound judgment, clear thought processes, constructive problem-solving strategies, eective emotion regulation techniques), your patient will not be appropriately prepared to take herself
and her self-care seriously at all stages of the surgical experience: preparation, initial recovery and healing, later recovery, and long-term maintenance of change.
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A Changed Relationship With Food and Eating

Exercise # in the patient workbook pertains to your patients relationship with food and eating and how these areas of her life specically will
be aected by the surgery. Obviously, it is impossible to understand the
extent to which your patients relationship with food will be changed by
the surgery, until the procedure has been done. But, clearly, her relationship with food and eating will be profoundly and permanently changed
(with the exception of lap band surgery, which can be to some extent reversible). While individuals become obese for dierent reasonssome
may have a very strong familial predisposition such that, despite basically
sound eating and activity patterns, obesity is a foregone conclusion, while
others may have had long-standing habits of overeating or binge eating,
combined with inactivity, that have caused or amplied the problem
food likely has played a signicant role in their lives no matter what the
fundamental contributions to their weight problem. This may be for
no other reason than the fact that, for good or for bad, the attention to
dieting causes one to focus on eating, thereby further amplifying its
importance.
Once the surgery is done, your patients relationship with food will have
to be more deliberate, careful and mechanical, at least at rst, until the
newly developed eating habits become second nature. Despite the fact
that the net eect of having weight loss surgery should be a decrease in
appetite and a speedier route to fullness, considerable thought needs to
be given to the experience of eating, to enable compliance with the medically necessary recommendations regarding the timing, contents, and
portions of eating episodes and uid intake. This deems ones relationship with food anything but spontaneous or reactive (to emotions, hunger
signals, cravings, or situational factors). This stands in contrast to what
many obese people would acknowledge about their eating before surgery, namely, that mostly their eating was in response to some type of
triggering agent that often had little to do with hunger or the goal of
making eating decisions that were ultimately in their best interest from
a health and weight-management standpoint.
Food and eating will no longer have the capacity to fulll a recreational
purpose for your patient. And in this sense, there will probably be feel-
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ings of sadness, loss, frustration, or even anger, as well as a very strong

need to ll the void left by the inability and unavailability of food to
meet so many of your patients needs that might have been addressed by
food in the past. In thinking through the earlier section on the costs of
undergoing the surgery, it is very important to encourage your patient
to devote special attention to the altered relationship that she will have
with food post-operatively and to think through how this might aect
her on multiple levels. After this exploration, the next exercise will help
your patient focus on shifting her mind to alternative activities that dont
involve food, that can be at least somewhat pleasurable and gratifying
(even if initially they are not as stimulating to her as food has been).
Alternative Pleasures Not Linked to Food

Exercise # in the patient workbook, What I Will Do to Fill the Voids
Without Eating, is meant to encourage your patient to take some time
to get in touch with a range of other emotionally gratifying or meaningful ways to spend her time and energy. Instruct your patient to review
chapter of the workbook, which discusses Pleasurable Alternative Activities. Also, direct her to the breathing, progressive muscle relaxation,
and visual imagery techniques in chapter of her workbook.
Handling Coaches and Saboteurs

Your patient has probably discovered that her relationships with the
people that she is closest to in her life have already begun to change since
her decision to undergo weight loss surgery. Similar to others responses
to any self-care decision that she might have made in her life in the past
(e.g., perhaps when she began a diet or started a new educational program, job, or relationship), others responses to her decision to undergo
the surgery are likely to be quite mixed. It is important that you help
your patient determine the stance that she wants to adopt regarding her
decision about the surgery and that you also help her think about the
members of her support teamwho is likely to be a coach and who is
likely to be a saboteur. Instruct your patient to complete Exercise #,
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Handling Internal and External Coaches and Saboteurs, in the patient

workbook.
In considering the issues of coach and saboteur, it is also important
that you help your patient sort out in advance how she is likely to respond to herself as she observes herself going through the process of preparing for and undergoing surgery. This gets back to the issue of deservedness and also hits upon reactions of anxiety, guilt, self-sabotage, and
acting out. Specically here, you should spend time helping your patient
create a mental image of herself progressing through all of the stages associated with her surgery, from pre-op to post, keeping in mind the possibility that while all can go exceptionally well, with your patient emerging from the surgery without complications or setbacks of any kind, it
is also possible that one or more problems could occur. In the instance
of an initial or later outcome that is not % perfect, it is important
that your patient has strategies that enable her to hold onto her earlier
commitment to feel deserving and self-caring in all respects regarding
her decision to undergo the surgery, no matter what unexpected and untoward complexities might arise. This work will require that your patient
get in touch with her deepest thoughts, feelings, and problem-solving
strategies as they relate to her goals for the surgery.

Obviously, if your patient is a teenager, their parents will be highly involved in all aspects of the pre-surgical and surgical processes. Teenage
patients will not be on their own. You will want to make sure that parents understand the work your patient has done pre-surgically with you
to make them condent that they will succeed as a family. Parents always
worry about their children and will want to protect their child as much
as possible from pain and harm. As a therapist, you are expected to be
called upon to support the parents during this process, as well as the
teenager. However, once they have gone through the pre-surgical
processes with their child, they will be a great resource for their child and
a great help to you in supporting your patient post-surgically. You
should try to identify how particular parents can be specically helpfulwho will be with the patient when, what they need to bring and
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have waiting in the room for the patient, how much and when it is appropriate to bring others (friends and relatives) to visit, and what to say
about the surgery to others more generally in keeping with their adolescents wishes. You will also want to help educate the parents to the role
therapy continues to play post-surgically and garner their support in
making sure their child continues to get help during the post-surgical
adjustment period.
When Surgery Goes Badly: Preparing for Unlikely Complications

Finally, as your patient has become more and more aware of the potential benets of the surgery, as well as the costs, the issue of mortality
(death) from surgery has to be on her mind on some level. While the
goal here is not to encourage her to dwell on worries about dying as the
result of surgery, it is important that you help her come to terms with
the possibility of this, no matter how remote it is, and make peace with
herself regarding her decision about the surgery and other aspects of her
life, as well as with the signicant others who are aected by all that happens in her life, including the possibility of losing her as a result of the
surgery. The way that your patient handles getting in touch with this
material by denition will be quite personal; there is no one way for her
to approach preparing herself and her signicant others for the remote
possibility that she could die as the result of what is in most cases an elective surgical procedure. Nevertheless, the recommendation is that you
encourage your patient to take some time to really think through these
issues. For example, you might consider recommending that she write a
letter to her signicant others incorporating all that she would want to
say to them, if this were her nal opportunity to do so. For example, she
might want to incorporate some of the above material regarding her decision to have the surgery, so that signicant others fully understand the
entirety of her experience.
Given the likelihood that all will go well with your patients surgery, it is
of the utmost importance that she plans for and prepares others to support her in the most helpful ways possible. For example, she might request certain family members or friends to provide transportation to the
hospital, to stay while she is undergoing the procedure, and to be pres-
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ent once she wakes up afterward, and so on. She might request assistance in
stocking her kitchen with all of the necessary foods and beverages that she
will need during the rst few post-op weeks. Others might be called upon
to visit her while shes at home, to provide transportation to follow-up visits and other appointments or activities, or to provide emotional assistance should she need that during periods of anxiety or worry before or
after the procedure. Your patients ability to communicate to her signicant others about her emotional state and needs is essential during
this planning stage. They cant know that in addition to feeling very excited about her upcoming surgery, your patient is also highly anxious,
worried, or struggling with guilt about whether or not she deserves it.
If your patient doesnt let people know what she is experiencing and
what she needs from them, they cant possibly respond. My Weight Loss
Surgery Support, Supplies, and Tasks List in chapter of the patient
workbook pertains to this issue of your patients relationship with the
important people around her.
Homework
Complete all exercises in the chapter.
Review these in sessions with your therapist.
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Chapter 10 What Happens After Surgery?
Materials Needed
My Weight Loss Surgery Support, Supplies, and Tasks List
Post-Surgery Journal
Outline
Help patient think through the range of challenges he will face
at various points after surgery
Facilitate patients taking charge of as many of these issues as possible
in advance of surgery
Introduce patient to CBT strategies that he can use should he
experience problems following the surgery (and review certain CBT
strategies that he has already learned)
This chapter discusses what your patient should expect immediately after
his surgery and in the rst few days and weeks that follow, and it will remind him of the importance of being fully compliant with the recommendations made to him regarding the initial post-operative phase. For
example, those recommendations involving dietary intake, the optimal
amount of rest and physical activity, and the necessity of being patient,
utilizing various supports, normalizing frustrations, and so on in the
short term are all important for him to heed in full. In this chapter, you
will nd strategies that you can use to encourage your patient to work
on various written plans of action for situations he might face after surgery; completing these exercises, or at least helping your patient to start
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to think them through nowwell before surgerywill enable him to

be more thoughtful than he might be otherwise when facing the immediate stress of surgery or the rigors of the recovery period immediately
after.
Since the focus of your therapy is mainly to prepare your patient for surgery, likely he is reading this chapter of the workbook well in advance of
the procedure, and the material presented here will prime him to think
about the way he needs to be treating himself, not only before but also
after the surgery has been completed. Once your patient has undergone
surgery, he deserves to give himself a big congratulations and pat on the
back, as he has followed through on an undertaking that was extensive in
terms of the mental, physical, nancial, social, and logistical challenges
involved. In any case, no matter how far along your patient is in the process, or how close he is to the actual surgery date at this point, he deserves to be commended for persevering with his goal and accomplishing what he set his mind to.
Hopefully, all will go well with your patients procedure. In advance of
undergoing surgery, it will be particularly helpful for him to identify
those who will be able to care for him at various stages pre- and postoperatively (refer your patient to My Weight Loss Surgery Support, Supplies, and Tasks List in chapter of his workbook). For example, he
should by now have created a very detailed and well-developed list of
the individuals who will be available to him and the specic tasks that
he would like to assign to them (of course, with their permission and enthusiasm). Your patient will want to know well in advance who will transport him to the surgery, who will stay in the hospital while the procedure is completed, who will be there to visit him in the hospital during
the initial hours and up to few days after the procedure (assuming there
are no complications), and what he would like various individuals to
bring with them or be on call to do for him should he have needs of
one type or another that arise that could not be predicted in advance.
As you help your patient prepare for what will happen after he is discharged from the hospital, he will also want to know exactly who will be
there for him in the hours, days, and weeks after the procedure when he is
at home recovering. For example, your patient will want to have some
sense of who will be there to keep him company, prepare any of the simple
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meals that he needs, and bring those meals and uid requirements to
him if he is having any trouble getting around. At some point before
your patients surgery, he will want to make a detailed list of all of the
food and other supplies that he will need (again, refer your patient to My
Weight Loss Surgery Support, Supplies, and Tasks List in chapter of
his workbook) so that either he or one of the members of his support team
can be sure to purchase the staples that will have to be on hand in the
initial post-op period. Also, there may be special rst aid supplies that
your patient should have available to address any issues associated with
taking care of his healing incision wounds or other issues like that. Your
patient might have been prescribed certain vitamins or other medications
that need to be picked up and prepared a certain way (possibly crushed,
halved, or softened in some cases). And, in addition, it will be extremely
important that he restarts, in the appropriate form, possibly changing
from pills to liquid, all necessary medications being used pre-op that
physicians recommended continuing. Particularly important is your patient restarting any medication related to mood. Helping your patient
devise a scheme for keeping track of all of these potential necessities in
advance of surgery is essential so that no detail comes as a complete surprise either for him or for any of those who are helping out.
Finally, your patient will be required to attend a number of post-operative
follow-up visits that are scheduled at various intervals after surgery, depending on the practices of the surgical center, the type of procedure
that was done, the initial surgical outcome, and any particulars involving his health status. Since it will be a matter of weeks (depending on
the exact nature of the surgery) before your patient can drive, it is also
imperative that he lines up members of his support team to transport
him to those visits. Obviously, it goes without saying that no follow-up
visit should be missed, as it is at these meetings that your patients surgeon and members of the team will fully assess his progress given the
length of time since his surgery relative to others that they have worked
with over time and, after they have made their assessments of your patients progress, make any suggestions, adjustments, or interventions that
might be necessary.
It is at these visits that your patient will also be able to obtain consistent
and reliable data about what is happening with his weight, again relative
to others who have undergone the same procedure. While your patient
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might be one of the few who has a scale at home that has had the capacity to accurately measure his weight both before surgery and after
(following some weight loss), usually the scales at physicians oces are
more accurate than a typical home scale, and thus your patient will be
more likely to get a spot-on reading when he sees his doctor(s) at these
regular visits.
The exercises included in chapter of the patient workbook, as well My
Post-Surgery Journal (also found in chapter of the workbook), can help
your patient organize the information discussed above, and of course he
should know that he can add as many people and tasks beyond to the
list that he wants to.
Assuming that the rst few days out of the hospital and then at home
have gone well, your patient might be quite relieved if not euphoric that
he has made it through this very crucial initial stage of healing. Once he
becomes aware that the rst few days have passed uneventfully, its possible that his state of mind might then shift into conjuring up the next
set of worries or excited plans that he might have about the surgery that
he has just experienced and what he wants to happen in the future relative to that. For example, your patient might become somewhat anxious
about either some of his bodys reactions to having undergone surgery
and/or some of the bodily changes that have already started to happen
(such as continued pain in the site of the wound[s] or changes in his bathroom habits). Perhaps, alternatively, his mind might have already jumped
to what the next few stages of healing, recovery, and adjustment will be
like. Some people may even feel an initial, somewhat catastrophic reaction of what have I done to myself ? that represents a type of buyers
remorse. This type of reaction reects anxiety about the unpredictability of what is in store and how things will progress or evolve over the next
few days, weeks, and months.
While some modicum of anxiety might be helpful to motivate an individual to stay on track regarding the magnitude and seriousness of the
surgery and the vigilance that self-care following the surgery will entail,
too much anxiety can actually have the negative eect of shutting a person down and thereby preventing him from caring for himself optimally
following surgery. For example, highly anxious thoughts, also known as
catastrophizing, might cause a person to lose sight of the positive aspects
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of the decision to undergo surgery and of all of the improvements in life

that await him as he loses weight. Instead, the person may be aware only
of pain and exhaustion, stiness and soreness, and other sensations that
might accompany most radical surgeries. Or the person may choose to
focus on some of the specic, slightly disorienting changes to the body
caused by this surgery, for example, having a distinctly dierent experience of appetite that requires very extreme changes in eating habits.
These imposed physical and behavioral modications might initially feel
very scary and permanent, and thoughts like it is always going to be like
this might occur along with worries such as what if the surgery doesnt
work and I dont lose weight? Or what if it wasnt worth it? (Refer
back to the list of basic cognitive distortions in chapter .)
Managing Anxious Thoughts After Surgery

It is very important if and when your patient experiences anxious thoughts
after surgery that he stare them in the face, embrace them, and then sensibly massage or transform them into thoughts that are much less worrisome and much more constructive. Your patient will know when appropriate and healthy thoughts are onboard because these will be oriented
toward keeping him in an optimistic frame of mind, on the right track
with respect to tasks associated with solidly recovering and healing after
surgery, and focused on his commitment to learning to relate to food
and his body in a new and more healthy way. At this juncture, it will be
important to review with your patient the cognitive-restructuring exercise introduced in chapter .
In addition, at such times of anxiety, when your patient may be secondguessing the decision to have surgery, or when he may actually be feeling some level of buyers remorse during the post-operative phase, it is
very important to help him gure out what other options he may have
to quell his anxiety. While his list of pleasurable activities that dont involve food or eating will obviously be somewhat limited in the early stages
after surgery (e.g., he most likely will not be able to take a bath or even
a shower, exercise, or drive anywhere), you should both work together
to create a short list of appropriate alternatives that includes simple, relaxing, and sedentary activities such as reading, watching TV, surng the
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Internet, chatting with a friend, and so on. It is very important that your
patient learn to overcome any signs of anxiety in this early post-op stage
because anxiety can cause him to act outthat is, engage in a behavior
that is ultimately not in his best interest given his desire to heal adequately
after surgery and get on with the business of serious weight loss.

Post-surgical worries of the parents of teenagers are similar to those of
most patients, while an adolescent may feel less worried than many adults.
If your patient is a teenager, therefore, you might want to work through
some of these exercises not only to help the patient but also his parents,
so that you can work together as a team to get on with post-surgical recovery with the minimum amount of worry.
You might also review with your patient the exercise on formal problem
solving (also found in chapter ) to help him work through additional
issues or obstacles as he is recovering.
After your patient has had at least a few weeks to adjust to the changes
associated with his surgery, he should have a sense of how he is coming
along in terms of following through with the dietary recommendations
appropriate to the specic post-op stage and feeling comfortable with
those changes in eating, as well as the actual rate of weight loss. At your
patients regular follow-up meetings with his physician(s), he should be
obtaining feedback about how he is progressing (including documentation of his continuing weight loss) and receiving many forms of encouragement to stay on the right track. These messages should correct any
misperceptions that your patient might have been struggling with, regarding how things should be going as opposed to how he is actually
doing, as well as any problem behaviors that he has been exhibiting.
Within the rst few weeks and months after surgery much of your patients focus will be on ensuring that he is handling his food and uid intake correctly, losing weight, healing from the wounds of surgery, and
generally staying positive and optimistic about all that hes been through
and all that he is hoping for.
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Mind and Mood

At some point within or shortly after the rst couple of months post-op,
your patient might be ready to shift focus from his body and all of the
changes that he is going through physically to his mind and his mood.
You might even encourage your patient to begin a process of querying
himself as to how he is really feelingin an emotional senseto help
him get in touch with this more subtle layer of perception (relative to his
body) that might have been overlooked in the urry of activity oriented
at keeping his body healthy after the surgery. While there are no established research statistics to date that specify the exact percentage of people
who might develop signicant, as opposed to mild, mood problems
(such as depression or anxiety) at some point after weight loss surgery,
there is always the possibility that a mood issue will develop. It makes
sense intuitively that this may be particularly true for those individuals
for whom mood issues have been present to a moderate or serious level
at some point in the past, before they underwent the surgery.
On the other hand, some individuals for whom mood issues were not
problematic before surgery might also be aected by mood problems
after. Again, without actual data to support it, this vulnerability might
be more pronounced in those who, prior to surgery, relied on food to a
great degree, in the form of binge-eating episodes or other compulsive
eating behaviors, to regulate their mood or relied on other substances or
alcohol for the same eect. In any case, given the very dramatic changes
to the body that happen on multiple levels following the radical weight
loss made possible by weight loss surgery, even previously nondepressed
and nondistressed individuals might begin to feel some mood changes
that are uncomfortable at some point post-operatively. For that reason,
you should prepare your patient for this possibility.
Depression
It is important to help your patient understand the signs and symptoms
of depression and other mood issues, should these start occurring at
some point after the surgery. In terms of sizing up a depressed mood,
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most likely what your patient would experience would be at least some
of the following symptoms: a feeling of sadness, a sense of pessimism
that is inconsistent with the positive decisions and changes he has made
surrounding the surgery, tearfulness, distractibility, diculty getting up
to greet the day, diculty performing his usual activities (any that are
appropriate for the post-op stage that he is in), and in the worst cases,
thoughts or plans pertaining to suicide. Clearly, if such extreme signs of
depressionsuch as your patient having thoughts pertaining to ending
his lifeare present, both of you would likely already be painfully aware
of his depressed mood, without having to do any structured form of
querying. (On the other hand, there are individuals who are quite
skillful at hiding from themselves and others, or denying, any negative
feeling states such as depression.) The next steps you and your patient
would need to take involve trying to understand all of the contributions
to his mood diculties (both from the biological perspective, possibly
seeking a second opinion of a psychiatrist or other M.D. and also from
the psychosocial perspective) and then helping him gure out what to
do to work through these problems. It would be most important to encourage your patient rst, to talk to the team of professionals already involved in his care, such as his surgeon and primary care physician, to
consider disclosing his diculties to trusted signicant others so that
they would also know what is happening with him, and to think about
either increasing the frequency of therapy sessions, adding in (or increasing) support group sessions of one type or another, or encouraging your
patient to take part in a regular, structured activity that has been known
to make him feel better in the past.
Once your patient lets at least one, but hopefully a few, of the doctors
he has been working with in on the fact that he has been struggling with
his mood, he should rest assured that they will have a number of options
at their ngertips for helping him out with respect to his depression (in
addition to all of the work the two of you are doing in therapy). They
might recommend that your patient start on an antidepressant medication, make a change to a dierent medication if he has been taking one
with limited eectiveness, increase the dose of a medication he is currently taking, or restart a medication that he may have discontinued but
had been taking with good results at some point before. In addition to
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discussing medications, at some point you might ask your patients spouse,
partner, or other family members to join you in one or more therapy sessions or take part in family or couples therapy (separate from the work
your patient is doing individually).
Anxiety
As with depression, any anxiety problems your patient might be having
would rst be identied by teaching him to become a good self-observer
(while you also observe his mood, thought processes, and behaviors in
your sessions, as well as his reports of such happenings outside of sessions).
Your patient would likely note the presence of a stressed, strained, or
fearful kind of mood, along with the occurrence of persistent worries
that feel intrusive and ongoing, as well as muscle tension, hypervigilance
and possibly even panic attacks, despite his attempts to use the recommended tools of cognitive restructuring, distraction, and relaxation activities and the like. Just as with the occurrence of a depressed mood, the
presence of moderate or serious anxiety would warrant that your patient
consult with the members of his professional team, disclose to signicant others what he is going through, and think through, together with
his team, the potential viability of options such as medication, additional
psychotherapeutic interventions (e.g., such as an anxiety-management
focused group), and so forth. Although to date there is only limited clinical and research data available to support this impression, it appears that
the experience of serious anxiety by some individuals at some point postoperatively is more likely to occur in those with a history of anxiety in
the past or a history of other diculties in mood regulation. Because
managing these in the past might have been done by nonproductive solutions such as overeating, frank binge eating, or substance use or abuse
tools that are no longer available following gastric bypass surgerypost-op
patients might be left feeling particularly uncomfortable and without access to their usual means of soothing or escape from these types of dicult feelings. For that reason, working hard on identifying optimal solutions in your work with your patient is key.
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Problem Eating
Another obvious category of potential problems after weight loss surgery
involves that of eating. Ideally, after surgery your patient will be following the program (in terms of all of the eating suggestions) in full, that is,
eating (and drinking) all that is recommended, at the appropriate times
and in the appropriate amounts. In the optimal case, your patients following his program in this mannerthat is, investing himself fully in
doing the program rightwill yield a return that equates to an absence of diculties or problems. Unfortunately, even in instances in which
an individual is doing his best to follow the program to the letter, your
patient might experience an eating diculty of one type or another, of
an inadvertent or involuntary nature. For example, not terribly uncommon is a side eect of occasional bouts of vomiting or other gastric upsets in response to eating certain foods, or in rare instances, in response
to eating anything at all. Although infrequent in occurrence, this type of
vomiting or other gastric incident (e.g., some version of dumping syndrome involving diarrhea after eating) might continue beyond a few
episodes to become more problematic over time. In more severe cases,
there could be a nutritional impact resulting from the too rapid transmission time of food, which accumulates over time, either in the form
of dehydration in the short term or even some level of malnutrition over
the long term due to not enough nutrients regularly being absorbed into
the system.
There are also obvious and noteworthy physical consequences of repeated
vomiting (or diarrhea, for that matter) including soreness or sensitivity
in the gut or esophagus (or lower, e.g., when going to the bathroom).
A psychological impact can also develop over time, after repeated bouts
of vomiting or dumping, for example, in which the aicted person
might fear eating due to the possibility of one type of problem episode
or another happening yet again. Over a period of time, this can develop
into a full-blown food phobia that might look like classic anorexia nervosa to some degree, in that the aected person is likely to deny hunger
or appetite, may or may not acknowledge a fear of eating, but is motivated primarily by this fear to avoid eating altogether. Clearly, if any of
this seems similar to what might be happening with your patient, it is
108
imperative that you help stop the progression of this problem as quickly
as possible.
The best course of action, in the event of what appears to be a food phobia in development, would be to combine a strictly behavioral and CBT
approach that includes helping your patient to stay vigilant about his
eating patterns and habits, as well as the thoughts and feelings that he is
experiencing in response to these. Encouraging him to keep regular food
records, on which he can document all of the above, can be quite useful
for both of you as you put your heads together to try to understand his
eating behaviors and associated attitudes and emotions in full. Also, encouraging your patient to take in feedback that signicant others might
have based on their observations of his eating patterns might also at
times be quite helpful, even though your patient might initially bristle
in response to what feels like judgmental control or criticism rather than
helpful wisdom that others in his personal life might be able to oer.
While others constant intrusion in a situation like this is obviously not
desirable, when it comes to matters like eating patterns, weight loss, selfcare, and mood states (including anxiety and depression), those around
your patient might sometimes see more clearly what is going on than he
is able to see for himself.
Binge Eating
A related but dierent problem that might happen for your patient postoperatively is that of the occurrence of overeating or binge-eating episodes, obviously on a smaller scale than what would have taken place
prior to the surgery. A pattern of overeating after weight loss surgery can
develop slowly or insidiously over time, or it might appear all of a sudden, as if out of nowhere. Again, based on clinical impressions, it appears that those who had problematic binge-eating habits prior to surgery are more at risk for redeveloping the problem after surgery (even if
there was a considerable binge-free phase before surgery was attempted)
than those who never binged in the past, but so far there is no research
data to support this impression in full. In any case, a number of dierent types of scenarios involving overeating might develop over time in
a post-op weight loss surgery patient. For example, in one individual, a
109
craving for just a little bit of a certain type of food might trigger the
beginning of what ultimately becomes an overeating episode, at least overeating from the standpoint of what is ideal in terms of food contents and
quantities that are recommended after weight loss surgery (even if this
exact eating episode would have been considered perfectly acceptable before surgery). At the point when the eating episode transitions from normal or acceptable to problematic, the person involved might also start
producing a number of problematic cognitions that might make it more
likely that he ends up eating more in response to this initial bit of overeating rather than stopping himself when he still can. This represents an
example of the type of catastrophic thinking described earlier in this
chapter and in chapter , which focused on cognitive distortions. For
example, your patient entertaining a thought, after consuming a nonoptimal food (either in content or quantity), that goes something like,
Now Ive gone and blown it! I am ruining my surgery and will never
lose weight! would obviously be more likely to perpetuate additional
problematic eating behaviors for your patient than if he curtailed these
behaviors at their earliest stages, which he would be more likely to do by
exercising more constructive thinking such as, OK, this was just a small
indulgence, and it will be best to quit now, while I am still ahead, with
no damage done.
Cravings
Another type of overeating or binge episode that might happen out of
the blue post-operatively involves an individual developing a strong
craving for a particular food. Thinking optimistically and in the direction of good self-carewhich can sometimes involve indulgence in
moderationyour patient might allow himself a treat of some type
and then end up having an experience characterized as my eyes were
bigger than my stomach. What this means is that, in his zeal to take in
as much of the really good indulgence food that he wants or can consume, he ends up signicantly overeating relative to the postweight loss
surgery recommendations. Some in this instance might go on to experience dumping syndrome in response, partly depending on the amounts
and types of foods that were ingested, that results in stomach upset at
minimum and sweating, trembling, diarrhea, and possibly vomiting as
110
other potentialities. In this instance, as much as the dumping syndrome

proves to be a negative reinforcer for overeating, that is, maximizing the
distress or negative consequence that results from overeating to the point
that many would then be tempted to avoid it at all costs, some may ultimately experience the dump as something akin to a purge. When it
is seen this way, as a purge that eliminates food from the body, it enables
them to feeleven if illogicallythat they have in essence rid themselves of the excess food and calories consumed and therefore can do it
again if and when they feel like it. (This is the same logic that keeps bulimic individuals tied to their habit of binge eating and purging.)
If overeating in this fashion has been a problem for your patient in the
past, there may be a greater likelihood that he develops a pattern like this
yet again, particularly if he has experienced mood issues related to all
stages of the binge and purge cycle (for example, experiencing initial prebinge anxiety, followed by a distracted euphoria during and immediately after eating, followed by panic as the reality of what has been consumed sets in, followed by discomfort as awareness returns and satiety
registers, followed by more panic pre-purge, followed by calm after purging is completed). In all such instances of chronic and frequent (e.g., more
than a few in a week or a few weeks time) occurrences of problematic
eating of this nature, it is absolutely essential that you and your patient
focus very specically on this problem as soon as possible.
In addition, you would also want to encourage your patient to discuss
what is happening in his eating patterns (including any purge-like behaviors) with his primary care physician and surgeon, so that they are
kept well informed about the problem behavior. Their involvement is
particularly important since they know what to look for in terms of any
potential physical damage or side eects that can stem from a combination of your patients surgery and this type of behavior, and they might
also have suggestions about additional personnel that might become involved in your patients care if necessary (such as a gastroenterologist).
It is also important that you discuss with your patient the option of a
psychiatric evaluation in which the likelihood of his beneting from
psychotropic medications, which might help him with both mood and
eating issues, can be assessed. No matter what the type of eating problem, always keep in mind for your patient that in addition to his work
with the medical professionals that are already part of his team (includ-
111
ing you), as well as any weight loss surgery support group meeting that
he is already attending, he always has the option of adding to the mix
attendance at another type of group meeting (for example, Overeaters
Anonymous or another type of support group if this seems appropriate),
along with expanding the involvement of signicant others in his care.
Alcohol and Drugs

Finally, one other cluster of problematic behavior patterns that can occur
after any type of stressful life experience such as that of radical surgery
is abuse of alcohol or drugs. Again, those with predispositions for this
type of problem, based on a family history of substance abuse or more
likely their own history of any type of substance abuse occurring even
years before undergoing the surgery (as stated earlier in this manual, most
programs require that patients are clean and sober for at least ve years
before going through weight loss surgery), are probably more at risk than
others who have had no experiences abusing or developing a dependency
on any type of substances. However, in a manner that is similar to the
development of the problematic eating behavior, these issues might occur
secondary to the existence of an as yet untreated, underlying mood disorder, such as anxiety or depression. Clearly, your patient obtaining speedy
and adequate treatment for any mood regulation problems he might be
having after surgery likely decreases the probability that he will rely on
these other inappropriate strategiesmisuse of food, drugs, or alcohol
for managing his mood. However, if you do notice that your patient is
engaging in any type of substance abuse problems, whether these are
newly developing or resurfacing at any point after surgery, the two of
you need to assess the degree of the substance problem and likely seek
an evaluation with a substance abuse expert, outside of your therapy sessions. You should also recommend that your patient attend Alcoholics
Anonymous (AA) or another appropriate meeting specic to the substance that he is abusing. Remind your patient that you commend him
for opening up to you about the nature of the substance abuse problem
and reassure him that he should not, under any circumstances, concern
himself with problematic thoughts related to feelings that he has let
down the members of his surgical or medical team or that he has bro-
112
ken the rules or will be getting in trouble. The simple fact of the
matter is that your patient is in acute need of professional assistance if
he is abusing or dependent upon any type of substance, whether alcohol
or drugs, and the sooner you are able to help him obtain the appropriate type of treatment, the better o he will be.
Options for Seeking Help

In all of the instances noted aboveinvolving mood, eating, and substance abuse issuesthe problems were serious enough to warrant and
require specic, expert, individual, professional assistance and, possibly
in addition, some form of group therapy or support. Keep in mind, however, that any type of problematic feeling or behavior that your patient
is experiencing, no matter how mild, deserves some type of attention
and treatment. Hopefully, many of the treatment needs that your patient might experience can be addressed in your therapy work. But at
times both of you might reevaluate the course of treatment that you are
engaged in together and decide to make some changes, even those requiring that you refer him to someone else. Remind your patient not to
keep a sti upper lip, symbolized by thinking along the lines of unless my problem is severe and includes depression, anxiety, major eating
issues, or substance abuse, I should not seek help. The reality is, even if
your patient is doing amazingly well, or moderately well with the exception of a few minor problems, if he wants extra help or assistance, either
in the form of some other type of individual psychotherapy (that may
or may not include a consultation for medications), couples counseling,
group interventionseither AA or OA in addition to his weight loss
surgery support groupor any other type of group forum, he should
feel that he is healthfully entitled to seek it out. In terms of individual
therapy, most important may be the t between your patient and the individual therapist that he decides to work with (if he makes a change
later to work with someone other than you). By the same token, there
are several dierent schools of individual therapy that you might educate your patient about, albeit somewhat briey, so that he knows at least
something about what the options are.
113
Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT )which is what your patient has
spent most of the time on in the current therapyin the most basic
sense would address the types of thoughts your patient is having along
with the behaviors he is exhibiting relative to the issues of weight loss
surgery, eating, weight, body shape, mood, self-esteem, cultural pressures to be thin, and other concerns. The sessions would likely be somewhat structured and driven by an agenda that is based on your patients
and the therapists ideas about appropriate goals for the stage of therapy
that they are in. In CBT, your patient will often be assigned homework
at each session, so that the between session time is like a laboratory in
that he is encouraged to experiment on various new perspectives and behaviors the two of you have been talking about in your sessions.
CBT Self-Help Manuals

This is a shorthand form of CBT therapy based on a written manual,
used in conjunction with intermittent and brief (e.g., every other week,
minutes each) therapy sessions that are oriented toward keeping the
patient focused on the tasks and issues presented in the book.
Interpersonal Therapy
Interpersonal therapy (IPT ) is a less directive approach to treatment, although there is a clearly dened agenda that involves a patient talking
about one or a few primary interpersonal problem areas that are integrally related to eating issues and weight concerns. Examples of core interpersonal problems might be navigating a dicult transition, such as that
associated with becoming a more assertive person or becoming thin for
the rst time ever or for the rst time in a long time; experiencing conicts with other people on a very frequent basis; or working through an
unresolved grief. In the initial few sessions of IPT, the therapist would
help the patient take some time to reect on his entire social life, the
number, quality, and type of relationships he has now and has had in the
past, in an attempt to identify the core problem areas that are troubling
114
to him. In many cases, it turns out that these same problem areas have
also been instrumental to one degree or another in triggering or perpetuating aspects of the patients disordered eating behavior and weight
problem.
Other Therapies
Many other types of therapies exist and are practiced in a form that could
potentially be very helpful for someone with eating problems and weight
concerns. These days, an extremely popular form of treatment is that of
emotion regulation therapy, in which an individual is taught a number
of dierent strategies and tools to embrace, validate, and gradually change
any excessive or nonconstructive emotional reactions they may have in
response to charged or stressful situations of one type or another. In
addition, there are several nonspecic therapies that may oer support, encouragement, feedback, reality checks, and an opportunity for
accountability that can be quite helpful if delivered by the right person,
to the right person, in the right circumstance. In any event, given the signicance of what your patient has been through, in terms of following
through with surgery after a long period of preparation and anticipation,
recovery, healing, adjustment, and the like, psychotherapy or counseling,
just to have someone in his court (in the form of a psychotherapist or
counselor) who is supportive, objective, there for him, and hopefully a
source of some wisdom and guidance, might be something to strongly
consider if he has any interest at all in continuing therapy beyond the
work that you two have done together.
Homework
Complete the exercises in this section.
Take some time to relax! (Use progressive muscle relaxation, breathing
exercises, items o your list of alternative activities that dont involve
food, or anything else.)
115
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About the Authors
Robin F. Apple received her PhD from the University of CaliforniaLos

Angeles in and has published articles and chapters in the area of eating disorders. She has also cowritten a patient manual and a therapist
guide that utilize cognitive-behavioral therapy (CBT) techniques for treating bulimia nervosa and binge eating disorder. In her current role as associate clinical professor, Department of Psychiatry and Behavioral Sciences, Stanford University, she has completed over pre-operative
evaluations of patients seeking weight loss surgery, has co-led a weight
loss surgery support group, and has provided short- and long-term individual therapy for those preparing for and adjusting to their surgery.
Apple maintains a varied caseload of patients with eating disorders and
other issues, both at Stanford and in her private practice in Palo Alto,
California. She consults on weight loss surgeryrelated research and forensics cases and is actively involved in Stanfords training program for postdoctoral psychology fellows and psychiatry residents.
James Lock, MD, PhD, is associate professor of child psychiatry and pediatrics in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine, where he has taught since . He
is board certied in adult, as well as child and adolescent, psychiatry. In
the Division of Child Psychiatry and Child Development, he is currently
director of the Eating Disorders Program that consists of both inpatient
and outpatient treatment facilities. His major research and clinical interests are in psychotherapy research, especially in children and adolescents, specically for those with eating disorders. In addition, he is interested in the psychosexual development of children and adolescents
and related risks for psychopathology. Lock has published over articles, abstracts, and book chapters. He is the author, along with Daniel
le Grange, Stewart Agras, and Christopher Dare, of the only evidence-
121
based treatment manual for anorexia nervosa, called Treatment Manual

for Anorexia Nervosa: A Family-Based Approach. He has also recently published a book for parents, Help Your Teenager Beat an Eating Disorder. He
serves on the editorial panel of many scientic journals especially focused on psychotherapy and eating disorders related to child and adolescent mental health. He has lectured widely in the United States, Europe, and Australia. Lock is the recipient of an National Institute of
Mental Health (NIMH) Career Development Award and an NIMH
Mid-Career Award, both focused on enhancing psychosocial treatments
of eating disorders in children and adolescents. He is the principal investigator at Stanford on a National Institutes of Healthfunded multisite trial comparing individual and family approaches to anorexia nervosa in adolescents.
Rebecka Peebles, MD, is an instructor in adolescent medicine at the
Department of Pediatrics at Stanford University School of Medicine. She
completed her training at the Cleveland Clinic Foundation and at Stanford University School of Medicine, and is board certied in pediatrics
and in adolescent medicine. She is a member of the Adolescent Bariatric
Surgery Board and works in the Eating Disorders Clinic and the Pediatric Weight Clinic at Lucile Packard Childrens Hospital at Stanford. Her
major research and clinical interests are in health outcomes of binge eating and purging behaviors, and in better understanding links between
eating disorders and obesity. In addition, she has researched the impact
of the Internet and proeating disorder Web sites on adolescent populations. She is the recipient of multiple awards for teaching and humanistic
medicine. She has written on eating disorders and obesity, and frequently
lectures on these topics and adolescent health in the community.
122

Preparing For Weight Loss Surgery - Therapist Guide

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Robin F. Apple James Lock Rebecka Peebles

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cillary materials that will approximate the supervisory process in assisting

Introductory Information for Therapists

Understanding Your Patients Eating Behavior

Helping Your Patient Keep Track of

Educating Your Patient About Weighing Behaviors

Pleasurable Alternative Activities

Challenging Eating Situations:

Teaching Your Patient About Problem Solving

Working With Your Patient on Body Image Issues

Congratulations! Your Patient Is on the Way

What Happens After Surgery?

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